THE 
SCIENCE AND PRACTICE 
OF 
MEDICINE. 
BY 
WILLIAM AITKEN, M.D., Edin., 
PROFESSOR OF PATHOLOGY IN THE ARMY MEDICAL SCHOOL. 
Third American from the Sixth London Edition, 
GREATLY ENLARGED, REMODELLED, CAREFULLY REVISED, AND MANY PORTIONS REWRITTEN; ADOPTING 
THE NEW NOMENCLATURE, AND FOLLOWING THE ORDER OF CLASSIFICATION OF DISEASES 
PUBLISHED BY THE ROYAL COLLEGE OF PHYSICIANS OF LONDON. 
WITH ADDITIONS 
BY 
MEREDITH CLYMER, M.D. (Univ. Penn.), 
EX-PROFESSOR OF THE INSTITUTES AND PRACTICE OF MEDICINE IN THE UNIVERSITY OF NEW YORK ; 
FORMERLY PHYSICIAN TO THE PHILADELPHIA HOSPITAL; ETC., ETC. 
IN TWO VOLUMES, 
WITH STEEL PLATE, MAP, AND ONE HUNDRED AND EIGHTY WOODCUTS. 
VOL. I. 
PHILADELPHIA: 
LINDSAY & BLAKISTON. 
187 2. Entered according to Act of Congress, in the year 1872, 
By LINDSAY & BLAKISTON, 
In the Office of the Librarian of Congress, at Washington, D.C. 
SHERMAN & CO., PRINTERS TO 
THE MEMORY 
OF 
SIR JAMES CLARK, M. D. (Edin.), K. C. B., E. R. S., 
BARONET OF THE UNITED KINGDOM. 
Born December 14, 1788, and Died June 29, 1870, 
WHOSE LIFE WAS A SUBORDINATION OF SELF TO PUBLIC INTEREST, TO THE ADVANCEMENT OF 
SCIENCE AND OF HUMAN PROGRESS-A LIFE OF DEVOTION TO THE QUEEN-A LIFE 
WHOSE INFLUENCE WAS LARGELY FELT AND WISELY EXERCISED IN THE 
ADVANCEMENT OF GENERAL AND OF MEDICAL EDUCATION-AND, A 
LIFE WHOSE CONDUCT REMAINS A MODEL TO PUBLIC MEN. 
Professionally, he largely contributed to promote, by exalting, the office of the 
Physician, by establishing the aim of the Science of Medicine as the means of Pre- 
venting Disease; for " he was one of the earliest of those who saw the importance of 
Sanitary Science, and one who was ever ready with time, thought, and influence, to 
aid its progress." To accomplish this end he secured the appointment and nomination 
of the first Health of Towns' Commission ; and he lived to see the hygienic measures 
he so zealously advocated, and was the main agent in securing, put into legal shape 
and active operation, first in most of our large towns and cities, and second, in reform- 
ing the hygienic regulations of Her Majesty's British 'and Indian Army and Navy; 
thereby helping to effect a great saving of human life-Civil, Military, and Naval- 
in every region of the world. 
He mainly aided to establish the College of Chemistry, " which has done so much 
to diffuse among our manufacturing and agricultural population a knowledge of 
applied chemistry, and to advance the Science by original research." 
He was especially earnest in the establishment of the Army Medical School, now 
stationed at Netley, for the special training of medical men in Military and Naval 
Professional duties ; and he continued to the last moment of his life to take the warm- 
est interest in everything connected with that institution. 
As a Member of the Senate of the London University, and always taking an active 
interest in education, he pointed out defects in Medical education which have since 
been removed, particularly as to "making examinations as practical and thorough as 
possible by bedside examination in Practical Surgery and Medicine-a method now 
generally adopted in testing the qualifications of candidates for a license to practice 
in civil life; and in competitive examinations for those who seek to enter the military 
and naval services. He greatly aided (in 1842), in improving medical teaching, by 
pointing out to the Government of the day the urgent need for " a good and uniform 
system of Medical Education, which should be the same throughout the empire for 
every medical practitioner." IV 
DEDICATION. 
" Modest in his nature, and singularly indifferent as to the recognition of his ser 
vices, provided the end was gained, he desired not that his share in it should be known ; 
so that much of what he did is scarcely now known ; and few men knew the extent of 
his acquirements" (Obituary Notice, Royal Soc. Proceed., No. 126). 
Widely he laid the foundation of his medical knowledge and experience at home 
and abroad-and widely has that experience been beneficial to mankind-which, com- 
bined with great benevolence of character, made him so excellent a Physician, and 
secured for him the highest position in the medical world. 
He lived for many years to enjoy his retirement from the active practice of his pro- 
fession, continuing almost to the last hour of his life to take the warmest interest in 
every question connected with the improvement of our Schools of Medicine-the prog- 
ress of Hygienic Measures for the Prevention of Disease-the practical application of 
scientific knowledge for the improvement and happiness of his fellow-men and the 
promotion of human progress. 
The author was privileged by permission, in 1863, to dedicate to Sir James Clark 
the Second Edition of this work; and now, in 1871, he dedicates to His Memory this 
Sixth,, but still imperfect attempt to teach in a text-book the Science and Practice 
of Medicine. PREFACE TO THE THIRD AMERICAN EDITION. 
The appreciation of Dr. Aitken's " representative book," as a 
full and fair exposition of the Medical Art and Science of the 
day, by the profession of this country, has been abundantly 
shown by the sale of two American editions. 
The present, and third, American reprint is from the sixth 
London edition, which has been carefully revised, and in part 
rewritten. The incorporation by the Author of about four- 
fifths of the matter of the Editor in the last American edition, 
either in form or in substance, has rendered his duties compara- 
tively light in the present one. Besides new material in the 
chapters on Fevers, and Diseases of the Nervous System, there 
are additional articles by the Editor on : Camp Measles, Spinal 
Symptoms in Typhoid Fever, Typho-Malarial Fever, Chronic 
Malarial Toxaemia, Epidemic Cerebro-Spinal Meningitis, Chol- 
era Morbus, Cholera Infantum, Chronic Alcoholism, Delirium 
of Inanition, Chronic Pycemia, Syphilitic Disease of the Liver, 
Shaking Palsy, Myo-Sclerosic Paralysis, and Cerebro-Spinal 
Sclerosic Paralysis, &c. 
The Editor's additions are thus designated [ 
65 West Thirty-eighth Street, New York, 
August 1, 1872. PREFACE TO THE SIXTH EDITION. 
Fourteen years have passed away since the first edition of 
this work was published; and five editions of it having been so 
favorably received since that time, I trust that this-the sixth 
edition-may deserve and continue to retain the confidence alike 
of Students of Medicine, of Teachers, and of the Profession. 
I have conscientiously endeavored to make each addition an 
improvement on its predecessor; and as with previous editions, 
so with this one, I have aimed at giving as faithfully and as fully 
as I can, the ideas and the views of the more advanced and able 
Physicians of the time, desirous that this text-book should be 
"a representative book" of the Medical Science and Practice of 
the day, as actually understood and followed by the best men of 
our profession. 
It aims, indeed, at being a text-book for Students of Medicine, 
following such a systematic arrangement as will give them a con- 
sistent view of the main Facts, Doctrines, and Practice of Medi- 
cine in accordance with accurate physiological and pathological 
principles and the present state of Science. 
During the past eighteen months I have been engaged in a 
careful revision of the whole work (which has been out of print 
nearly twelve months); and stimulated by the great encourage- 
ment I have received, I have spared no exertion to improve it 
and make it worthy of continued confidence, as orthodox in its 
aim and practical in all its details. 
The plan of the work has been again remodelled, so as to VIII 
PREFACE TO THE SIXTH EDITION. 
embrace a consideration of the topics in the order of the classi- 
fication of the College of Physicians of London, whose nomen- 
clature I had already followed in the last edition, thereby tend- 
ing to remove the difficulties which arise from the complexity 
and indefiniteness of medical terminology. 
It is still, however, a subject of regret that the medical pro- 
fession do not adopt a uniform system of Nosology-so essential 
for the purposes of Diagnosis and the Registration of Diseases 
and of Deaths-indeed, altogether " indispensable for the gath- 
ering in of trustworthy statistical information and knowledge 
respecting disease." 
Fully impressed as I am with the necessity for such uniformity 
of nomenclature, the profession cannot hope to see it secured 
unless a uniform system of naming diseases be taught in the 
Schools of Medicine. To aid in this education, I have endeav- 
ored to adhere closely to the new nomenclature, more especially 
as it has become the authoritative nomenclature of the country. 
The Secretary of State for War, the Board of Admiralty, and 
the Secretary of State for India have all and severally adopted 
the work of the College of Physicians, and have distributed it 
to the medical officers of their respective departments. 
It is now also put, at the expense of Her Majesty's Govern- 
ment, into the hands of every registered practicer of medicine 
in England, Scotland, and Ireland. 
Thus, issued with the stamp of authority, its use is secured in 
the records of all the public services-most of the large public 
hospitals of the country having previously adopted, spontane- 
ously, the new nomenclature and classification. 
It would now also be a good example if the Fellows of the 
London College of Physicians would themselves individually 
adhere steadily, in their published writings, to their adopted and 
accepted nomenclature. PREFACE TO THE SIXTH EDITION. 
IX 
The amount of matter contained in these volumes has very 
greatly increased-an increase which implies many more con- 
siderable changes (which it is hoped are improvements), as well 
as additions, than can be made obvious in a preface. The addi- 
tions and changes thus made are widely and generally distributed 
throughout every chapter of the book. 
Compared with the previous edition, the new material added 
in the present is equivalent in bulk to a third volume added to 
the last edition; yet the size of the work is not increased, as a 
special font of type was cast to enable the printer to preserve 
clearness without adding to the bulk of the volumes. 
Thus I have endeavored to embody an account of all the more 
recent advances in the Science and Practice of Medicine, which 
during the past fourteen years have been unusually numerous 
and important. Many chapters have been to a great extent re- 
written and remodelled, many new topics have been added, and 
every part has been thoroughly revised. 
The subjects composing Part I have been greatly expanded 
by " topics relative to pathology and morbid anatomy," which 
the classification of the College of Physicians rendered it neces- 
sary to notice as introductory to succeeding parts. Numerous 
additions have also been made where topics of importance had 
only been shortly noticed before; while the sections on the Pre- 
vention and Treatment of Diseases have been more fully consid- 
ered and expressed. 
