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NEEYOUS AFFECTIONS OF THE HAND 
 
 AND 
 
 OTHER CLINICA.L STUDIES 
 
NEEVOUS AFFECTIONS 
 
 OF 
 
 THE HAND 
 
 AND 
 
 OTHEE CLINICAL STUDIES 
 
 BY 
 
 GEOEGE VIVIAN POOEE, M.D., F.E.C.P. 
 
 Phj^siciau to University College Hospital ; Professor of Clinical Medicine and Medical 
 Jurisprudence, University College, London ; Consulting Physician to the Royal Infirmary 
 for Women and Children ; Physician to the Chej-ne Hospital for Incurable Children ; 
 Member of tlie Permanent Committee of the International Congress of Hygiene and 
 Demography ; Honorary Member of the Hungarian Society of Public Health ; 
 Commander of the " Dannebrog," &c. 
 
 LONDON 
 
 SMITH, ELDER, & CO., 15 WATEELOO PLACE 
 
 1897 
 c/ 
 
 [All rights reserved] 
 
TO 
 SAMUEL WILKS, ESQ. 
 
 M.D., LL.D., F.E.S. 
 PEESIDENT OF THE EOYAL COLLEGE OF PHYSICLA.NS 
 
 THIS WORK IS DEDICATED 
 WITH GREAT RESPECT 
 
PEEFACE. 
 
 The Lectures and Papers which have been collected in this 
 volume have all been previously published. For such previous 
 publication the author is indebted to the Editors of the 
 ' Lancet,' ' British Medical Journal,' ' Clinical Journal,' 
 ' Practitioner,' ' International Clinics,' ' Brain,' and ' Medical 
 Chronicle.' 
 
 For the lithographed plates illustrating Chapter II. the 
 author owes his thanks to Messrs. Smith, Elder, & Co., and 
 for the wood-blocks in Chapters III. and XV. to the Proprietors 
 of the ' Lancet/ and to Lippincott Company of Philadelphia, 
 respectively. 
 
 32 WiMPOLE Street : 
 April 1897. 
 
CONTENTS. 
 
 CHAPTER PAGE 
 
 I. The 'Bradshawe Lecture,' 1881, on 'Nervous 
 
 Affections of the Hand ' .... 1 
 
 II. ' Professional Neuroses ' 26 
 
 III. Tailor's Cramp, &c. . . . - . . 76 
 
 IV. Hammerman's Cramp 97 
 
 V. Conditions which interfere with Piano-playing 109 
 
 VI. Sawyer's Cramp 123 
 
 VII. Spinal Myelitis . . . . , . . . 129 
 
 VIII. Phosphorus Poisoning 155 
 
 IX. Chronic Lead Poisoning 172 
 
 X. Food Poisoning . 192 
 
 XI. Auto -intoxication . 205 
 
 XII. A Case of Gout 211 
 
 XIII. Hematuria following Influenza . . . . 224 
 
 XIV. Eelation of Albuminuria to Life Assurance , 234 
 
 XV. Congenital Heart Disease 242 
 
 XVI. Management of Chronic Heart Disease . . 253 
 
 XVII. Treatment and Management of Pulmonary 
 
 Tuberculosis 265 
 
 XVIII. Tumour of the Lung 281 
 
 XIX. Sulphur Waters of the Pyrenees . . . 286 
 
 XX. Laryngeal Spasm 299 
 
 Index 307 
 
LIST OP ILLUSTEATIONS. 
 
 PLATES. 
 
 Facsimiles of Handwriting, Geoege Gaie . To face page 42 
 
 „ „ Henry Milleed „ 66 
 
 ILLUSTRATIOI^S IN TEXT. 
 
 FIG. I'AGE 
 
 1. Method of Holding Needle , . . . , . 78 
 
 2. Normal Hand ..,,.,.,. 90 
 
 3. Hand of Contracted Limb . , . . . , 91 
 
 4. Diagram of the Normal Fcetal Cihculation through 
 
 the Heart just before Birth , . , , 247 
 
 5. Normal condition after Birth 247 
 
 6. Abnormal Obstruction of the Pulmonary Artery , 247 
 
 7. Abnormal Blocking cf the Arch of the Aorta . 247 
 
NERVOUS AFFECTIONS OF THE HAND 
 
 CHAPTER I 
 
 THE BRADSHAWE LECTURE, DELIVERED AT THE ROYAL 
 COLLEGE OF PHYSICIANS, 1881 
 
 [Before beginning to discuss the subject which I have chosen 
 for the first Bradshawe Lecture I feel that a few words about 
 him in whose memory this lecture was founded will not be 
 unacceptable. 
 
 William Woode Bradshawe studied medicine at the West- 
 minster and Middlesex Hospitals, and became M.D. of 
 Erlangen and M.R.C.S. in 1833, and an Extra-Licentiate of 
 this College in 1841. About this time he was practising at 
 Andover, and married there a widow lady, whose means were 
 sufficient to render him practically independent of his 
 profession. He subsequently moved from Andover to Reading, 
 where he continued to reside till his death on August 18, 
 1866. He appears to have made use of his ease and leisure 
 for the cultivation of his mind. He entered at New Inn Hall, 
 Oxford, and ultimately became M.A. and D.C.L. He was 
 elected a Fellow of the Royal College of Surgeons in 1854, 
 and became a Member of this College in 1859. Dr. Brad- 
 shawe's professional writings comprised papers on the use of 
 cod -liver oil, on narcotics, and on abdominal abscess. He also 
 wrote upon matters of general interest, and was an occasional 
 contributor to the magazines. Of his domestic character the 
 best evidence is the reverence shown for his memory by his 
 widow. This lady, who survived him some fourteen years, 
 bequeathed to this College, and also to the College of Surgeons, 
 
 B 
 
2 NEEVOUS AFFECTIONS OF THE HAND 
 
 i£ 1,000, for the endowment of a lecture upon some subject con- 
 nected with physic or surgery, to be called the ' Bradshawe ' 
 Lecture, and to be delivered annually upon August 18, the 
 anniversary of the death of William Woode Bradshawe. The 
 already existing endowed lectures of this College have been of 
 great service to scientific medicine, and it will be a satisfaction 
 to Mrs. Bradshawe's relatives to know that by founding this 
 lecture, which I have the honour to inaugurate, our munificent 
 benefactress has conferred what cannot but be of permanent 
 benefit to the profession of medicine, and indirectly to the 
 public. It is unfortunate that by the terms of the will the 
 date for the delivery of the lecture has been rigidly fixed for 
 what is nearly the middle of the medical vacation. I feel 
 deeply the honour and responsibility of being called upon to 
 deliver the first ' Bradshawe ' Lecture, and although I dare 
 not question the judgment of our President, I am very con- 
 scious that, in spite of every effort, I can barely hope to justify 
 the choice which he has made.] 
 
 I have chosen for my subject the ' Nervous Affections of 
 the Hand,' because I have enjoyed somewhat unusual oppor- 
 tunities of studying them, and the reflections and suggestions 
 which I shall have the honour of making have been prompted 
 by the study of 160 cases which I have seen during the past 
 ten years. I have thought it best to proceed methodically, 
 but in the course of an hour I can do little more than open 
 the subject and lay down some fundamental principles, and I 
 trust to be able to find some future opportunity of completing 
 what I have to say. 
 
 For a thorough understanding of the nervous affections of 
 the hand a knowledge of the nervous relations of the hand is 
 necessary. That form of the manifestation of nerve-force 
 which we call the will seems, in its passage to the upper limb, 
 to be in some way intimately connected with certain parts of 
 the brain-cortex on either side of the fissure of Rolando in the 
 so-called ascending frontal and ascending parietal convolutions. 
 This area of grey matter lies below the area which influences 
 the lower limb, above that connected with the face, and 
 behind that which seems to influence movements of the 
 
THE BRACHIAL PLEXUS 3 
 
 head and eye. Of the upper limb area itself the fore part 
 seems to control extension movements ; the middle part, 
 mainly in front of the fissure of Rolando, seems to control 
 adduction, abduction, flexion, pronation, and supination ; 
 while the hinder part, entirely behind the fissure of Rolando, 
 is said to control the special movements of the hand. Hitzig, 
 Ferrier, and their followers have shown that stimulation of 
 these convolutions produces movement in the opposite upper 
 limb, and clinical and pathological observations are daily 
 confirming the teaching of these physiologists. From these 
 convolutions, the will, on its way to the upper limb, seems to 
 pass through the internal capsule of the same side ; thence 
 along the lower layers of the crus cerebri, through the pons, 
 to the anterior pyramid of the medulla oblongata. At this 
 point the fibres forming the will-path divide. The greater 
 part cross over to reach the opposite side of the spinal cord, 
 while the smaller portion proceed direct to the same side of 
 the spinal cord. The crossed fibres occupy in the cord the 
 hinder central portion of the lateral column, while the direct 
 fibres lie close to the edge of the anterior fissure. Between 
 the fourth cervical and first dorsal nerves is the cervical 
 enlargement of the spinal cord, and here those fibres which 
 seem to originate in the grey matter of the brain presumably 
 form connections with the grey matter of the enlargement, 
 and, issuing from the cord with the anterior efferent roots, 
 they join the afferent posterior roots, and leave the spinal 
 canal to form the brachial plexus. The brachial plexus is a 
 complicated interlacement of nerves, and I have made a hypo- 
 thetical model of it in different coloured wools in order to 
 show the greatest conceivable complexity which can exist in 
 it. The plexus is formed by the fifth, sixth, seventh, and 
 eighth cervical and the first dorsal nerves, and I have 
 assumed that wherever these nerves effect a junction there is 
 a complete interchange of fibres. The nerves are represented 
 respectively by black, yellow, white, red, and green colours. 
 The fifth and sixth cervical unite, forming a black and yellow 
 cord, and, being immediately joined by the seventh cervical, 
 there results a cord containing black, yellow, and white fibres. 
 
 B 2 
 
4 KERVOUS AFFECTIONS OF THE HAND 
 
 The last cervical and first dorsal unite, forming a red and 
 green cord. From the black and yellow nerves come branches 
 which supply muscles used for respiration — viz. the diaphragm 
 by the communicating phrenic branch, the rhomboids which fix 
 the scapula during extraordinary respiratory efforts, and the 
 scaleni, serratus magnus, and subclavius, which elevate the 
 ribs. The black-yellow- white and the red -green cords each 
 give off a branch to form the posterior cord of the plexus. 
 This cord possibly contains all the five colours, and from it 
 arise the three subscapular, circumflex, and musculo -spiral 
 nerves. These nerves, therefore, possibly correspond, as it 
 were, to the whole of the cervical enlargement of the cord. 
 The median nerve in like manner is also formed by a branch 
 from both the inner and outer cords, contains all the five 
 colours, and presumably corresponds to the whole of the 
 enlargement. It is interesting to note that the musculo-spiral 
 and median nerves, which so largely antagonise each other, 
 both presumably are connected with equal lengths of the 
 cervical enlargement of the cord. The musculo- cutaneous 
 nerve which arises from the outer cord, and contains only 
 black, yellow, and white fibres, is connected with not more 
 than the upper three-fifths of the enlargement ; while the 
 ulnar nerve, which contains only red and green fibres, is 
 connected with not more than the lower two-fifths of the 
 cervical enlargement. The practical fact to be remembered is 
 this, that the motor and sensory branches of the median and 
 musculo-spiral have relations possibly with the whole of the 
 cervical enlargement, whereas the motor and sensory branches 
 of the musculo-cutaneous represent, as it were, not more than 
 the upper three -fifths, and the motor and sensory branches of 
 the ulnar not more than the lower two- fifths of the cervical 
 enlargement. These speculations, founded upon coarse 
 anatomical facts, receive a large amount of confirmation from 
 the recent experiments of Professors Ferrier and Gerald Yeo. 
 These gentlemen noted the muscles which were made to 
 contract when each of the anterior roots of the nerves form- 
 ing the brachial plexus of the monkey was stimulated. The 
 result of their experiments was shortly this. No ulnar 
 
THE BEACHIAL PLEXUS 5 
 
 movement occurred when any of the roots above the eighth 
 cervical were stimulated ; no musculo- cutaneous movement 
 followed stimulation of any roots below the fifth cervical, but 
 both median and musculo- spiral movement followed stimula- 
 tion of the fifth, sixth, seventh, and eighth cervical nerves. 
 These experiments, therefore, bear out the speculation already 
 made that the median and musculo-spiral have a wide origin 
 from the cervical enlargement, while the musculo-cutaneous 
 is limited to the upper and the ulnar to the lower end. One 
 of the effects of such an interlacement of fibres as is found in 
 the brachial plexus is necessarily to scatter, as it were, the 
 influence of the motor cells of the spinal cord, so that the 
 cells of a particular level have a widely diffused action on the 
 muscles of the hmb. We may conclude — 1. That as many 
 muscles receive their innervation through the cells correspond- 
 ing with more than one nerve root, the function of these 
 muscles will remain, in some degree, as long as any of the cells 
 are intact from which any nervous influence is derived. 2. 
 That when the motor cells in a limited area are destroyed the 
 abolition of function is extremely limited, while impairment 
 of function is far more extended.* 
 
 We are thus enabled to explain what takes place when, at 
 a certain level in the cord, the motor cells in the front horn 
 are destroyed, as in the disease which it is now the fashion to 
 call ' anterior poliomyelitis,' but which has long been known 
 as infantile or spinal paralysis. In this disease we constantly 
 find, after the acute stage has subsided, a few paralysed 
 muscles surrounded by others which are merely paretic. The 
 paralysed muscles probably derived their entire motor power 
 through the cells which have been destroyed, while the paretic 
 muscles were probably dependent upon the destroyed cells for 
 only part of their motor power. Let us suppose that the 
 motor cells at the level of the first dorsal nerve have been 
 destroyed. We should expect to find in such a case a complete 
 paralysis of some muscles in the hand, while certain muscles 
 supplied by nerves into which fibres of the first dorsal 
 
 1 See p. 132 for a description of Herringham's conclusions on this 
 subject. 
 
6 NEKVOUS AFFECTIONS OF THE HAND 
 
 penetrate would be to a greater or less extent weakened. 
 The improvement which always takes place in the paretic 
 muscles in anterior poliomyelitis is probably due to the fact 
 that the power lost is in time compensated by an increased 
 conduction of force through fibres of another colour. The co- 
 existence in infantile paralysis of paralysed and merely 
 weakened muscles is a fact of much practical importance. 
 
 Clinical observation has led Remak to think that the 
 motor cells in the cervical enlargement are arranged in func- 
 tional groups. The group for the deltoid, biceps, brachialis 
 anticus, and supinators he places in the upper part, and that 
 for the extensors of the digits and the intrinsic muscles of 
 the hand in the middle part of the cervical enlargement. A 
 study of the brachial plexus seems to render it unlikely that 
 any limited lesion of the cord would cause complete paralysis 
 of any considerable group of muscles ; the structure of the 
 plexus seems designed, among other things, to prevent such a 
 catastrophe. On the other hand, it is likely that a lesion 
 occurring at any of the junctions of the plexus might cause 
 curious combinations of muscular paralysis ; and indeed 
 Hoedemaker, who has recorded two cases of Erb's paralysis 
 (deltoid, biceps, brachialis anticus, and supinators), is 
 inclined to place the lesion, not in the spinal cord, but at 
 the point of junction of the fifth and sixth cervical nerves, 
 and the fact that faradisation of a spot in the neck close to 
 this point causes simultaneous contraction of the muscles 
 concerned in Erb's paralysis is in favour of Hoedemaker's 
 theory. 
 
 The junctions of the nerves are of importance in another 
 connexion. It is well known that inflammatory action occur- 
 ring in a nerve may travel in either direction along the nerve 
 trunk, and thus an ascending neuritis may strike a junction 
 and seriously impair the function of other nerves emanating 
 from that junction ; records of such occurrences are tolerably 
 common. Weir Mitchell gives the history of Stephen Warner, 
 who was shot through the left chest by a bullet. Three days 
 later the movements of the arm below the shoulder were 
 perfect, the pectoral muscles being alone paralysed. Shortly 
 
MOVEMENTS OF HAND 7 
 
 there ensued a neuralgia which spread to the median region of 
 the arm and hand, and was soon followed by wasting and 
 weakness of the flexors of the forearm and hand. Mitchell 
 thinks that the external anterior thoracic nerve had been 
 wounded, and that neuritis travelling along this nerve 
 reached the external cord of the plexus, and involved the 
 musculo-cutaneous and median trunks, which were distinctly 
 tender. Duchenne, Putzel, Csesar Boeck, and others have 
 recorded similar cases. Inflammation once set up in a nerve 
 seems to have a potentiality for evil not unlike that of a clot 
 in an artery or vein. 
 
 It must not be forgotten that the nerves of the brachial 
 plexus, as they issue from the spinal canal, form connexions 
 with the sympathetic chiefly by branches from the inferior 
 cervical ganglion. The many trophic changes occurring in 
 the upper limb in consequence of nerve lesions give importance 
 to this connexion between the nerves of sensation and muscle- 
 motion and those of vessel-motion. 
 
 It is not necessary to dwell upon the origin and distribution 
 of the nerves of the arm and hand. A few words may be 
 said, however, upon the efiect of paralysis of these nerves on 
 the attitude and movement of the hand. When the median 
 is paralysed we get an abolition of pronation and grasp (except 
 in the ring and little fingers). The near phalanges can still 
 be flexed by the interossei, and owing to the unopposed action 
 of these same muscles the mid and far phalanges are liable to 
 be over-extended and curved backwards. It is the median 
 nerve which confers what may be called the human functions 
 on the thumb, and when it is paralysed the thumb cannot be 
 abducted or opposed ; the first and second metacarpal bones 
 lie in the same plane, the thumb looks directly forwards, and 
 we get what Duchenne called the ' ape's hand.' In paralysis 
 of the musculo- spiral we get loss of supination and extension, 
 which is total in the wrist and thumb and partial in the 
 fingers — i.e. the near phalanges cannot be extended, but the 
 mid and far phalanges can still be extended by the interossei. 
 The ulnar nerve is the nerve j(;ar excellence of delicate mani- 
 pulation. It supplies all the intrinsic muscles of the hand^ 
 
8 NERVOUS AFFECTIONS OF THE HAND 
 
 except the two outer lumbricales, the opponens, abductor, and 
 outer head of the short flexor of the thumb. AU the ulnar 
 muscles acting together give a conical shape to the hand, like 
 that observed in tetany. When the ulnar is paralysed, sewing, 
 writing, and all delicate manipulation become impossible. The 
 patient cannot move the fingers to and fro in the same plane. 
 The mid and far phalanges cannot be extended, nor the near 
 phalanges flexed, and the patient cannot make a billiard 
 bridge. After a time the hand, by the unopposed action of 
 the flexors and extensors of the fingers, becomes ' clawed ' — 
 i.e. the near phalanges are extended, while the mid and far 
 phalanges are flexed. I need not specify the well-known 
 areas in the hand which cease to feel when either of these 
 nerves is paralysed. I will merely say that motor function is 
 always more easily abolished than sensory function ; that, in 
 cases of recovery from damage, sensation invariably returns 
 before motion ; and that occasionally sensation will return in 
 a nerve area, notwithstanding the continued severance of the 
 nerve-trunk. It must be remembered that anastomoses of 
 the sensory branches of the three nerves of the hand exist 
 on the back and palm and on the pulps and along the edges 
 of the digits, and that MM. Arloing and Tripier have proved 
 that the * persistence of sensibility' in nerve-areas after 
 division of the nerve itself is due to the conduction of sensory 
 impressions (by means of these anastomoses) through the 
 trunks of nerves which remain entire. 
 
 There are some purely mechanical conditions in the hand 
 which are liable to lead to misconceptions as to the power of 
 certain muscles. The fingers and the wrist-joint each have 
 their own flexor and extensor muscles, whicli act indepen- 
 dently of each other ; and it is obvious that the state of the 
 wrist-joint, whether flexed or extended, must influence the 
 tautness or slackness of those tendons which, having no 
 attachment to the wrist, pass over it to flex or extend the 
 fingers. When the wrist is in an extreme degree of flexion 
 or extension those tendons which run over the convex side of 
 the joint are taut, while those which run over the concavity 
 are slack ; and this tautness or slackness of the extensor or 
 
LUMBRICALES MUSCLES 9 
 
 flexor tendons of the fingers is, be it observed, quite indepen- 
 dent of any action on the part of the extensor or flexor 
 muscles of the fingers. The fingers can be extended with 
 greater ease and completeness with the wrist flexed than 
 with the wrist extended ; and, indeed, when the wrist is fully 
 extended a complete extension of the fingers can scarcely be 
 accomplished, and the attempt causes great fatigue-pain in 
 the palm owing to the efibrts of the interossei and lumbri- 
 cales. The cause of this difiiculty is clear enough. When 
 the wrist is fully extended the tendons of the extensors of 
 the fingers are slack, and this has to be overcome before ex- 
 tension of the near phalanges can begin. Hence part of the 
 difficulty. At the same time the flexor tendons are taut, and 
 tend, quite mechanically, to flex the mid and far phalanges. 
 This is a second obstacle to complete extension of the fingers 
 with the wrist extended. It is the interossei and lumbricales 
 combined which extend the two end phalanges, and the lum- 
 bricales seem especially designed to overcome the obstacle 
 oflered to complete extension of the fingers by extension of 
 the wrist. These muscles arise from the tendons of the flexor 
 profundus, and are inserted with the interossei into the apo- 
 neurotic expansion on the back of the mid phalanges. When, 
 therefore, they contract, they tend, by one and the same action, 
 to slacken the far ends of the flexor tendons and to tighten 
 the far ends of the extensor tendons. They thus permit ex- 
 tension by their action on the flexor tendons, and actively 
 produce it by their action on the extensors. I am not aware 
 that this view of the action of the lumbricales has been pre- 
 viously stated. The interossei and lumbricales have also the 
 power of moving the fingers from side to side ; but it must be 
 remembered that, as the tendons of the extensors radiate to 
 a slight extent from the wrist -joint, the fingers tend to sepa- 
 rate from each other during the full action of the extensor 
 communis digitorum. This may be mistaken for true inter- 
 osseal action. 
 
 We are now in a position to discuss the effects of diseases 
 at various points of the nervous system upon the form and 
 functions of the hand. Beginning at the highest point, we 
 
10 NERVOUS AFFECTIONS OF THE HAND 
 
 will consider first the effect of diseases of the brain-cortex. 
 There seems to be no doubt that a lesion of the upper limb 
 convolutions in one half of the brain is capable of causing 
 trouble in the upper limb of the opposite side, and what are 
 called ' brachial monoplegias ' have been reported tolerably 
 often. They are most common in tubercular meningitis and 
 syphilis, which, when it attacks the brain, often affects the 
 cortex. According to Landouzy, who has studied the subject 
 of cortical paralyses, these paralyses are characterised by the 
 following peculiarities : 1. They are partial and limited to 
 any extent — i.e. we may have paralysis of only one limb, or of 
 part of one limb. 2. They are very often incomplete — i e. 
 weaknesses rather than palsies. (3) They are often transitory. 
 4. They are variable — i.e. the area of the paralysis tends to 
 get smaller or larger. 
 
 Landouzy has collected over 100 cases from various sources 
 which seem to support the theory that motor functions are 
 localised in particular convolutions. A-mong them, however, 
 are not many cases of arm palsy, and of these most were 
 hemiplegic in the first instance. 
 
 In a case of congenital absence of the right hand recorded 
 by Gowers, the right ascending parietal convolution at its 
 middle third was found to be smaller than its fellow on the 
 left side, measuring transversely only '35 in. as against '65 in. 
 
 In a case of congenital absence of the right hand which I 
 lately had an opportunity of seeing, by the courtesy of my 
 friend Mr. Barwell, in the Cripples' Home, Marylebone, there 
 was a very noticeable inequality in the size of the two halves 
 of the skull, that opposite to the absent hand being very much 
 the smaller. A diagram made from measurements taken 
 with a cytometer showed this clearly, but the difference was 
 far more apparent to the eye than the diagram would lead 
 one to suppose. 
 
 In another case of congenital absence of one hand, which I 
 saw a few weeks since at Andover, the head appeared to 
 be perfectly symmetrical, but I had no opportunity of 
 measuring it. 
 
 Hahn has recorded the case of a young man of twenty who 
 
COKTICAL LESIONS 11 
 
 had a weakness of the first three fingers of the right hand, 
 for which he sought advice on August 11. He then became 
 epileptic and died comatose on August 30, without any 
 extension of the paralysis. Post mortem a part of the cortex 
 of the left hemisphere ' towards its hinder third ' was found 
 hardened and of a yellowish colour over an extent of 2 in. 
 by 1 in. 
 
 Cotard in 1868 recorded the case of an old woman in 
 whom an old paralysis of the left arm was found to correspond 
 post mortem with an atrophy of the convolutions at the upper 
 end of the right fissure of Rolando. 
 
 Bourdon, Rosenthal, Ringrose Atkins, and others have 
 put similar instances upon record, so that the fact of the con- 
 nexion of certain convolutions with the upper limb may be 
 regarded as clinically established. 
 
 I have only had one case in which I have had reason to 
 suspect a cortical lesion, and in this the hand was mainly 
 aft'ected. A gentleman, aged thirty-eight, actively engaged 
 in literary pursuits, was much occupied in looking over many 
 hundred examination papers. In order to get through this 
 work by a certain time he sat up at nights and goaded his 
 brain with tea, cofiee, and other stimulants. He was ' taken 
 ill,' and his queer state attracting the attention of his friends, 
 I was sent for about thirty-six hours after the attack. The 
 right hand was distinctly paretic. The patient could move 
 the right leg well enough, but he afterwards stated that when 
 firsT3 attacked there was a difficulty in moving the leg. The 
 right side of the face drooped perceptibly. Speech was un- 
 afiected. The patient was quietly delirious, but answered 
 some questions fairly well, and knew me perfectly. He had 
 pain on the left side of the head, and was possessed by a 
 fixed delusion that an insect had taken possession of his left 
 frontal sinus, and was trying to work its way into his nose. 
 (He had studied anatomy:) The urine contained a trace of 
 sugar. In a week or so he was practically well enough to go 
 a long voyage alone. There is now, two and a half years 
 after the attack, not a trace of paralysis about him except 
 that his handwriting is not so firm as it was. I believe this 
 
12 NERVOUS AFFECTIONS OF THE HAND 
 
 to have been a congestion of an overworked cortex, possibly 
 accompanied by a minute haemorrhage or thrombosis. 
 
 When, instead of the cortex, the internal capsule is 
 affected, we are confronted with an ordinary case of hemi- 
 plegia, which need not be discussed. In ordinary cases the 
 hand suffers more than the leg, and is the slowest to improve. 
 
 There are two results of hemiplegia which mainly affect the 
 hand, and which call for some special attention : these are 
 contraction and spasm. 
 
 Late contraction or contracture is an almost constant 
 phenomenon after hemiplegia ; its completeness is usually 
 proportionate to the completeness with which the limb is cut 
 off from the will, and it is generally ascribed to a degenerative 
 process descending along the path of the will. This degenera- 
 tion is best marked after lesions of the internal capsule, and is 
 said by Isidore Straus not to occur after lesions of the cortex ; 
 others, however, hold a different opinion. This degeneration 
 follows the course of all nerve degenerations, and travels 
 slowly down the course of the extinct function. Its 
 descent is completed in about two months, and then the con- 
 traction of the hand approaches its maximum. Ordinarily (in 
 two- thirds of the cases) the contracted limb is in an attitude 
 of flexion and pronation. As far as the hand is concerned, the 
 attitude is an exaggeration of the cadaveric position — the 
 fingers and thumbs being flexed upon the palm. It is probably 
 due to the extinction of the will and the abandonment of the 
 limb to reflex stimuli, reaching it through the cord, and the 
 consequent tonic contraction of the stronger group of muscles. 
 As a rule the muscles do not waste and respond to faradism, 
 as in health. The contracted flexors can be made to contract 
 still more by electric stimulation, showing that their contrac- 
 tion is not complete. The cadaveric position of the hand is 
 similarly due, probably, to the tonic contraction of the stronger 
 group of muscles in the interval between death and the dying 
 out of muscular irritability. The ' cadaveric position ' is 
 assumed, even though the force of gravity may tend to 
 counteract it. I cannot believe that the late contraction of a 
 hemiplegic arm is due to irritation, inflammation, or any 
 
POST-HEMlPLEaiC PHENOMENA . IB 
 
 form of discharge emanating from the brain. I have said 
 that there is no wasting or degeneration of the muscles of a 
 hemiplegic limb. The reason of this is, I believe, that sensory- 
 impressions made upon the palsied limb produce their effect 
 upon the muscles and vessels of the limb through the spinal 
 cord ; and that this exercise of spinal function, independent of 
 the will, serves to maintain the healthy nutrition of the limb. 
 The case is very different, as we shall see, when a limb is cut 
 off from both brain function and spinal function. 
 
 An apparent exception to this rule, that hemiplegic limbs 
 do not waste, is met with in brain paralyses occurring in early 
 life before development is complete. The wasting in these 
 cases is apparent only, and is due to the fact that the sound 
 limb, which is exercised, grows faster than the palsied limb, 
 and, as it were, leaves its fellow behind in the developmental 
 race. The practical lesson to be learnt from this fact is that 
 if we would prevent that distortion of the body which must 
 result from an unequal growth and an unequal use of the two 
 sides, the palsied limbs of children must be stimulated and 
 exercised artificially and methodically until growth has finished. 
 It is well to bear in mind that the amount of palsy or contrac- 
 tion in a hemiplegic limb may vary in degree from a maximum 
 which those who run may read, to a minimum which leaves 
 only a trifling degree of contraction of the flexor muscles, or a 
 little unsteadiness in the performance of delicate manipulative 
 acts. I have seen some eight or nine cases in which a functional 
 trouble, such as a writing difficulty, was distinctly due to what 
 I may be pardoned for speaking of as the dregs of a long ante- 
 cedent, and perhaps forgotten, hemiplegia. Hemiplegia is not 
 very uncommon in early life, and one must ever be watchful 
 in after life for the trifling effects of it. 
 
 Another, though rarer, result of brain lesion is spasm. I 
 shall deal exclusively with chronic spasms occurring some time 
 after the paralysing lesion, such as have been spoken of as 
 post-hemiplegic spasm, spastic contraction and athetosis. These 
 three forms dovetail into each other, and I think it will be 
 profitable to consider them together. These spasms vary 
 immensely in extent. 1. They may affect all four limbs and 
 
14 NERVOUS AFFECTIONS OF THE HAND 
 
 the face, such cases being common enough in idiot asylums. 
 Dr. Clay Shaw drew attention to them in 1873, and quite 
 recently, through the kindness of Dr. Langdon Down and Dr. 
 Grabham, I have been able to inspect several such cases at 
 Norman sfield and Earlswood. The movements are almost 
 continuous, varying in form, in the same case, within certain 
 limits ; and they are increased by attempts at voluntary acts. 
 They are congenital or begin very early in life. The intelli- 
 gence is usually not much impaired, and in idiot asylums these 
 patients rank high in the scale of intelligence. This general 
 spasm is common, it is said, in firstborn children ; and very 
 often some accident causing pressure and damage to the cortex 
 cerebri has befallen them during birth, so that they have been 
 thought to be stillborn and have been recovered by artificial re- 
 spiration, &c. Several of these children at Normansfield had 
 an exaggerated knee-jerk when the patellar tendon was struck. 
 In some cases there is contraction of the limbs as well as spasm. 
 2. In other cases this form of spasm follows an attack of hemi- 
 plegia. It is then limited to the paralysed limbs, and the arm 
 is usually worse than the leg. Gowers has recorded one case 
 in which there was late rigidity of the arm and spasm of the 
 leg. 3. In cases of paraplegia from a limited lesion in the 
 cord, with consequent degeneration in the lateral columns, 
 there is liable to supervene a rigid state of the legs, and if 
 voluntary power return to any extent there is a spastic spasm 
 on attempting to move. It is in these cases that we get the 
 most marked exaggerated knee-jerk and ankle-clonus. 
 
 Now, it seems probable that the mechanism of all these 
 varieties of spasm is similar. In all the forms there is some 
 amount of voluntary power, and in ail there is some severance 
 of the muscles from the will. In all, probably, there is more 
 or less descending degeneration along the path of the Avill, and 
 of this the existence of exaggerated knee-jerk is probably an 
 evidence. Ankle-clonus and knee-jerk are probably due to a 
 heightening of the spinal function (reflex or not), and it is 
 certain that phenomena of this class are most easily observed 
 in the legs whose reflex functions are more highly developed 
 than those of the arms. In these conditions of the cord, muscles 
 
POST-HEMIPLEGIC PHENOMENA 15 
 
 are in such a state that when stretched they contract visibly. 
 This is certainly only an exaggerated normal condition. Sir 
 Charles Bell in his classical treatise on the hand pointed out 
 that every voluntary movement implied, not only an active 
 contraction of the muscles which produce the movement, but 
 also a regulated contraction of the antagonist muscles, in 
 order to check the movement and to prevent its being too jerky 
 and sudden. Now, this check movement of a muscle is 
 possibly provoked by the mere act of stretching, such as 
 must necessarily occur in the extensors of a joint when the 
 flexors are made to contract actively. These movements, 
 provoked by stretching, if not true reflex movements, are in 
 some way dependent upon the spinal cord, and in certain 
 diseased conditions they apparently become so exaggerated as 
 not merely to check the movements dictated by a weakened will- 
 power, but even to cause movement in an opposite direction. 
 
 For the production of steady motion there must be a 
 proper balance between the amount of muscular contraction 
 caused by the will (the influence of which reaches the muscle, 
 be it remembered, from both sides of the brain, by the crossed 
 and the direct will-path) and the contraction caused by reflex 
 influences and the mere stretching of the muscles. In the 
 oases which I have been discussing one or other of the will- 
 paths is certainly more or less blocked at its source or 
 throughout its whole length ; certain spinal functions are 
 exaggerated, the balance of power is upset, and disorderly 
 movement results. 
 
 It is interesting to note that these spasms occur most 
 frequently in children, in whom all reflex phenomena are but 
 little under control. Of the seven cases which I have seen 
 six were congenital, or followed a hemiplegia occurring in 
 childhood. In these children the functions of the spinal cord 
 develop with the development of the child, while the brain 
 damage hinders the development of the controlling influence, 
 and thus we get the balance of power very greatly upset. 
 
 In one of my cases of spasm, which came on seven years 
 after a hemiplegic attack, caused by a blow on the head at 
 the age of twenty- six, the spasm which afiected the hemi- 
 
16 NERVOUS AFFECTIONS OF THE HAND 
 
 plegic (right) arm, and to a less extent the leg, was, in the 
 arm, of a very violent character, quite unlike the so-called 
 athetoti'^ spasm, and was, moreover, fixed and invariable in 
 its form. The wrist was bent, and the hand violently- 
 twisted to a position of extreme pronation. There was in 
 this case, however, evidence of a paralysis of the lower 
 branches of the musculo- spiral superadded, as it were, to the 
 hemiplegia. There was a characteristic prominence on the 
 back of the wrist,' impaired sensibility in the radial area on 
 the back of the hand, and the extensors of the wrist and fingers 
 gave degenerative reactions. The paralysis of the extensors 
 and supinators in this case was probably quite independent of 
 the brain lesion, and I believe it served, if not to start the spasm, 
 at all events to give it its determinate and fixed character. I 
 have observed similar facts in at least two other cases. 
 
 Finally, I believe that the prime factor in all these forms 
 of chronic spasm is the cutting off* of the full influence of the 
 will from the muscles, and their abandonment to other influ- 
 ences over which the patient has no control ; that they are 
 due, not to any active discharge from the brain, but are brought 
 about rather because the brain fails to discharge its normal 
 amount of voluntary stimulus to the muscles. I need not say 
 that I do not mean to apply these remarks to transient convul- 
 sions of an epileptic type. 
 
 In one class of idiots there is observed a peculiarity of the 
 hand which is worthy of mention, and which is said to be 
 diagnostic of their mental condition. I saw several of these 
 cases at Earlswood and Normansfield. The skin of the hand 
 is soft, wrinkled like a washerwoman's, and looking too big 
 for the hand, and the finger-tips are tapering and conical. 
 These idiots are often the youngest children of large families. 
 They have a fair amount of intelligence, are singularly 
 imitative, and have the eyes obliquely set, like a Chinaman. 
 The head is round. They never acquire a handicraft, though 
 they are often musical. There is a high arch to the palate, 
 the tongue is fissured, and they usually die of tubercle before 
 puberty. 
 
 Before leaving the subject of the influence of brain lesions 
 
ANTERIOR POLIOMYELITIS 17 
 
 on the hand, I must mention a case of a child in whom was 
 found a glioma as big as a small egg, growing from the left 
 lobe of the cerebellum, and largely occupying the fourth 
 ventricle. In this case, which was under my care at the 
 Royal Hospital for Children in the autumn of 1878, there was 
 observed the characteristic tetanic rigid conditions of the 
 limbs occasionally seen in cases of cerebellar tumour in children. 
 For the last month of life the child was continuously in a state 
 of opisthotonos, with the legs extended and rigid, the left toes 
 strongly flexed, and the right toes strongly extended ; no 
 rigidity about the jaws. As to the upper limbs, the arms 
 were powerfully rotated inv/ards so that the backs of the 
 extended elbows looked outwards and a little forwards, while 
 the hands with the fists clenched were so strongly pronated 
 that the palms looked almost directly forwards. 
 
 In dealing with those spinal lesions which cause troubles 
 in the upper limbs I shall try to avoid the repetition of well- 
 understood facts. 
 
 The best understood spinal lesion is probably that which 
 is characterised by ' inflammation ' of the front horns with 
 destruction of its motor cells. This disease, well known as 
 infantile, spinal, or essential paralysis, or anterior poliomye- 
 litis, begins with a sharp febrile attack. The area of the 
 paralysis is at first extensive, but gradually gets smaller as 
 the patient recovers, leaving one limb, or part of one limb 
 only, paralysed, and finally, in typical cases, a small group 
 of paralysed muscles is surrounded by a larger group of 
 muscles, which are merely weak. The reason for this I have 
 already tried to explain. The paralysed muscles being cut off* 
 from every physiological stimulus, whether direct or reflex (the 
 motor cells being apparently the path for both forms of stimu- 
 lation), rapidly waste and degenerate. Sensation is perfect or, 
 more often, the skin is over-sensitive. There are no trophic 
 lesions, but the afiected limb is always cold, and very often 
 blue and congested. The paralysed muscles, tested with elec- 
 tricity, give the degenerative reactions, and sometimes, in cases 
 which are recovering, we may find muscles, lately paralysed 
 but paralysed no longer, which also give the degenerative 
 
 c 
 
18 NERVOUS AFFECTIONS OF THE HAND 
 
 reactions. This curious fact has been noticed also in some cases 
 of lead palsy. 
 
 In the following case this phenomenon was observed. 
 
 Walter B , a schoolboy of sixteen, was seen by me on 
 
 August 3, 1881. Three months ago, after a game of play, 
 he had been seized with a typical attack of this disease, 
 and at first nearly every muscle in his body was paralysed, 
 and he was in a state of great danger. In a day or two he 
 began to improve, and has steadily progressed. At present 
 the legs are weak, but he can walk without much difficulty. 
 Both arms are still partially paralysed, and their condition is 
 almost symmetrical, but the right is rather the worst. On both 
 sides he can move the shoulders, flex the elbows, and extend 
 the wrist to some extent. He can flex the left wrist and 
 digits but not the right, and on both sides there is paralysis 
 of the triceps and of the interossei. The scapular muscles, 
 biceps, and supinators on both sides respond to faradism, as 
 do also the abductor and opponens of the left thumb. The 
 flexors and extensors of the wrists and digits, and the inter- 
 ossei on both sides, as well as the right abductor and opponens, 
 give degenerative reactions, although some of these muscles 
 (the extensor of the wrist on both sides and the left extensors 
 and flexors of the fingers) respond to the will and are no longer 
 paralysed. 
 
 I should mention also that I have seen hopelessly paralysed 
 muscles, which formerly gave degenerative reactions, begin, 
 after months of patient treatment, to respond to faradism, 
 but nevertheless continue to remain as hopelessly paralysed as 
 before. Thus in this disease, under certain exceptional cir- 
 cumstances, we may find non-paralysed muscles giving de- 
 generative reactions ; while muscles hopelessly and incurably 
 paralysed may respond normally to electricity. 
 
 The following case of complete paralysis of one arm is of 
 exceptional interest from the point of view of diagnosis. 
 
 Mrs. L , aged twenty-four, consulted me on August 1 2, 
 
 1880, by the advice of Dr. C. Daniel, of Epsom. A fortnight 
 previously the patient, who was pregnant, being heated by 
 exercise, had sat with her back to an open window and had 
 
ANTEEIOR POLIOMYELITIS 19 
 
 fallen asleep. Two days later she was seized with pain on the 
 left side of the neck and scalp. There was vomiting, and the 
 temperature rose to 102° F. There was noticed some want of 
 power in the left arm ; and after the pain subsided (in thirty - 
 six hours) it was found to be completely paralysed, sensation 
 remaining perfect. "When first seen every movement of the 
 arm caused pain, and there were pain and tenderness, but no 
 swelling, up the left side of the neck. The left arm was abso- 
 lutely powerless. The deltoid and pectoral muscles, and every 
 muscle of the upper limb supplied by the brachial plexus, with 
 the exception of the rhomboids, were paralysed, and gave 
 degenerative reactions ; sensation was perfect. There was no 
 trophic change or change of colour, and there was no tendency 
 for the arm to become cold. The pain soon left her. In 
 December she was confined with a healthy child. The general 
 health has steadily improved, and the patient has gained 
 weight, but in spite of a daily, methodical, and most efficient 
 galvanisation of the muscles, which I have myself seen per- 
 formed upon several occasions, and the administration of 
 mercury, strychnine, iodides, and arsenic, there has not been 
 as yet, though a twelvemonth has elapsed since the attack, any 
 tangible improvement in the power of the limb, which is still 
 absolutely useless. The arm has not wasted as much as might 
 have been expected, because of the constant galvanisation to 
 which it has been subjected. There has been no difficulty in 
 maintaining the temperature, no trophic change, and no 
 tendency to contraction or deformity, for the very good 
 reason that no muscles are capable of contracting. I have 
 been in considerable doubt as to the diagnosis of this case. 
 The early pain, the tenderness up the side of the neck, the 
 absence of lividity, the ease with which the temperature 
 has been maintained, and the fact that there has been no 
 diminution of the area of the paralysis, have inclined me to 
 think that this is not a case of anterior poliomyelitis, but 
 possibly a compression of the anterior nerve-roots by a rheu- 
 matic thickening of the meninges. Two physicians equally 
 eminent for their investigation of nervous diseases have seen 
 this patient with me ; the first, in January, thought with me 
 
 c 2 
 
20 NERVOUS AFFECTIONS OF THE HAND 
 
 that the motor cells were not affected ; the second, in July, 
 with the knowledge that no improvement had taken place in 
 eleven months, considered the case to be one of anterior 
 poliomyelitis. I confess I am still in doubt. It is needless 
 to say that the diagnosis of motor cell (?) or nerve-root (?) is 
 of great importance for prognosis. The regeneration of a 
 motor cell is inconceivable, while the power of regeneration 
 of conducting fibres seems almost unlimited. 
 
 For the sake of comparison with these cases I will now 
 bring forward a case of absolute paralysis of the right arm 
 from a bruise of the brachial plexus. 
 
 In March, 1877, Miss F. W , aged fifty, fell down a 
 
 flight of steps, alighting on her right shoulder. Shortly 
 after the accident the arm was devoid of motion and sensa- 
 tion from the shoulder downwards. When I saw her three 
 months later the arm was much wasted, the deltoid, triceps, 
 biceps, and all the other muscles of the limb gave degenera- 
 tive reactions. The limb was absolutely useless, and sensa- 
 tion was entirely wanting below the middle of the forearm, 
 and impaired elsewhere. On scratching the forearm it was 
 noticed that vascular reaction occurred far more readily on 
 the sensitive than the insensitive part. The galvanic current 
 applied to the sensitive parts caused an immediate uniform 
 redness, bat on the insensitive parts it slowly produced an 
 irregular patchy redness like a lichenous rash. The fingers 
 were scurfy and bulbous at the tips, and the patient complained 
 that they got hot at night. Gralvanisation was efficiently and 
 methodically applied to the arm by the patient's sister. By 
 November sensation had returned down to the finger-tips (im- 
 perfectly). Wrist movable ; hand clawed and paralysed ; nails 
 furrowed and white. During the winter the hand was covered 
 with chilblains. In April, 1878, the arm was well, but the 
 intrinsic muscles of the hand remained paralysed : the nails 
 were a dead white. In July, 1878, the motion and sensation 
 of the hand were still impaired, and the muscles of the hand 
 gave degenerative reactions. In June, 1879, the intrinsic 
 muscles of the hand responded to faradism. There were 
 glazy spots at the roots of the finger-nails ; nails harsh, hard, 
 
DEGENERATION AND EEaENERATION 21 
 
 and grooved. In June, 1880, the hand was fairly useful 
 though still liable to chilblains, and the sensation still imper- 
 fect. I have a water-colour drawing of the hand at this time. 
 In a letter dated August, 1881, this patient writes, 'It is 
 really quite a natural colour. Nails of thumb, first, and third 
 fingers well ; and the others much better. Performance on 
 the piano quite grand. I can reach an octave, but cannot 
 strike it without holding the thumb. The thumb and first 
 fingers are the worst parts, as the thumb will not go out 
 quite far enough, and the first finger is inclined to bend back. 
 The chilblains last winter were nothing to what they were 
 before.' 
 
 This case is one of surpassing interest, and is most in- 
 structive from the point of view of nerve pathology. First, 
 as to the time of duration of the symptoms. The accident 
 happened in March, 1877, and in August, 1881, her recovery, 
 though still progressing, is yet not complete, so that it has 
 already been protracted over a period: of nearly four years 
 and a half. During the whole of this time there has been a 
 steady, slow, evenly progressing recovery, so that her im- 
 provement was recognisable from month to month. Recovery 
 has taken place in a regular order : sensation returned first, 
 and always preceded the return of motion ; and muscles 
 situated nearest to the trunk recovered before those which 
 were more distant from it. At present two muscles of the 
 hand, the abductor of the thumb and the first dorsal inter- 
 osseus, alone remain paralysed. From what is known of 
 nervous degeneration and regeneration one could hardly 
 have expected the course of events to have been otherwise. 
 The injury in this case was severe. The nerve-trunks were 
 probably bruised and torn by the head of the humerus, so 
 that immediately after the accident they were completely 
 ' blocked ' to upward sensory impressions or downward motor 
 stimuli. A disused nerve degenerates along the line of 
 function, and the motor nerves in this case rapidly degene- 
 rated from the point of blocking down to their terminations, 
 for no stimulation could possibly reach them either directly 
 from the brain or be reflected to them through the spinal 
 
22 NERVOUS AFFECTIONS OF THE HAND 
 
 cord. Accordingly, within a month or so after her accident, 
 it is probable that each motor nerve had been converted inta 
 a degenerated cord some three-quarters of a yard long, as 
 incapable of conducting stimuli as the skin, fat, or con- 
 nective tissue. Now, as the degeneration of a nerve takes- 
 place from trunk to end, so its regeneration takes place in 
 the same direction, for there can be no regeneration unless 
 physiological or artificial stimuli reach the point to be re- 
 generated. Motor stimuli, both direct and reflex, impinging, 
 against the block, gradually induce molecular regeneration 
 and the power of conducting stimuli, and thus little by 
 little, as the stimuli are able to travel further, we get a com- 
 plete regeneration of the nerves (a process which, in this 
 patient, has already taken four and a half years). It is 
 quite inconceivable that the stimulus which seems necessary 
 for the regeneration of a nerve should be able to pass by any 
 unregenerated portion. One might as well expect the makers 
 of a well to begin their work in the middle. Just as a well 
 has to be tediously bored, so is a degenerated motor nerve 
 slowly opened for the traffic of stimuli from above. Pro- 
 vided stimuli can reach the nerve the power of regeneration 
 seems almost unlimited, and, indeed, when pieces are cut 
 out of a nerve-trunk the severed ends seem capable of 
 worming their way, as it were, towards each other, and 
 eventually effecting a junction in spite of every adverse cir- 
 cumstance. It seems probable that the bulbous ends in 
 amputation stumps must be looked upon as an overgrowth 
 due to the arrival of stimuli in the stump of the nerve, which 
 are unable to produce their proper physiological effect. Bul- 
 bous nerve ends, according to Weir Mitchell, are physiological 
 rather than pathological, and are almost invariably present in 
 stumps. 
 
 The earlier return of sensation in all cases of nerve injury 
 is due to the following facts : 1. That the sensory branches 
 from the periphery to the obstruction are not deprived of 
 their natural stimuli, and presumably do not entirely de- 
 rrenerate, and are consequently ready to resume their full 
 functions directly the obstruction on the up-path is removed^ 
 
TROPHIC LESIONS 23 
 
 2. That in the parts above the block the incidence of im- 
 pressions of various kinds probably serves to keep up in some 
 degree the healthy condition of the nerve ; it is, in short, next 
 to impossible to deprive a sensory nerve of its natural stimuli. 
 
 3. That, owing to the anastomoses which exist between sen- 
 sory nerve branches, impressions have the power to some 
 extent of choosing the path of least resistance. Hence, 
 happily, it results that sensory impressions, so important 
 for the nutrition of the limb, are able to produce their phy- 
 siological effects in spite of very serious injuries. 
 
 A few words as to the trophic troubles observed in this 
 jatient. These were of three kinds : 1. Muscle- wasting. 
 2 A sluggishness or absence of vascular reaction when the 
 sdn was stimulated. 3. Scurfiness of the skin. Joss of nails, 
 aid a tendency to chilblains. 
 
 Why does it happen that muscles paralysed from a brain 
 l©ion scarcely waste at all, while those paralysed from de- 
 struction of the motor cells of the cord or from injury to a 
 nerve-trunk rapidly waste and degenerate ? Because in the 
 first case physiological stimuli still reach it through the 
 cord, while in the second case it is completely cut off from 
 every source of physiological stimulation. So long as a 
 muscle be stimulated it will maintain its size, no matter 
 whether the stimulus come to it from the brain along the 
 will-path, or from the surface or deep parts along the path 
 of reflected impressions, or be artificially applied to it by 
 means of a galvanic battery. If, on the other hand, a 
 muscle be cut off from all sources of stimulation, it will waste. 
 I do not, of course, mean to say that there may not be other 
 causes for muscle-wasting, but I have never encountered an 
 exception to the rule I have enunciated. 
 
 With regard to the trophic changes I speak with less con- 
 fidence, but I must express my absolute disbelief in the 
 existence of special trophic nerves ; and we clearly ought to 
 exhaust every possible explanation before we proceed to do 
 what is far too common in nerve pathology, viz. to give ' to 
 airy nothings a local habitation and a name.' I believe that 
 tissue changes other than muscle wasting are often due to 
 
24 NERVOUS AFFECTIONS OF THE HAND 
 
 the cutting off from the vessels which supply those tissues 
 those physiological stimuli which produce the contraction 
 and dilatation of the vessels, and thus exercise a local control 
 over them. Every paralysed limb is deprived of one im- 
 portant aid to circulation, viz. the muscular contraction, 
 which is a material aid to the circulation, especially in 
 driving the blood towards the heart. Every paralysed limbi 
 must therefore be at a nutritive disadvantage, but yet inj 
 hemiplegic limbs whose connections with the spinal cord art 
 normal no trophic changes usually occur, except a little 
 congestion. When the motor cells of the cord are aloni 
 destroyed, no trophic changes occur. When a mixed ner\B 
 is destroyed, trophic changes are very liable to occur to sonte 
 extent. When the posterior roots and sensory paths of tie 
 cord are damaged, trophic changes often occur, as witnes 
 the joint affections and occasional zona of locomotor ata^y. 
 When a purely sensory nerve, such as the fifth, is damaged, 
 trophic changes are common, but not invariable ; their occtr- 
 rence, according to some, depending upon the implication or 
 otherwise of the Gasserian ganglion. 
 
 Now, in the case we have been considering there were 
 trophic changes. There was impaired vascular reaction on 
 stimulating the insensitive parts of the limb, and it is toler- 
 ably certain that cutaneous impressions were not reflected to 
 the vaso-motor nerves of the limb. Th6 local circulation was 
 therefore cut off from the stimulus of muscular motion and 
 from the stimulus of cutaneous impressions. It must not be 
 forgotten, however, that impressions made upon one limb seem 
 capable of being reflected to the vessels of the other, so that 
 impressions made upon the left arm and other parts of the 
 body were probably able to reach the paralysed limb. This 
 fact is very suggestive of the importance which it is in the 
 animal economy that cutaneous impressions should reach the 
 vaso-motor nerves. A sensory impression is felt, if I may 
 be allowed the expression— (1) by the brain; (2) by the 
 muscles being reflected to them by the spinal cord ; (3) by 
 the vessels being reflected to them by the cord or the ganglia 
 on the posterior nerve-roots. It must be remembered that 
 
TKOPHIC LESIONS 25 
 
 conceivably any one of these paths for sensory impressions 
 may be blocked, while the other two may remain open ; that 
 any two may conceivably be blocked, or that all three may 
 be blocked. The question is very complicated and very 
 difficult to study. The dependence of nutrition upon a due 
 connection between the sensory and vaso-motor nerves com- 
 bined with muscular motion seems to me extremely likely. 
 Its absolute proof or disproof seems almost impossible.^ 
 
 ' For a further discussion of this subject, see p. 145. 
 
26 NERVOUS AFFECTIONS OF THE HAND 
 
 CHAPTER II 
 
 PROFESSIONAL NEUROSES ^ 
 
 By ' professional neuroses ' I mean those troubles which result 
 from the constant repetition of the same act, the act gene- 
 rally being that which enters largely into the professional 
 work of the patient, and which too often constitutes his 
 means of livelihood. The most common of these professional 
 neuroses is ' writer's cramp ' ; but I need not remind my 
 hearers this evening that there are many analogous troubles, 
 such as piano cramp, telegraphist's cramp, sawyer's cramp, 
 tailor's cramp, milker's cramp, hammerman's palsy, dancer's 
 cramp, and so forth. 
 
 I shall limit my remarks almost entirely to ' writer's 
 cramp,' so called because it is infinitely the most common of 
 all, and because, in the stress of the nineteenth century com- 
 petition, it bids fair to become still more common. I have 
 chosen the subject for my paper this evening because I think 
 I may fairly claim to have had exceptional experience. It is 
 now twenty-two years ago since my first paper on the subject 
 was published in the Practitioner, and in consequence of this 
 first paper and two subsequent papers on the same subject 
 communicated to the Royal Medical and Chirurgical Society 
 I have enjoyed, thanks to the kindness of my professional 
 friends, exceptional opportunities of studying these interesting 
 and troublesome cases. I am sure I have seen and closely 
 examined and studied at least three hundred of these cases, 
 and this must be my excuse for bringing the matter to your 
 notice this evening. 
 
 One result of my study of the subject is a doubt whether 
 there is a distinct morbid entity which merits the name of 
 
 ■ A Paper read before the Thames Valley Branch of the British 
 Medical Association, 1894. 
 
WEITER'S CRAMP 27 
 
 writer's cramp. Writing difficulty is common enough, but it 
 depends on a great variety of causes, and my first duty to- 
 night will be to answer this question : Given a case of writer's 
 cramp, how are we to set about diagnosing its cause ? Let us 
 first consider the act of writing, an act practised in this 
 country exclusively with the right hand, and which we learn 
 to perform fluently only after inany years of patient labour. 
 We are none of us born writers, and the children of educated 
 people do not learn the art with materially greater ease;than the 
 children of the uneducated. There is no evidence whatever, I 
 think, that by constant practice of the art of writing we gene- 
 rate a faculty which is transmissible to succeeding generations. 
 In writing, the pen has to be held with very great steadi- 
 ness, and there are distinctly two acts involved in writing, viz. 
 'pen-'pTehension and pen-moveraent. The pen is kept steady 
 (when the art is perfected) mainly by the intrinsic muscles of 
 the hand, the interossei and the muscle of the ball of the thumb 
 being chiefly employed. In order that these muscles may 
 get a firm hold of the pen the carpal and metacarpal bones 
 must be held steady, and the wrist-joint must also be 
 fixed. This throws work on the muscles of the forearm. 
 The elbow must be steady, and this throws work on 
 the muscles of the arm. The shoulder and scapula must 
 also be steady, and therefore the shoulder and thoracic 
 muscles are brought into play. The trunk has to be kept 
 firm, which involves contraction on the part of the spinal 
 muscles, and in order that the pelvis may give a firm support 
 to the spine the legs have to be firmly fixed. There is scarcely 
 a muscle in the body that is not brought into play in the act 
 of writing, and if we watch a little child at its writing lesson 
 we generally see that it hitches one leg round the leg of the 
 chair in order to steady the pelvis and trunk, and so great is 
 the muscular efi'ect involved that the face muscles contract 
 consentaneously, and the movements of the pen are, as often 
 as not, followed by the tongue. We must always bear the 
 above facts in mind, and in examining a patient who has a 
 difficulty in writing we must remember that the seat of trouble 
 will often be found far away from the hand. In examining 
 
28 NERVOUS AFFECTIONS OF THE HAND 
 
 these cases the first thing necessary is to strip the patient to 
 the waist. Having your patient stripped, let him stand before 
 you, and look first at the shoulders and see whether any 
 muscles are wasted or whether any of them manifest any 
 tremor, fibrillary or otherwise. Turn him round and look at 
 the position of the scapulae, and whether their relation to the 
 spinal column is normally symmetrical. In my experience I 
 have seen some few cases of writing difiiculty which depended 
 on paralysis of the serratus magnus or some other scapular 
 muscle, which, by failing to keep the scapula steady, caused 
 an unsteadiness of the hand. Next examine the arms, fore- 
 arms, and hands to see if there be any wasting of muscles, 
 particular attention being paid to the interossei and the 
 muscles of the thenar eminence. 
 
 Next ask the patient to hold his hands above his head, 
 when any failure of the scapular muscles will be accentuated. 
 Then ask him to hold the arms in front of him, and examine 
 the hands very closely for tremor. 
 
 Next examine the joints to ascertain whether there is any 
 stiffness and whether there is any thickening round them, or 
 creaking on movement, or any nodular swellings of the fingers 
 indicative of gout or rheumatoid arthritis. 
 
 Further, examine the tendons for teno- synovitis. I have 
 seen several cases of writing difficulty dependent on rheumatism 
 of the joints of the arm or hand, and one case in a distinguished 
 member of our own profession, dependent upon gouty deposits 
 in the tendons of the flexor longus pollicis. 
 
 Next ask the patient to write. In extreme cases there 
 may be almost a complete inability to write a single legible 
 word. Such cases are rare, however, and usually the chief 
 detectable difference from health is the slowness of the act and 
 the evident effort with which it is performed. Watch the 
 pen, and you will generally see that it is grasped with almost 
 all the patient's might, and as the letters are formed one can 
 often see daylight through the nibs of the pen, showing how 
 firmly the pen is pressed upon the paper. At other times we 
 notice a good deal of shoulder movement, and these great 
 efforts usually indicate that the pen -prehension is done by the 
 
WRITER'S CRAMP 29 
 
 muscles of the forearm, and the movements of the pen are 
 mainly from the shoulder. This is an indication that the true 
 normal muscles of pen-prehension are not performing their 
 quota of work. 
 
 Sometimes the grasp of the pen suggests feebleness and 
 impotence, and, although the poise and movements of the hand 
 are in these troubles almost infinite in variety, it is very com- 
 mon to see the forefinger move away from the penholder, and, 
 becoming flexed, glide upwards. This almost certainly shows 
 that the first dorsal interosseous muscle, the abductor indicis 
 one of the most important of the muscles of pen-prehension, is 
 not performing its work properly. 
 
 The next step in the examination is one of great impor- 
 tance, viz. the search for any distinct tenderness of the nerve- 
 trunks in the arms or hands. In order to detect thi^, equal pres- 
 sure should be exercised, simultaneously, on the nerves of both 
 arms, and it is by the comparison of the two and the flinching 
 or expressions of pain on the part of the patient which enable 
 us to detect it. I am accustomed to ask the patient to stand 
 in front of me and rest his two hands, palms upwards, on my 
 shoulders. Then, grasping his arms, I press upon the median 
 nerves, the musculo-spirals, and the ulnars, and it is exceed- 
 ingly common to find very well marked tenderness in one or 
 other of the nerve-trunks of the afiected limb. This is prob- 
 ably to be taken as an indication of slight neuritis, and I 
 have no hesitation in saying that of all peripheral causes of 
 writer's cramp slight neuritis is the most common and the 
 most important. Occasionally some nutrition change, such as 
 glossy skin, congestion, furrowed nails, or herpetic eruptions, 
 afibrds additional evidence of neuritis. 
 
 Having found neuritis, we must look for the cause of it. 
 These are strain, pressure, rheumatism, gout, and diabetes. 
 The urine must be examined for signs of gout or diabetes. 
 Examine the chest with care for evidence of aneurism, or other 
 mediastinal tumour, and I would emphasise this advice by 
 saying that in one patient sent to me for writer's cramp I 
 discovered the trouble to be due to the pressure of an aortic 
 aneurism. 
 
30 NERVOUS AFFECTIONS OF THE HAND 
 
 Next, hunt for evidence of hemiplegia. A man may have 
 had an attack of hemiplegia so slight as to have escaped his 
 memory. His power may have practically been perfectly 
 restored, the only evidence of want of power being a slight 
 feebleness in the grasp of his pen and slight shakiness of the 
 handwriting. On careful examination of these patients I 
 have detected the slightest possible deviation of the tongue, 
 the slightest want of symmetry in the face, the slightest want 
 of power in the right hand, and the slightest tendency for the 
 toe of the right boot to wear out before the left. These trifles 
 all point in the same direction, and give a clue to the cause. 
 In this connection the examination of the heart becomes im- 
 portant, as the detection of a murmur tells us of a possible 
 cause of embolism. I would remind you that hemiplegia may 
 occur at birth or before birth as the result of injury of the 
 head, and is not by any means uncommon in infancy as the 
 result of fits. The hemiplegia of children often only becomes 
 manifest when they begin to use their limbs and specialise 
 their movements. 
 
 Congenital left-handedness is a not unfrequent cause of 
 writing difficulty, and these patients will tell you that 
 writing has always been to them a labour and a sorrow, and 
 you will learn that, whereas they perform almost all other 
 delicate acts with the left hand, they have been driven to use 
 the right for penmanship by dint of the obstinacy of their 
 writing masters. Left-handedness is not unfrequently due, I 
 believe, to damage to the left hemisphere of the brain in early 
 life or before birth, and in such cases I have occasionally 
 found obvious flattening of the left side of the skull and a 
 want of development of the right half of the body. The left 
 clavicle is longer than the right, and the size of gloves and 
 boots is greater for the left limbs than the right. 
 
 There are various chronic troubles of the brain and spinal 
 cord which lead to writing difficulty, and I have found it as 
 an early indication of general paralysis of the insane, loco- 
 motor ataxy, disseminated sclerosis, lead palsy, anterior 
 poliomyelitis, and paralysis agitans. This short review will, I 
 hope, impress upon my hearers how manifold are the causes 
 
WEITEB'S CRAMP 31 
 
 -which lead to difficulty in writing, and how essential in such 
 cases is a careful examination. 
 
 It will be found that the vast majority of cases of writing 
 difficulty are due to one or other of the causes I have 
 mentioned, but I admit there is a small residuum of cases 
 which merit the name of true writer's cramp, in which no 
 peripheral troubles and no evidence of coarse cerebral change 
 is detectable. Some of these (mostly women) are pure neuroses 
 and get well, but the remaining few afford grounds for a very 
 gloomy prognosis qua writing. 
 
 In the case of true writer's cramp (and in those due to 
 neuritis) it will be found that one or other of the muscles of 
 pen-prehension manifest a marked loss of irritability when 
 tested by electricity, and it will be found that a current just 
 sufficient to stir the muscles of the left hand has no effect 
 when applied to those of the right. The loss of irritability is 
 the same both for faradism and galvanism, and is probably 
 due to some change in the muscle-tissue and the intramuscular 
 nerves. In some of these cases I have thought that the 
 muscle felt hard and rigid, as though some fibroid change had 
 taken place. This, however, is pure speculation. 
 
 I have spoken of such cases as due to chronic fatigue of 
 the overused muscles. There is always a change in the 
 muscle, as evidenced by its inability to respond normally to 
 electricity, but I readily admit that there may be concomitant 
 changes in the whole motor-path from the grey matter of the 
 cerebral cortex through the internal capsule, crus cerebri, 
 spinal cord, and nerve-trunks and branches. It is generally 
 asserted that there is no difficulty in cases of ' writer's cramp ' 
 with any act other than writing. This is true only of a small 
 number of cases, and it will often be found that in delicate 
 acts such as manipulating a pin, winding up a watch, or 
 wielding a salt-spoon there is some slight disability. 
 
 It will be at once evident that the question of treatment 
 must depend upon diagnosis, and if the failure in writing 
 power is found to depend upon any of the morbid conditions 
 mentioned above the treatment appropriate for such morbid 
 condition must be adopted. 
 
32 NERVOUS AFFECTIONS OF THE HAND 
 
 The most treatable form of writing difficulty is that which 
 is accompanied by tenderness of one or other of the nerve - 
 trunks, which is caused apparently by a mild neuritis. 
 
 In order to cure the neuritis, the patient must cease for a 
 time to write, and must be careful not to overstrain the arm 
 by any excessive use of it, and especially he should avoid any 
 exercise which involves a prolonged muscular strain, such as 
 carrying a heavy handbag. 
 
 The tenderness of the nerves must be subdued by counter- 
 irritation, and nothing is more useful than a good blister 
 applied over the tender nerve-trunk at a point where it is 
 superficial. In some cases a more chronic form of counter- 
 irritation is useful, and I have found the application of a 
 piece of capsicum plaister of undoubted service. For this 
 purpose I always use the American capsicum plaister, which 
 is very thin and pliable, is perforated with holes, and is exces- 
 sively adhesive, having, I believe, a basis of indiarubber. 
 
 When the nerve-tenderness has been removed I think a 
 thorough rubbing and massage of the whole limb, but especi- 
 ally of the intrinsic muscles of the hand, is very useful. I 
 must give a word of warning as to the danger of practising 
 massage w^hile the nerve- tenderness persists, such a course, in 
 my experience, being always harmful. This, I think, is the 
 commonest mistake made in the treatment of writer's cramp, 
 and therefore I repeat that there must be no massage until 
 the patient has got rid of the nerve-tenderness. 
 
 In cases where there is no nerve-tenderness massage may 
 be commenced at once. The application of the continuous 
 electric current is of undoubted service, but I am not prepared 
 to say that it is more efficacious than rubbing, which is a 
 tolerably simple matter and easily applied. 
 
 If the patient be unable absolutely to abandon writing for 
 a time, he should do the writing of sheer necessity with a 
 pencil, or, better still, should use a typewriter. Here it may 
 be necessary to add that only those typewriters which work 
 with a keyboard are admissible ; those which involve the 
 continuous grasp of a handle are scarcely, if at all, less 
 dangerous than a pen. I must not forget to mention the not 
 
PEEVENTION OF WEITER'S CEAMP 33 
 
 uncommon association of alcoholism with writing difficulties. 
 I have seen cases where the whole writing difficulty was 
 caused by alcoholic tremor, and many more in which the 
 difficulty had been intensified by the fatal practice of drinking 
 spirits to ' steady the hand.' In both of these classes of cases 
 abstention from alcohol has been sufficient to cure or greatly 
 improve the condition of the patient. It is often very 
 necessary to seriously warn the patient against yielding 
 to the fatal practice of taking alcohol. I have not found 
 any drugs of much use in these conditions. In cases 
 which are presumably due to neuritis I have found benefit 
 from the administration of small doses of liquor arsenicalis 
 (ni.ij or niiij) combined with one grain of iodide of potassium, 
 and it is needless to say that if there be gout, glycosuria, or 
 rheumatism present these conditions call for suitable treat- 
 ment. The general health must be attended to, as any 
 derangement, such as dyspepsia, constipation, or even a 
 common cold seems to intensify the trouble. The arms should 
 be kept warm. Flannel or merino vests with long sleeves 
 should be worn, and in some cases I have ordered an extra 
 sleeve for the affected arm. 
 
 One word as to prevention. The frequency of writer's 
 cramp is due, in the first place, to the unwholesome life of a 
 clerk who spends his days in a stuffy office in a crowded city. 
 Secondly, it is due to the fact that the holding of a pen 
 involves the continuous contraction of the muscles of pen- 
 prehension, which get tired out, just as our arms get tired 
 when we hold them rigidly extended, and as our legs get 
 tired when we stand in one position for long periods. 
 
 The only remedy for this is to teach the child to write 
 with both hands, which I believe might easily be done. The 
 writing would have to be upright instead of slanting, and, 
 with a pen in both hands, the left half of the line might be 
 written with the left hand and the right half with the right. 
 We educate the left hand far too little. Girls in this respect 
 are better off" than boys, for such exercises as piano-playing 
 and knitting encourage a great amount of ambidexterity in 
 
 D 
 
84 NERVOUS AFFECTIONS OF THE HAND 
 
 girls. Why should not the clerk use either hand alternately, 
 and so give to each its much-needed rest ? 
 
 What effect has the exercise of the periphery upon the 
 development of the centre ? By constantly using the left 
 hand for written language might we not possibly educate our 
 right Broca's convolution instead of letting it lie idle ? 
 
 I once gave utterance to these opinions and speculations 
 at the bedside, and at their conclusion a student of more than 
 ordinary intelligence asked me whether the extreme fluency 
 of the female organs of speech might not be due to the fact 
 that the right side of women's brains had been developed by a 
 more constant use of the left hand than is common in males 1 
 
 In support of the statements and advice above given the 
 author would quote briefly from the papers published by him 
 in the ' Transactions of the Royal Medical and Chirurgical 
 Society,' in 1878 and 1887, a few cases illustrative of the various 
 classes into which cases of writing difficulty may be divided. 
 A few of the 168 cases reported are in no sense cases of 
 ' writer's cramp,' but it was the difficulty experienced in writ- 
 ing which caused them to seek medical advice. The numbers 
 refer to the table of cases given with the original papers. 
 
 The first group of cases is characterised by definite injury 
 to one or more of the nerves supplying the arm. 
 
 1. G. E. (male), aged 65, died in University College Hos- 
 pital in 1877 from the bursting of a large axillo— subclavian 
 aneurism. The first symptom of this trouble was a difficulty 
 in writing produced by the pressure of the aneurismal tumour 
 on the nerves of the brachial plexus. 
 
 2. A banker, aged 50, who suffered from syphilitic neuritis 
 of the musculo- spiral nerve, leading ultimately to paralysis of 
 the extensors of the wrist and fingers. One of his first 
 troubles was with the act of writing. 
 
 3. A male, aged 34, in whom the median nerve above the 
 wrist had been completely divided by a pane of glass. He could 
 only write when the pen was held between the thumb and ring 
 finger, in which sensation remained, and he was obliged to 
 watch the movements of the pen intently. The median area 
 
DAMAGE TO ULNAR NERVE 35 
 
 of the hand was ansesthetic and dead white in colour, and he 
 had lost his finger nails on the fore- and mid-finger. 
 
 4. A Government clerk, aged 23, who had neuritis of the 
 ulnar nerve at the olecranon, leading to loss of motion and 
 sensation in the ulnar area. His first symptom was difficulty 
 of writing, and his recovery was complete. 
 
 6. The Rev. Mr. R consulted me in June 1875 for im- 
 paired writing power. He was a public preacher and lecturer, 
 and had suffered from nervous exhaustion. Three months 
 previously he had been disturbed at night by a pricking 
 sensation in the hand, and the next morning he wrote with 
 great difficulty. At the time of his visit there was no loss of 
 sensation in the hand, and the muscles of the little finger were 
 acting healthily. There was wasting and paralysis of the 
 interossei and adductor pollicis, and there was characteristic 
 clawing of the fingers. A diagnosis of Cruveilhier's atrophy 
 had been previously made, but the fact that the atrophied 
 muscles all gave the so-called degenerative reactions when 
 tested with electricity made it more probable that definite 
 nerve lesion was the cause of the trouble. This supposition 
 was confirmed by the discovery of a tender point in the palm 
 near the base of the fifth metacarpal bone, and the eliciting of 
 a history of a bruise at this spot sustained while moving 
 furniture. The patient completely recovered, but the act of 
 writing is still an effort. He has since suffered from sciatica 
 with consequent wasting of the calf. 
 
 6a (not in the original paper). Mrs. S , aged 35, 
 
 October 1885. Paralysis of the deep branch of the ulnar nerve, 
 causing wasting of interossei, adductor pollicis, and the flexor 
 brevis pollicis and two outer lumbricales. Sensory branch is not 
 affected. There is a very tender spot just over the origin of 
 the deep branch, and a history of damage from moving heavy 
 furniture. 
 
 6b (not in the original paper). A clergyman, aged 52, who 
 had paralysis of the deep branch of the ulnar nerve, due 
 apparently to a bruise. He had an exquisitely tender point in 
 the palm just below the pisiform bone. There was complete 
 paralysis of the interossei, but the muscles of the little fingei- 
 
 d2 
 
36 NERVOUS AFFECTIONS OF THE HAND 
 
 escaped, and there was no sensory paralysis. The case had been 
 diagnosed as ' creeping palsy,' but he made a good recovery. 
 
 This and the two preceding cases point to the importance of 
 examining the fine nerve-twigs in the palm, and to remember- 
 ing that the deep branch of the ulnar nerve in the palm is 
 purely motor, and has not sensory functions. 
 
 The next group of cases is characterised by symptoms 
 which are attributable to cerebral lesions. 
 
 Two (Cases 7 and 8) of these were instances of ordinary 
 post-hemiplegic movement. In one case (7), a married lady, 
 aged 23, the symptoms had developed subsequent to a hemi- 
 plegia which followed diphtheria when she was seven. In 
 No. 8 (male, aged 36) there was a history of a blow on the 
 head, followed by prolonged insensibility (many days). The 
 uncontrolled movements developed when he was engaged in 
 almost constant writing, and have continued now for thirty 
 years in a most extreme form. At first the right arm only was 
 affected, but latterly the unsteadiness has extended to the leg. 
 
 In Case 9, a little girl aged 10, the movements began after 
 an attack of convulsions in early infancy. This patient had 
 been taught to write with her left hand, and she produced 
 backward (mirror) writing with absolute fluency. 
 
 Case 10 was that of a university student of high intelli- 
 gence who had suffered from athetotic movements from his 
 earliest babyhood. The act of writing demanded immense 
 mental effort, and these efforts to write had apparently caused 
 a considerable extension of the spasmodic movements of the 
 right upper limb. 
 
