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R 111.N52S4 e " UniVers " yLibrary 
 ^I^mX^?*®™** two essays 
 
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/cu31924011938721 
 
THE NEW SYDENHAM SOCIETY. 
 
 Instituted MDCCCLVHI. 
 
 VOLUME CXXI. 
 
SELECTED MONOGRAPHS; 
 
 .I.Y 
 
 RAYNAUD'S TWO ESSAYS 
 
 LOCAL ASPHYXIA. 
 
 KLEBS and CRUDELI 
 
 THE NATUBE OF MALARIA. 
 
 MAROHIAFAVA and OELLI 
 
 THE OBIGIN OP MELAMMIA. 
 
 NEUGEBAUER 
 
 ON 
 
 SPONDYLOLISTHESIS. 
 
 ^xmbon : 
 THE HEW SYDENHAM SOCIETY. 
 
 MDCCCLXXXVIII. 
 
 9 
 
ON LOCAL ASPHYXIA 
 
 AMD 
 
 SYMMETRICAL GANGRENE OF THE 
 EXTREMITIES. 
 
 BY 
 
 MAURICE RAYNAUD. " 
 
 TRANSLATED BY 
 
 THOMAS BARLOW, M.D. 
 
TRANSLATOR'S NOTE. 
 
 The papers translated are (1st) Raynaud's original thesis, which 
 was published in 1862, and (2nd) his last researches on the 
 subject of local asphyxia, which appeared in the Archives 
 Generates de Medecine, 1874, vol. i., pp. 5, 189. 
 
 An appendix has been added by the translator, containing 
 references to the chief additions made by others to the know- 
 ledge of the subject subsequently to the publication of Raynaud's 
 memoirs, but no attempt has been made to give a complete 
 bibliography. 
 
AUTHOR'S PKEFACE. 
 
 To describe a new disease, and especially to give a new name to 
 a group of symptoms which has been long observed and described, 
 is assuredly less difficult than to link together under a common 
 law which dominates them .many affections apparently different. 
 In the infinite variety of morbid phenomena which present them- 
 selves daily to our observation with a physiognomy always new, 
 it is easy to choose here and there some exceptional facts and 
 to constitute them a common type, omitting the differences 
 which separate them in order to see only the points of contact 
 between them. A little imagination suffices for this task, and 
 positive science has little to profit by it. Also, in spite of the 
 title which I have given to this thesis, I am bound to declare at 
 the outset that I do not aspire to the frivolous and dangerous 
 honour of making an innovation in pathology. My ambition 
 would be rather to demonstrate that certain facts of gangrene of 
 the extremities which one meets at long intervals in practice, 
 and of which the strange appearance is apt to disconcert the 
 most skilful, are in reality much less singular than one would 
 be tempted to believe, and can be connected by intermediate 
 steps with other facts much more common, and which only 
 escape attention by their everyday occurrence. 
 
 Unfortunately words have, in nosology, an importance of which 
 it would be useless to attempt to deprive them. 
 
 That which interests us in a given case is not to know in 
 which genus and in which species it is proper to classify it, 
 as we are in the habit of doing with objects of natural history ; 
 it is rather to discover by what series of deviations the normal 
 
X PBEFACB. 
 
 health has become altered up to this point, by what sequence of 
 phenomena the malady once constituted might pass over into 
 conditions still more grave. This is, in fact, diagnosis and 
 prognosis, that is to say, more than the half of medicine. 
 
 But if we were bound to restrict ourselves to this rigorous 
 order, medical language would be no longer possible, and it 
 would be necessary to wait indefinitely until science should be 
 constituted in all points. The best thing is, as a new variety 
 offers itself for observation, to give it some name in accordance 
 with the most striking characters, waiting for a future synthesis 
 to suppress these provisional landmarks. 
 
 This is what I have decided to do, not without some repugnance. 
 I have yielded to the natural instinct which leads us to seek 
 under the brute facts for the interpretation which is most satisfy- 
 ing to the mind. It is hardly necessary to add that, if the 
 future should demonstrate the falsity of my explanations, I hope 
 that I should have enough enlightenment and sincerity not to 
 attach any further importance to theoretical views inevitably 
 more or less incomplete. 
 
 It always obtains that facts are facts, and that there can be 
 nothing but advantage in grouping them together into a 
 picture. 
 
LOCAL ASPHYXIA AND SYMMETRICAL 
 GANGRENE OF THE EXTREMITIES. 
 
 CHAPTER I. 
 
 GENERAL CONSIDERATIONS ON SPONTANEOUS GANGRENE. 
 
 I. " Everything concerning spontaneous gangrene is in a state 
 of distressing uncertainty," wrote M. Victor Francois, of Mons, 
 in 1832, in a work which has justly become classical ;* and this 
 acknowledgment of the gaps of knowledge upon this important 
 part of pathology might at that time pass for the exact expression 
 of the truth. 
 
 If it is permitted to medicine to conceive a legitimate pride in 
 taking a general retrospective survey over its past, then assuredly 
 it is well to do so in all that relates to the subject which is about 
 to occupy our attention. 
 
 Since the above epoch, and thanks to the progress of patho- 
 logical anatomy, much of the darkness has disappeared, a goodly 
 number of positive facts have been added to knowledge, and if 
 there remains still much to be done, at least the direction is indi- 
 cated and the way opened. Amongst the writers who have con- 
 tributed most to this progress, it is right to assign an honourable 
 rank to the distinguished physician whom I have just cited; 
 his work, based upon a considerable number of observations, is 
 still the most complete treatise that we possess on the subject. 
 Without pretending, as one would do him wrong in saying, that 
 spontaneous gangrene has a vascular obstruction for its constant 
 cause, M. Francois at least established on an extensive basis of 
 statistics the very great frequency of this cause and sought to 
 estimate its mechanism. That is certainly the most practical 
 
 * Essai sur let gangrenes spontanees. A work crowned in 1830 by the Soc. Boy. de 
 Med. de Bordeaux. Mons, 1832. 
 
2 Raynaud's original thesis. 
 
 conclusion which results from his work. We must recognise 
 nevertheless that he only established a truth already presented 
 for several years, and many times even clearly announced before 
 his time. 
 
 Erom the middle, of the 18th century there, had been aivague 
 idea of the part which arteries play in the production of 
 gangrene, and Quesnay, in 1739 indicated as a; very probable 
 cause, that, which he called in his metaphorical language the 
 extinction of the organic action of the arteries ;* but men were 
 satisfied with that confused notion, which was spoiled directly by 
 the humoral hypotheses on the congelation of the juices and 
 fixation of the animal spirits, to which soon came to be added the 
 inevitable accompaniment of the venereal and scorbutic poisons. 
 We can retrace the steps of this confusion ,in the great, work 
 of Boyer, the successor .and representative . , of . the . ancient 
 Academy of Surgery; too often in speaking of gangrene he Jails 
 in that precision which is habitual to him, 
 
 Nevertheless, and already in his time the idea of a direct 
 obstacle to the course of the blood having its seat in the interior 
 of the vessels came to the front. Definitely stated by Hebreard 
 in 1817, t taken up and developed, two years , afterwards ■ by 
 Avisard,J this idea, which was so obvious, henceforth impressed 
 a new direction on research. Unfortunately there happened in 
 this subject what almost always occurs in subjects of. study : 
 two. distinct things were confounded, iviz., ossifications of the 
 arteries and blood concretions in > the. cavities. , of vessels ; hence 
 arose many misunderstandings. .-,...■-- ;s i ,„. 
 
 Meanwhile the physiological doctrine, which shone then with 
 all its brilliance here as elsewhere, made, its influence felt; it 
 had the good fortune to find support, in the great authority of 
 Dupuytren. Although M. Roche has claimed .subsequently^ and 
 with reason, the paternity of arteritis,, this malady-held such an 
 important place, in the teaching of the celebrated surgeon, of the 
 Hotel Dieu that he has preserved in great measure the glory and 
 the responsibility of it. Arteritis, a simple question of fact at 
 
 * Traite de la Gangrene. Paris, 1749. ■ < • • 
 
 t " Memoire sur la gangrene ou mprt partielle, consider dans les divers systenies 
 
 anatomiqnes qn'elle peat affecter," dans les Mcmoives et prix de la Socic'te de Medecine 
 
 de Paris, 1817. 
 X " Observatibns sur les gangrenes spontanees ou par ossification et obliteration 
 
 des arteres." BiblioMque Midicale, 1819. 
 
GENEEAL CONSIDERATIONS ON SPONTANEOUS GANGEENE. 3 
 
 first, then soon a question of doctrine, took a prominent place in 
 general pathology. From it was demanded the key, not only of 
 local phenomena, coagulations, ossifications, &c, but of import- 
 ant general states (the inflammatory fever of P. Frank, the 
 angeiotenic fever of Pinel) which formed a new source of dispute. 
 We cannot affirm that all the questions then raised have been 
 resolved. Nevertheless, disengaged from the hypothetical sur- 
 roundings with which it has too often been surrounded, the 
 arterial phlegmasia, either as cause or effect, has a demonstrated 
 existence ; to deny it, as they have recently attempted to do in 
 Germany, is to go against evidence. "Whilst discussion lost itself 
 in this polemic, in which people were not in accord either on 
 words, or things, . or symptoms, or lesions, two modest theses 
 were maintained at Paris which at first attracted no attention, but 
 which subsequently it was found necessary to reconsider. One 
 bore this title : " Researches on a little-known form of occlusion 
 of arterial vessels considered as a cause of gangrene."* The 
 author, M. Allibert, gave expression to this original idea : that 
 the inflammation under discussion might be only the effect, and 
 not the cause, the primitive fact being the coagulation of the 
 blood in its vessels. The other thesis, + of a little earlier date, 
 was that of the lamented M. Legroux. Limiting his ambition 
 to a still more restricted scale, this observer devoted himself to 
 a careful anatomical study of arterial concretions taken by them- 
 selves, a study which he pursued all his life, and upon which 
 he published his last word a short time before his death. $ 
 
 This was the true path. Subsequently many works were pro- 
 duced relating to the formation of clots in situ, to modifications 
 which may occur in their intimate formation, and to the effects 
 produced by their migration in the circulatory current. 
 
 Of all these works the most important, without contradiction, 
 are those of the celebrated Virchow, upon solid bodies transported 
 to a distance by the blood current, and to which he has given the 
 name of embolisms. 
 
 Embolism has had the lot of many discoveries : once the fact 
 demonstrated, and the principle laid down, it is perceived that 
 the same phenomenon had been not only seen, but interpreted 
 
 * These de Paris, 1828, No. 74. 
 
 t " Concretions sanguines dites polypifonnes de'veloppe'es pendant la vie." These 
 de Paris, 1827, No. 215. 
 % " Des Polypes arteriels (concre'rion sanguines)." Gaz. hehdomadaire, 1860. 
 
4 RAYNAUD S ORIGINAL THESIS. 
 
 in this sense by different authors. M. Legroux had recorded an 
 example of it in his thesis; M. V. Francois had cited a second 
 example of it.* Still further the same idea has been found 
 clearly expressed even in the Sepulchretum of Bonet and the 
 Commentaries of Van Swieten. But this is of little importance. 
 Far from diminishing the merit of M. Virchow, these facts 
 ought simply to pass for an anticipated confirmation of the views 
 of the eminent Berlin professor who, by the numerous experi- 
 mental proofs with which he has supported his theory, by the 
 extension which he has given to it, deserves to be considered as 
 its veritable founder. 
 
 Conclusive facts have been produced in this sense by M. 
 Schutzenberger . f 
 
 Finally, my learned teacher, M. Gubler, and quite recently 
 M. Ball, X have completed the demonstration, by making it clear 
 that fragments of clots found in very remote parts of the circula- 
 tory system can nevertheless be adapted very exactly one to 
 another in such a way as to permit the primitive clot to be 
 reconstituted. To-day we may say that embolism has gained its 
 cause, and there remains nothing more to be done except to 
 defend it against its own excesses. § But if we consider it along 
 with arteritis, we cannot but find between these two maladies the 
 greatest resemblance as to their effects. Both present this 
 common condition : the interference at first with the supply of 
 a sufficient quantity of oxygenated blood in a given area of the 
 arterial system. On the other hand, the study of the anatomical 
 lesions presented by the nervous system has for a long time 
 been made from the point of view of gangrene. In an excellent 
 memoir, published in 1836, M. Godin has rendered || the view 
 extremely probable that most gangrene has for its cause a venous 
 obliteration, and ought in consequence to be brought into 
 proximity with the cedemas; it is almost generally admitted 
 to-day that venous obstruction, although incapable by itself of 
 determining gangrene on account of the great number of 
 anastomoses, has at least the power of modifying its character. 
 
 * Op. cit., p. 202. 
 
 t "De l'oblite'ration subite des arteres par des corps Bolides," <fcc. Gaz. Med. de 
 Strasbourg, Feb. 28, 1857. 
 % These de Paris, 1862. 
 
 § Vide Klinik der embolichen Gefdss-Kranhheiten. Berlin, 1861. 
 || Archives generates de Mideeine, 1836, 2e Serie, T. xii., p. 52. 
 
GENERAL CONSIDERATIONS ON SPONTANEOUS GANGRENE. 5 
 
 II. From all that has preceded there would therefore appear 
 at present to result an almost complete certainty touching the 
 mode of production of gangrene. The general law might be 
 formulated in these two equations : arterial obliteration = dry 
 gangrene ; venous obliteration coinciding with arterial oblitera- 
 tion = moist gangrene. This is the opinion which has recently 
 been ably defended by M. Behier.* Everything is so satisfac- 
 tory, everything is so logical from this point of view, that in 
 truth it would be very desirable that such should be the case if 
 anything were desirable in the matter of science other than 
 knowledge of the truth. 
 
 But Nature does not accommodate herself so easily to our sys- 
 tematic views. There still remain the spontaneous gangrenes, 
 which it would be premature to introduce into one or other of 
 these groups. Perhaps with the spontaneous gangrenes, the 
 gangrenes of the mouth and vulva in children may be associated. 
 Does the gangrene produced by ergot of rye depend upon a 
 material obstacle to the course of the blood? It is at least 
 necessary to prove this, and dh the other hand during the last 
 few years new facts have been brought forwards which may 
 modify our views in this respect. 
 
 "We know that M. Bourgeois, of Etampes, has sought lo 
 establish that dry gangrene of the limbs may occur as a com- 
 plication of typhoid fever,t and he believes so strongly in the 
 union of these two conditions that he does not hesitate to propose 
 for this variety the name of typhoid gangrene. It is true that 
 M. Behier responds by a verdict of not proven, and contests 
 the exactitude of the diagnoses made by M. Bourgeois, who in 
 his opinion has taken for typhoid that which was only the 
 commencement of gangrenous symptoms. J It must be admitted 
 that the facts cited by M. Bourgeois are too incomplete for a 
 definite conclusion to be deduced from them. The state of the 
 arteries is not noted, and no autopsy is recorded. Nevertheless 
 one is most reluctant to admit an error of diagnosis on the part 
 of a physician so distinguished as M. Bourgeois. 
 
 Perhaps a distinction should be drawn between the fact and 
 
 * " Lettre sur la gangrene typhoide." L'Union Medicate, Oct. 22, 1861. 
 t Archives generates de Medecine, 5e Serie, T. x., p. 149. 
 
 % Rapport lu a la Socie'te" me'dicale des Hopitaux par M. BeTiier. L'Union medicate 
 13 Juin, 1857. 
 
6 baynaud's original thesis. 
 
 the interpretation. The fact, was gangrene supervening on 
 typhoid fever ; the interpretation was the theory proposed hy the 
 author, of a gangrene caused by a vital inscrutable action, by a 
 kind of metastasis. Without having recourse to these explana- 
 tions, which are a little mystical* might one not to admit, since 
 typhoid fever is frequently complicated with sloughs on the 
 sacrum, and since pressure of itself is alone insufficient to 
 explain them, that dry gangrene of the limbs might also occur ? 
 When moreover we think of the excessive readiness with which 
 coagula are formed after long illnesses, whatever their nature, 
 we come to believe that it is sufficiently probable that blood 
 concretions may form in the same way in the course of a 
 malignant fever, all the more so that the facts of typhoid 
 gangrene are not without examples in the history of science.* 
 Thus this variety comes within the general law, and this is 
 what seems to result from the new cases which have been since 
 observed, f 
 
 But the same thing does not hold, at least at present, with 
 regard to the diabetic gangrene ^described by M. Marchal (of 
 Calvi), and upon which the former professor of the Val de Grace 
 has insisted for many years. { The nature of the lesions, the 
 progress of the symptoms, the inflammatory appearance which 
 precedes mortification, all seem opposed to the idea of a vascular 
 obstruction. If these already numerous observations are con- 
 firmed (M. Marchal possesses now more than forty of them) it 
 will become necessary to admit a new variety. 
 
 Finally, here is a statement which is not less disturbing for 
 the vascular theory when stated in a too absolute manner : — 
 
 M. Virchow, the great promoter of the doctrine of thrombosis 
 and embolism, after having described ordinary mummified 
 gangrene, declares that the so-called senile gangrene differs from 
 it entirely. 
 
 As his opinions on this point are little known in France, and 
 as his authority is more often invoked than his writings read, I 
 ask permission to cite from them a few passages : — 
 
 * Vide Panaroli Jabrolog, Pentec. quinque. Hanov.. 1654. Hildenbrand has recorded 
 many cases of gangrene of the extremities in typhus. Vide also La Motte, Observa- 
 tions chirwrfficales, T. iii., p. 346. 
 
 f Trousseau, Clinique medicate de VBdtel Dieu, T. i,, p. 210. 
 
 % Vide "Remarques historiques sur la gangrene diabetique." V Union medicate 
 25 Juillet, 1861. 
 
GENERAL CONSIDERATIONS ON SPONTANEOUS GANGRENE. 7 
 
 " Senile gangrene differs essentially from the preceding (mum- 
 mine gangrene) and from that which we have described as spon- 
 taneous gangrene. It is quite erroneous to suppose that it is 
 regularly preceded by arterial thrombosis. I have had frequent 
 opportunities of examining it anatomically, and often I have 
 been unable to find any trace of diminution of the calibre of the 
 arteries, not even above the limits of the gangrene. Often, it is 
 true, the arteries are found diseased, sometimes hardened, some- 
 times atheromatous or calcareous, &c. Nevertheless I do not 
 consider these lesions as a sufficient cause, because it is recog- 
 nised that very extensive degenerations of arteries may exist 
 without gangrene. It is very important to examine at the same 
 time the condition of the muscular fibres of the heart ; it may 
 be atrophied, or have undergone fatty degeneration. Circulation 
 becomes difficult in the remote vessels, particularly in the 
 lower limbs ; nutrition suffers, &c. Senile gangrene is there- 
 fore essentially a necrosis from feebleness, and ought to be 
 brought into proximity with gangrene following upon decubitus, 
 and with those gangrenes which supervene in the ultimate 
 phases of grave fevers, and affect the ears, the nose, the fingers, 
 and the toes."* 
 
 We see that the last word has not yet been said on the subject 
 of gangrene, and on dry gangrene in particular. In the actual 
 state of our knowledge, and in order to avoid confounding in a 
 single description facts perhaps very incongruous, it becomes 
 more and more necessary, to give up an artificial unity which 
 can only satisfy minds who care little for new researches ; also 
 it is necessary to establish in the history of gangrene divisions 
 based upon pathological anatomy and etiology, and to study 
 separately each of these varieties, subject to the bringing them 
 together at a later period and discovering the bond which unites 
 them and the law which dominates them. 
 
 III. It is to this work of analysis (of which the attentive 
 reading of modern works on gangrene has made me strongly 
 feel the necessity) that I wish to contribute my part. I pro- 
 
 * Virchow, Handbuch der speciellen Pathologie und Therapie, T. i., p. 289. There 
 are many reservations to be made to the explanation given by M. Virchow. The 
 degeneration of the heart and that of the vessels seem to me to be inseparable lesions, 
 and it appears to me difficult to understand how a permanent and incurable cause, 
 like that of cardiac atrophy, should produce effects which are often transient, and also 
 difficult to explain caBes which are followed by recovery. 
 
8 eaynaud's obiginal thesis. 
 
 pose to demonstrate that there exists a variety of dry gangrene 
 affecting the extremities which it is impossible to explain by a 
 vascular obliteration — a variety characterised especially by a 
 remarkable tendency to symmetry, so that it always affects 
 similar parts, the two upper or lower limbs, or the four at the 
 same time ; further, in certain cases, the nose and the ears ; and 
 I hope to prove that this kind of gangrene has its cause in a 
 vice of innervation of the capillary vessels which it remains for 
 me to define. 
 
 As may be seen, it is a very limited corner of the general 
 history of gangrenes that I propose to consider. That history 
 I shall avoid even approaching ; it would be an immense task, 
 and I cannot forget Horace's line, " Quid ferre recusent quid 
 valeant humeri." I wish to state at the beginning that I 
 do not pretend in any way to attack the theory generally 
 admitted, of gangrene by obliteration ; I believe it to be perfectly 
 established in the majority of cases. At least, in presence of 
 the innumerable difficulties which encumber Science, let us 
 know how to respect the facts which are irrevocably acquired 
 by her ! 
 
 Few works have been undertaken up to this time from my own 
 point of view. It is true that many authors have maintained, 
 rather on theoretical grounds than on the basis of exact observa- 
 tions, the possibility of a gangrene occurring from the very fact 
 of a nervous lesion ; innervation having according to them an 
 influence upon the phenomena of nutrition at least equal to 
 that of circulation. 
 
 One of the most interesting memoirs in this sense is the 
 thesis of M. Zambaco, which bears this significant title : 
 " Spontaneous gangrene produced by nervous perturbation." 
 But M. Zambaco is wrong, in my judgment, in generalising 
 the cause too much and not precisely stating the mechanism. 
 He admits the direct and primitive influence of the nerves on 
 nutrition, which is far from being demonstrated by physiology ; 
 consequently he believes that the nervous system disturbed or 
 damaged in its functions can by itself alone determine gan- 
 grene without any lesion of the vessels. He goes so far as to 
 maintain that the nervous element predominates in all gangrenes, 
 which is inadmissible. The greater part of the facts gathered 
 by him relate to lunatics, and especially to patients affected with 
 
GENERAL CONSIDERATIONS ON SPONTANEOUS GANGRENE. 9 
 
 general paralysis ; as if in the last case paralysis and gangrene 
 were not allied to profound and general lesions of nutrition very 
 different from a simple neurosis. These facts have at least the 
 incontestable merit of establishing this capital point, that there 
 are gangrenes without alteration of vessels. 
 
 I have found valuable indications in a very remarkable memoir 
 by M. Charles Eacle, entitled, " Memoir on some new characters 
 of gangrene, and upon the existence of this lesion in maladies 
 in which it has not yet been described."* The chapter entitled 
 " Gangrene with nervous phenomena" contains some passages 
 which so closely resemble some of my own observations that I 
 cannot doubt that M. Bade has had before him similar cases 
 to those which I have recorded. He insists on the constant 
 limitation of this gangrene to the skin, on the white horn-like 
 aspect which the external tegument takes in these circumstances, 
 and upon the integrity of the general health which frequently 
 accompanies the appearance of this malady. 
 
 These remarks are obviously the result of exact observation. 
 I learn moreover from the brother of the author, who is at 
 present physician of the Hopital des Enfants Malades, that the 
 material for this memoir had been gathered in that institution, 
 and that M. C. Racle had been impressed like myself with the 
 symmetry of the gangrenous lesions. Unfortunately this work 
 remains unfinished, so that many features which are easily 
 recognised when one has observed them oneself remain enig- 
 matical for those who have not had the living picture actually 
 under their eyes. Before tracing the history of the malady 
 which* makes the principal object of this study, I believe it 
 necessary to discuss in some measure, spontaneous gangrene 
 considered by itself, and independently of the lesions which can 
 give rise to it. It is the necessary preamble of what I have 
 to say upon the particular variety with which we are concerned. 
 
 IV. Pathological Anatomy and Physiology of Spontaneous 
 Gangrene. 
 
 Almost all authors who have written upon gangrene define 
 it as "a partial death." A crowd of variations or circumlocu- 
 tions have been proposed in place of this brief exposition of the 
 
 * Published in the Gazette medicale de Paris. 1859, 
 
10 Raynaud's original thesis. 
 
 phenomenon. But the basis of them always rests on the same 
 doctrine. The more we reflect on this definition, the more 
 unsatisfactory or even erroneous we find it. It is insufficient, 
 because it explains neither the appearance nor the mode of evolu- 
 tion of gangrene. It is erroneous, because we assume thus a term 
 of comparison which is far from being always exact. I go into 
 an amphitheatre and detach there a limb of a corpse ; everybody 
 will admit that the limb is dead, and yet it is very certain that it 
 is not, and has never been gangrenous. To say that gangrene is 
 a partial death is in truth to say nothing at all, and to content 
 oneself with mere words. If we understand thereby that a part 
 more or less extensive ceases to belong to the organism, this 
 definition will apply to conditions which have nothing in com- 
 mon with what is generally designated by gangrene. And it 
 will be necessary at once to include all those morbid states to 
 which have been given in Germany the name of necrobiotic 
 processes, a somewhat bizarre term, which means simply an 
 interstitial process tending to the more or less complete destruc- 
 tion of the histological elements of a tissue. Further, may not 
 the purulent disintegration of a living part, from one point of view 
 be regarded as a partial death ? And without even leaving the 
 domain of physiology, may we not consider that the epithelial 
 desquamation which takes place incessantly on the surface of 
 the skin and of the mucous membranes has for its normal 
 tendency the elimination of a certain number of elements 
 which have belonged to the organism, and which cease to belong 
 to it ? 
 
 It is sufficient to consider attentively a limb affected with 
 diy gangrene to be convinced that there must have occurred 
 something very special ; the shrivelling up of the tissues, the 
 horny aspect, the woody hardness, the ebony black colour, give 
 to the skin, the aspect of an Egyptian mummy or of a piece 
 of gutta percha. It is impossible that these characters should 
 have been produced all at once, and we must assume the 
 intervention of one of the most complex of pathological pro- 
 cesses.* 
 
 There are only two alternatives : either the simple fact of 
 the removal of a limb from the influence of vital forces may 
 
 * The definition of the Compendium de Chirwgie, written in thia spirit, appears to 
 me the only one which approaches the truth. Vide T. iv., p. 236. 
 
GENERAL CONSIDERATIONS ON SPONTANEOUS GANGRENE. 11 
 
 suffice under the influence of physico-chemical- laws to produce 
 mummification ; or this phenomenon (which is not produced 
 normally upon a corpse, in which putrefaction always precedes 
 desiccation), is the effect of a morbid evolution of a quite special 
 character, and deserves to be studied as much as the inflamma- 
 tory process. 
 
 I hold that there was something fundamental in the distinction 
 established formerly by Galen, and subsequently by Fabrice de 
 Hilden, between gangrene and sphacelus, a distinction revived 
 and definitely stated in our days by Thomson.* From this 
 point of view gangrene would be none other than this morbid 
 evolution of which I have spoken ; sphacelus would be the con- 
 firmed and irremediable condition. Unfortunately usage has 
 prevailed in employing the two words as synonymous. After 
 all it is of little importance to give a definition of gangrene, and 
 it is even doubtful whether it is possible to give a sufficiently 
 comprehensive one in the actual state of knowledge. That 
 which is more interesting is to unravel what passes in the 
 interior of a tissue which undergoes this alteration. It is 
 this which I am about to attempt, restricting myself to dry 
 gangrene. 
 
 V. M. Cruveilhier was I believe the first to fully describe 
 the variety which he calls gangrene by cadaverisation. It 
 presents the greatest analogies, if not a perfect identity with 
 what Quesnay called white gangrene.f The dead parts present 
 themselves under the aspect of those of a fresh corpse, or of 
 a limb which has just been amputated. This form is always 
 accompanied by algidity (corpse-like coldness), and by a colour 
 which is very striking (the colour of the corpse), and quite 
 distinct from that of the adjacent parts. The epidermis is 
 easily detached by friction. This symptom is observed especially 
 in the cases where the death of the limb has taken place instan- 
 taneously without prodromata, in consequence of the complete 
 and sadden interception of the arterial blood. J 
 
 M. Cruveilhier admits that cadaverisation, which may be con- 
 sidered, according to his view, as the first period of gangrene, is 
 soon followed by the second period, which is at one time dry, 
 
 * Lectures on Inflammation. 
 t Op. cit., p. 337 and p. 348. 
 J Cruveilhier, Traite cCanatomie palhohgique generate, T. iv., p. 252. 
 
12 Raynaud's original thesis. 
 
 at another moist.* This may be true in certain cases. But 
 we must recognise fully that these cases are infinitely rare, and 
 the important part which subsequently the learned professor 
 rightly apportions to venous and lymphatic absorption in the 
 process of mummification, proves indeed that, as a usual thing, 
 he does not himself believe in the instantaneous character of 
 death of the extremities. 
 
 "We may admit that in these exceptional cases, desiccation 
 when it occurs is a simple physical phenomenon, to which the 
 means employed for treatment greatly contribute ; the glacial 
 cold which seizes the extremities leads naturally to the placing 
 them in an elevated temperature, and the very active evaporation 
 which ensues therefrom is responsible for much in the artificial 
 result which is obtained. Desiccation then ensues, a kind of 
 tanning process, which is quite comparable to what takes place 
 in an anatomical specimen which has been stoved in order to 
 preserve it. The tissues lose their transparency, take on a 
 brownish drab opaline colour, and can then be preserved indefi- 
 nitely. In such a case the word mummification is true to the 
 letter ; because it is identically that which has taken place in the 
 limbs of the Egyptian mummie's.t 
 
 M. Czermak, who has studied microscopically the tissues of 
 one of these mummies, dating from more than three thousand 
 years back, has found them so perfectly preserved that they 
 might have been supposed to be taken from a living body. 
 
 But I cannot too strongly state that this is not what we 
 observe in the ordinary cases of dry gangrene. The external 
 aspect is not the same ; the skin assumes at the outset a violet 
 tint, which deepens more and more, passing soon into a colour 
 as completely black as that of the sloughs produced by a burn of 
 the sixth degree. This condition resembles nothing that we are 
 acquainted with ; we are compelled therefore to admit a progres- 
 sive modification in tbe intimate structure of the tissues. This 
 modification, which, according to my view, is gangrene par 
 excellence, is so far a vital phenomenon that it affects by 
 preference the most living parts, and on the contrary the parts 
 least endowed with vessels and nerves — those, in one word, which 
 have least vitality, like the tendons, ligaments, aponeuroses 
 
 * Ibid., p. 258. 
 
 t In these cases especially the epithet of partial death would be convenient. 
 
GENERAL CONSIDERATIONS ON SPONTANEOUS GANGRENE. 13 
 
 are precisely, as I shall show, those which resist gangrene the 
 best. 
 
 VI. The most complete work, and, to speak truly, the only 
 one which we possess on the alterations of the tissues in 
 gangrene, is of quite recent date.* The author of this interesting 
 memoir, M. Hermann Demme, f has perhaps erred in studying 
 gangrene as a separate morbid entity, and in placing on one and 
 the same plan all the lesions of whatever form and to whatever 
 tissue they belong. There results from this method a certain 
 confusion inseparable from descriptions which are too general. 
 
 There are to be found, nevertheless, useful facts bearing on 
 the subject with which we are concerned. 
 
 M. Demme considers gangrene as characterised by the tend- 
 ency to decomposition of the immediate complex principles, and 
 to the formation at their expense of binary compounds (water, 
 carbonic acid, ammonia), besides sulphuretted and phosphoretted 
 products. But according to his view all these new combinations 
 are not produced with the same rapidity ; in the cases where 
 there is no preservation a progressive carbonisation occurs, which 
 depends on an incomplete combustion of carbon, whilst the 
 transformation is infinitely more rapid of nitrogen into ammonia, 
 and of oxygen and hydrogen into water ; to this it would be 
 necessary to add desiccation. M. Demme, we ought to say, only 
 presents these theoretical views as hypotheses, without support- 
 ing them by any experimental proof; he does not explain, 
 moreover, the cause which would produce this slowness in the 
 production of the phenomena. Now this is the whole question, 
 without which the evolution of gangrene does not differ from 
 the purely chemical process which constitutes putrefaction. I 
 shall soon have occasion to return to this. 
 
 Passing then to microscopic alterations, which are the true 
 object of his memoir, M. Demme divides them into three kinds : 
 1st. Elements which are found only in the gangrenous tissues 
 and not in normal tissues (fat of new formation, pigmentary 
 deposits, crystals which are not found in the healthy state, 
 parasitic organisms either vegetable or animal). 2nd. Altera- 
 tions in consistence of the normal histological elements. 3rd. 
 
 * I cite simply to note them, the incomplete observations of Carswell, Hastings, 
 and Martino. 
 
 ■f Ueber die Veranderungen der Geweie duraht Brand. Frankfort-on-Yain, 1875. 
 
14 Raynaud's original thesis. 
 
 Amorphous masses of substances more or less carbonised, the 
 ultimate products of gangrene. 
 
 The most remarkable and the most constant of the elements 
 of new formation is the fatty matter, the abundance of which in 
 the gangrenous tissues had been pointed out since 1847 by 
 Vogel and Michea, such an abundance, obvious to microscopic 
 examination, that it is impossible to explain . it by the mere 
 liberation of the fat existing in the normal condition, and 
 that one is led to admit ipso facto the transformation of the 
 proteid matters into fat. This hypergenesis of the adipose 
 elements shows itself primitively in the cells. The nuclei 
 are surrounded with refracting vesicles, and the walls become 
 granular and break, thus letting the contents escape into the 
 parenchyma. 
 
 In the second place, and this is the most original part of his 
 work, M. Demme describes with great detail a series of pigmentary 
 formations which may be the principal cause of the morbid 
 colour of the tissues. The most important of these elements 
 constitute that which he designates, with Valentin, by the name 
 of gangrenous corpuscles. Under a power of 75 diameters these 
 corpuscles appear as small black incommensurable points. Under 
 a higher power they are found tp be irregular bodies, which 
 never take on a definitely crystalline shape. They are insoluble 
 in alcohol and ether, which distinguishes them from fat ; they 
 are unaffected for the most part by acids and bases. Hydro- 
 chloric acid has the property of blanching them a little. Along 
 with these so-called corpuscles there is found a variety of rust- 
 coloured pigment, specially distributed in the vascular tissues 
 and in the muscles. These bodies are distinguished from the 
 preceding by their colour, by their granular surface, and by 
 their slightly larger size. They are probably formed of haema- 
 tosine. In the neighbourhood are found crystals of hsematoidin, 
 which differ chemically by the absence of iron. A third kind 
 of pigment is formed by the sulphide of iron, the appearance 
 of which is to be explained by the action of sulphide of 
 ammonium on the red corpuscles. Add to all these, fine dark 
 .granules, endowed with the Brownian movements, debris of 
 cells with the aspect of colouring matter (pseudo-pigmentary 
 cells), black masses remarkable for their resistance to all re- 
 agents, and which are formed in situ in the thickness of the 
 
GENEEAL CONSIDERATIONS ON SPONTANEOUS GANGKENE. 15 
 
 fibrous tissues, and you have nearly exhausted the already long 
 list of these pigments. 
 
 The addition of an alkaline liquid to these deposits singularly 
 favours the formation of a crowd of crystals (salts of fatty acids, 
 carbonates, sulphates, phosphates of lime, ammonium, and soda, 
 urates, butyrates,. &o. f &ct). This has only a moderate interest 
 for us, the only crystals •which we find present in mummified 
 gangrene being needles of margarine and tablets of choles- 
 terine, which are present only in minute quantity. 
 
 . The remainder of M. Demme's work is devoted to the study 
 of a crowd of parasites which have nothing special in them, 
 and to alterations of the primitive elements of the tissues cha- 
 racterised especially , hy softenings, by granular conditions, by 
 exudations of different kinds, in one word, a process of involu- 
 tion bearing at the same time upon almost all the derivatives of 
 the cell.. As. this description includes both dry and moist gan- 
 grene, and even simple softening, there results from it for us 
 very little practical instruction. Such is this workj of which I 
 have given a detailed summary in order to allow it to be judged 
 as a whple. 
 
 Whilst , rendering full justice to the many ingenious views 
 stated by the author, and to the conscientious exactitude 
 which has characterised his observations, I fear that the result 
 of his researches will only complicate the question by creating 
 new species. " Entia non sunt multiplicanda sine necessitate." 
 All these numerous varieties of pigments which we have seen 
 described in detail what are they definitively? Products more 
 or less. advanced of the effusion and of the decomposition of the 
 colouring ^matter of the blood. M. Demme recognises this 
 implicitly. But, why then not deduce this general conclusion? 
 And especially why. give to these products, which have neither 
 constant form nor special seat* the name of pigment, which has 
 in general anatomy a well-determined signification? 
 
 With, the. object, of controlling the statements of the young 
 and learned histologist of Berne I have of late neglected no 
 opportunity; of studying morphologically the tissues affected 
 witit drjj. gangrene, ..and whilst verifying the greater number 
 of the facts advanced by • M. Demme, it has appeared to 
 me to' be possible to simplify them considerably. . This study 
 has moreovet led . to. my discovering some new facts which it 
 
16 Raynaud's original thesis. 
 
 appears useful to mention now. The results which I am about 
 to state were submitted to the competent control of my friends 
 MM. Luys and Chalvet, whom I wish to thank for the help 
 which they have given me. 
 
 VII. When we examine attentively an extremity affected 
 with dry gangrene, that which strikes us at first is the perfect 
 preservation of the external form. The rows of the papillae of 
 the skin are even more apparent than in the normal condition, 
 on account of the thinning of the epidermis. On making 
 transverse sections we find sometimes, immediately under the 
 cutaneous envelope, small dark grains of irregular form of the 
 size of a pin's head which are easy to enucleate. Seen by re- 
 flected light they appear of the most beautiful black ; they are so 
 hard that they rebound when we let them fall on a solid body ; 
 they might be taken for small morsels of charcoal. Nevertheless 
 these grains are none other than blood concretions. When with 
 some difficulty a section has been obtained sufficiently thin for 
 microscopic examination, this section seen as a transparent object 
 appears of a beautiful red. Treated by ether, thin fragments 
 of this substance dissolve and communicate to the liquid a rose 
 tint. There remains in the preparation an infinite number of 
 irregular granules less refracting than fat, and which have all 
 the characters of broken-up albumen. Let us proceed now from 
 the surface to the deeper parts. 
 
 On examining detached portions with the point of a scapel, 
 under the microscope there is to be seen, amongst cells and 
 debris of epithelial cells more or less altered, a certain number 
 of free fatty vesicles and of small masses of dark tint with very 
 definite outline. These are, if one is not mistaken, the gan- 
 grenous corpuscles represented in the work of M. Demme. The 
 colour varies from clear brown to black, without its being 
 possible to establish between these varieties a precise limit. It 
 is easy to recognise in them the appearance of effusions of 
 colouring matter of the blood such as are to be found in a 
 crowd of pathological conditions. 
 
 It is much to be feared that the gangrenous corpuscle will be 
 regarded in the same way as the inflammatory corpuscle of Gluge 
 and the famous cancerous corpuscle ; that far from making of it 
 a specific element, it will be possible to regard it as none other 
 than one of the divers alterations of the normal tissues. 
 
GENERAL CONSIDEBATIONS ON SPONTANEOUS GANGBENE. 17 
 
 The triangular or spherical appearance which these bodies 
 sometimes present ought not to deceive. It is very probable 
 that these are not simple patches of blood colouring matter, but 
 that they are the debris of regular elements soaked with the 
 colouring matter of the blood, and which, although stained 
 thereby, have preserved the whole or part of their primitive 
 shape. We shall see directly how clearly this is the case with 
 regard to the fusiform bodies of the fibro-plastic tissue. As 
 to those bodies which present a definitely black colour and 
 a great resistance to reagents, is it possible that they are 
 granules of pure carbon? Many considerations tend to make 
 us believe this, but we must not hasten to conclude that their 
 origin is for that reason different from the other. Let us 
 limit Ourselves at present to the proposition that from most 
 characteristic patches of blood colouring matter up to the 
 most definite gangrenous corpuscles, there are only insensible 
 transitions. 
 
 What is the cause which thus leads to the transudation of the 
 colouring matter of the blood ? It is often easy to find in a 
 granular degeneration of the capillary vessels of the region. 
 
 On microscopic examination we may see a commencing dis- 
 appearance of the finest vessels of the papillae of the derma with 
 infiltration of blood colouring matter into the surrounding tissue. 
 In a more advanced condition all trace of vessels has disap- 
 peared, and the stroma of the derma presents a uniformly 
 reddish-brown coloration. On further investigation we find that 
 the papillary tissue has itself become granular. 
 
 But sometimes the malady having progressed rapidly, 
 coagulation has taken place spontaneously in the interior of the 
 last venous radicles, which then present under the microscope 
 the appearance of a vascular network, richly injected. 
 
 This occurs especially in the variety of gangrene which I shall 
 discuss subsequently in detail. The arteries remaining permeable, 
 this fact is not contradictory to the assertion made formerly by 
 Hourmann, who saw in his cases at the Salpetriere injections 
 made upon corpses penetrate abundantly and easily into all the 
 gangrenous parts. Hourmann deduced therefrom the existence 
 of a gangrene due to simple atony of the capillary circulation.* 
 
 * " Lef on orale de concours pour la chaire de pathologie interne." Gaz. midicale de 
 Paris, 1840, p. 32. 
 
 2 
 
18 Raynaud's original thesis. 
 
 In this case the presence of patches of blood colouring matter 
 can be explained either by small ruptures, or by gradual imbibi- 
 tion through the walls of the vessels. 
 
 The facts which I have just expounded, suffice to explain in 
 great part the black coloration of the affected tissues in dry 
 gangrene. Nevertheless this cause is not the only one. With 
 regard to this matter I have observed the following : on a foot 
 presenting a complete type of mummified gangrene (absolute 
 blackness and hardness), and which in spite of the already 
 ancient date of death was in a perfect state of preservation, I 
 was much surprised, whilst making a section perpendicular to 
 the axis of the limb, to find below a layer of skin which was quite 
 black the deeper tissues coloured red, of a very marked carmine 
 tint. 
 
 I believed at first that here again there was a true imbibition 
 of colouring matter of the blood, but microscopic examination 
 of the portion soon undeceived me. 
 
 Under a low power (20 diameters) the derma as well as the 
 fibrous tracts extending from its deep surface were seen to be of 
 a beautiful rose colour, which deepened at certain points. Con- 
 sequently the black colour of the derma depends solely on the 
 greater condensation of the tissue. Its true colour does not 
 differ sensibly from that of the subjacent parts. 
 
 The fatty cells contained in the areolae of the connective tissue 
 were found to possess also the same colour. But they had 
 undergone another modification not less curious. They were 
 completely emptied of their contents, and their walls pressed one 
 against another had taken by juxtaposition a polygonal figure, 
 simulating the aspect of the cellular tissue of vegetables. Under a 
 higher power (210 diameters) this arrangement was very obvious. 
 The polygonal cells not enclosing any granular contents presented 
 a rose coloration, which was disseminated in patches, more 
 marked in certain spots without being limited to any cell in 
 particular; it was a kind of general suffusion. In order to 
 be convinced that this colour belonged to the walls of the cells, 
 an exceedingly thin section was made and examined under 
 a higher power (500 diameters). The interior was found com- 
 pletely transparent, whilst the point where the walls were in 
 juxtaposition, and which at the same time offered a greater 
 thickness, presented only a rose tint. A few cells contained 
 
GENERAL CONSIDERATIONS ON SPONTANEOUS GANGRENE. 19 
 
 scanty fatty vesicles, traces of their former contents, or crystals 
 of margaric acid. 
 
 This rose colour did not dissolve in ether. This liquid carried 
 away the vestiges of fat, and the colouring matter remained 
 intact in the meshes of the substratum. When a fragment of 
 tissue thus coloured was treated with cold" water the fat was 
 again withdrawn, and under the influence of ebullition the rose 
 colouring matter took on a yellowish tint. Caustic potash 
 dissolved the fat, the liquid assumed a milky appearance, and 
 the colouring matter which remained became of an ochre colour. 
 Under the influence of hydrochloric acid the colouring, matter 
 was withdrawn, and the substratum beanie shrivelled. 
 
 All these reactions lead me to conclude that the colouring 
 matter in question differs essentially from hsematosine, which has 
 for its principal characters its solubility in ether and its insolu- 
 bility in water.* It is indeed only slightly probable that it may 
 be a product of the transformation of hasmatosine ; it approaches 
 much more closely to what we obtain by the action of nitric acid 
 on albumen. 
 
 I have only once had the opportunity of observing muscles- 
 affected with dry gangrene. I have found a very marked ten- 
 dency to the disappearance of the striation of the primitive 
 bundles, and in addition a very great number of disseminated 
 patches of blood colouring matter. In the fibrous tissues (ten- 
 dons) two kinds of alteration may be produced. In one form 
 there is a complete preservation of the cells of the tissue, with 
 infiltration of these cells by a reddish yellow colouring matter. 
 If they are treated with nitric acid, at tbe moment when the 
 acid penetrates, a crowd of small black granules escape from 
 the preparation; these are probably the debris of the walls. 
 The contents, when liberated, become aggregated into darkish 
 disseminated masses, which cannot be confounded with impri- 
 soned air, because they preserve here and there traces of their 
 former colour. In other cases there is a true fatty substitution. 
 The fibrous or fibro-plastic elements have totally disappeared. 
 There only remain fatty cells, disposed in longitudinal series, 
 which recall the former direction of the fibres of the tendon. I 
 have observed nothing in the osseous tissue which differs sensibly 
 from the normal condition. As to the nervous twigs, they were 
 
 * Malaguti, Leqons eletnentaires de Chimie, T. ii., p. 623. 
 
20 Raynaud's original thesis. 
 
 already so far thinned away in the parts which I had occasion to 
 examine that their alterations appeared to me to elude micro- 
 scopic study. 
 
 I conclude with one remark : in the variety of gangrene which 
 I am about to discuss, and in the case in which the lesion is 
 limited to the skin, we see a kind of bulla form which on drying 
 up takes a deep brown colour. It would be easy whilst looking 
 at these bullae with the naked eye to regard them as being 
 formed simply by epidermis raised up by serum. I must, how- 
 ever, anticipate by saying that this is not altogether accurate. 
 
 In such a case there is a true superficial gangrene, limited to 
 the papillary region of the derma. This appears clearly on the 
 vertical section of one of these thin sloughs. The serum effused 
 is therefore situated not between the epidermis and the derma, 
 but between the deep part of the latter and the slough. To sum 
 up : anatomy has shown us — 1. Different histological elements in 
 process of involution ; 2. A notable increase of the fat ; 3. Dif- 
 ferent effusions of colouring matter of the blood more or less 
 altered, in the skin, epidermis, subcutaneous cellular tissue, and 
 muscles ; 4. A staining of the connective tissue and of the fatty 
 cells by a true colouring matter. 
 
 It is to these two last causes combined that we must attribute 
 the dark colour presented by the gangrenous tissues, seen by 
 reflected light ; joining to them perhaps also the leaden aspect 
 which desiccation gives to all the organised tissues, independently 
 of all pathological modification. 
 
 VIII. It was interesting to complete these results by a chemical 
 study of the tissues attacked by gangrene ; all the more that this 
 inquiry, which had been stated more than once to be one of the 
 desiderata of science, had never been really made up to now. 
 
 Struck especially by the remarkable resemblance of the gan- 
 grenous tissues to tissues carbonised by physical or chemical 
 action, I wished to learn whether this resemblance was only 
 external, or whether it expressed the real state of things ? I 
 submitted these views to M. le Dr. Eeveil, professeur agrege of the 
 Faculty, who has been so good as to undertake a series of compar- 
 ative analyses referring to both healthy and gangrenous tissues.* 
 
 * I ought equally to address my beat thanks to M. Callman, interne in pharmacy 
 at thn Children's Hospital, for the minute care given by him to the details of these 
 delicate experiments. 
 
GENERAL CONSIDERATIONS ON SPONTANEOUS GANGRENE. 21 
 
 My principal object was, 1. To ascertain if chemical analysis 
 confirmed the presence of excess of fat revealed by the micro- 
 scope ; 2. To ascertain the quantity of carbon contained either 
 in the proteid matters taken separately, or in the whole of the 
 organic materials (proteid and fatty matters), in order to find out 
 definitely whether gangrene leads to an augmentation in the 
 relative quantity of carbon or not. 
 
 For this purpose I chose as far as possible similar regions, 
 either on the same subject or on subjects of the same age, in 
 order to compare them in the healthy state and in the state of 
 gangrene.* I deprived them very completely of the osseous 
 particles which they contained, in order that the residues of the 
 calcareous salts might not lead to a cause of error in the estima- 
 tions. It was most important to obtain similar conditions 
 throughout ; the principal obstacle was in the quantity of water 
 impregnating the tissues, a quantity which it was impossible to 
 foresee, since it depended on the state of engorgement of the 
 parts, and on the evaporation, which might vary considerably. 
 It seemed to us that this inconvenience might be avoided, and 
 that one might arrive at comparable results by proceeding in 
 three series of operations: 1. To place the parts to be analysed 
 in the stove at a temperature of 60° C. for several days, until 
 desiccation should be complete, weighing them before and after- 
 wards ; 2. To treat them with ether until the fat disappeared, 
 the difference giving the weight of fatty matter ; 3. To place the 
 residue in a tube for organic analysis, and estimate the carbon 
 according to the ordinary methods. It will therefore be well 
 understood that the carbon found in a hundred parts of the sub- 
 stance only belongs to organic matters deprived of all fat. 
 
 The following are the gross results : — 
 
 First Series of Analyses. 
 No. 1. — The lip of a child of 8 years old in the healthy condition. 
 
 Water 4923 
 
 Fatty material 14-91 
 
 Other organic material 35-86 of which 167 carbon 
 
 100-00 
 
 * It will be observed that these analyses bear both on dry and on moist gangrenes ; 
 the latter are not without interest, as a term of comparison. 
 
'i2 eaynaud's oeiginal thesis. 
 
 No. 2. — The other lip of the same child affected with gangrene 
 of the mouth ; presenting a dry black slough on the surface, 
 but forming a moist putrid mass in the deep parts — 
 
 Water 65-26 
 
 Fatty material 17*00 
 
 Other organic material 1774 of which 8-45 carbon 
 
 100-00 
 
 No. 3. — Portion of the face of another child affected with com- 
 mencing moist gangrene consecutive to variola — 
 
 Water 65-75 
 
 Fatty material 9-54 
 
 Other organic material 2471 of which 12-23 carbon 
 
 100-00 
 
 Second Series of Analyses. 
 
 No. 4. — Toes and part of the metatarsus of the foot of a man 
 aged 61 years, in healthy condition. 
 
 Water 53-18 
 
 Fatty material 629 
 
 Other organic matters. 40-53 of which 21'82 carbon 
 
 100-00 
 
 No. 5. — The same parts taken from an old man of the same age, 
 who died at Bicetre at an advanced period, although not yet 
 complete, of a dry gangrene of the lower limb — 
 
 Water 37-26 
 
 Fatty material 22-79 
 
 Other organic matters . 39-95 of which 2011 carbon 
 
 100-00 
 
 No. 6. — The same parts of a foot affected with dry gangrene as 
 complete as possible — 
 
 Water 8-45 
 
 Fatty material 23-80 
 
 Other organic matters. 67-76 of which 3351 carbon 
 
 100-00 
 
GENERAL CONSIDERATIONS ON SPONTANEOUS GANGRENE. 23 
 
 The first result which strikes us in these analyses bears upon 
 the quantity of water, very considerable in the case of moist 
 gangrene, very slight in the case of dry gangrene. This result 
 was foreseen ; but it is remarkable that in moist gangrene the 
 quantity of absolute water is much greater than it is in the 
 healthy state ; there has been, therefore, not only absence of 
 evaporation, but production of new quantities of liquid. 
 
 It is not less worthy of attention that this excess of water 
 corresponds to an important diminution of the organic materials, 
 the sum total of which descends from 50"77, the normal standard, 
 to 34 - 74 in one case, and to 34*25 in the second case. The 
 excess of water, about 16, is precisely equal to the diminution of 
 the organic materials, which renders it very probable that the 
 water has been formed at the expense of the latter. Let us add 
 that these two pieces exhaled an infective odour, and that there 
 was disengaged a certain quantity of volatile substances — am- 
 monia, sulphuretted hydrogen, carburetted hydrogen, &c. 
 
 In the second series the absolute quantity of the organic 
 materials (fat and albuminoids) has notably increased in per 
 centage. But we must take account of the diminution of the 
 water. 
 
 Now, excluding the water, let us see the relation of the quantity 
 of fat to that of the other organic matters. This relation is 
 expressed by the following standards : — • 
 
 No. 1. Healthy lip 0415 
 
 ;; !;}^edii PB (S 
 
 „ 4. Healthy foot 0-155 
 
 « ^Diseaeedfeet {°™ 
 
 Thus the quantity of fat, compared with that of the albuminoids, 
 slightly diminished in a case of commencing moist gangrene 
 (No. 3). This case ought to be considered as anomalous; 
 because in all the others this quantity considerably increased, 
 in one case even (No. 2) we see the relation expressed by a 
 standard approaching unity. Thus the fact resulting from the 
 microscopic examination is found confirmed. Gangrene, and 
 especially dry gangrene, is accompanied by a very notable increase 
 of fat. It is interesting to know the quantity of carbon existing 
 
24 baynaud's oeiginal thesis. 
 
 in 100 parts of organic matters previously deprived of water and 
 of fat. The accuracy of the figures which follow is guaranteed 
 to me by their approximate agreement with those which result 
 from the best analyses of the principal nitrogenous substances. 
 The mean quantity of carbon contained in fibrine, caseine, and 
 albumen is 53 - 26 per cent.* These are the figures : — 
 
 No. 1 4657 of carbon per cent. 
 
 „ 2 4763 
 
 „ 3 49-49 
 
 „ 4 53-83 
 
 „ 5 50-34 
 
 „ 6 ;.4916 
 
 Thus, in the cases of moist gangrene there is an increase of 
 the carbon of the nitrogenous materials, and diminution in the 
 cases of dry gangrene. 
 
 But let us not lose sight of the increase of fatty matter which 
 is the rule. The preceding facts enable us to investigate the 
 absolute quantity of carbon which exists in 100 parts of the 
 tissue (everything included). For this, it is sufficient to recall 
 that, according to M. Chevreul, human fat contains 79 per cent. 
 of carbon. We can therefore from each estimation of fat 
 ascertain the absolute quantity of carbon which enters into its 
 composition, and add this quantity to that of the carbon of the 
 proteid materials given directly by- analysis. 
 
 Working in this way we find the following figures : — 
 
 No. 1 28-47 of carbon 
 
 „ 2 21-88 
 
 „ 3 19-76 
 
 „ 4 26-79 
 
 „ 5 52-31 
 
 „ 6 38-11 
 
 It results from this calculation that the absolute amount of 
 carbon has diminished in the case of moist gangrene, and in- 
 creased in that of dry gangrene. 
 
 Whatever may be the cause of these differences, the only point 
 which it is important to retain is this : in dry gangrene there 
 is a slight diminution of the carbon of the nitrogenised 
 materials ; but this diminution is more than compensated by 
 a considerable increase of the quantity of carbon which exists 
 in a given region, and this increase is itself allied to the 
 increase of fatty material. Whence proceeds this increase of fat ? 
 * Vide Malaguti, op. cit., T. ii., p. 49. 
 
GENERAL CONSIDERATIONS ON SPONTANEOUS GANGRENE. 25 
 
 In a general way we may say that since the very active com- 
 bustions have for their known result the expenditure of fat, it is 
 not surprising that in a very slow combustion it should accumu- 
 late. But this does not suffice. This principle cannot have 
 been brought ready formed by the arterial blood (the arteries 
 being obliterated in the cases which I have cited) ; one is 
 therefore compelled to believe that it is formed in situ at the 
 expense of the nitrogenous materials. This transformation of 
 albuminoids into fat may be now considered, if not an actually 
 demonstrated fact, at least one in process of demonstration. I 
 cannot state here all the reasons which militate in favour of 
 this view, which has been keenly discussed by chemists during 
 the last few years. I will content myself by recalling that it is 
 definitely maintained by M. Boussingault*; that Lehmannf is 
 strongly inclined to support it ; that according to the experiments 
 of MM. Wagner and Husson on introducing into the ventral 
 cavity of a goose or of a pigeon crystalline lenses of the pig, the 
 calf, or of the human subject, of which the quantity of fat has 
 been previously determined, it is found that after a certain time 
 of sojourn this quantity has notably increased ; this transforma- 
 tion has even been obtained with cooked albumen. J The general 
 cause of the phenomenon would appear to be an incomplete com- 
 bustion, and it is considerations of this kind which have led 
 Liebig to conclude that in the physiological state the production 
 of fat in animals is the consequence of a disproportion between 
 the quantity of the aliments consumed and the quantity of 
 oxygen absorbed by the skin and the lung. 
 
 IX. Let us seek now to give a theory for the gross facts of 
 experience whilst stating precisely what takes place in dry 
 gangrene. 
 
 Let us take, for example, a slough produced by a burn of the 
 sixth degree. It is not pure carbon, but a material which in 
 composition closely approaches it. What then has taken place ? 
 Under the influence of heat there has been a combination of 
 the hydrogen of the living tissues with the oxygen of the air, and 
 also with that of the organs, to form water which is disengaged 
 
 * Eeonomie rurale, 2nd Edit., T. ii., p. 617. 
 t Precis de Chimie physiologique trad. Drum., p. 311. 
 
 % "Comptes rendus de l'Academie de MeVJecine de Belgique." Gazette medkale, 
 1853, p. 504. 
 
26 katoaud's original thesis. 
 
 as vapour. The combinations of nitrogen may be neglected on 
 account of the very small quantity of this element. The result 
 is the setting free the carbon, and this results simply from the 
 hydrogen having more affinity for oxygen than carbon. The 
 heat which suffices to carbonise a limb does not suffice to make 
 carbon pass into the condition of carbonic acid ; but this is 
 what would happen infallibly at a more elevated temperature, 
 and finally there would remain nothing more than a morsel of 
 inorganic ash. 
 
 Let us take a second example, viz., the slough formed by 
 sulphuric acid, which perhaps of all forms most resembles by 
 its aspect the sloughs of spontaneous gangrene. What happens 
 in this case ? Sulphuric acid having an immense affinity for 
 water, the oxygen and hydrogen of the tissues combine together 
 to form the molecule water which becomes absorbed by the 
 acid and carbon is then set free. 
 
 Now let us suppose that there is an arterial obliteration. From 
 the chemical point of view two important modifications result : 
 absence of water, absence of free oxygen. The remainder may be 
 neglected. Doubtless it will appear paradoxical to take for a 
 type the slough produced by a cautery, actual or potential, 
 which slough one commonly attributes to an exaggerated com- 
 bustion, and to place over against it the excess of carbon pro- 
 duced by a diminution of oxygen or, what comes to the same 
 thing, by a slow combustion. Nevertheless we shall see that 
 they are almost identical. 
 
 An important fact dominates the history of spontaneous gan- 
 grene, it is that everything does not die at the same time. At 
 first it is infinitely rare for the arterial blood supply to be 
 absolutely suppressed all at once; in the second place, when 
 even this suppression is complete, the action of the veins con- 
 tinues. Thus on the one side the venous radicles still absorbing 
 liquid, and the arteries no longer bringing new quantities, there 
 is present one cause of very rapid desiccation to which evapora- 
 tion comes to be added ; and on the other hand, thanks to the 
 persistence of the return circulation, the interstitial combustions, 
 although considerably slowed, continue to be effected in the 
 intimate structure of the tissues. Hydrogen by virtue of its 
 affinity with oxygen unites with that element to form a certain 
 quantity of water, whilst the more difficult combustion of carbon 
 
GENERAL CONSIDERATIONS ON SPONTANEOUS GANGRENE. 27 
 
 becomes more and more incomplete ; moreover the rapidity of 
 the drying up is opposed to the putrid fermentation. To these 
 phenomena of a purely chemical character we must probably 
 add a vital phenomenon, viz., that resistance to the causes of 
 destruction, of which the living organism each moment gives us 
 a proof, and in virtue of which a normal function when it is 
 accidentally hindered is supplemented by an accessory function. 
 We all know, for example, that in the case of an animal, if we 
 diminish the. amount of fatty food of which it has need for its 
 nutrition, it will supply itself by burning up what it holds 
 in reserve. 
 
 By an analogous mechanism, when an arterial obliteration 
 has diminished, if I may so speak, the supply of oxygen 
 to which the organs are habituated, the combustions are 
 not thereby annihilated ; they continue as long as possible, 
 and in order to satisfy them the living tissues consume their 
 own oxygen. 
 
 Hydrogen is first burnt, a little carbonic acid is formed, and 
 that is the cause of the slight diminution in the proportion of 
 the albuminoid materials. 
 
 The final result is a tendency more and more marked to the 
 setting free of carbon.* 
 
 Such is the phenomenon considered as a whole. But the 
 formation of water and that of carbonic acid are not the ultimate 
 products ; it is certain that in reality these transformations are 
 made by a series of intermediate compounds. " The nitrogenised 
 materials," says M. Longet,f " do not come from all sides to 
 offer themselves to the atmospheric oxygen introduced by the 
 respiratory organ, but they are probably split up into a car- 
 bonaceous material which is consumed in respiration, and into 
 a specially nitrogenised material which passes away by the 
 urinary excretion." In the case which now occupies our attention 
 it seems to me rational to admit that one of the first terms of 
 the reducing action which is exercised upon the albuminoid 
 materials, or if one prefers, one of the first effects of the 
 splitting up, is the formation of that rose colouring matter 
 which I have previously mentioned, and which one could not 
 
 * It is needless to add that I take no account of the nitrogen which enters doubtless 
 into the intermediate products, 
 f Traite de physiol, T. i., p. 1037. 
 
28 Raynaud's original thesis. 
 
 liken to anything better than the Chinese rose colour, obtained 
 by acting with hydrochloric acid in the cold on a solution of 
 albumen. 
 
 One degree further, a more complete splitting up would cor- 
 respond to the formation of fat, a ternary compound, and this 
 would not beTbe last of the series. 
 
 It is possible that hsemotosine may be the seat of analogous 
 phenomena, and that the deeper and deeper colour which it takes 
 up to the formation of the gangrenous corpuscle of Valentin may 
 only be the index of a carbonisation more and more advanced. 
 But this is only hypothetical. 
 
 The very low temperature of the gangrenous limbs does not 
 contradict the existence of chemical changes taking place in their 
 substance. 
 
 The slowness even of the combustions is a primary cause 
 of chilling. We must add (1) the absence of the hot permanent 
 injection which corresponds with the entrance of .the arterial 
 blood, (2) the evaporation. This cause by itself alone is adequate 
 to explain a notable lowering of temperature. 
 
 Dupuytren has been much criticised for the assertion that the 
 temperature of gangrenous limbs sinks below that of the sur- 
 rounding medium ; the statement is not so diametrically opposed 
 to physical laws as it has been represented. 
 
 X. Analogies are not wanting in support of the theory of gan- 
 grene which I have just proposed. 
 
 The common phenomenon of the combustion of a lamp may 
 serve here for useful instruction. 
 
 The oil and the match considered together may be thus 
 formulated : water, plus carbon, and an excess of hydrogen. 
 The water vaporises, all the hydrogen is combined with the 
 oxygen of the air ; as to the carbon, it passes into the condition 
 of carbonic oxide and carbonic acid in the points where com- 
 bustion is most active ; but in the centre of the flame carbon is 
 reduced, and it may be collected upon a cool body in the condition 
 of lamp-black. Carbonisation in a closed vessel rests on the 
 same principle. This is what takes place under the influence of 
 heat and in contact with the atmosphere. Now the same process 
 may go on for a long period in the interior of the earth, and it is 
 thus that lignites and coals are formed. 
 
 There is produced at first a series of tarry matters of which 
 
GENERAL CONSIDERATIONS ON SPONTANEOUS GANGRENE. 29 
 
 the composition is not without analogy with that of fats, and 
 from which on final analysis carbon is set free. Here we have 
 to do with one of those phenomena which the beautiful re- 
 searches of M. Berthelot have brought to light during late 
 years ; bodies obey their natural affinities, only the element of 
 time replaces that of heat, and the carbon which is formed 
 by super-oxidation in free air and under the influence of caloric 
 may be formed also without heat and without air, wood burning 
 at its own -expense. It is remarkable that in regard to cellulose 
 and sugar the dark coloration becomes more pronounced in 
 proportion as the composition of their derivatives approaches 
 pure carbon. 
 
 Starting from cellulose we have successively carramel, ulmic 
 acid, humic acid, &c, which are darker and darker. It is pos- 
 sible that the same may obtain with the azotised matters. 
 
 But as nothing is more variable than the phenomena of 
 coloration we can affirm nothing absolutely in that matter ; and 
 however this may be, there is no need of this explanation, as we 
 have already seen, to give an account of the colour of gangrenous 
 tissues. 
 
 To conclude, and in spite of the immense lacunae which the 
 actual state of science does not allow us to fill up, the intimate 
 phenomena of gangrene, which up to now have never, so to speak, 
 been studied, appear to me of the highest importance from the 
 physiological point of view. They represent to us, if I may so 
 speak, nutrition taken in the act and even analysing itself. 
 Normal nutrition passing to the confines of the arterial and 
 venous systems escapes from all study by its complexity, and it 
 is impossible to say how much belongs to one of these systems 
 and what depends on the other. Perhaps in following the way 
 which I have here indicated, in considering gangrene as the sup- 
 pression of half of the circulation with preservation of the other 
 half, it would be possible to arrive at some more rigorous results 
 on the mechanism which presides over the maintenance of local 
 life and over the phenomena of assimilation. 
 
 This leads me by a natural transition to the subject which I 
 shall approach in the following chapter. If, as I have attempted 
 to prove, the fundamental fact of gangrene consists in the dimi- 
 nution or the absence of oxygen necessary to the integrity of the 
 life of a tissue, the pathogenic conditions of gangrene considered 
 
30 Raynaud's original thesis. 
 
 from a philosophic point of view will bring us back to the fol- 
 lowing cases : — 
 
 1st. Absence of blood dependent on all causes which may 
 attack the normal functions of the arteries (obliteration of them 
 is only a particular case). This condition can be compared to 
 nothing better than syncope, in which the action of the heart 
 is momentarily suspended. I propose to call it local syncope. 
 
 2nd. Presence of a venous blood, that is to say, of a blood 
 insufficiently oxygenated. Continuing to use a term of com- 
 parison in the same order of ideas, I will designate this condition 
 local asphyxia. I do not invent this word, already employed by 
 many authors ; but I seek to give it a precise meaning. 
 
 3rd. It is possible that in consequence of an intoxication 
 inexplicable as to its nature the living cell, although having at its 
 disposal the elements destined for its nutrition, may be struck 
 with powerlessness to profit by them. This is possible, although 
 not demonstrated ; but we must admit that it may be possible. 
 I do not believe that we can imagine a fourth hypothesis. 
 
31 
 
 CHAPTER II. 
 
 CASES. 
 
 Before narrating the cases which will serve for the basis of 
 this memoir, I ought to say one word on the circumstances which 
 led me to collect them. 
 
 It was in the beginning of 1860 that one of the cases sub- 
 sequently reported (Case XV.) strongly attracted my attention. 
 
 The case was one of spontaneous gangrene of the four ex- 
 tremities, which had occurred unexpectedly in a young woman 
 aged 27 years. During nearly a month I saw a series of strange 
 and formidable phenomena unroll themselves under my eyes and 
 disconcert the vast experience of many eminent physicians who 
 saw this patient with me. In vain all the organs were minutely 
 explored ; in vain all the causes, known or probable, of gangrene 
 were sought. It was necessary to admit the intervention of some 
 influence up to that time ignored. I put myself in quest of 
 similar facts, and once forewarned of their possibility I soon met 
 with them. All appeared to me to present as a common cha- 
 racter the absence of a material appreciable obstacle to the course 
 of the blood, whether arterial or venous. That which I had seen 
 it was impossible but that others should have seen before me. 
 In going through medical literature from this point of view 
 I have found a certain number of precious documents. Thus I 
 have obtained a record of 25 cases, of which 5 are my own. 
 
 I am far from attributing the same value to all these facts. 
 
 Some of them are incomplete, some are doubtful, and would 
 appear at first contradictory to the conclusions which I profess 
 to draw. There was a very simple means of avoiding this in- 
 convenience, viz., to gather together all the facts which were 
 sufficiently obvious, and which could admit of neither difficulty 
 nor controversy, and to suppress the rest. There still remained 
 ample evidence to give the elements of a sufficient conviction 
 on the subject. But on the one hand it was incumbent on 
 me to show that a symptomatology more or less analogous to 
 
32 Raynaud's original thesis. 
 
 mine had already struck several observers, and on the other hand 
 I was anxious not to incur the reproach of having selected facts 
 which were favourable to my view, whilst deliberately omitting 
 those which were unfavourable to it. 
 
 Presented thus, the observations may give rise perhaps to 
 some doubts, but I should lie if I said that there were none 
 left in my own mind. 
 
 "Whatever the interpretation may be, there is interest in 
 gathering into one group this series of cases previously scat- 
 tered through literature, and the facts .themselves will remain. 
 I had perhaps to treat of a question which had already been 
 prejudged, viz., that of the possibility of a gangrene without 
 obliteration. I have already foreshadowed my views, and I refer 
 now to M. Zambaco's thesis on the subject, which contains many 
 conclusive proofs that such a form of gangrene is possible. 
 Moreover I believe that all the facts subsequently recorded in my 
 work may be used as an argument in support of this opinion, and 
 that thus they have a double use. 
 
 The order in which I have ranged these observations is not 
 indifferent. I consider syncope and local asphyxia as the first 
 indication of a state much more grave, characterised by a cooling 
 carried "to the extreme, by the formation of an eschar, and the 
 fall of many parts of the phalanges of the hands and the feet. 
 We arrive thus by degrees at the case which has served me as 
 a type. It has seemed to me nevertheless that this degree could 
 indeed not be itself the last of all. Also I have placed at the 
 end a certain number of cases in which without known cause 
 many segments of limbs have become detached by gangrene. 
 
 I could easily have collected others ; but as the greater part 
 are of ancient date I should have been wanting in respect to the 
 rules of a healthy criticism in accepting records which were 
 somewhat indefinite, and which were not always sufficiently 
 authenticated. 
 
 I have therefore only admitted those which have appeared 
 to me to present striking analogies with my typical observations. 
 
 Thus these facts, of which many were known and quoted only 
 as anomalies, acquire, when viewed alongside of those which 
 precede them, a value which they did not previously possess. 
 Between the simplest cases, and I would say even the most 
 common, and those which are most astonishing from their 
 
CASES. 33 
 
 gravity, there are only differences of degree and intensity. The 
 important thing is to find the intermediate cases. 
 
 1. Syncope and Local Asphyxia in their Simplest Form. 
 
 The most simple degree is a state which every one knows, 
 although it is not, so far as I am aware, described in any treatise 
 on pathology. It corresponds to that which in common language 
 is spoken of as the dead finger. This affection, which constitutes 
 hardly even an inconvenience, and which passes often unperceived 
 because it claims no treatment, is nevertheless very common, 
 and there is hardly a doctor who has not had many opportunities 
 of observing it. The following is an example which has no other 
 interest except that it faithfully summarises what takes place in 
 the majority of cases of the kind. 
 
 Case I. — Local Syncope of the most Simple Form. 
 
 Mme X., set. 26 years, has never been ill ; but she has been 
 the subject since childhood of an infirmity which makes her an 
 object of curiosity to her acquaintances. 
 
 Under the influence of a very moderate cold, and even at the 
 height of summer, she sees her fingers become ex-sanguine, 
 completely insensible, and of a whitish yellow colour. This 
 phenomenon happens often without reason, lasts a variable time, 
 and terminates by a period of very painful reaction, during which 
 the circulation is re-established little by little and recurs to the 
 normal state. 
 
 Mme X. has no better remedy than shaking her hands strongly, 
 or soaking them in lukewarm water. The index of the left hand 
 presents a susceptibility greater than all the other fingers, and 
 is often affected alone. The feet, more impressionable even 
 than the hands, are regularly attacked at meal times and whilst 
 digestion is going on. 
 
 Menstruation does not appear to have any influence upon the 
 appearance of the phenomenon, but it is a remarkable fact that 
 the complete disappearance of attacks of local syncope has always 
 been noted by this lady as the first index of a commencing 
 pregnancy. 
 
 If the distinction which I have drawn be accepted, this state, 
 which I dare hardly call a disease, is local syncope in its simplest 
 form. 
 
 3 
 
34 Raynaud's original thesis. 
 
 It is to be noted that we have here not a passive congestion', 
 but rather a momentary absence of local circulation, just as 
 syncope is a suspension of the general circulation. 
 
 When this state is repeated up to the point of becoming almost 
 continuous, it may at length lead to profound troubles in the 
 nutrition of the parts which are subject to it. Chilblains become to 
 some extent established, and the adipose tissue ultimately becomes 
 over-developed, as in all organs which perform their functions 
 incompletely. This is what took place in the following case. 
 
 Case IT.* — Habitual Local Syncope iviih Lesions of Nutrition. 
 
 X., 25 years, a young lady of small build, and of a very 
 clear, light complexion ; menstruation faulty during many years, 
 but regular since 24 ; slightly icteric ; has had several attacks 
 of " nerves," with loss of consciousness, globus, tears, and in- 
 voluntary laughtei\ 
 
 ¥rom the age of 14 to 18 years she suffered much from 
 chilblains,' which kept her laid up during three months of the 
 winter. She has for a long time suffered from dead fingers. These 
 were constantly becoming absolutely cold, pallid, and insensitive. 
 The return of the catamenia has not modified this condition. 
 
 The fingers present a conformation which is quite remarkable — 
 they are extremely gross and soft ; the hands themselves seem 
 cedematous, and this contrasts in a striking manner with the 
 wrists and very slender forearms. The nails are not clubbed. 
 The pulse is quite perceptible. The feet present the same 
 appearance as the hands ; they seem as though they were made 
 up entirely of skin and cellulo-adipose tissue. This young 
 woman died recently of a hydatid cyst of the liver. 
 
 Up to this point we have had to do with slight forms of local 
 syncope ; it may acquire enough gravity to become disquieting. 
 Everybody knows the curious fact recounted by Lamotte (Traiie 
 Complet de Chirurgie, 3rd Edit., T.. ii., p. 317). 
 
 A billiard marker received a stroke from a stick on the outer 
 part of his right arm. There was severe pain, the hand 
 became pale, cold, insensible ; the morning after, Laniottfe made 
 many cuts with a lancet without the patient perceiving it ; he 
 even crossed the hand without a drop of blood escaping. This 
 hand remained in the same state during ten days. At the end 
 * Communicated by Dr. Marey. 
 
CASES. 35 
 
 of this time a little heat returned, then the arterial pulsations, 
 which had been suppressed, reappeared, and the functions were 
 so well re-established that the man could use his limb very 
 cleverly at billiards. Now these phenomena, which in this case 
 evidently had a traumatic cause, may in certain circumstances 
 appear spontaneously. . Volfius (Lib. hi., Obs. 5) reports a 
 case in which a similar state appeared following a violent 
 fit of passion, and lasting eight to ten days. The treatises of 
 surgery contain many facts of this kind. The following, which I 
 owe to the kindness of Dr. Blachez is not one of the least curious. 
 
 Case. III. — Local Intermittent Syncope simulating Paralysis. 
 
 October 29, 1860, a young soldier was admitted into the 
 Military Hospital of Gros Caillon for diarrhoea. He has always 
 performed his duties well. 
 
 He gets out of breath rather easily. At the age of 16 years 
 he had a malady which caused him to become swollen. This 
 dropsy lasted seven weeks. He had never had any palpitations 
 of the heart. The dropsy commenced at the feet and extended 
 rapidly to all the body ; he could not pass any urine for three 
 days. After having consulted many doctors, he had recourse to 
 a sorcerer, who cured him in ten days by giving him powders of 
 burnt broom mixed in milk, and by rubbing him with fat. 
 Thirteen months afterwards he had typhoid fever at Marseilles. 
 He made a good recovery. He has had diarrhoea twelve days before 
 admission. No blood in the stools. He had lost his appetite, 
 but continued at his duty. During the night before his entrance 
 into the hospital he felt that his left arm was benumbed. For 
 several days he had felt some ill-defined pains. 
 ' Actual state on the 3rd November. 
 
 In the morning the left forearm is completely algid; the 
 radial pulse is almost imperceptible, the strokes of the brachial 
 call be felt at the bend of the elbow. On the right the pulse is 
 very feeble, 68 — 72. Nil cardiac. No feebleness of beats. 
 Sensibility is blunted; the hand is slightly swollen and stiff; no 
 ecchymoses; white patches on the forearm. The arm is of 
 normal temperature ; no .pain, no swelling along the track of the 
 vessels. The temperature of the right arm is a little lowered. 
 There are a few whif. e patches on it. 
 
 At eleven o'clock every day the heat and sensibility return. 
 
36 Raynaud's original thesis. 
 
 November 8. — In the morning, symptoms just as described. 
 About one o'clock at night he was wakened by prickings and a • 
 sensation of numbness ; then the right forearm became cooled ; 
 absence of radial pulse, analgesia, &c. At half-past twelve (noon) 
 the heat of skin returned and became even exaggerated ; pulse 68. 
 The left radial pulse is found to be always more feeble than the 
 right. The hand is slightly swollen, so that it is difficult for 
 him to bend his fingers. There is analgesia distributed in the 
 following manner : all the forearm and the hand are analgesic, 
 but it is especially in the external third (ring finger and little 
 fmger) that it is pronounced. The patient feels when he is 
 pricked rather strongly ; he cannot squeeze the hand nor move 
 the forearm; on pressure he complains of pain, or rather of 
 exaggerated sensibility, along the median line of the forearm in 
 front. There is a little headache, inappettncy, white tongue; 
 no spots on the belly. He rises in the afternoon. 0*4 grm. 
 of snlphate of quinine ordered. 
 
 November 9, morning. — Arm hot ; pulsations feeble, a little 
 more so than on the right side ; analgesia and amyosthenia as 
 before. Less pain and tingling ; the patient can seize nothing, 
 nor can he squeeze. Sulphate of quinine 04 grm. 
 
 November 10. — One feels the left radial less strongly ; cooling 
 less than before, most pronounced in the dorsal region ; analgesia 
 and paralysis more pronounced ; diarrhoea continues. Sulphate 
 of quinine - 4. grm. 
 
 November 11. — Forearm less cold than the day before; the 
 pulse is felt very feebly; the algidity goes up the posterior 
 surface of the arm ; the right arm is a little cooler than in the 
 normal state. Sulphate of quinine not given this morning. 
 
 November 15. — Arm always colder and pulse smaller on left 
 than on right side, but there are no more intermittent phenomena ; 
 a little oedema of the hand. Diarrhoea arrested for two days. 
 
 November 21. — Same state, save that the oedema is more 
 pronounced ; anaemia ; appetite well preserved. Sulphur douche 
 ordered. 
 
 November 26. — He has had the douche for a few days. The 
 algidity has reappeared and persists throughout the day ; the 
 arterial pulsation is only felt at the bend of the elbow; the 
 same signs as before. On electric examinUtion sensibility and 
 contractility much less developed on the left than on the right 
 
CASES. 37 
 
 side ; the inequality is even marked on the sides of the chest ; 
 the skin reddens on application of electricity. After a sufficiently 
 prolonged application tbere was no change in the temperature 
 nor in the pulsations. 
 
 November 29. — At the end of an application lasting for 
 ten minutes the patient was taken with an attack of hysteria, 
 tears, cries of despair ; no loss of consciousness ; contraction of 
 the fingers, not only of the electrified side, but also of the other ; 
 very violent pains in the arms ; nil in legs. The attack lasted 
 one hour. Nothing special followed. 
 
 The patient went away for the waters, not cured. 
 
 This case presents more than one remarkable circumstance. 
 The functional lesion which produced the local syncope extended 
 upwards from the capillaries to the arteries. Nevertheless 
 an obliteration of the calibre of the artery by a clot could not 
 be admitted ; tbe proof is that the circulation was interrupted, 
 but reappeared soon after, then was interrupted again — and 
 still more curious — this interruption took on the intermittent 
 type. Sulphate of quinine modified this condition, destroyed the 
 intermittence without curing the malady entirely. Further, 
 this man suffered from a hysterical attack which was quite 
 characteristic. This occurrence rare, although not without pre- 
 cedent, in the male sex, denotes in every case a nervous pre- 
 dominance, and suggests for want of a better hypothesis, a 
 spasmodic state of the radial and ulnar arteries. 
 
 Let us note that although the left upper limb was more 
 affected than the right, yet the right was not exempt, and indeed 
 presented an appreciable cooling of the surface. In that way 
 the case comes within the general law of symmetry. I am, 
 however, obliged to consider another case of local syncope 
 limited to one side. 
 
 Case IV.*— Local Intermittent Syncope confined to one Limb. 
 
 Some time ago I saw with M. Cusack a patient from the 
 North of Ireland. She was a young lady of very delicate con- 
 stitution, and who presented each day at a fixed hour very 
 singular phenomena ; the circulation seemed to become arrested 
 completely in one of her legs, which became then completely 
 pale and cold. This state persisted during ten or twelve hours, 
 
 * From Graves's Lectures. 
 
38 Raynaud's original thesis. 
 
 then a new modification supervened. The leg became hot and 
 painful, and this elevation of temperature was so painful for the 
 patient that she was obliged to place her leg outside the bed 
 clothes, and to sprinkle it constantly with cold water and vinegar. 
 During all this time the pulsations of the heart were normal, 
 and the circulation was natural in all the other parts of the body. 
 In the observations which are about to follow, the affection of 
 the extremities changes a little in character. It is a state much 
 allied to the preceding, but the cooling, the pain, the anaesthesia 
 seem to proceed less from the absence of blood in the tissues 
 than from the presence of blood which is unsuitable for the 
 proper maintenance of sensation and nutrition. It is in one 
 word local asphyxia properly so-called. 
 
 Case V. — Amenorrhcea, local asphyxia of the four extremities. 
 
 Louise, a sempstress, aged 18 years, admitted April 2, I860, 
 to the Necker Hospital, St. Anne Ward, No. 21, under the care 
 of M. Vernois. 
 
 This young woman had never had any other disease than an 
 enteritis at the age of 7 years. She had begun to menstruate- 
 at the age of 15 J years without difficulty ; the catamenia lasted 
 eight days. She was not specially impressionable, and had 
 never had any attack of " nerves." Her father died of cholera 
 in 1854 ; her mother died phthisical October 27, 1857. During 
 the last six weeks of her mother's life, whilst she was bathed 
 with continual sweats, her daughter slept with her, saw her 
 die, watched by her corpse, and received a vivid impression from 
 it. A short time afterwards the catamenia were suppressed 
 little by little ; they have not reappeared for the last two years. 
 About a month after the death of her mother, Louise saw the 
 fingers of her two hands become yellow as though she had had 
 jaundice. During a time which she cannot precisely give there 
 were alternations of appearance and disappearance of this yellow 
 tint of the fingers; cold provoked it, it disappeared in the 
 warmth of the bed ; it was accompanied with moderate pains ; . 
 then the coloration became black, and the pains increased. 
 Louise at that time followed the occupation of polishing plate, ■ 
 an employment which fatigued her fingers. 
 
 At the beginning of 1859 the feet became yellow, just as at 
 first the hands had been affected. They remained yellow and 
 
CASES. 39 
 
 painful during about three hours. At the end of two or three 
 months they gradually became black in their turn. In the 
 month of July, 1859, she entered the Asile de la Providence, rue 
 Oudinot, where they are occupied in washing linen every day. 
 Her condition was continually getting worse. Whenever she 
 placed her arms in water they became black, sometimes up to 
 the insertion of the deltoids ; she remedied this by placing them 
 in the warmth of the bed, but at the moment of reaction she 
 experienced a pain which she compared to that which nettles 
 would produce, whilst during the continuance of the cyanotic 
 tint it was rather a sensation of burning and shooting pains. 
 Habitually, even in the intervals of the attacks, there was always 
 a little pain, sometimes in one finger, sometimes in another. 
 
 Ordinarily when the cyanosis appeared without obvious cause 
 it was limited to the fingers, and this happened not only on 
 exposure to cold, but simply when the patient got up to go 
 into the wards. 
 
 As the cyanosis increased there appeared a little tumefaction 
 of the hands. On the feet the coloration rose as high as the 
 ankle, but there was no swelling. The fingers are short, 
 flattened, large at the ends, but not at all clubbed. There is at 
 the heart a very slight blowing prolongation of the first sound. 
 The patient takes cold easily. Nothing abnormal was to be 
 heard on auscultation of the lungs. She has never remarked 
 that there has been any monthly exacerbation. 
 
 On the 8th April, Easter Day, being at chapel, she was taken 
 without assignable cause with pains in the hands sufficiently 
 severe to make her cry ; in the back she felt as though violently 
 compressed by a vice. On the morning but one after (the 10th), 
 whilst examining her as she lay in bed, I saw the commence- 
 ment Of an attack of cyanosis coming on without appreciable 
 cause; the little finger was taken first, and the others soon 
 afterwards became black in their turn. The patient quitted the 
 hospital in the same state ; tonics which had been lavished on 
 her produced no improvement. The urine was examined, and 
 gave only negative results. 
 
 ,1 saw her again on the 12th December, 1861. I have not 
 seen her subsequently. Her catamenia had appeared three or 
 four times very irregularly, the last time a fortnight ago. The 
 condition was sensibly improved. There were no palpitations ; 
 
40 RAYNAUD^ ORIGINAL THESIS. 
 
 the skin of the face presented a slightly bluish and transparent 
 tint. I found her in the middle of an attack of cyanosis which 
 had lasted for two hours ; the pulse was quite perceptible ; the 
 skin of the hands was very cold, and of a violet tint. 
 
 The attacks recur now in the feet and in the hands five or six 
 times a day without any periodicity ; nevertheless in the moments 
 of remission she can hold and handle a needle, which she could 
 not do formerly ; she does much work in the house. Good 
 appetite ; sometimes pains in the four extremities ; nevertheless 
 these pains do not attract her attention much, she has become 
 habituated to them ; she cannot say whether the improvement, 
 of which she is conscious, has coincided with the return of the 
 catamenia or not. 
 
 I call attention to the pale colour which the hands presented 
 at first, and in like manner at a subsequent period the feet also, 
 before they assumed the bluish black tint. This colour, much 
 more pronounced than the pale yellow of ansemia, is not a fact 
 without precedents. Already Broussais had drawn attention to 
 the intense yellow tint which choleraic patients sometimes present 
 whose limbs in their external aspect assuredly show a great re- 
 semblance to the state which we are now considering. 
 
 Furthermore, we see in this case in a very trenchant manner 
 a remarkable coincidence between the affection of the extremities 
 and suppression of the catamenial flux. I bring into contiguity 
 with this case the following one, which is almost similar to it. 
 I reproduce the title as it is given in the original ; but it evidently 
 describes very inadequately what the author wished to express. 
 
 Case VI.* — Cyanosis appearing instantaneously on parts exposed, 
 to the cold, ceasing under the influence of heat ; re-establishment 
 of the normal colour along the course of the arteries ; no 
 symptom of heart lesion. 
 
 Rose G., washerwoman, aged 28 years, with fair skin and 
 bright complexion, enjoyed habitually good health. Her pulse 
 is small, feeble, and slow (65 to the minute). She has never 
 had either palpitation, or oppression, or cough ; she has never 
 felt pains in the chest. She had always menstruated regularly 
 up to the last three months, during which the catamenia had 
 notably diminished. 
 
 * By Dr. Marchaud, Journal des Connamances medicales de Nantes, 1837. 
 
GASES. 41 
 
 In the month of March she had several attacks of tertian fever, 
 which disappeared under the influence of a sedative. Towards 
 the middle of April she hecame very impressionable to cold. 
 
 Every time that she went out during weather at all cool, the 
 nose, chin, cheeks, hands, and feet became pale ; they passed 
 then to a violet tint, then to a slaty white. . It was in this state 
 that she presented herself on the 20th April at the consultation 
 at the Hotel Dieu (at Nantes). 
 
 A very cold wind had blown all morning when Bose entered 
 the room. Her cheeks and chin were of indigo colour; her 
 hands were as cold as marble. At the first view I believed 
 them to be gangrenous. The ends of the fingers were of a 
 greenish blue, the palms of the hands were of a deep purple. 
 On the forearms there were marblings similar to those which 
 are present on the legs of persons who use foot warmers. Above 
 the wrists the skin presented its natural colour. These pheno- 
 mena were less pronounced in the lower limbs, which were 
 clothed with woollen stockings. 
 
 Whilst this young woman spoke, a bright redness began to 
 develop itself at the root of the nose and over the cheeks ; then 
 it extended and invaded the blue colour, which soon formed no 
 more than a deep red patch on the tip of the nose, and ended by 
 disappearing entirely. One moment afterwards the pink colour 
 of the nose began to pale, and this organ resumed little by little 
 its ordinary colour. The same change came into operation at 
 the same time upon the cheeks and the chin ; upon the hands 
 the change did not take place so quickly nor in the same way. 
 
 The pulse was small, feeble, thready, disappearing easily 
 under pressure, especially in the left arm. 
 
 The right radial was a little more developed than the left, and 
 the pulsation was always stronger and more prompt in the right 
 than in the left. This was how the change took place : at 
 first less livid patches appeared in the palms of the hands along 
 the track of the palmar arches ; they extended until their borders 
 met, and took on a vermilion tint. At the same time other 
 patches were seen to form along the course of the digital arteries, 
 and shoot along the collaterals of the digits. 
 
 It was at the extremities of the fingers that the cyanosis and 
 the cold persisted longest. Finally at the end of a quarter or 
 half an hour the whole hand was of a vermilion red ; the pulse 
 
42 eaynaud's original thesis. 
 
 had regained its force, the warmth of skin was perfectly developed, 
 and a slight sweat had moistened the cutaneous surface. All 
 these phenomena were reproduced each time that Rose was 
 exposed to cool air, whether in the evening, morning, or at the 
 middle of the' day. The reaction only commenced when she 
 returned to her room. 
 
 One day when the outside temperature was at 54J° F. the 
 thermometer placed between her fingers only rose half a degree, 
 and stopped at 56|° F. in the palm of the hand. This experi- 
 ment repeated two days running always showed that the thermo- 
 meter placed in the palm of the hand only rose one degree above 
 the temperature of the air, and half a degree only when it was 
 placed between the digits. The means which were employed 
 during the sojourn of the patient at the Hotel Dieu from the 2nd 
 May to the 21st of the same month were as follows : frictions 
 were prescribed with camphorated brandy and laudanum over all 
 the parts which reddened. During two or three days we admin- 
 istered also two grains of sulphate of quinine ; then the patient 
 complaining of pains in the stomach the sulphate of quinine had 
 to be omitted, and it was replaced by a grain of extract of opium, 
 given night and morning. Constipation occurring at the end of 
 a few days we were obliged to give up the opium and recur to 
 purgatives. 
 
 These different remedies produced no manifest improvement, 
 but during their employment the external temperature rising 
 the cyanosis became less and less marked, and no longer ap- 
 peared when the atmosphere became warm. 
 
 Case VII.* — Local Asphyxia : beneficial employment of electri- 
 city. 
 
 A young woman, aged 17 years, experienced without appreci- 
 able cause violent pains in the hands, which appeared of a dark, 
 slaty colour ; there was cooling of the skin, and insensibility, in 
 short all the symptoms of a commencing gangrene occupying four 
 fingers on the right and two on the left hand. Power of move- 
 ment of these fingers was almost abolished. We employed the 
 induced current. Its application was at first very painful, but;, 
 soon it suppressed the pains which the patient experienced spon- 
 
 * By M. Duval, Echo Medical Suisse, Sep., 1858. This observation bears improperly ', 
 the title of " Spontaneous Gangrene of the Fingers." ..i 
 
CASES. 43 
 
 taneously. Ten or twelve applications brought back at the end 
 of about a week, sensibility, normal colour, and temperature, as 
 well as power of movement. The epidermis detached itself from 
 the two hands over the whole of the extent primarily occupied 
 by the commencing gangrene. There was remarked during 
 electrisation a very curious fact ; there was a foetid sweat over the 
 area of the electrified parts. 
 
 This patient succumbed a few weeks later to acute phthisis, 
 but no autopsy was made. 
 
 II. — Local asphyxia and superficial gangrene, with predomin- 
 ance of the nervous element. 
 
 I pass now to an order of facts in which the nervous element 
 takes a principal part, and conceals in part the influence — never- 
 theless very real — of the circulatory troubles. 
 
 I will record first a very interesting observation of Dr. 
 Landry's, who has already published an abstract of it in his 
 remarkable researches on the causes and curative indications of 
 nervous maladies. I restore it here in its entirety, as it has 
 been kindly communicated to me by the author. 
 
 Case VIII. — Chlorosis, Hysteria; remarkable symptoms on the:- 
 
 side of organic phenomena and of sensibility. 
 
 T. (Adolphine), wife of E., aged 22 years, a daily worker 
 at the Beaujon Hospital. Admitted April 5, 1851, under the 
 care of M. Sandras. 
 