The work has been to a great extent, indeed, rewritten; and 
descriptions of many diseases, altogether omitted in former edi- 
tions, are now introduced-so much has the new nomenclature 
and classification done to render uniform and to consolidate in- 
formation relative to diseases; and to render necessary a notice 
of topics which otherwise were lost sight of from the absence of 
that consolidation and uniform connection which the authority 
of the College of Physicians has now given by their classifica- 
tion of diseases, and which no single person could have accom- 
plished. X 
PREFACE TO THE SIXTH EDITION. 
The diagrams illustrative of the typical ranges of body-tem- 
perature in febrile diseases (which were given in the third edition 
of this work, in 1863, for the first time in a text-book) have 
been carefully reconsidered, together with the whole of this im- 
portant and practically useful subject now so generally adopted. 
The result has been that the diagrams have all, with few excep- 
tions, been redrawn and cut upon an improved model. Addi- 
tional woodcuts have been also introduced wherever it was 
thought they would render the descriptions in the text more in- 
telligible. 
In accomplishing this work I have again many obligations to 
acknowledge, as on former occasions, and especially to many kind 
fellow-workers in the profession, whom I do not personally know, 
but from whom I have received most useful hints in their oblig- 
ing communications, to be remembered by me with gratitude, 
and from which this edition has profited much. 
To my friend, Staff-Surgeon Dr. Blatherwick, in charge of 
the large Lunatic Hospital at Netley, I am indebted for many 
valuable notes and practical suggestions concerning "Disorders 
of the Intellect.'" 
To Dr. Balthazar W. Foster, Professor of Medicine in Queen's 
College, Birmingham, and Physician to the General Hospital of 
that town, I am under great obligations for his kind revision of 
the sections relating to the use of the " Sphygmograph," for much 
valuable new matter and new " Sphygmographic Tracings" in 
the sections on "Diseases of the Heart and Arteries." 
To Dr. Morell-Mackenzie, Physician to the London Hospital, 
and to his Assistant, Mr. Lennox Browne, I have to acknowledge 
the kind assistance given me in the sections where the "Laryn- 
goscope" is described and applied to the diagnosis and treatment 
of "Diseases of the Throat and Larynx," and for which Mr. 
Lennox Browne has kindly executed new woodcuts; while the 
text is partly based on the MSS. of Dr. Mackenzie's Lectures on 
" Diseases of the Throat," delivered at the London Hospital. PREFACE TO THE SIXTH EDITION. " 
XI 
To my friend Dr. T. W. Anderson, of Glasgow, I also owe 
my thanks for the woodcuts of parasitic diseases of the skin. 
My thanks are also again especially due to my friend Dr. 
Thomas Graham Balfour, F.K.S., the Chief of the Statistical 
Branch of the Army Medical Department, for his kindness in 
revising and correcting the part on " Medical Geography." To 
him, to Dr. Henry Marshall, and to the late Sir Alexander M. 
Tulloch, science is largely indebted for our knowledge regarding 
"Medical Geography and to the joint reports of these men 
may fairly be assigned the merit of having first called the atten- 
tion of the military authorities to the actual condition of the 
army in regard to health, and to the various deteriorating agen- 
cies by which the soldier comes to be affected in different regions 
of the world. That so distinguished an authority as Dr. Balfour 
should have been so kind as to revise that portion of my work 
which treats of these topics, as he has kindly done for all the 
previous editions, demands from me the most grateful acknowl- 
edgments. 
William Aitken. 
Royal Victoria Hospital, 
Netley, November, 1871. CONTENTS OF VOLUME I. 
PART I. 
TOPICS RELATIVE TO PATHOLOGY AND MORBID ANATOMY. 
CHAPTER I. 
PAGE 
Of Medicine as a Science and as an Art : its Objects and its Extent, . 49 
Medicine to be Studied as a Science and as an Art, 49 
Medicine considered as a Science, ......... 49 
Medicine considered as an Art, . . . . . . . . .49 
Topics of Human Knowledge which make up the Science of Medicine, . . 49 
Division of the Science into the Departments of-(1.) Physiology; (2.) 
Pathology; (3.) Therapeutics; (4.) Hygiene, 49 
The " Institutes," " Institutions," or " Theory of Medicine," . . . 59 
Principles of Pathology the most useful Guide to the Student, . . 50 
CHAPTER II. 
How the Province of Pathology is Mapped Out, 50 
Inquiry into the Nature or Pathology of Diseases embraces certain Topics : . 50 
1. Accurate Observation and Correct Registration of Facts in Pathology, 50 
2. Descriptive Pathology, General and Special, . . . . .50 
Range or Province of Special Pathology, 50 
Range or Province of General Pathology, ....... 50 
Accuracy of Observation the First Lesson for the Student to Learn, . . 50 
Registration of Facts in Pathology in Authentic and Permanent Forms, . 51 
(a.) History of Cases of Disease from their Origin to their end; (5.) 
Statistics of Disease, ......... 51 
Range or Province of Speculative Pathology, ...... 51 
Province of Pathology to Dictate the Maxims of Rational Practice, . . 51 
Subjects Treated of in the first part of this Work, and General Plan of this 
Text-book, 51 
CHAPTER III. 
Relative Nature of the Terms "Life," "Health," "Disease," . . 52 
Meaning implied by the Term " Disease," . . . . ■ . .52 
Meaning implied by the Term " Life," ........ 52 
Conditions of " Health " have considerable Latitude, . . . . .52 
Many Degrees of Feebleness and Delicacy of Health, 52 
Indefinite Notions of " Normal Life," . . . . .. . .52 
Indefinite Notions of " Disease," ......... 52 
Elements Required in a Definition of any State of Disease, . . . .52 XIV 
CONTENTS OF VOLUME I. 
CHAPTER IV. 
PAGE 
How the Nature and Causes of Diseases may be Elucidated, . . 53 
Aspects under which Diseases may be Studied, ...... 53 
1. Clinical Investigation and Instruction, . . . . . .53 
Natural History of Diseases a Special Subject of Study, . . . . .53 
2. Special Pathology or Special Nature of Particular Diseases, . . 53 
3. Primary Elements of Disease or General Pathojogy, . . . .53 
Subjects for Investigation by the Student, .... . . 53 
Symptoms of Disease {Symptomatology), and how Symptoms are Converted 
into Signs, ............ 53 
Causes of Disease {Etiology), . . . . . . . . .53 
Localities of Disease {Pathogeny), ......... 53 
Morbid Alterations in Textures {Lesions and Morbid Anatomy), . . .53 
Elementary Constituents of Disease {Morbid Histology), ... . . 53 
CHAPTER V. 
Of Morbid Phenomena, Symptoms, and Signs of Disease, . . . .53 
Meanings attached to the Terms "Symptom," "Sign," and "Diagnosis," . 53 
How "a Diagnosis is made" by the Conversion of "Symptoms" into 
"Signs," . . . . . . . . . . . .53 
How " a Prognosis is made" by Forecast of Events, . . . . .54 
Symptoms which are Pathognomonic of Disease, ...... 54 
Methodical Examination of Patients necessary, . . . . . . 54 
Works recommended for Study, ......... 55 
CHAPTER VI. 
Morbid Anatomy and Pathological Histology : the Special Means and 
Instruments by which the Nature of Diseases may be Investi- 
gated, 55 
Definition and Province of Morbid Anatomy, ...... 55 
Morbid Anatomy is a record of Facts, ........ 55 
Relation of Morbid Anatomy to Pathology, ....... 55 
Morbid Anatomy and Pathological Histology, ...... 55 
Medicine as a Science is Influenced by the Details of Morbid Anatomy, . 55 
Historical Retrospect of Morbid Anatomy, ....... 56 
Practice of Medicine Dictated by Physiology and Nature of Diseases, . . 56 
Physiology the Basis of Pathology, ........ 57 
How the Science of Pathology is being Advanced, . . ... . .58 
Delicate Physical Instruments of Research, ....... 58 
Organic Chemistry and Histology, ......... 58 
Characteristics of Medical Research, ........ 60 
Probation and Progress Characteristic of the Practical Medicine of the day, 60 
Province of Morbid Anatomy as now distinctly Defined, . . . .62 
Objects of the Science of Pathology, ........ 63 
CHAPTER VII. 
The Elementary Constituents of Lesions, as shown by Morbid Anatomy 
and other Means of Research, 63 
The Material Effects or " Stamps " of Disease, ...... 63 
Means and Instruments of Research for the Investigation of these Changes, 63 
Every opportunity to be taken of making Post-mortem Examinations, . . 64 
Forms of the Constituent Elements of Disease, ...... 64 
A. Morbid Elementary Products, ........ 65 
B. Complex Vital Processes whose Phenomena, more or less combined, 
Constitute Diseases and Lesions, ....... 66 CONTENTS OF VOLUME I. 
XV 
CHAPTER VIII. 
PAGE 
Description of Complex Morbid States, 67 
Catarrh, 67 
Definition of Catarrh, ........... 67 
Pathology and Anatomical Characters of the Disease, . . . . . 67 
Regions of Local Catarrh, .......... 67 
Evidence of Chronicity of Catarrh, ........ 67 
Results of Catarrh, 67 
Inflammation, 68 
Definition of Inflammation, .......... 68 
Pathology of Inflammation, .......... 68 
Phenomena and Theory of the Inflammatory Process, . . . . .69 
Altered Conditions of Healthy Nutrition, . . . . . .' . 70 
I. Alteration of Blood Supply and Bloodvessels, ...... 70 
Redness of Inflamed Parts, .......... 71 
Dilated Bloodvessels in Inflammation, . . . . . . .72 
Determination of Blood to a Part, ......... 72 
Active Congestion, 72 
Condition of the Capillaries in Inflammation, ...... 73 
Professor Stricker's Observations, . . . . . . . . .73 
Dr. William Addison's Observations regarding the White Corpuscles, . . 73 
Dr. Augustus Waller's Observations, 73 
Cohnheim's Experiments and Observations, . . . . . .73 
Soft, Yielding, and Permeable Nature of Living Capillaries, . . .73 
Passive Congestion, ............ 74 
" Determination " and " Congestion " resulting from Irritation, . . .74 
II. Altered Constitution of the Blood as regards its adaptability to nourish the 
part, . 74 
The Altered State cannot be Chemically expressed, but may be Microscopi- 
cally Demonstrated in relation to the State of the Tissues, . . .74 
Local Changes at the Inflamed Part, 74 
Tendency of the Blood-corpuscles to Run into Piles or Rouleaux, . . .75 
The Yield of Fibrin in Inflamed Blood and in certain Diseases, . . .75 
Fibrinous Coagula in Bloodvessels, . . . . . . . .75 
Results of Fibrinous Coagula in Bloodvessels, . ' . . . . .75 
Primary Seat of the Inflammatory Process, ....... 76 
Effects of Irritants on Minute Elements of Tissue, ...... 76 
" Resolution " of Inflammation, ......... 76 
Structural Elements of Minute Arteries, ........ 76 
Structure of Capillaries, 77 
Cause of Stasis or Stoppage of the Blood and Exudation of Liquor Sanguinis, 77 
Theories regarding these Phenomena, . 77 
Theory of Henle-the Neuro-Pathological Theory, . . . . .77 
Simon's View opposed to Reflex Action, and in favor of a Direct Change 
affecting Blood, Blood-nerves, and Molecular Structure, . . . .77 
Bennett's Belief in a Vital Force acting outside the Vessels, . . . .77 
Paget and Lister's Belief in a Mutual Relation between the Blood, the Ves- 
sels, and the parts around, ......... 77 
Dr. C J. B. Williams's Belief in the Accumulation and Adhesive Properties 
of White Globules, 78 
Rokitansky and Wharton Jones's Explanation, ...... 78 
Parenchymatous Inflammation of Virchow, ....... 78 
Example of Parenchymatous Inflammation, ....... 78 
Observations of Goodsir, Allison, Simon, Virchow, and Lister, . . .79 
Products, Effects, or Events of Inflammation, . . . .80 
Local Growth of Cells, ........... 80 
Process of Resolution, ........... 80 
Phenomena of " Delitescence " and " Metastasis,"- ...... 80 
Phenomena of Exudation and accompanying Changes, . . . . .80 
Productive Effects of Inflammation, ........ 81 
Inflammatory Effusions or Exudations, ........ 81 
(1.) Serous Effusions and Examples of such, ....... 81 
Essential Characteristics of Inflammatory Effusions, . . . .82 
Site of Serous Effusion sometimes an Element of Danger, . . .82 XVI 
CONTENTS OF VOLUME I. 