 I think there can be no doubt that in those patients who 
 are unable to write by reason of a cerebral (motor) lesion, the 
 effort to perform an almost (to them) impossible act is fraught 
 with danger, and is likely to increase their trouble. (See case 
 of hammerman's cramp on p. 97.) 
 
 In four of these cases it was observed that certain muscles 
 of the paralysed limbs were especially wasted and degenerated. 
 Thus Cases 7 and 8 had marked wasting of the extensors 
 of the wrist and fingers ; Case 9 had wasting of the tibialis 
 
SPASM OF THE RiaHT AEM 37 
 
 anticus and peronei, and Case 10 had wasting of some of the 
 ulnar muscles of the left hand with impaired sensation over 
 the area of distribution of the ulnar nerve in the left hand. 
 In these four cases there appeared to be a paralysis within a 
 paralysis, a peripheral lesion superadded to a cerebral lesion, 
 and this fact appeared to determine the direction and form of 
 the spasm, at least to some extent, the wasted muscles not 
 being able to satisfactorily oppose their antagonists. 
 
 I have had one case (Case 11), and one only, of tumultuous 
 spasm of the right arm in which there was no satisfactory 
 evidence of any coarse cerebral lesion. 
 
 This case was very remarkable. It was the first severe 
 case of writing difficulty which I ever had under my care. I 
 am now inclined to think that it must have been due to some 
 cerebral thrombosis in the cortical area connected v/ith the 
 hand, and that it is distinctly analogous to the case of 
 hammerman's cramp recorded on page 97. Unlike the 
 other cases of this class, it proved strangely amenable to treat- 
 ment, and in that connection it is in my experience unique. 
 It was reported in the 'Practitioner' for September 1872,' 
 and the following is an abstract : 
 
 ' Case 11. — George Gair, aged 32, single, A small man, well 
 made, rather muscular, and of very healthy appearance. No 
 history whatever of any hereditary neurotic tendencies. Has 
 always enjoyed most excellent health. He has always been 
 steady, and, while able, was hard-working and industrious ; 
 has never had syphilis. He is a well-educated and very 
 intelligent man. He left school when fourteen years old and 
 became a writing clerk in a commercial house in the City. He 
 wrote an excellent hand, and gained rapid promotion in his 
 office. In the year 1859 he left his situation and entered an 
 accountant's office, where he did, on an average, nine hours' 
 writing a day. By reason of his neat style of wi'iting he was 
 constantly employed in copying balance-sheets. In this situ- 
 ation, in which he remained for fifteen months, he earned five 
 pounds a week, and there can be no doubt that the amount of 
 writing which he was called upon to do was something pro- 
 digious. He left his situation because of his present illness 
 
38 NERVOUS AFFECTIONS OF THE HAND 
 
 which came on almost without warning of any kind. He had 
 been working as well as ever, when one day, towards the 
 close of his day's work, he says, " he had a difficulty in bringing 
 his right hand down upon the paper." He managed, however, 
 for that day and for the three following days to continue his 
 writing by holding his right wrist firmly on the desk with his 
 left hand. At the expiration of three days he found himself 
 wholly incapable of accomplishing the neat work required of 
 him, and he had to leave his employment. 
 
 ' For about a month subsequently he managed to write a 
 few letters by steadying the palm of his hand against the edge 
 of the desk and only using his lingers. Between that date 
 (October 1862) and January 1872 he has been totally unable 
 to accomplish any writing at all with his right hand. He 
 gradually acquired the art of writing with his left hand, and 
 what writing he has absolutely been required to do has been 
 accomplished in this way. During last year, however, the 
 left hand began to suffer from cramps, and ultimately became 
 as stubborn as the right. His means of subsistence being 
 taken from him, he was obliged to live upon his savings, 
 which were considerable ; but his store of money gradually 
 diminished ; and about the middle of last year he began to 
 experience real want and to be filled with apprehension for 
 the future. 
 
 ' About this time, and probably as an effect of his straitened 
 circum- stances and anxiety of mind, his right hand, which 
 hitherto had refused to write only, began to be affected with 
 spasms at other times. He gradually had lost the power of 
 using his knife at dinner, and occasionally he found himself 
 unable to accomplish the most ordinary acts by reason of 
 sudden spasms of the muscles of his right arm. Shortly 
 before I saw him he had broken the jug belonging to his wash- 
 hand basin, in consequence of a sudden spasm just as he was 
 about to pour out some water. 
 
 ' During the six weeks previous to his coming under my ob- 
 servatif)n there had been a further exacerbation of his condition, 
 and the right arm had become liable to sudden spasms even 
 when not called upon to perform any act. It was the seat of 
 
SPASM OF THE RIGHT ARM 39 
 
 an exaggerated local chorea ; it was always jerking about, and 
 at times would bounce out of the side pocket of his coat as he 
 was walking in the streets. These strange antics naturally 
 attracted attention, and immediately the patient saw that he 
 was observed the spasms became doubly severe. In January 
 of this year he came under my notice at the out-patient 
 department of the Charing Cross Hospital, and the following 
 account of his then condition is taken verbatim from my note- 
 book : " On asking him to strip him.self to the waist, he does 
 so without difficulty. There is no evident impairment of the 
 nutrition of the muscles of his right arm. The right arm hangs 
 by his side and is subject to constant twitchings. The deltoid, 
 the pectoralis major, the scapular muscles, as well as the biceps 
 and triceps, are all affected ; but the last-named muscle is the 
 worst offender, and in it the cramps are more constant and 
 more severe than elsewhere. While I am talking to him the 
 arm is forcibly extended, and the triceps is as tense and hard 
 as a board. The fingers and wrist are often flexed, but never 
 extended. The thumb and fingers do not seem liable to spasms 
 individually. At times the spasms subside for a few moments, 
 but any allusion to them seems to bring them back." [This 
 apparently was due to nervousness, and was exactly analogous 
 to the extra difficulties experienced by a stammerer when 
 attention is called to his defective speech.] " On being requested 
 to perform any act, the right arm 'jibs,' as it were, like a 
 stubborn mule, and it is only by main force and by the greatest 
 concentration of thought and determination that the most 
 simple things can be accomplished. Everything is done with 
 the arm extended. On being asked to unlock a box which 
 lay on the table the arm was stiffly extended, and the patient, 
 standing of course at arm's length from the box, managed with 
 great difficulty to unlock it. 
 
 '"Of all acts, writing occasions the greatest amount of spasm. 
 On asking him to write his name, he takes the pen in hand, 
 and immediately he does so there is a violent cramp of the 
 triceps ; the arm is forcibly extended, and with great difficulty 
 he manages to write ' Geor ' in a manner scarcely legible, when 
 the hand is twisted off the paper by a violent rotation of the 
 
40 NERVOUS AFFECTIONS OF THE HAND 
 
 wrist, and his fingers lose the grasp of the pen. On asking 
 him to continue writing, he is perfectly unable to do so, and 
 every effort even to place his hand on the paper seems to be 
 violently resisted by every muscle from the deltoid downwards. 
 ' " The spasms of the arm never come on during sleep. He 
 states, however, that latterly, owing to mental worry, he has 
 slept very badly." 
 
 ' The published cases of " writer's cramp " and the articles 
 upon the subject in our text-books gave one very little hope of 
 bringing about any improvement ; but as such cases are of a 
 peculiarly interesting nature, I resolved to try every therapeutic 
 agent which seemed in any way applicable. First, small doses 
 of strychnine were given, but as the patient said very decidedly 
 that the medicine made him worse they were soon discontinued. 
 ' Mental irritation and distress and sleeplessness being marked 
 features, bromide of potassium was given and with excellent 
 results, for it procured good nights' rest, and seemed to diminish 
 a little the spontaneous spasm of the arm. This seemed to be 
 due to his paying less attention to his condition. His power 
 of writing showed no improvement after the bromide alone ; 
 but in consequence of the sleep and mental ease which it 
 seems to give it has been continued in doses of fifteen grains 
 three times a day throughout his whole course of treatment. 
 
 ' From the very first rest was enjoined. In order to make 
 quite certain that the arm could be used for nothing at all, I 
 first attempted to put the whole of the arm in an immovable 
 apparatus of plaster of Paris, but this did not succeed, for the 
 spasms were so violent and constant that it was impossible to 
 get the plaster to "set'' properly, and very soon the rough ridges 
 which formed in the bandage began to bruise the arm. The 
 plaster of Paris was therefore removed within forty-eight hours 
 of its application, and the patient was merely ordered to keep 
 his arm in a sling. To this he adhered rigidly for two months 
 or so, and then, the general spasm having much diminished, he 
 was allowed gradually to use his arm more and more, and at 
 the present time he is allowed to use it as much as he likes for 
 every purpose except that of writing, 
 
 ' I first saw the patient on January 20, and for the first 
 
SPASM OF THE EIGHT AEM 41 
 
 three weeks the above methods of treatment were alone em- 
 ployed. 
 
 ' On February 8, in addition to the bromide of potassium 
 ^nd rest in a sling, I commenced the use of the continuous 
 galvanic current. At this date he had improved somewhat in 
 so far as his condition bothered him less, and he always slept 
 soundly at nights. The general spasms of his arm were still as 
 bad as ever, and his inability to write had not in the least 
 abated. The improvement in his mental condition, which 
 served as it were as a solid foundation for his further treat- 
 ment, was due, in my opinion, entirely to the bromide of 
 potassium, which he still continues to take. 
 
 ' The galvanic current was used in a peculiar way, and, as a 
 reference to the accompanying facsimiles of the patient's hand- 
 writing will show, with the best results. 
 
 ' One of Weiss's continuous current batteries was employed, 
 and twenty-three cells were used to begin with. The sponges, 
 being well wetted with salt and water, were first placed on 
 either side of the belly of the deltoid muscle (which at the 
 time was the seat of almost continuous spasm). The spasm 
 immediately subsided, and then the man was made to exercise 
 his deltoid while I counted " one, two," " one, two," like a drill 
 sergeant, every time he elevated or depressed his arm, the 
 patient keeping time to the counting. 
 
 ' Other muscles were then exercised in the same way — the 
 pectoralis major, biceps, triceps, pronators, supinators, and the 
 flexors and extensors of the wrist and fingers, care being 
 taken not to overtire the muscles. Every possible kind of 
 rhythmical exercise has been gone through. The pectorals 
 have been exercised by practising "extension movements" and 
 drawing back the shoulders, and the fingers and thumb have 
 been also drilled by opposing the thumb to every finger in 
 turn, and by making him run along the mantelpiece or the 
 table with his fingers as if playing the piano. It is unnecessary 
 to detail the way in which the galvanic current was employed 
 for every muscle or group of muscles, but the samples quoted 
 will serve to show the principle. The good effects of this 
 plan of treatment were soon manifested. It was commenced 
 
42 NERVOUS AFFECTIONS OF THE HAND 
 
 on February 8. On the 9th the patient stated that "his 
 arm had been remarkably quiet since the electricity yester- 
 day " ; and on the 11th he said that he had already derived 
 so much benefit that his arm was no longer a nuisance to him, 
 but, on the contrary, he was able to use it for dressing him- 
 self ; and on the 12th he buttoned his collar, which he had 
 not done for months before. A reference to the lithographed 
 facsimiles of his handwriting will show that this too began 
 to improve in a most remarkable way. The galvanism and 
 rhythmical exercise has been continued every day without 
 intermission from February to the present time, and the 
 patient still continues to make gradual and marked improve- 
 ment. He can now accomplish everything, except writing, 
 with perfect ease, and even the power of writing has improved 
 in a very great degree. He has written me two or three 
 letters, and has been able to embark in a small business. 
 When he writes, he says, he feels like a schoolboy beginning 
 to learn, and the act of writing is gradually becoming more 
 easy to him. The great bar to his writing hitherto has been 
 the triceps muscle, which, till recently, has taken on a spas- 
 modic action whenever he has taken a pen in his hand ; and 
 all his writing has been hitherto accomplished with the arm 
 forcibly extended. This condition of the triceps is being 
 gradually overcome, and the eighth sample of handwriting 
 was written " with the greatest ease, and with the arm 
 bent." 
 
 ' In addition to the galvanism he has had a daily hypo- 
 dermic injection of morphia (gr. ^). I do not think that this 
 was of any decided benefit to him. It has been discontinued 
 now for the past six weeks, and his improvement has been, I 
 think, more rapid since. At the beginning of June the 
 galvanism was discontinued for a fortnight while the battery 
 was under repair, and it was gratifying to find that during 
 this time he suffered no retrogression. 
 
 ' 1 append the dates and a few remarks concerning some of 
 the specimens of handwriting. 
 
 ' 1. Written on January 20, 1872, before the adoption of 
 any treatment. 
 
s 
 
 
 
oa 
 
 4:^|^f^;t.^> 
 
 ^^ ^ ^^^>^ 
 
 e ^ 
 
 ^^^ 
 
 
 l~ 
 
 -^4 
 
 ^ 
 
POST-HEMIPLEGIC CASES J:3 
 
 ' 2. Written on February 8, after first use of the galvanic 
 
 current. 
 ' 3. Written on February 9. The word " Gair " was written 
 
 while the sponges were held on the front and back 
 
 of his forearm. 
 ' 4. February 14. 
 ' 5. Middle of March. 
 ' 6. April 19. 
 * 7. July 6. 
 ' 8. July 25. Written with the arm bent and " with the 
 
 greatest ease." 
 ' 9. July 31.' 
 
 In a large number of cases the unsteadiness in writing 
 appeared to be the dregs, as it were, of a long antecedent and 
 perhaps forgotten hemiplegia, or else marked the commence- 
 ment of degenerative changes in the cerebral cortex. 
 
 None of these cases were coarsely hemiplegic, and in all 
 the evidence of previous cerebral paralysis had to be carefully 
 searched for. An attack of hemiplegia, even though it be 
 slight and occur no matter how early in life, always, I believe, 
 leaves its mark. Patients are often said to ' recover ' from 
 attacks of right hemiplegia, and are able to follow their 
 occupations without apparent difficulty. It is, however, in 
 the performance of a delicate muscular act such as writing, 
 which requires a maximum amount of steadiness and firmness, 
 that the previous cerebral damage asserts itself. The writing 
 is shaky or slowly executed, or executed with a certain sense 
 of difficulty. 
 
 In elderly people who come complaining of writing with 
 difficulty the evidence of slight hemiplegia must always be 
 looked for. Persons also who state that ' they have always 
 had a difficulty in writing ' must be examined carefully for 
 evidence of hemiplegia, a trouble which is by no means 
 uncommon in early life, but which, I believe, is often not 
 suspected, because the movements of an infant are too little 
 specialised to enable defects to be noticed. 
 
 When I speak of ' hemiplegia,' a term which it i^ con- 
 
44 NERVOUS AFFECTIONS OF THE HAND 
 
 venient to use, it must be understood that I include under it 
 such a condition as brachial monoplegia from cortical lesion. 
 
 Among the cerebral cases are included three of congenital 
 left-handedness, because I believe this defect to be often due to 
 lesion or anomaly of the left cerebral hemisphere. Of these cases 
 only one wrote with his left hand, which he did fluently, and 
 gave a normal slope to his letters. He was left-handed for 
 fine work (writing, playing flute, and violin) and right-handed 
 for coarse work (hammer, knife, cricket). The left hand and 
 foot were bigger than the right, and the left boot was the 
 first to wear out. Both this patient and another had injured 
 the left arm (dislocation of shoulder and fracture of arm) in 
 early life, but this had not cured the left-handedness. In two 
 cases the right clavicle was shorter than the left. In these 
 cases of congenital left-handedness, it is, I think, to be 
 regretted that the patients were not taught from the first to 
 use their left hands for writing. 
 
 I have seen so many cases of writing difficulty in left- 
 handed subjects that I now look for left-handedness as a 
 matter of routine. 
 
 Case 11a (not in the original paper). Mr. E. J. H., a clerk, 
 aged 43, who was rather fat, flabby, and tremulous, and probably 
 took too much alcohol, consulted me in February 1896. I found 
 that he was absolutely left-handed for cricket and left-footed 
 for football. He even dealt cards with his left hand. I told 
 him to give up alcohol and to practise left-handed penmanship. 
 In a fortnight he had learnt to produce most beautiful writing 
 (true left-handed caligraphy). In April he returned to his office 
 and did all his work with the left hand, and said that instead 
 of being the zvorst he had become the best writer in his office. 
 
 I last saw him in November 1896, and he was still work- 
 ing admirably and rightly regarded himself as the champion 
 left-hand writer. The writing is certainly marvellously good. 
 
 A very large number of my patients have been found to 
 be suffering from chronic degenerative changes of the spinal 
 cord or brain, and I have often found that their 'writer's 
 cramp ' was merely an early symptom of general ^:)ara/^2/6'i5, 
 
NEUKO-MUSCULAE CASES 45 
 
 lateral sclerosis^ posterior sclerosis, ^^ro^ressive muscular atrophy y 
 disseminated sclerosis, or paralysis agitans. 
 
 Of the 168 cases which I reported to the Royal Medical 
 and Chirurgical Society no less than 117 were not to be 
 classified under any of the previous, headings, and I accord- 
 ingly grouped them together and called them the 
 
 NEUROMUSCULAR GROUP. 
 
 The most important objective symptoms observed in this 
 group were (in addition to writing difficulty) — 
 
 (a) Tenderness of one or other of the nerves of the arm. 
 
 (h) Changed faradic irritability of muscles. 
 
 (c) Tremor. 
 
 The presence of nerve-tenderness is frequently recorded. 
 
 As to the pathological significance of nerve-tenderness I 
 shall have something to say hereafter. 
 
 In my first series of cases nerve-tenderness was not 
 systematically looked for, but out of the 66 cases of the 
 second series which fall into the neuro-muscular group, there 
 were 13 in which nerve-tenderness existed apart from change 
 of muscular irritability, 21 in which change of muscular 
 irritability existed without nerve -tenderness, 32 in which 
 these symptoms concurred. 
 
 The neuro-muscular group is thus divisible into three sub- 
 groups. 
 
 Sub-Group a. — Nerve-tenderness without change in 
 muscular irritability (13 cases). 
 
 In 12 the right median nerve was tender. 
 
 In 1 both medians were tender^ in 1 all the nerve- trunks 
 were tender, in 1 the musculo-spiral and median were tender, 
 and in 1 the nerve -tenderness was very doubtful. 
 
 Seven cases suffered from gout, rheumatism, dyspepsia, or 
 alcoholism. 
 
 Four cases had tremor. 
 
 Three are noted as being crippled in acts other than 
 writing. 
 
 The previous duration of the trouble in this group was. 
 
46 NERVOUS AFFECTIONS OF THE HAND 
 
 relatively not lon,£j. In the 9 cases in which this fact is 
 recorded these periods were eighteen months, thirteen 
 months, twelve months, nine months, six months, ' two or 
 three months,' ' some weeks,' ' a few weeks,' one month. 
 
 Sub-Group B. — Cliange of muscular irritability without 
 nerve -tenderness (21 cases). 
 
 By change in muscular irritability is meant merely a 
 change in the irritability to faradism, tested by a comparison 
 of the effects of equal currents applied to corresponding 
 muscles in either hand or arm. 
 
 The hands are placed symmetrically and at absolute rest 
 (usually hanging over the back of a chair). One rheophore is 
 then fixed to the nape of the neck, while the other (a rheo- 
 phore of small surface) is applied delicately to the muscles 
 which it is wished to test. Having determined the least 
 strength of current which will cause the contraction of a 
 muscle (and I usually begin with the first dorsal interosseous) 
 on the left (and presumably healthy) side, the same current is 
 then applied to the corresponding muscle on the right side, 
 and any difference in the effect is noted. When it is stated 
 that the muscular irritability is depressed or heightened, it 
 means that the muscle responds to the current less readily or 
 more readily than the same muscle on the left side. 
 
 To detect the differences requires some care, but not more 
 care than is required to detect the alterations of tone observed 
 in the eye- muscles in cases of diplopia. 
 
 Each of these 21 cases had muscles manifesting a decrease of 
 irritability. In 3 there were muscles manifesting an increase 
 of irritability alongside of others which showed a deficiency. 
 
 The first right dorsal interosseous (1st R. D. I.) was aftected 
 thirteen times. 
 
 The abductor and opponens poUicis eight times. 
 
 The second right dorsal interosseous six times. 
 
 The fourth right dorsal interosseous and flexor longus pol- 
 licis were affected twice, the third dorsal and fourth palmar 
 interosseous each once, and the extensors of the thumb and 
 small muscles of the little finger each once. 
 
NET] RO- MUSCULAR CASES 47 
 
 In 8 cases there was trouble (pain, enlargement, creak- 
 ing) in one or other of the joints, and in a ninth there was a 
 family history of rheumatic gout. 
 
 In 11 cases there was tremor. 
 
 Four are noted as being crippled in acts other than writing. 
 
 In 18 cases the previous duration was noted, and it will 
 be observed that it is longer than in the previous group, in 
 which no change in muscular irritability was detected. Thus 
 we have recorded periods of fifteen years, thirteen years, ' many 
 years,' 'some years,' 'years,' six years, six years, three years, 
 three years, fourteen months, 'some months,' one year, 'a few 
 months,' four months, two months, two months, one month. 
 
 Sub-Group C. — Nerve-tenderness mul change of musculcir 
 irritability combined (32 cases). 
 
 Kerve-tenderness occurred in the median only in 28 cases, 
 the ulnar only in 2 cases, and in the median and musculo- 
 spiral combined in 2 cases. 
 
 As regards muscular irritability, decrease only occurred 
 in 20 cases, increase only in 8, and a combination of the two 
 conditions in 4. ^ 
 
 As regards the muscles affected, we have : 
 
 The first right dorsal interosseous affected nineteen times. 
 
 Other interossei seven times. 
 
 Abductor and opponens pollicis seven times. 
 
 Extensors of thumb four times. 
 
 Flexor brevis pollicis three times. 
 
 Flexor longus pollicis twice. 
 
 All the muscles of the hand three times, and supinator 
 longus, supinator brevis, serratus magnus, and pectoralis major 
 each once. 
 
 In 2 cases there was a history of sprain of the wrist, and 
 one had had his right hand smashed in a mangle twelve years 
 previously. \ 
 
 Creaking of the right shoulder occurred in 3 cases, 9 are 
 noted as being dyspeptic, gouty, or alcoholic. 
 
 Tremor was noted in 18 cases. 
 
 In 1 1 cases there was disability in acts other than writing. 
 
48 NERVOUS AFFECTIONS OF THE HAND 
 
 The previous duration was for the most part considerable^ 
 in only three cases was it less than a year. 
 
 In the whole 66 cases of the neuro-muscular group the 
 previous duration was less than a year in 11, or 16*6 per cent. 
 
 In sub-group A the previous duration was less than a year 
 in 6, or 46 per cent. 
 
 In sub-group B the previous duration was less than a year 
 in 5, or nearly 24 per cent., and 
 
 In sub-group C the previous duration was under a year in 
 3, or 9 '4 per cent. 
 
 It is dangerous to form conclusions on averages of small 
 numbers, but these figures point in the direction that some 
 time is, as a rule, necessary for the production of change in 
 muscular irritability. 
 
 In the whole series of cases in both papers we find that of 
 the muscles whose irritability was found altered : 
 
 The interossei were affected seventy-nine times. 
 
 Abductor and opponens poUicis twenty-eight times. 
 
 Extensors of thumb twenty -three times. 
 
 Flexors of thumb thirty-two times. 
 
 Muscles of little finger nine times. 
 
 And other muscles only rarely and exceptionally. 
 
 In the second series of 93 cases nerve- tenderness (N. T.) 
 was noted fifty times, and in the subjoined table its distribu- 
 tion in the groups and its association or otherwise with altered 
 muscular irritability (A. M. I.) is shown. 
 
 N.T. only. A.M.I, only. 
 
 Paralytic (13 cases) ..4.4 
 Degenerative (14 cases) .0.3 
 Neuro-muscular (60 cases) .13 .21 
 
 Total cases (93) . . .17 .28 .33 .15 
 
 Of the 50 cases in which nerve-tenderness was noted it is 
 to be observed that in all but 8 it occurred in the median 
 nerve. I wish to call particular attention to the fact that 
 the muscles in which change of irritability has been most 
 frequently noted (the interossei) are supplied by the ulnar 
 nerve. 
 
 N.T. + 
 
 Neither N.T. 
 
 A.M.I. 
 
 nor A.M.I. 
 
 1 
 
 4 
 
 
 
 11 
 
 32 
 
 
 
ALTEEED MUSCULAR lEEITABlLITY 49 
 
 What is the pathological significance of altered muscular 
 irritability 1 
 
 We have seen it occurring in every group, cerebral, 
 degenerative, and neuro-muscular, so that it has no absolute 
 value for localising the writing trouble in the brain, cord, 
 nerve, or muscle. 
 
 It is probably due to some change in the muscle or intra- 
 muscular nerves, and it seems probable also that such change 
 may be primary, or secondary to a lesion in brain, cord, or 
 nerve. 
 
 These cases are strongly confirmatory of the fact that de- 
 pressed muscular irritability in cases of ' writer's cramp ' is 
 observed more often in the muscles of 2^en-prehension than in 
 those of pen-move7nent, i.e. in muscles which are subjected to 
 very prolonged contraction, and therefore very liable to get 
 over-fatigued. 
 
 It is possible that fatigue in a muscle is produced with 
 undue readiness when the voluntary motor stimulus is 
 impeded at any point. The man with cerebral paresis is 
 very conscious of muscular effort when he tries to write, and 
 the same is true of patients in whom the conducting power 
 of the nerves is interrupted by inflammation, congestion, or 
 pressure. 
 
 The following case is very instructive on this point. It 
 is that of a boy, aged twelve, in whom a congenital fracture 
 of the clavicle had caused pressure on the brachial plexus. 
 The case was brought before the Clinical Society by Mr. 
 Barker. The boy had peculiar trouble in writing, so that the 
 case had been spoken of as one of writer's cramp. In this 
 case there was very slight but quite obvious wasting (or non- 
 development) of the pectoralis major and the muscles of the 
 right arm and hand. The electric irritability was, however, 
 normal in all the muscles except the first right dorsal inter- 
 osseous, in which the irritability was depressed. The patient 
 was a lad of unusual intelligence, and had worked hard at his 
 writing lessons, which caused him fatigue and pain. It would 
 seem as though the pressure on the plexus had necessitated 
 increased effort, and had predisposed to the fatigue of the 
 
 E 
 
50 NERVOUS AFFECTIONS OF THE HAND 
 
 muscles of pen-prehension and the lessening of the electric 
 irritability in at least one of them, and that probably the 
 most important. The pressure on the nerves of the brachial 
 plexus was relieved by operation, and some weeks later I saw 
 the boy writing without difficulty, and I found on examination 
 that the depressed irritability of the first right dorsal inter- 
 osseous no longer existed. It must be remembered that not 
 only had the pressure been removed, but the boy had had a 
 prolonged period of rest. 
 
 Occasionally the irritability of one or more muscles has 
 been found exalted. The reason of this is doubtful. Oc- 
 casionally I have found a muscle suj^plied hy a tender nerve 
 manifesting exalted irritability, but this is by no means invari- 
 able. I feel sure that the practice of massage increases the 
 irritability of muscles. 
 
 It must be remembered that change in the irritability is 
 judged by no fixed standard, but only by comparison with the 
 opposite limb, so that we are always liable to the fallacy that 
 a relative change may not really mean an absolute change 
 from the physiological normal. For example, when we find 
 the right first dorsal interosseous more irritable than the left, 
 this fact may really be due to an abnormal depression in the 
 irritability of the left first dorsal interosseous. 
 
 It must be remembered also that a muscle which manifests 
 excess of irritability is not necessarily more efficient than the 
 corresponding muscle of the opposite limb. Some authors 
 have spoken of a condition of ' irritable weakness,' a condition 
 which is probably a fact. Not only have the muscles shown 
 great difierences in their readiness to respond to equal electric 
 currents, but their mode of contraction has often been ob- 
 viously different to the eye, the muscle which is presumably 
 healthy contracting forcibly and moving its point of insertion 
 vigorously, while the muscle which shows deficiency of irrita- 
 bility contracts in a hesitating, jerky, and unsatisfactory 
 manner. 
 
 The feeling of contraction (under electric stimulation) is 
 often very different on the two sides — at least, this is what 
 patients say ; but the fact has not been systematically recorded 
 
NEEVE-TENDEKNESS 51 
 
 because of the great difi&culty of making a satisfactory record 
 of such a fact. 
 
 For the same reason the record of cutaneous sensibility 
 has not been systematically made, although, to judge from 
 expressions used by patients, change has frequently been 
 present. 
 
 What is the pathological significance of nerve-tenderness ? 
 It is recorded fifty times in the second series of ninety-three 
 cases, viz. forty-five times in the neuro-muscular group, five 
 times in the paralytic group, and not at all in the degenerative 
 group. The conditions under which nerve-tenderness occur are 
 very varied. 
 
 It isoftenest and best observed in neuralgia of the fifth nerve. 
 Whether the neuralgia be definitely due to central change or 
 peripheral irritation or constitutional cause, we often find every 
 accessible branch of the nerve more or less tender on pressure, 
 and the tenderness, marked during a paroxysm, is absent or 
 scarcely noticeable in the intervals between the attacks. 
 
 In paralysis of the facial from exposure to cold we usually 
 find the trunk of this purely motor nerve more or less tender 
 at its point of emergence from the stylo-mastoid foramen. 
 
 In ' sciatica ' every accessible branch of the nerve is often 
 tender, and even when the sciatica is due to intra-pelvic irri- 
 tation we find tenderness of the ultimate branches, notwith- 
 standing that the source of trouble may be nearly a yard 
 distant from some of the tender twigs. 
 
 I have noticed great nerve- tenderness in cases of lead 
 palsy and in cases of muscular atrophy, but without any other 
 evidence of neuritis. 
 
 In true neuritis of a mixed nerve we find not only nerve- 
 tenderness, but changes in sensibility, neuralgia, causalgia, 
 trophic change, muscle wasting, and often distinct evidence 
 of swelling of the nerve involved. 
 
 In chronic rheumatic conditions and in gout the nerve - 
 trunks are often tender, and this without any good evidence 
 that they are irritated by thickenings or bony outgrowths. 
 
 Nerve-tenderness may certainly be produced by excessive 
 muscular exertion. I have seen such a condition in laun- 
 
 E 2 
 
52 NERVOUS AFFECTIONS OF THE HAND 
 
 dresses, who state that they have strained the arm from 
 wringing clothes, and also in men who have made excessive 
 muscular effort, and notably in one gentleman whose musculo- 
 spiral nerve had become excessively tender from prolonged 
 use of a heavy fishing-rod. 
 
 In some of my cases the nerve-tenderness was associated 
 with dyspepsia and alcoholism, 
 
 Mr. Barker's case may be again alluded to. In this 
 patient all the nerve-trunks of the arm were very tender 
 before the removal of the pressure on the brachial plexus, 
 but after the successful operation this tenderness quickly dis- 
 appeared. 
 
 From this resume it appears, therefore, that nerve-tender- 
 ness may, in regard to its cause, be 
 
 1. Functional (neuralgia). 
 
 2. Central. 
 
 3. Peripheral. 
 
 4. Due to cold. 
 
 5. Due to rheumatism. 
 
 6. Due to inflammation (neuritis). 
 
 7. Due to muscular exertion. 
 
 8. Toxic (lead, alcohol, gout). 
 
 In my cases of impaired writing power the median nerve 
 has most often been found to be tender. Muscular failure is 
 most often evident in the muscles of pen-prehension, and 
 notably in the interossei. When these small muscles of 
 pen-prehension fail, bigger muscles (such as the superficial 
 and deep flexor of the fingers and the long flexor of the 
 thumb) take their place, and I believe that the tenderness 
 of the median nerve is dependent upon the over-use of these 
 (median) muscles. 
 
 In the early days of these cases it is possible that one 
 or more of the deep branches of the ulnar nerve may have 
 been tender in association with over-use of ulnar muscles, 
 but this, of course, is only a surmise. 
 
 No thickening of any nerve- trunk was detected in these 
 cases. 
 
 Trophic lesions were not common. In Mr. Barker's case 
 
TEEMOR AND SPASM 53 
 
 the nails of the affected hand grew slowly. No. 78 was 
 troubled by coldness and blueness of the hand. No. 102 had 
 a congenital brown mark on the inner side of the right arm. 
 No. 128 had pitting of the right finger nails. No. 130 had a 
 crop of moles on the right arm and a lichenous rash on the 
 right forearm. No. 144 had brittleness and furrowing of the 
 right thumb nail, and No. 149 had throbbing of the thumb 
 after writing. 
 
 ' Goutj' ' rheumatism,' and creaking and thickening of 
 joints were tolerably common. 
 
 Tremor was a very common symptom, and is recorded in 
 87 out of the total of 168 cases. It is a symptom of varied 
 significance, and appears to be liable to occur with defects at 
 any part of the motor path. 
 
 In some few instances the tremor was of very limited 
 extent. No. 121 had tremor of the thumb only, accompanied 
 by slight wasting of the abductor and opponens pollicis. 
 No. 122 had tremor of the middle finger only. No. 150 had 
 tremor of the far-phalanx of the thumb only, and in this case 
 there was deficient irritability of the extensors of the thumb 
 as well as of the abductor and opponens. No. 160 had 
 tremor of the thumb from a similar cause. 
 
 Tremor of limited area may thus point to the fact that 
 the muscles moving the joints about which the tremor occurs 
 are especially affected. 
 
 Obvious sioasm was rare. No. 82 had slight athetotic 
 movements, but, as a rule, it was hardly possible to say, 
 from merely watching the act of writing, why the writing 
 failed. 
 
 There were some exceptions to this rule, however, and 
 these were instructive. 
 
 No. 76 suffered from extreme flexion of the far-phalanx of 
 the thumb associated with paralysis of the extensor of that 
 phalanx. 
 
 No. 117 suffered from a collapsing of the phalangeal joint 
 of the thumb and rotation towards the index, associated 
 with weakness of the extensor primi internodii and abductor 
 and opponens. 
 
54 NERVOUS AFFECTIONS OF THE HAND 
 
 No. 127 (like 76) suffered from flexion of the far-phalanx 
 of the thumb associated with weakness of the extensor. Nos. 
 140 and 144 were very similar cases. 
 
 In Nos. 129, 131, 139, and 140 there was inability to keep 
 the forefinger on the pen, associated with weakness of the 
 first right dorsal interosseous. 
 
 No. 156 did not use his thumb while writing, and in this 
 case there was weakness of the flexor brevis pollicis and 
 tremor of the thumb. 
 
 In No. 163 the phalangeal joint of the thumb collapsed, 
 and it was noticed that faradisation of the flexor longus 
 pollicis caused tremor of the thumb. 
 
 When writing is made impossible by some decided and 
 recurring spasmodic action we may expect to find either 
 deficient irritability in the muscles which normally antagonise, 
 or excess of irritability in the muscles which normally produce 
 such movement. 
 
 More than a quarter of my total cases of impaired writing 
 power have been due apparently to recognised morbid states 
 of the brain and spinal cord, and it must be borne in mind 
 that the act of writing — an act which requires at once so 
 much delicacy and firmness — would certainly afibrd evidence 
 of slight changes in the nerve-centres, of changes so slight as 
 not to be likely to materially interfere with the performance 
 of coarser and less sustained muscular exercises. 
 
 The majority of the cases seem to have been produced 
 by what I have ventured to call 'chronic fatigue' of the 
 muscles. 
 
 Since Fatigue is by no means an uncommon cause of 
 disease, it will be well in this place to make some general 
 remarks on the subject. 
 
 Work results in fatigue, and fatigue is a regular and 
 constantly returning symptom experienced by all of us. 
 Periods of functional activity invariably alternate with 
 periods of repose, during which the waste caused by the 
 exercise of function is repaired. We are indebted to Sir 
 James Paget for having pointed out in his Croonian Lecture, 
 delivered some years since before the Royal Society, that 
 
FATIGUE 55 
 
 * rhythmic nutrition ' is a law of nature ; but, although the 
 truth of this dogma is recognised on all hands, and may be 
 said to be axiomatic, it has hardly received that careful 
 consideration at the hands of practical physicians which it 
 deserves. 
 
 Our whole life consists of a series of vibrations — periods 
 cf tension alternating with periods of relaxation ; and, 
 although the rapidity of these vibrations varies immensely, 
 they are recognisable in all our acts, be they voluntary or 
 involuntary. Let us look first to the ' vibrations ' of an 
 organ the movements of which are placed entirely beyond 
 our own control — the heart. Now, the rate of vibration of 
 the heart is 72 per minute, and if the total period of each 
 vibration be divided into ten parts it will be found that 
 four of these parts are devoted to the process known as 
 systole, which may be looked upon as labour ; three are 
 occupied by the diastole, which, although hardly labour, is 
 nevertheless exercise of function ; and the remaining three 
 parts are occupied by the ]?ause, during which the heart ap- 
 parently enjoys absolute rest from any exercise of function, 
 and may be considered to be in a condition analogous to sleep. 
 May we not apply the rate of action of this organ, which has 
 been regulated for us, to our voluntary acts, and may not the 
 heart be made to give the key-note, as it were, to many ques- 
 tions, personal and social ? If we divide the day of twenty- 
 four hours into ten equal parts, and give four of these to active 
 work, three to functional exercise of other kinds, and three to 
 sleep, we shall find that nine and a half hours' work, seven 
 and a quarter hours' ' relaxation,' and seven and a quarter 
 hours' sleep is what a normal man may, and, as a rule, does, 
 perform without injury to himself. 
 
 To continue with the consideration of our ' vital vibra- 
 tions,' we may remark that it is universally ordained among 
 civilised nations that once in every seven days there shall be 
 a remission of labour and a change of occupation ; and we 
 further recognise the fact that it is highly advisable for those 
 who are occupied in monotonous pursuits to break away from 
 them at least once a year and indulge in that variety of 
 
56 NERVOUS AFFECTIONS OF THE HAND 
 
 work which we call amusement. Monotonous repetitions of 
 the same act are acknowledged, on all hands, to be the most 
 potent causes of fatigue. 
 
 Fatigue occurs directly we attempt to alter the rhythm of 
 our vital vibrations by prolonging the periods of tension at the 
 expense of the periods of relaxation, or by demanding for any 
 length of time a quickening of the normal rate of vibration; 
 and it is not unreasonable to suppose that every organ of the 
 body has its ' normal rate of vibration,' if we could only 
 determine what it is. 
 
 We recognise the fact that athletes who ' over-train ' run 
 risks of cardiac troubles and loss of wind ; that the man who 
 from any cause is unable to sleep runs a serious risk of 
 permanent impairment of health ; and when we find patients 
 pursuing their avocations too zealously we know that, if such 
 offence against the laws of nature be persisted in, general 
 paralysis or other form of ' break-down ' is likely to be the 
 result. 
 
 Fatigue may he general or local, and both forms may he 
 either acute or chronic. 
 
 That fatigue in all its forms is due to impaired nutrition 
 there can be little doubt, and we shall find that the symptoms 
 of chronic fatigue are often the prelude of definite and recog- 
 nisable degenerative changes. 
 
 As to general fatigue, it is recognisable with care both in its 
 acute and chronic forms. There is a disability for performing 
 either mental or physical work, and this disability is noticed 
 first in work requiring attention and sustained efibrt, and, 
 lastly, in those acts which have become automatic. The 
 symptoms of general fatigue are referable usually to the brain 
 and nervous system. 
 
 As to local fatigue, this, again, may be acute or chronic, 
 and the symptoms of it are referable usually to the muscles ; 
 but we must always bear in mind that muscle and motor 
 nerve are one and indivisible, and that recent experiments 
 have given great probability to the idea that every muscle 
 is connected with a certain definite spot in the brain. When, 
 therefore, we speak of a sense of fatigue we must necessarily 
 
LOCAL FATIGUE 57 
 
 be in doubt, notwithstanding the fact that the symptoms are 
 referred to the muscle, whether brain, nerve, or muscle, one 
 or all of them, be really at fault. The symptoms of acute 
 local fatigue are (1) loss of power to a greater or less extent. 
 By too frequent or too prolonged stimulation the irrita- 
 bility of muscular tissue becomes exhausted, and it either 
 refuses to respond or responds but feebly to the stimulus 
 of the will ; our power of adjusting the force of contraction 
 to the act to be accomplished is lessened, and accuracy of 
 movement and delicacy of co-ordination become impossible. 
 (2) Tremor is a symptom of acute local fatigue which 
 everyone who has been called upon for extraordinary muscular 
 effort must have experienced. (3) Cramp-like contraction 
 is the symptom of local fatigue which disturbs our rest after 
 a hard day's walking or riding, or muscular efforts in the 
 ball-room or elsewhere. (4) The p)ain of fatigue is familiar 
 to most of uSj and is readily distinguishable from other forms 
 of pain. 
 
 Local fatigue is caused far sooner by prolonged and sus- 
 tained muscular effort than by repetitions of short muscular 
 efforts having due intervals of relaxation between them. 
 Anyone who has attempted to hold out a weight at arm's- 
 length knows the impossibility of a long continuance of the 
 effort, and it is proverbially true that standing in one position 
 is to most people far more tiring than walking, the reason 
 apparently being that in standing the muscles which support 
 the body are subjected to a prolonged strain, while in walking 
 we use the muscles on either side of the body alternately. 
 The great increase of working power which we obtain by 
 this alternating use of the muscles would seem to be one of 
 the chief reasons for the bilateral symmetry of the body. 
 Not only is sustained effort a far more potent cause of fatigue 
 than repeated effort, but we find that, when fatigue super- 
 venes, actions requiring sustained effort, be they physical or 
 mental, are the first to fail, while automatic actions endure 
 the longest, and in this respect local fatigue resembles general 
 fatigue. It is quite possible to exhaust a muscle by artificial 
 stimulation, and if one of the small interossei muscles of the 
 
58 NEKVOUS AFFECTIONS OF THE HAND 
 
 hand be continuously faradised it will be found, as before 
 stated, that in a short time its power of contracting under 
 any form of stimulus will be absolutely abolished. It is 
 tolerably certain that the brain can have no share in artificial 
 fatigue thus produced, and there seems good reason to sup- 
 pose that in some people of energetic temperament the irri- 
 tability of a muscle may be exhausted while the power of 
 mental stimulation remains unimpaired. Although the author 
 dwells chiefly on the peripheral phenomena of fatigue, he 
 readily admits that these must be generally accompanied by 
 central changes. What these latter are must remain a matter 
 of speculation, but in the peripheral phenomena we have 
 something recognisable and certain, and deserving of our most 
 careful attention. 
 
 Chronic local fatigue has causes and symptoms similar to 
 those of acute local fatigue, and there can be little doubt 
 that this condition is a common cause of many of those 
 chronic maladies which seem to result from overwork, and 
 which are characterised by irregular muscular action. That 
 some cases of writer's cramp, torticollis, and hammer palsy 
 are due to chronic fatigue of the muscles employed there 
 can be little doubt. Duchenne and Mr. Brudenell Carter 
 have pointed out how, in cases of short sight, the prolonged 
 strain of the internal recti has caused troubles of vision 
 and even cerebral symptoms ; and Taylor, of Nottingham, and 
 Snell, of Sheffield, have shown reason for including in the 
 category of ' fatigue diseases ' a peculiar form of nystagmus 
 occurring amongst miners, who try their eyes by working in 
 the dark, and the author has little doubt that, attention having 
 been directed to the symptoms and effects of fatigue, additional 
 light on the subject will be forthcoming. 
 
 We are now in a position to apply these theories to the 
 act of writing. The act of writing is primarily divisible into 
 (1) the act of jwel tension, and (2) the act of moving the pen ; 
 and the act of movement may be again subdivided into (a) 
 the stroke-making movement ; (6) the movement of the hand 
 from left to right ; (c) from right to left ; and lastly {d) the 
 ink-dipping movement. Besides the act of prehension, there 
 
THE ACT OF WRITING 59 
 
 is (3) another muscular act : this is the poising of the fore- 
 arm and hand, which is ordinarily kept about three-quarters 
 prone, the hand being balanced upon the pisiform bone and 
 little finger. Thus it will be seen that writing is divisible 
 into three acts — the 'prehension of the pen^ the 'poising of the 
 hand and forearm^ and the Tnovement of the pen, and there is 
 probably no muscle between the shoulder and the fingers 
 which is not brought frequently into action during writino-. 
 
 The muscular action to which we wish to direct very par- 
 ticular attention is that of prehension. The pen is normally 
 held between the thumb and the first two fingers. The 
 thumb and the index finger form an oval ring through which 
 the penholder passes, being held by the distal and resting on 
 the proximal end of the said oval. The distal ends of the 
 metacarpal bones of the thumb and index fingers are widely 
 separated ; the first phalanx of the thumb is abducted ; the 
 phalangeal joint forms an angle which is more or less acute 
 in different writers ; and the pulps of the terminal phalanges 
 of the thumb and index finger are, but for the intervention of 
 the pen, almost directly opposed to each other. With regard 
 to the first two fingers, the proximal phalanges are flexed, and 
 the two terminal phalanges nearly straight. The muscles 
 which keep the thumb and fingers in this attitude of prehen- 
 sion are, we believe, with one exception, intrinsic nmscles of 
 the hand, in proof of which, if the rheophores of a faradising 
 apparatus with big sponges be placed, the one on the palmar 
 surface of the hand between the thumb and index fingers, and 
 the other on the dorsal surface over the metacarpal bone of 
 the index finger (so as to influence more or less the special 
 muscles of the thumb and first two fingers), the thumb and 
 first two fingers will assume an attitude of pen-prehension 
 (saving only the flexing of the phalangeal joint of the thumb), 
 and a pen held between them will be tightly grasped. 
 
 The muscles chiefly concerned in the muscular act are, we 
 believe, as follows : The inter ossei of the first two fineers 
 which flex their respective first phalanges (the dorsal muscles 
 further helping the act of prehension by dragging the first 
 two fingers towards the thumb) ; the abductor pollicis, which 
 
60 NERVOUS AFFECTIONS OF THE HAND 
 
 abducts the first phalanx of the thumb, an action without 
 which proper opposition of the pulps of the thumb and index 
 finger would be impossible. The opponens pollicis and Jlexor 
 brevis 2^ollicis, as their names indicate, are also important 
 muscles in the act of prehension. The phalangeal angle of 
 the thumb is maintained, in a great measure, if not entirely, 
 by the action of the extensor primi internodii pollicis. 
 
 The muscular effort of poising the hand is thrown chiefly 
 on the supinators. The hand is three-quarters prone, and in 
 this position the weight of the hand tends to make pronation 
 complete — a tendency which is checked by the supinator 
 longus, the supinator brevis, and possibly the extensors of the 
 thumb. 
 
 The stroke-making movements are accomplished by the 
 long flexor of the thumb, and the extensor secundi internodii, 
 the flexor profundus digitorum, and the extensor communis 
 digitorum. The up-strokes are in part dependent on an 
 increased action of the interossei. 
 
 The movement of the arm from left to right depends 
 chiefly on the triceps extensor, and that from right to left on 
 the pectoralis. The muscles concerned in the ink-dipping 
 movement scarcely require naming. 
 
 The five muscular acts above enumerated, which, taken 
 together, produce the complicated act of writing, are divisible 
 into two classes. In the first class {consisting of the prehension 
 of the pen and the poising of the hand) the muscles concerned 
 are subjected to prolonged strain^ and {especially those con- 
 cerned in prehension) are kei^t in a continuous state of contrac- 
 tion often for inordinately long periods. In the second class 
 of muscular acts the contractions of the muscles alternate 
 with periods of repose. 
 
 Now, as long as a muscle remains contracted it is in a 
 state of exercise, a condition which is attended with impair- 
 ment of composition such as can be repaired only during 
 repose. The muscles by which the prehension of the pen is 
 effected need not of necessity obtain any interval of rest for 
 hours together. During all the several acts which constitute 
 writing these muscles remain in a state of contraction, for 
 
THE ACT OF WEITIXG 61 
 
 the pen, in stroke-making, in horizontal movement, and in 
 ink-dipping, cannot be released from the grasp of the fingers 
 and thumb. 
 
 These muscles, whose function has been thus abused, soon 
 begin to respond but sluggishly, or refuse entirely to respond 
 to the stimulus of the will, and the scrivener finds that his 
 grasp of the pen is faltering and uncertain. He finds that he 
 is obliged to take a tighter grasp of the pen and (unconsciously, 
 of course, as far as he is concerned) he deposes the proper 
 muscles of prehension and substitutes others to perform their 
 office. He begins to grasp the pen, not with the intrinsic 
 muscles of the thumb and first two fingers, but uses for that 
 purpose the big flexors of the thumb and fingers situated in 
 the forearm. The flexor longus poUicis, the flexor sublimis 
 digitorum, and the flexor lorofundus digitoritm are now the 
 muscles of pen-prehension, and the stroke-making movements 
 of the pen are accomplished by the flexors and extensors of 
 the wrist, or the writer finds himself incapable of resting his 
 wrist upon the desk because the movements of the pen have 
 to be accomplished by the movement of the entire forearm by 
 the muscles of the shoulder (the forearm being kept by means 
 of its flexors at right angles to the arm). These new muscles 
 of pen-prehension are kept in a condition of prolonged contrac- 
 tion just as were their predecessors, and in time become 
 similarly sluggish, obstinate, and irritably weak, and the 
 scrivener has to resort to new methods of pen-prehension, 
 which generally consist of some mechanical contrivance, 
 either entirely artificial or such as interlacing the pen amongst 
 the fingers. The flexors of the elbow-joint (should they be 
 used) soon strike work from a similar cause, and the triceps 
 extensor is brought into use. The man writes with the pen 
 mechanically fixed in the hand and the arm rigidly extended ; 
 the stroke-making action being accomplished by the move- 
 ment of the entire body. 
 
 Other muscles which are very prone to sufler in writer's 
 cramp are those which poise the hand, and which, like those 
 of pen- prehension, are subjected to prolonged strain. It is a 
 common observation that the poising muscles suffer in writer's 
 
62 NERVOUS AFFECTIONS OF THE HAND 
 
 cramp, and the hand is very liable to roll over in the direction 
 of pronation (owing probably to the weakness of the supi- 
 nators), or more rarely to be jerked in the direction of supi- 
 nation (as in a case recorded by Dr. Buzzard^) by the irrita- 
 bility of those same muscles. Many persons affected with 
 writer's cramp become unable to poise the hand, and are 
 obliged to write with the entire forearm supported and the 
 hand in a state of complete pronation. 
 
 To illustrate our meaning, we have purposely supposed an 
 extreme case. The disease not unfrequently does not spread 
 beyond the fingers, but its rapid progression, as depicted above, 
 is occasionally observed. When once the disease has com- 
 menced (showing itself perhaps merely as a trifling awkward- 
 ness in writing) its progress is liable to be very rapid if writing 
 be persevered in. If, on the other hand, writing be aban- 
 doned on the first appearance of av/kwardness, and the patient 
 is able to give himself rest while his exhausted muscles of 
 pen-prehension recover their tone, he rapidly regains his lost 
 power. 
 
 Further, as to the act of writing, it must be borne in mind 
 that it is one of the most complicated possible, perhaps the 
 most complicated muscular act which is ever performed by the 
 body. The act of writing takes years of patient labour to 
 acquire, and although children begin to learn very early in 
 life, it is seldom before adult age is reached that their writing 
 loses those evident marks of juvenility which we all know how 
 to recognise. Perfect writing should be an act accomplished 
 without effort, and almost without thought, or, in other words, 
 it should be a purely automatic act, and one accomplished by 
 an expenditure of mental stimulus so small that we can 
 scarcely recognise it. For the accomplishment of the act of 
 writing a very large number of muscles is required, and when 
 we consider the light yet firm grasp of the pen which is neces- 
 sary, the poising of the hand in the .semi-prone position, the 
 stroke-making movements of the pen accomplished by the 
 flexion and extension of the fingers, the travelling of the hand 
 across the paper and back again, and the journey of the hand 
 ' Practitioner, August, 1872. 
 
EFFECT OF EMOTION 63 
 
 to the ink-pot, we see that nearly every muscle between the 
 shoulder and the finger-tips is brought into play, and we cease 
 to wonder that years are required for educating these muscles 
 to work accurately and harmoniously together. 
 
 There may or may not be a ' co-ordinating centre ' whose 
 function it is to control the act of writing ; this is a matter 
 of speculation. It is, however, tolerably certain that, should 
 one or more of the muscles which have been so laboriously 
 educated exceed or fail in its work by an increased or dimin- 
 ished response to stimulation, the harmony of the complicated 
 act of writing is interfered with, concord is converted into 
 discord more or less marked, and that which had become a 
 purely automatic act by dint of years of study relapses again 
 into an act which requires a greater or less amount of attention. 
 Now, directly an act which should be automatic begins to 
 demand our attention for its execution the difficulties of 
 executing such act are increased a hundredfold. Eear of 
 failure, especially before others, is ever present to the mind 
 and it would seem as if a certain proportion of that mental 
 stimulus which ought to animate the muscles suffered what we 
 have called emotional diversion, and thereby caused increased 
 muscular impotence. In every case of writer's cramjD that the 
 author has seen there has been an emotional factor. Those 
 who have had the most obvious physical cause for their troubles 
 have complained that their troubles are worst in the presence 
 of others, and especially when they have been called upon for 
 official signatures before official witnesses. Emotional natures 
 are those which are most prone to suffer from derangement of 
 educated actions. We have seen one case, and only one, in 
 which no cause, save an emotional one, could be discovered for 
 the failure in writing, and it is right to state that there was 
 nothing objectively wrong with the handwriting, the patient 
 merely stating that 'he felt a difficulty.' In two or three 
 others emotion, coupled with very trivial causes, such as alco- 
 holism or slight neuralgia, had caused the difficulty, and in 
 these patients again there was very little amiss with the writing. 
 In some cases rheumatic stiffening of one or other of the joints 
 of the thumb had rendered certain combined movements im- 
 
64 NERVOUS AFFECTIONS OF THE HAND 
 
 possible, and had thus destroyed the automatic character of 
 writing. In others the troubles seem to have originated 
 in stiffness of the shoulder and weakness of the deltoid (in- 
 sidiously following rheumatism). In four cases a general strain 
 of the arm had produced (through implication of the nerves) 
 o-eneral weakness of many of the muscles. In the remainder 
 of "the author's cases the difficulty in writing has been occa- 
 sioned by excessive use of the pen, and has arisen for the most 
 part in persons of energetic temperament who have written 
 ao-ainst time to accomplish some task. In these the failure of 
 writinor was undoubtedly due to chronic fatigue of some of the 
 writing muscles. 
 
 Now, immediately one small muscle — such as the first 
 dorsal interosseous — fails, the act of writing ceases to be auto- 
 matic. The attention of the scrivener is required, mental 
 effort is necessary, and mental effort for the accomplishment 
 of muscular acts means excessive stimulation of the muscles 
 employed. When once the patient becomes conscious of his 
 troubles the disease is sure to spread rapidly ; and, for the 
 same reason, if he uses his left arm it is sure to give out very 
 quickly. In these extreme cases the patients invariably suffer 
 from the acute pain of over-fatigue (sometimes accompanied 
 by headache) whenever they attempt to write. The fatigued 
 muscles will be found to respond less thoroughly to faradism 
 than the healthy muscles of the opposite limb, and the patient 
 either finds that voluntary action of these muscles is next to 
 impossible or, if possible, is very quickly arrested by fatigue. 
 In the author's experience it is not true, as is stated in most 
 text-books, that all acts save that of writing can be perfectly 
 accomplished. It must be borne in mind that for the accom- 
 plishment of most acts we have a great choice of muscles, and 
 hence muscular failure may be difficult to detect ; but it will 
 be certainly observed that all acts involving the affected 
 muscles are either impossible or performed in a clumsy manner. 
 The phenomena of writer's cramp vary somewhat. They gene- 
 rally consist of mere impotence, without evident spasm or 
 paralysis. Occasionally, however, there is cramp in the fatigued 
 muscles, and sometimes spasm of the muscles which are anta- 
 
CASE OF CHRONIC FATIGUE 65 
 
 gonistic to them is obsen^ecl. One definite cause of spasm is 
 undoubtedly faulty antagonisation, and whenever we investi- 
 gate local spasmodic action we must be careful to eliminate 
 this cause. 
 
 Case 58. — Writer's Cramp. Re2)0Tted hy the Author in the 
 'Practitioner,' Vol. 2, 1873. Henry Millerd, aged 40, in the 
 employ of the General Post Office, came to consult me at the 
 Charing Cross Hospital on October 5, 1872. He is a ' nervous 
 man, has suffered from neuralgia, and has one sister who suffers 
 from paraplegia. Has done an immense amount of writing 
 during the last thirteen years, often writing 'against time.' 
 States that in the summer of 1868 he felt that he had lost control 
 over his pen, and was obliged to grasp it tighter. He managed, 
 however, to continue writing tolerably well till April, 1872, when 
 ' he lost control over the fore-finger,' and was obliged to begin 
 holding his pen by interlacing it among the fingers. He can- 
 not rest his wrist upon the desk when writing ; if he does so, 
 the fingers and thumb ' start away from the pen.' He com- 
 plains of deep-seated pain in the wrist-joint and in the carpo- 
 metacarpal joint of the thumb. He has now completely lost 
 the power of writing with his right hand, and has learnt to 
 use the left ; but, strange to say, he is quite unable to write 
 with the left hand without making spider-like movements with 
 the fingers of the right. 
 
 Any attempt to use the right hand causes agonising pain 
 from the shoulder downwards. The pain is the pain of intense 
 over-fatigue, and does not follow the lines of the nerves. On 
 stripping him it was found that there was nowhere any de- 
 tectable wasting of any muscle, but that both arms were soft 
 and flabby, and the right rather smaller than the left. On 
 being asked to write, the whole body seemed to take part in 
 the exertion ; the pen was grasped as tightly as possible, the 
 forearm raised off the table, the shoulder elevated. An in- 
 complete signature was all that could be effected, and the 
 attempt caused great pain in the limb. On testing with 
 faradism it was found that the interossei, the abductor pol- 
 licis, the flexor longus pollicis, and the extensor primi inter- 
 nodii on the right side contracted far less readily and less 
 
 P 
 
66 NERVOUS AFFECTIONS OF THE HAND 
 
 forcibly than their fellows of the opposite limb. Voluntary- 
 movements of these muscles were performed with the greatest 
 difficulty, as was also the movement of supination, which could 
 only be effected four or five times in succession, notwithstand- 
 ing the strongest efforts to do so. The phalangeal joint of the 
 right thumb has a curious habit of ' snapping ' audibly at in- 
 tervals, which is due, apparently, to the spasmodic and unequal 
 action of the muscles moving it. The nails of both hands 
 are very bad, being ' pitted ' in an extraordinary manner. 
 
 His condition is ever present to his mind, and his mental 
 state is one of great depression, his writing power being his 
 source of income. Lithographed facsimiles of this patient's 
 handwriting are given, which show how rapid was his im- 
 provement under treatment. On the first application of the 
 current the pain in his arm disappeared, and within a week of 
 its first application he could manage to sign his name with 
 tolerable ease. His writing from this time rapidly improved, 
 and at present his handwriting, when he is allowed to use his 
 right hand (which is very seldom), is, as far as appearances 
 go, as good as it ever was. Samples of his handwriting are 
 given in the accompanying lithograph. The first three samples 
 were written respectively on October 5, 12, and 21, and the 
 fourth on November 1. The other two samples are dated. 
 Although the handwriting is now very good, the pen-prehen- 
 sion is still faulty, and I have forbidden him to write until he 
 can do so with the pen held properly and lightly between the 
 thumb and first two fingers. Pen-prehension has gradually 
 very much improved, and it was soon noticeable that the effort 
 of writing had much decreased, and such efforts soon ceased 
 to cause fatigue. First the elevation of the shoulder dis- 
 appeared ; then the forearm could be rested on the table 
 during writing. Next the phalangeal angle of the thumb no 
 longer gave way, and now he can write very comfortably if he 
 holds the pen only between the thumb and first finger (at one 
 time the first finger could not be placed on the penholder), 
 but any attempt to use the middle finger bothers him very 
 much. On testing the muscles with faradism, it is now found 
 that the dorsal interossei on either side of the middle finder 
 
•4 
 
 ^ 
 
 N^ 
 
TREATMENT BY GALVANISM 67 
 
 respond far less readily than their fellows of the left hand, 
 but that the other interossei, which were weak in the iirst 
 instance, have recovered their normal irritability. Earlier in 
 the case it was evident that the dorsal interosseous muscle 
 on the radial side of the middle metacarpal bone was less 
 irritable and more weak than the one on the ulnar side ; 
 and by placing a rheophore on the metacarpal bone so as to 
 influence equally the muscles on either side the first phalanx 
 was flexed, but dragged by the stronger muscle towards the 
 ulnar side. 
 
 The galvanism has been used in the manner stated at 
 p. 41, and the variety of exercises which he was made to 
 practise was very great. Especially he has been made to hold a 
 pen or pencil, or my finger, and to perform with it the move- 
 ments of writing a hundred times in succession, while the 
 current has been applied alternately to the nerves supplying 
 the muscles implicated. At first the difficulty of this exercise 
 was extreme, the pen frequently slipping from the grasp of 
 the fingers. A.t present it can be performed without any 
 difficulty whatever. The only movement at present in per- 
 forming which there is the slightest difficulty is the waggling 
 of the middle finger from side to side by means of the 
 interossei. It was noticeable very early in the case that the 
 forearm had got firm and muscular, and that the pitting had 
 disappeared almost entirely from the finger nails. The 
 patient's enjoyment of the current is quite remarkable, and 
 during its application he frequently uses such expressions as 
 * That's comforting,' ' That seems to give me strength,' &c. 
 The general health has much improved, a fact which is 
 attributable in great measure to the removal of the cause 
 of his mental depression as well as to the mixture of strych- 
 nine, perchloride of iron, and nitro -muriatic acid which he has 
 been constantly taking. The snapping of the thumb has 
 almost disappeared, and is now far less frequent and less loud. 
 He has continued to use the left hand for writing while he 
 has been under treatment. The movements of the right fingers 
 while writing with the left hand have quite disappeared. Once 
 or twice he has complained of a feeling of awkwardness with 
 
 F 2 
 
68 NERVOUS AFFECTIONS OF THE HAND 
 
 the left hand, but this has always been immediately removed 
 by the current. The amount of writing which he has done 
 during the treatment has been about two hours a day, but this 
 amount had to be performed often rapidly and against time. 
 
 The following cases are of sufficient interest to bear 
 quotation. Those not included in the original papers are dis- 
 tinguished by letters only. 
 
 It is important to remember that not a few cases of neuritis 
 are traumatic, or distinctly due to injury or to excessive mus- 
 cular efFort, and not infrequently the history of injury or strain 
 is only elicited on cross-examination. 
 
 Case A.— An under-gardener, aged 18, strains his arm 
 while wielding a spade. The next morning he cannot milk 
 the cow, and has all the symptoms of neuritis of the right 
 median nerve. 
 
 Case E.— Neuritis from strain. M. B., 39, surgeon, in 
 August, 1883, while pulling at a rope in a small yacht, fell 
 backwards, in consequence of the breaking of the rope, and 
 bruised the right axilla against the edge of a hatchway, and 
 generally strained the muscles. Felt very little inconvenience 
 at the time, but later in the day, after exposure to cold, felt 
 ' rheumatic ' pain in the arm, and the following day the arm 
 was stiff and painful. The acute symptoms passed off in a day 
 or so, but in a fortnight's time the musculo-spiral nerve was 
 distinctly tender over the head of the radius, and the use of 
 the extensors of hand and wrist caused pain, and the jolting 
 of a railway carriage caused much jarring and discomfort. For 
 many months this gentleman suffered from some disability of 
 the right hand after prolonged writing or during any strong 
 effort. The musculo-spiral nerve remained tender also for 
 months. The symptoms were much relieved by blisterings and 
 applying a piece of capsicum plaister over the tender nerve. 
 Twice, when the arm was apparently very nearly well, the 
 symptoms redeveloped, once after playing lawn tennis and 
 on anothei- occasion after making strong muscular efforts to 
 reduce an old dislocated elbow. 
 
 The patient recovered completely, except for some slight 
 numbness in the area of the distribution of the radial nerve,. 
 
NEUEITIS FEOM PEESSUEE 69 
 
 and also at the top of the palmar surface of the middle finger. 
 These regions have been numb throughout. The numbness 
 of the middle finger probably indicates that there must have 
 been some damage to the median as well as to the musculo- 
 spiral nerve. 
 
 Case C. — Neuritis from pressure. (Kindly communi- 
 cated by the patient, March 17, 1881.) Dr. N. M. travelled 
 from Scotland in a coiq^e lit on the night of February 9, 1881, 
 and slept with his right arm ' extended between his body and 
 the side of the couch.' On awaking the right forearm was 
 ' asleep,' and this condition continued. On February 10 a 
 bruise was noticed on the upper part of the arm, and the 
 musculo-spiral nerve was distinctly tender. For some days 
 this pain increased, and was sometimes almost severe when the 
 arm was in a position causing pressure of its muscles on the 
 nerve. Sensation was perfect, and all the muscles responded 
 perfectly to faradism. After a fortnight much inconvenience 
 was felt from the fatigue caused by writing, and also after 
 making post-mortem examinations, which was the patient's 
 almost daily occupation. By March 10 the writing power 
 began to improve, and by March 17 (36 days after the injury) 
 it was almost perfect again. Writing with a quill pen was 
 less fatiguing than writing with a steel pen. General con- 
 ditions aftected the local trouble, and one day, when the 
 patient spent ' about five hours in the post-mortem room with 
 a good deal of decomposed material the arm was so inclined 
 to " pins and needles " and so fatigued that he was able to do 
 very little work in the evening.' ' I have had,' he says, ' pre- 
 cisely the same kind of pain (only in both arms and back) as 
 the first symptom of an attack of intermittent fever. Though 
 I took quinine, I feel sure that the afiection I have described 
 was not neuralgia of malarial origin, as my temperature was 
 always normal.' 
 
 Case 21. — Neuritis from strain. Mary Anne C, semp- 
 stress, 27 (U. C. H., October, 1875), was kindly sent to me by 
 Mr. Morrant Baker. In June, 1874, she was working inordi- 
 nately hard, ' often nearly all night,' and one day, after using 
 a very big pair of scissors for ' cutting out,' thought she had 
 
70 NERVOUS AFFECTIONS OF THE HAND 
 
 strained her wrist. She then lost the power of plying her 
 needle, and the arm became comparatively useless for all acts, 
 whether coarse or fine. 
 
 When first seen (October, 1875) there was marked tremor 
 of right hand, tenderness over the median, ulnar, and musculo- 
 spiral nerves, and a great tendency for the hand to ' die away ' 
 and to get red and mottled. Using the arm or hand gave her 
 great 2Kcm. She had, she said, been faradised, but this had most 
 distinctly made her worse. She improved very sloivly, blisters 
 over the tender nerves seeming to do her most good combined 
 with tonics and iodides of iron and potassium. By June, 1876, 
 she was able to do a little work, and the hand had ceased to 
 ' die away ' and get mottled, but in the following October she 
 returned because the weakness of her hand had come back 
 again. In November, 1876, she had a crop oi Jive boils, almost 
 simultaneously, scattered over the right arm. She has since 
 been lost sight of. 
 
 Case D. — Neuritis from strain. A. C. S., 50, bar- 
 rister, July 29, 1885, complained of a numbness and want 
 of power in the right hand, which made him nervous and 
 apprehensive of a paralytic attack. Had recently been trout 
 fishing for many hours daily and wielding a rather heavy 
 fishing-rod. On examination the right musculo-spiral nerve 
 was found excessively tender and the right median slightly so. 
 There was numbness and tingling over the area of distribu- 
 tion of the right radial nerve in the hand, and in this area 
 the sun had produced spots of sunburn in well defined 
 patches of a size from a shilling to a threepenny-piece and of 
 a rich leaf-brown colour. 
 
 A piece of capsicum plaister was ordered to be worn over 
 the tender nerves, and the patient was soon quite well. 
 
 Case E. — Neuritis from straAii. A laundress, aged 34, 
 was seized with neuritis of the right median and musculo- 
 spiral nerves after very hard wringing of clothes. Both 
 nerves were tender and sensation was impaired over their 
 respective sensory areas in the hand. 
 
 There was burning pain, coming on in severe paroxysms, 
 accompanied by throbbing and swelling of the thumb and a 
 
* COMPOSITOE'S CRAMP ' 71 
 
 tendency for the hand to close. Rest, blistering, some 
 purgation and abstention from beer brought about a complete 
 cure. 
 
 Case F. — Co7npositor's Cramj?. James H., 31, com- 
 positor, November 30, 1880. Has a difficulty in filling his 
 * stick.' When the right arm is moved away from the side 
 and he attempts to move the right hand yrom the case towards 
 the ' stick,' held in the left hand, the elbow is forcibly jerked 
 up and rotated invxirds. There is pain round the right 
 scapula, and when, being stripped, he performs the movement 
 in which he finds a difficulty, the rhomboids, supra and infra 
 spinatus, and the upper fibres of the pectoralis major are seen 
 to contract forcibly, while the base of the scapula projects 
 unduly from the side. There is no difficulty in pushing the 
 arm forwards, which requires a strong contraction of the 
 serratus magnus. On faradising the muscles there is found to 
 be some want of irritability in the front fibres of the right 
 deltoid, and he says that the sensation (to faradism) over the 
 right deltoid and pectoralis major is less acute than on the 
 left side. 
 
 His difficulty seems to be to maintain the humerus, with 
 the elbow bent, away from the side. He is equally powerless 
 to comb his hair with his right hand. States that he could 
 ' clean his boots ' with his right hand, and this, at first sight, 
 was a movement very similar to that of combing the hair or 
 ' filling the stick.' On inquiry, however, it was found that 
 he invariably cleaned his boots on his feet, and this is a very 
 different movement. It is probable that some muscle neces- 
 sary for maintaining the proper position of the humerus has 
 become fatigued (possibly the anterior fibres of the deltoid or 
 the serratus or supra spinatus). 
 
 Case G. — Compositor's Cramp. J. P., aged 45, com- 
 positor, came to Charing Cross Hospital on April 19, 1873, 
 complaining that during the past nine months he had been 
 obliged frequently when at work to lay aside his ' compositor's 
 stick ' in consequence of 'the jumping of the nerves of his 
 left arm.' 
 
 He had had frequent ' hysterical fits ' with attacks of 
 
72 NEEVOUS AFFECTIONS OF THE HAND 
 
 giddiness. There was obvious tremor of both hands and a 
 doubtful ' lead-line ' on the gums. This patient was lost 
 sight of. 
 
 Case J. — Crmnp from tying pickle jars. Neville, J., 
 aged 31, traveller (U. C. H., October 13, 1875). This patient 
 was sent to me by Dr. Cooper. It has been his business to 
 cover pickle jars with bladders. Used to tie down 800 or 
 1,000 a week, and sometimes has done as many as 200 in a 
 morning. When the knot is tied and ' hauled taut ' the top 
 of the jar is grasped with all possible force with the left hand. 
 In February last he began to suffer from a twitching of the 
 left hand, and in July complained of pain at the lower part of 
 the cervical spine. 
 
 When seen there was marked tremor in the left trapezius, 
 biceps, deltoid, and the flexors and extensors of the arm and 
 fingers. There was marked tenderness over the sixth and seventh 
 cervical and first dorsal vertebrae. The tremor was not con- 
 tinuous, but came on during exertion and immediately he imi- 
 tated the act of pickle-jar tying. No pain in the arm, no 
 paralysis, no impairment of sensation. 
 
 Ordered a blister to back of neck, rest from his work, and 
 tonics, and in six weeks' time he was far on his road to 
 recovery. The tremor had gone, and he could pick up a 
 scrap of paper with the left thumb and forefinger without 
 tremor or other difficulty. This he could not do when first 
 seen. 
 
 Case K. — Paralysis of both hands from exposure to cold. 
 J. H., aged 43, master mariner (U. C. H., September, 1882). In 
 June 1882 made a very bad passage from Boulogne to Folke- 
 stone. Was three hours on the bridge of his boat in a biting 
 east wind and rain. He had left his warm gloves at home, 
 and was grasping the iron rail of the bridge the whole time. 
 The next day he found his hands clumsy at writing, and they 
 have got weaker ever since. 
 
 All the intrinsic muscles of both hands (median and ulnar) 
 are wasted, and give degenerative reactions. Extrinsic muscles 
 of the hand (long flexor of thumb, flexors and extensors of 
 fingers) are not affected. 
 
A'AEIOUS CASES 73 
 
 No fibrillary tremor observable. 
 
 Had a very strong hand, and states that he used to be able 
 to squeeze a pewter pot flat. 
 
 Case L. — The following case seems to be similar to one 
 recorded by Mr. Brudenell Carter in the ' Clin. Soc. Trans.,' 
 and illustrates the occurrence of fatigue in muscles other than 
 those of the hands. 
 
 Mr. A. C, aged 21, watchmaker (May 8, 1879), was sent to 
 me by Dr. Mitchell Bruce. Complains that after working with 
 a watchmaker's lens he gets a pain in the inner corners of his 
 eyes and that the sight becomes dim and blurred. On asking 
 him to hold the frame of his lens, with the lens itself removed, 
 he could do so without difficulty. His trouble was not there- 
 fore in the orbicularis. When the eyes were made to converge 
 by looking at a near object the pain was soon developed. Mr. 
 Brudenell Carter saw him with me in consultation, and ordered 
 a pair of prismatic glasses with the bases outwards. This 
 quite removed the difficulty. It should be mentioned that the 
 trouble had come on after a severe fall from a bicycle and 
 while the patient was in second-rate health. 
 
 Case M. — A 'cello player, aged 26, who experienced diffi- 
 culty with the bow. This was found to be due to rheumatism 
 of the extensor tendons of the right hand with tender nerve- 
 trunks. A small ganglion ultimately developed on the back 
 of the right wrist. 
 
 Case N. — A lady, aged 25, violinist, had trouble with the 
 bow hand. She had been overworked and underfed. On 
 examination she was found to be extremely left-handed, and 
 could write as well with the left hand as the right. The left 
 hand and foot were both larger than the right, but there was 
 no want of symmetry about the face. The right arm, how- 
 ever, was J inch longer than the left. This she attributed to 
 her profession, and asserted that it was ' literally universal 
 among violinists for the right arm to be longer than the left.' 
 This she attributed to the constant stretching of the right 
 arm with bow exercises — especially in early life. Since this 
 assertion was made I have only had an opportunity of 
 measuring the arms of one professional violinist, and certainly 
 
74 NERVOUS AFFECTIONS OF THE HAND 
 
 • 
 
 found the right arm, measured from middle of sternal notch to 
 tip of mid-finger, to be | inch longer than the left. 
 