 Constitution of debilitated appearance, nervous temperament. 
 Her parents are still living, and have never experienced any- 
 thing analogous to her actual state. Sickly up to 12 years' 
 old, convulsions in infancy, variola,, measles, &c. ; began to 
 menstruate at 14 years. At the end of a year the catamenia 
 were irregular for a short time, but then became regular again, 
 and each month the loss of blood was very abundant, and lasted 
 eight days. When the menstrual troubles first appeared (that is, 
 one year after the commencement of the catamenia) there 
 occurred simultaneously several different symptoms : pains in 
 the stomach, frequent breathlessness, and a subfebrile state with- 
 out cough or palpitations. After recovering from these symp- 
 toms her health. was good until she was 21. years old. At this 
 epoch she had a satisfactory labour, but it was followed by abscess 
 
44. Raynaud's original thesis. 
 
 of the breast' and by a tertian intermittent fever, which lasted 
 three months. A fortnight after its disappearance there was a 
 sharp pain in the left foot, exaggerated by walking, and indeed 
 preventing it. This pain had for its seat the tibio-tarsal articu- 
 lation, and was not accompanied either by redness, or sensible 
 tumefaction, or by fever. It came to an end of itself at the end 
 of a fortnight. Shortly afterwards the left arm became the seat 
 of severe pains, like those due to bruises, especially severe about 
 the articulations, and rendering movements impossible, or at least 
 difficult. There was no redness, tumefaction, fever, or general 
 trouble. This pain finally disappeared at the end of two months. 
 From that time the health was very good up to November, 1850, 
 but for a few palpitations and attacks of breathlessness. 
 
 At this epoch this woman experienced suddenly a considerable 
 feeling of cold at the end of her fingers, without having been 
 exposed to a low temperature. The nails became violet, and the 
 ends of the fingers a sombre red, and they were the seat of a 
 sharp pain, compared by the patient to that of benumbing by 
 cold. These symptoms continued; they were especially sharp 
 in the morning, disappeared during the day, then in the evening 
 and during the night the painful cold was replaced by a burning 
 and intolerable heat. During these periods cold water calmed 
 the sufferings, but on the contrary excited them in the cold 
 period. These symptoms gained gradually in intensity, and at 
 the end of a fortnight the cold became permanent, and the 
 extremities of the fingers took a tint of deep violet red, passing 
 into black at certain points. The pain similarly became much 
 more severe, and the least contact excited atrocious pains and 
 determined convulsions. All these symptoms were especially 
 acute on the left side. M. Kobert, on being consulted, believed 
 at first that there would supervene one or many whitlows ; but 
 after a more attentive examination he concluded that there 
 existed an alteration of the arteries (arteritis), and ordered forty- 
 four leeches to be applied to the palm of the hand and over the 
 ends of the fingers three times over, then laudanum poultices 
 and ethereal draughts. The symptoms were calmed without 
 being cured. At the same epoch the extremity of the nose took 
 a violet tint like the ends of the fingers, and each morning some 
 drops of blood escaped from the nostrils ; otherwise there was 
 no pain. 
 
CASES. 45 
 
 She left M. Eobert's ward after three weeks' stay. A fort- 
 night afterwards there was increase of pains with frequent 
 convulsions, for which they were obliged to tie down the patient. 
 She was admitted under the care of M. Huguier, and laudanum 
 was applied over the ends of the fingers. M. Huguier considered 
 these attacks as symptomatic of an affection of the heart, and 
 this opinion was based upon the existence of violent palpitations 
 and of a cardiac murmur, perhaps also upon the knowledge of 
 the antecedent articular pains of which I have spoken. 
 
 In the space of a fortnight he ordered wet cupping five times, 
 then blisters and cauterisations to be applied over the prsecordial 
 region, and digitalis to be given internally. The sum total of 
 this medication appeared to improve the pains without leading 
 to any change in the other conditions of the fingers, and without 
 modifying in any way the palpitations and the cardiac murmur. 
 At the end of January, 1851, the pinna of the right ear took the 
 same tint as the fingers and became the seat of pain and tingling, 
 which disappeared at the same time as the cyanosis, in the course 
 of the month of March. The patient passed from the care of 
 M. Huguier at the end of the same month. The pains of the 
 fingers and the convulsions appeared once more, and she came 
 under M. Sandras' care on the 5th April, when we noted the 
 following condition : general state is good, but there are fre- 
 quent vertigoes, hummings in the ear, palpitations, attacks of 
 breathlessness, constipation, with no other abnormality of the 
 digestive system ; pulse small, very compressible, but quite 
 perceptible in both radials ; with the first sound of the heart a 
 murmur, having its maximum intensity at the base, but most 
 intense over the aorta and the carotids ; murmur only slightly 
 harsh, and by no means in harmony with the view of organic 
 affection held by M. Huguier. The extremities of the fingers of 
 the two hands present a violet colour, which is seen also under 
 the nails, and occupies almost the whole of the extremity of each 
 finger, but decreases from the extremity towards the hand. This 
 colour, more marked in the right hand than in the left, extends 
 a little further along the internal border of the fingers than in 
 any other direction, and is prolonged along the internal border 
 of the little finger up to the inner side of the hand and the 
 inferior third of the forearm. The extremities of the fingers are 
 very cold, shrivelled, and withered ; even a moderate pressure 
 
46 Raynaud's original thesis. 
 
 determines in it a sharp pain; nevertheless a superficial prick of 
 a pin is not perceived at all, hut it is felt with pain if one 
 drives it in deeply ; tactile sensibility is lost at the ends of 
 the fingers, and the patient does not feel a pin roll between them. 
 For this reason it is impossible for her to pick up small bodies, 
 and not appreciating the volume of them she does not appreciate 
 the degree of pressure which she ought to exercise upon them 
 in order to retain them and lets them fall ; the tactile sensibility 
 is not otherwise altered except upon the distal phalanx, and 
 principally at its extremity. The epidermis . of the end of the 
 digits peels off gradually and in small patches ; the skin itself 
 is thin, dry, parchment-like, and shrivelled. The extremities 
 of the fingers are the seat of a pain compared by the patient 
 to that of being benumbed, with torpor and the sensation 
 of intense cold, cold moreover which is very real and quite 
 appreciable to the touch of the observer. The pain radiates 
 from these points up to the shoulder without taking any par- 
 ticular direction in relation to the track of any vessel or nerve. 
 The patient in spite of this sensation of cold and numbness 
 seeks cold rather than heat. The warmth of a fireside never- 
 theless does not sensibly increase the pains ; but when the hands 
 have remained for a certain time in the heat of a bed the 
 sufferings are increased, then alleviated by exposure to cold air. 
 Sometimes these pains take on an extreme intensity and radiate 
 more violently, but with a different character, towards the 
 shoulder ; then the least contact renders them atrocious and 
 determines violent convulsions, such as one observes in the most 
 disorderly attacks of hysteria ; nevertheless they are not ac- 
 companied by a sensation of globus, so common in hysteria, 
 and they show no epileptic character. This state of exag- 
 geration of pains comes back in attacks of about one hour's 
 duration, being renewed five or six times daily ; each of them is 
 marked by three or four attacks of convulsions ; otherwise there 
 is nothing constant in their manifestations. During these 
 attacks the extremities of the fingers take a violet colour, 
 and at the same time become warm ; at other moments, 
 and especially during the periods of remission of the pains, 
 the fingers become a dead white in colour and absolutely ex- 
 sanguine. 
 • All these phenbmena are much less marked in the left than in 
 
' CASES. . 47 
 
 the right. On the right side the index finger presents none of 
 these phenomena (it is not cyanosed, or cold, or shrivelled ; 
 the sensations perceived in the other fingers are not present 
 in this ; sensibility in it, is perfectly preserved). They are on 
 the contrary at their maximum of intensity on the middle 
 finger of the right hand. We have specially noted the following 
 fact. During the attacks chloroform was applied over the digits 
 of the right hand. The pains were calmed, but the tingling 
 which this liquid determined was only felt by the index ; and 
 upon this finger only, a blister was formed round the nail. This 
 .blister was evidently the result of vesication determined by 
 chloroform when the application had been too long prolonged. 
 
 The right ear showed nothing like what it presented before. 
 The end of the nose was slightly violet and cold, without 
 pain. 
 
 On the toes there was nothing similar to what was seen on 
 the fingers. There was no other lesion and no other alteration 
 of sensibility in any part of the body ; there was no pain over 
 any of the Spinous processes. 
 
 The history of the symptoms which I have just enumerated 
 was taken on the 13th April, that is to say, eight days after the 
 admission of the patient; and after having observed her during 
 that period she was ordered gelatine baths daily, and carbonate 
 of iron pills, four daily. When the attacks occurred compresses 
 soaked in water and chloroform were applied over the fingers; 
 These instantly quieted the pains, and since then she has had no 
 further attacks. 
 
 April 27. — There has been a sensible improvement in all the 
 phenomena. Nevertheless to-day the cyanosis is extended by 
 patches up to the dorsal surface of the hand. The radial pulse 
 has always been normal on the two sides, or rather has been 
 characteristic of the chlorotic state of the patient, that is to say, 
 small and compressible. We have remarked nothing special 
 with regard to the veins. The heart murmur is moreover almost 
 nil, and the palpitations only slight. The same treatment to be 
 continued. 
 
 May 4. — The pains and other symptoms have much dimin- 
 ished in the right hand, but have acquired more intensity in the 
 •left. ;. There was yesterday an attack of convulsions determined 
 by pains in the left hand ; there had been no convulsion since 
 
48 Raynaud's original thesis. 
 
 April 9th. The same prescription, and in addition a julep was 
 ordered with 30 grammes of syrup of morphine. 
 
 May 15. — The symptoms, and especially the pain, are almost 
 nil in the right hand, but sufficiently intense on the left side to 
 have determined yesterday morning another attack of con- 
 vulsions. The pain in the left hand exists especially in the 
 three digits, the thumb, index, and middle finger. General state 
 very good. The use of the gelatine baths is continued, but 
 every three or four days only, and the use of the chloroform 
 compresses is continued. The same prescription as before. 
 
 May 18. — The patient remarked to me that for several days 
 the cold and cyanosed extremities of the left hand have been the 
 seat of continual cold sweating, and that it is reproduced just 
 as one dries it. This perspiration recalls that of choleraic 
 patients. 
 
 May 21. — The symptoms are very intense in the left hand. 
 M. Sandras ordered cold irrigations to the ends of the fingers. 
 Same prescription. 
 
 May 23. — The irrigations quieted the pains considerably, 
 but the patient having suspended them the pains have suddenly 
 increased with great intensity. There has been a violent attack 
 of convulsions. The irrigations to be continued. The same 
 treatment. 
 
 * May 25. — This morning the fingers of the left hand have 
 almost returned to their normal colour, and their extremities 
 hardly present any violet tint. They are equally without pain, 
 and pressure only determines it on the index. The irrigations 
 have been continued since the 23rd of May without interruption. 
 The same treatment. 
 
 June 15. — The irrigations have been continued, but their 
 good effect has not persisted, and the patient is better for. the 
 chloroform applications, which instantly quiet the pains and make 
 the fingers assume a dead white colour. The right hand is 
 always in very good condition, and since the symptoms have dis- 
 appeared the skin of the extremities of the fingers has regained 
 its normal appearance, and the desquamation which was noted 
 previously has disappeared. Desquamation and parchment-like 
 atrophy of the skin are still observed on the fingers of the left 
 hand. The irrigations were suspended. The same prescription 
 to be continued. 
 
CASES. 49 
 
 i. June 17. — Since the suspension of the irrigations the pains 
 have reappeared more violently, and we have been obliged to 
 return to them. 
 
 ... June 19.; — The irrigations have diminished the pains. M". 
 Sandras ordered inunctions with an ointment containing lard 
 (5,0 grammes, sulphate of strychnia 1 gramme ; otherwise the 
 same prescription. 
 
 June 25. — Since the patient has made use of the strychnine 
 ointment the left hand has been much better. The right hand 
 appears as though it would be attacked again with the symptoms 
 which had absolutely disappeared from it. The chlorosis is 
 much improved. 
 
 July 10. — All symptoms had almost, entirely disappeared from 
 both -hands ; ^.yesterday they reappeared with great intensity 
 in both) but principally in the left. To-day this, alone presented 
 traces of.the recrudescence of yesterday. 
 
 July 25. — There has been for a few days a considerable and 
 persistent improvement, in all the symptoms. 
 
 , August 5. — : The improvement has continued ; nevertheless 
 the cyanosis comes on at times as before ; but contact is scarcely 
 painful. The tactile sensibility is almost normal and the patient 
 can sew very, well,, which she could. not do on admission. There 
 hasjbeen no further hysterical attack since May 23. The general 
 condition is, excellent,, and the, heart murmur and that of the 
 carotids have disappeared; more palpitation. She goes out. to-day, 
 promising to continue the use of the ; carbonate of iron pills. 
 „>■ October 28. — This woman living , at the hospital, I have had 
 the opportunity of seeing her. frequently. She continued YaUej^ 
 pills, about a, month after her dismissal, then ceased all treat- 
 ment. Her general state continued very good, and indeed has 
 improved. There have been no more convulsive attacks. The 
 .fingers, although sjtill niaintaining a violet tint and a tempera- 
 •ture generally low, are no longer the seat of the old pains, and 
 sensibility is almost normal, Every day their condition improves, 
 .and. this, patient may be considered as really cured, especially if 
 we compare this long period of suspen^iop of symptoms with the 
 short intervals , of improvement which, she had obtained in a 
 .^oubtful manner, by the different courses of treatment which she 
 underwent.at first. , She, believed herself nonpregnant one .month. 
 
 February 3, 1852. — For many months the violet colour of the 
 
 4 
 
50 Raynaud's original thesis. 
 
 fingers had disappeared, when after the death of her husband 
 (Jan. 6) this woman had violent convulsions followed by 
 nervous delirium. The fingers resumed temporarily their 
 cyanotic tint, which however was not maintained. The delirium 
 was cured in three days by simple draughts of syrup of narcotine 
 in strong doses. Subsequently a very pronounced chlorotie 
 state was noted with analgesia in almost the whole of the body, 
 without anaesthesia. She is in our wards, where she is under 
 treatment by Vallet's pills. 
 
 April 22. — The woman has not yet been delivered ; she 
 appears to be in the ninth month. Her general state is not- 
 improved. The analgesia and all the signs of chlorosis persist ; 
 there is a loud murmur at the base of the heart heard in the 
 carotids ; she has gastralgia, erratic pains, &c. For some time 
 she has been frequently seized with complete aphonia, with 
 absence of cough, pain in the neighbourhood of the larynx, 
 expectoration, or trace of inflammation in the back of the 
 throat. This often happens to her suddenly, and lasts some 
 hours, or some days. No other nervous symptoms accompany 
 this aphonia, and the patient pretends that it is from feebleness 
 that she cannot speak, although there is nothing to indicate 
 that her general feebleness is more marked at these times than 
 at any other times ; there have been np more convulsive attacks. 
 The fingers have a tendency to become blue, but without pain. 
 The Vallet's pills are to be continued, and also 2 grammes of 
 magnesia at each meal. The patient's accouchement took place 
 in June. For some time the analgesia had disappeared in part. 
 After the labour there was considerable haemorrhage. The 
 patient is very pale and wasted. The analgesia reappeared 
 everywhere. She left the hospital in June in order to go into 
 the country. 
 
 October 11. — This woman returned from the country a few days 
 ago, fresh, stout, and in excellent condition, showing none of the 
 old nervous symptoms ; no analgesia. Very slight palpitations ; 
 there is just a slight murmur with the first sound of the heart. 
 She resumes her work as a hospital servant at the Beaujon. 
 
 November 7. — After having cleaned the metal vessels with 
 potash, contraction occurred almost instantaneously of the 
 fingers of the right hand, which are strongly flexed into the 
 palm, the patient being unable to straighten them voluntarily. 
 
CASES. 51 
 
 November 8. — Pains in both hands, in the fingers, especially 
 on the right side; pains very violent, similar in character to 
 those formerly felt. Four attacks in the day, in which the 
 fingers became blue in both hands, glazed, insensible to contact, 
 and benumbed. Afterwards analgesia of the forearms and hands ; 
 murmur over the heart and the carotids. 
 
 November 9 and 10. — The same state, similar contractions ; 
 the same painful state, alternately blue and pale fingers, in- 
 sensible and benumbed. 
 
 November 12. — Poisoning by about two spoonfuls of laudanum. 
 Vomiting and coma, from which she was roused incompletely. 
 The. poisoning was not recognised. 
 
 - November 13.— She has vomited some laudanum. Similar 
 coma with incomplete resolution of the limbs ; unconsciousness, 
 pupils contracted. Coffea administered. In the evening tetanic 
 rigidity of the lower limbs, incomplete movements of the upper 
 limbs, insensibility, contracted pupils. Antimonial draught, 
 coffea enema, two blisters to the calves. 
 
 November 14.— Consciousness perfect, movements almost 
 complete; neither rigidity nor trismus. Analgesia almost general. 
 She recalls nothing. 
 
 November 20. — Analgesia complete, numbness of the four 
 extremities ; toes and fingers very pale and very cold, insen- 
 sible'; more cyanosis of the fingers, altered movements; of the 
 lower limbs, almost complete, paralysis of the muscles of the 
 toes and of the peronei. The patient walks on the outer 
 border of . the foot, especially so on the right side. Gait 
 trembling, frequent flexion of the knees. Slight contractility 
 of the muscles to electricity, feebleness of hands^ heart, murmur. 
 Four Vallet's pills ordered. 
 
 November 25.— Prolonged application of electricity. 
 
 November 27. — Marked improvement ; walking easier ; leas 
 numbness of the extremities, which are warm at present. Nothing 
 more noteworthy. She goes to the Salpetriere as a hospital 
 servant. I have learnt subsequently that this woman died of 
 phthisis. The autopsy revealed nothing special. 
 
 This case is extremely complex,, and I do not flatter myself 
 that I can disentangle all its obscurities,, nevertheless it presents 
 many special points which it. is important to place in evidence. 
 Although the malady affected the hands principally, it was not 
 
52 kaynaud's oeiginal thesis. 
 
 absolutely limited to them. The first indication appeared in the 
 left foot, at a later period the nose and the external ear were 
 temporarily attacked, and in spite of their short duration these 
 symptoms have a great value because they indicate a very general 
 affection which we cannot explain by a lesion of heart or vessels. 
 Moreover, these organs carefully examined, only furnished nega- 
 tive results. The progress of the symptoms was eminently 
 chronic with exacerbations. During the space of two years six 
 or seven of these attacks were observed and described ; they had 
 not all the same characters or the same duration, but they 
 presented nevertheless general features which were well recog- 
 nisable. There is a kind of prodromic period during which the 
 morbid features are not yet definitely marked, and present an 
 erratic character. But soon the malady finally leaves the lower 
 limbs, and attacks the upper limbs with great severity in a more 
 or less intermittent fashion. There is always a marked pre- 
 dominance on one side of the body ; but this predominance is 
 not constant, one time it is the 'right, another time it is the 
 left 'side which is most attacked. It is a remarkable fact 
 that, in a given attack the limb which presents the. greatest 
 exaggeration of symptoms is also that which improves most 
 rapidly. 
 
 The nervous phenomena which play so large a part in the 
 attacks deserve our attention, because it is necessary to estimate 
 precisely their value. Although the patient presents the attri- 
 butes of lihe nervous temperament, everything up to the present 
 illness had been limited to a < simple predisposition. With the 
 cyanosis of the extremities well-marked hysterical convulsions 
 showed themselves, but let us note that these convulsions always 
 accompanied the paroxysm of pains in such a way that it ■ is 
 legitimate to place them to the account of th& latter, which 
 would be only the occasional cause of them ; then in proportion 
 as the malady developed and became established the nervous 
 symptdms became generalised and aggravated, aided by moral 
 emotions of which the influence' was undoubted. 
 
 Let us turn now our attention to certain remarkable circum- 
 stances in the local state of the affected limbs, and first with 
 regard to calorification. ■ 
 
 . M. Landry observed with great acuteness that the moment of 
 the greatest pain is marked by the change of colour, of the 
 
CASES. 53 
 
 extremities to violet-black, and by n slight relative elevation of 
 temperature, and that to the moments of remission there corres- 
 ponded a deathlike pallor with cooling of the skin. This confirms 
 the distinction which I have established between asphyxia and 
 local syncope; in local syncope there is complete absence of 
 blood ; the fingers tend to assume rapidly equilibrium of tempera- 
 ture with the surrounding medium. In asphyxia. there is a 
 passage of venous blood, insufficient it is true to maintain a 
 complete nutrition, but enough to preserve a certain degree of 
 heat. 
 
 The sensibility entirely fled towards the deep parts ; the 
 finger, completely indifferent to superficial stimuli, was sensible 
 to and even very painful on pressure. A somewhat exceptional 
 circumstance was the improvement which the patient acknow- 
 ledged was brought about by exposure to the influence of a low 
 temperature. It is more difficult to give a reason for this than 
 for the good effect obtained by cold irrigations. These seem to 
 have had the results common to all hydropathic methods, that 
 of bringing about a local reaction in the parts endowed still with 
 sufficient vitality to respond to the action of stimuli. 
 
 As to the shrivelled aspect — the parchment-like character of 
 the ends of the fingers — the fact is so conformable to what I 
 have seen myself that I cannot but accept it as a faithful descrip- 
 tion of what actually took place. The whole process was 
 terminated by a characteristic desquamation. There was 
 nothing to lead to the belief that the tuberculisation to which 
 the patient subsequently succumbed had any relation to the 
 primitive malady. 
 
 We have now to deal with another observation which resembles 
 in more than one respect the one which we have just read. To 
 the cooling, the cyanosis, the mortification of the extremities, 
 always imminent and never complete, were joined in this case 
 also signs of hysteria, and further, a profound cachexia which 
 .the most rational treatment failed to cure. I shall have to 
 discuss subsequently the nature, the progress, and the mode of 
 evolution of this cachexia. I limit myself for the present to the 
 exposition of the facts. 
 
 i The patient who is the subject of this observation was for a 
 long time an inmate of the Paris hospitals. I had seen her at 
 the Clinical Hospital during my residence as interne, under IT. 
 
54 
 
 RAYNAUD S -ORIGINAL THESIS. 
 
 Nekton. When my attention was awakened to this curious 
 affection I recalled my former patient. I discovered her with 
 some difficulty, and persuaded her to come into the Necker 
 Hospital, under the care of M. Vernois, on April 12, 1869. 
 There she remained up to her death on the 26th July of the 
 same year. The account of this case has been given by my 
 friend Dr. Jules Simon, in his inaugural dissertation on leuco- 
 cythaemia (1861). I shall discuss his interpretation of the 
 case. To the notes taken by M. Simon I add the information 
 which has been furnished me by M. Herard, physician to 
 the Lariboisiere ; by M. Pean, my excellent colleague at the 
 Clinical Hospital, and finally the results of my own observa- 
 tions. 
 
 Case IX. — Chloro-hysteria ; local asphyxia and very superficial 
 
 gangrene of the extremities ; transition into a chronic state ; 
 
 profound cachexia ; death ; autopsy. 
 
 Anna B., aged 30 years, servant, born at Chabannais, Departe- 
 ment de la Charente. 
 
 This girl, born of poor parents, has been brought up in some- 
 what bad hygienic conditions ; often maltreated by her parents 
 she left them at the age of 16 years, in order to enter a position 
 with easy employers, where she had better food and less fatigue. 
 She began to menstruate at the age of 17 years with difficulty. 
 The catamenia, although regular, were painful. She recalls 
 having been since this epoch subject to suffocating feelings, and 
 different symptoms of chloro-hysteria, dyspepsia, intercostal 
 neuralgia, &c. Since then she has been liable to true hysterical 
 attacks after emotional disturbances. 
 
 The commencement of the symptoms which subsequently 
 brought her to hospital took place at Limoges. 
 
 She was then 27 years of age. For the last sixteen months 
 she had partaken by preference of a bread made exclusively of 
 rye flour. We are ignorant as to whether this bread was of bad 
 quality or not. On the occasion of a severe fright her catamenia 
 suddenly stopped, and at the same time the extremities became 
 painful, and of an icy cold. She experienced in the last phalanges 
 of several fingers, painful tinglings ; at the same time the skin 
 changed in colour, becoming pale and cold at some moments, 
 blue at others. All the fingers were attacked in three days; the 
 
CASES. 55 
 
 finger ends became so insensible tbat objects touched and held 
 up were not felt, and pins could be made to transfix the skin 
 without causing pain. Nevertheless, although there was the 
 loss of sensation of contact, the recognition of hot and cold was 
 preserved. The only means which led to improvement consisted 
 in warming the extremities with strips of cotton wool. On the 
 eighth day there was a period of calm of somewhat short dura- 
 tion because it was followed by a recrudescence of the local 
 affection, which lasted not less than eighteen months. The 
 physicians whom she consulted at Limoges experienced doubtless 
 the same difficulty which we encountered subsequently. It is 
 certain that they enjoined the suspension of the use of the rye 
 bread, thinking that this kind of alimentation might be adequate 
 to explain the nature of the malady. The catamenia were sup- 
 pressed from six to eight months ; their return coincided with a 
 remission of the symptoms of the extremities. Nevertheless she 
 was not cured. She had been six months ill when she came to 
 Paris, hoping to find some relief for her troubles. She entered 
 the Lariboisiere, where she passed eleven months. By degrees 
 the second and first phalanges of the fingers had presented 
 successively the same phenomena, that is to say, sensation of 
 habitual cold, tinglings, slaty tint, incomplete anaesthesia at the 
 moment of the attack, return of sensibility during the intervals, 
 and then acute pains in the region of the punctures which had 
 been made. Soon we saw bullae appear at the extremities of the 
 ungual phalanges ; they passed from one to the other, and 
 preceded the fall of all the nails, which came to pass in six 
 weeks' time. Nevertheless they reappeared in less than two 
 months. At the same time the left great toe was attacked with 
 the same affection, which ended in the fall of the nail and its 
 subsequent reproduction. 
 
 During the whole of the time of Anna's sojourn at the Lari- 
 boisiere, M. Herard, under whose care she was at that time, had 
 treated her vigorously with tonics — Vallet's pills, quinine wine, 
 &c. At the end of eleven months she left the hospital notably 
 improved (August, 1858), and hoping to be able to resume her 
 occupation as a chambermaid, which she had before followed 
 with much ability. This hope was not of long duration, because 
 on the 17th of December of the same year she entered the 
 Clinical Hospital, where she stayed several months. "We found 
 
5(5 eaynaud's original thesis. 
 
 her in the following state, which I describe with detail,' because 
 it gives a picture of the disease at its maximum : — 
 
 Extreme pallor. The lines of the countenance are flaccid, 
 and expressive of sadness. 
 
 So soon as she allows her hands to be exposed to a rather low 
 temperature the fingers become pale, cedematous, half flexed ; 
 they are attacked with painful sensations, numbness, and torpor; 
 shortly afterwards they become blue, then black, in their whole 
 extent, and there are to be seen traced along the surface tracks 
 like those of wine lees, which correspond to the veins, of which 
 the course is very marked upon the back of the hand and up to 
 the middle of the forearm, to a height which is quite symmetrical 
 on the two sides. At the same instant the fingers present that 
 insensibility of which I have previously spoken. The attack 
 lasts so long as the patient does not take the precaution of warm- 
 ing artificially the suffering parts ; it reappears indifferently by 
 day or night, and rarely a day passes without her experiencing 
 these symptoms. When she exposes her limbs to heat, every- 
 thing returns in order, but very slowly ; then the circulatory 
 troubles seem to disappear, the sensibility returns completely, 
 the black tint is effaced, but there remain traces of lines like 
 wine lees over the fingers, the hands, and the wrists, as well as 
 oedema, and here and there patches which seem to announce 
 a relapse. 
 
 This is not all ; bullae are formed at intervals on the extremi- 
 ties of the fingers, upon the pulp which is situated at the end of 
 the phalanges, and they are formed in this way : upon a single 
 digit, or upon two digits at a time, the epidermis is raised by 
 pus, so as to imitate a bulla, which develops, breaks, and leaves 
 the derma naked. Eight days afterwards a cicatrix is formed, 
 and this morbid process is repeated elsewhere. In front of the 
 nail there is found a conical tubercle, upon which the nail, per- 
 fectly healthy otherwise, comes to press. The pulse is feeble, 
 but veiy perceptible along the course of the brachial, radial, and 
 ulnar arteries. These vessels are compressible, as well as the 
 veins of the upper limbs, and in no sense give any sensation of a 
 cord whose calibre is contracted. 
 
 In one word, we found nothing abnormal either in the heart 
 or in tbe general circulation. The examination of the principal 
 organs only gave negative results. The general condition, how- 
 
CASES. 57 
 
 ever, left much to be desired. Formerly she had been robust 
 and stout, to-day she showed all the marks of confirmed anaemia. 
 
 To omit nothing, I will add that' shortly after her admission 
 into the hospital a large abscess formed under the sternomastoid. 
 It was extensively incised, and the finger introduced by the 
 opening penetrated into a deep cavity, so that the transverse 
 processes of the cervical vertebras could be touched. After this 
 operation the abscess healed as if by magic. The treatment was 
 limited to the continued use of the same means which had previ- 
 ously benefitted her (iron, meat, wine), but on the whole without 
 any marked results. Nevertheless the patient went out of the 
 hospital once more improved, but not cured. 
 
 In the course of 1859 she was in the Charite for a short time, 
 under the care or M. Briquet. Almost the same symptoms, the 
 same alternations of cold and heat of the fingers were observed. 
 In addition, there was discoloration of the skin and of the 
 mucous membrane, extreme feebleness, buzzings in the ears, a 
 little deafness, vision troubled, small appetite, and constipation. 
 No murmur was audible over the heart or the vessels of the 
 neck ; menstruation was slight and very irregular. 
 
 When in the month of April, 1860, an analogous case pre- 
 sented itself under my observation, I recalled the history of this 
 unfortunate young woman, and I wished to know what had 
 become of her. 
 
 After long searching I discovered her. She was in frightful 
 privation. Incapable of working she had exhausted her last 
 resources, lived on a few alms, and had not even nourishment 
 sufficient for each day as it came. I decided to admit her to the 
 Necker Hospital, under the care of M. Vernois (Salle Saint 
 Anne). There we learnt what had happened to her. Shortly 
 after leaving the Charite she had had modified small-pox, for 
 which she had been treated at the H6tel Dieu. In the month of 
 January, 1860, she had had, on the news of the death of her 
 father; a violent attack of "nerves," which had left her uncon- 
 scious one -night. This crisis, added -to her miserable circum- 
 stances, had profoundly altered her health. Three weeks before 
 her admission to the hospital she had had a series of attacks of 
 epista-xis, which had ended in wearing her out. For several 
 months the catamenia had been suppressed. 
 ; I examined her hands. The fingers presented indeed the 
 
58 Raynaud's original thesis. 
 
 same bluish violet colour which had previously struck me, but 
 it was less pronounced and more diffuse. The attacks which she 
 had presented before, and which were so characteristic, had given 
 place to a habitual lowering of the temperature of the extremities. 
 But there was to be seen on the pulp of all the fingers a crowd 
 of whitish, depressed cicatrices, somewhat analogous to those 
 which are disseminated on the forearms of blacksmiths ; these 
 were the traces of numerous partial gangrenes, which had succes- 
 sively affected the different digits. We were also the witnesses 
 of one of these attacks of gangrene. About one month after her 
 admission into hospital we saw form on the little finger of the 
 left hand, without appreciable cause, a small slough 1 centimetre 
 long, 5 millimetres broad. This sore took five weeks to recover, 
 including the time of cicatrisation. The extremities of the toes, 
 which had never been anything like so bad as the fingers, were 
 nevertheless withered. 
 
 The following is a summary of the condition of the principal 
 functions : colour of face and of body excessively pale, and of a 
 waxy yellow; mucous membranes discoloured; deafness very 
 marked ; extreme feebleness ; inappetence ; constipation ; fre- 
 quent vomiting ; very soft murmur over the heart region ; liver 
 large, extending from the fourth rib down to the false libs ; 
 spleen increased in size, easy to be felt below the thoracic mar- 
 gin, but difficult to define by percussion ; pulse small, soft, but 
 quite regular ; nothing abnormal in the respiratory system ; 
 slight oedema of the lower limbs ; feebleness, and mental weari- 
 ness. 
 
 From the day of her admission up to her death this woman 
 presented nothing special except a slow and progressive enfeeble- 
 ment. In vain was she treated with every possible care. In 
 vain was every kind of tonic and stimulant squandered upon her. 
 In spite of the excellent hygienic conditions in which we endea- 
 voured to place her, nothing could re-animate this profoundly 
 exhausted organism. In the last part of her life vomiting 
 became incessant. She ended by succumbing in the last stage 
 of cachexia, on the 25th July, 1860. 
 
 It would have been desirable that a chemical examination of 
 her blood should have been made. But her extreme ansemia 
 not permitting such an examination, we were obliged to content 
 ourselves with placing under the microscope a few drops of blood 
 
CASES. 59 
 
 extracted by the prick of a pin. The red corpuscles were much 
 diminished in number. The white corpuscles were present in 
 the proportion of 1 to 15 or 20 red, and ultimately they were 
 in the proportion of 1 to 5. 
 
 The autopsy was made with the greatest care. I have borrowed 
 the details from M. Simon's thesis : — 
 
 Body ex-sanguine, pale ; spleen, length, 20 centimetres ; 
 breadth, 12 centimetres ; thickness, 6 centimetres ; weight, 1 
 kilogramme. 
 
 Liver, antero-posterior diameter, 24 centimetres ; transverse 
 diameter, 24 centimetres ; thickness, 8 centimetres ; weight, 3J 
 kilogrammes. 
 
 Mesenteric glands pale, larger than normal, but only few in 
 number. Nothing abnormal in the intestine or in the lungs, 
 which show great discoloration. The pleural cavities contain 
 several spoonfuls of yellow fluid, no adhesions ; the kidneys, a 
 little enlarged, are pale, but not granular ; the pericardium con- 
 tains a little fluid ; the heart is of good size, but presents pale 
 and soft fibres, and contains dark diffluent currant jelly clots ; 
 There exists much fat over the heart, as also in the subcutaneous 
 cellular tissue. 
 
 Uterus healthy and small, with a small extra-uterine fibroid 
 attached to it ; the brain shows nothing special. 
 
 Further examination of the spleen by M. Simon gave the 
 following results : — 
 
 It capsule is thickened, opaline, difficult to strip off; on 
 section the spleen substance is of firm consistence, elastic, like 
 caoutchouc, and allows the finger to penetrate it with difficulty. 
 To the naked eye and with a lens one distinguishes very easily 
 that a red vinous coloration is present over the whole section, 
 on which stand out the trabecule and an infinite number of 
 marblings, patches of yellowish white, half to one millimetre in 
 diameter, rounded, some angular, and placed at a very short 
 distance from one another. 
 
 This spleen tissue cannot be compared with anything more 
 justly than that of a liver attacked with advanced cirrhosis. 
 With the microscope, besides deformed and scanty red cor- 
 puscles, and very abundant white corpuscles, we find in the 
 splenic tissue much fibro-plastic material, many fusiform fibres, 
 cells, and nuclei. 
 
60 Raynaud's original thesis. 
 
 This hypertrophy is not a simple one, it is accompanied- by 
 infiltration of plastic lymph unequally diffused. The small 
 patches seen on section before referred to are Malpighian bodies 
 altered, infiltrated with lymph, and containing many white 
 corpuscles. 
 
 I shall complete this pathological description by adding that 
 the arteries were healthy and patent. Having detached from 
 the body one of the upper limbs, I introduced into the brachial 
 artery a vermilion-coloured injection, and neither in the calibre 
 nor in the shape of the arteries which arose from this trunk, and 
 which I dissected with care, could I discover anything. which in 
 the way of material obstacle to the blood current could explain 
 the production of this strange malady. 
 
 This case amongst those which I have personally observed 
 being the only one which was completed by microscopic examina- 
 tion, I ought in the first place to state what was suggested by 
 the results of the autopsy. 
 
 As we have seen, the results are absolutely nil in so far as the 
 circulatory system is concerned. The heart was of ordinary size 
 and extremely flabby ; but there is nothing in this fact which is 
 not common to a crowd of very different pathological conditions, 
 and it ought not to surprise us after the long and profound 
 exhaustion from which this patient had suffered. We may say 
 as much with regard to the excessive fatty envelopment (I do 
 not say degeneration) of this viscus. 
 
 The complete integrity of the arteries is not less remarkable. 
 There was no appreciable narrowness of these vessels. The only 
 interesting lesion is the enormous size of the spleen and its 
 fibrous structure. It is especially this consideration which has 
 led M. Simon to consider Anna B.'s case as one of leucocy- 
 thsemia ; and it is certain that taking this word in its etymo> 
 logical sense, the relative abundance of white corpuscles would 
 justify its being quoted as an example of the disease. But the 
 point is whether leucocythsemia is indeed a disease properly 
 so-called. Without entering into a discussion upon this 
 burning question, I will only say that what has been described 
 under this title of late, has seemed to me to be only a 
 condition (real no doubt, but also probably very common) of the 
 liquids of the organism, an ultimate condition which has only 
 an anatomical signification, and to which many cachexias of 
 
CASES. 61 
 
 most diverse nature can tend. This is indeed precisely the 
 way in which the author whom I have just quoted regards it. 
 Thus far I am in harmony with my colleague. If 1 diverge 
 from him it is when he appears to consider the affection of the 
 extremities as one of the symptoms of leucocythsemia. Is it not 
 more rational to admit that in this case, the primary fact was a 
 profound trouble of nutrition, the cause of which was inex- 
 plicable, but the manifestations of which were on the one side 
 local asphyxia and superficial gangrene of the extremities, and 
 on the other side aglobulia, leucocytosis, hypertrophy of the 
 spleen and of the mesenteric glands ; the whole of which ought 
 to be placed upon one basis ? And if we must assign the order 
 of appearance of these different phenomena, . it is probable that 
 the establishment of the cachexia was much' posterior to. the 
 symptoms relating to the extremities, and that: the free nose 
 bleedings which characterised the month of March, 1860, were 
 only the first symptom of the congestion of the liver, and 
 perhaps also of an already advanced alteration of the. blood state. 
 The various disturbances of innervation shown by this patient 
 were intimately allied to anaemia ; the deafness and the mental 
 disturbances differed in no respect in this case from what one 
 observes in many chlorotic subjects. Let us note that the only 
 improvement at all definite, was. obtained by. the. prolonged use 
 of all kinds of tonics, so that in spite of the fatal issuedt would 
 ^appear that tonic treatment was the proper indication. i 
 
 In this case once more the local state presented, several special 
 •features worthy of attention. This woman was one of. those 
 who present in a very high degree, those marblings analogous to 
 what are found in persons who habitually use foot-warmers, a 
 certain indication of a venous stasis. Her sensation: .presented 
 during a certain, time an odd character which is not , very rarei; 
 I refer to complete anaesthesia and analgesia coinciding :. with 
 integrity of the sensation for temperature. 
 
 To the tapering form and shrivelling up of .the ends of the 
 digits was added a remarkable tendency to the formation of bullae, 
 which affected not only the epidermis but also the most superficial 
 layer of the true skin, as attested by the numerous small whitish 
 depressed cicatrices. We must in pathology take note of shades 
 of difference; if there is. not identity there is at least much 
 ■analdgy between the preceding case and the following. I owe 
 
62 kavnaud's original thesis. 
 
 this case to the kindness of my excellent master, Dr. Guhler. 
 He has been so good as to add some observations, which I repro- 
 duce with the more pleasure because they support my own view 
 with the weight of a considerable authority. 
 
 ' The part played by arteritis and arterial obliteration in the 
 production of the spontaneous gangrene which is called senile is 
 probably less than we think.' ' Such at least is the opinion which 
 I have endeavoured to set forth in my Lectures on General 
 Pathology (1858 — 59).' ' One fact amongst others of which I was 
 witness sixteen years ago at the Salpetriere convinced me of the 
 necessity of taking note of other conditions than the suspension 
 of the course of the arterial blood in the pathology of dry gan- 
 grene.' 'An old woman in the infirmary, under the care of one 
 of my masters, M. Natalis Guillot, had suffered for several days 
 from pains in the lower limbs.' ' It seemed to her, as she. expressed 
 it, that dogs had been set to gnaw her feet, and already we ascer- 
 tained that there was chilling of the lower extremities , and a 
 cyanotic tint of nails and skin, sure indices of approaching 
 mortification.' 'Nevertheless the dorsal arteries of the feet' and 
 the posterior tibials pulsated as usual, and they presented no 
 obvious modification of structure.' 
 
 ' This was still the case for one or two weeks longer, although 
 
 the tearing pains persisted to the same extent in spite of treat- 
 
 .ment, and the cyanosis and cooling became day by day more 
 
 pronounced.' ' Finally sphacelus commenced, followed the usual 
 
 progressive course, and soon brought the patient to the grave.' 
 
 ' In! this case arterial obliteration, at least obliteration of the 
 ' arteries of a certain calibre, not having preceded, but having on 
 the contrary succeeded the phenomena of mortification of the 
 tissues, it is evident that one ought not to attribute the mor- 
 tification to interruption of the blood current in such arteries.' 
 ;. 'I had an impression that the mechanical obstacle might 
 exist in a multitude of small canals at the same time, that the 
 hsemoplastic coagulation might have started in the capillary net- 
 work, passing thence to the arterioles and the arteries of a larger 
 Calibre.' ' However this may be, the coagulation- itself was only 
 a secondary phenomenon, of which the probable cause was to be 
 found in modifications in the, circulation, and calorification of the 
 affected regions brought about by nervous disturbances.' 
 
 ' Theneuropathic element would, according to this view, play an 
 
CASES. 63 
 
 essential part not only in the sphacelus of ergotism but in the 
 senile gangrenes.' ' A case which subsequently came under my 
 notice, and which I described to the Societe medicale des hopitaux 
 and also to my class, confirmed me in the opinion which I had 
 formed respecting the importance of the nervous system in the 
 production of certain spontaneous gangrenes.' ' The following 
 is a summary of it ' : — 
 
 Case X. — Neuralgic pains in the four limbs, more violent on the 
 right side, especially in the foot and the leg ; gangrene of the 
 second right toe limited to the ungual phalanx ; elimination 
 of the slough. Death from exhaustion. 
 
 Mile. X., native of the south of France, of a moderately strong 
 constitution, with a temperament predominantly lymphatic and 
 nervous, enjoyed up to the age of 40 years fairly good health. 
 When 20 she had given birth to a female child. No definite 
 evidence could be obtained that she had had syphilis, although 
 some circumstances of her life rendered this possible. As to 
 the hereditary antecedents I ascertained nothing more than the 
 existence of paralysis agitans in the father of the patient. In 
 1853 Mile. X. began without known cause to feel pains in the 
 limbs, which soon became sufficiently intense to spoil her sleep. 
 Nevertheless being in want, she at first neglected her health, 
 and whilst suffering these pains she came to Paris in the hope of 
 finding occupation there." Mile. X. had in fact a certain talent 
 as a sculptor. Her hopes were not realised, and the disease 
 making progress she applied to my regretted master, Dr. 
 Lallemand, whom she had known as professor of the faculty at 
 Montpellier. Lallemand, already suffering himself, entrusted 
 me with the care of treating this poor woman after having 
 visited her for awhile, and took me for the first time to see 
 her on the 3rd August, 1853. For more than six months the 
 pains had been intense and all but intolerable. They affected 
 the four limbs, but to a greater extent the lower than the upper, 
 and the right limbs more than the left ; they were also more 
 violent by night than by day. The patient was extremely thin, 
 not only by loss of fat, but also by the muscular wasting, which 
 was very pronounced. Her countenance was expressive of suf- 
 fering; her colour was yellowish; the cheeks, nose, and fore- 
 head were covered with tubercles of acme rosacea. Seated in 
 
64 Raynaud's original thesis. 
 
 bed, the body leaning forward, the lower limbs flexed and 
 drawn up towards the hands, she rubbed without ceasing one 
 or other leg, the right principally, whilst agitating the trunk 
 by alternate movements of flexion and straightening, and giving 
 utterance each moment to a continued moan or to a rending cry 
 extorted from her by the violence of the pain. It was thus that 
 the unfortunate creature passed sometimes the greater part of 
 the day and night. At times the crises were appeased, a little 
 calm returned, Mile. X. took a little nourishment, and allowed 
 herself to gain a ' little relief by sleep ; but soon roused again 
 she found herself a prey to the same tortures as before. 
 Examination of the principal viscera revealed no organic lesion 
 or tumour either- in the cavities or on the surface of the body, 
 not even the trace: of an exostosis. The principal functions 
 were performed regularly during the intervals of the. neuralgic 
 paroxysms, and if the general strength was diminished the motor 
 power was at least only slightly lessened even in the right lower 
 limb, which was principally affected. Gold water, general baths, 
 antispasmodics, pf all sorts, and narcotics in ordinary doses-only 
 having produced a momentary improvement, I attempted the 
 employment of sulphate of quinine, with a success of too short 
 duration to justify its continuance. Finally discouraged, I 
 renounced; all fresh attempts, contenting myself with prescribing 
 stronger and stronger doses of extract of opium, of which the 
 patient.took successively: from 10 centigrammes up to 1 gramme 
 and more. Thanks to this narcotisation she barely succeeded in 
 obtaining some remission, in ■. the tortures which, she endured 
 habitually. Many months passed without any fresh incident; 
 but at: the commencement of 1854 I, perceived one day a lilac 
 tint on the second toe of the right -foot, in which the patient 
 experienced the most severe shooting sensations. This toe had 
 been for a long time.the seat of more intense pain than the others. 
 Simultaneously with the appearance of this lilac- colour it was 
 also found that the temperature of the toe was very low, and the 
 capillary circulation was so slow that a white patch .produced by 
 .the pressure of the finger took about hajf a minute to disappear. 
 With, these signs it. appeared certain that the case was one of 
 spontaneous gangrene. Nevertheless the principal arteries of the 
 limb -carefully examined, appeared quite normal ; the dorealis 
 pedis, the posterior tibial, the popliteal and the femoral below 
 
CASES. 65 
 
 the ring presented pulsations as strong as in the corresponding 
 arteries of the other side, and there were no modifications either 
 of form or consistence to be made out. In spite of the appli- 
 cation of warmth and local stimulants the sphacelus became 
 more and more characteristic after a few days, and a greyish 
 dry slough soon formed at the extremity of the toe, occupying 
 a large part of the ungual phalanx. Strange to say the gangrene 
 limited itself to this small region, an eliminative inflammation 
 developed around the mortified tissue, which was detached at 
 length. The loss of substance left a bare surface, at the bottom 
 of which we discovered the phalanx denuded and partially 
 necrosed. Nevertheless the pains were not lessened in severity, 
 and the patient's strength was rapidly becoming exhausted. 
 Mile. X.,. no longer trusting in my treatment, gave herself up to 
 less rational measures. I ceased attending her on the 1st August, 
 1854, but I learnt subsequently that she had succumbed to 
 marasmus in a few weeks. 
 
 ' Here then,' adds M. Gubler, ' we have'a case of gangrene with 
 the absence of any obstacle to the arterial circulation ; it is 
 associated, on the contrary, quite naturally with disorders of in- 
 nervation.' ' By what mechanism ?' ' That is a difficult question 
 to answer.' ' If we believed in the necessity of the constant 
 intervention of the nervous system in the reparation of organs, 
 we might have supposed that in this ease there was a cessation 
 of influence on the part of the trophic nerves.' ' Without going 
 so far, it is rational to seek the cause of the mortification in 
 some morbid condition of innervation whether one admits a 
 local loss of strength in consequence of the pain, or rather 
 attributes the cessation of life in the gangrenous part to an 
 impediment to the arterio-capillary circulation determined by 
 some permanent affection of the vaso-motor nerves.' 
 
 This is the first time that we have met with a clear case of 
 dry gangrene inducing the loss of a portion of the digit. It is 
 to be observed, however, that one toe only was affected ; thus this 
 case, at once more and less complete than the others, is some- 
 what difficult to classify. Nevertheless, when we consider both 
 the integrity of the arterial pulsations, and the distribution of the 
 painful precursory symptoms of gangrene in the four extremities, 
 we are strongly inclined to the view that the gangrene existed, so 
 to speak, potentially in all the limbs, and that some umperceived 
 
66 kavnaud's oeiginal thesis. 
 
 cause, perhaps a simple local irritation, may have determined in 
 the second toe of the right foot a more complete manifestation 
 than in the others. 
 
 III. Symmetrical Gangrene of the Extremities of Benign Form. 
 
 Case XI.* — Syncope and local asphyxia ; gangrene of the skin 
 
 of the extremities; bleedings; cure. 
 
 A countryman, aged 40 years, a thrasher in a barn, who lay in 
 bed No. 70, Salle Sainte Marthe, was attacked in both hands 
 and feet with that rare variety of dry gangrene which some 
 authors have called white. The disease lasted four years, and 
 presented a succession of symptoms which were somewhat 
 remarkable. 
 
 Present state : fingers white, and cold to the touch, like ice ; 
 the extremities of the second and third fingers atrophied and 
 mummified ; the shape of each finger conical, fusiform ; the nails 
 raised up, and showing slight traces of suppuration at their 
 lower border; there is almost absolute impossibility of flexing 
 the digits ; there is complete insensibility of the last phalanges, 
 and a feeling of tingling and of cold in the remainder -of the 
 digits ; skin white and hard, like parchment ; absence of pains,+ 
 and absence of gangrenous odour. The feet present almost 
 the same anomalous conditions, especially a glacial cold to the 
 touch, impossibility of flexion, great difficulty in walking. The 
 ears, the nose, and the lips of this individual present a remark- 
 able want of vitality and of warmth, but to a less degree than 
 the hands. The radial pulse can be felt. The heart beats 
 strongly, and is somewhat irregular. Otherwise the functions of 
 this man are performed perfectly ; he does not consider himself 
 ill, and but for the impossibility of using his hands during the 
 last four years he would not have come to Paris for treatment. 
 
 Past condition : this illness, we have said, dates back for four 
 years, but it has not been continuous; it has shown itself at 
 certain times of the year, disappearing at others. During the 
 
 * By M. Eognetta, Revue medicate, T. i., p, 368, 1834, This case, obtained from 
 Dupuytren's clinic, is entitled by the author " White Gangrene" — a vicious title in 
 every respect, because this word has an accepted sense ; but the phenomena described 
 have no relation with the white gangrene of Quesnay. 
 
 t It is supposable that there had been pain. — II. 
 
CASES. 67 
 
 great heats of summer it was most frequently present — precisely 
 when the patient was obliged by his occupation to be exposed to 
 the sun. 
 
 During the first year or two this condition of glacial torpor or 
 asphyxia of the fingers only lasted a few days, but the present 
 attack has lasted for four months, in spite of all the remedies 
 which have been employed. "Whenever the affection does not 
 disappear spontaneously, nothing can make the fingers become 
 warm. 
 
 The etiology of this singular malady is very obscure. All our 
 questions concerning the nature of the food — and especially as to 
 the kind of bread, fruits, and vegetables of which he has par- 
 taken — have taught us nothing as to the causes of his illness. 
 It is to be remarked that in his occupation as thrasher at a barn 
 this individual has been exposed to severe changes of temperature. 
 Otherwise he had always enjoyed the best health. Moreover, 
 does not the form of this affection authorise us to consider the 
 illness as a veritable asphyxia, due to some internal cause, in 
 which the life of the digits, without being completely extin- 
 guished, is found, so to speak, in a state of coma ? 
 
 Considering the illness in question as an affection of the 
 extremities of the capillary arterioles of the fingers (which would 
 only itself be a symptom of a disease of the heart), M. Dupuytren 
 employed for it the treatment which he usually employs against 
 senile gangrene (bleeding from the arm, local poultices, mode- 
 rate regimen). In eight days of this treatment the heat, the 
 colour, the motility, and the life of the hands and feet of this 
 man returned as by magic ; the fingers seemed even to have lost 
 a part of that conical form which they had had before the treat- 
 ment. The patient was counselled to have recourse to the same 
 remedies if the affection should reappear at a later period. 
 
 M. Bognetta accompanies the record of this case with the 
 following remark: In medicine especially, we may say with 
 Voltaire, that "Systems are like rats, which can escape by 
 twenty different holes, and find at last two or three which will 
 not admit them." Here, however, is one of those cases in which 
 for the hundred and first time the theoretical views of M. 
 Dupuytren on spontaneous dry gangrene are applicable without 
 any restriction, and are followed by success. What is to be 
 thought of this ? We must be strongly prejudiced in favour of 
 
68 Raynaud's original thesis. 
 
 the views of the master if we find here a confirmation of the 
 doctrines of Dupuytren, the great apostle of arteritis, as every 
 one knows. I may perhaps be accused of prejudice in the oppo- 
 site sense, but it seems to me that the " system," of which I do 
 not deny the intrinsic value, has undoubtedly in this case met 
 with a " hole " through which it cannot pass. In any case it 
 must be admitted that the success of the general bleedings (if it 
 is indeed to them that we must attribute the cure) would not 
 suffice to establish the existence of an arteritis. 
 
 I now record two cases which I observed at the Hopital des 
 Enfants Malades, the one in 1860 during my internat under M. 
 Bouvier, the other quite recently in M. Koger's ward. These 
 two cases require to be compared one with the other, because 
 they are mutually complementary. I shall be pardoned, on 
 account of their importance, for the minute details into which I 
 have entered relating to the local state of the diseased parts. 
 
 Case XII. — Local asphyxia and superficial gangrene of the skin 
 
 of the lower extremities ; traces of the affection in the upper 
 
 limbs. Recovery. 
 
 Georges G., 3£ years old, admitted May 16, 1860, to the 
 Hopital des Enfants, under the care of M. Bouvier. 
 
 A puny child of brown skin and extreme emaciation, with 
 frontal bosses much developed, cheeks hollowed, aspect of the face 
 somewhat singular ; on the first look one would regard the child 
 as an idiot, but on getting him to talk we find that this is not 
 the case. His parents are healthy, there is no evidence of syphilis. 
 The child has a sister who was attacked with scurvy at Lyons 
 during the inundations of the Loire, and who has now vertebral 
 disease dating from when she was 18 months old. 
 
 He remained out to nurse up to 3 years old in the Depart- 
 ment of Cevennes; he was weaned at the age of 7 months. 
 From that time his nourishment was that of the peasants of the 
 district; it consisted in chestnuts boiled in milk, very black 
 bread, made chiefly of buckwheat, and with a certain proportion 
 of rye (about which one could never ascertain whether it had 
 been altered or not), sometimes vegetables, potatoes, rarely meat. 
 He often slept outside with the shepherds. He had never had ague 
 or convulsions; the only illness of which they had any knowledge 
 was a suppurating gland whilst he was being nursed. Since his 
 
CASES. 69 
 
 return to Paris, eight months ago, he has always eaten white 
 bread; he has been, very ravenous. Almost immediately he 
 began to waste, and this has been very marked during the last 
 month. Three weeks ago both legs began to swell, and two or 
 three days afterwards the extremities of the toes became blue, at 
 first clear, then deep, then of an inky colour ; this occurred in 
 both feet. Then on the left side the illness followed a retrograde 
 course, passing through the same phases as in its period of 
 increase, but in a reverse way. But on the right side the lesion 
 became more pronounced ; there was during three or four days a 
 slight blue tint of the extremities of the fingers of both hands, 
 well marked, especially over the nails; he had no affection of the 
 nose or of the ears. Whilst these symptoms lasted there was 
 some prostration. The child groaned, complained much during 
 the night, without referring specially to pains in the extremities. 
 His father, who examined his pulse, found it irregular and 
 intermittent. The extremities were cold ; there was no fever. 
 
 There were now ten or twelve days during which the blue colour 
 was succeeded by definitely black patches on the right foot. 
 
 The following note was taken on May 16 : the three first 
 toes present at their extremity, under the edge of the nail, a very 
 limited patch of a bluish black parchment-like character, slightly 
 rough. The anterior part of the nail participates in this colour 
 in consequence of its transparence. The fourth toe presents 
 only a slight coloration under the nail. The lesion occupies the 
 anterior quarter of the little toe, passing behind the nail, which 
 is entirely black. This toe is as black as charcoal; the bits 
 which one detaches from it by scratching, are white. There is 
 nothing similar on the extremities, but there is a small eschar 
 in process of cicatrisation over the point of the coccyx. 
 
 Pulse perceptible in the femorals, the dorsalis pedis, even on 
 the diseased side, and in the two radials. The pulse, which is 
 96 in the minute, presents remarkable irregularities. Every 
 three or four, sometimes every ten pulsations, there is a slight 
 retardation; sometimes thirty pulsations take place regularly, 
 then occurs an intermission ; besides this there are moments 
 when the pulse is very sensibly accelerated, and then becomes 
 slowed ; it varies also in force. When the radial pulse and that 
 of the dorsalis pedis of .the diseased side are examined simul- 
 taneously there is found from time to time a perceptible pulsa- 
 
70 Raynaud's original thesis. 
 
 tion in the first of these two arteries and not in the second. 
 Vice versd, there is more rarely a pulsation which is more feeble 
 in the radial than in the dorsalis pedis, but I have never found 
 it fail entirely in the radial. Auscultation of the heart furnished 
 nothing remarkable beyond the intermissions corresponding, with 
 those of the pulse ; auscultation of the lungs gave nothing 
 abnormal. 
 
 May 23. — The child has fever and prostration. On examining 
 it we find a large inflamed gland under the sterno -mastoid of 
 the left side. This abscess was opened eight days afterwards. 
 A second abscess formed in the neighbourhood was similarly 
 opened, and recovered rapidly. 
 
 As to the affected foot, this was the condition on the 5th 
 June : all around the black patches the epidermis is raised for 
 a breadth of about half a centimetre, and completely detached. 
 On the big toe the slough has fallen, and is replaced by a 
 delicate rosy epidermis. The nails just preserve a very slightly 
 dark tint. The fourth toe, which had no slough, is desquamating 
 like the others. 
 
 June 12. — All the toes are entirely clear except the fifth. 
 This subsequently became quite healthy, and the child quitted 
 the hospital, July 5, in very good condition. 
 
 I had news of him on December 12, 1861 ; he lived at 
 Orleans ; had not been ill since leaving hospital, was strong, and 
 developing rapidly. 
 
 Case XIII. — Local Asphyxia ; superficial gangrene of the lower 
 
 limbs with very marked tendency to symmetry. 
 
 Cecile B., Q\ years, an orphan, admitted November 28, 1861, 
 under M. Eoger. 
 
 We have no information as to the illnesses of which the parents 
 died. The patient has a brother aged 10 years, who is healthy. 
 Born at Versailles, she left that town after the death of her 
 parents four years ago. She lived some time at Paris, then at 
 Bourg-la-Beine. Since the end of last summer she has been 
 with the Sisters of St. Andre at Ivry. In these different resi- 
 dences she has always had good food, and has never eaten 
 anything but white bread. Hitherto she has only had slight' 
 indispositions; she is very subject to colds in the head; she 
 had ringworm for one year, which lasted up to a month ago. 
 
CASES. 71 
 
 She is in good condition, and has the signs of the lymphatic 
 temperament; bluish ' cornea, long eyelashes, very red cheeks, 
 and is fairly intelligent. 
 
 November 28. — About eight days ago she began to feel pains 
 in the feet, and up the lower half of the legs ; at the same time 
 the ends of the toes became violet or red. It was believed at first 
 that these were due to chilblains, the more so that she always 
 suffered badly from chilblains during the winter, and required 
 special dressings for them. Nevertheless there has been no 
 excessive cold this year, the child has not been exposed to a low 
 temperature, and her feet have always been washed in hot 
 water. 
 
 The pains becoming more and more intense she was taken to 
 a doctor, who recognised the gangrene, and considered it neces- 
 sary that she should be admitted to a hospital. On the day 
 of her arrival she suffered a great deal. In the evening, in order 
 to soothe her, poultices were applied ; far from being relieved 
 she passed a very bad night, and had some fever. 
 
 Actual condition. Eight foot : on the great toe a livid red 
 patch of the size of a 20 centimes piece ; behind this, and upon 
 the inner surface of the pulp, another similar patch. Areola of 
 a livid red, 1 centimetre broad, around the base of the nail ; on 
 the second and third toes very small red patches on the dorsal 
 aspect of the two last phalanges ; the fourth toe is darker, of a 
 slaty colour, not becoming pale on pressure, passing into red 
 near the base of the toe, and this shade is continued up to 3 
 centimetres backward ; little toe of a sombre red. 
 
 Left foot : broad violet patch occupying two-thirds of the 
 pulp of the great toe, epidermis slightly raised; second toe 
 healthy ; third presenting a black patch on the plantar surface, 
 and redness on the dorsal surface ; on the fourth a broader 
 patch, slate coloured, with a completely black area in the centre ; 
 it extends for a short distance ; almost nothing on the fifth. 
 
 The gangrenous spots are insensible, but the patient dreads 
 the concussion which results from the least touch. Arterial 
 pulsations very perceptible and regular in the dorsal arteries of 
 both feet, in the posterior tibials, as well as in the popliteals and 
 tumorals. 
 
 The tension of the abdomen prevents our feeling the aorta. 
 Pulse 100 to 102 ; skin cool ; nothing abnormal with respect to 
 
72 baynaud's oeiginal thesis. 
 
 the heart ; on the outer side of the right middle finger, but not 
 at the extremity, there exists a small bluish patch, surrounded 
 by an inflammatory areola, and which resembles in appearance 
 a scrofulous lesion of the skin. 
 
 November 30. — The same condition. To-day we note in 
 addition, symmetrically under each heel, a livid patch of the 
 breadth of half-a-franc piece ; on the left there is in addition a 
 second extremely small patch, situated at a little distance in 
 front of the first. M. Koger ausculted and percussed the heart 
 region, and discovered nothing abnormal. 
 
 December 2. — Nothing new ; the pains continue, especially at 
 night ; good appetite, no diarrhoea ; symmetry in the lesions of 
 the extremities is more pronounced. 
 
 December 4. — She has had again sharp pains in the night ; 
 the lesion is at its maximum on the fourth toe of each foot ; the 
 pulp is hard, shrivelled, black like charcoal ; this is more 
 marked on the right than on the left side ; then come the two 
 great toes, which present, one on its dorsal surface, the other on 
 its plantar surface, more or less extensive bullae. The second 
 and third toes present only insignificant excoriations, and on the 
 left side a thick inspissated liquid somewhat like plastic lymph 
 oozes out between the toes. 
 
 December 6. — The pains have ceased ; the mortification is now 
 well limited. 
 
 December 7. — Urine, specific gravity 1022, no trace of sugar. 
 No reduction with Fehling's solution, no brown coloration by 
 caustic potash. 
 
 December 9. — The pains have not reappeared. On the right 
 side the red tint at the base of the fourth toe has been followed 
 by a faded leaf colour ; the skin there is parchment-like ; the 
 great toe presents fine brown marblings. 
 
 On the left side the broad bulba of the great toe has withered 
 up. The gangrene of the fourth toe is still more pronounced. 
 
 Up to the 15th the symptoms continued to improve, so much 
 so indeed, that on that day the child could raise herself, and 
 walk easily. 
 
 December 18. — The toes are desquamating freely; from 
 several of them broad dry brownish pellicles can be partially 
 separated. "Where these small superficial eschars have greater 
 thickness we find the derma underneath of a pale violet tint. 
 
CASES. 73 
 
 On further examination it is clear that the rows of papillae have 
 undergone some loss of substance, and are less obvious than 
 those in the neighbourhood. There is desquamation over both 
 heels ; the livid patches previously noted have disappeared ; there 
 is slight desquamation of all the fingers of the right hand. 
 
 December 23. — The black slough of the fourth right toe, 
 which was the largest of all, and from under which pus has 
 oozed for several days, is now completely detached ; on its 
 removal fleshy granulations are to be seen. 
 
 December 28. — The superficial wounds suppurate, and tend 
 rapidly towards cicatrisation. 
 
 The child went out cured January 18, 1862. 
 
 Eeturned to the hospital February 12. During the day of 
 the 9th, the external temperature being moderate, and without 
 appreciable cause the child began to feel pains in the right foot, 
 but of much less intensity than during the first attack ; these 
 pains lasted three days. The third right toe presents under the 
 edge of the nail a small fringe of livid colour, of which a part is 
 raised in the form of a bulla, and on its dorsal surface there is a 
 little greyish patch ; there are slight traces of mortification in 
 the fourth toe. In the left foot the toes are healthy ; on both 
 heels, and on points symmetrically placed, there exist brown 
 irregular patches to the number of seven or eight on each side ; 
 besides this, one remarks on the plantar surface of the metatarsus 
 a certain number of very small gangrenous patches. Otherwise 
 the general condition is excellent ; the pulsations of the heart 
 are normal as well as those of the dorsal arteries of the feet ; 
 there is no fever ; the appetite is good. This relapse is in one 
 word the diminutive of that which was observed two months 
 ago ; the toes previously diseased present slight honeycombed 
 cicatrices ; everything points to an early cure. 
 
 IV. Symmetrical gangrene of the extremities of grave form. 
 
 Case XIV.* — Gangrene of the fingers of the two hands from 
 syncope and local asphyxia at the epoch of the menopause. 
 Mme. D. came to consult me on several occasions at the end 
 of the summer of the year 1849. She was then 48 years old. 
 
 * By M. Gintrac, Cours theorique et clinique de pathologie interne et de therapie 
 medicate, vol. iii., p. 420. Paris, 1858. 
 
74 kaynaud's okiginal thesis. 
 
 After having had during three years very abundant catamenia she 
 had arrived at the critical age. Some little time afterwards she 
 felt cramps and glacial cold in the fingers of the two hands ; the 
 digits became very pale, the little finger of the right hand 
 showed a patch of less than a centimetre in diameter on the 
 dorsal side of the last joint, but soon afterwards the extremity 
 of the middle finger and of the ring finger became gangrenous 
 and dried up. This malady had progressed very slowly. It had 
 lasted for ten months when I saw this lady. The affected fingers 
 had lost their extremities up to the level of the terminal articu- 
 lation ; cicatrisation had advanced in some measure under the 
 scar. There was commencing gangrene in the pulp of the right 
 index finger ; the left index and middle fingers showed a similar 
 condition equally limited to the pulp. On the scar being detached, 
 the nail corresponding to it was found curved so as to accommo- 
 date itself to the new form of the extremity of the finger. 
 
 The thumbs and toes took no part in the progress of the 
 disease, but the patient felt sometimes prickings in them. I 
 recommended infusion of cinchona bark with a little opium 
 internally, and for external use lotions of decoction of cinchona 
 bark with a little camphorated spirit added to it. 
 
 This gangrene was absolutely dry, without odour, without 
 suppuration or putrefaction; there were neither febrile nor 
 nervous symptom; there was no swelling or redness of the 
 hand or the fingers. The temperature of the affected fingers 
 was a little cool, but almost normal ; the pulsations of the radial 
 and ulnar arteries were easily felt. This woman, who is of a 
 sanguine temperament, with habitual injection of the capillaries 
 of the face, has enjoyed good health. Examination of the heart 
 revealed nothing abnormal about that organ ; there was neither 
 dyspnoea, cough, nor palpitation ; the digestive tract was in 
 good condition. The patient's habitual mode of life was healthy 
 and regular. She had been lowered by previous treatment, but 
 tonics very quickly improved her general condition. Mme. D. 
 was able to attend to her occupations as the mother of a family ; 
 her recovery was quite satisfactory, and her health has been 
 good for the last three years. 
 
 This case interested me very much. My endeavours to ascer- 
 tain the causes of the gangrene were altogether fruitless. If this 
 woman had had any previous illness one might have regarded 
 
CASES. 75 
 
 the mortification of the fingers as a critical and salutary (?) effort, 
 because it proceeded in a benign way, but nothing in the antece- 
 dents authorised this supposition. Although occurring after im- 
 moderate catamenia, this affection did not appear to be an effect of 
 anaemia. Although preceded by tinglings and pains the mortifi- 
 cation was not a purely nervous phenomenon; the patient had 
 never presented ataxic or hysterical phenomena, and subsequently 
 she presented nothing which could have justified the suspicion of 
 a trouble of innervation. There was no evidence of a phlegmasia 
 of the arterioles ; the fingers were from the first pale and cold. 
 
 Finding no alteration in the functions of the solids of the 
 body adequate to the explanation of so singular a condition, I 
 should place its cause in some alteration of the liquids, and 
 especially of the blood. 
 
 I come finally to the case which was the starting point of my 
 researches upon this obscure question of pathology, and which 
 I give as the most complete type of the malady under discussion. 
 
 Case XV. — Local asphyxia of the feet, hands, nose ; dry gangrene 
 of the four extremities, going on to the fall of many portions 
 of the ungual phalanges ; the whole supervening on a recent 
 parturition. Recovery. 
 
 Mme. E. X., aged 27, dark, well built, of a clear complexion, 
 enjoys habitually excellent health. Some tuberculous ante- 
 cedents on the mother's side. Menstruation regular since the 
 age of 14 years ; the catameina last about five days. No serious 
 previous illnesses ; she has had • mild attacks of most of the 
 eruptive fevers ; never any nervous attack ; extreme prone- 
 ness to chilblains. During the summer, the hands are habitually 
 very red ; this was especially marked during infancy ; frequent 
 sensation of dryness at the ends of the fingers, which has induced 
 the habit of often putting the tips of the fingers in the mouth. 
 I think we ought to note these slight predispositions, which 
 seem to indicate an exaggerated susceptibility on the part of the 
 extremities, and which would not merit our consideration but 
 for the grave symptoms which have subsequently supervened, 
 and have recalled these facts, of themselves unimportant. At 
 the end of October, 1859, Mme. X. had her first confinement, 
 which took place very satisfactorily. At the end of three weeks 
 she was in a condition to set out to Italy with her husband. The 
 
76 katoaud's original thesis. 
 
 catamenia reappeared six weeks after her confinement ; but she 
 had only two periods, and became pregnant again. The preg- 
 nancy progressed favourably in spite of much worry. 
 
 Mme. X. returned to France in the month of August and gave 
 birth to a daughter at Paris, November 28th, 1860. She took 
 during her labour about 1£ gram, of ergot. In spite of her 
 good constitution she had no milk after this labour, any more 
 than she had after the preceding one. Three days after her 
 confinement, which had a moderate duration, without severe 
 pains, M. Vernois whilst feeling the pulse, was struck by the 
 marked intermissions which occurred at every 4 or 5, some- 
 times every 8 or 10 beats. He ausculted the heart ; this organ 
 presented nothing special except the intermissions corresponding 
 to those of the pulse. The patient was aware of these inter- 
 missions, which were made manifest to her by a sensation of 
 pulsation in the head ; she assured us she was subject to them. 
 All that we know is that the pulse had not been examined 
 since the first confinement, and that then, there was nothing of 
 the kind. On the eighth day after her confinement the patient 
 was taken suddenly during the night with a choleriform attack 
 of the greatest gravity. There was chilliness, incessant diarrhoea, 
 smallness of pulse, faintness, and abdominal pains. At the 
 same time there was complete suppression of the lochia, which 
 the day before had presented a remarkable fcetor. 
 
 The patient was wrapped in warm cotton wool ; poultices were 
 applied over the abdomen ; internally opium was given in full 
 doses. About seven or eight o'clock in the morning a period of 
 reaction began with fever and moisture of skin. The day passed 
 pretty well ; the serious symptoms subsided ; the diarrhoea 
 persisted still a few days, then became arrested ; the lochia did 
 not reappear. 
 
 Nevertheless convalescence was slow and difficult. The patient 
 complained of great feebleness. At the end of a month she was 
 still in bed, and it was necessary in some degree to compel her 
 to get up. She complained of vague pains in the lower part of 
 the abdomen, and on examination a slight degree of anteversion 
 was found with engorgement of the pelvic viscera. 
 
 February 15. — Feeling much better she got up and went to 
 church for the baptism of her child. She experienced great 
 fatigue from this. 
 
CASES. 77 
 
 February 18. — On^awaking she felt itching at the end of her 
 fingers ; she thought her hands were chapped and put on some 
 gloves, but in the evening sbe found them too tight and felt her 
 hands swollen. The following days the ends of the fingers 
 became a little red and painful; she was obliged to cease 
 playing the piano; she had difficulty in eating; she could no 
 longer sew. 
 
 M. Hervez de Chegoin, who saw her then, on account of the 
 persistence of the uterine engorgement, prescribed iodide of 
 potassium internally and externally. This treatment was com- 
 menced on the 4th of March. The abdominal pains diminished 
 with great rapidity. At the same time the pains of the fingers 
 increased more and more ; the extremities became bloodless, 
 then assumed a clear blue colour, which went on deepening from 
 day to day. The forearms were covered with a lichenoid erup- 
 tion, which might well have been only the result of iodism. 
 The iodide of potassium was suspended on the 16th March. At 
 this epoch the malady affected the whole of the first phalanges. 
 They had a blackish colour, which one could not compare to any- 
 thing better than a finger stained with ink, and from which the 
 ink had been only wiped off superficially. Daring these early 
 days, yielding to the idea of waking up the vitality of the 
 extremities, I persuaded the patient once to plunge her hands 
 into mustard and water. I was frightened when at the end of a 
 few moments I saw the upper limbs up to the forearms become 
 extremely black. One may well believe that I was not tempted 
 to renew this attempt. 
 
 March 22. — The affection progresses every day. Violent 
 pains, absolute impossibility for the patient to use her hands. 
 The extremities of the toes have begun to be painful. 
 
 March 26 and 27. — Pains most severe, returning in crises of 
 an intensity truly frightful, drawing from the patient, who is 
 generally gentle and patient, yells of suffering, depriving her 
 entirely of sleep. There is a sensation of persistent burning 
 with exacerbations without any fixity in the return of the 
 attacks. 
 
 -March 28. — The blackish coloration of the extremities con- 
 tinues its invading march. The: black parts are cold to the 
 touch, covered with a viscid sweat. In one word, it is altogether 
 the aspect of limbs in which gangrene is imminent. The ex- 
 
78 Raynaud's original thesis. 
 
 tremity of the nose presents in its turn a blackish coloration, 
 which is exaggerated during the attacks of pains ; one sees 
 then marked out under the skin at the root of the nose great 
 livid veins with contours badly defined. No pains in this 
 situation; but the patient recalls now that about fifteen days ago 
 the extremity of the nose became painful to the extent of pre- 
 venting her from blowing it. Let us note in passing that just 
 four months have elapsed since the confinement, and that the 
 catamenia have not yet returned. 
 
 March 29. — Consultation, in which Messrs. Vernois, Barth, 
 and Hervez de Chegoin took part. These physicians found matters 
 in the following condition : the black coloration of the hands 
 has attained its maximum ; it occupies the two last phalanges 
 entirely, and has no precise limits ; the nails are entirely black. 
 The heart, which has moreover been constantly examined 
 since the commencement of the illness, presents nothing ab- 
 normal. One can count more than a hundred pulsations 
 without finding the least intermission ; thus the phenomenon, 
 which four months ago gave us the first warning, has completely 
 disappeared. The pulse felt at the radials and ulnars is full 
 and regular. Examination of the brachials at their origin gives 
 the same result. If the two arteries of the forearm be firmly 
 compressed so as to intercept the circulation it produces no 
 change in the coloration of the digits. If the compression be 
 made directly upon the digits it produces at the compressed spot 
 a dead white patch which takes a considerable time to disappear 
 (about one or two minutes). The same phenomena occur as on 
 a healthy limb, but with extreme slowness. This slowness of the 
 capillary circulation does not appear to be related to an obstacle 
 on the venous side, because there is only the slightest possible 
 fulness ; there is no oedema properly so called. There is slight 
 increase of temperature of the wrists and palms of the hands. 
 The severe pain prevents our examining the sensibility com- 
 pletely. It is found that the touch is extremely blunted; she 
 feels as through a thickened skin. Further, she experiences 
 spontaneously odd sensations ; she believes at times that both 
 her fingers are crossed one over the other, although there is in 
 reality nothing of the kind; she " feels the circulation of the 
 blood in her fingers,',' &c. 
 
 The pains begin to be very violent in the feet. Walking is 
 
CASES. 79 
 
 still possible if the toes are raised so as not to touch the ground. 
 The last phalanges of the toes are entirely black save those of 
 the great toes, which present rather a livid greenish colour. The 
 condition of the nose is stationary. There is nothing abnormal 
 about the ears. In the midst of this appalling group of symp- 
 toms the patient preserves a remarkable integrity of the other 
 functions. She eats with appetite and digests well. The colour 
 of the face retains all its freshness, which contrasts strangely 
 with the dark colour of the end of the nose. She is a little dark 
 around the eyes, which is not astonishing after many sleepless 
 nights. Auscultation of the lungs gives only negative results. 
 
 Treatment : Vichy water internally, also a little Friedrich- 
 shalle water in order to keep the bowels well opened. Tonic 
 regimen : meat, Bordeaux wine, quinine wine. To the ex- 
 tremities aromatic fumigations of benzoin. Four or five times 
 daily, frictions with mint water, with a little ammoniacum added 
 to it. (These frictions were employed for several days, and led 
 each time to a temporary but notable improvement of the local 
 state.) Finally, attempts to re-establish menstruation : twelve 
 dry cups to be applied to the inner surface of the thighs ; 
 poultices every night. 
 
 The morning after March 30 the pains of the feet became so 
 intolerable that standing was impossible. The patient passed 
 the night in her arm-chair, finding that the heat of the bed and 
 the weight of the coverlets exaggerated the pains. These follow 
 now a decreasing course in the hands, whilst in the feet they go 
 on increasing. There is still a sensation of severe pungent 
 burning, of which the patient cannot give the precise seat or 
 extent. This same day it is observed that the dark colour of the 
 extremities of the fingers is diminished in extent, and at the same 
 time it is more distinctly limited. All around there is a reddish 
 circle with elevation of temperature ; this is a beginning of local 
 reaction. When the patient succeeds in sleeping two or three 
 hours her sleep is extremely heavy ; on waking she remains ten 
 minutes without knowing where she is. M.Vernois recommends 
 the persons who surround her to wash her face with very cold 
 water as soon as she awakes. This troublesome symptom only 
 lasted two or three days. 
 
 April 1. — In the morning there was a painful attack, which 
 lasted twenty-five minutes, and which surpassed in intensity all 
 
80 Raynaud's original thesis. 
 
 that the patient had previously experienced (this attack was the 
 last) ; it was limited to the feet. During the whole day general 
 irritability carried to the extreme. The patient does not suffer 
 except when the feet are approached. There was fatigue and 
 prostration. In the evening there were some hysterical phe- 
 nomena ; desire to extend the limbs ; involuntary crying and 
 frequent emissions of urine ; urine was extremely clear with an 
 acid reaction, density of 1022, containing neither sugar nor 
 albumen; true nervous urine. 
 
 Local condition : in the hands slaty coloration tending towards 
 green, occupying about the lower third of the last phalanges ; it 
 is limited by a very definite sinuous border, behind which there 
 is an areola of intense red with some heat of skin. The colora- 
 tion of the nails is a little better excepting on the two little 
 fingers, which are still quite black. Aromatic frictions revive 
 these extremities to a slight extent. In the middle of the most 
 diseased part there are small violet patches as big as pin heads, 
 cut off by their colour from the remainder, not disappearing with 
 pressure or friction. These are small eschars completely formed. 
 
 April 2. — Almost the same condition. There have been no 
 severe attacks of pain since yesterday. The inflammatory circle 
 of the hands has gained a little in extent. The toes are entirely 
 black ; at their base there exists very clearly a red areola similar 
 to that of the hands. On the external border of the foot we see 
 livid marblings extending as high as the heel. Along the 
 outer border of the hands, and along the inner border of the 
 feet, there exists a lichenoid eruption characterised by small 
 red plaques scarcely at all elevated and very close one to • the 
 other. 
 
 April 3. — There has been no new attack ; when at rest there 
 is almost no pain ; the patient can assist herself a little in eating. 
 She feels, she says, with the pulp of the fingers as though through 
 a nail. With the right hand the extremity of the thumb is 
 entirely red. The nail of the index finger is rose-coloured. 
 The livid colour of the extremities has become much paler in 
 the three last digits ; it increases in extent from the middle to 
 the little finger, of which two-thirds are still affected. The nail 
 of this last digit is entirely black, save the lunula, which begins 
 to pale. Analogous condition of the left hand to a slightly 
 more pronounced degree. In the feet oedema of the two sides, 
 
CASES. 81 
 
 mounting in the left as high as the malleolus, preserving the 
 impression of the fingers. The nails of the great toes are of a 
 dead -white ; those. of the little toes are rose-coloured; the three 
 middle toes are still more or less hlack and have violet nails. 
 There is a broad zone of a bright red at the anterior extremity 
 of the plantar surface of the foot. Extensive marblings are 
 marked out along the external margin. 
 
 April 4. — On the hands a red-currant colour, limited by a 
 sinuous border, occupies the tips of the thumb and index, which 
 on the preceding days had a slaty colour. In the middle finger 
 only just a few whitish traces of the past condition, The ring 
 finger presents still a moderate amount of greenish white colour. 
 The nail of the little finger is black. 
 
 In the feet the three middle toes are still violet in one half of 
 'their extent,. red beyond. The marblings of the outer border 
 have a better aspect. 
 
 The night has been satisfactory. It was observed that the 
 patient was very flushed during sleep. She has not experienced 
 any more pains. She feels still as though through a glove, but 
 the least touch of the extremities causes an extreme irritation ; 
 she has tinglings similar to tho,se of chilblains. 
 
 April 5. — Consultation, in which Messrs. Nelaton, Vernois, 
 .Barth, Hervez de Chegoin took part. These gentlemen are 
 • unanimous in recognising a considerable improvement, and pre- 
 scribe the continuation of the treatment. 
 
 April 6. — All the nails of the hands are rosy save that of the 
 little finger. On the feet the black coloration of the three 
 middle toes does not pass beyond the first phalanx. It no longer 
 disappears with pressure. The left foot presents blisters on the 
 dorsal surface of all the toes. 
 
 The state of the sensibility now allowing a little more precise 
 examination, we applied a delicate thermometer to the black 
 extremity of the toes^ protecting it from the air; it registered 
 89'6° F. Applied in the same way, and under the same con- 
 . ditions, upon the foot of a healthy person it registered 95° F. "We 
 ; pricked these dark extremities somewhat strongly with the point 
 of a pin. The prick was not perceived, and not a drop of blood 
 issued from it. A prick made on the dorsal surface of a toe gave 
 a little blood. This examined with the microscope presented 
 normal conditions ; dimension of red blood corpuscles 0'0066 mm. 
 
82 Raynaud's original thesis. 
 
 The white corpuscles were present to the number of 10 to 12 
 in the field. 
 
 April 7. — The patient has been able to walk. Urine continues 
 abundant. 
 
 April 8. — The epidermis of the digital extremities of the 
 hands is reddish brown and parchment-like ; on pressing it one 
 feels clearly that it is no longer adherent to the subjacent true 
 skin. On many digits there exist true blisters. The pulp of 
 the little finger has become rosy again, with the exception of two 
 or three millimetres at the tip. The nail is only partially black, 
 and this is a phenomenon of transparency, because the free edge of 
 the nail is of a natural colour. On the two feet there are large 
 blisters. It is worthy of remark that at this period of, the 
 disease, that is to say, more than three weeks after the com- 
 mencement, the nails of the diseased parts have not pushed' 
 forwards at all, and have exactly the same length as at the 
 commencement. 
 
 April 10. — The right thumb has recovered almost all its 
 sensibility. In the other digits the feeling is blunted, and there 
 is still the sensation of things being felt as though through 
 parchment. Several digits are diminished in size at their ex- 
 tremities and shrivelled ; they look as if they had been for a long 
 time compressed by a ligature. The extremity is very much 
 tapered off. On the feet the blisters begin to dry up. The 
 second and third toes are very black ; the nails are of a greenish 
 tint. The other toes have lost a little of their dark colour. 
 During the day there were tinglings in the hands. On getting 
 up the patient has much difficulty in walking, especially on the 
 left foot. The oedema of the feet has diminished a little. 
 
 April 12. — Extreme excitement ; the patient does not feel any 
 actual pains, but sensations like small sudden pricks. The hands 
 to-day feel very numb. 
 
 Right hand : desquamation over the thumb and index fingers. 
 On the middle finger a black longitudinal band ; this digit, as 
 well as the ring finger, is as though it had been compressed. 
 On the little finger the nail is quite black. All these extremities 
 resemble parchment. 
 
 Left hand: here are black patches on all the digits. They 
 are shrivelled as though they had been compressed with a 
 string. 
 
CASES. 83 
 
 Right foot: little toe entirely clear. Inner half of the 
 fourth dark; the" pulp of the two following toes dry and black 
 like coal ; on the great toe deep marblings. 
 
 Left foot: the three middle toes are as though they had 
 been charred. The great toe is black in its outer half and 
 presents some blisters. Nothing on the fifth. The two feet are 
 still (edematous. 
 
 To-day the nose has had at times a violet colour. Some 
 small black points have shown themselves on one buttock. Pains 
 referred to the loins and the lower part of the abdomen. 
 
 April 19. — Desquamation is more pronounced. Many blisters 
 have burst. 
 
 Hands : the more external the fingers are, the more they 
 desquamate. The index finger is entirely stripped. On the 
 thumb there remains a small patch above the nail. On the three 
 last fingers there are longitudinal lines well marked, dark and 
 shrivelled. Tinglings excessive. 
 
 Feet : the skin of the two big toes has become deeper 
 coloured. The third and fourth toes begin to suppurate along 
 the limit of the dead and the living, and exhale a bad smell. 
 
 April 27. — In wiping the foot we swept away a broad . black 
 scab from the plantar surface of the second toe. 
 
 May 7. — On waking, the patient perceived that she had lost a 
 few drops of blood from the genitals. ■. The oozing continued till 
 next day. 
 
 May 14. — The catamenia have appeared abundantly enough 
 to make it seem desirable to prescribe a little sirop de Consovde. 
 
 They are now on the decline. The general condition is 
 excellent. Both indices are entirely stripped. The epidermis 
 desquamates everywhere in broad patches. The patient cuts 
 it .off as it desquamates. 
 
 On the feet suppuration continues moderately. They exhale 
 a disagreeable odour. The eliminatory process is the most 
 advanced on the fourth left toe. The nail has fallen some time 
 ago, the slough is ready to become detached. 
 
 June 1. — The catamenia reappeared and lasted until June 9th. 
 On each foot the great toe presents a broad black swelling, which 
 on the right side is in great part detached. The two following 
 toes present shreds completely detached at the lower part and 
 adhering to the nail by their upper surface ; one might call them 
 
84 RAYNAUD'S ORIGINAL THESIS. 
 
 bits of coal placed on the ends of the toes. The toes are clubbed. 
 The two last are healthy, with the exception that the fourth has 
 lost its nail. All the fingers are entirely stripped of epidermis ; 
 some nails are still brown in part. The two little fingers have 
 the lower half completely black. Pus oozes from under the 
 border of the nail. From this time the greatest possible care 
 was paid to cleanliness. In proportion as the dry scabs became 
 troublesome, and we could touch them without pain, we cut them 
 off in order to render walking easier for the patient. Cicatrisa- 
 tion took place at the same time. The last piece (from the last 
 phalanx of the fourth left toe) fell off on the 27th October, 1860. 
 
 The general health continuously improved. Menstruation 
 became regular, the colour became clear, and the patient became 
 fairly stout. 
 
 On two or three occasions this young woman again experienced 
 pulsations in the head with a feeling of fainting. One of the 
 last times that this phenomenon occurred (February 28, 1861} I 
 ausculted her ; the pulsations of the heart presented great 
 irregularities. The day after (March 1st) they became per- 
 fectly normal. Since then her health has been excellent, and 
 •there is no sign of any return of similar attacks. 
 
 To-day (Jan., 1862) the two feet present an exactly symme- 
 trical aspect. At the extremity of the great toe there is a 
 projecting tubercle upon which the deformed nail rests, and 
 around which the skin is raised and covered with scales. 
 The two succeeding toes present a massive stump, upon which 
 small crusts exist which have never disappeared. There is no 
 trace of nail. Pulse perfectly regular. Pulsations of the heart 
 normal. 
 
 A remarkable fact, and which I mention now without offering 
 any explanation of it, was observed in the child born of this 
 woman; three days after its birth we perceived that from time 
 to time the right hand and forearm presented a very marked 
 violet colour, which was not limited, and disappeared afterwards 
 to reappear at a later period without known cause. This con- 
 tinued during the four or five first months of life ; otherwise the 
 little child has been always healthy. 
 
 The considerable length at which I have reported this case 
 frees me from dwelling- upon the details, which were sufficiently 
 .vrinoTml for, such men as Nelaton. Barth. Vernois. Hervez de 
 
CASES. 85 
 
 Chegoin to declare that they had never observed anything 
 similar. I content myself with summing up the most striking 
 features : — 
 
 1. The condition of the pulse, which, although irregular at 
 different periods of the life of the patient, was always normal 
 whilst the illness lasted. 
 
 2. The condition of the heart, which, in spite of functional 
 troubles corresponding to those of the pulse^ presented certainly 
 no organic affection, at least so far as could be ascertained by 
 auscultation. 
 
 3. The remarkable slowing of the capillary circulation during 
 the painful attacks. 
 
 4. The probable influence of amenorrhcea, the return of the 
 catamenia being accompanied by the restoration to health. 
 
 5. The disastrous effects observed after a too active counter- 
 irritation. 
 
 6. The attack affecting all the extremities successively, which 
 excluded the idea of a cause acting simultaneously upon all the 
 vascular trunks. 
 
 7. Finally, the combination at a given moment in the same 
 patient of all the conditions between which I desire to establish 
 the relation from syncope up to confirmed gangrene, and the 
 spontaneous loss of the four extremities of the toes. 
 
 This is another fact of the same kind : — 
 
 Case XVI.* — Dry gangrene of the first phalanges of all the 
 
 digits of both feet and both hands. 
 
 R. M., of Palermo, aged 34 years, of robust constitution 
 and of bilious temperament, had abandoned himself without 
 restraint to pleasure and debauchery, and had contracted nume- 
 rous sypyhilitic affections which had been only partly cured. 
 He was obliged to undergo a considerable amount of hard work 
 and exposure, to which he was not accustomed, and in addition, 
 during the months of September and October, to bivouac out 
 during the night in the districts around Palermo. In the month 
 of October he experienced slight pains, accompanied by numb- 
 ness, in the little finger of the left hand, to which he paid little 
 attention; but in a few hours the toes were affected with the 
 same numbness, without any pain. The patient, attributing 
 
 * By Portal, Archives generales de mtdecine, Annrfe 1836, 2e S&ie, T. xi,, p. 223. 
 
86 Raynaud's original thesis. 
 
 these symptoms to a chill, went to bed and took sudorific drinks. 
 The following day a painful sensation was felt, not only in the 
 fingers but also in the toes, and extending up to the ankle. The 
 pains becoming very severe he consulted a doctor, who took the 
 malady for rheumatism, and prescribed mercurial frictions to the 
 inner part of the thighs. Nevertheless the illness made slow 
 progress ; the pain was especially severe in the radio-carpal 
 articulations. He consulted other doctors, who, having no hope 
 of curing the illness, asked him to call in a surgeon. Dr. Portal 
 was called to see the patient in the month of November ; he 
 recognised a dry gangrene which was ushered in by the above 
 symptoms, with general prostration of strength, without fever ; 
 the countenance as well as the whole body was of a deathly 
 pallor; the eyes were fixed, or rolled languidly in their orbits, 
 then were arrested like those of an idiot, or as if the enfeebled 
 mind of the patient had been struck by some terrifying object. 
 The abdomen was hard and tumefied ; micturition and defecation 
 were not affected ; the ends of the fingers and of the toes from 
 the first to the second phalanx had become as black as coal, as hard 
 as horn, and insensible to touch ; the healthy part, which was 
 contiguous to the gangrenous part, was slightly red. Decided 
 as to the nature of the malady, Dr. Portal prescribed stimulating 
 poultices to the hands and feet. He prescribed internally the 
 following mixture : extract of cinchona 2 drachms, assafcetida 
 12 grains, opium 4 grains, to take in four doses. He prescribed 
 besides 2 ounces of ass's milk every three hours. These orders 
 were only half carried out, which led Dr. Portal to admit the 
 patient to hospital under his care. He continued this local and 
 general treatment during many days, until he perceived at the 
 limit of the gangrenous part that a bright red inflammatory 
 circle was being formed, which indicated that the organism was 
 regaining strength, and that the separation of the dead from 
 the living was taking place. Then not wishing any longer to 
 defer the resection of the phalanges of the fingers and toes, he 
 performed this operation on the 2nd December, using a sharp- 
 edged tenaculum for the toes, and an ordinary saw for the fingers. 
 The wounds were treated at first with dry charpie ; subsequently 
 with Galen's cerate (almond oil, wax, and rose water) and styrax 
 ointment. The patient left the hospital perfectly cured at the 
 end of forty-six days. 
 
CASES. 87 
 
 V. Cases of symmetrical gangrene, with lesions oj the circulatory 
 apparatus, established by autopsy. 
 
 The above completes the list of cases which appear to me 
 clearly to enter into the category with which I am concerned. 
 Before going further, I propose to record three cases more or 
 less analogous to those previously narrated, but followed by 
 autopsy, and in which the lesions found post-mortem seemed up 
 to a certain point to account for the phenomena observed during 
 life. I shall have to discuss subsequently whether these lesions 
 were sufficiently important to play the part in the production of 
 the malady which one would at first be tempted to attribute to 
 them. 
 
 The first of these cases has unfortunately little value on 
 account of the obscurity of the pathological description. 
 
 Case XVII.* — Idiopathic gangrene of the four extremities, 
 
 resembling gangrenous ergotism. 
 
 A woman aged 46 years, a dressmaker, after a dissipated life, 
 had contracted syphilis, for which she had been treated at the 
 Blockley Hospital. When she presented herself under Dr. 
 Henry's observation the gangrenous affection had gone on for 
 two weeks ; it had commenced with a sensation of pricking in 
 the hands and feet. Soon these organs took on a deep sombre 
 eolour. Dr. West, who had seen her at first, thought that she 
 had purpura. 
 