FAWK 
(2.) Blood Effusions or Extravasation, ........ 82 
Post-mortem Evidence of Extravasation, ....... 82 
(3.) Inflammatory Lymph or Fibrin, . . . . . . . .82 
Typical Elementary Forms of Growth in Lymph, ..... 83 
Circumstances Modifying the Type of the Inflammatory Process, . . 83 
Granular, Molecular, or Fibrillated Development of Fibrinous Products, 83 
Corpuscular Forms of Fibrinous Products, ...... 83 
Fibrinous and Croupous Forms, ........ 83 
Plastic and Aplastic Forms, ......... 83 
Adhesive or Lymphy Inflammations, ....... 84 
False, Adventitious, or Pseudo-membranes, . . . . . .84 
Dysmenorrheal Membranes, . . . . . . . .84 
Corpuscular Forms seen in Lvmph-cells, Chyle and White Corpuscles of 
Blood, ... " 84 
Lymph of Herpes, . ' . . . . . . . .84 
Primordial Cell-forms of Inflammation-their Modes of Growth and De- 
generation of Lymph, as described by Sir James Paget, . . . .85 
Compound Granule-cell, Granule-cell, and Pus-corpuscles, . ... .85 
Formation of the Compound Granule-cell, and Mode of its Disappearance 
and its Use or Function, .......... 86 
The Swelling of Inflammation and its Cause, ....... 87 
Local and General Symptoms of Inflammation, ...... 87 
Local Generation of Heat, .......... 87 
I. Inflammatory Fever, Symptomatic Fever, or Sympathetic Fever, . . .87 
(1.) Condition of Nervous System in Inflammatory Fever, . . .88 
(2.) Condition of the Vascular System, ....... 88 
(3.) Condition of the Respiratory System, ...... 88 
(4.) Condition of Digestive System, ........ 88 
(5.) Condition of the Secerning System, ....... 88 
(6.) Condition of the Nutritive Functions, ...... 88 
Date of Febrile Disturbance, ........ 88 
General Conclusions as to Febrile Symptoms, . . . . .89 
Symptoms of Suppuration, . . . . . . . .89 
AstheAic and Sthenic Indications, . . . . . . .89 
Production of Pus, .......... 90 
II. The Typhoid Fever of Inflammation, . . . . . . . .90 
Its Type, Asthenic or Adynamic, ........ 90 
Nervous or Ataxic Symptoms, . . . . . . . . .90 
Causes of Inflammation, ........... 90 
(1.) Determining or Exciting Causes, ........ 90 
(2.) Predisposing Causes,........... 90 
Irritation, the Starting-point of Inflammation, . . . . .90 
Causes of Irritation Classified, ......... 90 
Nerve Fibres having a Special " Trophic " Function, . . . .91 
(3.) Predisposing Causes Classified, ......... 91 
Ulcerative Inflammation, 91 
Definition of Ulcerative Inflammation, ........ 91 
Pathology of Ulcerative Inflammation, 92 
Formation of an Ulcer, ........... 92 
Meaning of the terms "Ulceration," " Abrasion," and " Excoriation," . 92 
Appearance of Granulations, .......... 92 
Three Processes which Progress to Ulceration, namely: Exudation, Growth, 
and Liquefaction, ........... 92 
Healing by Granulation, ........... 92 
Healing by Second Intention, - . . . . . . . . .92 
Process of Granulation, ........... 92 
Grafting or Transplantation of Germs of Skin, ...... 93 
Repair of Parts by Granulation, . . . . . . . .93 
Reproduction of Original Tissue, how far it is accomplished, . . . .93 
Nature of Cicatrix Tissue, .......... 93 
Sites of Ulcerative Inflammation, ......... 93 
Suppurative Inflammation, 94 
Definition of Suppurative Inflammation,. ....... 94 
Pathology of Suppurative Inflammation,. . . . . . . .94 
Evidence of Formation of Pus from Pre-existing Germinal Matter, . . 94 CONTENTS OF VOLUME I. 
XVII 
PAGE 
Mucinous Exudation appertains to certain Parts, . ' . . . . .94 
Mucus as a Characteristic of Inflammation, ....... 94 
Formation of Pus-Suppuration, 94 
Description of the Pus-cell, .......... 95 
Good, Healthy, Praiseworthy Pus-Pus Laudabile, ..... 95 
Suppuration takes place under Three Conditions, ...... 95 
(1 j Circumscribed Suppuration, ......... 95 
An Abscess, Boil, or Phlegmon, . . . . . . .95 
Pyogenic Membrane, .95 
Old or Chronic Abscesses, .95 
Purulent Effusion into Cavities, ........ 95 
(2.) Diffuse Suppuration, or Purulent Infiltration, 95 
Formation of " Sloughs " and " Sinuses," ...... 96 
Pointing of a Phlegmonous Abscess, ....... 96 
(3.) Superficial Suppuration and Examples, ....... 96 
Proliferation, 96 
Pus-cells, Mucus and Epithelial Cells, Anatomically but not Physiologically 
Equivalent, ............ 97 
Process of Growth and Origin of Deepseated Pus-formation, ... 97 
Two Different Modes of Pus-formation to be Distinguished, .... 97 
Parenchymatous Inflammation, and Secretory Inflammation, ... 97 
" Centres of Nutrition " of Goodsir, ........ 97 
Three Events of Inflammation, ......... 97 
Softening or Diminished Cohesion of Tissue, ....... 97 
Interstitial Absorption, . . ... . . . . . .98 
Pointing of an Abscess, ........... 98 
Hectic Fever and its Distinguishing Characters as the Result of Prolonged 
Pus-formation,. ........... 98 
Type of Hectic Fever, ........... 98 
Symptoms of Hectic Fever, .......... 98 
Description of Hectic by Dickens-(Death of Smike), ..... 99 
Diagram of Body-Temperature in a Case of Hectic Fever, .... 100 
Plastic Inflammation, 101 
Definition of Plastic Inflammation, ........ 101 
Pathology of Plastic Inflammation, ........ 101 
Soft Lymph of Plastic Inflammation, as seen Growing from Serous Mem- 
branes, ............. 101 
Sir James Paget's Description of the Process, ....... 101 
Changes in the Elements of Lymph, ........ 101 
Process of " Proliferation," . . . . . . . ... . 101 
Proliferation of Lymph-cell Elements from Inflamed Pleura, . . , 101 
Nuclei in the Fibrinous Products of Lymph developing into Fibres, . . 102 
Fibro-Plastic Cells in Lymph developing into Fibres, ..... 102 
Perfect White Fibrous Tissue from Lymph, ....... 102 
Elements in the Lymph of Plastic Inflammation, ...... 102 
Rheumatic Inflammation, 103 
Definition of Rheumatic Inflammation, ........ 102 
Pathology of Rheumatic Inflammation, ........ 102 
Textures Implicated in Rheumatic Inflammation, ...... 102 
Gouty Inflammation, 103 
Definition of Gouty Inflammation, ...... '. 103 
Pathology of Gouty Inflammation, . . .. . . . . . 103 
Gonorrhceal Inflammation, 103 
Definition of Gonorrhceal Inflammation, . . . . . . . 103 
Pathology of Gonorrhoeal Inflammation, ....... 103 
Peculiarities of Gonorrhoeal Inflammation, ....... 103 
Gangrene, 104 
Definition of Gangrene, ........... 104 
Pathology of Gangrene, ...... .... 104 
Sphacelus, Caries, and Necrosis, 104 XVIII 
CONTENTS OF VOLUME I. 