 Case 0. — Mr. J. P., aged 36, violoncello player, October 28, 
 1879. In the spring of 1877 felt an aching pain down the left 
 thumb and the tip of the left forefinger while practising the 
 violoncello. There is now a numbness and fulness in the tips of 
 the left forefinger and mid-finger when they hang down, and a 
 feeling of ' pins and needles ' when he fingers the instrument. 
 He is in the habit of playing solos on the violoncello, and 
 makes the nut with the radial border of the phalangeal joint 
 of left thumb (at which point there is a corn), while he does 
 the fingering with the left fingers. The abductor poUicis is 
 very notably less irritable to faradism on the left side than the 
 right, and the sensation of the whole of the left hand is per- 
 ceptibly impaired. 
 
 Case P. — A violinist, aged 45, could not 'stop' the string 
 with his left little finger without consentaneous movement of 
 the other fingers. There was numbness of the left hand, and 
 he was found to be suffering from gouty neuritis. 
 
 Case Q. — Miss P., aged 33, consulted me in 1893 with 
 rather indefinite signs of neuritis of the right arm. She was 
 neurotic and extremely left-handed. Wrote fluently with the 
 left hand, and backwards (mirror fashion). This she accom- 
 plished without the slightest effort, and seemed amused that 
 I should think her performance in the least strange. 
 
 Case R. — In connection with left-handedness, allusion 
 may be made to a gentleman, aged 39, who consulted me for 
 writer's cramp. He had ' never been a good writer,' and he 
 was aware that his right arm and hand, leg and foot, were 
 smaller than the left. This was obviously the case, hut lie 
 was not left-handed. 
 
 Case S. — A silk weaver, aged 29, consulted me because he 
 could not release the shuttle from his left hand. ' If he 
 thought about it,' he said, 'the fingers closed instead of opening.' 
 A careful examination revealed very little amiss with this 
 patient. The left scapula was a little lower than the right, 
 the left rhomboids were slightly wasted and the left palpebral 
 fissure looked smaller than the right. 
 
VARIOUS CASES 75 
 
 Case T. — A lady post-office clerk, aged 29, consulted me 
 for writer's cramp in 1890. It appears that in 1883 she got 
 painful contractions of palmar fascia and neuralgic pains in 
 fingers. In 1885 her ulnar nerve had been stretched, and in 
 1887 her mid and ring fingers were removed. She now wrote 
 with her thumb and index, and was found to have painful 
 nerve-trunks and interossei muscles deficient in irritability on 
 both sides. 
 
 Case U. — A gentleman, aged 54, consulted me in Sep- 
 tember 1893 for rheumatism of the right arm and shoulder. 
 He sufiered great pain, which was often periodic and came on 
 at the same time every day. In November 1894 a piece of 
 a sewing needle nearly an inch long and quite black worked 
 out of his arm near the insertion of the right deltoid muscle. 
 How the needle got there he never knew, but with the escape 
 of the needle his symptoms disappeared. 
 
 [It is interesting to record that about this time another 
 j)atient of mine developed an ischio-rectal abscess, from which 
 a crooked black pin was liberated by the surgeon.] 
 
 One case of ' writer's cramp ' which was sent to me I 
 found to be caused by marked thickening of the first meta- 
 carpal bone, the result of injury. 
 
 It is interesting that I can only find notes of two tele- 
 graphists who have consulted me. These were both middle- 
 aged men, both beer drinkers, both had tremor which afiected 
 all acts performed with the right hand. They were both, in 
 short, cases of gouty neuritis and general nervous degeneration. 
 
 I have never yet seen a true case of ' telegraphist's cramp.' 
 
NERVOUS AFFECTIONS OF THE HAND 
 
 CHAPTER III 
 
 A CASE OF tailor's CRAMP, AND OTHER TROUBLES AFFECTING 
 
 THE FUNCTIONS OF THE HAND 
 
 There are many diseases which are caused by the occupation 
 
 of the patient. These might be divided into at least three 
 
 classes, viz. : (1) Irritant, in which the mechanical or chemical 
 
 irritation of the materials with which the workman is brought 
 
 in contact is the cause of trouble. Examples are found in the 
 
 eczema of the baker or grocer, or the phthisis of the stonemason 
 
 or knife-grinder. (2) Toxic, in which some poisonous matter 
 
 is absorbed into the blood. Such are chronic mercurialism 
 
 and the lead poisoning of plumbers and painters. (3) Fatigue 
 
 diseases, in which the constant repetition of some muscular 
 
 movement which constitutes the very essence of the trade or 
 
 handicraft produces an inability to perform such movement. 
 
 The most common example of this last class is ' writer's cramp.' 
 
 Case 1. — The first case to which I wish to direct your 
 
 attention to-day belongs to the class of fatigue diseases, and 
 
 may be shortly spoken of as a case of ' tailor's cramp.' The 
 
 patient is a tailor, aged 57. He has lived in London 
 
 for the last forty years. He is well built and temperate, 
 
 and is free from disease other than that for which he seeks 
 
 advice, and there are no facts in the family or personal history 
 
 which throw any light upon his condition. About a year ago 
 
 the patient began to experience a ' weakness ' of the right 
 
 thumb and forefinger, which made it difficult for him to hold 
 
 his needle, and this difficulty increased until about eight 
 
 weeks ago, when he was obliged to give up work. The patient 
 
 is here, and we will ask him to demonstrate his trouble ; and 
 
 it is quite characteristic of this class of malady that there is 
 
 ' Clinical Lecture, U.C.H., 1890. 
 
TAILOE'S CRAMP 77 
 
 very little to see. We talk of writer's cramp when there is no 
 visible cramp or spasm, of writer's palsy when there is no 
 obvious paralysis, and you will observe in this case that after 
 a few stitches the needle eludes the grasp of our tailor, and it 
 is rather difficult to say why. The needle is held between the 
 thumb and forefinger. The metacarpal bone of the thumb is 
 abducted and partly flexed on the palm, the near phalanx is 
 slightly flexed on the metacarpal bone and slightly rotated 
 towards the radial side, while the far phalanx is fully extended^ 
 so that the phalangeal knuckle makes an approach to a re- 
 entrant angle. (See fig. 1.) This is well shown in a drawing 
 made for me by Mr. Wells. The needle is held between the 
 pulps of the index finger and thumb, and in order that these 
 points may be in apposition the middle and far phalanges of 
 the index are both slightly flexed, and pressure appears to be 
 maintained by the flexion of the near phalanx. After working 
 for a short time the thumb and forefinger give way, the needle 
 is no longer grasped with sufficient firmness to push it through 
 the fabric, and in this failure the most noticeable fact which 
 an observer can detect is the giving way, as it were, of the 
 phalangeal joint of the thumb, the extension of the far phalanx 
 not being maintained. 
 
 We will now proceed to examine the patient to ascertain 
 why the failure takes place, and in order to do this satisfac- 
 torily we must have him stripped to the waist. Having done 
 this, we first determine that there is no sign of hemiplegia, 
 however slight. The movements of the tongue and face are 
 normal and symmetrical, the pupils equal and reacting 
 normally, the grasp of the two hands firm and equal, the 
 gait without a trace of limp. There is no sign of any coarse 
 cerebral lesion, whether old or recent. It is important to 
 determine this fact, because it often happens that the failure 
 to execute some delicate manipulation constitutes the one 
 lingering sign of an otherwise scarcely noticeable hemiplegia. 
 We next look carefully to the movements of the scapula, 
 because any want of firmness in the scapula necessarily 
 entails a corresponding want of firmness and certainty in the 
 use of the hand. We ask the patient to shrug his shoulders, 
 
78 
 
 NERVOUS AFFECTIONS OF THE HAND 
 
 to extend his arms in front of him, to raise his arms above 
 the head, to try to make his elbows meet behind his back, and 
 by this series of movements we ascertain that all the muscles 
 acting on the scapula act normally on the two sides. The 
 movements of the arm and forearm likewise appear normal. 
 There is no wasting of muscles, no change in the knee-jerks, 
 no sign of ataxy in the legs or arms. There is no tremor of 
 the hands or arms, or lower limbs. Asking the patient to 
 
 VX^A^ 
 
 Fig. 1. 
 
 stand facing me and to rest his arms upon my shoulder, with 
 the palms uppermost, I cross my own arms, and, grasping his 
 elbows, make gentle pressure with my thumbs over the median 
 nerve as it lies to the inner- side of the biceps tendon. There 
 is very distinct tenderness on the right side, but not on the 
 left. The trunk of the right median nerve is distinctly tender. 
 I find also that there is a very tender spot in front of the 
 right wrist just where the median enters the palm, and a 
 
TAILOK'S CKAMP 79 
 
 third tender spot in the palm itself at the base of the thenar 
 eminence. There thus appears to be well marked tenderness 
 over the trunk and branches of the median nerve in the fore- 
 arm and palm. There is no similar tenderness over the 
 musculo-spiral or ulnar nerve. The sensation of the right 
 hand appears to be duller (front and back) than on the left, 
 but this blunting of common sensibility is especially marked 
 in the ' median ' area of the palm, and you will observe that 
 the patient distinctly states that sensation is far more acute 
 on the ulnar side of the right ring finger than on the radial 
 side. This impairment of sensation is slight in degree, but, if 
 carefully looked for, is perfectly evident. We have so far 
 shown that the right median nerve is tender, and that its 
 sensory functions are impaired. Looking more closely to the 
 hand, we find no wasting of muscle, no impairment in the 
 strength of rapid movements, no enlargement of joints, no 
 creaking about the wrist, no teno- synovitis, or other trouble 
 interfering with the freedom of movement of the tendons. 
 The muscles of the ball of the right thumb are perhaps harder 
 to the touch than those of the left side, but the difference is 
 not very marked. Proceeding now to test the muscles with 
 faradisation, I ask the patient to sit on a common Windsor 
 chair with the wrists resting on the back of a second chair, 
 upon which I sit astride for the purpose of testing the muscle. 
 One rheophore of the faradising battery is made fast to the 
 nape of the neck in order that the current to reach the hands 
 may pass through equal lengths of the body on either side. 
 The muscles of the hand are then tested with a small rheo- 
 phore, the skin being well moistened with hot salt-and- water. 
 I begin with the left hand, taking the muscles singly, and, 
 finding what is the least current which will produce a contrac- 
 tion, I then watch the effect of the same current applied to 
 the corresponding muscle of the right hand. 
 
 The result of this investigation is to show a very distinct 
 impairment of irritability of the first dorsal interosseous and 
 the muscles of the thenar eminence on the right side. A 
 current which produces a quick and vigorous contraction on 
 the left side has no appreciable effect on the right. When the 
 
80 NERVOUS AFFECTIONS OF THE HAND 
 
 strength of the current is increased, the right hand muscles 
 contract, but with less vigour than the corresponding muscles, 
 and, especially in the ball of the thumb, there is a little hesi- 
 tancy about the contraction, owing apparently to a lengthening 
 of the latent period of stimulation. This difference in irrita- 
 bility was very much more marked a month ago than it is at 
 present, rest and other measures having done much to restore 
 the normal condition of the muscle. Now it is obvious that 
 the muscles in which we are able to demonstrate this impaired 
 irritability are precisely those which are essential for holding 
 the needle ; for keeping the needle firm between the pulps of 
 the thumb and index the muscles of the thenar eminence and 
 the first dorsal interosseous are precisely those which are 
 employed. Duchenne pointed out that the muscles of the ball 
 of the thumb are analogous to the interossei muscles in the fact 
 that their action is to flex the near and extend the far phalanx. 
 The radial head of the short flexor and the abductor pollicis 
 may be regarded as functionally one. These maintain the 
 thumb in the needle position ; they are markedly deficient in 
 irritability, and the ' giving way ' of the phalangeal angle is 
 due mainly to the failure of these muscles to remain con- 
 tracted. The first dorsal interosseous is similarly deficient in 
 irritability, and there is no doubt that the impaired condition 
 of these muscles as demonstrated by electricity is amply suffi- 
 cient to account for the ' professional impotence ' of our tailor. 
 We have also as an interesting fact in this case the well- 
 marked tender spots along the course of the median nerve, tlie 
 nerve supplying those muscles of the thenar eminence whose 
 loss of irritability is especially well marked, and also the 
 markedly impaired sensibility in the median area of the palm. 
 There is no well marked tenderness along the course of the 
 ulnar nerve (supplying the first dorsal interosseous), although, 
 be it remembered, there is some dulling of common sensibility 
 in the hand as a whole. Having found that our patient 
 has the muscles wliich are essential for holding his needle 
 functionally impaired, and also well marked evidence of 
 impaired functions in one of the nerves supplying those 
 muscles, his condition ceases to be a mystery, because we 
 
TATLOE'S CEAMP 81 
 
 can put our fingers on the precise anatomical seat of his 
 troubles. 
 
 We have made an anatomical diagnosis. Can we go a step 
 further and make a pathological diagnosis ? If we could see 
 this patient's median nerve and the muscles which have their 
 irritability impaired should we be able to see anything amiss 
 either with the naked eye or the microscope ? The median 
 nerve is tender and the involved muscles are perhaps a little 
 harder than their corresponding muscles of the left limbs. Is 
 the nerve slightly hypersemic, and is there a slight increase of 
 cellular tissue in the muscle 1 Possibly, but in the absence of 
 any observations it is wiser to say we do not know. The con- 
 dition is brought about by excessive work, and the electrical 
 reactions are those of fatigue, so that we are quite justified in 
 talking of the condition as one of ' chronic fatigue,' especially 
 as such a term does not involve any assertion as to the his- 
 tology of the implicated muscles or nerve. 
 
 Next a few words as to treatment, and as this patient 
 has greatly improved since he has been under observation I 
 will recount what has been done for him. In the first place, 
 he has been ordered to desist from his occupation, rest being 
 the most essential part of the treatment. Rest from the 
 occupation which has brought about the trouble is sufficient. 
 There is no need to put the arm in a sling, as is occasionally 
 done. No harm will result in this case from the use of the 
 arm for all ordinary purposes so long as the fatigue of the 
 thenar muscles and the first dorsal interosseous be not 
 intensified by excessive use of the needle. After rest the 
 next step in treatment is to diminish the tenderness of the 
 nerve-trunks, and to this end we placed three blisters over 
 the tender points along the course of the median ; as a result 
 of this the tenderness has now almost completely disappeared. 
 My experience of these cases has led me to consider that it is 
 very undesirable to use electricity or massage for the muscles 
 so long as the nerve-trunks be tender, and if this be done 
 I believe there is no little risk of making the patient worse 
 rather than better. When, however, any nerve-tenderness 
 which may have been present has been removed by blistering, 
 
 G 
 
82 NEEVOUS AFFECTIONS OF THE HAND 
 
 we may have recourse to electricity or massage with a fair 
 chance of benefiting the patient. 
 
 The use of electricity is attended by good results in a fair 
 proportion of these cases. The galvanic current must be 
 employed, and not the induced current. The latter produces 
 strong tetanic contractions of the muscles, and is apt to 
 intensify the fatigue which it is sought to allay. It is pos- 
 sible that an occasional application of the faradic current 
 may do good by quickening the blood and lymph currents 
 in the muscle, but anything like a continued employment of 
 this form of electricity is calculated to do harm. With the 
 continuous galvanic current, used of a strength sufficient to 
 redden the skin and produce a slight movement in the muscles, 
 it is otherwise. The refreshing effect of this current when 
 applied to acutely fatigued muscles is very remarkable. You 
 will remember that I demonstrated this fact a few days ago, 
 when I asked the patient to keep his arm extended at right 
 angles to his body for as long a period as he could ; and you 
 will remember that the passage of a galvanic current through 
 the arm just when the fatigue pains became almost too intense 
 to bear removed the pain, refreshed the muscles, and enabled 
 the patient to continue the extension of his arm for a very long 
 time. The same refreshing effects are observed when the 
 current is used for the relief of these chronic fatigue diseases, 
 and I strongly advocate its employment in cases where the 
 irritability of the muscles is lessened and the nerve-trunks are 
 7i(>t tender. The employment of massage is very beneficial, but 
 it must be used with judgment, and, like electricity, it must 
 not be used while there is any tenderness of the nerve-trunks. 
 
 The massasfe should be directed to the whole of the 
 implicated limb, and especially to those groups of muscles in 
 which the irritability is lessened. Massage, like electricity, 
 reddens the surface and causes a flow of blood to the limbj 
 and it further quickens nutrition by increasing the current 
 in the deeper blood-vessels and lymphatics. If fatigue be 
 caused by the accumulation of fatigue products in the 
 blood, and if this condition, which we call chronic fatigue, be 
 due to the same cause, then massage and kneading of the 
 
GOLDBEATEE'S CRAMP 83 
 
 muscles must commend themselves as means of cure likely to 
 be beneficial. In any case the result of treatment in this case 
 has been very encouraging, and the combination of rest, 
 blisters, electricity, and massage has had the effect of bringing 
 the muscles to something like their normal condition again, 
 and the patient's power of sewing is very gTeatly increased. 
 
 Internal remedies are not unimportant in these cases. 
 The general health must be attended to, and any derangement 
 in the functions of internal organs be rectified if possible. 
 There is one specific remedy which I very often prescribe, and 
 from which I think I have seen good results. This is arsenic 
 combined with iodide of potassium. Our patient is taking one 
 grain of the latter combined with two minims of liquor arseni- 
 calis three times daily. It is difficult to say which of our 
 remedial measures has been most beneficial, but there is no 
 doubt as to his very great improvement. I believe this to be 
 the only true case of ' tailor's cramp ' that I have ever seen. 
 I have seen many tailors who had a difficulty in the use of the 
 needle, but in all of the cases the difficulty was only an acci- 
 dental complication, so to say, of some other trouble, such as 
 alcoholism, hemiplegia, paralysis agitans, or locomotor ataxia. 
 
 I have often had occasion to remark that all ' fatigue 
 diseases ' are prone to occur in those professions which entail 
 prolonged rather than intermitting muscular contraction. 
 The scrivener may not be able to lay down his pen for hours, 
 but the tailor must relax his grasp of the needle between 
 every stitch. Hence it is that ' writer's cramp ' is very common 
 and ' tailor's cramp ' is very rare. 
 
 The next case is that of a goldbeater by trade, who comes 
 to us complaining that he is unable to wield his goldbeater's 
 mallet with his accustomed force or precision. 
 
 Case 2. — B. H. is fifty-seven years old, and has been 
 engaged at his present occupation for eleven years. He has 
 been a soldier, and served in the Crimea. He has enjoyed 
 good health, and there are no facts in his personal or family 
 history which apparently have any bearing upon his present 
 condition. From the account he gives of his trouble we 
 
 g2 
 
84 NEEVOUS AFFECTIONS OF THE HAND 
 
 gather that he beats gold with a mallet weighing about 
 sixteen pounds ; that his difficulty consists not in any cramp 
 or spasm of the hand, but rather in a general weakness, 
 which makes it necessary for him to shift his mallet at 
 frequent intervals into the left hand, which obliges him to 
 grasp the mallet with abnormal firmness, and which inter- 
 feres at once with tlie force of the blow and the exactness 
 of aim. The patient is thin and emaciated, and has a worn 
 look, as though he had worked hard and had not fed very 
 well. On asking him to strip to the waist, we notice he is 
 thin, but we are unable to detect any morbid condition of 
 the muscles of the uf)per limbs. There is v:ell inarked tremor 
 of both hands, especially when they are extended in front 
 of him. This tremor is rather more marked in the right 
 hand than in the left, and on looking attentively at the 
 right hand we are able to say that the tremor is more 
 marked in the thumb than elsewhere. This intensification 
 of tremor in certain places is important, and not infrequently 
 gives us a clue to the muscles which are especially implicated. 
 I have occasionally noticed that tremor in a limb is not 
 noticeable until some group of muscles which is morbidly 
 weak is brought or is attempted to be brought into action. 
 Then the tremor Ijegins sometimes in the limb as a whole, 
 and sometimes only in some small section of the limb, 
 which is moved by a muscle which is especially weak. It 
 is important, therefore, to notice that not only is there 
 tremor of both hands, but that the tremor is more marked 
 in the right hand than the left, and most marked of all in 
 the thumb of the right hand. The tongue is tremulous as 
 well as the hands. The tremor of the hands is not intensi- 
 fied by the attempt to perform any delicate act such as the 
 picking up of a scraj^ of paper. The palm of the right hand 
 has several corns upon it, but these, he says, are not cha- 
 racteristic of his trade. ' Not one goldbeater in five hundred,' 
 he says, ' has such corns.' ' They are due to my being obliged 
 to grasp the mallet so tightly.' There are one or two corns 
 on the left hand also, which is due to the fact that he is 
 obliged to use his left liand when his right hand gets tired. 
 
GOLDBEATEE'S CEAMP 85 
 
 Both arms are tender, especially tender over the nerve-trunks. 
 The right arm is more tender than the left, but he shrinks as 
 if in considerable pain when very moderate pressure is made 
 on either arm, especially over the trunk of the median nerve 
 as it lies to the inner side of the bicej)s tendon. There are no 
 tender points in the palm. On testing the muscles with 
 faradisation it is noticeable that all the muscles respond 
 equally on the two sides, with the exception of the muscles of 
 the right thenar eminence and the right flexor longus poUicis, 
 in which, especially the latter, there is observed a well marked 
 depression of the normal irritability — i.e. a current which 
 causes a forcible contraction of these muscles on the left side 
 has little or no effect upon those on the right side. It is 
 obvious that in the grasp of a goldbeater's mallet the muscles 
 of the thumb are all-important. It is very interesting also 
 to note this depression of irritability, especially in connection 
 with the distribution of tremor, upon which I have just been 
 remarking. Now although we have made in some sort an 
 anatomical diagnosis in this case, and although we have 
 demonstrated that certain muscles of the right thumb, muscles 
 essential for a goldbeater's work, are abnormally weak, I am 
 in doubt whether we ought to regard the case as a true fatigue 
 disease or professional ailment. The patient is nearly sixty, 
 and is emaciated and tremulous, the tremor being quite 
 independent of his work, and noticeable, be it observed, in 
 the tongue as well as the hands. I regard the case as one 
 of senile tremor occurring in an over- worked and ill nourished 
 man, whose arteries are certainly degenerating, and whose 
 nerve-centres are beginning to be imperfectly nourished. 
 When senile tremor commences it is not surprising that it 
 should show itself most and earliest in the muscles which 
 are most used. This seems to be the case in the patient 
 under observation. The man is very feeble, and especially 
 feeble at his trade, which is a laborious one. Such cases 
 must not, I think, be classed with the true professional ail- 
 ments caused by fatigue, in which an otherwise strong and 
 healthy subject finds himself incapable of some one delicate 
 manipulation. The treatment in the present case must be 
 
86 NEKVOUS AFFECTIONS OF THE HAND 
 
 directed to the improvement of the general health, food and 
 warmth, rest and tonics. 
 
 Case 3. — The next case I have to bring to your notice 
 is one in which a man has been rendered unfit for followinof 
 his trade owing to the toxic effects of the trade which he fol- 
 lows. It is, in short, a case of mercurial tremor. The patient 
 is an Italian aged sixty-two. He came to this country when 
 he was seventeen years old, and for the past thirty-four years 
 he has been a looking-glass silverer. His duty is to ' run ' the 
 mercury over tinfoils spread upon sheets of glass. He is 
 therefore constantly handling mercury, and is exposed to its 
 fumes. He is a strongly- built, dark-haired, olive-complexioned 
 man, of cheerful manner and well nourished. He is hard 
 working and temperate, and there are no facts in his imperfect 
 family history which have any bearing upon his present con- 
 dition. A careful medical examination leads to the conclusion 
 that, with the exception of the tremor, the patient is in per- 
 fect health. The tremor affects the hands mainly, and the 
 right hand more than the left. When the patient is at rest 
 the hands and arms are steady, but the instant that he at- 
 tempts to use the hands the trembling and shaking become 
 excessive. He cannot pick up a scrap of paper, he cannot 
 feed himself, and is obliged to drink through a glass tube 
 owing to the impossibility of holding a cup steadily to his lips. 
 There is some slight tremor of the legs, but this is scarcely 
 noticeable, and does not prevent him from walking freely 
 about. There is no tremor of the face or tongue, and no marked 
 change of speech. The eyesight is good ; no nystagmus ; no 
 change in the discs. Turning to the hands, it is noticeable 
 that the tremor is very coarse, and that when he attempts to 
 use his hands they jerk to and fro through several inches of 
 space. There is no wasting or paralysis of any muscle, no 
 rigidity or contraction of any muscle, and no deformity of the 
 hand. There is no marked tenderness of any nerve, no joint 
 affection, no trophic change, and the muscles respond normally 
 to electricity. This apparently is the third attack of 'the 
 trembles ' from which the patient has suffered. The first was 
 twenty-six years ago, and his arms, legs, and head shook 
 
MEECUEIAL TREMOE 87 
 
 equally. He was treated for thirteen weeks in the London 
 Hospital and completely recovered. About eight years after 
 the first attack (i.e. eighteen years ago) he had a second attack. 
 In this the legs were mainly affected, and occasionally trembled 
 to such a degree that he was obliged to crawl upon his hands 
 and knees. The arms were also affected, but less so than on 
 the present occasion, for he could always feed himself. At 
 this time he lost several of the teeth, the gums were ulcerated, 
 and there was tremor of the tongue and an affection of the 
 speech so that he could hardly get his words out. From this 
 second attack he also completely recovered and returned to his 
 work. He was able to follow his occupation (except during a 
 short attack of ' lumbago ' some eight years ago) until Christ- 
 mas, 1888, when his arms began to tremble, and, his troubles 
 increasing, he ultimately sought advice here, and after some 
 three weeks' attendance in the out-patient department he was 
 admitted as an in-patient at the end of February, 1889. Our 
 patient was treated with hot sulphur baths and iodide of 
 potassium, and left the hospital much improved and able to 
 feed himself, but still far from well. 
 
 Cases of mercurial tremor are of rare occurrence in this 
 country, although cases are met with among workmen whose 
 occupation brings them in contact with mercury or its salts. 
 The danger appears to be greatest in those cases where 
 (as in 'water gilding') heat is employed to volatilise the 
 metal ; but, now that electro-plating has supplanted gilding 
 by means of mercurial amalgams, such cases are rarely 
 seen. Our patient is a mirror maker, and therefore belongs 
 to a class of workmen who have always been recognised 
 as liable, but not very liable, to chronic mercurial poison- 
 ing. Mirrors are, however, made largely now by means of 
 chemical methods, in which the salts of silver and not those 
 of mercury are employed, and mirror-makers by the old- 
 fashioned method of using a tin-mercury amalgam are a 
 dwindling class. Rare as these cases are, they are likely, there- 
 fore, to become more rare. The point of main interest in the 
 case is the diagnosis. This is made for us to a large extent by 
 a knowledge that the patient is exposed to mercurial fumes in 
 
88 NERVOUS AFFECTIONS OF THE HAND 
 
 his business, and by the patient's own experience, this being 
 the third attack of ' the trembles ' from which he has suffered. 
 But, without the history to guide us, should we feel sure as to 
 the diagnosis ? The tremor in this case is the only symj)tom 
 of mercurialism, and is the tremor sufficiently characteristic to 
 warrant us in attributing it to that cause ? The tremor began 
 in the hands, and is mainly limited to the hands. This is said 
 to be characteristic of mercurial tremor, although it is no 
 absolute rule, for even in this patient's previous attacks the 
 legs mainly suffered upon one occasion, and upon another the 
 head trembled and speech was affected, which is not the case 
 now ; for, although the patient speaks English like an Italian, 
 there is no other peculiarity of articulation. The tremor is so 
 coarse, jerking, and peculiar that it does not suggest tremor 
 from alcohol, paralysis agitans, senile weakness, or 'general 
 paralysis.' It only occurs when the patient attempts to use 
 the hand for the purpose of a voluntary act. In this parti- 
 cular it resembles the tremor seen in cases of so-called ' dis- 
 seminated or insular sclerosis,' and the diagnosis, judging only 
 by the tremor, would be between that condition and mercurial- 
 ism. That the tremor of disseminated sclerosis and mercurial- 
 ism may be practically identical in form seems to be admitted 
 by Charcot and other observers. The age of our patient is 
 against the diagnosis of disseminated sclerosis, that disease 
 seldom commencing after forty, and terminating fatally within 
 a few years of its commencement. The absence of nystagmus 
 is also against the diagnosis of dessenunated sclerosis, as is 
 also the fact that the superficial and deep reflexes are in the 
 present case practically normal instead of being exaggerated, 
 as is often the case in disseminated sclerosis. The absence of 
 any speech difficulty is against the diagnosis of disseminated 
 sclerosis, but since its absence is, so to say, merely accidental, 
 and his present attack differs from his last in this particular, 
 this is a point of not much value. Speech is often affected in 
 both these conditions, so that changes in articulation are of 
 doubtful value in the differential diagnosis of the two conditions. 
 Case 4. — The last case is that of a mat-maker, aged forty, 
 who was admitted to the hospital with his left arm stiff, 
 
CONTEACTUEE OF AEM 89 
 
 contracted, and absolutely useless, so that he is quite unable 
 to follow his occupation. On examining the arm it was found 
 to be contracted and stiff. The humerus was adducted to the 
 side of the chest, the elbow flexed, and the wrist and fingers 
 flexed. On attempting to move the limb passively it was found 
 that all the joints were very stiff, and creaked audibly. The 
 power of voluntary movement was almost nil. Sensation but 
 little impaired. The state of nutrition of the left arm and 
 hand, especially the latter, was obviously defective. The limb 
 as a whole was emaciated. All the muscles were small, but 
 there was no muscle or group of muscles which was atrophied 
 in any special degree. The left hand was very markedly 
 smaller than its fellow, the skin harsh and dry, the finger nails 
 deeply grooved, pitted, and incurved. The state of the hand 
 and the contrast in the two hands are well shown in the 
 accompanying drawings kindly made for me by Mr. Wells, 
 M.B. (See figs. 2 and 3.) The sensibility of the left arm and 
 hand is slightly impaired. All the muscles of the left hand and 
 arm respond normally to faradisation, "With the exception of 
 the arm the patient appeared healthy. He was somewhat 
 thin, but all the organs appeared to be in a normal condition. 
 It is not possible to form a judgment as to the pathology of 
 this man's condition without reference to the history. The 
 patient has had four attacks of rheumatic fever, viz., in 
 1876, 1879, 1881, and 1885, and it was after the last attack 
 that the left arm and hand became stiff and powerless. 
 The history of his last attack is very important, and I 
 may add that it was elicited only after careful questionmg — 
 questioning which was instituted because (as will be presently 
 explained) the condition of the left hand and arm was sugges- 
 tive of cerebral mischief. The patient lives at Sudbury in 
 Suffolk, and he states that on March 18, 1885, he felt ' dizzy ' 
 before going to his work, that he had to leave his work because 
 he felt ill ; and that on his way home he sat by the roadside, 
 and lost consciousness for tioo hours in consequence, as he says, 
 of faintness. This attack was followed by the ' rheumatics,' 
 which kept him in bed. The left arm was swollen, and re- 
 mained so for three weeks, and when the swelling subsided the 
 
90 
 
 NEKVOUS AFFECTIONS OF THE HAND 
 
 arm was stiff and the fingers contracted. The patient further 
 states that at this time he had some loss of taste on the left 
 side of the tongue, some numbness of the head, and some 
 impairment of vision. It is all-important to bear in mind that 
 the condition of the left arm from which this patient is suffer- 
 
 FiG. 2. 
 
 ing, although originating in a condition of obvious rheumatic 
 swelling, came on after an attack of loss of consciousness, which 
 was immediately followed by sensory troubles. I do not think 
 that the cause of the arm trouble in this case is purely local 
 and rheumatic, but I am of opinion that there is cerebral 
 
CONTKACTUEE OF ARM 
 
 91 
 
 mischief as well, and that one element (perhaps the most 
 important element) of the condition is hemiplegic contrac- 
 ture ; and I say this notwithstanding that the evidence of 
 hemiplegia other than the state of the arm is practically nil^ 
 and there is no cardiac murmur, which might suggest the 
 
 .^^.frfTT''^ 
 
 Fig. 3. 
 
 probability of embolism as a cause of the trouble. This question 
 is of great importance from the point of view of prognosis. If 
 the trouble be local and rheumatic there are possibilities of 
 absolute cure, which can hardly exist if the voluntary centre 
 for the arm be destroyed. Why, it will be asked, do I 
 
92 NERVOUS AFFECTIONS OF THE HAND 
 
 think that there is cerebi'al mischief ? Because the left 
 upper limb has all the appearance of ' contracture ' after 
 cerebral lesions. The arm is adducted, and the whole limb 
 is uniformly flexed, and an examination of the hand shows 
 that the fingers can be easily straightened, the contracture 
 being due to a shortening of the flexor muscles, and not 
 to any stiffening or deformity of the finger joints. Again, 
 all the muscles respond normally to faradisation, and there 
 is no marked wasting of any of them, although there is 
 general emaciation of the whole limb. In cases of old 
 rheumatic paralysis due to the involvement of nerve-trunks 
 in rheumatic exudations it is usual to find that some 
 of the muscles are markedly atrophied and give degenera- 
 tive reactions. The condition of the arms without a word 
 of history would lead one to suspect a central cause 
 for the mischief. When to this is added ' faintness ' and loss 
 of consciousness as the initial feature of the trouble, I think 
 there is scarcely room to doubt. On the other hand, there 
 are features in this case which seem to show that hemiplegic 
 contracture, if such it be, is complicated by a distinct local 
 rheumatic condition. We have the history of a swelling of 
 the left arm and hand in his last attack of rheumatism, and 
 we find now that there is a marked amount of stiffiiess of the 
 big joints of the limb and audible creaking when they are 
 forcibly moved. All joints which are not sufficiently used, 
 and which are maintained in the same position, are apt to get 
 stiff", and to creak when forcible movements are imposed upon 
 them ; but in this case there has probably been definite 
 rheumatic exudation, as we gather from the history and infer 
 from the degree of stiffness. There are other considerations 
 which warrant us in believing that at some time the nerve- 
 trunks which cross the scapulo-humeral joint were to some 
 extent involved in and compressed by rheumatic exudation. 
 My chief reason for this belief is the condition of the hand. 
 The wasting of it is greater than is usually observed in cases 
 of hemiplegia ; and the condition of the finger nails, which 
 are markedly grooved and pitted and incurved, is very 
 suggestive of a true tropho- neurosis or a change in nutri- 
 
CONTEACTUEE OF AEM 93 
 
 tion brought about by pressure on or injury to a mixed nerve. 
 There is some harshness and dryness of the skin of the left 
 arm and hand, and also some slight impairment of common 
 sensibility which point in the same direction. We must 
 remember that the last rheumatic attack was more than four 
 years ago, and that time enough has been allowed for rheumatic 
 exudations to be absorbed and for recovery of damaged nerve 
 to take place. I therefore regard the condition of the nails and 
 the excessive wasting of the hand as evidence of what has 
 been rather than of what actually exists at present. 
 
 The case is not without its difficulties, but, to sum up, I 
 may state my belief that the condition of this patient's left 
 hand and arm is partly due to a cerebral damage and partly 
 to a local rheumatic trouble. What was the nature of the 
 cerebral mischief ? As it occurred at the commencement of 
 a fourth attack of acute rheumatism, it very possibly was 
 embolic, although at the present there is absolutely no evi- 
 dence of any morbid condition of the heart. We are free to 
 imagine a slight degree of hypersemia and swelling of a valve 
 sufficient to give rise to a deposit of fibrin, and we can imagine 
 such deposit being washed off and lodging in one of the branches 
 of the Sylvian artery, giving us a ' brachial monoplegia ' 
 and leaving the heart practically sound. I say we can imagine 
 this, and there is no harm in doing so if we distinguish between 
 imaginings and proved facts. The case presents difficulties 
 from every point of view, but these speculations are by no 
 means idle, because they have a most important bearing on 
 the prognosis, as I have explained. The results of treatment 
 in the case under consideration have been most excellent up to 
 a certain point. When we have to do with a limb which is 
 stiffened, wasted, and beyond, so to say, the reach of the will, 
 our chief aim should be to replace voluntary exercise by every 
 means which is available, and passive movements, rubbing, 
 artificial warmth, and electricity will be found of service. 
 With a limb in the condition of the one we are considering 
 the worst course to pursue is to leave it alone, for it will in- 
 evitably result that the disused joints will get, so to say, glued 
 up, and the limb will soon assume a position of stiffened con- 
 
94 NEEVOUS AFFECTIONS OF THE HAND 
 
 tracture, as has happened in the case under consideration. 
 Every joint must be methodically worked in every direction so 
 as to maintain absolute freedom of movement. I do not 
 think that, unless the stiffness be very excessive, much good is 
 got by forcible movement under an anaesthetic. If, after such 
 forcible movement, daily exercises and passive movements be 
 not persisted in the joint will soon be glued up as tightly as 
 before, and since the daily exercises are iri any case necessary 
 it is generally advisable to trust to these alone, and to a mode- 
 rately forcible and judicious coaxing of the stiffened limb, 
 rather than a too forcible extension. This has been done in the 
 present case with admirable zeal by my clinical clerk, and with 
 the best results, as the stiffness and creaking of the joints 
 have disappeared, and the freedom of movement of shoulder, 
 elbow, wrist, and finger joints has been greatly increased. The 
 next point is to improve the nutrition of the limb, and this is 
 done by causing a ' determination of blood ' to it. The passive 
 movements of the joints have done much to quicken the blood 
 stream. In fixed limbs the venous current does not receive the 
 help of movement, whether articular or muscular, and the passive 
 movements of the joints and the kneading of the muscles do 
 much to counteract the evils of this deficiency. Artificial warmth 
 is all-important in improving the nutrition, and to warmth 
 should be added a stimulation of the skin sufficient to produce 
 a thorough redness of the surface. Such a limb should be kept 
 in a flannel sleeve, and the hand should be covered with a warm 
 glove so as to run no risk of its getting chilled. Warm bath- 
 ing is also of great use, and when the trouble is strictly local, 
 as in this case, a soaking of the limb in hot water is of service, 
 the soaking being followed by passive movements and massage. 
 It is of some use, probably, to add salt to the water, as thereby 
 its stimulating effect upon the surface is increased. Had our 
 patient been rich he would very probably have been sent to Bath, 
 Aix-les-Bains, or some similar place, where the machinery for 
 bathing and rubbing and douching has been elaborated to the 
 utmost ; but I would have you observe that it is possible to 
 do a great deal by similar methods employed tuith a will at 
 home. 
 
CONTRACTUEE OF ARM 95 
 
 Electricity is of great service in these cases. If the irri- 
 tability of the muscles is lessened the application of 
 faradisation is often very useful, and it should be employed 
 until the irritability reaches the normal. There has been no 
 noticeable diminution of irritability in this case, and none of 
 the muscles give the ' degenerative reactions,' so that the good 
 effects of faradisation have not been as noticeable as some- 
 times is the case. The good effects of faradisation are, in 
 cases like this, often very marked at first. By its use we 
 succeed in ' stirring up ' the disused muscles, and greatly 
 increased freedom of movement is the result. The effect of 
 the first application is often very marked, occasionally it is 
 astounding, while subsequent applications produce hardly any 
 noticeable effect. The continuous current is also extremely 
 serviceable. Large sponge rheophores should be used, and 
 these should be moistened with salt-and-water made as hot as 
 it can be borne. I know of nothing equal to this as an 
 effectual skin reddener, and it is undoubtedly to its power in 
 this direction — the causing a ' determination of blood ' to the 
 limb — that much of the utility of the continuous current is 
 due. Cases of this class are often very chronic. Chronic 
 rheumatic affections are very prone to last (with considerable 
 exacerbations and remissions) for a lifetime, and contractures 
 following upon cerebral lesions will certainly do so. The 
 patient's discomforts are very much lessened if we can main- 
 tain the nutrition and the suppleness of the limb. This is 
 done by the methods I have indicated, and it is very advisable 
 to use one method at a time and not to exhaust your resources 
 all at once. Human nature loves a change, and will have a 
 variety, and far be it from me to say that change and variety 
 are not of solid use. We all strive to get, and all enjoy, a 
 change in the matter of diet, and that much in excess of what 
 the physiologists tell us is necessary. So the chronic invalid, 
 the nutrition of whose paralysed or rheumatic limb has to be 
 artificially maintained, will have a change of method. It is 
 therefore advisable to use one method at a time. Massage, 
 hot bathing, electricity, liniments, &c., are all means of main- 
 taining nutrition, and when the patient has tired of one 
 
•96 NERVOUS AFFECTIONS OF THE HAND 
 
 method we may try a second. As soon as the limb is left to 
 itself it will stiffen and get glued up and fixed. The great use 
 of liniments in such cases is found in the fact that they are all, 
 so to say, vehicles for friction. The only thing to bear in mind 
 about them is that they should be oily and not too stimulating. 
 Great care must be taken that no excess of zeal in the matter 
 of rubbing produces any abrasion of the skin, and it is in order 
 to avoid the risk of skin abrasion that I recommend the use 
 of oily liniments, which serve to lubricate the surface. It is 
 needless to say that the patient should be encouraged to use 
 the damaged limb as much as possible, and the exercises pre- 
 scribed will of course depend upon the amount of voluntary 
 power. In order to keep the shoulder- and elbow -joints 
 supple it is a good plan to get the patient to work the limb by 
 means of an elastic band with a stirrup handle, which must be 
 hung to the ceiling or the wall of his room. With methods like 
 those I have been describing our patient has improved very 
 rapidly indeed iiip to a certain point. The joints move easily, 
 and the contraction of the arm and fingers has disappeared. 
 His power of using the limb has not kept pace with the greatly 
 improved local condition, and it is this fact which strengthens 
 and confirms me in the diagnosis of a central cerebral lesion in 
 addition to his local rheumatism. By local measures we may 
 succeed, as we have done, in loosening stiffened joints and in 
 improving local nutrition. There is, however, the scar of an 
 old injury in the area for the arm in the motor region of the 
 cortex cerebri on the right side. This is not to be reached by 
 our rubbings, frictions, and electricity, and, although the local 
 improvement has been immense, there has not been and never 
 will be any commensurate improvement in the voluntary use 
 of the limb. It is easy, therefore, to see the great importance 
 of diagnosis and its influence on prognosis. 
 
97 
 
 CHAPTER IV 1 
 
 CASE OF hammerman's CRAMP 
 
 The case which I wish to bring to your notice to-day is one 
 belonging to the class of ' professional ailments,' in which the 
 constant repetition of the same movements begets an inability 
 to perform that movement — a movement which often consti- 
 tutes the profession of the sufferer, and is his sole source of 
 income. 
 
 Careful examination of these cases has shown me that the 
 breakdown is generally most evident in those muscles which 
 are subjected to prolonged strain rather than in those in which 
 the periods of contraction and relaxation are more equally 
 divided. Thus in writer's cramp it is the muscles of pen- 
 prehension rather than those of pen-movement which are 
 liable to fail. In the comparatively few cases of pianist's 
 cramp which I have seen the extensors of the wrist and the 
 near phalanges have been at fault. In a packing-case maker 
 who could not wield his saw the chief trouble seemed to be 
 in the supra-spinatus muscle, which during the act of saw- 
 ing is subjected to prolonged strain. ' Dancer's cramp ' would 
 probably be unknown if rhythmical movements, such as con- 
 stitute dancing proper, alone were executed. It occurs only 
 in those who abandon the rhythm which is the very essence of 
 dancing for the performance of an acrobatic tour deforce. 
 
 The following history of our patient is summarised from 
 the very excellent record which has been made by Mr. L. 
 Barnett, house physician. 
 
 J. M , aged 25, nailmaker, admitted February 2, 1886. 
 
 He is a piece-worker — i.e. the more nails he can make the 
 more money he will earn. He has worked from 7 a.m. to 
 
 1 Clinical Lecture, U.C.H., 1886. 
 
 II 
 
98 NEEVOUS AFFECTIONS OF THE HAND 
 
 7 P.M., with about forty minutes' interval for meals. He 
 has worked in a hot place indoors, and has been in the 
 habit of taking three or four pints of beer per diem with 
 occasional spirits. There is nothing in the family history of 
 definite import, but the death of his parents at 54 and 50 and 
 the loss of eleven brothers and sisters (out of thirteen) in 
 infancy make it probable that our patient's ' constitution ' is 
 not very robust. His work consists in forging nails with a 
 moderately light hammer. The iron is seized with pincers in 
 the left hand, placed in position, and then forged into shape by 
 a rapid succession of blows dealt by the hammer in the right 
 hand. The onset of his trouble was almost sudden. He 
 states that on Monday, June 8, 1885, after he had been at 
 work for about two hours, he was seized with an inability to 
 direct the blows with his right hand. The trouble increased 
 during the ensuing three hours, when, in consequence of the 
 intense feeling of fatigue, he was obliged to ' knock off work ' 
 for the day. On June 9 he managed, by dint of holding the 
 elbow close to the side, to get through his day's work. On 
 June 10, 11, 12, and 13 he worked as well as ever. On the 
 following Monday (June 15) his trouble returned, but not to 
 the same extent, and he got through his week's work fairly 
 well by holding his elbow close to the side. After this the 
 feeling of loss of aim in the arm recurred every Monday, and 
 gradually wore off during the week, but the period it took to 
 wear off got greater each time. By September the constant 
 pressure of the elbow against the side produced soreness, and 
 when attempts were made to keep the arm against the side 
 the limb jerked, so that further work became impossible, and 
 on September 4 he had to leave it off. The patient states 
 that after this everything he did with his right arm was done 
 clumsily. He was then admitted into the Royal Free Hospital 
 under Dr. Harrington Sainsbury, by whose kindness I first 
 was enabled to see him. 
 
 Leaving the Royal Free Hospital, he next went to St. 
 Bartholomew's, and from the latter institution he came here. 
 On admission the ' present state ' was taken with great care 
 and minuteness by Mr. Barnett. On the chest are a few 
 
CASE OF HAMMERMAN'S CRAMP 99 
 
 small scars, the result of burns from sparks ; otherwise the 
 skin is normal. The circulatory, respiratory, digestive, and 
 genito-urinary systems present no abnormalities of any kind. 
 The temperature during his stay in hospital was always normal, 
 but the pulse, when recorded, was found to be rather infre- 
 quent, being 62 on one occasion and 56 on another. 
 
 As regards the nervous system, it is noted that the intelli- 
 gence was good, that there was no headache, and that the 
 special senses were normal. The third, fourth, fifth, and 
 sixth cranial nerves were apparently normal. The right naso- 
 labial fold was rather less marked than the left ; the mouth 
 dropped a little on the right side when at rest and moved a 
 little less vigorously than the left side. The tongue is slightly 
 tremulous when protruded, and the median furrow deviates 
 very slightly to the right side. The right upper limb, if care- 
 fully observed, will be noted to be seldom or never quite still. 
 "When sitting up with the arms hanging by the side the right 
 arm is the seat of constant slight movements — elevation, and 
 adduction of the humerus, and flexion of the elbow. When 
 an attempt is made at voluntary movement the spasmodic 
 action of the muscles of the upper limb is increased. The arm 
 is held fixed to the side, the wrist is extended, the hand 
 supinated and closed. The spasmodic action is seen to extend 
 to the deltoid, trapezius, and pectoral muscles. The right 
 sterno-mastoid is also slightly afiected. When an attempt is 
 made to use the hammer the spasm reaches its maximum, 
 and afiects the right arm and shoulder to an extent which 
 makes analysis impossible. It is evident that some of the 
 muscles attached to the scapula are in an abnormal condition. 
 I have followed my invariable plan and have carefully out- 
 lined both scapulae with a blue pencil. By this means we see 
 that the inferior angle of the right scapula is at a higher level 
 than the left, that the distance between the mid-vertebral 
 line and the base of the scapula is 5 inches on the right side and 
 4 J inches on the left. The spinal border of the right scapula is 
 somewhat tilted, and stands away from the surface of the 
 back. The mass of the rhomboid muscles is very distinctly 
 larger on the right side than the left. Looking to the lower 
 
 H 2 
 
100 NERVOUS AFFECTIONS OF THE HAND 
 
 axillary region, it is evident that the mass of the serratus 
 magnus muscle is distinctly less evident on the right side 
 than on the left. There is nothing wrong with the lower 
 limbs except that the plantar reflex is more marked on the 
 right side than the left. Sensation is everywhere normal. 
 The muscles were tested electrically. When I first saw this 
 patient at the Royal Free Hospital, with Dr. Sainsbury, the 
 irritability of the right serratus magnus to both forms of 
 current was distinctly diminished. Now, however, the 
 difference in irritability of the two serrati is scarcely notice- 
 able. The patient is free from pain. After attempts at 
 voluntary use of the arm there is a sense of fatigue and 
 some aching, especially beneath the prominent rhomboid 
 muscles on the right side, but beyond this his condition 
 causes no suffering. None of the nerve -trunks are in the 
 least tender. It is very evident that the spasm is not now 
 special to the performance of his professional act of hammering. 
 When he is asked to write he picks up the pen with his left 
 hand and then transfers it to the right, and his attempt tO' 
 sign his name is interrupted by repeated slight shocks of 
 spasm, and the resulting signature bears evidence of the 
 jerking of the hand. No treatment has been of any service 
 to him. He has previously been in two hospitals without 
 benefit. In this hospital he has had electrical treatment, and 
 in addition he took one-sixteenth of a grain of extract of 
 physostigma from February 6th to the 15th, and twenty 
 minims of paraldehyde three times daily from February 15th 
 to the 21st. He is no better. 
 
 There are some points about this patient to which I desire 
 to direct your attention, because they seem to me to place 
 his case in a category different from some of the other pro- 
 fessional ailments to which I have alluded. First, as to the 
 mode of onset ; it is to be noticed that it was comparatively 
 sudden, and the patient fixes the date absolutely, and he 
 states that before June 8, 1885, he had no trouble at all, 
 but since then he has never worked satisfactorily. In most 
 other ' professional ailments ' the onset is gradual, the loss 
 of function increases by scarcely perceptible degrees, and 
 
CASE OF HAMMERMAN'S CRAMP 101 
 
 for a patient to be able to fix the exact day of onset is 
 infinitely rare. I took occasion to tell you in my preliminary 
 remarks that these professional ailments most commonly 
 affect movements which necessitate, as in writing, a pro- 
 longed contraction of muscles. Now, in hammering it is 
 difficult to say where (if anywhere) this prolonged contrac- 
 tion occurs. It would be most likely to occur in some of 
 the muscles which steady the shoulder, and the permanent 
 slight displacement of the right scapula in the case we are 
 considering rather favours such an idea, but I am unable to 
 say anything more definite. 
 
 The act of hammering is probably less automatic than 
 many other acts of a similar kind. The action of the right 
 hand depends to a certain extent upon that of the left, which 
 places the metal in position for being struck. The action of 
 the left hand in selecting and placing in position the nails 
 to be forged is far from being a mere monotonous repetition 
 of the same act, and hence the position of the nail when 
 receiving the blows from the hammer must be to some ex- 
 tent uncertain. Hence it follows that each blow with the 
 hammer involves the taking aim and the exercise of no in- 
 considerable amount of judgment. The act is as much 
 mental as it is automatic, and both arms and the eyes have 
 to act in harmony for its accomplishment. It seems to me 
 such an act as would be likely to produce a considerable 
 amount of mental worry, which would be redoubled on the 
 first appearance of any failure of accuracy. The repetitions 
 of the act were very numerous, and during the eleven hours 
 of work very many thousand blows with the hammer must 
 have been delivered. Dr. Frank Smith of Sheffield, who 
 published a very able paper on this subject in the ' British 
 Medical Journal' of October 31, 1874, estimated that a pen- 
 blade forger who suffered similarly to our patient delivered 
 about 28,000 blows per diem, and if we assume that the 
 hammer weighs 3 lb. and is lifted 1 foot for the delivery of 
 each blow, this amounts to 35 foot-tons per diem. If we 
 assume that the wovk of delivering the blow is equal to 
 that of raising the hammer, and if we add to the weight of 
 
102 NEKYOUS AFFECTIONS OF THE HAND 
 
 the hammer the weight of the arm, we must allow that the 
 work done is about 150 foot-tons per diem. This is by no 
 means a very excessive day's work. 
 
 You will observe that, as I ha^e previously said, the 
 trouble is by no means limited to the act of hammering. 
 It very obviously interferes with the accuracy of all volun- 
 tary efforts of the right hand, and, indeed, the spasm is 
 noticeable to some extent when the patient is making no 
 voluntary effort with it. It is, or used to be, stated in text- 
 books that in these cases, beyond the professional trouble, 
 there is nothing detectably wrong, and that all movements, 
 excepting the professional movement, are perfect. I dissent 
 from both these statements ; but, nevertheless, the present 
 case differs from the great majority of professional troubles 
 in the very large amount of peripheral evidence of mischief 
 which is present and the rapidity with which the motor 
 trouble has spread, as it were, from the professional act to 
 the involvement of other acts. Indeed, one cannot escape 
 from the belief that the motor trouble is part of a hemi- 
 plegia, for added to the disorderly movements of the upper 
 limb we have evidence of slight failure of the right side of 
 the face and the right half of the tongue, and probably 
 the exaggerated plantar reflex on the right side tells of 
 diminished cerebral control over the right leg. These trifling 
 signs of hemiplegia, added to the fact of comparatively 
 sudden onset, make it highly probable that the lesion, 
 whatever it may be, would be found in the motor area of 
 the cerebral cortex on the left side. In addition, notwith- 
 standing that I can find no defect of intelligence of any 
 definite kind, I confess that there is something vacuous in the 
 expression of his face which, added to a certain listlessness 
 of manner and utterance, leaves upon me the impression that 
 mentally he is below the average. He further admits that 
 since his trouble he is more easily moved to anger than formerly 
 was the case. 
 
 There is now loss of control over a large group of muscles, 
 and the history of the case makes it probable that at the 
 beginning of his trouble the area of diminished control was 
 
CASE OF HAMMERMAN'S CKAMP lOB 
 
 smaller than at present, and possibly was limited to one or 
 two muscles, or perhaps a single muscle. That the serratus 
 magnus was the first, or one of the first, muscles to be 
 affected seems to me very likely. It certainly is smaller 
 ihan its fellow ; it certainly was at first less irritable to both 
 forms of the electric current than its fellow ; it was the 
 only muscle that I could definitely say was not in a healthy 
 condition ; it certainly is brought into play whenever the 
 £,rm is raised in the act of hammering, and most certainly 
 the plan adopted by the patient of holding the elbow close 
 to his side in the act of hammering would enable him to do 
 without scapular movement, and thus save the muscle over 
 which control had been lost. Again, the slightly faulty 
 position of the right scapula points to some weakness of 
 the serratus magnus. The slight tilting backwards of the 
 vertebral border and the slight elevations of the lower angle 
 are both indications that the serratus is weak, and the large 
 size of the rhomboid muscles on the right side looks as if they 
 had been employed to compensate for the weakness of the 
 serratus and had been used for steadying the scapula. The 
 prominence of the rhomboid muscles, even when the scapula 
 is at rest, coupled with the fact that the vertebral border of 
 the right scapula is ^ inch further from the middle line than its 
 fellow, led me to think that possibly a bursa or abscess had 
 formed beneath the muscles, and at my request Mr. Godlee 
 very kindly inserted an aspirator at the spot where the 
 prominence is most marked, but with no result. 
 
 This case is of interest because of its rarity. It is the first 
 of its kind that I have seen, and for me its chief interest lies 
 in the fact that in many points it offers a striking contrast 
 to all the other cases of professional ailments (and they are 
 not few) which I have seen. In every case of professional 
 trouble that I have seen I have been able, as in this one, to 
 detect peripheral evidence of mischief, but this one is ex- 
 ceptional in the fact that the peripheral evidence is evidence 
 of cerebral mischief, and enables us to conclude that the 
 lesion is in the brain. This is the only case of hammerman's 
 cramp that has come under my notice, and the only record of 
 
104 NERVOUS AITECTIOXS OF THE HAND 
 
 similar cases which I can find is in the short paper by Dr. 
 Frank Smith previously alluded to. He was physician to the 
 Sheffield Infirmary, and had seen, naturally, a very large 
 number of hammermen among the patients of the infirmary, 
 and he has placed upon record eight cases analogous to the 
 one we are discussing, and which he called cases of ' hephestic 
 hemiplegia or hammer palsy,' the word ' hephestic,' it is per- 
 haps necessary to state, being derived from the Greek word 
 'H^aioToc, Vulcan. Of these eight cases six were distinctly 
 hemiplegic in character, while two were cases of brachial 
 monoplegia. In one there was spasm with wasting of the 
 forearm. In one other case there was spasm. In the other 
 cases the symptoms were paralytic, and in four of the cases 
 there was derangement of tactile sense. The ages of Dr. 
 Frank Smith's patients were thirty-one, forty, thirty-two, 
 eighteen, twenty- four, thirty-five, twenty-nine, and fifty-five. 
 He alludes to the points of similarity between these cases and 
 those of writer's cramp, but says that the disease positively 
 differs from writer's cramp in the fact that the cerebral centres 
 are implicated. 
 
 It is the difference from rather than the similarity to 
 cases of writer's cramp which constitutes the interest of the 
 case. Cerebral symptoms in writer's cramp and allied pro- 
 fessional ailments are infinitely rare, and when present are 
 very vague and consist at most of some slight dizziness 
 during attempts to exercise the deranged function. In the 
 case we are considering and in Dr. Frank Smith's case 
 cerebral symptoms have been prominent, and, once esta- 
 blished, persistent, and in no sense intermittent. Why should 
 this be ? 
 
 I would offer the following explanation : Muscular acts 
 differ enormously in the amount of cerebral effort they 
 demand. In some muscular acts we are unconscious of any 
 cerebral effort. This is notably the case in walking, which 
 appears to be almost a purely reflex act, and is often accom- 
 plished unconsciously. The woman who walks about gossip- 
 ing and knitting will do an extraordinary amount of work 
 without apparently giving a thought to her knitting-needles. 
 
CASE OF HAMMEKMAN'S CKAMP 105 
 
 Even writing — i.e. quill- driving and copying — may be done 
 almost automatically, and so, indeed, may any act in which 
 the tactile sense is largely employed to guide the limb in 
 its movement. An incident which once occurred to myself 
 will serve to show how very automatic a delicate act may 
 become. Some years ago I got a small flake of iron rust 
 into my eye while railway travelling. This caused slight 
 annoyance at the time, but in a day or so I began to suffer 
 from catarrh of the eye, which was excessively painful at 
 times, causing a spasmodic flood of tears and the forcible 
 closing of both eyes. It was in the days when I used a 
 razor, and one morning I was shaving my chin before a 
 looking-glass when suddenly the eyes filled with tears and 
 I closed them ; but, nevertheless, I unconsciously finished 
 my shaving, and shaved my chin quite smooth with my eyes 
 shut. There must have been very little cerebration in this 
 act ; in fact, had I appreciated what I was doing I should 
 inevitably have cut myself. My shaving on this morning 
 must have been almost a pure reflex, brought about by 
 constant daily repetition of the same act. 
 
 Other acts, again, can never become automatic, and this is 
 notably the case when the movement of the limb is not 
 guided by tactile sense in the performance of the special act. 
 When, for example, did anyone ever thread a needle auto- 
 matically or unconsciously 1 During such an act as this 
 there is evidence of strong cerebral effort, as is shown in 
 the face of the sempstress. The taking aim — whether it 
 be at a needle's eye, a bull's eye, or the bit of iron to be 
 forged into a nail — involves the bending of the mind towards 
 the object aimed at ; and the aiming at an object against 
 time, as occurs to the pieceworker forging nails, is an act, one 
 would think, which is calculated to cause brain-fag rather 
 than muscle-fag. And the limited number of clinical facts 
 at our disposal seem to point to the correctness of this 
 assumption. When the work done by the muscle is great, 
 and the cerebral effort involved is small, we may well expect 
 the muscle, rather than the brain, to show signs of failure. 
 Whenj however, the cerebral effort is out of proportion to 
 
106 NERVOUS AFFECTIONS OF THE HAND 
 
 the mechanical work, as in the repeated act of aiming with a 
 hammer, it is not surprising that, if breakdown occurs, it 
 should occur in the brain. It might be urged that this is 
 not a ' professional ' trouble — that it is merely a hemiplegic 
 attack followed by post-hemiplegic spasm occurring accident- 
 ally in a nail forger. Against this supposition we have to 
 put the fact that his first sign of trouble was in connection 
 with the professional act ; that the spasm of the arm is only 
 seen at its maximum when he attempts to perform the 
 professional act ; and that the case does not stand alone, 
 two of Dr. Frank Smith's cases having been very similar in 
 character. 
 
 In the average case of writer's cramp I have always con- 
 tended that, although peripheral evidence of mischief is 
 always present, the evidence does not enable us to say that 
 the lesion is central, although, of course, I very well know 
 that brain cell, nerve fibre, and muscle are practically one. 
 Ordinarily professional ailments never spread to other func- 
 tions, and certainly the man with writer's cramp is not 
 more likely to become hemiplegic than anyone else. In the 
 case we are considering the trouble, from being merely pro- 
 fessional to begin with, quickly spread. This in itself is 
 evidence that in one case the lesion is peripheral and in the 
 other case central, for at the centre, where the nerve fibres 
 converge almost to a point, any sudden lesion is not likely to 
 be limited to the cells connected with one small function 
 only. The nervous system may be compared to a railway 
 with branch lines and a ' central ' terminus. Now, a fire at 
 Holyhead would not cause any disturbance at Carlisle, not- 
 withstanding that they are both stations on one system of 
 railway, but a fire at Euston would certainly derange the 
 functions of l>oth these outlying stations, and of many 
 others. 
 
 The lesion in our case probably began in the part of the 
 centre corresponding to the serratus magnus muscle (for as 
 each limb has its controlling ' centre ' in the brain, so, we 
 must assume, has each muscle of each limb), and thence 
 quickly spread until the right upper limb, the right side of 
 
CASE OF HAMMERMAN'S CEAMP 107 
 
 the face, the right half of the tongue and the right leg (?) 
 became involved. 
 
 Seeing that the leg is very slightly and doubtfully in- 
 volved, the lesion, whatever it may be, is apparently almost 
 limited to the left ascending frontal convolution, to an area 
 to which the blood is brought by the ascending frontal 
 branch of the Sylvian artery. Seeing that the onset of the 
 trouble was comparatively sudden, it is not probable that 
 the change which has taken place in the brain is of the nature 
 of a slow degeneration or sclerosis. It is to the vessels of the 
 part to which we must look for an explanation, to ha3mor- 
 rhage in the area of the ascending frontal artery or embolism 
 or thrombosis of it. There are manifest difficulties in accept- 
 ing the theory of hsemorrhage or embolism, and against the 
 latter supposition is the absence of any source of emboli. 
 On the whole, I adhere to the belief that the physical basis 
 of our patient's trouble will be found in thrombosis of the 
 ascending frontal and parietal branches of the Sylvian artery. 
 In favour of this theory is the fact that his trouble at its 
 commencement was always worse on Monday morning, when 
 the overworked area of his brain had had a period of rest, 
 and when the circulation through it had been, presumably, 
 slow. If we imagine a clot forming in one of the smallest 
 branches and gradually spreading backwards, so as to involve 
 the larger branches of the ascending frontal branch of the 
 Sylvian branch of the middle cerebral artery, we have condi- 
 tions which, automatically and pathologically, would account 
 for the clinical facts. Thrombosis on the side of the veins 
 leading from this area might conceivably lead to a similar 
 condition, and cause such derangement of nutrition as to 
 prevent the proper control of movement and lead to such a 
 state of things as we are confronted with. 
 
 The prognosis in this case is, I fear, not good. Between 
 September, 1885, and February, 1886, his progress has been 
 niV, in spite of complete rest, good nourishment, and the 
 therapeutic skill in at least three of our metropolitan hospitals. 
 The deficient irritability of the serratus magnus has disap- 
 peared, but even this has not caused more benefit than a 
 
108 NERVOUS AFFECTIONS OF THE HAND 
 
 similar recovery of normal irritability causes in ordinary 
 hemiplegia. With the exception of this diminished irritability, 
 there have been no indications for treatment in the affected 
 limb. No tender nerves have seemed to demand a blister 
 (which is often of very great use in cases of professional 
 trouble), and no massage or shampooing of the limb would be 
 likely to influence the brain. Rest, if anything, should lead 
 to recovery or improvement ; but six months' rest has done 
 nothing, and I very much fear that his trouble is likely to be 
 permanent, and that his loss of control over the affected group 
 of muscles will continue. 
 
109 
 
 CHAPTER V 
 
 ON CERTAIN CONDITIONS OF THE HAND AND ARM WHICH 
 
 INTERFERE WITH PIANO-PLAYING 
 
 1 
 
 Gentlemen, — I wish to-day to direct your attention to a 
 group of patients who have sought advice because of some 
 difficulty which they have experienced in playing the piano, 
 a condition which has in many instances been apparently 
 brought about by the over-exercise of their professional 
 functions as pianists. We might speak of this condition (as 
 indeed it has been spoken of) as ' pianist's cramp,' but I 
 hesitate to do so because I think such a word would be mis- 
 leading, and might tend to encourage the belief that a failure 
 in piano-playing is something more than a symptom, and 
 might tend to make you believe that you had made a diagnosis 
 when, in fact, you had only used a word. You will find that 
 a failure in playing the piano may depend upon a variety of 
 causes, a fact which I believe to be true in the great majority 
 of professional ailments. Your reason, backed by your know- 
 ledge of anatomy and physiology, will tell you that this must 
 be so. The machinery involved in the delicate manipulations 
 necessary for a pianist is, indeed, so complicated that the 
 wonder is breakdown does not oftener occur. ^ 
 
 ' Clinical Lecture, U.C.H., 1886. 
 
 ^ Sir James Paget, in a public address some years ago, stated that : 
 ' He remembered once hearing Mdlle. Janotha play a presto by Mendels- 
 sohn, and he counted the notes and the time occupied. She played 
 5,595 notes in 4 mins. 3 sees. It seemed startling, but let them look at 
 it in the fair amount of its wonder. Every one of those notes involved 
 certain movements of a finger, at least two, and many of them involved 
 an additional movement laterally as well as those up and down. They 
 also involved repeated movements of the wrists, elbows, and arms, alto- 
 gether probably not less than one movement for each note. Therefore 
 
110 NERVOUS AFFECTIONS OF THE HAND 
 
 In playing the piano all forms of sensation (cutaneous, 
 articular, muscular) must be perfect ; from peripheral nerve - 
 endings to brain the sensory path must be free from all 
 defects. The motor path must be equally free from defect 
 from the cerebral cortex to the motor end plates on the 
 muscles, and it must be borne in mind that a trouble affecting 
 a fine nerve -twig supplying some little muscle of the fingers 
 is as capable of upsetting the harmony of a delicate act like 
 piano-playing as is a damage to one of the chief cords of the 
 brachial plexus. The muscles involved in the act must one 
 and all be healthy. We do not know much of the minor 
 pathological changes which affect the muscles. Fatty and 
 fibroid change may occur, and we know that a muscle may be 
 painful, or tender, or stiff, as the result of cold, gout, rheu- 
 matism, or fatigue, and we speak of such conditions as ' mus- 
 cular rheumatism,' or myalgia, without having anything very 
 solid behind the expression. Not only must the fibres of the 
 muscles be healthy, but the tendons and their sheaths also ; 
 too much or too little of the fluid which lubricates the tendon 
 in its sheath, or the deposit of a small amount of urate of 
 soda in the sheath, must necessarily interfere greatly with the 
 performance of a delicate act. 
 
 there were three distinct movements for each note. As there were 24 
 notes per second, and each of those notes involved three distinct 
 musical movements, that amounted to 72 movements in each second. 
 Moreover, each of those notes was determined by the will to a chosen 
 place, with a certain force, at a certain time, and with a certain dura- 
 tion. Therefore there were four distinct qualities in each of the 72 
 movements in each second. Such were the transmissions outwards. 
 And all those were conditional on consciousness of the position of each 
 hand and each finger before it was moved, and, while moving it, the 
 sound of each note and the force of each touch. Therefore there were 
 three conscious sensations for every note. There were 72 transmissions 
 per second, 144 to and fro, and those with constant change of quality. 
 Let them imagine it in telegraph wires. And then, added to that, fill 
 the time the memory was remembering each note in its due time and 
 place, and was exercised in the comparison of it with others that came 
 before. So that it would be fair to say that there were not less than 
 200 transmissions of neive force to and from the brain outwards and 
 inwards every second, and during the whole of that time judgment was 
 being exercised as to whether the music was being played worse or 
 better than before, and the mind was conscious of some of the emotions 
 which the music was intended to impress.' 
 
PIANO-PLAYING 111 
 
 I would direct your attention to the great number and 
 very wide extent of the muscles used in piano-playing, and 
 also to the fact that for the performance of delicate acts we 
 need steadiness quite as much as agility. For piano-playing 
 the scapula must be steady, the shoulder must be steady, the 
 elbow must be steady, and the wrist must be steady in order 
 that the fingers may act with certainty and precision on the 
 keys. When I use the word ' steady,' I mean, of course, 
 steady in movement, and not necessarily fixed. In examining 
 such cases you must therefore bear in mind that the shoulder 
 may demand examination equally with the hand and 
 fingers. 
 
 It is needless to say that a sound condition of all the 
 articulations of the upper limb is necessary for piano-playing. 
 
 The frequency of piano-failure is not very great. I find I 
 have seen only twenty-one cases in a period extending over 
 many years. In the same time, I have seen about eight times 
 as many cases of writing-failure. The comparative infre- 
 quency of piano-failure is due to the fact that the number of 
 persons who are obliged to play the piano excessively is 
 infinitely smaller than of those who write excessively. The 
 class of clerks is decidedly larger than the class of pianists. 
 The pianists belong mainly to the female sex, and hence it is 
 not surprising that out of my twenty -one patients all but two 
 were females. There is another and more important reason 
 for the comparative rarity of piano-failure as compared with 
 writing-failure — namely, that in piano-playing there is no 
 prolonged strain upon the muscles, at least, to the same 
 degree, as there is in writing. I have again and again pointed 
 out that in writing it is in the muscles of pen-prehension 
 rather than in muscles of pen-movement that failure is Kable 
 to occur, and that in all of these ' professional ' ailments break- 
 down most often takes place, or, at least, is most apparent in 
 muscles which are maintained in a state of contraction for 
 long periods. 
 
 In examining the cases of professional failure, we must 
 always try to discover which muscles, if any, are likely to be 
 most subject to fatigue in performing the professional act, and 
 
112 NERVOUS AFFECTIONS OF THE HAND 
 
 we must be very careful to investigate the condition of these 
 muscles. 
 
 Now, in piano-playing, it is, at first sight, very difficult to 
 say which muscles, if any, are subjected to prolonged strain. 
 The very essence of piano-playing, as of all musical perform- 
 ances, is rhythm, and rhythm in movement means that in the 
 muscles producing the movement, periods of contraction 
 alternate with periods of relaxation with regular intervals, 
 and therefore breakdown from fatigue is scarcely more liable 
 to occur than in the heart itself, the untiring prototype of 
 rhythmical movement. Piano-playing does not, however, 
 consist entirely of rhythmical movement, as might appear to 
 be the case. Professors are very exacting with their pupils 
 as to the position of the hand. There is a way of holding 
 the hand in piano-playing which, I am told, is called the 
 ' Stuttgart method,' in which the extension of the wrist is 
 most rigidly maintained during the whole performance, and, 
 except during the instant when the finger is depressed on the 
 key, the extension of the near phalanges of the fingers is also 
 maintained. In this method of holding the hand there is 
 considerable strain thrown upon the extensors of the wrist 
 and the extensors of the near phalanges (extensor communis 
 digitorum, extensor indicis, extensor minimi digiti). In order 
 to be sure that this orthodox manner of holding the hand is 
 maintained, I have known young ladies practise their scales 
 with a coin balanced on the back of the hand, the falling off 
 of the coin showing at once that the absolute level of the 
 carpus and metacarpus has not been maintained. It is 
 obvious that this position of the hand has the effect of 
 keeping the finger-tips constantly as near their work as 
 possible, and that it must conduce to great rapidity of finger- 
 ing. If the ' Stuttgart method ' were not of i^ractical value, 
 one may conclude that it would not be insisted on. Certain 
 it is, however, that a large proportion of my patients have had 
 symptoms referable to the extensor muscles of the wrist and 
 fingers and the musculo-spiral nerve. I will briefly give you 
 the facts of a case which will serve as an illustration. 
 
 Case 1. — MissR , aged 24, consulted me in November 
 
PIANO-PLAYING 113 
 
 1875. She had been working at the School of Music in Berlin, 
 and had practised as much as eight hours a day, besides using a 
 digitorium for the exercise of the fingers. She had found the 
 Stuttgart position very trying. Her trouble was in the left 
 hand, and was mainly experienced in playing staccato 
 passages, necessitating a sudden extension of the wrist and 
 fingers ; and further, there was a tendency, during the 
 exercise of runs and scales, for all the fingers of the left hand 
 to ' run together,' as she said, owing apparently to a failure 
 of the extensor communis digitorum steadily to maintain the 
 extension of them. There was some tenderness of the left 
 ulnar nerve at the elbow, and excessive irritability (to 
 faradism) of the interossei muscles. There was, further, this 
 peculiarity that, when the first left dorsal interosseous muscle 
 was faradised, all the left interossei muscles responded to the 
 current. This phenomenon was not observed in the right 
 hand, and disappeared in the left hand when she recovered, 
 as she eventually did. This peculiarity was due, probably, 
 partly to the irritable condition of the left ulnar nerve and 
 interossei, and partly to the weakness of the extensor com- 
 munis digitorum, which in part antagonises the interossei 
 muscle. It was very interesting to see that faradisation of 
 one interosseous produced, as it were, the very trouble of the 
 ' running together of the fingers,' which was one of her chief 
 difficulties when playing. Although the disability of the left 
 hand was most marked in piano-playing, it was not limited to 
 this act. The limb was generally inefficient in the perform- 
 ance of all acts, and readily got fatigued. It often ' died 
 away, ' and was sometimes burning hot, and at other times 
 was blue, cold, and mottled. She was worse in cold weather, 
 and her trouble was intensified by emotional excitement, such 
 as was caused by playing before an audience or her music- 
 master. There was well marked tremor of the left hand. 
 This patient was in depressed health, due to overwork ; and 
 also, as she said, to the fact that the diet and mode of life in 
 Berlin had not agreed with her. She was treated by rest, tonics, 
 a blister over the tender ulnar nerve, and friction for the arm. 
 In February, 1877, she called upon me to say she had recovered. 
 