 The following is the description which Dr. Bernard Henry 
 gave of the condition of the patient when she entrusted herself 
 to his care : general subicteric tint, with a marked expression 
 of anxiety; yellow conjunctivae and swollen eyelids; intelligence 
 remarkably clear. The hands and forearms for about a third of 
 their length of a lead-like colour, becoming darker towards the 
 digits, which were flexed on the hand, black, dry, and shrivelled 
 in appearance. 
 
 The feet and lower thirds of the legs presented the same 
 aspect. The extremity of the nose, and the skin covering the 
 two patellae, were of the colour of bronze, and appeared as if they 
 had been painted over with a brush. The tongue was dirty, but 
 presented two reddish brown longitudinal patches. Pulse 80, 
 
 * By Dr. Bernard Henry, Gazette medicate, 1857, p. 323. Translated from the 
 Medical Examiner (American), Dee., 1855 to April 1856. 
 
88 Raynaud's original thesis. 
 
 small and rapid. The diseased extremities presented a glacial cold 
 to the touch, the coloured portions had lost all sensibility, but 
 above the coloured limit they were very sensitive. The cartilages 
 of the ears began to show the same morbid conditions. There was 
 constipation, and the quantity of urine passed was very small. 
 
 The woman succumbed two months after her admission to the 
 hospital, in spite of stimulants, opium, nutritious diet, &c. 
 
 Post-mortem examination showed engorgement of all the 
 venous system by dark, thick blood, whilst the arterial trunks 
 were almost empty. The femoral and brachial arteries were 
 examined, and presented nothing which differed from the normal 
 appearance, except that they were adherent to the bone, and 
 closed at the line of demarcation. Lungs healthy. The heart 
 showed a tendency to fatty degeneration. The liver large, 
 cirrhotic. The other organs were healthy. 
 
 In discussing the nature of the disease in question, Dr. Henry 
 considered that it showed great resemblance, if not complete 
 conformity with gangrenous ergotism, and nevertheless he 
 believed that it was a new affection. Against the view that it 
 was a case of gangrenous ergotism he gives the statement of the 
 patient, who affirmed that she had always had good food, and 
 had never eaten bread of bad quality. In the absence of any 
 other cause Dr. Henry holds that the gangrene declared itself 
 spontaneously as a sequel of the exhaustion of the constitution 
 induced by debauchery. 
 
 What a pity that this autopsy should be unintelligible at the 
 very point which interests us ! What is meant by arteries 
 normal but adherent to the bone, and closed along the line of 
 demarcation ? Was there a clot or only a simple retraction of 
 the vessel on itself ? 
 
 Case XVHL* — Spontaneous gangrene of the two feet. Death. 
 
 Autopsy. Contraction of the mitral orifice and narrowness of 
 
 the arterial system. 
 
 M. Godin showed the arterial system of a woman aged 25 
 years who had succumbed to a spontaneous'gangrene of both feet, 
 brought on without any other cause giving rise to it than an 
 excessive cold experienced during the night of the 25th of 
 December, 1835. This woman had always been thin, and on 
 
 * Taken from the Bulletins de la SociiU anatomiqne, 1836, T. xi., p. 109. 
 
CASES. 89 
 
 seeing her, one might have believed her much older than she 
 really was. When she died, on one side the gangrene was 
 limited to the foot; on the other it had extended up to the 
 malleoli. At the autopsy the abdomen and the viscera were 
 found perfectly healthy, as well as the lungs ; only two or three 
 tubercles of the size of small nuts were found at the apex of the 
 right lung. The heart was remarkable for its small size ; it' was 
 well formed otherwise. There was considerable contraction of 
 the left auriculo-ventricular orifice from induration of the mitral 
 valve. The aorta at its origin was only 2 inches in circum- 
 ference, and progressively contracted, so that its circumference 
 was not more than 1 inch below the cceliac axis and superior 
 mesenteric ; the iliac arteries were in like manner very small ; 
 the femorals were not bigger than the axillary arteries generally 
 are in a subject of the same size ; the anterior tibial and the 
 tibio-peroneal trunk were not three-fourths of a line in diameter ; 
 finally, the peroneals and posterior tibials traced into the 
 gangrene were about the size of the articulars in a healthy 
 subject. Otherwise these arteries were perfectly permeable, and 
 there was no modification or morbid colour in the interior. The 
 venous system was healthy ; there was no oedema. 
 
 M. Godin thought that in this subject the efficient cause 
 (cold), which in any other case would not have had such an 
 effect, sufficed to determine the gangrene ; the contraction of 
 the left auriculo-ventricular orifice, in consequence of which the 
 blood arrived in tbe ventricle in small quantity, and consequently 
 also in small quantity into an arterial system already insufficient 
 to nourish suitably the parts to which it was distributed, also 
 contributed to produce the malady. 
 
 Case XIX.* — Convulsive attacks, spontaneous gangrene of the 
 
 toes, local asphyxia of the hands, complication of pneumonia. 
 
 Death. Autopsy. Contraction of the two auriculo-ventricular 
 
 orifices. 
 
 Abstract. — T., aged 32 years, worker in lace, arrested many 
 times for vagrancy, sent to the Salpetriere, November 7, 1855, 
 on account of epileptiform attacks. Notable alteration of 
 intelligence, incoherence of ideas. 
 
 * By M. Topinard, Bulletins de la Societe anatomique, Ire S&ie, T. xxx., p. 523, 
 ann. 1825. 
 
90 Raynaud's .original thesis. 
 
 Ulcers on the legs for more than two years of irregular 
 progress ; legs warm to the touch, shining, excoriated in some 
 places, and painful. 
 
 November 15. — The pains became much more intense ; bluish 
 livid points appeared on each side around the toes, and soon 
 afterwards on the dorsal surface of the feet ; the legs in their 
 lower two-thirds became cold and cedematous ; pulse irregular, 
 small, frequent, perceptible in all the limbs ; impulse of the 
 heart strong and extended. 
 
 Constipation. 
 
 November 23. — Gangrene had increased ; shreds of sloughy 
 skin had become detached all in a piece leaving a sanious surface. 
 The patient maintained that her upper as well as her lower 
 limbs were dead ; she complained of intolerable pains in them. 
 Around the nails on the dorsal surface of the hand and on the 
 forearm violet marblings were seen. 
 
 On the following days the sloughs became more and more 
 limited to the dorsal surface of the feet. The oedema disappeared, 
 but the general condition became aggravated ; a comatose con- 
 dition came on, subcrepitant rales mixed with crepitant gurgling 
 were heard behind at the base of each lung. 
 
 November 31. — Death. 
 
 Autopsy. — The vessels at the margins of the gangrenous area 
 contain recent clots, but in no part are there to be found free 
 rolled up clots formed manifestly ante-mortem. 
 
 The internal surface of the arteries is of an intense red, 
 uniformly distributed, not disappearing with maceration, the 
 more pronounced as one approaches the heart.* 
 
 No ossification. Venous system filled with diffluent blood. 
 
 Pericardium healthy. The heart is neither dilated nor 
 hypertrophied. Arterial orifices normal. But the two auriculo- 
 ventricular orifices have diminished about three-quarters their 
 normal size by soldering together of the valves ; there is a 
 narrow cleft half a centimetre broad, its lips furnished with 
 small excrescences of cartilaginous aspect. Bed hepatisation at 
 the base of the left lung. 
 
 Without for the moment estimating the value of the cardiac 
 lesions reported by M. Topinard, I will mention only that this 
 
 * Upon the small value of redness of the internal coat as a sign of arteritis vide 
 Laennec, Traite de V Auscultation, T. ii., p. 606. 
 
CASES. 91 
 
 explanation did not appear to satisfy the members of the 
 Anatomical Society. M. Broca drew attention to the absence 
 of vascular lesions, and expressed the opinion that in this case 
 the gangrene was related to some unknown cause, perhaps to an 
 alteration of the blood. The epileptic antecedents of the patient 
 ought to enter into account. 
 
 VI. Appendix. — Doubtful Cases. 
 
 The cases which follow present less and less certainty. Never- 
 theless they are interesting as a group, because they are in a 
 marked degree removed from what occurs in the common cases, 
 and because they may perhaps one day contribute to clear up 
 many obscure points. It is not impossible that we may have 
 here a very advanced form of the malady which occupies our 
 attention. 
 
 Case XX.* — Gangrene occurring each month in a young 
 woman, aged 23 years, at the extremities of the fingers, ears, 
 nose, dtc. 
 
 In 1629, travelling with my brother, Jean Schrader, and 
 Alexander Lak, whilst studying surgery, we found ourselves in a 
 town called Geest, and having entered a hostelry the master, 
 who was called Jean Brandes, made us see his daughter, aged 
 23 years, who was attacked with the following malady : each 
 month she suffered from severe pains in the extremities of the 
 fingers and of the toes, accompanied by (Edematous swelling of 
 the face, feet, and hands ; this was followed by sphacelus or 
 mortification of the extremities of those parts in which the pain 
 was first felt, which became pale, dry, insensitive, nevertheless 
 with no bad smell, and with no humour proceeding from them. 
 These gangrenous parts separated each month in small morsels, 
 which preserved their normal form. Whilst informing me more 
 particularly of the circumstances of this illness, the father of the 
 girl showed me a box in which there were more than a hundred 
 of these morsels of dead flesh, which in the space of three years 
 had been thrown off and detached from the extremities of 
 different parts of the body of this girl. 
 
 * By Bernard Schrader, Collection academigue partie elrangere, T. iii., p. 238. 
 Eph. cur. not., 1773—74. 
 
92 Raynaud's original thesis. 
 
 Case XXI* — A young woman of this town, aged 26 years, 
 having been tormented for a long time with an insupportable 
 heat, accompanied by the most severe pain, in the feet and 
 the hands which all remedies failed to quiet, was advised to 
 plunge them many days running into the coldest water which 
 she could find, renewing it from one moment to another 
 (because it became hot almost as promptly as if it had been 
 over the fire). She continued this manoeuvre during so long 
 a time that gangrene supervened on the parts where she 
 felt the heat and pain, and she lost all the digits of the 
 toes and many of the extremities of the fingers. They succeeded 
 in arresting the progress of the gangrene excepting in the right 
 foot, which it was necessary to remove, but the patient up to 
 the present time has not been willing to have the operation 
 performed. 
 
 Is it not probable that in this case the intolerable pains which 
 appeared at the outset were the initial pains of the gangrene, 
 and that the influence of the cold water only acted as an adjuvant 
 cause ? 
 
 Case XXII. f — "William Chandler, aged 3 years and 7 months. 
 Seen first on January 29, 1839. He was the son of a bargeman 
 who earned about a pound a week. The mother was delicate. One 
 child had died aged 2 months, another was weakly. The general 
 food of the family had been bread and potatoes, with meat two 
 or three times weekly. William Chandler had been weakly from 
 birth but free from any evident disease, and he had run alone at 
 2 years old. When first seen asleep his cheeks were pale but 
 plump. On removal from the cradle his cheeks became rather 
 purple, and a dark livid spot appeared on his nose, which I was 
 informed was the scar of a former slough, but it appeared the 
 precursor of a second gangrenous spot. His right forearm was 
 gone, having been partially amputated by nature at the articula- 
 tion of the radius, though the ulna had been divided lower down. 
 The slough had extended above the elbow joint, where nature 
 seemed to be making a second attempt at amputation from the 
 pale line of ulceration between the living and dead portions 
 
 * By Christophle Hertius, of Nassau, Ephemerides des curieux de la Nature, 1685. 
 t By Mr. Solly, Med. Chir. Trans., vol. xxii., p. 253, 1839, and vol. xxiv., p. 237, 
 1840. 
 
CASES. . ' 93 
 
 of the limb. The whole of the left forearm and about half of 
 the upper arms were in a state of dry gangrene, but there was 
 a distinct line of separation in the upper arm. 
 
 The left foot was completely removed just above the ankle 
 joint, between the epiphysis and the shaft of the tibia and fibula, 
 leaving the extremities of the bone exposed, the soft parts pre- 
 senting a surface healthy and granulating in one part but sloughy 
 in another. On the right foot the. second and third toes had 
 been removed, the stumps having a healthy cicatrix; but on 
 the calf and knee there were livid spots. The pulse in the caro- 
 tids was 140, feeble and easily arrested. 
 
 The action of the heart was more feeble, than natural, but 
 unaccompanied by any unnatural sound. 
 
 The intelligence was good and the child quiets but complained 
 much of feeling cold unless close to the fire. From the mother's 
 account I learned that the disease commenced at the, latter end 
 of last August, both the feet becoming of a blackish purple 
 colour ; that hot flannels relieved them only for a short time. 
 Sloughs began about the beginning of September on the right 
 leg, first above the. heel. These sloughs separated. The sore 
 healed in about a month ; that on the left leg never healed but 
 gradually extended, over the foot; a line of demarcation was 
 ultimately set up. Amputation gradually took place, and the 
 limb was entirely removed. by December 20th. 
 
 The disease began in the left upper arm about the middle 
 of November on the dorsal surface of the wrist.. It followed 
 on the right about a fortnight afterwards, commencing below the 
 ulna, and the ulna was divided on the 18th of January. , But 
 nature apparently not being. able to effect the amputation per- 
 fectly in that spot, recommenced above it. The radius, together 
 with the hand, were separated at the elbow joint on the 26th 
 January. The date of the amputation of the two toes on the 
 right foot could not be ascertained. 
 
 From a surgeon, under whose charge, the patient had been at 
 the outset, Mr. Solly learned that when the child was seen at the 
 beginning of September there were large vesicles on the right 
 foot and forearm, , containing a dark livid fluid. Warm 
 fomentations were ordered, and stimulants internally. The 
 vesicles broke and left a gangrenous. surface, which progressed 
 -vm to the condition previously described. By the end of April 
 
94 Raynaud's original thesis. 
 
 the three stumps had nearly healed and the child's health im- 
 proved, and he was suffering much less pain. 
 
 The sequel of the case published in the 23rd volume records 
 that on July 21st the dry gangrene recommenced in all four 
 extremities, or rather in the remaining parts. The upper stumps 
 were swollen and livid, and indicated a line of separation parallel 
 with each acromion process, and almost circular. The right leg 
 was in the same state up to the middle of the calf, and there 
 was a large patch over the patella and front of the knee. The 
 left leg from the point of the stump to the middle of the thigh 
 was similarly affected. On the right cheek there was a super- 
 ficial eschar. There was an abundant miliary eruption diffused 
 over the whole body, and considerable feverishness. He was 
 languid and restless, with a clean but dry tongue and feeble 
 and rapid pulse. 
 
 August 9. — The soft parts of the left lower extremity below 
 the middle of the thigh came off on the 6th inst. in a dead and 
 shapeless state, leaving the shaft of the os femoris bare, but 
 deprived of its condyles. There is, however, a healthy granu- 
 lating surface on this fresh stump, affording a free purulent 
 discharge. The right foot is nearly detached just; above the 
 ankle joint. On the shoulders the disease has apparently 
 stopped suddenly, as they present merely superficial crusts of 
 gangrene, shortly about to be thrown off. A similar patch has 
 exfoliated from the front of the right knee and is succeeded by a 
 pretty healthy wound. 
 
 September 8, — The child was found dead in his cradle in the 
 morning. 
 
 Post-mortem examination by Mr. Bury showed great emacia- 
 tion, and the skin contained the remains of the miliary eruption 
 in the form of small dried scabs. There was a subcutaneous 
 haemorrhage on the left cheek nearly equal to the size of a 
 shilling. Alike spot was visible on the epigastrium. The stumps 
 of the arms were conical and nearly healed, their apices being 
 enclosed in a small dry crust. The left thigh presented in its 
 middle a small granular surface surrouuding the bone, by no 
 means indicating want of vital action, beyond which the shaft 
 of the bone itself projected undiminished in size or length. In 
 the calf of the right leg there was the same kind of amputation 
 observable, with the tibia and fibula protruding; but the wound 
 
CASES. 95 
 
 was dark and the integuments above were of a deep modena hue, 
 showing that mortification was here re-established and spreading. 
 The wound over the knee was contracted but purple. 
 
 Both lungs were remarkably pale. The pericardium contained 
 a small quantity of clear serum. The heart, beyond some pallor 
 of the muscular walls, showed no structural change. There 
 was dark coagulum in all the cavities, and in all the vessels. 
 Both femoral arteries were remarkably shrunk, being obviously 
 less in calibre than their veins, very pale, and were not patulous 
 on division with the knife. The liver was bloodless, though 
 otherwise healthy, and this may likewise be said of the other 
 abdominal organs. 
 
 Mr. Solly himself dissected the sympathetic in the neck, chest, 
 and abdomen, but the dissection revealed nothing abnormal. 
 The arteries were traced, but nothing abnormal in structure or 
 distribution was found. He thought they might have been 
 rather smaller than natural, but even this was doubtful. 
 
 Case XXIII.* — Pains in the Four Extremities ; appearance of 
 gangrenous patches on different parts of the body; mortification 
 of the two hands. Many relapses. Cure. 
 Abstract. — The case was that of a little girl, aged 3 years, 
 who complained in January, 1803, of very acute pains in all 
 the limbs, and especially in the lower extremities. There was 
 fever, wasting, and appearance on all the surface of the body, the 
 head excepted, of brown patches, which disappeared in the month 
 of April of the same year. Good health up to January, 1804. 
 Then the fever and the brown patches reappeared, and in ad- 
 dition there occurred pains in all the limbs. The last phalanges 
 of the digits of the left hand became black, and in a short time 
 the whole of this hand was affected with gangrene. The 
 malady continued its ravages up to the following June ; the 
 left hand kept attached to the forearm only by a small shred of 
 skin and the tendon of one of the flexors. The last phalanx 
 of the thumb, of the ring finger, and little finger of the right 
 hand were on the point of separating, and two phalanges of the 
 right foot had fallen off. There were many sloughs on the 
 shoulders, on the lumbar region, and on the posterior part 
 
 * By Bocquet, Journal de Corvisart, T. xvi., p. 283, ann. 1808. Extrait du Bulletin 
 piiUle" par le Comite" Central de la Soc^te" de me"decine du department do l'Eure. 
 
96 Raynaud's .original thesis. 
 
 of the right thigh. Slight fever and good appetite. M. Bocquet 
 ended by removing the hand, covering the wounds with pledgets 
 steeped with storax surrounding the limbs, with compresses 
 steeped in ammonia and camphor lotion, and prescribing quinine 
 •wine internally in strong doses. At the end of a fortnight 
 the feet. were in very good condition, and all the gangrenous 
 phalanges were detached. The same treatment was continued ; 
 three weeks sufficed to cicatrise all the wounds, but the left 
 radius and ulna, which had been denuded, only exfoliated in 
 the month of August. There was a return to health and good 
 nutrition. 
 
 In the early days of January, 1805, the symptoms returned 
 and continued up to the month of August, but there, were 
 no sloughs. In the month of January, 1806, the same phe- 
 nomena reappeared for the fourth time. They only lasted a few 
 days. (Treatment as above.) The skin regained its natural 
 colour. 
 
 January 23, 1807. — There was no symptom to announce the 
 return of this terrible malady. 
 
 Case XXIV.* — M. Molin.saw a young woman affected with a 
 gangrene, which seized one foot at first and led to its .separa- 
 tion from the leg. The other foot then became gangrenous and 
 separated like the first. The patient lost successively many 
 .fingers, and then the gangrene proceeded no further. This 
 young woman then became well again, and even stout. 
 
 Case XXV.f — The Academy saw a young woman, called 
 Anne P., of Moustier Saint Jean, who was nearly 21 years old, 
 and who when she was 7 years old, after an ordinary fever, had 
 both hands and forearms wither away up to the commence- 
 ment of the elbow, so that she had only two stumps left. She 
 brought her hands in her pocket to the assembly, and drew them 
 forth with one of her stumps, which she used adroitly; they 
 were black and dry like the hands of a little mummy. 
 
 It would have been well in concluding this narrative of cases 
 to demonstrate that the connection between them rests upon true 
 
 * By M. Molin, Journal de Corvisart, T. xvi,, p. 283, ann. 1808. Extrait du Bulletin 
 publie' par le Comild Central de la Socie'td da mddecine du ddpartement de l'Eure. 
 
 t Histoire de TAcqdemie des Sciences, ann. 1703, p. 41. Might this be a case of 
 typhoid gangrene?, .... 
 
CASES. 97 
 
 analogies, and that it is not the result of an artificial arrange- 
 ment. But I could not do this without continual repetitions of 
 observations. The care which I have taken to classify the cases 
 as much as possible in order of gravity, and to distinguish the 
 principal groups, will suffice I hope to indicate their connection 
 and reciprocal affinities and permit me now to make a general 
 summary of the whole subject. 
 
98 
 
 CHAPTER III. 
 
 PATHOLOGICAL HISTORY OP LOCAL ASPHYXIA AND OF SYMMETRICAL 
 GANGRENE OF THE EXTREMITIES. 
 
 I propose in this chapter to give a general description of the 
 affection of which I have hitherto presented only isolated ex- 
 amples. One word at first upon the name by which I propose 
 to designate it. The term local asphyxia is not new ; it has had 
 scientific circulation since Boyer's time, and is based upon real 
 analogies. With regard to the variety of gangrene which appeared 
 to me capable of resulting from it as the more advanced expres- 
 sion of a similar morbid state I have for a long time sought a 
 distinctive and special character. The absence of arterial 
 obliteration has only a negative value, and also applies to diabetic 
 gangrene. In examining closely the preceding cases I have 
 been struck with the remarkable tendency of the mortification 
 to affect symmetrically similar extremities ; thus it is the two 
 hands, or the two feet, or all four at a time, sometimes the nose, 
 composed, like all the median organs, of two equal halves ; they 
 are, in one word, similar parts which become affected together in 
 the very great majority of cases. 
 
 Further, I have recorded cases in which the localisation of the 
 pathological process to the fingers or to the toes has taken place 
 under the same form and with an equal intensity in exactly 
 corresponding parts. Thus in Case XIII. on each side it was 
 the fourth toe which presented the most advanced lesion ; then 
 came the big toe, then the third, then the fifth ; finally, the 
 second was almost healthy. In Case XV. the similitude was 
 perhaps still more complete, because it existed at the same time 
 in the hands and the feet. On examining this patient long 
 after her recovery I was struck with the remarkable similarity 
 on the two sides, even of the stumps and cicatrices which had 
 been left after the separation of the sloughs on the two sides. 
 These are, it is true, the most trenchant cases, and those which 
 
PATHOLOGICAL HISTORY. 99 
 
 may serve as types for the description. Some deviate from the 
 type more or less ; the morbid results are produced somewhat 
 irregularly, or to an unequal depth, on the two sides. But the 
 tendency of gangrene to localise itself at the same time to the 
 right and left halves of the body is not the less pronounced, 
 and would suffice, I think, to justify the title of symmetrical 
 gangrene, which I give as a simple statement of fact, and 
 as having the advantage of not prejudging the nature of the 
 malady. 
 
 I come now to the exposition of the symptoms, premising that 
 there is no general description which can replace the reading of 
 the recorded observations. 
 
 Symptoms. 
 
 In order to introduce order into the symptomatology and to 
 avoid confounding together conditions very different, in their 
 gravity, I shall describe first syncope and local asphyxia, and 
 afterwards symmetrical gangrene of the extremities. 
 
 In its simplest form, local syncope is a condition perfectly 
 compatible with health. Persons who are attacked with it, and 
 who are ordinarily females, see under the least stimulus, 
 sometimes without appreciable cause, one or many fingers 
 become pale and cold all at once ; in many cases it is the same 
 finger which is always first attacked; the others become dead 
 successively and in the same order. It is the phenomenon 
 known under the name of the " dead finger." The attack is-, 
 indolent, the duration varies from a few minutes to many hours- 
 The determining cause is often the impression of cold ; but that 
 which is only commonly produced undej- the influence of the 
 most severe cold, appears in the subjects of whom I speak on the 
 occasion of the least lowering of temperature ; sometimes even a 
 simple mental emotion is enough. It would appear that the 
 same cause which acts upon the capillaries of the face, and brings 
 the red colour to the face, may in other circumstances act speci- 
 ally on the capillaries of the extremities ; the skin of the affected 
 parts assumes a dead white or sometimes a yellow colour ; it 
 appears completely exsanguine. The cutaneous sensibility 
 becomes blunted, then annihilated; the fingers become like 
 foreign bodies to the subject. They can be pinched and pricked 
 with impunity ; they may entirely lose the sense of contact and 
 
100 Raynaud's original thesis. 
 
 yet be able to distinguish heat and cold. Their temperature is 
 notably lowered ; this can be easily ascertained by touching them. 
 It was established in one case that the temperature remained 
 constantly one degree R. above that of the surrounding air. 
 Ought the loss of movement in these cases to be attributed to 
 a momentary paralysis of the flexor and extensor muscles ? This 
 is hardly possible if one considers that this syncopal state is 
 often limited to a single digit, whilst a single muscle gives rise 
 to many tendinous insertions. It is more reasonable to admit 
 that the diseased part no longer transmitting sensation to the 
 brain, the brain itself loses temporarily, for want of excitant, the 
 power of determining movements. In rare cases the secretions 
 are affected and the dead finger becomes covered with a cold 
 sweat. The slight importance of this local abolition of the cir- 
 culation is probably due to the fact that it is so transient. The 
 fingers are not the sole subjects of the affection, and if they 
 appear to be more frequently attacked it is solely because they 
 are of more immediate need for the usages of life than the toes. 
 The attack is followed by a period of reaction, which is often 
 very painful, and which gives place to a sensation quite analogous 
 to that of being benumbed by cold. 
 
 We must not confound this condition with the numbness 
 "which succeeds the concussion or compression of a nerve. In 
 the latter case it is the sensibility and motility which are pri- 
 marily attacked, the circulation remaining intact ; it is precisely 
 the reverse which occurs in local syncope. When this, in place 
 of affecting one or many digits, occupies the whole of a limb, 
 then the circulatory troubles which one was forced to admit in 
 some sort by induction become very evident. 
 
 In Case III. there was noted an excessive feebleness of the 
 pulse at the moment of the commencement of the attack, which 
 might have suggested some arterial obstruction if the increase of 
 the pulsations during the intermissions had not appeared to 
 negative this supposition. 
 
 In the more pronounced cases, those in which the asphyxial 
 phenomena predominate, the pallor of the extremities is replaced 
 by a cyanotic colour. This colour offers many different shades. 
 Sometimes it is of a bluish white ; it seems as though the skin 
 had acquired a greater transparence than natural, so as to allow 
 the subjacent tissues to be perceived ; sometimes it is violet or 
 
PATHOLOGICAL HISTOBY. 101 
 
 slate- coloured, even becoming black, quite comparable to that 
 which a slight blot of ink produces on the skin. When 
 one presses on the parts thus altered in colour, the patch of 
 dead white produced by pressure, in place of disappearing 
 instantly, as happens to a healthy extremity, takes a con- 
 siderable time before recovering the colour of the neighbouring 
 parts, which denotes an excessive slowness of the capillary 
 circulation. 
 
 Habitually to this is added a little swelling in the neighbour- 
 hood. Very frequently also we see marked out up to a variable 
 height livid venous marblings and which are very like those 
 produced along the legs and thighs of persons who make use of 
 foot-warmers. Pain is almost a constant phenomenon, it may be 
 sufficiently sharp to draw forth cries from the patients ; to a 
 painful numbness there succeeds a sensation of burning and 
 shooting which increases on pressure. Meanwhile the cutaneous 
 anaesthesia is complete, and interferes with the prehension of small 
 objects. The period of reaction is accompanied by irritating 
 tingling sensations, which the patients compare to tingling from 
 cold, or to the stinging of nettles. 
 
 Then less livid patches appear on the cyanosed parts ; they 
 extend and join one another, at the same time a vermilion colour 
 shows itself at the margin ; little by little it gains ground,, 
 chasing before it the bronzed colour which persists longest in 
 the parts where it commenced, that is, in the most peripheral 
 portions. Finally, a patch of deep red is formed on the ex- 
 tremities of the fingers. This patch gives place to the normal 
 pink colour, and then the skin is found to have entirely returned 
 to the primitive condition. 
 
 This condition presents with cyanosis properly so-called 
 analogies upon which there is no need to insist ; the anatomical 
 fact is the same — the presence of venous blood in tbe capillary 
 system. Nevertheless there are important differences. I have 
 never observed in local asphyxia the blue colour of the lips 
 which is constant in cyanosis. But it is also important to note 
 from the point of view of symptoms that cyanosis is related in 
 the immense majority of cases to an organic lesion (persistence 
 of the ductus arteriosus, &c), the cause being permanent, the 
 effect is so also ; it is increased under the influence of an effort ; 
 there are no pains, there are no intermissions, although this 
 
102 Raynaud's original thesis. 
 
 obtains in local asphyxia.* Another difference is drawn from 
 the modifications of nutrition which the parts at length undergo. 
 In cyanosis the ungual phalanges take almost constantly the 
 clubbed shape, that shape wrongly attributed by some physicians 
 exclusively to pulmonary phthisis, which is designated by the 
 name of the hippocratic nail. In local asphyxia there is nothing 
 similar to this. The only modification which can occur consists 
 in an excessive predominance of the cellulo-adipose system 
 leading to an exaggerated softness, a kind of false oedema of the 
 extremities ; it seems as if this were somewhat analogous to that 
 accumulation of fat which is so frequent in all the organs which 
 perform their functions incompletely. I could not without falling 
 into common-places describe here the general symptoms which 
 belong to local asphyxia of the extremities, they are often abso- 
 lutely nil. A little breathlessness, muscular feebleness, signs 
 of chloro-hysteria, which have otherwise nothing special ; that is 
 all that I should have to say about them. I hasten now to the 
 symptoms of symmetrical grangrene properly so called. 
 
 III. The commencement takes place in different ways. 
 In one case the extremities become pale, exsanguine, and then 
 take on a lilac tint ; at the same time tinglings or shooting pains 
 occur. These are bearable at first, and accompanied by the 
 sensation of numbness, but are soon replaced by a burning 
 heat, which cold water calms for a time, but this improvement 
 is only momentary ; after changes of colour which are impossible 
 to describe, the ends of the fingers take on a violet colour which 
 becomes more and more pronounced, and in which the nails 
 participate ; on touching these parts they are found to be icy 
 cold. In another case it is a livid redness which appears first. 
 The patients believe ordinarily that they have chilblains, the 
 more so that they are subject to them ; but at the end of a few 
 days the itchings to which they paid no attention become pains 
 of which the severity goes on exasperating and no longer permits 
 of any doubt. 
 
 From this epoch the livid marblings show themselves in the 
 neighbourhood of the affected parts along the digits, over the 
 course of the collateral arteries, and rise sometimes to a great 
 
 * It is to local asphyxia that Boiseau gave the bizarre name of uterine cyanosis, 
 basing it solely on the undoubted influence of suppression of the menses in certain 
 cases. He has reported two examples, vide "Me'moire sur la cyanose cholerique, 
 Journal hehdomadaire, vol. ix., p. 277, 1832. 
 
PATHOLOGICAL HISTOBY. 103 
 
 height over the corresponding limbs. Arrived at this point the 
 lesion becomes more pronounced according to different modes. 
 
 Sometimes the digits become entirely black and insensible ; 
 small phlyctenulas appear upon one digit (particularly the little 
 finger), then on another, always at the extremity. This phlycte- 
 nula develops, fills with seropurulent liquid, breaks and leaves 
 the derma naked. 
 
 The small excoriation which results from it persists some 
 days. To see this lividity, this glacial cold, one would believe 
 that the grangrene was about to extend more and more ; but the 
 malady recedes, the parts become reanimated, the small ulcer 
 cicatrises and contracts, and there results a kind of conical 
 tubercle immediately subjacent to the nail. This recovery is 
 only temporary. Soon we see the same series of phenomena 
 recommence either on the same digit or on another, and I have 
 seen this state of things renew itself during two years with 
 intervals of passing remission. At an advanced epoch on the 
 pulp of all the digits a great number of small, white, depressed, 
 very hard cicatrices is seen, which are, so to speak, the stigmata 
 left after the malady, and which prove that it is not arrested by 
 the epidermis, but that the most superficial layer of the true 
 skin has been attacked. At a given moment all the nails may 
 fall simultaneously. This progress of the malady is not incom- 
 patible with the formation of veritable sloughs, especially on the 
 little finger. But that which strikes one most is the slender 
 form which the ends of the digits take, the hardness of their 
 tissue, and their shrivelled aspect. 
 
 It may happen that this parchment-like appearance may 
 supervene without having been preceded by the formation of 
 blisters. The skin takes on a drab colour, it seems thinned, 
 dried up, shrivelled, and there results from it a conical form to 
 the finger. One could compare it to nothing better than to the 
 state of things which would have ensued if one had violently 
 squeezed the finger in a chain band, and if it had retained the 
 form impressed upon it thereby. Spon desquamation occurs, 
 and thickened pellicles of wooden hardness are raised up in 
 shreds. There is a form allied to this which I have particularly 
 observed in children. It affects specially the feet. The blisters 
 instead of breaking dry up at the end of a few days by resorp- 
 tion of the liquid, become dark, and are detached in layers ; the 
 
104 Raynaud's original thesis. 
 
 subjacent skin is found rosy and smooth. On examining it 
 attentively it is seen that the papillae have been more or less 
 eroded, and that they present at the maximum point of the 
 lesion a pale violet colour; the skin soon recovers its normal 
 appearance. The whole process takes about a fortnight for 
 completion. If the gangrene at the very outset appears in all 
 its intensity there are no phlyctenule, the tendency to mummi- 
 fication becomes manifest, the nail becomes quite black, an 
 entire phalanx takes on a more or less dark colour, and rapidly 
 becomes as dark as charcoal. One might believe then in a pro- 
 found alteration. But at the end of a few days an inflammatory 
 circle appears at the base of the toe. It becomes more and more 
 pronounced as it approaches the extremity. A thick viscous 
 liquid similar to plastic lymph oozes out of the circumference, 
 and becomes hardened into brownish crusts. Then a true sup- 
 puration of healthy character appears at the limit of the disease 
 and under the free border of the nail. The slough becomes 
 mobile, detaches itself, and on withdrawing it we find that it 
 is 1 or 2 millimetres thick ; on its surface the papillae are seen 
 neatly marked out ; the deep aspect is soft and tomentose. The 
 remaining living parts are rough, with fleshy granulations which 
 soon cicatrise. It is in this form that I have seen a slough form 
 on the tip of the coccyx, and in another case I have seen brown 
 patches appear symmetrically on the two heels, then disappear 
 by exfoliation. 
 
 Finally, in the most pronounced cases all the forms already 
 prescribed present themselves in different degrees on the fingers 
 and toes — viz., the parchment-like condition, with tapering of the 
 ends of the digits, the livid marblings along the track of the 
 superficial veins, the bullae, &c. These last, I repeat, are formed 
 at the expense not only of the epithelial layer, but of a part of 
 the derma itself. In the parts which are most attacked there is 
 a real carbonisation, which terminates at length in the fall of a 
 third or a half of the ungual phalanx. The whole is accom- 
 panied by a very slight oedema of the lower part of the limb. If 
 the nail has not been attacked at its root, a singular thing hap- 
 pens — viz., that the eliminatory circle, becoming more and more 
 hollowed out, the slough ends by detaching itself along the whole 
 of its circumference, except at its upper part, where it remains 
 adherent to the nail. This continuing its growth forwards from 
 
PATHOLOGICAL HISTOBY. 105 
 
 the base, there arrives a moment when the slough is found sepa- 
 rated from the living parts by a groove of a few millimetres' 
 width. Cicatrisation takes place proportionally, and to remove 
 the slough it is only necessary to cut through along the edge of 
 the growing nail. Nevertheless the growth of the nails has not 
 been continued ; it is completely suspended, and their length 
 remains stationary during all the time that the great pains of 
 mortification last. 
 
 Then they recommence to grow, and present at their surface a 
 transverse depression, which indicates thus the period of arrest 
 in their nutrition. 
 
 The black colour which they present is a simple effect of 
 transparence; at a later period it is replaced by a greenish 
 colour. Some may fall entirely, others, not finding any further 
 support at their extremity, curve round more or less irregularly, 
 and remain permanently deformed. 
 
 I have no need to insist on the lowering of temperature which 
 accompanies the production of gangrene in these cases, as in all 
 others. I will only mention that I have noted at the same time 
 a slight increase of heat over the wrists and on the palms. 
 Since I have made this observation M. Broca has generalised 
 the fact, whilst showing that in senile gangrene there is always 
 exaggeration of heat in the upper part of the diseased limb ; he 
 thinks that this phenomenon is due to a supplementary capillary 
 circulation.* 
 
 The nose and the external ears are sometimes more or less 
 attacked ; but I am not aware that in these situations complete 
 mortification has been observed. The lobule and the alae nasi 
 present, it is true, a black colour, livid marblings extend to the 
 cheek, but this coloration disappears on pressure, to reappear 
 subsequently. The parts become reanimated little by little, 
 without even passing through the period of desquamation. 
 
 IV. In the description of general symptoms we must carefully 
 distinguish those which belong strictly to the malady which now 
 concerns us, from those which are allied either to an antecedent 
 malady or to a concomitant diathetic state. 
 
 The symptom which first attracts attention is pain. This is 
 sometimes the primary phenomenon, and generally it rapidly 
 takes on a truly frightful intensity; it is not limited to the 
 
 * Comptes rendus de la Societe de Chirv/rgie, 1861. 
 
106 Raynaud's original thesis. 
 
 affected extremities, it radiates to every limb ; it is a sensation 
 of burning and tearing ; it cornea on in paroxysms, and it is 
 remarkable tbat tbese painful exasperations coincide witb a 
 manifest increase of tbe cyanotic tint. I have seen it give rise 
 to howls of pain in persons habitually quiet and patient ; bent 
 double, sitting up in bed, one sees the unfortunate creatures pass 
 all their time, seeking in vain a position of relief, or in rubbing 
 alternately one or other of their affected extremities, uttering a 
 continuous groan, which is only interrupted by piercing cries. 
 Even in the moments when there occurs a little calm the feet 
 and hands remain in a state of irritability, such that the patients 
 conjure you not to approach them. We have seen in Case VIII. 
 each painful exacerbation give place to veritable convulsive 
 attacks. At a later period aphonia, partial paralyses, &c, super- 
 vened. But this woman was eminently hysterical, subsequently 
 she attempted to poison herself with opium ; there were, there- 
 fore many exceptional circumstances in her case which we can- 
 not consider as typical. 
 
 These are doubtless very distressing symptoms ; the remark- 
 able feature is the almost complete integrity of the principal 
 functions, which is observed at the same time. The patients 
 preserve their habitual aspect, and it is extraordinary to see the 
 feet and hands becoming gangrenous, whilst the nose is almost 
 entirely black in the midst of a face fresh and vermilion-coloured. 
 Respiration goes on freely, the appetite is preserved, the tongue 
 is clean, the digestion goes on well ; there is sometimes a little 
 constipation; the urine, rarely diminished, is more often abun- 
 dant, pale, and limpid, presenting in one word the characters of 
 nervous urine. The intelligence remains quite clear during the 
 attack, but when the oppression caused by the suffering leads to 
 a little drowsiness, it may happen that the sleep is heavy and 
 the face red and congested. On waking, the patient knows no 
 longer where he is ; he has lost the notion of the time, seems 
 foreign to all that surrounds him, and remains a considerable 
 time. in a state of profound hebetude. It is of some importance 
 to rouse the patient promptly from this condition, because what- 
 ever may be the cause of it we have reason to fear, on the part 
 of the brain, a morbid process, analogous to that which affects 
 the periphery. It is wise to rouse the patient, by throwing cold 
 water on his face. 
 
PATHOLOGICAL HISTORY. 107 
 
 The most important symptoms to note are those which the 
 circulatory apparatus presents ; they are sometimes absolutely 
 nil. The pulse never ceases to be perceptible in the arteries of 
 the affected limbs, but it may present remarkable alterations. As 
 to frequency : there may be at the time of the attack a little 
 rapidity of the pulse, which never exceeds 100 a minute, and 
 which is not accompanied by febrile heat of skin. 
 
 As to intensity : although ordinarily the pulse is full, it may 
 become small, thin, and compressible ; but this is the exception. 
 With regard to alterations of rhythm, I ought to draw a distinc- 
 tion. Intermissions, irregularities more or less pronounced may 
 show themselves at an epoch which is remote from that of the 
 attacks. 
 
 In Case XV. this symptom had been noted two days after the 
 confinement, consequently two-and-a-half months before the 
 appearance of the signs of gangrene; it was observed again nearly 
 a year after the cessation of the attacks ; we may consider it as 
 purely nervous ; it is, however, certain that it was not present 
 when looked for at any time during the continuance of the 
 malady. On the other hand, in Case XII., these irregularities of 
 pulse have appeared with the commencement of the phenomena 
 of mortification. Not only was there a retardation in the arterial 
 pulsations from time to time, but when the radial and dorsalis 
 pedis were examined simultaneously, at times a perceptible pul- 
 sation was felt in the first of these two arteries, and none in the 
 second ; at other times, but more rarely, the pulsation was more 
 feeble in the radial than in the dorsalis pedis, but it did not 
 vanish entirely, as in the other case. In the great majority of 
 cases' the pulse continued regular throughout. "With regard to 
 the venous system, I have already noted the livid marblings 
 corresponding to the course of the subcutaneous veins, also a 
 slight oedema, indicating a retardation of the return circulation, 
 but nothing which would make one suppose that there was a 
 permanent obstacle to the course of the venous blood. 
 
 As to the heart, sometimes palpitations have been present 
 which were evidently nervous, and in some cases a slight mur- 
 mur, but so soft as to exclude the idea of a valvular lesion. It 
 is unnecessary to state that in the case of intermissions of the 
 pulse there were corresponding intermissions of the heart's beats, 
 but it is important to note that these functional troubles are 
 
108 Raynaud's original thesis. 
 
 eminently fugitive, and disappear as they come without any 
 assignable cause. 
 
 To omit nothing, and although quite convinced that it is only 
 a fortuitous coincidence, I will add that twice I have observed a 
 phlegmon of the neck, having for its point of departure the 
 glands situated under the sternomastoid, and presenting the 
 aspect and progress of an ordinary acute abscess. 
 
 Progress, Duration, and Termination. 
 
 V. The malady may follow a continuous course, or be pro- 
 longed over a considerable time with periods of intermission. 
 There is a relation to be established between the acute form and 
 the gravity of the observed symptoms. In a general way one 
 may say that the most profound gangrenes, those which go the 
 length of causing the fall of many ends of fingers and toes, are 
 also those which present most regularity in their development. 
 We can then distinguish three periods. 
 
 1. An insidious period of invasion, during which the 
 symptoms of local asphyxia predominate.* We might believe 
 at first that the whole process would be limited to this ; and it 
 is only when gangrene is imminent that we are undeceived. 
 This period, which may be only a few days, never goes beyond 
 a month. 
 
 2. A period during which the attention is especially directed 
 to the painful crisis coming on in paroxysms ; sometimes each 
 attack is terminated by an abundant emission of urine. This 
 period lasts about ten days ; at the end of that time the gangrene 
 is limited and complete. 
 
 3. A period of elimination. The duration is very variable, 
 and depends much on the activity of nutrition in different 
 subjects, and the depth of the lesions. 
 
 The most general statement that can be [made is that it is 
 never less than twenty days, and never more than ten months ; 
 but these two terms are exceptional, and ordinarily the duration 
 is from three to four months. 
 
 As to the order of appearance of gangrene in the different 
 
 * This is not absolute. Thus in Cases XX., XXII., and XXIII. the gangrenous 
 process led to very grave mutilations, and nevertheless had a chronic course; but 
 these facts, which it was desirable to draw attention to, by way of information, are too 
 obscure to justify their inclusion in the general description. 
 
PATHOLOGICAL HISTORY. 109 
 
 extremities I have noted nothing constant. It is sometimes the 
 hands, sometimes the feet, which become first affected. Some- 
 times the local asphyxia shows itself at the same time in the 
 four limbs, then it leaves the upper limbs and runs its course 
 up to gangrene in the lower limbs. 
 
 The termination even in this grave form of the malady is for 
 the most part favourable. The sloughs detach themselves 
 slowly. Cicatrisation takes place pari passu under the dead 
 parts. But the cicatrix remains a considerable time before it is 
 quite complete, and sometimes during more than a year crusts 
 are formed which successively drop off. The chronic form with 
 remission belongs more specially to the benign cases. Here the 
 commencement is ordinarily more or less sudden ; the malady 
 following immediately on an emotional disturbance, or on a 
 menstrual suppression, arrives at its full intensity from the 
 very outset. 
 
 In these cases we must distinguish the general progress of 
 the malady, and that of each attack. 
 
 Many of the patients whose history I have recorded have been 
 traced for two or three years. During this period we have 
 observed three, four, and five recrudescences or attacks, some of 
 which have lasted many months ; each attack was in certain 
 cases brought on by the return of the same accidental cause 
 which had determined the first appearance of the illness. The 
 attack may present the continuous type (this is the rarest form) ; 
 more often it is of the remittent type, or even there is a well- 
 marked periodical intermission ; this is then the quotidian type. 
 Each time the commencement takes place at the same point, 
 the index or little finger for example, then the affection invades 
 successively the neighbouring parts. This is especially marked 
 in cases of local asphyxia pure and simple. When the malady 
 has taken, so to speak, right of domicile, a kind of tolerance is 
 produced ; the attacks are less grave, but the extremities remain 
 habitually in a state of cold and torpor. One might say there 
 is a permanently benumbed condition ; and this state of things 
 may last up to death, which, however, does not appear to have 
 been directly caused in these cases by the lesion of the extremi- 
 ties. 
 
110 RAVNAUD V S ORIGINAL THESIS. 
 
 Diagnosis. 
 
 VI. The diagnosis of the affection is generally easy. Never- 
 theless, especially at the outset, it is well to take precaution 
 against several causes of error. 
 
 The phenomenon of "dead finger" is too well known by 
 everybody for it to be necessary for me to delay in discussing it. 
 The affection might be confounded with the state of habitual 
 pallor which the extremities so often present in chlorotic females. 
 But the preservation of movement and of sensibility in the 
 latter case, and especially the persistence of the ansemic state, 
 joined to the general trouble, of which it is only the expression, 
 would suffice to remove all difficulties. Is it possible to estab- 
 lish a diagnosis between local asphyxia and frost bite ? The 
 phenomena are so similar that in truth it is not a simple 
 analogy that they present to us, it is a perfect identity. But 
 there is this important difference, that frost bite has a constant 
 and perfectly known cause— the impression from excessive cold 
 — whilst syncope and local asphyxia occur under the influence 
 of an insignificant lowering of temperature, or even in the 
 absence of this adjuvant circumstance. 
 
 I have already indicated some of the signs which separate 
 congenital cyanosis from local asphyxia ; in one clubbing of the 
 nails ; in the other the tapering appearance of the last phalanges ; 
 and in rarer cases fatty increase at the extremities. I have 
 added that in the morbus cceruleus the deep tint of the fingers 
 and of the toes is only the exaggeration of what occurs over the 
 whole surface of the body. The ground colour is always more 
 or less blue ; this colour, which increases under the influence of 
 an effort, never entirely disappears. The breath is always short 
 and difficult, there are frequent faintings. We must bring into 
 proximity with congenital cyanosis that which results acciden- 
 tally from organic affections of the heart ; but in this case the 
 signs furnished by the general condition and by auscultation are 
 so manifest that mistake would be inexcusable. 
 
 Diagnosis may offer more difficulties when pain precedes by a 
 longer or shorter interval the appearance of a livid colour of the 
 extremities. We have seen in one case of this kind (X.) the 
 malady taken for rheumatism by a distinguished surgeon, and 
 treated for that disease ; in this case the pain was situated not 
 
PATHOLOGICAL HISTORY. Ill 
 
 in the extremities, which subsequently mortified, but in the 
 tibio-tarsal joint and in that of the wrist. It will suffice to recall 
 that in acute articular rheumatism the pain of the joints is 
 almost always accompanied by redness, tumefaction, synovial 
 effusion, and fever, and that in the disease in question nothing 
 of this kind occurs. Sometimes in place of this pseudo- 
 rheumatic appearance the malady assumes a neuralgic form. 
 In this case, and before the appearance of the morbid colour of 
 the skin, the error would be an easy one to commit, especially 
 if there were well-marked periodicity. Yet still if we must 
 acknowledge that local asphyxia is a rare malady, do we know 
 on the other hand many neuralgias which affect simultaneously 
 the four limbs ? 
 
 This would in itself be a proper reason for suggesting a warn- 
 ing. One may further remember that neuralgic pains follow the 
 known course of a nerve, that they are increased by pressure on 
 special points, whilst the initial pain of gangrene has no precise 
 seat, and extends often from a very limited point to spread 
 vaguely round the shoulder or the thigh. By reason of these 
 characters confusion would be much more easy with the osteo- 
 scopic pains of tertiary syphilis, all the more that we have had 
 some cases in which the suffering was exaggerated during the 
 night. Syphilis is so common a malady that it is better to 
 suspect it where it does not exist than to fall into the opposite 
 error ; it will be therefore always wise to examine patients from 
 this point of view. 
 
 When either primarily or after a prodromal period the 
 imminence of gangrene is indicated by a change of colour of the 
 extremities we may have to do with one of the two forms upon 
 which I have already so much insisted : either the excessive 
 pallor with cooling and insensibility, or the livid tint of the 
 skin passing on to blue then to black. In the first case the 
 numbness and the muscular anaesthesia might lead one to 
 believe that there was a partial paralysis by section or alteration 
 of structure of a nerve. An attentive examination will prevent 
 our .being deceived. But there is another form of partial 
 paralysis more insidious, and which is but little known, although 
 it is not very rare to meet with it in practice, viz., the essential 
 paralysis which is observed especially in infants.* We know 
 
 * Vide Kffliet et Barthez, Maladies des Enfdnts, 2e Edit., T. ii., p. 645. 
 
112 kaynaud's oeiginal thesis. 
 
 that some cases of clubbed foot have no other origin than in 
 partial paralysis. Adult life is not exempt from this form of 
 partial paralysis, and I had last year the opportunity of observing 
 two cases of this kind under the care of M. Vernois, once in the 
 leg, the other time in the forearm. This paralysis occurs 
 suddenly, so much so that patients can indicate the hour and 
 the minute when they felt themselves attacked. It is accom- 
 panied by anaesthesia and absolute akinesis, and ordinarily 
 disappears in a few days. It is sufficient to be forewarned. 
 Moreover there is absence of discoloration of the skin, the 
 deprivation of sensation and of movement is limited to a single 
 limb, and is distinguished thereby from local gangrenous syncope, 
 of which the symmetry is the principal character. 
 
 If, on the contrary, the gangrene commences by a diffuse livid 
 colour it is almost always confounded at the commencement with 
 chilblains, and this error on the part of the patients is also 
 easily made by the doctor; moreover the itching and painful 
 smarting are naturally referred to a very common affection. 
 Whatever may be the true nature of chilblains (and it is very 
 probable that they have some relation with gangrene of the 
 skin), since in every case the cause is very different, it would be 
 very important from the beginning to establish a diagnosis. 
 Unfortunately this is often very difficult. I will say only, 
 distrust chilblains which form simultaneously on many digits 
 of both feet and both hands in a season and at a temperature 
 when they are not habitual. 
 
 Gangrene once confirmed, the diagnosis is obvious. There 
 only remains further to determine with what variety of gangrene 
 we have to do. As this touches on a point of doctrine I must 
 refer the reader to the article on the nature of the disease. For 
 the present I content myself with summing up the diagnosis 
 in the following propositions : — 
 
 Symmetrical gangrene of the extremities approaches the so- 
 called senile gangrene by virtue of its mummy-like form. It 
 differs from senile gangrene in (1) the seat of its lesions. Senile 
 gangrene affects, in the immense majority of cases, a single limb, 
 and almost always a lower limb. Symmetrical gangrene, as the 
 word indicates, occupies simultaneously two similar extremities, 
 as well the upper as the lower, or all four at the same time, and 
 on these extremities it tends to occupy parts similarly situated. 
 
PATHOLOGICAL HISTORY. 113 
 
 (2) By extent. Senile gangrene never occupies less than a 
 single toe, and very frequently extends up to the malleoli and 
 beyond. Symmetrical gangrene is mostly limited to the skin, 
 or to a very small extent beyond, as, for example, to the extremity 
 of the ungual phalanx. 
 
 (3) By its progress. Senile gangrene is ordinarily ser- 
 piginous ; it commences at a single point, radiating thence 
 without regularity. Symmetrical gangrene affects all at once 
 many points at the same time, which become sphacelated in an 
 isolated way. In this variety alone the nose and the ears may 
 present unequivocal signs of local asphyxia. 
 
 (4) By the state of the vessel. In senile gangrene one gene- 
 rally feels along the course of the artery a hard cord which rolls 
 under the finger, and the arterial pulsations are diminished or 
 even suppressed. In symmetrical gangrene the pulsations, some- 
 times irregular, are ordinarily normal ; they never fail entirely. 
 
 I shall have to investigate soon the points in common and 
 the differences between the disease which we are now studying 
 and gangrenous ergotism. I hope to be able to separate them 
 clearly. The main diagnostic sign is given by the history of the 
 case. 
 
 It will therefore never be superfluous to inquire minutely into 
 the mode of alimentation of the patients. 
 
 Prognosis. 
 
 TIL From the practical point of view this is perhaps the most 
 important part of the history of the disease. A dry gangrene is 
 always a grave condition, and Fabrice de Hilden, during a 
 practice of forty years, declared that he had never seen a single 
 case of cure. Suppose a doctor called to a young woman of 
 25 to 30 years old, and sees her unfold the picture^ of which I 
 have attempted to give an idea. 
 
 In the presence of these atrocious and persistent pains, of this 
 deep black coloration, invading at the same time the hands up 
 to the base of each digit, the feet up to the tarsus, the nose up 
 to the root, I ask, what well-informed doctor who seeing, so to 
 speak, his patient die at all extremities at the same time would 
 not give the most gloomy prognosis ? 
 
 Nevertheless the issue, as we have seen, is far from being con- 
 
 8 
 
114 Raynaud's original thesis. 
 
 stantly fatal. This error is very natural ; it is because I have 
 committed it myself, because I have seen it committed by 
 eminent physicians, that 1 wish to rectify it. Let us eliminate 
 the first seven observations, in which there was no confirmed 
 gangrene. One may remark, however, that these observations 
 are not without value, if it is admitted that these cases only 
 represent less advanced degrees of the same malady. Let us 
 eliminate also the six cases which I have recorded under the 
 name of doubtful observations, and which by the way ended in 
 cure. Twelve cases remain in which there was confirmed gan- 
 grene. Of these twelve, six were fatal. But in Case VIII. the 
 patient died phthisical long after the cessation of the attacks ; it 
 is perfectly well known that gangrene of the extremities is no 
 guarantee against tuberculosis. In Case XIX. there was, besides 
 contraction of the two auriculo-ventricular orifices, pneumonia 
 with hepatisation. In Cases XVII. and XVIII. it was believed 
 that gangrene and death could be explained by vascular lesions. 
 I will explain subsequently the reasons which have led me to 
 bring these cases as well as the preceding into the category 
 with which we are now concerned. But I do not pretend to 
 deny the value of the lesions, which, insufficient perhaps to 
 explain everything, are not the less important as complications. 
 Case IX. was that of a woman who became at length profoundly 
 cachectic, and who succumbed three years after the beginning 
 of the attacks. In her the heart and the vessels were found 
 healthy, subsequently the condition of the extremities was 
 relatively improved. "Were the local asphyxia and superficial 
 gangrene of the fingers the remote symptom of aD alteration of 
 the blood ? or rather were the alteration of the blood and the 
 gangrene only two different and simultaneous manifestations of 
 one and the same diathesis? I am very far from denying it. In 
 any case one could but say that this woman had succumbed to 
 gangrene of the extremities. 
 
 Case X. is therefore the only one in which the patient 
 appeared to succumb directly to the malady by progressive 
 exhaustion. Nevertheless an autopsy was not made which pre- 
 vented our affirming anything positively. And however it may 
 be, there remain six well-marked cases, perhaps the most com- 
 plete of all, in which the recovery left nothing to be desired.* 
 
 * Save in Case XIII., where there was a Blight relapse. 
 
PATHOLOGICAL HISTOKY. 115 
 
 If now we analyse the sum total of our observations from the 
 point of view of the final result, setting aside the criticism to 
 which I have just submitted, then we find that they are dis- 
 tributed thus : — 
 
 Condition stationary at the moment when the patients ceased to be 
 
 under observation 6 
 
 Recovery 11 
 
 Death 8* 
 
 Total 25 
 
 The progress of the malady constitutes an element of prog- 
 nostic importance. When ten to twelve days after the invasion 
 of the severe pains one sees black dry sloughs form symmetrically 
 on the extremities, it may be hoped that the process of mortifi- 
 cation will soon be arrested, and that after a period of elimination, 
 of which the duration will not exceed four to five months, the 
 cure will be complete. If, on the contrary, the tendency to 
 gangrene is less clearly shown, if we observe only cooling, 
 cyanosis, bullae returning from time to time with or without 
 periodicity, we ought to fear that the malady may be prolonged 
 a considerable time ; and this form, although it may not imme- 
 diately compromise life, is nevertheless the most grave because 
 it renders life miserable from intolerable suffering, and opposes 
 a permanent obstacle to the accomplishment of social duties. 
 
 Etiology. 
 
 VIII. — In spite of the obscurity which obtains with regard to 
 many points of this curious malady, some important etiological 
 considerations result from comparison of the facts which I have 
 collected. I will follow the classical division into predisposing 
 and exciting causes. 
 
 A. — Predisposing Causes. 
 
 Sex. — This influence is very marked in favour of the female 
 sex. In my 25 cases 20 are females ; 5 only are men. 
 
 Age. — The influence of age is not less important ; it obtains 
 to such a degree that regarding it from this point of view one 
 might be almost tempted to reserve to this variety the name 
 
 * Of these 8 fatal cases, 3 at least were due to foreign causes, viz., 1 acute phthisis, 
 1 chronic phthisis, 1 hydatid of the liver. 
 
116 Raynaud's, original, thesis. 
 
 of juvenile gangrene. In the Jvery great majority of cases the 
 malady appeared between the ages of 18 and 30 years, the period 
 about 25 constituting a marked predisposition. Nevertheless 
 we have met with five children between 3 and 9 years old who 
 suffered from it. There is a slight increased liability about the 
 age of 40 years ; finally, a single case occurred at the age of 
 48 years, the age of the menopause, which period places women 
 for the time in analogous conditions to those which obtain at the 
 establishment of the catamenia. 
 
 Temperament ; constitution ; previous illnesses. — All tem- 
 peraments are exposed to this malady ; but it affects lymphatic 
 and nervous subjects especially. One might have believed that 
 it would attack by preference individuals with puny constitution, 
 or who had been exhausted by long illnesses ; on the contrary, 
 the greater part of our cases have enjoyed excellent health up to 
 the epoch of the invasion. In one case a scorbutic cachexia 
 developed itself concurrently with the affection of the extremities. 
 As to previous maladies I have especially noted neuroses, par- 
 ticularly hysteria, and accessorily epilepsy ; once tertian inter- 
 mittent fever ; twice syphilis ; once tinea ; twice there had been 
 a recent confinement. It will be readily seen that in none of 
 the above is there anything of special importance. 
 
 Hygienic conditions ; professions.— Our cases are divided 
 almost equally between subjects belonging to the well-to-do and 
 the poor; but if the social condition be immaterial in the 
 production of the malady it cannot be an indifferent question 
 as regards prognosis ; other things being equal, it is evident 
 that one ought to expect a cure in proportion as the patients 
 are able to receive thorough attention. A certain number of 
 patients had manual occupations, such as washerwoman, cham- 
 bermaid, burnisher, sculptor, &c. But as this circumstance was 
 wanting in many other cases it appears to me that we cannot 
 attach any importance to it. 
 
 Idiosyncrasies. — However vicious may be this word, which in 
 reality only expresses our ignorance, there can be no doubt about 
 the thing itself. Just as there are some individuals specially 
 predisposed to brain, chest, or abdominal affections, so also there 
 exists in others a true morbid, liability with regard to the 
 extremities ; in these individuals the extremities cool easily, 
 chilblains frequently occur in the winter, there is habitually a 
 
EAJTHOLOGICAL HISTORY. 117 
 
 feeling of dryness: at the ends of the fingers, &c. ; symptoms 
 insignificant in themselves, but which when the malady in ques- 
 tion becomes manifest, acquire a certain importance in relation 
 to it. 
 
 Seasons. — Whether by chance or from some other cause, it is 
 in autumn and spring that the disease has generally commenced, 
 and more particularly during the month of November. 
 
 Heredity. — Here we may recall the singular observation nar- 
 rated in Case XV. with respect to a little girl who, during the 
 early months of her life, presented a remarkable tendency to local 
 asphyxia, and at the very time when her mother was herself 
 experiencing dry gangrene of all her extremities, 
 
 B. — Exciting Causes. 
 
 I have much less to say on this subject. I have sufficiently 
 insisted already on the part which the lowering of the external 
 temperature plays in the production of the attack ; if sometimes 
 severe cold was a necessary antecedent, more often an imper- 
 ceptible change of temperature was sufficient, such as the passage 
 from the heat of the bed to the temperature of a warm room. 
 And as if to demonstrate the slight importance of this cause, in 
 one case (XI.) local asphyxia and gangrene of the extremities 
 occurred during hot weather. 
 
 The only well-marked exciting cause has appeared often in 
 women to consist in the suppression of the menses ; and as a 
 counter-proof we have seen also a notable amelioration, or 
 indeed complete cure, coincide with the re-establishment of this 
 function. In Schrader's curious case it is not stated whether the 
 monthly periodicity of the attacks had any relation with men- 
 struation or not. 
 
 Finally, in some cases the appearance of the malady has 
 appeared to be excited by a violent moral emotion. 
 
 Nature of the Disease. 
 
 It is of set purpose that I bring the question of the true nature 
 of the disease into close proximity with that of its etiology. 
 What in fact is the nature of a malady if it is not the sum 
 total of the anatomical and physiological causes which bring 
 it into existence ? By this I mean not assuredly the internal 
 
118 Raynaud's okiginal thesis. 
 
 and proximate cause, which always escapes more or less our 
 observation, but the appreciable mechanism by which the facts 
 are linked together one with another, the morbid process, in one 
 word. Let us pass in review the principal known causes of 
 spontaneous gangrene ; if we are able to demonstrate that 
 none of these are adequate to explain the phenomena thus far 
 recorded, that will be already a first step towards the solution of 
 the question. 
 
 And first, Arteritis. Thank heaven I have not to express 
 any opinion either upon its frequency, or upon the share which 
 belongs to it in the different arterial changes, or to the part 
 which it plays in gangrene in general. I take this ready made, 
 if I may so say, from the hands of its partisans with the 
 anatomical and semeiological characters which are attributed 
 to it ; then I place on the opposite side the cases which we have 
 to interpret. These cases are of two kinds ; some have been 
 followed by autopsy, others have recovered. 
 
 The first are far the less numerous. In many of them from 
 the outset the idea of any inflammatory state of the blood- 
 Tessels is excluded. I will cite amongst others that of Case IX., 
 in which I myself made the autopsy. Two only lend themselves 
 to a certain extent to this hypothesis, viz., that of Dr. Bernard 
 Henry (Case XVII.), and that of Dr. Topinard (Case XVIII.). 
 I have already quoted Dr. Henry's description and shown how 
 defective it is. " The femoral and brachial arteries presented 
 nothing which deviated from the normal state, but we found 
 them adherent to the bone and closed along the line of demarca- 
 tion." When dealing with a phrase which it is impossible to 
 understand, it would be best perhaps to abstain from any judg- 
 ment whatever. It seems to me, however, that these few words 
 -are enough to exclude arteritis, because the lesion, whatever its 
 nature, was circumscribed to a very limited part of the vessels ; 
 now one of the most constant characters of arteritis is that it 
 always occupies a considerable extent of the vessel without any 
 well-marked line of demarcation. 
 
 M. Topinard's description would seem more conclusive : the 
 internal surface of the arteries was of a bright vermilion tint, 
 extended in a continuous manner — not in points or patches, not 
 disappearing after more than forty-eight hours of maceration. 
 But if any one thing clearly results from the discussions to 
 
PATHOLOGICAL HISTORY. 119 
 
 which this malady has given rise during the last thirty years, it 
 is that redness by itself is insufficient to characterise arteritis. 
 Laennec* considered it to be a simple result of imbibition 
 resulting from a prolonged dying. Andralf thought that it was 
 impossible to distinguish it from active hyperemia. M. Bouil- 
 laudj himself admits, that in the majority of cases it is a cada- 
 veric phenomenon ; and this phenomenon may be produced very 
 rapidly, since MM. Trousseau and Leblanc have observed it 
 experimentally in horses before the heart had ceased beating. 
 The persistence of this colour after maceration proves nothing, 
 because a commencing putrefaction is sufficient to produce it 
 even where it did not exist before. 
 
 To admit arteritis, therefore, it is necessary to have other 
 characters. These characters are, according to Delpech and 
 Dubrueil,§ alterations of the texture of the vessel, injection of 
 the vasa vasorum ; according to M. Francois, || velvety aspect, 
 friability of the internal coat, &c. And in fact if arteritis can 
 and ought to be considered as a cause of spontaneous gangrene, 
 is it not by the obstacle which it offers to the course of the blood, 
 either by favouring the formation of clots on the spot, as M. 
 Cruveilhier holds, or by provoking on the inner surface the for- 
 mation of fibrinous or pseudo-membranous exudations, as 
 Hodgson holds ? Nothing of the kind existed either in the 
 cases with which I have been concerned, or in those which I 
 have collected. 
 
 There remain then the cases not followed by autopsy. But 
 these are still more inconsistent, if possible, with any such hypo- 
 thesis. In none of them have we found either increase with 
 widening of the area of arterial pulsations, or that redness over 
 the course of the vessels which Broussais regarded as constant 
 in arteritis, or those nodosities which indicate a thickening of 
 the arterial eoat, still less the important and almost pathogno- 
 monic symptom of arteritis — viz., the disappearance at a given 
 moment of pulsations in the points where they had previously 
 been exaggerated. 
 
 * TraitS de rauscultation midiate, T. ii., p. 606. 
 
 t Pricis ct anatomic pathologique, T. ii., Ire partie, p. 350. 
 
 J Diet, de medecin et de Chirurgie pratiques, T. iii., p. 405. It is true, as M. 
 Bouillaud admits, that on the other hand redness may be wanting in arteritis. 
 
 § Memorial del hopitavx da Midi, Mai, 1829, p. 252. 
 
 || Diet, de Medicine et de Chirurgie pratiques, Art. " Maladies des Aretres," T. iii., 
 p. 394. 
 
120 eaynatjd's okiginal thesis. 
 
 In the face of these negative characters, who then, I ask, would 
 dare to invoke the existence of a lesion which at least cannot be 
 demonstrated in the living subject, and which even on the dead 
 body, and when one has the specimens before one's eyes, gives 
 rise to so many doubts ? 
 
 I know that the partisans of arteritis will not admit that they 
 are beaten, and in the last resort will invoke capillary arteritis. 
 This is the opinion of Delpech and Dubrueil,* who have shown 
 remarkable skill in discovering the cause of senile gangrene in 
 this lesion. According to them, false membranes form in the 
 interior of the last twigs of the arterial tree, which obliterate the 
 cavity. This theory appears at first beyond all control, since it 
 transports the malady into a region inaccessible to our senses. 
 At the same time one cannot deny the possibility of the truth of 
 the doctrine in certain cases where the absence of any general 
 case of gangrene compels us to look for their origin in a local 
 alteration of the tissues. It is with respect to these cases also 
 that M. Cruveilhier holds an analogous opinion as regards the 
 importance of obliteration of the small arteries of the third and 
 fourth degree. M. DeBpaignetf in his thesis has given a good 
 clinical study of these cases of gangrene produced by lesions of 
 the capillaries, which cases are often observed in hospitals for old 
 people. They are distinguished by the adynamia from which 
 the patients suffer from the onset,+ by the severe local inflam- 
 mation which precedes mortification, by the radiating striae 
 around a central point along which the slough is propagated. 
 The circumference of the malleoli is the habitual point of depar- 
 ture, its cause is ordinarily an irritating agent, such as a mustard 
 plaister or a blister, applied inconsiderately. I refer to the 
 course of the malady in order to show how it differs from the 
 cases which I have reported. These, far from starting with an 
 inflammatory redness, always begin with a state of atony and 
 glacial torpor of the tissues. 
 
 Moreover, a very simple experiment, which I have already 
 described in speaking of the symptoms, proves that there is no 
 obstacle to the course of the blood inside the capillaries. After 
 the skin has assumed the bronzed tint of local asphyxia which 
 
 * Memorial des hopitaux du Midi, p. 241. 
 
 t Quelques considerations stir la gangrim spontanea des extremites. 1859, Paris, 
 p. 47. 
 
PATHOLOGICAL HISTORY. 121 
 
 precedes gangrene, if we bring to bear upon it a slight pressure 
 there is produced a dead white patch, similar to that which is 
 obtained by the same means on a healthy skin. But this patch, 
 instead of disappearing instantaneously, takes one or two minutes 
 to regain the tint of the neighbouring parts ; and we can follow 
 with the naked eye the re-establishment of the capillary circula- 
 tion from the periphery to the centre of the patch. This pheno- 
 menon is quite peculiar to the case which now occupies us. 
 Constrict the base of a finger tightly with a cord ; you will pro- 
 duce there, it is true, a venous congestion, a bluish coloration, 
 comparable to that of local asphyxia, but the white patch 
 produced by pressure will disappear more quickly than in the 
 normal state. 
 
 What do we conclude from all this ? That in local asphyxia 
 the capillary circulation is only slackened, but not arrested by 
 an obstacle situated in the interior of the vessels, and that in a 
 short time it becomes re-established in the canals of the smallest 
 diameter as completely as in the healthy state. We may there- 
 fore affirm that the capillaries contain neither fibrinous plugs 
 nor pseudoHmembranes. 
 
 X. Arteritis being then placed outside the range of causation, 
 ought we to ask for an explanation in arterial ossifications ? 
 " There is nothing more absurd," says M. Malgaegne,* " than to 
 pretend that the ossification of arteries is a cause of gangrene." 
 Without going so far one cannot but recall that, according to the 
 researches of Bichat,t out of ten bodies of old men seven pre- 
 sented ossifications, which would lead one to consider the fact as 
 physiological, and only to admit the influence of calcareous 
 deposits as a predisposing cause to obliteration.^ So much for 
 theory. As a fact, nothing in our observations justifies the 
 suspicion of this leBion, which is always easy to discover when it 
 exists in the arteries of the limbs, and this is not astonishing 
 since these calcifications are found mostly in persons advanced 
 in age. I should not even have spoken of it, if I had not found 
 briefly reported in an English magazine a fact, for which the 
 name of the author commands attention. When Mr. Solly's 
 case, previously described (Case XXII.), was presented to the 
 Medico-Chirurgical Society of London, Dr. Bright, who was pre- 
 
 * Anatomie Chwurgical, T. i., cap. 9. f -Anat. gen., T. ii., p. 292. 
 
 J Vide Laennec, Victor Andry, loc. cit. 
 
122 
 
 RAYNAUD S ORIGINAL THESIS. 
 
 sent at the meeting, mentioned an observation of his own with 
 regard to a very young woman who was affected with a similar 
 form of gangrene ; in addition, the end of the nose had been 
 attacked. It was found at the autopsy that the aorta was 
 ossified, and that a complete osseous circle was formed round its 
 circumference. The absence of details prevents any comment 
 on my part, but I felt bound to mention this interesting observa- 
 tion. 
 
 Congenital or acquired narrowing of the calibre of the arteries 
 appears to me very worthy of attention, because I find it twice 
 indicated with sufficient detail (Cases XVIII. and XXII.) ; more- 
 over, I do not hesitate in these two cases to attribute to it a 
 certain part in the production of the attacks. But is it right to 
 make this the sole and determining cause of the gangrene ? If 
 such were the case we might expect that sphacelus would appear 
 as a frequent complication in the numerous cases of arterial 
 atresia on record. Moreover, in submitting to the Societe 
 anatomique the results of microscopic examination of his case, 
 M. Godin expressed the view that the exciting cause — cold — 
 which in a normal subject would have been inadequate to the 
 production of gangrene, sufficed in his patient in consequence of 
 individual predisposition. 
 
 The name of M. Godin, who is an authority on the subject of 
 spontaneous gangrene, gives support to this opinion, which is one 
 with which I entirely agree. 
 
 After having enumerated, in order to exclude them, the most 
 common arterial changes, it would be easy for me to submit to the 
 same criticism, the possibility of similar lesions of the veins 
 acting as causes of the disease under consideration. Amongst 
 these phlebitis alone deserves serious discussion. Happily the 
 history of phlebitis is much better known than that of arteritis, 
 the symptoms are sufficiently clear for it to be hardly possible to 
 mistake them, and I hope that it will suffice to read attentively 
 my observations in order to be convinced that phlebitis may be 
 put aside as the cause of local asphyxia. Further, when we 
 remember that tbe part which phlebitis plays in the production 
 of gangrene is now regarded as more than problematical, it seems 
 useless to prolong this discussion. 
 
 To sum up that which concerns the blood-vessels. Although 
 structural lesions of these vessels may have sometimes played 
 
PATHOLOGICAL HISTORY. 128 
 
 the part of adjuvant and accessory circumstances, we have been 
 unable to discover in such lesions a cause adequate in itself alone 
 to the production of symmetrical gangrene of the extremities. 
 It is scarcely necessary to add that, even if in any case we had 
 found such a cause, it would not have invalidated the cases in 
 much greater number in which the most minute examination has 
 furnished only negative results. 
 
 XI. We might say as much for the organic lesion of the heart. 
 It is well to state at once that the cases in which these lesions 
 have been found are precisely those which have furnished us 
 with arterial lesions, a new proof in support of the pathological 
 solidarity too often unrecognised of the whole circulatory 
 apparatus. 
 
 In one case (Case XVIII.) we found a contraction of the mitral 
 orifice ; in another (Case XIX.) a contraction of both auriculo- 
 ventricular orifices. That in certain cases at a very advanced 
 epoch of valvular affections of the heart gangrenous affections of 
 the skin may appear is known to us all. A considerable oedema 
 then distends beyond measure the lower limbs, which attain an 
 enormous size. The capillary circulation becomes feeble, and an 
 insignificant cause suffices, as for example the punctures made 
 to favour the escape of serum, or simply the pressure of the 
 clothes, to provoke a gangrene which is almost always preceded 
 by erythema ; but this has nothing in common with the possi- 
 bility of a spontaneous gangrene, properly so-called, in cardiac 
 affections. " In none of my own cases,' says Corvisart, " and in 
 a much larger number which I could cite of heart affections, have 
 I ever seen the sphacelus occur which is now in question."* 
 Laennec gives the same opinion.- MM. Bertin and Bouillaud 
 do not mention it as a complication. When such observers 
 specially given up to this kind of research have never seen gan- 
 grene of the extremities from heart disease, are we not justified 
 in rejecting its existence? If, moreover, we reflect on the 
 excessive frequency of heart affections, and on the extreme rarity 
 of spontaneous gangrene, is it not rational, when we happen by 
 chance to note their coincidence, to seek the explanation else- 
 where? M. V. Francois seems to me to have very happily 
 expressed the truth when he says, " a lesion of this viscus 
 which would be sufficient to oppose to the blood stream an 
 
 * Essai sur les lesions organiques dm cceur. Paris, 1818. 
 
124 
 
 KATOATJD S ORIGINAL THESIS. 
 
 obstacle capable of occasioning mortification of a limb, would 
 be more tban sufficient to determine general deatb."* 
 
 But if an auriculo-ventricular contraction is incapable by itself 
 of provoking gangrene, we may well believe tbat if gangrene exists 
 it may up to a certain point modify its form. In M. Topinard's 
 case, for example, tbe patient presented initial phenomena similar 
 to those which we have several times recorded — cooling, bluish 
 coloration, severe pains in the four extremities, &c. ; also by 
 her sex, her age, her nervous antecedents she came into close 
 relation with the subjects who have furnished our typical cases. 
 Is it not probable that her affection was of the same character ? 
 
 In her case, however, the permanent obstacle to the reflux of 
 venous blood led to oedema of the lower extremities, which was 
 opposed to complete, mummification, and consequently the gan- 
 grene assumed a more or less moist character. I am bappy to 
 say that this view is also taken by M. Topinard himself, and that 
 he inclines to believe from the progress of the symptoms that 
 the gangrene of the feet would have been dry in his patient if the 
 cardiac complications had not modified the condition of things. 
 
 XII. It is important to reduce to its just value the part 
 played in our cases by the central organ of the circulation before 
 entering on the difficult and delicate question of embolism. 
 The last word has not been said on this subject — far from it ; 
 but it may be safely affirmed that there will be no agreement on 
 this point unless clinical observations are considered in the 
 light of pathological anatomy. 
 
 All the known cases of embolism of the limbs have presented 
 up to this point a remarkable similitude in the progress of 
 events. Either during the course of an organic affection of the 
 heart, or even in the absence of that antecedent, suddenly pro- 
 found troubles become manifest in that organ, the pulsations 
 become indistinct, unequal, tumultuous, then a state of tran- 
 quility returns, but at the end of a few hours an acute pain is 
 felt in a limb ; the limb becomes exsanguine, cold, and insensi- 
 tive ; on examining it attentively we perceive that the arterial 
 pulsations have ceased ; finally gangrene appears. At the 
 autopsy we find a fibrinous clot, an atheromatous plug situated 
 in the arterial trunk corresponding to the diseased limb, and 
 sometimes we are fortunate enough to discover in a remote part 
 
 * Op. cit., p. 145. 
 
PATHOLOGICAL HISTOBZ. 125 
 
 of the circulatory apparatus the solid body from which a frag- 
 ment has been detached .and projected to a distance. This 
 sequence of events is so characteristic, that on comparing with it 
 the cases of which I have given the history it is clear that they 
 will not bear a similar interpretation. Our autopsies being 
 altogether negative from this point of view, let us return to 
 clinical facts. Let us refer to the only one of our observations 
 which to a superficial examination might pass for a case of 
 embolism (XV.). A young woman three days after her confine- 
 ment presented suddenly extreme cardiac irregularity with a 
 sensation of beating in the head and fainting. Then one might 
 have feared the formation of cardiac clots, and their escape into 
 the pulmonary artery. But there was nothing of the kind. 
 The only event which happened was a choleriform diarrhoea 
 which came on a few days afterwards, and which endangered the 
 patient's life. Then she gradually convalesced. Nearly three 
 months passed, then cyanosis appeared, progressive cooling of 
 the nose and the extremities, and in fifteen days there was 
 confirmed gangrene of the limbs. 
 
 Let us examine the series of hypotheses necessary in order to 
 regard this as a case of embolism. It would be necessary (1) 
 that a clot should have formed in the heart under the influence 
 of the puerperal state — this is quite possible ; (2) that it should 
 be ultimately organised ; (3) that it should remain three months 
 without giving rise to accidents, in the latent state so to speak. 
 
 This is more difficult to realise, because where would this 
 clot be lodged ? In the heart. But in that case how is it that 
 it did not once provoke the return of those irregularities which 
 were so alarming at the commencement ? In the aorta without 
 obliterating its calibre ? But by what mechanism could it be 
 maintained free ? In the arteries of the limbs ? But why 
 then was the gangrene not immediate ? But this is not all. 
 It is necessary that on one fine day fragments of clot taking on 
 the character of plugs should penetrate simultaneously the 
 brachio-cephalic trunk, the left subclavian, the two iliacs, the 
 two carotids. I acknowledge that this hypothesis of multiple 
 migratory clots distributed regularly to all the extremities had 
 appeared to me at first so unlikely as to be equivalent to an 
 absurdity. 
 
 Nevertheless a recent case has shown me that to the very 
 
126 ravnaud's original thesis. 
 
 letter events might happen thus. It was observed at theNecker 
 Hospital by my colleague and friend, Dr. Bricheteau, who has 
 communicated it to the Sbciete medicale d'observation. This 
 is the substance of it : — 
 
 A woman, aged 68 years, having undergone for many years all 
 kinds of privations, was brought to the hospital for diarrhoea 
 dating back for three weeks. Attentive examination of the 
 different organs, and of the heart in particular, failed to discover 
 any lesion. Under the influence of appropriate regimen the 
 diarrhoea disappeared, and the patient improved, when all at 
 once she fell into an adynamic condition. The pulsations of 
 the heart became very feeble, embarrassed, and scarcely per- 
 ceptible to the hand. At the same time there appeared a 
 notable cooling of the lower extremities, then of the hands, 
 soon accompanied by oedema. The pulse was small, thread-like, 
 at the radials, nil in the dorsal arteries of the feet. Black 
 patches showed themselves on the dorsal surface of both hands. 
 The day after the oedema and chilling had still further extended, 
 the general condition had become worse, the radial pulsations 
 had disappeared. The pulsations of the brachials and of the 
 femorals had become very feeble. On the contrary the pulsa- 
 tions of the heart had recovered more force and intensity. The 
 patient died forty hours after the onset of these symptoms. At 
 the autopsy a voluminous resisting elastic organised clot was 
 found in the right ventricle. The left ventricle was perfectly 
 free. The pulmonary artery was healthy. The aorta presented 
 no alteration, but above its bifurcation a voluminous clot was 
 found 8 centimetres long, soft, and blackish at the extremities, 
 and the middle part occupied by a white centre, solid, evidently 
 fibrinous, and of old formation. The two brachial arteries pre- 
 sented at their division at the bend of the elbow a small clot 
 uniformly white and solid, folded upon itself like a worm, and 
 not penetrating into the bifurcating branches, free otherwise, 
 and adhering in no part to the walls of the artery, which was 
 itself perfectly healthy. 
 
 M. Bricheteau, eliminating the different suppositions which 
 could be suggested by the presence of these clots, thinks that 
 they were formed primarily in the two cavities of the heart in 
 consequence of a cachectic condition. That the contractions of 
 the right ventricle were unable to expel the clot from its cavity, 
 
PATHOLOGICAL HISTORY. 127 
 
 the left ventricle on account of the greater thickness of its walls 
 forced out the clot from its cavity, and this clot having become 
 partially disintegrated some of the fragments penetrated into 
 the principal arterial trunks. 
 
 After a careful examination of the specimen I was obliged to 
 come to the same opinion. 
 
 But this fact, although of the highest importance in the 
 general history of embolism, has no value in explaining the 
 phenomena noted in our Case XV. In fact there remain two 
 important differences. (1) In M. Bricheteau's case gangrene of 
 the extremities succeeded the cardiac failure with very great 
 rapidity, in ours there was an interval of three months. (2) In 
 the one the complete disappearance of the arterial pulsations 
 preceded the gangrene, in the other these pulsations were 
 perceptible throughout. 
 
 Here again, as in regard to arteritis, one may perhaps appeal 
 from embolism visible to the naked eye to capillary embolism. 
 But I reply as in regard to arteritis, that in our cases the capil- 
 lary circulation is only slowed, and not suppressed. Moreover 
 embolism of the finest arterioles invoked by the Germans to 
 explain softenings and metastatic abscesses has not been, so far 
 as I know, invoked as a cause of gangrene. Since I must now 
 express my opinion on the significance to be accorded to the 
 irregularities of the heart pulsations in the case in question, I 
 will say that by exclusion it is impossible for me to recognise 
 anything more in them than a purely nervous phenomenon. In 
 fact, (1) these irregularities, of which the patient was conscious, 
 were not new to her, and consequently could not be connected 
 with the accidental formation of a clot ; (2) they appeared all at 
 once with a dreadful intensity, then disappeared as easily as 
 they appeared ; (3) we found them present temporarily a year 
 after the cure of her gangrene was established; (4) nothing 
 subsequently has led us to believe that there is any organic 
 lesion of the heart. I hold the same view with regard to the 
 cardiac irregularities of Case XII., and still more with regard to 
 those of Case VIII. 
 
 XIII. Finally, let us separate diabetic gangrene. Here it is 
 true, in order that the demonstration might be complete, it would 
 be necessary that in all cases the urine should be examined for 
 sugar with a negative result. I have reported two cases very 
 
128 
 
 EAYNAUD S OKIGINAL THESIS. 
 
 fully (XIII. and XV.) in which it is positively stated that the 
 urine contained no trace of sugar. I believe that I can affirm 
 the same in two others (V. and XII.). There is a strong pre- 
 sumption in regard to the other cases. It is completed by the 
 absence of the characters attributed by M. Marchal (of Calvi) to 
 diabetic gangrene. The majority of the facts recorded by this 
 physician* refer to gangrenous phlegmons developed upon 
 different parts of the body, and especially on the nucha. There 
 are added, it is true, some rare cases of dry gangrene of the toes, 
 but all are characterised by well-marked inflammatory antece- 
 dents. Although reserved on many points, M. Marchal is very 
 explicit on this. " I limit myself to the statement that in more 
 than forty cases diabetic gangrene and ulceration have always 
 commenced with inflammation." This statement alone will 
 suffice for a broad distinction between the diabetic cases and 
 ours. 
 
 The majority of the more or less probable causes of dry 
 gangrene are now eliminated; there remains only one which 
 merits our further attention, viz., ergotism. 
 
 XIV. It is remarkable, after the frequent opportunities which 
 we have had of observing this singular intoxication, and after the 
 numerous monographs written upon it, how very little we really 
 know on the subject. What is required is not accounts of 
 epidemics, but individual and detailed observations. Thus in 
 many of these narratives — and in some of the most estimable 
 ones — numbers of gangrenous arms and legs are added up, but it 
 is impossible to know whether in each patient one or many limbs 
 had been attacked, and which, and in which order. All that 
 one can say upon this point is that gangrenous ergotism is much 
 more frequent in the lower than in the upper limbs, and that in 
 many cases two feet have been seen gangrenous at the same 
 time. It would be extremely interesting to learn what is the 
 mechanism which produces gangrene in these cases. Victor 
 Andryf advanced the view, which M. KocheJ has since then 
 sought to prove, that this mechanism is none other than 
 arteritis. If this opinion were demonstrated there would be no 
 further necessity to establish a distinction between our cases and 
 those of gangrenous ergotism, since arteritis has been already 
 
 * Vide I' Union midicale, 1861. + Journal desprogres, &c, T. x., p. 156. 
 
 J Nouveaux Eldments de pathologic medico-chirurgicate, T. i., p. 217. 
 
PATHOLOGICAL HISTORY. 129 
 
 excluded. Unfortunately M. Boche proceeds only by way of 
 reasoning, basing his argument on the similarity of the symptoms. 
 The direct proof, the proof of fact, is absent. In a more recent 
 work giving an account of an epidemic of ergotism observed in 
 1854 and 1855, M. Barrier tells us indeed that the patients pre- 
 sented local signs of arteritis,* but as he does not tell us what 
 these signs were, nor by what lesions he verified them after 
 death, and as on the fact of arteritis we are by no means satis- 
 fied, these are simple assertions of which it is impossible to take 
 account. The same may be said of the opinion advanced by M. 
 Boujeanf (of Chambery). This chemist having demonstrated 
 the coagulating action exercised by the badly defined principle to 
 which he gives the name of ergotine, concludes therefrom that 
 the same effect is produced in the interior of the vessels of 
 the living subject. I hardly know an author who has written 
 from actual inspection of the state of the vessels in this malady. 
 Ergot, says Courhaut, acts on the animal economy as a styptic. 
 We find on post-mortem examination the arterial trunks reduced 
 in size by the approximation of their tunics, which are of a brown 
 colour, and that a stylet cannot be passed along their lumen.J 
 In the absence of adequate information drawn from the exami- 
 nation of dead bodies, one would have been glad to rely upon the 
 numerous experiments performed on animals. 
 
 Those of Kead§ and Tessier || have often been invoked, but as 
 M. Foiling has observed, these experiments cited everywhere are 
 far from giving what it has been pretended can be drawn from 
 them. The gangrene of the tongue or of certain muscles, the 
 ecchymoses on the abdomen, the sanious discharge from the ears, 
 as occasionally met with in pigs and ducks, these phenomena 
 are far removed from mummified gangrene such as it is observed 
 in man. 
 
 The more recent experiments of Parola and Millet are hardly 
 
 * Gazette medicale de Lyon, 1855, p. 181. 
 
 f Traite the'orique et pratique de Vergot de seigle, 1845. 
 
 ■%' Traite de Vergot. Cbllons sur Saone, 1827. Courhaut had noted the disappear- 
 ance of the arterial pulsations (vide the report of M^rat upon this work in the Arch, 
 generates de medecine, le serie, T. xv., p. 459. Bourdot, cited by M. Courcelle 
 Seneuil (These de Paris, 1846, No. 23), found in one case the femoral reduced to the- 
 volume of the temporal. 
 
 § Traite de Vergot, p. 8. 
 
 || Memoires de la Societe royule de Medecin, 1777—8, p. 587. 
 
 % Traite Elementaire depathologie externe, T. i., p. 114. 
 
 9 
 
130 Raynaud's original thesis. 
 
 more conclusive, so that one cannot refuse to admit a certain 
 value in the negative results of Parmentier, Schleger, and 
 Model. 
 
 XV. Desiring to arrive at some opinion on this controverted 
 point, and especially curious to ascertain the state of the arteries 
 in gangrenous ergotism, I have made during the last six 
 months a good number of experiments on animals. I cannot 
 describe them here in detail, but will content myself with stating 
 the principal results obtained, results which were very incomplete, 
 because, as I expected, many accidents and sources of error inter- 
 fered with the investigation. I experimented on dogs, rabbits, 
 and ducks. With respect to dogs, it was^found that when a small 
 dose of ergot of rye was administered, viz., 2 to 4 grammes daily, 
 mixed with food, there was at first an increase in the urine, 
 and a progressive emaciation. The animal continued neverthe- 
 less to eat, but after a little time it seemed to become habituated 
 to the poison. The experiment was continued for two months. 
 When, on the other hand, the dose was rapidly increased up to 
 10 grammes in the twenty-four hours, the animal even on the 
 second day vomited all the ingested material. Dogs seem to me, 
 therefore, unsuitable for this kind of research. One ought to 
 choose as much as possible animals which do not vomit. 
 
 Two of my rabbits offered most interesting phenomena. One 
 of them had taken with impunity during a fortnight 2 grammes 
 daily ; I forced it to swallow a considerable dose, which I 
 estimated at about 15 grammes. In the evening it was in a 
 state of stupor and extreme prostration. On the morning after, 
 it was found dead in its hutch. I am ignorant as to whether 
 it had any convulsions or not. I made the post-mortem 
 examination immediately. The right heart as well as the pul- 
 monary artery was engorged with dark blood, extremely liquid 
 in character ; the left heart was empty. 
 
 I followed the aorta and the branches distributed to the limbs 
 as far as possible, they were perfectly healthy ; but the mucous 
 membrane of the stomach presented forty to fifty ,patches of 
 brownish black colour, rounded, varying [in size fromjj the head 
 of a pin to a centimetre broad, and presenting a [very slight 
 elevation under the finger. Nothing in the condition of the 
 arteries of the stomach appeared to me to explain them, only 
 that there were in the neighbourhood small vascular arborisations 
 
PATHOLOGICAL HISTORY. 131 
 
 full of coagulum. These were probably the same sort of 
 patches which Eead had observed on the liver, and which he 
 designated gangrenous patches. Lorinser and Diez, who have 
 seen them in the stomach, hold the view (which is incorrect) 
 thai they are situated between the mucosa and the epithelium. 
 I can affirm, after having had them examined microscopically by 
 M. Ch. Eobin, that they occupy the thickness of the mucosa 
 itself; they are not formed by extravasated blood, but of the 
 colouring matter of the blood infiltrated into the interstices of 
 the glandular follicles. The mucosa of the oesophagus and of 
 the intestines presents nothing like them. A second rabbit 
 which had taken 25 to 30 grammes in two days died accidentally. 
 The mucous membrane of the stomach presented the same fine 
 dark arborisations, but almost no patches. 
 
 A single duck succumbed evidently from the effects of the 
 poison without any other obvious phenomenon except profound 
 depression. In this animal I found no lesion except a pro- 
 nounced venous congestion associated with extreme fluidity of 
 the blood. If therefore I should report on that which I have 
 seen, I should be led to believe that ergot of rye given in toxic 
 dose kills in the same way as alteratives. 
 
 But I do not positively affirm this. Since after all, experiments 
 made on animals have only an approximate value, it is much to 
 be desired that all opportunities should be seized of observing 
 the condition of the arteries in ergotic gaDgrene in man. 
 
 XVI. Reduced to clinical facts alone, let us see if our cases 
 agree with the hypothesis of an intoxication of this kind. 
 
 At the outset there is a notable difference as to the subjects 
 affected. Noel, surgeon at the Hotel Dieu of Orleans, who 
 described the epidemic of 1710, made' the remark that this 
 form of gangrene attacks men by preference. What is most 
 astonishing, says he, is that this malady does not attack women, 
 at most a few little girls.* 
 
 The same observation has been made in subsequent epidemics. 
 I have previously established, on the contrary, the great predilec- 
 tion of symmetrical gangrene of the extremities for the female 
 sex. But let us go further. 
 
 Amongst the facts reported previously there is a certain 
 number in which the cause is not indicated ; but in many the 
 
 * Histoire de VAcademie des Sciences, 1710. 
 
132 Raynaud's original thesis. 
 
 social condition of the patients and their abode seem to negative 
 the possibility of ergotism. Four times inquiries have been 
 made in this direction, information has been obtained, but it 
 has been unsatisfactory. Finally, there are three cases which by 
 a kind of fatality seem expressly devised so as to leave the mind 
 in some doubt on the subject (IX., XII., and XV.). 
 
 In Case IX. we know that at the period when the first 
 symptoms appeared, the patient, who then lived at Limoges, 
 had been brought up for sixteen months on bread made ex- 
 clusively from rye flour. Many questions were asked with a 
 view to discover whether the rye flour had been altered; the 
 fact that it was by taste and not by necessity that the patient 
 had adopted this kind of bread would, so far as it goes, be against 
 the hypothesis that the rye flour was ergotised; to anybody 
 who knows the disgusting appearance and execrable taste of 
 ergotised bread such a preference would be inconceivable. 
 