PAGE 
Slough, Sequestrum, and Process of Sloughing, 104 
Humid Mortification and Formation of Phlyctense, ..... 104 
Dry Mortification, as from Ergotism, ........ 104 
Gangrene to be distinguished from Degeneration, . . ... 105 
"Suspenned Animation " of Parts, 105 
Passive Congestion, 105 
Definition of Passive Congestion, . . . . . . . . .105 
Pathology of Passive Congestion, or Hypersemia, ...... 105 
Active and Passive Congestion to be distinguished, ..... 105 
Confusion regarding the use of the term Congestion, ..... 106 
Relations between Active and Passive Congestion, . . . . . 106 
Examples of Mechanical Congestion, ........ 106 
Results of Mechanical Congestion of Veins, . . . . . . 106 
Passive Congestion: how it differs from Mechanical Congestion in Seat and 
Cause, ............. 107 
Examples of Passive Congestion, and Combinations of the two Forms, . 107 
Results of Passive Congestion, ......... 108 
Redness of Passive Congestion, ......... 108 
Summary of the Causes of Passive Congestion, ...... 108 
Extravasation oe Blood in Hemorrhage, 108 
Definition of Extravasation of Blood, ........ 108 
Pathology of Hemorrhage-Spontaneous or Traumatic, .... 108 
Hemorrhage by Exhalation of Blood, or Hemorrhage without Rupture, . 108 
Examples of Hemorrhages from Mechanical Obstacles to the Circulation, . 108 
Examples of Active and Passive Hemorrhages, ...... 109 
Seats of Hemorrhage and Technical Names of the Hemorrhages, . . 110 
The Effects of Hemorrhage and Signs of Danger from it, . . . .110 
Examples of Secondary Hemorrhages, . . . . . . . .110 
Conversion of Hydrocele into Haematocele, . Ill 
Cause of Hemorrhagic Pericarditis, Ill 
Hemorrhagic Diathesis, Haemophilia. Haemorrhaphilia, Hremorrhophilis-a 
disposition or constitutional liability to habitual hemorrhage, . . Ill 
Molimina Haernorrhagicum, Ill 
Symptoms of the Constitutional Tendency to Bleeding, . . •. .111 
Congenital or Acquired Constitutional Tendency to Bleeding, . . . Ill 
Its Hereditary Transmission an instance of Atavism, . . . . . 112 
Relation of the Diathesis to Scrofula and Scurvy, . ..... 112 
Special Hemorrhages and their Nomenclature, ...... 118 
Results of Blood Extravasation, ......... 113 
Pigment in Apoplectic Cicatrix, . . . . . . . . .113 
Crystals of Haematoidin in Different Forms, ...... 113 
Prognosis in Cases of Hemorrhage, . . . . . . . .114 
Treatment of Hemorrhage in Cases of Hemorrhagic Diathesis, . . . 114 
Dropsy, 115 
Definition of Dropsy, ........... 115 
Pathology of Dropsy, ........... 115 
Nature of the Fluid of Dropsy, ......... 115 
Difference between Inflammatory and Dropsical Effusions, .... 115 
Nomenclature of Dropsies, . . . . . . . . . .115 
Constitution and Analysis of Dropsical Fluids, . . . . . .116 
Origin of Dropsy, ............ 116 
Wateriness of the Blood [Hydrcemia), . . . . . . . .116 
Combined Conditions Productive of Dropsy, ...... 116 
Distinction between General Dropsy and Local Dropsy, .... 117 
Cardiac Dropsy (Dyspnoea), .......... 117 
Renal Dropsy, ............. 117 
Local Dropsy (Ascites) (Cirrhosis), ........ 117 
(Edema of Lungs (Mitral Obstruction), ........ 117 
(Pneumatosis), . . . 118 CONTENTS OF VOLUME I. 
XIX 
PAGE 
Fibrinous Deposit, 118 
Definition of Fibrinous Deposit, 118 
Pathology of Fibrinous Deposit, ......... 118 
Theories regarding the Production of Fibrinous Deposits, . . . 118 
Polypi, Fibrinous Vegetations, and Emboli, ...... 119 
Alteration of Dimensions, 119 
Definition of Alteration of Dimensions, ....... 119 
Pathology of Alteration of Dimensions, ....... 119 
(a.) Dilatation and its Definition, 119 
Pathology of Dilatation-Active Dilatation, Simple Dilatation, and 
Passive Dilatation, . 119 
Causes of Dilatation of Hollow Organs, ...... 119 
How Dilatation tends to Destroy Life, ....... 119 
(&.) Contraction and its Definition, 120 
(c.) Hypertrophy and its Definition, 120 
Pathology of Hypertrophy, ......... 120 
Conditions Essential for Hypertrophy, ....... 120 
Diagrams illustrative of the Distinction between Hypertrophy and 
Hyperplasia, ........... 121 
(d.) Atrophy, 122 
Definition of Atrophy, .......... 122 
Pathology of Atrophy, 122 
Senile Atrophy, ........... 122 
Progressive Muscular Atrophy, ........ 122 
Phthisis, Consumption, Marasmus, . ....... 122 
Degeneration, 122 
Definition of Degeneration, . . . . . . . . . . 122 
Pathology of Degeneration, . 122 
Separation of Degeneration from Substantive Diseases, .... 122 
Sir William Jenner's Account of the Nature of Degenerations, . . . 122 
The Characteristics of Degeneration, ........ 123 
Histolysis, ... .......... 123 
Degenerative Changes to be distinguished from Inflammation, . . . 123 
How the Recognition of Degenerative Changes has influenced the Practice 
of Medicine, . 124 
(a.) Fatty Degeneration-the most widely spread, ..... 124 
Examples of Fatty Degeneration, ........ 124 
(b.) Mineral Degeneration distinct from Ossification, 126 
Petrified Tissue-Petrifaction or Calcification, ..... 126 
Examples of Mineral Degeneration, ....... 126 
(c.) Pigment Degeneration-Pigmentation, ....... 127 
Examples of Pigment Degeneration, ....... 127 
Melanaemia, ............ 128 
Post-mortem Evidence of Pigmentation, ...... 128 
Origin of Blood-crystals, ......... 128 
Crystals of Hsematoidin, ........... 128 
Crystals of Hiemin, ........... 128 
Crystals of Haemato-Crystalline, ........ 129 
(d.) Fibroid Degeneration, . . . . . . . . . 129 
Examples of Fibroid Degeneration, ....... 129 
Lardaceous Disease, 129 
Definition of Lardaceous Disease, ......... 129 
Pathology of Lardaceous Disease, ......... 130 
Nomenclature of Lardaceous Disease, ........ 130 
Chemical and Micro-chemical Investigation of Lardaceous Disease, . . 130 
Directions which the Investigation of Lardaceous Disease have taken, . 130 XX 
CONTENTS OF VOLUME I. 
PAGE 
Chemical Nature of the Lardaceous Lesion, ....... 130 
Nomenclature of the Disease from its supposed Chemical Nature and Alli- 
ances, ............ .132 
Albuminoid: Nature of the Substance, ........ 132 
General Character and Anatomical Description of Tissues affected with Lar- 
daceous Disease, ........... 133 
Reaction with Iodine, . . . . . . . . . . .134 
Composition of Iodine Test for use in Post-mortem Room, .... 134 
Elements of Tissue in which Lardaceous Disease has been Demonstrated, . 134 
Diseased States with which Lardaceous Disease has been found associated, 135 
Dr. Dickinson's View regarding the Nature of Lardaceous Disease, . . 135 
Clinical History of Lardaceous Disease, . . . . . . . .136 
Signs or Symptoms associated with Lardaeeous Disease, . . . .136 
Cyst 137 
Definition of Cyst, 137 
Pathology of Cyst, . . . . . . . . . . . .137 
Theories regarding the Formation of Cysts, ....... 137 
Three Modes of Cyst Formation, ......... 138 
(A.) Simple or Barren Cysts, ......... 139 
(B.) Compound or Proliferous Cysts, ........ 139 
Examples of Simple or Barren Cysts, ....... 139 
(a.) Gaseous Cysts (Pneumatoses), ......... 140 
(b.) Serous Cysts, or Hygromata, ......... 140 
Nature of the Contents of Serous Cysts; ....... 140 
Usual Situation of Serous Cysts, ........ 140 
" Hydroceles of the Neck," ......... 140 
Instance of Serous Cyst Development Proving Fatal, .... 141 
Congenital Character of some Serous Cysts, ...... 141 
Cysts in the Gums and Mamma, 141 
(c.) Synovial Cysts, 142 
Three Modes of Formation, ......... 142 
(d.) Mucous Cysts, 142 
Examples of Mucous Cysts, and Microscopic Character of Contents, . 142 
(e.) Ranula, 142 
(f.) Sanguineous Cysts, ........... 142 
(g.) Cysts containing Oil or Fat, ......... 142 
(h.) Colloid Cysts, ............ 142 
(C.) Proliferous or Compound Cysts, ........ 142 
Example of Complex Ovarian Cysts, ....... 142 
Parasitic Disease, 
Definition of Parasitic Disease, ......... 143 
Pathology of Parasitic Disease, ......... 143 
Nature of Blight, ............ 143 
History of Parasitic Diseases, ......... 143 
Elementary Facts regarding Parasitic Disease, 144 
Hypothesis of " Spontaneous Generation," ....... 145 
Wide Range of Study required to obtain a Knowledge of Parasitic Disease^ 145 
Classified List of Human Parasites, ........ 146 
Distinction between Mature and Immature Parasites, 147 
Habitat of the Sexually Mature Entozoa, 147 
Cystic or Vesicular Entozoa to be distinguished ; Non-vesicular Parasites 
Inclosed in Cysts, .......... 148 
Examples of such Distinctions, ......... 148 
Process of Fecundation and Development of Ova, ....,' 148 
Migration of Parasites, ......... 148 
Examples of Alternate Generation or Metagenesis, ..... 148 
Lesions and Diseases caused by Parasites, ..... 149 
Cerebro-spinal Symptoms caused by Parasites, . 149 
I.-Entozoa, 
Class A.-Ccelelmintha, or Hollow Worms, .... 150 
Definition of this Class of Worms, 150 
Pathology of the Ccelelmintha, ....... 150 
A Knowledge of the Generation of these Worms necessary, .... 150 CONTENTS OF VOLUME I. 