 I 
 
114 NERVOUS AFFECTIONS OF THE HAND 
 
 Case 2 was similar in many respects. Miss L., aged 33, 
 a teacher of music, had been practising the ' Stuttgart 
 method.' Piano-playing had become painful and impossible. 
 All the nerve-trunks of the left arm were very tender. She 
 suffered from great discomfort in the arms at night, an uneasy 
 feeling, and a difficulty in getting them into a comfortable 
 position in bed. Her hands were crippled for all acts, and 
 she was worse in cold weather. She was worried and sleep- 
 less. With rest, tonics, and blisters to the painful nerve- 
 trunks, she recovered. 
 
 Case 3. — Miss F., a music teacher, aged 33. Had been 
 practising the ' Stuttgart method.' Marked tenderness of the 
 right musculo- spiral nerve and over the extensors of wrist 
 and lingers. She was anaemic, and attributed her trouble to 
 catching cold. 
 
 Case 4. — Miss O., aged 20, in delicate health, had 
 'strained her arm playing the piano.' There was pain, 
 tremor, tenderness of the right musculo-spiral nerve, and 
 excess of irritability to faradism of the extensor muscles. 
 There was discomfort in the arms at night, as in Case 2. 
 After rest, tonics, and blisters to the tender nerves, she 
 completely recovered. 
 
 Case 5. — Miss W., aged 20. Marked tenderness of the 
 median and musculo-spiral nerves and tremor of the hand. 
 She was in ill -health and dyspeptic. 
 
 Case 6. — Miss CI., aged 19, a pupil at the Royal College 
 of Music ; and 
 
 Case 7. — Miss M., aged 35, were in a condition almost 
 exactly similar to the preceding, so that I need not trouble 
 you with further details. 
 
 Case 8. — Miss Y., a governess, aged 22. Her difficulty 
 was mainly with the left hand. Extension of the wrist and 
 fingers caused her pain, and she had marked tenderness of the 
 median and ulnar nerves. Tremors of both hands, highly 
 nervous, and a history of family trouble and loss of rest. 
 
 Case 9. — Miss F. complained that ' the left forefinger 
 would not keep oflf the keys.' There was marked deficiency 
 of irritability of the left extensor indicis and extensor primi 
 
PIANO-PLAYING- 115 
 
 internodii poUicis. No nerve- tenderness. The patient attri- 
 buted her trouble to a whitlow which she had had on the 
 left forefinger two years previously. She was nervous and 
 sleepless. 
 
 These nine cases are of interest as showing a distinct 
 involvement of the extensor muscles or the musculo-spiral 
 nerve in each case. They also serve to illustrate other points 
 which many of these cases of piano-difficulty have in com- 
 mon. 
 
 First, there is the nerve-tenderness which accompanies 
 almost all of these cases. This may definitely be brought 
 about by over-use of the muscles ; it may also occur in 
 connection with a wrench or strain of the arm, or may follow 
 a bruise (as we shall see in connection with a case to be 
 presently recited), and it seems very liable to occur in persons 
 of delicate organisation who are in depressed health or who 
 have been exposed to cold. We have no right to assume 
 that it, in all cases, indicates neuritis, but it may do so ; or it 
 may point to hypersemia or congestion of the nerve. There 
 are four conditions which may accompany nerve-tenderness ; 
 these are (a) muscular disability which, although it may be 
 specially manifest in one particular act, will generally be 
 found to affect other acts as well ; (b) more or less tremor ; 
 (c) pain or early fatigue during muscular exertion ; (cZ) a sense 
 of discomfort in the limb (not exactly pain), which is always 
 worse at night and makes it difficult to put the limb in a 
 comfortable position in bed and often keeps the patient awake. 
 This latter symptom is both interesting and curious, and one 
 which is often complained of. This sense of discomfort is an 
 effect, probably, of the tenderness of the nerves, whereby they 
 become sensitive to the slight degrees of pressure which are 
 inseparable from almost every position. Not only, however, 
 are the nerves sensitive to pressure, but also to slight degrees 
 of stretching. This fact was well illustrated by a case of so- 
 called multiple neuritis due to alcohol which was in Ward 3 
 last summer. This patient's nerve-trunks were all tender 
 (median, ulnar, and musculo-spiral), and I had frequent 
 opportunities of showing you that when either of these nerve- 
 
 i2 
 
116 NERVOUS AFFECTIONS OF THE HAND 
 
 trunks were put upon the stretch, the patient (who was 
 habitually drowsy and in a state of partial mental incapacity) 
 invariably manifested pain, and when asked where the pain 
 was, invariably pointed to the position of the trunk of the 
 nerve which was being stretched. Thus, with the elbow bent 
 and the wrist forcibly extended, if the ring and little fingers 
 were pulled back so as to stretch the ulnar nerve to the 
 utmost, the patient pointed to the back of the olecranon as 
 the seat of the pain. If, with the elbow straight and the 
 wrist extended, the thumb and forefinger were pulled back so 
 as to stretch the median nerve, the patient pointed to a point 
 internal to the biceps tendon at the bend of the elbow as the 
 seat of pain. If, with the elbow straight and the wrist 
 forcibly flexed, the thumb and forefinger were bent strongly 
 into the palm so as to stretch the musculo-spiral nerve, the 
 patient complained of pain in the position of the trunk of the 
 nerve above the outer condyle of the humerus. We tried 
 these experiments again and again, and always with the same 
 result. If, then, the nerves are sensitive both to pressure and 
 tension, it is not surprising that trouble should be experienced 
 in finding a comfortable position for the affected limb. 
 
 Another fact worthy of notice is the x3ommon implication 
 of the left hand, either alone or to a greater extent than the 
 right. The left hand is less expert and more diflicult to train 
 than the right, and it is not to be wondered at that it should 
 be the most prone to suffer from overwork in acts which call 
 upon both hands equally or nearly so. Because of the diffi- 
 culties experienced with the left hand, it is often inordinately 
 worked while practising exercises. 
 
 The next four cases are similar to those already given^ 
 except in the fact that the extensors and the musculo-spiral 
 nerve were not specially involved. 
 
 Case 10. -Miss G., aged 20, experienced pain and difficulty 
 in playing, and to a less extent in all acts with both hands. 
 All the nerve-trunks were tender. She was dyspeptic, and 
 there was a strong family history of gout. Cured by rest, 
 diet, and change of air. 
 
 Case 11. — Mrs. A., aged 34, complained of pain and * creepy 
 
PIANO-PLAYING 117 
 
 feelings ' after playing the piano. There was a distinct 
 tenderness of the right median nerve, and the cervico- dorsal 
 spine was also tender. 
 
 Case 12.- -Miss A. B. experienced difficulty in lateral (inter- 
 osseal) finger movements, and to a less extent in all acts, both 
 coarse and fine. It was found that the median and ulnar 
 nerves on both sides were distinctly tender. 
 
 Case 13. — Miss B., aged 21, had been working hard at the 
 Leipsic Conservatorium. The right median nerve was 
 exquisitely tender. The patient was anaemic and dyspeptic. 
 Completely cured by rest, iron, blistering the tender nerve, 
 and massage. 
 
 The next two cases are of interest as examples of difficulty 
 caused by trouble apparently limited to the region of the 
 shoulders. 
 
 Case 14. — Miss E. B., aged 27, a teacher of music, suffered 
 from pain in the shoulder after playing — or, indeed, after any 
 work with the right hand. There were no tender nerve- 
 trunks, but a very tender spot was found close to the insertion 
 of the levator anguli scapulae, at the superior angle of the right 
 scapula. She improved after blistering the tender spot and 
 the administration of arsenic. 
 
 Case 15. — Miss R., aged 29, a governess, came complaining 
 of an ill-defined awkwardness of the right arm, which inter- 
 fered not only with piano -playing, but with other acts, such as 
 cutting her dinner. The elbow, she said, had a tendency to 
 stick out. There was no nerve-tenderness, and no well- 
 marked change in electric irritability. On removing the 
 clothing and faraclising the right deltoid, it was noticed that 
 the vertebral border of the right scapula was tilted away from 
 the thorax, whereas nothing of the kind occurred when the 
 left was faradised. This was due, apparently, to a relatively 
 weak condition of the right serratus magnus. There was a 
 disturbance of the normal balance of power between the right 
 deltoid and right serratus, which became manifest to the eye, 
 not during forced voluntary acts so much as during the 
 forcible faradisation of the deltoid. When the right scapula 
 was tightly bound or held against the ribs, the clumsiness of 
 
118 NEEVOUS AFFECTIONS OF THE HAND 
 
 the right hand was much lessened. This weakness of the 
 serratus was of long standing ; its cause was not evident, and, 
 when last seen, the condition had not materially improved. 
 
 The next two cases were, in a mild sense, traumatic. 
 
 Case 16. — Miss E. E., aged 23, complained of a trouble with 
 her left hand when playing. The metacarpo-phalangeal joint 
 of the left thumb was found to be weak and tender, and on being 
 questioned, she remembered that she had strained the joint a 
 few weeks previously, while struggling with her brother. 
 
 Case 17. — Miss F. B., aged 31, bruised the right arm 
 eighteen months ago, and since then she has had pain and 
 disability of the limb. All the nerve trunks were tender, and 
 she was ordered to counter-irritate the skin over the tender 
 nerves, and rest the limb. 
 
 The next case I have to quote is one of considerable 
 interest, in which the primary trouble seems to have been in 
 a tendon. 
 
 Case 18, — Miss Ada H., aged 21, pianist, complained of 
 weakness in the right hand while playing, and in all acts. 
 There was special difficulty with lateral (interosseal) finger 
 movements, and in turning the hand and little finger towards 
 the ulnar side, and she further complained of a quivering in the 
 first right dorsal interosseous muscle after playing. There was 
 found a considerable thickening on the tendon of the flexor 
 carpi ulnaris muscle, which not only interfered with the use 
 of that muscle, but also, by pressing on the ulnar nerve, 
 seriously hampered the use of the muscles in the palm supplied 
 by that nerve. The thickened tendon was blistered, and the 
 patient was ordered to take a tonic and go for a holiday. She 
 made a good recovery. 
 
 Case 19. — Miss L. H., a pianist, whose performances were 
 hindered by a troublesome cramp of the flexor minimi digiti. 
 The cause of this cramp was not very evident ; but she was 
 dyspeptic, and this fact, combined with excessive use of the 
 muscle, may be regarded, perhaps, as sufficient to account for 
 the cramp. 
 
 I have only seen two males who have come to me com- 
 plaining of difficulty in piano-playing. 
 
PIANO-PLAYING 119 
 
 Case 20. — Mr. P., aged 60, a professional pianist of intem- 
 perate habits. He had all the symptoms of senile tremor 
 and degeneration. His eyesight was failing, and there was 
 grey atrophy of the optic discs. He went gradually from 
 bad to worse. Tremor was most marked in the left arm, 
 which was very tender, so that he could hardly bear to have it 
 touched. The musculo-spiral and ulnar nerves of this arm 
 were especially tender. He said that he could not strike the 
 keys with any certainty, and he complained that the left ring- 
 finger always gave him the most trouble. The left ring-finger 
 is the finger which pianists always find the most difficult to 
 educate. This case is of interest as showing how a well- 
 recognised pathological condition may first show itself in parts 
 which are especially overworked. 
 
 Case 21 was that of a professional pianist, aged 23, who for 
 the last few months had experienced an ill-defined difficulty in 
 playing in both hands. The right little finger and the back of 
 the left hand were particularly painful. There was slight 
 rheumatic thickening of some of the small joints of the fingers. 
 Each nail of both hands had a white mark above the middle. 
 These must have been formed at about the same time. The 
 patient stated that, about three months previously, he had 
 kept the house for a feverish cold. Tliis may have entailed 
 some failure of nutrition, and it was subsequent to this that 
 he experienced his difficulty in performing. I could make out 
 nothing definitely wrong with nerves or muscles, and I have 
 no knowledge of the subsequent course of this case. 
 
 The short summary of these twenty -one cases shows us 
 that in no two cases was the cause of breakdown precisely 
 the same. These cases afford no justification for using such a 
 term as 'pianist's cramp,' to imply a morbid entity having a 
 special cause, and a pathology of its own. Confronted with a 
 pianist who has broken down, our first duty is to make a 
 diagnosis, and answer the questions. Where ? and Why ? The 
 most common symptom in these cases was nerve-tenderness 
 (indicative possibly of congestion or mild inflammation), which 
 affected different nerves, and seemed to depend, not only on 
 overwork, but on such accidental causes as strain or cold, and 
 
120 NERVOUS AFFECTIONS OF THE HAND 
 
 to be predisposed to by various bodily conditions, such as 
 anaemia, rheumatism, gout, and dyspepsia. 
 
 You will have noticed that, although the act of piano- 
 playing was most seriously affected, there was usually some 
 general disability of the limb as well, which accompanied the 
 ' professional ' trouble in almost every case. You are aware 
 that, with regard to ' writer's cramp,' it is often asserted that, 
 with the exception of the act of writing, there is nothing 
 wrong. Although I cannot quite endorse this statement with 
 regard to ' writer's cramp,' still I must admit that these cases 
 of pianists' trouble offer a contrast to ' writer's cramp ' in the 
 large amount of disability which generally existed for ads 
 other than piano-playing. This is due, I believe, to the fact 
 that the muscles, the derangement of which causes breakdown 
 in piano-playing, are larger, more numerous, and in more 
 common requisition for general purposes than are the muscles 
 (most commonly the interossei) whose breakdown causes 
 writer's cramp. 
 
 The prognosis necessarily depends upon the diagnosis. In 
 cases where nerve-tenderness and local muscular weakness are 
 the only troubles, I believe the prognosis to be good. Cases 
 of this kind occurring, as very often is the case, in young- 
 girls, nearly always recover, although I am bound to say that 
 recovery is sometimes very tedious. 
 
 Treatment. — The most important point in treatment is 
 rest. The excessive use of the hand must be discontinued, 
 and it is often necessary to insist upon this rather forcibly. 
 Piano-playing, if not prohibited altogether, must only be 
 practised to a degree short of that which causes pain or 
 annoyance. It is often difficult to restrain the ardour of these 
 patients in the matter of playing. Directly they feel in a 
 small degree better, they fly to the piano ; and I have known 
 the progress of more than one case very seriously retarded by 
 the undoing, as it were, of the good effect of rest by an hour's 
 injudicious and prohibited ' practising.' 
 
 I need hardly say that constitutional treatment is all- 
 important. The body must be healthy in order that the arm 
 may recover. Anaemia and dyspepsia must be attended to 
 
PIANO-PLAYING- 121 
 
 and counteracted by diet, medicines, and change ; and no 
 change is better than to a mountainous climate, where the 
 advantages of a chalybeate water may be enjoyed. St. Moritz 
 in the Engadine, Rippoldsau in the Black Forest, Schwalbach, 
 and Spa have a well-deserved reputation for benefiting these 
 cases. Any indications caused by gout and rheumatism must 
 be met, and if there be evidence of gastric irritation, you may 
 be sure that the arm will not be well until this trouble has 
 been cured. 
 
 In many cases the administration of arsenic has seemed to 
 be of decided benefit. The most important local measure is 
 the employment of counter-irritation over the tender nerve- 
 trunks. This may be accomplished by means of blisters or 
 by the application of strips of capsicum plaister. Douching, 
 friction to the arm, and systematic massage are often of 
 great use, but the last-named mode of treatment is not to be 
 adopted as long as the nerve-trunks are tender, for under 
 these circumstances it seems decidedly to do harm rather 
 than good. You must remember that the professional masseur 
 is not infrequently over-zealous, and that the mere passive 
 act of being rubbed is very exhausting to the patient. You 
 must take care that the massage is neither too long nor too 
 vigorous. If massage be well timed, and be reasonably and 
 sensibly carried out, it is undoubtedly of great value. It 
 seems necessary, in view of the sort of fashion which has set 
 in towards this mode of treatment, to warn you not to 
 recommend a patient to place himself in the hands of a 
 ' professional rubber ' unless you know something of his or her 
 character and capabilities. While on the subject of treatment 
 I may allude again to the fact that pianists have special 
 difficulty in educating the ring-fingers, which have less power 
 of independent movement than the other fingers. This is 
 partly due to the absence of special extensor muscles, such as 
 are provided for the index and little fingers, and partly to the 
 fact that the extensor tendon of the ring-finger is joined to its 
 fellows on either side by a fibrous band, near the far end of 
 the metacarpal bone. With the hand in the pianists' position 
 it will be found that the power of raising the ring-finger while 
 
122 NERVOUS AFFECTIONS OF THE HAND 
 
 the middle and little fingers are resting on the keys is not 
 great, less than that possessed by either of the other fingers 
 when similarly circumstanced. It cannot be raised more than 
 about three-quarters of an inch, and hence the power of 
 striking the key is small. To remedy this it has been pro- 
 posed to divide, by means of a tenotome, the bands connecting 
 the extensor tendon of the ring-finger wdth the extensor 
 tendons on either side of it. This operation has been 
 performed in America and in this country, and it is said with 
 good results. How the reunion of the divided band is 
 prevented I do not know. I confess that the operation seems 
 to me to be one likely to produce weakness at first, and to be 
 followed by greater fixity in the end, wheti the cicatricial tissue 
 of the divided bands contracts and draws them tighter than 
 before. It must not be forgotten that the ring-finger has its 
 special use, which appears to me to be to grasp firmly in the 
 palm, while the other fingers of the hand are otherwise 
 employed. The great characteristic of the ring-finger is its 
 power of firm grasp, and we should not rashly do anything 
 which is likely to lessen this firmness. 
 
123 
 
 CHAPTER VI 
 
 ON A CASE OF ' SAWYER's CRAMP ' ^ 
 
 The patient whose case is recorded in the following short 
 paper was sent to me by my friend Dr. de Watteville, who was 
 kind enough to remember that I took an interest in ' pro- 
 fessional ' ailments. 
 
 W. W., set. 38, came as an out-patient to University 
 College Hospital on March 8, 1883. He was a maker of 
 packing-cases and had been engaged in piece-work, making 
 his packing-cases against time, as it were, for 10 or 11 hour& 
 a day, and occasionally for as much as 14 hours. He was a 
 strongly-built man, but looked a little worn about the face, 
 and had a certain earnestness of manner which I have often 
 seen associated with genuine professional ailments. He did 
 not drink, and there were no facts in his personal or family 
 history which need to be recorded. His only trouble was an 
 inability to use the saw. As soon as he took his saw in his 
 hand, his efforts to use it were thwarted by disorderly move- 
 ments which he could not explain. 
 
 In order to better understand the case, I asked him on 
 the next occasion to bring his saw with him to the hospital,, 
 together with a piece of wood such as he habitually used in 
 his trade. This was done, and the patient was stripped to the 
 waist, and was made to go through the act of sawing. 
 
 On taking the saw in his hand, there was noticed a slight 
 tremor of the blade, due to a little shake of the hand. The 
 saw was thrust forward through the wood fairly well, but the 
 back stroke could not be accomplished, and the attempt was 
 accompanied by abnormal elevation of the shoulder, scapular 
 
 ' From ' Brain,' 1883. 
 
124 NEKVOUS AFFECTIONS OF THE HAND 
 
 movement, adduction of the elbow, rotation outwards of the 
 forearm, flexion of the wrist, and swaying to and fro of the 
 body. These movements were difficult to analyse, the general 
 impression left upon the observer being that the whole of the 
 muscles of the right upper limb behaved tumult uously when 
 the patient attempted to saw. 
 
 With the left arm he could saw perfectly well. 
 
 From the character of the movements I thought it not 
 unlikely that some of the scapular muscles were at fault, and 
 my first step in the examination was to outline both scapulae 
 with a blue pencil, to see if there was any want of symmetry 
 in the position of the scapulae on the two sides. This examina- 
 tion gave a negative result. 
 
 On close inspection, there was seen to be distinct flattening 
 of the right supra-spinous fossa as compared with the left. 
 That this was not due to any wasting of the trapezius was 
 shown by putting the trapezii in action, when the muscles on 
 the two sides appeared to be equally developed. The first 
 positive fact with regard to this patient then was — 
 
 (a.) Diminutions in size of the right supra-spinatus muscle. 
 
 On close inspection of the chest, there was noticed a slight 
 degree of flattening of the right infra-clavicular region, and I 
 came to the conclusion that there was — 
 
 (6.) Diminution in size of the right pectoralis major, 
 especially the clavicular portion. 
 
 The muscular wasting in the above situations, though very 
 slight, was undoubted, and when pointed out was readily 
 admitted by all who saw the patient. 
 
 I was almost inclined to think that there was a little want 
 of plumpness about the right infra- spinous fossa, and that the 
 muscular mass between the spinal border of the scapula and 
 the spine was more flabby on the right than the left side ; but 
 of these two facts I could not feel at all sure. No other 
 muscles except those in the situations named were in the 
 least degree wasted. 
 
 The next step in the examination was to determine if any 
 of the nerves of the brachial plexus were tender. There was 
 no tenderness above the clavicle, nor over the situations of 
 
ON A CASE OF ' SAAVYEE'S CRAMP' 125 
 
 the great nerve-trunks (musculo-spiral, median, or ulnar) in 
 the upper limb. 
 
 (c.) There was a markedly tender spot in the right pectoral 
 region, in the second interspace, midway between the mid- 
 sternal line and the point of the shoulder. 
 
 {d.) An equally tender spot beneath the spine of the right 
 scapula, just where the supra-scapular nerve enters the infra- 
 spinous fossa of the scapula. 
 
 The next step was to test the irritability of the muscles to 
 faradism. It was found that the muscles of both upper limbs 
 manifested equal degrees of irritability, with one exception. 
 
 (e.) Both portions of the right pectoralis major (clavicular 
 and sternal) showed a marked degree of excessive irritability, 
 and contracted readily to a current which produced no effect 
 on the left side. The right muscle was far more sensitive to 
 the current, and manifested what Duchenne would have called 
 excessive amount of electro-musculo sensibility. 
 
 It must be remembered that the position of the supra - 
 spinatus (which was wasted) prevented its being accurately 
 tested, since the movement of the trapezius effectually masked 
 any movement of the muscle beneath it. 
 
 The patient stated that he could perform every movement 
 and every act with the right hand with perfect readiness, 
 with the exception of the act of sawing, which, unfortunately, 
 was the one upon which his livelihood largely depended. 
 
 Upon examining the individual movements of the limb with 
 great care, it was found that the approximation of the scapula 
 to the mid-vertebral line (by means of the rhomboids) was not 
 so readily accomplished on the right side as on the left ; and 
 that when the latissimus dorsi was put into extreme action, 
 he complained of pains in the pectoral region. I am inclined 
 to think that the difficulty of the rhomboidal movement, and 
 the pain during the action of the latissimus dorsi, were both 
 in part attributable to the stretching of the pectoralis major 
 which these movements caused. 
 
 Questioned as to the origin of his trouble, he stated that it 
 began in March, 1882, and that the first symptom was a pain 
 in the pectoral region during the back stroke of the saw 
 
126 NEKVOUS AFFECTIONS OF THE HAND 
 
 {during which movement the pectoralis major was certainly 
 put on the stretch). 
 
 It will be observed that the case lends no support to the 
 statement which is generally found in text-books, that in pro- 
 fessional ailments of this kind there is nothing the matter 
 except the derangement of a special co-ordinated movement. 
 
 In this patient distinct evidence was obtained of derange- 
 ment of special muscles and special nerves, but this derange- 
 ment was not of a kind to attract the attention of a careless 
 observer. On the contrary, it was only discovered after a 
 very diligent search. 
 
 This case, again, lends no support to the theory that ail- 
 ments of this kind are due to the failure of some co-ordinating 
 centre. 
 
 Two muscles were found slightly wasted (the supra-spinatus 
 and the pectoralis major), and the nerves supplying them 
 were distinctly tender ; at least two sharply defined tender 
 spots were found over the anterior thoracic and the supra- 
 scapular nerves. 
 
 It will be at once conceded that an irritable condition of 
 the pectoralis major would be likely to seriously interfere with 
 the act of sawing. 
 
 The connection of the supra-spinatus with the act of 
 sawing is, however, not at first apparent. 
 
 In my papers on ' writer's cramp ' I have insisted on the 
 fact that the muscles which are subjected to prolonged strain 
 are more likely to be affected than those in which contraction 
 and relaxation quickly alternate, and accordingly we find that 
 the muscles of pen- prehension more often suffer from over- use 
 that the muscles of pen-movement. 
 
 In the act of sawing, what muscles, if any, are subjected to 
 prolonged strain ? Not the muscles of the hand, for the saw 
 is alternately thrust and pulled, and during the former act 
 the grasp is released. Not the muscles which move the elbow, 
 for in this joint flexion and extension alternate with each 
 other during the act of sawing. Not the muscles which pull 
 the humerus backwards and forwards (among which are the 
 two halves of the deltoid), because when the back-pulling 
 
ON A CASE OF 'SAWYER'S CRAMP' 127 
 
 muscles are contracted the forward-pulling muscles must be 
 relaxed, and vice versa. Clearly fche muscles which are most 
 likely to suffer from prolonged strain in this act are those 
 which maintain the head of the humerus securely in the 
 glenoid cavity, for if the head of the humerus were not lirmly 
 held during the powerful swaying to and fro of the bone, the 
 act would certainly become unsteady. For sawing, also, the 
 humerus must be held sKghtly removed from the trunk. Now, 
 the maintenance of the head of the bone in the glenoid cavity, 
 and the slight separation of the humerus from the trunk, 
 which are essential for the act of sawing, both demand the 
 contraction of the supra-spinatus. 
 
 Duchenne {Physiologie des Mouvements^ p. 73 e^.seg.), when 
 speaking of the actions of the supra-spinatus muscle, says that 
 it (1) moves the humerus away from the trunk and slightly 
 forward, and at the same time rotates it inwards very slightly, 
 and (2) 'it depresses the external angle of the scapula. It 
 usually co-operates with the deltoid and serratus magnus in 
 raising the arm, and in the absence of the former muscle the 
 supra-spinatus and serratus magnus combined can raise the 
 arm very considerably. He further says, ' The supra-spinatus 
 does not merely help the deltoid in its action by its slight 
 power of raising the arm, but its assistance is needed for main- 
 taining the head of the humerus in the glenoid cavity during 
 the raising of the arm. I have noticed, indeed, in my experi- 
 ments, that when the deltoid contracts by itself, the head of 
 the humerus has a tendency to escape from the glenoid cavity 
 and to be dislocated downwards.' When summing up the 
 actions of the supra-spinatus, Duchenne speaks of it as an 
 ' active ligament of the scapulo-humeral joint.' It is easy to 
 understand how necessary the supra-spinatus must be for the 
 act of sawing, not only in holding the head of the humerus 
 firmly in the glenoid cavity, but also in holding the humerus 
 slightly removed from the side. 
 
 It may be noted that the clavicular portions of the pecto- 
 ralis major, which was wasted in this case, and amongst the 
 fibres of which there was a tender spot, is also indispensable 
 for the act of sawing, not only by helping in the to and fro 
 
128 NERVOUS AFFECTIONS OF THE HAND 
 
 movement of the humerus, but also in holding the head of the 
 humerus in the glenoid cavity. 
 
 In this case of ' sawyer's cramp,' then, there were found two 
 muscles wasted, both of which were indispensable for sawing 
 and both of which were presumably subjected to iwolonged 
 contraction during the act. 
 
 What was the nature of the pathological changes % and what 
 was their order in time of occurrence ? Were the nerves 
 affected before the muscles, or vice versa % Was the nervo- 
 muscular condition merely the expression of central (spinal 
 cord) change ? These questions remain to be answered. The 
 peripheral changes were certain. 
 
129 
 
 CHAPTER YII 1 
 
 THREE CASES OF SPINAL MYELITIS 
 
 Gentlemen, — The only place to study clinical medicine is in 
 the ward ; and those of you who wish to make sure of passing 
 your examination must recognise that medicine is not to be 
 learnt fj'om books alone, or from lectures alone. Cases of 
 disease which you have seen or tried to understand will never 
 be entirely eradicated from the mind. They constitute the 
 real foundations of medical knowledge, and I think it is not too 
 much to say that every case which you have really studied will 
 help you in greater or less degree to understand every other 
 case which you will see in the future ; and I am quite sure 
 that you will assimilate the knowledge conveyed in your text- 
 books with far greater ease in proportion as your experience 
 enables you to conjure up mental pictures of actual cases to 
 illustrate the text. 
 
 Nevertheless, books and lectures form a very necessary 
 adjunct to clinical observation. In the lecture-room we are 
 able to talk with more freedom than is always possible in the 
 presence of the patient, and I have asked you to meet me to- 
 day in order that we may discuss three cases of spinal myelitis 
 which have lately been in my wards. I shall compare these 
 three cases, and you will find that although the pathological 
 process was in each case very similar, they differ very widely 
 from each other as to course, symptoms, and causes, and I 
 trust that the remarks I shall have to make will not only 
 throw new light upon the cases which form the subject of these 
 remarks, but that a study of these cases, slightly more 
 methodical than is possible in the wards, will enable you to 
 ^ Clinical Lectures, U.C.H., 1896. 
 
 K 
 
130 SPINAL MYELITIS 
 
 understand many of the symptoms which arise in other 
 diseases of the spinal cord. 
 
 Case 1. — Unilatei^al focal myelitis in the lower cervical 
 
 region implicatinc/ the cervical sympathetic nerve. J. E , a 
 
 painter, aged 32, was admitted to the hospital, on the recom- 
 mendation of Dr. Hackney, of Hythe, on October 3, 1895, com- 
 plaining of weakness of the left hand and foot, a tingling 
 sensation the left side of the head, palpitation of the heart on 
 exertion, and sleeplessness. His trouble began in May with 
 weakness of the hand and leg, and he states that there has 
 been some recovery of power in the leg, but otherwise his con- 
 dition remains iyi statu quo. He had influenza in 1891, and 
 again in the spring of 1895, and he has never been well since 
 the first attack. 
 
 He is fairly temperate, and has a healthy complexion. 
 There is no blue line on the gums, and there are no facts in 
 his history which point directly to lead poisoning ; no history 
 of syphilis ; no pyrexia ; urine of normal specific gravity, 
 and otherwise healthy. On examination we found — 
 
 1. No paralysis of the face or tongue, but the left palpe- 
 bral fissure narrowed, and the left pupil smaller than the right. 
 Both pupils reacted to light and accommodation. Sight good ; 
 no contraction of the field of vision as tested with the peri- 
 meter ; optic discs normal. He complains of some headache, 
 principally on the left side. No giddiness ; no vomiting ; no 
 staggering during locomotion ; no deafness. 
 
 2. There is distinct wasting of the interossei of the left 
 hand, and also of the muscles of the thenar and hypothenar 
 eminence, more marked in the latter than in the former. The 
 left arm and hand are small and flabby as compared with the 
 right, but there is no marked wasting of any muscles other 
 than those named. The muscles of the hypothenar eminence 
 give degenerative reactions. The interossei, the muscles of 
 the thenar eminence and the extensors, respond feebly to both 
 currents as compared with the corresponding muscles on the 
 right side. There is no contracture or rigidity of the left 
 hand or arm. 
 
 3. The left leg is weak, and he drags it very slightly in 
 
IMPLICATION OF SYMPATHETIC 131 
 
 walking. There is no wasting or absolute want of power in 
 any of the muscles. The knee-jerk is increased on the left side. 
 
 4. Sensation is everywhere normal — touch, pain, and tem- 
 perature. 
 
 5. No circulatory troubles, functional or otherwise, were 
 detected during his stay in hospital. 
 
 6. No tenderness or deformity of the spinal column. 
 Here we have a history of a moderately acute onset, and 
 
 objectively we find symptoms referable to the left side of the 
 face, the left arm, and the left leg ; and in seeking to make 
 a diagnosis, and localise the lesion which gives rise to the 
 symptoms, we shall do right to take the brain into considera- 
 tion in the first instance. Now, although the onset was mode- 
 rately acute, it was not sudden, as are the majority of cerebral 
 lesions giving rise to hemiplegia ; and we must note that there 
 is no paralysis of the lower part of the face or tongue, as is 
 common in hemiplegia. Further, it is evident that although 
 the palpebral fissure is narrowed on the left side, there is no 
 ptosis, and no evidence of paralysis of the third or any other 
 orbital nerve. The left pupil is indeed contracted, which 
 might be taken as evidence of paralysis of the sympathetic or 
 irritation of the third nerve. 
 
 As there is no implication of any other muscle supplied 
 by the third nerve, we are forced to the conclusion that para- 
 lysis of the left cervical sympathetic is the cause of the 
 contraction of the pupil and the narrowing of the palpebral 
 fissure in this case. The sympathetic is supposed to give tone 
 to certain unstriped muscular fibres in the orbit which keep 
 the lids to a certain extent retracted, and maintain the due 
 prominence of the globe. Certain it is that division of the 
 sympathetic in the neck causes precisely the condition of the 
 eye and palpebral fissure which we have here. The condition 
 of the palpebral fissure is very like what is seen in old cases of 
 facial paralysis, in which the paralysis of the orbicularis muscle 
 is followed by contracture with narrowing of the palpebral 
 fissure. 
 
 Leaving for a time this condition, which is probably caused 
 by paralysis of the sympathetic, let us turn our attention to 
 
 K 2 
 
132 SPINAL MYELITIS 
 
 the condition of the left arm and hand. It is to be noted that 
 while the nutrition of the arm is below par, duer probably to 
 want of use, there are certain muscles, such as those of the 
 little tinger and the interossei, which are definitely wasted ; 
 and we find that the muscles of the little finger (hypothenar 
 eminence) give degenerative reactions when tested with 
 electricity, and that the interossei and other muscles of the 
 hand and forearm respond somewhat feebly to both forms of 
 current, but do not give degenerative reactions (i.e. response to 
 galvanic and no response to faradic current). 
 
 In the absence of any sensory change, or any evidence of 
 disease or injury of the ulnar nerve in the hand, we are bound 
 to assume that the wasting and degeneration of the muscles of 
 the hypothenar eminence is due to the destruction of motor 
 cells in the anterior cornu of the left side, and we have to 
 answer the question, ' At what level has this destruction taken 
 place ? ' 
 
 The muscles of the hypothenar eminence are supplied by 
 the ulnar nerve, and the ulnar nerve is derived from the intri- 
 cate interlacement of nerve-fibres called the brachial plexus, 
 and this plexus is formed by the last four cervical (5, 6, 7, 8, c.) 
 and first dorsal (i d.) nerve-roots, which have their origin in 
 the cervical enlargement of the spinal cord. 
 
 A consideration of this plexus led me to say in 1881 (Brad- 
 shawe Lecture on ' Nervous Affections of the Hand ') that 
 whereas the median and musculo- spiral nerves possibly had 
 connections with all the nerve-roots forming the brachial 
 plexus, the musculo-cutaneous nerve represented not more than 
 the three upper nerve -roots (5, 6, 7, c), and the ulnar nerve 
 not more than the two lower nerve-roots (8 c. and i D.) ; ^ and 
 this speculation has been largely justified by the laborious 
 researches of Dr. Herringham, who traced out the fibres, and 
 in a communication to the Royal Society in 1886 showed that 
 the musculo-cutaneous nerve was derived from the two upper 
 roots and the ulnar from the two lower roots, while the median 
 was derived from the four lower roots, and the musculo-spiral 
 from the four upper roots. Considering that the formation of 
 
 ' See p. 3. 
 
BRACHIAL PLEXUS 133 
 
 the brachial plexus varies considerably, Dr. Herringham's 
 research very closely confirms my speculation on the matter, a 
 speculation founded on considerations with which I need not 
 trouble you now. Thus, on anatomical grounds alone, the 
 muscles of the hypothenar eminence must be supplied by one 
 or other or both of the lower two roots of the plexus. 
 
 The experimental investigation of the function of the 
 nerve-roots going to form the brachial plexus in the monkey, 
 made by Terrier and Gerald Yeo in 1881, showed that the 
 small muscles of the monkey's hand only moved when one or 
 other of the two lower roots (8 c. 1 d.) was stimulated, so 
 that there is a perfect agreement between the anatomical and 
 physiological facts established by dissection and experiment. 
 
 We are therefore justified in coming to the conclusion that, 
 in the case which we are considering, there has been a destruc- 
 tion of the motor cells of the left anterior cornu at the level 
 of the eighth cervical and first dorsal roots. 
 
 The muscles of the hypothenar eminence alone gave 
 definite and undoubted degenerative reactions, but it was 
 found that the extensors of the fingers and interossei re- 
 sponded very feebly (as compared with the muscles on the 
 opposite side) to both forms of current, and we are justified in 
 concluding that these muscles still received sufficient nerve 
 impulses to prevent their complete degeneration ; and we 
 found that the extensors, receiving their supply from the 
 musculo- spiral (having connections with the four upper roots), 
 responded to electricity more readily than the interossei which 
 are supplied by the ulnar. 
 
 It very often happens in anterior polio-myelitis that a 
 small group of muscles which is completely degenerated is 
 surrounded by others which are much weakened, but not 
 completely degenerated ; and it is, I think, evident that the 
 interlacings of the brachial plexus not only facilitate the 
 purposive co-ordination of physiological acts, but by widely 
 scattering the influence of the motor cells in the cornu they 
 lead to the semi-preservation of muscles which, by means of 
 the plexus, receive their nerve-supply from several nerve- 
 roots. 
 
134 SPINAL MYELITIS 
 
 The next point to which I would direct your attention is 
 the weakness of the left leg without marked wasting or 
 degeneration of any of the muscles, and the exaggeration of 
 the knee-jerk on the left side. This points to a descending 
 degeneration of the left pyramidal tract, and we have a right 
 to assume that the process which has damaged the motor 
 cells at the level of the eighth cervical and first dorsal roots 
 has also blocked the pyramidal tract at that point, and has 
 caused it to degenerate below. 
 
 Looking to the fact that the onset of the case was com- 
 paratively sudden, that it followed an attack of influenza, and 
 that there has been no increase and no great improvement in 
 the symptoms from the first, we are justified in concluding 
 that the trouble is caused by a patch of myelitis involving the 
 anterior cornu and pyramidal tract, and limited to the left 
 side of the cord on a level with the eighth cervical and first 
 dorsal segments of the cord. 
 
 Having, by means of the muscular paralysis, localised the 
 patch of myelitis, we are now in a position to account for the 
 symptoms which we have presumed are due to a paralysis of 
 the cervical sympathetic. The lower cervical region of the 
 spinal cord has long been remarkable for the fact that injury 
 of it has often been accompanied by contraction or dilatation 
 of the pupil, and also by symptoms referable to vaso-motor 
 disturbance, such as dilatation of the blood-vessels, abnormal 
 body temperature, and occasionally priapism. The ciliary 
 muscle derives its sympathetic supply from the superior 
 cervical ganglion, which, according to the researches of 
 Gaskell, receives its cerebro- spinal filaments from the upper 
 dorsal nerves, or, according to other authorities, from the 
 seventh cervical to the first dorsal segments, this region being 
 spoken of as the cilio-spinal centre. 
 
 Our anatomical diagnosis is thus complete, and we are in 
 a position to say that the contraction of the left pupil and 
 the left palpebral fissure, the weakness of the left arm, and 
 the wasting and degeneration of the muscles of the hypothenar 
 eminence, and also the weakness of the left leg and the 
 increased knee-jerk on the left side, are all caused by a 
 
MYELITIS FROM TUMOUR OF VERTEBRA 135 
 
 localised damage (probably myelitis) on the left side of the 
 spinal cord at the level of the eighth cervical and first dorsal 
 segments. 
 
 There are points in the history of this patient which 
 make it probable that in the earlier days of his illness he 
 presented evidence of vaso -motor disturbance, for he tells us 
 that he has suffered from palpitations, tingling of the left side 
 of the head, tinnitus, and sleeplessness. We have never been 
 able to discover any evidence of vaso-motor disturbance, and 
 the temperature, which has been normal, was found to be 
 practically equal in both ears. The case is one of rarity and 
 great interest, and the ' hemiplegic symptoms ' might have led 
 a careless observer to place the lesion on the right side of the 
 brain. 
 
 The cause of the myelitis is a matter of doubt. Such 
 troubles have arisen from lead poisoning (and be it re- 
 membered that our patient is a painter), and they have been 
 observed as a sequel of influenza (from which our patient has 
 suffered). He improved very slightly, if at all, under treat- 
 ment, and it was demonstrated that large doses of iodide of 
 potassium produced no appreciable amelioration of his con- 
 dition. I believe the lesion to be myelitis, and I fear the 
 prospects of complete recovery are very slight indeed. 
 
 Case 2. — Transverse myelitis in the upper dorsal region, 
 caused hy a round- celled sarcoma originating in the third 
 intervertebral cartilage. The next case which I have to bring 
 to your notice is one of great interest, and is very full of 
 instruction for all of us ; and you will note that although 
 the patient was suffering from a serious and necessarily fatal 
 trouble, his symptoms were most indefinite, and to a large 
 
 extent subjective. Emile J , a French commercial 
 
 traveller, aged 36, was admitted on November 22, 1895. He 
 complained of pain in the back, weakness of the legs, and 
 some difficulty in passing urine. The patient looked ill, pale, 
 and thin. The pain in the back was referred to the scapular 
 region, not very defined, and unaccompanied by any tenderness 
 or prominence of the vertebrse. When asked to walk he did 
 so readily, but with evident feebleness, and there was nothing 
 
136 SPINAL MYELITIS 
 
 in his gait which was characteristic of any recognised systemic 
 disease of the spinal cord or brain. 
 
 Sensation of all kinds was perfect, but the legs were cold ; 
 the knee-jerks were markedly exaggerated, and ankle-clonus 
 was readily produced on both sides. The skin reflexes, 
 plantar, cremasteric, and hypogastric, were not obtained. It 
 is of interest to state that Dr. Isaac, of Gower Street, who 
 sent the patient to the hospital, stated that both by himself 
 and at the Middlesex Hospital systematic examination had 
 been made four or five weeks previously for evidence of disease 
 of the spinal cord or vertebral column, but with negative 
 results in both instances. 
 
 The symptoms from which the patient was suffering had 
 been coming on for ten or twelve months. There was a 
 history of discharge of mucus and blood from the naso- 
 pharynx, but an examination of these parts revealed no 
 disease. He attached considerable importance to a crop of 
 boils which had appeared between the buttocks and the knees 
 a few weeks before his admission, and he said he had got 
 ' much weaker since the boils,' which had disappeared before 
 he was admitted to our hospital. 
 
 It should be stated that the difficulty of micturition was, 
 on his admission, more subjective than objective. There was 
 no dribbling or incontinence, and no sign of distension of the 
 bladder. The urine usually contained phosphates, but it was 
 otherwise normal, and was not ammoniacal. 
 
 The case was puzzling. The exaggeration of the knee-jerks 
 and the presence of ankle- clonus caused us to search for 
 localised disease in the cord above the lumbar enlargement. 
 The chest moved symmetrically, but he experienced difiiculty 
 in changing from the recumbent to the sitting position, and 
 we thought there was want of power in the recti abdominales 
 muscles. When he coughed he complained of pain (not great), 
 but there was a complete absence of any tenderness of the 
 vertebral column. 
 
 The power of the arms was good, and there were no sensory 
 symptoms referred to the upper limbs. The left pectoral muscle 
 appeared smaller than the right, and the left side of the face 
 
MYELITIS FEOM TUMOUE OF VEETEBE^E 137 
 
 appeared to move less freely than the right. There was some 
 stiffness of the left shoulder, and this we thought probably 
 accounted for the comparative smallness of the left pectoral 
 muscle. There was no wasting of the dorsal muscles. The 
 symptoms of motor disability, whether of the trunk or lower 
 limbs, were all slight, and in short there was a want of corres- 
 pondence between the objective symptoms and the subjective 
 symptom of pain between the scapulse. Pain in this situation 
 is often due to stomach trouble, but there was no direct 
 evidence of disease of the digestive system. It was a case to 
 watch, in the hope that new symptoms might bring new 
 light. 
 
 The suggestion was made that it might be a case of dis- 
 seminated sclerosis, and a note was made on one occasion of 
 slight lateral nystagmus ; but this latter symptom was not to 
 be obtained on subsequent occasions, and in the absence 
 of other evidence of disseminated sclerosis (such as intention 
 tremors and staccato speech) I did not consider this view of 
 the case as tenable. 
 
 Again, the patient was a rather emotional Frenchman, 
 and possibly made the most of his troubles, and we considered 
 whether the case was a so-called ' pure neurosis ' ; but this 
 view was abandoned because there was an absence of sensory 
 symptoms, such as are common to 'hysteria,' and the patient 
 seemed really ill, and further, he had an unsteady tempera- 
 ture, which fluctuated between 98-4° and 100° during the 
 first five days of his stay in the hospital. 
 
 On December 2 (ten days after admission) the patient sud- 
 denly lost all power in his legs, and a few days later all sensa- 
 tion had disappeared in the legs, and the ankle-clonus and the 
 excessive knee-jerks disappeared, so that the knee-jerk was 
 only present to a very slight extent on the right side. Incon- 
 tinence of urine supervened. The temperature on the 10th of 
 December ran up to 104°. For the last few days of his life he 
 was troubled with vomiting. He became comatose, and died 
 on December 11, nineteen days after his admission. 
 
 The phenomena of December 2 and the subsequent days 
 made it tolerably certain that we had to deal with a trans- 
 
138 SPINAL MYELITIS 
 
 verse myelitis of the dorsal region, and the post-mortem 
 examination, which was made twelve hours after death, showed 
 the correctness of this diagnosis, and also revealed the cause 
 of the trouble. 
 
 The spinal cord was first examined. The neural arches 
 were removed, and the dura mater beneath looked normal. 
 On slitting up the dura mater it was noticed that the vessels 
 on the posterior aspect of the cord were somewhat dilated 
 below the mid-dorsal region. On removing the cord we found 
 that the bodies of the third and fourth dorsal vertebrae were 
 freely movable owing to softening of the third intervertebral 
 disc, and we found at this level a growth not much bigger 
 than an almond, pinkish in colour, projecting into the spinal 
 canal between the bone and the dura mater, and evidently 
 compressing the cord at that point. On making sections of 
 the cord we found that for about an inch there was softening 
 approaching to diffluence where the tumour had compressed 
 the cord, but that above and below this level the cord was 
 apparently healthy. A microscopic examination by Dr. 
 Bradford confirmed the macroscopic appearances, the softened 
 patch giving evidence of acute myelitis, while the cord was 
 elsewhere perfectly healthy. 
 
 There was no disease of the brain or of any of the thoracic 
 or abdominal viscera, but on inspecting the cavity oi the 
 thorax we found a growth concealing the bodies of the third 
 and fourth dorsal vertebrae, and projecting for about an inch 
 beneath the pleura on the left side. This growth was 
 examined by Mr. Drew, and pronounced to be a round-celled 
 sarcoma. 
 
 The post-mortem examination cleared up the case, and 
 showed us why the symptoms were so indefinite. We had 
 not to do with a tumour of the cord or its membranes, but 
 with a tumour originating probably in the tliird intervertebral 
 disc, and involving the bodies of the third and fourth vertebrse. 
 It extended forwards and backwards, more forwards than 
 backwards. When the patient was admitted to the hospital 
 the backward extension was beginning to exercise pressure 
 upon the cord, and when it ultimately produced myelitis we 
 
MYELITIS FKOM TUMOUR OF VERTEBK^ 139 
 
 diagnosed the effect, but remained ignorant of the cause until 
 the post-mortem examination made the course of the patient's 
 troubles quite clear. 
 
 I think I may say that our failure to diagnose the exact 
 cause of the myelitis in this case was quite excusable. He 
 had been examined both before admission and subsequently 
 for disease of the vertebrae, but with a negative result, and it 
 is certainly remarkable that a tumour which, before death, 
 had loosened the connection between the third and fourth 
 vertebrae, should not have produced tenderness of the verte- 
 bral spines or deformity of the back. The tumour, by its 
 growth, kept the bodies of the vertebrae in their normal rela- 
 tive position, and had not, as in caries, allowed the bodies of 
 the vertebrae to soften and become merged in each other so 
 as to produce angular curvature. ISTeither had it projected 
 forward sufficiently to interfere with the function of the 
 thoracic organs. Neither had it pressed upon the nerve-roots 
 so as to give rise to neuralgia and definite referred pains at a 
 distance from the seat of disease. 
 
 It is probable that the growth was definitely the cause of 
 some of the early symptoms from which the patient suffered, 
 such as the weakness of the rectus abdominis and the relative 
 smallness of the left pectoralis major. The intercostals, 
 levatores costarum, obliquus externus, and rectus abdominis 
 receive nervous supply from the third, fourth, and fifth dorsal 
 roots, but the nervous supply of the pectoralis major is not, 
 according to Professor Thane, in any degree derived from any 
 root lower than the first dorsal. Every muscle, for its satis- 
 factory working, is largely dependent upon the muscles which 
 maintain the fixity of the parts to which, at one or the other 
 end, it is attached ; and it may well be that a growth, such 
 as was present in this case, by loosening the spinal column in 
 a slight degree, and by interfering with the fibres of some of 
 the muscles nearest to it, might cause much more muscular 
 incapacity than could be inferred by a mere reference to 
 anatomy. 
 
 There is one point in connection with this case which 
 demands, attention. It is this. It will be noticed that when 
 
140 SPINAL MYELITIS 
 
 first admitted the patient manifested increased knee-jerks and 
 ankle-clonus, or an exaggeration of the deep reflexes ; but 
 some days before death these deep reflexes had almost entirely 
 disappeared, their disappearance being probably coincident 
 with the completion of the destruction by softening of the 
 entire thickness of the spinal cord on a level with the third 
 intervertebral cartilage. 
 
 This fact is in accordance with the observations of Dr. 
 Bastian, who has combated the opinion which has been 
 generally held hitherto, and has asserted that so soon as a 
 limited transverse lesion in the dorsal or higher regions of 
 the cord becomes total the so-called ' deep reflexes,' which 
 previously were exaggerated, become depressed and abolished. 
 This condition of the deep reflexes is generally explained 
 by saying that the exaggeration is due to an increase of 
 muscular tonus caused by the cutting off* of cerebral control. 
 The reflex movements in the frog are, as is well known, 
 demonstrated far more easily when the animal has been pithed, 
 or the brain removed. In man, the muscular movements 
 which are excited by (a) direct cerebral or (b) reflex (peri- 
 pheral) stimulation seem to bear, as it were, an inverse ratio 
 to each other. The greater the former, the less the latter, 
 and vice versa. In sclerosis of the pyramidal tracts following 
 a cerebral lesion, or a lesion high up in the cord, the move- 
 ments in response to cerebral stimulation are lessened or lost, 
 and the reflex movements are exaggerated. In posterior 
 sclerosis reflex movements are lost, but the direct movements 
 are sudden, violent, and impulsive. When lateral sclerosis 
 follows as a consequence of a limited lesion which blocks the 
 pyramidal tracts, the reflex movements may, in the very early 
 hours of the trouble, be entirely lost, which we account for 
 by using the term ' shock.' This is seen in cases of sudden 
 hsemorrhage or embolism affecting the motor tracts of the 
 brain. After this the reflex movements reappear, and reach 
 their full development in a week or ten days, when the de- 
 generation of the pyramidal tracts is complete. The motor 
 cells in the anterior cornu are the points towards which the 
 cerebral stimuli and the peripheral stimuli converge, and when 
 
VAEIATION OF DEEP EEFLEXES 141 
 
 either one or the other set of stimuli is in abeyance those 
 which remain produce an exaggerated effect. We must, I 
 think, assume that after the cerebral influence has been cut 
 off, and before the degeneration of the pyramidal tracts is 
 complete, stimuli from other points than the brain may travel 
 down the pyramidal tracts, and produce an effect upon the 
 motor cells ; but after the degeneration is complete the motor 
 cells can only be stimulated by peripheral stimuli at their own 
 level, and this stimulation produces an exaggerated effect. 
 
 It has been suggested that the increase of the reflex 
 effects is due not only to the cutting off of the cerebral 
 control, but to the non-antagonised influence of the cerebellum. 
 The experiments of Risien Russell and others conclusively 
 show that a removal of one-half of the cerebellum produces 
 an exaggeration of reflex action on the same side, and these 
 and similar experiments lend no support to the theory of 
 cerebellar action as the cause of the exaggeration of the deep 
 reflexes. 
 
 In the lower animals a clean and complete division of the 
 spinal cord does not abolish the deep reflexes, which, on the 
 contrary, are exaggerated. It is well known, also, that slow 
 compression of the cord, as in vertebral caries, leads to an 
 exaggeration of the deep reflexes. On the other hand, in 
 cases of fracture of the vertebrae it commonly happens that 
 the deep reflexes are abolished, as has been demonstrated by 
 the careful clinical observations of Mr. Thorburn of Man- 
 chester, and others. 
 
 It is possible that the sudden occlusion of the spinal 
 arteries, either by fracture of the vertebrae or the effect of 
 acute inflammation, may so cut off the blood supply from the 
 central parts of the spinal cord below, as to prevent the 
 manifestation of reflex action, and it is possible that this 
 effect may be more easily produced in man, in whom the 
 spinal cord runs vertically, than in other animals which carry 
 the spinal cord horizontally. The spinal arteries (one anterior 
 and two posterior) are derived from the vertebrals, and the 
 pressure of blood in them must be considerable. These arteries 
 are, it is true, plentifully reinforced by other arterial twigs, 
 
142 SPINAL MYELITIS 
 
 and it is probable that the loss of the blood supply by the 
 arteries running vertically downwards would be soon com- 
 pensated by those which reach the cord along the nerve-roots, 
 travelling horizontally or, in the lower parts of the cord, nearly 
 vertically upwards. I think it is not possible, especially in man, 
 to neglect the cutting off of a portion of the blood supply as a 
 factor in the production of abolition of the reflexes in cases of 
 fracture or sudden occlusion of the arteries by inflammation. 
 
 This interesting point, to which Dr. Bastian has called 
 attention, stands in need of further elucidation. 
 
 Case 3. — Transverse myelitis in the lower dorsal region 
 
 occurring in a syphilitic subject. W. D , aged 38, a stoker, 
 
 was admitted on August 14, 1896, suffering from paraplegia. 
 He states that about the middle of July he experienced some 
 difficulty in passing urine, and that this difficulty, with some 
 fluctuations, increased, and that he became an in-patient in a 
 surgical ward of this hospital, where he underwent circum- 
 cision on account of a swollen prepuce with purulent discharge 
 from beneath it. No stricture was discovered, and on 
 August 6 he was discharged, ' cured.' 
 
 The onset of his attack was fairly sudden, and he names 
 August 7 as the day upon which his legs became, as he says, 
 ' shaky,' and a few days later he had lost all power in them. 
 On admission, both legs were completely paralysed, and the 
 acts of defalcation and micturition occurred automatically and 
 unconsciously. 
 
 Tactile sensation was almost absent in both legs and up- 
 wards to a line midway between the costal margin and the 
 umbilicus. Painful sensations and the appreciation of heat 
 and cold were also deranged, and there was obvious delay in 
 the recognition of tactile impressions. 
 
 There was a big blister on the sole of each foot in the arch, 
 and there were blisters behind the head of each fibula and 
 above the sacrum, on spots where counter-irritants had been 
 applied. No counter-irritant had been applied to the soles. 
 
 There was a blotchy eruption over both legs, and the 
 patient gave an undoubted history of syphilis which had been 
 contracted ten months before his admission. 
 
TRANSVEKSE (SYPHILITIC) MYELITIS 143 
 
 The knee-jerks were increased, but there was no ankle- 
 clonus. The plantar (?) and cremasteric reflexes were absent. 
 The abdominal and epigastric reflexes were present. 
 
 The urine (which was passed involuntarily) was ammoniacal, 
 and contained pus. There was no marked wasting of the 
 muscles, and none of them gave degenerative reactions. 
 
 Since his admission he has very much improved. The 
 sensory symptoms were, as is usual, the first to pass off. 
 Tactile sensation was the earliest to recover, and the other 
 sensory derangements followed. Next he got some control 
 over his rectum, so that incontinence of fgeces is no longer 
 present, and finally, he has a considerable return of motor 
 power in the legs. 
 
 The knee-jerks are still exaggerated, and there is well- 
 marked ankle-clonus. 
 
 The sores upon the soles of the feet are healing well, and 
 showing no tendency to extend either in breadth or depths 
 The other blebs mentioned healed readily, and, thanks to 
 excellent nursing, there have been no ' bedsores.' 
 
 There is less incontinence of urine, but the urine is no 
 longer ammoniacal, and the pus has almost disappeared. 
 
 In considering this case we have to decide (a) the situation 
 and (b) the nature of the lesion. As regards the situation, 
 the facts which guide us are : (1) The complete paralysis of 
 the legs, showing that the anterior crural as well as the 
 lumbo-sacral cord were implicated, which would place the 
 lesion as high as the first or second lumbar segments ; (2) the 
 disappearance of the cremasteric reflex and the persistence of 
 the abdominal reflex, which makes it highly probable that the 
 lesion was situated at the level of the junction of the roots of 
 the twelfth dorsal and first lumbar nerves with the cord, and 
 about the level of the tenth and eleventh dorsal spines. 
 
 As regards the nature of the lesion, the points which lead 
 to a diagnosis are : (1) The sudden onset. There had been 
 some premonitory difiiculty of micturition, which is common 
 in these cases ; but when the paraplegia declared itself it did 
 so suddenly, so that the patient had no hesitation in fixing 
 the date. This is very characteristic of myelitis. (2) The 
 
144 SPINAL MYELITIS 
 
 patient was undoubtedly syphilitic, and the concurrence of 
 syphilis and myelitis is sufficiently common to make it 
 probable that there is some relation between them. The 
 absence of marked pain in the back, or of neuralgic symptoms 
 referable to the terminations of the sensory nerves which run 
 into the cord at the level of the injury, make it unlikely that 
 we have to do with gumma or pachymeningitis. The attack 
 was too sudden for such an explanation. Syphilis, however, 
 is a great cause of arterial disease, and it seems highly 
 probable that an endarteritis of some of the vessels at this 
 level, leading to their obstruction and consequent faulty 
 nutrition of the cord, may have contributed to the catastrophe. 
 The spinal cord, you will remember, is nourished by one 
 anterior and two posterior spinal arteries, derived from the 
 vertebrals and running nearly the whole length of the cord, 
 and these three arteries are supplemented by others which 
 reach the cord through the intervertebral foramina in its 
 entire length, and travel along the nerve-roots to reinforce 
 the three long arteries derived from the vertebrals. 
 
 The sensory symptoms in this case (especially the thermic 
 symptoms and analgesia), combined with the trophic lesions, 
 of which I shall have more to say presently, point to the fact 
 that the parts around the central canal are implicated. These 
 parts are supplied by the anterior spinal artery, and it seems 
 very probable that a blocking of the anterior spinal artery by 
 syphilitic endarteritis at the level of the lesion is the cause of 
 our patient's trouble, or at least an accessory cause. Such a 
 theory will account also for the perfect symmetry of the 
 symptoms. The very marked improvement which has taken 
 place as the result of treatment makes such a theory still more 
 plausible. It is possible also that there may have been some 
 hsemorrhage into the softened cord, which has since undergone 
 absorption. 
 
 The almost complete absence of ' girdle sensation ' in this 
 case seems to point to the lesion being limited very much to 
 the anterior and central parts, and avoiding the posterior 
 roots, upon irritation of which girdle sensation is supposed to 
 depend. 
 
TROPHIC LESIONS 145 
 
 A very notable feature in the case we have been discussing 
 are the trophic lesions. By a ' trophic lesion ' we mean a 
 failure of nutrition. The nutrition of an organ depends upon 
 its power of exercising function. Growth and use are to a 
 large extent mutually dependent. We know that muscles 
 may be increased in size by exercise, and that when not used 
 they waste. The degree of wasting which a muscle may 
 undergo varies immensely. It may be partial or it may be 
 absolute. Lesions of the nervous system which lead to a 
 partial disuse of muscles cause only partial failure of nutrition, 
 while lesions which necessitate a total disuse lead to total 
 wasting, degeneration, and practical abolition. 
 
 Our muscles can be made to contract by direct or reflex 
 stimulation, i.e. the stimuli which bring the muscle into use 
 may reach it from the brain or from the periphera. In 
 ordinary hemiplegia the wasting of the paralysed muscles is 
 only partial, because contraction takes place in response to 
 reflex stimulation, a stimulation which is often sufficient to 
 lead to the permanent contracture of the paralysed muscle. 
 
 Again, in locomotor ataxy there is seldom more than 
 slight wasting of the muscles, because although reflex stimula- 
 tion of the muscles may be abolished, direct stimulation is 
 still capable of being exercised. 
 
 If a nerve supplying a muscle be divided, a total wasting 
 rapidly follows, because direct and reflex stimulation are 
 alike impossible. If an anterior nerve-root be divided, or if 
 the motor cells of the anterior cornu be destroyed, the muscle 
 undergoes total wasting, because direct and reflex stimulation 
 are alike impossible. 
 
 It is common to hear it said that the motor cells in the 
 anterior cornu exercise a ' trophic influence ' upon the muscle, 
 but there is no evidence of any trophic influence beyond the 
 fact that all stimuli which reach the muscle, whether direct 
 or reflex, must pass through these cells, and when they are 
 destroyed no stimuli can possibly reach the muscle. Function 
 is the only thing having a ' trophic influence ' on organs of 
 which we have any knowledge. A healthy muscle is plump, 
 
 L 
 
146 SPINAL MYELITIS 
 
 firm, elastic, and is constantly contracting in obedience to 
 stimuli, of many of which we are unconscious. These con- 
 tractions must influence the blood and lymph currents and 
 reo-ulate nutrition. The muscle which is isolated from all 
 stimuli is flabby, limp, and absolutely inert, yielding to 
 pressure, and having no use for nutriment. 
 
 With regard to the blebs and sloughs upon the skin, we 
 must, I think, iia looking for a cause have regard to the 
 general circumstances, and not attend too exclusively to 
 individual factors. My belief is that they are due, if I may 
 say so, to an unlucky concurrence of adverse circumstances, 
 any one of which might be powerless to produce them. 
 
 Pressure alone, if prolonged, is capable of producing a 
 slough even in a healthy man, as occasional accidents in 
 surgical practice bear witness. 
 
 The efiects of pressure may be intensified by a variety of 
 circumstances. Thus, in fevers and other prolonged and 
 exhausting diseases accompanied by emaciation with wasting 
 of fat and muscles, the squeezing of the skin between the 
 bones on the one hand, and even an air cushion on the other 
 hand, is sufficient to cause a slough over the sacrum. The 
 pain of prolonged pressure makes us alter the point of pressure 
 ourselves or leads the sick man to ask his nurse to shift his 
 position. If the fever patient is unconscious he will not seek 
 to shift his position, and his danger of bedsore is therefore 
 increased. 
 
 A man in a deep drunken slumber will sometimes compress 
 the musculo-spiral nerve between his ' heavy head ' and his 
 humerus to such a degree as to interfere with its nutrition and 
 cause paralysis of the muscles supplied by the nerve, but the 
 average man is awakened by the pain long before the com- 
 pression reaches the dangerous point. If the parts which are 
 compressed are an aesthetic, as in many cases of paraplegia, 
 the danger of sloughing from compression is very great, for 
 the patient not only feels no pain, but, being paralysed, is 
 powerless to shift his position. 
 
 When there is anaesthesia without paralysis, as happens in 
 some hysterical cases, the danger of sloughing from pressure 
 
TKOPHIC LESIONS 147 
 
 is almost nil, because the muscles are plump and serve as 
 protective cushions, and the patient can move freely. 
 
 If the skin be irritated the danger of sloughing from 
 pressure is increased, and I would here caution you as to the 
 risk of applying strong counter-irritants, such as blisters, 
 to any part of the back of a fever-patient. The irritation 
 caused by lying in a mess of urine and faeces enormously 
 increases the danger of sloughing, and hence it is that all 
 patients who are unmindful of the calls of nature, whether as the 
 result of paralysis or from the stupor and exhaustion of fevers, 
 require the most watchful care on the part of the nurses and 
 doctors. A sore once formed may be infected by septic 
 organisms, and a rapid extension may result. 
 
 It is obvious, therefore, that a patient who is paralysed 
 and anaesthetic must be very vulnerable to the effects of 
 pressure or irritation of the skin. We must remember that 
 muscular action is an important factor in the circulation of 
 the blood, and that in a paralysed limb the return of the 
 venous blood and the flow of lymph are alike deprived of the 
 aid they derive from muscular contraction. 
 
 If the muscles underlying the part which is subjected to 
 pressure be really cut off from the motor cells, they lose tone — 
 they no longer serve as elastic cushions to ease the pressure — 
 they sag, as it were, under the weight of the body, and allow the 
 skin to be squeezed to death between the dead weight of bones 
 above and the unyielding bedclothes beneath. 
 
 There can be little doubt that vaso- motor irregularities 
 may contribute towards the occurrence of trophic lesions, but 
 our knowledge of these conditions is very slight. The redness 
 which follows an irritation of the skin is, one must suppose, 
 a. vascular reflex. If we tickle the skin we get a rapidly 
 following muscular action. If we slap the skin or make a 
 limited firm pressure upon it there is no involuntary muscular 
 movement, but the pallor which is caused by the pressure is 
 leisurely followed by a blush. In certain conditions of intra- 
 cranial pressure, such as tubercular meningitis, this blush is 
 very pronounced and very enduring, and this exaggerated form 
 of vascular reflex has been called the ' tdche cerehrale.^ 
 
 l2 
 
148 SPINAL MYELITIS 
 
 That gentle tactile impressions made upon the skin should 
 produce reflex muscular acts, while impressions of a more 
 penetrating kind, such as firm pressure, scratching, and the 
 application of heat or chemical irritants, should produce 
 vascular dilatation, is interesting, and seems to point to the 
 fact that the dilBferent end -organs in the papillae and in the 
 deeper layers of the skin may have different central 
 connections. 
 
 Although I have lectured on Medical Jurisprudence for 
 many years, it has never fallen to my lot to see an acute case 
 of strychnine poisoning. In these cases, as you are aware, 
 any slight unexpected cutaneous impression will produce a 
 paroxysm of tetanic convulsions, and yet these patients will 
 often ask to be turned over or held, and von Boeck, the writer 
 on the subject in von Ziemssen's ' Encyclopaedia of Medicine,' 
 says, with regard to sufferers from strychnine poisoning, that 
 they ' have asked their attendants to rub the skin vigorously, 
 and that this friction did not induce tetanus,' while slight 
 unexpected impressions, such as an accidental kick against the 
 bedstead, produced the most violent convulsions. 
 
 It may be, of course, that this difference in effect was due 
 to the mental attitude of the patient — to the absence or 
 presence of cerebral control ; but there is a fair amount of 
 evidence to show that slight tactile impressions and firm 
 rubbing produce different physiological effects, the former 
 being mainly reflex muscle-motor, and the latter mainly reflex 
 vasomotor. 
 
 I need not remind you that in the skin there are varieties 
 of nerve ' end-organs,' and that while some, such as the 
 Pacinian bodies, lie deeply in the true skin, others, such as 
 the tactile corpuscles, are more superficial. In cases of 
 paralysis, whether cerebral or spinal, we do not get many very 
 obvious vaso-motor disturbances. There are occasional 
 differences of temperature between paralysed and non- 
 paralysed limbs, and sometimes, as in anterior polio-myelitis, 
 there may be a blue congestion of the paralysed limb, and we 
 have alluded to the tdche cerehrale. 
 
 The subject is one which is difficult of investigation, but 
 
TKOPHIC LESIONS 149 
 
 we must admit the possibility that lesions of the nerve centres 
 may derange the vaso-motor connections, and that such 
 derangements may play a part in the production of skin 
 lesions. 
 
 The occurrence of trophic changes in the eye in cases of 
 paralysis of the fifth nerve is very uncertain, and division of 
 the sympathetic causes no trophic change in the rabbit's ear. 
 Anaesthesia alone, and vaso-motor paralysis alone, are unable 
 to cause trophic disturbance ; and I would again repeat what 
 I have already said, that these trophic lesions depend upon a 
 concurrence of many adverse circumstances. 
 
 It is clearly our duty to exhaust all the causes which may 
 possibly produce trophic disturbance before we avoid the 
 whole difficulty by calling them ' tropho-neuroses,' and 
 attribute them to the action or want of action of hypothetical 
 ■* trophic nerves,' which in the present state of our knowledge 
 is no explanation at all. 
 
 But let us return to our patient. When he was admitted 
 there were blebs on the soles of both feet, and behind the 
 heads of both fibulae, and also over the sacrum. They had 
 appeared in the very early days of his paralysis when the 
 lesion was at its height. After his admission there was no 
 extension of trophic disturbance, and the blebs on the sacrum 
 and behind the heads of the fibulae soon disappeared. The 
 blebs on the back and behind the heads of the fibulae followed 
 the application of mustard, but those on the soles of the feet 
 appeared quite spontaneously, and as they were in the hollow 
 of the arch of the foot they could hardly be attributed to 
 pressure. My view being that a small amount of irritation 
 would be sufficient to develop the blebs in the then condition 
 of the patient, I should think of scalding hot foot-warmers 
 before flying to ' trophic nerves.' 
 
 But there is one other circumstance which may have acted 
 as a determining factor in the localisation of these blebs. 
 
 Dr. Henry Head has shown that our internal organs are 
 functionally related with definite areas of the skin, which fact 
 is accounted for by assuming that the afierent and vaso-motor 
 nerves of the skin area and the like nerves from the related 
 
150 SPINAL MYELITIS 
 
 viscus join the spinal axis at the same level, and come into 
 intimate relationship therein. 
 
 In Dr. Head's very able and elaborate papers, published 
 in 'Brain,' and also in the last edition of Quain's 'Anatomy,' 
 you will find diagrams in which these zonal areas on the trunk 
 and similar areas on the limbs are set forth, and accurately 
 referred to certain levels of the spinal axis. 
 
 Suppose, therefore, that you find one of these definite areas 
 the seat of subjective pain or demonstrable tenderness, or 
 reddened or occupied by an herpetic eruption, you will have a 
 right to assume one of two things, either (a) there is disease 
 more or less permanent in the related segment of the spinal 
 axis, or (b) there is disease of an internal viscus or organ 
 which is in relation with the identical segment. 
 
 If we apply Dr. Head's diagrams to the elucidation of the 
 present case we shall find that the areas upon which the blebs 
 appeared (sacral, solar, and behind the heads of the fibulae) are 
 related to the sacral segments of the cord, the same segments 
 which are in relation with the afiereat and efferent nerves of 
 the bladder. 
 
 My view of the case would be as follows : We know that 
 the bladder symptoms preceded the paralysis by a month, and 
 that when he was admitted here there was well-marked vesical 
 catarrh. When, therefore, he became suddenly paralysed and 
 anaesthetic, and was, so to speak, ripe for trophic lesions, the 
 already existing serious condition of the bladder determined 
 the seat of the blebs, which may possibly be considered as 
 analogous to herpes, a ' trophic ' disease definitely related to 
 the sensory nervous system. 
 
 Yet another point is worthy of mention. So-called trophic 
 troubles are said to be very liable to occur in central diseases 
 of the cord, such as syringomyelia. Or we might put the 
 matter in another way and say that when conduction for pain 
 and temperature are interfered with, trophic troubles are more 
 likely to occur than when tactile sense is mainly affected. 
 
 If all the sensory paths be blocked, as was the fact for a 
 short time in the case we have been considering, the danger of 
 trophic changes is greatly enhanced. 
 
TREATMENT 151 
 
 Finally, a few words as to the treatment and manage- 
 ment of these cases. The third case has proved amenable to 
 treatment, and therefore it will be most profitable to deal 
 with it. 
 
 The undoubted history of syphilis led at once to the 
 administration of mercury and iodide of potassium. The 
 mercury has been given by inunction and by the mouth in the 
 form of hydrargyrum c. creta, one grain three times daily. 
 And the iodide of potassium has been given in doses running 
 up to twenty grains three times a day. Now and again the 
 administration of these medicines has been intermitted for a 
 few days when the appetite appeared to be flagging, and a 
 simple stomachic tonic has been given instead. 
 
 For the rest the treatment has been directed to keeping 
 the patient clean and endeavouring to keep the bladder dis- 
 infected. 
 
 It is impossible to insist too strongly on the absolute im- 
 portance of attention to the bladder. If the bladder be 
 permitted to remain foul, the patient is tolerably certain to 
 go from bad to worse. When there is paralysis of the bladder, 
 with constant dribbling of urine, as in this case, the organ- 
 isms which produce ammoniacal decomposition of the urine 
 travel up the urethra and find lodgment in the bladder, with 
 the result that the contents of the bladder become ammoniacal 
 and irritating, and set up a supjDurative catarrh which may 
 travel up the ureter and produce secondary nephritis, and lead 
 almost certainly to a fatal result. The bladder must be 
 washed out daily, the greatest care being taken that the catheter 
 is in an aseptic condition. Carbolised oil (absolute phenol 1, 
 castor oil 7, almond oil 8) should be used as a lubricant, and 
 a wash composed of five grains of quinine (with sufiicient 
 dilute sulphuric acid to dissolve it) in a pint of water should 
 be used. If this be not successful in disinfecting the bladder, 
 recourse may be had to an iodoform wash made by stirring up 
 a couple of teaspoonfuls of iodoform emulsion (iodoform five 
 grains, glycerine two drachms) into a pint of tepid water. 
 This seldom fails to be of service. A lotion of boric acid (1 in 
 20) is also useful. If one lotion does not succeed, another 
 
152 SPINAL MYELITIS 
 
 must be tried, and we must remember that the bladder must 
 be kept sweet. 
 
 I wonder how often it has happened that a doctor called to 
 a patient, who cannot pass his water, has used a dirty 
 catheter, rendered the bladder foul, and thereby has de- 
 prived an incipient case of paraplegia of any chance of 
 recovery. 
 
 When the bladder is emptied by catheter previous to wash- 
 ing, some of the urine should be received into a clean vessel, 
 to ascertain whether it is sweet. It is impossible to form any 
 conclusion from the urine collected in a bed-bottle, for these 
 bottles are nearly always foul, and the urine will undergo de- 
 composition in them in a very short time. These patients 
 must be furnished with a urine bottle which lies between the 
 legs, and into the neck of which the penis is inserted. There 
 should always be two bottles in use for every case of paraplegia, 
 one in use and one being cleaned. To clean these bottles it is 
 necessary to rinse them out with dilute acid and then boil 
 them. The bottles should be absolutely aseptic, and should be 
 changed two or three times daily. 
 
 It is surprising to see how greatly the patient's general 
 condition improves when the bladder has been thoroughly dis- 
 infected. 
 
 The prevention of bedsores is sometimes very difficult, but 
 no pains are too great in order to prevent them if possible. 
 Absolute cleanliness is most important. The patient must be 
 scrupulously washed whenever he gets fouled by urine or 
 faeces, and, after washing, the part must be thoroughly dried 
 with a warm soft towel and powdered. If the draw- sheet be 
 damp it must be changed. Some nurses advocate the washing 
 of the sacral region with spirits of wine, which is said to 
 harden the skin. The use of water cushions and of perforated 
 cushions to relieve pressure is often very necessary, and the 
 frequent shifting of the patient so as to alter the points of 
 pressure is useful. The prevention of bedsores is an affair of 
 nursing, and every good nurse feels that a bedsore is a matter 
 which more than any other touches her professional reputation. 
 Nevertheless, you must remember that the doctor is the 
 
TEEATMENT 153 
 
 responsible person, and my advice is that you should never 
 visit a para2ylegic patient without looking at the hack. 
 