 But it is more important to note that in reality the symptoms 
 presented by this patient were not by any means those of ergot- 
 ism. In her the malady did not go beyond local asphyxia, and 
 the formation of bulls and of very small eschars on the skin of 
 the fingers. Moreover it was continued for three years after the 
 suspected alimentation had been suspended, with alternations of 
 improvement and relapse. Now I do not know that there exists 
 a single example of ergotism in which this progress has been 
 observed ; mortification has taken place all at once, sometimes 
 to a considerable depth, elimination may be a longer or shorter 
 time in its accomplishment, but there is no such thing as chronic 
 ergotism, properly so called. 
 
 The child who was the subject of the 12th case had been 
 brought up in the Cevennes mountains ; there its nourishment 
 consisted of chestnuts and of bread made with buckwheat and rye. 
 But in the first place we are ignorant absolutely as to whether 
 the rye was ergotised or not ; and, secondly, we know that 
 during eight months the child only ate white bread. 
 
 Finally, in Case XV., the patient, who was confined on 
 November 28, 1860, had taken during her labour 1J gramme of 
 ergot of rye. The first symptoms appeared on the following 
 18th February. So improbable is the supposition, that I hardly 
 dare discuss the question whether so small a dose -of ergot would 
 have been sufficient after an interval of three months to induce 
 
PATHOLOGICAL HISTORY. 133 
 
 gangrene, when thousands of women take every day a larger 
 quantity with impunity. Nevertheless for those who are difficult 
 to convince, it is necessary to remove this difficulty. 
 
 There exist, it is true, a few rare examples of gangrene 
 developed after the administration of ergot in obstetrical doses. 
 Such is M. Kobert's* case, in which 12 grains (0*6 centigrammes) 
 had been prescribed and swallowed ; whereupon this physician 
 treats as fools the practitioners who should dare again to employ 
 this medicament. But in this case, according to his statement, 
 the gangrene appeared some little time after delivery. The 
 patient succumbed one month after accouchement ; the progress 
 of events was therefore rapid. Are our Cases XII. and XV. 
 then the only ones in which the tonic action of ergot of rye was 
 manifested at several months' interval ? After careful search I 
 have found a third, in which this remote action of ergot was 
 assumed. This case is sufficiently curious to be reorded.-j- 
 
 February 1, 1854. — Catharine C, aged 22 years, domestic 
 servant, presented herself at M. Maisonneuve's consultation, 
 complaining that she had not been able to use her fingers for 
 more than a month. The two hands presented an aspect suffi- 
 ciently striking and characteristic to attract attention, and make 
 one think of some serious disease. The age of the patient, the 
 absence of all traumatic cause, and the characteristic aspect of 
 the affection, left no doubt as to the existence of a gangrenous 
 ergotism. The patient moreover confirmed immediately the 
 diagnosis by announcing that she had always lived on rye bread, 
 that this was regarded as damaged when four months ago she 
 had left the mountains of Auvergne in order to come and live in 
 Paris. Up to then nothing in her health had made her aware of 
 the hurtful influence to which she was subjected. Two months 
 after her arrival in Paris she became very sensible to cold, and 
 her hands and her feet became swollen and covered with numerous 
 bullae. The patient believed that she was suffering from chil- 
 blains, and although she had never been subject to them pre- 
 viously she was not disquieted by them. But this irritation, 
 instead of subsiding, became aggravated from day to day, and 
 ended by rendering all work impossible, and forcing her to enter 
 the hospital. 
 
 The two hands presented changes not to the same degree but 
 
 * Gazette medieale, 1832, p. 31P, f Gazette des hopitava, 1854, p. 69. 
 
134 kaynaud's original thesis. 
 
 evidently of the same nature. The first thing to arrest attention 
 was the uniform dark colour of the last phalanx of the little 
 finger of the right hand, and that of the middle finger of the left 
 hand. This dark colour disappeared almost abruptly at the 
 level of the posterior border of the nail. The extremities of 
 the other digits presented a violet tint, which was not uniform, 
 but was probably of like nature with that above mentioned. 
 These extremities were also very cold. The fingers, besides 
 being stiff, cold, and painful to pressure, were thin, pointed, 
 and shrivelled, and were quite useless. The two hands were 
 covered here and there with reddish erysipelatous-like patches, 
 and were the seat in some spots of desquamation and of cracks, the 
 probable sequels of the chilblains complained of by the patient. 
 The radial pulse was perceptible at the finger, and was even 
 moderately full in character. The feet, although tumefied in 
 some places, showed no sign of approaching gangrene. The 
 limbs had never been the seat of any spontaneous pain, and there 
 had been no vertigo at the beginning of the affection. 
 
 If it were possible to rely upon the statement of the patient, 
 this then would be another case in which gangrene had set hi 
 more than a month after the cessation of the tonic nourishment. 
 Now this woman had always eaten rye bread. In truth we could 
 not describe this as a case of gangrene from ergotism, and one 
 might have been tempted to call it rather gangrene from the use 
 of white bread ! 
 
 This long interval appears strange when we remember that on 
 comparison of the different epidemics M. Follin has found that 
 the first symptoms of ergotism generally appear after five or six 
 days of the use of this kind of alimentation. 
 
 This objection seemed to me so strong that I thought it 
 desirable to obtain information from original sources. I wrote 
 therefore to Entraignes (Aveylon), the place of sojourn of this 
 young woman before her arrival at Paris. This is what M. 
 Calsat (who was doctor and mayor of that locality) replied : — 
 
 " The young woman, Catharine C, no longer lives at Paris ; 
 she returned to Entraignes about four years ago, after having 
 been married in Paris. She was in good condition when she 
 returned. I can affirm that during the forty-nine years that I 
 have practised in this district, I have only seen rye attacked by 
 ergot once, and in such small quantity that I have hardly been 
 
PATHOLOGICAL HISTORY. 185 
 
 able to collect it for my medical use. As to gangrenes, whether 
 of toes or digits, I have not met with a single case, nor learnt 
 that any of my colleagues of this part of the country have had a 
 case to treat." 
 
 This testimony, assuredly more reliable than that of a poor 
 servant, is such as to make one believe there must have been 
 some misunderstanding of the case. The form and progress of 
 the symptoms, their localisation to the upper limbs, and the age 
 and sex of the subject, would have led me to the view that this 
 case belonged to the same group as that which I have already 
 described. I cannot unfortunately with regard to ergotism draw 
 upon any experience of my own. Nevertheless some facts with 
 which I am acquainted lead me to think that the use of bread 
 made with rye of bad quality does not suffice by itself to produce 
 gangrene. 
 
 It is necessary in addition to have the unknown quantity, which 
 for want of a better word we are forced to call predisposition. 
 Now this predisposition may become settled in certain families. 
 The following is one of the most curious examples still unedited : — 
 
 On March 1, 1855, there were admitted to the Children's 
 Hospital, under the care of M. Guersant, two brothers, named 
 Vidal and Jean K., aged — one 14 years, the other 12. They 
 had lost both parents at the same time during the cholera in 
 1849. Dependent upon public charity they had been taken to 
 different abodes, and for the last four years they had been living 
 in an agricultural settlement situated two leagues from Gien 
 (Loire). On their admission Jean had two feet mummified up 
 to the tarsus ; a deep groove separated the dead from the living ; 
 at the bottom of the wound the articulations were seen quite 
 exposed. In Vidal the five toes of the left foot were gangrenous ; 
 on the right side there was only a superficial mortification of the 
 last phalanges of the first and of the fifth toes. In neither was 
 there any symptom of arteritis or of phlebitis. In Jean's case 
 a few cuts with the scissors sufficed to detach the dead parts. 
 Enormous wounds resulted, which suppurated for a long time. 
 In the absence of flaps cicatrisation appeared impossible. After 
 having temporised for awhile, M. Guersant saw that it was 
 necessary to amputate the right leg at the seat of election. 
 Then it was found necessary to perform sub-malleolar amputation 
 on the left side. 
 
!36 Raynaud's original thesis. 
 
 In VidaPs case the progress of events was much simpler. 
 The sloughs having separated, cicatrisation soon took place. 
 
 I have taken these details from M. Guersant's note book. 
 
 I have recently sought out Jean R., now aged 19 years. 
 He is a very intelligent young man, and has given me circum- 
 stantial information on the commencement of the illness. His 
 brother and he had undergone great hardship ; the winter had 
 been very severe. They worked in sabots in the quarries. On 
 their return to the house they walked with bare feet on the floor. 
 Both had had chilblains all winter. Jean began in the early part 
 of January, 1854, to feel severe pains in the lower limbs; in Vidal 
 symptoms began at the moment when the gangrene was already 
 confirmed in his brother. With regard to the cause of this ill- 
 ness Jean R., whom I interrogated with all possible care, 
 aflirmed to me that their food was composed in great part of rye 
 bread, that at that time the rye was ergotised, and the descrip- 
 tion he gave me appeared to be conclusive. He added that at 
 the beginning of the illness there was a period of delirium. But 
 what appears to me essential in this history is the following : 
 thirty-six children lived at this settlement. All were subjected 
 to the same regimen, ate the same food, and were exposed to the 
 same hygienic surroundings. Now of these thirty-six, two only 
 were affected, and these were the two brothers. However one 
 may explain this singular coincidence, it seems to me worthy of 
 the most serious attention. 
 
 I may perhaps be pardoned for having entered upon this long 
 discussion with regard to gangrenous ergotism. The description 
 which I have given of symmetrical gangrene of the extremities 
 would have had no value, if there had remained any doubt as to 
 its being distinct from the lesions produced by ergot. 
 
 XVII. I have said what this gangrene is not. It remains now 
 to ask what it is. Upon this question it is necessary to be 
 more circumspect. It has long been admitted that gangrene 
 might be produced by alterations of the blood. But to admit 
 this alteration, without knowing wherein it consists, is in truth 
 to have made a very slight advance. Nevertheless it is possible, 
 and since the symptoms described as ergotism have probably no 
 other cause than ergot, there is nothing fundamentally absurd in 
 supposing that there exists around us some mysterious poison, 
 the accidental introduction of which into the economy may be 
 
PATHOLOGICAL HISTORY. 107 
 
 able to determine the symptoms which are now under considera- 
 tion. 
 
 Gangrene has been said to be produced by opium, and also by 
 damaged potatoes. M. Jobert has cited cases of dry gangrene 
 produced by septic matters, &c. If it be so, it is much to be 
 desired that new researches should reveal to us the nature of 
 this mysterious agent. In which case there would still remain 
 that which remains to be done for ergot — viz., to investigate the 
 mechanism of the poisoning. Meanwhile it appears to me 
 possible to invoke another cause. Can a vice of innervation 
 produce gangrene? M. V. Francois admits this variety as 
 probable. But it is all-important here to establish a distinction 
 between nerves of relation and the system of the great sympa- 
 thetic. 
 
 With regard to the first, our knowledge is very limited. 
 Although the section of these nerves leads infallibly to paralysis, 
 it is infinitely rare for it to cause sphacelus. Nevertheless M. 
 Longet has observed that many months after section - of the 
 sciatic nerve in dogs, the paw becomes covered with gangrenous 
 patches, loses its hair and its claws, and that the limb begins to 
 show signs of fatty degeneration.* 
 
 Haller had seen similar facts. M. Bernard has observed, after 
 the section of the fifth and of the seventh, a constant lowering of 
 temperature of 1 to 2 degrees in the paralysed part. M. Rom- 
 berg f has specially studied the effects of cutaneous anaesthesia 
 on nutrition. He reports them under three groups. 1. Diminu- 
 tion of calorification. He cites the history of two patients who, 
 after traumatic lesions of nerves of the lower limbs, presented a 
 notable diminution in the temperature of the paralysed limbs. 
 2. Inaptitude of the affected part to resist changes of tempera- 
 ture. These same patients could not undergo the contact of 
 cold water, or be exposed even to a moderate heat, without the 
 occurrence of blisters on the ends of the fingers. "We may 
 associate with this, Dieffenbach's remark, that after plastic 
 operations of the nose blisters are apt to arise on the least 
 chilling, and that this phenomenon ceases on the re- establish- 
 ment of sensibility. 3. Slowing of the capillary circulation, 
 whence a livid colour appears. Romberg cites many cases, 
 
 * Traiti de physiologie, T. ii., p. 93. 
 
 t Lehrbuch der Nerven Krankheiten, 1 Bd., p. 232. Berlin, 1851. 
 
138 
 
 KA\NAUD S OKIGINAL THESIS. 
 
 gathered from different authors, of sections of nerves, which 
 led either to ulcerations or to the appearance of small vesicles 
 occurring from time to time on the paralysed digits, or to an 
 epidermic desquamation, and loss of nails and hairs. I myself 
 observed a fact of this kind during the time that I was resident 
 under M. Robert in 1858. 
 
 A man had a cicatrix at his elbow, which, from its situation, 
 led us to believe that the wound had affected the ulnar nerve. 
 All along the course of this nerve, quite definitely, there appeared 
 from time to time vesicles which were filled with reddish serosity, 
 these dried up, and fresh vesicles appeared soon afterwards at a 
 short distance. 
 
 It appears then to be proved that lesions of nerves may lead 
 in certain circumstances to alterations of nutrition, which are 
 somewhat profound. But let it be noted that in all these cases 
 there is a traumatic antecedent, which is wanting in our obser- 
 vations ; that generally, if not always, there is the coincidence of 
 a true paralysis ; finally, and above all, that it is not true gan- 
 grene which is produced, and that the anatomical form of the 
 lesion differs essentially from that which we have described. So 
 that in the actual state of knowledge we are authorised in believ- 
 ing with M. Follin* that the cessation of nervous influx, whilst 
 blunting the sensibility of the parts, favours the action of causes 
 which without it would remain without effect. Moreover, 
 when we reflect on the numerous anastomoses which the nerves 
 of the cerebro- spinal system have with the great sympathetic 
 more or less near their origin, we cannot affirm that the lesion 
 of nutrition, when it occurs, is not dependent on a lesion of the 
 ganglionary system. This appears to result from M. Claude 
 Bernard's experiments, and this leads us naturally to consider 
 the bearing of his experiments on our subject. 
 
 XVIII. The physiology of the circulation has been enriched 
 in late years by one of the most beautiful discoveries of the cen- 
 tury, with which is coupled the name of the illustrious professor 
 whom I have just quoted. In repeating the experiments of 
 Pourfour du Petit on the section of the great sympathetic of the 
 neck, M. Bernard recognised that this lesion is accompanied always 
 by a very notable elevation of temperature in the corresponding 
 parts of the head. The same fact, studied subsequently by M. 
 
 * toe. tit. 
 
PATHOLOGICAL HISTOBY. 139 
 
 Brown-Sequard, and by M. Schiff, of Berne, has been not only 
 verified but generalised. Since then the doctrine of vaso-motor 
 nerves has passed from the domain of hypothesis to that of fact. 
 On the one hand anatomy demonstrated the existence of smooth 
 muscular fibres in the middle coat of the arteries, on the other 
 physiology established the subordination of these fibres to ner- 
 vous influence. Thus Valentin's phrase was realised, " The 
 vascular contractility is the moderator of the course of the 
 blood." 
 
 It was reserved to M. Bernard to add another discovery to the 
 preceding. He demonstrated that the branches of the lingual 
 nerve which go to the submaxillary gland have a property which 
 is precisely inverse to that of the great sympathetic : when cut 
 they provoke an acceleration of the blood current in that vascular 
 region ; galvanised at their peripheral end they cause slowing 
 of the circulation ; these vessels are thus subjected to two 
 opposite local influences, of which the equilibrium is necessary 
 for the maintenance of the normal circulation. Whence arises 
 this conclusion : the pressure of the arterial system and the 
 cardiac impulse are common mechanical conditions which the 
 general circulation dispenses to all the organs. But the special 
 nervous arrangement which has to do with each capillary 
 system and each organic tissue regulates in each part the course 
 of the blood in relation with the chemical functional conditions 
 of the organs; these nervous modifications of the capillary 
 circulation take place on the spot, and without any disturbance 
 of the circulation of the neighbouring organs, or still less of 
 the general circulation. Each part is united to the whole by 
 the common conditions of the general circulation, and at the 
 same time by means of the nervous system each part can have 
 a circulation of its own and become physiologically indi- 
 vidualised. Now whether this takes place only in the fine 
 arterioles, the capillaries properly so called remaining foreign 
 to it, in consequence of the constitution of their walls ; or 
 whether, on the contrary, according to Hastings and Milne 
 Edwards, the capillary vessels themselves may take part, is of 
 little importance from the physiological and pathological point 
 of view ; that which is certain is that on the confines of the 
 arterial and venous systems important phenomena take place 
 having to do with the volume, the temperature, and the colour of 
 
140 Raynaud's original thesis. 
 
 the parts, and of which the vascular contractility can and ought 
 to render an account. 
 
 But here a serious difficulty presents itself. By virtue of 
 what mechanism does this elevation of temperature take place, 
 which M. Bernard has proved for the first time on the rabbit's 
 ear ? There are two theories on the subject ; the first is a far- 
 off echo of the old doctrine of Galen, who saw in the pulse a 
 phenomenon of active expansion of the arteries ; this theory 
 maintains that the dilatation of the capillaries, whence results 
 the increased warmth of the part, is an active phenomenon. 
 Consequently inflammation would be, as Broussais held, an 
 exaltation of the vital properties of the region, an excess of force. 
 According to the second theory the dilatation of the capillaries 
 is purely a passive effect, a true paralysis, and the increase of 
 temperature results from the free passage at a given moment of a 
 larger quantity of blood than normal, with more than normal 
 capacity of transmitting to the extremities the heat of the 
 centres, and of resisting the causes of chilling. The doctrine of 
 activity was strongly maintained by Graves long before the 
 discovery of the vaso-motor nerves. He considered that in all 
 congestive phenomena the initiative was taken by the capillaries. 
 He was opposed strongly to the theory of the vis a tergo ; he 
 developes the opinions of Carpenter upon what that physiologist 
 calls the capillary power, which is charged, according to his 
 view, with regulating the flow of nutritive liquid and controlling 
 the growth and maintenance of the parts of the body. We 
 recognise here the famous theory of the " demand of the 
 blood" held by John Hunter and Tommasini, and at a later 
 period modified somewhat as to form, but the same fundamentally, 
 as the system of attraction of Wharton Jones and Paget, who 
 believe in a true affinity between the blood and the parenchy- 
 matous tissues. 
 
 I should not have dwelt upon this subject, if at the same time 
 that he discovered the primordial fact M. Bernard had not given 
 to this doctrine the support of his authority. According to his 
 view, from the fact that the temperature is raised after the 
 section of the great sympathetic, we must not conclude that there 
 is a paralysis of the capillary vessels. " This circulatory phe- 
 nomenon," he says, "appears to me to be active, not passive."* 
 
 * Corns de 1858, p. 510. 
 
PATHOLOGICAL HISTOEY. 141 
 
 In other words, the ganglionar^ nervous system exercises a 
 direct influence on calorification; its section does not act 
 positively upon the circulatory state, but upon the heat pro- 
 duction by an inscrutable mechanism like that of the vital 
 properties. 
 
 XIX. Ought we to admit this interpretation? In a still 
 recent thesis — one of the most remarkable which have been 
 sustained at the Faculty of Paris* — my colleague and friend 
 M. Marey has combatted with talent, and in my opinion has 
 successfully refuted, the arguments of the eminent professor of 
 the College de France. Not having either authority or space 
 sufficient to enter here upon this difficult discussion, I can only 
 refer the reader to that excellent work. Amongst the points 
 which M. Marey seems to me to have decisively established, I 
 will limit myself to the following, . which bear directly on, my 
 subject : — The true obstacle to the course of the blood, and 
 consequently the cause of the tension of the arteries, consists 
 in the friction of the liquid against the walls of the capillaries. 
 There is a constant antagonism between the tension of the blood 
 and the contractile force of the vessels which support it, so that, 
 contrary to the general opinion, their dilatation produces a more 
 easy passage of the blood, and an excess of calorification ; their 
 contraction produces inverse effects. 
 
 The muscular fibres of the arteries supplied by the great 
 sympathetic are entirely comparable with those of the organs of 
 vegetative life, and as such susceptible in the physiological state 
 of contraction, fatigue, and of adaptation to work, in the 
 pathological state, of spasm, and of paralysis. 
 
 It is physically impossible that a tube witb membranous wall 
 should actively dilate under the enormous resistance opposed by 
 atmospheric pressure. 
 
 This law, enunciated by Hunter, remains indisputable, viz., 
 that in the warmest peripheral parts the temperature never goes 
 beyond that of the centres. Consequently, according to M. 
 Marey, the phenomena of calorification and of redness observed 
 by M. Bernard upon the rabbit's ear ought to be considered as 
 purely passive. 
 
 I shall not follow my distinguished colleague in his ingenious 
 
 * " Becherche3 sur la circulation du Sang a V&at physiologique et dans lea maladies." 
 These de Paris, 1859. 
 
142 Raynaud's original thesis. 
 
 views upon vascular debility considered as a cause of inflamma- 
 tion ; in my sense there is in inflammation quite another thing 
 than a simple phenomenon of irrigation, otherwise how could 
 one conceive it in the tissues which have no vessels, such as the 
 cornea ? I hold that the famous aphorism, " Ubi stimulus ibi 
 fiuxus," will still remain, clinically at least, indisputable. I will 
 add only that in the capillary circulation there are two elements 
 which we must carefully distinguish ; the rapidity of the current, 
 and the quantity of the blood which is found at a given moment 
 in a given region. Of these two elements the first is only a 
 question of mechanics, and affects us to a moderate degree.* 
 The second has an immediate interest, since the possibility of 
 nutrition and of its proper performance of function are related 
 to the quantity of blood in contact with the living solid. Now 
 from what we have just seen, the quantity of blood in circulation 
 in a part increases in the state of relaxation of the capillaries, 
 it diminishes when they are narrowed or contracted, it becomes 
 nil if the narrowing goes on to the suppression of the lumen of 
 the vessel. 
 
 XX. Starting from these facts, let us see if there is any 
 temerity in admitting that in certain circumstances there may 
 occur a spasmodic contraction of capillary vessels. Far from 
 this being so, this spasm is precisely one of the most common 
 phenomena of pathology. We have only to look for it to find 
 it. What is the common phenomenon of frost bite ? and what 
 does that deadly pallor, that chilling of the extremities which 
 occur in the algid period of cholera, and the intermittent fevers 
 signify ? What means the bluish tint which affects the nails, 
 the violet aspect of the extremities so habitual in general 
 paralysis, &c. ? 
 
 What is the significance, in one word, of algidity, that symptom 
 which is one of the most frequent that we have to observe, if it is 
 not a fact of transient ischaemia, a condition only to be explained 
 by a spasm of capillary vessels ? 
 
 Let us take now algidity in itself, and let us see how it 
 terminates. In one of two ways it may give place to what we 
 
 * M. Marey has also the merit of having pointed out the difference between what 
 is called the quantitative rapidity and the molecular rapidity. " From the rapidity of 
 each molecule being augmented at a contracted part, it does not follow that the con- 
 traction is a cause of the absolute rapidity of the current — quile the contrary ; this 
 confusion is based on a misunderstanding." 
 
PAXHOLOGICiL HISTORY. 143 
 
 have agreed to call the period of reaction, characterised by heat 
 and redness which go beyond the normal state. 
 
 This mode of termination, by far the most frequent, is in some 
 sort physiological. It takes place by virtue of that general 
 law according to which every muscular contraction is followed 
 by relaxation ; if contraction has been spasmodic, excessive 
 relaxation will extend up to momentary abolition of the tonicity 
 of the muscular fibres, and this tonicity will only be re-established 
 by degrees. 
 
 Or, on the contrary, the cause continuing to act, the capillary 
 spasm may extend beyond its habitual duration ; the parts 
 deprived of blood lose the elements of nutrition, and gangrene 
 occurs. This is what happens in algidity caused by the im- 
 pression of cold. It is generally held that in this case there is 
 freezing of the liquids in the interior of the capillaries, then 
 rupture of these vessels at the time of tbe passage of the icicles 
 to the liquid state. I do not deny that this may occur in certain 
 cases, but nobody so far as I know has ever seen these ruptures, 
 and they seem to me to be difficult to admit when one considers 
 the extreme elasticity of the membranous walls of the vessels. 
 Is it not more simple to admit that gangrene may occur 
 primarily, being caused by the persistence of the capillary spasm 
 which has occasioned at the commencement the exsanguine 
 condition of the extremities ? 
 
 Is it not possible that these different phenomena, which 
 take place every moment under our eyes, and under the in- 
 fluence of well known causes, may occur spontaneously, and 
 explain to us in a very satisfactory manner the different degrees 
 which we have noted in symmetrical gangrene of the extremi- 
 ties? 
 
 It commences by a spasm of the capillary vessels, and let us 
 remark that this spasm occurs in subjects who are characterised 
 by a nervous predominance, young women, hysterical people, 
 children, &c. In the simplest cases those in which the malady 
 remains, if I may so say, in a rough state, the exaggerated 
 peristaltic contraction of the capillaries drives the blood before 
 it, the extremities become pale, withered looking, and insen- 
 sible. This is the " dead finger." But this phenomenon does 
 not persist long enough for gangrene to follow. To contraction 
 succeeds relaxation, the circulation is re-established, and every- 
 
144 Raynaud's original thesis. 
 
 thing returns to the normal state after a period of reaction more 
 or less painful. Such is local syncope, in which the venules 
 participate in the contraction of the arterioles. 
 
 Local asphyxia is only a more advanced condition. After an 
 initial period of capillary spasm there occurs a period of reaction, 
 but it is incomplete reaction. The vessels which return first 
 to their primary calibre, or even beyond, are naturally those 
 which present in their structure the fewest contractile elements, 
 viz., the venules. At the moment when these are opened, the 
 arterioles being still closed, the venous blood, which had been 
 at first driven back into the great trunks of the dark blood 
 system, flows again into the finest vascular divisions, and then 
 the extremities will take on that tint varying from blue to 
 black which is a certain index of the presence of venous blood 
 in the capillary network. This explains two phenomena to 
 which I have called attention in speaking of the symptoms. 
 The first is that the cyanotic tint of the extremities succeeds in 
 general to an extreme pallor, or in other terms that syncope 
 precedes asphyxia. 
 
 The second is that at the outset at least the asphyxiated parts 
 have not that very deep tint which one observes following 
 on a violent constriction of a limb ; in this last case, in fact, 
 there is venous blood extending into arteries of a calibre 
 which is relatively considerable. In local asphyxia the venous 
 reflux does not go beyond the capillary network properly so- 
 called; it results therefrom that the colour which is observed 
 has a certain transparence; it is a mixture of cyanosis and 
 pallor. During the convulsions or painful crises, effort deter- 
 mines a more abundant reflux still of venous blood, and the 
 extremities become warm at the same time that they become 
 black (Case VII.). 
 
 In the meantime the vis a tergo having ceased its action on 
 the venous side, the return circulation is no longer favoured 
 except by the causes which in the physiological state are limited 
 to the part of accessory conditions ; such are the muscular 
 contraction of the limbs, the play of the valves, the aspiration 
 exercised by the thoracic cavity, &c. Consequently the blood 
 stagnates even in the great venous trunks, and then are pro- 
 duced along with a very slight cedematous suffusion those 
 subcutaneous livid venous markings which have been rightly 
 
PATHOLOGICAL HISTORY. 145 
 
 compared to those which the prolonged use of warming pans 
 produces.* 
 
 This state may be chronic, and the spasm of vessels may only 
 have a limited duration so as to return in irregular or intermittent 
 attacks. This case is itself susceptible of many degrees: at one 
 time everything is comprised in local asphyxia pure and simple ; 
 at another, each attack having a longer duration, the tendency to 
 gangrene is more pronounced; bullae form with very small 
 sloughs, then at the moment when gangrene is on the point of 
 becoming confirmed the parts revive momentarily, to be soon 
 afterwards attacked in the same way ; and this may go on for 
 years. Finally it may happen, although much more rarely (but we 
 have collected several examples of it), that the capillary spasm 
 comes on all at once with an intensity and a duration altogether 
 extraordinary. Syncope and local asphyxia succeed one another 
 rapidly ; the venous blood becomes insufficient to nourish the 
 parts ; the colour becomes deeper and deeper ; small blood- 
 stained infiltrations take place through the walls of the venules ; 
 these walls may themselves become granular ; in one word, there 
 is confirmed gangrene, and gangrene which may go on to the 
 fall of many ends of fingers or toes. 
 
 But on final analysis all these varieties of functional lesions, 
 which may each present an infinity of shades, realise always one 
 or other of the two conditions which I have previously indicated 
 as essential to dry gangrene ; that is to say, absence of blood, or 
 presence of blood unsuitable to nutrition. When the principal 
 artery of a limb is found obliterated by a clot, or when its last 
 ramifications are contracted on themselves up to the obliteration 
 of the lumen of the capillary vessels, fundamentally the result is 
 the same, and these conditions, although very different, all end 
 in the impossibility of those molecular changes taking place 
 which constitute the intimate phenomena of nutrition. 
 
 And now why is it the extremities only which become gan- 
 grenous ? It is because it is necessary, in order that things 
 should arrive at this point, that there should be a combination at 
 one and the same point of two important causes of chilling : first, 
 the loss of afflux of a warm liquid ; second, a powerful radiation 
 capable of causing the acquired caloric to be lost; all things 
 
 * Are the spontaneous pains of syncope and of local asphyxia in relation to the 
 vascular contraction a sort of painful cramps of arteries ? 
 
 10 
 
146 Raynaud's original thesis. 
 
 being equal, it is evident that the parts which radiate most will 
 become gangrenous first. Thus it is at the extremities that 
 this second condition exists at a maximum ; the digits, the toes, 
 the ears, the nose, are certainly the parts of the body which 
 present the most considerable surface relatively to their volume. 
 
 It is probable that at times the primary phenomenon, the 
 capillary spasm, is not limited to the extremities, and is gene- 
 ralised over a more or less extensive area of the body, as indeed 
 is indicated by the excessive pallor of the skin which has been 
 noted in some cases. 
 
 But in these cases this cause of itself alone has not sufficed to 
 bring about a general gangrene, because the trunk, the face, the 
 roots of the limbs are situated near enough to the centres to 
 preserve a sufficient heat for the maintenance of life. 
 
 It is not impossible that the variety of gangrene which 
 approaches nearest to ours, viz., ergotism, may depend on an 
 analogous mechanism. Everybody knows the obvious action 
 which ergot of rye exerts on the contractile fibres of the uterus ; 
 there would be nothing astonishing in that it should produce 
 the same effects on the smooth muscular fibres which enter into 
 the composition of the arteries, and which are in fact, or as 
 nearly as possible, the same histological element ; in this case 
 the tonic action would show itself by preference in individuals 
 whose muscular fibre is endowed with an excessive irritability, 
 and this would be the reason of those individual predispositions 
 of which I have previously spoken. Perhaps, again, we ought 
 here to take account of another influence. M. Poiseuille has 
 very well demonstrated that the chemical nature of bodies held 
 in solution in a liquid has a sensible influence upon the rapidity 
 of flow in canals of narrow calibre, and this independently of 
 viscosity. Does ergot communicate to the blood a property of 
 this kind ? 
 
 Finally, let us not forget that all this exists in the organism, 
 and that if we can hypothetically study separately the capillary 
 vessels, and the parenchymas in which they are plunged, in 
 reality all these elements are united with one another in the 
 most intimate fashion. I admit therefore very willingly that, by 
 virtue of a cause which escapes us, the anatomical structure 
 of the extremities may predispose them to gangrene, just as the 
 lung is predisposed to inflammation, as the muscles are to 
 
PATHOLOGICAL HISTOEY. 147 
 
 hypertrophy, &c. The striking symmetry which often occurs 
 would favour such a view. We might conceive that up to a 
 certain point, a general cause being given capable of acting 
 upon the capillary circulation, this cause might affect simulta- 
 neously paired extremities. We might conceive less easily how 
 without a very speeial predisposition it might manifest its 
 influence upon points perfectly similar, and with the same 
 intensity on each side of the body. These are questions which 
 present themselves naturally to the mind; they. are not the only 
 ones. But in the actual state of our knowledge there would be 
 some temerity in attempting to answer them. 
 
 Treatment. 
 
 XXI. It will, I trust, be readily understood that for a malady 
 of which so many points are still obscure, I am not quite 
 prepared to formulate a complete treatment. It is desirable, 
 nevertheless, to state the principal indications which are to be 
 fulfilled, and especially some gross errors which are to be avoided. 
 
 We have seen that in one case (XV.), dominated by the desire 
 of irritating and stimulating the torpid parts, I advised the 
 patient at the beginning of the affection to use local mustard 
 baths. I have reported the disastrous results which immediately 
 followed the employment of these means. This is what I 
 think takes place in such a case : the application to the ex- 
 tremities of a powerful modifying agency, whilst locally com- 
 bating the vascular spasm, causes the vascular spasm in some 
 sort* to retrograde to the larger arteries ; hence the sudden 
 eruption of venous blood into parts which it did not previously 
 occupy, and consequently blackness of the extremities rising 
 much higher towards the root of the limbs. Whether this be 
 the explanation or not, we must avoid the use of a therapeutic 
 measure which is as treacherous as it is dangerous, and in general 
 terms we must forbid the employment of energetic rubefacients. 
 
 Aromatic substances have been employed with some advantage ; 
 thus embrocations of benzoin appeared in one case to lead to 
 improvement. When the spontaneous pains felt by the patients 
 do not prevent our being able to touch their limbs, it is well to 
 rub them gently with a piece of flannel dipped in eau de Cologne, 
 or in peppermint water slightly sharpened with ammoniacum. 
 
148 kaynatjd's okiginal thesis. 
 
 I have seen this treatment diminish in a very evident manner, 
 and somewhat rapidly, the dark colour of the fingers, or at' least 
 circumscribe it to the extremities of the ungual phalanges. It 
 is true that it reappeared some time afterwards ; but an improve- 
 ment even transient is not to be disdained in an affection which is 
 so painful. Perhaps the simple fact of a soft and prolonged 
 friction was responsible for this half success. We have seen 
 in one case (VII.) a very good result obtained by the local 
 application of induced electricity. This measure, at first very 
 painful, led to a complete cure after ten or twelve applications in 
 a week. The case is too briefly reported for an absolute con- 
 clusion to be drawn from it. Nevertheless electricity being one 
 of the most powerful of the known modifying agencies of con- 
 tractility, it would not be surprising if favourable results could 
 be obtained from it. It is a method to be tried with all requisite 
 prudence. 
 
 Amongst the topical remedies of which the employment is 
 recommended in some of the cases are aromatic spirit ; the 
 ointment used by M. Sandras, of lard 60 parts and sulphate of 
 strychnia 1 part ; and especially compresses soaked in chloroform, 
 which in one case led to marked improvement in several attacks. 
 As to cold irrigations, the benefit attendant upon their use seemed 
 to be balanced by the inconvenience, that on their suspension 
 painful recrudescences of the malady occurred. If used in any 
 given case the greatest caution should be observed in withdrawing 
 the application. 
 
 Are local bleedings advantageous ? Surgeons know very well 
 that after a plastic operation, when the newly restored part is 
 menaced with gangrene, the application of leeches over the patch 
 is often an heroic remedy. By analogy one may be led to employ 
 it upon the extremities in a state of grave local asphyxia. Case 
 VII. offers us a favourable example of the use of this therapeutic 
 measure. 
 
 It is hardly necessary to add, that to all these methods of 
 treatment it will always be opportune to add the envelopment of 
 the affected limb in close fitting material, and especially in cotton 
 wool. If radiation has upon the progress of the symptoms the 
 dangerous influence which I have attributed to it, it is evident 
 that it must be useful to try to neutralise this cause of chilling. 
 
 Gangrene once confirmed, there is no need for any further 
 
PATHOLOGICAL HISTORY. 149 
 
 local treatment except waiting until the sloughs become limited. 
 The question of the proper time for amputation in cases of gan- 
 grene is far from being settled in surgery. But in the variety 
 which now concerns us (whilst eliminating, as is well understood, 
 the doubtful cases in which the entire limbs have become gan- 
 grenous), this question can hardly arise. With a mortification 
 so limited, with the certainty that the elimination will take place 
 satisfactorily, it is evident that surgical intervention can only 
 lead to inconvenience, the more so that in some cases the great 
 extent of the sloughs of the skin might lead us to believe that 
 there was a gangrene of a whole toe, whilst in reality the lesion 
 is very superficial. We are therefore limited, after the sub- 
 sidence of acute symptoms, if the sloughs should be a permanent 
 difficulty, to the partial cutting them off, and to favouring their 
 removal by gentle traction. 
 
 XXII. Finally, all these local means are only secondary, since 
 manifestly we have to do with a malady of general origin. If I 
 am not deceived as to the mechanism which produces it, the 
 desideratum is to find a medicament which would have a constant 
 resolving action on the smooth muscular fibres of the arterial 
 coats. 
 
 Is opium such a medicament? We know the unbounded 
 confidence which Pott accorded to it as curative of gangrene. 
 Since his time we have been compelled to abate some of the 
 enthusiasm roused by the early cases in which this drug was 
 employed. Nevertheless in every causal condition, and quite 
 apart from all theory, we must acknowledge that opium, being 
 the first of the narcotics, at least responds to this primary indi- 
 cation — viz., to calm the atrocious pains of mortification of the 
 .extremities. In this respect it will always find its use, which, 
 moreover, is free from any inconvenience. 
 
 In one of my cases, in which the cure left nothing to be desired, 
 Vichy water had been given in strong doses. Was it by fluidi- 
 fying the blood that it contributed to the satisfactory result ? 
 Did it really contribute to the result ? I do not know. In any 
 case this fluidification of the blood from the theoretical point of 
 view must be advantageous. 
 
 Quinine enjoyed for a long time during the last century an 
 immense reputation as a specific for gangrene. Although its 
 reputation as a specific may be gone, yet in cases where there is 
 
150 bavnatjd's oeiginal thesis. 
 
 a well-marked intermission, sulphate of quinine as an antiperiodic 
 ought to take the principal part in the treatment. It will not 
 always cure — one ought to be forewarned of that — but a skilful 
 therapeutist will he able at all events to take advantage of the 
 modification which this remedy will infallibly introduce in mani- 
 festations of the disease. 
 
 All the measures which I have enumerated ought to be 
 seconded by good alimentation. As in the severest attacks the 
 patients preserve a good appetite, whilst they have no fever, it 
 would be irrational and cruel to deprive them of nourishment. 
 In spite of the successful results attributed in one case to 
 general bleedings (Case XI.) I should not hesitate to forbid the 
 use of lowering measures. Often the patients are young, ner- 
 vous, chlorotic women ; in such cases especially a tonic and 
 substantial regime is imperative ; it is perhaps the one indication 
 which is more important than all the rest. 
 
 In the matter of general treatment each practitioner must be 
 guided by circumstances. For my own part I should, I confess, 
 sincerely regret if I have given an erroneous interpretation of the 
 facts which have come under my observation. But I should not 
 pardon myself if in consequence of theoretical views I should 
 lead physicians into the beaten tracks of a hazardous and fatal 
 therapeutics. It is in this part of our art more than in 
 any other that we must be specially careful of the a priori 
 method. Happy shall I be if at least in attempting to make the 
 nature of the disease precise, I shall have been able to indicate 
 in what direction it may be well to seek the remedy. 
 
 Moreover, in conclusion, I repeat that this malady, so strange, 
 so formidable in appearance, is far from having in reality all the 
 gravity which at first one would be tempted to attribute to it. 
 To moderate the pains, to prevent the use of unsuitable measures 
 and doubtful remedies, such ought to be in the majority of cases 
 the part played by the physician. Nature will do the rest. We 
 shall be sufficiently satisfied, although we cannot immediately 
 relieve our patients, if we can still encourage them with the 
 hope of a probable and approaching recovery, and should this 
 point be the only one which clearly results from the work just 
 completed, I should not regret the pains which I have bestowed 
 upon it. 
 
NEW RESEARCHES 
 
 ON THE 
 
 NATURE AND TREATMENT OF LOCAL 
 ASPHYXIA OF THE EXTREMITIES. 
 
 By Dr. MAUKICE RAYNAUD. 
 
 TRANSLATED BY 
 
 THOMAS BARLOW, M.D. 
 
NEW RESEARCHES ON THE NATURE AND 
 TREATMENT OP LOCAL ASPHYXIA OE THE 
 EXTREMITIES.* 
 
 The account which I gave a few years ago of local asphyxia and 
 symmetrical gangrene of the extremities appears to have been 
 accepted by the medical public. New observations have been 
 published in France and abroad, theses have been sustained, 
 and the affection in question has found a place in treatises on 
 pathology. In fact, as we always find with regard to diseases 
 hitherto undescribed, it has proved to be much less rare than 
 had previously been imagined. When once attention has been 
 called to the subject, cases which would have escaped recognition 
 are recorded, and the number of known facts rapidly increases. 
 
 Perhaps I may now be allowed to criticise the name which I 
 gave to this disease. I have found many defects in it. First, 
 there is always a real inconvenience in giving two distinct names 
 to one and the same object. Local asphyxia and symmetrical 
 gangrene are not two distinct maladies, but two degrees of one 
 and the same malady. Of these two degrees, the second is 
 often absent, which prevents our being able to adopt it as 
 the basis of a precise nomenclature. On the other hand, the 
 term local asphyxia, which I had borrowed from Boyer, may give 
 rise to misunderstandings. Objection might be made to the 
 word asphyxia, and yet I believe it expresses an exact phy- 
 siological fact. A really valid objection would arise to the use 
 of the word " local," if it led to the inference that the malady 
 is exclusively local, that is to say, that it is in the affected parts 
 themselves that the origin of the disease is to be sought, which 
 is quite contrary to my view. For all these reasons it would be 
 desirable that this nosological species — for such indeed it is — 
 should be designated by one of those simple words which have 
 absolutely only one acknowledged signification, the advantage of 
 
 * Archives Generates de Medecin, Jan., 1874. 
 
154 Raynaud's new ebseakches. 
 
 which Trousseau was so fond of setting forth. Provisionally, 
 and not to complicate matters, I will continue nevertheless to 
 use the term " local asphyxia," asking the reader meanwhile to 
 look upon it as a name and nothing more. 
 
 The clinical characters of this singular affection are re- 
 markably constant. I have recently given a summary of them 
 in the article on Gangrene in the New Dictionary of Practical 
 Medicine and Surgery. In the slight cases the ends of the 
 fingers and toes become cold, cyanosed, and livid, and at the 
 same time more or less painful. In grave cases the area affected 
 by cyanosis extends upwards for several centimetres above the 
 roots of the nails ; at the same time the nose and the ears may 
 become the seat of analogous phenomena. Finally, if this state 
 is prolonged for a certain time, we see gangrenous points appear 
 on the extremities ; the gangrene is always dry, and may occupy 
 the superficial layers of the skin from the extent of a pin's head 
 up to the end of a finger, rarely more. 
 
 That which gives to this malady its special feature is the 
 remarkable symmetry which the lesions manifest, symmetry 
 such that when, for example, a single digit is affected on one 
 side, its corresponding digit on the opposite side is also affected, 
 and almost always nearly to the same degree. This interesting 
 peculiarity, taken in connection with the intermittency of the 
 attacks in many cases, would in itself justify the belief that there 
 exists no material obstacle to the course of the blood in the 
 arteries. This presumption is confirmed by the examination of 
 the arteries so far as it can be made during life ; and they have 
 been found healthy. 
 
 Thus I have been led to enunciate the hypothesis of a con- 
 traction of the- terminal vascular ramifications, varying from a 
 simple diminution of calibre up to the complete obliteration of 
 the lumen of the vessel. To the total closure of the arterial and 
 venous vessels would correspond an exsanguine and cadaveric 
 state of the extremities very analogous to that which is observed 
 in frost-bite, whilst the arterioles only being closed and the 
 venules open one would see a venous stasis produced by failure 
 of vis a tergo, whence the cyanosis and livid aspect which are 
 seen in the majority of cases. 
 
 To attribute these phenomena to a fault of vaso-motor inner- 
 vation, was an interpretation which physiology assuredly 
 
CASE I. 155 
 
 authorised. I have further maintained that the marked sym- 
 metry of the lesions ought to suggest that they originate in a 
 discharge either spontaneous or reflex, starting from the cord and 
 radiating thence to the vascular nerves of the extremities. 
 
 But as it is necessary to observe, these explanations were 
 hypothetical, and I have always recognised that a hypothesis, 
 even when it is in harmony with the sum total of the facts which 
 it is intended to explain, ought not to be accepted as a proof 
 until it has been demonstrated. It is precisely this lacuna 
 which I wish to fill up in the pages which follow. It is clear 
 that the theory which I have proposed would acquire a high 
 degree of plausibility if one could demonstrate — 
 
 1. That there actually occur in this malady, spontaneous vas- 
 cular spasms, inappreciable in the great vessels, but very obvious 
 in arteries of small calibre. 
 
 2. That it is possible to modify the asphyxial state of the 
 extremities by action from a distance, and especially by acting 
 upon the cord. 
 
 This double demonstration will follow, I hope, from the facts 
 which are about to be recorded, and from which I propose to 
 deduce the treatment applicable to local asphyxia of the 
 extremities. 
 
 Case I. — In the month of April, 1872, being judge of a 
 concours of the Central Bureau at the Charite, I found in 
 M. Bourdoir's wards, amongst the patients whom I was about to 
 examine, an individual who at once arrested my attention by the 
 dark colour of his extremities, and roused my curiosity by his 
 description of peculiar visual defects, connected, according to his 
 statement, in the most direct way with the morbid state of his 
 limbs. I owe to the extreme kindness of my learned colleague 
 the permission to transfer the patient to my ward at the St. 
 Antoine Hospital, where I had leisure to examine him. 
 
 L., aged 59, a journeyman printer, is a vigorous man of a 
 very healthy appearance, and who has never had any other 
 illnesses than intermittent fever contracted in Africa in 1836, 
 and of which he has never felt the effects subsequently. His 
 hygiene is good ; he has no excesses ; he has never suffered 
 either in regard to his abode or his food. About the month 
 of December, 1871, during a moderately cold season, he per- 
 
156 Raynaud's new researches. 
 
 ceived with astonishment that the little finger of his left hand 
 became dark every morning. This unusual colour was at first 
 accompanied by so little discomfort that he referred it to the 
 black dye of the pocket of his trousers. Soon the ring and 
 middle fingers of the same hand were also invaded. In the 
 month of January, 1872, the right hand was attacked in its 
 turn. Then, finally, it was the turn of the feet. The symptoms 
 continued to increase up to the month of April ; they became 
 sufficiently intense to absolutely prevent the patient from using 
 his hands in his work, and to render his walking extremely diffi- 
 cult. The sight troubles began to manifest themselves towards 
 the month of February. The following was the condition of the 
 patient, according to our careful observations, during the first 
 fortnight of May : — 
 
 The affection from which he suffers exhibits intermittent 
 attacks without any kind of periodicity. The attacks recur prin- 
 cipally when the patient goes into the air, or when he bathes his 
 hands in water of the temperature of the ward ; they appear very 
 often without any appreciable cause. Their duration is variable ; 
 it is ordinarily from one to two hours. 
 
 In these attacks the two hands, especially the left, assume a 
 livid tint, either violet or blackish, which extends up to the 
 wrists ; the tint is almost uniform and without marbling ; the 
 pulp of the fingers is completely bloodless except in the two 
 thumbs. 
 
 On pressing somewhat firmly with the fingers upon any point 
 of this cyanosed skin, a dead white spot is produced, which 
 only disappears very slowly, a certain indication of the difficulty 
 with which the capillary circulation takes place. The return to 
 the primitive tint extends either from the periphery to the centre, 
 or from a central point which appears in the middle of the white 
 patch, and which little by little, ends by rejoining the border. 
 
 In the palms (and they persist during the interval between 
 the attacks) we find indurations situated along the course of 
 the flexor tendons, and they seem to be due to a thickening 
 of the fibrous tissue of the cutis. One experiences on touching 
 the hands a sensation of extreme cold, of which the patient has 
 perfect consciousness. A thermometer held by him in the palm 
 of the hand does not rise above 21 - 1° C, whilst the axillary 
 temperature is 36 , 1°C. 
 
CASE I. 157 
 
 There are no spontaneous painful sensations ; there are no 
 tinglings ; but the sensibility to contact is completely blunted. 
 There results therefrom much embarrassment in movements, 
 the patient not feeling the objects which he holds between 
 his fingers. This embarrassment is increased by the difficulty 
 which he experiences in extending his fingers on account of 
 the rigidity of the skin in the palmar region. The muscular 
 sensibility of the hands is intact. 
 
 In the feet we observe the same phenomena a little less 
 marked. There is the same violet colour, the same sensation of 
 cold complained of by the patient. The objective sensation of 
 cold is less pronounced than in the hands. The cutaneous 
 lividity extends as high as the level of the tarsus under the form 
 of marblings indicating the track of the veins. The symmetry 
 in the distribution of this morbid tint is very remarkable ; in 
 both feet it is the second toe which is least affected. 
 
 The tactile sensibility of the soles of the feet is less blunted 
 than it was. Only a few days ago the anaesthesia was such that 
 it completely prevented walking ; the patient was unable to say 
 whether his feet rested on marble or on the flooring. On watch- 
 ing his gait from a distance one would have been tempted to 
 take him for an ataxic ; and this mistake was actually made. 
 The other extremities, the nose, the ears, are not attacked. 
 
 At the moment when the attack ceases, at the same time that 
 the colour, the heat, and the tactile sensibility return to the 
 extremities, the patient experiences in them a sensation of 
 pricking, painful, but not extremely so. Let us note that the 
 colour never becomes entirely normal on the hands, especially on 
 the left hand. 
 
 The careful examination of the circulatory apparatus, both 
 during and between the attacks, gives only negative results. 
 The heart beats are perfectly normal in their rhythm, their 
 intensity, and their tone. The pulsations are perfectly percep- 
 tible in the radial arteries, in the posterior tibials and in the 
 arteries of the foot. The arteries are not at all indurated. 
 
 Such are the phenomena which we have observed at leisure, 
 and which leave no doubt as to the diagnosis for local asphyxia 
 of the extremities. 
 
 Let us now consider what occurred in the eyes, which is the 
 most instructive part of the case. 
 
158 eaynaud's new eeseaeches. 
 
 The patient affirms that his sight is good in the two eyes dur- 
 ing the attack, but that during the period which follows, and 
 whilst the fingers return progressively to their normal colour, 
 the sight, especially that of the left eye, becomes troubled and 
 confused, recovering at the moment when a new attack super- 
 venes. He has used for four years a No. 16 convex. 
 
 It was of the greatest interest to see if the ophthalmoscopic 
 examination would give the explanation of this singular pheno- 
 menon of intermittent amblyopia. It was to be presumed a 
 priori that this would depend on disturbances of the circulation 
 in the fundus of the eye. The result of this examination was as 
 follows : the pupil was dilated by atropine. When the left 
 eye (the worse of the two) was examined during a period- of reac- 
 tion — that is to say, when the cyanotic colour of the extremities 
 was at its minimum — we saw that the central artery of the retina, 
 and the arteries which proceeded from it, presented in all their 
 extent very clear contours ; further, we established very definitely 
 that they were narrower in their commencement near the* papilla 
 than at the periphery. Here and there we observed a sort of 
 partial strangulation. The papilla itself was of a very clear tint. 
 The veins were the seat of extremely remarkable pulsations. We 
 know that pulsation of the central vein of the retina is a pheno- 
 menon which is frequently observed in the normal state, and 
 that one can bring it about at will by exercising a gentle pressure 
 upon the globe of the eye; but this physiological pulsation is 
 limited to a very small area at the point of entrance of the vein 
 into the non-transparent parts of the optic nerve. Here we have 
 to do with something quite different ; the pulsations are remark- 
 able for an intensity and an extent altogether unusual. They 
 are a little later than the radial pulse. At each pulsation we see 
 the central vein not only dilate and deepen in colour, but elongate 
 itself very notably in the region of its origin in the papilla, so as 
 to simulate a small aneurysm by its expansion in every direction. 
 The pulsation extends well beyond the limits of the papilla. It 
 can be observed in at least three vessels simultaneously, and in 
 almost all the venous capillaries. The right eye (the less 
 affected) presented analogous phenomena, but in less degree. 
 The narrowness of the arteries was certainly less marked than in 
 the left, and the relative diminution of the central artery in 
 relation to its branches less appreciable. 
 
CASE I. 159 
 
 The venous pulsations were observed over a very great extent, 
 greater perhaps than in the left eye, but there was no trace of 
 pulsations on the side of the capillaries. 
 
 The ophthalmoscopic examination during the period of cyanosis 
 of the extremities furnished less decisive results than the preced- 
 ing, and presented several material difficulties of observation. 
 Thus the moment of the attack did not always coincide with the 
 hour of the visit. The examination of the eye, when it is a 
 question of establishing and measuring differences of calibre 
 between two arteries, is a delicate operation, and one which 
 requires time. It happened to us more than once to commence 
 this examination during the cyanotic period, and to perceive on 
 finishing it that the colour of the extremities had changed. 
 This, however, is what resulted from the. examination : — 
 
 During the duration of the attacks the venous pulsations 
 persisted in both eyes ; nevertheless they were much less marked 
 in the left than in the right. The arteries did not recover, as 
 one might have expected, their normal calibre in all their extent. 
 They present partial diminutions of calibre, which in places 
 render them filiform. By patient watching the observer may be 
 fortunate enough to see these contractions form under his eyes, 
 persist a certain time, then disappear, to be reproduced in 
 another vessel. 
 
 Guided by theoretical considerations, of which this particular 
 case appeared to me a manifest confirmation, I resolved to 
 attempt in my patient the employment of continuous currents. 
 This treatment was commenced on the 18th May. Electricity 
 was applied for ten minutes daily, descending currents being 
 always used, the positive pole applied over the spinous process 
 of the seventh cervical vertebra, and the negative pole over the 
 lumbar region. The apparatus employed was the sulphate of 
 copper battery of Messrs. Trouve and Onimus. The number of 
 elements employed was at first 20 ; it was progressively increased 
 up to 64. 
 
 This mode of treatment is very easily tolerated. The patient 
 presented in a high degree a very curious feature, which has 
 appeared to me to be very common, and indeed almost the rule 
 in individuals whose spinal cord is being galvanised in the 
 cervical region when the number of elements employed is from 
 20 to 30. I refer to a very abundant hyper-secretion of the 
 
160 eaynaud's new researches. 
 
 sweat glands of the axillary region, a hyper-secretion which only 
 lasts during the time of the passage of the current. The treat- 
 ment was continued up to the 7th June. We were then obliged 
 to interrupt it for several days, on account of a lymphangitis 
 which occurred, without obvious cause, on the right foot, and 
 which was certainly not due to the electrical treatment, since it 
 had commenced before the currents were used. The use of 
 galvanism was resumed on the 12th, and continued to the 18th. 
 The following is the result of the treatment. From the first 
 employment of electricity an improvement was observed, which 
 became more pronounced each day. After the sixth application 
 the state of the extremities was entirely modified; there per- 
 sisted indeed a little livid pallor of the terminal phalanges, 
 but the fingers tended more and more to resume their normal 
 colour. When the patient left the hospital on the 22nd June, 
 for more than ten days past the extremities had returned 
 to their physiological tint, all the functions of sensibility and 
 movement had become re-established, and, what is not less 
 curious, the induration of the skin on the palm of the hand, 
 to which I have before referred, had now in great part dis- 
 appeared. 
 
 The restoration of sight had followed a parallel course. At 
 the same time that the extremities became warm the vision 
 became more distinct. I transcribe here some of the results 
 furnished by ophthalmoscopic examination. 
 
 May 28. — The venous pulsations are still very markedly appre- 
 ciable to the naked eye in the region of the papilla ; they 
 disappear beyond it. The narrowness of the arteries remains 
 more marked in the left than in the right; one is no longer 
 able to demonstrate any local contractions. 
 
 June 7. — Left eye. The veins are generally much larger than 
 on the first examination ; but they no longer present any pulsa- 
 tion. The arteries are much larger than they were, and it is to 
 be noted that there is now an ampler blood supply, both to the 
 optic papilla and to the retina in general. 
 
 June 15. — The ophthalmoscopic examination of the two eyes 
 reveals nothing abnormal. 
 
 It will not be useless to add that the ophthalmoscopic examina- 
 tions, of which I give the general results, were verified by Dr. 
 Galezowski, who, at my request, had taken part in the investiga- 
 
CASE I. • 161 
 
 tion of these phenomena, which are so interesting in regard to 
 the study of the retinal circulation. 
 
 Leaving on one side for the moment the therapeutic question, 
 to which I will soon return, the history of this patient may be 
 thus summarised : — 
 
 Simultaneous appearance and development, in some sort 
 parallel, of a perfectly characteristic local asphyxia of the extremi- 
 ties, and of visual disturbances manifestly connected with modifi- 
 cations in the circulation of the fundus of the eye ; intermission of 
 these two orders of phenomena with this remarkable feature, that 
 they alternate one with the other ; moreover, both recover at the 
 same time and under the same influence. This relation is so 
 striking that it seems to me to speak for itself. 
 
 Hitherto one might indeed have suspected that the local 
 asphyxia was connected with a spasmodic state of the vessels. 
 But whatever foundation there might be for this supposition, as 
 the digital exploration of the accessible arterial trunks did not 
 reveal in these cases anything special, one was obliged to admit 
 by induction a functional trouble localised to the arterioles 
 immediately contiguous to the capillaries. Now here is a case 
 in which the local asphyxia takes place along with an ocular 
 lesion. The two affections are so closely linked that they make 
 in fact only one. The spasmodic contraction of the central 
 artery of the retina can actually be seen. The contraction, ' I 
 repeat, of this artery, which from its small size assuredly deserves 
 the name of arteriole, takes place under the eyes of the observer. 
 How can it be maintained that it is not an identical phenomenon 
 which occurs in the extremities of the limbs ? Here the induction 
 acquires such a certainty that it is equivalent, I think, to a 
 direct demonstration. 
 
 But however important may be the result of this observation, 
 it only resolves a part of the question of pathological physiology 
 which occupies us. Spasm of the small vessels exists and 
 causes partial anasmia of the points where these extend ; this 
 partial anaemia manifests itself in the eye by the visual troubles. 
 This position one may consider as established. But under 
 what influence does this spasmodic contraction take place ? It 
 is not sufficient to say that it is due to an anomalous excita- 
 tion of the vaso-motor nerves, which in the actual state of our 
 knowledge is equivalent almost to a truism. We must be more 
 
 11 
 
162 Raynaud's new researches. 
 
 precise, and ascertain what are the vaso-motors which preside 
 over the contraction of the central artery of the retina. With 
 regard to this, one might make two hypotheses. We have long 
 known, on the one hand, that besides vascular and calorific phe- 
 nomena, section of the cervical branch of the great sympathetic 
 produces in the eye remarkable modifications, designated by the 
 physiologists under the name of oculo-pupillary phenomena, and 
 consisting amongst others in a contraction of the pupil, which 
 gives place to a dilatation when one galvanises the upper end 
 of the cut nerve. It is therefore certain that the cervical branch 
 sends sympathetic twigs to the eye, and one may suppose that 
 some of these twigs serve for the innervation of the vessels of 
 this organ. But on the other hand we know also that the fifth 
 pair contains a certain number of sympathetic fibres, which 
 come directly from the encephalon, and which are present in the 
 nerve before its entry into, the Gasserian ganglion. The first 
 branch of the fifth pair taking part in the formation of the 
 ophthalmic ganglion, whence arise the ciliary nerves, one might 
 suppose that the vaso-motors of the retina have in reality a 
 cerebral origin. 
 
 Between these two equally tenable hypotheses it was impos- 
 sible to decide a priori ; it was necessary to have recourse to 
 direct experiment. This I have done, and the former hypothesis 
 I have found to be correct. I divided the cervical sympathetic 
 in several rabbits, and I observed with the ophthalmoscope the 
 vessels of the fundus of the eye before and after the section, 
 taking for standard of comparison the eye of the side not operated 
 on. The result of this observation, considered by itself, might 
 have left some doubt, the veins alone appearing a little dilated. 
 The central artery of the retina did not undergo any very mani- 
 fest change of calibre ; however, the capillary networks appeared 
 a little more full of blood than normal, and one was able to 
 trace the network over a larger area in the' fundus than usual. 
 But in order to get a clear idea of the result we must galvanise 
 the upper end of the divided sympathetic. This I did with the 
 kind help of Dr. Moreau. The effect of this galvanisation is 
 as manifest as that which may be observed on the ear of the 
 rabbit. In observing the central artery with the ophthalmoscope 
 it is seen to become narrow by a sort of peristaltic contraction 
 to grow pale, then to disappear almost entirely, reappearing 
 
CASE I. 163 
 
 when the current is interrupted, and then gradually regaining 
 its original calibre. 
 
 It is therefore certain that the central artery of the retina 
 receives its innervation from the cervical branch of the great 
 sympathetic by means of the carotid twigs of this nerve. 
 
 This being the case, one is naturally led to seek the first 
 cause of the spasmodic contraction of this artery in an anomalous 
 excitation at the very origin of the nerves which supply it, that 
 is to say, in the cilio-spinal region of the cord. Now we already 
 possess experimental facts which give important confirmation to 
 this hypothesis. I borrow the account of these facts from Dr. 
 Adamiuk, of Cazan, who in the course of his researches upon 
 the etiology of glaucoma was led incidentally to study this 
 question. 
 
 He states that if in an animal poisoned by curare the sym- 
 pathetic centre of the spinal cord, at the level of the two lower 
 cervical vertebrae, be irritated, and if at the same time the eye 
 be examined with the ophthalmoscope, we recognise immediately 
 in the vessels the same distribution of blood which is to be 
 found in glaucoma ; the veins are widely dilated, the arteries 
 contracted. This state is not immediately accompanied by an 
 increase of internal pressure, as proved by means of a mano- 
 meter adapted to the eye ; it is only after a little time— more 
 than a minute — that this tension gradually increases little by 
 little. We shall have to return soon to this remarkable contrast 
 between the state of the veins and that of the arteries. 
 
 Let us content ourselves for the present with noting the con- 
 traction of the central artery of the retina under the influence 
 of the irritation of the cilio-spinal region. 
 
 Thus far, as one sees, physiological facts agree well with 
 clinical observation and yield us a satisfactory account of the 
 phenomena observed in our patient. The agreement would be 
 perfect throughout if the troubles of vision due to the contraction 
 of the arteries of the fundus of the eye were synchronous with 
 the cyanosis of the extremities. That there is an intimate 
 relation between these two orders of phenomena is what one 
 would not dream of contesting. Both made their appearance at 
 the same time ; they disappeared together and under the same 
 influence. The mind might easily picture to itself a spinal 
 excitation expressing itself simultaneously by vascular con- 
 
164 Raynaud's new researches. 
 
 tractions in different regions. Unfortunately things do not 
 always come to pass in nature in a way which is most agreeable 
 to our comprehension. In fact we have seen that the cooling 
 with cyanosis of the extremities and visual troubles did not 
 coincide, but alternated with a perfect regularity in such a way 
 that the diminution of one of these phenomena infallibly 
 announced the appearance of the other, and this many times in 
 the same day, and this state of affairs persisting for several 
 months. It is precisely on account of this singular alternation 
 that there was good reason to inquire if the vascular nerves of 
 the fundus of the eye had not an origin entirely different from 
 those of the limbs ; in which case one could have better under- 
 stood a kind of balance being re-established between the bulbar 
 region and the cord, properly so called. One is more embarrassed 
 in explaining this balance, when one thinks of the short 
 distance which separates the cilio-spinal region from the origin 
 •of the affected ganglionary nerves which go to the vessels of the 
 upper limbs. I know indeed, and everything demonstrates it, 
 •that nerve cells very adjacent anatomically can present a function 
 •entirely independent; but in spite of the immense progress 
 made during the last few years in the study of the intimate 
 structure of the nerve centres there are obscurities in the subject 
 before which we are brought to a standstill for the present. 
 
 AH attempts at interpretation would be here purely hypo- 
 thetical. It is probable that in other cases we may find local 
 asphyxia and visual troubles coinciding as to time, appearing 
 and disappearing together. 
 
 I am now quite prepared to cite an example of it. 
 
 Cask II. — The patient V., who is the subject of this case, 
 was for a long time under the care of M. Cadet de Gassicourt at 
 the St. Antoine Hospital, where I was able to observe him. He 
 passed thence into the St. Louis under the care of M. Vidal. His 
 history is somewhat complex. He is a young man of 22 years 
 of age, of good appearance, admitted in order to be treated for 
 boulimia with polydipsia, dating back for several months. He 
 eats from 4 to 6 rations daily. He has eaten up to 12 a 
 day. He drinks 4 to 5 litres of liquid, and passes almost 
 an equal daily quantity of water. The urine contains no sugar. 
 One is struck at first with the livid tint which the hands and 
 
CASE II. 165 
 
 face present. This tint, which appears sometimes spontaneously, 
 especially in the morning, shows itself in a marked manner 
 when the patient goes into the open air. It is accompanied by 
 an excessive cooling of the livid portions of the skin. No 
 similar symptoms exist in the lower limbs. At this moment the 
 radial pulse is very small. These symptoms taken altogether 
 constitute a kind of paroxysm the duration of which varies, and 
 which presents no regularity as to the period of its recurrence. 
 The patient complains of some palpitation. There is a cardiac 
 murmur, with the first sound having its maximum at the 
 left border of the sternum in the second intercostal space. V. 
 complains also of experiencing at the moment of the commence- 
 ment of the cyanosis a notable obscuration of sight, which dis- 
 appears at the time when the face and the hands return to their 
 natural colour. He has been carefully examined by Dr. Panas 
 at the moment when the circulatory troubles have just been 
 developed in their greatest intensity by a prolonged exposure to 
 the open air. At the commencement of the examination a 
 narrowing of the arteries of the fundus oculi is clearly seen. 
 These vessels become widened at the moment when reaction is 
 produced. The retinal veins are generally turgid ; they present 
 no appreciable pulsation. 
 
 If I give here only an abstract of this observation it is because 
 the multiplicity of the phenomena has introduced into it great 
 difficulties of appreciation. It is infinitely probable that the 
 coincidence in this patient of polyuria and local asphyxia of the 
 extremities is not fortuitous, and that these two symptoms 
 depend on one and the same fault of the innervation of the great 
 sympathetic. But on the other hand there is a cardiac lesion, 
 and this fact suffices to throw doubt on the nature of the 
 phenomena of cyanosis observed in the extremities and in the 
 face. I do not believe for my part that these symptoms are 
 attributable to a blood stasis depending on the heart disease. 
 The proof is that they do not exist in the lower limbs, which, 
 according to this hypothesis, ought to be the seat of predilection ; 
 further, they are manifestly influenced by temperature ; it suffices 
 in order to bring them out, to expose the patient during a 
 certain time to external cold. I feel, nevertheless, that these 
 reasons, decisive for one who has seen the patient in question, 
 might not convince everybody. On account of the situation of 
 
166 eaynaud's new researches. 
 
 the murmur one might suspect an anomalous communication 
 between the two sides of the heart. Accordingly from this case 
 I prefer only to deduce the following conclusion : to wit, that 
 the visual troubles complained of by the patient are symptomatic 
 of a contraction of the central artery of the retina, and that 
 these -visual troubles coincide exactly with the cyanosis of the 
 hands. 
 
 I return now to my first patient, in whom there remains a 
 question very difficult to elucidate ; it is that of the venous pulse, 
 so intense and so extensively propagated that it is perceived 
 up to the last ramifications of the retinal veins. 
 
 I devoted myself to very extensive researches on this subject, 
 but to detail them would carry me too far from my present 
 purpose, and moreover I propose to publish the results else- 
 where. 
 
 The existence of a retinal venous pulse, infinitely less, it is 
 true, than that with which we have here to do, is a physiological 
 fact in a sufficiently large number of individuals ; in others it is 
 manifested quite easily under the influence of a run; of an effort, 
 of a moral emotion; in everybody one can produce it artificially 
 by exerting slight pressure on the globe of the eye. 
 
 Our French authors are almost silent on the cause of this 
 phenomenon. According to Donders, Von Graefe, Stellwag 
 von Carion, the venous pulsations are the visible effect of 
 arterial pulsations, invisible in ordinary conditions. The pul- 
 sations of the central artery of the retina transmit to the 
 vitreous body an increase of pressure, of which the effect is con- 
 centrated upon the point where the vein passes into the lamina 
 cribrosa. In presence of the difficulties raised by this theory, 
 and notably with the lack of harmony which it presents with 
 certain phenomena observed in glaucoma, I have asked myself if 
 it were not possible to seek the cause of the venous pulsations in 
 • a normal anatomical arrangement. We know tbat the central 
 vein of the retina empties itself into the ophthalmic vein, which 
 itself communicates directly and abruptly with the cavernous 
 sinus, through which passes with a sinuous course the internal 
 carotid artery. 
 
 It may easily be supposed that the pulsations of such a large 
 artery could be communicated to the blood column in the veins 
 which meet in the sinus — all the more that this is a cavity with 
 
ON VENOUS PULSE. 167 
 
 inextensible walls. These pulsations, transmitted by a kind of 
 eddy, would then manifest themselves in the point where the 
 central vein is sharply bent at its entrance into the ocular 
 globe. 
 
 This theory, which I propose with some reserve, would have at 
 least the advantage of satisfactorily explaining the phenomena 
 observed in our patient. The question stands thus : how does 
 it come to pass that the interruption of the course of the blood 
 caused by the spasmodic narrowing of the arteries of the fundus 
 of the eye can determine a colossal exaggeration of the retinal 
 venous pulse ? In the normal state, the blood which circulates 
 in the retinal veins, according to the hypothesis which I have 
 just given, is acted upon by two opposing forces : on the one 
 side the vis a tergo, which is simply the impulse transmitted by 
 the movement of the arterial blood itself through the capillaries, 
 and which exercises its action from before backwards ; on the 
 other side the intermittent impulse coming from the cavernous 
 sinus, as stated above. Of these two opposing forces, the first 
 evidently overpowers the second, because the direction of the 
 blood current continues from the heart onwards. 
 
 Nevertheless to a certain extent they balance one another, 
 and this antagonism regulates the flow of the venous blood in 
 the retina. If the antagonism disappears the one of the two 
 elements which remains exerts an exclusive action. It is pre- 
 cisely this which happens when the excessive contraction of the 
 arteries of the retina annuls the vis a tergo. The blood yields 
 without any obstacle to the impulse from behind forwards which 
 comes to it from the cavernous sinus. Hence arise these pulsa- 
 tions, which affect all the veins of this vascular area, and which 
 make themselves felt even in the capillaries. 
 
 Let us further note that the pulsations in question by no means 
 indicate an excessive fulness of the retinal venous system. It 
 is a simple reflux under feeble tension, the capillaries allowing 
 little or no arterial blood to pass in the direction of the heart. 
 It was in fact noted in the case previously described, that when 
 the patient recovered the retinal veins no longer pulsated, but 
 that they appeared much fuller than when the pulsations existed. 
 Before discussing the value of the treatment adopted I will 
 record some other cases fairly comparable with this in many 
 respects. 
 
168 Raynaud's new researches. 
 
 Case III.* — Mme. T., aged 52 years, admitted to the St. 
 Antoine Hospital, July 15, 1872. 
 
 This woman presents all the appearances of a robust constitu- 
 tion. She menstruated first when 16 years old, was married 
 when she was 17 years, and has had 5 children, all of 
 whom have died. Her life has been marked by pecuniary losses 
 and troubles of all kinds. The catamenia have disappeared 
 for the last five years. Her health has been generally excellent. 
 She states, nevertheless, that twenty-five years ago she was 
 taken with severe pains and sensations of pricking in both 
 breasts ; pains and prickings which were not accompanied by 
 change of colour f in the skin, but which the patient compares 
 to sensations which she at present experiences in the fingers. 
 
 These symptoms lasted one year, and yielded to the use of a 
 kind of wadding breastplate, which this patient has never ceased 
 since then to wear on the chest. Twelve years ago she was 
 attacked with an eruption on the thigh, probably of dartrous 
 nature. Finally, two years ago she appears to have had an 
 attack of cerebral congestion. Whilst at church she suddenly 
 lost consciousness and became hemiplegic on the left side for 
 two hours. The symptoms yielded to one application of leeches 
 behind the ears. At the end of a few days she was in a condition 
 to return to her usual occupations, 'and since that time no 
 similar attack has shown itself. 
 
 The illness which brought her to the hospital dates from the 
 1st of October, 1871. 
 
 Without any cause appreciable to her she perceived that the 
 fingers of her hands were attacked by numbness and chilliness. 
 Her fingers were, she said, as though they were dead. The 
 insensibility to touch was almost complete ; they presented a 
 livid coloration with violet marblings extending up to the 
 middle of the hands. At the end of a fortnight pains were 
 felt in the extremities, which soon acquired such a degree of 
 intensity that they drew from her almost continuous cries. She 
 passed eight days without sleep. The sensation was comparable 
 
 * Second Article, p. 189. 
 
 f I insist on this fact, because I hare observed elsewhere a painful neurosis of the 
 breasts, accompanied by very pronounced lividity ; a very remarkable affection, which 
 would merit in some respects the name of local asphyxia of the mammae, and which 
 has appeared to me to be in relation with hysteria. 
 
CASE III. 169 
 
 to that of a red hot iron drawn over the fingers ; these became 
 completely blue. 
 
 This severe pain finally disappeared, but the fingers remained 
 livid ; at the extremities of all the digits loss of substance 
 occurred, which led to the formation of small dark and depressed 
 cicatrices. At the moment when we first observed this patient 
 (it was in midsummer) the condition of the fingers had been for 
 many months almost stationary. The cold weather brought 
 on recrudescences in the symptoms ; the lividity then became 
 still more accentuated. The numbness gave place to a veritable 
 hyperesthesia, which acquired its maximum in the periods of re- 
 action when the extremities tended to become warm again. For 
 about six weeks there has been in the morning a little tingling 
 in the feet, which otherwise present no modification appreciable 
 to sight. 
 
 Besides their colour the fingers of the hands present, espe- 
 cially at their roots, a sort of cedematous puffiness which extends 
 up to the middle part of the dorsal aspect of the hands. The 
 nails have fallen from the index, from the middle, and the ring 
 finger of the left side, from the index and middle finger of the right 
 side. All these lesions are remarkably symmetrical, the parts 
 most attacked on one side are the same as those on the other. 
 
 The arterial pulsations are perfectly perceptible and regular in 
 the forearms. No sinuosities or indurations on the course of the 
 arteries can be discovered. The patient states that during the 
 last two months she has experienced a little oppression in the 
 precordial region. Attentive examination of the heart furnishes 
 only absolutely negative results. 
 
 It is needless to add that in this case, as in the last, we inquired 
 with care into the possible causes of gangrene, diabetes, ergotised 
 grain, &c, and that we found nothing of the kind. I ought 
 to say in conclusion that I sought in vain, in this patient, for the 
 visual disturbances to which my attention had been awakened by 
 the preceding case. 
 
 The treatment by continuous currents was commenced on the 
 17th July and contained daily until the 5th of August. 
 
 We began the first day by applying for ten minutes a descend- 
 ing current of 30 elements over the vertebral column ; the 
 positive pole over the fifth cervical vertebra, the negative pole 
 near the commencement of the cauda equina. 
 
170 Raynaud's new researches. 
 
 Towards the end of this first application the patient admitted 
 that there was an improvement, feeling the hlood, as she 
 expressed it, return into her fingers. "We could perceive, in 
 fact, that the tips of the fingers, which were dark before the 
 application of galvanism, became of a leaden white, and that at 
 the same time the terminal phalanges gave to the hand a 
 sensation of less cold. She continued to improve day by day. 
 Each day we saw the colour of the fingers become less and less 
 dark, and grow pale each time after the galvanism. From the 
 26bh July we diminished the number of the elements, which was 
 reduced progressively down to 10. But from this day each 
 application of galvanism to the spine was followed by a local 
 application of continuous currents always in the centrifugal 
 direction, the positive electrode being applied over the brachial 
 plexus, in the axilla, and the negative over the ends of the 
 closely approximated fingers. 
 
 The patient could support at first as much as 16 elements 
 employed by this new method of application without experiencing 
 more than a few pricking sensations, which made themselves 
 felt at the end of five minutes. After a few days the extremities 
 of the fingers perceived the passage of a current of 15 ele- 
 ments. Finally, on the 5th of August the patient, completely 
 cured, asked for her discharge, and set out for Chartres, not 
 showing any other traces of her malady than the small cicatrices 
 at the ends of the phalanges. 
 
 About a month after her departure she wrote to me that she 
 believed she had again felt some pricking sensations in the 
 fingers, and that she would come to us again if these sensations 
 increased. Since then I have heard no more of her. 
 
 Such is the second case of cure obtained by means of the con- 
 tinuous current. In connection with the first it appears to me 
 of a nature to call for the most serious attention of prac- 
 titioners to this therapeutic measure. It would be absurd to 
 suggest that the improvement obtained was a mere coincidence. 
 In both cases the malady was of several months standing at 
 the time when the treatment was commenced, and seems to 
 have had no tendency to disappear spontaneously. In both cases 
 also the electrical treatment was not complicated by the employ- 
 ment of any other means; it was followed by an immediate 
 improvement. Hence there was no question here of one of those 
 
GASES IV. AND V. 171 
 
 approximate coincidences which so often leave the mind in doubt 
 when one wishes to estimate impartially the value of a thera- 
 peutic agent. The first application was followed immediately by 
 a notable alleviation. This alleviation was greater after the 
 second than after the first, greater after the third than after the 
 second, and so on up to complete cure. Chance is very powerful, 
 but one will acknowledge that it hardly proceeds with this regu- 
 larity. The following are two additional facts favourable to the 
 employment of the same therapeutic method. 
 
 Case IV. — V., a locksmith, aged 47 years, entered on the 5th 
 November, 1873, the Lariboisiere Hospital, under the care of 
 Dr. Panas. 
 
 This patient, who has always enjoyed good health, began on 
 the preceding 8th October to feel the first symptoms of local 
 asphyxia of the extremities. The ends of the fingers became 
 cold and cyanosed ; the illness continued by attacks which 
 returned every day, and lasted a great part of the day. It soon 
 became impossible for the patient to use his hands, and he was 
 completely prevented from following his trade. On the day of 
 his admission we applied descending continuous currents along 
 the vertebral column. At first the malaise produced by these 
 applications prevented our employing more than 17 elements. 
 
 By degrees he became able to tolerate 28. At the very 
 first applications the hands were seen to lose their bluish 
 or black colour, and regain the normal appearance ; soon the 
 improvement was maintained during the intervals between the 
 applications. 
 
 I saw this patient for the last time on the 17th December, 
 after about six weeks' treatment. At that date he thought he 
 was not in a state immediately to return to his work, but the 
 change was complete. He could easily use his hands for the 
 ordinary occupations of life. The attacks did not return more 
 than three or four times a day, and they lasted little more than 
 an hour. The colour of the extremities tended more and more 
 to become normal. 
 
 Case V. — The patient who is the subject of this case is a 
 young woman aged 22 years, who had never before had a serious 
 illness. She has experienced at times since infancy the 
 phenomenon of "dead finger" in the index of the left hand. 
 
172 Raynaud's new researches. 
 
 At the commencement of September, 1872, she was taken with 
 febrile attacks, which lasted fifteen days. Then she had swell- 
 ing in the two hands, which pitted on pressure. 
 
 I accept this statement of the patient because it is not the 
 only case in which I have seen oedema as premonitory phenomenon 
 of local asphyxia in the limbs destined to be attacked. Soon 
 the fingers became completely black up to the roots; dark 
 patches appeared on the nails, the whole attack being accom- 
 panied by pains so severe as to deprive the patient of sleep and 
 appetite. There was no affection of the other extremities. 
 
 She presented herself as an out-patient at the Lariboisiere, 
 where chloroform frictions and pills of sulphate of quinine were 
 ordered for her. 
 
 This treatment appeared to produce a real amelioration, 
 because starting from this day the symptoms above mentioned 
 only returned in separate attacks. At the time when this 
 young woman came under my care at the St. Antoine Hospital 
 the attacks recurred two or three times a day; their duration 
 varied from one hour to one hour and a half. The fingers were 
 then black in their two distal thirds, and completely insensible. 
 They remained cold and slightly violet beyond the attacks. 
 Very small cicatrices indicated slight losses of substance of 
 the digital pulp. The fingers presented a remarkably tapering 
 aspect. Some of the nails were deformed. In the cardiac 
 region there only existed an anaemic bruit at the base, with a 
 double murmur in the vessels of the neck. 
 
 The treatment by continuous currents was commenced on the 
 23rd November and pursued up to the 20th December. It con- 
 sisted from the beginning in the applications every morning and 
 evening of a descending current, the positive pole being placed 
 on the nape of the neck, and the negative applied to the tips of 
 the fingers approximated together. From the beginning the 
 attacks became at once less frequent and less severe; the 
 cyanotic tint of the extremities became- more and more limited. 
 At the end of a few days the patient could use her fingers to 
 sew, which she had been unable to do for a considerable time. 
 When she had reached this stage of marked improvement she 
 came to a standstill, and inasmuch as the patient had had 
 intermittent attacks, and as she had derived benefit from the 
 use of sulphate of quinine, I thought it wise to return to the 
 
CASE VI. 173 
 
 employment of that remedy. This drug seemed about to cure 
 her once more when she suddenly left the hospital. 
 
 I saw her again at the end of some months. The improve- 
 ment observed had been maintained, but during the last few 
 days the fingers had shown signs of being cyanosed again. I 
 pressed her to undergo the treatment which had benefited her 
 so much before. But she did not reappear at the hospital, and 
 I do not know what became of her. The improvement obtained 
 in this patient was the more worthy of remark since the case 
 was treated at the beginning of the winter, that is to say, at the 
 time of year most apt to aggravate her complaint. What share 
 had intermittent fever in the development of local asphyxia of 
 the extremities in this young patient? That is a question 
 which I find difficult to answer, but I think that as a clinical 
 indication it ought to be taken into account, as in fact it was in 
 the treatment of the patient. Nevertheless this case affords 
 additional experience of the benefit gained by the use of the 
 continuous current. Shall I conclude then that the use of the 
 continuous current constitutes a panacea against local asphyxia 
 and against gangrene of the extremities ? Such a contention 
 would be absurd so far as concerns gangrene by vascular obstruc- 
 tion; it would not even be well founded if one applied it to all 
 forms of gangrene without obstruction of vessels. 
 
 I had occasion last year to make a fruitless attempt with this 
 mode of treatment in a patient whom I saw in consultation with 
 Professor Richet, and in whom the gangrene of the extremities 
 presented a form and a progress assuredly very unusual. As this 
 fact only touches indirectly on the question which I treat at this 
 moment I content myself with extracting from my notes details 
 adequate for the estimation of the valuex>f the treatment employed. 
 
 Case VI. — This patient, aged 44 years, a native of San Salvador 
 (Central America) came to France in order to be treated for an 
 affection from which he now suffers for the third time. It is 
 eleven years since the first attack, which began without any 
 known cause, and lasted nearly a year. It was characterised 
 by lividity with partial gangrene of the toes of the right foot ; 
 it ended by the loss of the last phalanx of the little toe, and of 
 the nails of the four other toes. The left foot only presented 
 during all this time some blushes of redness without pain. 
 
174 eaynaud's new researches. 
 
 Seven years afterwards a fresh attack occurred, which lasted 
 fourteen months. This time it was the left foot which was 
 invaded. Half the right big toe fell off. The right foot only 
 presented redness and intermittent pains. 
 
 Twenty months ago the third attack began, and continues till 
 now. This has presented two periods : a first period of sixteen 
 months, during which the right foot only was invaded and lost 
 its third and fourth toes, and almost ail that remained of the fifth ; 
 and a second period, which commenced four months ago (May, 
 1872), and which is now running its course under our observation. 
 At the same time that the cicatrisation is taking place rapidly on 
 the right foot, which was the first attacked, the left foot is 
 attacked, and we see first the base of the big toe (which had been 
 spared in the second attack), and then one after another the 
 four other toes become cold, blue, then black, and present all the 
 phases of mummified gangrene. Nothing, can give an idea of 
 the agonising pains which accompanied the work of mortification 
 in this unfortunate patient. He could hardly gain a few moments 
 of sleep by means of enormous doses of opium. All his manner 
 expressed the most acute suffering ; he ate extremely little, and 
 wasted considerably. Some indications of the morbid process 
 which has affected the lower extremities have become manifest 
 during the last year in the left hand. The index and the middle 
 fingers have become in different attacks distinctly cold. A minute 
 eschar which was formed at the extremity of the index finger 
 has just become detached. Nothing similar to this has ever 
 shown itself on the right hand. As in the preceding cases, we 
 sought what cause could be invoked to explain these singular 
 phenomena. The patient is not diabetic. Like all his fellow- 
 countrymen he lives habitually on maize, but nothing indicates 
 that he has used damaged maize. None of the persons who live 
 with him have ever experienced similar symptoms. Examination 
 of the heart furnished negative results. The pulsations were 
 perceived in the radial, ulnar, femoral, popliteal and posterior 
 tibial arteries. But it was impossible for us to feel the pulsations 
 of the dorsal arteries of the feet, perhaps on account of the 
 tightness of the skin, and because on the left side the least touch 
 gave rise to pain. I ought to add that it is not without great 
 difficulty that I was able to distinguish the left posterior tibial, 
 of which the pulsations appeared to me very small. 
 
CASE VI. 175 
 
 These last circumstances are evidently of a nature to leave a 
 doubt in the mind upon the clinical estimate which is to be made 
 of the fact with which we are concerned. 
 
 Although convinced, on account of the excessive slowness and 
 dissemination of the sphacelus, that this lesion depended in our 
 patient upon a purely functional circulatory trouble, I am by no 
 means able to prove that there was no obstruction in the arterioles. 
 But even if one admits as certain the absence of all obliteration, 
 it appears to me very difficult to include this case in the noso- 
 logical group of symmetrical gangrenes. It is true that both 
 inferior extremities were invaded, but the attacks occurred at long 
 intervals from one another, and differed considerably in intensity. 
 So that in reality there was rather alternation than symmetry of 
 the phenomena on the two sides. This inequality was still more 
 pronounced in the upper limbs, of which only the left suffered 
 from gangrene. For my part, when called upon to give advice 
 as to the treatment to be followed, I was of opinion that one 
 might attempt without risk of harm the use of continuous 
 currents, but without any great expectation of benefit. This 
 treatment was employed regularly during twelve days without 
 leading to the least improvement. I do not enlarge here upon 
 the other therapeutic attempts which were made; everything 
 failed completely, oxygen baths included. Finally, the gangrene 
 was limited by the sole efforts of nature, and the patient, entirely 
 discouraged by the uselessness of remedies, returned to America, 
 not yet cured, at the beginning of November. 
 
 I considered that I ought to place this unsuccessful case 
 alongside the facts of recovery which I have recorded above. 
 The latter are, I submit, none the less valuable, just for the 
 reason that the therapeutic indication is related to an order of 
 facts clearly defined to which the history of our American patient 
 presents only a dubious analogy. I ought to add that as regards 
 the intensity of the symptoms, our cases of cure were distinctly 
 slight cases. Would the electrisation of the cord bring about 
 equally rapid ameliorations in those grave cases of local asphyxia 
 of which I have reported examples, and which induce almost at 
 the very onset extensive symmetrical gangrenes ? It is at least 
 permissible to doubt it. The best means to avoid disappointment 
 is to guard against exaggerated hopes. 
 
 It would be premature with a number of observations so 
 
176 Raynaud's new bbseaeches. 
 
 limited to attempt to lay down in a general manner the rules of 
 treatment by continuous currents. I will mention simply the, 
 results of my experience. 
 
 At the commencement of the treatment one can generally 
 employ without inconvenience 25 to 30 of Daniell's or 
 Trouve's elements ; nevertheless in one of my patients this 
 number of cells was only attained gradually. The positive pole 
 should be placed on the fifth cervical vertebra, the negative pole 
 over the last lumbar or over the sacrum. When it is placed 
 directly over the level of the inferior part of the cord a very 
 painful sensation of spasm is produced in the lower limbs and in 
 the abdomen. 
 
 Applied as I have just said, the current only gives a sensation 
 of heat easily borne. At the end of a few minutes one may 
 gradually slide the negative pole up to the eighth dorsal. 
 
 The duration of each application ought to be from ten 
 minutes to a quarter of an hour. A single application each 
 day has appeared to me to suffice, but it may be repeated if 
 required. During the application of galvanism of this strength 
 one observes an increase of the circulatory rapidity, with accelera- 
 tion of the respiratory movements and abundant perspirations, 
 principally in the axillae and on the hands. This perspiration 
 ought not to be identified with that which shows itself so often 
 in the case of severe and prolonged pain. Here the pain is nil. 
 We have to do with a secretory phenomenon directly provoked 
 by the excitation of the cord, and which bears witness to an action 
 exercised on the nutritive functions by the current. 
 
 Independently of this perspiration directly caused by the 
 passage of the current, I will add that one of the first signs of 
 improvement obtained consists in the establishment of a habitual 
 moisture of the hands, which previously were completely dry. 
 I consider this phenomenon as one of the most favourable 
 elements of prognosis. When this treatment has been followed 
 during some days, and improvement has distinctly commenced, 
 some unpleasant effects begin to manifest themselves — viz., 
 headache (intensified by the passage of the current), painful 
 sensation of constriction of the throat, and general excitement. 
 
 Although these symptoms are not serious, it is nevertheless 
 proper to diminish the number of elements employed. We have 
 seen that in one of my cases (Case III.) the number was pro- 
 
TREATMENT BY GALVANISM. 177 
 
 gressively reduced from 30 to 10. At this moment the violet 
 colour of the fingers had entirely disappeared ; 12 elements 
 then produced a feeling of burning which was tolerated with 
 difficulty. 
 
 It is especially when the application of the rheophores over 
 the cord begins to be troublesome that I have found it useful to 
 make, a centrifugal current pass through the affected limbs, the 
 positive pole being applied over the nervous plexus at the root of 
 the limb, and the negative pole over the extremity itself. This 
 local application is much more easily tolerated than the spinal 
 one. We have been able to raise the number of elements up to 
 60 without inconvenience ; but 30 elements appear to me in 
 general to suffice for the necessities of practice. 
 
 Finally, it is worthy of note that a difference of action is to be 
 observed according as the rheophore is applied over the dorsal 
 surface, or over the palmar surface of the digits. In the first 
 case a smaller number of elements is necessary to produce a 
 sharp pain at the moment of making and breaking. In the 
 second one observes a rather curious phenomenon. At the first 
 moment the current seems hardly to pass, the patient feels 
 nothing ; but little by little one sees the needle of the galvano- 
 meter deviate more and more, and at the same time there 
 develops a feeling of smarting, which ends by becoming difficult 
 to bear; but at this moment the normal colour of the extremities 
 is already re-established. 
 
 This progressive passage of the galvanic current seems to me 
 to be quite easily explained by the greater thickness of the 
 epidermis on the palmar side than on the dorsal, in consequence 
 of which there is a slower infiltration of moisture from the 
 wetted rheophores. However that may be, this direct action of 
 the continuous current on the peripheral circulation constitutes' 
 a valuable resource in the treatment of local asphyxia of the 
 extremities. I have never seen it fail, and the change has taken 
 place under one's eyes. Supposing even that the effect may not 
 be always so lasting as I have found it, it would not the less be 
 an element of considerable security to be able, so to speak, at 
 will to bring back, even though it be only transiently, the circu- 
 lation of the extremities to its ^physiological conditions. One 
 ought indeed to remember that local asphyxia of the extremities 
 is not only an inconvenient and painful affection, but that it can- 
 
 12 
 
178 Raynaud's new researches. 
 
 at a given moment produce the gangrene and loss of the ends of 
 the lingers. I possess a collection of the ends of fingers thus 
 detached from the hand. It may be hoped that, thanks to the 
 means which I have just pointed out, this sad termination will 
 in future be observed quite exceptionally. Should one renew the 
 galvanic applications a great number of times daily, the distress 
 of the infliction would be largely compensated by the certainty 
 of preventing an imminent gangrene. 
 
 After all, the therapeutic action is here in perfect accord with 
 the facts of physiology. If there still exists a certain disaccord 
 between experimenters touching the real action of induced cur- 
 rents on the capillary circulation, on the other hand it is well 
 established that continuous currents augment the circulation. 
 Messrs. Kobin and Hiffelsheim had established in 1861 that the 
 continuous current, when once the circuit is closed, dilates the 
 capillaries, and seems to establish at the same time a regular 
 and uniform circulation of the blood. These results have been 
 confirmed by the very exact researches of Messrs. Onimus 
 and Legros ; they are produced whether one acts on the sympa- 
 thetic nerves, or whether one acts on the skin. Only these 
 skilful physiologists add one condition : it is that the current 
 shall be centrifugal, that is to say, that the positive pole shall 
 be placed on the cord side, and the negative pole on the peri- 
 pheral side. This condition has always been maintained in our 
 researches. 
 