XXI 
Fertility of the Round Worms enormous, ....... 150 
Description of the Ova and Organs of Generation in Round Worms, . . 150 
Development of the Ova in Water, ...... .# 150 
Period of Incubation of the Ova, ......... 151 
1. Description of the Ascaris Lumbricoides, ....... 152 
2. Description of the Ascaris Mystax, ........ 152 
3. Description of the Trichocephalus Dispar,. . . . . . .152 
4. Description of the Trichina Spiralis, . . . . . . . . 153 
Its First observed Occurrence in the Human Body, ..... 153 
Examples of the Parasite in the Encysted and non-Encysted State, . .154 
Drs. Cobbold's and Leuckart's Account of the Parasite, .... 154 
Symptoms in the Human Subject induced by the existence of Trichina 
Spiralis, 155 
History of Cases of its Occurrence in Man, ..... 155-159 
Its Occurrence in the Flesh of certain of the Lower Animals, . . . 156 
Its frequent Occurrence in Subjects brought to Dissecting-Rooms, . . 157 
History of the Development of the Parasite, ...... 157 
Occurrence of Severe Cases in Germany, ....... 158 
Occurrence of Cases in America, recorded by Dr. Clymer, . . . 160 
Remedies for the Destruction of the Parasite, ...... 162 
5. Description of the Filaria Medinensis, commonly called Guinea-worm 
or Dracunculus, . . . . . . . . . . . 163 
Essentially a Tropical Parasite, ........ 163 
Geographical Limits of its Occurrence, . 163 
Prevalence amongst Soldiers at different Stations, 163 
Duration of Illness caused by the Parasite, ...... 164 
Deaths resulting from Guinea-worm, ....... 164 
Great Destruction of Tissue caused by the Parasite, ..... 164 
Number of Guinea-worms sometimes found in the Human Body, . . 164 
Locality of the Body where it most frequently is found, . . . .164 
Migratory Powers exhibited by the Guinea-worm before Extraction, . 165 
Structure of the Dracunculus, ......... 166 
Forms of the Head and Tail-end of the Worm, ..... 166 
Arrangement of the Intestine and Genital Organs, ..... 166 
Parthenogenis supposed to occur with Guinea-worms, .... 167 
Symptoms of Guinea-worm in the Human Body, ..... 168 
Phases of its Existence or Forms of Life, ....... 168 
Period of the Year when Dracunculus is most Prevalent, . . . 169 
Annual periodic Recurrence of the Parasite, ...... 169 
Periods of Annual progressive Increase of the Parasite, .... 169 
Fixed Latent Period of Residence-a period of Incubation-in the Human 
Body, 169 
Cases which fix the Period of Incubation, ....... 169 
Geological Features of Locality and Soil where the Guinea-worm is 
Endemic, ............ 170 
History of the Guinea-worm and its Progeny unknown after it leaves 
the Body, 171 
Spontaneous Evolution or Expulsion of the Parasite, .... 171 
Vitality of the Guinea-worm in Water, ....... 172 
Examination of Water, Mud, and Tanks recommended, .... 172 
Description of the Tank-worm of India, . . . . . . .173 
Generation and Propagation of the Guinea-worm, ..... 174 
Periods in its Natural History to be recognized, . . . . . 174 
Contagion of Guinea-worm, ......... 174 
Problems for Solution in the History of this Parasite, .... 175 
6. Description of the Filaria Oculi-two kinds, ...... 175 
7. Description of the Strongylus Bronchialis, ...... 176 
8. Description of the Eustrongylus Gigas, ....... 176 
9. Description of the Sclerostoma Duodenalis, ...... 176 
10. Description of the Oxyuris Vermicularis, .176 
Treatment oe those Infested with Round Worms, .... 176 
Class B.-Sterelmintha, or Solid Worms, 178 
11. Description of the Bothriocephalus Latus, 178 
Regions where it Exists, 178 
Structure of the Parasite and its Ova, . ' 178 XXII 
CONTENTS OF VOLUME I. 
PAGE 
12. Description of the Bothriocephalus Cordatus, 179 
13. Description of Taenia Solium, . . . . . . . . .179 
Varieties of Tape-worms found in Man, ....... 180 
Two only of Frequent Occurrence, ........ 180 
Head of the Taenia Solium, ......... 180 
Anatomy of the Tape-worm Segments, ....... 181 
Process of Expulsion of Ova, . . . . . ... . . 181 
Contraction of Proglottides, ......... 181 
Structure of Tape-worm Ova, ......... 183 
Development of Tape-worm Embryo, ....... 185 
14. (Described at page 187.) 
15. Description of Taenia Mediocanellata, ....... 185 
16 Description of Taenia Acanthotrias, ....... 185 
17. Description of Taenia Flavopunctata, ....... 186 
18. Description of Taenia Nana, ......... 186 
19. Description of Taenia Lophosoma omitted. 
20. Description of Taenia Elliptica, ........ 186 
Immature Tape-worms, Non-sexual, Cystic, or Vesicular Parasites, . 186 
Description of (14) Cysticercus of the Taenia Solium, .... 187 
Description of the (15a) Cysticercus ex Taenia Mediocanellata, . . 187 
21. Description of the Cysticercus of the Taenia Marginata, .... 188 
22. Description of the Echinococcus Hominis, ...... 188 
Hydatids, or Echinococcus Cysts, ......... 188 
Description of the Capsule and Embryo of the Echinococcus, . . . 189 
Clusters of Echinococci Embryos, ......... 189 
Description of the Head and Hooklets, ........ 190 
Description and Nature of Acephalocysts, ....... 191 
Relation between the Cystic and Cestoid Entozoa, ..... 191 
Nature of the Experiments made to determine this Relationship, . . 192 
Kuchenmeister's Experiments, ......... 192 
Von Siebold's Experiments, .......... 192 
Experiments of Leuckart and Cobbold, . ... . . . . . 192 
Elementary Facts regarding Entozoa, . . . . . . . .194 
Cyst-infected Ration-beef from the Punjaub, ...... 194 
Drawing of Cysts from Ration-beef-Natural Size, . . . . . 195 
Sources of Taenia Ova which Infect the Ration-beef, ..... 196 
Prevalence of Watery Bag or Hydatid Cyst in Commissariat Cattle, . . 196 
Power of Preventing the Cyst-infection of Beef, ...... 197 
Customs in India favorable to Parasitism, ....... 198 
Symptoms of the Presence of Tape-worm and Cystic Parasites, . . . 200 
Prevention and Treatment of Tape-worm, ....... 200 
Prevention and Treatment of the Tape-worm and Vesicular Parasites, . 200 
Medical Treatment of Tape-worm and Vesicular Parasites, ... . . 201 
Medicinal Remedies for Tape-worm, ........ 201 
Description of Fluke-like Parasites, ........ 202 
The Rot in Sheep, . . , 203 
Egg of Distoma and Opalina, .......... 203 
Development of Distoma, .......... 203 
Distoma found in the Human Body, 204 
Fasciola Hepatica, 205 
Distoma Crassum, 205 
Distoma Lanceolatum, 205 
Distoma Ophthalmobium, 205 
Distoma Heterophyes, 205 
Bilharzia H^ematobia, 205 
Lesions from Bilharzia Haematobia, 205 
Ova and Embryo of Distoma Haematobia, 206 
Tetrastoma Renale, 206 
Hexathyridium Venardm, ' .' ' 206 
Hexathyridium Pinguicola, 207 
Symptoms of Distoma, . . 207 
•Class C.-Accidental Parasites, 207 
Description of Accidental Parasites, .... ... 207 CONTENTS OF VOLUME I. 
XXIII 
PAGE 
PENfASTOMA CONSTRICTUM IN THE LUNGS AND LlVER, .... 207 
Pentastoma Denticulatum, 207 
Pentastoma in the Human Liver, 207 
Description of the Pentastoma Constrictum and the Lesions it Produces, . 208 
Drawing of Parasite in situ in Portion of the Human Liver, . . . 208 
Drawings of the Parasite Removed from the Cysts, ..... 208 
Drawings of Pentastoma Constrictum in Human Liver, from Specimens 
preserved in the Museum at Netley since 1854, ... . 211 
Oestrus Hominis, 211 
Anthomyia Canicularis, 211 
Pathology and Treatment of Bulama Boil, . . . . . . . 212 
Larva found in Bulama Boil, . . 212 
II. Ectozoa 212 
Description of Animals living upon the Skin and Hair, and the Lesions 
they Produce, 212 
Phthiriasis, ............ 213 
Description of the Inguinal and Head Louse, ...... 213 
Nit or Egg-capsule of the Louse glued to a Hair, ..... 214 
Description of the Louse of the Eyebrows and Body Louse, . . . 214 
Description of the Distemper Louse, . . . . . . 215 
Treatment of Lousiness, .......... 215 
Description of the Itch Spider, Sarcoptes Scabiei, ..... 216 
Development of the Itch Spider, ........ '218 
Description of Demodex Folliculorum, ....... 219. 
Description of Pulex Penetrans, Chigoe or Jigger, .... 219 
III. Entophyta and Epiphyta, 220 
Definition of Algae, Confervse, and Fungi, ...... 220 
The Structural Elements of Fungi, ........ 220 
Influence of Fungi on Disease, ........ 222 
Transmission of Fungi from the Lower Animals, ..... 223 
Pathognomonic Sign of Fungic Lesions, ...... 223 
Non-identity of Parasitic Fungi, ........ 225 
Di-morphism of Fungi, .......... 226 
Multiple Forms of Fructification of Fungi, ...... 226 
Artificial Cultivation of Fungi, ........ 227 
Apparatus required for Cultural Experiments, ..... 228 
Objects aimed at by the Cultivation of Fungi, ..... 228 
Calculus and Concretion, 228 
Definition of Calculus and of Concretion, ....... 228 
Pathology of Calculus and Concretions, ....... 228 
Sources of Concretion, ........... 229 
(1.) Concretions of Protein Substances, ....... 229 
(2.) Concretions of Fats, .......... 229 
(3.) Concretions of Pigment, .......... 230 
(4.) Concretions of Uric Acid and Urates, ....... 230 
(5.) Concretions of Lime Salts, ......... 231 
(6.) Concretions of Ammonio-phosphate of Magnesia, ..... 231 
Elementary Constituents of Concretions and Calculi, ..... 232 
Malformations, 233 
Definition and Pathology of Malformations, ....... 233 
Origin of Malformations, .......... 233 
Classification of Deformities, .......... 234 
Elementary Facts in " Teratology," ........ 234 
I. Malformations Resulting from Incomplete Development or 
Growth of Parts, 234 
(a.) Of the Body generally, ......... 234 
(6.) Of the Nervous System, ......... 234 
(c.) Of the Organs of Special Sense, ....... 235 
(d.) Of the Vascular System, 235 
(e.) Of the Respiratory System, 235 
(/.) Of the Digestive System, 235 XXIV 
CONTENTS OF VOLUME I. 