 If there be an abrasion the best treatment probably is to 
 dust it with iodoform, and then cover it with boric ointment 
 spread upon folded lint (two or three thicknesses). The patient 
 must lie upon a perforated pillow or a graduated pad. 
 
 When the patient's recovery has somewhat advanced, as 
 shown in this case, by recovery of power over the rectum or 
 the return of sensation, it is usually advisable to stimulate 
 the paralysed muscles by means of electricity. 
 
 This must be done methodically, and in applying the 
 current you must take care that the patient is not made either 
 cold or wet. Take a faradising battery, with two moderately 
 big sponge -holders moistened with hot salt and water. Begin 
 above, and go down the front of the abdomen and legs. I lay 
 stress upon the abdomen because the weakness of the rectus 
 and other abdominal muscles is a contributory cause of the 
 difficulty of micturition, which is so marked a feature in these 
 cases. Use a current of sufficient strength to cause a contrac- 
 tion of the muscles, and make each muscle or group of muscles 
 contract two or three times and no more. 
 
 Having attended to the extensors and adductors of the 
 thigh, the tibial and peroneal groups of muscles, proceed to 
 faradise the foot, and I may say that it is most important not 
 to neglect the interossei and other small muscles of the foot, 
 because the contraction of these muscles has the effect of 
 causing a flow of blood to the very extremity of the limb. 
 Having attended to the front of the right leg, wipe it dry with 
 a soft hot towel, cover it up to protect it from the cold, and 
 proceed to do the same with the left leg. Then turn the 
 patient over, and faradise the various groups of muscles from 
 the loins to the soles of the feet, taking care when you have 
 finished to leave your patient dry, warm, and comfortable. 
 
 The application of the faradising current in these cases is 
 often productive of great good, and the same current applied 
 to the sphincter and bladder will often impart tone to 
 those parts and make an incalculable difference in the patient's 
 comfort. 
 
154 SPINAL MYELITIS 
 
 It will sometimes happen that the first application of elec- 
 tricity does an amount of good which astonishes both doctor 
 and patient. These are the cases in which time has worked 
 an almost complete cure of the central lesion, and the muscles, 
 long disused, were only waiting for a stimulus of sufficient 
 strength to rouse them to their former activity. Such cases 
 are few and far between, and the applications of electricity 
 subsequent to the first are not productive of the same degree 
 of improvement or anything like it. Yery often electricity 
 does no good. If it be used too earl}'^ in the case, while the 
 spinal cord is still the seat of active disease, it may do 
 harm. When, however, a patient, as in this case, has been 
 lying by for months, when his temperature goes to normal and 
 stops there, when he improves in appearance and begins to put 
 on flesh, then is the time when electricity is to do good, and 
 its beneficial results make us recognise that ' There is a tide 
 in the ajffairs of men, which, taken at the flood, leads on to 
 fortune.' 
 
155 
 
 CHAPTER VIII 
 
 TWO CASES OF PHOSPHORUS POISONING 
 
 In my systematic lectures on Medical Jurisprudence I am in 
 the habit of insisting that the study of toxicology is of great 
 scientific value, on account of the fact that the symptoms 
 manifested by the poisoned person flow from a single cause. 
 In the majority of cases which we study in the hospital a 
 number of causes have been at work, and it is often difficult; 
 for us to say which out of many may have been most potent 
 in the production of the efiects observed. When, however, a 
 healthy person takes a dose of poison and is immediately made 
 ill thereby, we can be in no such doubt, and it is most instruc- 
 tive to observe the numerous and varied symptoms which may 
 arise as the result of a single cause. Poisoning by phosphorus 
 has an especial interest, because in combination it exists plenti^ 
 fully in the body, and it is in itself an interesting fact that 
 a few grains of pure phosphorus should be able to cause the 
 death of the individual, and this without the production of an 
 immediate and severe local lesion such as is produced by the 
 corrosive acids. 
 
 It is only in recent years that phosphorus poisoning has 
 become common, and it is evident that until phosphorus itself 
 became a tolerably common article of commerce it was impos- 
 sible for cases of poisoning by it to be observed and studied. 
 Phosphorus is said to have been discovered by the German 
 alchemist Brandt in 1678, who obtained it by the dry distil- 
 lation of urine solids ; but it remained a rare chemical curi- 
 osity until Scheele succeeded in producing it from bone ash. 
 It was not, however, until phosphorus became a common 
 article of commerce for the manufacture of lucifer matches 
 
 ' Clinical Lecture, U.C.H., 1888. 
 
156 PHOSPHOKUS POISONING 
 
 that cases of poisoning by it began to be recorded. The phos- 
 phorus match industry (according to Paton in the article 
 * Matches ' in the * Encyclopaedia Britannica ') had its origin 
 in Vienna in 1833, and for a long series of years Austria and 
 the South German states were the principal centres of the new 
 industry. Before this date cases of phosphorus poisoning were 
 very rare, and arose from its injudicious use as an aphrodisiac 
 (Briand and Chaude). Orfila's knowledge of the subject seems 
 to have been derived solely from experiments on animals ; and 
 Christison (writing in 1836) had never seen a case of phos- 
 phorus poisoning in the human subject, though he mentions 
 three cases recorded by continental observers (the earliest 
 being one by Worbe in 1824). The use of phosphorus as a 
 poison has been hitherto more in vogue on the Continent than 
 in this country ; and Briand and Chaude, writing in 1869, 
 say, ' This form of poisoning increases in an alarming manner,' 
 and they utter the warning that phosphorus paste used for the 
 destruction of vermin may be the cause of poisoning if animals 
 used for food accidentally partake of it. How small has been the 
 amount of phosphorus poisoning observed in this country may be 
 judged of by the fact that in the first edition of Guy's ' Forensic 
 Medicine' (1854) it is not mentioned ; and that Dr. Wilks, in 
 the first edition of his lectures on ' Pathological Anatomy ' 
 (1859), does not mention phosphorus as a cause of fatty de- 
 generation of the liver. It was not, indeed, until about the 
 year 1861 that the action of phosphorus in producing fatty 
 degeneration began to be appreciated. Jaundice had been 
 noticed as a symptom of phosphorus poisoning, but its occur- 
 rence was regarded as a coincidence, and was attributed to 
 the blocking of the bile duct by the swelling of the mucous 
 membrane of the duodenum, brought about by the irritation 
 of the poison. Fatty degeneration of the liver is a suflliciently 
 common post-mortem appearance, and its occurrence in phos- 
 phorus poisoning did not at first excite any special attention. 
 It is now, however, recognised that jaundice and fatty degenera- 
 tion of the liver and other organs are the chief phenomena of 
 phosphorus poisoning. 
 
 Cases of phosphorus poisoning are usually accidental or 
 
HISTORY OF PHOSPHORUS POISONING 157 
 
 suicidal. Its accidental occurrence has been seen in children 
 who have sucked the ends of matches tipped with common 
 phosphorus, or have eaten bread-and-butter smeared with 
 phosphorus paste, which has been prepared for the destruction 
 of vermin. Suicides in this country usually make use of phos- 
 phorus paste, a compound composed of fatty matter, flour, and 
 colouring material, and containing about 4 per cent, of phos- 
 phorus. On the Continent, however, the heads of lucifer 
 matches have been frequently used for suicidal purposes. It 
 may be well to remind you that the ordinary form of phos- 
 phorus which fumes in the air is alone poisonous. Amorphous 
 phosphorus is believed to have no poisonous action. 
 
 The cases to which I wish to direct your attention are two 
 in number. The patients were both women, one of whom 
 died, and the other recovered. The first case was one which 
 I saw in consultation with Dr. Hurd "Wood, of Leatherhead, 
 and it is by his kind permission that I am enabled to bring 
 the facts before you. 
 
 A. L , aged twenty-three, a young woman living 
 
 ' under the protection ' of a gentleman, in consequence of some 
 annoyance to which she had been subjected in her quasi- 
 connubial arrangements, took at about 4 p.m. on the afternoon 
 of August 30th the gTeater part of a fourpenny pot of rat 
 paste, and it is a remarkable fact that in doing this she fol- 
 lowed the example of her elder sister, who under similar cir- 
 cumstances had destroyed herself a few years previously by 
 taking phosphorus paste. Five hours later — i.e. about 9 p.m. 
 — she vomited, and medical assistance was summoned. It 
 must be borne in mind that she had probably had eight or ten 
 gTains of phosphorus (about two grains being a fatal dose) 
 lying in her stomach for five hours, so that ample time had 
 been allowed for the absorption of the poison. Headache 
 and vomiting were the chief symptoms. The first matter 
 vomited, which it was alleged smelt of phosphorus, was thrown 
 away ; and it is to be noticed that none of the subsequent 
 vomit had any smell of phosphorus, nor did it fume, nor was 
 it luminous, which sometimes is the case. On August 31st 
 and September 1st she continued to vomit. On September 2nd 
 
158 PHOSPHOEUS POISONING 
 
 the vomit had the appearance of altered blood. The vomiting 
 was so incessant that it was practically impossible to give 
 either food or medicine by the mouth. On the 2nd, jaundice, 
 a symptom of very grave import, showed itself ; and on the 
 3rd I saw the patient, about ninety-eight hours after taking 
 the poison. She was in bed, lying on one side, complaining of 
 great pain in the abdomen, which was covered by a linseed 
 poultice. She was quite sensible, but was very unwilling to 
 talk or be disturbed or to attempt to take nourishment. The 
 skin was very sallow. The ocular conjunctivae were distinctly 
 yellow ; the depth of icteric tint was not very great. The 
 pulse was regular, slightly quickened, and of good force. The 
 heart sounds were normal. Tongue slightly coated ; papillse 
 at tip and edges rather enlarged. The liver dulness was 
 decidedly increased ; the lower margin was well below the 
 ribs ; and the abdomen over the liver was exquisitely tender, 
 but there was no tenderness elsewhere over the abdomen. 
 There was no diarrhoea, and the stools were said to be natural. 
 The patient complained of ^ery severe pain in the back, and 
 the least vibration or movement of the bed seemed to cause 
 her great agony. There had been severe cramp in the legs. 
 The urine was, it was said, scanty and high coloured ; the 
 bladder was apparently empty. It was not till the following 
 day that Dr. Hurd Wood managed to get a sample of urine 
 for examination, concerning which I will presently speak in 
 detail. As the patient had taken no food since the poisonous 
 dose, and very little during the previous week, I advised that 
 she should have some morphia administered by the mouth, 
 and that after an injection of turpentine she should be fed with 
 peptonised arrowroot and milk per rectum. Owing to the irri- 
 table state of the stomach, it was impossible to give turpentine 
 (the recognised antidote) by the mouth ; and I considered it 
 probable that, seeing that ninety-eight hours had elapsed since 
 taking the poison, not much good could have resulted, and pro- 
 bably some harm, by increasing her vomiting and exhaustion. 
 We considered the prognosis to be very bad — almost hopeless. 
 She continued in much the same state till her death, which 
 took place on September 5th. There was no delirium or coma, 
 
POST-MOKTEM APPEAEANCES 159 
 
 the cause of death being attributable to gradual failure of the 
 heart. The patient lay at last almost motionless, and for some 
 hours before death there were lengthy periods during which 
 the radial pulse was not perceptible. The only symptom dis- 
 tinctly referable to the nervous system was cramp in the legs, 
 from which the patient suffered during one night. 
 
 The post-mortem examination was not until ninety-three 
 hours after death, because Dr. Hurd Wood and myself hesi- 
 tated to make it, under the circumstances, until the coroner 
 had given his order. The cause of death was not a matter of 
 doubt, and it was only after the inquest and verdict that the 
 order was given. The examination was made under circum- 
 stances of difficulty, as are all necropsies made in private 
 houses, but the main facts were sufficiently well ascertained. 
 The body was still rigid, and was fairly well nourished. The 
 skin was distinctly yellow, the post-mortem staining being 
 strongly marked. The abdomen was distended, and blood- 
 stained fluid exuded from the mouth and nostrils. No lumi- 
 nosity was observed, but it should be added that the day was 
 bright, and it was not possible to absolutely darken the room. 
 There was no smell of phosphorus either before or after open- 
 ing the body, but those present agreed that it had a peculiar 
 odour. The chief facts observed were the following : 1. Marked 
 fatty degeneration of the liver. It was distinctly not enlarged, 
 but was of about average size. It was yellow in colour, sticky 
 looking, and pitting on pressure. When divided, and looked 
 at from a little distance, it had the appearance of a mass of 
 soft yellow faeces. It broke down easily under the finger. 
 Acini well marked. The microscope confirmed the marked 
 fatty degeneration. The gall bladder was nearly empty, and 
 contained little more than mucus. 2. The heart was per- 
 fectly empty, flabby, and flaccid, and in an advanced stage of 
 fatty degeneration. 3. Kidneys soft and flaccid ; pyramids 
 deeply congested ; cortex swollen, of a dirty grey colour, 
 mottled with yellow. A microscopical section kindly made by 
 Mr. Murray showed the epithelium to be full of granular 
 and fatty particles. 4. Spleen not enlarged, very soft, and of 
 dirty plum colour, 5. Lungs deeply congested (hypostatic). 
 
160 PHOSPHORUS POISONING 
 
 6. Stomach : Mucous membrane swollen, yellowish, and very 
 soft. Not hypersemic. No congested patch, except at one spot, 
 where there was seen a white .particle in the middle of a patch 
 of congestion the size of a pea. This particle we took into a 
 corner of the room, and, producing all the darkness we could, 
 we gradually applied the heat of a spirit lamp, but no phos- 
 phorescent fumes were observable. 7. Duodenum yellow and 
 soft ; mucous membrane swollen ; no ulceration or hypersemia. 
 8. Colon fairly normal, and containing some masses of abso- 
 lutely pale faeces. 9. A small ecchymosis was observed on 
 the mesentery, but no ecchymoses were observed elsewhere. 
 10. Urinary bladder slightly injected ; empty. 11. The 
 vagina contained a good deal of grumous yellowish mucus. A 
 small clot was observed blocking the os uteri. The uterus was 
 deeply blood-stained inside, and contained some clot ; and the 
 ovaries on section showed some Graafian follicles, also contain- 
 ing clots. With the exception of the genital organs, no clots 
 of blood were found anywhere, the blood appearing to be 
 uniformly fluid. We could not ascertain whether or not the 
 patient was menstruating at the time of her decease. 
 
 The symptoms and post-mortem appearances which I have 
 shortly laid before you are those of the majority of cases of 
 phosphorus poisoning. In some cases haemorrhage is a more 
 marked feature, and petechial ecchymoses are more abundant 
 post-mortem. The liver is uniformly fatty, as in this case, but 
 is sometimes mottled with patches of yellow and red. Its 
 size varies : if the patient die early, it may be big ; if, on the 
 other hand, the patient survive some time, it may be in a state 
 of marked atrophy. The kidneys vary also ; they may almost 
 escape, or may be nearly as fatty as the liver. The same may 
 be said of the heart. These variations are to be expected, and 
 depend on the amount of poison absorbed and the duration of 
 the case. Sometimes delirium and coma are a marked feature, 
 which depend probably upon the fatty degeneration of the 
 blood-vessels of the cortex cerebri, and also probably to some 
 extent on the conditions of the kidney, the coma being in a 
 sense 'uraemic' 
 
 Rationale of the Symptoms. — When a poison is absorbed 
 
POST-MORTEM APPEARANCES 161 
 
 from the alimentary tract and enters the portal circulation, 
 the liver is necessarily the first organ to suffer from the effects 
 of it, and is usually more markedly affected than any other 
 organ of the body. The effect produced when phosphorus is 
 the poison is that of rapid fatty degeneration. The liver cells 
 are found to be filled with oily particles, and when the fatty 
 change is as marked as in the case under review, it is impos- 
 sible to believe that the organ is capable to any extent of 
 performing its normal functions. The extent to which the 
 other organs suffer from fatty degeneration depends upon the 
 amount of phosphorus which passes through the liver or is 
 subsequently given off by it into the general circulation. 
 
 Why does phosphorus produce fatty degeneration ? Here 
 is a field for speculation ; but probably our best course pend- 
 ing more exact information is to accept the fact, which is 
 undoubted, and, with regard to the cause of this remarkable 
 property of phosphorus, to say we do not know. This power 
 of producing fatty degeneration is possessed by some other 
 bodies, and notably by antimony and arsenic, but these latter 
 bodies (which, be it observed, belong to the same chemical 
 group as phosphorus) possess the power in a degree very 
 inferior to phosphorus. It is possible that some interference 
 with the process of oxidation in the liver cell may be the 
 cause, and that in the readiness with which phosphorus com- 
 bines with oxygen may be found the explanation. That this 
 has something to do with it seems the more likely from the 
 fact that it is only phosphorus in its fuming active form that 
 is harmful, and that amorphous phosphorus is not a poison. 
 Further, oil of turpentine, the vapour of which destroys the 
 ' fuming ' power of phosphorus, is apparently an antidote to 
 it as a poison. It may be that phosphorus acts primarily upon 
 the blood, and only produces its effect on the liver as a conse- 
 quence of the blood change. It is certain, however, that in 
 order of time and in severity of effect produced, the liver holds 
 the first place among the organs of the body in phosphorus 
 poisoning. This fatty degeneration ultimately affecting all 
 the tissues of the body accounts for all the symptoms, at least 
 in part. The jaundice is partly caused by the swelling of the 
 
 M 
 
162 PHOSPHORUS POISONING 
 
 fatty liver ; the albuminuria by the fatty change in the kidney ; 
 the haemorrhage so often observed is probably due to a fatty 
 degeneration of the blood-vessels ; and the coma and delirium 
 may be due partly to a fatty change in the nerve cells and the 
 blood-vessels of the cortex cerebri, partly to defective meta- 
 bolism, the result of the liver change, and partly to ' uraemia ' 
 (using the word in its broadest sense), the result of the kidney 
 change. Finally, the weakness is due to fatty degeneration of 
 the heart and voluntary muscles. 
 
 The jaundice in these cases does not, I believe, differ from 
 ordinary obstructive jaundice, except that the bile which pro- 
 duces it is the final product of a liver whose power of physio- 
 logical work is rapidly decreasing. The obstruction to the 
 bile duct is produced partly in the duodenum, where the 
 swollen mucous membrane obstructs the entrance of the com- 
 mon bile duct, and partly, probably, by the swelling of the liver 
 itself causing an obstruction in the smaller ducts. In the 
 above case the bile pigment was plentifully present in the skin 
 and the white of the eye. At the post-mortem examination 
 it was found absent from the faeces in the colon. It is to be 
 remarked, however, that there was no bile pigment in the 
 urine, as shown by the negative result of the nitric acid test. 
 The sample of urine examined (of which I shall say more pre- 
 sently) was obtained on the fifth day of the illness, and pro- 
 bably many hours after the bile-forming power of the Jiver 
 had ceased. When you have obstruction to the duct of a 
 healthy liver, the formation of bile is continuous, the jaundice 
 gets deeper and deeper in tint, and the bile pigment in the 
 urine increases in amount with the increasing depth of the 
 yellow colour of the skin. In ordinary obstructive jaundice 
 the yellow colour is detectable in the skin after it has dis- 
 appeared from the urine, and so in this case the yellow colour 
 remained in the skin when not a trace of pigment was to be 
 found in the urine, the reason being that the liver ceased to 
 form bile after the jaundice had been produced. Whether 
 or not there was bile pigment present in the urine in the 
 earlier stages I cannot say, but probably there was. Again, 
 looking at the state of the kidneys, it is not to be wondered 
 
STATE OF UEINE 163 
 
 at if the elimination of bile pigment by these gravely affected 
 organs was deficient. It must be borne in mind that in ail 
 cases of jaundice the urinary bile pigment appears early, and 
 usually disappears before the skin has cleared. 
 
 A few words about the urine ; and, in saying these few 
 words, I must not forget to thank Mr. Ransom, who has very 
 kindly subjected the sample of urine obtained to a careful 
 chemical examination. The only sample of urine examined 
 was obtained on the day before death. This must be borne 
 in mind, and you must not assume that it is characteristic of 
 all stages and all cases of phosphorus poisoning. When this 
 urine was passed the patient was almost moribund, the liver 
 had been changed to a (probably inert) mass of fat and 
 incapable of proper function, and the kidneys were severely 
 damaged. The quantity of urine obtained for examination 
 was less than sufficient to fill an eight- ounce bottle, and of 
 this only about three ounces were available for Mr. Ransom's 
 investigations. It was turbid, with a considerable sediment, 
 and of a golden yellow colour. It was very acid in reaction, 
 and of high specific gravity (1,035). The acidity was also 
 remarkably persistent, and was very manifest even four days 
 after the urine had been passed. It was distinctly albuminous, 
 and after boiling and standing the albumen formed about 
 one-fifth of the bulk. The albumen was caused by the fatty 
 change which the renal epithelium had undergone, a fact 
 which was further indicated by the presence in the sediment 
 of a few granular casts. The high specific gravity was not 
 caused by urea, for, on testing by the hypobromite method, 
 the amount of urea was estimated, first by Mr. Kitchin, the 
 clinical clerk, and afterwards by Mr. Ransom, to be 0*5 per 
 cent. only. Mr. Ransom very thoughtfully suggests in his 
 report that, since the hypobromite method ' decomposes other 
 nitrogenous bodies, this result was probably in excess of the 
 truth, and,' he says, ' I failed to obtain any crystals of nitrate 
 of urea. It is probable, therefore, that urea was almost if not 
 totally absent.' This deficiency of urea has been noticed in 
 other cases of phosphorus poisoning, and also in ' acute 
 yellow atrophy of the liver,' a disease which bears the closest 
 
 yi 2 
 
164 PHOSPHOKUS POISONINa 
 
 resemblance to phosphorus poisoning, and of which I shall 
 have more to say presently. The absence of urea is due partly 
 to the inability of the patient to take nitrogenous or other 
 forms of food, and partly also to the incomplete metabolism 
 which results from the disorganisation of the liver. The urine 
 contained sugar, which is a fact that I do not find^mentioned in 
 connection with phosphorus poisoning or acute yellow atrophy. 
 It reduced Fehling's copper solution, and also gave a rich 
 Madeira wine colour when boiled with liquor potassse, and 
 this after the albumen had been removed by filtration. After 
 being fermented with yeast for thirty hours, liquor potassse 
 and Fehling's solution gave negative results, so that we may 
 feel sure that sugar was really present. Mr. Ransom esti- 
 mated the amount of sugar to be equal to three per cent. 
 Seeing that the urine was passed when, as I have said, the 
 patient was almost moribund, and when the liver was in an 
 extreme state of fatty degeneration, it seems impossible that 
 the sugar in the urine was due to an increased activity of the 
 liver cells. The more probable explanation seems to me to 
 be that, owing to the disorganisation of the liver, glucose 
 passed from the alimentary tract and through the liver withr 
 out undergoing any change, or, if the patient was fed upon 
 peptonised aiTowroot by the rectum, sugar may have found 
 its way direct into the general circulation through the 
 hsemorrhoidal veins. ^ There was, as I have said, a con- 
 siderable sediment to the urine, and microscopically this 
 sediment was found to be formed of (1) a very large quantity 
 of epithelium, mainly from the vagina ; (2) a few granular 
 casts from the kidney ; and (3) a very copious deposit of 
 acicular crystals, arranged in bundles and occurring in small 
 groups and singly. These were at first supposed to be tyrosin, 
 and a well-known authority on the urine, to whom I showed 
 them, pronounced them to be tyrosin. When dealing with a 
 rare deposit like tyrosin, one with which even the most 
 experienced cannot be very familiar, it is never advisable to 
 
 ' Dr. Hurcl Wood informs me that it was found impracticable to 
 administer nutritive enemata, so that the sugar cannot be accounted for 
 by this theory. 
 
STATE OF URINE 165 
 
 trust to form only as a means of diagnosis. Mr. Ransom left 
 a portion of the urine to stand for twenty-four hours with a 
 quarter of its bulk of strong hydrochloric acid, when it was 
 found that the crystals, instead of being dissolved, were even 
 more numerous ; ' moreover, they were accompanied by and 
 merged into larger crystals, which were obviously those of 
 uric acid,' These larger crystals had the colour of uric acid, 
 but the small acicular crystals seen in the urine were very 
 faintly tinged. The crystals were in reality crystals of uric 
 acid, and one of my colleagues informs me that he has seen 
 fine acicular crystals of this kind in diabetic urine. The 
 urine, however, contained tyrosin, which was shown by the 
 following method adopted by Mr. Ransom : 1. The strongly 
 acid urine was filtered to remove uric acid, then neutralised 
 and left to stand under four times its bulk of methylated 
 spirit. A precipitate formed, and tyrosin crystals were 
 obtained both from the precipitate and the supernatant fluid. 
 2. Crystals of tyrosin were also obtained from the original 
 urine. Crystals of tyrosin were also formed from a decoction 
 of the liver, which was first treated by basic lead acetate, and 
 the filtrate subsequently treated with sulphuretted hydrogen 
 to free it from lead, and evaporated to a syrup. In this way 
 the characteristic crystals were obtained by further evapora- 
 tion on glass slides, and the syrup gave a pink colour with 
 Millon's reagent. No crystals of leucin were found in the 
 liver or urine. The presence of sarcolactic acid was, however, 
 demonstrated, and it is possible that the persistent acidity of 
 the urine may have been due to this body. The condition of 
 this urine affords much food for reflection. The ultimate stage 
 of the metabolism of nitrogenous matter is, in health, urea ; 
 and the chief place where urea is formed is probably the 
 liver. The diminution or absence of urea has been noticed 
 by Parkes in cases in which a great destruction of the liver 
 has taken place as the result of cancer or suppuration, and 
 especially has it been noted in cases of acute yellow atrophy. 
 In place of the urea, we find in these cases bodies which are 
 the result of incomplete metabolism — such as uric acid, tyrosin, 
 and leucin. Whether these bodies are formed in the liver 
 
166 PHOSPHORUS POISONING 
 
 instead of urea, as the result of an interference with oxidation, 
 or whether, being formed by the spleen and pancreas they 
 merely pass through the inert liver, is an open question, but I 
 confess that in the present case the latter seems to me the 
 more probable explanation. We have seen how grave and 
 widespread are the consequences when a healthy person takes 
 a small quantity of pure phosphorus : vomiting, haemorrhages, 
 jaundice, headache, pain, cramps, albuminuria, coma, and 
 death in five days, without fever ; and post-mortem evidence 
 of extreme fatty degeneration involving the liver and other 
 glandular and muscular tissues. A point of great interest in 
 phosphorus poisoning is the complete similarity, both clinically 
 and pathologically, to that very rare disease which is described 
 in our text-books as 'Acute yellow atrophy of the liver' — 
 a disease which is characterised by vomiting, haemorrhages, 
 jaundice, headache, pain, cramps, albuminuria, coma, and 
 death, usually within five days, without fever ; and post- 
 mortem by fatty degeneration of the liver, heart, kidneys, and 
 other organs. It has been sought to distinguish these two 
 diseases in various ways. For example, it has been said that 
 in acute yellow atrophy the liver is small, while in phosphorus 
 poisoning it is big. To this rule, however, there have been 
 found many exceptions, and, in fact, the conditions have at 
 times been reversed. It has been asserted that histologically 
 the livers in the two conditions vary, but now it is admitted 
 that in both the predominant change is fatty degeneration. 
 It was at one time thought that leucin and tyrosin were not 
 found in the urine in phosphorus poisoning ; but this, again, 
 has been shown not to be true, and the case I have narrated 
 is an example. Cases of phosphorus poisoning have been 
 diagnosed as acute yellow atrophy. T believe I am right in 
 stating that a mistake (if mistake it can be called) was made 
 a few years since in this hospital, owing to the patient 
 concealing the fact of having taken phosphorus, and a similar 
 mistake was made some years ago at Netley. In short, I 
 think there can be no doubt that, clinically and pathologically, 
 the two conditions are indistinguishable. There are some 
 other facts which tend to bring these two conditions (if they 
 
ACUTE YELLOW ATEOPHY 167 
 
 be two) together. Acute yellow atrophy is a very rare disease. 
 Thierfelder, who writes the article upon it in Ziemssen's 
 Encyclopeedia, and who, with characteristic German thorough- 
 ness, has ransacked medical literature for his material, has to 
 found his article on 143 cases only, scattered over a period 
 of forty years. Like phosphorus poisoning, it is a modern 
 disease, and its history is about co- extensive with that of 
 phosphorus poisoning, the first cases having been described by 
 Rokitansky, of Vienna, in 1842, or nine years after the 
 establishment of the lucifer match industry. Whether, as 
 phosphorus poisoning has become more common and better 
 understood, acute yellow atrophy has become less frequent, I 
 do not know, but it is certain that the rarity of the latter 
 condition is at least as great as ever. Acute yellow atrophy, 
 it will be urged, differs from phosphorus poisoning in the fact 
 that it is more common in women than in men. Of Thier- 
 f elder's 143 cases, 49 were males and 86 (or just 60 per cent.) 
 were females. In the five years 1876-80 there were in this 
 country (according to the Registrar- General's returns, as 
 quoted by Mr. Wynter Blyth) 46 deaths from phosphorus 
 poisoning. Of these 46, 17 were males and 29 were females, 
 the females constituting 63 per cent, of the total. Of 56 
 adult cases collected by Falck, 43 were women and 13 men ; 
 and of 71 suicidal cases collected by Otto Schraube, 47 were 
 women and 24 were men. Again, acute yellow atrophy has 
 often occurred in pregnant women. The same may be said 
 of phosphorus poisoning. Thus Hamberg, at the meeting of 
 Swedish physicians in 1881, stated that of 19 fatal cases of 
 phosphorus poisoning collected by him in Sweden, 16 were in 
 women mainly between twenty and thirty years of age ; and 
 of these 16, 15 were pregnant— the phosphorus being pre- 
 sumably taken to produce abortion. Jaderholm has also 
 published tables showing the increase of phosphorus poisoning 
 in Sweden. He has made post-mortem examinations of 15 
 cases ; of these 15, 3 were men and 12 women; of the 12 
 women, 2 were pregnant and 3 had recently aborted. In this 
 connection I may quote Hessler, who says that phosphorus 
 has a great reputation as an emmenagogue and abortifacient. 
 
168 PHOSPHORUS POISONING 
 
 Thus it appears to be a fact that phosphorus poisoning not 
 only has the closest resemblance to acute yellow atrophy, both 
 clinically and pathologically, but that it still further resembles 
 it in the great proportion of women (and especially pregnant 
 women) who suffer. 
 
 Why are women more liable to suffer from phosphorus 
 poisoning than men ? In the first place, it may be urged that 
 when women wish to commit suicide they adopt drowning or 
 poison, while men more frequently make use of hanging or 
 firearms. Dr. Ogle has pointed out that women, when bent 
 on suicide, are less careful than men to select painless poisons, 
 nearly 50 per cent, of female suicides by poison in England 
 during the years 1863-82 being effected by strychnia, vermin 
 killer, carbolic acid, and oxalic acid, while 60 per cent, of men 
 employ prussic acid, laudanum, and other comparatively pain- 
 less poisons. Again, it is evident that accidental poisoning 
 and suicidal poisoning are very likely to be effected by poisons 
 which are at hand, and phosphorus paste is, so to say, a 
 household poison used by women and bought by women for 
 the destruction of rats and beetles, while poisonous matches 
 are, or were, everywhere to be found. Why should pregnant 
 women suffer from phosphorus poisoning more than others ? 
 In the first place, it is probable that phosphorus is taken to 
 cause abortion, and I think it will be found that many of the 
 women who have died of phosphorus poisoning were not 
 married, and were persons to whom pregnancy meant disgrace 
 or inconvenience. Of the 47 female cases collected by Otto 
 Schraube (as quoted by Wynter Blyth) 12 were prostitutes. 
 The girl whose case I have been dealing with, and also her 
 sister, who died in the same way, were ' kept women.' A 
 case recorded in The Lancet in 1882 by Dr. Capon occurred in 
 a ' kept woman ' ; and I have heard of a case very recently, 
 the details of which were given me by a well-known prac- 
 titioner in the south of London, in which the victim was also 
 in the same condition of life. Thus facts seem rather to point 
 to the conclusion that phosphorus poisoning is prone to occur 
 among women of dissolute life, and it is possible that the 
 traditional use of pliosphorus as an aphrodisiac may liave 
 
PREDISPOSING CAUSES 169 
 
 some connection with this fact. Among the causes which 
 predispose to acute yellow atrophy are mentioned (in addition 
 to female sex) mental worry, dissolute habits, syphilis, and 
 pregnancy. This rather points to the fact that acute yellow 
 atrophy, like phosphorus poisoning, is prone to occur among 
 women of dissolute habits. Dr. Fagge and other writers on 
 acute yellow atrophy quote Graves's well-known case of three 
 members in the same family, sisters, who died of the disease 
 within eleven months. But in phosphorus poisoning there is 
 also occasionally a family predisposition. I may remind you 
 that, according to the evidence given at the inquest, the 
 sister of my patient had previously committed suicide with 
 phosphorus, and it was whispered — but only whispered — that 
 the mother had met her death in a similar way. 
 
 The question will naturally arise, ' Are all or the majority 
 of cases of acute yellow atrophy really cases of phosphorus 
 poisoning V It is not possible to answer this question, but 
 the conditions being clinically indistinguishable, there can be 
 little doubt that the latter condition has often been mistaken 
 for the former. It must be remembered that suicidal patients 
 are often very reticent, and when really bent on suicide they 
 have every reason for concealing the fact that they have taken 
 poison. If phosphorus has been given with murderous intent, 
 the fact will certainly be concealed. Again, phosphorus may 
 be taken accidentally, and a drunken woman would not be 
 unlikely to take phosphorus paste spread on bread if such had 
 been prepared for the destruction of vermin. Again, it is 
 possible that the flesh of animals, and especially chicken, who 
 have died from eating vermin which have met their death by 
 phosphorus, may be the cause of the symptoms in human 
 beings. But we must not forget that other bodies besides 
 phosphorus are capable of causing fatty degeneration, and 
 among these are arsenic, antimony, chloroform, and the 
 mineral acids. The fact that in acute yellow atrophy the 
 liver is especially affected points to the conclusion that the 
 poison, whatever it may be, is probably absorbed from the 
 alimentary tract. The liver may atrophy rapidly under certain 
 other conditions. Thus, Dr. Murchison, in his classical work 
 
170 PHOSPHORUS POISONING 
 
 on the liver, records two cases of ' acute atrophy ' which 
 occurred in his own practice. One was that of a tailor, aged 
 sixty-six, who was in the Middlesex Hospital for twenty-hve 
 days, and in whom, post-mortem, was found an atrophied and 
 fatty liver, with the common bile duct completely blocked by 
 gall stones, with great dilatation of the bile ducts and some 
 purulent deposits both in the liver and kidneys. The patient 
 was febrile except for the last three days of life. This wa& 
 clearly not a true case of acute yellow atrophy. The other 
 case given by Dr. Murchison occurred in a girl who had been 
 ill for a month. In this case there was acute peritonitis, and 
 she was febrile to the last. This, again, was not an ordinary 
 ease of acute yellow atrophy. In short, acute yellow atrophy 
 is a very rare disease indeed, and I think we shall all do well, 
 whenever we feel justified in making such a diagnosis, to be 
 exceedingly careful to investigate the possibilities as to the 
 patient having had phosphorus administered either intention- 
 ally or accidentally. Phosphorus poisoning is of great 
 interest as an example of profound constitutional disturbance 
 (,)ccurring as the result of the ingestion of a chemical poison 
 and running a fatal course without fever. In these days, 
 when infective microbes are demanding a very large amount 
 of our attention, it is well to be reminded that such things 
 may happen. 
 
 The other case I have to mention (and I am enabled to do 
 so through the kindness of Dr. Ringer, under whose care 
 the patient was admitted) need not detain us long. A 
 married woman, aged thirty-eight, took phosphorus paste on 
 bread at 8 p.m. on Sept. 14, and she was admitted to the 
 hospital within an hour. A powerful emetic was at once 
 administered, and she vomited in ten minutes. The breath 
 and vomit both smelt of phosphorus, but there was no 
 luminosity. The stomach was then washed out by the 
 stomach pump, and a drachm of old commercial turpentine 
 was administered at 10 p.m., 11 p.m., 2 a.m., 4 a.m., and 7 a.m., 
 and half a drachm at 9 a.m. — 5. drachms in all. Vomiting 
 and retching continued, with burning pain in the stomach 
 and great tenderness of abdomen, and especially of the hepatic 
 
TREATMENT 171 
 
 region, going through to the back. This persisted through 
 the next day, and at 3 p.m. drachm doses of French turpentine 
 were again ordered. There was diarrhoea, and one of the 
 stools contained altered blood. This patient seemed very- 
 sensitive to vibrations, and complained that persons walking 
 about the ward jarred her. The temperature was 100° when 
 admitted, and then became normal. The urine never contained 
 albumen or sugar, but contained a fair percentage of urea. 
 The blood, when examined under the microscope, appeared 
 normal. She gradually recovered, and left the hospital on 
 Sept. 26.^ There can be little doubt that this patient owes 
 her life to the active treatment pursued. The phosphorus 
 had not been long taken when she was seen, and probably no 
 great amount had been absorbed when the stomach was so 
 promptly emptied of its contents by the emetic and stomach 
 pump. The administration of turpentine was, however, 
 probably conducive to the favourable result. This is 
 regarded as an antidote to phosphorus ; it appears to render 
 it inert ; and we get a clue to its mode of action from the 
 fact that the vapour of turpentine destroys the luminosity of 
 phosphorus. 
 
 * This patient was readmitted a few weeks after her discharge, and 
 was found to have slight albuminuria. She made a good recovery, and 
 was again discharged. 
 
172 LEAD POISONING 
 
 CHAPTER IX 
 
 CHRONIC LEAD POISONING ^ 
 
 In Ward 8 you have frequently seen a patient who was 
 admitted to the hospital on September 26, 1895, suffering 
 from obstinate constipation and great muscular weakness. 
 He is a painter, aged 34, and stated on admission that his 
 bowels had not acted for ten days, and he informed us that 
 on three previous occasions (in 1879, 1888, and 1891) he had 
 suffered from obstinate attacks of ' colic ' and constipation. 
 As he is a painter by trade, and has a well-marked blue line 
 upon the gums, we have little hesitation in attributing his 
 troubles to lead poisoning. He thinks the present attack 
 was determined by his working, during very hot weather, at 
 painting the vaulted ceiling of a room, all the windows of 
 which were closed. 
 
 The attack of colic in September was accompanied by 
 other symptoms from which he has not previously suffered. 
 He stated that for three weeks prior to his admission he had 
 been feeling weak and ill, and three days before his admission 
 he found that, owing to weakness in his arms, he could not 
 lift a cup to his lips. 
 
 On admission his complexion was sallow and muddy, and 
 he was much emaciated. He could not extend the wrist, 
 nor, owing to weakness of the deltoid, could he raise his arm. 
 He could not as he lay in bed change from the recumbent to 
 the sitting position without assistance ; he straightened his 
 back with difficulty, he could not stand without help, and was 
 quite unable to walk. 
 
 In short, every muscle of the limbs and trunk was in an 
 extreme degree of paresis. All the muscles were soft and 
 ' Clinical Lecture, U.C.H., 1895. 
 
SYMPTOMS 17^ 
 
 flabby, and to a certain degree wasted. I use the term 
 paresis instead of paralysis, because every muscle seemed to 
 be capable of a certain degree of feeble movement, and all of 
 them responded to the farad ic current. There was no extreme 
 wasting of any muscles, except perhaps the erector spinas on 
 the right side. The face rather lacked expression, but no 
 definite paralysis of face or lips or ocular muscles could be 
 detected. 
 
 He feels when he is touched, and can tell when he is 
 pricked with a pin, but nevertheless I doubt whether his sense 
 of pain is very acute, because, when the hair of the leg was 
 suddenly pulled he did not flinch to the degree which is usual 
 in a normal subject. 
 
 All the nerve-trunks in the upper limbs are exceedingly 
 tender, and it is evident that the nerve-trunks are much more 
 tender than the muscular masses. 
 
 When I first saw this patient I was much struck by his 
 voice, which was feeble and toneless, without being hoarse or 
 stridulous. The voice was of a character to excite suspicion 
 of laryngeal paralysis, and on examination with the laryngo- 
 scope we found well-marked immobility of the left vocal cord, 
 which was not adducted to the middle line during phonation. 
 
 The urine since his admission has been of average quantity 
 but pale, of low specific gravity (fluctuating between 1,014 
 and 1,008), and up to November 5 contained a trace of 
 albumen, which has not been detected since that date. The 
 urine, kindly examined by Dr. Kenwood on January 9, gave 
 evidences of a slight trace of lead only. 
 
 The temperature has been normal except for a few days, 
 when he suffered from slight tonsilitis. 
 
 The hsemocytometer on October 1 showed that the red 
 corpuscles were about eighty per cent, of the normal. 
 
 For the first week of his admission he suffered from con- 
 stipation and abdominal pain, but since that time the alimen- 
 tary tract has afforded no evidence of disease. 
 
 In some respects this is not quite a typical case of lead 
 poisoning, although there are no symptoms which have not 
 been caused by lead again and again. 
 
174 LEAD POISONING 
 
 As to the paralysis from lead, you are most of you pro- 
 bably aware that the typical form of lead paralysis is ' wrist 
 clrop,' in which the extensors of the fingers and wrists are 
 paralysed on both sides. As a rule the paralysis from lead is 
 limited to the forearms, and to the muscles named. The 
 supinator longus and the intrinsic muscles of the hand usually 
 •escape. The paralysis is generally symmetrical, but while 
 both limbs are implicated, it is usual to find that the right 
 arm is affected earlier, and rather more severely, than the 
 left. The affected muscles waste rather rapidly, and in a 
 severe case of long standing give, when tested with electricity, 
 the reaction of degeneration. 
 
 With regard to this ' Reaction of Degeneration,' please 
 remember that the important fact to bear in mind is that the 
 muscles do not respond, as normal muscles do, to the faradising 
 current, while they respond with undue readiness to the con- 
 tinuous galvanic current. 
 
 The non-reaction of the muscle to faradism is said to be 
 due to the degeneration of the intra-muscular nerves. This 
 explanation is probably correct, but it is well to remember 
 that a paralysed muscle which is recovering will sometimes 
 give the reaction of degeneration at a time when it is re- 
 sponding to the stimulus of the will, i.e. it is the seat of 
 voluntary contraction when artificial contraction cannot be 
 evoked by faradisation. This may be due to the fact that 
 the intra-muscular nerves have regenerated on the under-side 
 of the muscle, where the faradic stimulus is not easily applied. 
 Why these muscles should show an increased irritability to the 
 galvanic current it is difiicult to say, and still more difficult to 
 say why the reaction to the galvanic current shows a qualitative 
 as well as a quantitative change. This qualitative change con- 
 sists in the fact that the muscle reacts to anodal opening or 
 anodal closure before it responds to cathodal closure, which is 
 the first reaction to be obtained in health. These qualitative 
 changes are interesting, but their importance from the clinical 
 point of view is as yet not understood, and I want you to 
 cling to the main fact of these reactions of degeneration, which 
 is that the 'muscle which does not respond to faradism, responds 
 
DEGENERATIVE REACTIONS 175 
 
 readily {sometimes too readily) fo gcdvanism. The degenera- 
 tion of the intra-muscular nerves is brought about by extinc- 
 tion of the motor cells in the anterior cornua, so that no 
 stimulus can reach the muscle from the brain, or by a block 
 in the nerve itself clue to neuritis, morbid growth, extravasa- 
 tion of blood from bruising, or the actual division of the nerve. 
 So soon as a motor nerve is severed or blocked by the 
 processes named, degeneration begins to extend centrifugally 
 until it reaches the muscle. In mixed nerves which serve 
 both sensory and motor functions, a blockage of any kind 
 occurring in the trunk probably produces a certain amount of 
 centripetal degeneration, as well as centrifugal ; but this 
 latter is far more difficult to demonstrate. 
 
 The patient whose case we are considering is not to be 
 regarded as a typical example of lead paralysis. In him the 
 paralysis is of very wide extent, but it resembles other cases 
 of lead paralysis in this, that it began in the forearms, and 
 that the deltoid muscles are among those which are most pro- 
 foundly affected. Scarcely a muscle in his body has escaped ; 
 all are feeble in an extreme degree, but none appear to be 
 totally paralysed, and all of them, which are accessible, 
 respond to a strong faradic current. 
 
 The paralysis of one vocal cord is to be regarded as excep- 
 tional. Cases of such paralysis from lead are recorded, but I 
 do not recollect having personally observed it before. Naunyn 
 states that in horses which work in lead mills paralysis of 
 the abductors of the vocal cords is common, and that, not 
 unfrequently, this necessitates the performance of tracheotomy. 
 Paralysis of the left vocal cord in an adult is a physical sign 
 which raises a strong suspicion of aortic aneurysm ; but re- 
 peated examinations of our patient to this end have always 
 given negative results. 
 
 How profound is the change produced in the human body 
 by the continued introduction into it of small quantities of 
 lead ! Lead holds an important position in the Pharmacopceia 
 on account of its styptic qualities, and is frequently ad- 
 ministered in cases of internal haemorrhage. It has a reputa- 
 tion also as a valuable astringent when applied externally, 
 
176 LEAD POISONING 
 
 and the solutions of the salts of lead are probably antiseptic- 
 to a considerable degree. This poisonous metal is retained in 
 the Pharmacopceia for its styptic and astringent qualities — 
 qualities which are due to its stimulating action upon the 
 muscular coats of the small arteries and arterioles. It is said 
 to have a similar action upon the muscular coats of the intes- 
 tines, and to cause in this way the phenomena of ' painter's 
 colic' Our patient on admission had been constipated for 
 ten days. His intestines, and probably his arterioles, had 
 been the subject of a muscular spasm so sluggish and inert as 
 to be regarded as permanent. When the full styptic effect of 
 lead has been produced the patient is in great danger if it& 
 administration is continued. It seems probable that when 
 lead produces a toxic effect the calibre of every arteriole in 
 the body is diminished. If this be the case, can we wonder 
 that the nutrition changes are profound ? Absorption from 
 the alimentary tract is diminished, the elimination of waste 
 products by the kidney is seriously checked, and the starved 
 tissues tend to degenerate, so that in many places we find 
 that the connective tissues tend to increase at the expense of 
 gland-cells and nerve-tissue. 
 
 Dr. Thomas Oliver, of Newcastle, in his Goulstonian 
 Lectures on ' Lead Poisoning,' gives an excellent series of 
 drawings of the histological changes in lead poisoning. In 
 the kidneys the shedding of the epithelium of the tubules is 
 accompanied by interstitial overgrowth of connective tissue ; 
 in the liver cirrhotic changes occur ; the fibres of the nerve - 
 trunks are pressed upon by the fibroid overgrowth ; and 
 similar changes also occur in all parts of the body. The 
 kidneys are very liable to be affected in lead poisoning. 
 However the poison be introduced, whether by the stomach, 
 by inhalation, or by the skin, the kidneys must perform an 
 important part in eliminating it, and the contraction of the 
 renal vessels seriously damages the organ, and thus its 
 physiological action of eliminating the end products of meta- 
 bolism is damaged, and we are liable to get gouty symptoms 
 in those who are otherwise predisposed to gout, and not un- 
 frequently uraemic symptoms, inclusive of epileptiform convul- 
 
GOUT 177 
 
 sions. It is evident that when the kidneys are damaged, the 
 danger caused by the poison circulating in the blood is 
 enormously increased. It is also evident that if a worker in 
 lead acquires a granular interstitial nephritis, the danger he 
 runs from his occupation is increased, and his liability to 
 suffer from recurrent attacks of lead poisoning is very great. 
 The really operative dose of a poison is the balance between 
 the amount absorbed and the amount eliminated. If elimina- 
 tion keeps pace with absorption no symptoms are caused, but 
 if elimination be slower than absorption, or if elimination be 
 checked by disease of the kidneys, then, as we all know, very 
 small doses of such poisons as mercury and opium are liable 
 to produce most untoward results. 
 
 The physiological action of lead salts being to cause con- 
 traction of the vessels and intestines, it almost necessarily 
 follows that so soon as absorption takes place elimination is 
 checked, and in this fact we find the explanation of the 
 insidious nature of lead poisoning. There seems to be no 
 quantity of a lead salt too small to produce symptoms, 
 provided it is taken continuously. 
 
 In the patient whose case we are considering there is no 
 history of any attacks of gout, but it is well known that 
 workers in lead are very liable to gout, and that sufferers from 
 gout are peculiarly intolerant of lead. It was Sir Alfred 
 Garrod who first demonstrated in this hospital that the 
 administration of a few grains of lead acetate to a gouty 
 patient almost invariably produced a paroxysm. 
 
 This liability of the lead worker to suffer from gout has 
 not been observed in Edinburgh to the same extent as in 
 London, and lately Dr. T. Oliver has shown that the lead 
 workers of Newcastle, and the northern towns generally, 
 enjoy a similar comparative immunity from gout. It used to 
 be thought that the difference in the liability to gout in 
 North and South was to be accounted for by the fact that 
 while the northerners stimulated themselves with non-gouty 
 whisky the southerners used beer, the reputation of which as 
 a gout-producer is considerable. This difference in habits may 
 partly account for the difference in pathological tendencies, 
 
 N 
 
178 LEAD POISONING 
 
 but that it is not the sole explanation seems certain from the 
 work of Dr. T. Oliver and others. The true explanation of 
 this strange difference is still to be sought. 
 
 The symptoms produced by lead are protean, and there 
 is not a single symptom which is constant unless it be the 
 sallow pallid complexion. The an?emia produced by lead is 
 extreme, and the presence in the blood of a very small 
 quantity seems to cause a rapid diminution of both haemo- 
 globin and red corpuscles. 
 
 The lead, after absorption, circulates with the blood, and 
 its effect seems to fall upon different organs in different 
 individuals. We all have our vulnerable points, and these 
 are not the same in any two persons. There seems nothing 
 unreasonable in supposing that any part of the body which 
 has been damaged, and the nutrition of which has been 
 impaired by previous disease or injury, is likely to constitute 
 a vulnerable point. We know, also, that persons have a 
 family tendency towards chest diseases, vascular degenera- 
 tions, insanity, &c. Did time permit one could bring forward 
 many familiar examples of these propositions. Occasionally 
 it may happen that the parts most used are the ones to suffer 
 most, and this explanation has been offered of the tendency 
 of painters to suffer from wrist- drop. The tendency of 
 different individuals to be differently affected by lead caused 
 Tanquerel des Planches to classify his cases, and to speak of 
 (1) lead colic, (2) lead paralysis, (3) lead arthralgia, and (4) 
 lead encephalopathy. Lead arthralgia, which is not very 
 common, would probably resolve itself nowadays into gouty 
 pains, and pains due to spinal sclerosis and neuritis. Lead 
 encephalopathy (headache, convulsions, tremor, optic neuritis, 
 and atrophy) may be primary, but is more probably, in most 
 cases, secondary to chronic kidney trouble. 
 
 What we have to remember is the great fact that the 
 symptoms of chronic lead poisoning are varied and far from 
 unifomn, and, in short, that lead may be the unsuspected 
 cause of chronic trouVjles affecting nutrition generally, or the 
 digestive, renal, or nervous organs. 
 
 Many poisons manifest a peculiar affinity for the cells of 
 
' LEAD-LINE ' 179 
 
 certain tissues, which stand in relation to the poison in a 
 position analogous to that of preference shareholders in a 
 trading company. Few, if any, poisons, however, have an 
 exclusive affinity for the cells of any tissue, and it is usual to 
 find that after those cells for which the poison has a ' prefer- 
 ence ' have been supplied other cells in the body begin to get 
 some of the dividend. Lead is more impartial in the bestowal 
 of its injuries than most poisons, and although ' lead colic ' is 
 the commonest symptom, we have seen how insidious is the 
 action of lead, and how it may affect every organ in the body. 
 It has been said that ' lead has a peculiar affinity for nerve 
 tissue, but analyses made on the bodies of animals which have 
 succumbed to lead poisoning show that it is universally 
 distributed, and that every part of the body can be made to 
 yield lead.' The distribution of the lead in the body varies 
 considerably. 
 
 As lead poisoning is insidious in its onset and very protean 
 in its manifestations, it becomes important to consider what 
 symptoms, if any, are to be regarded as pathognomonic. The 
 blue line which appears on the margin of the gums next the 
 teeth, often spoken of as the lead-line (and which is due to 
 the precipitation of lead sulphide in the tissues of the gums, 
 hy the action of the hydrogen sulphide formed by the decom- 
 position of albuminous food particles in the mouth), is the 
 most valuable aid to the certain diagnosis of lead poisoning. 
 Other things being equal, the patient who generates most 
 hydrogen sulphide in his mouth will have the best marked 
 lead-line ; while those whose mouths are inapt, either by 
 design or accident, for this, decomposition, may suffer from 
 lead poisoning without any lead-line upon the gums. Persons 
 who have no teeth, or those who are blessed with very 
 regular teeth which they keep scrupulously clean and which 
 afford few opportunities for the lodgment of food-particles, 
 may fail to afford the evidence of a lead-line, even though 
 they be saturated with lead. On the other hand, a lead-line 
 once formed may persist, it is said, after recovery has taken 
 place. 
 
 Without forgetting the exceptional conditions named, we 
 
 N 2 
 
180 LEAD POISONING 
 
 may say that a blue line on the gums is a very sure evidence 
 of lead poisoning. 
 
 The important point to bear in mind is that the absence 
 of a lead-line does not exclude lead poisoning. 
 
 Again, the onset of lead paralysis of typical form 
 (paralysis of extensors of wrist and fingers, without implica- 
 tion of the supinator longus) in persons who have previously 
 suffered from colic is a combination of circumstances which 
 justifies us in regarding the case as one of lead paralysis, even 
 in the absence of a ' lead-line,' and in the further absence of 
 any assignable cause. 
 
 Even if there be no lead-line, and if the paralysis be not of 
 a typical kind, we are justified in assuming lead to be the 
 cause of the trouble if the patient's occupation is one which 
 brings him into intimate and daily contact with poisonous 
 salts of lead. 
 
 A case of great interest in this connection was under my 
 care in 1894. 
 
 The patient, E. S. H , aged 35, a packer of furniture,, 
 
 was admitted on September 27. 
 
 He had previously been admitted twice under Dr. Ringer, 
 on July 5 and August 18, sufiering from abdominal pains, con- 
 stipation, and albuminuria, and on both occasions he left the 
 hospital cured of his abdominal trouble, and with his albumi- 
 nuria reduced to a ' trace ' of albumen. 
 
 When admitted under my care he was again suffering from 
 abdominal pain, vomiting, and constipation. His urine was 
 of low specific gravity (1,012), containing one-third albumen, 
 and there were superadded paralytic symptoms, affecting 
 mainly the arms. 
 
 On electrical examination we found that the deltoids gave 
 degenerative reactions, and were absolutely powerless, so that 
 the patient could not raise either arm to the level of the 
 shoulder. 
 
 The extensors of the wrist and fingers responded only to 
 the strongest faradic currents, while the flexors of elbow, wrist, 
 and fingers, and also the supinators longi and the interossei 
 
DIAGNOSIS 181 
 
 muscles responded normally to faradism, but were obviously 
 paretic. 
 
 The patient complained of pain in both arms, and the 
 nerve-trunks were everywhere tender, especially in the axillae. 
 There was some impairment of sensibility to pains, but tactile 
 sensibility appeared normal. The legs were paretic, but there 
 was no actual paralysis. The patient walked fairly well, but 
 feebly, and the reflexes were normal. There was no lead-line, 
 and the teeth were exceptionally clean. There was a distinct 
 history of two attacks of typical gout during the previous 
 year. The patient had been a moderate beer drinker, but he 
 had not the aspect of a drunkard, and he persistently denied 
 that he had ever taken alcohol to excess. He had drunk tea 
 rather to excess. He made a fairly good recovery, and, after 
 a sojourn at Eastbourne, and a few weeks at the Mineral 
 Water Hospital, Bath, he returned to his work. 
 
 At the end of June, 1895, he paid his fourth visit to the 
 hospital, but on this occasion his symptoms were mainly 
 abdominal, and there was no marked recrudescence of his 
 paralytic troubles. The urine, however, was still of low 
 specific gravity, and contained a trace of albumen. 
 
 Here, then, was a case in which there was no lead-line, and 
 in which there was no obvious risk of lead poisoning in the 
 patient's occupation or surroundings, but which, nevertheless, 
 we have felt justified in regarding as one of lead paralysis 
 from neuritis. The justification of this diagnosis is found in — 
 
 1. The form of the paralysis, which is more typical of lead 
 than of any other form of multiple neuritis. 
 ^^ 2. The absence of other causes of multiple neuritis. It is 
 true we have never discovered the cause of the lead intoxica- 
 tion in this case ', but of all intoxications which give rise to 
 neuritis, lead is apt to be the most insidious and the most 
 difficult to discover. 
 
 3. The history of four attacks of colic, one of which 
 immediately preceded the onset of the neuritis, give a very 
 strong support to our diagnosis, because recurring attacks of 
 colic without evidence of any cause of permanent intestinal 
 
182 LEAD POISONING 
 
 obstruction, and without rise of temperature or distension of 
 the abdomen, are extremely characteristic of lead poisoning. 
 
 4. The history of two attacks of gout, and the occurrence 
 of albuminuria tending to become permanent, also lend support 
 to the diagnosis of lead poisoning. 
 
 5, Finally, his recovery in hospital on four different 
 occasions, and the immediate recrudescence of his troubles 
 when he returns to his business and domestic surroundings, is 
 a circumstance which points almost conclusively to the fact 
 that his troubles are toxic, and that they are not autotoxic. 
 Therefore the probability that they are caused by lead is very 
 great. 
 
 One of the points in connection with lead poisoning, which 
 has been much debated, is the seat of the lesion which produces 
 lead paralysis ; and while some have placed the lesion in the 
 spinal cord, others have contended that the symptoms are 
 compatible with a neuritis. 
 
 The fact that the paralyses are generally symmetrical 
 might cause one to infer that the lesions are spinal, but a 
 little reflection will serve to convince us that arguments based 
 upon this ground are untenable. I may remind you that un- 
 doubted anterior polio myelitis — spinal or infantile paralysis — - 
 is more often unilateral than bilateral in distribution, and that 
 the undoubted neuritis which occurs from alcoholic, or as the 
 result of diptheritic, poisoning is almost always bilateral and 
 symmetrical; in short, that while some undoubted spinal con- 
 ditions are unilateral, some undoubted neurites are bilateral. 
 The poison with which we are dealing circulates in the bloody 
 and there is no more difficulty in assuming that corresponding 
 nerve twigs on the two sides of the body suffer than there is 
 in assuming that both anterior cornua at the same level should 
 be attacked. Again, there is no more difficulty in assuming 
 that certain nerve twigs are attacked than there is in assuming 
 that the motor cells of the cervical enlargement at a cei'tain 
 level are selected for attack in preference to those above and 
 below them. 
 
 If we admit bliat certain cells of the body stand in relation 
 to certain poisons in the position of preference shareholders— 
 
SEAT OF LESION 183 
 
 which seems to be an undoubted, although an inexplicable 
 fact — we must concede that such preference may be manifested 
 towards cells at the periphery equally with those situated at 
 the centre. If we accept so much, then there is no difficulty 
 in admitting that nerve twigs supplying muscles may suffer in 
 preference to nerve twigs and end organs conveying impres- 
 sions from the skin. 
 
 One must admit that it may be impossible, in certain cases, 
 to say whether the paralysis and wasting of a muscle be due to 
 destruction of a group of cells in the anterior cornu or destruc- 
 tion of or pressure on the axial cylinders of certain nerves, or 
 whether the second condition has followed as a consequence of 
 the first. 
 
 The presence of pain in the limb, combined with tenderness 
 of nerve-trunks and muscles, undoubtedly points towards 
 neuritis. 
 
 I think, however, that that which should make us regard 
 lead paralysis as due to implications of nerve twigs rather 
 than motor cells is the fact of recovery. A large number of 
 cases of lead paralysis, if the cause be removed, get perfectly 
 well ; and as it is an admitted fact that the regeneration of a 
 motor nerve is common, while the regeneration of motor cells, 
 if it ever take place, is excessively rare, this fact of recovery 
 may almost be regarded as excluding much damage to the 
 anterior cornua. 
 
 But it is not reasonable to assume that lead or any other 
 poison has an exclusive preference for any particular organ or 
 area, and one must be ready to admit that lead may inflict a 
 damage upon the spinal cord or brain just as it does upon 
 motor nerves, kidneys, liver, or intestines. 
 
 If we come to the conclusion that any case of recurrent 
 abdominal trouble or paralysis is due to lead, then, assuming 
 this conclusion to be correct, the prevention and treatment of 
 the condition is within our grasp if we can succeed in detecting 
 the source of the poison. The insidious and dangerous effects 
 of lead seem to have been known to the Romans, and 
 Vitruvius, the great Roman writer on architecture, mentions 
 the danger of using leaden pipes for the conveyance of water. 
 
184 LEAD POISONING 
 
 It is to be presumed, therefore, that the knowledge that lead- 
 poisoned water will produce colic is very old. Vitruvius was 
 also acquainted with the use of ' red lead ' for a pigment, but I 
 have been unable to discover who first pointed out that painters 
 who used lead paints were liable to colic. From the six- 
 teenth century downwards descriptions of colics which were 
 endemic in certain countries have been given by various 
 physicians. One of the first writers was Francis Citois, a 
 native of Poitou, and physician to Cardinal Richelieu, who 
 described the colica jnctoman, or the colic of the inhabitants of 
 Poitou. Please note that the word j)ictonur)% has no relation 
 to inctor^ a painter. There is no evidence that Citois knew 
 anything of ' painter's colic,' and he attributed the colic of 
 Poitou to the acidity of the local wine. Similar endemic 
 colics had l^een described in Normandy among the cider 
 drinkers, and in this country an endemic colic was described 
 as occurring among the cider drinkers of Devonshire, first by 
 Musgrave, in 1703, and secondly by Huxham, who in 1739 
 published a treatise, ' De Morho Colico Damnoniorum.' These 
 writers had no notion as to the real cause of the colic, as a 
 reference to the pathology of Huxham will show. Huxham 
 attributed the colic to the acidity of the cider, and he says : 
 
 ' By long and frequent drinking of a liquor of this kind, 
 such a quantity of crude, gross tartar is thrown into the blood 
 that it thence becomes very acrid ; and not only the blood, but, 
 from that impure source, all the humours thence secreted. So 
 that, instead of a very soft lubricating mucus, separated by 
 the glands, discovered by Dr. Havers, we have, as it were, a 
 sharp coagulated matter, whence arises great pain in the joints 
 and impotence of their motion. Instead of an exceedingly 
 soft lymph to moisten the nerves, a corrosive ichor ; and hence 
 epileptical attacks. . . . At length, even the very bile, that 
 variously useful balsam of the body, becomes corrupted and 
 quite enervated by the superabundant apple-acid, though in 
 its natural state it was designed to correct acidity.' 
 
 I give you this as a very good sample of the pathology of 
 1739, but you will observe there is no mention or hint of the 
 true cause of the Devonshire colic. 
 
'ENDEMIC COLIC 185 
 
 It was not until 1767 that Sir George Baker conclusively 
 proved that the Devonshire colic was caused by lead poisoning 
 in a masterly communication to the Royal College of Physicians, 
 on June 29, entitled an ' Essay concerning the Endemial Colic 
 of Devonshire.' Baker showed — 
 
 1. That acid drinks are not necessarily the cause of colic. 
 
 2. That the cider drinkers of Devonshire suffered more 
 than the cider drinkers of Gloucester, Hereford, and Wor- 
 cester. 
 
 3. That lead entered largely into the composition of the 
 cider-presses of Devonshire, but not into those of the neigh- 
 bouring counties. 
 
 4. He finally demonstrated that 18 bottles of Devonshire 
 cider taken from his own cellar contained over four grains of 
 metallic lead. 
 
 Not only in Poitou and Devonshire did these endemic 
 colics get a footing, but in tropical countries as well. The 
 ' dry belly-ache ' of the West Indies, and of some of the 
 Southern States of North America, was thought to be a cli- 
 matic disease until it was shown to be due to the contamination 
 of rum by lead. Madrid was much troubled with an endemic 
 €olic, as were also the sailors in the French navy, but both 
 these ' endemics ' have now been shown to be caused by lead 
 poisoning, that in the French navy being attributed to the 
 use of lead in the apparatus for distilling water. I may 
 further remind you that in the old bills of mortality, issued 
 by the parish clerks of London, ' griping in the guts ' was a 
 common cause of death, and there can be little doubt that a 
 fair proportion of these were cases of lead poisoning. 
 
 I mention these facts in order that we may appreciate the 
 services of Sir George Baker. By showing conclusively that 
 Devonshire colic was really lead colic, he gave us the power of 
 arresting all the so-called ' endemial ' colics, and thus saved 
 countless lives, and, what is far more important, prevented the 
 crippling of useful lives. 
 
 Now that the symptoms of lead poisoning are well under- 
 stood, and we are thoroughly alive to the dangerously insidious 
 qualities of the poison, the question of ' lead ' is sure to cross 
 
186 LEAD POISONINa 
 
 the mind of the physician when confronted with cases in which 
 the suspicion of lead is warranted. 
 
 In one of the cases which I have brought before you the 
 suspicion of ' lead ' is so strong as to amount to a positive 
 conAdction in my own mind ; but we have never been able to 
 demonstrate the source of the lead, and in that important 
 respect our duty towards the patient remains to be completed. 
 
 As regards the toxicity of the various preparations of lead, 
 it is admitted that the salts of lead are far more dangerous 
 than the metal. It is, indeed, a question whether metallic lead 
 is to be regarded as a poison. 
 
 I remember hearing the late Mr. Hulke make allusion to 
 the case of a gamekeeper who was troubled with that form of 
 dyspepsia which, on account of the accompanying flatulence, 
 the uneducated masses frequently characterise as the ' rising 
 of the lights.' Whenever this gamekeeper was troubled with 
 the ' rising of the lights ' he took a charge of shot to, as he said, 
 ' keep 'em down.' This gamekeeper is said never to have 
 suffered from saturnine intoxication ; but we must remember 
 that metallic lead must be liable to be converted into a lead 
 salt by the acids of the stomach or by the acids taken with the 
 food. The doctrine that metallic lead is not poisonous is, in 
 all probability, a false doctrine for practical purposes, and in 
 fact I was informed a few weeks ago, by Dr. George Oliver, of 
 Harrogate, of a patient whose toxic symptoms were caused, he 
 believed, by the practice of putting a shot in his mouth and idly 
 chewing it. 
 
 By far the most important manner in which lead gains access 
 to our bodies is by the contamination of drinking-water. The 
 result of such contamination is that lead is taken whenever the 
 water is drunk, or whenever hot infusions made with the water 
 are drunk, or whenever soup or food which has been made with 
 or cooked in the water is consumed. If, therefore, the domestic 
 water supply be contaminated with lead (no matter how slight 
 such contamination may be), some of the dwellers in the house 
 are sure to suffer eventually. 
 
 Not all waters dissolve lead. One of the advantages of a 
 hard water containing lime, such as we use in London, is that 
 
CONTAMINATED WATEE 187 
 
 it has little or no solvent power upon the leaden water-pipes 
 and fittings. When we get our new supply of soft upland 
 water from the Welsh hills we may have to alter our water 
 fittings, but not till then. The conditions which favour the 
 solution of lead in Avater are not completely understood, but it 
 may be taken as an approximation to the truth that the purer 
 and softer the water, the greater is its lead -dissolving power. 
 Rain-water has great solvent power on lead : and in houses 
 which are dependent upon rain for their water supply the 
 greatest care must be taken to avoid the use of lead for water- 
 pipes and gutters, storage tanks and service pipes. Waters 
 which are acid in reaction seem to dissolve lead with a most 
 dangerous facility, and the most recent investigations seem to 
 show that the lead poisoning which has occurred in some of 
 the Yorkshire towns during the last few years is caused by the 
 acidity of some of the peaty waters with which they are supplied. 
 
 I have no intention of taking up your time by cataloguing 
 all the possible sources of lead poisoning. Suffice it to say, 
 that the lead may be absorbed from the alimentary tract, the 
 respiratory tract, or the skin, and that the economic uses for 
 lead and its salts are very numerous. Acid liquors must not 
 be kept in leaden vessels, or in earthenware vessels finished 
 with a lead-glaze, as we have learnt from the study of cider 
 colics. Where lead poisoning is suspected, you must closely 
 scrutinise the sources and surroundings of all food and drink. 
 Food wrapped in lead — such as tea ; canned or tinned foods, 
 hermetically sealed with a leaden solder ; soda-water syphons 
 with leaden fittings ; tobacco wrapped in lead foil ; snuff adul- 
 terated with chromate of lead ; anchovy paste, or lozenges 
 coloured with the same material, are a few among the many 
 recorded instances of accidental lead poisoning by food. 
 
 That lead can be absorbed by the skin seems also to be 
 established, and not a few cases of lead poisoning have resulted 
 from the use of hair dyes containing lead, or from the applica- 
 tion of pigments containing lead by theatrical artists for the 
 purposes of ' making up .' 
 
 Lead poisoning is common to many trades — as the manu- 
 facturers of 'white lead,' and other lead pigments, colour- 
 
188 LEAD POISONING 
 
 grinders, painters, pottery-glazers, makers of glazed cards, 
 &c. ; but it seems clearly established that those who are 
 engaged in the manufacture of lead products, such as pigments, 
 are more liable to suffer than those who are engaged in manu- 
 facturing articles from the pure metal. 
 
 I have said enough to show that lead is almost omnipresent, 
 and that when you have reason to suspect lead poisoning, the 
 source of it often requires diligent search, in which the 
 assistance of a skilled chemist is necessary. One word of 
 oaution. A medical friend of my own, practising in the 
 country, was confronted with several scattered cases of lead 
 poisoning, and for a very long time he failed to discover the 
 ■cause ; but finally he found it, as he thought, in certain packets 
 of an article of consumption which was being rather freely 
 distributed in his district. Lead was actually found, on 
 chemical analysis, in the article contained in these packets, 
 -and, armed with this knowledge, my friend, acting as every 
 doctor should do, in the best interests of his patients, gave a 
 warning that the article in question was unfit for consumption. 
 Thereupon the proprietors threatened him with an action for 
 libel ; and, although the action was settled out of Court, it 
 was the source of considerable worry and expense while it was 
 pending. 
 
 I take it that the proper course to pursue in such a case 
 would be to impart your suspicions to the sanitary authority 
 •confidentially, and allow them to deal with the matter, with 
 the assistance of their analyst. 
 
 Finally, I have to speak of the treatment of lead poisoning. 
 
 Our first duty is, if possible, to discover the source of the 
 lead and stop its administration, and no more need be said on 
 this head. 
 
 But it often happens that it is impossible to change the 
 occupation of the patient, and when that is the case we must 
 adopt such measures as may commend themselves for lessening 
 the risks of such occupation. The chief of these are cleanliness 
 and ventilation. A painter or any other worker in lead should 
 be scrupulously careful to wash his hands before eating, and 
 to thoroughly cleanse his hair, body and mouth every day. 
 
TEEATMENT 189 
 
 He should always work in washable overalls, and a clean suit 
 should be put on at least once a week. If this be done the 
 worker with lead pigments runs far less risk than if he inhabits 
 for months together the same dirty paint-bedaubed suit of 
 clothes, and is content to eat his meals with paint-bedaubed 
 hands and to wear a mass of dirty hair. A moustache, if it 
 be properly washed and cleaned, is probably a protection to 
 the worker in lead. 
 
 Good ventilation is essential, and I would remind you that 
 one of the patients, whose case I have related, attributed his 
 attack to working in an unventilated room in hot weather. 
 
 Workers in lead must be well nourished. Dr. Thomas 
 Oliver, of Newcastle, has made experiments which show 
 clearly that saliva, gastric juice and bile, are all capable of 
 dissolving lead, but that if starch be mixed with the lead, 
 less of the lead salt is dissolved by the saliva ; if proteid be 
 mixed with the lead, less of the lead is dissolved by the gastric 
 juice ; and that if fat be mixed with the lead, less of the lead 
 is dissolved by bile. 
 
 The conclusion is, then, that saliva, gastric juice and bile 
 have no preference for lead in the presence of those alimentary 
 principles upon which these three digestive fluids are designed 
 to act. The well fed lead-worker runs less risk than the 
 semi-starved, ill-fed worker, and the man who goes to his 
 work with a stomach full of food is less likely to suffer from 
 lead poisoning than he who goes to his daily toil on an empty 
 stomach. Dr. Thomas Oliver is fully supported in this conclu- 
 sion by the experience of the manufacturers of lead products. 
 
 Dr. Oliver is of opinion that all lead-workers should be 
 total abstainers from alcoholic drinks, and this conclusion is 
 supported by the well-known liability of lead-workers to suffer 
 from kidney disease and gout. 
 
 As a prophylactic it has been the custom, in some lead 
 works, to provide the employes with a ' lemonade ' made with 
 dilute sulphuric acid instead of lemon juice, with the object 
 of converting the lead in the alimentary tract into the com- 
 paratively insoluble lead sulphate. Dr. Oliver supports this 
 practice, but it must not be forgotten that lead poisoning has 
 
190 LEAD POISONING 
 
 resulted from taking lead sulphate, and that the constant 
 administration of dilute sulphuric acid is apt to produce con- 
 stipation, which, in the lead-worker, is very undesirable. It 
 is stated, also, that when this acid drink is provided it is 
 difficult to get the workpeople to take it continuously. 
 
 To get rid of the poison from the system and overcome the 
 lead colic, the continued administration of magnesium and 
 sodium sulphate, combined with potassium iodide, has given the 
 best results. It is a good plan also to give the saline aperients 
 mixed with hot water. Enemata may be employed with 
 advantage. Belladonna is also a useful adjunct to the salines. 
 
 Lead is eliminated from the system by the bowels and the 
 kidneys. Dr. Dixon Mann is of opinion that when lead is 
 administered medicinally by far the greater part is eliminated 
 by the bowels. Thus he gave two grains of acetate of lead 
 to a patient on five consecutive days. On the fifth day the 
 faeces yielded the equivalent of five grains of lead, and on the 
 sixth day four grains, while one milligramme of lead was the 
 largest amount eliminated by the kidneys on any one day. 
 Whether the lead eliminated by the faeces had simply passed 
 through the alimentary tract is doubtful, but I would remind 
 you that arsenic, antimony and mercury appear to be excreted 
 by the large intestine after absorption from the higher parts 
 of the alimentary tract, and it is possible that the same process 
 may take place in lead poisoning. 
 