 I call attention very particularly to the fact, which has been 
 very manifest in our fifth case, viz., that on prolonging suffi- 
 ciently the electrisation of one hand the cyanosis is observed to 
 disappear, not only in that hand but in that of the opposite side, 
 which the rheophores have not touched. This interesting 
 phenomenon denotes between the vaso-motors of the two upper 
 extremities a close solidarity, which can only be established by 
 the intermediation of the cord. This leads us to inquire how 
 the passage of a galvanic current through the spinal cord brings 
 about the diminution, and finally the cessation, of the spasmodic 
 state of the small vessels which determines the local asphyxia ? 
 To this question also physiology gives a satisfactory answer. I 
 have no need to recall here the facts which establish that the great 
 sympathetic takes its origin in the central parts of the spinal 
 axis, and that the cord possesses veritable vaso-motor centres, 
 
TBEATMENT BY GALVANISM. 179 
 
 situated at different heights in its whole extent, centres of which 
 many have been determined with great precision by experi- 
 menters. These same effects, which are obtained by section of 
 the great sympathetic, can be obtained by sections systematically 
 made of the spinal cord ; upon this point the results of experi- 
 mentation upon animals can be rigorously applied to man. 
 This is demonstrated by a great number of clinical observations 
 especially collected by Dr. J. "W. Dgle* and by M. Brown- 
 Sequard,t in which accidental lesions of the cord have deter- 
 mined the appearance of vaso-motor symptoms, absolutely 
 comparable witb the effects of the section of the sympathetic in 
 the celebrated experiments of Claude Bernard. These facts 
 suggested to me to act directly upon the cord in order to 
 influence the peripheral circulation, and the result appears to 
 have justified my expectations. In employing continuous de- 
 scending currents, I had moreover another reason. 
 
 Amongst the effects produced by continuous currents on the 
 spinal cord there is one which has been especially well studied 
 latterly, and to which MM..Legros and OnimusJ have devoted 
 special attention ; whilst the ascending current excites the cord 
 and augments the reflex actions, the descending current hinders 
 the reflex actions and diminishes the excitability of the cord. 
 After having in an animal separated the cord from the brain, 
 when the reflex actions are very manifest, if one makes a descend- 
 ing current pass through the cord one no longer obtains during 
 the whole duration of the electrisation any reflex action, however 
 strong may be the excitation of the posterior extremities. In 
 paraplegics who have presented a great exaggeration of reflex 
 movements, one has been able to moderate considerably the- 
 intensity of this symptom by means of currents in a descending 
 direction applied over the cord. This sedative effect of the con- 
 tinuous current is certainly not the only one which one obtains, 
 by electrisation of the cord, and I could if there were need, report 
 many observations relative to therapeutic facts which bear witness 
 strongly in favour of a salutary action exercised on the nutrition 
 of this nervous centre. 
 
 One might object that in the foregoing examples we have only 
 
 * Med. Ch. Trans., vol. xli., 1858. 
 
 + Lancet, Nov. and Deo., 1868 ; Lectures on the Vaso Motors, Paris, 1872. 
 
 J Treatise on Medical Electricity, Paris, 1872. 
 
180 Raynaud's new researches. 
 
 to do with the arrest of reflex movements having to do with 
 external relations, and that the case may be different with regard 
 to the vaso-motor innervation. That is a very improbable sup- 
 position ; stimuli applied directly to the grey matter of the cord 
 affect in the same way the nerves of movement and the vascular 
 nerves ; there is little reason to suppose that the laws of spinal 
 reflection are different for these two orders of nerves. Never- 
 theless it has appeared to me important not to allow the least 
 doubt to remain in this matter. Everybody knows an experiment, 
 as simple as it is interesting, due to Messrs. Brown-Sequard, 
 and Tholazan, and which recalls that to which I made allusion 
 a propos of Case V. When one plunges one hand into water at a 
 very low temperature (from freezing point to a degree above it) 
 one sees the vessels of the other hand contract strongly. The 
 contraction of the vessels of the hand which is not plunged into 
 water commences all the more promptly, and is the stronger, the 
 more severe is the pain experienced on contact with the cold 
 water. 
 
 This phenomenon demands necessarily the intervention of the 
 spinal cord; the sensation received by the sensory nerves is 
 transmitted to the excito-motor centre, and provokes in return a 
 stimulation of the vascular nerves, which stimulation produces 
 its effects principally upon the hand which is plunged in water, 
 but also very distinctly upon the opposite hand. There is evi- 
 dently then a phenomenon of reflex nature. After having repeated 
 this experiment, I have modified it in the following manner, 
 whilst operating either on myself or on several pupils who have 
 been so good as to assist me in this matter. A current of 
 25 to 30 elements is applied over the vertebral column. By 
 the aid of a commutator it is easy to get either a descending 
 or an ascending current. The subject under experiment bathes 
 one of his hands in water of the temperature of melting ice, 
 whilst the other remains in the free air, and one examines 
 carefully the state of the vessels before, during, and after the 
 passage of the current. 
 
 This experiment is very delicate, and it is not so easy as one 
 might believe to appreciate the changes of calibre of the vessels. 
 I have repeated it many times. The result which has appeared 
 to me most marked is the exaggeration of the reflex vascular 
 contraction under the influence of the ascending current. The 
 
SUMMARY. 181 
 
 inverse effect, that is to say the diminution or suspension of this 
 contraction under the influence of the descending current, this 
 effect I say being negative is more difficult to establish ; it 
 appeared to me, nevertheless, that the narrowing of the vessels 
 became more pronounced after the interruption of the current, 
 that immediately after the interruption the veins of the back of 
 the hand contracted visibly. 
 
 The passage of a descending continuous current therefore had 
 for its effect the suspension, or at least notable diminution, of the 
 reflex movements placed under the control of the vaso-motor 
 nerves. 
 
 This experiment, taken along with the therapeutic effects 
 obtained by the same agent in the treatment of local asphyxia of 
 the extremities, fairly suggests that in this case also electricity 
 acts in the same way, viz., that it diminishes the reflex con- 
 traction of the vessels by weakening the excito-motor power 
 of those parts of the cord which govern this exaggerated con- 
 traction. 
 
 Hence applying the adage, " The cures of diseases set forth 
 the nature of the diseases," I arrive at this proposition, which 
 is only the expression of the facts observed, that is to say, that 
 in a certain number of cases, and perhaps in all, the permanent 
 vascular contraction, which is the dominant phenomenon of the 
 malady in question, is of reflex nature. 
 
 One question only remains : What is the sensory origin of 
 this reflex contraction ? Probably there are many such points 
 of origin. It has appeared to me in several cases that it ought 
 to be sought in the genital apparatus of the female. But more 
 commonly the peripheral excitation appears to consist in the 
 impression produced by temperature upon the cutaneous nerves. 
 We have almost always seen the symptoms notably exaggerated 
 by exposure to cold air, or by immersion of the hands in cold 
 water. 
 
 Only whilst in the normal state exposure to very low tem- 
 peratures for a considerable period are necessary for the pro- 
 duction of more or less analogous effects ; in the malady which 
 now occupies our attention an insignificant difference of tem- 
 perature suffices to. produce symptoms comparable with the 
 most intense numbing of the fingers. One may see them appear, 
 for example, in midsummer, when from a room at 18° C. the 
 
182 Raynaud's new reseabches. 
 
 patient passes into the external air, at a temperature 11 or 12 
 degrees above zero. 
 
 To sum up in a more definite form, I would say that in the 
 present state of our knowledge local asphyxia of the extremities 
 ought to be considered as a neurosis characterised by enormous 
 exaggeration of the excito-motor energy of the grey parts of the 
 spinal cord which control the vaso-motor innervation. 
 
 In conclusion it will be useful to summarise the main points 
 of this paper. 
 
 (1) The existence of a spasm of the small arteries, as proxi- 
 mate cause of the local asphyxia of the extremities, had been 
 admitted on inductive grounds. I have reported in detail a 
 case of very remarkable coincidence between the peripheral cir- 
 culatory troubles and identical phenomena observed with the 
 ophthalmoscope in the retinal circulation, which phenomena 
 have become manifest clinically by an intermittent obscuration 
 of vision, a condition which we ought henceforth to look for 
 in the symptomatology of this affection. This observation fur- 
 nishes important confirmation to the theory of vascular spasm. 
 
 (2) I have thereupon discussed the question of the relations 
 existing between the contraction of the central artery of the 
 retina and the pulsations of the corresponding vein, and I have 
 suggested a new theory as to the mode of production of these 
 pulsations. 
 
 (3) I have reported the favourable results of the treatment of 
 local asphyxia of the extremities by continuous electrical cur- 
 rents, showing the possibility of preventing by this treatment 
 the consecutive gangrene. 
 
 (4) The electrical treatment consists in the employment of 
 descending currents, applied either over the vertebral column 
 to act on the spinal cord, or over the extremities themselves. 
 Although the first method employed alone has furnished me 
 very satisfactory results, I prefer in practice to use the two 
 methods combined. 
 
 (5) The action exercised by the current on the cord appears 
 to consist in an enfeeblement of the excito-motor power, whence 
 there results a corresponding relaxation of the reflex vascular 
 contractions. 
 
 (6) This mode of action of continuous currents leads us to 
 think that local asphyxia of the extremities is essentially a 
 
SUMMARY. 188 
 
 neurosis characterised, as I have just said, by increased irri- 
 tability of the central parts of the cord presiding over vascular 
 innervation. 
 
 (7) Whatever may be the theory of it, local asphyxia of the 
 extremities, considered up to the present as a simple pathological 
 curiosity against which art had no resources, is a morbid con- 
 dition which is now amenable to therapeutic measures. 
 
APPENDIX BY THE TEANSLATOE. 
 
 A few words may be added by way of postscript to Kaynaud's 
 Memoirs on some of the additions which have been made to our 
 knowledge of the disease in question, especially since Raynaud's 
 final utterances. 
 
 Several cases of spontaneous symmetrical or asymmetrical 
 gangrene, arising independently of obvious vascular obstruction, 
 have been recorded in English and American medical literature. 
 One of the most striking examples was a carefully reported case 
 by Dr. Myrtle, under the title of Anaemic Sphacelus {Lancet, i., 
 1863, p. 602). 
 
 But Raynaud's researches were first brought prominently 
 before English readers by Dr. Southey, in the St. Bartholomew's 
 Hospital Reports for 1880 (case of symmetrical gangrene), and 
 about the same time by Mr. Hutchinson in his Hunterian 
 Lectures at the College of Surgeons. 
 
 The subsequent papers of Dr. Southey (case of local asphyxia, 
 symmetrical gangrene, Trans. Clinical Society, xvi., 1883, p. 
 167 ; case of symmetrical gangrene, Trans. Pathological Society, 
 xxiv., p. 286 ; of the Translator (three cases of Raynaud's disease, 
 Trans, of Clinical Society, xvi., 1883, p. 179 ; and sequel, Trans, 
 of Clinical Society, xviii., 1885, p. 307) ; of Dr. Colcott Fox 
 (Trans. Clinical Society, xviii., p. 300) ; of Mr. G. H. Makins 
 (case of spontaneous gangrene of toes in a child, St. Thomas's 
 Hospital Reports, vol. xii., p. 155), and of several other English 
 and American observers, have made the clinical features of this 
 group sufficiently familiar. 
 
 Is there anything of importance to add to Raynaud's delinea- 
 tion ? 
 
 I. The most noteworthy addition is the association of inter- 
 mittent hemoglobinuria with some of the cases of local asphyxia 
 and symmetrical gangrene. 
 
APPENDIX BY THE TRANSLATOB. 185 
 
 There is a suggestion of this association in the history of a 
 case recorded hy Mr. Hutchinson so far back as 1871.* A 
 woman, aged 30, had suffered during the winter with frequent 
 shivering fits after exposure to cold. These attacks were accom- 
 panied or followed by general malaise, and the urine often became 
 dark after them. One cold day after returning home, she found 
 that her nose and left ear were quite black. During her stay in 
 hospital small superficial sloughs gradually separated from the 
 above-mentioned spots. She was liable to slight shiverings, 
 during which she got icy coldness and purple congestion around 
 the sloughing patches, but no blood or colouring matter appeared 
 in the urine. 
 
 Mr. Hutchinson, in commenting on the above case, was 
 inclined to the view that the history pointed to hsematinuria, 
 and that this and the limited localised gangrene of extremities, 
 in the absence of malaria, had a common origin in exposure to 
 cold, the patient's idiosyncrasy being taken into account. 
 
 In 1879 Dr. Wilksf had a boy aged 16 under his care, who, in 
 consequence of some injury to the hip, had had profuse suppura- 
 tion from the bursa between the gluteus maximus and the great 
 trochanter. The patient, when transferred to Dr. Wilks's care, 
 was cyanotic, and had a systolic murmur at the third right 
 space. The edges of the ears became very blue, and the nose 
 and toes likewise, but the tips of the thumbs and of several 
 fingers became affected with definite gangrene, from which they 
 slowly recovered. 
 
 The urine was at different times dark in colour, and gave 
 the guaiacum test ; granular casts and debris were present, 
 but on several occasions no blood corpuscles could be found. 
 At a later period, however, some blood corpuscles were 
 present. 
 
 In Dr. Southey's first case J there was a history of the patient 
 having passed black urine with some of her attacks, in which 
 the fingers became numbed, black, and dead ; but during her stay 
 in hospital with symmetrical gangrene on the legs and attacks 
 of local asphyxia of the fingers, though a trace of albumen is 
 
 * Medical Times and Gazette, 1871, vol. ii., p. 678. Gangrene of tip of nose and 
 part of ear ; iiidoplegia. 
 t Medical Times- and Gazette, 1879, vol. ii., p. 207. 
 % St. Bartholomew's Reports, xvi., 1880, p. 15. 
 
186 APPENDIX BY THE TRANSLATOR. 
 
 noted as being present in the urine, there is no record of haemo- 
 globin. 
 
 In Dr. Southey's second case* of local asphyxia and symme- 
 trical gangrene, there was for several days a true intermittent 
 hsematuria, provoked apparently by impressions of external cold 
 to the surface of his body. It is noted that the blood was usually 
 very apparent by its dark colour, and the obvious sediment it 
 gave, but its presence was at times only detectible by the guaiacum 
 reaction. Oxalates either preceded or accompanied the haema- 
 turia usually. It seems probable that this case was at times, at 
 all events, one of haemoglobinuria. 
 
 In one of the cases recorded by the translator,f the onset was 
 marked by epigastric pain, and hemoglobinuria was observed to 
 occur within one or two hours from the beginning of the local 
 asphyxia of the limbs. The dark urine only appeared once after 
 a given attack. It gave the reaction with guaiacum, and presented 
 under the microscope pigment and oxalates, but no blood cor- 
 puscles. The urine gave the spectrum characteristic of met- 
 haemoglobin. The translator pointed out the marked parallelism 
 between typical cases of intermittent haemoglobinuria and cases 
 of Raynaud's disease, strictly so called, in which the paroxysmal 
 character of the local asphyxia must be considered an essential 
 "note" of the morbid phenomena. "They are not in a true 
 sense periodic, but they are both paroxysmal." "Attacks in both 
 affections have a remarkable relation to changes of temperature." 
 "By far the greater number of cases of both are exclusively 
 winter or cold weather affections, and if not exclusively 
 they are primarily so, and if the attacks do not vanish, they 
 notably diminish when the warm weather appears." " In both, 
 the paroxysms may begin with yawning or with vomiting, and 
 the extremities, as I can testify, may in the onset of an attack 
 of paroxysmal htemoglobinuria become extremely cold and 
 blue." In both, the attacks may be accompanied by some 
 abdominal pain, and both may be followed next day by sleepiness 
 and by a certain sallowness of complexion and of conjunctives. 
 It is the rarest event for an attack of intermittent haemoglobinuria 
 to occur when the patient is in bed, and this exemption also 
 
 * Trans. Clin. Soc., xvi., 1883, p. 167. 
 
 f Dr. Barlow, three caBes of Raynaud's disease. Trans. Clinical Society, xvi., 1883, 
 p. 179. Also sequel to above, Trans. Clinical Society, xviii., 1885, p. 307. 
 
APPENDIX BY THE TRANSLATOR. 187 
 
 obtains in the typical paroxysmal cases of Raynaud's disease. 
 The translator also suggested as "worthy of investigation whether 
 any other visceral paroxysmal affection could be ascertained like 
 the temporary splenic enlargement which he had noticed in one 
 of the hsemoglobinuria cases." The analogy of Raynaud's disease 
 with intermittent haemoglobinuria has been very frankly accepted 
 by the chief English authority on the latter disease, viz., Dr. 
 Dickinson, in the last published part of his work on kidney 
 diseases.* 
 
 He holds that the difference may declare itself by little else 
 than the more narrow limitation and the greater intensity of the 
 superficial arrest of circulation in the one case than in the other. 
 " Indeed the two conditions seem so to approach each other and 
 mingle as to make it impossible to make a distinct demarcation 
 between them" (p. 1187). 
 
 One of Dr. Dickinson's cases (Ellen Colling bourne), vide p. 
 499, is most important as bearing on this point, because the 
 history of the case whilst under observation in the hospital shows 
 that the typical attacks of intermittent haemoglobinuria were on 
 one occasion replaced by a typical attack of paroxysmal local 
 asphyxia affecting one hand, and unattended with the usual 
 urinary affection. 
 
 Dr. Druittf in the account of his own case shows that he 
 suffered from obvious ague attacks, and also from distinct attacks 
 of haemoglobinuria, related to cold, exposure, and to worry. 
 These attacks were associated with very marked proneness to 
 numbness, tingling, and blueness of the extremities, the blue 
 patches at times being almost suggestive of imminent gangrene. 
 
 Dr. John Abercrombie { observed in one case that in certain 
 attacks of local asphyxia, affecting chiefly the hands, the child 
 passed urine which was of sp. gr. 1023, and contained about ^ - 
 of albumen. It gave the guaiacum reaction, and microscopically 
 oxalates, and some amorphous material were found, but no 
 blood corpuscles. 
 
 Dr. Abercrombie holds that we are warranted in believing that 
 
 * " Renal and Urinary Affections," Part III. Miscellaneous Affections of the 
 Kidney and Urine, 1885, p. 1185. 
 
 t Two cases of intermittent hsematinuria. Med. Times and Gazette, April 19, 1873. 
 
 X " On Some Points in Connection with Raynaud's Disease." Archives of Pediatrics, 
 Oct., 1886. 
 
188 APPENDIX BY THE TRANSLATOB. 
 
 paroxysmal hsemoglobinuria and Eaynaud's disease are the same 
 thing, i.e., that hsemoglobinuria is a symptom of the more 
 general affection. He suggests even that the jaundice some- 
 times found after attacks of hsemoglobinuria (and also after 
 attacks of local asphyxia) is the result of arterial spasm of the 
 hepatic vessels. 
 
 The view which would now probably find more acceptance, is 
 that the discoloration is a hsematogenous jaundice, due to the 
 breaking up of haemoglobin in the blood stream elsewhere. 
 
 Several observers have pointed out that during a paroxysm of 
 intermittent hsemoglobinuria, blood drawn from a cold extremity 
 shows marked changes in respect to the corpuscles. They do 
 not form rouleaux, and are markedly crenated, and granular 
 masses appear in the surrounding serum. Murri,* of Bologna, 
 believes that there is corpuscular destruction in the superficial 
 vessels in which stagnation has occurred, and that arterial spasm, 
 whatever its cause, is an essential factor in the disease. He 
 holds that the corpuscles are broken up by the combined action 
 of cold and carbonic acid.f 
 
 Boas J found that corpuscular changes could be brought about 
 in the blood drawn from the finger of a patient who was the 
 subject of paroxysmal hsemoglobinuria, by plunging the finger 
 for a time into a dish of iced water ; and Fleischer § found that 
 in one of his hsemoglobinuria patients a blister, which had been 
 applied to the skin during an inter-paroxysmal period, gave 
 evidence of the presence of haemoglobin in its serum, after a 
 paroxysm of hsemoglobinuria had occurred. 
 
 In the above observations no special regard lias been made to 
 the occurrence of local asphyxia of the extremities, but Dr. 
 Mvers || has recorded a case which completes the group in the 
 sense that there are blood changes, local asphyxia of extremities, 
 and intermittent hsemoglobinuria occurring in the same patient. 
 
 A boy, aged 12 years, who was under the care of Dr. Cavafy 
 for paroxysmal haemoglobinuria, dated his first attack five years 
 back when recovering from measles. About the same time, or 
 
 * Dell Emoglvbinwia dajreddo. Bologna, 1880. 
 
 f Quoted from Dickinson. Vide also lecture by Dr. Stephen Mackenzie, Lancet, 
 1884, i., p. 156. 
 t Deulsches Archiv fur Klinische Medicin, 1883, p. 3:"i6. 
 § Btrl. Klin. Wochemehrift, 1881. No. 47, p. 694. 
 II Trans. Clin. Soc., xviii., p. 336. 
 
APPENDIX BY THE TBANSLATOB. 189 
 
 soon after it, the ears were noticed to be very much cyanosed 
 when the boy was chilly, and they ached much as he got warm. 
 Subsequently gangrene of both ears set in, and this relapsed 
 several times in successive winters. During the last two years 
 the gangrene had stopped, but there was extreme cyanosis, ten- 
 derness, and aching of the ears on exposure. The attacks of 
 paroxysmal haemoglobinuria had continued, being more frequent 
 in winter than in summer. The attacks were typical in every 
 respect. The blood was examined during the attacks, being 
 taken from the cyanosed ears and from the hands. " The 
 coloured corpuscles were fairly normal in outline, but sometimes 
 had crenate edges ; there was always an abnormal disinclination 
 to form rouleaux, as Boas and others have noticed. Blood 
 'flakes,' as they have been called, were found, varying in colour 
 from a deep reddish black to a thin transparent red, and in size 
 from about four to ten times as large as a normal coloured 
 corpuscle." 
 
 " On one occasion they seemed to be contained in a transparent 
 envelope, and to be themselves somewhat granular, shading off 
 into the colourless envelope." 
 
 II. With respect to the skin : (1) Although chilblains properly 
 so-called are rare in Raynaud's disease, there are some cases of 
 localised patches of subcutaneous mottling in which the deep 
 purplish colour is permanent for a time and then gradually clears 
 up, with or without pigmentation, which have a close connection 
 with local asphyxia and symmetrical gangrene. Perhaps also 
 the cases described by Dr. Cavafy (Clinical Society's Trans- 
 actions, xvi., p. 43), as " symmetrical congestive mottling of the 
 skin " are examples of an allied condition. Of the cases to 
 which Dr. Weir Mitchell has applied the name of erythro-melagia, 
 or the "red neuralgia" (vide American Journal of Medical 
 Sciences, July, 1878, on "A Bare Vaso-Motor Neurosis of the 
 Extremities ") there are certainly some, which are examples of 
 Raynaud's disease. 
 
 (2) Urticaria has been observed by Dr. Southey in one case to 
 occur in the paroxysms of Raynaud's disease, and the same 
 skin affection has been observed by Dr. Dickinson, Dr. Stephen 
 Mackenzie, and Dr. Forrest in paroxysmal hemoglobinuria. 
 
 (3) There is a considerable number of observations bearing 
 on the relationship of local asphyxia, -symmetrical gangrene of 
 
190 APPENDIX BY THE TRANSLATOR. 
 
 extremities, and scleroderma recorded by Ball, Vidal, Favier, 
 and others. 
 
 Ball's case, reported by him as a new variety of scleroderma 
 (Bulletins, &c, de la Societd Medicale des Hopitaux de Paris, 
 1872, p. 59), was that of a woman who for five years had suffered 
 during the winter from hard yellowish patches on the extremities 
 of the fingers, which subsided with the return of spring. Ulti- 
 mately the fingers were permanently altered in that the extremities 
 became cold, hard, somewhat unsensitive, and decidedly atrophied. 
 The last phalanges were contracted in a state of semiflexion. 
 The lesions were symmetrical, all the fingers of both hands 
 being affected, but the thumbs were intact. Subsequently the 
 toes were similarly affected. The patient was liable to crises 
 from time to time, during which the finger reddened and became 
 painful, then ulceration occurred and tardy cicatrisation with 
 loss of substance. After each crisis the affected finger became a 
 little more atrophied and deformed than before. There was no 
 trace of scleroderma in other parts of the body. 
 
 This case was claimed by M. Raynaud as an example of the 
 chronic form of local asphyxia and symmetrical gangrene. Dr. 
 Colcott Fox states that in two of his cases of scleroderma, in 
 which the hands were involved, the patients had been long 
 subject to dead fingers, and one of them continued to have mild 
 attacks of asphyxia of fingers after the onset of the scleroderma. 
 
 A very valuable case has been recorded by Dr. Finlayson 
 (Medical Chronicle, vol. i., p. 316). The patient was a mason, 
 aged 36, who presented well-marked scleroderma of hands, feet, 
 legs, front of chest and abdomen, neck and face. This patient 
 was much influenced in regard to the hardness of the skin by 
 exposure to cold. He ultimately developed gangrene of fingers 
 and toes, for which no gross lesion was found to account post- 
 mortem. 
 
 In an unpublished case under the care of the translator the 
 order of events was the reverse of that which obtained in Dr. 
 Finlayson's case. A lady suffered for a considerable period with 
 attacks of local syncope of the finger ends, which culminated in 
 symmetrical gangrene of the tip of each index finger. From 
 this she recovered, but afterwards slowly drifted into a state 
 in which the fingers generally presented the atrophied tapering 
 parchment-like character described by Raynaud, with some con- 
 
APPENDIX BY THE TRANSLATOR. 191 
 
 tractions of the last phalangeal joints, whilst the chest walls 
 hecame decidedly sclerodermatous. 
 
 III. With respect to the joints and structures surrounding 
 joints, Raynaud has referred to fibrous anchylosis of the terminal 
 phalangeal articulations and to thickenings along the processes 
 of the palmar fascia in some of the cases, and the remarkable 
 way in which especially the palmar thickenings may clear up 
 (vide New Researches, p. 160). This was strikingly illus- 
 trated in an unpublished case under the care of the translator. 
 But it would appear that occasionally the larger joints may 
 become temporarily involved. Thus in Dr. Southey's second 
 case (Clin. Trans., xvi., p. 174), whilst under observation, effu- 
 sion was noted to occur during one of the attacks in both knee- 
 joints. No details are given as to the duration and character of 
 the joint affection, but in the remarkable case recorded by Dr. 
 Weiss (" Ueber Symmetrische Grangran," Wiener Klinik, Oct., 
 Nov., 1882) there is a long series of observations on these points. 
 In the early attacks only the finger joints suffered, but subse- 
 quently the left knee, the right elbow, the right shoulder, and 
 the right wrist were affected. 
 
 Weiss thus sums up the clinical characters observed :— There 
 was effusion in joint cavities, and infiltration of connective tissues 
 above and below the joints. Once there was synovitis of the 
 metacarpo-phalangeal joint of the right middle finger, followed 
 by tenosynovitis of the flexor tendons of this finger. On one 
 occasion there was effusion into the knee-joint, associated with 
 exudation into the cellular tissue of the thigh and knee. Some- 
 times the joint effusion was preceded by pain, in other cases it 
 was painless. The swollen joints and the swelling of the soft 
 parts were not specially tender to pressure. The skin was only 
 reddened once, viz., in the case of effusion into the shoulder 
 joint. The temperature was not raised at the outset, and the 
 course throughout was afebrile. In most cases absorption was 
 rapid, and the constituent parts of the joints returned completely 
 to the normal state. Weiss is inclined to bring these transitory 
 joint affections "into line" with the benign forms of arthro- 
 pathy described by Charcot and others as occurring in many 
 cerebro-spinal diseases, looking upon the central affection in his 
 case as a temporary anaemia of the hypothetical trophic joint 
 centres in the cord. 
 
192 APPENDIX BY THE TRANSLATOR* 
 
 IV. Eye Symptoms. — No further definite example of amblyopia 
 alternating with attacks of local asphyxia in limbs (as in Case I., 
 New Researches, p. 155), or coinciding with such attacks (as in 
 Case II., p. 164), has been recorded. But Weiss's case, to. 
 which reference has already been made, presented some remark- 
 able eye phenomena, referred by him to the involvement of the 
 cervical sympathetic. These phenomena occurred in attacks 
 which were interposed between some of the frequent seizures of 
 symmetrical gangrene of the fingers, and although these attacks 
 had special features, there were other points in which they con- 
 formed to the usual order of events. For several days the patient 
 had retraction of the eye-ball, narrowing of the palpebral fissure, 
 contracted pupil with no reaction to light, and a slight degree of 
 ptosis. There was at the same time reddening of the zygomatic 
 region and of the external ear of the same side, some elevation 
 of temperature, and some hyperidrosis. As the attack cleared 
 up, a slight degree of superficial gangrene of the skin of the 
 zygomatic region appeared in the shape of some small patches of 
 first brown then blackened epidermis, which ultimately sepa- 
 rated. The patient had several such attacks, affecting the left 
 side of the face and left ear, and some also affecting the right 
 side, and at times both sides simultaneously, but only on the 
 left side were the eye phenomena marked. On the left side of 
 the face there remained subsequently a slight degree of atrophy. 
 
 Weiss was inclined to explain the eye phenomena by some 
 central cause, e.g., ischeemia of the cilio- spinal region of the 
 cord. 
 
 In Mr. Hutchinson's case, mentioned at the outset of this 
 appendix, of gangrene of the tip of the nose and tip of the left 
 ear, there was also iridoplegia on the left side. The pupils were 
 large and unequal, the left being bigger than the right and 
 motionless, both on exposure to light and on accommodation 
 efforts. There was contraction to Calabar bean, and the vision 
 was good. Syphilis was suspected in this case. 
 
 V. Cerebral Symptoms. — Some of Kaynaud's cases were 
 markedly hysterical and chlorotic (VIIL, IX., pp. 43, 54), and 
 one of them (XIX., p. 89) was admitted to the Salpetriere on 
 account of " epileptiform attacks, with notable alteration of 
 intelligence and incoherence of ideas." 
 
 In Dr. Southey's third case, a boy aged 9 (Clin. Trans., xvi., 
 
APPENDIX BY THE TRANSLATOR. 193 
 
 p. 167), there were curious maniacal attacks in the early part of 
 the illness, when gangrene of one finger tip was already present. 
 
 Dr. Southey has informed the translator that he has since the 
 publication of the above seen several examples of Raynaud's dis- 
 ease in " asylum cases," and Dr. Wiglesworth's case (vide postea), 
 in which the disease occurred in a young woman who was the 
 subject of epileptic dementia, is another illustration of this. In 
 an unpublished case under the care of the translator the patient, 
 a middle-aged woman, during a slight remission of her attacks of 
 local asphyxia, became the subject of delusions which were always 
 worse in the evening. The possibility of her requiring to be 
 removed to an asylum was considered, but she ultimately made 
 an excellent recovery. 
 
 In Weiss's case there occurred during one phase of the illness 
 a period during which the patient had markedly ataxic aphasia, 
 without any paralytic manifestation whatever. For other eases 
 in which Raynaud's disease occurred in patients who were suffer- 
 ing from grave organic disease of the nervous centres, vide next 
 section. 
 
 VI. Pathology and Etiology. — Consideration of his later 
 examples, and of others akin to them, shows that some of the 
 points upon which Raynaud laid great stress in his early typical 
 cases cannot be maintained in an absolute sense. Amongst 
 these points are (1) the bilateral symmetry, (2) the successive 
 stages of the affection, (3) the depth of the gangrene. There 
 have been several undoubtedly paroxysmal cases in which some 
 of the attacks were bilateral and others entirely unilateral. The 
 stages of the affection in a given case are not always as Raynaud 
 stated them — viz., first local syncope, then local asphyxia, then 
 gangrene. Several cases have been observed in which there was 
 no stage of preliminary ischsemia, but in which the local asphyxia 
 was the first event. Finally the gangrene produced has occa- 
 sionally in cases of Raynaud's type been observed to extend to 
 the deeper structures, and even involve the end of a limb, instead 
 of being limited to the true skin, or the extremity of the ungual 
 phalanx, as described in the text (p. 113). 
 
 Relation to Ague. — It is strange indeed that the possibility of 
 any connection between the disease which he described and 
 malarial fevers does not appear to have been considered by 
 Raynaud. In two of his earlier cases (VI. and VIII., pp. 40, 
 
 13 
 
194 APPENDIX BY THE TBANSLATOE. 
 
 43) the symptoms of local asphyxia of limbs appeared about a 
 fortnight after recovery from tertian ague, and the first of his 
 later cases (p. 155, New Researches) had suffered from ague 
 thirty years previously. 
 
 In the article on gangrene (p. 679, Diet, de Med. et de Chir. 
 prat.) Eaynaud says that " although after repeated attacks of 
 intermittent fever oedema of the limbs, with or without throm- 
 bosis, may often be observed, no examples are known of gangrene 
 special to the malarial cachexia." Since the publication of 
 Raynaud's memoirs several cases of local syncope, local asphyxia, 
 and gangrene have been recorded as occurring in persons who 
 either were suffering at the time or had suffered from ague. The 
 most complete review of this subject has been given by Petit and. 
 Verneuil (Rev. de Chirurgie, 1883, pp. 1, 161, 432, 699). The 
 cases of gangrene described by them are very miscellaneous in 
 character, some of them resembling the form which occurs as a 
 complication of various exanthemata, and not strictly comparable 
 with Raynaud's type, but there are others which seem to conform 
 to it in that the gangrene occurs in young subjects,, and is sym- 
 metrical, terminal, dry, and circumscribed. It is also clear that 
 in some of the cases recorded, both of local asphyxia and of gan- 
 grene, there was a definite response to the use of quinine. M. 
 Mourson, in his second memoir (Arch, de Med. Nav., 1880, p. 
 340) on this subject, places the local asphyxias in malarial sub- 
 jects in juxtaposition with some of the anomalous central and 
 peripheral nervous affections which occur as sequelae and 
 " larval " forms of ague, and he broaches the theory of melan- 
 semic deposits in the vessels of the cord, &c, as a possible agent 
 of their production. 
 
 It is of importance to note the evidence which has been 
 brought by Dr. Dickinson and others in support of the malarial 
 origin of some of the cases of the allied affection, intermittent 
 hemoglobinuria. 
 
 Relation to Syphilis. — Two of the examples quoted by Raynaud 
 (XVI., XVII., pp. 85, 87) were patients who had suffered previously 
 from acquired syphilis. This has also obtained in some of the 
 subsequently reported cases; and in a remarkable instance of 
 symmetrical gangrene recorded by Dr. Henry Humphreys, the 
 patient was a syphilitic child. The obvious objection arises that 
 in these cases there may have been present some syphilitic 
 
APPENDIX BY THE TRANSLATOR. 195 
 
 endarteritis capable of causing vascular obstruction ; and in 
 future observations this question ought to be carefully investi- 
 gated. It is noteworthy that both Boas and Murri mention 
 syphilis along with ague as a probable determining factor in 
 the production of hemoglobinuria (vide paragraph I.) . 
 
 Relation to Peripheral Neuritis. 
 
 Raynaud's cases in respect to post-mortem evidence are defec- 
 tive, except in a negative sense, as putting out of question any 
 naked-eye vascular lesions adequate to explain the local asphyxia 
 or tbe gangrene. The investigations which of late years have 
 been made into the lesions of peripheral nerves have been ex- 
 tended to some cases of gangrene. Whether these cases would 
 have been accepted by Raynaud as clinically conforming to his 
 type is a question ; but they deserve consideration. The first 
 was recorded by Mounstein (quoted by Hochenegg, Ueber Sym- 
 metrische Gangran und Locale Asphyxie. Vienna, 1886, p. 35). 
 The patient was a man, aged 51, for whom amputation of the 
 right leg in the upper third was performed on account of gan- 
 grene of the foot, which had commenced two months previously. 
 A week after the amputation was performed the patient succumbed, 
 with a high temperature. His urine was natural. The gangrene 
 had led to the separation of the first, second, and fifth toes, 
 whilst the third and fourth were isolated; but the skin over all 
 the toes was involved in the gangrenous process as well as that 
 covering the heel, the inner side of the foot, and the dorsum. 
 The vessels generally of the lower extremity were free from 
 abnormal contents ; only in the capillary vessels adjacent to the 
 gangrenous focus were microscopic hyaline thrombi present. 
 The posterior tibial artery showed many calcareous plates, but 
 no thrombi adherent to them. The posterior tibial nerve was 
 greatly thickened in its lower part; microscopic investigation 
 showed great wasting of the myelin with collapse of Schwann's 
 sheaths, and chronic inflammatory proliferation of the interstitial 
 connective tissue, especially in the parts close to the gangrenous 
 area. The nerves in the left sound lower limb showed similar 
 changes to those in the gangrenous limb. 
 
 The nerve roots of the lumbar region were only affected with 
 neuritis on the right side. 
 
196 APPENDIX BY THE TRANSLATOR. 
 
 Brain and cord were markedly anaemic, and the examination 
 of the viscera gave negative results. 
 
 The clinical history of this case is too meagre to allow of its 
 being definitely placed in Kaynaud's group, but the double-sided 
 affection of the nerves, more extensive on the gangrenous side, 
 is very suggestive. The cases recorded by Pitres and Vaillard 
 (Archives de Physiologie normale et Pathologique, 1885, p. 106) 
 are given much more fully. The first was that of a young 
 woman, aged 24, of feeble intelligence from childhood, but who 
 at 18 began to suffer from tremors and stiffness of limbs, until 
 at length walking became impossible ; the lower limbs passed 
 into a state of extreme contracture, and the patient was bed- 
 ridden and demented. After a time the feet were noticed to be 
 cold, blue, and insensitive ; they gradually became gangrenous ; 
 the left foot underwent spontaneous amputation, and the' right 
 was all but separated. Numerous eschars appeared in various 
 parts of the body; many of these suppurated, and the patient 
 died from exhaustion. On post-mortem examination the tibial 
 arteries were seen each to terminate in a cicatricial cul de sac, 
 which was surrounded by fleshy granulations. In no part of the 
 arteries of the lower limbs were adherent thrombi found, only 
 here and there soft clots. The aorta and its branches and the 
 veins of the limbs were healthy, and the examination of the 
 viscera gave negative results. In the nervous system there was 
 found chronic hydrocephalus of the lateral ventricles, and some 
 undue adhesion of the pia mater to the cortex of the hemispheres, 
 and the skull was greatly thickened. There was a slight diffuse 
 sclerosis of the dorso-lumbar part of the cord affecting the whole 
 of the antero-lateral columns and the whole of the posterior 
 columns except their anterior fifth. The spinal ganglia and 
 nerve roots, so far as they were examined, were natural. The 
 principal nerve trunks were carefully examined throughout the 
 body. Those of the upper limbs were normal, and the nerves of 
 the thighs were also normal ; the anterior and posterior tibial of 
 both sides presented changes of varying extent, but which were 
 fairly symmetrical. The changes consisted in extensive atrophy 
 of nerve fibres with empty sheaths, presenting numerous nuclei 
 and, at long intervals, varicose dilatations, which contained 
 masses of granular protoplasm and drops of myelin. Between 
 the fibres in many places was found abundance of leucocytes 
 
APPENDIX BY THE TRANSLATOR. 197 
 
 infiltrated with small granules, and having the aspect of Gluge's 
 corpuscles. 
 
 The second case is that of an old woman, aged 56, a rag 
 gatherer, who had been subjected to great hardships, and for six 
 months, along with a sensation of considerable fatigue, had found 
 that in walking she no longer felfrthe soil on which she trod. 
 Two months before her admission to hospital, bullae formed on 
 the soles of her feet. These she pricked, and they gave her little 
 trouble. About the same time she began to suffer with obstinate 
 diarrhoea. Three days before admission the feet became swollen, 
 painful, and covered with reddish patches on the dorsal surface.. 
 Fresh bullae formed on the feet ; they were perfectly cold, and 
 anaesthesia on the left side extended up to the ankle, on the 
 right side to the middle of the tarsus. The line of separation 
 formed at this level on both sides, but the patient died from 
 exhaustion and diarrhoea before actual separation had taken 
 place. Post-mortem examination showed neuritis of the plantar 
 and tibial nerves, but the vessels of the limbs were natural, and 
 the brain, spinal cord, and viscera were also natural. 
 
 The authors of this memoir meet the objection, that in the 
 above case the neuritis might have been consecutive to the 
 gangrenous process by recording the results of an examination 
 of peripheral nerves in a case of gangrene of embolic origin. 
 The nerves in the gangrenous extremities were found to be 
 normal throughout. 
 
 Thus Pitres and Vaillard are inclined to regard the peripheral 
 neuritis in their cases as the cause of the gangrene, and they 
 hold that most of Raynaud's cases of gangrene were of like 
 origin. 
 
 Dr. Wiglesworth has recently recorded a case of very extensive 
 peripheral neuritis in a woman, aged 26, who was the subject of 
 epileptic dementia and of chronic Bright's disease, and who had 
 suffered repeated attacks of spontaneous grangrene of fingers and 
 toes (Path. Trans., 1887, p. 61). 
 
 Hochenegg (Uber Symmetrische Gangran und Locale Asphyxie. 
 Vienna, 1886), whilst admitting the soundness of the conclusions 
 of Pitres and Vaillard on their own cases, disputes the universality 
 of their propositions. He reports a case at considerable length 
 of a man, aged 51, who developed gangrene of the left hand 
 independently of vascular causes. The post-mortem examination 
 
198 APPENDIX BY THE TRANSLATOR. 
 
 showed chronic hydrocephalus and syringomyelia. In regard to 
 the peripheral nerves only a slight degree of atrophy was found, 
 which was held to he secondary to the cord lesion. Hochenegg 
 maintains that the gangrene was caused by the central lesion, 
 but in view of the existence of the nerve changes, slight and 
 non-inflammatory though they were, this conclusion seems 
 hardly satisfactory. 
 
 We must wait for the " last word " which further investigations 
 will justify as to the part played by peripheral neuritis in the 
 final stage of Eaynaud's disease, viz., that of symmetrical gan- 
 grene, and there will still remain the question as to how the 
 peripheral neuritis is itself initiated. But it is safe to assert 
 that peripheral neuritis alone is quite inadequate to explain the 
 early and paroxysmal stages of the affection. For the cases 
 which only become manifest during exposure to cold, and which 
 during the intervals return to absolutely normal conditions, no 
 better explanation is yet forthcoming than Raynaud's hypothesis. 
 
 VII. Treatment. 
 
 In the treatment of the cases which go on to gangrene of the 
 limited form which Raynaud describes, the expectant method 
 which he recommends has been repeatedly justified ; but with 
 deeper involvement of tissues amputation has been performed 
 with advantage as for other forms of spontaneous gangrene. The 
 use of the constant current, as recommended by Raynaud, has 
 been adopted with advantage by several observers in cases of 
 local asphyxia. The method which has been found most satis- 
 factory by the translator in four separate cases has been the 
 following : immerse the extremity of the limb which is the sub- 
 ject of local asphyxia into a large basin containing salt and water ; 
 place one pole of a constant current battery on the upper part of 
 the limb, and the other in the basin, thus converting the salt and 
 water into an electrode. Employ as many elements as the patient 
 can comfortably bear, make and break at frequent intervals so as 
 to get repeated moderate contractions of the limb. In a typical 
 paroxysmal case, if two limbs be similarly affected, it will be 
 found that the limb which is subjected to the above treatment 
 will more rapidly recover than the one which is simply kept 
 warm. It will also generally be found that the patient can 
 
APPENDIX BY THE TEANSLATOE. 199 
 
 tolerate the above mode of stimulation much more readily than 
 he can bear friction with the hand, and that the use of galva- 
 nism in the way indicated, or by simply "painting" with two 
 sponge electrodes, held on the limb at a short distance from each 
 other, will so far diminish the pain that the patient becomes 
 able to bear shampooing afterwards. 
 
 In chronic cases, although the relief is not so obvious, there 
 can be no doubt at times as to the value of this measure in im- 
 proving the nutrition of the limb, and in keeping the threatened 
 gangrene at bay. Even when gangrene in the limited form 
 which Eaynaud describes has supervened, galvanism to the parts 
 above and around may be tried with advantage. 
 
 Shampooing ought certainly to be employed in conjunction 
 with galvanism, especially in the chronic cases in which the 
 extremity of the limb undergoes a degree of atrophy, or in which 
 contractions and fibrous ankyloses take place. Strange as it 
 may seem, the local application of cold is occasionally more com- 
 forting during the painful paroxysms than heat. Dr. Southey 
 found in one of his cases that an ice bag applied over the painful 
 extremity gave considerable relief. 
 
 In addition to diffusible stimulants and the whole category of 
 sedatives, nitrite of amyl has been recommended on theoretical 
 grounds with a view to relax spasm of arterioles. The translator 
 tried it many times, both in a paroxysmal case, and in chronic 
 cases, but with only negative result. 
 
HE ALE ACADEMIA DEI LTNCE1, ROMA (1878—9). 276«A Year. 
 
 ON THE NATURE OF MALARIA. 
 
 MEMOIK BY 
 
 Peofessobs EDWIN KLEBS and C. TOMMASI-CBUDELI. 
 
 RE ALE ACADEMIA DEI L1NCEI (1883-4). 
 
 ON THE 
 
 ALTERATIONS IN THE RED GLOBULES 
 IN MALARIA INFECTION, 
 
 AND 
 
 ON THE ORIGIN OF MELANtEMIA. 
 
 MEMOIR BY 
 
 Pbofessob ETTOEE MAECHIAFAVA and Db. A. CELLI. 
 
 TRANSLATED AND EDITED BY 
 
 EDWARD DRUMMOND, M.D., Rome. 
 
PREFACE. 
 
 The plan which I have adopted in preparing these Memoirs 
 for publication in England has been, first, to make a careful 
 verbatim translation of them ; and, secondly, as the amount of 
 space assigned to me in this volume did not allow of their 
 being published in extenso, to condense and summarize them, 
 which I believe has been accomplished without obscuring the 
 text, or misrepresenting the meaning, of the Authors. 
 
 I have to thank the Authors for their courteous assistance 
 in the study of this subject. 
 
 EDWARD DRUMMOND, M.D. 
 3, Piazza di Spagna, Rome. 
 
CONTENTS. 
 
 PAGE 
 
 Chapter I. — Production of Malaria. Statement of Researches in the Past for 
 
 Determining its Nature 1 
 
 „ II. — Method of Eesearch 16 
 
 „ III. — Researches 21 
 
 Experiments on Rabbits 26 
 
 1st Group — Normal Rabbits 27 
 
 2nd Group — Researches with Infecting Material from the Pontine Marshes 29 
 
 A. Parall el Researches with Mud of Caprolace Lake 29 
 
 B. Parallel Researches with Mud of Caprolace Lake and Samples of 
 
 Air of Ninfa and Eogliano 31 
 
 C. Parallel Researches on the Morbigenous Efficacy of Liquid obtained 
 
 by Filtration of the Cultivation of Samples of Air of Ninfa and 
 
 Fogliano 37 
 
 D. Parallel Researches with Bacillus Malarias cultivated in Open and 
 
 Closed Vessels 39 
 
 3rd GroMp<r-ResearcheB with Samples of Soil of Janiculan 41 
 
 ith Group — Researches with Samples of Soil of Agro Romano 43 
 
 5th Group — Researches with Samples of Soil derived from non-malarious 
 
 places , 48 
 
 6(A Group — Septic Infections Spontaneously Produced 50 
 
 SUPPLEMENTARY NOTES. 
 
 1st. Anatomical Changes observed in Animals in which Malarious Infection 
 
 had been induced 51 
 
 2nd. Bacillus Malarial 52 
 
 3rd. Bacillus Malariaiva Man 55 
 
 On the Alterations in the Red Globulus in Malaria Infection, and 
 
 on the Origin of Melan^mia 59 
 
ON THE NATURE OF MALARIA. 
 
 CHAPTEE I. 
 
 PRODUCTION OF MALARIA. STATEMENT OF EESEAECHES IN THE 
 
 PAST FOB DETERMINING ITS NATUBE. 
 
 Endemic malaria has, in the natural and civil history of man, a 
 higher importance than that of all other endemic diseases to 
 which the human race is subject. The latter are met with in 
 more or less limited regions of the globe, but it is, as yet, 
 impossible to define the geographical boundaries of the produc- 
 tion of malaria. It reaches its highest point in the tropics, but 
 may be very marked in the temperate zones, and is found even 
 in cold climates. In the northern hemisphere it may originate 
 in all latitudes up to 60° N., and some facts observed in Switzer- 
 land by Bergmann tend to show that it may be developed in 
 districts hitherto deemed exempt (the circumstances suggest 
 importation). Hence we cannot at present state what portions 
 of the earth, between the polar circles, may be considered abso- 
 lutely free. In places liable to it, its production is in inverse 
 ratio to the latitude, and the severity of malarious disease aug- 
 ments in like ratio. 
 
 In temperate regions, and still more in the tropics, it may 
 render districts uninhabitable. No other endemic or epidemic is 
 able to do this to the same extent. It constitutes the chief 
 obstacle to the exploration and colonization of the African con- 
 tinent; threatens to reduce to the condition of a desert, vast 
 tracts of the Southern States of America, which were very 
 flourishing so long as they were cultivated by the negro race, 
 which, better than any other, resists its action. In Europe it 
 has desolated whole provinces, populous and flourishing in 
 ancient times. Even where its intensity is not such as to cause 
 
 1 
 
S3 ON THE NATTJRE OF MALAEIA. 
 
 a great annual mortality, it induces a progressive decadence of 
 race, -which no other endemic is capable of. 
 
 The preservation of society from injurious^nfluences so grave 
 is therefore a socio-economic problem of the first order. The 
 statesmen of all civilized nations have, at all times, striven to 
 get rid of or limit it ; and even in semi-civilized Peru, we find 
 water systems, founded and watched by the prudent government 
 of the Incas, in the low lands which skirt the Pacific, in order 
 to increase their fertility and salubrity. In ancient times the 
 Eoman rule was pre-eminently distinguished for the vastness 
 and grandeur of the works undertaken to vanquish this public 
 enemy, and such were regarded as among the chief titles of the 
 rulers to honourable recognition by the people. Even in modern 
 times, one of the governments most eminent for civil wisdom 
 and sagacity — that of the two last Grand Dukes of Tuscany — 
 owed its chief claim to renown to the works completed or begun 
 to render salubrious vast malaria-desolated lands. Italy, where 
 malaria has made uninhabitable a great extent of country (chiefly 
 on the western slopes of the Apennines, in Sicily, and in Sar- 
 dinia), has set herself, since 1870, to the radical solution of this 
 problem, as a great political question. The capital is situated 
 in the centre of one of the most insalubrious regions of the 
 temperate zone, and the soil on which it is built is capable, in 
 the hot season, of originating malaria. 
 
 ■ The unhealthiness of this season has become greatly less in 
 many parts of the city, owing to the great works of drainage, 
 street construction, &c, carried out during the last nine years, 
 but it exercises, nevertheless, an injurious influence on the 
 development of the city and the public life concentrated there. 
 These conditions of the capital have stimulated research directed 
 to discover the origin of malaria foci and the means best suited 
 to limit and extinguish it. 
 
 All our knowledge of malarious diseases proves that their true 
 causes must be sought for in the soil of the places chiefly 
 affected, and that the poison, produced in the soil, may be raised 
 to different altitudes by ascending currents of air. In marshy 
 lands its production is nil or very slight, even when the tempe- 
 rature is very high, so long as the marsh bottom is separated from 
 the air by a sufficient layer of water. It grows -gradually during 
 tho hot season, as the evaporation diminishes this water, and 
 
PRODUCTION OF MALARIA. 3 
 
 attains its maximum when a great part of the marsh is uncovered 
 or only separated from the atmosphere by a thin covering of 
 water. There then arises a great quantity of poison which has 
 come to be called by many, even now, marsh miasm. 
 
 This term ought to be abandoned, because malaria is not 
 developed in all marshy places, and may be abundantly generated 
 in lands which were never marshy. Its production . in non- 
 marshy lands was supposed to be due to a special chemical and 
 geological constitution — a view chiefly maintained by Heyne and 
 Kirke, but it is untenable. 
 
 It originates in soils of very different composition, whilst soils 
 of the same composition, and placed under the same physical 
 conditions, sometimes do, and sometimes do not, produce it. 
 This shows that its development is not bound up with any special 
 chemical composition of the soil, but is insufficient to exclude 
 that, other things being equal, its development may be, more or 
 less, influenced by some chemical quality in the soil. It is not 
 improbable, though it is not proved, that judicious cultivation 
 may so modify the chemical composition of the soil as to 
 diminish its aptitude for originating malaria. 
 
 Moreover, the experiments made by Lanzi and Terrigi in 
 1873,* and repeated by them on a large scale in successive years 
 during the works at the Colosseum,t render it Very probable that 
 the addition of lime and its soluble salts to some malaria-pro- 
 ducing soils diminishes or suspends this production. It is desir- 
 able that such experiments should be made in all malarious soils. 
 
 Hygienic researches have hitherto been directed to the physical 
 conditions which favour malaria production in non-marshy lands. 
 All these contain a notable quantity of water in the rainy season, 
 either from their low level or the slight permeability of the 
 subsoil which underlies them. During the hot season this pro- 
 duction may take place in the upper strata of the soil when these 
 remain sufficiently damp, as happens in malarious lands covered 
 with woods. If, on the other hand, the ground is uncovered, 
 the summer evaporation may entirely dry the superficial, but 
 does not ordinarily go on to the exhaustion of the lower, strata, 
 which may preserve a remarkable degree of humidity till the 
 return of the next wet season. 
 
 * Trans. 11th Congress of Ital. Scient. : Rome, 1873. 
 t Trans. Academy of Medicine : Rome, 1879. 
 
4 ON THE NATURE OF MALARIA. 
 
 Malaria cannot originate in these superficial strata, remaining 
 dry, but does so in the wet underlying ones, whenever the air is 
 able to gain access to them through fissures or the porosity of 
 surface soil, or when excavations lay them bare. 
 
 In low lands these subterranean foci are sometimes formed by 
 the old marsh bottoms covered by natural or artificial colmate * 
 (such as, for example, the cuoraf of many places on the coast or 
 Tuscan Maremma, and the subsoil of most of the Val di Chiana). 
 The subterranean marshes are harmless even when they remain 
 wet during the hot season, if the soil of the colm&ta covering 
 them is deep and sufficiently compact. On the other hand, they 
 generate malaria when only separated from the air by a thin 
 stratum of disintegrated soil, % or when the air can reach them 
 owing to excavations or fissures in the overlying soil. 
 
 Often, however, subterranean foci have no marsh origin, are 
 poor in organic detritus, and are found at high altitudes of 
 mountains. The preservation of humidity in lower strata of this 
 sort of soil is chiefly due to the sparing permeability of their 
 subsoil and the irregular inclination of its surface impeding the 
 escape of water. Such are frequent in Italy, and especially in 
 the Reman Campagna and City of Eome, as may be seen by 
 examining a section plan of the aquiferous zone from the Jani- 
 culan to the Porta S. Lorenzo past .the Pantheon. In such 
 soils malaria is not generated unless the access of air to them is 
 brought about by excavations and other such means. Other 
 hypotheses have been started unconnected with these conditions 
 of soil, and have become sometimes popular traditions. One of 
 the most common is that which attributes to forests the power 
 of generating malaria from the decomposition of the leaves and 
 dead branches which strew the ground. This has been suggested 
 by the existence of many forests in Europe, Africa, India, &c, 
 &c, in which malaria attains great proportions ; and because 
 disafforesting has had the effect of rendering many such districts 
 salubrious. 
 
 Even in the Pontine marshes an analogous fact was witnessed 
 after the clearing made twenty years ago in the great wood 
 
 » Colmata, embankment, levelling up of hollow places with earth, r 
 
 f Cuora, equivalent to bog or turf ; the carbonized black ooze of marshes resulting 
 
 from the decay of successive generations of organic materials ; a term alto used for 
 
 marsh conduits. 
 J Dr. G. Lindi, Paper read before th,e Medical Congress at Arezzo, July 10 1877. 
 
PRODUCTION OF MALARIA. 
 
 which surrounds the Cisterna country on the south. This wood 
 is that of which Lancisi prevented the felling in 1714, being 
 persuaded that woods ameliorated the air of marshes, and in this 
 case protected Cisterna from the south wind which he believed 
 conveyed the malaria. 
 
 On the contrary, the destruction of this great wood has pro- 
 cured for Cisterna a marked increase of salubrity and population.* 
 In spite of this, the explanation is fallacious. The existence of 
 decomposing vegetable detritus in a forest is not sufficient of 
 itself to cause malaria, as we see in other parts of the globe vast 
 forests, containing such detritus, which are, notwithstanding, 
 salubrious, as, for example, some virgin forests of South America. 
 It is, however, certain that when woods cover malarious lands, 
 they may favour its production, especially if situated at a level 
 which hinders the outflow of water. 
 
 The wood, intercepting the sun's rays, impedes evaporation 
 and allows the malarious soil to retain much moisture during the 
 hot season, even in the strata most exposed to the action of the 
 atmosphere. 
 
 This obstacle being removed, the consequent summer de- 
 siccation markedly diminishes the malaria production, and if the 
 soil be not deep may go so far as to arrest it. One can under- 
 stand, therefore, how disafforesting alone may increase the salu- 
 brity of such places, and how, on the other hand, in deep soils, 
 it cannot arrest malaria without the help of such drainage as 
 may exhaust the water of lower strata which the sun's rays are 
 not able to dry. 
 
 It is the opinion of many that malaria may be generated by 
 the decomposition of low organisms, animal and vegetable, which 
 die in large numbers when sea water is mixed with fresh water, 
 collected in its vicinity. This opinion is based on the coinci- 
 dence that in some parts of the Italian coasts where fresh water 
 ponds are only separated from the sea by dunes, intermittent 
 fevers occur. 
 
 This has, however, only been met with where the surrounding 
 lands are malarious ; or were so formerly, and appear still capable 
 of becoming such again, whenever the old marsh cuora which 
 they contain are placed, in summer, under favourable conditions 
 
 * Lancisi, Unedited Addresses ore the Catting of the Woods of Cisterna and 
 Semoneta. 
 
O ON THE NATURE OF MALABIA. 
 
 of moisture and exposure to atmospheric air. Besides, this 
 coincidence is not observed except in seasons abundantly ma- 
 larious. At other seasons of the year this mixture occurs so as 
 to determine the death of a very great quantity of animal and 
 vegetable organisms, rendering turbid and foetid the waters of 
 these coast lakes {e.g., Burano, Fogliano, dei Monaci, Caprolace), 
 without, fever showing itself even amongst those who spend whole 
 days in fishing and shooting on them. If, then, the lands 
 adjoining be not malarious, the mixture of salt and fresh water 
 may assume vast proportions without the malaria appearing, as 
 is seen in large littoral lakes of the Baltic (Frisches Haff and 
 Curisches Haff), which do not generate malaria, while it is pro- 
 duced in localities identical as to latitude and climate (Jahde- 
 busen and Wilhelmshafen), which, however — a difference of the 
 first importance — are surrounded by malarious lands. 
 
 If, therefore, we have not sufficient evidence to exclude that 
 this mixture may aggravate the unhealthiness of a place, we have 
 enough to show that it cannot, of itself, generate malaria in a 
 healthy locality. The same holds true of the opinion that 
 steeping hemp and flax may evolve malaria. Such become 
 offensive from the putrid effluvia they give off, and from contami- 
 nating drinking water, but they do not cause malaria. 
 
 Such macerations are largely practised in districts which are 
 not malarious and do not originate fevers in them. This does 
 not prevent the possibility that, when practised in malarious 
 localities, they may aggravate the evil, if in no other way, by the 
 excavations necessary in making the tanks, by which air may be 
 admitted to otherwise harmless infection foci. Certainly every 
 reason of prudence counsels the removal of all concomitant causes 
 of unhealthiness, that nothing tending to amelioration may be 
 left untried. But the essential aim of the latter is that of 
 modifying the true seats of production — viz., the malarious lands 
 — in such a way as to take from them the possibility of offering a 
 field for the development of malaria. 
 
 Experience has shown that this cannot take place without a 
 combination of three factors : 
 
 1. A very high temperature. 
 
 2. A persistent humidity of the soil. 
 
 3. The access of air to the moist strata of the soil. 
 When one of these is eliminated development of malaria cancot 
 
PRODUCTION OF MALARIA. / 
 
 take place. Even in malarious districts left to themselves, it 
 sometimes happens that, if the mean summer temperature be 
 very high and no rain falls, the production of the poison is 
 arrested, because evaporation from the soil exhausts all the 
 moisture it contains. The occurrence of rain will, however, 
 determine its development in a few hours. So, also, if the 
 summer mean is very low malaria is not developed, or is confined 
 within narrow limits, but it recovers all its force in a very short 
 period if the temperature of the air is raised. The chief aim of 
 works of amelioration up to the present time has been to effect 
 the removal of one of these factors by drying malarious soils. 
 The necessary hydraulic works have varied according to the 
 quality and level of these. 
 
 In low-lying lands, to prevent the stagnation of water in the 
 soil and subsoil, the system of open channels has been adopted, 
 in order to secure at all seasons of the year the escape of water. 
 When the land has a level equal, or nearly equal, to that of the 
 sea or natural collectors of the district, this system has been 
 combined with pumping machines, or with the system of colmate, 
 wherever it is possible to introduce watercourses rich in sus- 
 pended soil to the lands to be ameliorated. The rise of level 
 procured by the colmate has the twofold advantage of draining 
 the soil and burying that part of it in which the malaria origi- 
 nates, so that, when successful, this secures the removal of two 
 of the factors. 
 
 In lands situated at higher levels, measures have been adopted 
 according to the conditions present — open canals, great collecting 
 pipes, superficial drainage by open canals and earthen pipes, and 
 even drains constructed at a remarkable depth. The most 
 beautiful examples of these last are afforded by the cunicular 
 drains, met with in the Eoman hills and Agro Romano, where, 
 according to Lanciani, this system reached its highest develop- 
 ment in the imperial epoch.* 
 
 These methods remove one or two of the external conditions 
 indispensable to malaria production, but do not destroy that 
 special tendency of malarious lands which constitutes the essen- 
 tial difference between them and those which, identical as to 
 chemical composition and surrounding conditions, are incapable 
 
 * Lanciani, Some Works of Amelioration of the Agro Romano, executed by the 
 Ancients. Also Secchi, di Tucei and others. 
 
b ON THE NATURE OF MALARIA. 
 
 of originating this poison. The cause is simply reduced to 
 impotence; but examples are not rare in which, after this has 
 happened, the development has recommenced and attained large 
 proportions when the external conditions, which had been 
 banished, were reproduced. In a district long free from malaria, 
 neglect of the water scheme, inundations, or superabundance of 
 rain, or accidental opening up to the air of some of the old foci, 
 suffices to start the malaria again. 
 
 The conversion of the Crown domains of the Val di Chiana 
 into private property has led, in a great part of the valley, to 
 neglect of the hydraulic works, allowing a return to the former 
 state, and consequent reappearance of malaria in many places 
 in which there had long been no trace of it. 
 
 It is this which has happened in the Agro Komano, which in 
 the imperial epoch had been rendered so healthy as to permit of 
 a summer residence in villas situated in spots now regarded as 
 amongst the most insalubrious in the temperate zone, showing 
 that not even centuries of exemption can ensure that the cause 
 has been got rid of, beyond the possibility of recurrence. This 
 remarkable tendency of malarious lands has stimulated research 
 as to the nature of the agent that produces this effect, in the 
 hope that, this being once known, means might be discovered of 
 destroying it and rendering its development impossible, and thus 
 obtaining a lasting and secure amelioration. The first researches 
 were directed to the examination of the gases diffused in the soil 
 for one capable of generating it, but with only negative results. 
 Again, the supposition that some volatile product of animal or 
 vegetable decomposition might be the cause has not been borne 
 out by facts. 
 
 It has never been shown that the mud and air of marshes 
 contain an inorganic substance capable of developing, without 
 the intervention of any other substance, malarious fever. 
 
 Moreover, its production, even in marshy lands, is sometimes 
 wanting, although animal and vegetable organisms undergo 
 putrefaction as actively as in those which are malarious ; while, 
 on the other hand, malaria may develop in non-marshy lands in 
 which such putrefaction does not occur. 
 
 The want of exact correspondence between the quality of the 
 soil and the production of malaria has led some to suppose that 
 such may not be due to a specific cause, but rather the result of 
 
PRODUCTION OF MALARIA. 9 
 
 sudden or very rapid lowering of temperature, rendered more 
 injurious by the marked humidity generally found in malarious 
 countries. This opinion has been adopted by even distinguished 
 observers like Santarelli,* and sustained recently by Oldham, t 
 Here the essence of the disease has clearly been confounded with 
 a frequent, but not invariable, cause, determining development. 
 
 Undoubtedly many persons, so long as they use every precau- 
 tion against chill, live with impunity in malarious countries, but 
 are seized with an attack if they leave off such precaution, and 
 this even after having left the malarious district. 
 
 The same holds good of cholera and other like diseases, and 
 is easily explained by the disturbances of the circulation which 
 chilling brings about in vascular areas, which allow the disease- 
 ferment, already in the system, to fix itself in some part of the 
 body and there display its evil influence. Besides, malarious 
 fevers may arise without the intervention of this cause, as one 
 may easily satisfy himself, especially in places where the graver 
 forms of malaria prevail. On the other hand, in non-malarious 
 countries, this cause (chilling), however severe it may be, never 
 originates a malarious fever. 
 
 The same reason — viz., the inconstancy of the relation between 
 condition of soil and malaria production — which has led some to 
 reject the idea of a specific cause of infection, has suggested to 
 others that malaria may be due to a parasitic organism which 
 requires for its development not only favourable external condi- 
 tions, but also the presence of a germ capable of giving rise 
 to it. 
 
 Various reasons tell in favour of this hypothesis ; among 
 others, certain analogies which are common to malaria and other 
 known parasitic infections, and the augmented production of the 
 former when left to itself. When man's industry ceases to 
 remove the external favouring conditions of malarious produc- 
 tion, this assumes such vast proportions as are inconceivable 
 without the existence of an organism capable, when its evolution 
 is no longer checked, of infinite multiplication. This enormous 
 increase is historically proved, especially in Italy. 
 
 The Tuscan and Roman Maremma, the Eoman Campagna, 
 Pesto, Selinute, had malaria in ancient times, but were inhabited 
 by numerous and prosperous populations ; now they are hardly 
 
 * Santarelli, Researches, f Oldham. 
 
10 ON . THE NATURE OF MALARIA. 
 
 habitable except where man's industry has again been applied to 
 remove the conditions on which malaria depends. 
 
 The conception of a living organism which, finding no check 
 to its development, has the power of extension by an infinite 
 number of progressively increasing generations, seems to fit best 
 the magnitude of the phenomena. 
 
 The diffusion of malaria, in the air overlying lands which pro- 
 duce it, furnishes some arguments in support of the hypothesis 
 that it is due to the agency of solid particles. 
 
 The first hours of morning, and still more of evening, are the 
 most perilous to those who breathe this air ; besides, experience 
 has shown that the cause to which this insalubrity is due is often 
 confined to the lower strata of the air, and at a few metres from 
 the ground ceases or notably diminishes. In the Pontine 
 marshes, whilst the effect of sleeping during a summer night, so 
 as to breathe the air nearest the ground, would inevitably cause 
 an attack of perniciosa, people sleep with impunity on a platform 
 raised on piles a few metres from the ground. In South America 
 people similarly circumstanced preserve themselves by sleeping 
 in hammocks suspended from the trees. This is explicable on 
 the supposition that malaria is due to solid particles of slight 
 specific gravity contained in the soil, and raised to a certain alti- 
 tude during those hours in which the difference of temperature, 
 in the lower strata of air and in the soil, causes an upward cur- 
 rent ; and that this does not happen, or only in a minor degree, 
 when the two temperatures are almost equal. Were the agent a 
 gaseous one due to chemical action, it should be at its acme in 
 the day hours, when the soil is most heated by the sun's rays. 
 
 Not less does the hypothesis that malaria may be due to a 
 volatile substance united with watery vapour, raised with it in 
 the atmosphere during the day and reconducted back to the 
 earth at sunset, afford an explanation of that immunity which is 
 enjoyed at a few metres from the soil. 
 
 Lastly, the mists which form at evening in malarious places, 
 and which are often fcetid, from the products of putrefaction they 
 contain, are not confined to the strata nearest the ground. 
 
 They may be very thick even at high altitudes, so that in the 
 plains and valleys they appear, in the early dawn, when the sun 
 has not yet appeared above the horizon, like a sea which covers 
 and conceals all, even the church towers. 
 
PRODUCTION OP MALAEIA. 11 
 
 These considerations, therefore, if they give some probability 
 to the hypothesis of the parasitic origin of malaria, are certainly 
 insufficient to convert it into a scientific theory. 
 
 In addition to this it is necessary to show — 1st. The constant 
 presence of a determinate organic species in the various hinds of 
 malarious soils and in the air which overlies the same. 2nd. 
 That this organic species can alone — viz., without the interven- 
 tion of any other morbific agent — generate a true specific inter- 
 mittent fever. 
 
 This double demonstration, indispensable to the theory, has 
 not yet been obtained, although for thirteen years researches have 
 been instituted with this object. 
 
 In 1866 Salisbury believed he had discovered the cause of 
 malaria in an alga of the genus Palmella, which he had found in 
 certain marshes in Ohio.* 
 
 He maintained that the spores of this alga, diffused in the air 
 and penetrating within the human organism, produced malaria. 
 In support of this opinion he adduced the fact, that having 
 placed some boxes of earth containing this alga on the window- 
 sill of the room in which slept two young men with the window 
 open, both took intermittent fever in fourteen days. Their 
 dwelling was five miles from the spots whence the earth was 
 taken, but it was not certain that they might not have visited 
 these places and others equally unhealthy. 
 
 But granted that the fever in these two persons was due to 
 the earth contained in the boxes, one such experiment was insuf- 
 ficient to prove that it was due to the Palmella gemiasma of 
 Salisbury, and not to other organisms contained in the same. 
 
 Later, this Palmella gemiasma has been found in very healthy 
 places, and even on the Alps, and Lanzi and Terrigi have seldom 
 found it in the stagnant waters of the Campagna, and have never 
 met with its spores in the air of the most malarious places 
 examined by them. 
 
 In 1869 Dr. P. Balestra described an alga found by him in the 
 Pontine marshes and in those of Ostia and Maccarese, which he 
 held was the cause of malaria. He described neither its genus 
 nor species ; however, Lanzi and Terrigi decided to regard it as 
 Cladophora or CEdogoniumj which abound in these places. In 
 a later edition (1877) Dr. Balestra, without yet determining the 
 
 * American Journal of Medical Sciences, 1866. 
 
12 ON THE NATUKE OF MALAKIA. 
 
 plant, still less stating its exact dimensions, gave two figures of 
 it entitled Alga miasmatica, so shapeless that one cannot tell 
 what it was meant for — an alga, a fungus, or some other 
 organism. 
 
 The experiments made by Balestra to prove that the plant 
 studied by him was febrigenous do not avail to prove it. He 
 treated some fluids containing it with quinine, arsenious acid, 
 and sulphite of soda in solution, and found that they, especially 
 the quinine, arrested its growth and altered its structure. 
 
 It is insufficient to establish such relation between this plant 
 and quinine, as Binz proved long ago that the latter kills a large 
 number of animal and vegetable organisms which certainly have 
 no influence on malaria. In Balestra's experiments the quinine 
 also killed all the infusoria and suppressed putrefaction for a 
 very long time. This author has not sought to show the specific 
 action of this plant by isolating it and procuring intermittent 
 fever by introducing it into the organism. The only evidence of 
 this kind adduced by him is that he was himself seized with 
 intermittent fever, eight hours after having accidentally drunk 
 from a carafe containing marsh mud, on the surface of which a 
 stratum of this plant had formed. When we remember that this 
 happened when he was working during the height of summer in 
 Borne, and making excursions to the Pontine marshes, Ostia, 
 and Maccarese to collect material for study, we cannot but think 
 that the fever might have had another origin ; and however 
 ready to admit that it was due to the contents of the carafe, there 
 is no proof that the cause was this particular plant, and not an 
 inorganic substance or one of the numerous other organisms 
 contained in marsh mud. His drawings show this variety of 
 organisms, and along with sporules of this alga, many others 
 besides — small granules like micrococci of Schistomycetes, and 
 also larger bodies and filaments like the germs of Hyphomycetes. 
 Probably the author did not attach any importance to these, as 
 he still believes in the polymorphism of Hallier, and holds that 
 these organisms may pass from the one form to the other without 
 change of nature ; but now for many years the works of De Bary, 
 F. Cohn, Naegeli and others have shown the insufficiency of this 
 convenient hypothesis. It is to be noticed finally tliat Balestra 
 does not appear to have found the plant he believed to be febri- 
 genous in the non-marshy malarious lands of this province. 
 
PRODUCTION OF MALAKIA. 13 
 
 Safford and Bartlett believed they had discovered the cause of 
 malaria in Hydrogastrum granulatum, Archer in Chtonobldstus 
 aeruginosus, and Bargellini in Palmoglea, micrococca, simply 
 because each had found in abundance the plant which arrested 
 his attention in the marshy soil taken for examination ; but these 
 three are found abundantly in all soils rich in moisture, while 
 Lanzi and Terrigi have rarely met with them in the soil of the 
 Roman Campagna; besides, these authors observe that the spores 
 of the Hydrogastrum g. and Chtonoblastus a. are of larger dia- 
 meter than the capillaries, and it is therefore impossible for them 
 to enter the circulation and cause fever. 
 
 Griffini, in 1873, performed experiments on dogs and rabbits 
 with dew collected on the marshes and rice-fields. 
 
 This dew contained a bacteria, vibriones, some filaments of 
 leptothrix, some spirillum, and many infusoria of the genera 
 Monas and Cercomonas. 
 
 Injecting it in quantities from 75 — 100 cc. into the veins of 
 dogs, he obtained after the first injection augmentations of tem- 
 perature of 0°*6 — 1°"5 C, which lasted a short time and gradually 
 passed away. 
 
 The injection of 100 cc. of water from a rice-field, taken 
 July 16th, into the jugular vein of a dog, produced a temporary 
 rise of 0°"6 C, whilst the injection of 96 cc. into the jugular vein 
 of another dog produced a rise of 0°'5, which lasted three hours 
 and then passed away. In rabbits the injection of dew into the 
 jugular (8 — 10 cc.) caused the death of the animals after 5 — 12 
 hours, without notable rise of temperature. A rabbit, under the 
 skin of which 2 cc. of the same dew was injected, died in 28 hours 
 without having shown any rise, but, on the contrary, a progressive 
 fall, of temperature. A rabbit which was made to swallow 
 20 grammes of dew, and had 5 grammes more injected per rec- 
 tum, showed from the beginning a rise of o, 6, but afterwards 
 the temperature fell 2 0, 5 C. On the second day it died. In none 
 of these animals in which the injection produced a rise of tempe- 
 rature did there follow a second access of fever, and the measure- 
 ments were too few to determine the type of fever. The spleens 
 were normal, but do not appear to have been examined micro- 
 scopically. The blood showed no increase of the organisms 
 contained in the dew. 
 
 Drs. Lanzi and Terrigi, of Rome, applied themselves to the 
 
14 ON THE NATUKE OP MALARIA. 
 
 study of the subject in 1870, and communicated the results of 
 their first observations to the Medical Section of the 11th Con- 
 gresB of Italian Scientists, October 19th, 1873. 
 
 At that time Dr. Matteo Lanzi 'had by a series of artificial 
 cultivations, instituted with mud collected in certain malarious 
 spots in the City of Eome, and the salt marshes of Ostia and the 
 Pontine marshes, obtained the specimen called Monilia penicel- 
 lata, Fr. (Briarea elegans, Corda), and was disposed to consider 
 it the cause of malaria. Later on, however, continuing his 
 researches with the conscientious assiduity which characterizes 
 him, he obtained so many organic species as did not permit him 
 to retain his first opinion, so that he and his colleague Terrigi, 
 fearing to be misled by fallacious appearances, abandoned the 
 parasitic theory of malaria which they had sustained in 1873, 
 and admitted instead that malaria consisted in a cadaveric vege- 
 table product generated by putrefaction of algae and other plants. 
 They undertook, therefore; new experiments with mud from the 
 marshes of Ostia. The hypodermic injection of dogs during 
 winter with Ostia mud (collected during the previous summer) 
 gave rise only to passing disturbances, and in the bodies of the 
 animals no post-mortem evidence of malaria was found. The 
 simultaneous injection of guinea-pigs with the same material 
 produced some ill-defined morbid states, and in one of the animals 
 was found, in the spleen and liver, some black pigment. The 
 temperature does not seem to have been taken in the first experi- 
 ments. The experiments were repeated in the height of summer 
 with mud (August) from the Stagni of Ostia. This was injected 
 hypodermically into two animals — the observers having first ascer- 
 tained by a few autopsies on healthy guinea-pigs that the blood 
 contained no organisms and the spleen and liver no black pigment. 
 
 The first of the two died in 57 hours, after a rise of temperature 
 which reached 40° C, and then fell to 34° and ultimately to 
 31° C. (axilla). Autopsy. — Many bacteria at injection site, spleen 
 and liver enlarged, and containing small quantity of black pig- 
 ment ; a few granules also in the blood of the portal vein. 
 
 The second animal died on the thirty-second day ; maximum 
 temperature, 38° C. ; minimum, 37° C. An abscess, which 
 opened spontaneously on the twenty-second day, formed at the site 
 of injection. Autopsy. — Spleen and liver enlarged. Granules of 
 pigment in the spleen and blood of the portal vein. The same 
 
PRODUCTION OF MALARIA. 15 
 
 results, with the sole difference of greater amount of pigment, were 
 found in guinea-pigs made to breathe for many hours, in a confined 
 atmosphere, the effluvia from Ostia mud, and in the case of one 
 to breathe like effluvia from decaying grasses collected in August 
 outside the Lateran gate. Parallel to each of these experiments 
 another guinea-pig was kept in an equally confined atmosphere 
 containing no effluvia for a like number of hours. None of the 
 animals, in this counter-experiment, showed any signs of patho- 
 logical disturbances. Each was killed at the same moment as 
 the corresponding animal experimented on, and no trace was 
 found of the alterations met with in those which breathed infected 
 effluvia. Lanzi and Terrigi* have the merit of having used a 
 more rigorous method than any of their predecessors, and of 
 having taken the first step towards the solution of the problem ; 
 and the discovery of black pigment shows that they first succeeded 
 in procuring malarious infection in animals. As, however, they 
 did not examine the splenic swelling, ascertain the proportionate 
 weight of the spleen to the entire body, or make sufficient ther- 
 mometric observations to determine the type of fever, the 
 observations are inadequate. Nor did they ascertain if the black 
 pigment contained iron in inorganic combination, which distin- 
 guishes the melancemic pigment of malaria from other black 
 pigments (melanin). 
 
 It is therefore uncertain whether the fevers were really ma- 
 larious or were produced by septic infection, all the more as the 
 materials used were rich in putrefying organic matter. 
 
 As regards the nature of malaria, these talented observers have 
 only expressed the opinion that its cause is a, cadaveric vegetable 
 poison — a non-living ferment — but they have adduced no proof, 
 direct or indirect, in support of their opinion; they have not 
 isolated the substance and shown that it can generate malaria ; 
 nor were they certain before commencing the experiments that all 
 the organisms were dead. 
 
 After the meeting of naturalists at Cassel, September, 1878, 
 we undertook the study of this question in the Roman Campagna 
 in the spring of the following year, and one of us (Tommasi- 
 Crudeli) set himself to study and define the foci of malaria in the 
 extent of the Agro Eomano in the course of the winter. 
 
 * Lanzi and Terrigi " On "Vegetable Miasm, Malaria, and the Climate of Rome," 
 Acad. Med., Rome, 1876, 
 
1G 
 
 CHAPTEE II. 
 
 METHOD OF BESEARCH. 
 
 To achieve the aim of our researches, it was necessary that they 
 should take into account all existing opinions respecting mycotic, 
 and the special peculiarities of malarious, disease ; and that these 
 should be dealt with by such rigorous method as should enable 
 us to avoid the petitio principii into which some of our pre- 
 decessors had been led. We had to decide what symptoms and 
 morbid appearances should be regarded as characteristic and 
 establishing the identity of malarious disease artificially pro- 
 v duced. This presented little difficulty, as regular intermittency 
 of febrile attacks, enlargement of the spleen, and the special 
 anatomical characters of malarious splenic hyperplasia are amply 
 sufficient for the purpose. 
 
 Omitting the so-called " larval forms," we have to consider the 
 febrile states of continuous course which are seen alone or in 
 combination or alternation with the more regular intermittent 
 forms, such as the form of malarious fever seen in Italy, to which 
 has been given somewhat loosely the term " Eoman fever." Such 
 differ so materially in their clinical aspects from ordinary inter- 
 mittents, that some have believed them to be non-malarious, 
 an opinion long since refuted by clinical experience, or as due 
 simply to chill, of which the fallacy was shown in the last 
 chapter. 
 
 The opinion that malarious is convertible into typhoid fever is 
 one of which no proof has been adduced, and while it is most 
 improbable that one disease should be converted into another, it 
 is not improbable that the two may sometimes be united and run 
 parallel in the same individual, although this has not yet been 
 demonstrated by an autopsy. 
 
 That an intermittent may be converted into a continuous or 
 subcontinuous malaria fever, a fact long known in human patho- 
 logy, has been shown, by our experiments, to happen in the 
 
METHOD OF RESEARCH. 17 
 
 artificial malaria of animals.* A priori, artificial production of 
 malaria in the latter would seem unlikely, as in malarious dis- 
 tricts most deadly to man they appear to enjoy a perfect immunity; 
 and certain diseases and poisons which attack man seem not to 
 affect animals, and -vice versd. 
 
 Experimental pathology has Bhown, however, that such im- 
 munity is more relative than absolute; and the tubercular and 
 diphtheritic infection have been produced in animals, while one 
 of us (Klebs) has shown that syphilis may be communicated to 
 monkeys. 
 
 Contrasting the unhappy condition of man in, for example, the 
 Pontine marshes, with the thriving state of thousands of mam- 
 mals, there exposed much more completely to malarious infections, 
 it is difficult to explain the immunity of the latter. 
 
 The rule, however, seems to have its exceptions, as certain 
 breeds of horses introduced into the Campagna are said to suffer 
 from enlarged spleens ; and flocks of goats are said to be deci- 
 mated in such localities by disease attended with splenic enlarge- 
 ment. Some part of the immunity of animals may be due to 
 acclimatization, just as the negro race resists as no other can the 
 malarious poison, and thrives in tropical lands uninhabitable by 
 the less resistant white races. This may in part be the outcome 
 of natural selection in the hereditary struggle against malaria 
 aggression, and in the long course of centuries animals may 
 acquire a power of resistance to malaria so long as it only reaches 
 them through accustomed channels. The greater extent and 
 tortuosity of the nasal respiratory passages, and the necessity for 
 air laden with malaria germs to traverse such an extent of moist 
 membrane, may, in animals, place .them at an advantage in com- 
 parison with man, whose respiration, unlike theirs, is chiefly 
 buccal. Experiments might settle this question, but it only falls 
 within our design to secure the introduction, into the circulation, 
 of malaria poison, and to observe if a true malaria fever results. 
 We confined ourselves to the subcutaneous injection of the sus- 
 pected material, and obtained the positive results set forth in the 
 next chapter. 
 
 In order to judge of the precise nature of the fever so origi- 
 
 * My experience coincides with that of Sir Joseph Jfayrer and others, that a fever, 
 clinically indistinguishable from typhoid, arises in malarious countries, from a cause 
 other than fcecal emanations. — E, D. 
 
 2 
 
18 ON THE NATTJEE OF MALARIA. 
 
 nated it is necessary that the temperature should be taken very 
 accurately and often. We, in our experiments, had it taken 
 every two hours from 6 a.m. to 10 p.m., and sometimes also at 
 midnight, at first using a maximum centigrade (Geissler), and 
 when this was broken, a good Eoman one — both by a curious 
 coincidence, indicate an error of — 0°'l, as ascertained by our 
 colleague Cannizzaro. In our tables and temperature curves this 
 error requires to be corrected. 
 
 The weight of the animals was carefully ascertained before 
 commencing the experiments and during their course. At the 
 beginning of malarious fevers, especially the intermittent, there 
 is slight increase of weight ; but later on, and particularly in the 
 continuous forms, there is loss, and often rapid loss, of weight. 
 This point is of very great importance. 
 
 In malarious infection naturally occurring in man and arti- 
 ficially produced in animals there is enlargement of the spleen, 
 from hyperplastic tumefaction, with uniform increase of all its 
 dimensions without loss of sharpness in its angles and borders. 
 In septicemic enlargement the organ is uniformly rounded and 
 altered in sectional outline. The method which we adopted to 
 record the size of the spleen was a species of " nature printing." 
 The convex surface of the spleen was smeared with blood and 
 applied to sized paper to obtain an accurate print ; afterwards the 
 transverse section was so taken. In this way we obtained the 
 figures in Table I. 
 
 Another characteristic of malarious affection is the production 
 of black pigment of hsemic origin, which is not only found in 
 perniciosa, but in milder and more chronic intermittents. In 
 severe forms it is produced in great abundance, and is met with 
 in the blood, spleen, and bone marrow. Unlike melanin, it con- 
 tains iron in inorganic combination, and treated with hydrochloric 
 acid and ferrocyanide of potassium produces Prussian blue. Its 
 derivation direct from the blood is now ascertained. No like 
 change of haemoglobin during life is met with in any other 
 disease (with the exception perhaps of Melanosarcoma), and its 
 presence is therefore a sure evidence of naturally or artificially 
 produced malaria. 
 
 Once satisfied of the identity of maladies artificially produced 
 in animals by the injection of a crude material with those result- 
 ing from spontaneous malarious infection in man, it becomes 
 
METHOD OF EESEABCH. 19 
 
 necessary to separate from this material the true excitor of 
 disease. Assuming that this infection, like some others of which 
 the etiology is now well known, may be due to animal parasites, 
 its isolation becomes possible. In this material it is presumable 
 that, besides the true excitors of the disease, there are other 
 substances which do not contribute to this result. There may 
 be living organisms or inorganic matter. 
 
 We are not concerned with the latter, whose development 
 should encounter more difficulty as conditions are supplied 
 favouring the growth of the former. We know the three condi- 
 tions (Chapter I.) experience has shown to be indispensable to 
 malaria development. We reproduced these conditions in the 
 following way. In a large well-ventilated air bath were placed 
 on wooden shelves, above a layer of sand heated by gas, some 
 large flat capsules of porcelain. Some of these were filled to the 
 height of 5 cm. with earth kept constantly wet. Others contained 
 a layer of water, renewed as it evaporated, and within which were 
 placed some small tin boxes full of earth. The sides of these 
 were perforated a little way from the bottom, so as to allow the 
 water to penetrate and keep constantly moist the lower strata of 
 the earth. Thermometers were placed so as to show the tem- 
 perature of the air and earth, and during the entire day a 
 temperature of 30° — 35° C. was kept up. In the evening the 
 gas was extinguished, and the air bath and earth in the boxes 
 remained at the same temperature as the air of the laboratory. 
 
 In this way we reproduced, in these artificial marshes, similar 
 to those of the Campagna, all the conditions of temperature, 
 moisture, and access of air which are found in malarious lands at 
 the time of their greatest activity. 
 
 The most notable result was that almost immediately a large 
 number of the organisms in the earth ' and mud died. The 
 development of diatoms and desmideae and also of hypomycetse 
 was suspended. Moulds ceased to form on the surface of the 
 earth and vases, the phenomena of putrefaction were arrested in 
 the marsh mud, whilst they attained a high degree when this was 
 kept under a bell-glass. The elimination of a great part of the 
 organisms in the crude material rendered easy the search for 
 those which are concerned in causing malaria. In this we era- 
 ployed the method devised by one of us (Klebs) — called by him 
 " fractional cultivation," afterwards adopted by Pasteur, and by 
 
20 ON THE NATURE OF MALARIA. 
 
 means of which he has procured the isolation of various patho- 
 genetic organisms. 
 
 "When from a liquid containing a not too great variety of 
 organisms one takes a single, drop and places it in a cultivation 
 fluid, if tjiis is fit to favour ;the development of such organisms, 
 these develop in greater number, which are most numerous in the 
 original drop. Ordinarily this preponderance is found iu those 
 organisms to which is due the morbigenous energy of the original 
 fluid. If not, the basis of culture and atmospheric conditions 
 are so altered as to result in killing the pathologically inactive 
 organisms, or at least to oppose such obstacles to their develop- 
 ment as allow the pathogenetic ones to gain the supremacy. If 
 this happens in one cultivation only, it becomes easy, by repeating 
 the operation, to separate the sparsely developed organisms from 
 the pathogenetic ones, which are always developed more abun- 
 dantly, and at last obtain a cultivation of these to the exclusion 
 of all others. 
 
 If the experiments made with the pure culture show that it 
 excites the same morbid processes as the crude material, it then 
 remains to ascertain if these are due to the liquid basis of culti- 
 vation or to the organisms which it contains — probably the latter, 
 as the former is undergoing a geometrically progressive dilution. 
 
 To obtain direct proof of the exclusive pathogenetic efficacy of 
 the organisms cultivated, it is necessary to ascertain,: by direct 
 experiment, the impotency of the liquid part of the final cultiva- 
 tion. 
 
 This is done by filtration through cylinders of potter's clay or 
 filters of plaster of Paris by means of the air-pump (Klebs, Zahn, 
 Pasteur), or even by passing through good filtering paper. The 
 use of this last method is certainly more simple and convenient, 
 but insufficient when one has to do with very minute organisms, 
 as those of septicaemia, diphtheria, rheumatism, and the like; 
 but in jthe case of malaria we have been able to obtain sometimes 
 by its means a progressive diminution of the efficacy of the 
 filtered liquid. Since all the fluid parts traverse without obstacle 
 the pores of the filter, one obtains even in this way the proof that 
 the solid particles, retained wholly or for the most part on the 
 filter, are the holders of the pathogenic activity displayed by the 
 cultivation, taken as a whole. 
 
21" 
 
 CHAPTER HI. 
 
 RESEARCHES. 
 
 For the sake of brevity I have introduced the following con- 
 tractions into the chapter, more particularly in recording the 
 experiments : — 
 
 temp.... temperature cent. 
 max. ... maximum, 
 mill. ... minimum. 
 
 L length. 
 
 B breadth. 
 
 T thickness. 
 
 W weight. 
 
 I. S index of spleen. 
 
 F. A. ... febrile acces.' 
 
 Our researches, being occupied with the solution of the general 
 question, were also directed to the special one of malaria in the 
 Roman Campagna, and it became necessary to select a locality in 
 which, beyond doubt, the gravest forms of the malady are seen 
 in the hot season. The Pontine marshes offered the most suit- 
 able conditions, especially as we were able to avail ourselves of 
 the liberal help of the Prince of Teano (Onorato Caetani). 
 Indeed, Cisterna, the central point of the property of the Gaetani 
 family, enabled us to extend our observations, on the one side to 
 Ninfa, at the foot of Monte Lepini, and on the other as far as 
 the coast of the Tyrrhene Sea, in the district of the lakes of 
 Fogliano, dei Monaci, and Caprolace. 
 
 Although malarious fevers had not yet appeared in" these 
 districts at the time of our visit, we determined to examine the 
 air of the same. For this purpose we provided ourselves with a 
 ventilator devised by one of us (Klebs) and made by Herr Rothe, 
 Mechanician to the Physical Institute, Prague. - - 
 
 It consisted of a brass box, elliptical on section, in the centre 
 of which revolved an axle, which sustained four metallic wings, 
 fitted to the cavity of the box and slightly curved. 
 
 The aperture for entrance of air is at the side, circular, dia- 
 meter 2 - 5 cc. In order to take air from any given point, even at 
 a distance, one can elongate the short metallic tube attached to 
 this aperture, by affixing slender tubes of gutta-percha, united 
 together by caoutchouc tubes. The air issues from the box by 
 means of an aperture of the diameter of a centimetre, to Which is 
 fitted a metallic tube projecting beyond the apparatus, and to 
 which can be applied means for collecting the air, either tubes 
 containing liquids or glass slides smeared with gelatine or gly- 
 
22 ON THE NATURE OF MALARIA. 
 
 cerine to fix the solid particles which impinge upon them. The 
 interior and the fans are kept perfectly clean, because the box is 
 formed of two symmetrical halves united by means of screws. 
 The rotation of the ventilator is secured by clockwork set in 
 motion by two bilateral handles. By its agency one can aspirate 
 300 litres of air in 16 or 17 minutes, by 50,000 revolutions of 
 the axle, recorded by a register. 
 
 We believe this instrument to be the most efficient, superior 
 to the apparatus used by Lewis and Cunningham and to the 
 aspirator of Pouchet. Direct microscopic examination of the air 
 of towns did not yield much result (although we did not neglect 
 to make such in Rome), because of the smallness of the micro- 
 cocci and their mixture with so many other objects. We attach 
 much greater importance to the " cultivation " of such material, 
 because by its means we obtained some of our most certain 
 results, which prove that " in malarious districts the poison is 
 raised above the level of the ground, even be/ore the time when 
 the infection becomes manifested in man." 
 
 Previous to our excursions into the Pontine marshes we col- 
 lected in Rome four samples of air ; and April 9th, one at Ninfa 
 (No. 5) ; April 10th, one at Tre Ponti, on the Appian Way 
 (No. 6) ; and on 11th five at the coast lakes (,Nos. 7—11). For 
 each sample were employed 300 litres of air from near the ground, 
 in Ninfa from land covered with vegetation, near a ruined church; 
 at Tre Ponti from marshy land ; No. 7 from the lake of Fog- 
 liano, near to a dune, in a spot exhaling a foetid odour. The 
 temp, of the water of the lake was 15° at 9.15 a.m. ; that of the 
 air, 15 0, 75. At noon, after rain, the temp, of the water was 
 in the Fossa papale, which unites the lakes dei Monaci and 
 Caprolace, 16 0l 5 and 16°-17 ; that of the air, 18°'2. Samples 
 Nos. 8 and 9 were taken on the lake of Caprolace between 1 and 
 2 p.m. ; Nos. 10 and 11 on the east bank of the same lake 
 between 2 and 3 p.m. At 4 p.m. the temp, of the water of the 
 Fossa papale was 17° ; of the air, 17°"6. At 5 p.m., lake of 
 Monaci, temp, of water, 16°; air, 16 0- 75. At 5.30 p.m., lake of 
 Fogliano, temp, of water, 16 0, 5 ; air, 15°'5. 
 