PAGE 
(g.) Of the Urinary System, ......... 236 
(A.) Of the Male Organs of Generation, ....... 236 
(i.) Of the Female Organs of Generation, 236 
II. Malformations Resulting from Incomplete Coalescence of the 
Lateral Halves of Parts which should become Conjoined, 236 
(a.) On the Anterior Median Plane, ....... 236 
(6.) On the Posterior Median Plane, ....... 236 
III. Malformations Resulting from Coalescence of the Lateral 
Halves of Parts which should remain Distinct, . . . 237 
IV. Malformations Resulting from the Extension of a Commissure be- 
tween the Lateral Halves of Parts (causing Apparent Du- 
plication), 237 
V. Malformations Resulting from Repetition or Duplication of 
Parts in a Single Fcetus, 237 
VI. Malformations Resulting from the Coalescence of two Fcetuses, 
or of their Parts, 237 
VII. Congenital Displacements and Unusual Positions of Parts of the 
Fcetus, 237 
Examples of Double Monsters from One Germ, ..... 238 
Functional Diseases, 238 
Definition and Pathology of Functional Diseases, ...... 238 
Fever, 240 
Definition and Pathology of Fever, ........ 240 
Natural History of Fever generally, ........ 240 
Galen's Definition of Fever, .......... 241 
Two points to be determined where Fever is present, namely: (1.) The 
Amount of the Preternatural Heat; (2.) The Amount of the Tissue 
Change, ............. 241 
The Sequence of Phenomena necessary to be known in Fever, . . . 241 
Pernicious System of Naming Fevers from Names of Places, . . . 241 
Defervescence in Fever and its Significance, ...... 242 
Significance of the Terms "Crisis," " Lysis," and "Insensible Resolution," 242 
Usefulness of the Thermometer in Diagnosis, ...... 242 
The Usefulness of the Thermometer at the Bedside in the Diagnosis of 
Pyrexia, ............. 242 
Importance of determining the Thermometry of Disease, .... 243 
Methods of Recording the Fever-heat of the Body, ..... 243 
I. The Instruments, Methods, and Practical Rules for Observing and Record- 
ing the Temperature of the Human Body in Disease where Fever is 
present, ............. 243 
Description of Clinical Thermometers, ....... 244 
Differences in different Thermometers, ....... 244 
Verification of Instruments at Kew or Greenwich Observatories necessary, 244 
Mode of Using the Clinical Thermometer, ...... 245 
Scales of Temperature Compared, ....... 246,247 
Blank Forms for Records of Temperature, Pulse, Respiration, and Ex- 
creta, ............ 248, 249 
II. Fluctuations of Temperature within the Limits of Health, and the Cor- 
relation of the Animal Heat with the Pulse and Respiration, . . 250 
Development of Body-heat, . ., . . . . . . 250 
Normal Temperature of the Human Body, ...... 250 
Periods of Minimum and Maximum Temperature, ..... 250 
Circumstances which Influence Body-heat, ...... 251 
Correlation of Pulse and Temperature, ....... 252 
Bodily Temperature of Children, ........ 252 
III. Ranges of Temperature in Disease, 253 
Instances of Disease indicated by the Thermometer, .... 254 
Typical Ranges of Daily Temperature in certain Febrile Diseases, . . 256 
IV. Ranges of Temperature in Diseases where Fever is present, as related to the 
Amount of Excreta, . . f ...... 259 
Amount of Excreta Normal to the Body, 259 CONTENTS OF VOLUME I. 
XXV 
( PAGE 
Relation of Excreta to Fever-heat, . . . . . . . . 262 
Rev. Samuel Haughton's Table for the Determination of Urea in 
Urine, ........... 259, 260, 261 
" Getting the Turn " of a Fever, ......... 263 
Table I. Abstract of Cases in which some of the Excretions are Increased 
in consequence of the Febrile State (Dr. Parkes), . . . 263 
" II. Cases in which there was Diminution of the Excretions (Dr. 
Parkes), ........... 263 
" III. Table of Cases to show Local Lesions coincident with sudden Re- 
tention of the Excretions in Fever (Dr. Parkes), . . . 264 
Large Amounts of Urea Excreted, ......... 265 
Retention of Water in the Febrile Body, ....... 266 
Condition of the Urine in Fever, ......... 266 
Condition of the Blood in Fever, ......... 266 
Condition of the Pulmonary Excretion in the Febrile State, . . . 266 
Condition of the Nervous System in the Febrile State, ..... 267 
Conditions which combine to Produce the Complex Phenomena of Fever, . 267 
CHAPTER IX. 
Types of Disease and their Tendency to Change, 269 
Definition of the Type or Form of a Disease, ....... 269 
Results of Sanitary Science, .......... 270 
Agencies Modifying the Types of Diseases, ....... 272 
Change of Type in Continued Fever, ........ 274 
Examples of Change of Type in Disease, ....... 275 
Active Sources of Degeneracy, ......... 276 
Changes in the Medical Constitution, ........ 278 
CHAPTER X. 
Modes by which Diseases terminate Fatally, 279 
Death from Decay of Life, by extreme Old Age, 279 
Death by Syncope and Asthenia, ......... 280 
Death by Starvation, ....... .... 281 
Death by Suffocation, or Apnoea, ......... 281 
Death by Coma, ............ 282 
CHAPTER XI. 
Principles which Dictate the Treatment of the Two Complex Morbid 
Processes-Fever and Inflammation, 283 
I. As regards Fevers or the Febrile State, ....... 283 
Four Modes by which Fevers may naturally Terminate, . . . 283 
Combination of Measures necessary in the Treatment of the Febrile State, 283 
(1.) To Reduce Excessive Heat, ........ 283 
Methods of Reducing the Heat of Fever, ..... 284 
Rules for the Use of Alcohol in Fever, ..... 286 
(2.) To insure sufficient, but not excessive Excretion, and to Promote 
its Elimination in Fever, ... . . . . . . 286 
(3.) Restorative Agents in the Febrile State, ...... 287 
II. As regards Inflammation, .......... 288 
Nature of Antiphlogistic Treatment, ....... 288 
Bloodletting, ............ 289 
Immediate Effects of Loss of Blood, ....... 290 
General Rules as a Guide to Bloodletting, ...... 290 
Indications as to the Repetition of Bloodletting, ..... 292 
Methods of Bloodletting, General and Local, ..... 293 
Other Antiphlogistic Remedies, ........ 294 
Use of Purgativesand Mercury, ........ 294 
Use of Iodide of Potassium, Antimony, and Opium, .... 295 
Use of Aconite, ........... 295 
Use of Alkalies, ........... 296 XXVI 
CONTENTS OF VOLUME I. 
PART IL 
PAGE 
Methodical Nosology-Systematic Medicine, or the Distinctions and 
Definitions, the Nomenclature and Classification of Diseases, . 297 
CHAPTER I. 
The Aim and Objects of Nosology, 297 
I. The Definition of Diseases, 297 
Method of Defining Diseases, ......... 298 
II. The Nomenclature of Diseases, 299 
Principles influencing the Names of Diseases, ...... 299 
III. The Classification of Diseases, . . . . . . . . 300 
Principles of Classifying Diseases, . . . . » . . . 301 
Systems of Classification of Diseases, ....... 301 
I. According to the Nature of the ascertained Causes of Disease, . 301 
II. According to the Pathological States or Conditions which attend 
Diseases, 301 
III. According to the Properties, Powers, or Functions of an Organ 
or System of Organs being Deranged, ..... 302 
IV. According as Diseases are Structural or Functional, . . . 302 
V. According to the Pathological Nature of the several Morbid Pro- 
cesses, ........... 302 
VI. According to the General Nature and Localization of the Morbid 
States, ........... 303 
VII. According to the Principles of a purely Humoral Pathology, . 303 
VIII. According to the supposed Elements of Disease, .... 303 
IX. Dr. Stark's Classes of Diseases, . . . . , . . . 303 
X. Classification of Dr. William Farr, ...... 303 
No perfectly Philosophical or purely Natural Classification, . 304 
Conditions for a Philosophical Classification of Diseases, .... 304 
Present State and Aim of Nosology, ........ 305 
Origin of the New Nomenclature of Diseases by the College of Physicians 
of London, ............ 306 
Plan of the New Nomenclature, ......... 307 
Classification of Diseases by the College of Physicians of London, . . 307 
General Diseases (arranged into two Sections) and Local Diseases, . . 307 
Some Deficiencies of Practical Importance in the Nomenclature, . . 308 
The Future Prospects of Nosology, ........ 309 
Provisional nature of the Nomenclature, 309 
CHAPTER II. 
Tabular View of "The Nomenclature of Diseases," drawn up by a Joint 
Committee appointed by the Royal College of-Physicians of London 
(1869). 
General Diseases (Sections A and B), ........ 310 
Local Diseases, ............ 311 
Arrangement of Local Diseases, . . . . . . . . .311 
Names of Diseases of the Nervous System, ....... 312 
" Diseases of the Eye, ......... 312 
" Diseases of the Ear, . . . . . . . . .313 
" Diseases of the Nose, . . . . . . . . . 313 
" Diseases of the Circulatory System, ...... 314 
" Diseases of the Absorbent System, ....... 314 
" Diseases of the Ductless Glands, ....... 315 
" Diseases of the Respiratory System, ...... 315 
" Diseases of the Digestive System, ....... 316 
" Diseases of the Urinary System, ....... 318 
" Diseases of the Generative System, ...... 318 
" Diseases of the Male Organs of Generation, ..... 318 CONTENTS OF VOLUME I. 
XXVII 
PAGE 
Names of Diseases of the Female Organs of Generation in the Unimpreg- 
nated State, .......... 319 
" Affections connected with Pregnancy, •. . . . . . 320 
" Affections connected with Parturition, ...... 320 
" A ffections consequent on Parturition, ...... 320 
" Diseases of the Female Breast, ....... 320 
" Diseases of the Male Mammilla, ....... 321 
" Diseases of the Organs of Locomotion, ...... 321 
" Diseases of the Cellular Tissue, . . . . . . ' 322 
" Diseases of the Cutaneous System, ...... 322 
" Conditions not necessarily associated with General or Local Dis- 
eases, . ........ . . 323 
" Poisons. ............ 323 
" Injuries, ............ 324 
" Local Injuries, .......... 324 
PART III. 
The Nature of Diseases, Special Pathology, and Therapeutics, . . 326 
Objects of this Part, ........... 326 
Nature of the Diseases comprehended in the Sections A and B of the Gen- 
eral Diseases, ............ 326 
Nature of the General Diseases comprehended in Section A, 326 
Specific or Miasmatic Fevers, ......... 326 
Malarious Fevers, 326 
Epidemic Diseases, ............ 326 
Febrile Affections due to the introduction of Animal Matter in a State of 
Change, ............. 326 
Nature of the General Diseases comprehended in Section B, 326 
Constitutional Character of the Diseases, ....... 326 
Method to be followed in the Chapters relative to the Pathology of General 
Diseases, ............. 326 
Necessity for Limiting and Fixing the Significance of the Terms " Mias- 
matic" and "Zymotic," .......... 326 
Pathology of Zymotic Diseases, ......... 327 
Special Pathology, Special Diseases, ........ 327 
CHAPTER I. 
On the Nature of the Specific or General Diseases commonly called 
Miasmatic, 327 
The Blood generally is more or less Changed in the General Diseases, . . 327 
Specific Poisons believed to Affect the Blood, 328 
Nature and origin of "Acute Specific" or "General Diseases," . . . 328 
Contagious Nature of the Specific General Diseases, ..... 328 
Nature of the " Specificity " of these General Diseases, .... 328 
Essential Characters of the Specific Diseases, ...... 328 
Causes and Origin of Specific Diseases, 329 
Communication of Specific Diseases, ........ 332 
CHAPTER II. 