 In Dr. Oliver's cases the largest amount of lead eliminated 
 by the kidneys in a single day was "17 grains, and the lowest 
 amount recorded was "002 grains. The daily eliminations 
 fluctuate in a remarkable way, and occasionally the elimination 
 of uric acid and lead appeared to bear an inverse ratio to 
 each other. 
 
 It has long been the practice to administer potassium 
 iodide (gr.ij to gr.v) in cases of lead poisoning, and Dr. Oliver 
 supports this practice ; but it may be stated that Dr. Dixon 
 Mann has failed to find that this drug increases the elimina- 
 tion by the kidney. Iodide of potassium is frequently ad- 
 ministered with apparent success in cases of sclerosis and 
 neuritis, no matter from what cause : and, seeing that lead 
 
TEEATMENT 191 
 
 produces sclerotic changes in a most remarkable way, I think 
 we are justified in continuing to administer potassium iodide 
 in moderate doses. 
 
 Warm baths are of undoubted service in lead poisoning. 
 They were in repute more than a century ago, and sufferers 
 from Devonshire colic found benefit from the warm baths of 
 Bath long before Baker showed that this colic was caused by 
 lead. It is probable that soaking in warm water stimulates 
 nutrition and metabolism, and there seems to be no doubt 
 that it is useful in lead poisoning. Sulphur baths have 
 enjoyed a great repute, but whether they are more efficacious 
 than the ' indifferent ' water of Bath is doubtful. 
 
 For the treatment of the paralysis the most important 
 thing is to keep the limbs protected and warm. Warm baths 
 are very useful, and a man who cannot move a paretic limb 
 in the air may manage to do so when it is immersed in water, 
 which helps to buoy up the limb and diminish the work of 
 the muscles. 
 
 Massage and electricity are both useful in the treatment 
 of lead paralysis, but neither of these agents must be employed 
 so long as the nerves and muscles remain tender. If either 
 of these agents be used in the painful stage of the paralysis 
 they are apt to do harm rather than good. One of our patients 
 was subjected to this treatment when the nerves were tender. 
 The right arm and shoulder were daily rubbed by the clinical 
 clerk, while the left arm and shoulder received no such treat- 
 ment, and it is certain that in this case the left arm (which 
 was not rubbed) seemed to recover power more quickly than 
 the corresponding limb. 
 
 While the nerves are tender I think it is a good plan to 
 apply strips of capsicum plaisters along the line of the tender 
 nerves. These serve as a protection, and act also as a mild 
 counter-irritant. 
 
 When the patient begins to improve, he is benefited by 
 the administration of tonics, such as liquor strychninse, com- 
 bined with mineral acids. The diet should be light and 
 nourishing, and finally the patient should be sent to a con- 
 valescent home before returning to his work. 
 
192 FOOD POISONINO 
 
 CHAPTER X 
 
 FOOD-POISONING^ 
 
 In commencing these lectures on toxicology I told you that 
 it would be necessary to impose some arbitrary limits on the 
 range of subjects to be treated, and accordingly that we should 
 not deal with those poisons which are the products of living 
 microbes, and which more properly come within the domain 
 of the pathologist. Food-poisoning, however, stands upon the 
 borderland of toxicology and pathology. Food-poisoning is often 
 so sudden in its onset and so rapid in its progress as to give rise 
 to suspicions of foul play, and on that account comes within the 
 range of the medical jurist, albeit that the vera causa of the 
 trouble is in many cases not to be distinguished from that which 
 gives rise to a true infective fever. One of the best-known forms 
 of food -poisoning is sausage-poisoning^ which has been studied 
 in Germany, and has been called botulismus. Let us clear 
 the way by stating that the form of ' sausage-poisoning,' of 
 which I am about to speak, does not include infection with 
 parasites, such as trichinae or taeniae, and you will soon per- 
 ceive that it is something far more serious than an ordinary 
 attack of gastritis from indigestible food. Most of the cases 
 which have been described occurred in the Wiirtemberg 
 Black Forest, where the incidence of the disease has often 
 resembled that of a limited epidemic attacking whole families 
 or small communities. Up to 1853, four hundred cases had 
 been published, of which one hundred and fifty had been fatal. 
 The sausages which have produced these troubles are of the 
 kind often spoken of in this country as 'German sausages,' 
 that is, sausages which are of large dimensions, and which are 
 ' smoked ' and not cooked. 
 
 ' Part of Toxicological Course, U.C.L., 1896. 
 
FOOD-POISONING- 193 
 
 In the Wiirtemberg Black Forest it is customary to make 
 such sausages of pig's meat, and to ' cure ' them by smoking 
 them in the chimney over a wood fire. It is stated that the 
 sausages which have given rise to poisoning have been made 
 and cured carelessly and in such a way as to encourage putre- 
 factive changes. The danger is said to be greatest when" the 
 sausages are too moist and watery in consistence, due to the 
 composition of the sausage or the unsteady drying of it when 
 made. Accordingly, we find that sausages made with liver, 
 brains, or blood, or to which milk has been added, have been 
 particularly blamed ; also that very big sausages have proved 
 dangerous because of the difficulty of drying them in the 
 middle. Further, it is stated that sometimes the accident has 
 arisen because the drying and smoking have not been properly 
 carried out. If the tire go out and the sausages are allowed 
 to freeze in the chimney and to thaw again, it is said that 
 putrefactive changes are very liable to occur. 
 
 Let me remind you that ' sausage-poisoning ' was well 
 recognised before the knowledge, which we now have, of 
 putrefactive and other organisms and their mode of cultiva- 
 tion was current. We now know that for the cultivation of 
 a large number of these organisms fluid media are necessary, 
 or media in which the proportion of water is relatively 
 large. They flourish in sewage water, in hay-infusions, in 
 the discharge from wounds, and in milk, and the media which 
 are used for their cultivation in bacteriological laboratories 
 consist of sterilised broths or broths mixed with just sufficient 
 gelatin or agar-agar to make them firm at ordinary tempera- 
 tures. ' German sausages,' to be safe, must be continuously 
 dried in antiseptic smoke, and the conditions in which sausages, 
 which have proved dangerous, have been found, are precisely 
 those in which the growth of putrefactive and pathogenic 
 organisms is likely to occur. 
 
 Some of the sausages when cut across have been evidently 
 permeated with fungoid growths, and a micrococcus, called 
 'sarcina botulina,' was many years ago discovered in them. 
 It is noteworthy that in these cases of sausage-poisoning an 
 incubative period, ranging from eighteen to twenty -four hours, 
 
 o 
 
194 FOOD-POISONING 
 
 has generally been described, and it is said that the fatal 
 cases have terminated, as a rule, in five or six days. In addi- 
 tion to more or less gastro-intestinal irritation those attacked 
 have suffered from extreme muscular weakness, sore throat, 
 and dysphagia, and various nervous symptoms, such as squint, 
 ptosis, loss of visual accommodation, stupor, and convulsions. 
 The immediate cause of death in most cases has been a gradual 
 failure of the heart. 
 
 It is impossible not to be struck with the similarity of 
 these nervous and cardiac troubles with those which so often 
 supervene as a sequela of diphtheria. In diphtheria these 
 nervous symptoms are due to nerve degenerations brought 
 about, according to Dr. Martin, by an acid and an albumose, 
 which are formed as a consequence of the cultivation of the 
 bacillus diphtherias on the palate, fauces, or elsewhere. In 
 sausage-poisoning the cause of the phenomena is strictly 
 analogous, the only difference being that the toxic bodies are 
 brewed outside the body, and not in it. 
 
 Sausage-poisoning is not common in England, because our 
 habits do not lend themselves to this particular form of food- 
 poisoning, but outbreaks of a disease of a distinctly analogous 
 kind have been observed again and again. Many of these 
 outbreaks have been observed and recorded by Dr. Edward 
 Ballard, F.R.S., one of the most distinguished of the Alumni 
 of University College, to whom the public is indebted for 
 many important discoveries in connection with public health. 
 In all the cases observed the phenomena were those of gastro- 
 intestinal irritation, with febrile and nervous symptoms such 
 as accompany infective fevers, and were preceded by an incu- 
 bative period. In 1880, at Welbeck, nearly one hundred 
 persons suffered, and four died from eating cold hams which 
 had been stored in a dirty place for the four days preceding. 
 In 1881, at Nottingham, several families were attacked after 
 eating ' cold gravy,' which was made from ' stock' which had 
 been kept in a filthy cellar. At Chester ' tinned sausage ' has 
 proved fatal, and at Oldham ' tinned ' pigs' tongues produced 
 serious illness in several persons. At Bishop Stortford three 
 families were made ill from eating cold ribs of beef, and at 
 
FOOD-POISONING 195 
 
 Whitchurch (Salop) cold brawn and cold roast pork on two 
 separate occasions produced similar results. At Wolver- 
 hampton, in 1884, a 'blown tin' of salmon not only proved 
 fatal to two persons, but was found to be most fatal to 
 animals inoculated with it. In 1886 twenty out of twenty- 
 four persons who partook of a wedding breakfast at Carlisle 
 were attacked. The breakfast was cold, and consisted largely 
 of gelatinous dishes, such as jelly and game pie, which had been 
 stored in an ill-ventilated cellar. Twelve persons suffered at 
 Iron Bridge from eating veal pie ' warmed up ' on the second 
 day. and at Retford eighty persons in twenty- two families were 
 made ill from eating pork pie and brawn. At Carlisle pork 
 and brawn produced similar results in 1889, and at Portsmouth 
 cold pies proved harmful to nine boys and four adults. 
 Finally, Dr. Ballard seems to have shown that at Middles- 
 brough, in 1888, an epidemic of pneumonia was largely due to 
 the consumption of half-cooked ' American bacon,' which had 
 been hastily and improperly cured in this country in a factory 
 built over a sewer grating. 
 
 In all these cases of Ballard's micro-organisms were found 
 in the food and in the bodies of animals fed or inoculated with 
 the food, and the poisonings were doubtless caused by the in- 
 gestion of the bacilli themselves or of the chemical products 
 formed by them. The presence or absence of a well marked 
 incubative period appears to depend upon whether the product 
 of the organism is present in the food in toxic quantities (in 
 which case the incubative period is absent or very short) or 
 whether the bacillus alone is taken and the poison is brewed 
 by it in the body of the infected person. 
 
 Ballard points out that in the fourteen instances which he 
 brings together pig meat was the cause of the food-poisoning 
 in nine of them, and the explanation is probably to be found 
 in the fact that not only is pork often eaten cold, but its 
 gelatinous nature lends itself to the cultivation of microbes. 
 Finally, in studying the etiology of food -poisoning, and after 
 arriving at the conclusion that it is due to the fact that the 
 food has accidentally become a medium for the cultivation of 
 pathogenic microbes, we have to inquire how such so-called 
 
 o2 
 
196 FOOD-POISONING 
 
 accidents arise. It will be observed that food-poisoning has- 
 most often arisen in connection with food which has been 
 stored after cooking, and has been eaten cold after an interval 
 of one or more days, and Dr. Ballard was able to show that in 
 all but one of the cases he reported the food had been stored 
 in a foul place. 
 
 An interesting case in which the same class of facts was 
 observed was lately brought to my notice by Mr. T. Bullock, 
 of Isleworth. A family bought a leg of pork, and ate it hot 
 on Sunday. None of those who shared this Sunday dinner 
 were made ill, but of those who partook of the cold remains on 
 Tuesday three or four suffered severely from gastro-enteritis. 
 What still remained was given away, and of the three who 
 ate it all were dangerously ill, and two died on the following 
 Sunday. When the facts came to be investigated it was 
 found that the meat after cooking had been stored in a filthy 
 larder under the stairs, communicating, on the one hand, by 
 means of a ' ventilator,' with a dog-kennel, which had ' never ^ 
 been cleaned, and, on the other, by means of the stairs with the 
 damp basement of an ill-drained house. In the Middlesbrough 
 epidemic it was found that the bacon fat which was removed 
 from the sewer grating was singularly fatal to the animals to 
 which it was given. 
 
 It is well known that mussels and other forms of ' shell- 
 fish ' are liable under certain circumstances to produce gastro- 
 enteritis of a violent kind, and recent cases seem to show that 
 an important factor in the causation of limited epidemics of 
 ' mussel-poisoning ' is the water in which the mussels have 
 grown and been nourished ; and that in not a few instances 
 poisonous mussels have grown in harbours and similar foul 
 places into which sewage has been allowed to flow, and in which 
 there has been more or less stagnation. Not only mussels, but 
 other ' shell-fish/ such as crabs and lobsters, and certain other 
 kinds of fish, such as mackerel, have an evil reputation for being 
 occasionally dangerously unwholesome. It must be remem- 
 bered, however, that fish of all kinds is very prone to undergo 
 putrefactive changes, and that any evil qualities which it may 
 acquire are not necessarily due to its mode of nourishment. 
 
FOOD-POISONING 197 
 
 but to its being stored in unwholesome places on land. The 
 cause of these epidemics is alleged to be the formation of 
 alkaloidal bodies having poisonous properties, and which have 
 received various names, according to their source of origin. 
 
 It appears, however, to have been recently established 
 that certain ' shell-fish ' which are habitually eaten raw may 
 become the vehicle for the conveyance of the germs of specific 
 disease, such as cholera and enteric fever. This fact appears 
 to have been first pointed out by Johnson Lavis and other 
 practitioners at Naples, where the oysters nourished in the 
 then filthy little harbour of Santa Lucia were frequently the 
 means of conveying the infective poisons of enteric fever and 
 cholera to the consumers of them. In 1893 there were in this 
 €Ountry a few cases of cholera, which were investigated by 
 the Local Government Board, and in not a few instances the 
 infection appears to have been traced to oysters grown in 
 
 * beds ' situated at G and C ; the ofiQcial report on 
 
 the subject concludes with the following words : 
 
 'One thing is certain, oysters and shell -fish, both at the 
 mouth of the Humber and at other points along the English 
 coast-line, are at times so grown and stored that they must of 
 necessity be periodically bathed in sewage more or less dilute ; 
 oysters have more than once appeared to serve as the medium 
 for communicating disease, such as enteric fever, to man ; and 
 so long as conditions exist such as those with which the 
 
 oyster trade of C and G is shown to be associated — 
 
 conditions which may at any time involve the risk of the 
 fouling of such shell-fish with the excreta of persons suffering 
 from diseases of the type of cholera and enteric fever — so long 
 will it be impossible to assert that their use as an article of 
 diet is not concerned in the production of diseases of the class 
 in question.' 
 
 It will be remembered that in 1895 several cases of enteric 
 fever in this country were traced to the consumption of oysters. 
 
 These food-poisonings may be arranged in three classes : 
 
 1. Cases in which a diseased state of the animal consumed 
 as food has been the means of causing disease of a similar kind 
 \n the consumers. The cases reported in Germany in which 
 
198 FOOD-POISONING 
 
 gastro-enteritis closely resembling typhoid has followed the 
 consumption of diseased veal belong to this category. 
 
 2. Cases in which the food, without being in itself un- 
 wholesome, is made the vehicle for conveying pathogenic 
 microbes to the consumer. Most of the ' milk epidemics ' of 
 enteric or scarlatina and moUusk enteric and cholera belong 
 to this class, but it must be remembered that classes one and 
 two are not always to be easily distinguished. 
 
 3. Cases in which food which was wholesome when bought 
 and wholesome when cooked has become infective from being 
 kept in a filthy place. The cases described by Ballard mainly 
 belong to this category, which seems to cover the majority of 
 the cases of food -poisoning. 
 
 What has been said with regard to these cases must impress 
 us with the strong analogy existing between many cases of 
 food-poisoning and the specific infective processes which are 
 met with in the various fevers. 
 
 The pathology of fever which is now generally accepted is 
 that the body is invaded by microbes which, growing, brew 
 ' toxines ' from the blood and tissues, and that these toxines, 
 after absorption, cause the various phenomena of the fever. 
 
 Food -poisonings are distinctly analogous. The food may 
 contain microbes which, taken into the body, tardily brew a 
 ' toxine,' which thus produces its effect after a relatively long 
 incubative period ; or the toxine may have been previously 
 brewed in the food in large quantities, and then the toxic 
 effects closely follow the ingestion of the meal. 
 
 In the former case, where the attack is slow and insidious, 
 it may be impossible to connect the symptoms with any par- 
 ticular article of diet, but in the latter case the connection 
 between the food and symptoms is obvious. It is clear that 
 the investigation of cases of infective fever and pneumonia 
 cannot now be considered complete without careful inquiry 
 into the food consumed by the various persons attacked. 
 
 The chemical nature of the bodies which are the actual 
 cause of the poisonous effect occasionally produced by food has 
 received considerable attention from chemists. 
 
 Many of the bodies formed during putrefaction appear to 
 
FOOD-POISONING 199 
 
 resemble alkaloids in their general chemical reactions, and 
 Selmi, who was one of the early investigators of these bodies, 
 proposed for them the name of ptomaines, or cadaveric alkaloids. 
 Selmi derived his word from Trrw/xa, a corpse, and it has been 
 not unusual to speak of food-poisoning as ' ptomaine '-poison- 
 ing. It would seem that the time has come for abandoning 
 this barbarous and unpronounceable word, for not only are 
 poisonous bodies found in other things than corpses, but it is 
 certain that not all the poisonous bodies which result from 
 putrefaction resemble alkaloids. Further, we now know that 
 although found in corpses these bodies are the products of the 
 active life of micro-organisms. It seems better, therefore, in 
 every way, to speak of them as food toxines or putrefaction 
 toxines, and in so doing we call attention to the analogies 
 which exist between food-poisoning and the other infective 
 processes. 
 
 For this view I am happy to find that I am able to quote 
 the authority of Dr. Kanthack, who, in his article on the 
 * Pathology of Infection ' in AUbutt's ' System of Medicine ' 
 (vol. i. p. 527), says, speaking of the uncertainty which still 
 overhangs the chemistry of bacterial products : 
 
 ' In the meantime we may sum up that among the specific 
 toxines there have been found — 
 
 ' (a) Ptomaines. 
 
 ' (h) Toxic proteins, toxalbumins. 
 
 ' (c) Nucleo-albumins and albuminoid substances. 
 
 ' (d) Ferment-like bodies (enzymes) secreted by the 
 bacterial cell ; and, knowing as little as we do, it is safest to 
 apply to the bacterial poisons the general term toxines.' 
 
 It is well to bear in mind that these ' toxines ' may be 
 derived from vegetable bodies (such as ergot of rye and mouldy 
 maize, which have in times past produced epidemics of 
 ergotism and pellagra), and that in all probability they may 
 be volatile and assume a gaseous form. Thus Dixon Mann, 
 in a paper on ' Ptomaines,' published in the ' Medical Chronicle ' 
 in 1888, says: 'The peculiar effects — drowsiness, mental de- 
 pression, and lassitude — which I experienced in the early 
 stage of the operations, when working at the isolation of 
 
200 FOGD-POISONING 
 
 pathogenic ptomaines from the organs of patients who had 
 died from infective diseases, incline me to believe that some 
 of these products are volatile.' 
 
 Hiinefeld found that tissues impregnated with arsenic and 
 allowed to decompose gave off an odour of garlic, and that the 
 arsenic tended to disappear entirely ; and Victor Vaughan 
 also found that at the end of six months he could get no 
 evidence of arsenic from chopped liver which had been kept 
 in a bottle, and which had previously yielded unmistakable 
 evidence of arsenic. 
 
 Among the common products of the putrefaction of organic 
 matters are gases such as carbonic acid, hydrogen, marsh gas, 
 and sulphuretted hydrogen, and we know that the latter 
 produces poisonous effects even in small quantities, and, 
 according to Haldane, is the probable cause of the death of 
 sewer men who enter unventilated sewers, and must be re- 
 garded as a gaseous toxine resulting from the putrefaction of 
 food refuse such as the contents of kitchen sinks and the 
 abominations known as ' fat traps. ' The fact that gaseous 
 toxines undoubtedly exist is one which must not be lost sight; 
 of, and is of great practical importance. 
 
 It must be borne in mind that food which has become 
 toxic is not necessarily in a repellent condition, and in some 
 instances it has been observed that the toxic qualities of food 
 have lessened when the grosser and more repellent forms of 
 putrefaction have set in. Many persons habitually eat ' game ' 
 in a condition which to many of us is sickening and repellent, 
 and others highly appreciate the flavour and odour of * ripe ' 
 cheese — i.e. cheese which is riddled with moulds of various 
 kinds. 
 
 It has been stated that the toxines which are the result of 
 anaerobic microbes are especially dangerous, but of this further 
 evidence is necessary. It is the anaerobic fermentation, such 
 as putrefaction under water, which especially gives rise to 
 foul-smelling bodies, but, as has been said, the toxicity of 
 such bodies differs immensely. We are in want of exact 
 information on the whole subject, and doubtless such informa- 
 tion will in the course of time be gradually furnished. 
 
FOOD-POISONING- 201 
 
 . . The treatment of food-poisoning need not detain us, as it 
 Las to be conducted on ordinary medical principles, and must 
 necessarily vary with the time which has elapsed between the 
 ingestion of the poison and the commencement of treatment. 
 It must be both eliminative and restorative, but must vary 
 with the symptoms. A certain number of cases end fatally 
 in spite of treatment, just as is the case in the other infective 
 •diseases. 
 
 It is far more important to consider the measures which 
 must be taken to prevent the occurrence of food-poisoning. 
 
 A large proportion of cases have occurred in food eaten 
 raw, and there can be no doubt that the thorough cooking of 
 food, by killing the micro-organisms upon which the toxic 
 changes depend, would tend in many instances to prevent the 
 occurrence of the mishaps we have been considering or to 
 lessen the severity of the symptoms. 
 
 If the toxines be already formed in large quantities the 
 effect of heat is not always to destroy their toxicity. Some 
 toxines, such as cobra-poison, are said to be very tolerant of 
 high temperatures, and it is certain that food- poisoning has 
 occasionally followed the ingestion of well cooked food, showing 
 that the food toxines are also occasionally tolerant of heat. 
 
 In food which is stored after being cooked it is very 
 important to prevent the growth of micro-organisms, or, in 
 other words, to keep it sterile. 
 
 I remember once ordering a quart of turtle soup to be sent 
 to an invalid in the country, and I asked the tradesman who 
 supplied it how it was to be kept from ' going bad,' as it was 
 probable that the quantity supplied would be enough for four 
 or five days. His answer was that if it was just raised to the 
 boiling point every day it would keep as long as one chose. 
 This answer was exactly what would have been given by a 
 bacteriologist, and it is noteworthy that many of the sterilis- 
 ing and antiseptic processes which are so frequently employed 
 by scientists and surgeons have been practised by well trained 
 cooks for centuries. Practice and ' rule of thumb ' is often 
 perfectly sound, although we may be ignorant of the rationale 
 of the process. 
 
202 FOOD-POISONING 
 
 In every well conducted kitchen a ' stock pot ' (i.e. a pot 
 in which bones and meat are boiled) is kept going for the 
 furnishing of a foundation for soups and gravies, and if its 
 contents are raised to the boiling point every day they will 
 keep continuously wholesome. If, however, the stock pot be 
 neglected, its gelatinous contents are very liable to serve as a 
 cultivating medium for pathogenic microbes. It will be 
 remembered that in more than one of Dr. Ballard's cases of 
 food-poisoning it was the cold gravy which proved to be the 
 toxic material. 
 
 It is not likely that we shall abandon the use of cold 
 food, which is both convenient and agreeable, and the 
 danger of eating cold food is not great if certain precautions 
 be taken. 
 
 The place where cooked and uncooked food is stored — the 
 larder — must be wholesome, and to this end some care must 
 be used in its construction. The following appear to me to 
 be the points which demand attention in the larder, an 
 apartment which may influence the health of a household to 
 a very great extent. 
 
 1. The larder must be dry. Both walls and floor should 
 be above suspicion as to dampness. Any mould or mildew 
 growing on the floor or walls is very apt to infect the food. 
 The floor should be of concrete, without seams or joints. The 
 walls should be whitewashed every year, and the shelves (if 
 expense be no object) should be of some non-absorbent 
 material, such as marble, slate, glazed earthenware, or glass. 
 It is better to have a larder above the ground level than below 
 it, because in the latter situation it is very difficult to prevent 
 dampness. 
 
 2. A larder must be cool. If it have no rooms above it 
 the roof must be so constructed as to keep out the heat of the 
 sun. It is essential that its windows and ventilator should 
 face the north. The temperature which is most favourable 
 for the growth of microbes is one which approaches the 
 blood heat, and, speaking generally, one may say that the 
 higher the temperature the more likely is the ' cultivation ' of 
 microbes to go forward. It is important that neither the flue 
 
FOOD-POISONINa 203^ 
 
 of the kitchen fire nor that of any other fire should touch 
 the wall of the larder. 
 
 3. Good ventilation is essential. The windows should be 
 big, and should be protected on the outside with wire gauze, so 
 as to prevent the access of flies or other insects. 
 
 4. On no account must there be a pipe communicating 
 with any underground drain or sewer either inside or, indeed, 
 near to any place where food is stored. The Middlesbrough 
 case shows the possibility of food being contaminated by 
 emanations from a sewer, and also the possibility of epidemic 
 pneumonia resulting therefrom. In short, we must bear in 
 mind that sewer-poisoning may be indirect through the food 
 as well as direct from the sewer itself. When the shelves and 
 floor of a larder are washed they should be wiped dry, and 
 such washing should be carried out preferably in dry weather,, 
 so that the drying process may be complete. 
 
 We also know how sensitive food is to unwholesome con- 
 taminations, and we may well have a doubt as to the sanitary 
 condition of show dairies where a cool splashing fountain 
 plays in the centre, because such a fountain must cause 
 dampness and have a waste pipe, and we must fear that such 
 a waste pipe communicates with a drain. A dairy equally 
 with a larder should be kept cool and dry, and offer no 
 facilities for the ingress of putrefactive products from a 
 sewer. 
 
 I would point out that it is not any protection to have 
 pipes trapped, because in every form of trap one must have 
 stagnation, and wherever stagnation occurs there must be 
 putrefaction. A very small quantity of food refuse or milk 
 is enough to set up putrefaction in a trap. If any outlet for 
 water is thought desirable in a larder it should be in the form 
 of an open gutter, which can be thoroughly cleaned and dried, 
 and which should pass directly through the wall on the floor 
 level, the opening in the wall to be closed by a sKding trap- 
 door when the gutter is not being used. No bacteriologist 
 needs to be reminded that a water trap is necessarily a 
 cultivating chamber. 
 
 The fact, now only too well established, that food or water 
 
204 EOOD-POISONINa 
 
 or milk may convey pathogenic microbes to the consumer has 
 led to the advice that all food, milk, water, meat, oysters, &c., 
 should be cooked thoroughly before being consumed, and if 
 this be done it is thought that we shall get no harm from 
 mixing our faeces with our water supply, as we are now prac- 
 tically compelled to do by Act of Parliament. 
 
 It is, however, more than doubtful whether we can alto- 
 gether do without some forms of raw food. Certain it is that 
 our natural appetites impel us to the consumption of many 
 forms of raw food, and that we, most of us, enjoy new milk, raw 
 oysters, fruit, salads, and fermented drinks, which are all in a 
 sense ' alive.' Certain it is that nature intended sucklings to 
 live on raw milk, and we must have misgivings as to the advisa- 
 bility of disallowing this natural nutriment. Our numerous 
 experiments with animal extracts seem to enforce the conclu- 
 sion that cooked food may be very different in its physiological 
 effect from raw food. The marvellous results which follow 
 upon the administration of thyroid extract prepared by evapo- 
 ration under a vacuum or by extraction with glycerin are not 
 observed when the cooked gland is given. Most of us also 
 have had experience of the great value of uncooked meat 
 juice, and it is not improbable that the high value of cod-liver 
 oil is due to the fact that it is extracted at a temperature 
 under 180° F. 
 
 It is possible that our knowledge on these questions will 
 be more certain at no distant date, but the considerations I 
 have brought forward make it certain that we must pause 
 before we throw over articles of diet which have been used for 
 centuries by the human race. 
 
205 
 
 CHAPTER XI 
 
 AUTO-INTOXICATION^ 
 
 A case of insensibility suddenly supervening on extreme 
 muscular exertion 
 
 On February 25 a strongly built man, twenty-one years of age, 
 was brought to University College Hospital in a semi-conscious 
 and irritable condition with the following history. The previous 
 day, February 24, 1894, he had come up to London, a distance 
 of 120 miles, to take part in a cross-country ten mile race, for 
 which he had been in training for some time previously. At 
 6.30 A.M. on that day he had for breakfast two eggs, a few 
 pieces of toast, and two cups of tea. This was the last time 
 he had anything to drink until after the race. He had lunch 
 in London about midday. This consisted only of a chop and 
 dry toast. The race commenced at 4.30 p.m., and the 
 course, which was partly through plough land, taken as a 
 whole was extremely heavy, owing to recent rain. The 
 patient said that he felt out of sorts before the race began, 
 but he finished well up, doing the ten miles in sixty- six and 
 a half minutes. During the race he did not perspire as much 
 as he ought to have done, and afterwards, when he went to 
 the dressing-room, he felt very thirsty, and drank off about a 
 pint and a half of cold water. After this he became ill, did 
 not recollect dressing himself, and, in fact, remembered nothing 
 more until he found himself in the hospital next evening. 
 His friends state that the race was finished about 5.45 p.m., 
 and after this the patient dressed himself with very little 
 assistance, but he did not seem well ; he appeared ' over 
 run.' Just after leaving the dressing-room with his friends 
 he ' fainted.' They gave him some brandy, but, as he 
 1 Clinical Lecture, U.C.H., 1894. 
 
206 AUTO-INTOXICATION 
 
 became unconscious and helpless, they carried him to a 
 neighbouring house and laid him down on the floor. Here 
 he lay quite still, with semi-closed eyes, occasionally groaning 
 as though in pain. His breathing was stertorous, and his 
 pupils are said to have been dilated equally and his teeth 
 clenched. He continued thus until 7 p.m., when he began 
 to have convulsions, which appear tf) have been epileptiform 
 in character. They came on with intervals of one or two 
 minutes, in which the breathing was stertorous and the patient 
 was quite still. A considerable quantity of saliva ran from 
 his mouth, but he did not bite his tongue. At 8 p.m. the 
 convulsions became so violent that it was found necessary 
 to restrain the patient, and at 11 p.m. he was given a 
 hypodermic injection of morphia. This controlled the fits, 
 and he lay quiet during the rest of the night, but was quite 
 unconscious. All next day, February 25, he remained in the 
 same condition, and in the evening was brought up to Univer- 
 sity College Hospital. 
 
 Condition on admission. — The patient lies on the couch in 
 a curled-up position, with his legs flexed on to his abdomen 
 and his arms crossed over his chest. He is in a state 
 of extreme cerebral irritation and resists all attempts to 
 examine him. If his eyelids are opened to look at his eyes 
 he closes them tightly and rolls over on the couch with his 
 face to the wall. He lies quite still, except that occasionally 
 he puts his hand to his head and rolls over on the couch, 
 especially when any attempt is made to examine him. His 
 pupils are equal and semi-dilated ; the conjunctivae are sufiused. 
 He will not say anything in answer to a question, but only 
 opens his eyes and stares vaguely about. He will not put out 
 his tongue. The breath is foul. Pulse regular, fuU, and 
 bounding. No paralysis can be made out anywhere ; knee- 
 jerks equal on both sides. Except that he at times passes his 
 hand across his forehead he does not seem to sufler any pain. 
 Urine, obtained later, found quite normal in every respect. 
 At 11 p.m., as the patient had had no food for the last twenty- 
 four hours, preparations were made to feed him nasally. The 
 passage of the tube caused such violence on the part of the 
 
AUTO-INTOXICATION 207 
 
 patient that the tube was taken out. He then sat up in bed, 
 seemed quite rational, drank about a pint and a half of milk, 
 and took three grains of calomel. 
 
 During the night the patient was restless, but quite con - 
 scious, and took his food well. The next day, February 26, he 
 complained of some headache, but was quite sensible and took 
 interest in what was going on. The headache disappeared 
 towards the end of the day. Examination of the patient 
 revealed nothing abnormal. He left the hospital on March 4, 
 no bad symptoms having developed in the interval. 
 
 Clinical remarks. — Prolonged insensibility resulting from, 
 or determined by, excessive muscular exertion is sufficiently 
 rare to merit rather special attention. It would, to say 
 the least, be rash to conclude that an insensible and semi- 
 comatose condition betokened any coarse lesion of the brain. 
 There is abundant evidence that such a condition is com- 
 mon without any cerebral lesion whatever. What, indeed, 
 is sleep — that daily recurring attack of insensibility from 
 which, happily, we all suffer — but the physiological prototype 
 of the more intense pathological conditions ? Sleep might 
 be light or heavy, sound or disturbed, and accompanied by 
 mutterings, dreams, nightmares, or movements, but it was 
 very seldom that any of these morbid complications of normal 
 sleep were attributable to any definite brain lesions. Sleep 
 was probably brought about by the action of waste products 
 circulating in the blood, and it was said to be generally accom- 
 panied by contraction of the cerebral vessels. We have 
 lately had in the ward a case of so-called ' ursemic coma ' and 
 another case of ' diabetic coma,' and I would remind you that 
 in both these cases the cause of the coma was to be looked 
 for in the deranged composition of the blood, and not in any 
 definite lesion of the brain or its membranes. On the other 
 hand, we have now in the ward a patient suffering from pro- 
 found and complete right-sided hemiplegia, in which the lesion 
 in the brain is certainly very extensive, and yet there has 
 never been so much as a cloud over the man's intellect, and he 
 has astonished us all by his singular quickness, accuracy, and 
 volubility. These cases all point to the fact that the connec- 
 
208 AUtO-INTOXICATION 
 
 tion between insensibility and brain lesions is by no means 
 constant. The patient under consideration has never mani- 
 fested any symptoms which warrant us in concluding that 
 there has been any lesion of the brain or its membrane. He 
 has been insensible, he has had tits ; but in the absence of 
 any localising symptoms we should be wrong to regard the 
 fits as ' cerebral ' or ' meningeal ' in origin. It is certain that 
 forty- eight hours after the onset of his trouble a careful 
 examination of the patient failed to reveal anything amiss 
 with any organ of the body. What, then, was the cause of 
 the attack ? The answer which is most probably correct is 
 that the patient was poisoned by his waste products. We 
 must remember that ten miles across a heavy country 
 and over obstacles represents a prodigious amount of work, 
 and that this heavy work was concentrated in a very 
 short period of time. If the products of tissue metabolism, 
 as must have been the case, were excessive, and if their 
 eliminations did not keep pace with their formation, then we 
 have a condition distinctly analogous to uraemia or diabetes, 
 and we cannot wonder that symptoms such as insensibility 
 and convulsions should supervene. But, it will be urged, 
 'this man is a trained athlete, well accustomed to such 
 work and no similar accident has befallen him on any 
 previous occasion.' This is doubtless true, and it behoves 
 us to review the history which is given by the patient and 
 his friends, and try to discover what were the exceptional 
 circumstances (if any) which led to such an exceptional 
 result. First, we have the statement of the patient that 
 he felt ' out of sorts ' when he started for the race. This 
 is a sufficiently indefinite statement, but we shall not be 
 wrono- in insisting that the functions of our bodies are 
 not so well performed when we are ' out of sorts ' as when 
 we are ' fit.' Next we have the statement that he did not 
 perspire as much as is usual with him in such contests. His 
 statement to me on this point was very definite ; he said 
 he ' scarcely perspired at all,' and ' nothing like as much 
 as usual.' If we accept this statement we have a right to 
 assume that, the great cooling mechanism of the body being 
 
AUTO-INTOXICATION 209 
 
 relatively inactive while heat production was excessive, there 
 must have been hyperpyrexia and a condition not unlike some 
 forms of heat apoplexy. If there was hyperpyrexia, we have 
 a condition, in addition to the exercise, which certainly would 
 exert an influence over the nature and quantity of the tissue 
 waste. I think there is no evidence whatever that the attack 
 was in any degree attributable to heart failure. The heart 
 has always appeared strong, and in every way normal, and 
 the vigorous struggles of the patient during his unconscious- 
 ness negative the idea of cardiac exhaustion. It is possible, 
 however, that the copious draught of water which he took in 
 the dressing tent may have caused a flow of blood into the 
 abdominal vessels and have indirectly produced sufficient cere- 
 bral anaemia to determine the sudden onset of unconsciousness. 
 You will have gathered from these remarks that there were 
 three conditions which, so to say, made for unconsciousness — 
 viz. (a) waste products circulating in the blood, (b) hyper- 
 pyrexia, and (c) sudden cerebral ansemia. A very important 
 point is the prognosis. Is this man's career as an athlete at 
 an end 1 Or may we tell him to go on attempting to add to 
 the 140?. worth of prizes which he states he has won in the 
 last three years ? Is this attack a pure accident, or is it liable 
 to recur ? These are questions to which an answer is expected. 
 It would be safest, perhaps (for ourselves), to tell him on no 
 account to run again, but by giving such safe advice we may 
 deprive him of a not inconsiderable income, which he may 
 still be quite competent to earn with safety. Certain it is that 
 the man is organically quite sound, and before advising him to 
 give up using his fine body in manly exercises let us look to his 
 history and see if there be any circumstance which may have an 
 important bearing upon the matter. First, the patient stated 
 that he felt ' out of sorts ' when he started for his race, and 
 although all one can say of being ' out of sorts ' is that it indi- 
 cates some derangement in the working of the machinery of 
 the body, it is impossible not to believe that such derangement 
 must have had an important bearing on the contretemps for 
 which he was admitted here. I am inclined to attach con- 
 siderable importance to his diet on the day of the race. At 
 
 p 
 
210 AUTO-INTOXICATION 
 
 6.30 A.M. he had two eggs, two cups of tea, and some toast, 
 and at 11.30 a.m. he had a mutton chop and dry toast, but 
 nothing to drink. A cup of tea was put before him at the 
 midday meal, but he did not like it, and put it aside. The 
 amount of food taken on the day of the race seems small in 
 its relation to the man and his work, and it is almost certain 
 that the amount of fluid taken was too small, and I am inclined 
 to attach considerable importance to the fact that, owing to an 
 accidental circumstance, he took no fluid with his midday 
 meal. If a man starts on such a race with too little fluid in 
 him the excretion by the skin and kidneys will be hampered, 
 and his risk of auto-intoxication and hyperpyrexia be increased. 
 In the Turkish bath, when a bather does not sweat the atten- 
 dants offer him some tepid water, and in the majority of cases 
 the body will bead with perspiration within a few seconds of 
 taking it. If a normal amount of diaphoresis had been started 
 in our patient it is possible that his attack of insensibility 
 might not have occurred. In his work on bodily exercise 
 Lagrange touches upon the subject of auto-intoxication, and 
 he asserts that, although not very common in human beings 
 (unless we include many of the cases of so-called ' sunstroke ' 
 occurring in soldiers after a long march), it is far from un- 
 common in hunted animals, which, he says, are not seldom 
 found dead in their lairs on the day following a prolonged 
 hunt. It is to be regretted that no careful examination of the 
 patient was made in the hours immediately succeeding the race. 
 A record of temperature and an analysis of the first urine 
 secreted might have thrown considerable light on the case, 
 but the circumstances were obviously of a kind to preclude 
 such investigations. After his admission here the highest tem- 
 perature recorded was 99° F., the urine was high coloured but 
 otherwise normal, and the one other point of note is that the 
 Ijreath was 'foul,' a fact which tends to justify one in ranging 
 the case alongside of ' uraemia ' and ' diabetes.' 
 
211 
 
 CHAPTER XII 
 
 A CASE OF GOUT ^ 
 
 Patients with acute gout are not among the commonest of 
 those admitted to a general hospital, and therefore I deem it 
 advisable to say a few words on the perfectly typical case of this 
 disease which was recently in my wards. 
 
 S. P., a man aged forty-three, earning his living by doing 
 ' odd jobs,' was admitted on May 17 with a swollen and pain- 
 ful condition of the right big toe. The swelling, which was of 
 a dusky red colour and extended round the metatarso- 
 phalangeal joint and on to the dorsum of the foot, was very 
 tender, and was the seat, as the patient informed us, of 
 continuous pain of a burning, throbbing character. This 
 swelling prevented him from wearing a boot, and made stand- 
 ing at once difficult and painful. Beyond the local condition 
 there was little amiss. The patient was well nourished, 
 plump, and rubicund ; the tongue slightly furred ; the 
 temperature slightly raised (99*2° F.) ; the urine was acid ; 
 specific gravity 1,015, and contained no albumen nor any 
 abnormal sediment beyond a slight deposit of urates. He 
 was kept in bed, placed on a soft diet, and given some saline 
 aperient, and left the hospital quite well at the end of a week. 
 The inflamed joint was painted with collodion, which gave 
 marked and almost immediate relief, but beyond the saline 
 aperient no other drugs were in this case necessary. 
 
 The attack had commenced suddenly at three o'clock in 
 the morning four days before he was admitted. He states 
 that he is fond of beer and has drunk it freely all his life, and 
 he admits that the day before the onset of his attack he had 
 drunk very freely of beer. He says he 'cannot remember 
 
 ' Clinical Lecture, U.C.H., 1894. 
 
 p2 
 
212 A CASE OF GOUT 
 
 how much.' The patient states that he had a similar attack 
 eighteen months ago, and that his father died after an opera- 
 tion for stone at the age of forty-two. 
 
 In this case the age, the habits, the previous attack, the 
 sudden onset at 3 a.m., the podagra, the duration, are all 
 typical, and the further fact of his apparent hereditary 
 tendency to gout, as evidenced by the death of his father from 
 stone, is also typical. 
 
 The inflammation of the joint was, in all probability, due 
 to a deposit of urate of soda in and around the joint, and it is 
 probable that we might have obtained crystals of uric acid 
 from the blood -serum had we seen him in the earlier days of 
 his attack. An acute attack of gout is always accompanied 
 by an excess of uric acid in the blood, some of which, being 
 deposited in the joints, produces the gouty inflammation. 
 This explanation of a gouty paroxysm, which we owe to 
 Garrod, is universally accepted. Nevertheless, I would ask 
 you not to be too exclusive in your attitude towards the uric 
 acid, but to regard it merely as a tangible and invaluable 
 evidence that the blood is overcharged, and for some reason 
 contains an excess of excremental matters which ought to 
 have been withdrawn from it by the kidneys or other 
 excretory channels. 
 
 Gout is due to auto-intoxication owing to a want of 
 balance between the processes of absorption, metabolism, and 
 excretion. 
 
 In my lectures on medical jurisprudence I am accustomed 
 to teach that the really operative dose of a poison is the 
 balance between absorption and excretion. It is due to this 
 fact that poisons injected into a vein or hypodermically act, 
 as a rule, far more vigorously than when slowly absorbed 
 through the alimentary mucous membrane. In the first 
 instance the blood suddenly receives a dangerous charge of 
 poison, while in the second absorption is so slow that elimina- 
 tion is able to keep apace with it, and little or no toxic efiect 
 results. It is due to the slow absorption and rapid excretion 
 that snake venom seldom produces any toxic efiect when 
 introduced into the stomach. 
 
ABSORPTION AND EXCRETION 213 
 
 In works on toxicology it is customary to quote the ' fatal 
 dose ' of each poison. Such figures are very fallacious, 
 because not only do healthy individuals vary in susceptibility, 
 but the possession of impaired power of elimination owing to the 
 presence of granular contracted kidney increases incalculably 
 the danger caused by the administration of toxic bodies. We 
 all know, for instance, the extreme intolerance for such drugs 
 as opium and mercury which is manifested by the patient 
 with a ' gouty kidney.' These patients have an equal difficulty 
 in eliminating the ' toxines ' of specific fevers, and I have on 
 several occasions during the past few years pointed out to you 
 patients in my wards whose tendency to relapse in typhoid 
 and rheumatic fevers seemed to be accounted for by the low 
 specific gravity of the urine, which indicated a feeble power 
 of urinary excretion. 
 
 It may help towards an appreciation of gout to shortly 
 consider some other forms of auto-intoxication. In diabetes 
 we have to do with a poison which is the result of deranged 
 metabolism, and so soon as elimination of the morbid products 
 is checked distinct toxic efiects are produced. Kot only is 
 the diabetic liable to coma, but, equally with the gouty subject, 
 he is liable to a variety of local troubles. 
 
 That form of auto-intoxication which we call * uraemia,' and 
 which is produced by disease of the kidneys, is due in the 
 main to faulty excretion, and not unf requently constitutes the 
 final phase of gout. 
 
 I may remind you of a case of acute auto-intoxication 
 which was admitted under my care last year — the case of a 
 young athlete who became insensible and slightly convulsed at 
 the close of a ten mile race across country — due, as we 
 thought, to the sudden overcharging of the blood with waste 
 products. (See page 205.) 
 
 The ordinary 'bilious attack,' with its headache, malaise, 
 vomiting, &c., such as is common in schoolboys who have 
 overgorged, is due to absorption being greatly in excess of 
 excretion. 
 
 These cases of auto -intoxication are due, then, to excessive 
 absorption, deranged metabolism, and defective excretion. 
 
214 A CASE OF aOUT 
 
 Normally the three processes bear a due proportion to each 
 other, the balance of power is maintained, and ' health ' is the 
 result. George Herbert's dictum that ' man is all symmetry ' 
 is only true sometimes. I was once informed by a person of 
 good education who had undergone ' two months' hard labour ' 
 that he never knew till then the bliss of being in perfect 
 health — a bliss attributable to the fact that his intake was 
 certainly not greater than (probably slightly below) his output. 
 There can be no doubt that a fair proportion of those who 
 become gouty are endowed with exceptional powers of primary 
 digestion and a keen appreciation of the pleasures of the 
 table. It is the maintenance and indulgence of these powers 
 and pleasures after the completion of the full development 
 of the body which often determines the occurrence of gout, 
 an occurrence which is hastened by a forced abstinence from 
 physical work or any impaired power of excretion by the 
 kidneys. In these cases the gout is due to a relatively 
 excessive intake. 
 
 It has fallen to my lot to see not a few very athletic men 
 with enormous muscular development who have been sorely 
 tried when they have been called upon to exchange the bat 
 for the pen and the sliding seat for an office stool. Their 
 symptoms have been obscurely gouty and accompanied by 
 marked hypochondria. Enormous muscles inadequately 
 worked seem to be a doubtful blessing. The symptoms in 
 these cases are presumably due to a deficient output in the 
 form of muscular work and its accompanying respiratory 
 products. 
 
 The marvellous power of primary digestion which is often 
 possessed by the diabetic must have the effect of putting a 
 severe strain upon the liver, and whether the faulty metabolism 
 of the diabetic may not in part be due to the want of balance 
 between gastro-intestinal and hepatic function is at least a 
 question. The great good obtained in some of these cases by 
 administering opium by the mouth, which must partly stop and 
 delay primary digestion, is an interesting fact. 
 
 The man with a feeble power of primary digestion, to whom 
 all the pleasures of the table mean stomach ache, and who 
 
A CASE OF GOUT 215 
 
 manages to live on a surprisingly small quantity of the 
 simplest food, not unfrequently outlives many of the jovial 
 companions of his youth, who succumb to some form of visceral 
 disease shortly after they have passed their prime. 
 
 There is probably no absolute measure by which we can 
 gauge the assimilative and excretory power of any individual. 
 Men are as unequal in this as in all other respects. The gouty 
 are, however, distinctly divisible into two classes, the plethoric 
 and the anaemic and emaciated. In the former class the 
 appetite is good, the assimilative power great, and the attacks 
 of gout are acute and often precipitated (as in the case I have 
 brought before you) by dietetic excess. The health between 
 the attacks is often robust. In the latter class adequate 
 nutrition is impossible, there are generally distinct evidences 
 of chronic kidney trouble, and it is probably the chronic 
 difficulty of excretion which determines the malnutrition. 
 Workers in lead afford typical examples of this latter class. 
 Lead is a styptic causing contraction of the blood-vessels and 
 anaemia. It checks excretion from the bowel by bringing 
 about colic and constipation, and very rapidly induces (as has 
 been pointed out by Oliver, of Newcastle) a fibroid change in 
 the kidneys and liver. It is to Garrod that we owe a knowledge 
 of the relation of lead-poisoning to gout. He it was who showed 
 that the administration of lead salts to gouty subjects almost 
 invariably determined a gouty paroxysm. This paroxysm is 
 almost certainly due to the arrest of all excretory functions by 
 the physiological action of the lead salts. Although we have 
 at the opposite ends of the scale cases of gout which in the one 
 case are due to excessive assimilation and in the other to 
 defective excretion, we must not forget that we have all grades 
 between, and, undoubtedly, the defective excretion is the fact 
 of most practical value when we are called upon to treat cases 
 of gout. 
 
 In treating cases of gout our efforts must be directed 
 towards the maintenance of a tolerably even balance between 
 assimilation and excretion. Undoubtedly much can be done 
 by dietetic means, but I am inclined to think that hitherto too 
 much attention has been given to the uric acid factor in gout, 
 
216 A CASE OF GOUT 
 
 and, instead of regarding it merely as a certain and most 
 valuable evidence of a loss of assimilative and excretory- 
 balance, attempts have been made to check the formation of 
 uric acid in the system by an over-nice and sometimes fanciful 
 regulation of the diet. 
 
 Physiologists have not yet given us any acceptable theorj?- 
 of the genesis of uric acid, and one who has thought deeply oil 
 the subject and has enjoyed much practical experience of gout 
 has lately warned us that he has been unable to accept any 
 theory. He has abandoned theories in despair, and says ' that 
 way madness lies.' 
 
 It seems certain that it is not an intermediate product 
 between proteid food on the one hand and urea on the 
 other, and there is no evidence that uric acid can be changed 
 to urea by increased oxidation within the body. The fact 
 that uric acid constitutes the chief urinary constituent alike 
 of the hot-blooded and rapidly breathing bird and the cold- 
 blooded and torpid snake makes any such possibility very 
 unlikely. 
 
 The fact that all snakes are carnivorous and birds largely 
 graminivorous, and the further fact that uric acid calculi are 
 frequently met with among teetotal Mohammedans and the 
 vegetable feeders of India, makes it very unlikely that we can 
 control the deposition of uric acid in the tissues by merely 
 withholding certain articles of diet. 
 
 Gouty persons are usually depressed and very often come 
 to us asking for ' tonics,' and saying they are a ' peg too low ' 
 and want 'keeping up.' To accede to their wishes is a great 
 mistake, and is analogous to heaping coals on a dimly burning 
 fire instead of raking out the bars and getting rid of the waste 
 products which prevent free combustion. Gouty patients are 
 often told to eat poultry instead of ' butcher's meat,' but this 
 cannot be defended on purely chemical grounds, for analysis 
 shows there is very little difierence indeed in the chemical 
 composition of ' white meat ' and * red meat.' As the 
 picking of the bones of a bird is a longer process than the 
 gorging of slabs of solid meat it is proljable that the poultry 
 eater gets less flesh than the consumer of butcher's meat, and 
 
UEIC ACID 217 
 
 this may be a good thing for him. If, however, the patient 
 translate ' poultry ' into ' boned quails stuffed with foie gras 
 and served in aspic,' or similar dainties, he may effectually 
 defeat his doctor's intentions. 
 
 Gouty persons are often warned against sugar, and are told 
 on no account to touch fresh fruit such as peaches, grapes, and 
 strawberries ; and, although the restrictions cannot be upheld 
 on any chemical theory having reference to uric acid, there 
 seems little doubt that gouty persons are not tolerant of sugar 
 and sweet fruits. 
 
 It is clear that the gouty man must ' eat to live,' and must 
 avoid pampering his stomach and taking more food than he 
 requires. If he assimilate more than his excretory organs can 
 satisfactorily deal with his auto-intoxication commences. If 
 his urinary organs be overtaxed it is no wonder that the most 
 insoluble of the urinary constituents (uric acid) should be one of 
 the first things to be left behind. I would remind you that 
 birds and snakes, in which uric acid is the chief urinary excre- 
 ment, pass a urine which is semi-solid. This is necessitated, 
 so to say, by the comparative insolubility of uric acid, which 
 requires some fifteen hundred times its weight of water for 
 solution, and which is insoluble in alcohol and most acids. It 
 is no wonder that uric acid should be left behind when a com- 
 petition arises among the candidates for urinary excretion. 
 The greater the amount of material which has to be excreted 
 by the kidneys the greater the likelihood that uric acid 
 will be left behind among other things. It is manifestly im- 
 portant to cut off the pampering extras from the gouty man's 
 diet. Among these extras are the majority of sweet things and 
 fruits, both dried and fresh. If these things were taken as a 
 real part of the meal for the purpose of satisfying a legitimate 
 appetite the gouty person would soon accommodate himself to 
 his diet, just as do those patients who undergo the ' grape cure ' 
 in Switzerland ; but when, after satisfying the appetite with 
 soup, fish, entree, joint, sweet, savoury, he continues to sit at 
 the table and amuse himself with ' dessert according to season,' 
 which he consumes without appetite, he necessarily overtaxes 
 his excretory organs and increases his risk of gouty troubles.. 
 
218 A CASE OF GOUT 
 
 The very bad reputation which strawberries have with the 
 gouty is due to the fact that they are an extra tacked on to a 
 diet already too liberal, and that, being cool and soft, any 
 quantity almost can be eaten tvithoiU ajypetite. Those articles 
 of diet which demand little or no appetite on the part of 
 those who consume them are very dangerous for the gouty. 
 Sugar is essentially a diet for the young and rapidly develop- 
 ing, who have a natural craving for it, a craving which usually 
 disappears as life advances. By freezing syrups so that the 
 coolness masks the sweetness sugar is taken by the adult with- 
 out appetite. The punch a la Romaine in the middle of dinner 
 and the concentrated mixture of cream and syrup (called ice 
 cream) at the end of dinner are the means of putting a mass of 
 very strong and concentrated food into the stomach of a man 
 who probably has already eaten more than he requires. 
 
 If a gouty man restricts himself to plain, simple food, and 
 rigidly avoids all extras, such as dessert, his own appetite is 
 probably his best guide in the selection of food. If he wishes 
 to indulge occasionally in fruit he should take it as a sub- 
 stitute for pudding, or eat it at breakfast in lieu of something 
 else. 
 
 Legitimate appetite and the craving for special articles of 
 food is an astonishing fact of probably the first importance, 
 notwithstanding that writers on dietetics are nearly silent on 
 the subject. It is always a dangerous thing to make very 
 sudden and arbitrary changes in the diet of those whose hal)its 
 are formed, and in doing so I think no wise physician should 
 neglect to attend to the clearly expressed likes and dislikes of 
 his patient. In this connection I may mention the case of a 
 singularly hale and hearty gentleman of eighty-seven years, 
 whose dark hair, perfect set of teeth, and boy's appetite were 
 the wonder of his friends and acquaintances. When this 
 gentleman was recovering from influenza and pneumonia his 
 doctor, finding something in his urine which reduced ' Fehling,' 
 promptly cut off all the sugar from his diet. But the ' old boy ' 
 was fond of his pudding, and when the pudding was placed 
 upon the table he always clamoured (and successfully) to be 
 served. Thereupon the family entered into a saintly con- 
 
LEGITIMATE APPETITE 219 
 
 spiracy in their father's interest to eat no pudding, in order 
 that eighty-seven might not be led into temptation. The 
 result of this was that the patient was detected in the pastry- 
 cook's shop wolfing up tarts like a schoolboy. This gentleman 
 is now in his ninety- second year, still has a craving for sweet 
 things, and is practically sound in body, very active, and clear 
 in intellect. Undoubtedly in this case the natural cravings 
 for sweets have done him no harm. 
 
 Another instance of irresistible appetite has come under 
 my notice in the case of a naval officer who had been many 
 months at sea in a ship in which the fresh meat and tinned 
 vegetables ran out. The men were put upon a daily allowance 
 of lime-juice, but my friend had neglected to take his daily 
 dose. This officer was the pink of good manners and a perfect 
 stranger to the vice of gluttony ; nevertheless, when the ship 
 stopped at an obscure port and he took a walk on shore his 
 eye caught sight, in the window of a general store, of a bottle 
 of ' piccalilli ' bearing the label of a well-known firm. The 
 sight of the bottle produced a cra^dng, and in a few minutes 
 he had bought the pickles and consumed a large part of them 
 by the aid of a button-hook. This is another instance of the 
 right guiding of the appetite. 
 
 Why is it that the whole human race when it has reached 
 a certain degree of civilisation has taken to fermented drinks 1 
 Why does the whole world use allyl in some form or another ? 
 What is it that has prompted us to cultivate plants which 
 contain an alkaloid which chemists call theine, caffeine, theo- 
 bromine, &c., according to its source of origin 1 Finally, what 
 is it that enables my dog to select the ' agropyrum caninum ' 
 with absolute certainty and without any previous instruction in 
 the matter ? If we cannot answer these questions, let us 
 remember to be sure of our grounds before we decide that our 
 patients are not to be allowed reasonable scope in the selection 
 of food. 
 
 In the selection of the gouty man's drink we have to take 
 care that he gets as little food as possible in the guise of beve- 
 rages. Thirst is the cry of the blood for water, and for the pur- 
 pose of slaking thirst water alone is necessary. Unfortunately, 
 
220 A CASE OF GOUT 
 
 water is not popular with those who have become accustomed 
 to the various alcoholic beverages which the human race has 
 used for a good many thousand years. The alcohol which the 
 gouty man takes with his meals may be of use to him by 
 delaying the digestive process in the stomach and putting a 
 slight check upon assimilation. That alcohol is a food there 
 can be no doubt, but, unlike most other foods, it seems incapable 
 of being stored in the body, so that any excess is rapidly 
 excreted by the lungs and kidneys. Uric acid is insoluble in 
 alcohol, and the man who takes an excess of alcohol with his 
 excess of food is more likely to suffer from deposits of uric acid 
 than he who takes excess of food only. 
 
 Port wine and strong beer are the types of drinks which 
 undoubtedly favour the occurrence of gout, because they are 
 not only rich in alcohol but in extractive matters or ' body ' 
 also. The rich alcoholic drinks are really foods in disguise, 
 for they contain, in addition to the alcoholic food which can- 
 not be stored in the body, a large amount of carbohydrate 
 which is stored in the body, as the brewer's drayman, fattest 
 and placidest of beings, bears witness. The gouty man's drink 
 must be the thinnest which he can be got to take, and it is 
 now very much the fashion to order a small quantity of dis- 
 tilled drink drowned in mineral waters as a substitute for 
 wine. The effervescing wines, in which there is a large amount 
 of natural and added syrups, are very bad for the gouty, and 
 when they have been made ' dry ' by the addition of consti- 
 pating astringents they are not much better. All syrups and 
 liqueurs must be avoided by the gouty, and it is probable that 
 syrups bring quicker trouble to the gouty man than the raw 
 sugar, which has to be dissolved (more or less slowly) in the 
 stomach. 
 
 All the so-called teetotal drinks which are made with 
 syrups are probably as bad from the point of view of gout as 
 beer. 
 
 The greatest mistake, however, which the adult can make 
 when he discards alcohol is to fly to milk. 
 
 When * he asked water, and she gave him milk,' we must 
 remember that she was contemplating murder, and we must 
 
MILK NOT A BEVEEAGE 221 
 
 not forget that milk is one of the strongest foods, if not the 
 strongest, which is within the reach of man. Milk has no 
 right to be regarded as a beverage, and the gouty adult who 
 abandons alcoholic drinks and takes to milk as a beverage 
 jumps, I believe, ' out of the frying pan into the fire.' I am 
 not arguing against the use of a milk diet, which is valuable 
 enough in some cases of disease, nor do I object to the use of 
 milk in cookery, but a word of warning needs to be given to 
 those adults who employ milk instead of water for slaking 
 thirst, or, in other words, use milk as a beverage, or, to repeat 
 the expression I have used earlier, take a strong and insidious 
 food without ajjpetite. 
 
 It has fallen to my lot to see several worthy persons in 
 whom this great dietetic error had produced undoubted symp- 
 toms of gout, including deposits of urate of soda. The man 
 whose blood is habitually overcharged gets nervous, gloomy, 
 and apprehensive, almost to the verge of melancholia, and I 
 have seen this condition produced not only in those who are 
 gluttonous and wine-bibulous, but also in those who for con- 
 science' sake have forsworn the pleasures of the table and who 
 have fallen into the error of using milk as a beverage. Milk 
 is a marvellous yboc? for children, and upon it they will grow 
 and develop in a way which is simply astounding. Those 
 whose growth and development are at an end cannot digest 
 and assimilate milk as the child can, and the adult who drinks 
 milk instead of water for the purpose of washing down a mixed 
 diet commits a very dangerous dietetic blunder. 
 
 You will have gathered that the great dietetic rule for the 
 gouty is to live on simple food, and to be ever on his guard 
 against all those forms of food which we habitually take with- 
 out appetite. It is doubtful if any rule of life for the gouty 
 can be better than Abernethy's, which was ' to live on six- 
 pence a day and earn it.' Plain food to satisfy appetite, with 
 plenty of exercise in the /resh air, at once checks assimilation 
 and spurs excretion, and these are the indications for treating 
 the gouty. 
 
 As regards the treatment of the gouty, next in importance 
 to the diet is to keep the bowels rather freely open. In this 
 
222 A CASE OF GOUT 
 
 way not only is the nutritive matter kept for a shorter time 
 in contact with the alimentary tract, but it is also probable 
 that the large intestine serves very considerably as a channel 
 for the elimination of waste products. In cases of poisoning 
 with antimony, arsenic, and mercury it is certain that much 
 of the poison is eliminated by the large intestine, and it is also 
 probable that in the cases of auto-intoxication which we have 
 been considering it serves a similar purpose. It is always 
 undesirable to check the occasional diarrhoea which is common 
 in gouty subjects, and equally undesirable to check occasional 
 haemorrhage from piles. For plethoric subjects the best pur- 
 gatives are saline aperients, or aperient mineral waters, which 
 they take well. For anaemic subjects it is better to give an 
 aloetic pill with the meals. 
 
 When patients go abroad to ' take the waters ' not only are 
 their habits of life completely altered, but the copious draughts 
 of warm saline waters have the eflfect of washing the waste 
 product out of the blood. When a patient has been through 
 a London season, rising late, eating and drinking a great deal 
 too much, and spending his time in overcrowded rooms, it is 
 no wonder that he improves when he rises at six, drinks a 
 pint or so of hot saline water before breakfast, lives sparely 
 and carefully, and spends his whole day in exercise in the 
 open air. Life at these baths is very pleasant, and the regime 
 which is necessary is fashionable. Of late the fashion of 
 drinking hot water at home has been advocated, but if a man 
 prolongs this treatment he is apt to become anaemic, flabby, 
 and washed out. The waters which are most in vogue for the 
 gouty are Carlsbad (purgative), Homburg and Kissingen 
 (saline), Contrexeville and Vichy (alkaline), Buxton, Bath, 
 Baden, and Gastein (warm and indifferent). 
 
 For the gouty paroxysm, in addition to a saline purgative, 
 colchicum may be given, a drug which has retained its popu- 
 larity with the gouty for many years, although how it acts 
 towards this end is by no means certain. 
 
 I am accustomed to prescribe something like the fol- 
 lowing : 
 
TREATMENT 223 
 
 ^: Sodii sulphatis, 
 
 Magnesii sulphatis, aa 5ss ; 
 Sodii carbonatis, 
 Sodii chloridi, aa gr. v ; 
 Potassii iodidi, gr. i ; 
 Vini colchici seminum, iiixv ; 
 Aq. ad 5 i. Fiat haustus. 
 Sig. — To be taken every four hours in a claret glass of hot water. 
 
 It is generally admitted that gout may be inherited ; and 
 there is no difficulty, on physiological grounds, in accepting 
 the fact that a man may resemble his parents internally as 
 well as externally. Just as deficiency, redundancy, or peculi- 
 arity of external features may run in families, so may similar 
 qualities of internal organs be inherited. We know that 
 certain families have good appetites and fine digestions, while 
 others, to use a phrase of the late Sir Andrew Clark, may 
 inherit ' renal inadequacy ' with a consequent tendency to 
 gouty manifestations. 
 
 On the other hand, it must not be forgotten that ' inherit- 
 ance ' may not be of a true physiological kind, but may depend 
 upon an education in luxury and indolence or the inheritance 
 of a large income and a well stored cellar. 
 
224 H^MATUKIA 
 
 CHAPTER XIII 
 
 A CASE OF HEMATURIA FOLLOWING INFLUENZA ^ 
 
 The chief symptom from which this patient has been suffering 
 is the presence of blood in the urine. 
 
 The urine was blood-coloured and highly albuminous, while 
 under the microscope we found a large number of blood 
 corpuscles. We were therefore enabled to pronounce the case 
 to be one of hmmaturia, and not hcemoglobinuria, in which the 
 colouring matter of the blood finds its way into the urine with- 
 out the corpuscles. 
 
 Having satisfied ourselves that the urine contains blood, 
 the next question to be answered in such a case is as to the 
 source of the blood. From what part of the urinary tract 
 does the blood come — kidney, ureter, bladder, or urethra ? 
 
 If the urethra be the source of blood only the first portion 
 of the urine passed contains blood ; if the bladder be the source 
 of the blood the last portions of the urine passed are most 
 liable to contain blood. This is a very good practical rule, and 
 one which you will find most useful if you are careful not to 
 become the slave of it. In medicine it might almost be said there 
 are no absolute rules for diagnosis, and anything like a ' rule of 
 thumb ' must ever be employed with a wary eye for exceptions. 
 
 In this case the blood was equally distributed throughout 
 the urine, and was in large quantity. These facts alone 
 seemed to indicate that in all probability the blood came from 
 the kidneys. 
 
 For the further eluci dation of the case we must leave the 
 one great objective fact of blood in the urine, and have recourse 
 to the history of the patient, and such subjective facts as he 
 may submit to us. 
 
 ' Clinical Lecture, U.C.H., 1893. 
 
H^MATUEIA FOLLOWING INFLUENZA 225 
 
 The patient is a well made, temperate young man of 20, 
 earning good wages as a jeweller, and in his family history 
 there is no evidence of any hereditary taint. His occupation 
 is sedentary (making filigree ornaments), but is carried on in 
 a well ventilated workshop. 
 
 On June 21, 1893, the patient was seized with influenza, 
 and it appears that the symptom so common in that disease of 
 pain in the back and loins was rather unduly pronounced. 
 There seems also to have been some tendency to vomit. He 
 improved up to July 2, when the pains and sickness recom- 
 menced with greater violence, and on the following day the 
 pain in the back and loins was sufficient, as the patient says, 
 to ' double him up.' 
 
 He was admitted to the hospital on July 6. The expres- 
 sion which the patient uses to describe his pains, that ' it 
 doubles him up,' gives us a clue to the fact that the pain is 
 paroxysmal, and he further tells us that he suffers no pain in 
 the intervals between the paroxysms. When asked to indi- 
 cate the spot which is chiefly aflfected by the pains he puts his 
 hand over the right loin and flank. Severe paroxysmal pain 
 referred to the abdominal region is most commonly caused by 
 intestinal, hepatic, or renal colic, and in the case we are dis- 
 cussing it certainly is due to the latter cause. 
 
 We have next to consider what is amiss with the right 
 kidney that it should become a source of haemorrhage, and 
 whether the blood comes from the right kidney only or from 
 both. That the blood is present in the urine in considerable 
 quantity, and that the amount has shown no tendency to 
 fluctuate, is rather in favour of its coming from both kidneys, 
 and the fact that the symptoms of renal colic are referred to 
 one side only must not be taken as conclusive evidence that 
 the lesion is unilateral. 
 
 When admitted the patient had a persistent, moderately 
 high temperature, which fluctuated from a little below to a 
 little above 100° F. Notwithstanding the slight pyrexia and 
 the hsematuria, it was not possible to regard the case as one of 
 acute Bright's disease or acute tubular nephritis, and for three 
 reasons — (1) that the amount of urine passed was not far 
 
 Q 
 
226 HEMATURIA 
 
 short of normal ; (2) that there is a complete absence of 
 oedema, so that the finger firmly pressed upon the sacrum fails 
 to make the slightest impression ; and (3) that on examination 
 of the urine with the microscope we fail to see any renal epi- 
 thelium, whether in the form of casts or otherwise. 
 
 The evidence of any local condition in the pelvis or body 
 of the kidney adequate for the production of such marked 
 hsematuria is not very great. There is no swelling in either 
 flank or loins, and palpation of the kidney has failed to detect 
 any enlargement or tumour, or, except on one occasion, tender- 
 ness. 
 
 Pyelitis, whether tubercular or calculous, is usually accom- 
 panied by more or less tenderness on palpation ; and if the 
 pelvis of the kidney contains a stone of any kind not only is 
 there more or less tenderness on palpation, but a persistent 
 pain, which is usually referred to the loins. 
 
 Again, an irritant in the pelvis of the kidney or in any part 
 of the urinary tract usually leads to frequency of micturition,^ 
 a symptom which, in the case we are discussing, was rather 
 remarkable for its absence. 
 
 We have no evidence that the symptoms of renal colic were 
 ever present before the appearance of blood in the urine, and 
 that being the case one is inclined to attribute them to the 
 passage of small clots from the pelvis of the kidney along the 
 ureter. 
 
 On microscopic examination of the urine we have once or 
 twice found crystals of uric acid ; and, although this may 
 warrant us in suspecting that there may be a so-called sabu- 
 lous deposit of uric acid in one or both kidneys, it is well to 
 bear in mind that we have no very strong evidence of such a 
 condition, and no evidence whatever of any calculus in any 
 part of the urinary tract. We have not been able to make 
 out that any stone has been passed into the bladder or from 
 the bladder. The symptoms of stone in the bladder have 
 been, and still are, absent. 
 
 If there be a sabulous or sandy deposit in the pelvis of one 
 kidney, say the right, and if there be some general cause (such 
 as influenza) which may determine an engorgement of, and 
 
H^MATUEIA FOLLOWING INFLUENZA 227 
 
 lisemorrhage from, the kidneys, then it is reasonable to suppose 
 that a kidney which is already in a pathological condition 
 would suffer more than its fellow, and it is conceivable that 
 blood finding its way into the pelvis of the kidney would be 
 more likely to coagulate if the pelvis had been previously 
 roughened by uric acid. These facts are brought forward in 
 <lefence, as it were, of the position previously taken up — that 
 the haemorrhage is probably from both kidneys, in spite of the 
 unilateral symptoms, and that the accident, so to say, of a 
 little uric acid in the pelvis of one kidney would be sufficient 
 to account for the unilateral symptom of renal colic. 
 
 It is more than probable that a fine young man like the 
 patient, whose natural destiny should have been some mus- 
 cular exercise in the fresh air, but who is fated to sit on 
 a bench making filigree in Clerkenwell, should develop what 
 may be spoken of as the uric acid diathesis. This so-called 
 diathesis is, broadly speaking, due to the imperfect metabolism 
 of the nitrogenous food and nitrogenous waste-products, and 
 it not only makes its appearance in those who over indulge in 
 the pleasures of eating and drinking, but also in those who 
 follow sedentary occupations, and who look pale, thin, and 
 under-fed. It may be that our patient will develop a renal 
 calculus in the future, but one must guard against attaching 
 too much importance to the appearance of a few crystals of 
 uric acid, which may be present from causes which are 
 transient and temporary. 
 
 We now come to what is, perhaps, the most interesting 
 part of the case, viz., the occurrence of the hsematuria during 
 an attack of influenza. 
 
 Of ail the acute infective diseases influenza is, perhaps, 
 the least definite in its character. In its simplest form it 
 consists of pyrexia, with the addition of malaise and certain 
 aches and pains, but it seems to have the power of producing 
 congestions and inflammation of any organ of the body. 
 When an epidemic wave of influenza has passed over London 
 the Registrar- General's returns have shown that the mortality 
 from all classes of disease has been increased, and this may be 
 taken as evidence of the power of influenza to find out the 
 
 q2 
 
228 HEMATURIA 
 
 weak spots of the individuals which it attacks. Pneumonia 
 and bronchitis are the most common complications of influenza, 
 but instances of digestive troubles, diarrhoea, vascular dilata- 
 tion, ear troubles, brain troubles, and spinal cord troubles 
 have come within the experience of most who have seen much 
 of the disease. 
 
 Kidney troubles seem to be among the least frequent of 
 the manifestations of influenza, but the case under considera- 
 tion is at least the third which has come within my own ex- 
 perience. 
 
 The first case was that of a young lady who was a member 
 of a household which was smitten by influenza in the first 
 quarter of 1892. The symptoms at first were not particularly 
 alarming, but hsematuria showed itself, and this was followed 
 by a suppression of urine, which led to a fatal result. This. 
 young lady had never suffered from pronounced kidney disease, 
 but on making inquiries to ascertain whether there had been 
 any manifestations of unsoundness of the urinary organs 
 previous to the fatal attack, we found that she had been in the 
 habit of rising once or twice during the night for purposes of 
 micturition. There was no post-mortem examination, but the 
 frequency of micturition and a rather pronounced family 
 tendency to tubercle gave support to the supposition that 
 there was a chronic kidney trouble sufficient to constitute a 
 vulnerability of that organ in the event of the invasion of the 
 body by an infective disorder. 
 
 The second case was that of a gentleman between 40 and 
 50 years of age, who, towards the close of an attack of influ- 
 enza, was alarmed by the onset of hsematuria, and who took 
 the somewhat imprudent course of travelling eighty miles by 
 train in order to get advice. The patient completely recovered 
 from his hematuria, but the impression left upon me was that 
 previous to the onset of the influenza the kidneys had been 
 overtaxed by the jovial habits of their owner, who I suspected 
 had been endowed by nature with a somewhat keen apprecia- 
 tion of the pleasures of the table. 
 
 The third patient, the one before us, has suffered from 
 hsematuria during an attack of influenza, and in him, as in the 
 
VOMITING 229 
 
 other two, we have reason to suspect a vulnerability of the 
 kidneys because of the crystals of uric acid which have been 
 •discovered in the urine. 
 
 These cases illustrate what is very common in medicine, 
 viz. the plurality of causes. When we ask, ' What is the 
 ■cause of our patient's hsematuria ? ' we seem compelled to 
 reply that the predisposition to hgematuria was due to the 
 uric acid diathesis, but that the actual occurrence of hsematuria 
 was determined by the attack of influenza. 
 