 There were also placed on the waters of the lakes pieces of 
 perforated cork, glass slides smeared with gelatine or glycerine 
 being placed on the perforations, face downwards, and covered 
 with little roofs of wax-cloth to protect them from the rain. 
 
EESEARCHES. 23 
 
 The examination of No. 9, made at the summer-house of 
 Fogliano, showed some short rods of the length of 2*25 — 6 - 75m. 
 and breadth qf 0*225 — 0*45 m. ; one of the length of 11"25 m., 
 and a piece of vegetable epidermis and a cotton fibre. 
 
 In No. 11, besides mineral powder and a few vegetable fibres, 
 were found similar rods to those of No. 9, and some long, curved 
 filaments 22 - 50 micromillimetres in length. 
 
 The water taken April 11th in the middle of the lake of Capro- 
 lace, and examined three days after, contained a great quantity 
 of motionless bacteria, threads of algas coloured with chlorophyl, 
 a few infusoria, the following forms of schistomycetes : 1st, 
 delicate filaments, sometimes very long, homogeneous; 2nd, 
 small rounded corpuscles (micrococci ?) ; 3rd, automatically 
 moving rods of different lengths ; 4th, rounded corpuscles arranged 
 in rows ; 5th, filaments, partly jointed, containing shining cor- 
 puscles. The mud of Caprolace, taken at the same point on the 
 bank as air samples Nos. 10 and 11, contained the same organic 
 forms, a notable quantity of large infusoria, very many diato- 
 macese, and some small worms endowed with very active move- 
 ments, probably larvae of nematoids. 
 
 April 11th, a very small quantity of this mud was introduced 
 by means of a pin into a cultivation tube, filled with very pure 
 fish gelatine, and immediately closed with cotton already kept at 
 a high temp. (Cultivation tube No. 1.) 
 
 April 14th, a portion of the Caprolace water was placed in a 
 similar tube and closed by the lamp. (Cultivation tube No. 2.) 
 
 Both were placed in a hot-air bath, temp. 30° — 34°. 
 
 April 15th, a small portion of the contents of cultivation tube 
 No. 1 were placed in a microscopical air chamber. The exami- 
 nation of it showed that the diatoms were all dead; of the 
 nematoids no trace; the filaments of hypomycetes had not under- 
 gone further development. Two forms of schistomycetes were 
 seen ; some threads, curved, sometimes twisted ; others forming 
 loops in which no trace of differentiation of their structure was 
 found, and some rods with a shining granule at each extremity 
 (Table I., fig. 7, c) ; others even smaller contained a third granule 
 in the middle (Table II., fig. 1, /). Besides some filaments 
 devoid of nuclei, others exhibited no sign of division (Table II., 
 fig. a), whilst in others the protoplasm was in the middle of. its 
 length divided into two by a clear space, in which the presence 
 
24 OK THE NATURE OF MALARIA. 
 
 of a membrane might be discerned (Table II., fig. 1, b). 
 Finally, some long and tortuous filaments were like those of 
 fig. 7, which contained a notable quantity of brilliant granules 
 (Table IE., fig. 1, d). In these last an extraordinarily rapid 
 development was observed, for whilst fig. d represented exactly 
 Buch a filament as seen at midday (April 15), the same filament 
 had at 2 p.m. assumed the appearance of d'; that is to say it had 
 increased to almost double the length, had become larger, and 
 contained a quantity of shining corpuscles, which, especially at 
 the fine extremity, had accumulated so as to give to the proto- 
 plasm a much more granular appearance than appears in the 
 figure. Two principal forms, therefore, prevail — homogeneous 
 filaments with commencing scission, and others producing spores, 
 in some of which the protoplasm had become granular. It was 
 only by continued observations of the preparation that it was 
 possible to decide that the two forms were connected. A third 
 form (Table II., fig. 1, e) consisted of fusiform cells containing 
 very large protoplasmic masses, of which examples are seen in 
 this preparation, belonging to another organic series, and dis- 
 appearing as the others developed. 
 
 The same cultivation examined April 16th, after having "been 
 constantly maintained at a temp. 30°— 34°, showed a large 
 quantity of very long filaments with many granules, and others 
 with homogeneous protoplasm sometimes arranged parallel to 
 one another, and in some of which were seen manifold transverse 
 divisions (Table IT., fig. 3). April 17th, 9 a.m., were found, in 
 addition, very numerous tortuous filaments, especially at the 
 edge of the air channel, the short rods containing two or three 
 nuclei (fig. 7, c, and fig. 1,/), which the day previous had been 
 observed at points accurately noted, were no longer visible. 
 Instead, the forms were found which are depicted Table II., fig. 2, 
 as shown by the l-12th inch objective of Zeiss (oil immersion). 
 The smaller figure represents these same shown with eyepiece 
 No. of Zeiss, and the other two as seen with eyepiece No. IV. 
 They were jointed filaments, each joint of which was limited by 
 a membrane even at the points of division. The smaller of these 
 had a homogeneous protoplasm ; the larger contained a granule, 
 very large, oval, shining, and attached to the wall about the 
 middle ; or two granules, smaller, and rounded at the ends ; or 
 a median and two terminal granules. Some observations have 
 
EESEAECHES. 25 
 
 led us to think it likely that at the place of occurrence of the 
 median granule an ulterior division of joints may take place, but 
 we have not been able to watch the process, which probably is 
 very rapid. The same day at 2 p.m. the articulated filaments 
 with homogeneous protoplasm (fig.- 3) were studied with l-12th 
 inch Zeiss and No. II. eyepiece. The joints were separated from 
 each other by fine interstices, in which could be seen traces of a 
 dividing membrane, rarely clear lines were distinguished between 
 the two extremities of the joint. The joints were disposed in 
 linear series or were dichotomous. We do not know, however, 
 if this dichotomy is the result of dichotomous division of a joint 
 or of lateral deviation of new terminal joints. The latter is much 
 more probable, as we have never been able to see anywhere the 
 beginning of longitudinal division of the protoplasm. 
 
 Sometimes the terminal joints are found in a direction per- 
 pendicular to that of the preceding,' so that one is led to think 
 that they have been detached, and that the position assumed by 
 them is due to resistance accidentally encountered in the fluid in 
 which they are immersed, as well as to the activity of growth of 
 the joints which had pushed them forward. 
 
 At this period of evolution all automatic movement of proto- 
 plasm is wanting. 
 
 April 26th — i.e., after twelve days of cultivation — at a temp, oi 
 30° — 34°, were seen along the whole border of the preparation 
 these filaments, in which no further division had been produced. 
 , They were disposed in groups which, leaving the edge of the 
 air chamber, extended in the form of a fan towards the centre of 
 the preparation ; one of these, weakly magnified with objective E 
 of Zeiss and eyepiece No. II, is shown in fig. 6, Table II. 
 Although the joints are feebly connected together, the filaments 
 maintain their continuity, run at first parallel, then diverge, and 
 even cross. 
 
 The smaller joints have a length of 2'25 m. and breadth of 
 1*125 m. From. these samples one sees how, under the com- 
 bined influence of the material chosen as the basis of cultivation, 
 of a fixed temperature, and of the action of the atmosphere, many 
 of the organisms contained in the crude material had perished ; 
 whilst from the other part had been developed, in great abun- 
 dance, forms of schistomycetes, belonging to the genus Bacillus. 
 The two different species — the one with homogeneous joints, and 
 
26 
 
 ON THE NATURE OF MALARIA. 
 
 the other with joint3 containing granules or spores — most prob- 
 ably are derived from one another, because sometimes conjoined 
 in the same plant. 
 
 This, therefore, would be a Bacillus, which might be distin- 
 guished from the B. subtilis (F. Cohn) of hay infusions, as from 
 the Bacillus anthracis (Kach) of carbuncle, and would be 
 described thus : — 
 
 "Bods of the length of 5 — 10 micromillimetres, which, in 
 developing, are converted into tortuous filaments, divided into 
 joints by means of clear spaces in their protoplasm, or, more 
 rarely, by dividing membranes. These filaments, in the surface 
 exposed to the action of air, produce rows of very short joints, 
 and develop in their interior spores before their division into 
 joints, or after this has happened. These spores occupy the 
 middle, or extremities, of the joints, or both at the same time ; 
 when the division into joints does not happen they are multiplied 
 by becoming still smaller, and the interior of the filament is 
 filled by a granular mass." 
 
 Inasmuch as the same forms are repeatedly produced by like 
 cultivation, practised in fish gelatine, with different kinds of soil, 
 taken from malarious places (whilst other organic forms are not 
 seen except occasionally, or perish, in consequence of the prepon- 
 derating development of this Bacillus), we supposed that perhaps 
 this plant might be the carrier of malaria, which led us to 
 proceed by experiments on animals to test the value of this 
 conjecture. 
 
 Our experiments were performed on rabbits of good breed, for 
 the most part very robust, in which autopsies never disclosed any 
 change due to antecedent disease. They were kept in spacious 
 and well- ventilated stalls of wood, placed in a part of the labora- 
 tory near our work room, the large windows of which were always 
 kept open. The floor of each was formed of a network of iron 
 wire, and under this a zinc funnel received and conveyed the 
 urine to a vessel outside the stall. The stalls and floor of the 
 room were cleansed most scrupulously. The animals were fed 
 with cabbage leaves, and on their entrance into the laboratory 
 were marked with Koman numerals, which, to avoid confusion, 
 were written with aniline colours on the skin of the back, denuded 
 of fur. 
 
 The same number has been used to distinguish the temp. 
 
RESEARCHES. 
 
 27 
 
 curve (Tables III., IV., V.) and the " nature print " of the spleen 
 (Table I.) of each animal, to facilitate comparison. 
 
 Since, for the most part, parallel researches were made with 
 various substances, we may divide the former into groups. 
 
 Group I. Normal rabbits. — In order to determine the normal 
 size of the spleen, two very fine rabbits were selected, strong and 
 healthy (XVII. and XVIII.), and killed as soon as they were 
 brought to the laboratory. Death was effected by means of a 
 tight noose round the neck and strong simultaneous traction on 
 the hind legs. This mode was adopted with all our animals except 
 Nos. I. and II., which were killed by bleeding. It procured an 
 immediate death without convulsions, so as to avoid disturbance 
 of the circulation capable of altering the volume of the spleen. 
 
 In order to avoid the action of extraneous fluid on the spleen, 
 we abstained from determining the volume of this organ. 
 
 Even an exact determination of its weight was difficult, owing 
 to evaporation in an organ which, though small in rabbits, has 
 a relatively very large surface. 
 
 We therefore, instead of determining the volume and weight, 
 sought to obtain from the nature-print of the organ, immediately 
 after death, some figures in relation to the weight of the animal's 
 body. We did this by multiplying together the three measure- 
 ments (L., B., and T.) in millimetres of the print and calculating 
 the value of this parallelopiped, in relation to a chilogramme of 
 the body weight. To this relative value we gave the name Index 
 of the Spleen, indicated by the letters I. S. 
 
 In these two rabbits all the organs were healthy, and the 
 spleens are represented Table I., Nos. XVII. and XVIII. We 
 obtained the following values : — 
 
 Table I. — Spleen of Normal Rabbits. 
 
 Number. 
 
 Weight 
 of Body 
 
 in 
 Grammes. 
 
 Diameters of Spleen in Millimetres. 
 
 Product 
 
 of 
 
 Three 
 
 Dimensions. 
 
 I.S. 
 
 Length. 
 
 Breadth. 
 
 Thickness. 
 
 XVII.... 
 XVIII... 
 
 Mean ... 
 
 1,755 
 1,591 
 
 38-8 
 38-7 
 
 8-2 
 9-4 
 
 3-6 
 3-7 
 
 1,145 
 1,079 
 
 — 
 
 1,673 
 
 38-75 
 
 8-8 
 
 3-65 
 
 1,112 
 
 664 
 
28 
 
 ON THE NATTJEE OF MALABIA. 
 
 Immediately before death the temperature -of XVII. was 39°, 
 and that of XVIII. 88 p- 6: This temperature, however, is not 
 considered normal, because we often found that the animals on 
 entering the laboratory had a subnormal temperature, and only 
 recovered' the normal after 24 hours. The following table shows 
 the means obtained by 7 — 9 daily measurements, made for nine 
 days on six rabbits. 
 
 (Before calculating the means, it was necessary to make the 
 correction of the thermometer, which, as already stated, was o, l 
 C. below the normal.) 
 
 Table II — Calculation of Mean Rectal Temperature of Rabbits. 
 
 
 Date 
 
 
 No. of 
 
 Place 
 
 Number. 
 
 of 
 
 Daily Mean. 
 
 Daily Measure- 
 
 of 
 
 
 Observation. 
 
 
 ments. 
 
 Observation. 
 
 V. 
 
 April 30 
 
 39-556 C. 
 
 9 
 
 Eome 
 
 99 
 
 May 1 
 
 39-516 
 
 J» 
 
 
 XII. 
 
 „ 9 
 
 39-457 
 
 7 
 
 
 
 „ 10 
 
 39-483 
 
 9 
 
 
 ?» 
 
 „ 11 
 
 39-471 
 
 
 
 XV. 
 
 » 17 
 
 39-162 
 
 8 
 
 
 XVI. 
 
 j> >j 
 
 39-768 
 
 it 
 
 j» 
 
 XIX. 
 
 June 8 
 
 39-368 
 
 ») 
 
 Prague 
 
 XX. 
 
 i> » 
 
 39-475 
 
 JJ 
 
 j) 
 
 General m 
 
 ean 
 
 = 39°-4745, fi 
 
 'om 75 meas 
 
 arements. 
 
 
 We. believe we are near the truth in estimating the mean 
 temp, of the rectum in rabbits at 39°"5, and therefore in our 
 temp, curves (Tables III., IV, and V.) we have at this level 
 drawn a well-marked line representing this normal. 
 
 In the analysis of pathological cases, we think it convenient to 
 form three groups (II., III., and IV.), according to the source of 
 infecting material used — Pontine marshes, Janiculan, Valchetta 
 in the Eoman Campagna. In a fifth group, researches made at 
 Prague in the same way as at Eome ; and in the sixth group, 
 cases of septic infection accidentally produced in some animals 
 not used in our experiments, but offering excellent means of 
 comparison with those of malarious infection, artificially induced 
 at the same time and place. 
 
RESEARCHES. 
 
 29 
 
 Group II. Researches, with .infecting material collected in 
 the Pontine. Marshes. — These, made on Nos. I., II., III., IV., 
 V., served to test the material collected at the lake of Caprolace 
 and in the, air of Ninfa and ; Fogliano,. without preparation or 
 after- cultivation (microscopic analysis already given)i ; 
 
 A. Parallel researches with Caprolace mud. — No. I. was 
 injected April 16th, 10 a.m., with 1-6 cc. of water which had 
 rested three days on Caprolace mud, and immediately afterwards 
 No. II. was injected with 0"6 cc. of fluid from cultivation tube 
 No. I., in which the same mud had been cultivated in fish gela- 
 tine since April 11th, and on the same day (April 16th) showed 
 the bacilli provided with spores in , fig. 7, c, and fig. 1, /, 
 Table H. 
 
 Table HE. — Temperature and Weights of Nos. ] 
 
 . and II. 
 
 
 
 
 Rectal 
 Temp. 
 
 Weight 
 of Body In 
 Orammeg. 
 
 ■- 
 
 
 Rectal 
 Temp. 
 
 Weight 
 of Body In 
 Grammes. 
 
 Day. 
 
 Hour. 
 
 
 
 Day. 
 
 Hour. 
 
 
 
 T. 
 
 II. 
 
 I. 
 
 II. 
 
 I. 
 
 ii. 
 
 I. 
 
 II. 
 
 Apr.15 
 
 _ 
 
 
 * 
 
 1,560 
 
 1,804 
 
 Apr. 20 
 
 11.40 a.m. 
 
 40-8 
 
 39-8 
 
 _ 
 
 _ 
 
 „ 16 
 
 10 a.m. 
 
 39-2 
 
 39-0 
 
 — 
 
 — 
 
 J) JJ 
 
 2.30p.m. 
 
 40-5 
 
 39-4 
 
 
 
 — 
 
 JJ JJ 
 
 2.30p.m. 
 
 40-15 
 
 399 
 
 — 
 
 — 
 
 JJ JJ 
 
 3 ., 
 
 40-5 
 
 39-4 
 
 
 
 „ 
 
 JJ JJ 
 
 8 „ 
 
 39-85 
 
 40-2 
 
 — 
 
 — 
 
 JJ JJ 
 
 640 „ 
 
 40-7- 
 
 39-8 
 
 
 
 — 
 
 „ 17 
 
 9.30 a.m. 
 
 39-5 
 
 39-7 
 
 1,443 
 
 1,684 
 
 J! 'J 
 
 10 „ 
 
 40-3 
 
 39-6 
 
 
 
 — 
 
 JJ JJ 
 
 2 p.m. 
 
 38-4 
 
 38-9 
 
 — 
 
 ' — 
 
 „ 21 
 
 6 a.m. 
 
 40-8- 
 
 39-7 
 
 
 
 — 
 
 „ 18 
 
 9.40 a.m. 
 
 39-4 
 
 39-45 
 
 1,445 
 
 1,708 
 
 JJ JJ 
 
 8 „ 
 
 40-7 
 
 39-7 
 
 . t 
 
 — 
 
 J) H 
 
 3 p.m. 
 
 38-4 
 
 39-7 
 
 1,461 
 
 1,780 
 
 JJ JJ 
 
 9.15 „ 
 
 40-9 
 
 — 
 
 1,837 
 
 "' — 
 
 JJ JJ 
 
 5 „ 
 
 39-75 
 
 39-7 
 
 — 
 
 — 
 
 JJ JJ 
 
 11.30 „ 
 
 — 
 
 39-65 
 
 — 
 
 i — 
 
 JJ JJ 
 
 8.30 „ 
 
 39-7 
 
 39-5 
 
 
 
 — 
 
 JJ JJ 
 
 7 p.m. 
 
 — 
 
 39-8 
 
 — 
 
 . — 
 
 „ 19 
 
 9.15 a.m. 
 
 40-0 
 
 39-6 
 
 1,408 
 
 1,783 
 
 JJ J' 
 
 10.45 „ 
 
 — 
 
 39-8 
 
 — 
 
 — 
 
 JJ J) 
 
 » „ 
 
 40-2 
 
 39-6 
 
 — 
 
 — 
 
 >, 22 
 
 6 a.m. 
 
 — 
 
 39-8 
 
 — 
 
 — 
 
 JJ 3J 
 
 2 p.m. 
 
 406 
 
 40-1 
 
 — 
 
 — 
 
 JJ JJ 
 
 12.45p.m. 
 
 — 
 
 39-4 
 
 — 
 
 — 
 
 JJ JJ 
 
 3 „ 
 
 40-65 
 
 40-05 
 
 — 
 
 — 
 
 JJ JJ 
 
 1 „. 
 
 — 
 
 39-9 
 
 — 
 
 — 
 
 J) JJ 
 
 i » 
 
 40-85 
 
 40-2 
 
 — 
 
 — 
 
 JJ 'J 
 
 3 „ 
 
 — 
 
 39-9 
 
 — 
 
 — 
 
 JJ JJ 
 
 5 „ 
 
 40-8 
 
 40-2 
 
 — 
 
 — 
 
 „■ 23 
 
 12 a.m. 
 
 — 
 
 39-5 
 
 — 
 
 — 
 
 JJ JJ 
 
 6 „ 
 
 40-5 
 
 402 
 
 — 
 
 — 
 
 J) JJ 
 
 6 p.m. 
 
 — 
 
 39-5 
 
 , — 
 
 — 
 
 JJ J) 
 
 8 „ 
 
 406 
 
 40-6 
 
 — 
 
 — 
 
 » 24 
 
 6 a.m. 
 
 — 
 
 39-2 
 
 — 
 
 — 
 
 JJ JJ 
 
 11 „ 
 
 40-5 
 
 40 3 
 
 — 
 
 — 
 
 JJ JJ 
 
 12 „ 
 
 — 
 
 39-6 
 
 — 
 
 — 
 
 .» 20 
 
 6 a.m. 
 
 40-7 
 
 39-6 
 
 — 
 
 — 
 
 )J JJ 
 
 6 p.m. 
 
 — 
 
 39-8 
 
 — 
 
 — 
 
 JJ J' 
 
 8.10 „ 
 
 40-6 
 
 39-7. 
 
 — 
 
 — 
 
 ;; 25 
 
 7 a.m. 
 
 — 
 
 39-5 
 
 — 
 
 — 
 
 " , " 
 
 8.10 „ 
 
 40-65 
 
 39-8 
 
 — 
 
 — 
 
 
 
 
 
 
 
 * Subcutaneous injection of above mentioned material into both r< 
 
 ibbits. 
 
 t No. 1 killed by bleeding. 
 
 
 Add correction o, l in each table. 
 
 Autopsy of No. I., immediately after death. At injection site 
 
 large callosity (4 cm. x 3:5 cm.) of whitish and apparently 
 
 fibrous connective tissue, containing, blood vessels filled with 
 
30 ON THE NATURE OP MALARIA. 
 
 hard, dark red thrombi, subcutaneous tissue slightly cedematous. 
 The oedema fluid, collected immediately by means of capillary 
 tubes, contains a great quantity of automatically moving cor- 
 puscles, of oval or rounded form, shining, some showing on 
 opposite sides small blunt prolongations. In addition, immov- 
 able or feebly moving filaments, 5-9001 m. max. L. ; 0-7143 m. 
 B. Mesenteric lymphatic glands swollen, and contain large 
 quantity of opaline fluid. Spleen, enlarged : 55 mm. L., 9 B., 
 and 4 T. Examination of its fresh tissue shows a great quantity 
 of dark brown pigment in irregular masses ; adding aqueous 
 humour taken from eye of the same rabbit, and perfectly normal, 
 a great number of actively moving rounded corpuscles were seen. 
 No change in other organs. 
 
 To determine well the nature of the rounded bodies in the 
 splenic pulp and lymphatic fluid, two air cells were employed 
 (Nos. 7 and 8). In the first was placed serum of the lymph, in 
 the second a little splenic pulp diluted with aqueous humour. 
 Both were maintained at 30° — 35° (the glasses having previously 
 been heated to 120° to kill any organisms on them). After 
 24 hours No. 7 contained motionless filaments with brilliant 
 granules (spores) and self-moving rods, sometimes united in 
 couples,- besides free oval bodies, like those in the filaments 
 (Table II., fig. 4). In No. 8 were formed, besides many free 
 spores, some filaments with homogeneous protoplasm. 
 
 These, especially the smaller ones, could only be seen with* 
 1-12 or 1-18 inch objective of Zeiss and Abbe illumination. 
 (Afterwards they were seen well with weaker objectives.) 
 
 In both rabbits a fever of intermittent character followed the 
 injection of the above substances (Table III., curves I. and II.). 
 After injection an immediate rise to 40° took place ; next day, a 
 fall below the normal; 3rd day, a slight rise; 4th, a new F. A. 
 (febrile acces) to 46-85 in No. I., and to 406 in No. II. 
 After the 5th day the course was different in the two. No. I. 
 maintained a high temp, for 48 hours with slight oscillations, 
 whilst No. II. showed slight rises on the 5th, 6th, and 7th days, 
 with daily remissions ; on the 8th, a normal temp. ; on the 9th, 
 a subnormal in the morning and a slight rise in the afternoon. 
 On the 10th, used for another experiment. 
 
 We see, therefore, the fever in No. I. continue after the second 
 F. A., and in No. II. an almost normal condition after the second 
 
RESEARCHES. 31 
 
 F. A. — a difference dependent upon the quantity of infecting 
 material used. 
 
 As to the post-mortem appearances met with in No. I. — killed 
 during the F. A. — we note, 1st, the absence of suppuration at 
 injection site; 2nd, the increase, in all dimensions, of the 
 spleen, especially its length, I. S. 1,298, i.e., almost double the 
 normal (664) ; 3rd, the presence of the organisms of the injected 
 liquid, in the injection site, spleen, and lymph. Neither the 
 course nor post-mortem conditions correspond to those of putrid 
 and septic fevers. Also the increase of weight between first and 
 second F. A. 
 
 B. Parallel researches with Caprolace mud and with material 
 collected in the air of Ninfa and Fogliano, to ascertain if the 
 infecting agent is, even before the fevers appear, diffused in the 
 lower strata of the air of such places. It is not unlikely that 
 the greater activity displayed by the sample from Foglianft, 
 where the odour of putrescence was strong, may point, in 
 accordance with the ideas of the inhabitants, to a greater infective 
 power. 
 
 April 17th were begun some cultivations with the samples of 
 air Nos. 5 and 7, collected at Ninfa and Lake Fogliano. The 
 isinglass with which the slides had been smeared was dried : a 
 portion placed with albumen in two air cells (microscopic), a 
 second in two tubes of very pure fish jelly, and a third in urine. 
 The latter had long been boiled in a small retort, which was 
 afterwards closed with cotton, and remained perfectly clear 
 during 24 hours. The cultivation with albumen gave no result. 
 In the tubes of fish gelatine the development of bacteria took 
 place, and was reserved for other researches. The urine cultiva- 
 tion was used at once. It was pale yellow, clear, and acid; 
 contained long motionless filaments, partly jointed, and in some 
 of the joints spores were seen. 
 
 April 25th, 1*6 cc. of this urine were injected under the skin 
 of No. II., and simultaneously No. III. (not used before in any 
 experiment) was injected with 3 cc. of water, which had long 
 stood on Caprolace mud, containing some oval corpuscles and 
 slender, twisted filaments.* There were also injected into 
 another rabbit, No. IV., 1*6 cc. of a cultivation tube in which 
 
 * The microscopic examinations were always made by both observers, and sepa- 
 rately recorded by each. 
 
32 
 
 ON THE NATUEB OF MALARIA. 
 
 had been placed; April 23rd, a very small quantity of Gaprolace 
 mud with fish gelatine. In this liquid were seen only small 
 shining granules. - . 
 
 - The results are seen in the follpwing table : — 
 
 Tab^e IV.- 
 
 —Temperature 
 
 md Weights of Nos. II., III., arid IV. 
 
 Day. 
 
 Hour. 
 
 Temperature. 
 
 Weight of Body. 
 
 ■ Observations. 
 
 
 
 
 
 
 
 
 
 II. 
 
 III. 
 
 IV: 
 
 II. '■ 
 
 III. 
 
 IV. 
 
 
 4pj;.25 
 
 7 a.m. 
 
 39-5 
 
 
 _ 
 
 
 
 
 
 » „ 
 
 8 „ 
 
 — 
 
 38-9 
 
 38-5 
 
 
 
 
 
 )! " 
 
 9 „ 
 
 — 
 
 — 
 
 — 
 
 1,686 
 
 1,546 
 
 1,824 
 
 Injection. 
 
 M J' 
 
 10 .„ 
 
 39-4 
 
 39-3 
 
 39-1 
 
 
 
 
 
 » « 
 
 12 „ 
 
 39-6 
 
 39-6 
 
 39-2 
 
 
 
 
 
 »' ■» 
 
 2 p.m, 
 
 39-6 
 
 39-2 
 
 38-8 
 
 
 
 
 
 » » 
 
 4 „ 
 
 3!>-7 
 
 39-3 
 
 38-7 
 
 
 
 
 
 Jl D 
 
 6 „ 
 
 39-9 
 
 39-2 
 
 39-0 
 
 
 
 
 
 »r . 7> 
 
 -8,. „ 
 
 39-8 
 
 39-2 
 
 39-2 
 
 
 
 
 
 )» » 
 
 10 „ 
 
 398 
 
 39-2 
 
 392 
 
 
 
 
 
 » 26 
 
 6 - a.m. 
 
 39-4 
 
 38-9 
 
 39-1 
 
 
 
 
 
 " II 
 
 s ;, 
 
 39-6 
 
 39-4a 
 
 38-75 
 
 5 — 
 
 — ■ 
 
 — 
 
 a. Boring the movements of 
 
 )J » ' 
 
 10.15 „ 
 
 394 
 
 394 
 
 39-8 
 
 
 
 
 the animal, 39-6. 
 
 
 2 pit. 
 
 39-35 
 
 39-5 
 
 38-5 
 
 
 
 
 a. At 8.30 a.m. No. IV. in- 
 
 "" - JJ " ) 
 
 39-5 
 
 39-0 
 
 38-6 
 
 • 
 
 
 
 jected with 3-4 cc. of the 
 
 
 4 » 
 
 39-6 
 
 39-3 
 
 39-0 
 
 
 
 
 same cultivation. 
 
 ' 
 
 6 „ 
 
 39-7 
 
 39-5 
 
 39-5 
 
 — 
 
 — 
 
 — 
 
 No. IV. had six young ones. 
 
 * 
 
 5- „ 
 
 395 
 
 39-4 
 
 39-4 
 
 
 
 
 
 u.. » 
 
 » 27 
 
 10 „ 
 
 39 ; 6 
 
 39-4 
 
 39-4 
 
 
 
 
 
 6 a.m. 
 
 39-3 
 
 39-2 
 
 39-5 
 
 
 
 
 
 
 8 » 
 
 39-6 
 
 393 
 
 39'45 
 
 1,717 
 
 1,871 
 
 1,532 
 
 The weight of the young ones 
 
 
 
 
 
 
 
 
 
 was 262 ; that of the mother, 
 No. IV., 1,532 : total, 1,794. 
 
 
 10 „ 
 
 39-4c 
 
 39-2d 
 
 39-6 
 
 
 
 
 
 — 
 
 c. Injection of 3 cc. of culti- 
 
 " " 
 
 12 „ 
 
 39-5 
 
 40-5 
 
 39-65 
 
 
 
 
 vation in urine of sample of 
 
 " '• 
 
 2 p.m, 
 
 4 „ 
 
 39-7 
 
 40-1 
 
 40-05 
 
 
 
 
 air of Nhrfa and Fogliano. 
 
 " " ' 
 
 39-7 
 
 40-2 
 
 39-9 
 
 
 
 
 d. 3 cc. of water from mud of 
 
 »J 11 
 
 6 „ 
 
 39-8 
 
 40-2 
 
 39-6 
 
 
 
 
 Caprolace injected. 
 
 8 „ 
 
 39-8 
 
 39-9 
 
 39-8 
 
 
 
 
 
 " " 
 
 10 „ 
 
 39-8 
 
 39-9 
 
 39-9 
 
 1,833 
 
 1,615 
 
 1,530 
 
 
 » .*. 
 
 6 a.m. 
 
 39-65 
 
 39-3 
 
 39-7 
 
 
 
 
 
 
 8 „ 
 
 39-7 
 
 39-4 
 
 39-6 
 
 
 
 
 
 ' 
 
 10 ,. . 
 
 39-3 
 
 39-25 
 
 39-5 
 
 
 
 
 
 ' 
 
 12 „ 
 
 39-4 
 
 39-3' 
 
 30-4 
 
 
 
 
 - 
 
 '' 
 
 2 p.m. 
 
 39-5 
 
 39-45 
 
 39-5: 
 
 
 
 
 
 " 
 
 4 „ 
 
 39'75 
 
 39-4 
 
 39-45 
 
 
 
 
 
 ■ ' 
 
 6 ' „ 
 
 S9- v 6 
 
 39-4 
 
 39-7 
 
 
 
 
 
 i ; 
 
 8 ,i 
 
 39-6 
 
 39-5 
 
 39-65 
 
 
 
 
 
 » » 
 
 10 „ 
 
 3965 
 
 39-25 
 
 39-8 
 
 
 
 
 
 ,/ 29 
 
 6 a.m. 
 
 39'4 
 
 '39-3 
 
 •40-05 
 
 
 
 
 
 8 » 
 
 39-6 
 
 39-0 
 
 41-00 
 
 
 
 
 
 " 
 
 10 „ 
 
 39-5 
 
 39-2 
 
 39-9 
 
 
 
 
 
 
 12 „ ■ 
 
 39'6 
 
 39-2 
 
 40-2 
 
 
 
 
 
 
 2 p.m. 
 
 §9-4 
 
 39-3 
 
 40-05 
 
 
 
 
 
 
 « » 
 
 39-6 
 
 39-2 
 
 40-05 
 
 
 
 
 
 ' 
 
 8 
 
 39-95 
 
 39-55 
 
 40-3 
 
 
 
 
 
 
 io ;; 
 
 39-8 
 
 39-46 
 
 41-05 
 
 
 
 
 
 » 30 
 
 6 a.m. 
 
 41-0 
 
 39-1 
 
 41-0 
 
 
 
 
 
 
 8 ,, 
 
 39-95 
 
 39-2 
 
 39-8 
 
 
 
 
 
 » » 
 
 10 „ 
 
 40-2 
 
 39-0 
 
 40-2 
 
 1,749 
 
 1,668 
 
 1,632 
 
 
 » ?' 
 
 12 ' » 
 
 40-1 
 
 89-2 
 
 40-4 
 
 
 
 
 
EESEAKCHES. 38 
 
 Temperatures and Weights of Nos. II., III., and IV. — Continued. 
 
 1 
 
 
 Temperature. 
 
 Weight of Body. 
 
 Observations. 
 
 Day. Hour. 
 
 
 
 
 
 
 
 1 
 
 II. 
 
 III. 
 
 IV. 
 
 II 
 
 III. 
 
 IV. 
 
 
 Apr. 30 
 
 2 p.m. 
 
 39-8 
 
 39-2 
 
 40 2 
 
 
 
 
 
 !' JJ 
 
 4 » 
 
 39-5 
 
 392 
 
 40-2 
 
 
 
 
 
 
 6 „ 
 
 39-55 
 
 39-3 
 
 40-15 
 
 
 
 
 
 
 8 » 
 
 394 
 
 39-2 
 
 39-9 
 
 
 
 
 
 
 10 „ 
 
 395 
 
 39 2 
 
 40-1 
 
 
 
 
 
 Slay'l 
 
 6 a.m. 
 
 39-5 
 
 39-2 
 
 401 
 
 
 
 
 
 " 
 
 8 „ 
 
 3935 
 
 39-4 
 
 39-9 
 
 
 
 
 
 
 10 „ 
 
 39-1 
 
 39-5 
 
 39-85 
 
 
 
 
 
 
 12 
 
 39-25 
 
 39-3 
 
 39-95 
 
 
 
 
 
 !' 
 
 2 . p.m. 
 
 39-45 
 
 39-2 
 
 40-05 
 
 
 
 
 
 
 4 „ 
 
 39-4 
 
 39-3 
 
 39-9 
 
 
 
 
 
 
 6 „ 
 
 39-4 
 
 391 
 
 40-0 
 
 
 
 
 
 
 8 „ 
 
 39-5 
 
 39-4 
 
 40-1 
 
 
 
 
 
 
 10 „ 
 
 39-6 
 
 39-3 
 
 400 
 
 
 
 
 
 » 2 
 
 6 a.m. 
 
 39-3 
 
 39-4 
 
 40-1 
 
 
 
 
 
 
 8 » 
 
 39-4 
 
 39-1 
 
 3985 
 
 
 
 
 
 \ ;; 
 
 10 „ 
 
 39-2 
 
 39-3 
 
 39-9 
 
 
 
 
 
 12 „ 
 
 39-5 
 
 39-2 
 
 39-6 
 
 
 
 
 
 
 2 p.m. 
 
 39-5 
 
 39-2 
 
 39-7 
 
 1,745 
 
 1,612 
 
 1,490 
 
 
 
 4 » 
 
 39-4 
 
 39-3e 
 
 399 
 
 
 
 
 
 — 
 
 e. At 3.30 p.m. No.III.injected 
 
 
 6 i> 
 
 39-7 
 
 — 
 
 40-5 
 
 
 
 
 with 16 oc. of filtered fluid 
 
 " " 
 
 8 „ 
 
 39-8 
 
 — 
 
 39-9 
 
 
 
 
 of cultivation of Ninfa and 
 
 ?) jj 
 
 10 „ 
 
 40-0 
 
 
 39-95 
 
 
 
 
 Fogliano air, in urine. See 
 parallel experiment follow- 
 ing. 
 
 » 3 
 
 6 a.m. 
 
 39-5 
 
 
 
 / 
 
 
 
 
 
 
 
 f. Thermometer broken. New 
 
 
 12 „ 
 
 39-2 
 
 , 
 
 
 
 
 
 one also. 0-1 below normal. 
 
 1) JJ 
 
 2 pm. 
 
 39-85 
 
 — 
 
 40 
 
 
 
 
 
 J) )) 
 
 4 „ 
 
 39-7 
 
 — 
 
 40-0 
 
 
 
 
 
 'J JJ 
 
 6 ,, 
 
 40 
 
 — 
 
 40-1 
 
 . 
 
 
 
 
 J' J> 
 
 JJ J) 
 
 8 „ 
 10 „ 
 
 40-1 
 400 
 
 — 
 
 398 
 39-9 
 
 
 
 
 
 ,. 4 
 
 6 a.m. 
 
 39-9 
 
 — 
 
 401 
 
 
 
 
 
 
 8 » 
 
 395 
 
 
 
 39-9 
 
 
 
 
 
 JJ Jt 
 
 12 „ 
 2 p.m. 
 
 39-6 
 400 
 
 — 
 
 40'0 
 40-1 
 
 
 
 
 
 JJ J) 
 
 4 „ 
 
 40-1 
 
 — 
 
 40 
 
 
 
 
 
 JJ JJ 
 
 6 ' „ 
 
 39-8 
 
 — 
 
 40 05 
 
 
 
 
 
 'J )J 
 
 8 „ 
 
 39-85 
 
 — 
 
 40-0 
 
 
 
 
 
 JJ J) 
 
 10 „ 
 
 39-7 
 
 — , 
 
 400 
 
 
 
 
 
 » 8 
 
 6 a.m. 
 
 39-5 
 
 — 
 
 40-0 
 
 
 
 
 
 p jj 
 
 8 „ 
 
 39-7 
 
 — 
 
 39-8 
 
 
 
 
 
 
 12 „ 
 
 39-7 
 
 — 
 
 39-2 
 
 1,9U 
 
 — 
 
 1,529 
 
 
 
 2 p.m. 
 
 398 
 
 
 
 36-6 
 
 
 
 — 
 
 — 
 
 At 2.30 No. IV. killed. 
 
 5J JJ 
 
 4 „ 
 
 39-8 
 
 — 
 
 — 
 
 
 
 
 
 J) JJ 
 
 8 » 
 
 40-0 
 
 — 
 
 — 
 
 
 
 
 
 1' )J 
 
 8 „ 
 
 40-1 
 
 — 
 
 — ' 
 
 
 
 
 
 JJ 5) 
 
 10 „ 
 
 40-0 
 
 
 
 • 
 
 
 
 
 Temp, table of No. III. will be continued below. 
 
 No. II. killed May 6th by bleeding. At 6 a.m. of tbis day its 
 rectal temperature was 39 0, 9 ; at 8 a.m., 39°*8 ; at 10 a.m. 39 q, 4. 
 Weight, 1,602 grammes. 
 
 Autopsy. — Well nourished (on the 11th day of observation it 
 weighed 224 gr., and on the day of death 116 gr., more than 
 
 3 
 
34 ON THE NATURE OF MALARIA. 
 
 when it came to the laboratory). Spleen much enlarged (Table 
 I., fig. 2.) ; L. 52-6 mm. ; B. 11'5 mm. ; T. 5'8 mm. ; I. S. 
 (compared with maximum weight on 11th day) 1,832, i.e., 
 almost treble the normal — firm, not rich in blood, of clear red 
 colour, and its capsule wrinkled. Intestinal glands not swollen, 
 but mesenteric lymphatics much enlarged, forming at the root of 
 mesentery a mass — 3 cm. x l - 8 cm. — firm, whitish, and con- 
 taining much lymph. Liver rich in blood. Kidneys less so. 
 Slight pulmonary oedema, with subpleural ecchymoses. At one 
 injection site a small capsuled abscess. 
 
 Temp, curve (Table III., curve II.) very interesting. First 
 two days after first injection temp, oscillations slight. First 48 
 hours after second injection notable perturbations observed. 
 Temp, commenced to rise rapidly 51 hours after second injection, 
 arriving in 16 hours at 41°. The F. A. had a duration of 24 
 hours. 
 
 In 36 hours following, minima of 39°"1 — 39 0- 2, and maxima 
 almost normal. Then a series of 4 F. A. (/, g, h, i), each lasting 
 about 24 hours, with maxima of 40°, 40 Ol l, 40°-l, 40 o, l, and 
 maxima of 39 0, 2, 39°'5, 39°'5. 
 
 The quartan type of fever after F. A%^-f. was transformed 
 into a quotidian type. 
 
 The post-mortem appearances exclude septic complication. 
 
 Melanffimic pigment was found in the spleen. In the lymph 
 were found many brilliant actively moving oval bodies, 0*00095 
 
 mm. long. 
 
 It results, therefore, that the air examined contained corpuscles 
 capable of development, which, after multiplication in urine, were 
 rendered capable of producing attacks of intermittent f eve)' in the 
 animals injected with them. 
 
 To get this result it was necessary to use a considerable 
 quantity of cultivation liquid, and it occurred after a period of 
 latency of 48 hours. Tbis is explained by the large quantity of 
 fluid (400 cc.) in which was diffused the material in cultivation. 
 
 It remained to be seen if the febrigenous action was due to 
 the solid particles in this liquid, or to some otber substance in it. 
 And to this end we made the following experiment : — 
 
 No. Ill-, already injected twice with water from Caprolace 
 mud (l - 6 cc. April 25th, 8'2 cc. April 27tb), showed two slight 
 rises after the first injection (Table III., curve III., a, b), the 
 
EESEAECHES. 35 
 
 maxima being 24 hours apart, and the difference of max. and 
 min. only o, 7. 
 
 All this curve is subnormal. After the second min. the temp, 
 ascended to the mean. (Such oscillations are very often seen in 
 rabbits placed under new conditions of life, food, &c, and have 
 nothing to do with intermittent fever. Of this in the present 
 case we had a positive proof.) When the temp, had become 
 normal, a double dose of the same fluid was injected, and the 
 temp, at once rose to 40 o- 2, then fell, so that for five days the 
 curve was subnormal, only once passing the normal by 0°"1. 
 Therefore the two injections were powerless to produce an inter- 
 mittent fever, or in other words, water which had long been in 
 contact with mud rich in malaria did not seem apt to transmit 
 this poison. 
 
 The negative result in this case was not due to immunity 
 of the animal, because a later experiment on it showed that such 
 immunity did not exist. This result has an important bearing 
 on the fact, that the natural development of malaria is known to 
 be wanting when a sufficient layer of water covers and separates 
 the soil from the atmosphere. -The Caprolace water was in our 
 researches shown to be devoid of those organisms which may be 
 developed in such quantities from cultivations made with the 
 mud. itself, which produced such positive results in No. II. 
 
 This water was rich in self-moving schistomycetes, but in no 
 cultivation with fish gelatine, albumen, urine, or even left to 
 itself in flasks closed with cotton, were bacilli ever seen to 
 develop containing nuclei. The forms were always such as one 
 of us (Klebs) has described as monadine, which goes to prove 
 that the bacillus described by us is eminently aerobic, which only 
 grows in contact with the air, and accords with the conditions 
 of malaria development set forth in Chapter I., and with our 
 researches, in which the plant always grew on the surface of the 
 fluid. 
 
 No. IV., the third of this series, which was injected with 1*6 cc. 
 of a cultivation of the bacillus in fish gelatine, was in con- 
 formation and origin like No. III. Both were strong albinoes, 
 probably of one litter, and were kept in the same stall. 
 
 No. IV. had also at first a subnormal temp. In the first days 
 after injection it showed slight temp, oscillations, but always 
 subnormal. Towards the middle of the third day, temp, rose 
 
36 
 
 ON THE NATURE OP MALARIA. 
 
 above the mean, and at 2 p.m. surpassed 40°, then slowly fell 
 to 39°-4 on the day following. On the fifth there was a strong 
 F. A. (max. 41°), so that, as happens in the tertian type, the two 
 accesses were separated by a day of complete apyrexia. But the 
 same evening there was a stronger and more lasting rise of eight 
 hours' duration, temp. 41°"05. For five days the temp, remained 
 high (40°) with slight exacerbations and remissions. So that 
 after the strong acces of eight hours the fever became subcontinued. 
 
 On the sixth day the fever declined (temp. 39 0, 2). The 
 animal was killed. Before entering on the details of the autopsy, 
 we think it would be useful to note a fact which seems important. 
 Our expectations of positive results in Nos. III. and IV. were at 
 first illusory, and the sudden strong acces of the 29th took us 
 by surprise. It is noteworthy that on this day heavy falls of 
 rain occurred, and a great fall of temp., and that in No. II., 
 on which three days before had been practised the last injection, 
 there took place a notable rise immediately succeeding the 
 strong acces, e (Table III., curves I., II.) On the contrary, 
 Nos. V. and VI., not yet used for experiments, and No. III., 
 which had been injected with -an inactive material, showed a 
 conspicuous fall of temp. 
 
 It seems that the infected animals resisted this atmospheric 
 .change differently to the non-infected ones. 
 
 The following data, furnished by the Director of the Observa- 
 tory of the Roman College, show what these were : — 
 
 Day. 
 
 Barometer 
 lieduued 
 
 to 
 Sea Level. 
 
 Temp. 
 
 Humidity 
 per cent. 
 
 Bain 
 
 Milli- 
 metres. 
 
 Wind. 
 
 Max. 
 
 Min. 
 
 „ 26 
 
 „ 27 
 
 „ 28 
 
 . » 
 
 „ 30 
 
 » « 
 
 " 2 "■•■■-■ 
 
 " 5 
 
 756-6 
 759-5 
 758-7 
 754-5 
 754-0 
 756-8 
 759-0 
 758-8 
 755-3 
 757-8 
 760-9 
 
 19-7 
 19-1 
 19-2 
 16-7 
 13-2 
 15-0 
 17-9 
 153 
 14-5 
 16-5 
 180 
 
 9-1 
 
 7-0 
 
 121 
 
 9-7 
 94 
 8-3 
 83 
 
 7-S 
 8-2 
 80 
 80 
 
 66 
 68 
 69 
 66 
 88 
 79 
 68 
 78 
 80 
 71 
 83 
 
 3-3 
 
 drops 
 
 2-7 
 11-3 
 66-0 
 
 80 
 
 
 
 6-0 
 30-2 
 10-0 
 22'4 
 
 N., S.W. 
 
 N., S.W. 
 
 S.W.,S.E.,N.W. 
 
 E., S.E., S W. 
 
 N., N.E. 
 
 N., N.W. 
 
 N., S.W. 
 
 S.E. 
 
 S.B. .. 
 
 N., S.W. 
 
 N., S.W., N. 
 
 We see corresponding to the, 29th, lower temp. ; diminished 
 ■atmospheric pressure; greater humidity; heavy rain. On the 
 
KESEAKCHES. 37 
 
 30th the atmospheric pressure increases, but the min. temp, is 
 still lower. 
 
 It is therefore probable that cooling of the air and increase of 
 its humidity had influenced the production of the strong febrile 
 accesses in the infected, and had determined a fall of temp, in the 
 non-infected animals. 
 
 Autopsy, No. IV. — "Well nourished; had gained W. 63 gr. 
 since April 26th. Spleen greatly enlarged (Table L, fig. 4) ; 
 L. 67-3 mm.; B. 13 mm.; T. 4-3 mm.; I. S. 2,460, i.e., 
 four times the normal, contracted, capsule wrinkled, and poor 
 in blood. Liver and kidneys congested, but normal. Mesenteric 
 glands enlarged, whitish, rich in lymph. Patches of Peyer 
 slightly elevated, and greyish white. Intestinal mucous mem- 
 brane slightly reddened. Uterus large, placental insertion faint, 
 mucous membrane smooth, reddish. Lungs large, subpleural 
 ecchymoses. Heart contracted. Abdominal veins contain much 
 fluid blood. In the lymph many oval shining corpuscles with 
 active movement ; a few also in the spleen. Cultivations were 
 made with blood collected in capillary tubes. In one bacillus 
 development took place. In the spleen were many large cells 
 containing fragments of red globules and many shining granules ; 
 much brown and a considerable quantity of black pigment in 
 this spleen, which pigment was stained blue by ferrocyanide of 
 potassium and hydrochloric acid. 
 
 C. Parallel experiments on the efficacy of fluid obtained by 
 cultivation in urine of samples of air collected in Ninfa and 
 Fogliano. — These had for their object to discover if any difference 
 existed between the action of the cultivation fluid before and 
 after filtration. 
 
 The cultivation fluid, by means of which the malarious infec- 
 tion had already been produced in No. II., was filtered through 
 a cell of plaster of Paris by means of a Bunsen's pump. 
 
 Sixteen cc. of filtered fluid were injected, May 2nd, by several 
 punctures under the skin of the back of No. III., which had 
 since April 29th onwards had a normal temperature, and from 
 previous researches might be supposed to have a predisposition 
 to resist malarious infection. 
 
 Into No. V., not used in any previdus experiment, was injected 
 only 3'2 cc. of the liquid remaining in the filter. 
 
38 
 
 ON THE NATURE OF MALAKIA. 
 
 Table V. — Temperatures and Weights of Nos. IIT.jind V 
 
 
 
 
 Temperatures 
 
 Differ- 
 
 
 
 
 Temperatures 
 
 Differ- 
 
 
 
 
 and 
 
 ence in 
 
 
 
 
 and 
 
 ence in 
 
 Day. 
 
 Hour. 
 
 Weights. 
 
 Tempe- 
 rature of 
 
 Day. 
 
 Hour. 
 
 . Weights. i 
 
 Tempe- 
 
 
 
 
 III. 
 
 V. 
 
 No. V. 
 from III. 
 
 
 
 
 III. 
 
 . V. 
 
 rature of 
 
 No. V. 
 
 from III. 
 
 May 2 
 
 6 
 
 a.m. 
 
 39-4 
 
 39-7 
 
 + 0-3 
 
 May 6 
 
 8 
 
 p.m. 
 
 39-8 
 
 40-1 
 
 + 0-3 
 
 » j) 
 
 8 
 
 » 
 
 39-1 
 
 39-6 
 
 + 0-5 
 
 ii u 
 
 10 
 
 
 395 
 
 40-8 
 
 + 0-5 
 
 )) 11 
 
 10 
 
 » 
 
 39-3 
 
 39-5 
 
 + 0-2 
 
 „ 7 
 
 6 
 
 a.m. 
 
 39-55 
 
 39-8 
 
 + 0-26 
 
 )J J) 
 
 12 
 
 » 
 
 39-2 
 
 39-6 
 
 + 0-4 
 
 JJ JJ 
 
 8 
 
 
 39-7 
 
 39-9 
 
 + 0-2 
 
 11 J) 
 
 2 
 
 p.m. 
 
 39-2 
 
 39-5 
 
 + 03 
 
 5) J) 
 
 10 
 
 
 39-5 
 
 39-9 
 
 + 0-4 
 
 » J) 
 
 
 — 
 
 1612gr. 
 
 I798gr. 
 
 — 
 
 JJ )J 
 
 12 
 
 noon 
 
 39-3 
 
 39-8 
 
 + 0-5 
 
 11 11 
 
 4 
 
 » 
 
 39-3 
 
 39-4 
 
 + 0-1* 
 
 JJ 11 
 
 2 
 
 p.m. 
 
 39-4 
 
 40-1 
 
 + 0-7 
 
 ii n 
 
 6 
 
 » 
 
 39-fi 
 
 40-0 
 
 + 0-2 
 
 JJ JJ 
 
 4 
 
 
 39-7 
 
 40-1 
 
 + 0-4 
 
 n « 
 
 8 
 
 ii 
 
 40-1 
 
 40-42 
 
 + 0-32 
 
 " 3) 
 
 6 
 
 
 400 
 
 40-2 
 
 + 0-2 - 
 
 » H 
 
 10 
 
 ii 
 
 40-25 
 
 40-2 
 
 — 0-05 
 
 11 11 
 
 8 
 
 
 39-7 
 
 40-1 
 
 + 0-4 
 
 » » 
 
 12 
 
 ii 
 
 40-2 
 
 39-9 
 
 — 0-03 
 
 JJ )) 
 
 10 
 
 
 39-8 
 
 40-0 , 
 
 + 0-2 
 
 ., 3 
 
 12 
 
 noon 
 
 39-1 
 
 40-4 
 
 + 1-3 
 
 
 6 
 
 a.m. 
 
 39-3 
 
 40-0 
 
 + 0-7 
 
 11 J) 
 
 2 
 
 p.m. 
 
 39-5 
 
 40-2 
 
 + 0-7 
 
 J> JJ 
 
 8 
 
 
 39-65 
 
 39-9 
 
 + 0-25 
 
 » )) 
 
 4 
 
 ii 
 
 39-35 
 
 402 
 
 + 0-85 
 
 11 11 
 
 10 
 
 ' 
 
 39-3 
 
 39-85 
 
 + 0-55 
 
 )> 11 
 
 6 
 
 ii 
 
 3S-7 
 
 40-3 
 
 + 0-6 
 
 JJ H 
 
 12 
 
 
 39-4 
 
 39-9 
 
 + 0-5 
 
 11 1) 
 
 8 
 
 i; 
 
 39-8 
 
 40-3 
 
 + 0-5 
 
 JJ JJ 
 
 2 
 
 p.m. 
 
 39-2 
 
 40-0 
 
 + 0-8 
 
 )1 11 
 
 10 
 
 ii 
 
 39-6 
 
 40-1 
 
 + 0-5 
 
 JJ 11 
 
 4 
 
 
 39-5 
 
 40-1 
 
 + 0-55 
 
 „ i 
 
 6 
 
 a.m. 
 
 39-5 
 
 40-0 
 
 + 0-5 
 
 11 11 
 
 6 
 
 
 39-6 
 
 40-3 
 
 + 0-7 
 
 11 11 
 
 8 
 
 ii 
 
 39-65 
 
 39-85 
 
 + 0-2 
 
 11 11 
 
 8 
 
 
 39 5 
 
 40-0 
 
 + 0-5 
 
 11 51 
 
 12 
 
 noon 
 
 39-7 
 
 39-6 
 
 — o-i 
 
 » 11 
 
 10 
 
 
 39-4 
 
 399 
 
 + 0-5 
 
 « » 
 
 2 
 
 p.m. 
 
 39 8 
 
 39-5 
 
 — 0-2 
 
 11 J 
 
 6 
 
 a.m. 
 
 39-4 
 
 39-8 
 
 + 0-4 
 
 JI 11 
 
 4 
 
 » 
 
 39-6 
 
 400 
 
 + 0-5 
 
 » JJ 
 
 8 
 
 
 39-2 
 
 39-7 
 
 + 0-5 
 
 11 J) 
 
 6 
 
 » 
 
 39-4 
 
 40-0 
 
 + 0-6 
 
 JJ 11 
 
 10 
 
 
 39-2 
 
 39-9 
 
 + 0-7 
 
 » J» 
 
 8 
 
 
 39-6 
 
 40-05 
 
 + 0-45 
 
 11 11 
 
 2 
 
 p.m. 
 
 39-5 
 
 400 
 
 + 0-5 
 
 11 J) 
 
 10 
 
 ii 
 
 39-55 
 
 39-95 
 
 + 0-4 
 
 » 11 
 
 4 
 
 
 
 
 400 
 
 
 ,. 5 
 
 6 
 
 a.m. 
 
 39-2 
 
 39-9 
 
 + 07 
 
 JJ 11 
 
 6 
 
 
 39-7 
 
 39-9 
 
 + 0-2 
 
 )> 11 
 
 8 
 
 ii 
 
 40-0 
 
 39-85 
 
 — 15 
 
 11 11 
 
 8 
 
 ii 
 
 39-6 
 
 39-95 
 
 + 0-35 
 
 » JJ 
 
 11 
 
 ii 
 
 1657gr. 
 
 1767gr 
 
 — 
 
 11 11 
 
 10 
 
 
 39-65 
 
 40-0 
 
 + 0-35 
 
 )I ?! 
 
 12 
 
 noon 
 
 39-35 
 
 39-9 
 
 + 0-55 
 
 ,, 10 
 
 6 
 
 a.m. 
 
 39-3 
 
 39-9 
 
 + 0-6 
 
 1) 'i 
 
 2 
 
 p.m. 
 
 39-7 
 
 39-8 
 
 + 0-1 
 
 JJ JJ 
 
 8 
 
 
 39-6 
 
 39-9 
 
 + 0-3 
 
 I) )) 
 
 4 
 
 ii 
 
 39-6 
 
 40-0 
 
 + 0-4 
 
 JJ 11 
 
 10 
 
 
 39-6 
 
 39-85 
 
 + 0-25 
 
 JJ 11 
 
 b" 
 
 ii 
 
 39-7 
 
 40-5 
 
 + 0-8 
 
 
 12 
 
 
 39-5 
 
 399 
 
 + 0-4 
 
 11 11 
 
 8 
 
 ii 
 
 39 8 
 
 40-4 
 
 + 06 
 
 11 11 
 
 2 
 
 p.m. 
 
 39-4 
 
 400 
 
 + 0-6 
 
 JJ J5 
 
 10 
 
 ii 
 
 39-7 
 
 40-1 
 
 + 0-4 
 
 
 4 
 
 
 39-6 
 
 40-05 
 
 + 0-45 
 
 ■i « 
 
 6 
 
 a.m. 
 
 39-3 
 
 39-6 
 
 + 0-3 
 
 11 11 
 
 6 
 
 
 39-7 
 
 400 
 
 + 0-3 
 
 ;i n 
 
 8 
 
 ii 
 
 39-7 
 
 39-8 
 
 + 0-1 
 
 11 11 
 
 8 
 
 n 
 
 39-8 
 
 39-9 
 
 + 0-1 
 
 ji ii 
 
 10 
 
 
 391 
 
 39-7 
 
 + 0-6 
 
 
 10 
 
 
 39-6 
 
 39-85 
 
 + 0-25 
 
 i) >i 
 
 12 
 
 noon 
 
 39-3 
 
 39' 9 , 
 
 -)- 06 
 
 ," 11 
 
 6 
 
 am. 
 
 39-5 
 
 39-9 
 
 + 0-4 
 
 ji ii 
 
 2 
 
 p.m. 
 
 39-4 
 
 40-0 
 
 + 0-6 
 
 
 8 
 
 
 39-4 • 
 
 39-7 
 
 + 0-3 
 
 ii ii 
 
 4 
 
 ii 
 
 39-6 
 
 40-15 
 
 -f 0-55 
 
 ii ii 
 
 10 
 
 ii 
 
 1759gr 
 
 1807gr. 
 
 t 
 
 11 1! 
 
 6 
 
 V 
 
 39-7 
 
 401 
 
 + 0-4 
 
 
 
 
 
 
 
 
 
 » In 
 
 jection of both. 
 
 
 
 t Both killed. 
 
 Autopsy. — Results identical with the cases explained further 
 back. No suppuration at injection sites, not even No. III., in 
 which there were so many punctures ; sup. mesenteric glands 
 enlarged. Both spleens enlarged, but in different proportions. 
 (Table I., figs. 3 and 5.) 
 
 L. B. T. W. of Body. I. S. 
 
 No. III. 51mm. ... 11-8 ... 4-2 ... 1,757 ... 1,410 
 
 „ V. 56 „ ... 11-2 ... 5-6 ... 1,807 ... 1,943 
 
RESEARCHES. 39 
 
 Whilst spleen No. III. contained no pigment except in the 
 form of small granules of a rusty colour, enclosed in a few white 
 cells scattered widely apart, that of No. V. was rich in pigment. 
 The most of this was nickel-coloured, and enclosed in the white 
 cells as granules or in very voluminous masses, or had taken the 
 place of hsemoglohin in the red. globules. - Some of these had 
 preserved their dimensions, homogeneity, and discoid shape, but 
 the haemoglobin was replaced by pigment. Besides the nickel- 
 coloured, a certain amount of black pigment was met with in the 
 spleen, chiefly as granules enclosed in white cells. These 
 results and the temp, curves (Table III., curves III. and V.) show 
 that a malarious infectidn was produced in both, but of less 
 intensity by the filtered than by the unfiltered fluid, although 
 No. III. was weakened by a previous experiment. 
 
 The fever type in V. was quotidian, with max. intensity 
 at the 1st, 4th, and 7th F. A., as if it was a combination of a 
 quotidian and a tertian. Without wishing to assign an undue 
 value to the manifold distinctions in the simple and compound 
 forms of intermittent, we think it very probable that the 
 great variety of type depends on , corresponding variety in the 
 intensity of the infecting agent, which may have a diagnostic 
 importance. Probably very frequent measurements of the 
 temp, in man would tend to increase the number of recognized 
 forms. 
 
 This experiment tells in favour of the conclusion that separa- 
 tion of the solid particles of an infecting fluid robs it of much of 
 its power and generates a mild type of fever. The degree of 
 completeness of the separation is, in our cases, uncertain, but at 
 all events it goes to confirm what was discovered by cultivations, 
 viz., that the solid particles capable of development are the 
 carriers of the virus ; however, we cannot yet absolutely exclude 
 the possibility that the fluid in which the organisms are sus- 
 pended, and in which the products of their material change are 
 found, may concur in the morbigenous action they undoubtedly 
 possess. Experiments on Nos. XV. and XVI., and on VIII. and 
 XII., gave an analogous result. 
 
 D. Parallel researches with the bacillus malaria, cultivated in 
 an open and a closed vessel. 
 
 April 23rd. — To two cultivation tubes of fish gelatine was 
 added a very small quantity of Caprolace mud, one sealed by the 
 
•10 ON THE NATURE OF MALARIA. 
 
 lamp, the other plugged with cotton, previously kept at a high 
 temp. ; both maintained at 30° to 50°. 
 
 May 5th. — A whitish scum appeared on the first tube denser 
 than that on the second. Examined microscopically, motionless 
 rods were seen in the first cultivation, ajid others which oscillated 
 gently. In the first were brilliant nuclei, which were wanting 
 in tbe second; in addition many free oval spores were seen. 
 In the second cultivation only rods and motionless filaments 
 with spores. Tubes closed, and, May 9th, contents used for two 
 parallel researches. 
 
 May 9th, 10 a.m. — No. IX. injected with 1;04 cc. of open 
 cultivation, and No. X. with 32 cc. of closed cultivation. 
 
 No. IX. had from the commencement a strong F. A. of 
 24 hours' duration, with two max. temp, of 40 o- 3 and 40°"2, 
 and interposed min. of 39 0, 45 (Table IV., curve IX.). On the 
 11th, 12th, and 13th the temp, was normal, with rather marked 
 oscillations ; 14th appeared a F. A., which lasted 48 hours, and 
 in which three notable rises of temp, were observed with inter- 
 vening falls, during which the temp, was always above tha 
 normal (curve IX., a, b, c). May 16th, 6 a.m., temperature still 
 40° ; at 10 a.m. fell to 39 a 2, i.e., sub-normal ; 17th, 18th, and 
 19th, temp, at or below normal ; 20th, in the morning aborted 
 [two] ; temp, at 6 p.m., 39 0, 8. Killed. 
 
 No. X. Very similar temp, curve (Table IV., c. X.) ; first 
 F. A. after injection and two maxima, but nearer together. 
 Three days following temp, fell, but always above the normal. 
 13th, 6 a.m., temp. 40 o, 05. This second acces commenced a 
 day earlier than in No. IX., lasted three days, and showed four 
 chief phases of recrudescence and remission (c, X., a, b 2 , c, d). 
 The maxima and minima are a little lower than in No. IX. On 
 five succeeding days temp, above, and then fell to -normal. 
 
 Although in No. X. the quantity of injected material was. 
 greater than in No. IX., the first F. A. was shorter, and the second 
 represented a subcontinuous of less intensity and longer dura- 
 tion. It is probable the infective power of the closed was less 
 than that of the open cultivation, and would have been more 
 marked if the former had not contained a notable quantity of air. 
 In fact, in the cultivations made with absolute exclusion of air, 
 the development of the bacillus was suspended, and they could 
 not be used for experiment. 
 
RESEARCHES. 41 
 
 The following table shows that after the injection and first F. A. 
 they gained weight, and this in No. X. continued up to death: — 
 
 May 8... 
 
 ... 1,902 gr. .. 
 
 .... 1,819 gr. 
 
 
 » 9... 
 
 ...1,818 „ .. 
 
 .... 1,715 „ 
 
 Injection. 
 
 „ 16... 
 
 ...1,893 „ .. 
 
 .... 1,796 „ 
 
 After second acces of 
 fever. 
 
 „ 17... 
 
 ...1,775,, .. 
 
 .... 1,813 „ 
 
 
 „ 18... 
 
 ...1,777,, .. 
 
 — 
 
 
 „ 20... 
 
 
 
 No. IX. aborted (weight 
 of two abortions, 65gr.) 
 
 >, 21... 
 
 ...1,596 „ .. 
 
 .... 1,847 „ 
 
 
 Both killed May 21st. No. IX., spleen moderately enlarged, 
 firm and dark-coloured ; that of No. X. more voluminous, clearer 
 coloured, and softish. In both slight pulmonary oedema, and in 
 No. X. intra-alveolar extravasations. Size of spleen as follows 
 (Table I, figs. 9 and 10) :— 
 
 
 L. 
 
 B. 
 
 T. 
 
 i.s: 
 
 No. IX. . 
 
 .. 46-0 mm. 
 
 ... 10-8 mm. , 
 
 ... 3-0 mm. 
 
 ... 934 
 
 ., x. . 
 
 .. 60-8 „ 
 
 ... 13-7 „ 
 
 ... 6-1 „ 
 
 ...2,754 
 
 These two experiments prove that bacilli cultivated in fish 
 gelatine produce intermittent fevers, but do not establish a. 
 decided difference between those cultivated in open and in closed 
 vessels. 
 
 Group III. Researches with samples of soil of the Janiculan. 
 — Dr. Fleischl, physician in Home, politely informed us that 
 Signor W., proprietor of the Villa Spada, on the Janiculan, had 
 been attacked by a grave form of fever, at a time when such had 
 not yet appeared in Rome. This was owing to a great dis- 
 turbance of the soil near the villa, in immediate proximity to the 
 bedroom of Signor W. (on the ground floor). These excavations 
 had been made in soil rich, in humus, which had long been used 
 as a garden, and in a clayey soil lower down, where an orange 
 plantation was being made. May 2nd we brought to the 
 laboratory specimens of both kinds of soil, taken from below the 
 superficial layers of soil, and made with them artificial marshes, 
 as described in Chapter II., which were kept in an air bath at a 
 temp, of 35° — 36°. In water mixed with these soils were seen 
 
42 
 
 ON THE NATUKE OP MALARIA. 
 
 very many self-moving oval corpuscles, of max. diam. 0*00095 
 mm., sometimes united in twos and threes, in rows which 
 oscillated. In specimens of soil from the new Botanic Gardens 
 on the Viminal, used for comparison, these bodies were found 
 but sparingly, and never united in rows. 
 
 May 6th. — Nos. VII. and VIII., not previously employed for 
 experiment, were injected with mixtures of these soils, from the 
 artificial lakes, with water — No. VII., 6 - 4 cc. of fluid from clayey 
 soil, and No. VIII., the same quantity from soil rich in humus. 
 
 No. VII. had in eight days four F. A., with ever-increasing 
 temp. (1st, 39°-9; 2nd, 39 a 8; 3rd, 40 a 3; 4th, 40°-3, 40°.l, 
 40 o, 3). Even in the remissions the temp, went on increasing. 
 In the next six days the fever assumed the quotidian type, and 
 the max. rose gradually to 41 0, 1. 
 
 No. VIII. from May 6th to 16th showed much less marked 
 temp, rises. The maxima oscillated between 39°'9 and 40°"05 ; 
 the two first 24 hours, and others 48 hours apart. 
 
 
 Table of Weights. 
 
 
 Til. Till. 
 
 Observations. 
 
 May 6 . 
 
 .. 2,429gr. ... l,838gr. 
 
 Injections practised. 
 
 „ 14 . 
 
 — ... — 
 
 No. VII. had seven young 
 ones, not weighed. 
 
 „ 16 . 
 
 .. 2,092 „ ... 1,898 „ 
 
 
 „ 17 . 
 
 .. — ... 1,878 „ 
 
 
 „ 19 • 
 
 — ... — 
 
 No. VIII. had five young 
 ones, weighing 214 gr. 
 
 „ 20 . 
 
 .. 1,965 „ ... 1,719 „ 
 + 214 „ 
 
 • 
 
 1,933 gr. 
 
 May 20th, both killed. Aufopsy, No. VII.— Spleen much 
 enlarged (L. 56"3 ; B. 12"8 ; T. 3-5 mm. ; I. S. 1,289), colour 
 darker and consistence less than normal; small quantity of 
 black pigment. Many ecchymoses of pleura, and in superior 
 (in man, posterior) parts of lungs diffused hypersemia and 
 cedema. Eight heart gorged with fluid blood. Injection sites 
 normal. 
 
 No. VIII., spleen less enlarged (L. 49-0; B. 11-0; T. 3'0 ; 
 I. S. 837). Normal colour and consistence ; very few granules 
 
RESEARCHES. 43 
 
 of black, and considerable quantity of dark red pigment; san- 
 guinolent fluid in pleural cavities ; partial atelectasis of lungs 
 with slight emphysema of lower (in man, anterior) border. 
 Injection sites normal. 
 
 The results of these experiments point to the great difference 
 of development of the agent in virgin soils, compared with those 
 long under garden culture. It would seem as if the latter 
 reduced the danger to a minimum, but one experiment with 
 soils from one place is not conclusive. 
 
 Group IV. Experiments with samples of soils of Agro- 
 Romano. — The soils used in these were taken from the farm of 
 Valchetta (Cav. Francesco Piacentini). The first from a marsh 
 situated on one of the hills. The second from a marsh near the 
 hamlet. The third from a pasture lately broken up by the 
 plough in the valley of the Cremera. All collected May 9th. 
 A fourth from an artichoke ground was received May 17th from 
 Signor A. Piacentini. 
 
 With the first three artificial marshes were farmed and kept at 
 30° — 35°. May 14th a first experiment was performed with earth 
 from the marsh near the hamlet. A portion was mixed with an 
 equal volume of Marcia water,* and after the heavier particles 
 had subsided 6'4 cc. were injected under the dorsal integument 
 of No. XII., which had had a slightly subnormal temp, for six 
 days, except on the 13th (Table V., curve XII.). After the 
 injection the temp, rose to 38°" 6, and then fell below the normal. 
 15th, about noon, it rose to 39° # 9, and again descended below 
 the normal, 38 0, 6. These brief and slight rises of temp, were 
 not considered to be due to the injection, as a similar one had 
 occurred the day before it was practised. It was used therefore 
 in another experiment. 
 
 With soil from the hill marsh two parallel experiments were 
 instituted, the injection fluid being prepared as before, and 
 No. XII. was injected (May 16th) with 6 - 4 cc. It was then 
 filtered through Swedish paper, and 6-4 cc. of the filtered liquid 
 injected into No. VIII., already used in an experiment (see last 
 group). After injection the temp, in No. XIII. rose to 40 o, 2, 
 then fell below the normal. On the 17th, at 10 a.m., a second 
 injection was used of an equal quantity of the filtered fluid. 
 
 * A very pore Roman water. 
 
44 
 
 ON THE NATUKE OP MALAEIA. 
 
 The temp, rose for a short time to 40°, but was not renewed. 
 Animal killed May 20th. The filtered fluid had produced 
 an intermittent fever, with slightly elevated maxima. In last 
 intermission temp, subnormal. 
 
 No. XII., which had been simultaneously injected with an 
 equal quantity of the same liquid unfiltered, had in 36 hours 
 3 F. A., with always higher max. and min. Two maxima 
 reached 40°-8 and 40 o, 6, then rapidly diminished, and the last 
 temp, registered (10 p.m.) was 39°-4. The night of 17th the 
 animal died. 
 
 From 16th to 17th it had lost 166 gr. On the 16th it had 
 one abortion, weighing, 30 gr. Autopsy.— Blood coagulated— a 
 second abortion protruding from vaginal orifice. Suppuration 
 at injection sites. 
 
 The usual oval self-moving corpuscles mixed with the pus cells 
 in large quantity. Many filaments of bacillus malaria, some 
 very' long. Some of the joints contained spores. 
 
 Spleen much enlarged (Table I., fig. 12), it had reached 
 dimensions never before witnessed by us in these malarious 
 infections; L. 81*8 mm.; B. 19"4; T. 6"9; I. S. = 5,903, i.e., 
 almost eight times the normal. It was rather soft, but its 
 angles and borders were not rounded ; the transverse section was 
 triangular, the colour slate. In the splenic pulp examined fresh, 
 were seen many oval self-moving spores, some bacilli. L. 0"001 
 — # 002, and even long or homogeneous filaments. Many cells of 
 the spleen contain granules of black pigment. Even the bone 
 marrow contained many self-moving spores and bacilli. In 
 addition were found long and homogeneous filaments of the width 
 o/0'0006 mm., and mean length of 0*06 mm., some reached a 
 length of 0*084 mm. All these observations were made with a 
 solution of 0"75 per cent, of chloride of sodium in distilled water, 
 freshly prepared, and in which a most careful examination failed 
 to detect any trace of organisms. Without adding any liquid, 
 however, we could observe these filaments in the bone marrow 
 and the spleen. Professor Bizzozero, who was in Borne at the 
 time, kindly assisted in these observations and measurements. 
 The kidneys were very large, especially the left. Their upper 
 surface was bounded by the limit of the inflammatory foci in 
 the injection sites. The liver was dark-coloured and very large. 
 The uterus contained four immature young ones. The right heart 
 
RESEARCHES. 
 
 45 
 
 was gorged with grumous blood. Both lungs oedematous with 
 diffuse hyperemia, and some recent ecchymoses. We here see 
 rise up from the action of the liquid prepared from the hill 
 marsh (which after filtering produced the weak infection in 
 No. VIII.) a true pernicious fever, which killed the animal in 
 36 hours, and in the course of which, bacillus malaria, diffused 
 through the body, accumulated in the spleen and bone marrow, 
 where it attained a very high development.* The doubts which, 
 might in this case exist, from the complication of suppurations 
 in the back, will vanish from the study of the following case, in 
 which the malarious infection produced by the same material 
 ran its course without complication of any kind. This com- 
 plication was probably due to the fact that the earth employed 
 contained much excrementitious matter, and might easily cause 
 suppurative inflammation. Of a liquid prepared in the same 
 way from earth derived from the hill marsh of Valchetta 
 unfiltered, were injected 6"4 cc. into the back of No. XIII. 
 (May 14th, 8 a.m.), which had been under observation for 
 three previous days, and not used in any other experiment. 
 From the importance of the case, we think it well to give in 
 addition to the temp, curve (Table V., curve XIII.) the table 
 of figures. 
 
 Table VI. — Temperature and Weight of No. XIII. 
 
 Day. Hour. 
 
 Temp. 
 
 Weight. 
 
 Day. 
 
 Hour. 
 
 Temp. 
 
 Weight. 
 
 Observation.". 
 
 May 12 
 
 4 
 
 p.m. 
 
 39-5 
 
 l,567gr. 
 
 May 13 
 
 10 
 
 p.m. 
 
 39-65 
 
 
 
 jj » 
 
 6 
 
 » 
 
 3935 
 
 
 „ 14 
 
 6 
 
 a.m. 
 
 396 
 
 
 
 i> « 
 
 8 
 
 » 
 
 39-3 
 
 
 JJ JJ 
 
 8 
 
 jj 
 
 39 5 
 
 l,481gr. 
 
 Injection. 
 
 JJ JJ 
 
 10 
 
 jj 
 
 39-2 
 
 
 JJ JJ 
 
 10 
 
 jj 
 
 40-5 
 
 
 
 „ 13 
 
 6 
 
 a.m. 
 
 393 
 
 
 JJ JJ 
 
 12 
 
 noon 
 
 401 
 
 
 
 » jj 
 
 8 
 
 » 
 
 397 
 
 
 JJ JJ 
 
 2 
 
 p.m. 
 
 41-1 
 
 
 
 jj j) 
 
 10 
 
 » 
 
 39-3 
 
 
 J) JJ 
 
 4 
 
 » 
 
 41-5 
 
 
 
 
 12 
 
 noon 
 
 39-5 
 
 
 JJ JJ 
 
 6 
 
 
 41-2 
 
 
 
 
 2 
 
 p.m. 
 
 39 9 
 
 
 JJ JJ 
 
 8 
 
 
 41-15 
 
 
 
 
 4 
 
 jj 
 
 397 
 
 
 IJ JJ 
 
 10 
 
 
 41-2 
 
 
 
 
 6 
 
 jj 
 
 39-3 
 
 
 „ 15 
 
 6 
 
 a.m. 
 
 374 
 
 
 • 
 
 » jj 
 
 8 
 
 JJ 
 
 398 
 
 
 jj jj 
 
 8 
 
 jj 
 
 — 
 
 — 
 
 Found dead. 
 
 * It is important to notice that the greatest malarious infections (XII., XIII., and 
 XIV.) were produced by soil which had for three days been subjected to treatment, which, 
 as we have said already, impedes the development of algce, and arrests it at the outset 
 in mud, in which it was most luxuriant, a fact which has an important bearing on 
 the o'.servations of Salisbury and Balestra. 
 
46 ON THE NATURE OF MALARIA. 
 
 Autopsy made immediately. Spleen much enlarged, soft, 
 dark-coloured (Table I., fig. 13) ; L. 58'0 ; B. 143 ; T. 4-8. 
 Having omitted to weigh the animal before opening it, the I. S. 
 was calculated in reference to the animal's weight before the 
 febrile acces. It was 2,124 ; therefore it had become 3"2 times 
 larger than the normal in 24 hours. 
 
 The splenic pulp examined fresh contained granules and, 
 irregular masses of brown and black pigment, very many auto- 
 matically moving spores, some bacilli and long homogeneous fila- 
 ments of a breadth of 0*0006 mm. and a mean length of 0'07 mm. 
 In the marrow of the bone were found many oval corpuscles, 
 some of them enclosed in the large white cells, some of those 
 free were double. Some self-moving oval bodies found in the 
 blood of the portal vein, and inferior vena cava. 
 
 In the lymph of the superior mesenteric glands were found 
 very many oval spores and bacilli in abundance. 
 
 No other change was found in the other organs of the body. 
 The gravity of this case, in which, without any complication, a 
 pernjciosa even more intense than that which killed No. XII. 
 with identical microscopic results, renders very interesting the 
 comparison of it with No. VIII. In the latter the same sub- 
 stance was injected in equal quantity to that used for No. XII., 
 and double that used for No. XIII., but the liquid was first 
 filtered through paper, and this simple and incomplete filtration 
 was sufficient to reduce the morbid power from the proportions 
 it assumed in Nos. XII. and XIII. to the slender ones even in 
 
 No. VIII. 
 
 The third sample of soil, taken from a field recently ploughed 
 in the Val de Cremera, was derived from a non-marshy soil, 
 which owing to the ploughing had been exposed to the action 
 of air more than the two preceding. This circumstance made 
 us suppose that the development of malaria might here have 
 attained greater proportions, and this was borne out by the 
 
 results. 
 
 No. XIV. not used before, and whose temperature had 
 been normal for two whole days, was injected May 14th, at 
 10 A.M., with 6'4 cc. of a mixture of equal parts of Mareia 
 water and the soil in question, after subsidence of the heavier 
 particles. 
 
EESEARCHES. 
 
 47 
 
 Table VII. — Temperatures and Weights of No. XIV. 
 
 Day. 
 
 Hour. 
 
 Temp. 
 
 Weight in 
 Grammes. 
 
 Day. 
 
 ■ Hour. 
 
 Temp. 
 
 Weight in 
 
 Grammes. 
 
 May 12 
 
 4 p.m. 
 
 393 
 
 1,421 
 
 May 
 
 16. 
 
 10 p.m. 
 
 40-5 
 
 
 JJ JJ 
 
 6 j, 
 
 39-3 
 
 
 
 17 
 
 6 a.m. 
 
 40-7 
 
 
 JJ JJ 
 
 8 j. 
 
 393 
 
 
 
 
 8. „ 
 
 40-8 
 
 
 jj jj 
 
 10 „ 
 
 39-25 
 
 
 
 
 10 „ 
 
 406 
 
 1,309 
 
 „ 13 
 
 6 a.m. 
 
 3925 
 
 
 
 
 12 „ 
 
 40-8 
 
 
 JJ JJ 
 
 8 „ 
 
 39-2 
 
 
 
 
 2 p.m. 
 
 40-7 
 
 
 JJ JJ 
 
 10 .„ 
 
 39-0 
 
 
 
 
 4 „ 
 
 40-6 
 
 
 JJ JJ 
 
 12 noon 
 
 39-1 
 
 
 
 
 6 „ 
 
 40-7 
 
 
 JJ JJ 
 
 2 p.m. 
 
 394 
 
 
 
 
 8 „ 
 
 41-1 
 
 
 JJ JJ 
 
 4 „ 
 
 39-5 
 
 
 ,j 
 
 jj 
 
 10 „ 
 
 41-3 
 
 
 JJ JJ 
 
 6 „ 
 
 393 
 
 
 
 18 
 
 6 a.m. 
 
 41-1 
 
 
 JJ JJ 
 
 8 „ 
 
 396 
 
 
 5J 
 
 JJ 
 
 8 „ 
 
 41-2 
 
 
 JJ JJ 
 
 10 „ 
 
 395 
 
 
 
 
 10 „ 
 
 40-9 
 
 
 ,, " 
 
 6 a.m. 
 
 39-4 
 
 1,412 
 
 
 
 12 noon 
 
 40-7 
 
 
 JJ J) 
 
 8 „ 
 
 39-4* 
 
 
 ,5 
 
 )J 
 
 2 p.m. 
 
 40-6 
 
 
 JJ JJ 
 
 10 „ 
 
 40-2 
 
 
 5, 
 
 JJ 
 
 4 „ 
 
 40-7 
 
 
 JJ JJ 
 
 12 „ 
 
 39-9 
 
 
 
 
 6 „ 
 
 40-75 
 
 
 JJ JJ 
 
 2 p.m. 
 
 41-25 
 
 
 
 JJ 
 
 8 „ 
 
 40-5 
 
 « 
 
 JJ JJ 
 
 3 „ 
 
 41-8 
 
 
 55 
 
 JJ 
 
 10 „ 
 
 40-4 
 
 
 JJ JJ 
 
 6 „ 
 
 41-3 
 
 
 
 19 
 
 6 a.m. 
 
 40-4 
 
 
 JJ JJ 
 
 8 „ 
 
 41-0 
 
 
 ,5 
 
 
 8 „ 
 
 40-4 
 
 
 JJ JJ 
 
 10 „ 
 
 40-9 
 
 
 55 
 
 » 
 
 10 „ 
 
 40-5 
 
 
 „ 15 
 
 6 a.m. 
 
 407 
 
 
 
 
 12 noon. 
 
 40-4 
 
 
 J) JJ 
 
 8 „ 
 
 40 6 
 
 
 55 
 
 jj 
 
 4 p.m. 
 
 40-3 
 
 
 JJ JJ 
 
 12 noon 
 
 40-4 
 
 
 55 
 
 jj 
 
 6 „ 
 
 41-2 
 
 
 JJ JJ 
 
 2 p.m. 
 
 40-8 
 
 
 55 
 
 jj 
 
 8 „ 
 
 41-5 
 
 
 JJ JJ 
 
 4 „ 
 
 40-0 
 
 
 
 jj 
 
 10 „ 
 
 41-2 
 
 
 JJ JJ 
 
 6 „ 
 
 407 
 
 
 55 
 
 20 
 
 6 a.m. 
 
 40-7 
 
 
 JJ JJ 
 
 8 ' „ 
 
 40-4 
 
 
 55 
 
 JJ 
 
 8 „ 
 
 40-6 
 
 1,345 
 
 JJ JJ 
 
 10 „ 
 
 40-6 
 
 
 55 
 
 JJ 
 
 12 „ 
 
 401 
 
 
 „ 16 
 
 6 a.m. 
 
 40-1 
 
 
 55 
 
 
 2 p.m. 
 
 40-5 
 
 
 JJ )J .' 
 
 8 „ 
 
 40-0 
 
 
 55 
 
 J) 
 
 4 „ 
 
 40-2 
 
 
 ■ JJ JJ 
 
 10- „ 
 
 398 
 
 1,303 
 
 J5 
 
 JJ 
 
 6 „ 
 
 40-2 
 
 
 JJ JJ 
 
 2 p.m. 
 
 ■ 40-95 
 
 
 5, 
 
 JJ 
 
 8 „ 
 
 40-0 : 
 
 
 JJ JJ 
 
 4 „ 
 
 40-2 
 
 
 ,5 
 
 JJ 
 
 10 „ 
 
 40-5 
 
 
 )J JJ 
 
 « „ 
 
 40-1 
 
 
 55 
 
 21 
 
 6 a.m. 
 
 40-9 f 
 
 1,373 
 
 JJ JJ 
 
 8 „ 
 
 40-6 
 
 
 
 
 
 
 
 
 * Injection 
 
 , 6-4 cc. of liquid. 
 
 
 t Was killed. 
 
 
 This fever is one of the most characteristic in its course, and 
 at the same time one of the gravest, produced by us, having a 
 maximum temp, in the first F. A. of 41°"8, and in the third 
 of 41° - 5. And although it was so grave, the weight went on 
 increasing after the first remission, but not much (70 gr.) 
 
 Autopsy. — Great poverty of blood in the entire organism, and 
 this so pale that it could not be used to obtain the nature print 
 of the spleen, so that the blood of No. X., killed the same time, 
 had to be used instead. Spleen very large, soft, dark-coloured, 
 triangular on section (Table I., fig. 14). L. 62"4 ; B. 12'8 ; 
 T. 4'8 ; I. S. 2,793, i.e., four times the normal ; contained large 
 
48 ON THE NATURE OF MALARIA. 
 
 quantity of black pigment and self-moving oval spores, diameter 
 0"00095, but no bacillus or filament. 
 
 The oval corpuscles also existed in the marrow and aqueous 
 humour of the eye, reserved for microscopic use to dilute other 
 preparations. 
 
 The lymph was very rich in these oval bodies, of the superior 
 mesenteric glands, which was charged with pigment. In classi- 
 fying these soils according to their infective power, the lowest place 
 must be assigned to that from the marsh near the hamlet, and this 
 and the soil from the garden of the Villa Spada seems to indicate 
 that culture and admixture of excrementitious matter diminish 
 the infective energy. We therefore made another experiment 
 with soil from an artichoke ground near the ploughed field of 
 which the soil was used in No. XIV. Time not permitting the 
 employment of the means used in that case, we contented our- 
 selves with mixing it with an equal quantity of water, and used 
 the liquid after subsidence of the heavier particles. Nos. XV. 
 and XVI. (not used before, and of which the temp, had been 
 normal for two days) were injected with 6'4 cc. of the turbid 
 unfiltered liquid in the case of No. XVI., and of the same after 
 passing through a double filter in the case of No. XV. (Table 
 V., curves XV. and XVI.) 
 
 No. XVI. had three febrile accSs in three days, with always 
 diminishing maxima and increasing minima. The type being 
 quotidian passing into subcontinuous remittent. No. XV. had 
 one acces of 40°'15 of short duration, then for 14 hours a sub- 
 normal temp. Afterwards three slight rises of 0°"1 or 0°*2 
 above the mean at irregular intervals. 
 
 This double experiment, while showing that the infective 
 power of the liquid was diminished by filtration, also showed 
 that it had been already much limited even before filtration, 
 which may be cited in favour of the hypothesis, that a judicious 
 cultivation of the soil diminished the production of malaria, even 
 in regions in which this production is greatest. 
 
 "We have the intention to undertake much more extensive and 
 complete researches to endeavour to solve this problem. 
 
 Group V. Experiments with specimens of earth derived 
 from non-malarious places. — We only had time for two experi- 
 ments of this kind. It is very probable that the diffusion of 
 these germs is greater than may be revealed by the existence of 
 
RESEARCHES. 
 
 49 
 
 endemic malaria ; and that they exist in many places where this 
 is lacking, simply because the necessary conditions of complete 
 development are not present. By artificially prbctiring these 
 conditions, we may render infective samples of earth from places 
 where malaria shows no influence on the human body. 
 
 These two experiments were made with soil from a garden 
 attached to the Pathological Institute of the University of 
 Prague. This, earth was a disintegrated silurian schist, in situ 
 for twenty years, manured for the two last years, but not touched 
 this year, and therefore very compact. 
 
 With this soil an artificial marsh was made as before, and 
 kept for four days at a temp, of 35°— 40°. June 9th, a portion 
 of this was mixed with water, in the usual way, and 10 cc. of 
 the turbid liquid injected under the skin of the back of a large 
 rabbit, No. XIX., weighing 2,479 gr. 
 
 The liquid was then passed through a double filter of Swedish 
 paper, and 10 cc. injected in the same way into No. XX., which 
 weighed 1,680 gr. 
 
 After the injection there arose in No. XIX. a fever, during which 
 the temp, was much above the normal (Table V., c. XIX. and XX.). 
 This continuous fever had after the first remission (39°'9) two 
 recrudescences, during which the temp, ran up to 41°"1 and 41°'8. 
 From the last up to its natural death, which happened when the 
 animal had still a temp, of 40 o, 4, elapsed 22 hours. 
 
 In No. XX. after injection arose a fever, similar to a quotidian. 
 The six accesses are divided into two groups of three each, sepa- 
 rated by an intermission between the 3rd and 4th acces, in which 
 the temp, fell from 40 o- to 37°'5, to rise again during the 4th 
 acces to 40 o, 3. No. XX, was killed when No. XIX. died, and 
 the two autopsies made at once. 
 
 In No. XIX. a large abscess at injection site, grave pulmonary 
 oedema ; organs atrophied and poor in fat ; spleen enlarged and soft. 
 
 In No. XX. general atrophy very pronounced; spleen very 
 
 small. Both had lost weight largely. 
 
 Weight. 
 
 At commencement. At the end, Los-3. 
 
 XIX 2,749 gr 2,285-5 gr 463-5 gr. 
 
 XX 1,680 , 1,175-5 504-5 „ 
 
 SrzE of Spleen. 
 L. B. : T. 1.8. 
 
 XIX 60-8 mm. ... 11-2 mm. ... 4-0 mm. ... 1,261 1 Normal Index, 
 
 XX 30-8 „ ... 4-8 „ ... 1-6 „ ... 201 J 6C4. 
 
 4 
 
50 
 
 ON THE NATTJEE OF MALARIA. 
 
 In No. XIX. the fever was undoubtedly septic. In No. XX, 
 probably hectic from septic infection, in which, as often happens 
 in man, the temp, alternations resemble malarious quotidian. 
 
 Group VI. Septic infections produced spontaneously in 
 animals under experiment. — In two animals introduced into the 
 laboratory septic infection occurred before they had been used 
 for experiment. In one, No. VI., the temp., at first subnormal, 
 increased continuously till it reached, before the natural death 
 of the animal (Table IV., curve VI.), the height of 40 o, 9. 
 At the autopsy was found grave peritonitis with effusion of 
 serum and masses of fibrin, produced by perforating ulcer of the 
 large intestine ; anasmia, with dense grumous clots in the heart ; 
 lungs extremely oedematous ; spleen moderately enlarged, soft, 
 pale red coloured, angles much rounded (Table I., fig. 6). It 
 contained no pigment. 
 
 So. 
 
 Weight of Body. 
 
 Dimensions of Spleen. 
 
 I. S. 
 
 Beginning. 
 
 End. 
 
 Length. 
 
 Breadth. 
 
 Thickness. 
 
 YI. 
 
 1,V36 gr. 
 
 1,057 gr. 
 
 63 00 mm. 
 
 90 mm. 
 
 4*6 mm. 
 
 1968 
 
 
 The second was a large rabbit (No. XL), which had fever when 
 brought to the laboratory (Table IV., curve VI.). The temp, 
 rose on the second and third days to 40°'0 and 40 o, 3, then came 
 two short remissions ; the fourth day it rose gradually to 40 a 8. 
 Abscess in neck opened. Gradual fall of temperature for two 
 following days, perhaps helped by magnes. benzoate. Strong 
 fever lasting six and a half days, until it was killed. Fever 
 always high even in the remissions, except at the middle of the 
 second day, when for a very short time it was subnormal. This 
 animal during the fever ate enormously and gained weight a 
 little. 
 
 Autopsy.— Spleen very large and soft, with rounded borders 
 and elliptical section (Table I., XI.); no pigment; blood watery 
 and colourless ; pleura pulmonalis ecchymosed ; luDgs hyper- 
 semic and oedematous; right heart gorged, left empty; an 
 immense abscess in submaxillary, and extensive purulent infil- 
 tration in scapular region. 
 
RESEARCHES. 
 I 
 
 51 
 
 No. 
 
 Weight of Body. 
 
 Dimensions of Spleen. 
 
 i.s. k 
 
 Beginning. 
 
 End. 
 
 Length. 
 
 Breadth. 
 
 Thickness. 
 
 XI. 
 
 2,57'8 gr. 
 
 2,655 gr. 
 
 79 mm. 
 
 138 mm. 
 
 65 mm. 
 
 2669 
 
 
 Supplementary Notes. 
 
 While the authors are aware that further and very extensive 
 researches are required before the subject is exhausted, they 
 claim to have proved — 1st. That malarious affections may be 
 produced artificially in animals in the identical forms known to 
 human pathology. 2nd. That these artificially-produced ma- 
 larious affections are excited by organisms, which are found in 
 the soil of malarioua places before the appearance of the fevers, 
 and are, even then, diffused in the strata of the air nearest the 
 soil. 
 
 Certain farther facts, not fully set forth in the preceding, the 
 confirmation of which was independently arrived at by Professor 
 Marchiafava, call for statement. 
 