Theory of Specific Diseases, ... 332 
Differences in the Constituent Elements of the Diseases in Sections A and B, 333 
Additional Distinguishing Elements of Specific Diseases, .... 333 XXVIII 
CONTENTS OF VOLUME I. 
CHAPTER III. 
PAGE 
The Physiological Modes in which Poisons Act Illustrated by Anal- 
ogy with the Specific or Miasmatic Fevers, 334 
Action of Poisons Subject to Certain Laws, ....... 334 
(1.) Definite and Specific Action of Poisons, ...... 335 
(2.) Latency of Poisons, .......... 335 
(3.) Modifications of Action by Dose, Temperament, and Constitution, . 335 
Physiological Actions of Poisons, ........ 336 
Constitutional Susceptibility of some Persons to Poisons, .... 336 
The Specific Action of Poisons which Produce Specific Disease, . . . 337 
Peculiarities in the Action of Poisons which Induce Specific Diseases, . . 339 
Multiplication of the Morbid Poison in the System, ..... 340 
Protective Influence of one attack from other attacks, ..... 340 
Condition of the Blood in Specific Fevers, ....... 341 
Deaths from Specific or Miasmatic Diseases, ....... 342 
Specific Disease Poisons, .......... 343 
Endemic and Epidemic Influences, ........ 344 
[Summary of Dr. Murchison on the Pathology and Treatment of the Specific 
Pyrexise in Miasmatic Fevers], ........ 344 
CHAPTER IV. 
On the Nature of Malaria and Malarious Fevers, .... 345 
Forms of Malarious Fevers, .......... 345 
Specific Effect of Malaria Poison on the Body, ...... 346 
Persistent Pernicious Influence of Malaria Poison, ..... 347 
Causes and Modes of Propagation of Malarious Fevers, .... 348 
Conditions for the Development of Malarious Fevers, ..... 349 
Varieties of the Malarious Poison, . . . . . . . 351 
CHAPTER V. 
On the Nature of Endemic, Epidemic, and Pandemic Influences, . 352 
Whence Endemic Influences Result, ........ 352 
Conditions through which Endemic Influences become Active, . . . 352 
Question as to the Spontaneous Origin of Specific Miasmatic Diseases, . . 354 
Nature of Epidemic Influence, ......... 355 
Epidemic Influence on Constitution, and Evidence of its Presence, . . 355 
Laws of Epidemic Influence, and Conditions under which it Acts, . . 356 
Nature of Pandemic Influence, and Evidence of its Existence, . . . 357 
Nature of Animal Malaria,, .......... 857 
CHAPTER VI. 
Management of Epidemics; and on Proceedings which are advisable 
to be Taken in Places Attacked or Threatened by Epidemic 
Diseases, 359 
Possibility of Extinguishing or "Stamping out" the greater number of 
Epidemic Diseases, ........... 359 
Elementary Facts which Dictate the Steps to be taken, .... 359 
Details of Proceedings advisable to be taken in Places Attacked or Threat- 
ened by Epidemic Diseases, ..... .... 359 
Rules for the Management of Epidemics, ....... 359 
Rules for the Observation of Cases and the Government of Fever Hospitals, 362 
Processes of Disinfection, .......... 362 CONTENTS OF VOLUME I. 
XXIX 
CHAPTER VII. 
PAGE 
Pathology of the Enthetic, Implanted, or Inoculated Kind of Specific 
or General Diseases, 363 
Sources of the Poison of such Diseases, ........ 363 
Definition of Poisoned Wounds, 363 
How the Poison is Received into the System, 363 
How Germs of a Specific Kind become Directly Implanted, . . . 363 
Specific, Local, and Constitutional Effects of an Inoculated Morbid Poison, 364 
Example of the Action of a Poison from the Bite of a Bug, . . . 364 
Example of the Action of the Poison of a Cobra di Capello, . . . 364 
Changes said to be Visible in the Blood-corpuscles subsequent to the Bite, . 365 
Pathological Action and Pathology of Specific Venoms, .... 365 
Nature of the Venom Secreted by Serpents, ....... 365 
Deaths from Snake Bites in India are very numerous, ..... 366 
Names of the very Deadly Poison-snakes, ....... 366 
Nature of the Venom secreted by Serpents-its General Appearance and 
Properties, ............ 366 
Different Effects of the Venom according as it comes from Different Fami- 
lies of Snakes, ............ 366 
Effects of the Venom of the Cobra {Naja^ ....... 366 
Effects of the Venom of the Viper (Daboia), ...... 366 
Effects of the Venom of the Rattlesnake (Crotalidce'), ..... 366 
Subsequent Effects of the Action of Serpent-venom, ..... 367 
Analysis of the Symptoms from Rattlesnake-venom, ..... 367 
Chemical Analysis of Serpent-venom, ........ 368 
Digestion Destroys the Poisonous Properties of Serpent-venom, . . . 368 
Blood of an Animal killed by Snake-venom is itself Poisonous or Venomous, 368 
Morbid Anatomy of Brain, Blood, and Tissues, after death from Snake Bite, 369 
Effects of the Venom of the Cobra and Daboia Russellii, .... 369 
Effects of the Venom of the Bungarus, ........ 369 
Question regarding " Antidotes " for the Venom of Snake Bites, . . . 370 
No Antidote for Serpent-venom, ......... 370 
Changes which the Absorbed Virus of Specific Diseases Undergo in the Hu- 
man Body, ........ - . . 371 
How Specific Disease-poisons differ from Venom, ...... 371 
Evidence of Increase of Virus of Disease-poisons within the Body, . . 371 
Evidence of Transformation of their Virus, ....... 371 
Evidence of the Combination of Morbid Poisons with some Blood Compo- 
nent, ............. 372 
Evidence of Separation or Excretion of Morbid Poisons, .... 372 
Rapid Effects of the Cadaveric Poison, ........ 372 
Tardy Process of Incubation of some Poisons, ...... 372 
Varieties of Poisoned Wounds enumerated from the Nomenclature, . . 373 
CHAPTER VIII. 
On the Nature of the General Diseases of a Specific or Miasmatic 
Kind comprehended in Section B, 373 
Nature of Constitutional Diseases, ......... 373 
A Cachectic State or Bad Habit of Body, ....... 373 
Course of Constitutional Diseases, ......... 374 
Personal Peculiarities, Temperament, Diathesis, Hereditary Transmission, 
and Predisposition, ........... 374 
Alternate Generations Suffer-Law of "Atavism," ..... 374 
Blood Diseases and Constitutional Diseases, ....... 375 
CHAPTER IX. 
Detailed Description of the General Diseases-Section A, . . . 376 
Small-Pox, 376 
Definition and Pathology of Small-pox, ....... 376 
Fever and Defined Course of Small-pox Eruption, ..... 376 XXX 
CONTENTS OF VOLUME I. 
PAGE 
Morbid Anatomy of Small-pox, ......... 377 
Nature of the Small-pox Eruption, and Anatomical Structure of the Small- 
pox Pustule, . .......... 377 
Varieties and Symptoms of Small-pox, ........ 379 
Symptoms of Natural Small-pox, ......... 379 
Group A.-Unmodified or Natural Small-pox, ...... 379 
Symptoms of Distinct Small-pox, ......... 380 
Course of the Disease, ........... 380 
Typical Range of Temperature in a Case of Natural Small-pox and Fever of 
Suppuration, ... ......... 381 
Description of Confluent Small-pox, ........ 383 
Symptoms of Inoculated Small-pox, ........ 385 
Complications of Small-pox and Special Morbid Tendencies, , . . 386 
Pyogenic Fever after Small-pox, . . . . . . . . 386 
Sequelae of Small-pox, ........... 387 
Course of Small-pox after Vaccination, ...... . 388 
Group B.-Small-pox after Vaccination-Varioloid, or Modified Small-pox, 388 
Definition of Small-pox after Vaccination (Modified Small-pox), . . . 388 
Symptoms, Course, and Modifications of Small-pox after Vaccination, . 388 
Typical Range of Temperature in a Case of Small-pox Modified by Vaccina- 
tion, 389 
Exhaustion of Susceptibility after an Attack of Small-pox, . . . 389 
Coexistence of Small-pox with other Morbid States, ..... 390 
Cause and Propagation of Small-pox, ........ 390 
Causes which Predispose to Small-pox, ........ 391 
Prognosis and Causes of Death in Small-pox, ...... 391 
Diagnosis of Small-pox, ........... 392 
Treatment of Small-pox, .......... 393 
(1.) Therapeutic, Curative, or Sanative Treatment of Small-pox, . . 394 
Dietetic and General Medical Treatment of Small-pox, . . . 394 
Preventive Treatment of Small-pox, ........ 396 
(2.) The Prophylactic, Sanitary, or Preventive Treatment of Small-pox, 397 
Inoculation of Small-pox : Its Significance and Illegality, . . 398 
Cow-pox, j. 398 
Definition and Pathology of Cow-pox, ........ 398 
Pathology and Symptoms of Cow-pox, ........ 399 
Nature and History of Dr. Jenner's Discovery after 1780, .... 399 
Evidence that Animals (including Monkeys, Sheep, and Cattle) suffer from 
Small-pox, ............ 399 
Evidence of Cases of Small-pox in Man communicating Variolous Disease 
to Cows, ............. 400 
Direct Inoculation of Small-pox into the Cow from Man, .... 401 
Origin of all such Specific Poisons Unknown, ...... 401 
Means adopted to Modify the Disease amongst Animals, . . . 402 
Local Symptoms of Cow-pox in the Cow, ....... 404 
Nature of Primary Vaccine Lymph, ........ 405 
Howto Procure Primary Vaccine Lymph direct from the Cow, . . . 405 
Useful Substitute for Liquid Lymph, . 405 
Vaccination, 405 
Discovery and Nature of Vaccination by Dr. Jenner, ..... 405 
Nature and Imperfection of the Vaccination Acts, ..... 406 
Present Position of our Knowledge regarding Vaccination, .... 407 
(1.) Nature and Evidence of the Protection conferred by Vaccination, . 407 
Influence for Good of Vaccination, ....... 408 
Beneficial Influence of Perfect Vaccination, ..... 409 
(2.) How the Protective Influence of Vaccination has been Impaired, . 411 
No Definite Conclusion as to the Absolute Duration of Protection 
afforded by Vaccination, ......... 411 
Vaccine Virus apt to Deteriorate from Bad Vaccination, .... 413 
Results of Spurious Vaccination, 414 
The Operation of Vaccination, ......... 415 
Amendment of Vaccination Act of 1867 Proposed, ..... 415 
Recommendation of the College of Physicians relative to Revaccination, . 415 
Signs of Successful Vaccination, 417 CONTENTS OF VOLUME I. 