 A very troublesome symptom when the patient was ad- 
 mitted was vomiting, and concerning this symptom a few 
 words may profi^tably be said. Vomiting is a common occur- 
 rence during attacks of renal colic, and it is also an equally 
 •common symptom of ' uraemia.' An attack of renal colic may 
 be regarded, for all practical purposes, as a local disorder ; but 
 ' uraemia ' is a grave general condition — a blood state — depen- 
 dent upon the inability of the kidneys to perform their proper 
 function of excreting the waste products of the body. The 
 vomiting of renal colic is a purely reflex phenomenon due to 
 the irritation of the pelvis of the kidney and ureter, and may 
 be compared to the vomiting which follows the tickling of the 
 fauces. Ursemic vomiting, however, must be regarded as due 
 to an inability of the stomach to ' deal ' with materials put into 
 it, whether by digestion or absorption. The body being un- 
 able to excrete its waste material with freedom, it is evident 
 that the absorption of new material will but increase its 
 difficulties, and that the rejection by vomiting of material put 
 into the stomach is, under the circumstances, highly desirable 
 in the best interests of the patient. 
 
 Now, the vomiting of the patient whose condition we are 
 considering was not limited to the periods covered by the fits 
 of paroxysmal pain, but occurred independently of these ; and, 
 in fact, the patient rejected by vomiting nearly everything 
 which was given him. This very important fact aflfords evi- 
 dence that we are dealing with a general condition, and not 
 merely a local trouble in the pelvis of one kidney. It supports 
 the theory that both kidneys are engorged with blood, and 
 consequently hampered as to their physiological functions, and 
 
230 HiEMATURIA 
 
 that the occurrence of pain on one side only is, so to say, due 
 to an accidental circumstance. 
 
 This discussion as to whether the hsematuria is due to a 
 local or general condition, and whether the patient has both 
 kidneys dangerously engorged or is merely passing a calculus 
 from the pelvis of one kidney, is of great practical importance, 
 and must largely influence the treatment to be adopted and 
 our forecast of the result. If treatment is to be reasonable 
 and scientific we must have before the mind's eye a picture of 
 the pathological condition with which we have to cope. In the 
 case before us I think we must picture two engorged kidneys 
 seriously hampered in their action, and not merely a little 
 stone in the pelvis of an otherwise healthy kidney. 
 
 The patient was in a critical condition because of the 
 danger of uraemic poisoning. The loss of blood, although con- 
 siderable, was not sufficient to cause us any anxiety ; and 
 attacks of renal colic, although severe and hard for the patient 
 to bear, are so rarely accompanied by rupture of the ureter or 
 any similar accident that they can scarcely be said to have 
 increased the gravity of the prognosis. 
 
 Having discussed the case, and having arrived at the views 
 which seem most reasonable, we are in a position to consider 
 the treatment. The chief danger being that the engorgement 
 of the kidneys may increase, and that the patient may die of 
 uraemic poisoning, we must adopt such measures as may lessen 
 the engorgement, and be careful to do nothing which may 
 overtax the kidney. 
 
 Clearly the worst thing we could do would be to check the 
 haemorrhage. The loss of blood is not sufficient to endanger 
 life, the patient's pulse is fairly good, and his condition does 
 not indicate a dangerous degree of weakness. The engorged 
 kidneys are bleeding, and we ought to be thankful for it, for 
 there can be no surer road to disengorgement. 
 
 The worst thing to do would be to give astringents inter- 
 nally to check the haemorrhage ; and about the most dangerous 
 combination in such a case as the one before us would be the 
 very common one of Lead and Opium. Lead would increase 
 the tendency to the deposit of uric acid ; and the eliminating 
 
TREATMENT 231 
 
 power of the kidney is, in its present condition, so doubtful 
 that comparatively small doses of opium might produce un- 
 toward results. 
 
 In consequence of the very doubtful capacity for excretion 
 possessed by the kidneys in their present condition, I would 
 recommend no narcotic drug for the relief of the pain until 
 other less dangerous measures having a reputation as anodynes 
 have failed in their effect. 
 
 To help to disengorge the kidneys we may endeavour to 
 produce ' a determination of blood ' to some other part of the 
 body, and to this end nothing is more efficacious than counter- 
 irritation. In selecting our counter-irritant, however, some 
 caution is necessary. We must not employ any counter-irritant 
 which is likely to irritate the kidneys, and therefore the use of 
 cantharides or turpentine is not permissible. Again, while 
 we want a counter-irritant which will act quickly and with 
 vigour, we must be careful not to raise blisters, for a raw 
 surface, especially over the loins, is a thing to be avoided at all 
 times, but most particularly when the kidneys are inactive 
 and in cases, like the one under discussion, in which oedema 
 might make its appearance at any minute. The best counter- 
 irritant in such a case seemed to me to be ' dry cupping ' over 
 the loins followed by hot fomentations. This was employed, 
 and you saw how in a very few minutes we had succeeded in 
 making the whole of the lumbar region of the back look red 
 and swollen. We had ocular demonstration that our mode of 
 counter-irritation was effectual, and there can be no doubt that 
 ' dry cupping ' (the application of cupping glasses without the 
 withdrawal of blood) is a most valuable mode of treatment, and 
 one which, just now, is a little too much out of fashion. 
 
 When I was a student we had upon the staff of this hospital 
 ' a cupper,' whose duty it was to make the round of the wards 
 after the visits by the physicians and surgeons and apply 
 cupping glasses (with or without the subsequent application of 
 the lancet) to those patients for whom this method of treatment 
 had been prescribed. The rapidity and effectiveness of ' cup- 
 ping,' as practised by the late Mr. Betts, can hardly be con- 
 ceived by those who never saw that professor of the art operate 
 
232 H^MATUEIA 
 
 on the loins with three or four glasses and a spirit lamp, and 
 convert the concavity of the lumbar region into a big red 
 protuberance in scarcely more time than it takes me to tell 
 you of it. 
 
 The next point in the treatment is to make sure that the 
 bowels are kept freely, but not excessively, moved. The 
 bowels in cases where the free action of the kidneys is inter- 
 fered with become an important channel for the elimination 
 of waste. To this end our patient has had a daily dose of saline 
 aperient, which has produced the desired effect. 
 
 Finally, it is desirable to give the kidneys all the resi 
 possible. Food and exercise both tend to throw work upon 
 the kidney. The patient, therefore, must be kept absolutely 
 ill bed, so as to reduce the external and internal work of the 
 body to a minimum, and thus bring the need for food to a 
 minimum also. 
 
 The regulation of the diet is all-important. In this case 
 nature has taken the law into her own hands, for the patient 
 vomited almost everything which was given to him. The 
 patient vomited because his kidneys were engorged, and I 
 pointed out that so soon as the kidneys were disengorged the 
 vomiting would cease, but no sooner. The vomiting was not 
 sufficient to cause any alarm, and our patient's condition was 
 not such as to raise in us any serious apprehensions of a 
 dangerous degree of inanition. If a man be allowed water ad 
 lib. for the purpose of quenching his thirst he is able to stand 
 the deprivation of food for a long time ; and the public ex- 
 hibitions of ' fasting men,' of which we have had several of late 
 years, have taught us that the human body may be maintained 
 for several weeks without the administration of any visible 
 food other than water. Now, our patient's pulse was good, and, 
 even supposing that he should continue to reject his nourish- 
 ment for several days by constantly repeated vomiting, we had 
 to remember that the vomiting was a physiological conse- 
 quence of the inefficiency of the kidneys, and that until the 
 efficiency of the kidneys should l^e restored the proper 
 nourishment of the patient was impossible. No attempt was 
 made to give nutritive enemata or peptonised food, nor was 
 
DIET 233 
 
 any drug given with the intention of arresting the vomiting 
 by acting on the stomach. The patient was placed upon a 
 spoon diet from which the nitrogenous elements were removed 
 as far as practicable. Farinaceous food, grapes, stewed fruits, 
 bread and butter, weak tea and a little milk were allowed, 
 together with as much water as the patient felt a need for. 
 As for the times of giving food and the amount given, the 
 regulation was left to the patient's inclinations, for in such a 
 case as this the appetite is the best guide. 
 
 These measures — absolute rest, dry cupping, slight purga- 
 tion, and a restricted diet — proved adequate. The tempera- 
 ture fell to normal ; the urine showed less and less blood until, 
 finally, not a trace of albumen was found in it ; the pains in 
 the loins ceased ; the vomiting stopped ; the appetite returned, 
 and, finally, our patient left the hospital about a fortnight 
 after his admission, in a state of practical health, for the pur- 
 pose of recruiting his strength at one of our convalescent 
 homes before returning to his jeweller's bench in London. 
 
234 ALBUMINURIA 
 
 CHAPTER XIY 
 
 THE RELATION OF SLIGHT DEGREES OF ALBUMINURIA TO LIFE 
 
 ASSURANCE 
 
 When your secretary did me the honour to suggest that I 
 should open a discussion upon some subject of interest to the 
 members of this society, I at once selected one which seemed 
 to me to be of great importance and much in need of 
 discussion. It is a subject which is not only of interest to 
 medical officers, but is one, I fancy, upon which the minds of 
 managers and actuaries are apt to dwell ; and I think T 
 should not be wrong in stating that there are many managers 
 who are under the impression that there is a growing tendency 
 among medical officers to keep away business on the ground 
 of albuminuria — a ground which does not always seem to 
 them to be adequate. Although I feel greatly the honour of 
 being allowed to address you, I must crave your indulgence, 
 and ask you to discriminate between a paper which is volun- 
 tarily offered and one which is furnished, on rather short 
 notice, in response to a request. Your secretary's request 
 has been made at a period of the year when my time is very 
 much occupied in a variety of ways, and I have been quite 
 unable to find leisure to look up the literature of the subject 
 and to make myself acquainted with the opinions of all the 
 authorities who have written upon it. You must excuse my 
 shortcomings in this respect, and I must take comfort to 
 myself in the thought that in the discussion which is to 
 follow other members will make good my deficiencies. This 
 paper has been written, not with the idea that I shall teach 
 any of our members very much, but most certainly in the 
 expectation that I shall learn a great deal from others, and I 
 
 ' Communicated to the Life Assurance Medical Officers' Association, 
 1894. 
 
TESTS FOR ALBUMEN 235 
 
 hope I am not wrong in regarding our association as a co-opera- 
 tive society in which the experience of each is for the benefit 
 of all. 
 
 Let me first define what I mean by albuminuria. I wouict 
 define it as the formation of a precipitate in an acid urine 
 when it is boiled, and which remains persistent after the 
 addition of a few drops of additional acid. This is the 
 commonest test for albumen, one which has stood the test of 
 time, one with which we are all intimately acquainted, and 
 one concerning which we may fairly claim to have an 
 adequate knowledge of the clinical import. As far as our 
 Jsnowledge goes, the test I have mentioned is more free from 
 sources of fallacy than any other, and reacts with albumen 
 and albumen only. 
 
 Of late years several other tests for albumen have received 
 attention, and, although they are very delicate and very con- 
 venient, they precipitate peptones, albumoses, and alkaloidal 
 bodies in addition to albumen, and I would humbly submit that 
 our knowledge of the clinical import of these bodies in the 
 urine is, as yet, too imperfect to enable us to base upon their 
 presence a definite line of action in relation to the insura- 
 bility or otherwise of the lives of persons whose urine gives 
 evidence of their presence. If a medical examiner hastily 
 rejects or loads the life of a person whose urine becomes 
 cloudy on the addition of potassio-mercuric-iodide or picric 
 acid it may well happen that he may keep away ' good 
 business ' from the office. If a cloud appears when these 
 tests are used it should always be a rule to confirm the pre- 
 sence of albumen by the older and commoner test before 
 making any recommendation as to the acceptance or other- 
 wise of the life. It is necessary to say this because students 
 and young men fresh from the schools are often rather prone 
 to put their trust in the last new thing, and to discard the 
 older and better understood processes, and it may well be 
 that candidates have been reported as sufiering from albu- 
 minuria when, in fact, they have been sufiering from nothing 
 of the kind. 
 
 When we are confronted with slight albuminuria we have 
 
236 ALBUMINUKIA 
 
 to determine whether or no the life is insurable. The dis- 
 covery of slight and unsuspected albuminuria should, I think, 
 make us look carefully at the candidate a second time, to be 
 sure that we have not overlooked some of the usual concomi- 
 tants of such a condition. A trifling hypertrophy of the 
 heart, slight pallor, deficient body weight, slight increase in 
 the tension of the pulse, ever so slight a puffiness round the 
 ankles, a tongue slightly furred or slightly tremulous, a florid 
 complexion or any other evidence of intemperance ; or any 
 slight evidence of an old and perhaps forgotten syphilis at 
 once assume an importance when joined with slight albu- 
 minuria which otherwise they would not possess. 
 
 Then, again, we probably all know the candidate who 
 impresses us unfavourably without our being able to 
 say very definitely why. Examiners for life assurance 
 become like practised horse dealers. We cast an eye 
 over the candidate and we get an instant impression 
 from his physique and demeanour that he is likely to 
 turn out, on examination, to be either ' sound ' or 
 otherwise. It is never satisfactory to recommend the rejec- 
 tion of a life without being able to put upon paper such 
 reasons for the rejection as may seem adequate to the lay 
 members of the ' board.' We must have examined not a 
 few unsatisfactory and unwholesome-looking subjects that 
 impress us as ' bad lives,' and yet it has been impossible to 
 find adequate reasons for rejection. In a few of such cases 
 slight albuminuria has solved my doubts, and I have recom- 
 mended rejection on the grounds of slight albuminuria and 
 general appearance. Sometimes a candidate is unable to 
 furnish a sample of urine at the time of examination ; and if 
 the examination has otherwise proved in all respects satis- 
 factory we give him the benefit of the doubt and accept the 
 life without examining the urine. In the case of candidates 
 whose general appearance gives an adverse or doubtful im- 
 pression I always postpone my recommendation until the 
 urine has been examined. The discovery of slight albuminuria 
 is thus of great importance, because it necessarily tinges all 
 the facts of the case, including the family history, and gives 
 
• TEMPORARY AND PERMANENT ALBUMINURIA 237 
 
 an importance to trifles which otherwise we might feel inclined 
 to neglect. 
 
 If, on finding a trace of albumen in the urine, a second 
 examination of the candidate fails to reveal any other adverse 
 fact, what is to be done ? Clearly the case must be post- 
 poned for a second or a third examination of the urine, and I 
 think it is important that the second examination should not 
 be too soon after the first. An interval of at least a week, 
 or better still a fortnight, should be allowed in order to give 
 ample time for the subsidence of any temporary disturbance 
 which may have caused the albuminuria. This second or 
 third examination of urine tells us whether or no the albu- 
 minuria is temjyorary or permanent. 
 
 If the albuminuria is slight and temporary, and if the 
 candidate is otherwise sound, looks strong and hearty, with 
 no suspicion of intemperance and with no flaws in the family 
 history, I should feel inclined to recommend him as an 
 average risk, but, of course, I should rate him up for trifles- 
 which, under other circumstances, I might feel inclined to 
 neglect. 
 
 If the albuminuria is slight and permanent, what is 
 to be done ? This is a question which can hardly be 
 answered categorically. Some lives (perhaps the majority) 
 will undoubtedly have to be rejected, and I think we shall 
 all agree that, if accepted, an extra premium will have to be 
 charged. 
 
 "We have all of us certainly had experience of patients 
 who have lived for many years with albumen constantly in 
 the urine. I have in my mind the case of a lady, aged 
 seventy- six, whose urine has certainly been albuminous for 
 twenty years. Dr. Francis Hawkins has communicated to 
 the Clinical Society two remarkable cases in which life had 
 been prolonged to extreme age in spite of persistent albu- 
 minuria of very many years' duration, and doubtless the 
 members of this society will be able to tell of many more 
 such cases. On the other hand. Dr. Munn, of New York, 
 who is quoted by Dr. Hilton Fagge, has reported on sixty- 
 nine lives rejected in the space of four years by a ISTew York 
 
288 ALBUMINURIA 
 
 office on account of albuminuria. Within the four years he 
 tells us that four of the cases had died, and that the others 
 were evidently deteriorating. Such an observation as this, 
 apart from details, is not of much service, and I believe the 
 question of the rejection or loading of cases of slight per- 
 manent albuminuria is one which must be left to the individual 
 judgment of the examiner. The eligibility or otherwise of 
 a candidate for life assurance depends on a variety of circum- 
 stances, and, while on the one hand none of these can be 
 neglected, I think it would be unwise to allow any one fact 
 to outweigh all the others, and act, as it were, automatically as 
 an absolute bar. 
 
 We shall all of us probably agree that a candidate whose 
 urine repeatedly shows the presence of a distinct amount of 
 albumen is to be accepted, if at all, only with a considerable 
 amount of loading. 
 
 Since it has become the custom to examine the urine of 
 patients as a matter of routine we have come to a know- 
 ledge of the fact not only that albuminuria is much more 
 common than was previously suspected, but that albumen 
 may be temporarily present in the urine of those who afford 
 no reliable evidence of kidney disease as the result of various 
 causes, such as cold bathing, excessive exercise, injudicious 
 diet, sexual excess, &,c. Whether or no the increased fre- 
 quency with which albuminuria is reported is entirely due to 
 the routine searching for it is doubtful. That it is mainly 
 due to that cause there can be no doubt. If we could be sure 
 that it was entirely due to that cause our business colleagues 
 might say with some justice : ' We made good profits in the 
 days before the institution of such a routine. We are con- 
 tent with the profits we have made, and we object to have 
 business kept away by such routine.' The calculations of 
 actuaries are made, it must be remembered, on 'average lives,' 
 and if everybody who passed the door of the office came in 
 and effected an insurance no medical examination would be 
 necessary. 
 
 In these days of competition insurance offices form no excep- 
 tion to the rule, and it is quite natural and quite proper that 
 
DEATH KATE OF MALES 239 
 
 managers of offices should jealously watch any action on the 
 part of their medical officers and medical advisers which 
 may appear to them to have the effect of keeping away ' good 
 business.' A man who presents himself for insurance is a 
 * bird in the hand,' and if he be outwardly sound and 
 healthy-looking our business colleagues naturally feel dis- 
 appointed if such a life be rejected, and scarcely less disap- 
 pointed if it be ' postponed ' (with the risk that he may go to 
 a competing office) because the urine shows a cloud of albumen 
 when it is acidified and boiled. 
 
 Some offices are inviting bad lives by doing away with 
 their medical watch dogs, and are holding out the induce- 
 ment of ' no medical examination.' This is a very hazardous 
 policy, for it is idle to shut our eyes to the fact that minor 
 degrees of fraud are not uncommon among candidates for 
 insurance. False statements, doubtless, are not infrequently 
 made from ignorance or carelessness, but equally, undoubtedly, 
 they are often made intentionally. When a man insures 
 for the sake of making provision for his wife and children he 
 is tolerably sure to think twice before he makes any untrue 
 statement which may invalidate the policy ; but the man who 
 is insuring for the protection of a money-lender is less likely 
 to be so scrupulous, even if we set aside the fact that these 
 persons often belong to a class which, to put it mildly, is 
 little troubled by scruples. Those who are driven to their 
 wits' end to raise money do not hesitate to become mildly 
 fraudulent, and it is well to remember an old proverb to the 
 effect that ' it is difficult for an empty purse to stand upright.' 
 
 It must by no means be forgotten that the increasing 
 frequency of albuminuria among candidates for life assurance 
 may be due to causes of far more serious import than the 
 mere fact of the establishment of a routine among the 
 examiners of lives. We must not forget the fact that the 
 expectation of life in males after twenty years of age was, 
 according to Dr. Ogle, less in the decade 1871-80 than in the 
 period 1838-54, which was used for Dr. Farr's life table. 
 The great majority of those who insure their lives are males 
 over twenty, and the fact that the expectation of life in this 
 
240 
 
 ALBUMINUKIA 
 
 particular section of the public is tending to decrease is one 
 which insurance offices cannot afford to neglect. This fact is 
 brought out very forcibly in the annual reports of the 
 Registrar- General, who gives the death rates at twelve age 
 periods for five successive decades between 1841 and 1890. 
 It will answer my purpose and make the matter less com- 
 plicated if I give the results for the first and last decades 
 only. It will be seen that the decrease of the death rate in 
 males, which has been so remarkable during the last half- 
 century, is most marked in the first three decades, after 
 which there is a considerable increase up to the age of 
 seventy-five : 
 
 England. 
 Death Bates at Twelve Age Periods — Males. 
 
 — 
 
 0- 
 
 5- 
 
 10- 
 
 15- 
 
 20- 
 
 25- • 
 
 1841-50 . 
 1881-90 . 
 
 71-2 
 
 58-7 
 
 9-2 
 5-3 
 
 5-1 
 30 
 
 7-1 9-5 
 
 4-4 5-8 
 
 9-9 
 7-9 
 
 1841-50 . 
 1881-90 . 
 
 35- 
 
 45- 
 
 55- 
 
 31-8 
 340 
 
 65- 
 
 75- 
 
 85- 
 
 12-9 
 12-5 
 
 18-2 
 19-7 
 
 67-5 
 71-3 
 
 148-3 
 146-5 
 
 312-3 
 305-8 
 
 It is not unimportant to notice that this increase in the 
 death rate of males in the prime of life is far more marked in 
 urban than in rural places, for I suppose one may take it for 
 granted that the urban population furnishes more candidates 
 for insurance than the rural population. Let us take the age 
 period of forty-five to fifty-five, and see how the death rate 
 for this period varied in different localities for the year 1890 
 (the returns for which I happen to have by me). The death 
 rate of males between forty-five and fifty-five in the whole of 
 England was, in 1890, 19*2 ; in London, 22*8 ; in Lancashire, 
 27*1 ; in the West Riding of Yorkshire, 22*9 ; in Wiltshire, 
 14*1 ; in Dorsetshire, 12-0; in Huntingdon, 9-4. These are 
 facts which cannot be neglected, because they show an in- 
 creasing mortality among tlie class from which candidates for 
 life assurance are largely drawn. 
 
 Again, let me point out that the death rate from diseases 
 
PEECAUTIONS AGAINST PRAUD 241 
 
 of the urinary system is tending steadily to increase. The 
 annual death rates per 1,000,000 persons living from diseases 
 of the urinar}'- system for the six quinquennial periods inter- 
 vening between 1861 and 1890 were as follows : 246*2, 286*8, 
 326*4, 374*8, 422*2, 446*6. Since 1858 the death rate from' 
 urinary diseases has doubled. A part of this increase in the 
 Registrar- General's returns of the death rate from urinary 
 diseases may be accounted for by increased knowledge and 
 change in nomenclature, but I take it that it is not all due 
 to these causes, and we should be very wrong to neglect so 
 startling a fact. Clearly, then, ' albuminuria ' is a matter 
 which demands very careful consideration by examiners for 
 life assurance and also by managers and actuaries. 
 
 Seeing that we have always to be on our guard against 
 jmild forms of fraud, it is necessary to be quite sure that 
 the urine we examine is the urine of the candidate for 
 insurance. The urine must always be passed in the presence 
 of the medical officer, and I may as well state that I am prac- 
 tically certain that on two occasions an attempt has been 
 made to deceive me. One person, I believe, brought a small 
 quantity of urine in a test-tube which he surreptitiously tilted 
 into the urine vessel (he was a chemist), while another handed 
 me a sample of urine which was cold and thick, and which I 
 have no doubt he brought in a six-ounce bottle concealed in 
 his pocket. Both were rejected, and it was ascertained that 
 the latter had been previously rejected by another office for 
 albuminuria. 
 
 The urine of women is far more difficult to form an opinion 
 upon than the urine of men, because there is a periodic 
 cause which may give us slight albuminuria, not to mention 
 so frequent a trouble as leucorrhcea. Again, it is not possible 
 to remain in the room while a lady is furnishing a sample of 
 urine, and thus the fraud of urinary personation, if I may 
 call it so, is more easy for a woman than a man. 
 
 It is to be regretted that we have no means of getting the 
 after-histories of persons rejected for albuminuria. This seems 
 to me to be necessary before we can come to any very decided 
 opinion on the subject. I am, however, unable to suggest 
 any method by which such after-histories can be obtained. 
 
 R 
 
242 
 
 CHAPTER XV 
 
 A CASE OF CONGENITAL HEART DISEASE ^ 
 
 The patient whose case we have to consider is a child 
 (William F.) aged four years. He is suffering, and has 
 suffered from birth, from ' cyanosis ' ; and a glance is suffi- 
 cient to tell us that he has what used to be called ' the 
 blue disease.' He was admitted the day before Christmas 
 (December 24, 1895), and this is the third time within a year 
 that he has been in this hospital. In the early spring he was 
 admitted to the children's ward, and while there he developed 
 measles and was discharged. After his measles he suffered 
 from whoo2nng cough, and recovered from it without difficulty. 
 On May 20 he was admitted a second time into the hospital 
 under my care. At this time he was dangerously ill with 
 high fever, the temperature 104° F., the pulse 160 and over, 
 and the respirations 52. This febrile attack lasted some 
 three weeks and gradually subsided. There was a cloud of 
 albumen in the urine during its height, there was some en- 
 largement of the spleen, no throat trouble, some slight 
 bronchial catarrh, no pneumonia, no diarrhoea, no character- 
 istic eruptions. It seemed to run a definite course, and the 
 child made a good and complete recovery. That it was an 
 acute fever due to an infective process one could not doubt, 
 but as the materials for a more exact diagnosis are wanting 
 we will call it ' simple continued fever.' The patient made a 
 o-ood recovery and was sent to a convalescent home. He has 
 been in fairly good health from the time of his discharge, in 
 June, until his third admission here on December 24, when he 
 was suffering from urgent dyspnoea, and within a few days of 
 
 ' Clinical Lecture, U.C.H., 1896. 
 
PHYSICAL SIGNS 243 
 
 his admission developed typical chicken pox, from which he 
 has completely recovered. 
 
 I have dwelt upon these facts because it is of interest to 
 note that this child of four, with serious congenital heart 
 disease, has passed through four severe ' acute specifics ' in a 
 twelvemonth, and has recovered from them quite as readily as 
 a normal child. The parents and all the brothers and sisters 
 of the patient are reported as alive and healthy. 
 
 The patient's trouble is ' breathlessness.' While lying in 
 bed or sitting quietly in a chair the child is quite comfortable, 
 and laughs and plays with his toys in a state of evident enjoy- 
 ment. Any attempt at exertion brings on extreme shortness 
 of breath, accompanied by marked lividity of the skin. 
 These attacks of breathlessness are at times alarming, and 
 more than once have caused us to think that death was 
 imminent. 
 
 The child is fairly well developed and nourished. It has a 
 slight 'pigeon breast,' but beyond this there is nothing which 
 calls for remark excepting that the fingers and toes are exces- 
 sively cluhhed, and the long diameter of the nails is far more 
 convex than usual. 
 
 This clubbing of the fingers and toes and the lividity of 
 the lips, ears, fingers, and toes, combined with the statement 
 that the child has always been blue from birth, and has always 
 been liable to attacks of dyspnoea, make us certain that we 
 have to do with a condition of congenital heart disease. 
 
 When we proceed to make a methodical examination of 
 the organs of circulation we notice on ins2oection that the 
 beat of the heart is nowhere visible, and that, in spite of the 
 cyanosis, there is no distension of any venous trunk either in 
 the neck or elsewhere. 
 
 On 2^cd2Kition we find the apex-beat of the heart is faintly 
 perceptible in the fourth, fifth, or sixth interspaces between 
 its normal situation and the nipple line. No thrill is any- 
 where to be felt, and no trace of oedema is anywhere to be 
 detected throughout the body. 
 
 Oi^ perc^('SS^07^ we find that the cardiac dulness extends 
 from the left edge of the sternum to a parallel line slightly 
 
 B 2 
 
244 CONGENITAL HEAET DISEASE 
 
 outside the left nipple, while its upper level is at the upper 
 edge of the fourth rib. So far, therefore, the physical signs 
 are those of slight enlargement of the left side of the heart. 
 
 On auscultation we hear all over the cardiac area a loud, 
 blowing, systolic murmur, which reaches a maximum of loud- 
 ness and harshness at the junction of the second left costal 
 cartilage with the sternum. Under ordinary circumstances 
 we might feel absolutely certain that the lesion in the case 
 before us consisted in stenosis of the pulmonary artery. It is, 
 indeed, the only diagnosis which we are warranted in making, 
 and, judged by the statistical records of lesions observed in 
 similar cases, it is probably the correct diagnosis. But when 
 one is dealing with a condition which is certainly congenital 
 it must always be borne in mind that the malformations of 
 the heart brought about by faults of development are so varied 
 and so bizarre that even with the organ before one it is often 
 difficult to say which cavities and blood-vessels merit the names 
 which are used in relation to the norma] heart and vessels. 
 
 When we find, as in the present instance, that the physical 
 signs point to a lesion of the right side of the heart, this may 
 be taken as affording in itself strong presumptive evidence that 
 the lesion was formed while the patient was still in utero. 
 
 These lesions may be caused by defects of development or Ijy 
 definite endocarditis occurring in utero. Endocarditis occurring 
 after birth almost invariably attacks the left side, but when it 
 occurs before birth it almost invariably attacks the right side. 
 This is a fact which has to be accepted, but the explanations 
 hitherto offered have not been altogether satisfactory. Before 
 we can pursue this subject further it will be well to glance at 
 a few facts connected with the ftietal circulation, which the 
 accompanying figures may help us to comprehend more readily. 
 
 In the foetus you will remember : 
 
 1. That the blood of the superior vena cava — true venous 
 blood from the head and upper limbs of the foetus — passes (as 
 in the adult) through the right auricle to the right ventricle 
 and the pulmonary artery. The lungs not being in action, 
 very little, if any, enters the branches of the pulmonary 
 artery, but the whole, or nearly the whole, is conducted to 
 
FCETAL CONDITIONS 245 
 
 the descending aorta through the ductus arteriosus or ductus 
 Botalli. 
 
 2, The blood of the inferior vena cava — placental blood, 
 some of which has passed through the liver of the fcetus — enters 
 the right auricle, and is conducted by the Eustachian valve 
 directly through the foramen ovale into the left auricle, and 
 thence, as in the adult, to the left ventricle and aorta. 
 
 You will see, therefore, that the right ventricle of the 
 heart, as in adult life, is filled with venous blood, while the 
 placental blood, which may be regarded as quasi- arterial, 
 passes direct through the foramen ovale to the left side of tne 
 heart, as in the adult. 
 
 Further, it is evident that the work of the two foetal ven- 
 tricles cannot be far from equal, a proposition which is sup- 
 ported by the fact that the thickness of the ventricular walls at 
 birth is equal, or nearly so. The liability of the right cavities 
 of the foetal heart to suffer from endocarditis is not to be 
 accounted for by the character of the blood supplied to them, 
 nor by the fact that, being more worked than the left cavities, 
 they are more liable to disease. Unless the pressure exerted 
 by the two halves of the ventricular portion of the heart were 
 equal, or nearly so, it is difficult to believe that the dividing- 
 septum, which grows gradually between the right and left 
 ventricles, could undergo its regular development. 
 
 So far, then, the physical signs in our patient point to 
 ' pulmonary obstruction,' which is the lesion most frequently 
 found in those patients with congenital heart disease who 
 have succeeded in living for any considerable time. 
 
 One would expect that an obstruction of the pulmonary 
 artery would lead to great hypertrophy and dilatation of the 
 right ventricle, Avith damn>ing back of the venous blood, 
 general oedema, and obvious distention of the systemic veins 
 throughout the body. But in the patient before us there is 
 no venous engorgement or oedema, and no evidence whatever 
 that the right ventricle is enlarged. There is, however, some 
 evidence of enlargement of the left side, but we must remember 
 that we may be quite wrong, because anomalous conditions are 
 not to be judged by ordinary rules. 
 
246 CONGENITAL HEART DISEASE 
 
 You will bear in mind that in the foetus the blood coming 
 to the right auricle has two courses open to it, (1) through the 
 tricuspid orifice to the ventricle and pulmonary artery, and 
 (2) through the foramen ovale to the left auricle, and, there 
 being two channels of escape from the right side of the heart, 
 we shall find that the redundancy of one compensates for 
 deficiencies of the other. If our assumption in the case before 
 us be correct — that there is a pulmonary stenosis — it is evi- 
 dent, from the absence of all signs of venous engorgement, that 
 the blood finds another channel of escape, and the probability 
 is that the foramen ovale is widely open. If we could be sure 
 that the endocarditis, which presumably has partially closed 
 this child's pulmonary artery, occurred in the later weeks of 
 intra-uterine life, after the completion of the septum ventri- 
 culorum, we might feel perfectly sure that the foramen ovale 
 is patent ; but as we cannot be sure that the foramen ovale is 
 patent, and as the endocarditis may have occurred at an earlier 
 period, before the closing of the septum ventriculorum, we 
 must admit as an alternative that this septum may be deficient. 
 A third and by no means improbable suggestion is that the 
 blood from the right side of the heart passes partly through 
 the foramen ovale, partly through the defective septum ventri- 
 culorum, and partly through the stenosed pulmonary artery. 
 A reference to the diagrams will show clearly how a stoppage 
 of the normal channels in foetal life leads inevitably to the 
 permanency of the foetal channels. 
 
 Fig. 4 is intended to bring before you the normal circula- 
 tion of the foetus shortly before birth, with the patent foramen 
 ovale, the ductus arteriosus, and as yet undeveloped branches 
 for the lungs. 
 
 Fig. 5 shows the circulation shortly after birth, with 
 developed branches for the lungs, closed ductus, and closed 
 foramen. 
 
 Fig. 6 shows the effect of complete occlusion of the 
 pulmonary artery, entailing a patent foramen (or septum ven- 
 triculorum, or both). In this case the branches for the lungs 
 are supplied through the aorta, and the ductus remains patent. 
 A very few cases have been recorded in which a fatal endo- 
 
NOEMAL AND ABNOEMAL STATES 
 
 247 
 
 carditis has blocked the tricuspid orifice, a lesion which entails 
 patency of the foramen and ductus. 
 
 Fig. 4. Fm. 5. 
 
 Diagram of tlie uormal fcetal circulation 
 through the heart just before birth. 
 
 Fig. 6. 
 
 Xormal condition after birth. The fora- 
 men ovale and the ductus arteriosus are 
 both closed. 
 
 Fig. 7. 
 
 Abnormal obstruction of the pulmonary 
 artery. 
 
 Abnormal blocking of the arch of the 
 aorta. 
 
 Fig. 7 shows the effect of obstruction on the left side of 
 the foetal heart. We have supposed a complete blockage of 
 
248 CONGENITAL HEAKT DISEASE 
 
 the aorta. In this case the blood, being unable to escape 
 from the left side, travels through the patent foramen (or 
 septum, or both) to the right side, and the aorta is supplied 
 through the patent ductus arteriosus. 
 
 In these diagrammatic schemes, in order to bring the 
 issues clearly before you, I have assumed the complete blockage 
 of this or that channel, but this I have done for the purposes 
 of demonstration only, and I will ask you to remember that 
 such blockages are generally partial only, and not complete. 
 
 In order that the development of the septa of the heart 
 may make normal progress it is evident that the pressure on 
 each side of the line of the septa must remain nearly equal 
 or absolutely equal on the two sides of it. If any hindrance 
 be offered to the escape of blood from either side of the heart 
 the pressure increases on that side, and the ventricular septum 
 cannot develop or the auricular septum remains patent. 
 
 The absence or deficiency of the ventricular septum is 
 shown in none of these diagrams, although it is a very common 
 defect The septum may be entirely wanting, so that there 
 is practically only one ventricle, or there may be only a small 
 opening in it, which is practically of no importance. A not 
 uncommon defect is the transposition of the aorta and the 
 pulmonary artery, the former rising from the right ventricle 
 and vice versa. Several hearts have been described in w^hich 
 the ventricle has been divided into three imperfect cavities by 
 two imperfect septa. Such hearts have been described by 
 Theremin, Peacock, Stephen Mackenzie, and others. 
 
 It is not uncommon to find an opening in the auricular 
 septum from imperfect closure of the foramen ovale, even in 
 old subjects who have never afforded any evidence of circula- 
 tory derangement. In such cases there is no admixture of 
 the blood in the heart, and it is conceivable to anyone who 
 has watched the Rhone and the Arve flowing side by side in 
 the same channel at their confluence without noticeable 
 admixture that there may be very little admixture of blood 
 even with considerable ventricular deficiency, provided the 
 muscular strength of the cavities on either side of the defect 
 is tolerably equal, and the normal outlets from each ventricle 
 
CAUSE OF CYANOSIS 249 
 
 are open. Thus it has happened that considerable defects 
 have been found post-mortem where there has been no 
 ajDpreciable cyanosis during life. 
 
 As to the cause of the cyanosis, T think there can be no 
 doubt that it is due to imperfect aeration of the blood, as 
 asserted by Lees. 
 
 In the normal adult heart no blood is driven into the 
 systemic arteries that has not been thoroughly aerated. 
 
 If the pulmonary artei"y or the aorta be completely 
 blocked, then the aeration of the blood which is driven into 
 the systemic vessels cannot be more than half the normal 
 amount. When the aeration of the blood is hindered, as in 
 cases of dilated right heart with emphysema and bronchitis, 
 we get cyanosis, but the cyanosis is in these cases largely due 
 to an increase of the blood-pressure in the veins, leading to 
 their over-distention, and it is probable that this over-disten- 
 tion is the chief cause of the evident blueness of the com- 
 plexion. I would, in passing, remind you that cyanosis may 
 be caused by the administration of certain bodies which are 
 now much used as medicines, such as aniline, antipyrin, 
 exalgine, and antifebrin. The cause of the cyanosis produced 
 by some of these antipyretic coal-tar products is uncertain. 
 There may be some paralysis of the haemoglobin analogous to 
 what takes place in poisoning with carbon monoxide, but there 
 is usually no marked dyspnoea. 
 
 In cyanosis from congenital heart disease there is always 
 more or less dyspnoea, and, although this symptom may not be 
 noticeable when the patient is at rest, it generally becomes 
 urgent when any extra exertion is made. Dyspnoea may, of 
 course, occur without venous obstruction, as we see every day 
 in cases of ordinary anaemia. Sufferers from this congenital 
 trouble are obliged to lead very tranquil, sedentary lives. 
 
 It is to be noticed that in the case which forms the basis 
 of our lecture to-day the temperature, when not febrile, has 
 been normal. Body temperature, we must remember, depends 
 on many factors, of which oxidation is only one, and even 
 though this factor of oxidation may be below the normal, this 
 may be compensated by diminished loss of heat. Cases of 
 
250 CONGENITAL HEAET DISEASE 
 
 congenital cyanosis have been recorded in which the body 
 temperature was habitually below the normal. 
 
 The temperature of our patient, apart from the definite 
 attacks of acute specifics which have been mentioned, is 
 suspiciously unsteady, and repeatedly has run up to 100° F. 
 and over. One cannot but fear that tuberculosis may be the 
 cause of this, although we may have been unable to find any 
 more definite evidence of this condition. Tuberculosis has 
 frequently been recorded in conjunction with congenital 
 cyanosis, and there is no justification for the statement which 
 has been made that these conditions of the heart are 
 antagonistic to tuberculosis. This child has another symptom 
 which is very commonly but not universally present in con- 
 genital heart trouble — viz., well marked clubbing of the fingers 
 and toes. The second toe on each foot is shaped like a clove, 
 the end of the toe being irregularly globular. The finger nails 
 (and to a less extent the toe nails) are very convex in their 
 long diameter. 
 
 This clubbing of the fingers and toes is often said to be 
 due to venous congestion, which thus makes itself evident at 
 the extremities, but we must remember that it is not observed 
 in persons who have swollen legs, the result of tortuous 
 varicose veins, nor is it seen in cases of bronchitis and emphy- 
 sema with dilated right heart and obvious general venous 
 engorgement. 
 
 In phthisis we get the curving of the finger nails, but it is 
 not common to see clubbing in cases of even advanced 
 phthisis. It is very often seen, however, is cases of empyema, 
 but is not one of the recorded symptoms of ordinary serous 
 pleurisy. In empyema it may appear very rapidly after sup- 
 puration has commenced, and it is said to disappear when the 
 thoracic abscess has been drained and cured. The clubbing 
 seen in empyema does not appear to have any very definite 
 relation to the amount of dyspnoea caused by the embarrass- 
 ment of the lung. 
 
 I am very much in doubt whether the clubbing is due 
 (entirely, at least) to venous engorgement. In this child there 
 
TEEATIVIENT 251 
 
 is no evidence of venous engorgement, but the clubbing is 
 very marked. 
 
 It is right, however, to mention that Dr. J. W. Ogle 
 recorded ('Pathological Society's Transactions,' vol. x. p. 103) 
 a case of clubbing of fingers, with cyanosis of the tips and great 
 hypertrophy of the nails, on the right side only, due to the 
 pressure of a large subclavian aneurism on the axillary vein, 
 thereby causing an ' exalted nutrition ' of the finger tips. 
 
 Mr. Canton also ('Pathological Society's Transactions,' 
 vol. xvii. p. 428) recorded the case of a negro who had clubbing 
 of the fingers of the right hand only, which is also attributed 
 to the pressure of a subclavian aneurism on the axillary vein. 
 
 Dr. Lees, who recorded a case of transposition of aorta 
 and pulmonary artery, with a deficient septum ventriculorum, 
 which had marked cyanosis of the head and upper limbs 
 without a trace of clubbing, expresses his opinion that clubbing 
 is due to venous congestion, and its absence in the case which 
 he records (' Pathological Society's Transactions,' vol. xxxi. p. 
 62) is attributed to the fact that no obstruction to the return of 
 blood from the systemic veins was present. Dr. Lees's patient 
 was only seven months old at death, and it was not until the 
 fifth month of life that a systolic murmur at the left base was 
 developed. 
 
 I am of opinion that venous obstruction cannot be regarded 
 as the sole factor in the production of clublDed digits. The 
 true explanation remains to be found. 
 
 As regards the treatment of congenital heart disease, not 
 much need be said. The condition is essentially incurable, 
 but many of the patients manage to live on for considerable 
 periods. One case at least died at over sixty years of age, and 
 a case recorded by Dr. Stephen Mackenzie died at the age of 
 thirty-nine, after leading a fairly active and useful life. 
 
 It need hardly be said that febrile diseases are usually 
 dangerous to such patients, and that any pulmonary disorder 
 which interferes with the physiological action of the lungs 
 greatly increases the discomfort and liability to attacks of 
 dyspncea. During his recent attack of chicken pox our little 
 
252 CONGENITAL HEART DISEASE 
 
 patient was intensely cyanotic and breathless, and appeared 
 to be much relieved by inhalations of oxygen. 
 
 The arrangement for a tranquil life, the avoidance of all 
 excitement and exertion, and the protection as far as possible 
 from intermittent maladies are the lines of treatment to be 
 ordered, but beyond this one can say very little. 
 
253 
 
 CHAPTER XVI 
 
 THE MANAGEMENT OP CHRONIC HEART DISEASE ^ 
 
 In dealing with sufferers from chronic heart disease we 
 must not allow the fact that the lesions of the valves due to 
 endocarditis are certainly permanent, to take too strong a 
 hold of our minds. Whether the valvular lesions be permanent 
 or otherwise, there is nothing more certain than the fluctua- 
 tions which take place in the condition of sufferers from 
 chronic heart disease. There are many such who may be 
 spoken of as among the permanent clients of this and of every 
 hospital. They are admitted in^ state of great suffering and 
 danger, during their stay in hospital they improve, and recover 
 sufficiently to go out and pursue their occupations for a time ; 
 but after a few months we are tolerably sure to see them back 
 again, and so these sufferers spend their lives in a painful 
 endeavour to fight the battle of life with damaged organs. 
 
 Let us take the common case of a sufferer from mitral 
 disease with thickening and deformity of the valves permit- 
 ting regurgitation through the mitral orifice with each systole 
 of the ventricle. With this condition of the mitral there is 
 often some thickening of the aortic valves as well, which 
 offers obstruction, perhaps slight, to the outflow of the blood 
 into the aorta. 
 
 The suffering of the patients in this condition necessarily 
 depends upon the amount of valvular disease and the amount 
 of work which they have to do. There are many patients of 
 this class engaged in quiet pursuits who go on for years, and 
 manage to do a large amount of useful work. As long as they 
 are not hurried, and are able to 'take their time,' they do very 
 well ; but a little over-exertion or any failure of general 
 ' Clinical Lecture, U.C.H., 1893. 
 
254 CHKONIC HEAET DISEASE 
 
 health is a severe trial to them, and often brings their life 
 into jeopardy. 
 
 In these cases there is always an accentuation of the 
 second sound over the pulmonary cartilage, indicating increased 
 tension in the pulmonary artery. This is the key to the 
 danger, as indicating that the encumbered left ventricle is 
 throwing extra strain upon the lungs and pulmonary 
 artery. The failure of the left ventricle to completely propel 
 its contents in the proper direction necessarily leads to an 
 engorgement of the lung and increased pressure on the right 
 side of the heart and the venous system generally. 
 
 We must never fail to regard the heart and lungs as one 
 organ, and to remember that the lungs are in reality placed 
 between the two halves of the heart. We must bear in mind 
 that grave damage to the circulatory part of this compound 
 organ must affect the pulmonary part, and vice versa. 
 
 I want especially to say a few words on the hygienic 
 management of patients with chronic heart disease, and for 
 this purpose I will select, out of several cases which have 
 lately been in my wards, one which, in particular, has given 
 us proof of the good results of such management. 
 
 W. G., aged 41, bricklayer, admitted June 1, 1892. Had 
 scarlet fever fourteen years ago. Works hard, and is a good 
 deal exposed to weather ; drinks moderately, and has had 
 syphilis. Al)out four years ago he first noticed that his legs 
 swelled, and that he was very short of breath on exertion. 
 At this time he was an out-patient of the Middlesex Hospital. 
 Two years ago he was a patient at the Royal Free Hospital 
 for the same condition, so that when here he was paying his 
 third visit to a hospital in four years for shortness of breath 
 and swelled legs. 
 
 The patient, on admission, complained of swelling of the 
 legs and abdomen, shortness of breath, and a difficulty of 
 passing water, the urine only amounting to half a pint in the 
 twenty-four hours. This condition of things began a month 
 previously, and had got steadily worse. 
 
 The physical examination of the patient revealed the 
 following facts : marked oedema of the legs, scrotum, and 
 
DILATATION OF HEART 255 
 
 trunk, with slight indications of fluid in the peritoneal cavity. 
 The lungs were big, slightly emphysematous, and overlapped 
 the heart, so that the size of the heart could not with 
 certainty be made out. There was a loud mitral murmur. 
 The heart sounds were somewhat feeble. The pulse rather 
 hard. The urine was scanty (less than a pint in 24 hours), 
 high coloured, sp. gr. 1,022, and contained a considerable trace 
 of albumen, but no casts. The tongue was flabby and slio-htly 
 furred. 
 
 Here, then, we have an ordinary typical case of chronic 
 heart disease, with slight emphysema of the lungs, and 
 probably, very slight chronic kidney trouble as well. This is 
 the third attack, and what we have to ask is. Why do these 
 attacks recur ? Why, if they be due to heart disease, do they 
 get practically well 1 When one gets a complete circle of 
 symptoms, as in this case, it is often difficult to say what part 
 of the circle is most important, but I should look to the vary- 
 ing conditions of the left ventricle as most likely to afford an 
 explanation of the trouble. We have, probably, some slight 
 thickening of the mitral valve, caused by endocarditis, occur- 
 ring as a complication of scarlet fever fourteen years ago. 
 This condition does not seem sufficient to cause him any 
 annoyance under ordinary circumstances. If, however from 
 any cause, the left ventricle dilates, then the mitral incom- 
 petency becomes serious, the tension in the pulmonary artery 
 rises, the right side of the heart dilates, and the venous system 
 throughout the body becomes engorged. 
 
 The left ventricle will dilate (1) from weakening of the 
 cardiac muscle, so that it becomes incapable of withstandino- 
 its normal amount of internal pressure. This might arise 
 from anaemia, the result of insufficient food or debauchery 
 from fatty degeneration, or from the weakening effect of high 
 body temperature, the result of a febrile attack such, for 
 example, as influenza. 
 
 (2) The ventricle may dilate in consequence of over- 
 exertion and excessive effort in the course of his ordinary 
 occupation, or as the result of some accidental occurrence 
 necessitating effort. 
 
256 CHRONIC HEART DISEASE 
 
 (3) The ventricle may dilate in consequence of obstruction 
 to the outflow of blood, either by a narrowing of the aorta or 
 by a rise in the tension of the systemic arterial system 
 generally, an occurrence which is very liable to take place 
 in those who have a gouty condition of the kidneys. 
 
 As our main object in the treatment of such cases is to 
 get the dilated ventricle to resume its normal dimensions, it 
 becomes very necessary to bear in mind the possible causes 
 which may determine its dilatation. 
 
 When we look at a patient such as the one with which 
 we are dealing we have to remember that the outward 
 condition is the evidence of the inward condition. The 
 encumbered circulation gives us the cedema of the lower 
 limbs and trunk. This oedema, although most marked in the 
 dependent parts, is due to a central cause, and as a con- 
 sequence every organ in the body is more or less congested — 
 lungs, stomach, and intestines, liver, kidneys, and brain. As 
 a result of this every organ performs its duty imperfectly. 
 There are difficulties of primary digestion, metabolism, de- 
 f^ecation, urination, and at night when the head is somewhat 
 lowered in position the patient wanders instead of enjoying 
 sound sleep. Evidence of this inefficient action on the part 
 of the kidneys is afforded by the urine, which is scanty and 
 slightly albuminous. In the state of the kidneys we have 
 evidence of the vicious circle in which a patient may move. 
 The condition of the heart causes an engorgement of the 
 kidney, the engorgement of the kidney and the faulty purging 
 of the blood of the products of nitrogenous metabolism 
 increases arterial tension, and this in its turn increases the 
 tendency of the left ventricle to dilate. Do not let us forget 
 that, in the general venous engorgement, the heart does not 
 escape, and that, its nutrition being interfered with, the 
 tendency to dilate increases equally with the active causes of 
 dilatation. 
 
 There is room for doubt in this case as to whether the 
 condition of the urine is or is not entirely secondary to the 
 heart disease. The main reason for leading me to believe that 
 there is a chronic kidney change independent of the heart 
 
EEST 257 
 
 trouble is the fact that the dropsy is rather out of propor- 
 tion, if one may say so, to the other symptoms ; and this 
 belief that the kidneys are the seat of independent trouble is 
 rather strengthened by the history of scarlet fever as a very 
 probable cause of chronic kidney mischief, and by the fact 
 that when the patient left the hospital there was still a slight 
 trace of albumen in the urine. If, however, there be a 
 chronic induration of the kidney apart from the heart trouble 
 it must be very slight. 
 
 In the treatment of such a case and in the endeavour to 
 bring about a diminution in the size of the left ventricle, 
 clearly the first indication is rest as absolute as possible. The 
 circumstances of the patient must be such that the heart has 
 only the internal work of the body to grapple with, and to 
 this end he must be put to bed and ordered to remain there. I 
 think it is most important that the patient should remain in 
 bed during the whole 24 hours, for if he be allowed to get up 
 and make any effort which materially quickens the action of 
 the heart he may undo in ten minutes the good which may 
 have been gained during the previous hours of rest. Nothing 
 is so damaging to a weakened heart as any muscular act 
 accompanied by 'effort,' i.e. an act which necessitates the fixa- 
 tion of the thorax and the suspension of the respiratory act. 
 When we see a man strain (whether it be at a massive act, 
 such as lifting a sack of flour, or a trivial act such as cracking 
 a walnut with the fingers), and watch the face get purple and 
 the veins stand up upon the forehead, we cannot fail to be im- 
 pressed with the strain which is put upon the organs of cir- 
 culation by the act. No person with chronic heart disease, 
 especially if he be under medical treatment, is likely to attempt 
 any massive acts involving strain, but I must remind you 
 that among minor acts which often necessitate effort is the act 
 of defsecation, and it becomes very important to protect the 
 patient from the evils of straining at stool and to keep the 
 bowels moderately relaxed by the aid of gentle purgatives. 
 
 If the heart is to have the greatest amount of rest attain- 
 able the patient must be kept comfortably warm and be fed 
 upon a sufficiency of food, while every precaution is taken 
 
 s 
 
"158 CHEONIC HEAKT DISEASE 
 
 against giving any excess. If the temperature of the body be 
 not artificially maintained in cold weather more food must be 
 taken, and the more food that is taken the more work the 
 heart has to do. The digestive and assimilative powers are 
 both lowered, and it becomes necessary to give food in the 
 most digestible form. The patient must be put upon a strict 
 spoon diet, but not too fiuid, and it may be advisable to use 
 peptonised food for a time. 
 
 In such cases as these it is sometimes difficult in private 
 practice to prevent injudicious friends from stuffing the patient 
 with turtle soup, wines, and various delicacies, in the mistaken 
 belief that he can be ' fed up.' No greater mistake can be 
 made, for not only is the patient placed in circumstances 
 which necessitate a minimum of food, but the engorged viscera 
 are barely capable of dealing with that minimum. Nothing 
 is so prone to produce palpitation of the heart, even in health, 
 as the administration of an excess of food. If the food lie un- 
 digested in the stomach it may produce irritation and reflex 
 palpitation, or if it decompose and undergo fermentation it 
 may produce flatus, which will not only set up reflex palpita- 
 tion, but cause direct encumbrance of the heart as well by 
 distention of the stomach. Or if it be digested and absorbed, 
 and if elimination of the waste by the kidneys do not keep 
 pace with absorption, we get the blood overcharged, increased 
 tension in the systemic arteries, and palpitation of the heart 
 as a consequence. I am inclined to think that, on the whole, 
 excess of food does most harm if it be absorbed, and that the 
 midnight palpitation of gouty subjects is, broadly speaking, 
 due to the fact that eliminative processes do not keep pace 
 with absorption. 
 
 I think that as a rule the best guide for the administration 
 of food is the patient's appetite, and that if there be, as often 
 is the case, a purple furred tongue and a disagreeable taste in 
 the mouth it is unwise to push the feeding. While the patient 
 is in bed endeavouring to get the physiological rest for his 
 heart he must have nothing but spoon food, which should be 
 given in small quantities and at frequent intervals. The 
 bowels must receive careful attention, and if the urine be 
 
DIURETICS 259 
 
 scanty and albuminous a rather free flux from the bowel will 
 do nothing but good. Anything like violent purgation must 
 be avoided, but it must also be ever present in the mind that 
 constipation is sufficient p^r se to produce functional disturV)- 
 ance of the heart, and that in the treatment of chronic heart 
 disease the care of the bowels is all-important. 
 
 But to resume the history of the case with which we are 
 dealing. He was admitted with cardiac dropsy, a mitral mur- 
 mur, and scanty albuminous urine on June 1, and he was f)ut 
 to bed and placed on a spoon diet. In addition to this, his 
 prescription paper will show you that he had one dose, and one 
 only, of purgative medicine, and not a single dose of any car- 
 diac tonic or any other drug. 
 
 What was the result ? Perhaps this is best answered by 
 a reference to the urine chart, which shows that on the first 
 day of admission the amount passed was 17 oz., and the next 
 day only 20 oz. After this the quantity gradually increased 
 until, some ten days after admission, it amounted to 168 oz. 
 
 As the quantity rose the specific gravity fell, and with the 
 increase of the flow of urine the dropsy gradually disappeared. 
 
 The urinary flow having reached a maximum, gradually 
 declined again, until the physiological quantity of 48 oz. in the 
 twenty-four hours was reached. All the other symptoms 
 improved, and on June 22, on which day the patient was 
 discharged, the ynitral inurmur loas no longer audible, the only 
 sign of dropsy ivas a slight j^itting on firm pressure over the 
 sacrum, and the urine was normal in amount and specific 
 gravity, and contained only a very faint trace of albumen. 
 
 This patient was practically cured ; and if his condition of 
 life had been such as to allow of his making health his main 
 object in this world one would have been justified in predict- 
 ing still further improvement in the course of time. As it is, 
 one must^ I fear, predict that sooner or later he will reappear 
 here or elsewhere with a recrudescence of his chronic trouble. 
 
 The case is, as regards symptoms and physical signs, a very 
 ordinary one, and yet I have thought it advisable to bring it 
 very specially to your notice as being worthy of more than 
 ordinary attention. 
 
 s 2 
 
260 CHRONIC HEART DISEASE 
 
 Why did the man, who was admitted suffering from a con- 
 siderable suppression of urine, manifest such copious diuresis 
 after being a few days in bed ? The partial suppression of 
 urine was due to the venous engorgement of the kidneys, the 
 result of his dilated left ventricle, and the regurgitation through 
 the mitral orifice, causing increased tension in the veins 
 throughout the body, inclusive of those of the kidneys. 
 
 When the heart was put to rest, and had only the internal 
 work of the body to do, the strain on the left ventricle dimin- 
 ished, the blood was driven forwards into the capillaries with 
 hourly increasing force, and driven backwards into the auricle 
 with a force which hourly diminished. Thus the arterial 
 tension was maintained while the venous tension diminished, 
 and the kidneys were soon able to perform their functions in 
 a normal manner. 
 
 But, you will say, the function of the kidneys became more 
 than normal ; it was excessive, for the diuresis was extreme. 
 This is true, and the cause for it is to be found in the large 
 amount of anasarca — the large quantity of watery fluid which 
 had to be removed from the body. 
 
 Dropsical fluids vary much in specific gravity ; those which 
 are caused by inflammatory processes, as in pleurisy and peri- 
 tonitis, have a specific gravity of 1018 or higher (Halliburton), 
 while non-inflammatory transudations have a specific gravity 
 of 1015 or lower (Halliburton), and of these latter the fluid of 
 oedema in cardiac dropsy has the lowest specific gravity (1010). 
 With enough fluid exuded into his cellular tissue to cause 
 marked oedema of the legs and trunk it is not to be wondered 
 at that when the kidneys became sufficiently disengorged to 
 perform their functions that the diuresis became excessive. 
 
 Now, in cases like the one with which we are dealing we 
 commonly follow a routine ; and when we are confronted with 
 a case of cardiac dropsy we prescribe, almost automatically, one 
 of the common cardiac tonics and diuretics, such as digitalis, 
 or strophanthus, or citrate of caffeine. If either of these drugs 
 or any other drug having a reputation as a diuretic had been 
 oriven we should, perhaps, have been quite ready to ascribe all 
 the improvement which took place to the drug which had been 
 
TONICS 261 
 
 administered, and we should have said that, certainly, it was a 
 powerful and valuable remedy. But the only cardiac tonic 
 and diuretic which this patient had was rest — rest which was 
 afforded by his bed and his diet. In clinical therapeutics it is 
 always impossible to get rid of the 2^ost lioc fallacy. Of all 
 therapeutic agents rest is probably the most important. This 
 patient's organs were unable to functionise normally, because 
 they were being over-pressed \ we gave them rest, and their 
 function was resumed. 
 
 Tonics and stimulants are therapeutic agents which are 
 given with the object of, so to say, spurring an organ to make 
 increased efforts, but we must remember that ' action and re- 
 action are equal and contrary,' and that after stimulation there 
 is the reaction of depression. It is sometimes very desirable 
 and very useful to give stimulants in order to enable a 
 patient to tide over a crisis ; but you must remember that, as 
 the spurs alone will not keep a horse going, unless there be 
 intervals for rest and nourishment, so cardiac tonics are of no 
 permanent use unless it be found possible to give the organ 
 rest as well. 
 
 It very often happens that a few doses of digitalis will do 
 great good by enabling a heart to systolise with sufficient 
 energy to commence grappling with its difficulties ; but it is 
 my invariable custom, unless the patient's condition is one of 
 urgency and danger, to delay the administration of cardiac 
 tonics until a few days' rest have enabled us to see whether or 
 no the organ has sufficient muscular power to overcome the 
 obstacles which are hindering it, without artificial help. If, as 
 in the present case, the heart recovers with rest alone, I am 
 sure it is a great gain for the patient. No one is more con- 
 scious than I of the great use of drugs in cases of heart dis- 
 ease, but I am sure that it is well to do without them if such a 
 course be possible. 
 
 A few words may be said as to the general advice which 
 should be given to sufferers from heart disease. 
 
 There be many such who can scarcely be said to need such 
 advice, their condition being one of chronic dyspnoea, which 
 makes exertion or excess of any kind an impossibility. There 
 
262 CHRONIC HEART DISEASE 
 
 are, however, many persons Avith damaged hearts who are- 
 either quite ignorant of the fact or who suffer so little in- 
 convenience that they might, if properly managed, remain 
 practically unconscious of their trouble. 
 
 Take the common case of a young man with a mitral 
 systolic murmur. He is brought to me, possibly, because he is 
 ' out of sorts,' and in the course of examination the mitral 
 murmur is discovered. Do not on any account tell such a 
 patient bluntly that he has ' heart disease.' Your patient 
 does not understand pathology, and the word ' heart disease ' 
 is in his mind associated with sudden death and coroners' 
 inquests. The shock of hearing such intelligence may do him 
 definite harm, and certainly the after moral effects are likely 
 to be serious. You must convey to him the idea that his 
 circulatory organs have been a little overstrained, and you 
 must impress upon him that if he be careful of himself he will 
 probably practically recover. 
 
 The main indication in all these cases is to regulate the 
 pace of living by the condition of the damaged organ. 
 
 Everything which involves hurry or effort is to be avoided. 
 Moderate exercise does nothing but good, but such patients 
 ought never to work themselves into a state of ' breathless- 
 ness ' or anything approaching it, and I think that, for such,, 
 all games and exercises involving competition are to be abso- 
 lutely disallowed. Gentle rowing will do good, but anything 
 in the shape of boat racing is most harmful. Such patients 
 must never play ' matches ' of any kind, because when one is 
 associated with others in games and exercises one is in honour 
 bound to make every effort, and put forth one's whole strength, 
 and it must be remembered that a single serious muscular 
 effort may so strain a damaged heart that the patient, instead 
 of being practically unconscious of his condition, may find 
 himself permanently short of breath. 
 
 For sufferers such as these competitions of all kinds, both 
 mental and physical, should be disallowed. 
 
 The great danger which is run by a sufferer from mitral 
 disease is from cold. The lungs are permanently congested, 
 which makes them very susceptible to the effects of cold,. 
 
PEoaNOSis 263 
 
 and an attack of bronchitis is sure to overstrain the ricrht 
 side of the heart by increasing the already slight difficulties of 
 the pulmonary circulation. A sufferer from mitral disease 
 may be unconscious of his trouble, but after ' catching cold ' 
 he may come to us complaining of puffiness about the feet and 
 breathlessness, which shows conclusively that the right side of 
 his heart has been overstrained. 
 
 Sufferers from mitral disease seldom die suddenly. Their 
 progress downhill is gradual, and lung complications are 
 generally very active in bringing about the fatal result. 
 Although sudden death is not common in mitral disease, the 
 tenure of life is very uncertain, because the patients have 
 little power of resisting common ailments. ' Colds ' are very 
 apt, in these cases, to ' attack the lungs,' and it goes hard 
 with them when they fall victims to influenza or similar 
 troubles, which usually cause small inconvenience to the 
 physically sound. I am accustomed to regard sufferers from 
 mitral disease as ineligible for life assurance. 
 
 The wealthy sufferer from chronic heart disease should 
 live in a place where fresh air and gentle exercise may be got 
 without climbing hills, and he should live upon the ground 
 floor of the house in order that the fatigue of going upstairs 
 may be avoided. 
 
 No two cases of chronic heart disease are precisely alike, 
 for it is evident that with the possibility of obstruction or 
 regurgitation, or both, at each of four orifices, combined with 
 many different conditions of the lungs, the permutations and 
 commutations become almost infinite. 
 
 Perhaps the most incapacitating form of chronic heart 
 disease is mitral obstruction, for not only does it produce 
 serious engorgement of the lung, but there is a failure to 
 supply the left ventricle with its proper quantity of blood, and 
 the systemic arteries are starved, while the pulmonary vessels 
 are gorged. Sufferers from this disease are always weakly 
 and breathless. 
 
 Simple aortic regurgitation, however, although liable to 
 terminate suddenly, often incapacitates the patient singularly 
 little. We have two extreme cases in the wards now, one of 
 
264 CHRONIC HEART DISEASE 
 
 whom has followed the occupation of a horse cleaner and the 
 other that of a tinplate worker, both laborious employments 
 involving much muscular exertion, up to the time of admis- 
 sion. I can also call to mind the case of a young man 
 suffering from aortic incompetence who used to come occa- 
 sionally to my out-patient room, and who earned his living as 
 an acrobat upon the stage. The left ventricle readily hyper- 
 trophies, and in this way compensates for the regurgitation, 
 and so long as the mitral valve remains fairly competent the 
 patients do not complain of breathlessness, there is no oedema, 
 and they look hard and healthy in the face. These patients 
 are, as you are aware, in danger of sudden death, and their 
 lives are absolutely uninsurable. 
 
265 
 
 CHAPTER XVII 1 
 
 TREATMENT AND MANAGEMENT OP PULMONARY TUBERCULOSIS 
 
 Before coming to details of treatment and management, and 
 in order that any recommendations I may make to that end 
 may appear reasonable and justifiable, it is necessary to give 
 a comprehensive glance at certain points in the aetiology and 
 pathology of tuberculosis, concerning which there is now a very 
 general agreement. 
 
 The labours of many statisticians during the past half- 
 century have shown conclusively that the death rate from 
 phthisis bears a very general direct proportion to the degree of 
 concentration of population. It is essentially a disease of cities, 
 and amongst dwellers in cities and large towns it affects 
 especially those who are engaged in sedentary indoor employ- 
 ments, such as clerks, shop assistants, and compositors. Where 
 many persons are congregated under a common roof, with in- 
 sufficient cubic space, phthisis is prone to be very rife, especially 
 if the other hygienic conditions are defective. We accordingly 
 find that the death rate from this cause in barracks and 
 prisons formerly reached a very high figure. Now, however, 
 that greater attention is paid to cubic space and ventilation 
 the death rate from phthisis among soldiers and prisoners is 
 very much lessened. It is important to bear in mind that in 
 comparison with overcrowding, and especially overcrowding 
 indoors and under a common roof, all the other setiological 
 factors of phthisis hold a very subordinate position. It is a 
 disease of all climates, and its occurrence does not seem to be 
 much influenced by latitude. In warm climates, where city 
 populations bask out of doors in the sunshine, there is, generally 
 speaking, less phthisis than in cities which have a rough and 
 
 1 Clinical Lecture, U.C.H., 1894. 
 
266 PULMONAEY TUBEKCULOSIS 
 
 variable climate, like Vienna, whose inhabitants suffer more 
 from phthisis than those of any other city in the world. In 
 Vienna the population is largely devoted to indoor indus- 
 tries, and the inhabitants live in large tenement houses which 
 are warmed by stoves. The variations in temperature are 
 often sudden and extreme, and few who have been there in 
 winter will forget the cutting severity of the wind. There 
 are certain islands in Europe which are said to enjoy an 
 immunity from phthisis which is more or less complete, and 
 it is interesting to note that these islands — Iceland and the 
 Faroe Islands — have cold and severe climates. It is also in- 
 teresting to note that among European cities the northern cities 
 — Christiania, Copenhagen, Stockholm, Konigsberg— have a 
 slightly lower death rate from phthisis than some of the cities 
 lying in warmer latitudes. Other things being equal, it would 
 seem that elevation above the sea -level lessens the tendency to 
 phthisis. The plains are, as a rule, more crowded than the 
 mountain tops, and there can be no doubt that the immunity 
 of mountaineers is due not only to their well-developed chests 
 and athletic lives, but also to the sparse population of the 
 regions which they inhabit. 
 
 Having arrived at the conclusion that the main factor in 
 the causation of tuberculosis is overcrowding, the great dis- 
 covery of Koch comes, as it were, to give additional point to 
 our conclusion. 
 
 Before Koch's discovery medical opinion was becoming 
 more and more firm as to the infective nature of pulmonary 
 tuberculosis, and the discovery of a c^ntagium vivutn in the 
 form of the tubercle bacillus converts a theory into a fact, and 
 gives us a solid basis both for treatment and prevention. 
 
 While one must not forget the possibility of the convey- 
 ance of tuberculosis by tuberculous meat or milk (uncooked), 
 we shall all readily admit that the usual channel of conveyance 
 is the air, and that tuberculosis, although a chronic trouble 
 with a doubtful incubative period, must, for practical purposes, 
 be classed with air-hor7ie contagia, such as diphtheria, and the 
 other infective fevers which are conveyed through the aii-. 
 Although it is possible that the air may be infected by the 
 
OVERCEOWDIXG 267 
 
 coughing and sneezing of tuberculous patients, still the most 
 probable source of infection seems to be from tuberculous 
 sputa, which, becoming dried, are raised in the form of dust. 
 
 It stands to reason that the danger of being infected in this 
 way is much greater indoors than out of doors. Tuberculous 
 sputa falling out of doors probably quickly succumb to the 
 saprophytic organisms which aboiuid everywhere. When, on 
 the other hand, they fall indoors, they dry up, and, not being 
 kept moist, putrefaction is delayed, they do not succumb to 
 saprophytes, but, being persistent spore-bearing organisms, 
 they remain ready to commence growing so soon as they fall 
 upon a congenial soil. A volume of air which is enclosed in a 
 room cannot, in spite of all our efforts, be renewed with any- 
 thing approaching the completeness and frequency that a 
 similar volume is renewed when not so enclosed. If we assume 
 that a given volume of air contains a certain number of 
 infective particles, it follows that such particles are the more 
 likely to infect the greater the difficulty of renewing the air. 
 Hence it follows that our danger of infection from all air-borne 
 contagia is much greater indoors than out of doors. Given the 
 number of infective particles in any volume of air, the danger 
 of infection might be stated mathematically. There seems, 
 however, good reason to believe that overcrowding in rooms 
 and houses intensifies the danger of infection from air-borne 
 contagia apart from mere mathematical considerations. It is 
 evident that if our danger of infection is due to the particles 
 of dried sputum raised in dust, the stirring the air and rais- 
 ing the dust, which is much greater in a crowded room than 
 an empty one, is, in itself, a source of danger. Again, it 
 appears probable that air which is heavy with carbonic acid 
 and watery vapour has a greater power of carrying floating 
 particles than air which is pure and dry, and thus we are able 
 to adduce two physical reasons which may account for the 
 danger of overcrowding apart from the mathematical con- 
 siderations based upon a knowledge of the cubic contents of 
 the room and the number of sources of infection. It is prob- 
 able that there are other causes besides physical ones which 
 enhance the danger of overcrowding, and it may well be that 
 
268 PULMONAEY TUBERCULOSIS 
 
 the difficulties experienced in the proper aeration of the blood 
 may increase the liability of the infective particles to ' take 
 root ' in the individual who inhales them. All these consider- 
 ations show how important it is that sputa should be received 
 into vessels, and be systematically burnt or chemically disin- 
 fected. 
 
 It must never be forgotten that the liability of the infective 
 particle to ' take root ' and grow varies with the individual. 
 Some are very susceptible to phthisis, others very insusceptible. 
 Tuberculosis is so common that one would suppose that in a 
 great city like London there must be large numbers of tubercle 
 bacilli floating in the air, and yet comparatively few of us become 
 definitely infected. It must be supposed that a large number of 
 those who get infected practically recover without suffering 
 seriously, i.e. they throw off* the infection. We know how 
 common it is in the post-mortem room to find lungs adherent 
 at the apex, or calcified or caseous glands, in subjects who have 
 never been regarded as phthisical, and we may justly conclude 
 that a fair proportion of these appearances are the records of 
 a successful fight with the bacillus tuberculosus. 
 
 It is difficult to say precisely what it is that causes the 
 excessive vulnerability to phthisis in certain individuals, and 
 why the bodies of some should prove a more congenial soil for 
 the growth of tubercle bacilli than the bodies of others. Few of 
 us doubt that a tendency to tuberculosis is distinctly heritable, 
 and we know that the families in which such liability exists 
 contain a large number of individuals who are feeble, 'lax- 
 fibred,' prone to anaemia, and very liable to catarrh. Not 
 infrequently they have a characteristic figure, with a long, 
 narrow chest, and it may well be that with chests of such a 
 shape the expulsion of bacilli which may gain access to the 
 lung is no easy matter. 
 
 Now, our main subject, the prevention and cure of pul- 
 monary tuberculosis, may perhaps be best handled by con- 
 sidering what we can do to protect persons having a liability 
 to phthisis from their probable fate. 
 
 In the first place we must seek by fresh air and exercise 
 to * develop the chest,' and see that the expansion and con- 
 
'CATCHINO COLD' 269 
 
 traction of the lungs are both improved by exercise. Walking, 
 running, climbing, or anything which calls for full inspirations 
 will do this. Lagrange has pointed out that during exercise 
 our need of deep inspirations is largely in proportion to the 
 muscular mass which we put in action, and he therefore holds 
 that the exercise of the legs in running is the best form of 
 exercise to develop the chest. There are some who hold, as I 
 hinted just now, that the immunity or comparative immunity 
 from phthisis enjoyed by dwellers in mountainous districts 
 is due not so much to peculiarities of climate as to the well- 
 developed chest of the mountaineers, whose deep and forcible 
 respiratory movements give but a small chance for the per- 
 manent lodgment of bacilli. 
 
 While endeavouring to ' develop the chest ' we must take 
 care that it is not overdone ; for if, by excessive exercise, we 
 allow the subject to get ' blown,' we may induce emphysema, 
 which may give us enormous girth of chest with very feeble 
 contractile power in the lung. Subjects who are prone to 
 phthisis should carefully guard against over-training and 
 exercises which induce breathlessness. The exercise should be 
 carefully graduated, and the amount slowly and cautiously 
 increased. 
 
 Such persons should be careful to avoid, if possible, ' catching 
 cold.' This is a difficult matter, for the proneness to catarrh 
 probably constitutes one of the chief causes of the liability to 
 tuberculosis. Catarrhal secretions from mucous membranes 
 obviously form a nidus for the growth and increase of bacilli ; 
 and there can be no doubt that a most important part in the 
 prophylaxis of consumption in all its forms is to keep the 
 mucous membranes clean and free from catarrh. To this end 
 there must be strict attention to diet, rigid temperance in the 
 use of alcohol, and the avoidance of all sources of mechanical 
 and chemical irritation, such as dusty atmospheres and (espe- 
 cially if there be a liability to laryngeal catarrh) tobacco 
 smoking in all forms, inclusive of cigarette smoking. 
 
 Directly a patient gets a chronic cough, whether it be laryn- 
 geal, pharyngeal, or bronchial, there can be no doubt that his 
 liability to become infected with tuberculosis is appreciably 
 
270 PULMONARY TUBERCULOSIS 
 
 increased. The caution, therefore, to mcdntaht clean mucous 
 membranes is most important. 
 