 1st. Anatomical changes observed in animals in which ma- 
 larious infection had been induced. 
 
 a. The uniform swelling, triangular section, sharp edges and 
 borders, markedly distinguish malarious from septic enlargement, 
 in which the organ is rounded. 
 
 b. The presence of black pigment, derived, as Marchiafava has 
 shown, from the haemoglobin of the blood, and containing iron in 
 inorganic combination, as shown by the blue colour resulting 
 from the reaction with weak hydrochloric acid and ferrocyanide 
 of potassium. Therefore it is indisputable that in malarious 
 diseases hamoglobin becomes decomposed even in the blood 
 globules still intact, in such a way as to set free the iron which 
 at first was united with other organic compounds, and could not 
 be traced by this reaction. The name melancemic, by which it is 
 distinguished, is therefore justified. In the greater part of our 
 artificially produced cases this pigment was present. The largest 
 quantity was seen in the spleen of No. XIV., in which recently 
 ploughed earth of Valchetta was used, and in which severe fever 
 occurred running up to 41 0, 8. The pigment was most abundant 
 
52 ON THE NATUEE OF MALAEIA. 
 
 in the peripheral parts of the spleen,, and formed masses, large 
 and irregular, or of a rounded contour, slightly smaller than a 
 blood globule. The transformation of the haemoglobin was, in 
 the preparations, traced through all its stages, .and also in those 
 preserved in Canada balsam. 
 
 In No. XIV. only was melansemic pigment found in any other 
 organ but the spleen. Perhaps the brief duration of very severe 
 fever in this case, and the slight gravity but long continuance of 
 it in the others, explains this difference. Even in this animal, 
 however, the pigment could not be seen. except in the superior 
 mesenteric glands, which were of a greyish brown colour. The 
 pigment was chiefly accumulated in the lymph sinuses* where 
 groups of granules were seen, some transparent and of a nickel 
 colour, others opaque and black. 
 
 The perfect identity of these with those found in the spleen; 
 the smallness of- the pigment masses, the absence of transition 
 forms, and the site of the accumulations, show that the pigment 
 had not been formed in those glands, but conveyed to them after 
 tbe disintegration of the pigment masses. Since neither the 
 blood nor inferior lymphatic glands contain traces of this pig- 
 ment, it cannot have been derived from trie intestines or blood 
 vessels, but must be supposed to have been .imported into the 
 superior lymphatic vessels by the lymphatics which connect them 
 with the spleen. 
 
 In Nos. XII. and XIII. the amount of pigment was much less 
 than in No. XIV. Of the two former, the spleen of No. XIII. 
 was richest in melansemic pigment; although the duration of 
 fever was shorter, the temperature and swiftly fatal course point 
 to a severer form of infection than in No. XII. The greater 
 proportion was found in the Malpighian corpuscles and in the 
 vicinity of the arteries, probably owing to rapid introduction of 
 pigment into the circulation, as we cannot admit that it had 
 formed in these corpuscles, in which we never found any trace 
 of pigmentation, not even in No. XIV., which had a true black 
 spleen. 
 
 The two cases of septicaemia are directly opposite in this 
 respect. In neither was any black, or even brown, pigment 
 found in the spleen, but only large white cells full of small 
 granules of an uniformly orange colour. 
 
 2. Bacillus malaria.— We have described in Chapter III. the 
 
RESEARCHES. §3 
 
 principal forms of the plant found in the soil and air of malarious 
 places, which, after cultivation, produced forms of disease exactly 
 the same as those produced by the crude material which was the 
 basis of cultivation; and it is sufficient to have shown experi- 
 mentally that one determinate form of bacillus must be regarded 
 as the exciting cause of the disease. It remains for botanists to 
 determine what ulterior developments this organism may have, 
 and all its biological attributes. We have stated how the 
 commoner forms of bacillus malarice proceed from homogeneous 
 filaments often twisted or looped, which, when cultivated in. fish 
 gelatine, in egg albumen, urine, divide into joints, and produce 
 spores in their interior both before and after this division. The 
 situation of the spores varies ; sometimes they are only found at 
 the two ends of the articulation, at other times in the middle, 
 and again at another time there may be a median spore and also 
 two terminal ones — characteristics which distinguish bacillus 
 malarice from all other bacilli. 
 
 Some cultivations showed us very well the development of 
 filaments from these spores when set free. In the oval shining 
 corpuscles so often described, one of the poles is elongated into 
 an appendix, which is slowly converted into a rod ; sometimes 
 in young spores one sees the clearing up of the substance of one 
 pole precede the formation of the appendix ; at other times the 
 formation proceeds from both poles of the spore at the same 
 time, leading to the formation of two appendices. 
 
 The rods elongating produce homogeneous filaments; some- 
 times two terminal spores are developed in the interior of these, 
 or one median ; in a few cases the spores are developed in their 
 interior in such a way as to make one think that they are the 
 products of the division in situ of a previously formed spore. 
 Sometimes before the production of articulated filaments we see 
 form in their interior some brilliant oval bodies (Table II., fig. 
 1, d), and the filament grows so rapidly that one can watch its 
 increase with the eye, becoming full of small brilliant granules, 
 whilst the oval spores fade away. 
 
 We are not in a position to decide whether the small granules 
 are derived from the breaking up of the spores, or a multiplication 
 of them due to a new precipitation of plasma. 
 
 This mode of evolution seems to be connected with certain 
 forms seen by us in cultivation of the air of Ninfa and Fogliano 
 
5i ON THE NATURE OF MALARIA. 
 
 in urine, and of Caprolace inud in fish jelly. They are shown in 
 fig. 8, Table II., as seen with 1-12 in. objective (oil immer- 
 sion), and No. IV. eyepiece of Zeiss —jointed filaments, full of 
 small shining granules (a, a, a). The division into joints com- 
 mences in these filaments with the formation of a dividing 
 membrane which separates the two masses of protoplasm. The 
 extremities of these newly-formed joints are rounded, the distance 
 between two contiguous joints becomes greater, and the uniting 
 band so weak as to be readily severed. The granular homo- 
 geneous masses contained in tbe joints divide longitudinally or 
 transversely, or both, producing spherules separated by clear 
 spaces. 
 
 We are unable to say whether these forms belong to the 
 normal evolution of this bacillus, or represent anomalies pro- 
 duced by the special accidents of our cultivation. The sum of 
 our observations leads us to think that the forms of fig. 8 belong 
 to this species of bacillus. Should further observations show 
 the contrary, that would not change our conclusions, because in 
 such a case we should regard it as an admixture with other forms 
 jof schistomycetes. 
 
 Fig. 5, Table II , shows exactly the advanced development 
 •of the plant seen in the serum of the lymph of No. I. This was 
 . enclosed, April 21st, in a microscopic air-cell. It contained oval 
 self-moving bodies, some of which had two polar appendices, 
 and some homogeneous, slightly oscillating filaments. Next 
 day were found the forms of (fig. 4, Table II.), viz., free spores, 
 twisted filaments, some of which had spores at the two ends. 
 
 April 23rd the development of filaments was enormously 
 increased, the bundles forming a network. 
 
 So that from a liquid of the body of an infected animal 
 were obtained, without the addition of any other substance, 
 forms identical irith those obtained by means of the first culti- 
 vation of the crude material and subsequent cultivations of the 
 
 ■tame. 
 
 Long homogeneous filaments, identical with those obtained 
 by cultivations, were met with in the spleen of No. XIII., and in 
 the spleen and bone marrow of No. XII. 
 
 3. Bacillus malaria in man. 
 
 Dr E. Marchiafava, first assistant to the Professor of Patho- 
 logical Anatomy in the University of Rome, had an opportunity 
 
BESEAECHES. 
 
 55 
 
 of examining the bodies of three persons very recently dead of 
 perniciosa. The autopsies were made with the utmost care to 
 avoid sources of error. In the first, made July 25th, the exami- 
 nation of the blood was omitted. In the spleen and bone 
 medulla no bacillary forms were met with, but only a large 
 quantity of spores. 
 
 The second was made August 19th, on a man who died in 
 the second acces of perniciosa eomatosa, in the Santo Spirito 
 Hospital. The spleen was doubled in size, brown, and very 
 soft ; the bone marrow brownish-red ; the kidneys, liver, brain 
 and its membranes rich in blood ; the right heart full of fluid 
 blood, the left empty ; bilateral hypostatic congestion of lungs. 
 No other change. The splenic pulp, juice of bone marrow, 
 and of cseliac lymphatic glands, the blood of the splenic vein, 
 hepatic veins, portal vein, and of the right heart, collected in 
 capillary tubes, and sealed with the lamp. In the splenic pulp 
 and bone marrow a small quantity of rusty pigment was found 
 in free masses, or inclosed in the cell elements, a distinct 
 quantity of oval spores, and some rods like those in fig. 1, a, 
 Table II. In the lymphatic gland juice and in all the samples 
 of blood were found a great quantity of bacilli, some homo- 
 geneous, others jointed and perfectly identical with those in 
 fig. 3, Table II. Cultivation of splenic pulp and a few drops of 
 blood in urine, in the usual way produced forms identical with 
 figs. 5 and 6, Table III. In the third case, similar in every 
 respect, there was in addition very grave general melanjEmia ; 
 spleen doubled in size ; pulp diffluent and black ; bone marrow 
 chocolate colour; liver lead colour, and grey substance of tht> 
 brain slate colour. In the blood and throughout the body pig- 
 ment masses free and inclosed in the white cells. In the blood, 
 marrow, and spleen, very numerous oval spores, endowed with 
 very active movements. In addition, in the spleen and blood 
 oscillating rods like fig. 1, a, Table II., and nucleated bacteria 
 like fig. 1, /, and fig. 7, c. 
 
 In the blood, everywhere, and in the spleen and marrow a 
 very large number of long homogeneous filaments, some twisted 
 like fig. 7, Table II., and long homogeneous and jointed filaments 
 perfectly identical with fig. 5. 
 
 Dr. Yalenti, Professor of General Pathology in the University 
 of Home, took part in some of these observations, and the 
 
56 ON THE NATUKE OF MALARIA. 
 
 results of the last autopsy were verified by Professor Tommasi- 
 Crudeli. 
 
 NOTICE TO THE KEADEB. 
 The original of this Paper is profusely illustrated by plates and 
 temperature charts. The reproduction of these would have involved 
 too great expense, and they have therefore been omitted. The 
 references have, however, been retained in the translation as being 
 useful to those readers who may wish to pursue the subject in more 
 detail in the Author's own words.' 
 
 The same statement applies also to the following Paper. 
 
ON THE 
 
 ALTERATIONS IN THE EED GLOBULES 
 IN MALARIA INFECTION, 
 
 AND 
 
 ON THE ORIGIN OF MELANjEMIA. 
 
 MEMOIK BY 
 
 Pbofbssor ETTORE MARCHIAEAVA and Db. A. CELLI. 
 
ON THE 
 
 ALTERATIONS IN THE RED GLOBULES 
 IN MALARIA INFECTION, 
 
 AND ON THE 
 
 ORIGIN OF MELANJEMIA. 
 
 Of all the changes which malarious infection determines in the 
 human organism, the most characteristic is that which takes 
 place in the blood, and is called melancemia.* This dyscrasia 
 consists in the presence in the blood of brownish yellow or black 
 pigment, rarely free, generally collected in the white cell elements. 
 The existence of pigment in the blood is easily verified by ex- 
 amining a very thin film ; and in the bodies of persons who have 
 died from pernicious fevers a great abundance of pigment is 
 found, free, or inclosed in the cell elements, in the blood vessels 
 of the spleen, marrow, brain, kidneys, &c. When the melanaemia 
 has ceased, there remains vielanosis of the organs, i.e., deposit of 
 granules and pigment masses around the vessels and perilobular 
 connective tissue of the liver, and in like manner in and around 
 the lymphatics. The melanosis witnesses to the antecedent 
 melancemia. 
 
 The origin of this pigment has been by almost all authors 
 derived from the colouring matter of the blood, but there has been 
 no agreement as to the site or manner of its formation, as will be 
 seen from the following resume of the history of melanaemia. 
 
 The ancient school of physiciansf held that sometimes black 
 material was formed in the spleen and blood of the portal vein, 
 capable of giving rise to diseases. The " black bile " formed an 
 
 * Melaneemia, so far as we dow know, occurs only in malarious infection, and possesses 
 characters so special that one cannot conceive how they have been confounded by 
 some authors with the hemorrhagic diathesis, Addison's disease, &c. 
 
 t Frerichs, Clinic of Liver Diseases. 
 
60 ALTERATIONS IN KBD GLOBULES IN MALARIA INFECTION, 
 
 essential part of their humoral pathology, and Galen held that it 
 accumulated in the spleen and caused engorgement of the blood 
 vessels, destruction of the intestines, and serious disturbances of 
 the nervous system. Leaving on one side, however, the views 
 of the ancients about "black bile," we find that from the last 
 century it began to be noticed that some organs showed a black 
 or blackish colour in grave malarious fevers, so that Lancisi,* for 
 example, speaking of the changes met with in persons dead from 
 malaria, says : Primum in Us qui ob tertianos pemiciosas 
 occiderunt, ingens malorum sedes sub aspectum venit in abdomine 
 ubi omnia livida, et potissimum hepar subfusci, ac bilis cystica 
 tri coloris passim occurrerunt. 
 
 Mekel, however, was the first to observe pigment in the blood, 
 and held that it passed from the spleen into the blood. 
 
 Virchowt discovered pigmented elements in the blood and 
 spleen of a man who died of dropsy following repeated attacks of 
 malarious fever. He believed the pigment to be derived from 
 the spleen, and persisted in affirming melanasmia to be a 
 dyscrasia of that organ. 
 
 Tigri saw and described melanosis of the spleen as " black 
 spleen." 
 
 Frerichs J accurately described melanaemia and its effects. He 
 observed black granules, pigment cells, masses of black granules 
 held together by hyaline substance, delicate or dense, but always 
 without fixed shape, and pigment masses, sometimes cylindrical 
 with parallel facets, surrounded by a ring of pellucid substance. 
 He believed the pigment formed in the spleen, and passed into 
 the general circulation. In proof of this he adduced the following 
 arguments : — 
 
 a. Pigment is found in the healthy spleen, b. In melanaemia 
 the spleen is always more largely charged with pigment. 
 c. Pigmented epithelium of the spleen is found in the general 
 circulation. 
 
 He believed that the liver shared in this power of forming pig- 
 ment. He confirmed the view of Virchow that in intermittents 
 pigment forms in the spleen and passes into the circulation. 
 Colin § holds, on the other hand, that this formation is not 
 
 * De noxiis pallidum effluviit eorumgue rernedik. Roma, 1727. 
 
 f Cellular Pathology. Berlin, 1881. 
 
 J Loc. cit. 
 
 § Trailt dujtivres intermittentci. Paris, 1870. 
 
AND ON ORIGIN OP MELANEMIA. 61 
 
 confined to the spleen but occurs also in. other organs, and has 
 no specific character, because it happens, for example j- in the 
 mesenteric lymphatics in typhus and dysentery. In malarious 
 fever, however, the destruction of the red globules is more rapid 
 and remarkable than in other infectious diseases. 
 
 Mosler* is inclined to admit the doctrine of Virchow and 
 Frerichs, of the primitive formation of pigment in the spleen. 
 He holds that the peculiar structure of this organ predisposes to 
 this pigment formation, that is to say, that the blood flowing from 
 the capillaries into the intermediate vessels Often stagnates, so 
 that conglomerations of red globules occur, which are gradually 
 converted into pigment. 
 
 Arnstein t rejects the doctrine of Virchow, &c, and maintains 
 that the pigment is formed in the circulating blood during the 
 fever acces. He says the pigment is found free in the blood 
 when the fever has proceeded for a short time, and that in the 
 majority of cases it is met with in the white cells. He examined 
 the organs chiefly melanotic. In the spleen he found pigment 
 round the arteries, capillaries, and veins, and in all these enclosed 
 within the white cells. In recent cases only he found it in other 
 organs. 
 
 He maintains that the view of Virchow and Frerichs is destitute 
 of any support from facts. On the other hand, he regards the 
 melansemia as primary, and the melanosis secondary; and this 
 chiefly because the melansemia can only be found shortly after 
 the febrile attack (which is unintelligible if the melanosis of the 
 spleen was primary), and because the disposition of pigment in 
 the. circulating. blood corresponds perfectly to what happens when 
 colouring matter like cinnabar is introduced into the circulation. 
 According to Arnstein, therefore, the red globules are destroyed 
 during the fever paroxysm, the pigment formed from them is 
 immediately taken up by the white globules, which stagnate in 
 the veins and capillaries of those organs in which the current is 
 .feeble, viz., the spleen, bone marrow, and liver. The pigmented 
 white cells are deposited in the tissues of those organs, whilst 
 they linger longer in the capillaries of the liver. As to the mode 
 of formation of the pigment he says he knows nothing, because 
 the process of destruction in the red globules is too rapid to be 
 
 * Ziemseen, Handbuch, T. 8, Part. Milzkrankheiten, 1874. 
 
 t Bemerhmgen iiber Melanemie wad Melanose. Virchow's Archives, T. 61. 
 
62 ALTERATIONS IN BED GLOBULES IN MALARIA INFECTION, 
 
 followed. He admits that it may occur in the serum of the blood 
 from the haemoglobin issuing from the red globules. He does 
 not believe it is formed in the white cells, according to what 
 Longhaus has observed in haemorrhage, because free pigment is 
 found in the circulating blood and globuliferous cells are not. 
 The latter, however, are found in the spleen and marrow, but 
 are few in comparison with the enormous quantity of pigment 
 which exists in the blood. 
 
 Mosler,* in a later work, does not agree with Arnstein, that the 
 pigment is only found after a febrile accfe, and that it is erroneous 
 to hold that its formation takes place in the spleen. He cites 
 the case of a man affected with malarious fever, in whom the pig- 
 ment was present, not only during, and shortly after the febrile 
 paroxysm, but several months afterwards. + He persists in 
 maintaining that it takes place only in the spleen, or that at 
 least it happens in this organ more rapidly and abundantly in 
 consequence of severe congestions. 
 
 Lanzi and TerrigiJ notice the great analogy between the pig- 
 ment granules found in the blood and organs in melanoemia, with 
 those which exist in marsh soils, and especially in the cells of 
 marsh algae, and suspect that they are identical. 
 
 Kelsch,§ in a very accurate work, sums up the observations 
 made in 1881 on the sick in the Hospital at Philippeville. He 
 was chiefly occupied with the histology of the blood and organs. 
 He found in the blood a diminution in the number of red globules 
 computed by the method of Melassez. He observes that few 
 maladies produce so rapid and serious an oligocitaemia as malaria ; 
 twenty or thirty days of quotidian or tertian suffice to lower the 
 number of red globules in a C» mm. from five millions to one 
 million, or even less than half a million. • The rate of diminution 
 in the number of red globules has its maximum at the outbreak 
 of the disease, and goes on diminishing as the oligocitaemia 
 increases, and the febrile attacks become more distant. In the 
 cachexia the number of red globules becomes almost stationary. 
 Kelsch found, in addition to this diminution of red globules, the 
 presence in the blood of pigment granules, free or inclosed in 
 
 * Vber das Varkommen der Melanemie. Virchow'a Archives, T. 61. 
 f Cases, analogous to this narrated by Mosler, are seen in our hospitals. See 
 Jiaggualgio di due Tumi di Clinica Medica di Roma di Professor C. Maggiorani, 1873. 
 % La Malaria ed il Clima di Roma. Rome, 1877. 
 § Contribution d Vanatomit pathologique des maladies palustres endemiques. 
 
AND ON ORIGIN OF MELAN^MIA. 63 
 
 hyaline masses, but oftener in the white cells. The melaniferous 
 elements enclose 3 — 6 granules, sometimes massed in a series 
 like a crown in the periphery of the cell. Besides these, others 
 are met with which present a brownish reflection accentuated in 
 the marginal zone, in which are sometimes found very fine black 
 granules, and in the blood of the splenic and portal veins he 
 observed the presence of melaniferous cells, very variable in form 
 and size, viz., spherical, polyhedric, ovoid, elongated, biscuit- 
 shaped, &c. From observations of the organs he comes to the 
 conclusion that inelanaemic pigment is deposited absolutely in 
 the same way as an artificial pigment, injected into the veins, 
 either free or enclosed in the cells. As to the mode of formation 
 of pigment he rejects the doctrine of Virchow and Frerichs. 
 
 In one case of " perniciosa fulminante " he found little pigment 
 in the spleen, but the blood very rich in it. He therefore 
 believes it is formed in the circulating blood. He is, however, 
 unable to accept that some melaniferous cell elements represent 
 the stroma of decolourized blood globules with pigment granules, 
 formed at the expense of the haemoglobin, because he has not 
 met with the intermediate stages of this retrograde metamor- 
 phosis. Nor does he admit the intracellular formation of the 
 pigment, with Longhaus, because it is also met with free in the 
 blood. He therefore takes refuge in the hypothesis, that the 
 melanic material exists in the serum in a state of solution, and 
 proceeds from the destruction of the red globules ; this material 
 precipitates, when the blood is saturated with it, under the form 
 of granules, which are quickly included in the white cells, as 
 happens when cinnabar is injected into the blood. 
 
 One of us (Marchiafava*) studying the splenic pulp and bone 
 marrow of melanEemic children, found red globules generally 
 inclosed in white cells (globiferous cells), which exhibited a varied 
 colouring, which passed from a brownish yellow to a more or 
 less intense black, presenting the appearance of black spherules 
 of a diameter somewhat less than a red globule. He concludes, 
 therefore, that the red globules do not give rise to the formation 
 of pigment after their destruction, but that the conversion of 
 haemoglobin into pigment occurs gradually within them. 
 
 Klebs and Tommasi-Crudeli,f studying the changes in the 
 
 * Commentario Clinico di Pirn. Genaaio, 1879. 
 | Sulla natara cklla melaria. 1879. 
 
64 ALTERATIONS IN BED &LOBULES IN MALARIA INFECTION, 
 
 spleens of rabbits in which they had produced' malarious fevers 
 artificially, found red globules, at first nickel-coloured and pre- 
 serving their discoid shape, afterwards of a black, colour, and 
 inclosed singly or in groups in the white cells, with the 
 destruction of which they became free and reduced into masses. 
 They conclude that the conversion of haemoglobin into black 
 pigment takes place in the red globules while they yet retain 
 their semi-fluid consistence. 
 
 Tommasi-Crudeli* also holds that this degeneration of red 
 globules oceurs throughout the whole vascular system, and 
 chiefly in the vessels of the spleen and bone marrow. He says 
 that in melansemia takes place a necrobiosis of red globules, 
 produced by a specific degenerative atrophy of their protoplasm. 
 
 Afanassiewf made his Observations on the sick amongst the 
 troops in the last Russo-Turkish war. He describes the affections 
 of the spleen, kidneys, liver, and brain in those dead from malaria. 
 His description is in accord with other observers as regards the 
 spleen, liver, and kidneys. In the brain he found distinct cloudi- 
 ness of the protoplasm of the nerve cells, with enlargement of 
 the pericellular spaces ; the capillary walls sometimes granular ; 
 the endothelium swollen ; pigment granules in the lumen of 
 the vessels, in the endothelial cells, in the perivascular areas. 
 He describes such granules when they are isolated, and not 
 formed into masses, as perfectly round, of equal size, and having 
 a shining brown centre. He doubts their origin from the 
 colouring matter of the blood; suggests that they may have 
 another origin ; finds that they have an analogy with the cromi- 
 genous micrococci of Cohn, and suspects their parasitic nature. 
 With the history of melanaernia are connected some recent 
 researches of Laveran and Richard. 
 
 LaveranJ holds that the pigmented elements described in 
 part by Kelsch, and different from melaniferous white cells, 
 represent parasitic elements. He describes three forms of these 
 pigmented elements, which he holds to be of parasitic nature. 
 1st. Elongated elements, threadlike at the ends, almost always 
 curved like a crescent length 0"008 — 0'009 mm. ; mean breadth 
 
 * Institutes of Pathological Anatomy. Turin, 1882—4. 
 f Beitrag zur pathologic der malaria infection. Virohow's Archires, 1881, 
 J Nature parasitaire des accidents de I'impaludisme. Paris, 1881. Comptes renins 
 (1882). 
 
AND ON OEIGIN OF MELANJBMIA. 65 
 
 0*003 ; their contour marked by a very fine line ; the body 
 transparent except in the centre, where there exists a spot 
 formed of blackish granules ; often on the concave side is seen a 
 fine line uniting the two extremities of the half moon. 
 
 2nd. Spherical transparent bodies, of the mean diameter of a 
 red globule containing pigment granules, which in repose often 
 describe a very regular circle, and when in movement are actively 
 agitated. Sometimes at the periphery of these elements are 
 observed very fine filaments, which are apparently inserted 
 into them, are animated by very rapid movements, and have 
 the free extremity slightly swollen. Such filaments may be 
 detached, and move freely in the midst of the red globules. 
 
 3rdly. Spherical elements, of irregular form, transparent and 
 finely granular, diameter 0*008 — - 010 mm., containing pig- 
 ment granules disposed very irregularly at the periphery, Home- 
 times collected in the centre, sometimes at a point of the 
 periphery itself. 
 
 There are also found in the blood, according to Laveran, 
 spherical transparent elements, containing movable and im- 
 movable pigment granules, elements of smaller diameter than 
 the preceding, isolated or united, and adhering to the red discs 
 and the leucocytes. 
 
 Laveran believes that these pigmented bodies represent 
 different stages of an elementary parasite, which he is unable 
 to pronounce to be animal or vegetable, which exists in an 
 encysted condition, and in its perfect form becomes free as a 
 movable filament. 
 
 Besides these, Laveran has observed in the blood shining, 
 round, movable bodies, without specific character ; melaniferous 
 leucocytes, red globules which appear perforated in one or more 
 points, inclosing pigmentary granulations, free pigment granules 
 resulting from the destruction of the parasitic elements. 
 
 Richard* confirms fully the observations of Laveran, but 
 instead of holding, like this observer, that the small pigmented 
 forms are found adhering to the red corpuscles, he maintains 
 that they, existing within the latter, where they are developed, 
 grow and issue from them in a perfect state. He describes 
 these pigmented parasites in various stages of development in 
 the red globules, when arrived at a state of maturity perforating 
 
 * Sur leparasite de la Malaria. Comptes rendus (1882). 
 
 5 
 
66 ALTEEATIONS IN BED GLOBULES IN MALAEIA INFECTION, 
 
 the membrane (?) of the red globule, and becoming free in the 
 blood, presenting themselves thus sometimes furnished with 
 movable filaments, like the bodies described by Laveran. 
 
 Both these last observers note that, in the organs of those 
 dead from grave malarious infection, these supposed parasites 
 are recognized by the pigment, which is arranged in circular 
 series at their periphery. 
 
 It is right to observe at once that both these authors_ are 
 entitled to the credit of having called attention to the pigmented 
 elements, already to some extent noticed by others (Frerichs, 
 Kelsch, &c), which are not white cells of the blood ; and to the 
 second, viz., Eicbard, of having shown that the'pigmented bodies 
 are found in the red globules. 
 
 From this risum6 of the history of melansemia, it is clearly 
 seen how the opinions of authors vary, not only as to the place 
 of formation of pigment, but the precise way in which it is 
 formed. 
 
 •There is another category of .authors, of whom some suspect 
 the parasitic nature of the pigment granules ; others hold these 
 as partly constituting the parasitic element. It is therefore of 
 some importance to return to the accurate study of melansemia, 
 and employ the means which the microscope has lately placed 
 at our disposal. 
 
 This research could not be made with all the completeness 
 desired, because for some years the malarious infection has in 
 Eome and the Eoman Oampagna become mild, and consequently 
 the grave forms of malaria have not been frequent in the hos- 
 pitals, where, however, the slighter forms of intermittent abound. 
 This diminution in the severity of the malarious infection has 
 been further confirmed in the anatomical rooms, where in the 
 bodies of peasants dead from other diseases it does not happen 
 so frequently as in the past to meet with melanosis of the 
 spleen, liver, and bone marrow — the melanosis which testifies 
 to antecedent melanasmia. 
 
 The researches which we now describe were made in the 
 blood of fever patients, taken at the Santo Spirito Hospital 
 from July to the middle of October, 1883. 
 
 The method of examining the blood adopted by us was as 
 follows : — 
 
 The blood was taken from a puncture, or small incision with a 
 
AND ON OEIGIN OF MELANJEM1A. 67 
 
 lancet, in the finger of a fever case at different stages of the 
 attack. The skin was previously washed with alcohol, and allowed 
 to dry hy evaporation. The first drop of blood was removed, 
 and the succeeding ones used. On a drop of blood which welled 
 from the wound a covering glass was delicately applied, so that a 
 very small quantity might be deposited upon it ; this was after- 
 wards rapidly compressed against another covering glass, and they 
 were then made to slide one upon the other, so that upon each 
 remained a very thin film of blood, which was dried by passing 
 it two or three times through the flame of a spirit lamp. 
 Afterwards were dropped upon the preparation one or two drops 
 of a recently filtered solution in alcohol and water of methylin 
 blue, and after a few minutes washed thoroughly in a vessel 
 containing distilled water, dried again, and the preparation 
 mounted with oil of cloves, of citron, and balsam ; the method 
 being that used by E. Koch and P. Erlich.* The microscopic 
 examination was made with a 1-12 in. (homogeneous immersion) 
 lens, Zeiss. 
 
 We now set forth the result of the observations. 
 
 The normal red globules are stained faintly blue, and if the 
 solution has only acted for a short time, or perhaps according to 
 the degree of desiccation, remain of their usual yellowish colour. 
 
 The white globules exhibit a pale blue staining of their 
 protoplasm, and an intense staining of the nucleus. The 
 "piastrine "* are stained blue, a little less pale tban the protoplasm 
 of the white cells. But in the blood of persons affected with 
 malarious infection, are found in the midst of the normal red 
 globules, other red globules, which present alterations in their 
 protoplasm, most evident in those which are not stained blue. 
 These alterations consist in the presence within the globule of 
 corpuscles in varying number, of different size and form, which 
 are conspicuous from their more or less intense blue colour, 
 always sufficiently to be distinguishable readily from the pro- 
 toplasm, coloured or not, of the red globules. These corpuscles, 
 advancing from the smaller to the larger, are seen — 
 
 (a) As granules, generally round, which are stained uniformly 
 and more or less deeply blue, and often resemble micrococci. 
 Of these one or more are found in a blood globule ; in such 
 
 * Elementary Granulations (Bizzozero). BliUplattchen (German), a third cell 
 element in the blood, according to Bizzozero. — E. D. 
 
68 ALTERATIONS IN EED GLOBULES IN MALARIA INFECTION, 
 
 cases about two-thirds of the red globules present one, two, 
 rarely three or four, of these corpuscles. Their size varies ; some 
 appear as very small granules, and others as a large micro- 
 coccus. 
 
 (b) As corpuscles larger than the preceding, with a vacuole in 
 the centre so as to represent rings, more or less large and 
 delicate. Of these rings some are found large enough to occupy 
 one-third, or even one-half, of a red globule, sometimes spherical, 
 sometimes oval, irregular or dentated, sometimes having a fine 
 prolongation which terminates free in the protoplasm of the red 
 globule or unites with an adjacent ring. One, two, three, or 
 even more such are found in one blood globule. 
 
 (c) As corpuscles larger than the first, uniformly stained or 
 with vacuoles, in form spherical, oval, spindle-shaped, semi- 
 lunar, triangular, sometimes forming irregular masses which 
 present in their interior granules or masses of black or rusty 
 black pigment. The larger masses invade, in some red globules, 
 all the protoplasm coloured by haemoglobin, of which there 
 remains either a delicate outline or a more or less subtile rim at 
 some point of the periphery, scarcely visible with the most 
 careful examination. Besides the red globules thus altered are 
 found coloured bodies like the masses described, rich in clusters 
 and granules, spherical, oval, irregularly semi-lunar. These 
 evidently represent the last stage in the alteration of the red 
 globule, which is thus converted into a body devoid of haemo- 
 globin, stainable with methylin blue, and containing pigment. 
 Besides these red globules, of which the phases of change may 
 be followed up to their conversion into a pigmented mass, there 
 are found in ■ preparations fragments of the latter in various 
 forms, always pigmented, and white globules, in whose proto- 
 plasm pigment is found in granules and larger clusters than 
 those found inclosed in the red globules. 
 
 If the blood issuing from the wound is mixed with a drop of 
 pure distilled water, and then dried as in the first method, there 
 are seen, together with normal red globules, which have lost 
 their haemoglobin and are only marked by a faint outline, others 
 which have also lost their haemoglobin and are distinguished by 
 this faint outline, but which contain in their interior the cor- 
 puscles mentioned, stained deeply blue and clearly defined. 
 
 We have stained the blood with other aniline colours, acid and 
 
AND ON OEIGIN OF MELANffiMIA. 69 
 
 basic, and here is the result. With eosin the corpuscles are 
 stained pale rose, while the rest of the red globule is intensely 
 yellowish red ; the pigment remains unchanged. With vesuvin 
 they stain red-brown. With tropceolin they are not stained at 
 all, but are recognized, in the red globule stained a beautiful clear 
 yellow, as so many spots containing pigment or not. 
 
 Examining the fresh blood without any treatment, we see only 
 the larger corpuscles appear as colourless and pigmented specks, 
 as already described by Eichard. The red globules in which 
 are found the corpuscles (small, round, analogous to micrococci) 
 appear normal, or if there are specks, these are indistinguishable 
 from the lacunas which are formed accidentally in normal red 
 globules. 
 
 The pigmented Bpots present various shapes, increase gradu- 
 ally, and coalesce, so that the entire red globule is converted into 
 a decolorized body of hyaline aspect, containing granules and 
 masses of pigment. When it contains one or two pigmented 
 corpuscles and still retains a distinct portion of its coloured 
 protoplasm, it preserves its normal elasticity. When it is con- 
 verted into a hyaline mass it sometimes preserves its elasticity ; 
 sometimes this is diminished, and the globule adheres to the 
 slide or covering glass, does not move, or only moves slightly 
 when pressed. 
 
 The pigmented granules, which are found in the spotted 
 globules as well as in those completely decolorized, assume 
 various figures when the globules move, viz., circles round the 
 periphery of the specks, circular groups or irregular forms. 
 When the globules are at rest, the pigment granules are motion- 
 less or move actively, especially those found in the serum on the 
 blood clot. 
 
 In preparations of fresh blood other forms of red globules are 
 encountered, viz., such as present only one half decolorized and 
 of a semi-lunar form, having in the centre or at a point of the 
 periphery clusters of pigment ; or such as have lost wholly or 
 partially their haemoglobin and exhibit in the centre a single 
 spot of black pigment, rounded, irregular, having somewhat the 
 shape of an embryo. 
 
 In addition are found round, hyaline, or irregularly pigmented 
 bodies and richly pigmented white cells. On adding distilled 
 water, the altered red globules first become shapeless, and 
 
70 ALTEKATIONS IN RED GLOBULES IN MALARIA INFECTION, 
 
 then assume a perfectly . spherical figure, like the other red 
 globules. 
 
 With the reaction of acetic acid and alcohol these altered red 
 globules are recognized by the pigment which they contain ; 
 with liquor potassas the pigment dissolves slowly after ten to 
 fifteen minutes. Ferrocyanide of potassium and hydrochloric 
 acid do not produce their characteristic reaction on the pigment. 
 
 Such is the result of the examination of the blood in persons 
 affected with malarious infection, especially during the fever 
 paroxysm. 
 
 Is this alteration of red globules always found in malarious 
 infection ? To this we must reply, that if in many cases the 
 altered blood globules are very numerous, in others they are yery 
 scarce, so that it is necessary to make many preparations in 
 order to find them ; in other instances they have not been found 
 at all. The latter has been the case in simple intermittent, and 
 in some forms held clinically to be graver manifestations of 
 malaria. 
 
 In comatose pernicious fevers terminating fatally we have 
 always found it, as also in the sub-continued forms. 
 
 When we have found such appearances in the red globules the 
 individuals always presented a peculiar aspect in the course of 
 the disease, viz., the skin became rapidly earthy yellow, the 
 weakness was extreme, and the strength re-established slowly 
 and with difficulty. 
 
 The relation of the degree of alteration of the blood to the 
 clinical course of the infection will be an interesting subject of 
 study. 
 
 We come now to speak more particularly of the alterations 
 found in the blood and organs of persons dead from pernicious 
 fevers. 
 
 We shall only speak of the cases which have occurred this 
 year, i.e., after we had studied the alterations in the red globules 
 during life, and give them as a whole, prefacing a note of the 
 history and examination of the blood before death. 
 
 1st Case. Algide Pernicious Fever. — B. D., aatat 25, entered 
 the hospital August 11th, suffering from intermittent fever (quo- 
 tidian), and had several paroxysms in the hospital. 14th, at 
 evening visit in a state of profound collapse; skin very cold, 
 cyanotic, and pulse almost imperceptible. Hypodermic injec- 
 
AND ON OKJGIN OF MELAN.HMIA. . 71 
 
 tioris of quinine, which had been administered internally "on 
 previous days. Died next day at 2.45. a.m. 
 . Examination of the fresh blood during life showed numerous 
 white globules much pigmented, red globules not visibly altered. 
 
 After staining, many red globules showed in their interior, one, 
 two, rarely three corpuscles, of which a few were small, and 
 more or less deeply stained, others somewhat larger, with a 
 vacuole in the centre, appeared as blue rings. 
 
 Autopsy (7 a.m., same day). — Persistent cadaveric rigidity. 
 Skin pale ; brain and meninges exsanguined ; grey substance 
 pale; heart normal; myocardium greyish red colour; lungs 
 slightly cedematous; spleen doubled in size, with numerous 
 recent peripheral hsemorrhagic infarcts ; parenchyma soft and 
 dark red ; liver normal in size, with icteric staining of central 
 parts of lobules ; kidneys, capsule readily detached, surface 
 greyish, glomeruli not prominent, pale, substance of convoluted 
 tubes yellowish grey; numerous haemorrhages of the pelvis 
 and calices; stomach, mucous membrane swollen and hyper- 
 aemic, with numerous scattered haemorrhages ; intestine normal ; 
 bladder dilated. 
 
 The blood of various vascular areas and from the splenic 
 pulp and bone marrow collected, and stained preparations made. 
 These showed under the microscope numerous red globules, 
 containing the corpuscles observed during life; some larger 
 ones containing pigment ; numerous nucleated red globules. 
 
 The microscopic examination of the various organs hardened 
 with alcohol, and stained with Bismarck brown or methylin 
 blue, showed in blood vessels, chiefly in the capillaries, the 
 corpuscles described, deeply stained; if the red globules are 
 recognizable by their contour, these corpuscles are seen distinctly 
 inside of them; but if the globules were disintegrated and reduced 
 to the well-known yellowish-grey detritus, the corpuscles were 
 equally distinctly seen scattered through this detritus, and 
 therefore not destroyed like the red globules. In the capil- 
 laries of various organs, and -chiefly the brain, these corpuscles 
 were at so regular a distance from each other as to make it 
 evident that they were still within the red globules, even when 
 the contour of these: was indistinct. In all the vessels were 
 found in addition pigmented white globules and pigmented 
 bodies stained blue, representing the last change of red globules. 
 
72 ALTERATIONS IN BED GLOBULES IN MALARIA INFECTION, 
 
 2nd Case. Comatose Pernicious Fever. — P. E., setat 40, 
 entered the hospital September 29th, in the afternoon, in an 
 acces of comatose perniciosa. There was no previous history, 
 only that he came from the Campagna. He died next morning. 
 
 Microscopic examination showed scattered pigmented white 
 cells ; red globules with pigmented corpuscles ; numerous hyaline 
 bodies of different shapes, spherical, oval, fusiform, semi-lunar, 
 containing granules and pigment masses. Some of these hyaline 
 bodies had at their periphery a zone of protoplasm coloured with 
 haemoglobin ; a certain semi-lunar form was the result of the 
 conversion of one-half a red globule into a pigmented hyaline 
 mass, whilst the other remained decolorized, and only its delicate 
 outline was visible. The examination made shortly before death 
 showed a great number of pigmented white globules. 
 
 The stained preparations presented numerous red globules 
 containing round corpuscles either in centre, at periphery, uni- 
 formly stained, with a vacuole in the centre, or blue rings of 
 various size and form. 
 
 Autopsy (7 hours after death)., — (Edema of the membranes ; 
 punctiform haemorrhages of white cerebral substance; grey 
 substance dark red ; bilateral pulmonary oedema ; hydrothorax ; 
 hydropericardium ; heart normal ; myocardium brownish red 
 colour ; spleen triply enlarged, of triangular form, very soft, of 
 a chocolate colour; liver dark grey colour; lobules indistinct; 
 kidneys dark grey colour, exsanguined. 
 
 . The result of the microscopic examination was the same as 
 during life. As to the examination of organs hardened and 
 stained, it deserves to be recorded that the capillaries of the 
 brain were distended with red globules, containing the corpuscles 
 mentioned, deeply stained, and without trace of pigment. The 
 pigmented white globules were rarely met with in these capil- 
 laries. 
 
 Sbd Case. Comatose Pernicious Fever. — M. L., a carter out- 
 side the Porta Maggiore, entered the hospital at 10 a.m., Oct. 6, 
 already profoundly comatose and with high fever ; said to have 
 suffered some days from fever, and found that morning in this 
 condition in a stable. After injection and internal administra- 
 tion of quinine he rallied somewhat, reacted to cutaneous stimuli, 
 but did not recover his senses. After a little he sank into pro- 
 found coma. Had very grave dyspnoea; pulse 140; temperature 
 
AND ON OBIGIN OF MELAN2EMIA. 73 
 
 39° ; dirty yellowish-grey colour of the skin ; spleen swollen and 
 tender ; tracheal rales. Died at 6 p.m.* 
 
 Examination of fresh blood: white pigmented globules in 
 great number, a few red globules with clear spots containing 
 granules of black pigment. Examination after drying and stain- 
 ing : in about half the red globules were found either corpuscles 
 perfectly spherical, stained intensely blue, or larger ones with a 
 vacuole in the centre, presenting the aspect of rings of varying 
 size and shape, some furnished with a prolongation terminating 
 free or united to the next ring. 
 
 Autopsy (12 hours after death). — Body that of a robust man, 
 well nourished ; colour of skin livid yellow ; ocular conjunctiva 
 slightly icteric. On the internal surface of the dura mater cor- 
 responding to the right frontal lobe were found two clots inclosed 
 by delicate membranes furnished with numerous small blood 
 vessels. Two other haemorrhages having the same characters 
 corresponded to the left central convolutions. 
 
 Haemorrhagic infiltration of the meninges of the occipital lobes ; 
 punctiform haemorrhages of centrum ovale of occipital lobes ; grey 
 substance leaden red colour; grey substance of the ganglia pre- 
 sented the same in a minor degree, as did the grey matter of the 
 pons, bulb, and spinal marrow ; heart normal form and volume ; 
 myocardium brownish, lacerable; lungs congested and cedema- 
 tous posteriorly ; spleen triply enlarged, capsule tense, parenchyma 
 dark chocolate, very soft; lymphatic glands of the hilum dark 
 red, swollen, very soft ; kidneys pale, flaccid ; stomach and duo- 
 denum with numerous mucous hasmorrhages ; liver normal size, 
 rich in dark blood ; surface on section lavender red ; gall bladder 
 turgid with bile ; intestines normal, except last part of the ileum, 
 which presents spots of hypersemic haemorrhage, and soft swelling 
 of the agminated glands; bladder, small quantity of turbid 
 urine, containing, as found on chemical examination, albumen 
 and bile pigment, red and white blood cells, granular casts of 
 varying size, some convoluted. 
 
 Microscopic examination, same results as during life, but the 
 corpuscles contained in the red globules more numerous. Splenic 
 pulp and bone marrow rich in more or less altered red globules, 
 
 * Professor Marchiafava and Dr. Ferraresi have not unfrequently found snch cere- 
 bral haemorrhages, which explains the fact that hemiplegia is often left behind after 
 attacks of comatose perniciosa. 
 
74) ALTERATIONS IN EED GLOBULES IN MALAKIA INFECTION, 
 
 and the latter contains a remarkably large number of nucleated; 
 red globules. 
 
 ' Spleen and marrow of these corpses served also for ascertain- 
 ing if the black pigment which they contained gave the reaction 
 with iron which had not resulted from the same pigment 
 inclosed within the red globules. We used as the re-agent a 
 solution of ferrocyanide of potassium (1 in 12) slightly acidulated 
 with pure hydrochloric acid. Small fragments of melanotic 
 spleen, dissected out with glass needles, and placed under the 
 microscope with a drop of the re-agent, showed the reaction in 
 some red globules, in very many white ones, in many globuli- 
 ferous cells, of which some have only diffused staining of the 
 protoplasm alone ; others show the same reaction in the inclosed 
 globules.* But nevertheless, after twenty-four hours of the re- 
 action, the bulk of the granules and pigment masses lost their 
 proper rusty black colour. The treatment was repeated with 
 the same negative result in the liver and brain containing pig-, 
 ment. In these, however, was found a slight blue staining of 
 the corpuscles inclosed in the red globules, whilst their con- 
 tained pigment remained unaltered. The reaction was not 
 assisted by a gradual increase of temperature up to 80° C. 
 Perls + had already observed that all the black pigment, in the 
 liver and spleen did not give the iron reaction, as it was not 
 given by the bile pigment, hsematoidin, the choroid pigment, and 
 its homologue in retinitis pigmentosa. 
 
 From these three characteristic cases of malarie infection 
 terminating fatally we have a confirmation of the existence of 
 the alteration of red globules, especially from the fact that the 
 capillaries of various organs, above all the brain, were seen to 
 be gorged with red globules containing corpuscles, in two 
 instances almost all primary, round, small, and not having any 
 pigment granules. 
 
 It is noteworthy also that these corpuscles were not free, but, 
 on the contrary, always enclosed within the red globules, and 
 only appearing free when their contour was lost after the action 
 of alcohol. 
 
 From what we have stated, it is clearly shown that in malarious 
 
 * Compare Studi patkologici e chimici sulla fanzitme ematopoelica. Tizzoni e Fileti. 
 Trans. E. Acad. Liuoei, 1880—81, vol. x. 
 t Virchow's Archives, T. 39. 
 
AND ON OKIGIN OF MELANiEMIA. 75' 
 
 infection there occurs a change in the red globules, which can 
 be followed in all its phases ; which begins with the presence of 
 granules or corpuscles, generally spherical, stainable with any 
 aniline dye, progressing with enlargement of these bodies, with 
 their fusion, and the formation of blackish pigment in the form 
 of granules and clusters, and ending in the reduction of the red 
 globule into a pigmented body of a hyaline aspect, which is 
 afterwards destroyed, and the pigment, set free, is inclosed in 
 the white cells, and by them deposited in certain organs (spleen, 
 bone marrow, liver). 
 
 Now what is the nature of this change in the red globules ? 
 That the change is to be regarded as of a retrogressive nature 
 does not admit of doubt. We may, with Tommasi-Crudeli, 
 define it to be a necrobiosis of the red globule, in which takes 
 place the transformation of its hcemoglobin into melanin, whereby 
 it only remains as a circulating cadaver, incapable of fulfilling 
 its very vital function. This admitted, it may now be decided 
 in reference to the site of formation and origin of pigment in 
 melansemia, 1st, that the pigment is formed within the blood 
 vessels and in the circulating blood; 2nd, that it is derived from 
 the colouring matter of the red globule, and is formed absolutely 
 in the protoplasm of the same. The first conclusion is evidently 
 admitted, that the pigment is formed in the circulating red 
 globules, and agrees with what had already been established by 
 Kelsch and Arnstein. It is intelligible from this reason alone 
 why the hypothesis that the pigment is formed from extravasa- 
 tions of blood in the spleen and other orgaas cannot be received. 
 The second conclusion is not less obvious, because whilst the 
 red globule' is decolorized, the black pigment is deposited, and 
 this • decolorization and pigmentation may be followed in all 
 their phases. 
 
 Kelsch, as already mentioned, surmised that many of the 
 pigmented forms represented decolorized and pigmented red 
 globules, but abandoned this idea because he did not succeed in 
 seeing all the steps of the pigmentation, and thought that the 
 pigment was formed in the blood plasma from dissolved haemo- 
 globin. 
 
 As to the cause of such necrobiosis of red globules, we cannot 
 at present say anything definite, any more than we can of other 
 degenerations and necroses of elementary organisms in other 
 
76 ALTERATIONS IN RED GLOBULES IN MALARIA INFECTION, 
 
 infectious diseases. To say that malaria attacks and determines 
 the destruction of red globules, is only to repeat what clinical 
 observation has already established. Bacelli * in fact long ago 
 said that malaria struck not only the ganglionic system, whence 
 the congestive processes from vasomotor paralysis, but also 
 undermines the existence of the red globules, which lose their 
 functional activity and perish. Besides the changes in red 
 globules described by us, some other peculiarities seen are 
 deserving of attention. The commencement of the change is 
 indicated by the appearance in the red globules of granules and 
 corpuscles generally spherical, which are deeply stainable by any 
 aniline' dye. Might these corpuscles represent micro-organisms 
 which invade the red globules and penetrate their protoplasm ? 
 
 No hypothesis could well be more seductive, but these 
 characters do not suffice to make it acceptable. The granu- 
 lations of the mastzellen of Ehlich present characteristics 
 analogous to micrococci, and are yet only granulations of the 
 protoplasm. 
 
 We have tried to settle the question by trying to cultivate the 
 blood of the malarious, to see if these corpuscles would be mul- 
 tiplied. 
 
 The first attempts made had no result. Thus the cultivation 
 of blood in Koch's gelatine produced no result, although the 
 surrounding conditions were varied in many ways. The tem- 
 perature of the hot box was, in the first experiments, maintained 
 at fever heat; but in later experiments was, by the advice of 
 Professor Filehne, who happened to be in Borne, kept at the 
 normal of the human body, and gradually lowered to below 
 30° C. Blood was selected for cultivation in which the red 
 globules showed the commencement of change, viz., very small 
 corpuscles. The other conditions necessary for success were in 
 the greater number of instances well attained, but round the 
 little drops of blood and elsewhere not the slightest development 
 of micro-organisms took place. Under like circumstances no 
 result followed repeated cultivations, made in ossihsemoglobulin, 
 prepared according to the directions of Hoppe Seyler and fur- 
 nished by Professor Kossoni. After the failure of these attempts, 
 others were made on the assumption that these supposed para- 
 sites might require, in order that their development might be 
 
 * La Pemicioaa. Clinical Lectures, 1869, 
 
AND ON OEIGIN OF MELANEMIA. 77 
 
 seen, to be furnished with a soil of cultivation analogous to that 
 of the red globule. 
 
 The necessity for using sterilizing temperatures, without at 
 the same time altering the haemoglobin, led to these ending in 
 failure. 
 
 Finally, by a long process, resulted the preparation of a solid 
 soil of cultivation answering to the conditions mentioned. In 
 this was placed a drop of blood, taken with every precaution 
 from the finger of a young man in the commencement of the 
 cold stage of an ordinary intermittent. The hot box was kept 
 at 36° — 36 0, 5. During the first three days no change was seen 
 round the tiny drop, but on the fourth day began to be seen a 
 greyish-coloured halo, which was, on examination, found to be 
 composed of round corpuscles of varied size, the larger colourless 
 in the centre and resembling rings. Notwithstanding the 
 apparent identity of the forms seen in the cultivation with 
 those found in the blood of certain cases of perniciosa, we do 
 not think any conclusions can be drawn from them. We 
 only refer to the fact, which requires further research for its 
 elucidation. 
 
 After the researches of Klebs and Tommasi-Crudeli,* bacillary 
 forms were described by one of us (Marchiafava) and Cuboni 
 as existing in malarious blood, swollen at the extremity and 
 sometimes also in the middle, of varied length, and endowed 
 with very active wriggling movements and locomotion. After- 
 wards the same forms were described by Marchaudf and by 
 Ziehl.J 
 
 Marchaud found in the blood of a fever patient bacillary forms 
 with slightly swollen extremities, having about half the length 
 of a red globule, and endowed with active movements. Ziehl 
 found in the blood of three fever patients small bacillary forms, 
 swollen at the ends, moving gently, but also found them in the 
 blood of a diabetic who had no fever, but was thought to have 
 latent malarious infection. In all four cases these disappeared 
 under quinine. Subsequent observations showed that the para- 
 sitic nature of these was only apparent. Many such are figured 
 in books on histology (Frey, Kanvier, &c), and are well-known 
 
 * Loc. cit. 
 
 f Kwrtze Bemerhmg zur cstiologie der Malarie. Virch. Arch., 1880. 
 
 t Einige Beobachtvmgea iiber den Bacillus Malaria, CI. Me, Woch., 48. 
 
78 ALTERATIONS IN BED GLOBULES IN MALARIA INFECTION, 
 
 to depend on the mode of preparation and chiefly on the action 
 of heat. > 
 
 It is reasonable to hold, as already noted by Tommasi- 
 Crudeli, that many of the forms described in the blood of 
 malarious persons are due to filaments of this kind issuing from 
 the blood corpuscles, and liable to impose on the observer as 
 bacillary forms. 
 
 The small forms described by Marchaud and Ziehl remain to 
 be more fully studied, especially as they have never been able to 
 stain and preserve preparations of such. 
 
 The filaments described by Laveran and Eichard, repre- 
 senting, according to the former, the parasite in its perfect state, 
 originate in the way just mentioned. We have found in fresh 
 blood that when the degeneration of the j:ed globule is almost 
 complete, and the normal protoplasm only remains as a delicate 
 zone, very movable filaments separate from it, which after a 
 time become free. These are never stained with aniline dyes, 
 and however careful our examination we never discovered 
 coloured prolongations in the degenerate and pigmented globules. 
 The semi-lunar forms of Laveran originate when only half a red 
 globule is converted into a pigmented semi-lunar body, whilst 
 the other half is decolorized and only retains its subtile outline. 
 Leaving these pseudo-organisms we come to the last part of our 
 observations this year. 
 
 We have seen how in certain cases, from the cause described, 
 an enormous quantity of red globules perish. We must add that 
 in the same patients in whom this destruction of red cells occurs 
 are found red nucleated globules, larger red globules (macrocytes), 
 and red globules which are coloured differently from ordinary 
 ones. 
 
 We cite the following case in point : — 
 
 C. L., setat 19, of Eome, carter, entered the hospital September 
 10th. He had never previously suffered from malarious fevers. 
 From September 1st to 8th he had attacks of quotidian inter- 
 mittent. From the 8th he said the fever had never left him- A 
 few hours after admission the fever was very high (41°), skin 
 earthy yellow, spleen swollen and tender, sensorium blunted. 
 Examination of the blood shows many red globules altered as 
 described, pigment white ones. Quinine injected. Next morn- 
 ing temperature 88 0, 5, evening 40°. New injection of quinine. 
 
AND ON OEIGIN OP MELAN.EMIA. 79 
 
 Blood examined with same result. Subcontinued form lasted 
 until the 15th, when the evening temperature was 37°"7. Blood 
 examined with same result until the 13th, when there began to 
 appear nucleated red globules, very voluminous red globules, with 
 a diameter nearly twice that of a normal red globule. The 
 number of the white cells and of the piastrine was clearly 
 increased. Improvement continued until he left the hospital 
 cured on the 28th, and whilst the altered and pigmented red 
 globules and pigmented white cells went on diminishing, the 
 nucleated red globules increased, and the macrocytes in their 
 turn also became few in number. The convalescence was rapid. 
 The appetite become voracious. The vital powers, which were 
 reduced, returned quickly. 
 
 The red nucleated globules and macrocytes in many cases of 
 acute malarious infection are recognized in the fresh and in the 
 dried and stained preparations. In those, stained with methylin 
 blue the nucleated red globules exhibit their protoplasm greenish 
 blue in colour, the outline and corpuscles of the nucleus dark 
 blue. The form varied;, protoplasm sometimes abundant, 
 sometimes scarce. Usually they have one but sometimes two 
 nuclei, one in process of division or germination. 
 
 This nucleus often seems issuing from the protoplasm. The 
 macrocytes, which in the fresh state are very pale, are coloured 
 by methylin blue less intensely greenish blue than the nucleated 
 red cells. 
 
 The " piastrine " are coloured slightly blue, and appear alone 
 or in groups, almost always with sharp outlines. 
 
 What is the meaning of the presence of all these elements, and 
 especially of the nucleated red globules ? 
 
 It is known that the nucleated red globules are not normally 
 found in the circulation in extrauterine life except in the first 
 days of the same, but are found sufficiently frequently in the 
 grave essential and symptomatic anaemias, in more or less con- 
 siderable number, whilst they are very abundant in the bone 
 marrow, and even spleen* Erlichf drying and staining blood 
 preparations found them easily. Hitherto, however, they have 
 
 * In a case of grave anaemia in a young person Marchiafava found numerous 
 nucleated red globules (10 — 12 in each preparation), and after death a large number 
 in the spleen and bone marrow. 
 
 t Berlin Klin. Woch., 1881. 
 
80 ALTERATIONS IN BED GLOBULES IN MALARIA INFECTION, 
 
 not been described in acute malarious infection. Their presence, 
 as well in the later stages of the disease as during convalescence, 
 has without doubt a connexion with the destruction of red 
 globules, and is a sure indication of the greater energy of function 
 of the hemopoietic organs rendered necessary by the destruction 
 of red globules in- such large numbers.* As to the macrocytes 
 and red globules coloured differently to the ordinary ones, they 
 are evidently young red globules which have recently lost their 
 nucleus, and this coincides with what has been observed by 
 Bizzozero and Salviolif on the blood of animals rendered anaemic 
 by frequent bleedings. 
 
 We wished by experiments, in which destructions of red blood 
 globules had been artificially produced, to institute a comparison 
 with those cases in which this was due to malarious dfsease. 
 We selected pyrogallic acid as the agent for this destruction, 
 as shown to be such by the experiments of Neisser, Afanassiew, 
 &c. 
 
 1st Experiment. — White dog of medium size. 
 
 3. X. 83. 11 a.m., subcutaneously injected with gr. 0*5 of 
 pyrogallic acid dissolved in 10 cc. of distilled water. 7 p.m., 
 animal not at all ill. 
 
 4. At 11 a.m., injected gr. 1 pyrogallic acid in 10 cc. distilled 
 water. 1 p.m., blood examined. Numerous red globules in 
 process of destruction, or reduced to simple decolorized bodies. 
 Masses of haemoglobin of varied size, staining with eosin. Ani- 
 mal collapsed. Urine olive green. No jaundice. Died at 5.30 
 
 P.M. 
 
 Autopsy. — All the viscera of a leaden grey colour ; spleen 
 swollen and black; liver dark blue; gall bladder surcharged 
 with fluid bile ; kidney same colour ; bladder empty ; bone 
 marrow chocolate ; black coagula in heart and blood vessels. 
 Blood examined, shows red globules undergoing destruction ; 
 numerous red globules perfectly decolorized ; granules and 
 masses of pigment, and some nucleated red globules. Splenic 
 pulp and bone medulla, especially the latter, show numerous 
 nucleated red globules. 
 
 * Professor Rossoni has often observed with the spectrum of Vierordt the gradual 
 diminution of haemoglobin in the blood in relation to the quantity of altered red 
 globules, and its gradual daily increase in convalescence along with the appearance 
 of numerous nucleated red globules in the blood. 
 
 f Bictrche sperimentali sulla Emaiopoesi splenica. Archiv. Bizzozero, vol, iv. n. 2. 
 
AND ON ORIGIN OF MELAN.EMIA. 81 
 
 2nd Experiment. — Black dog, middle size. 
 
 5. X. 83. 10 a.m., subcutaneous injection of gr. 0'5 pyrogallic 
 acid in 10 cc. of distilled water. 1 p.m., examination of blood 
 negative. 
 
 6. 7 pm., examination of blood. A few red^globules under- 
 going destruction. 
 
 7. 10 a.m., injection as above. 11 a.m., blood examined. 
 Many red globules in process of destruction ; a few nucleated 
 red cells. Animal much depressed. Urine dark olive. Micro- 
 scopic examination of urine shows casts of haemoglobin. No 
 jaundice. 
 
 8. 11 a.m., blood examined. Small number of red globules 
 in process of destruction; nucleated red globules. Animal 
 gradually recovered up to 15th, when no altered red globules 
 nor nucleated red globules were found. 
 
 3rd Experiment. — Small black dog. 
 
 11. X. 83. 12 noon, subcutaneous injection of gr. 1 pyro- 
 gallic acid in 10 cc. of distilled water. 
 
 12. 8 a.m., dog collapsed — somnolent. Does not eat. Urine 
 olive green ; vomits yellowish-green liquid streaked with blood ; 
 sclerotic, not jaundiced. Blood examined; numerous red glo- 
 bules in course of destruction ; cells decolorized ; masses of 
 haemoglobin. 5 p.m., same state. 
 
 13. Blood examined. Same as above. Animal continues 
 sunken — somnolent. Does not eat. 
 
 14. Examination of blood fresh and after staining. Very few 
 nucleated red globules ; red globules very much larger than 
 normal. Dog in same state. 
 
 15. Examination as above. Animal collapsed. 
 
 16. 9 a.m., found dead. 
 
 Autopsy. — All the organs leaden grey colour. In every dried 
 and stained preparation of blood of right heart numerous red 
 globules in course of destruction; normal red globules; red glo- 
 bules larger, and even double normal diameter; red globules 
 normal in size, stained greenish-blue; a few nucleated red 
 globules (4 — 5 per preparation) ; numerous white globules, less 
 or more nucleated with protoplasm, granular and hyaline; endo- 
 thelial cells. In the splenic pulp numerous white cells, con- 
 taining coloured fragments of red blood globules and nucleated 
 red globules. The bone marrow, microscopically of dark red 
 
 6 
 
82 ALTERATIONS IN EED GLOBULES IN MALARIA INFECTION, 
 
 colour, contained white cells inclosing fragments of red globules; 
 proper cells of marrow; cells with budding necleus, and nucleated 
 red globules in greater quantity than in the spleen and blood of 
 the heart. The nucleated red globules both in the circulating 
 blood and in the spleen and marrow showed more distinctly by 
 staining with methylin blue the preparation dried by heat.* 
 
 From these experiments it results, therefore, that by pro- 
 ducing destruction of red globules, after a very short time are 
 found in the blood nucleated red globules ; red globules of more 
 than normal size ; globules staining differently to ordinary ones — 
 ■elements all met with more abundantly in the spleen and bone 
 marrow after death. That the presence of such nucleated red 
 globules is derived from augmented haemopoietic activity, and 
 ■expresses a true regenerative compensation, is beyond doubt. 
 The same explanation is given by all who have of late studied 
 the physio-pathology of the blood. 
 
 This view is strongly confirmed by our observations, because 
 in some cases of malaria infection one is almost able to see 
 before his eyes the two processes of destruction and regeneration 
 ■of red globules. 
 
 Thus by examining the blood of a subcontinued fever patient, 
 from the day of his entrance into hospital to that on which he 
 left it cured, we see that three or four days after the. destruc- 
 tion was arrested nucleated red globules began to appear, 
 increased rapidly in number, and once more diminished as 
 convalescence became established. 
 
 It is reasonable therefore to hold that the passage into the 
 -circulation of nucleated red globules happens, because the forma- 
 tion of red globules in the haemopoietic organs is so active and 
 hurried that the red globules, in course of formation, are forced 
 into the circulation before they have lost their nucleus. 
 
 Although these, researches of ours have not yet fully attained 
 their aim, we believe we have helped to make better known the 
 change produced in the blood in malaria, and to clear up the 
 origin of melansemia. It still remains to determine the nature 
 of the specific agent, to which these changes are due, and to this 
 end further researches will be directed. Finally, it will be easy 
 to judge if any advantage is likely to accrue from them to clinical 
 medicine. 
 
 * Bizzozero, Neumann, Salvioli, Foa, Pellucani, Orth, Lillen, Ac. 
 
AND ON ORIGIN OF MELANZEMIA. 88 
 
 It has been already said that they are not always found in 
 slight, and are also absent in some grave forms, clinically con- 
 sidered to be malarious, therefore their absence does not exclude 
 malarious infection, while their presence does not render it indis- 
 putable; and, furthermore, it has not occurred to us to find 
 them in other infections (typhoid fever, cerebro-spinal meningitis, 
 measles, pneumonia), in which we have had an opportunity of 
 examining the blood. 
 
A NEW CONTRIBUTION 
 
 HISTORY AND ETIOLOGY 
 
 SPONDYLOLISTHESIS. 
 
 FRANZ LUDWIG NEUGEBAUER, M.D., 
 
 OF WARSAW. 
 
 TRANSLATED BY 
 
 FANCOURT BARNES, M.D., 
 
 Physician to the Chelsea Hospital for Women, to the British Lying-i t Hospital, 
 and to the Royal Maternity Chari'y of London, 
 
TRANSLATOR'S INTRODUCTORY NOTE. 
 
 Since Kilian, in 1853, first drew the attention of obstetricians 
 to the spondylolisthetic pelvis through the specimen known as 
 the Prague pelvis, no new light had been thrown upon the con- 
 dition until Neugebauer, in 1884, propounded his views in the 
 Annates de Gynecologie. Until Neugebauer had examined and 
 described the seventeen pelves recognised as spondylolisthetic 
 up to that date, the views of Rokitanski and Kilian, that the 
 lesion originated in caries of the vertebra, were generally accepted. 
 Neugebauer, however, demonstrated by his specimens at the 
 Obstetrical Society in 1884 that in many cases the deformity 
 arose from some breach of continuity, either traumatic or con- 
 genital, in the neural arch. A committee was appointed by the 
 Obstetrical Society, consisting of Dr. Robert Barnes, Messrs. 
 William Adams, Alban Doran, and Noble Smith. These gentle- 
 men, after having examined the specimens and consulted thereon, 
 reported that they agreed with Dr. Neugebauer in his views, 
 and confirmed the accuracy of his conclusions. It is now 
 generally accepted that this deformity in the majority of cases 
 results from a solution of continuity across the neural arch of 
 the fifth lumbar vertebra between its superior and inferior 
 processes on either side. This theory is in opposition to the 
 views formerly held, namely, that the deformity occurred from 
 caries, rickets, osteomalacia, tuberculosis, or hydrorachis. The 
 solution of continuity of the neural arch may, according to 
 Neugebauer, be congenital or acquired. Neugebauer suggests 
 that pathologists should carefully examine the pelvis in all 
 fatal cases of injury from falling. He believes that if this 
 is done, commencing or advanced spondylolisthesis will be 
 occasionally discovered. 
 
 FANCOURT BARNES. 
 
A NEW CONTEIBUTION 
 
 TO 1HB 
 
 HISTORY AND ETIOLOGY OF SPONDYLOLISTHESIS. 
 
 Although the history of spondylolisthesis has quite recently 
 been enriched by the interesting work of Swedelin in the last 
 number of the Archives of Gyncekology, I nevertheless am 
 induced to publish separately some fresh clinical observations, 
 made by me since that time, as they are valuable from several 
 points of view. Some time ago 17 cases of lumbo-sacral 
 spondylolisthesis as pathological specimens and only 16 cases 
 seen clinically were published and made known to a large circle 
 of the profession. It now appears that two accounts published 
 in 1875 were overlooked in the making the list of the literature 
 of the subject, as they were accessible only to a limited number 
 of readers : one of these was a case of spondylolisthetic pelvis, 
 seen during labour at Christiana, and published in the trans- 
 actions of the medical society of that place ; the other was a 
 dissertation published at Friburg in 1875, in which two other 
 cases were described by Egger. The number of clinical observa- 
 tions was thus increased to 19, to which I will now add 
 6 more ; of these one was seen by Hegar in Friburg, one by 
 Freund in Strasburg, while one at Strasburg, another at Paris, 
 and two more at Berlin have lately come under my own observa- 
 tion. The total number of clinical cases, including one of 
 Zweifel's at Erlangen yet unpublished, would therefore amount 
 to 26.* 
 
 * In all, therefore, 43 cases of spondylolisthetic pelvis (including one clinical case 
 in a man) were known up to January 1884, viz. : — 
 
 (o) 17 anatomical preparations : 2 each at Prague, Vienna, and Wiirtzburg ; 1 each 
 at Bonn, Breslau, Giessen, Halle, Liege, Moscow, Munich, Paderborn, Paris, Treves, 
 Zurich (in 9 of these cases the subjects had been under clinical observation during 
 life). 
 
 (i) 26 clinical observations : in Berlin, Friburg, and Strasburg, in each 3 cases ; in 
 
6 NETJGEBATJEB ON 
 
 Before describing my own observations at Strasburg, Paris, 
 and Berlin, I will give a short report of the other cases 
 mentioned. 
 
 Clinical Observation in Christiana. 
 
 This case is published in the Forhandlinger i det norske 
 medicinske Selskab i 1874, Christiana, 1875 ; contained in the 
 journal Norske Magazin for Lagevidenskab, Udgivet of det 
 medicinsk Selskab i Christiana Tredie raekke. Redigirt af 
 Jacob Heiberg. Tjerde Bind, Christiana, 1874 (?). 
 
 Unfortunately I was unable, in spite of much trouble, to 
 obtain the journal in question, and must therefore confine 
 myself to the transcription of the written account brought to 
 me from Christiana by my father on the occasion of a summer 
 trip to Norway. 
 
 On pp. 173—200, 189—200 of the journal mentioned in the 
 report of the meeting of the Society under the Presidency of 
 Dr. Schonberg, on the 23rd September, 1874, the following 
 communication is to be found : Dr. Vedeler, assistant to Pro- 
 fessor Faye, describes a case of spondylolisthetic pelvis seen in 
 his clinic in 1874. The woman, aged 28, was admitted into the 
 hospital pregnant for the eleventh time, and in the absence of 
 Professor Faye, and was delivered by the induction of premature 
 labour by Dr. Vedeler and Dr. Kaiser. In the report of the 
 meeting on the 7th October, 1874, pp. 200—213, 202—204, 
 
 Dresden, Halle, and Prague, in each 2 cases j and 1 case in each of the following towns : 
 Basle, Berne, Christiana, Coblenz, Brlangen, San Francisco, Leipsic, London, Peters- 
 burg, Stuttgart, and Paris. 
 
 Lastly, I learn from Professor Nicoladoni that there is an anatomical preparation 
 at Innsbruck ; and Professor Mayer, of Friburg, informs me that he has such a pelvis 
 in his collection. Professor Mayer could not, however, find it during my stay iu 
 Friburg, as he was just in the act of occupying a newly built institution, and a large 
 number of the preparations were still packed up on account of their removal. 
 
 The French obstetrician, Charpentier, in his comprehensive text-book of midwifery, 
 which was published in two volumes only a few months ago, has given the total of 
 spondylolisthetic, including spondylizematic pelves, as only 29 (Traite pratique des 
 Accoiichements. Paris, 1883, Tome ii., p. 110), although he so freely cites the foreign 
 literature of the subject. In the section relating to this affection no reference is 
 made to the more recent studies on the etiology of spondylolisthesis, even the 
 clinical aspect of this anomaly is lightly mentioned, and the historical information 
 from the literature is not always accurate. M. Charpentier had at the time, as he 
 informs me, no knowledge of the more recent works on the subject of spondyl- 
 olisthesis, and this defect will be remedied in the next edition of his work. 
 
THE HISTOEY AND ETIOLOGY OF SPONDYLOLISTHESIS. 7 
 
 it is stated : Professor Schonberg said in reference to Vedeler's 
 communication on spondylolisthesis that he had himself 
 examined the woman during labour, and must confirm the 
 diagnosis. 
 
 In a later volume of the same journal, in the proceedings of 
 1876 (Christiana, 1877), it is stated in the report of the meet- 
 ing on March 8th, 1876, pp. 31—48, 33—41, L. Faye (p. 33) 
 gives a description of the twelfth labour of the same woman in 
 whom in November, 1875, he had, in conjunction with his father, 
 F. C. Faye, induced premature labour, the child being still-born 
 and the mother recovering. Faye declares the pelvis not to be 
 spendyl-olisthetic, and quotes a remark made at the time by 
 Professor Faye, to the effect that he also thought the dislocation 
 of the vertebral column to be the result of inflammatory soften- 
 ing. He says further, on page 41, " Vedeler holds to his 
 diagnosis of spondylolisthesis ; ' ; and finally, on pp. 41, 42, it is 
 stated, " Schonberg points out that the fifth lumbar vertebra 
 was dislocated downwards, and that there actually was a spondyl- 
 olisthesis." The extracts here given are not sufficient to explain 
 clearly the exact abnormality existing in this pelvis, and it would 
 be desirable to get further details from Christiana. 
 
 The next two cases, seen by Hegar before 1875, are described 
 by Egger,* but as his dissertation had only a limited circulation, 
 I will, with the permission of Herr Hegar, give an extract from 
 it here. 
 
 After a general and historical introduction a description is 
 given of the 
 
 First Clinical Case of Spondylolisthesis at Friburg. 
 
 The patient was a married primipara, aged 28. Her father 
 died from consumption in his 62nd year ; her mother died in her 
 45th year, but no history of her mother's health or cause of her 
 death could be obtained. Two sisters are living, and healthy. 
 During early childhood she had no illness, but she had an 
 attack of pituitary fever when she was four years old. She 
 learnt to walk at the end of her first year ; no signs of rickets. 
 Her mother died when she was five years old, and she was given 
 up to the care of strangers, and had to help in field labour, 
 * Siegfried Egger, Das Spondt/1-olisthetische Becken, Matig. Diss. Friburg, 1875. 
 
8 NEUGEBATJER, ON 
 
 carry heavy loads on her head, and undertake work for which 
 from her age and bodily strength she was still unfit. 
 
 In 1861, in her 14th year, while she was descending a 
 small hill, carrying a heavy water-bucket on her head, she un- 
 fortunately tumbled, and falling backwards on to her sacral 
 region the water-bucket fell on her belly. She was not able to 
 get up again from the ground, and had to be carried home to 
 bed. Severe pains came on in the sacral region, and about the 
 hypogastrium, and it was only after three months had passed 
 that she was able to make careful attempts to walk, with the 
 aid of a stick, which she had to use for three months longer. 
 Her body was passably bent, and from time to time the sacral 
 pains recurred when she walked. By degrees she was able to 
 walk upright and unaided, and from that time also the sacral 
 pains disappeared. She does not believe that she has grown 
 any shorter since the accident. 
 
 Menstruation came on in her 18th year, on the first and 
 second occasions with some difficulties ; it was regular, but was 
 always preceded by slight sacral pain, which disappeared during 
 the three days of the discharge. These pains did not interfere 
 with her work as a domestic servant. Iu 1868, while lifting a 
 heavy weight, she was suddenly seized with severe pain in the 
 back, and was obliged to seek relief in the hospital, from which 
 she was discharged cured, after stopping there only fourteen 
 days. From that time she felt perfectly well ; was married in 
 1874, and on the 10th of November of the same year after a 
 normal pregnancy her labour commenced. On the same even- 
 ing, the labour pains not having been particularly strong, the 
 waters broke and the cord prolapsed. Next day, after version 
 had been attempted, a dead child was delivered by the forceps. 
 The haemorrhage was moderate, and the placenta came away of 
 itself. 
 
 Puerperal endometritis coming on, she remained in bed for 
 four weeks, but was then compelled by circumstances to leave it, 
 and immediately she was attacked with the most violent pains 
 in the right hypogastrium. A swelling the size of an egg was 
 found in the right parametrium, which gradually diminished 
 under the use of moist applications, and was on a subsequent 
 examination found to be the size of a nut. She had then no more 
 pain, but only a feeling of tension in the hypogastrium ; besides 
 
THE HISTOBY AND ETIOLOGY OF SPONDYLOLISTHESIS. 9 
 
 which she was feverish, felt very weak, and as she could not 
 receive proper attention at home, she sought assistance in the 
 Gynaecological Hospital. The patient is 165 cm. in height, well 
 developed as to hony structure, and moderately fat. Cheeks and 
 mucous membranes are pale; stands and walks upright. There 
 is a slight lordotic sinking in of the lumbar vertebra, which is 
 more noticeable when the patient lies prone. There is no indi- 
 cation of hydro-rachis in the sacrum or skin of the pelvis. The 
 spinal column can be easily felt through the abdominal walls 
 with quite moderate pressure. The symphysis is very high, 
 somewhat perpendicular, the inclination of the pelvis is slight, 
 and the genitals are directed forwards. The legs are quite 
 straight, and there are no signs of rickets in the costal carti- 
 lages. The vagina is fairly capacious ; the vaginal portion lies 
 somewhat posterior to the vertebral line ; the corpus uteri 
 enlarged, but in fair position. Both body and neck of the uterus 
 are slightly movable. The linea terminalis is considerably 
 elongated in its anterior segment ; the pubic arch narrow. The 
 bifurcation of the aorta cannot be felt, nor any large pulsating 
 vessel corresponding to one of the iliac arteries. Projecting 
 from the anterior surface of the sacrum for about the thickness 
 of a vertebra, immediately behind the vaginal portion, is a hard 
 prominence, which is apparently the last lumbar vertebra, this 
 having slipped down a little to the right, so that the left half of 
 the pelvic inlet is wider than the right. The projecting angle 
 of dislocation is exceptionally distinct. 
 
 In the rectum one can feel the projecting dislocated vertebra 
 as well as the projecting angle of dislocation, and also both 
 sacro-uterine ligaments very much thickened and unyielding. 
 The following measurements of the pelvis should be recorded 
 here : — 
 
 Diameter between the anterior superior spines 27"0 
 
 ,, „ crests of the ilia 31'0 
 
 Distance between the trochanters 340 
 
 Diameter of Baudeloque 18'5 
 
 External oblique diameter, left 230 
 
 right 240 
 
 Distance between the tubers of the ischia 100 
 
 Distance from the lower margin of the pubic arch to the angle of dis- 
 location 12 
 
 Distance from the lower margin of the pubic arch to the most pro- 
 minent point of the lumbar vertebra within each 90 
 
10 NEUGEBAUEE ON 
 
 The auamuesis with the present condition completely justify the 
 diagnosis of spondylolisthesis. 
 
 In conclusion, Egger disposes of certain objections as to the 
 existence of rickets, exostoses of the pelvis, &c, &c. 
 
 Second clinical case at Friburg (I. c. pp. 16, 23), Salome 
 Haug, of Eichstellen, aged 33, single, a primipara. Her father 
 died at the age of 67 from an attack of apoplexy. Her mother 
 is alive and in good health, and she has eight brothers and sisters 
 in the enjoyment of the best health ; she herself was never ill 
 when young. She learnt to walk even in her first year, and did 
 not again leave off doing so. At the age of 14 she went into 
 service and had to work hard. 
 
 Menstruation was normal from her 16th year. In her 19th 
 year she was suddenly attacked by severe pains in the sacral 
 region, without any definite cause, and noticed during her 
 illness an increasing weakness in her lower extremities. Under 
 careful treatment this condition improved so that she was again 
 able to take service in an easier place, and only suffered off and 
 on from some sacral pain; one day, however (1870), while she was 
 lifting a pail of water she was seized suddenly with violent pain in 
 the sacral region, and at the same time noticed a cracking noise 
 in that locality. She broke down, and had to keep her bed for 
 a whole three months. At every attempt to stand the pains 
 were at first very severe, but became less so as time went on, 
 and she gradually regained her power of standing and moving 
 about ; she remarked, however, that she was shorter than before 
 her illness. Her poverty compelled her to go into service again, 
 and she had very good health until May, 1872, when she con- 
 ceived. The course of her pregnancy was on the whole normal ; 
 she only suffered at times from sacral pain, and was very 
 quickly fatigued if she walked about. She went home and 
 prepared for her lying-in, and labour pain, began on 28th 
 January, 1873. The presentation was transverse; and on the 
 morning of the 29th January the medical attendant made several 
 attempts to turn under profound chloroform narcosis, unfor- 
 tunately in vain. Herr Hegar was consequently called in. 
 
 He did not arrive at the place, which was at some distance, till 
 five o'clock in the evening. The right arm protruded outside 
 the vulva, and the uterus was most firmly contracted round the 
 child lying across the pelvis. Several attempts at turning were 
 
THE HISTORY AND ETIOLOGY OF SPONDYLOLISTHESIS. 11 
 
 made, but in vain. The neck of the child was within easy 
 reach, and decapitation was therefore carried out by means of 
 long scissors. The operation was comparatively easy, as was 
 also the delivery of the trunk depending on it. The principal 
 difficulty, however, remained in the delivery of the head left 
 behind in the uterus, and this difficulty was increased by the 
 circumstance that in the decapitation the first cervical vertebra 
 had been left attached to the head, and as a consequence the 
 foramen magnum could not be made use of. The next thing to 
 be done was to steady the head, and for this purpose a hook was 
 passed into the mouth on which traction was made. The 
 assistant, however, pulled too hard on the hook and broke the 
 lower jaw. As the best point to lay hold of for fixing the head 
 was lost, it was while continually rolling about laid bold of by a 
 sharp hook carried through the roof of the orbit and the cephalo- 
 tribe applied, the assistant at the same time affording support 
 to the head by external pressure. 
 
 This attempt itself was not successful. The cephalotribe had 
 only seized a small segment of the head and began to slip off, just 
 as the hook lost its hold in the same way as in the attempt to fix 
 the head by the mouth. A similar failure resulted from the 
 same process in the other orbit ; and as all means of delivering 
 the head hitherto attempted had failed, Herr Hegar tried to 
 reach the posterior side of the head by carrying his hand up 
 along the sacrum, and he was able to get at a point in the 
 squamous suture which admitted of the introduction of the 
 scissors-shaped perforator. This passed upwards along squamous 
 portion of the temporal bone, yet its application to the squamous 
 suture was very difficult because the squamous part overrid the 
 edge of the parietal bone, bevelled off in the opposite direction, 
 and slipped away over it. Only after much trouble did the 
 instrument pass through the suture, and at first it slipped 
 upwards between the inner side of the skull and the dura mater, 
 because its handle could not be sufficiently depressed. At last 
 the membranes were perforated and the cranioclast applied ; the 
 extraction of the head was then easily accomplished. The 
 placenta followed spontaneously. 
 
 The patient lay sick for eight weeks, feeling extremely weak, 
 with high fever and profuse perspirations. The lochial discharge 
 was moderate, and there were occasional pains in the abdomen. 
 
13 NEUGEBATJEIt ON 
 
 During these eight weeks the urine was passed involuntarily; 
 the menses had not reappeared since the labour. In this state 
 she was admitted into the Friburg Gynsekological Clinique, 
 where the incontinence of urine, which was due to paralysis of 
 the sphincter vesicae, was cured, and after three months' stay 
 in the hospital she left it fairly recovered. She still suffered 
 from slight occasional pain in the sacral region, and had some 
 difficulty in standing and walking, feeling quite well only in the 
 horizontal posture. 
 
 Salome Haug was 157 cm. in height, of rather powerful, bony 
 development, fairly covered with muscular and adipose tissue. 
 Her extremities were not crooked ; her thorax, not unduly arched, 
 was smooth without any rachitic change. The cervical and 
 dorsal vertebrae were regular, but there was a well-marked 
 lordotic depression in the lumbar spine. The sacrum only 
 moderately steep. In the lumbo-sacral region no hiatus could 
 be felt, nor could any scar or puckering be found which would 
 have indicated the presence of a congenital hydrorachis. The 
 symphysis pubis was very high up. On pressure on the abdomen 
 the lumbar vertebral column could be very easily felt, and 
 appeared to be displaced forwards. A plumb line held against 
 the dorsal vertebra falls into the base of the sacrum, and the 
 distance from the deepest point of the lumbar lordosis measures 
 2 cm. to this line, while the distance from the same point to a 
 line joining the most prominent point in the thoracic vertebra to 
 the most prominent point in the sacrum, is 4"5 cm. The plumb 
 line in the axilla falls in front of the trochanter major, and if 
 suspended in the line of the trochanter lies posterior to the 
 scapula. Haug, who when young used to walk bolt upright, now 
 walks slowly, unsteadily, and with difficulty, like one with sacral 
 paralysis. Her feet are turned rather inwards, and in standing 
 and walking the upper part of her body is bent forwards and the 
 knees are decidedly bent. 
 
 On examination the vagina was found moderately capacious 
 and short, the arches of the anterior half of the pelvis convergent, 
 and more so on the left side than on the right. The vaginal 
 portion was short, and in normal position ; from the right com- 
 missure there was a cicatricial band running to the vaginal roof. 
 The body of the uterus was retroflexed. On the posterior wall 
 of the pelvis there was a hard blunt projection at the level of 
 
THE HISTOKY AND ETIOLOGY OF SPONDYLOLISTHESIS. 13 
 
 the first sacral vertebra, which was, however, not very distinct. 
 The bifurcation of the aorta could not be reached, nor could any 
 large pulsating vessel corresponding to the right or left iliac artery 
 be felt. 
 
 Examination per rectum, though the different parts of the 
 pelvis were easily felt, threw no fresh light on the spondyl- 
 olisthesis; the blunt projection in the vertebral column lay 
 directly in the middle, inclined neither to the right or left. 
 
 The following pelvic measurements should be mentioned here : — 
 
 Diameter between the anterior superior spines 25 , 
 
 „ ., crests of the ilia 285 
 
 „ „ trochanters 3I"5 
 
 Baudeloque's diameter 190 
 
 External oblique diameter, right 210 
 
 „ „ left 22-5 
 
 Distance between the tubers of the ischium 95 
 
 Diameter of cavity of the pelvis 11-0 
 
 From the lower margin of the pubic arch to an angle in the lumbar 
 
 vertebrae 100 
 
 The information derived from the history of the case, especially 
 the fact that the patient used to walk quite straight, and that the 
 change described afterwards took place in the way she held her- 
 self and walked, in addition to the fact that subsequent to pains 
 in the sacral region, the patient while lifting up a heavy weight 
 felt a distinct snap in that part of her body, the pains which 
 followed, and the three months inability to stand or walk, all 
 indicate a pelvic spondylolisthesis existing in her case. 
 
 Egger adds to the description of these two cases some remarks 
 on the various modes of standing and walking of different women 
 affected with spondylolisthetic pelvis, and says on page 23, 
 " In the carriage and deportment of persons with pelvic spondyl- 
 olisthesis nothing typically characteristic has been observed," and 
 he endeavours to justify this statement by a collection of all the 
 information published on the subject. Now, I believe that the 
 analysis I have published in my various works, of the carriage of 
 body, the mode of progression, and foot-prints, in the different 
 stages of spondylolisthesis, completely disproves this view of 
 Egger's. As for the rest I would refer to the description given 
 further on of my Strasburg case, in which my . presumptive 
 diagnosis actually depended on the typical character of the mode 
 of progression. On the etiology of these cases Egger says on 
 pp. 29, 30, "It has already been mentioned that both- these 
 
14 NBUGEBAUER ON 
 
 patients had when young suffered from inflammatory processes 
 in the sacral region, and these chronic processes probably ex- 
 tended to the joint between the inferior oblique process of the 
 last lumbar and the articular process of the first sacral vertebra. 
 In the first case (that of Engler) a fall while descending a small 
 hill, in the second case (that of Haug) was the immediate cause of 
 rupture of the ligaments and laxation of the oblique processes 
 which had been the seat of that chronic inflammation, and thereby 
 was the signal for the slipping in of the last lumbar vertebra." 
 
 He concludes on page 30 as follows : " Herr Hegar assures 
 me that the delivery of Salome Haug was the most difficult he 
 had met with in his extensive practice, and in his opinion the 
 difficulty in the delivery of the head was considerably increased 
 by the previous decapitation, whereby the possibility of fixation 
 of the head was lost. In such cases eventration, or even the 
 bisection of the trunk, would be preferable." 
 
 The diagnosis appears from the conditions as reported to have 
 been correct in each case. I cannot, however, agree with Egger 
 that the deformity was caused by the inflammatory processes in 
 the sacral region which existed in earlier years, but would rather 
 in each case attribute it as directly due to an injury, a fracture. 
 In the second case a congenital spondylolysis interarticularis of 
 the arch of the fifth lumbar vertebra may be accepted as a predis- 
 posing cause of the development of the deformity. Yet this idea 
 seems rather at variance with (or somewhat hardy in view of) 
 the principles I have elsewhere advanced on the development of 
 olisthesis in early life, before the occurrence of pregnancy, &c., 
 &c. How easily an accidental injury of this kind may be over- 
 looked, is proved by those cases in which, though the occurrence 
 of anything of the sort is denied, on the first investigation of the 
 case it is nevertheless subsequently ascertained that such an 
 injury did take place (vide Archiv fur Gynakologie, Bd. xix., 
 Hft. 3, § 463). However, as - 1 have completely proved elsewhere, 
 all the results of anatomical and clinical study of the etiology of 
 spondylolisthesis certainly oblige us in most cases to look on an 
 injury as the cause, and in any case this second Friburg case is 
 not singular as regards its etiology, for the same statements 
 have been made in several others as to the time and manner of 
 the commencement of the deformation — "Sudden sacral pain, 
 without any alleged inducing cause." 
 
THE HIST0KY AND ETIOLOGY OF SPONDYLOLISTHESIS. 15 
 
 It would not be easy to obtain a supplemental and more exact 
 anamuesis in tbese cases. Salome Haug, for example, is now 
 dead, and even if in these exceptional cases there is no history 
 of any previous injury, we are nevertheless obliged, by the more 
 exact details given in the vast majority of recent cases, to believe 
 in the previous occurrence of an injury, or fall back on the exist- 
 ence of a congenital spondylolysis. It might also be said that in 
 this second Friburg case, that the first attack of sacral pain and 
 difficulty in moving about in the. patient's 19th year must 
 be attributed to some cause quite independent of the spondylolis- 
 thesis, and that the latter was only brought on by lifting a 
 bucket of water in her 29th year, and therefore ten years 
 later. To this I would answer that a better explanation for 
 those symptoms which occurred in the patient's 19th year than 
 a commencing olisthesis is, must at least be looked for. And 
 moreover it is definitely stated that from the time of the first 
 sudden attack of sacral troubles in her 19th, up to that of the 
 injury in her 29th year, Salome Haug continually suffered off 
 and on from sacral pain, and was obliged to look for an easier 
 place of service. There is, therefore, in all probability a distinct 
 connection between her sickness when 19 years old and that in 
 her 29th year. Finally, from the pelvic measurements taken in 
 1873, from the account of the delivery, and also from the fact 
 that Salome Haug's attitude in moving about was later on one 
 bending over forwards, it appears that the spondylolisthesis was 
 one of a considerable degree. Now the development of olisthesis 
 is most gradual, according to our present clinical experience it is 
 a question of years, and it is therefore far more natural to suppose 
 that the process of olisthesis had as a matter of fact begun when 
 the patient was 19 years old, and that the injury ten years after- 
 wards, when she heard a snap in the sacral region, was important 
 as making matters much worse. Indeed I would suppose that 
 this injury in the 29th year corresponded with the moment in 
 which the process passed out of the stage of spondylolisthesis of 
 Lambl into the stage of spondyloptosis, in which a secondary 
 infraction of the interarticular portions of the arch of the fifth 
 lumbar vertebra took--place, and that to this infraction is to be 
 ascribed the sensation of the snap in the sacral region. I have 
 elsewhere pointed out how under pressure and tension the arch 
 of the fifth lumbar vertebra becomes elongated to the greatest 
 
16 NEUGBBAUEK ON 
 
 possible extent, and bent over forwards and downwards, and have 
 theoretically deduced the occurrence of this secondary infraction, 
 and am rejoiced to find this very interesting point in (he 
 anamuesis of Salome Haug supporting my theoretical deduction 
 of secondary infraction of the vertebral arch, to avoid the repeti- 
 tion of which I refer to my earlier works on the etiology of 
 spondylolisthesis. I would therefore consider the injury that 
 Salome Haug suffered in her 29th year as a consequence of the 
 maximum elongation gradually attained under tension of the 
 arch of the fifth lumbar vertebra, on the occasion of a sudden 
 increase of the body weight by taking up a burden, and I would 
 date the origin of the olisthesis back to her 19th year, ascribing 
 it principally to an injury sustained before that time, though not 
 recorded in the anamuesis, and in a less degree to a congenital 
 spondylolysis articularis of the arch of the fifth lumbar vertebra. 
 That this latter as a matter of fact led to a spondylolisthesis is 
 proved by the pelvis of the Hottentot Venus, the Prague- Wurz- 
 burg pelvis, that at Bonn, the second Wurzburg pelvis, and two 
 cases of olisthesis of the body of the last lumbar vertebra but 
 one, which I have myself described, and other cases also. In 
 most such cases of congenital interarticular spondylolysis of the 
 vertebra, which are indeed often enough accidentally revealed on 
 a post-mortem examination, the ligaments which hold together 
 the disunited portions of the vertebral arch are still powerful 
 enough to keep the parts in position under pressure, and to pre- 
 vent the slipping downwards and forwards, the displacement, the 
 olisthesis of the anterior half of the vertebra, which is directly 
 subjected to the body weight, and especially so if pregnancy does 
 not occur. 
 
 Finally, this sudden and abrupt transition out of the stage of 
 olisthesis of Lambl into that of complete spondyloptosis, accom- 
 panied by an appreciable " snap " in the patient's 29th year, 
 induces me to believe that there was in this case a secondary 
 infraction, which of course excludes the pre-existence of a 
 spondylolysis. 
 
 The question of the genesis of this second Friburg case cannot 
 be definitely settled from its history. But the experiences of 
 the past two years have shown that spondylolisthesis lumbo- 
 sacralis is however by no means such a very rare affection, and we 
 may hope in future, by the greatest care in noting the anamuesis, 
 
THE HISTOKY AND ETIOLOGY OF SPONDYLOLISTHESIS. 17 
 
 to obtain in every case decisive evidence as to whether the affec- 
 tion owes its origin to a fracture or to a congenital spondyl- 
 olisthesis (? olysis) sic. 
 
 Nothing new is added to our knowledge of the symptoms of 
 the disease by the histories of these two cases, though very 
 many of the facts stated so completely correspond with or are 
 supplemented by those recorded in other cases of the same sort, 
 that I regret not having sooner met with this Friburg dissertation. 
 The second case is particularly interesting obstetrically, showing 
 as it does that though the character of the pelvis had not yet 
 become that of one outwardly kyphotic in the extreme, the 
 shortening of the conjugate diameter of the pelvic inlet was so 
 considerable, and the delivery so exceptionally difficult, that Herr 
 Hegar pronounced it to be more so than any he had met with in 
 the many years of his extensive" practice. In particular the dis- 
 tance between the great trochanters of the femora (31"5) still 
 remained 3 cm. greater than the distance between the crests of 
 the ilia, an excess still so large as to show that the rotation of 
 the hip bones outwards, and proportionately therefore the rota- 
 tion of the sacrum backwards, was as yet by no means consider- 
 able, and nevertheless the delivery by operation was exceptionally 
 difficult. It is stated that the conjugata diagonalis spuria, 
 measured from the pubic arch to an angle in the lumbar vertebra, 
 was 10"0 cm., but the particular angle or vertebra is not men- 
 tioned. It may be presumed that the smallest conjugate 
 measurement of this pelvis lay above* the proper plane of the 
 pelvic inlet, and indeed so high up that its dimension could 
 hardly if at all be ascertained per vaginam, and could only be 
 approximately estimated from measurements taken above it 
 through the abdominal walls. 
 
 However that may be, there is ^exceptional interest clinically 
 in the case of Salome Haug, because it proves that the degree 
 of contraction of the pelvis in a conjugate direction, in and 
 superior to the plane of the pelvic inlet, which is most to be 
 thought of in delivery, cannot be estimated with absolute exacti- 
 tude from the other dimensions of the pelvis. For example, in 
 Minna Berndt (first Dresden case, 1882), in whom the distance 
 
 * This is also probable, from the fact that inJSalome Haug, as also in Katharina 
 Lommins, Theresa Barta, and Henriette Rudolph, when moving about the attitude of 
 the trunk was bent over forwards, the inclination of the pelvis being more or less 
 diminished. 
 
 2 
 
18 NEUGEBAUER ON 
 
 between the crests of ilia was 27* 5 cm., and that between the 
 trochanters 27 cm., and therefore only 0'5 cm. less, while the 
 distance between the tubers of the ischia was 6"0 cm., and there- 
 fore the external kyphotic character of her pelvis was far more 
 developed, the natural forces were sufficient to cause the advance 
 of the foetal head as far as the pelvic outlet, and the pregnancy 
 terminated normally in the birth of a living child, while in other 
 cases, in which the external kyphotic character of the pelvis has 
 been far less developed, the delivery has been fatal to mother or 
 child, or to both. I cannot here digress to enter on this most 
 interesting obstetric question, which I must leave for a separate 
 work. I would only insist that the danger attending a delivery 
 cannot be estimated from the external dimensions of the pelvis 
 by themselves, nor is obstetric aid to be doled out by centi- 
 metres. One may indeed determine the amount of contraction 
 in the outlet and cavity, and in favourable cases where the head 
 presents and is still movable even that of the anatomical inlet, 
 of the pelvis, but when labour is going on we cannot make an 
 exact estimate of the contraction in the median plane above the 
 plane of the anatomical inlet to the pelvis, the very seat in many 
 cases of the greatest obstacle to delivery, of the greatest con- 
 traction. That not only during labour itself, but even when 
 pregnancy is not far advanced, it may be very difficult under 
 certain circumstances to feel the lumbar vertebral column in the 
 plane of the anatomical pelvic inlet, or even somewhat lower down, 
 was proved in the first Dresden case, in which at his first inde- 
 pendent examination Winckel was unable to reach the lumbar 
 column or angle of dislocation per vaginam, and only concurred 
 with my diagnosis after he had again examined the woman 
 lying on her side. Indeed in one case in practice, in which it 
 was stated that on account of the fetal parts presenting, the 
 lumbar column could not be distinctly made out per vaginam, 
 the obstetrician in attendance quite disregarding on that account 
 the angle of dislocation, made his diagnosis of spondylolisthesis 
 only on the external kyphotic form of the pelvis, the attitude of 
 the body, &c, &c, combined with the absence of any kyphotic 
 lumbo-sacral convexity. The place of the greatest contraction, 
 whether in the median plane, or if the case is complicated by 
 scoliosis, in a somewhat extramedian but parallel plane, is 
 often out of the reach of digital examination per vaginam or per 
 
THE HISTOHY AND ETIOLOGY OF SPONDYLOLISTHESIS. 19 
 
 rectum, and naturally one cannot on account of the pregnancy 
 even reach the vertebral column through the abdominal walls. 
 One can therefore in such cases do no more than estimate the 
 degree of the inclination of the lumbar column forward com- 
 pared with the inclination of the pelvis. It is not without reason 
 that the spondylolisthetic pelves have been grouped among the 
 pelves obtectae. The task is to find out up to what distance the 
 lumbar column has bent itself over towards the anterior arch of 
 the pelvis. We have a means of approximately determining 
 this contraction in the degree of lumbo-dorsal lordosis, in the 
 attitude of the body, the amount of sinking of the thorax into 
 the greater pelvis. A spondylolisthetic pelvis often enough 
 passes unnoticed during a labour, for out of consideration of the 
 exhaustion of the woman in her travail, the attending prac- 
 titioner neglects to observe her attitude when standing up, and 
 her gait when moving about (as was, for example, the case in the 
 third Strasburg case to be hereafter described). It is therefore 
 manifestly of particular importance to take at least one oppor- 
 tunity of observing the lying-in woman when standing up, at all 
 events in those cases there is great and unexpected difficulty in 
 delivery, from delay in the engagement of the child in the small 
 pelvis, whether it be a spondylolisthetic or any other kyphotic, 
 spondylizematic, rachitic, or osteo-malacic, pelvis obtecta, a 
 luxation pelvis, or otherwise. And here also no measurements in 
 centimetres from the upper margin of the pubic symphysis to the 
 fifth, fourth, third, second, or first lumbar spine, nor to the dorsal' 
 or cervical spines, can lead to any exact conclusions, but the degree 
 of inclination of the lumbar column to the plane of the pelvic 
 inlet should be at all events approximately determined. One 
 should keep before one's mind that inclination is the chief 
 danger and primary obstacle in the way of labour in the pelvis 
 obtecta, and modify one's conduct of the case according to the 
 degree of this obstacle to delivery. 
 
 If once the obstetric inlet of the pelvis is passed, unless com- 
 plications exist, the outlet is generally reached without special 
 difficulty. Happily in most cases (as for example in both the 
 Dresden cases, and many others) any operations which may 
 still be necessary are undertaken at the pelvic outlet, and far 
 less significance for the integrity of mother and child than those 
 at the inlet of the pelvis. 
 
20 NEUGEBAUEB ON 
 
 Third Clinical 'Case at Friburg. 
 
 During a short visit I made to Friburg at the time of the 
 meeting of scientific men (Naturforscherversammlung), Herr 
 Hegar informed me that he had recently seen another clinical 
 case of spondylolisthesis. 
 
 The woman in question, Frau Caroline Schweizer, 41 years 
 old, from Hofsgrund (see the Poliklinical Journal of the Friburg 
 Clinique for Women, 1883, i., No. 46), had had seven children 
 and one abortion, and in the spring of this year had come to the 
 Poliklinical Dispensary (Ambulanz) on account of some uterine 
 affection. After Herr Hegar had diagnosed a spondylolisthetic 
 pelvis, and she had been examined by Herr Wiedon, the 
 assistant physician, also, the woman was requested to come 
 another time in order that the anamuesis and present condition 
 should be accurately taken ; from that time, however, up till 
 the present she has not again presented herself, and conse- 
 quently the detailed description and history of the case are still 
 to be expected in the future. 
 
 Second Strasburg Case.* 
 
 I have to thank Herr Freund for the notes of the following 
 case, which he examined two years ago with Herr Bayer, at that 
 time his assistant. 
 
 Christine Kuiz, from Eschau, was sent to the Strasburg 
 University Clinique for the Diseases of Women for the closure 
 of a vesico-vaginal fistula. She was operated on on July 14th, 
 and discharged on July 26th. 
 
 She had never been sick. Her menstruation, commencing in 
 her 16th year, had been always regular, though rather painful. 
 She had had nine children, of whom three had died, and of 
 these two from protracted labour. All her confinements had 
 been very difficult, in two cases because of cross-birth. There 
 had never been any puerperal disturbances. In the last confine- 
 ment ten weeks previously, the waters began to come away on 
 Sunday. There were no effective pains till Monday night, and 
 the child, which is still living, was born after excruciating pain 
 on Tuesday evening. Immediately after the delivery the patient 
 
 * As the first Strasburg case I count the one described by von Hueter in 1875, as 
 seen in the Clinique there at that time under GuEserow. 
 
THE HISTOKY AND ETIOLOGY OP SPONDYLOLISTHESIS. 21 
 
 began to feel stabbing pains in the right groin and iliac region, 
 which were greatly aggravated when she passed water. There 
 was no other particular symptom, and micturition went on as 
 before. She left her bed as early as the fifth day, and it was 
 not until the eleventh day that she noticed that her water flowed 
 from her vagina, as it has done ever since, though she can now 
 and then pass a little water voluntarily. The catamenia have 
 not returned since her delivery. 
 
 She is 150 ct. in height, strongly built as to bone. In the 
 lumbar region there is extreme lordosis, with a most remarkable 
 saddle-shaped sinking in of the loins, which is not altered in 
 any movement she makes. There is an angle in the spinal 
 column, between the sacrum and the lowest lumbar vertebra, 
 the angle opening backwards. From the remarkably small 
 difference between the diameters through the crests and tro- 
 chanters, the external appearance of the pelvis is extremely 
 kyphotic, being distinctly quadrangular, " like that of a cow." 
 The sacrum sticks out prominently behind just as in a kyphotic 
 pelvis, the rhomboid is pretty large, the nates very thin and 
 remarkably hollow. The posterior superior spines of the ilia 
 are well marked and tolerably symmetrical in position, the 
 posterior S-shaped incurvation of the crest of the hip bones are 
 remarkably abrupt and far apart. 
 
 The lines joining the S angles to the posterior superior spines on 
 either side, when produced, intersect in an unusually obtuse angle, 
 the apex of which is about 2"5 cm. above the commencement of 
 the anal fissure. The abdomen is very short and pendulous, and 
 consequently there is a well-marked fold of skin passing in a curve 
 transversely above the symphysis pubis. The position of the 
 navel is very low down, only 8 cm. above the symphysis, and the 
 distance of the latter from the ensifoYm cartilage is only 20*5 cm. 
 
 Pelvic measurements — 
 
 Distance between the trochanters SO'Ol 
 
 „ the crests of the ilia 29-0 
 
 „ anterior superior spines 27 - 
 
 „ „ posterior „ 8 - 5 
 
 n „ S angles of the curves of the iliac crests 12"0 
 
 „ tubers of the ischia 8'0 
 
 Length of the sacrum 13-0 
 
 External conjugate diameter 19'5 
 
 Length of the symphysis pubis 6-5 
 
 Conjugata diagonalis spuria measured to the lower margin of the 
 
 fourth lumbar vertebra 10-5 
 
22 NEUGEBAUEK ON 
 
 The genitals are situated pretty far forward. The vicarious 
 conjugata vera, as measured externally through the abdominal 
 parietes in narcosis, was 7 "5 cm., and as some addition must be 
 made to this for the thin abdominal walls it may be estimated 
 at 8 cm. The pelvic outlet seems somewhat contracted trans- 
 versely. On an internal examination one is at once struck by 
 the high situation, great thickness, and remarkably upright 
 position of the symphysis pubis, the cartilage of which is 
 unusually large and prominent. The sacrum is very long, and 
 its course from below upwards passes well backwards. At the 
 level of the pelvic inlet the finger is stopped by the anterior 
 surface, now quite horizontal, of the depressed body of the last 
 lumbar vertebra, which rounds itself off backwards on either 
 side, and extends well beyond the linea innominata ; from either 
 side of the projecting vertebral body the finger passes into an 
 empty space ; one can feel on each side of the prominent lumbar 
 column a pulsating vessel, probably the two common iliac 
 arteries, but the bifurcation of the aorta cannot be reached. The 
 lower margin of the body of the fourth lumbar vertebra, which is 
 within reach, takes the place of the promontory. The right half 
 of the pelvis is in every way somewhat smaller than the left, 
 corresponding with a scoliosis. The upper part of the back is 
 flat, the left shoulder being higher than the right ; no sign what- 
 ever of rickets. 
 
 The involuntary flow of water has caused eczema in the neigb- 
 bourhood of the genitals. The anterior lip of the cervix uteri is 
 slit up in the middle as if with a knife, and when both parts of 
 the lips are drawn apart, one can see in the cervix, as large as a 
 pea, the mouth of the vesico-vaginal fistula. The patient was 
 operated on on 19th July, but had to be allowed to leave before 
 the healing was complete. * The complication of this case by 
 vesico-vaginal fistula, the mode of origin of which can be easily 
 understood, makes it particularly interesting. 
 
 The three clinical cases which fell under my own observation 
 during the current year, and a fresh case from Paris, are now to 
 be described. 
 
 I came across the first case accidentally while I was acting as 
 assistant in the general dispensary (poliklinischen Ambulanz) 
 of the Surgical Clinique of Berlin University. 
 
 I must, unfortunately, confine myself to the following short 
 
THE HISTOEY AND ETIOLOGY OF SPONDYLOLISTHESIS. 23 
 
 registration of the case, as no complete notes or drawings are at 
 my command. 
 
 Second Berlin Case* 
 
 Mrs. Auguste H., aged 52, the wife of a mechanic from the 
 neighbourhood of Brandenburg, came in the spring of 1883 to 
 the general surgical dispensary on account of a painful ulcer on 
 the nose. Herr Sonnenburg, under whose direction the Poli- 
 clinique was at that time, diagnosed a carcinoma, and immedi- 
 ately removed the neoplasm by operation. The appearance of 
 the woman struck me as suggesting the existence of spondyl- 
 olisthesis lumbo-sacralis by the short back, projecting hip bones, 
 and by the peculiar attitude of the body and mode of progression. 
 An inspection of the back and pelvis confirmed my suspicion, 
 which was still further supported by an internal examination of the 
 pelvis which I took the opportunity of making while the woman 
 was under chloroform for the removal of the carcinoma. On 
 account of her age examination per vaginam was of little use ; 
 I was, however, able to feel per anum, the lumbar column bend- 
 ing forwards, the angle of dislocation, the lateral angle, described 
 by Breisky, &c. The external appearance of the woman, the 
 sinking down of the thorax into the pelvis, the deep lumbo- 
 dorsal groove, the folds of skin between the thorax and pelvis, 
 the upright, heart-shaped buttocks, with deep lateral depressions 
 over the incisuras ischiadse majores, the external kyphotic 
 character of the pelvis, the pendulous belly, and the advanced 
 position of the external genitals, all corresponded to the usual 
 type. 
 
 Unfortunately I have not any measurements. The angle of 
 dislocation lay very high, and if one passed the finger upwards 
 along the posterior pelvic wall, could only be reached with 
 extreme difficulty on account of the diminished inclination of 
 the pelvis. It can be easily understood, that as in this sort of 
 pelvis the sacrum is rotated backwards, and the distance from 
 the arch of the pubes to the upper edge (indeed to the whole) of 
 the body of the first sacral vertebra is thereby increased, and 
 therefore the length of the conjugata diagonalis also, the manipu- 
 lation of the examiner's hand is further obstructed by the con- 
 
 * I have counted a case in Rabenau's prac.ice, described by Swcdelin, as the first 
 Berlin case. 
 
24 NEUGEBAUER ON 
 
 traction of the pelvis in both transverse and conjugate directions, 
 and one must press up the coccyx and soft parts with a certain 
 amount of force. I may mention on this point that it is much 
 better practically, instead of at first feeling along the anterior 
 surface of the sacrum for the angle of dislocation, which, for 
 example, in the cases of Olshausen and Billeter was indeed 
 believed to exist but not properly reached by the finger, to 
 pass the finger in the anterior vaginal vault or in the rectum 
 directly upwards close along the posterior surface of the sym- 
 physis, and try first to feel the lumbar and vertebral column and 
 the so-called false promontory. When the lumbar column is 
 reached, as I have always been able to do without special diffi- 
 culty in the nine living cases I have examined up to the present, 
 one can then find the angle of dislocation more easily by 
 slipping the finger back along the anterior surface of the lumbar 
 column. 
 
 The fact that at times the angle of dislocation and the lumbar 
 column can only be reached with great difficulty, unless the 
 examination is conducted in an appropriate way, may be the 
 reason that spondylolisthesis remains undetected in so many 
 cases in practice, especially as during labour the presenting parts 
 of the child make it still more difficult to reach the lumbar 
 column and angle of dislocation with the hand unless the woman 
 is examined standing up, or lying on her side. 
 
 When Mrs. H. had recovered from the chloroform, I eagerly 
 sought for a detailed history of her case ; it was interesting. She 
 at first denied that she had suffered from any spinal affection, 
 but afterwards admitted that since her 46th year she had 
 had constant sacral pain, which she attributed to hemorrhoids ; 
 nevertheless a searching examination of the rectum and genital 
 organs revealed nothing of a pathological character. The history, 
 slight creeping pain in the sacrum and the gradual development, 
 apparently almost without any symptoms, of the externally 
 noticeable deformity, was certainly in favour of the suspected 
 spondylolisthesis, although no injury or fall could be re- 
 membered. The negative results of the anamuesis recall several 
 of the cases described by others. 
 
 That the diagnosis of spondylolisthesis was correct is ex- 
 tremely probable, any spondylizema may be at once excluded ; 
 any sort of exostosis of the lumbar vertebras would in the first 
 
THE HISTORY AND ETIOLOGY OF SPONDYLOLISTHESIS. 25 
 
 place give rise to an abnormal condition to be detected on 
 internal examination, and in tbe next place would not have 
 caused the changes described in the external form of the pelvis. 
 In any case the olisthesis may be one of no very high degree. 
 Unfortunately nothing definite can be said as to the etiology of 
 this case. The woman went back to her home the same day, 
 and to my regret has not since returned to Berlin. 
 
 Third Berlin Case. 
 
 Mrs. Clara Fischur, aged 28, the wife of a tinsmith of 
 Brandenberg, applied for advice at the Surgical Clinique of 
 Berlin University, on the 10th September, 1883, on account of 
 sacral pains. The external appearance of this woman also was 
 so strikingly suggestive of spondylolisthesis as to make me 
 think at once that such was the case. This presumptive 
 diagnosis was supported by examination of the woman, only 
 leaving a certain indecision between spondylizema and spondyl- 
 olisthesis lumbo-sacralis. 
 
 The patient had measles and scarlet fever as a child ; mens- 
 truation commenced in her 16th year, and she was married 
 when 24 years old. She has had two children, the first in 
 January, 1880, and the second on 2nd April, 1882. The first 
 child was spontaneously, two weeks too soon. The second was 
 extracted by forceps, the head having been arrested for some 
 hours at the pelvic outlet. Puerpery was normal on both 
 occasions, but ever since her first confinement she has suffered 
 from debility, and more or less sacral pain ; her figure also has 
 gradually altered so that she has become rather shorter, her 
 hip bones have gradually become very prominent, and her 
 abdomen became pendulous during her second pregnancy. She 
 especially complains of stiffness in the sacrum and inability to 
 exert herself; and in particular that she is unable to carry any- 
 thing in her arms in front of her from the feeling that she must 
 let her burden fall. It also struck her that during her second 
 pregnancy she could not move about except when she held herself 
 bent very much backwards. She passed through an attack of 
 pneumonia shortly before the end of the first pregnancy, and was 
 at that time bedridden for four weeks. 
 
 She cannot call to mind that when she was young she suffered 
 
26 NBUGEBAUER ON 
 
 from an injury or a fall of any kind, but states that even as a 
 child she could not bend herself forwards because of the pain she 
 suffered in doing so, and was often scolded on that account, who, 
 as Mrs. F. characteristically repeated, used to say, "Here am I 
 an old woman stooping down to my work, and you, a young girl, 
 can't do so." While still a girl, and therefore nine years ago, her 
 mother suspecting that she had one high shoulder took her to the 
 local physician, who did not consider any treatment necessary, 
 but said it would grow all right again. 
 
 She concluded by saying that when she walks she always has 
 a feeling of fatigue in the sacrum, and is obliged to support 
 herself with both hands on her hips, thereby obtaining immediate 
 relief. She has never suffered from any form of suppuration, nor 
 from rickets, nor does she remember anything of the sort in her 
 family. She had herself learnt to walk by the end of her first 
 year, and apparently developed in due time. 
 
 Measurements — 
 
 Height 1520 cm. 
 
 Distance between the great trochanters 300 ,, 
 
 „ ., crests of the ilia 29 5 „ 
 
 „ ,, anterior superior iliac spines 285 „ 
 
 „ „ posterior superior iliac spines : 90 „ 
 
 „ „ S angles of the posterior curves of the iliac 
 
 crests 140 „ 
 
 ,, ,, tubers of the ischia 1/75 ,. 
 
 External conjugate diameter 19'5 ,, 
 
 Conjugate diameter of the outlet 65 
 
 „ >, cavity 9- 
 
 Direct distance from the pubic arch to the fifth lumbar spine 190 ,, 
 
 False conjugate diagonal diameter .• 100(?) ., 
 
 „ „ of inlet of smaller pelvis 80(?)„ 
 
 Length of the symphysis pubis Co „ 
 
 Instead of a minute description of tbe noticeable points of the 
 individual deformity, which would be almost an exact repetition 
 of that of other similar cases, I give (figs. 1, 2, 3) three drawings 
 showing in the clearest way the external configuration of this 
 woman, in the trace of whose footprints it is most interesting to 
 find that character corresponding to a pelvic spondylolisthesis 
 of a moderate degree. 
 
 From the drawings and measurements given above it is quite 
 evident that in this case we have to do with a pelvis, externally 
 of the so-called kyphotic character, and with a pelvis obtecta, and 
 after the exclusion of other abnormalities, the differential diagnosis 
 
THE HISTORY AND ETIOLOGY OF SPONDYLOLISTHESIS. 
 
 27 
 
 has to be made between spondylizema and spondylolisthesis 
 lumbo-sacralis as illustrating which the case is particularly 
 interesting. 
 
 From a consideration of the posterior and lateral views of the 
 woman (figs. 2 and 3) it will be seen that though there is no 
 
 Figs. 1, 2, 3. — Anterior, posterior, and lateral vitw of Mrs. Clara F., II-para aged 28. 
 
 pathological angle in the upper part of the vertebral column, the 
 fifth lumbar spine forms a projection behind somewhat like a 
 lumbo-sacral kyphosis. One can however convince oneself that 
 the projection is formed by the fifth lumbar spine only, for it 
 can be readily felt above and below, and on either side, and a 
 kyphotic gibbus consisting of one single spine may be said to be 
 
28 NBUGEBAUEE ON 
 
 never found except as a cervico- dorsal kyphosis. Besides, if this 
 convexity was kyphotic, or rather as it is in the lumbo-sacral 
 region spondylizematic, the lumbar column would be far more 
 inclined, forward in toto. The fifth lumbar spine sticks out by 
 itself exactly as in the spondylolisthetic pelves at Munich and 
 Zurich, cases in which during life it was thought to be the first 
 sacral spine. In angular pathological kyphosis, the spines of 
 those vertebrae of which the bodies have given way under the 
 action of caries form in toto a less acute curve, while here the 
 fifth vertebral spine projects quite independently, and the fourth 
 lumbar spine stands back from it like the step of a staircase. 
 For example, if one compares this profile (fig. 3) with the lateral 
 view of Mrs. Ottilie Grassau,* a woman with a spondylolisthetic 
 pelvis, one can immediately see the remarkable difference 
 between the blunt lumbo-sacral convexity of the less acute 
 kyphosis in Mrs. Grassau, and sharply isolated projecting 
 lumbar spine in this case. Between the latter and the rest of 
 the lumbar column there is in this case that angular, saddle- 
 shaped depression caused by the upper part of the lumbar 
 column (that is, the whole of the spinal column down to the 
 fourth lumbar vertebra), and the anterior half of the fifth 
 lumbar vertebra, including the body and anterior half of the 
 ring, upon which indeed the superior part of the spinal column 
 rests directly, has slipped down forwards, while the posterior 
 half of the fifth lumbar vertebra, that is to say its spine, only has 
 remained behind upon the sacrum. Strictly speaking, there- 
 fore, this saddle-shaped depression in the posterior aspect of the 
 spinal column lies between the arches of the fifth and fourth 
 lumbar vertebras, and not directly between the sacrum and 
 lumbar vertebral column. Indeed the character of this angular 
 saddle-shaped depression is so typical, that in itself it seems 
 sufficient to exclude spondylizema in this case as against 
 spondylolisthesis. 
 
 In the next place, in spondylizema, as has already been 
 pointed out, the spinal column and upper part of the body would 
 be inclined more forwards, as is represented in the picture of 
 Mrs. Grassau that has been referred to ; but in Mrs. F. the 
 
 * Neugebauer, " Zur Caeuistik dea Spondylolisthetischen BeckenB," Arcldv fur 
 Gynakologie, Bd. xix., Hf . 3, S. 448, fig. 3 ; or Winckel, Klinische Beobachtunqen zur 
 Dystohie durch Beckenenge. Leipzig, 1882, Tafel II., fig. 6. 
 
THE HISTORY AND ETIOLOGY OF SPONDYLOLISTHESIS. 29 
 
 attitude of the upper part of the body is one still inclined back- 
 wards. In olisthesis the body is not bent over forwards till the 
 degree is extreme. 
 
 Thirdly, there are no statements in the anamuesis to be 
 referred to the development of a spondylizematic pelvis. And 
 yet such a development is never so completely hidden ; the 
 characteristic group of symptoms associated with Potts' curva- 
 ture are familiar enough to be omitted here. On the other 
 hand, the development of spondylolisthesis is, for the most part, 
 almost without symptoms, but rarely rapid, and occasionally 
 its gradual progress is greatly promoted by intercurrent preg- 
 nancies. 
 
 Now in the present case some anomaly had existed ten years 
 previously, for the girl, though almost quite healthy, could not 
 bend herself forwards, and from her first conception the deformity 
 was continually becoming greater, especially so during her second 
 pregnancy, from the renewed and continued increase in the 
 weight on the lumbar column. 
 
 Five days after the first examination I took the woman to the 
 Berlin University Clinique for the Diseases of Women, and asked 
 Herr Schroder, and Herr Miiller of Bern, who was present at the 
 time, to examine her. The apex of the angle of dislocation 
 could not now be distinctly felt, and the soft parts about it were 
 so considerablj- swollen, almost fluctuating, as to suggest the 
 possible presence of a commencing, descending abscess at the 
 promontory of a well-marked Potts' kyphosis of the lumbo-sacral 
 region. This caused Herr Schroder and Herr Miiller to have 
 some doubt as to whether the case was not one of spondylizema. 
 This swelling of the soft parts struck me the more, as it had not 
 been so considerable five days before at the time of my first 
 examination, after which the woman had suffered for twenty-four 
 hours from pain in the abdomen. I had, on that first occasion 
 at the general clinique, on account of the great interest afforded 
 by the case, allowed a large number of medical men and students 
 to examine the woman, and it is quite possible such repeated 
 examination was not without results. Besides, a quite similar 
 swelling of the soft parts existed on the examination of Henriette 
 B. of Halle, Amalie H. of Dresden, and Francisca D. of Prague. 
 And this, circumstance is no evidence against olisthesis, for it 
 may well be admitted that such marked deformation and disloca- 
 
30 NBUGKBAUER ON 
 
 tion of the vertebral column cannot take place without an accom- 
 panying condition of irritability in the surrounding soft parts. 
 Quite apart, however, from this, and from the history of the case, 
 several other points corroborate the diagnosis. As has been 
 stated, the angle of dislocation was on one occasion felt below 
 the level of the anterior superior margin of the os sacrum, while 
 in a case of lumbo-sacral spondylizematic kyphosis the apex of 
 the angle of flexion is situated exactly at this margin, and there- 
 fore the finger tip passing outwards on either side from this 
 angle of flexion must hit upon the anterior edges of the lateral 
 masses of the sacrum. Moreover, the thickness of the posterior 
 pelvic wall in a median plane at the level of the plane of the 
 pelvic inlet is evidently too great ; the posterior pelvic wall now 
 consists at this place of the body of the fifth lumbar vertebra + 
 the body of the first sacral vertebra, the posterior arch, and the 
 spine of the fifth lumbar vertebra, a diagnostic mark on the value 
 and mensuration of which, by means of subtracting the direct 
 thickness of the posterior pelvic wall at this part from the length 
 of the external conjugate diameter, and so getting the length of 
 the false conjugate, I have already written in my earliest work 
 and elsewhere.* 
 
 We have, finally, the assistance of the characteristic condition 
 of the solid angle of Breisky, as well as the circumstance that 
 to reach the lateral parts of the anterior superior margin of the 
 base of the sacrum one must on each side pass one's finger 
 upwards along the posterior pelvic wall above the depressed body 
 of the fifth lumbar vertebra. The history of the case, its course 
 and symptoms, the progress of the development of the existing 
 deformity, the attitude of the body, &c, all give additional 
 support to the clinical presumptive diagnosis, every objection to 
 which may in the face of these circumstances be considered 
 removed, as indeed Herr Schroder himself considered. 
 
 Mrs. F. had stated that she found relief if she supported 
 
 * Zur Enlvrichelungeschichte des Spondylolisthetischen Becken's u.s.w." S. 36, f£. 
 
 "A further peculiarity of the spondylolisthetic pelvis is found theoretically 
 and practically in the position of the lumbar vertebrae (especially of the fifth lumbar 
 vertebra) in front of the first sacral vertebra. The increase in the direct thickness of 
 the posterior pelvic wall at the level of the base of the sacrum which this causes, 
 leaves a striking difference between Baudeloque's diameter and the conj ugata paeudo- 
 vera, &c." ; and S. 37, "If in certain cases we were able to measure with instru- 
 ments the thickness of the posterior pelvic wall, the estimation of the conjugata 
 spuria from Baudeloque's diameter would (sic) be possible," el sequent. 
 
THE HISTOEY AND ETIOLOGY OF SPONDYLOLISTHESIS. 31 
 
 herself when walking by placing her hands on her hips. It was, 
 therefore, only following the hints of nature for us to lessen, as 
 far as possible, the burden on the lumbo-sacral joint by a support- 
 ing apparatus, as I had already done in a case at Halle, where 
 Volkmann had also done it in a case of his own. I applied a 
 provisional plaster of Paris corset to the woman in Sayers' sling, 
 with the assistance of Dr. Barth of Berlin, intending if this was 
 of the desired benefit to have a felt splint apparatus made for the 
 case. The patient felt immediate relief after the application of 
 this corset, and journeyed home contentedly. On the 25th and 
 27th September she wrote to me, saying that the corset had 
 been for the first few days rather uncomfortable and burdensome 
 to her, but that now she could sleep better at night, and get 
 about better in the day time, and was very contented with it. 
 The corset must indeed relieve her, but how will it be with the 
 deformity ? 
 
 As a rule the development of the latter is only arrested when 
 in the stage of complete spondyloptosis the bodies of the two 
 vertebrae concerned form with each other a right angle, or even 
 an acute angle. Then if the arch of the fourth lumbar vertebra 
 has come to rest almost directly upon the first sacral vertebra — 
 that is to say, if the body of the first sacral vertebra has then 
 been forced so far into the aperture of the vertebral canal in the 
 fifth lumbar vertebra, that either it has completely separated the 
 anterior and posterior halves of the arches of the fifth lumbar 
 vertebral ring, or the interarticular portions of the ring have 
 elongated and wasted away under the extreme pressure — no 
 further elongation of the arch of the fifth lumbar vertebra results ; 
 the body of the fifth lumbar vertebra then lies entirely against 
 the anterior surface of the sacrum, its axis quite perpendicular, 
 or even at an acute angle to that of the first sacral vertebra. 
 Now, then, should every attempt to lessen the pressure be aban- 
 doned in order to promote the development of the deformity to 
 this extent ? Fortunately this is not the case, for experience 
 has shown that an arrest, and consequently a cure by synostosis, 
 may take place at any stage of spondylolisthesis. Another 
 pregnancy would be the most likely thing to render all curative 
 treatment useless. I will however, if possible, keep the case 
 under observation, and hope to be able to give an occasional 
 report of this attempt at the orthopaedic treatment of the disease. 
 
32 NETJGEBAUER ON 
 
 Third Strasbivrg Case. 
 
 On page 53 of my earliest work I said* : 
 
 "Experience has not taught me that I undertake too much 
 in promising to recognise any woman with a spondylolisthetic 
 pelvis among the throng in the street." 
 
 The peculiar appearance of such persons has become still more 
 familiar to me since I wrote this. It was on the 7th October of 
 last year that Dr. Swedelin, of St. Petersburg, and I met in 
 Strasburg in one of the streets by the Minster a woman in the 
 costume of Alsace, whose external appearance was so striking 
 that I looked at her more carefully. Both the manner in which 
 she held her body, and her mode of progression, were those of 
 spondylolisthesis lumbo-sacralis. When I had learnt, through 
 a third person, that she suffered from sacral pain, had been 
 delivered by forceps, &c, &c, I soon got the good woman to 
 come to the Gynaecological Clinique, where I could justify the 
 accuracy of my presumptive diagnosis to my friend. In it 
 Doctors Freund, Haeckel, and Swedelin completely concurred, 
 and the following representations should remove any doubt 
 of it:— 
 
 Measurements — 
 
 Height „ 154-0 cm. 
 
 Distance between the iliac crests 32'0 „ 
 
 ,, „ great trochanters 31'0 „ 
 
 „ „ anterior superior spines 28 „ 
 
 „ ,, posterior „ 95 „ 
 
 „ „ S angles of the iliac crests 14'0 „ 
 
 „ ,, tubers of the ischia fi'7 „ 
 
 Conjugate diameter, external 18'0 „ 
 
 normal 1S'5 „ 
 
 ofthecavity 10'0 „ 
 
 of the outlet 7°5 „ 
 
 to angle of dislocation 12 „ 
 
 to most prominent part of the lumbar vertebrae ? 
 
 false about 9 - 5 cm. to 100 „ 
 
 The pelvis was slightly unsymmetrical from scoliosis. A 
 simply unilateral olisthesis could not be certainly made out. 
 While the lordotic lumbo-sacral groove was very deep, on account 
 of the thickness of the integument, and the plentiful develop- 
 ment of subcutaneous adipose tissue could be but very indis- 
 
 * Zur Eiitwickehrngsgeschichte des Spondylolisthetischen Beckens und seiner Diagnose 
 (mit Beriickeichtigung vom Korperhaltung und Gangspur), mit 97 Holtzschuitten im 
 Teste Halle und Dorpat, 1882. 
 
 ■isH 
 
THE HISTORY AND ETIOLOGY OF SPONDYLOLISTHESIS. 33 
 
 tinctly made out, on the other hand the sacral hiatus, and the 
 fourth and third sacral spines, were easily felt. 
 
 The spinal column exhibited a compound scoliotic rotation— 
 in the cervico-dorsal portion to the right, in the dorso-lumbar to 
 the left, and in the lumbo-sacral back to the right.; the right 
 hip projects more backwards, and at a greater angle with the 
 trunk than the left, on which side the line from the axilla to the 
 crest of the ilium is straighter or more easily curved. The 
 thorax is turned about, and sunk down into the pelvis, as the 
 folds of skin across the abdomen above the pubes show. The 
 rotation inwards of the lower end of the sacrum and the coccyx 
 is evident externally from the prominence of well-marked lateral 
 depressions in the buttocks corresponding to the greater sciatic 
 notches. The pendulous abdomen, the anterior position of the 
 genitals, and the diminished inclination of the pelvis, can all be 
 seen in the pictures (figs. 4, 5, 6). I have also added a picture 
 of the woman in costume, since it was this view of her, supported 
 by her peculiar manner of walking, that forced the diagnosis on 
 me. 
 
 These pictures show the most remarkable agreement in most 
 points with the many others published. As a matter of fact the 
 appearance of a person affected with a high degree of spondyl- 
 olisthesis lumbo-sacralis is so striking that it impresses itself 
 on the memory for eyer, and without any special examination 
 this deformity, hitherto considered an extremely rare one, 
 betrays itself in the ordinary intercourse of daily life. In proof 
 of this I will insert here without any comments figs. 9, 10, 11, 
 which represent Mrs. E., of Berlin, in her ordinary dress, a 
 woman delivered by Dr. v. Rabenau in 1883, and described in 
 the Archiv fur Gyndkologie by Swedelin, and suggest a 
 comparison of fig. 7 of this work and the pictures in Swedelin's 
 article. 
 
 Mrs. Sophie 0., 45 years of age, a native of Nymphersheim, 
 and the wife of a joiner in Strasburg. .Asa child had always 
 good health,' and was well developed, but while still a young 
 girl she was subject to sacral pain, and was never able to lift up 
 anything heavy from the ground, or to carry it; she was par- 
 ticularly unable to carry anything in front of her. She has had 
 three children ; her first- labour, eleven years ago, was compara- 
 tively easy ; the next, eight years back, more difficult ; and one 
 
 3 
 
34 
 
 NEUGEBAUEB ON 
 
 a year ago, when as the head remained for more than three 
 hours at the outlet, Dr. Hueter had to deliver with the forceps. 
 Since the last delivery but one, the sacral pains have increased, 
 and a deformity has developed ; the patient has got shorter, and 
 her hips have gradually become more prominent in the mean- 
 
 Fig. 4. 
 
 Fig. 5. 
 
 Figs. 4—7. — Mr& Sophie O., 45 years old, Ill-para. 
 
 time, but especially during the third pregnancy her abdomen has 
 become pendulous to a burdensome extent, and her previously 
 normal gait has turned to a waddle. 
 
 The track of her footprints (fig. 8) is that characteristic of a 
 person with a pelvis of an externally kyphotic form which I have 
 
THE HISTORY AND ETIOLOGY OF SPONDYLOLISTHESIS. 
 
 m 
 
 fully delineated in my previous works. I would 
 only add that with the waddling gait like that of 
 a duck the upper part of the body sways freely 
 from side to side. 
 
 Fig. 6. 
 
 Fig. 7. 
 
 Herr Hueter, of Strasburg, informed me that 
 he never saw the woman again after her delivery. 
 As he found the head already lying in the outlet, 
 he made no exploration of the pelvis, and only 
 states that the outlet was very decidedly con- 
 tracted transversely. 
 
 f 
 
 jQ. 
 
 0',, 
 
 % 
 
 Fig. 8. — Footprints 
 of Mrs. Sophie 0., 
 /jth natural size. 
 
36 NETJGEBATJER ON 
 
 Case at Paris. 
 
 When I was visiting Professor Charpentier in Paris, he drew 
 my attention to the striking resemblance which a woman he 
 had seen in 1868 bore in external appearance to the picture of 
 Mrs. Berndt (see fig. 18, inserted for comparison, on page 39). 
 This woman had been a patient in the Obstetric School at Paris 
 in 1868 for her fourth confinement, which terminated naturally, 
 and the late Professor Depaul, at that time director of the insti- 
 tution, had diagnosed a congenital dislocation of both femora, 
 and two photographs taken at the time were afterwards inserted 
 in the text books as typical of the appearance of the trunk in 
 this dislocation ; for example, in Charpentier's own text book, 
 Traite des Accouchcments, Tome ii., p. 116, figs. 418, 419 ; and 
 in Gueniot's treatise, Des luxations coxo-femorales soitcong6nitales, 
 soit spontanees an point de vue des accouchements, Paris, 1869, 
 pp. 108, 109, figs. 11 and 12. Was this woman's pelvis really 
 one with bilateral femoral luxation, or was Depaul mistaken in 
 his diagnosis ? I do not myself think there was any dislocation 
 of the femur in the case ; at first sight the waddling gait (marche 
 en canard), which is a characteristic of these dislocations, but 
 which is often associated with a spondylolisthetic, together with 
 the general deformity and shortening of the body, might well 
 suggest such luxation ; besides which the symptomatology of the 
 spondylolisthetic pelvis was at that time little understood, had 
 indeed been so little Btudied that this affection of thepelvis was 
 as a rule overlooked. A careful consideration of these, pictures 
 (figs. 12 — 14) will, however, at once show that the trochanters 
 are in their normal position,; that the greatest width of the pelvis 
 lies in the line between the iliac crests, and not in that between 
 the trochanters ; that the shortening is in the lumbar region, 
 and not in the upper thighs; that the pelvis corresponds in 
 shape with the so-called kyphotic pelvis, that is to say the 
 change it has undergone is exactly opposite to that which takes 
 place in luxatio duplex femorum iliaca. The shape and position 
 of this pelvis, its diminished inclination, the prolonged appear- 
 ance of the lower extremities, the form of the buttocks, the 
 anterior position of the external genitals, and the general 
 external configuration, most certainly indicate not only that 
 there is no luxation of the femora, but that there was here some 
 
THE HISTORY AND ETIOLOGY OP SPONDYLOLISTHESIS. 37 
 
 Fig. 9. 
 
 Fig. 10. 
 
 Fig. 11.. 
 
 Fig. 9—11. — Anterior, posterior, and lateral view of a woman with a spondyl-alisthetic pelvis 
 
 (spondyloptosis), 
 
 u :.- s-rit-.zn,-' •>. 'I 
 
$8' NEUGEBAUER ON 
 
 form of the pelvis obtecta, and that that form is either spondyl- 
 izematic or spondylolisthetic, and Bince the posterior view 
 proves the absence of any projecting gibbus, the pelvis must 
 consequently have been spondylolisthetic. 
 
 For the rest, Doctors Charpentier, Gueniot, Tarnier, Porak, 
 Doleris, Trelat, Despres, and several other Parisian obstetricians 
 and surgeons, to whom I stated this deduction, completely 
 agreed with it. 
 
 I will not argue further in favour of my view of the case, as I 
 believe these drawings afford a proof of its accuracy, and will 
 only mention a most simple key to the analysis of such cases by 
 the proportions of the pelvis in length and breadth. 
 
 By a comparison of figs. 15, 16, 17, and 18, we can see that 
 if in each of these diagrams we lay down the bitrochanter line 
 A B, the line joining the crests of the ilia C D, and if on either 
 side join A to D and B to C by straight lines A D and B C 
 produced to meet on that side to which they converge, these 
 J,jnes from the iliac crests to. the trochanters will intersect in 
 some point E, which in the normal pelvis (fig. 15) lies a. long 
 way above the bitrochanter line, in the luxation pelvis. (fig. 16) 
 it lies considerably lower down, while in the spondylolisthetic 
 pelvis it lies below the bi-trochanter line. 
 
 In the first case, and also in the second, the figure A B C D 
 forms a trapezium with the base downwards ; in the third case 
 the base of the trapezium is the upper line C D ; or taking the 
 isosceles triangle A B E, in the two former cases the apex E is 
 situated above the pelvis, while in the third case it is below it. 
 The shape, height, and width of the trapezium and triangle are 
 of course quite different in the three cases, and are typical in 
 each diagram. Now in an outline sketch of Depaul's case 
 ' (fig. 18), treated in the same way, the base of the trapezium and 
 of the triangle is formed by the bitrochanteric line, though in 
 this case the triangle is not isosceles, its apex being displaced to 
 the right by the existing scoliosis. The variation in the figures 
 here shown has its primary basis in the alteration of the position 
 of the hip bone in relation to the femur. 
 
 The changes in the shape of the pelvis are represented dia- 
 grammatically in the transverse perpendicular section of the 
 pelvis (fig. 19). In the normal pelvis A B C D, straight lines 
 drawn through the sides of the pelvis intersect when produced at 
 
THE HISTORY AND ETIOLOGY OF SPONDYLOLISTHESIS. 
 
 39 
 
 Pig. 13: 
 
 Fig. 14. 
 
 Fig. 12. 
 
 Figs. 12 and 14. — Anterior and posterior view of a woman delivered naturally of her 
 fourth child at the School of Obstetrics at Paris, in the year 1868, during the 
 direction of Professor Depaul, the presumptive diagnosis ex aspectu being pelvis 
 spendyl-olisthetica (drawn on a diminished scale from a photograph). 
 
 Pig. 13. — Minna B., aged 26, in her second pregnancy, inserted for comparison (from 
 Neugebauer's paper, Archiv.fiir Gynciiologie, Bd. xix., S. 448, fig. 1). 
 
40 NEUGEBATJEB. ON 
 
 the angle X, in the luxation pelvis under consideration, these 
 lines intersect at an angle Z, which is more acute, and of which 
 the apex lies lower down, while in the spondylolisthetic pelvis 
 the angle of intersection is more obtuse, and its apex lies higher 
 up. Corresponding to the alteration in the pelvis, the hip bones, 
 apart from their characteristic change in shape, their increased 
 or diminished length from behind forwards, are rotated outwards 
 in the spondylolisthetic pelvis with a decrease, and in the 
 luxation pelvis in the opposite direction, as is shown by the 
 arrows in the diagram. * 
 
 Direction of Rotation of the Hip Bone. 
 
 The height^ h, of the pelvis, &c, &c, is proportionately 
 altered. This diagram is only designed to illustrate the funda- 
 mental principles above- stated, and therefore all other marks of 
 the two anomalies are omitted, indeed I have not even inserted 
 the head of the femur in its dislocated positions, because there 
 are various forms of this dislocation, each of which would require 
 a separate diagram.' Nor have extreme cases been held in view ; 
 what has been said is borne out by ordinary cases. 
 
 In spite of all my efforts I could unfortunately learn but little 
 of the history of the labours or sickness of the, Parisienne G. 
 The scanty notice in the journal only stated that on the 18th 
 May, 1868, Elise Guinot, a milliner, aged 27*, was admitted into 
 this institution in her fourth confinement, the three previous 
 ones having been premature. She was delivered on the 20th 
 May after a natural labour, and discharged on the 1st , June. 
 The infant was healthy, weighing 3,160 grammes. 
 
 In reference to the anamuesis it is said (I. c. in Giieniot) : 
 " 1st pregnancy, abortion at three months and a half; 2nd 
 pregnancy, abortion at six months ; 3rd pregnancy, labour at 
 term, prolapse of the cord caused the application of forceps; 
 4th pregnancy, natural labour." 
 
 Finally, there is a remark in pencil writing in the Clinical 
 Journal of the confinements : " The patient has a considerable 
 convexity at the level of the lumbar region." 
 
 This last notice is of special interest, inasmuch as it appears 
 to contradict my deduction as above. In the meanwhile a 
 careful consideration of the back view in the original photograph 
 
THE HISTORY AND ETIOLOGY OF SPONDYLOLISTHESIS. 41 
 
 Kg. 15. 
 
 Fig. Ifi. 
 
 Figs. 15 — 18. — Outline diagrams (Figs. 15, 16, and 18 drawn from photographs). 
 Fig. 15.— Normal configuration (See Neugebauer, Archivfur Gyndkologie, Bd. xix., 
 
 S. 450, fig. 4). 
 , , Fig. 16.— Configuration in luxatio femorum congenita iliaoa duplex. (After 
 
 Hamilton.) 
 
42 NEXJGEBAUEB ON 
 
 shows that no convexity in the sense of a spondylizematic 
 pelvis existed, it is therefore prohable that the term " consider- 
 able convexity " was applied to the very prominent lower part 
 of a spondylolisthetic lumbar saddle, that is, to the base of the 
 sacrum, together with the fifth lumbar spine. 
 
 A few weeks ago chance once more threw in my way an obser- 
 vation that is, I think, appropriate here. My attention was 
 attracted by the peculiar conformation of a woman 26 years old, 
 the daughter of a master baker, P. Unfortunately all my 
 efforts to arrange for a proper examination of the case were 
 upset by the opposition made by her and her relatives. I have 
 nevertheless no hesitation in going into the case, for I entertain 
 a firm opinion that sooner or later the maiden, provided she gets 
 married, will come under medical observation; I have particularly 
 recommended her to the attention of a colleague in Paris. 
 
 Miss P., as a child, well-formed, and well-developed for her 
 age, free from hereditary disease. When 2 years old she had 
 a. fall, and since that time until two years ago has suffered more 
 or less, and was for ten years under medical treatment. Her 
 first symptom was a difficulty in moving about,, followed. by 
 vague pains in the sacral and lumbar regions ; she was never 
 bedridden for any considerable time,; and her illness was of an 
 insidious character with few marked symptoms. At first one 
 knee was treated with sinapisms ; later on the affection, moved 
 up to the loins. The most prominent mark of the disease was 
 a very gradual shortening of the upper part of the body and 
 lateral growing out of the hips. Her dresses became-.too long 
 for her ; her attitude, however, remained upright, and she had no 
 forward stoop. There was never any fever or suppuration, or any- 
 thing of the kind, and her general condition as to nourishment and 
 strength was always good. For the last two years the pains in 
 the sacral region have more or less gradually disappeared, so 
 that at present she does not feel ill. This is all I was able to 
 learn. Her external appearance bears the closest resemblance to 
 that of Mrs. R. of Berlin (vide figs. 9 — 11 of this work), but un- 
 fortunately I cannot exhibit a single picture of her. From her 
 
THE HISTORY AND ETIOLOGY OF SPONDYLOLISTHESIS. 43 
 
 Fig. 13. 
 
 Pig. 17. 
 
 Fig. 17. — Configuration of the spondylolisthetic pelvis. (See Neugebauer, loco cit., 
 
 fig. 6.) 
 Fig. 18. — Configuration of the Parisienne G. (From a photograph taken by Depaul 
 
 in 1868.) 
 AB Bitrochanter line. 
 CD Bicristal line. 
 E Point of intersection of the lines from the trochanters to the crests of the ilia 
 when produced on the side of their convergence. 
 
44 NEUGEBAUER ON 
 
 external appearance and gait she certainly has in my opinion a 
 pelvis obtecta of an outwardly kyphotic character, and both from 
 her exceedingly upright attitude, and from the history of the 
 case, I believe that she has a |spondyl-olisthethic pelvis. Potts' 
 disease in the lumbar region, or Herrgott's spondylizema, may 
 exist withoirt any sinking down of the spinal column over the 
 pelvic inlet, and without forming any characteristic convexity, 
 but I doubt whether a high degree of pelvis obtecta spohdyl- 
 izematica can occur without a hump or without decided inclination 
 forwards of the upper trunk. J. would also refer- to the differential 
 diagnosis between spondylizema and spondylolisthesis in the 
 case of Mrs. Ottilie Grassau, of Dresden (vide Neugebauer, 
 Archivjur Gyniik. Bd., xix., Hft. 3, fig. 3, &c.)^ 
 
 From my past experience I might reckon this as the second, 
 or, if the Hottentot Venus is counted, as the third Parisian case , 
 of.spondyl-olisthesis. I will, however, at present simply mention 
 it here as the results of a inore exact internal and external 
 examination have still to be obtained, and I have not, even ,a 
 picture to illustrate the case, moreover all possible care has begn 
 taken to secure sooner or later the particulars of the case for, the, 
 benefit of science. If the presumptive diagnosis I made ; from 
 her appearance is not correct, no loss can in any case. result;, 
 to" our diagnostic knowledge.' May I be allowed to add here 
 some explanation* of the difference of opinion existing between 
 Herrgott and myself in respect to the genesis of spondyl- 
 olisthesis? 
 
 As is well known, Herrgott (sen.), of Nancy, published ; in Mb. 
 time several works upon the ^spondylolisthetic and the<.lumbo- 
 sacral kyphotic pelves, and made use of the expression " spondyl 
 izematic" pelvis to describe tbe latter (<nr6v&v\o<; = vertebra, 
 and ?fi?/ia = sinking, depression, Lusammen-sinken). . [.. 
 '- In this Herrgott essentially improved the nomenclature -of .the. 
 pelvis. In Germany we are in the habit of speaking of a -pelvis, 
 as kyphotic if we mean the pelvis of a person affected with 
 kyphosis of the vertebral column, but in these cases the- pelvis 
 itself is not in the least kyphotic, its posterior wall exhibits no 
 hump of any kind, but it is a pelvis changed in shape by the 
 body weight in consequence of a kyphosis of some part of the 
 vertebral column, be the same higher up or lower down, though 
 it is true that this change in shape varies in degree according to 
 
THE HISTORY AND ETIOLOGY OF SPONDYLOLISTHESIS. 45 
 
 Fig. 19. — Metamorphosis of the diagram of the transverse section of the pelvis. 
 Normal pelvis. 
 
 H 
 
 ++++. Pelvis with luxatio femorum duplex iliaca congenita, 
 oooooooo Spondylolisthetic pelvis. 
 AB Line between iliac crests. 
 TT Bitrochanter line. 
 JEE Transverse diameter of inlet 
 FF „ of hollow J-of the pelvis. 
 
 CD „ of outlet 
 
 GG Transverse axis of the pelvis. 
 hh Height of normal pelvis. 
 x Angle of intersection of the straight lines through the sides of the normal 
 
 pelvis, produced. 
 y Angle of intersection of those of the pelvis with luxatio fern, iliaca congenita, 
 s Angle of intersection of those of the spondyl-olisthetie pelvis. 
 Direction of rotation of the hip bone. 
 
46 NEUGEBATJEB ON 
 
 the position of the kyphosis. The pelvis itself is kyphotic only 
 when its posterior wall has a share in the formation of the hump 
 (icv<f>v<;). But from an obstetric point of view the anatomical 
 character of a kyphotic pelvis varies so much with the situation 
 of the kyphosis, that it seems to be essentially desirable to dis- 
 tinguish at all events the principal forms of it by different 
 expressions ; and unless we are willing to use the expression 
 kyphotic pelvis only in cases of lumbo-sacral kyphosis, and to 
 describe the other cases as pelves with dorsal kyphosis, &c, 
 a separate description of the lumbo-sacral kyphotic pelvis, such 
 as Herrgott has invented for it under the expression spondyl- 
 izematic, is very desirable, and we can then continue to include 
 under the term kyphotic those pelves in which the kyphosis is 
 situated higher up, though the term is not strictly accurate. A 
 separate description of the lumbo-sacral kyphotic pelvis seems 
 the more necessary, since it is always of a character essentially 
 different from any other so-called kyphotic pelvis. While in the 
 latter the change in the dimensions of the smaller pelvis has alone 
 to be considered, in the former the size of the greater pelvis is 
 altered, and there is a contraction in its conjugate diameter of 
 much importance in obstetrics. In the lumbo-sacral kyphotic 
 pelvis we have a " pelvis obtecta," which obstetrically is twice as 
 important as any other so-called kyphotic pelvis. Moreover, a 
 description of the lumbo-sacral kyphotic pelvis different from 
 the spondylolisthetic is most desirable for diagnosis, and con- 
 sequently Herrgott's expression spondylizema is doubly welcome. 
 . Now Herrgott has wished to include spondylolisthesis and 
 spondylizema in one general group of pelvic deformities caused 
 by one and the same process, Potts' disease, and has made this 
 distinction between them. 
 
 (n) If the bodies of the vertebra are affected and lose their 
 resistance, the spinal' column sinks downwards and forwards 
 with the formation of a lumbo-sacral hump (in consequence of 
 their obliteration) — spondylizema. 
 
 (b) But if it is the vertebral arches which are affected and lose 
 their resistance, so that they can no longer effectually oppose 
 the tension caused by the pressure on the lumbar vertebral body, 
 the body of the fifth lumbal- vertebra slips down forwards, re- 
 sulting in spondylolisthesis. 
 
 In French literature this view of Herrgott's has been so 
 
THE H1ST0KY AND ETIOLOGY OF SPONDYLOLISTHESIS. 47 
 
 generally adopted up to tire present time, that for example 
 Charpentier in his lately published text book in 1883 does not 
 even enter on the discussion of other and more recent theses, 
 and even sets down in a categorical manner Potts' disease as 
 the unique cause of spondylizema and spondylolisthesis, 
 although this view has long ago been set aside, and as we shall 
 see further on, is now abandoned by Herrgott, its originator, 
 himself. 
 
 In my previous works I have given prominence to the proof 
 that in relation to its origin, spondylolisthesis differs most 
 essentially from spondylizema ; for while in the latter there is a 
 specific caries with loss of substance, and with or without 
 suppuration, that is to say Potts' disease, in olisthesis there is 
 neither caries nor loss of substance, and up to the present time 
 caries, even when affecting the vertebral arches, has in no single 
 well proved case caused olisthesis properly so-called. (In the cases 
 of Blasius and Ender it appears to me that the diagnosis was 
 by no means established.) I have looked upon spondylizema, 
 i.e., Potts' curvature, more as a deformity caused by a dys- 
 crasia, spondylolisthesis on the other hand as purely surgical, 
 and have referred the genesis of the latter exclusively to a con- 
 genital defect in ossification, or to a corresponding fracture. 
 
 Herrgott having become acquainted with my works, has done 
 me the honour to translate into French as much as relates to the 
 etiology of spondylolisthesis (vide Annates de Gynticologie, Mai 
 1883 : " Spondylizeme et spondylolisthesis, nouveaux docu- 
 ments pour l'etude de ces deux especes de lesions pelviennes ") 
 and has taken up the following position. 
 
 In the first place, Herrgott does not appear to be quite willing 
 to admit the cases of spondylolisthesis developed on the basis 
 of congenital spondylolysis, vide I. c, p. 329 : " We do not think 
 it necessary to mention (in the list of spondylolisthetic pelves 
 given by Herrgott) either the pelvis of the Hottentot Venus or 
 the pelvis at Bonn, the documents about which do not appear to 
 us to be sufficiently accurate." But since this mode of origin 
 is proved in the cases of olisthesis of damaged vertebra at 
 Breslauand Berlin, and in the two pelves at Wurzburg, &c.,the 
 doubt as to the spondylolisthesis of the Hottentot Venus might 
 well be abandoned. 
 
 In reference to the other cases referred by me exclusively to a 
 
43 NEUGEBAUEK ON 
 
 fracture of the arch of the fifth lumbar vertebra, or of the sacral 
 articular processes, Herrgott attributes the development of the 
 deformity not to this fracture, but to a loss of resistance in the 
 lumbar, vertebral arches due to inflammation. 
 
 On page 350, "It is evident that the vertebra must lose its 
 normal resistance." " One cannot admit more than two possible 
 causes of this effect ; the. arch supporting the articulations must 
 be broken or softened — broken by some violent injury which 
 would cause the displacement immediately, or softened by patho- 
 logical action." " Since then," Herrgott continues, " the 
 olisthesis does not occur suddenly but gradually during the long 
 years duration of the disease," he decides for the latter mode of 
 genesis, the rather so as " manifest traces of bony inflammation, 
 osteophytes, osseous rarefaction (osteoporosis ?), loss of bone 
 substance," are to be found, " everything to prove that a chronic 
 inflammatory process has accompanied the evolution of the 
 lesion." 
 
 On page 351 it is stated, " We were not, therefore, so far 
 from the truth when we said that the same affection, of the 
 nature of chronic inflammation (we said caries, which while 
 incontestable for the body of the vertebra may be less exact for 
 the arch), attacking two different parts of the vertebra may be 
 the cause of two pelvic deformities essentially different. 
 
 Herrgott says in conclusion, p. 852, " We equally regret not 
 to be able to admit completely the final conclusion of Neuge- 
 bauer, which is thus stated, ' Spondylolisthesis is a surgical 
 deformity, which is sometimes caused by an anomaly in the 
 ossification of a vertebral arch, but which is more frequently 
 caused by an injury.' " 
 
 The view of Neugebauer, it is said, moreover, "appears less 
 satisfactory to us than the one which we have given, for it does 
 not attribute to inflammatory action the important rtile that it 
 appears to us belongs to it. If.the injury was the efficient cause, 
 the deformity would immediately follow it, which is not the case ; a 
 time, short or long, and most frequently very long, months, even 
 years, pass away before the deformity is produced; the latter 
 does not come on until the inflammation has accomplished its 
 modifying action-on the consistence of the vertebra, which becomes 
 unequal to the maintenance of the continuity of the column." 
 
 I would to this reply as follows : in the first place, Herrgott 
 
THE HISTORY AND ETIOLOGY OF SPONDYLOLISTHESIS. 49 
 
 has now abandoned the Potts' disease he formerly insisted oh, 
 and refers the loss of resistance in the interarticular portion of 
 the vertebral arch to " a chronic inflammatory state." Now 
 then, by what has this state of chronic inflammation and giving 
 way been called forth ? Was it primary ? Surely not. By what 
 then was it caused ? By a fracture, an injury ? I refer the 
 genesis of the olisthesis to this injury, without which the chronic 
 inflammatory process of He'rrgott would not have occurred, and 
 consequently there would have beeu no olisthesis. Herrgott, oii 
 the other hand, refers the genesis to the condition of the vertebral 
 arch that I assert is secondary, yet he himself says on pp. 350, 
 351 : " This chronic inflammatory state of irritation is according 
 to the history generally caused by an injury." 
 
 He quotes the statements from anamueses brought forward by 
 me as examples, in regard to ascertained fractures and injuries 
 and says, es seien dies. 
 
 " All traumatic actions the maximum result of which must 
 affect the lumbo-sacral region." 
 
 " Is not the most frequent cause of chronic osseous inflam* 
 matioh to be found in these ? " 
 
 "Once the inflammatory condition following injury is admitted 
 the process becomes clear." Such a deformation of the bone as 
 we see can .only be produced if the bone has lost its resistance 
 .under the chronic influence, for then alone can it be extended 
 and flattened out, and undergo such transformations under new 
 statical conditions. "In one word, as origin of the lesion we 
 look upon an injury which need not break the bone, it may be- 
 some other injury, but which inflames it, causes it to soften r . 
 and allows the entire metamorphosis to take, place." 
 . , In the first place, it is not true that a fracture must cause the? 
 deformation to arise at onCe, that is to say, immediate dislocations- 
 It may do so, but there is no must in the case. The dislocation 
 after fracture is indeed very often -only brought about by 
 secondary influences, internal or external, muscular tension, 
 overburdening during the process of union, or something of the 
 kind, as soon as the force of the full blow or other injury has 
 already been exhausted on the resistance of the bjne Indeed 
 the appearance (eintritt) of the dislocation of the fragment may 
 be separated to a certain degree in time from the fracture ; for 
 example; dislocations and deformities often occur in consequence 
 
 4 
 
50 ' NEUOEBAUER ON 
 
 of unsuitable bandaging apparatus, that would sometimes not 
 happen had the repair been left to nature. And Herrgott says 
 also. (p. 352): "We much regret that we cannot completely 
 agree with Neugebauer's final conclusion, which is thus stated : 
 ' Spondylolisthesis is a surgical deformity, occasionally due to 
 some anomaly in the ossification of a vertebral arch, but more 
 frequently caused by an injury.'" 
 
 " Neugebauer's view," he states further on, "appears to us 
 less satisfactory than our own, for he does not give to inflam- 
 matory action that important part in the matter which it appears 
 to us to play. If the injury was the effective cause, the deformity 
 would be an immediate result, and this is. not the case ; more or 
 less time, and generally a' very long time, consisting of months, 
 or even years', elapses before the deformity, which does not arise 
 until the consistence of the vertebra is so modified by inflanv- 
 mation that it is too feeble to support the rest of the spinal 
 •column, is produced." 
 
 In answer to this I would in the first place point out that 
 Herrgott has now abandoned the causative :action of Potts' 
 disease he formerly insisted on, and attributes the loss s£ 
 resistance in the interarticular portion of the vertebral arch to a 
 •" chronic inflammatory condition^" But to what is this chronic 
 inflammatory state and softening itself . due ? It cannot be a 
 primary condition, but is itself due to some fracture or injury. 
 While I look. upon this injury, without which neither Herrgott's 
 chronic inflammatory softening nor olisthesis could have occurred, 
 as the origin of this olisthesis, Herrgott, on the other hand, 
 refers the genesis of the olisthesis to a condition of the vertebral 
 arch which I. insist was secondary, and says, nevertheless, on 
 pp: 350, 851, " This chronic inflammatory state of irritation is 
 .according to the anamuesis generally due to an injury." 
 . . He enumerates all the fractures and injuries mentioned in the 
 .anamuesis of the several cases which I have set down, and then 
 .says, " The maximum effect of all of these injuries must result in 
 the lumbo-lsacral region." " Have we not here the most frequent 
 cause of chronic inflammations of the bone ? " " Once the 
 inflammatory condition resulting from injury is admitted, 
 the- process becomes clear." " The deformation of the bone, such 
 as we Bee> can only result if the bone has lost its resistance 
 -under- some chronic influence, for only then could it be elongated, 
 
THE HISTORY AND ETIOLOGY OF SPONDYLOLISTHESIS. 51 
 
 flattened out, and imder the altering statical conditions undergo 
 such transformation; in one word, as the origin of the lesion, 
 we look on an injury which does not break the bone (the lesion 
 may be quite different), but which inflames it, softens it, and 
 allows all that metamorphosis to take place." 
 
 Now it is not true that the deformation or dislocation must be 
 ;an immediate result of the fracture. It might, but by no means 
 must be so. Indeed many a dislocation occurring after fracture 
 is secondary, due to internal or external influence, muscular 
 tension, strain during the process of repair, or some similar 
 cause," the power of the fall or blow, or whatever it may be, 
 having exhausted itself on the resistance of the bone, or a dislo- 
 cation of iihe broken fragments may not happen till sometime 
 after a fracture, and we know that dislocations and deformities 
 which would perhaps not have occurred if the cure had been left 
 to nature, are not infrequently caused by improper bandaging. 
 So.ihjolisthesis the injury, or fall, causes the. fracture, and then 
 the predisposition to olisthesis, due to the weight of the body, 
 necessitates .' the deformity, or rather the deformation. That 
 from the alteration in the statical conditions or deformation, as 
 well as in consequence of the fracture, infraction, or other injury 
 itself, a chronic inflammatory condition of the bones does arise, 
 and plays a certain part'ih the olisthesis, is" self-evident, and has 
 never been denied. But this inflammatory condition is always 
 secondary, and therefore is not the cause of the spondyl- 
 olisthesis, but Is only a process accompanying it, and is like it, 
 a result of the injury; the' spondylolisthesis itself is' therefore 
 due to the' injury. - 
 
 However, Herrgott himself says this chronic inflammatory 
 condition, put forward as the controlling cause, is a result of the 
 injury. 
 
 The difference, therefore, between Herrgott'S view and my own 
 is only that he looks upon a chronic inflammatory condition of 
 the vertebra^ itself due to an. injury, as that primary cause, which 
 I find in the injury itself, for without the latter that " primary " 
 chronic inflammatory condition would never have existed. It is 
 essentially a difference in words only, for Herrgott, with whom I 
 had an opportunity Of conferring personally in Nancy not long 
 ago about it, explained to me that in distinguishing between 
 spondylizema and spondylolisthesis he had not intended to insist 
 
52 NEUGEBAUER ON 
 
 that both affections were due to the same specific process, i.e., td 
 Potts' ' disease, but rather to indicate that spondylizema was a 
 result of a softening or dissolution of the body of the vertebra^ 
 and was therefore due to disease of the body of the vertebra^ 
 while spondylolisthesis was a result of disease (=ramollissemeti,t, 
 softening) of the arch of the vertebra, even if this disease was 
 itself due to an injury. 
 
 At Friburg, towards the end of September, I received from 
 Professor Frankenhauser, to whom I would here express my 
 thanks for his prompt courtesy, the Zurich pelvis for examina- 
 tion. In one half of the specimen I softened off the ligaments, 
 and separated the fourth lumbar vertebra in toto from the fifth, 
 so as to expose the corpus delicti, the fifth vertebral arch, and I 
 removed as far as was necessary and possible the irregular 
 attachments from both halves of the preparation. I found 
 unmistakable traces of a fracture, which I had previously 
 suspected a priori, on either side of the interarticular portion of 
 the fifth arch. The conditions were very similar to those found 
 in Olshausen's pelvis at Halle, in that at Liege, and to those in 
 the B pelvis at Prague, in particular. 
 
 Without any detailed description of this interesting and fatal 
 Zurich pelvis, I may illustrate the condition of the affected parts, 
 i.e., of the lumbo-sdcral symphysis, by a few drawings. The 
 olisthesis had, as is known, reached the stage of spohdyloptosis ; 
 the body of the fifth lumbar vertebra lay well within the true 
 pelvis, while the posterior part of its arch, and its isolated and 
 extremely prominent spine, remained in the normal position ; the 
 body of the first sacral vertebra has been forced like a wedge into 
 the lumen of the vertebral canal of the last lumbar vertebra, with 
 proportionate enlargement of this lumen from behind forwards, 
 and it is therefore quite evident that the interarticular portions 
 of the arch of the last lumbar vertebra must be lengthened to 
 the same extent that the body has been separated from the 
 posterior transverse part of the arch. In fig. 20 the fifth lumbar 
 vertebra is exposed by taking away the upper part of the 
 vertebral column, and shows such an extension has really taken 
 place. The arch is extremely elongated from behind forwards, 
 the superior or anterior articular process (a) has in fact been 
 separated to the extent of several centimeters from the inferior 
 or posterior articular process (b), corresponding with the olis- 
 
THE HISTORY AND . ETIOLOGY OF SPONDYLOLISTHESIS. .03 
 
 thesis of the anterior half of the vertebra. The length of the 
 superior or anterior articular process (a) is greatly increased, 
 and a corresponding flattening out and secondary deformation 
 (from pressure) of the inferior articular process of the fourth 
 lumbar vertebra may be seen in fig. 21. On comparing fig. 20 
 with the corresponding pictures of the specimens at Liege and 
 Halle (see Neugebauer, Archiv fur Gynakologie, Bd. xx., Hft. 
 1, fig 29 and fig. 11), we see that the condition of the parts is 
 
 Fig. 20. 
 
 Fig. 20. — Left half of the sacrum and fifth lumbar vertebra of the Zurich spondyl- 
 olisthetic pelvis as seen from above (from a photograph). 
 
 h $ i Osteophytes projecting from the , 
 fifth lumbar vertebra. 
 
 c x c xx Portions of the superior articular 
 process (») and interarticular 
 portion (e) wasted under pres- 
 sure. 
 
 nn Exposed upper surface of the first 
 sacral vertebra. 
 
 A sacrum, 
 
 B Mana lateralis ossis sacri sinistea. 
 a Superior articular process. 
 b Inferior articular processes, 
 c Interarticular portio of the arch, 
 d Neck. 
 .« Body. 
 /' Spine. 
 g Transverse process. 
 
 exactly similar. Indeed a special description of this Zurich case 
 seems almost superfluous. 
 
 In fig. 21 we see that the interarticular portion of the fifth 
 arch has nearly or quite disappeared. Under pressure and 
 tension the wasting and elongation have gone so far that tiae 
 
54 NEUGEBAUER ON 
 
 lower articular process of the fourth lumbar vertebra and the 
 posterior transverse part of its arch are situated in direct contact 
 with the lateral parts of the first sacral vertebra, so that the 
 body of the latter is driven so far into the sacral aperture of the 
 fifth lumbar vertebra, that it has forced the two segments of this 
 vertebra quite apart, dislocating the anterior segment completely 
 forwards, and interposing itself entirely between them. 
 
 The fourth lumbar vertebra lies therefore directly upon the 
 first sacral vertebra, in the interval between the anterior (dislo- 
 cated) and posterior (stationary) fragments of the fifth lumbar 
 vertebra. 
 
 In fig. 22, which represents the same parts in situ, one can 
 easily make out the anterior and posterior segments of the arch 
 of the fifth lumbar vertebra, and observe the direct contact 
 between the first sacral vertebra and the fourth lumbar vertebral 
 arch, at the previous situation of the interarticular portion of 
 the arch of the fifth lumbar vertebra. 
 
 The fifth lumbar vertebra of the Zurich pelvis is a typical 
 instance of Lambl's dolicho-hyrto-platyspondylus, and its shape 
 gives evidence of the gradual origin of the deformity. 
 
 Now what was the origin of the process in this case ? Since 
 the continuity of the arch of the fifth lumbar vertebra is not 
 absolutely destroyed on both sides we may exclude the idea of 
 any congenital lateral fissure in >the-, vertebral arch, nor is there 
 any indication of a primary fracture of the" sacral articular 
 process. We can therefore only suppose a primary fracture or 
 infraction of the interarticular portions of the arch of the fifth 
 lumbar vertebra. As a matter of fact the arch shows the traces 
 of such an infraction, i.e., dislocation of the fragments,- diffuse 
 callus, wasting from pressure, osteophytes, and marks of that 
 insidious process of secondaiy inflammation. 
 
 But one cannot say from the preparation whether there may 
 not have been in this case a secondary infraction of the arch 
 after it had been extremely elongated and compressed under 
 excessive pressure and tension bent into an acute angle, and 
 atrophied that secondary infraction in which the sudden transi- 
 tion takes place from the last stage but one of the deformity 
 into the last, into complete spondyloptosis. 
 
 Considering the tens of years that have passed since the 
 commencement of the disease, it can easily be understood that 
 
THE HISTOBT AND ETIOLOGY; Oy. J3P.ONDYL-OLISTHESIS. 5£ 
 Kg. 21. 
 
 Fig. 21'.— View of a median section, from before backwards, of the left half of the 
 lumbosacral region of the Zurich pelvis. (From a photograph.) 
 
 The fourth lumbar vertebra has been lifted away from the fifth after the ligaments 
 were removed. 
 
 Ill, IV, VL The bodies of the third, fourth, and fifth lumbar vertebra. 
 
 SI, II, III The bodies of the first, second, and third sacral vertebra. 
 
 m Dried up intervertebral disc. 
 
 '£ Body. 
 
 f Spine. 
 
 a Superior (anterior) articular process (a r and a" its median and posterior 
 margins) 
 
 b Inferior (posterior) articular process I 
 
 . e Ihterarticular portion of the arch (wasted ad maximum under pressure) 
 
 d Pedicle J vertebra. 
 
 J, The articular surface of the inferior articular process of the fourth lumbar 
 vertebra, changed in form and extended in length and breadth by pressure, 
 f Fourth lumbar spine. b 2 Posterior part of the inferior articular process (i), 
 and under surface of the posterior transverse portion of* its arch ; the latter, since 
 resting on the anterior half of the last vertebra it has slipped forward with it, is 
 lying almost directly on the lateral part of the first sacral vertebra. 
 
 h Part of the ligamentary attachments which united the fourth and fifth lumbar 
 vertebras, hardened like an osteophyte; this arising from the fifth arch, surrounds, 
 like a claw, the arch of the fourth lumbar vertebra, which is gradually slipping 
 out of it. 
 
 » A tooth- shaped, rudimentary relic of the former interarticular portion of the fifth 
 arch, or a ligamentary mass hardened by ossification. 
 
 of the 
 
 fifth 
 
 lumbar 
 
5& NETJGEBAUEB ON 
 
 all traces of primary and of secondary deformation are only too 
 completely confused or blotted out. The question therefore 
 whether there was or was not a primary infraction in the arch 
 of the fifth lumbar vertebra of the Zurich pelvis must remain 
 open for the present. Such probably is the etiology of the case, 
 but it can only be proved in the course of time by a process of 
 exclusion. 
 
 Of the 17 specimens of spondylolisthetic pelvis known to 
 exist I have had at one time or another an opportunity of 
 examining 10, namely, the two at Prague, Olshausen's case at 
 Halle, that at Breslau, the Prague-Wurzburg case, the second 
 Wurzburg case I have now recorded, that at Munich, those at 
 Paderborn (?) and Zurich, the pelvis of the Hottentot Venus, 
 and besides these ten the two specimens of olisthesis in the 
 penultimate lumbar vertebra lately described at Berlin and 
 Breslau. In reference to the other seven cases the Halle- 
 Giesener one of Blasius appears to be lost, and in this case, as 
 well as in that of the pelvis at, Treves, I decidedly doubt 
 the accuracy of the pathological-anatomical diagnosis between 
 spondylolisthesis and caries. As to the remaining six pelves, I 
 must confine myself to a consideration of the verbal descriptions 
 which have been given of them, and of the pictures. 
 
 My investigations at present have led me to take the following 
 view of the etiology of the so-called spondylolisthesis : — 
 
 (1) A Congenital Spondylolisthesis Inteeaeticulabis mat 
 
 EXIST IN THE AECH OF THE FlFTH LUMBAE VeETEBEA ON 
 ONE OE BOTH SIDES.* 
 
 This mode of origin is certainly indicated anatomically in 
 several cases of the class ; for example, in those at Paris and 
 
 * In reference to spondylolisthesis interarticularis congenita, I would now add to 
 the 59 cases enumerate* in my last work (Arclriv fur Gynak., Bd. xxi., Heft 2) 
 some new cases that I have met with in Friburg, Basle, Strasburg, and Paris. 
 
 No. 60.— Bilateral of the fifth lumbar vertebra, number 0.11.6 of the Friburg 
 Anatomical Museum. 
 
 No. 61.— Bilateral of the fifth lumbar vertebra, with separation of the posterior 
 part of the arch into two lateral arches through the spine [ibidem). 
 
 No. 62, — Bilateral of the fifth lumbar vertebra, unnumbered, in a vertebral column 
 with six sacral and five lumbar vertebra {ibidem). 
 
THE HISTORY AND ETIOLOGY OF SPONDYLOLISTHESIS. 57 
 
 Fig. 22. 
 
 Kg. 22. — Internal view of the left half of the lumbar sacral parts of the Zurich 
 
 pelvis, from a median section (from before backwards) by a saw. 
 HI, IV, V, Bodies of third, fourth, and fifth lumbar vetebra?. 
 oIII, oIV, oV, and oVI, The corresponding intervertebral foramina. 
 o First anterior sacral forameD. 
 
 /"/Fourth and fifth lumbar spines the former has slipped forwards, so that the latter 
 forms a solitary projection (compare Fr. Billeter, "Ein neuer Fall von hooh 
 gradiger Spondylolisthesis des Beckens." Mang. Diss., Zurich, 1862. Tafel III.). 
 « Superior articular process "I Qf fte fifth lumbar yertebra 
 o Inferior „ „ J 
 
 b' Inferior articular process of the fourth lumbar vertebra. 
 n Exposed upper surface of the body of the first sacral vertebra. 
 Isolated spikes of bone (compare i in figs. 20 and 21). 
 
 No. 63. — Indicated spondylolisthesis interarticularis on the right arch of the 
 second lumbar vertebra in the spinal column of a child two or three years old 
 [specimen in spirit] (ibidem). 
 
 No. 64. — Bilateral of the fifth lumbar vertebra of a female pelvis in the Obstetrical 
 Collection at Basle (from a woman with a funnel-shaped pelvis, who, a primipara 42 
 years of age, after the delivery with perforation of the head of the child, died on 7th 
 February, 1880). (See Journal, No. 68, 1880.) 
 
 No. 65. — Bilateral of a lumbar vertebra. 
 
58 
 
 NETJGEBATJER ON 
 
 Bonn, tLe Prague-Wurzburg pelvis, the second Wurzburg pelvis, 
 and in the two specimens of olisthesig of the penultimate lumbar 
 vertebra, and possibly in the B pelvjs at Prague. ... 
 
 A decision cannot be 
 made, though it would be 
 then a certain one, until 
 consent has been given for 
 separating the fourth lum- 
 Lar vertebra from the fifth, 
 as I have personally con- 
 vinced myself may be done 
 without injuring the speci- 
 
 ^,■23. — Spondylolisthesis interarticularis 
 congenita, on the left side of a lumbar men. 
 vertebra (Strasburg Anatomical Museum, 
 1880, No. 106). (Compare with the pic- 
 ture Neugebauer, Archiv.J'ur Gyncik., Bd. 
 xx., Heft 1, fig. 16.) 
 
 No. 66.— Unilateral (right) of a lumbar vertebra, apparently of the same person 
 (Anatomical Museum at Basle). 
 
 No. 67.— Bilateral of the last Tertebra of a lumbar column of four vertebrae only 
 (ibidem). ' , ■ i 
 
 No. 68 and 69.— Bilateral of 'the. fourth and fifth lumbar vertebrae, under No. 
 0. iii. 8, Museum of Pathological' Anatomy at Friburg. 
 
 No. 70.^-BiIateral of a lumbar vertebra under No*! 62, 1881 (Anatomical Museum 
 at Strasburg). 
 
 No. 71.— Unilateral on the left side, under No. 106, 1880 {ibidem), but without 
 bipartition of the spine and middle posterior part of the arch (see fig. 23)., , 
 
 Nos. 72 and 73.— Bilateral of the fourth and fifth lumbar vertebrae in a male, under 
 No. 0. iii. 8, in the Anatomical Museum at Strasburg. 
 
 No. 74.— 'Unilateral on the right side of the fourth dorsal vertebra of the abnor- 
 mally and perversely ossified Epecial column of a. foetus with sacral spina bifida, 
 hydrocephalus, &c. {ibidem). 
 
 (Besides these specimens, I found in the Friburg Pathological Museum another 
 fracture of the portio interarticularis of the second lumbar vertebra fiom a gunshot 
 wound. The body of the vertebra was bisected in the median line, besides w hich the 
 left half was divided transversely j the whole of the posterior part of the arch was also 
 split off from its spine, so that the vertebra appeared cut into four pieces.) 
 
 Finally, I have lately obtained several specimens of spondylolysis, in which the 
 condition varies considerably from the ordinary one. 
 
 No. 75. — Bilateral spondylolysis interarticularis congenita in a female pelvis, from 
 the anatomical collection of Professor Farabceuf of Paris. This pelvis exhibits also a 
 complete ossification of the left sacro-iliac ligament. 
 
 No. 76.— Fifth cervical vertebra of an adult (see fig. 24) ; on the left side, close 
 behind the margin of the superior articular process, the arch is traversed by a con- 
 genital dividing fissure which gapes to ths extent of 1 — 2 mm., and which divides 
 the surface of the inferior articular process, or so to speak the inferior articular 
 surface, into two parts, an anterior and a posterior segment. 
 
 There is therefore a spondylolysis interarticularis only in this case ; the inferior 
 articular process is also divided. This variation may perhaps be caused by some 
 anomaly in the ossification of the vertebra. This case calls to mind the one described 
 
THE HISTORY AND ETIOLOGY OF SPONDYLOLISTHESIS. 59 
 
 I had this day, while visiting the collection in the Jardin des 
 
 Fig. 21. 
 
 Fig. 24.— Fifth cervical vertebra with a congenital spondylolysis 
 lateralis sinistra of the arch. 
 
 a Posterior articular process 1 
 b Inferior „ „ 
 
 V Posterior portion of the articular surface of the in- 
 ferior articular process 
 c Spine 
 d Body 
 
 e Interarticular portion 
 f Transverse process 
 x Spondylolysis 
 
 of the 
 
 fifth 
 
 cervical 
 
 vertebra. 
 
 Plantes in Paris, the opportunity of personally examining the 
 
 by Grnber (see Neugebauer, Arcldvfiir Gynakologie, Bd. xx., Heft 1, fig. 12), and 
 the spondyloschiz : s lateralis sinistra of the Prague-Wurzburg pelvis. 
 
 Nos. 77 and 78. — Fourth and fifth lumbar vertebrae with an extremely peculiar and 
 unique form of spondylolysis. Whereas in general the fissure traverses the portio 
 interarticularis of the arch, and the spine itself is generally divided into two parts, in 
 this case the posterior span of the arch in both vertebrae with the spine is perfectly 
 developed, but the left inferior articular process of the fourth vertebra, and the left 
 superior of the fifth, is formed of one single piece of bone. The condition of the sur- 
 faces of separation of the central parts and the external appearance are direct evidence 
 of a congenital condition. 
 
 The peripheral parts of th's specimen, that is to say, the two isolated articular 
 processes, have unfortunately teen destroyed. The fifth lumbar vertebra is depicted 
 in fig. 25. 
 
 No. 79. — Fifth lumbar vertebra of a child about ten years old, in which the posterior 
 half of the arch on the right side is an isolated piece of bone, united by ligamentary 
 bands with the right interarticular portion, and with the pedicle of the spine on the 
 left side. 
 
 No. 80. — Fifth lumbar vertebra, with bilateral congenital interarticular fissure. 
 Many of the last preparations are derived from the private stores of the servants of 
 different anatomical institutions, where so many interesting specimens, carelessly 
 thrown aside, are destined to be worked up into some heterogeneous skeleton or other. 
 I also found some specimens among the vertebra in the collections of the Parisian 
 dealers in natural history specimens. 
 
 No. 81. — Bilateral interarticular spondyloschisis (the eMigenital nature of which 
 cannot be absolutely insisted on, because of some unfortunate fractures) in one of the 
 lumbar verteb-a, which I found about three weeks ago during an inspection of the 
 
,60 NEUGEBAUER ON 
 
 skeleton of the Hottentot Venus, who died in Paris on . 1st 
 January, 1816, at the age of 38, and must agree completely with 
 the opinions of Hennig and Lambl, that it is a case of spondyl- 
 olisthesis, but that it would probably never have reached a higher 
 degree if no further pregnancy had occurred to promote it. If 
 the superior articular process on each side is placed perpendicu- 
 larly above or immediately in front of the inferior, the separated 
 halves of the vertebral arch cannot be placed in contact, but 
 
 Kg. 25. 
 
 Fig. 25. — Fifth lumbar vertebra, with a defect in the ossification between 
 the arch and left inferior articular process. The latter (J) forms in the 
 specimen an isolated piece of bone. 
 
 stand somewhat apart. There is therefore some elongation of 
 the interarticular portion, and the body of the fifth lumbar 
 vertebra must during life have been displaced forwards, as is 
 also proved to have been the case by the depression and grinding 
 away of the anterior edge of the body of the first sacral vertebra, 
 and the condition of the lumbar spines, which show there was a 
 considerable lumbar lordosis with a corresponding^, position of 
 the body of the fifth lumbar vertebra. 
 
 (2) Fracture of the Articular Processes of the Sacrum. 
 
 This mode of origin also is absolutely proved anatomically 
 by the specimen of spondvl-olisthesis lumbo-sacralis at Breslau, 
 
 bony treasmes stored up in the Catacombs of Paris, in company with Dr. Bonnaire, 
 Interne of the Paris Maternity, where so many interesting pathological specimens 
 have been found. 
 
 No. 82. — Bilateral congenital spondyloschisis interarticularis vert, lumbalis, V., in 
 the skeleton set up a la Beauchene in the Museum of the Amphitheatre des 
 B ospiteaux in Paris. 
 
 In any case, the important series of 82 observations of these lateral fissures in the 
 vertebra, which manifest such numerous variations, will help to develop the historical 
 knowledge of the manner of ossification of the vertebra. Unfortunately up to the 
 present time this question has been very imperfectly investigated, and it is desiralsle 
 that some embryologist' or histologist should undertake it, as an independent work. 
 
THE HISTORY AND ETIOLOGY OF SPONDYLOLISTHESIS. 6J 
 
 described first by Strasser, and afterwards by myself,- and was I 
 believe the mode of origin in the Paderborn pelvis. 
 
 In these cases one may speak of a dislocation of the last 
 lumbar vertebra as a whole, for as sure as the sacral articular 
 processes are broken under the action of the body weight the 
 fragments cracked off the arch of the fifth lumbar vertebra sup- 
 ported by them, and therefore the whole of the last lumbar 
 vertebra slips a little forwards. But this movement soon ceases, 
 for the fragments broken off the articular processes are arrested 
 by the posterior edge of the upper surface of the body of the first 
 sacral vertebra, and with this arrest the displacement of the fifth 
 lumbar vertebra in toto is put an end to, and it is only [the 
 anterior half of this vertebra, as in the other cases, that now con- 
 tinues to slip forwards under the mechanical conditions of its 
 present position. 
 
 (3) Primary Lateral Fracture of the Arch of the Fifth 
 Lumbar Vertebra. 
 
 This is anatomically evident in the Munich pelvis, and may be 
 suspected in many other cases, probably was so in the B pelvis 
 at Prague, unless this was a case of congenital spondylolisthesis: 
 In reference to this, the third mode of origin, there are still 
 many points to be discussed. 
 
 In the first place, it is certain that in many cases of complete* 
 spondyloptosis, the highest degree of olisthesis— and fortunately 
 it is only such pelves for the most part which reach the museums 
 in consequence of deaths in labour directly due to the spondyl- 
 optosis — the fifth lumbar vertebra is closely united to the sacrum 
 by synostosis, and their anatomical investigation is very difficult. 
 The lumbo-sacral articulation must be most carefully examined 
 for any fracture, especially for any fracture of the sacral articular 
 processes such as that in the Breslau pelvis. Unfortunately 
 this endeavour is generally unsuccessful, for these lumbo-sacral 
 articular processes are for the most part completely united by 
 synostosis, so that ho fracture can be proved by appearances. 
 The shape, that is the antero-posteror extension of the articular 
 surfaces of the lumbo-sacral joint, always gives a certain amount 
 of evidence, and where a primary fracture of the sacral articular 
 processes has taken place, the lumbar articular processes seen 
 
62 NEUGEBAUEE ON 
 
 from above are abnormally elongated in proportion to- the interval 
 between the fragments. Tor example, in the Paderborn pelvis I 
 believe that a primary fracture of the sacral articular processes has 
 occurred, because the lumbar articular processes are drawn out 
 to a most unusual length, so that the entire posterior transverse 
 span of the arch of the fifth lumbar vertebra, in consequence of 
 this elongation of its inferior articular processes, an eloDgation 
 which, as already mentioned, corresponds to the degree of the 
 interval between the fragments of the broken sacral articular 
 processes, is moved somewhat forward. And as regards the pelvis 
 at Halle and the A pelvis at Prague, I have already stated my 
 belief that this primary fracture of the sacral articular processes, 
 which unfortunately from the extensive synostosis in both cases is 
 unsupported* except by the elongation of the inferior lumbar 
 processes, was the mode of their origin. Be this, as it may, there 
 is still a very important question to decide. If a fracture or 
 infraction in the interarticular portion of the arch of the fifth 
 lumbar vertebra has evidently taken place in a pelvis, was this 
 fracture or infraction, as the case may be, primary or secondary ? 
 The mode of origin-' of the secondary infraction, at the moment 
 when elongation of the arch of the fifth lumbar vertebra having 
 already reached, a maximum, on the occasion of some sudden 
 forcible strain, while the upper trunk is bent over forwards,- the 
 body of the fifth lumbar vertebra is tilted completely over, 
 forwards and downwards, and passes out of the third stage. of 
 olisthesis of .Lambl into the fourth stage, that of complete ptosis* 
 is perfectly comprehensible, and my theory of it has not as yet 
 been opposed. • Now this question is a most difficult one. 
 According to the principles of mechanics, secondary infraction is 
 Gertainly more probable than primary. But whether the infrac- 
 tion is always secondary is a question that cannot be at present 
 settled, the less so as there certainly are cases in which the 
 spondyloptosis, the complete tilting over of the body of the 
 fifth lumbar vertebra, takes place quite gradually without any 
 infraction of the arch. 
 
 On the other hand, it is proved by several pathological anato- 
 mical preparations that a primary fracture of the interarticular 
 portion of the vertebral arch does sometimes occur. Those cases, 
 therefore, in which there has not been any congenital spondyl- 
 olysis interart.icularis, and no fracture of the sacral articular 
 
THE HIST0BY AND ETIOLOGY OF SPONDYL-OLISTHESIS. 63 
 
 processes can be pointed out, where in fact these processes are 
 unaltered, nothing can be supposed except this questionable 
 primary fracture of the arch of the fifth lumbar vertebra until we 
 can find some other mode of origin of spondylolisthesis ; and 
 indeed this supposition seems to be the more justifiable, for it is 
 admitted that in by far the greater number of cases the anamnesis 
 gives evidence that the spondylolisthesis commenced in a fracture. 
 If the entire posterior transverse span of the arch of the fifth 
 lumbar vertebra is still in its normal place, that is, not displaced 
 forwards, and if it is either not ossified on to the sacral articular 
 processes, or if it be, if there is no elongation in the inferior 
 lumbar articular processes from behind forwards, we may then 
 suppose a primary fracture of the interarticular portion of the 
 arch of the fifth lumbar vertebra (no congenital spondylolysis 
 existing at this place) ; but if the entire posterior transverse 
 span of the arch of the fifth lumbar vertebra has moved forwards 
 with the rest, and if its inferior articular process exhibits an 
 elongation from tensions corresponding with this forward move- 
 ment, I think that the idea of a primary fracture in the sacral 
 articular processes with separation of the fragments from each 
 other is more justifiable. 
 
 Summarising what has been said, we may formulate the 
 etiology of spondylolisthesis at the present time as follows— 
 Olisthesis may exist— 
 
 (1) On the ground of congenital lateral defect in the ossifi- 
 cation of one or both sides of the arch of the fifth lumbar 
 vertebra, especially in the interarticular portion of the arch 
 (spondyloschizis interarticularis congenita arcus vertebralis). 
 
 (2) On the ground of a primary fracture — 
 
 (a) Of the sacral articular processes, if the posterior trans- 
 
 verse span of the arch of the fifth lumbar vertebra is 
 displaced forwards, and its inferior articular process 
 exhibits a corresponding antero-posterior elongation. 
 
 (b) Of the interarticular portion of the arch of the fifth 
 
 lumbar vertebra, if the posterior transverse span of the 
 arch is not displaced forwards, but has remained in its 
 normal position, and whether the lumbo-sacral joint is 
 ankylosed or not. 
 It lies with anatomists and pathological anatomists, and with 
 
64 THE BISTOKY AND ETIOLOGY OF SPONDYL-OLiSTfiESIS. 
 
 those who make surgical and forensic postmortems to look out 
 for the early stages of spondylolisthesis in all fatal cases of 
 injury from falling. If this is done, I am sure that before very 
 long commencing or advanced spondylolisthesis lumbo-sacralis 
 will be occasionally discovered during the examination of dead 
 bodies at various places. 
 
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