 Persons who have a family tendency towards puhnonary 
 tuberculosis should, if possible, live in the pure air of the 
 country, and should select a profession or occupation which 
 involves as little confinement indoors as possible. So long as 
 they be free from actual lung disease, and provided they be 
 warmly clothed and have a sufliciency of good wholesome 
 simple food, I do not think it is necessary to ' coddle ' them 
 too much. I am rather an advocate for sending them to 
 tolerably bracing places, and rather prefer the east or south- 
 east coasts of this country to the more soft and warm climates 
 of the south and south-west. The life of a farmer or a sailor 
 is the ideal life for these persons. I have seen, I think, some 
 few lives saved by being taken from a close office and sent to 
 work in the fields ; and I can recall one case, the son of a 
 mother who was the subject of pronounced tuberculosis, in 
 whom the enlarged and shotty glands completely disappeared 
 during two years' schooling at Ramsgate, and who became 
 quite strong when he emigrated to Manitoba, where the extreme 
 severity of the Canadian winter produced no ill effect. 
 
 If circumstances render it impossible to select a completely 
 outdoor life, we must do the best we can. Only the other day 
 I saw the son of a small builder, who had never shown any 
 manifestations of phthisis until he was moved from the car- 
 penter's shop to the office, whither he had been attracted by 
 the mistaken notion that the desk is a nobler field for energy 
 than the bench of the handicraftsman. By my advice he left 
 the office to enjoy the muscular exercise and the comparatively 
 pure air of the carpenter's shop. 
 
 These delicate subjects should carefully avoid all over- 
 crowded places, and especially in the evening, when the danger 
 of catching cold on changing the stuffy atmosphere of the 
 theatre or meeting-room for the chilly night air is very great 
 indeed. 
 
 Now, when these persons develop the first signs of phthisis 
 we commonly send them away to some health resort, and it is 
 well that you should thoroughly understaTid the object with 
 
HEALTH RESORTS 271 
 
 which they are thus sent into temporary exile. The main 
 object is that they should breathe as much pure air as possible. 
 
 jSTotwithstanding that cold cannot be regarded as in any 
 sense a cause of tuberculosis, it is nevertheless a great source of 
 discomfort and danger to those who, having become tubercular, 
 are the subjects of that chronic pneumonia which is caused by 
 the growth of bacilli in the lung, and which we usually speak 
 of as phthisis. Persons with chronic lung disease are as a rule 
 very intolerant of cold, and any undue chilling of the surface 
 of the body is apt to produce a congestion of the lung with an 
 extension of bronchitic and pneumonic troubles. The Regis- 
 trar-General's returns show with never-failing regularity that 
 with a fall of temperature there is invariably an increase of 
 deaths from respiratory disease — phthisis, bronchitis, and pneu- 
 monia. The true meaning of this is, I take it, not that cold is 
 a great cause of respiratory disease, but that it is a great cause 
 of death in those who are the victims of respiratory disease. 
 
 Since we are accustomed to send wealthy patients suffering 
 from incipient phthisis to the sunny south to pass the winter 
 months, I will, without going into details as to the relative 
 merits of this or that place, make a few general observations 
 which may be of help to you in giving advice on this matter. 
 
 Now, remember that our object in sending the patient 
 away is that he may breathe pure air, and that the amount of 
 exercise which he will get in the pure air will very largely 
 depend upon the amount of fine weather and sunshine. 
 
 But we must bear in mind that in the winter the hours for 
 outdoor exercise extend from about 9 a.m. to 4 p.m., so that in 
 the 24 hours there are about 7 hours in which the patient may 
 be out and 17 hours when practically he 7}iust be indoors. He 
 will breathe the air of his house for twice as many hours as he 
 breathes the open air. Therefore it follows that the selection 
 of the patient's house or rooms is quite as important as the 
 selection of the locality in which the house is situated. I may 
 say at once that in my opinion there can be no worse place for 
 a sufferer from chronic phthisis than a monster hotel built 
 tier upon tier, with overcrowded public rooms, in which 2>oit- 
 rinaires are often herded together in a manner which is most 
 
272 PULMONARY TUBERCULOSIS 
 
 undesirable. I believe that the aspect of the patient's rooms 
 is a matter of prime importance, and one which is too often 
 neglected. The bedroom should face the south-east, in order 
 that the early visit of the sun may tempt him from his bed, 
 enable him to dress in the warmth, and to admit the fresh air 
 by opening the window more frequently than otherwise would 
 be the case. 
 
 South-east is admittedly the ideal aspect for a house, but I 
 would say that for patients visiting the Riviera a south-east 
 aspect is almost essential, because of the virulence of the dry, 
 cold, north-west wind, or mistral, which is very trying for 
 invalids. If the windows of the rooms occupied by the patient 
 look to the south-east he gets the whole benefit of the morning 
 sun with absolute protection from the mistral, which, when it 
 blows with violence, is far more keen and cutting than any of 
 our east winds here. 
 
 A word of caution must be given as to allowing real invalids 
 to participate in the gay social life which is rather too common 
 in health resorts which have become fashionable. When last 
 I was in the Riviera I remember encountering a young 
 American who was suffering from laryngeal phthisis, and who, 
 instead of basking in the sunshine, spent the greater part of 
 his days in the rooms at Monte Carlo, and of course was getting 
 far more harm than good from his expensive journey to Europe. 
 I think it is most important to lay stress on the fact that, for 
 those who are suffering from incipient phthisis, all participa- 
 tion in crowded entertainments of every sort and kind should 
 be absolutely disallowed. 
 
 I am inclined to think that in this country there are few 
 spots better suited for the residence of patients in the early 
 stages of phthisis than our own dry bracing sunny south downs, 
 always provided that there be sufficient shelter from the north. 
 A good well-built warm cottage facing south-east or south, 
 with a wide verandah, and situated on the slope of a chalk 
 down, is an almost ideal dwelling for the phthisical. 
 
 There is no greater practical mistake than to send patients 
 to distant health resorts if they are unable to bear the expense 
 of obeying one's orders comfortably. To send persons away 
 
POST HOC FALLACY 273 
 
 who are obliged to calculate the expense very narrowly ; to 
 send them from ' home comforts ' to spend the winter in some 
 cheap ' pension,' of which overcrowding and underfeeding are 
 the main characteristics, is to court failure. 
 
 I am not going to discuss the merits of different health 
 resorts or dwell upon the distinguishing characteristics of the 
 sea-shore and the mountain tops. The main object which the 
 doctor has in view is to enable the patient to breathe pure 
 air. Some health resorts are being killed by their own 
 popularity, which has increased the price of building land, 
 and has led to the building of houses in too close proximity to 
 each other. In a health resort every house should be isolated 
 and stand in a garden of its own. It is well to bear in mind 
 the difference between a holiday resort and a health resort. 
 As a rule we shall find that in proportion as a place grows in 
 popularity with ' trippers ' and holiday excursionists it becomes 
 undesirable as a residence for real chronic invalids. 
 
 So far my advice has been to encourage persons who have 
 a constitutional tendency to tuberculosis, or who may afford 
 actual evidence of the disease in its early stages, to select 
 callings and professions and to live in places which will give 
 them a fair chance of throwing it off, and afford as few 
 opportunities as possible for their favourable ' soil ' being 
 frequently re-seeded by the bacilli which are likely to be 
 present in the air of houses or places to a degree bearing some 
 proportion to the density of population. 
 
 But, it will be asked, can we do nothing to help the 
 individual except by attending to his surroundings ? Has the 
 discovery of the bacillus tuberculosus given us no clue to some 
 method of destroying the microbe m situ ? 
 
 The answer to this question is very doubtful, and mainly 
 for the reason that we are unable to get away from that 
 stumbling-block of scientific therapeutics known as the post 
 hoc fallacy. If, when a patient with phthisis is removed from 
 the foetid atmosphere of some wretched hovel, where he has 
 been half starved and overworked, to the comparative purity 
 of our hospital ward, where light, air, good food, and absolute 
 repose are afforded him, we administer to him some remedy 
 
 T 
 
274 PULMONAEY TUBERCULOSIS 
 
 which has acquired a reputation for the 'cure' of consumption, 
 and if, in a few days' time, his cough be easier, or his tempera- 
 ture lower, his appetite improved, or his weight increased, to 
 which of many circumstances are we to attribute his improve- 
 ment 1 Assuredly we have very slender grounds for attributing 
 it to the drug. To a certainty the j^atient would attribute his 
 improvement to the drug, for with patients, as a rule, post hoc 
 is pro23te7' hoc, and belief in drugs is absolute. 
 
 When a drug rapidly produces some easily appreciated 
 change in the bodily condition we manage to escape from the 
 post hoc fallacy. That purgatives cause diarrhoea, that anti- 
 pyretics lower febrile temperatures, that morphia causes sleep 
 and contraction of the pupils, that pilocarpine and atropine 
 influence the secretion of sweat are facts which nobody can 
 doubt. When, however, we are told that the cessation of 
 vomiting is due to the administration of ipecacuanha in doses 
 so small as to elude every known test we may accept the 
 statement as a matter of faith, but we must admit that it is 
 absolutely incapable of experimental proof. 
 
 In the same way the cause of the improvement of chronic 
 invalids whose condition is known to be for ever fluctuating 
 is almost incapable of demonstration, although one is glad to 
 be able to say that the improvement of myxoedema by the 
 administration of thyroid extracts is apparently an exception 
 to the rule. 
 
 It follows, therefore, that we must receive all statements 
 as to the efiect of drugs on such a disease as pulmonary 
 tuberculosis with the utmost caution and reserve. 
 
 In discussing the treatment of phthisis by drugs I shall 
 limit myself entirely to a consideration of those measures 
 which have had for their object the destruction of the bacilli 
 at the seat of their formation. 
 
 The use of inhalations of various kinds had been recom- 
 mended and largely employed before the discovery of the 
 bacillus, and since its discovery this line of treatment has had 
 a fair trial. In many cases inhalations may have alleviated 
 the patient's condition by somewhat lessening cough and 
 secretions, but it cannot be claimed for any of them that they 
 
GARLIC 275 
 
 have had any effect in arresting the progress of the disease. 
 When we consider how very dilute must be any antiseptic 
 vapour which is capable of being inhaled into the lungs, when 
 we consider that there is always residual air in the lung, and 
 when we consider still further that only a small minority of 
 the bacilli lie on the free surface of any cavity in the lung so 
 as to be within reach of any antiseptic vapour which may be 
 inhaled, we cannot be surprised at the failure of this mode of 
 treatment to arrest the disease. 
 
 Koch's efforts to kill the bacilli by the injection of ' Tuber- 
 culin ' — the product afforded by the pure cultivation of the 
 bacilli — will be long remembered as one of the most inter- 
 esting episodes in the history of therapeutics. Although the 
 treatment was not destined to fulfil the sanguine expectations 
 of the originator, the work which led to its promulgation was 
 of the highest scientific value. The rapidity with which the 
 profession throughout the world came to the conclusion that 
 the dangers of employing Tuberculin were considerable, while 
 the advantages were doubtful, was also creditable to the 
 scientific methods of the nineteenth century. 
 
 The administration of antiseptics by the mouth has not 
 been productive of any decided benefit. The salts of mercury 
 and the tar products have been used without decided effect. 
 Among the latter one must mention creosote, which is just 
 now going ' out of fashion,' after having been very much in 
 vogue. 
 
 It seems to me that if any useful result is to be obtained 
 by the employment of antiseptics in pulmonary tuberculosis 
 it is important to choose one which is eliminated by the lung 
 — something which is absorbed from the stomach, mingles 
 with the blood streams, and is eliminated by the lungs. 
 
 The bodies containing the active principle ' allyl,' such as 
 garlic and onions, seem to fulfil these indications, and seem 
 worthy of a trial. The most potent of these bodies appears 
 to be garlic, for it is well known that the smell which garlic 
 imparts to the breath is most persistent, and is produced by 
 very small quantities. The allyl compounds such as allylic 
 alcohol and oil of mustard were shown by Koch to be strongly 
 
 T 2 
 
276 PULMONAEY TUBERCULOSIS 
 
 antiseptic, and to have a remarkable power of inhibiting the 
 growth of the bacillus anthracis. In this respect they rivalled 
 the salts of mercury. If it be possible to hinder the growth 
 of the bacillus tuberculosus in the lung, it seems at least 
 reasonable to try the effect of such a body as garlic. But, it 
 will be said, if garlic is capable of hindering the growth of 
 bacilli tuberculosi, we ought to find that phthisis is less 
 prevalent among garlic-eating populations than elsewhere. 
 Facts are wanting to decide this point either one way or the 
 other, but even should it be shown now or hereafter that there 
 is no correspondence between the habit of eating garlic and a 
 small deatn rate from phthisis it would not, to my mind, be a 
 very strong argument against giving garlic a trial, for one 
 could only suppose that such a method of treatment would be 
 useful as a help when other circumstances were favourable. 
 It could not reasonably be expected to be of any use in the 
 face of overcrowding, starvation, dirt, and squalor such as are 
 common enough in many of the cities of southern Europe. 
 
 Xow, I think I may safely say that I have found garlic of 
 distinct service in cases of dilated bronchi with foetid ex- 
 pectoration. In two such cases in which the expectoration 
 was purulent and horribly foetid we administered garlic in the 
 food until the odour of garlic was permanently present in the 
 breath. In both cases the disgusting fcetor of the expectora- 
 tion was replaced by an odour not foetid, but pungent, and 
 reminding one in some degree of the odour of syringa. The 
 change in the odour of the sputa was the same in both cases. 
 The fcetor disappeared, and was replaced by an odour which 
 was not that of garlic, but distinctly sui generis. 
 
 Mr. lonides, who was my house physician when one of 
 these cases was in hospital, treated the sputa with ether, 
 and manufactured in this way a very pungent 'scent,' in 
 which the syringa quality was distinctly present. In these 
 cases the expectoration lessened, and the condition of the 
 patient was distinctly improved. 
 
 Dr. Sidney JNIartin tells me that he also has given garlic 
 to patients suffering from dilated bronchi and foetid expectora- 
 tion, and with distinctly good results. 
 
USE OF GARLIC 277 
 
 Then we have had two cases in the wards of boys who 
 were apparently suffering from basic phthisis, and who made 
 no improvement until they were placed upon garlic, when a 
 rapid and complete recovery took place. 
 
 In private practice I can recall the case of a gentleman 
 suffering from fibroid phthisis who improved most remarkably 
 and gained weight very rapidly while he was taking garlic, 
 which he did most persistently. 
 
 Another case was that of a girl with aphonia, who had 
 very characteristic pyriform swelling of the aryteno-epiglottic 
 folds, so that neither I nor Dr. Adams, of Buckhurst Hill, who 
 brought the patient to me, had the slightest hesitation in 
 making a diagnosis of tubercular laryngitis, and giving the 
 most guarded prognosis. The patient among other measures 
 was ordered to eat garlic. When next she came to see me, 
 a month or so later, the laryngeal condition had completely 
 subsided. The result was so remarkable that one is inclined 
 to doubt the accuracy of one's diagnosis, but nevertheless the 
 result justifies one in trying the remedy again in similar 
 cases. 
 
 I have usually given the garlic in the food, A ' clove of 
 garlic ' has been chopped up and mixed with the beef tea, 
 and only very few patients have been unable to take it in this 
 way. The evidence that the patient is under the influence of 
 garlic is the persistent smell of it in the breath, a smell which 
 is equally present when the garlic has been administered 
 in the form of an extract enclosed in gelatine capsules. 
 
 Garlic, I need not say, is no new remedy. It formerly held 
 a place in the London Pharmacopeia, but the extant British 
 Pharmacopeia does not recognise it. I see that Dr. Brunton 
 states in his work on pharmacology that garlic is still in the 
 Pharmacopeia of the United States. It is mentioned by 
 Pereira and by most of the previous writers on Materia 
 Medica. It was used by Hippocrates. Among the properties 
 ascribed to garlic by old writers is that of a stimulating ex- 
 pectorant, so that its employment in lung diseases is no new 
 idea. Its acrid taste and the disagreeable smell which it gives 
 to the breath have naturally militated against its becoming a 
 
278 PULMONAKY TUBERCULOSIS 
 
 very popular remedy. I have found, however, no difficulty in 
 persuading patients to take it. Administered with food, it 
 has never caused any serious gastric disturbance, the only 
 trouble in its administration being a natural repugnance to 
 the flavour and odour on the part of some patients. 
 
 The essential oil of garlic is said to contain a sulphide of 
 allyl, and in this connection I would remind you that other 
 sulphides, such as sulphuretted hydrogen, sulphur waters, 
 the sulphides of calcium and potassium, have enjoyed a 
 certain reputation in tuberculosis and ' scrofulous ' diseases. 
 
 Among other remedies which I think I have found 
 serviceable in phthisis are the so-called ' alteratives,' such 
 as arsenic or potassium iodide in small doses and the sul- 
 phides above alluded to. 
 
 Counter- irritation by means of iodine or stimulating 
 liniments, well rubbed in until the skin of the chest is 
 thoroughly reddened, often have the effect of lessening the 
 cough and expectoration. 
 
 Garlic is not only given off by the breath, but by the skin 
 also, and I have been for some years in the habit of 
 administering it to those cases, especially common in children, 
 in which a cadaveric odour of the skin develops after attacks 
 of acute specific disease. In such cases warm baths and soap 
 are of no use, but I have found that if garlic be administered 
 until the skin reeks of it the cadaveric odour is got rid of, 
 and is no longer noticeable when the smell of the garlic dis- 
 appears. 
 
 I have thus brought to your notice a body which, on 
 theoretical grounds, seems worthy of a trial, and which from 
 practical experience I feel inclined to continue to administer 
 to sufferers from phthisis in its early stages. 
 
 The following very interesting letter and history was 
 most courteously sent to me by Dr. Skelton, of Bristol, and 
 seems to me to be worthy of reproduction without abridge- 
 ment : 
 
 May 24, 181)4. 
 
 'Dear Sir, — Seeing your paper on the treatment of pul- 
 monary tuberculosis in the " Clinical Journal " of January 31, 
 
USE OF aARLic 279 
 
 in which you advocated the use of garlic, I happened to be 
 able to give it an immediate trial. Mr. P., my patient, was 
 at that time expectorating very offensive sputa to a large 
 amount after a slight attack of haemorrhage. He has been 
 inder my care for some years, having come here from Derby 
 (he is an employe of the Midland Railway Co. in a responsible 
 position in the head office here) for the benefit of his health, 
 as he had been subject to haemoptysis. He has had several 
 returns of the haemorrhage, sometimes to a very profuse 
 extent. The blood comes from what apparently is a large 
 cavity or dilated bronchus about the middle of the left lung. 
 
 ' Between the attacks, which are generally annual, he gets 
 fairly strong again, though I think he is gradually losing 
 flesh. He is a most intelligent man, and of a cheerful 
 disposition, making the best of everything. When he started 
 taking the garlic I told him to keep an account of his 
 condition from day to day. This I enclose, and it, I think, 
 tells its own story very graphically. 
 
 ' I remain, yours faithfully, 
 
 ' H. Skelton.' 
 
 Diary written hy the patient himself. 
 
 January 3rd, 1894. — Slight attack of haemorrhage. 
 
 Qth. — Discharge cleared. 
 
 7th. — Last injection of ergotine. 
 
 8th to 20th. — Increase in discharge to nearly half a pint 
 per day, very offensive to taste and smell. Inhaling turpentine 
 and creosote. 
 
 21s^. — Commenced taking creosote, mixture and pills. 
 
 22nd to 3\st. — Gradual decrease in discharge to about a 
 quarter of a pint per day, but still offensive. Slowly increas- 
 ing in strength. 
 
 February \st, 1894. — Commenced eating garlic. One 
 piece at tea time (5 p.m.). 
 
 2nd. — Garlic three times. Twice raw and once cooked. 
 Marked decrease in discharge. 
 
 ord. — Garlic three times. Further decrease in discharge. 
 Considerable increase in strength 
 
280 PULMONi^KY TUBERCULOSIS 
 
 ^th. — Garlic twice. Further decrease in discharge. 
 
 bth. — Garlic three times. Discharge reduced to my normal 
 quantity, i.e. only a few expectorations during the day. 
 
 ^th mid Ifh. — Garlic three times daily. Result as above. 
 
 '^th to lOtli. — Garlic twice daily. Result as above. 
 
 11 ^A to 17 th. — Garlic twice daily. Gaining strength. 
 
 ISfh to '24:th. — Garlic once daily. Gaining strength, 
 
 '24:th to March 'Srd. — Garlic once daily. Discharge so 
 slight that I have not required the use of an ' invalid's mug.' 
 This I have not been able to dispense with during all my 
 illness, viz. five and a half years. Strength still increasing 
 
 March 3rd to 10th. — Influenza cold. Continued with the 
 garlic. No increase in discharge. 
 
 lO^A to 17 th. — Still suffering from cold, damp weather. 
 Continued taking garlic ; increase in discharge towards end of 
 week. 
 
 17 th to 31 6'^. — Cold better and discharge reduced. 
 
 April 1st to 30th. — Continued the garlic, small piece each 
 day. Discharge slight all the month. 
 
 Garlic. — February 1st., 1894. — Purchased 1 oz., cost l\d. 
 This I ate in five days, having (about) one section of a bulb 
 at each meal, viz. breakfast, dinner, and tea. 
 
 Once I tried it cooked, but found it then had little flavour ; 
 all the other I took raw. Relished it best with bread and 
 mild cheese, or bread and butter. 
 
 After eating the first piece the discharge from the lung, 
 from being of a pale green colour and very ofiensive, became 
 almost white in colour and without any objectionable taste or 
 smell. On the second day it tasted and gave an odour of 
 garlic. 
 
 Urine gave a strong odour of garlic. 
 
 As soon as I commenced eating it my appetite increased, 
 digestion improved considerably, and I noticed a marked 
 daily increase in strength. Had much better sleep, and per- 
 spiration at night entirely ceased. 
 
281 
 
 CHAPTER XVIII 
 
 A CASE OF TUMOUR OF THE LUXG ^ 
 
 A MAX aged twenty was admitted to University College 
 Hospital on December 12, 1894. He stated that on October 8 
 of the same year he noticed, on getting up to go to his work in 
 the morning, that he was very short of breath and felt cold 
 all over. He had been quite well previously, but the symptoms 
 were so severe that he took to his bed at once and sent for 
 medical advice. He remained in bed, till the end of the 
 month, when, feeling better, he got up and went about for a 
 fortnight, but did not resume his occupation. One morning 
 about the middle of November, while out walking, he was 
 suddenly seized with a severe aching pain in the middle of his 
 back, which caused him to double up. He immediately re- 
 turned home and took to his bed, stopping there till he entered 
 the hospital. Since the middle of October he had suffered 
 from pain in the left side, which was worse on coughing. For 
 a week — a month before the date of his admission — he 
 expectorated sputum stained with blood. He had been treated 
 during his illness with poultices, blisters, &c. He had had 
 influenza three years before, but no other illnesses. He said 
 that he had always been delicate. There was nothing note- 
 worthy in the family history. On his admission it was found 
 that he had a slight cough, but no expectoration ; he had 
 some dyspnoea on exertion ; there was no cyanosis ; the 
 respirations were 40 per minute. On examining the chest 
 it was noticed to be poorly covered, long, and narrow, 
 and that the intercostal spaces were better marked on the 
 right side than on the left, which side hardly moved at 
 all on respiration. Below the third rib on the left side 
 
 1 Clinical Lecture, U.C.H., 1895. 
 
•282 TUMOUR OE LUNG 
 
 there were absolute dulness on percussion and loss of vocal 
 fremitus, of breath sounds and of voice sounds. In the 
 second left intercostal space there was distant bronchial 
 breathing with segophony, the percussion note being impaired 
 very much. In the first left intercostal space the percussion 
 note and breath sounds were normal. Behind there were on 
 the left side, below the spine of the scapula, very diminished 
 vocal fremitus and dulness on percussion, with faint bron- 
 chial breathing and very weak voice sounds. In the left 
 supra-spinous fossa the percussion note was impaired and the 
 breath sounds very weak, but bronchial in character. The 
 physical signs over the right side of the chest were normal, 
 except that the heart could be seen beating over the second, 
 third, and fourth spaces on the right side internally to the 
 right nipple line, with the heart's apex beat in the fourth 
 space midway between the right nipple line and the right 
 border of the sternum. The impulse was somewhat heaving 
 in character. On listening at the aj)ex a well marked systolic 
 murmur was heard, which was only conducted inwards as 
 far as the middle of the sternum. There was nothing ab- 
 normal in the urine ; appetite fairly good, bowels regular. 
 There was no cedema anywhere, and there were no dilated 
 veins and no enlarged glands. As the patient had all the 
 signs of an extensive effusion into the left pleural cavity, 
 an attempt was made on the day after his admission to 
 aspirate the chest in the sixth space in the mid-axillary line. 
 An ordinary bottle aspirator was used with a moderate-sized 
 needle, but as nothing but a little blood was drawn off the 
 needle was again inserted on the same day, this time just 
 internally to the angle of the left scapula, with the same result. 
 The blood drawn off contained nothing but corpuscles. The 
 temperature was 100'2° F. on his admission, and varied between 
 that point and 98° for the next few days, and after that 
 kept below 100° for some days. Soon after admission he was 
 noticed to have a slight prominence of the chest wall in the 
 left mammary region, which gradually became more marked, 
 and on comparing a tracing of the chest wall taken on 
 January 12, 1895, with one taken a month previously, a con- 
 
PHYSICAL SIGNS 283 
 
 siderable difference could be noticed in the size of the left 
 side of the chest, especially in the anterior part. His general 
 condition altered very little during this time ; the tempera- 
 ture chart from December 23 to 30 showed an evening 
 rise to nearly 101°, with a morning fall to normal, but from 
 the latter date till his death his temperature did not rise 
 above 100°, and after January 1 or 2 it never rose above 
 normal. His pulse during the whole time he was in the 
 hospital was rapid, on an average 120 to the minute, with the 
 respiration 30 per minute. On January 3 an exploring needle 
 was again introduced (this time into the left side of the chest 
 in front), but with a negative result. On the 15th some 
 cedema of the chest wall in the left mammary region was 
 noticed, which gradually increased. About this time, also, 
 some dilated veins were noticed in the left axilla, and both 
 external jugular veins were found to be distended j there 
 was also some distention of the veins of the forehead. 
 From the 15th till the time of his death the patient passed 
 very small quantities of urine, which was of high specific 
 gravity and contained a trace of albumen on two occa- 
 sions, but at other times was normal. On the 29th some 
 oedema of the lower part of the back on the left side was 
 noticed, that on the front of the chest being more marked ; 
 there was also some on the left side of the face. He now 
 could only lie on the left side, being unable to breathe in any 
 other position. On February 2 a small, rounded, almost 
 fluctuating swelling was found just over the anterior surface 
 of the head of the right humerus ; it was painless, and the 
 skin over it showed no signs of inflammation. On puncturing 
 the tumour a little blood escaped, which on microscopical 
 examination was found to contain cells of a sarcomatous 
 nature. The dulness on percussion, loss of vocal fremitus, &c. 
 now extended over to the right as far as a line drawn down- 
 wards from the middle of the right clavicle to the right 
 nipple, and then to the costal margin, the heart's apex beat 
 being just to the left of the right nipple in the fourth 
 space. The signs were limited to the left side behind. From 
 this time the patient became rather rapidly worse, the 
 
284 TUMOUR OF LUNG 
 
 cedema increasing and the dyspnoea being more marked ; 
 he, however, apparently did not suffer any pain, and slept 
 well. The growth at the head of the humerus increased 
 slowly in size, and another small tumour was found on 
 February 10 just below the left scapula attached to a rib. 
 He became delirious on the evening of the 18th, and died 
 the next morning. 
 
 At the post-mortem examination the diaphragm on the 
 left side was found to be very much depressed by, and 
 the whole of the left side of the thoracic cavity filled with, 
 an extremely soft growth ; it was dark brown in colour 
 and enclosed in a capsule formed apparently of thickened 
 pleura, which was firmly attached to the chest wall every- 
 where. At the upper and anterior part of the tumour, and 
 continuous with it, was found a layer of collapsed lung about 
 half an inch thick, seven inches long, and four inches wide at 
 its upper part and narrower below. The heart and pericardium 
 were displaced to the right, as was also the right lung. The 
 two former were healthy, but the right lung contained a small 
 growth about the size of a marble on its posterior surface. 
 The liver contained a few small growths about the size of peas 
 scattered through its substance. All the other organs were 
 healthy. There were no enlarged glands, except one in the 
 anterior mediastinum. Microscopic examination of the tumour 
 showed it to be a round-celled sarcoma, which was rapidly 
 ■degenerating. 
 
 Remarks. — The great interest of this case consists in the 
 impossibility of diagnosis in the early stages. The history 
 was that of an acute onset, and the physical signs on admis- 
 sion were those of effusion into the left pleura. Even after 
 the failure of aspiration, which necessarily aroused one's sus- 
 picion as to the true cause of the trouble, it was hard to 
 believe that such failure was not due to some mechanical con- 
 dition — such as profuse and cedema tous adhesions — which 
 prevented the flow of the fluid from the pleura. The physical 
 signs were uniform in character, and there were no patches of 
 dulness and resonance or of diminished and increased vocal 
 fremitus, such as are common in growths in the lung. The 
 
REMARKS 285 
 
 necropsy, which revealed a soft pultaceous tumour uniformly 
 distending the visceral pleura, fully accounted for the physical 
 signs during life. There was a history of very slight haemop- 
 tysis, but this was never repeated, and merely gave rise to the 
 suspicion that there was tubercle as well as fluid. When, 
 towards the end, there appeared marked oedema of the chest 
 and distention of the veins on the left side of the face 
 and chest, and this ivithotU any rise of temperature^ the 
 diagnosis became almost certain, and with the appearance of 
 the soft tumours on the neck of the humerus and one of the 
 ribs one felt quite sure as to what would be found post- 
 mortem. It is interesting to note that the weight of the 
 patient, which was 6 st. 11 lb. on admission, fell to 6 st. 7^ lb. 
 on December 22, 1894, and rose to 7 st. 2Jlb. on January 14, 
 1895. The last weight recorded (od January 22) was 7 st. 
 
286 SULPHUR WATERS OF THE PYRENEES 
 
 CHAPTER XIX 
 
 THE SULPHUR WATERS OF THE PYRENEES ^ 
 
 Nothing is more gratifying in the treatment of disease than 
 the occasional success which attends the employment of so- 
 called alterative medicines, among which we may place mer- 
 cury, iodine, arsenic, phosphorus, and the sulphides. It is 
 common to see effects produced by these preparations which 
 are at once tangible and decided, but unfortunately it is common 
 also to see them utterly fail to produce the effect desired. 
 
 Anyone who has employed the sulphides in the treatment 
 of disease must have been alternately pleased and disappointed ; 
 for although the effect produced is often exactly that which 
 Dr. Ringer describes in his Handbook of Therapeutics, equally 
 often, if not more often, the result appears to be absolutely 
 ne^^ative. One reason for this is undoubtedly to be found in a 
 faulty selection of cases ; and it may reasonably be hoped that 
 an increasing knowledge may cause a diminution in the number 
 of patients who, having been treated with sulphides, have failed 
 to derive the expected benefit. Another reason also is to be 
 found in the great instability of the sulphides themselves, 
 which immediately oxidise on exposure to air ; and it may 
 safely be said that a very large proportion of the patients for 
 whom the sulphides are prescribed get scarcely a single dose 
 of the medicine which it is desired to give them, but receive in 
 lieu of it a quantity of harmless or inactive sulphate. 
 
 When prescribing sulphides it has been my invariable 
 custom to advise the patient to get very small quantities made 
 up at a time, and to warn him that unless the medicine has 
 the familiar odour of rotten eggs it can do him no good. Better 
 than <yiving a solution of the sulphides is to allow the patient 
 ' Communicated to Lancet, 1879. 
 
ANALYSES 287 
 
 to have a small and well stoppered bottle filled with potassium 
 or calcium sulphide, whence he may take his dose, roughly 
 estimated on the point of a penknife, as required. Good ser- 
 vice has undoubtedly been done by the introduction of the 
 sulphides in perles, and I have reason to believe that the 
 sulphide remains unoxidised in the perles for indefinite periods. 
 I have lately, however, seen a sample of so-called ' perles of 
 calcium sulphide ' which on examination were found to contain 
 no sulphide at all. The best way of all, no doubt, to prescribe 
 sulphides is to send the patient, if possible, to a so-called 
 sulphur spring, where he may drink the water, impregnated 
 with hydrogen sulphide and holding other sulphides in solution, 
 before oxidation has had time to occur. Then one may be sure 
 that the medicine prescribed is actually being taken. 
 
 Having during the autumn of last year paid a visit to the 
 sulphur springs of the Pyrenees, I have thought that possibly 
 the information thus acquired might prove serviceable to 
 others besides myself. 
 
 There are many sulphur springs in the Pyrenees, but the 
 best known are those situated in the western half, in the 
 departments of the Basses Pyrenees, Hautes Pyrenees, and 
 Haute Garonne. Going from west to east, we have Eaux 
 Chaudes, Eaux Bonnes, Cauterets, St. Sauveur, Bareges, 
 Bagneres de Luchon, and Bagneres de Bigorre. Excepting at 
 the last-named place, the prevailing waters are those containing 
 sulphuretted hydrogen and other sulphides, and there is a 
 strong family likeness between them all. These waters are 
 excessively weak, and contain not more than from 0'5 to 0*2 
 grm. of dissolved matter in each litre of water, or from about 
 4^ to 2 grains in the pint — thus offering a striking contrast to 
 the waters of Harrogate and Aix-la-Chapelle, which contain 
 respectively 137 and 37 grains in each pint. The amount of 
 free hydrogen sulphide in the Pyreneean waters is exceedingly 
 small, the salt which gives to them this sulphurous quality 
 being sodium sulphide, of which there is from 2 to 5 centi- 
 grammes in each litre, or from i to ^ grain in each pint. The 
 bulk of their small quantity of solid ingredients is composed of 
 silicates, chlorides, and organic matters. The following schedule 
 
288 
 
 SULPHUK WATERS OF THE PYRENEES 
 
 will serve to show at a glance what are the chief ingi*edients 
 of these springs : 
 
 Gramjiks ix A Litre. (Parts in 1,000.) 
 
 
 Eaux 
 Ohaudes 
 
 Eaux 
 Bonnes 
 
 Caute- 
 rets 
 
 St. Sau- 
 
 Bareges 
 ( L'Eu- 
 
 Luclion 
 (La 
 
 Bigorre 
 (Labas- 
 
 
 (Le Clot) 
 
 (Cesar) 
 
 
 tree) 
 
 Reiue) 
 
 s^re) 
 
 Sodium sitlphide . 
 
 0-0080 (?) 
 
 0-0214 
 
 0-0226 
 
 0-0218 
 
 0-U344 
 
 0-0508 
 
 0-0464 
 
 Sodium cliloride . 
 
 0-0900 (?) 
 
 0-2640 
 
 0-0178 
 
 0-0695 
 
 0-0544 
 
 0-0624 
 
 0-2058 
 
 Silicates . 
 
 0-0041 (?) 
 
 0-0500 
 
 0-1114 
 
 0-0867 
 
 0-1087 
 
 0-0614 
 
 0-0555 
 
 Sotlium sulphate . 
 
 0-0234 
 
 0-0277 
 
 0-0080 
 
 0-0400 
 
 0-0169 
 
 0-0312 
 
 — 
 
 Calcium sulphate . 
 
 0-0791 
 
 0-1644 
 
 — 
 
 — 
 
 — 
 
 0-0312 
 
 — 
 
 Organic matter 
 
 (?) 
 
 0-0480 
 
 0-0450 
 
 0-0320 
 
 0-0510 
 
 CO 
 
 0-1450 
 
 Total solids . 
 
 (V) 
 
 0-5760 
 
 0-2019 
 
 0-2500 
 
 0-2654 
 
 0-2511 
 
 0-4813 
 
 Temperature (C.) . 
 
 36-25° 
 
 32-00° 
 
 48-00° 
 
 34-60° 
 
 40-00° 
 
 51-00° 
 
 15-00° 
 
 A typical spring has been taken as a representative of 
 each of the localities, but these form only a very small pro- 
 portion of the total number. Thus at Bareges there are 
 upwards of a dozen springs ; at Luchon there are nearly 
 thirty ; at Eaux Chaudes, six ; at Eaux Bonnes, six ; at Cau- 
 terets, thirteen ; and at St. Sauveur certainly two or three. 
 There are differences in the compositions of these several waters, 
 and the local practitioners profess to be able to select the cases 
 which are best treated at each of them, and make the most of 
 the milligrammes and fine shades of temperature which consti- 
 tute the differences. 
 
 At Bigorre there are a great many different springs, the 
 majority of which belong to the group of salme waters, the 
 chief saline ingredient, however, being sulphate of lime. These 
 should properly be classed among indifferent waters. There 
 are a few sulphurous springs also, the chief of which is that 
 called Labassere. 
 
 It will be noticed that the analyses make mention of organic 
 matter found in the springs, which is generally present in 
 considerable quantities. This organic matter collects in the 
 reservoirs and conduits through which the water is brought on 
 its way to the baths and drinking fountains, and seems to be 
 spoken of by various authors under the names of ' Baregine,' 
 ' Glairine,' or ' Sulfurine.' These names would lead the unwary 
 to suppose that this organic substance is the active principle 
 of the water, and indeed we find it so spoken of in more than 
 one monograph, and notably in the advertisement of the 
 
GROWTH OF ALG^ 289 
 
 Bareges waters, which says :^' Cette baregine donne aux eaux 
 de Bareges line onctuosite particuliere, qui est un des elements 
 de leur efficacite therapeutique.' The director of the bathing 
 establishment at Bareges very kindly ordered one of the 
 attendants to collect for rae a sample of this so-called bare- 
 gine, and in a very short time after the order was given I was 
 furnished with as much as could be put in a half-pint bottle. 
 To the naked eye it looked slimy, and was of a grey greenish 
 tint, with here and there portions which were nearly black. It 
 felt like mucus, and under the microscope was found to be 
 composed of the filaments and reproductive organs of various 
 algee. These algse must be regarded as purely accidental, and 
 are merely due to the fact that the sulphurous waters form a 
 suitable nidus for their propagation. The growth of algse in 
 the water of hot sulphur springs has been noticed elsewhere 
 than in the Pyrenees. In the fourteenth volume of the ' Journal 
 of the Linnean Society ' will be found an interesting paper by 
 Mr. H. ISr. Moseley, F.B.S., who accompanied the Challenger 
 expedition in the capacity of naturalist, ' On Fresh Water Algse 
 obtained at the Boiling Spring at Furnas, St. Michael's, 
 Azores, and their neighbourhood.' The whole group of the 
 Azores is pronounced to be decidedly volcanic in character, and 
 in the largest island of the group (St. Michael's) hot springs 
 abound in many parts, but notably at the western extremity 
 of the island in the valley of Furnas, where are situated the 
 boiling fountains known as the Caldeiras, which have enjoyed 
 for a considerable period no little reputation for their curative 
 action upon palsy, rheumatism, scrofula, and similar maladies. 
 Mr. Moseley describes how he cut away portions of a vegetable 
 deposit from the sides of some of the boiling springs in situa- 
 tions where the heat of the water was so intense that sfreat 
 care was necessary not to scald the hands while collecting it. 
 These hot waters contained an abundance of sulphuretted 
 hydrogen. Mr. Moseley estimates the temperature of the 
 water in which the algae were found to have been from 149° F. 
 to 158° F. This estimate was made by dipping the finger in 
 the water, since unfortunately he had no thermometer with 
 him at the time of his visit. Near the margin of the lake of 
 
 u 
 
290 SULPHUR WATERS OF THE PYRENEES 
 
 Furnas are several spots where hot gas, charged with sul- 
 phuretted hydrogen, is discharged through the water, and, 
 curiously enough, the algae were found to grow more luxuriantly 
 in the immediate neighbourhood of these discharges. 
 
 The alga peculiar to the Pyreneean sulphur springs has 
 been described by Camille Montague in the ninth volume 
 (Botanique) of the ' Annales des Sciences Naturelles,' and ha» 
 been named by him Leptomitus sulphurarius. It is said to 
 grow especially in waters having a temperature between 50° F. 
 and 100° F. It cannot exist without exposure to air, and 
 sulphur seems also to be indispensable to its proper develop- 
 ment, as well as an azotised substance dissolved in the water. 
 An alga of a very similar description has been found growing 
 in the hot water of Carlsbad, but it has been decided not 
 to be precisely similar to that which constitutes baregine. 
 Not only do vegetables flourish in these sulphurous waters, 
 but animals as well, and many species of anguillula have 
 been discovered by various observers in the waters of Bareges 
 and other bathing resorts of the Pyrenees. 
 
 It is much to be regretted that a nonsensical and mis- 
 leading name has been given to the aggregate growths which 
 occur in these sulphur waters. There is no evidence whatever 
 that they have any part in the therapeutic value of the 
 waters, and it is very undesirable that a word should be re- 
 tained which, in our present state of knowledge, not only 
 savours of quackery, but is undoubtedly used for quackish 
 jDurposes. Another regrettable fact is the part which limited 
 companies are beginning to play in the management of mineral 
 springs. It has been discovered that a spring of water, if it 
 be sufficiently puffed, is a surer and more valuable source of 
 income than a gold mine, and the statements put forward in 
 advertisements are very often absolutely unwarrantable. It 
 is desirable that the profession on the Continent, and especi- 
 ally in France, should unite for the purpose of restraining the 
 statements of those who have merely a money interest in 
 mineral springs, for it will become exceedingly difficult to 
 prescribe this or that water if, by so doing, one should seem 
 to countenance the unwarrantable assertions which are made 
 
USE OF SULPHUE WATERS 291 
 
 concerning them. It would be satisfactory if such rash 
 assertions were made only by the trading companies, but this, 
 unfortunately, is not the case ; for many of the medical 
 monographs appear to show a very undue amount of local bias, 
 and to lend a too ready credence to startling therapeutic 
 theories. It would be a great boon if the examination of the 
 mineral springs of Europe could be made by an international 
 commission which should be entirely without interest in the 
 popularity or earnings of any popular spring. 
 
 Looking once more to the nature of the waters, we see 
 that there is only one ingredient — the sodium sulphide — which 
 can fairly be credited with any therapeutic value, and if cata- 
 logued in the order of their sulphide strength they would 
 read thus — Luchon, Labassere (Bigorre), Bareges, Cauterets, 
 St. Sauveur, Eaux Bonnes, Eaux Chaudes. The amount of 
 sulphides contained even in the strongest of them is but small 
 — so small as to call forth the remark from Braun (' Curative 
 Effects of Baths and Waters,' p. 419, Weber's translation) 
 that ' only a few of them contain an amount which admits 
 the possibility of the effect of sulphuretted hydrogen.' The 
 writer can see no reason for this opinion ; for there is no 
 more difficulty in believing in the therapeutic effect to be 
 derived from a tenth or a quarter of a grain of sodium 
 sulphide than in that which is known to result from the 
 thirtieth of a grain of phosphorus or a twelfth of arsenious 
 acid. The chief use of sulphur water, according to Braun, is 
 for treating ' stasis of the portal system,' and conditions which 
 are secondary thereto, and he seems to have no knowledge of 
 their very great utility in combating the various manifesta- 
 tions of a scrofulous diathesis. It is equally remarkable that 
 Birch-Hirschfeld, in his treatise on Scrofulosis in Ziemssen's 
 Encyclopaedia, makes no mention of the sulphides in the 
 sections devoted to treatment. 
 
 The power which the sulphides possess of stimulating- 
 nutrition in scrofulous subjects whose nutrition is sluggish 
 must have been often observed by anyone who has made 
 a patient trial of their therapeutic value. At the Boyal 
 Infirmary for Children I have repeatedly ordered them for 
 
 u2 
 
292 SULPHUR WATERS OF THE PYRENEES 
 
 patients with enlarged glands ; and although I have fre- 
 quently failed to obtain any result I have at least as 
 frequently seen, as an immediate consequence of their ad- 
 ministration, activity replace torpor and absorption or sup- 
 puration be quickly produced, these effects being usually 
 accompanied by cutaneous hypersemia, and sometimes by a 
 slight tingling of the skin. 
 
 Faith in mineral waters is far more easily produced when 
 the alleged effect of the water is obviously due to the chief 
 ingredient, and when the administration of the chief ingre- 
 dient iier se produces results identical with those which arise 
 from taking a course of the waters. The fact, therefore, that 
 the sulphur waters of the Pyrenees are found chiefly useful 
 n those cases for which sulphides are administered at home 
 is greatly in favour of the genuineness of the therapeutic 
 action of the waters. 
 
 The majority of the monographs which deal with this 
 group of waters claim for them that they may be used as a 
 panacea against every known ailment ; and the reader who 
 has any yearnings after an approach to scientific therapeusis 
 soon throws them away in disgust, having only learnt one 
 important fact from them — viz. that patients visiting the 
 Pyrenees are to be warned against authors as persons of a 
 dangerously sanguine temperament. There are, of course, 
 exceptions, and amongst these may be mentioned the very 
 excellent and temperate monograph on the Waters of 
 Bareges by Dr. Armieux, and the scarcely less able treatise 
 on Eaux Bonnes by Dr. Prosper de Pietra Santa. Andrieu, 
 who published an essay on the Eaux Bonnes some thirty 
 years ago, says : ' The stimulating properties of the Eaux 
 Bonnes make them of value in cases where it is necessary 
 to rouse the torpid vitality of organs, and to contend with 
 a chronic condition by impressing on the sluggish and ob- 
 scure disease a quicker, freer, and more sharply marked 
 course.' The idea seems to have been held, at one time, that 
 the best way to cure a chronic malady was to convert it into 
 an acute one, and this power was claimed by Andrieu for 
 the waters of Eaux Bonnes. Pietra Santa, in summing up 
 
USE OF SULPHUR WATERS 293 
 
 the indications and counter-indications for employing these 
 waters, makes use of the very words of Andrieu, and says : 
 ' Chronicity, asthenia, catarrhal conditions, the scrofulous 
 diathesis, a lymphatic habit, laxity and habitual passive 
 congestion of the tissues, an obtuse sensibility with slight 
 tendency to irritability, the "herpetic diathesis," rheumatic 
 and hsemorrhoidal affections, . . . these are the conditions 
 in which the administration of the waters of Eaux Bonnes 
 is especially indicated. ... A state of inflammation, an 
 exaggerated nervous erythism, excessive pain, violent spasm, 
 copious discharges, pyrexia, pronounced plethora, colliquative 
 sweats — these are the main counter-indications, absolute or 
 relative, to the administration of these waters.' 
 
 The waters of Eaux Bonnes have a great repute in the 
 treatment of follicular pharyngitis, and in those forms of 
 phthisis which are the result of the scrofulous diathesis. 
 
 Armieux, whose position as head of the Military Hospital 
 at Bareges allows him to take an entirely unbiased view of 
 the utility of the sulphur waters, is quite in accord with Pietra 
 Santa. He says : ' One can say in general that the waters or 
 Bareges are most favourable for lax-fibred and lymphatic 
 patients suffering from sluggish affections, for the lesions 
 resulting from scrofula, and for traumatic lesions occurring in 
 subjects without rallying power or reaction in whom the 
 fibrous tissues, the lymphatic glands, and the articulations 
 readily swell, but are slow to subside.' 
 
 In the Military Hospital at Bareges great success attends 
 the treatment of the various scrofulous affections of bones and 
 joints, and during the late war it was found that sluggish 
 wounds occurring in scrofulous subjects soon became active 
 when removed to Bareges for treatment. 
 
 Hitherto the probable effect of drinking sulphur waters has 
 alone been considered, and we have found that the results 
 obtained by drinking the natural water are distinctly similar 
 to those which are brought about by taking artificially pre- 
 pared solutions, so that there is no necessity, in accounting 
 for the action of the former, to make any reference to an 
 inscrutable divinum quid. It must be remembered, however, 
 
294 SULPHUK WATERS OF THE PYRENEES 
 
 that a visitor to the Pyrenees comes under other influences 
 besides those of the sulphur in the water ; and chief among 
 these are the temperature of the water, which allows him 
 to combine hot-bathing with water-drinking ; and the height 
 above the sea-level of the place where he sojourns while 
 undergoing the cure. 
 
 That warm bathing is a valuable auxiliary in the treat- 
 ment of many chronic ailments nobody will deny, and 
 especially in those conditions occurring in scrofulous patients 
 where the nutritive processes are sluggish. It has been said 
 by Braun that 'heat favours function,' and there can be 
 little doubt that a hot bath is admirably calculated to assist 
 the action of the sulphide, which is given with a view of 
 stimulating function. There is no reason to suppose that 
 the sulphide contained in the water of the bath exercises 
 any specific effect, although possibly the vapour of hydrogen 
 sulphide which is inhaled during the act of bathing may 
 excite some beneficial influence. For bathing purposes the 
 chief merit of the Pyreneean waters is their heat, the con- 
 tained sulphide being wholly inactive. The fact that the 
 waters when drunk are taken hot may help to produce the 
 desired effect. 
 
 Of the various methods of bathing and applying the 
 waters it is not necessary to speak, for they do not materially 
 differ from those which are in use at other baths. There 
 are piscines, swimming baths, private baths, foot baths, 
 ascending and descending douches, inhalation rooms, and 
 pulverisation rooms. With regard to the pulverisation of 
 sulphur waters, it may be mentioned that Pietra Santa 
 proved conclusively that the act of finely dividing the water 
 brought about at once the oxidation of the sulphide into sul- 
 phate. 
 
 All the Pyreneean bathing resorts are at a considerable 
 elevation above the sea-level, and it has been supposed that 
 this fact has more influence on the welfare of the visitors 
 than the sulphides or other ingredients of the water. Moun- 
 tain air, like hot bathing and the sulphides, is a powerful 
 stimulant to function, so that all three of these factors in the 
 
TOPICAL DATA 295 
 
 treatment of a patient in the Pyrenees work in the same 
 direction. As regards height above the sea-level, Bareges 
 stands first, with an elevation of upwards of 4,000 feet ; then 
 follows Cauterets, with 3,000 feet ; next come in order 
 St. Sauveur, Eaux Bonnes, and Eaiix Chaudes, at a height of 
 2,500feet, 2,400 feet, and 2,200 feet respectively ; then Luchon, 
 with an elevation of 2,000 feet ; and lastly Bigorre, which is 
 only 1,800 feet above the sea. 
 
 As a matter of course, these Pyreneean health resorts are 
 used by a great variety of invalids other than those of the 
 scrofulous class. Whoever may expect to find benefit from 
 a sojourn in a mountain climate or from a systematic course 
 of warm baths will find it here as well as elsewhere. 
 Patients sufiering from rheumatism or gout, or from the 
 efiects of paralysis, come to the Pyrenees in great numbers, 
 as well as a vast crowd of semi-invalids who have lived too 
 freely or worked too hard. To these must be added many 
 more who make some real or fancied ailment the excuse for 
 spending a month or six weeks in localities which are at 
 once pleasant and fashionable. I have merely tried to in- 
 dicate that class of patients which, more than any other, 
 may expect to find relief from drinking Pyreneean sulphur 
 waters. 
 
 Since it is very necessary to know something more about 
 a health resort than its elevation above the sea-level and the 
 analysis of its water, I feel that a few words of description of 
 the various places named will probably prove acceptable. 
 There are certain points which they all have in common. 
 Natural beauties abound on every side, and in the Pyrenees, 
 as in the Alps, the wonders of nature form pleasing objects 
 for excursions and occupation for the mind . The expense of 
 getting to the Pyrenees is rather greater than that of getting 
 to Switzerland, and the time occupied in the journey is 
 rather longer. The expense of living is rather greater than 
 in Switzerland, and the cost of locomotion is considerably 
 more. All the bathing resorts are united by a magnificent 
 road, the Route Thermale, as it is called ; but there are not 
 the same facilities for the transport of persons and baggage as 
 
296 SITLPHUE WATERS OF THE PYRENEES 
 
 are found in Switzerland. The public diligences are few in 
 number and second-rate, and the only really comfortable mode 
 of locomotion is by private carriages, for which the tariff is 
 decidedly high. It is always advisable to ask what price is 
 to be paid for a room before engaging one in an hotel, and 
 the only way to guard against imposture is always to ask 
 beforehand what price is to be paid for everything. The 
 following passage, taken from Dr. Armieux's monograph, 
 gives an excellent notion of some of the worse qualities of the 
 inhabitants. My own short experience fully accords with 
 that of the writer : ' Les Baregeois sont intelligents, leur 
 imagination est vive, ils sont tres pres de leurs interets, et ne 
 se font aucun scrupule quand il s'agit d'obtenir le plus 
 d'argent possible des services qu'ils rendent aux etrangers. 
 Dans un pays ou chacun est proprietaire il n'y a pas de 
 pauvres ; cependant on voit beaucoup de mendiants, et les 
 petits enfants sont instruits de bonne heure a tendre la main 
 aux passants, avec cette particularite caracteristique que, 
 quand on leur refuse, ils vous insultent, et que si Ton se 
 fache ils vous jettent des pierres. L'argent gagne pendant la 
 saison thermale n'est pas employe a ameliorer le bien-etre de 
 la famille et a amasser des reserves pour la morte saison. De 
 deplorables habitudes se sont introduites dans ces paisibles 
 vallees, et I'intemperance des deux sexes est un objet 
 d'etonnement et de degout pour le voyageur.' 
 
 As regards accessibility, Eaux Bonnes and Eaux Chaudes 
 are each about twenty miles from Pau, which is the nearest 
 railway station. Cauterets, St. Sauveur, and Bareges are 
 at distances varying from five to ten miles from the railway 
 terminus at Pierretitte, while Luchon and Bigorre have each «u 
 railway station in the town. 
 
 Eaux CJiaudes is a quiet place, situated in a very narrow 
 gorge, and has all the disadvantages of places so situated — 
 viz. great cold before the sun's rays reach the bottom of the 
 gorge, great heat during the middle of the day, and in- 
 cessant draughts. It is not a place for persons with weak 
 iungs. 
 
 Eaux Bonnes is fashionable and lively, and is built into a 
 
BIGOERE 297 
 
 rocky cul de sac with sides which are absolutely perpendicular. 
 Many of the hotels have rooms literally hewn out of the rock. 
 The centre is occupied by a garden, where the band plays. The 
 situation of the town is very picturesque, and the huge rocky 
 summit of the Pic de Ger overhanging it forms a most striking 
 object. Nearly every house in the place is an hotel or a 
 lodging-house, and in the height of the season the populatir)n 
 is almost dangerously dense. 
 
 Cauterets is a large, fashionable place, attracting thousands 
 of visitors during the season. It is surrounded by hills on 
 every side, but it is less closely hemmed in than Eaux Bonnes. 
 Here, as at Eaux Bonnes, every kind of amusement is pro- 
 vided. 
 
 St. Sauveur is a quiet place, built on one side only of a 
 tolerably wide valley. From it the Cirque of Gavarnie, one 
 of the most interesting natural curiosities of the Pyrenees, is 
 easily reached. 
 
 Bareges consists of one long, straggling, old-fashioned 
 street, built on the side of a hill facing the west. There are 
 several hotels, but few of them are really first-rate. Bareges 
 is more frequented by genuine invalids, probably, than any 
 other point in the Pyrenees. Owing to its elevated situation 
 the climate is rough at times, and but little suited for persons 
 with delicate lungs. There is a famous military hospital here, 
 and the Pic du Midi and some of the grandest scenery in the 
 Pyrenees are within easy reach. 
 
 Luchon is decidedly the most fashionable of all the Pyreneean 
 health resorts, and for beauty of situation it certainly eclipses 
 all the others. It lies in a wide, well watered, and verdant 
 valley, facing the north, and being in close proximity to some 
 of the highest mountain peaks it is as much frequented by 
 tourists as invalids. The hotels are numerous, and are mostly 
 first-rate, and the visitors are largely composed of French and 
 English fashionables. Few pleasant er places than Luchon for 
 spending a summer holiday could be found. 
 
 Big or re is situated on the Adour just where the mountain 
 slopes subside into the plains of Tarbes. Unlike the place* 
 I have previously mentioned, Bigorre is not a mere bathing. 
 
298 SULPHUE WATEKS OF THE PYRENEES 
 
 resort, or vilh dete^ but is the capital of an arrondissement, 
 and a town of some local commercial importance. Its per- 
 manent population is considerable, amounting to nearly 10,000 
 persons. Its sources of water are very numerous, and the 
 waters are varied in character, only a few of them being 
 sulphur waters. Its hot springs were well known to the 
 Romans. The town is picturesque, and is well provided with 
 good hotels. Some of the winter residents from Pau take up 
 their quarters in Bigorre for the summer months. 
 
•299 
 
 CHAPTER XX 
 
 LARYNGEAL SPASM^ 
 
 The involuntary contraction of a muscle, which we call 
 ' spasm,' is of two kinds, prolonged and momentary, tonic and 
 clonic. A typical tonic spasm has occasionally been seen and 
 felt by everybody during an attack of cramp in the calf of the 
 leg. The muscle is hard and contracted, and there can be no 
 doubt about the condition. ' Clonic spasms ' are often so 
 rapid that the condition of the muscle is rather to be inferred 
 than demonstrated. The various forms of tremor, the jerking 
 movements of nystagmus, or of histrionic spasm, the unpre- 
 dicable jerking of chorea, post-hemiplegic movements (co- 
 ordinated or otherwise), and the rhythmical movements to 
 which the name of clonus is given are all samples of clonic 
 spasm. In the two acts of yawning and laughing we have, 
 as it were, the physiological prototypes of tonic and clonic 
 spasm. Both these acts, when fully developed, are accom- 
 panied by laryngeal sounds, but neither of these sounds is 
 ordinarily attributed to 'laryngeal spasm,' although there 
 can be little doubt that in both instances there is involuntary 
 movement of the laryngeal muscles, in one case tonic and in 
 the other clonic. 
 
 In yawning and laughter the sound is truly vocal, and is 
 produced in each instance mainly by expiration, any inspiratory 
 sound being only occasionally interpolated. 
 
 The word ' spasm ' is also often applied somewhat loosely 
 to any sudden attack of pain or difficulty ; but it is well to 
 remember that when we speak of intestinal, renal, biliary, or 
 pulmonary spasm the actual condition of any muscle con- 
 
 ' Medical Chronicle, 1895. 
 
BOO LARYNGEAL SPASM 
 
 cerned is more a matter of inference than demonstration. 
 The term ' laryngeal spasm ' is usually reserved for certain 
 sudden attacks of inspiratory dyspnoea, or for certain laryngeal 
 sounds suddenly produced during inspiration. It is hardly 
 too much to say that every inspiratory crowing sound is liable 
 to be spoken of as ' laryngeal spasm,' although any condition 
 of spasmodic contraction on the part of any of the laryngeal 
 muscles is incapable of actual demonstration. 
 
 The act of inspiration is generally noiseless. All the inspi- 
 ratory muscles act in harmony. The act may be either forcible 
 or feeble, but the strength or weakness of the act depends on 
 a harmonious conspiracy of many muscles, which contract 
 strongly together, or feebly together, as the case may be. 
 
 Let us confine our attention to two sets of inspiratory 
 muscles only— the diaphragm and the abductors of the vocal 
 cords. With every descent of the diaphragm the abductors 
 come into play and the glottis is opened. These muscles are 
 both actuated through the respiratory centre in the medulla, 
 and the width of the glottic opening always bears a direct pro- 
 portion to the force with which the diaphragm descends. So 
 long as this direct proportion is maintained the inspiratory 
 act is noiseless, but so soon as the glottis fails to open to a 
 degree which is proportioned to the strength of the dia- 
 phragmatic contraction the act of inspiration is accomj)anied 
 Vjy stertor. 
 
 The patient who has some slight thickening of the 
 vocal cords or abductor j^araljsis of one or both cords may 
 breathe quite naturally and noiselessly, notwithstanding the 
 narrow glottis, so long as he is at rest and the diaphragm 
 is working gently and slowly ; but if he is asked to walk 
 upstairs or to run a few steps the breathing quickly becomes 
 stertorous or stridulous, because the glottic opening no longer 
 has a width proportionate to the strength of the diaphragmatic 
 contraction, and the incoming air rushes through the compara- 
 tively narrow glottis with a rapidity which is sufficient to pro- 
 duce noise. 
 
 In the cases we have imagined the noisy breathing is 
 due to the fact that the orifice of the pipe is too small for the 
 
CHLOROFOEM STEETOR 301 
 
 blast, but there is no question of muscular spasm, the rela- 
 tive smallness of the orifice being caused, in the one case 
 by exudative thickening, and in the other case by muscular 
 paralysis (!). 
 
 If the diaphragm descend with a force which is abnormally 
 great, the incoming blast may be sufficiently strong to produce 
 stertor in a normal glottis. This is heard in whooping cough 
 and in vomiting. 
 
 In whooping cough the continued and repeated action of 
 the expiratory muscles has the effect of emptying the thorax 
 to its maximum extent. The arch of the diaphragm is driven 
 upwards to the highest possible point, and when the patient 
 seems to be on the very verge of asphyxia down comes the 
 diaphragm with a force and rapidity far in excess of the 
 normal ; there is a disproportion between the incoming blast 
 and the size of the pipe, and the stertorous noise known as the 
 ' whoop ' is produced. This ' whoop,' time out of mind, has 
 been spoken of as being caused by a * spasm of the glottis,' 
 a statement which is a mere assertion incapable of proof. 
 That the glottis is too small to allow the incoming blast to 
 pass without noise is true. That the incoming blast by which 
 a paroxysm of whooping cough is terminated must of necessity 
 be one of exceptional force is certain, but whether the glottic 
 aperture be opened to its normal extent or be lessened 
 either by abductor insufficiency or adductor spasm must always 
 remain a matter of speculation. 
 
 In vomiting the abdomen is compressed, and the whole of 
 the lower part of the thorax is in a position of extreme 
 expiration. The vomiting effort being ended, down comes 
 the diaphragm, and. not infrequently a ' whoop ' is generated by 
 the exceptional blast passing through the relatively small glottis. 
 
 In the same way, and from similar causes, one has heard 
 a ' whoop ' occasionally interspersed among the noises of a 
 paroxysm of uncontrolled laughter. 
 
 Perhaps the most common instance of laryngeal stertor is 
 'hiccup,' when the contraction of the diaphragm, taking place 
 suddenly and irrespective of any respiratory need, is not 
 accompanied by any corresponding abduction of the vocal 
 
302 LAKYNGEAL SPASM 
 
 cords. Hiccup has frequently been spoken of as a laryngeal 
 spasm ; but of this there is no evidence whatever. It is 
 probably much nearer the truth to speak of it as a dia- 
 phragmatic spasm caused by local or reflex irritation, and 
 occurring at a time when the glottis is not sufficiently 
 open to allow the noiseless passage of the sudden incoming 
 blast. 
 
 In the administration of chloroform, when the patient 
 is deeply under the influence of the anaesthetic the act of 
 inspiration is liable to be accompanied by a slight laryngeal 
 stertor, a sound which warns the administrator to be careful, 
 and tells him that the respiration is encumbered. This stertor 
 has been spoken of as due to glottic spasm, but, in reality, it 
 is almost certainly due to paralysis of the abductors, which 
 succumb to the influence of the narcotic earlier than the 
 diaphragm. The diaphragm contracts vigorously at a time 
 when the posterior crico-arytsenoid muscles, following the lead 
 of the other voluntary muscles, are beginning to fail ; the 
 glottis is not opened, the volume of the blast is too big for 
 the orifice, and stertor is the result. 
 
 The laryngeal stertor of chloroform narcosis, which is 
 always a sign of danger, will often disappear if the chin of 
 the anaesthetised person is pulled upwards ; and if this fails 
 the tip of the tongue must be seized in a pair of forceps and 
 be pulled forward with a sharp sudden jerk. This manoeuvre 
 is effectual by its reflex effect upon the abductors of the 
 glottis, and not by a mere mechanical pulling forward of the 
 mass of the tongue. It was Sir Joseph Lister who pointed 
 out that for the removal of laryngeal stertor the effect pro- 
 duced upon the tip of the tongue must be of a sharp stimu- 
 lating character. 
 
 So far reasons have been given for doubting the dogma 
 that laryngeal stertor is caused by a spasmodic action of the 
 adductor muscles of the glottis. Direct observation of the 
 larynx at the time of the stertor is impossible, and even were 
 it possible we should only be able to infer the condition of the 
 laryngeal muscles from the position of the vocal cords, and the 
 difficulty of determining whether any abnormality of the glottic 
 
LAEYNG-ISMUS STEIDULUS 303 
 
 aperture was due to over-action of one set of muscles, or under- 
 action of their antagonists, would still confront us. 
 
 There still remains for consideration one condition which 
 is enshrined in all the text-books of medicine as a spasmodic 
 disease, and is regarded by many as a disease of the nervous 
 system allied to epilepsy, angina, or chorea, and which has 
 received the name of laryngisimis stridulus. This is a disease 
 which is met with almost exclusively among very young and 
 rickety children. As a rule the child is awakened by, or 
 is seized on waking from a sound sleep with, an acute 
 difficulty of breathing, accompanied by a crowing noise. The 
 difficulty of breathing is extreme, so that evidence of an 
 asphyxial condition is apparent in the countenance, and if 
 this condition is prolonged there are not uncommonly con- 
 tractions of the hands and feet, which have been spoken of as 
 carpo-pedal contractions, and the occurrence of which has 
 been considered as affording a reason for considering the 
 laryngeal condition spasmodic, and for placing the disease 
 among the neuroses. 
 
 Laryngismus stridulus is a symptom of rickets, and occurs 
 only in those who have the soft bones and cartilages, the 
 flabby muscles, and the general anaemic feebleness which are 
 characteristic of that condition. 
 
 Many rather fine spun theories have been put forward to 
 account for laryngismus by referring its pathology to the 
 nerve-centres, but it is not too much to say that none of these 
 are entirely satisfactory. 
 
 It seems to me to be more reasonable to assume that this 
 sudden difficulty in breathing arises from the softness and 
 feebleness of cartilage and muscles and other tissues, and that 
 when the child calls, so to say, upon its diaphragm for a more 
 vigorous contraction than usual the glottis fails to open 
 adequately and the soft parts sink inwards. 
 
 When Marshall Hall was experimenting on ' asphyxia ' he 
 tied the nozzle of a big syringe into the tracheal end of a 
 donkey's trachea and larynx removed from the body. He 
 found that when the piston of the syringe was withdrawn 
 gently air passed freely through the larynx, but that if the 
 
304 LARYNGEAL SPASM 
 
 piston were withdrawn suddenly the upper end of the larynx 
 was driven inwards by the pressure of air, and the passage of 
 air through the larynx was arrested. This experiment is 
 interesting, but one must remember that there is a great 
 difference between a dead larynx and a living one, and that 
 the posterior crico-arytsenoid muscles, whose duty it is to open 
 the door for the incoming blast, play a most important part in 
 the act of respiration. 
 
 We have only to look at the pigeon breast of a rickety 
 child in order to be reminded of Marshall Hall's experiment 
 alluded to above, and to be impressed with the fact that the 
 softest part of the too flexible thorax of these flabby little 
 patients cannot withstand the external pressure of the atmos- 
 phere when the diaphragm descends. The respiratory power 
 of rickety children, in consequence of their soft bones and 
 feeble muscles, is necessarily imperfect ; it is very difficult (if 
 indeed it is possible) for them to inflate their lungs completely ; 
 they are very prone to sufier from partial collapse of the lung, 
 and it is well known that rickety children form a large pro- 
 portion of the victims of respiratory disease. Children 
 circumstanced as are the rickety, who cannot play, who dislike 
 to be moved, who habitually keep perfectly still and work 
 their diaphragms at half pressure, now and again feel the need 
 of a really deep breath, and this is especially the case when 
 the feeble respiration has been still further reduced by sleep. 
 When the diaphragm descends with extra force the crico- 
 arytjenoidei postici do not contract with proportional force, 
 and the flabby larynx closes before the external pressure of 
 the air and the soft epiglottis is driven down upon the larynx 
 before the inspiratory current. The tube of the larynx, not 
 being stiflf enough, collapses, just as the indiarubber tubes of 
 an aspirator are liable to do. Incarceration of the epiglottis 
 in the upper part of the larynx has been described as occur- 
 ring in this condition, a fact which would lend considerable 
 support to the argument which I have advanced. All the 
 phenomena which follow the closure of the rickety child's 
 windpipe are consequent upon it, and are bred of terror phis 
 asphyxia, and any convulsions from which the child may suffer 
 
TREATMENT 805 
 
 may be regarded as a consequence of the asphyxial condition, 
 which, as a cause, is perfectly adequate, and renders it 
 gratuitous on our parts to seek another explanation. 
 
 Few of us have had the experience of suddenly awaking 
 from sleep with an impermeable windpipe. It is difficult, 
 however, to imagine anything which can be more distressing 
 or alarming, or bring more vivid conviction of impending 
 death. 
 
 This question as to whether in laryngismus stridulus the 
 phenomena are caused by muscular cramps in the larynx or 
 by the collapse of the soft tissues out of sheer feebleness is by 
 no means unimportant, because the treatment to be adopted 
 will necessarily be influenced by the view which is taken by 
 the practitioner of the pathology of the disorder. Is the child 
 to have antispasmodics or tonics ? Is it to have chloroform 
 for the spasm and to be drenched with chloral, bromide, bella- 
 donna, et hoc genus omne, or is the tongue to be pulled sharply 
 forward, as in chloroform stertor, the respiration to be roused 
 by cold affusion, and, subsequent to the attack, the body to be 
 strengthened by fresh air and the various means, dietetic and 
 therapeutic, which need not be dwelt upon here ? 
 
 The fact that the strengthening and rousing regimen— cod- 
 liver oil and iron, milk, and cold bathing — is that which finds 
 most favour with writers on the subject is perhaps another 
 argument for abandoning the spasm theory in relation to the 
 stridulous dyspnoea of the rickety. 
 
 So many reasons have been brought forward for doubting 
 whether many of the conditions which are associated with 
 laryngeal stertor are really due to a spasmodic cramp-like 
 action of the adductors of the cord that one is compelled to 
 ask whether spasmodic closure of the glottis ever occurs 1 Its 
 occurrence, as has been said, must always be a matter of 
 inference rather than demonstration. To use the laryngoscope 
 during an attack of spasm is impossible, and even could this 
 be done the cause of a narrow or closed glottic chink would be 
 doubtful. 
 
 When a crumb ' goes the wrong way,' and there occurs 
 that cataclysmic explosion of coughing and stridor which we 
 
 X 
 
806 LARYNGEAL SPASM 
 
 have all witnessed, it is in the highest degree probable that a 
 spasmodic action of the adductors of the vocal cord is one of 
 the elements of the crisis ; but as this is in the highest degree 
 purposive, and is, as it were, Nature's therapeusis to prevent 
 the crumb being drawn inwards, and to enable the patient 
 to expel it by coughing, it can hardly be regarded as patlio- 
 logical. 
 
INDEX 
 
 Albuminueia in relation to Life 
 
 assurance, 234 
 Appetite, 218 
 Auto-intoxication, 205 
 — — from excessive exertion, 
 
 207 
 
 Bed-sobes, 152 
 Brachial plexus, 3 
 Bradshawe Lecture, 1 
 — W. W., Memoir of, 1 
 
 Cheonic fatigue ; 65 
 Clubbing of fingers, 250 
 Compositor's cramp, 71 
 Congenital heart disease, 242 
 Contracture of arm, case of, 88 
 Contracture of hand, 12 
 Cortical paralyses, 10 
 Cramp from tying pickle-jars, 72 
 Cyanosis, causes of, 249 
 
 Deep reflexes, variations of, 140 
 Degeneration and regeneration of 
 
 nerves, 20 
 Devonshire colic, 184 
 Diet in chronic heart disease, 
 
 258 
 Diuretics in chronic heart disease, 
 
 259 
 
 Effobt and strain 
 heart disease, 257 
 
 in chronic 
 
 Fatigue, 54 
 
 Fobtal conditions of heart, 246 
 
 Food poisoning, 192 
 
 Food toxins, 198 
 
 Gold-beateb's cramp, 83 
 Gout, clinical lecture on, 211 
 Gout, diet in, 217 
 
 H^MATUEIA, 224 
 — treatment, 230 
 Hammerman's cramp, 97 
 Hand, nervous affections of, 2 
 
 relations of, 2 
 
 Heart disease chronic, manage- 
 ment of, 253 
 
 Laedees, construction of, 202 
 Laryngeal spasm, 299 
 
 whooping cough, 301 
 
 hiccup, 301 
 
 chloroform stertor, 302 
 
 laryngismus, 303 
 
 Lead-line, 179 
 
 Lead paralyses, seat of lesion, 
 
 183 
 Lead-poisoning, 172 
 
 and gout, 177 
 
 treatment, 188 
 
 Left-handedness, 73 
 Liver, acute yellow atrophy, 166 
 Lumbricales muscles, 9 
 Lung, tumour of, 281 
 
308 
 
 
 Lung, tumour of, physical gi^s, 
 
 282 
 post mortem, 284 
 
 Mercurial tremor, 86 
 Mirror-writing, 74 
 Muscular strain, prolonged, 60 
 Myelitis, implicating sympathetic, 
 130 
 
 — from tumour of vertebrae, 135 
 
 — syphilitic, 142 
 
 — treatment, 151 
 
 — urinary complications, 151 
 
 Nerve tenderness, 51 
 Neuritis, 68 
 
 Paralysis from cold, 72 
 Phosphorus and fatty degenera- 
 tion, 161 
 Phosphorus poisoning, 155 
 
 — — urine in, 163 
 
 treatment, 170 
 
 Piano-playing, 109 
 
 Polio-myehtis, 17 
 
 Professional neuroses, 26 
 
 Ptomaines, 199 
 
 Pulmonary tuberculosis, 265 
 
 overcrowding as a cause, 
 
 265 
 
 individual susceptibility, 268 
 
 general management, 269 
 
 — — health resorts, 271 
 
 drug treatment, 273 
 
 post-hoc fallacy, 273 
 
 use of garlic, 275 
 
 Pyrenees sulphur waters, 286 
 analyses, 287 
 
 — algffi in, 289 
 
 Pyrenees sulphur waters, relative 
 strength, 291 
 
 — use in scrofula, 291 
 
 topical data, 295 
 
 Eaw food, importance of, 204 
 Keaction of degeneration, 174 
 
 Sawyer's cramp, 123 
 Spasm, post hemiplegic, 14 
 Spinal myelitis, 129 
 
 Tailor's cramp, 76 
 
 Telegraphist's cramp, 75 
 
 Tonics in chronic heart disease, 
 
 261 
 Traps, danger of, 203 
 Trophic lesions, 23, 145 
 
 Uric acid, 216 
 
 Vomiting in renal disease, 229 
 
 Writer's cramp, 26 
 
 Writing, analysis of, 58 
 
 Writing difficulty, from nerve 
 
 injury, 34 
 
 from cerebral causes, 36 
 
 from slight hemiplegia, 43 
 
 from left-handedness, 44 
 
 from chronic degenerations 
 
 of brain or cord, 44 
 
 wuth nerve-tenderness, 45 
 
 with changed irritability of 
 
 muscle, 46 
 muscles implicated in, 47 
 
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