XXXI 
PAGE 
Signs of Successful Revaccination, ........ 418 
Characters of the Cicatrix after Vaccination, ...... 418 
Number and Quality of Vaccination Marks, ...... 419 
Four Degrees of Protection Indicated by Vaccination Marks, . . . 420 
Selection of Lymph for Vaccination, . 420 
Chicken-pox 421 
Definition and Pathology of Chicken-pox, . 421 
Symptoms of Chicken-pox, .......... 422 
Diagnosis of Chicken-pox, 422 
Treatment of Chicken-pox, 423 
Measles, 424 
Definition and Pathology of Measles, ........ 424 
Characters of the Eruption of Measles,........ 425 
Diagram representing the Range of Temperature in a Case of Measles in 
which the Fever is Severe, ......... 426 
Symptoms of Measles, ........... 428 
Characteristics of Severe Forms of Measles,....... 429 
[Camp Measles in the American Armies], ....... 429 
Diagnosis of Measles, ........... 430 
Prognosis in Measles, ........... 430 
Causes of Measles, . . . . . . . . . . . .431 
Propagation of Measles by Direct Communication and Infection, . . 431 
Propagation of Measles, .......... 431 
Communication of Measles by Inoculation, . . . . . . . 431 
Treatment of Measles, ........... 432 
Scarlet Fever,-Syn., Scarlatina, 434 
Definition of Scarlet Fever, .......... 434 
Significance of Synonyms in the Nomenclature of Scarlet Fever, . . 434 
Pathology and Morbid Anatomy of Scarlet Fever, ..... 434 
Three Forms of Eruption, .......... 435 
Symptoms of Scarlet Fever, .......... 436 
Varieties of Scarlet Fever, .......... 436 
Albuminuria with Anasarca in Scarlet Fever, ...... 436 
Symptoms of Simple Scarlet Fever, ........ 437 
Typical Range of Temperature in a Case of Scarlet Fever, .... 439 
Dropsy after Scarlet Fever, .......... 440 
Condition of the Urine in Scarlet Fever, ....... 441 
Anginose Scarlet Fever,. . . . . . . . . . 442 
Malignant Scarlet Fever, . . . . . • . . . . . 443 
Symptoms of Malignant Scarlet Fever, ....... 443 
Special Lesions (or Localizations of them) in Scarlet Fever, . . . 445 
Diagnosis of Scarlet Fever, . . . . . . . . . 446 
Cause and Propagation of Scarlet Fever, ....... 446 
Propagation of Scarlet Fever through Milk, . . . . . . 447 
Prognosis in Cases of Scarlet Fever, ........ 448 
Treatment of Scarlet Fever, .......... 448 
Preventive Treatment of Scarlet Fever, ....... 452 
Hybrid of Measles and Scarlet Fever, 454 
Definition of the Hybrid of Measles and Scarlet Fever, .... 454 
Pathology of the Hybrid between Measles and Scarlet Fever, . . . 454 
Symptoms of the Hybrid of Measles and Scarlet Fever, .... 455 
Symptoms of " Rotheln," .......... 456 
Lesions Seen in Fatal Cases of "Rotheln," 457 
Diagnosis of " Rotheln," 457 
Table showing the most Prominently Distinguishing Characters of Scarlet 
Fever, Rubeola, and Measles (Paterson), ...... 457 
Prognosis in Cases of "Rotheln,". 458 
Treatment of " Rotheln," .......... 458 
Dengue, 459 
Definition of Dengue, . . 459 XXXII 
CONTENTS OF VOLUME I. 
PAGE 
Pathology and Symptoms of Dengue, . . . • . . . . . 459 
Diagnosis and Treatment, .......... 460 
Typhus Fever 460 
Definition of Typhus Fever, .......... 460 
Varied Significance of the Term Typhus, ....... 460 
Historical Notice of Typhus Fever, ........ 461 
[Immunity from Typhus Fever in the American Armies during the War 
of the Rebellion], ........... 462 
Causes of Disease in the British Army in the Order of their Greatest Influ- 
ence (Note), 462 
Phenomena and Symptoms of Typhus Fever, ...... 463 
The Eruption of Typhus Fever, ......... 464 
Body-temperature in Typhus Fever, ........ 464 
Typical Range of Temperature in a Case of Typhus Fever, .... 467 
Correlation of Temperature and Pulse, ........ 469 
Table showing Correlation of Pulse to Temperature, ..... 470 
General Indications in Typhus, ......... 470 
Complications of Typhus Fever, ......... 471 
Occurrence of Convulsions and Cerebral or Head Symptoms in Typhus Fever, 471 
Secondary Pulmonic Complications in Typhus Fever, ..... 473 
Gangrene of the Pulmonary Tissue in Typhus Fever, ..... 474 
Secondary Cardiac Lesions in Cases of Typhus Fever, ..... 474 
Prognosis in Cases of Typhus Fever, ........ 474 
Combined Value of Temperature and Pulse in Cases of Typhus Fever, . 475 
Summary of Prognosis in Typhus, ........ 476 
Combinations of Symptoms and Phenomena which are of extremely Unfa- 
vorable Import, ........... 477 
. Combinations of Symptoms and Phenomena which may be regarded as of 
Favorable Import, ........... 477 
Modes of Fatal Termination, 477 
Condition of the Blood in Typhus Fever, ....... 478 
Treatment of Typhus Fever, . . . . . . . . . 478 
General Indications for Treatment, . . . . . . . . 479 
Special Indications for Treatment, ........ 479 
Guide for the Administration of Alcoholic Stimulants in Typhus Fever, . 481 
Forms of Alcoholic Stimulants in Use, ........ 483 
Necessity of Careful Nursing, ......... 483 
Treatment of Headache and Delirium in Typhus, ...... 483 
Origin and Propagation of Typhus Fever, ....... 486 
Communication of Typhus Fever by Fomites, ...... 486 
History of an Epidemic on Board the Egyptian Ship, " Scheah Geheld," at 
Liverpool in 1860, ........... 487 
Question as to the Origin of Typhus Fever de novo, ..... 488 
Summary of Evidence as to Contagious Nature of Typhus Fever, . . 488 
Conditions Essential for Propagation, . . . . . . . . 490 
Question as to the Period when a Typhus Patient ceases to Infect, . . 490 
Latent Period of Typhus Fever, 490 
Individual Susceptibility to Typhus Fever, ....... 491 
[Epidemic Cerebro-Spinal Meningitis, 492 
Definition of Epidemic Cerebro-spinal Meningitis, ..... 492 
The Name " Epidemic Cerebro-spinal Meningitis " an improper one for this 
Affection, ............. 492 
History and Geographical Distribution of Epidemic Cerebro-spinal Mening- 
itis, .............. 492 
Morbid Anatomy of Epidemic Cerebro-spinal Meningitis, .... 494 
Symptoms of Epidemic Cerebro-spinal Meningitis, . . . . . 496 
Prognosis in Cases of Epidemic Cerebro-spinal Meningitis, .... 499 
Mortality in Epidemic Cerebro-spinal Meningitis, ..... 499 
Diagnosis and Etiology in Epidemic Cerebro-spinal Meningitis, . . . 500- 
Question as to the Contagiousness of Epidemic Cerebro-spinal Meningitis, . 501 
Nature of Epidemic Cerebro-spinal Meningitis, ...... 502 
Treatment of Epidemic Cerebro-spinal Meningitis, ..... 503 
Bibliography of Epidemic Cerebro-spinal Meningitis,] ..... 505 CONTENTS OF VOLUME I 
XXXIII 
PAGE 
Enteric Fever-Syn., Typhoid Fever, . . , 506 
Definition of Enteric Fever, .......... 506 
Pathology of Enteric Fever, . . ... . . . . . . 506 
Differences between Typhus and Enteric Fever, ...... 507 
Various Beliefs Entertained regarding Enteric and Typhus Fever, . . 508 
Points of Differences between Enteric and Typhus Fever, .... 509 
Morbid Anatomy of the Lesions in Enteric Fever, with Special Reference to 
the Phenomena and Progress of the Disease, ...... 510 
Anatomy of Special Lesions in Enteric Fever, . . . . . .511 
Anatomical Forms of the Intestinal Glands, ....... 511 
Prevalence of Enteric Fever at Different Ages, ...... 511 
Elimination of the New Material from Peyer's Glands during Enteric Fever, 513 
(1.) Elimination without Ulceration, ........ 513 
(2.) Elimination by Ulceration, ......... 514 
Characters which distinguish the Ulcers of Enteric Fever from other . 
Ulcers, 514 
(3.) Elimination of Enteric Growths of Peyer's Patches by Sphacelus, . 515 
(4.) Reabsorption of Enteric Material, ....... 516 
Catarrh and Atrophy of Intestine in Enteric Fever, . . . . .516 
Mesenteric Gland-lesion in Enteric Fever, ....... 516 
Enlargement of the Spleen in Enteric Fever, ...... 516 
Pulmonary (Secondary) Lesions in Enteric Fever, ..... 516 
Tendency to Ulceration of Mucous Membrane in Enteric Fever, . . . 517 
Growth of Tubercle during Enteric Fever, . . . . . . .517 
Erysipelas, Phlebitis, and Parotitis during Enteric Fever, .... 518 
Microscopic Structure of the New Growth in Enteric Fever, . . . 518 
Symptoms, Course, and Duration of Enteric Fever, . . . . .519 
Commencement of the Disease, ........ . 519 
Characters of the Stools and the Pulse, ........ 519 
[Duration of Convalescence], ......... 519 
Condition of the Mind in Severe Cases of Enteric Fever during Recovery, . 521 
[Spinal Symptoms in Typhoid Fever, ........ 521 
Description of the Spinal Symptoms in the Famine Fever of 1848], . . 522 
Relapses of the Fever, ........... 523 
The Cutaneous Eruption in Enteric Fever, ....... 524 
[A Miliary Eruption, of slight Diagnostic value, frequently occurs in Ty- 
phoid Fever, ............ 525 
Typhoid Fever in Children], .......... 525 
The Body-temperature during Enteric, Typhoid, or Intestinal Fever, . . 525 
Duration of Attack and Mode of Recovery in cases of Enteric Fev^r, . . 529 
Diagram Showing Range of Body-temperature in a Severe and Prolonged 
Case of Enteric Fever, .......... 530 
Relapses in Enteric Fever, . . . . . . ... . 531 
Condition of the Urine in Enteric Fever, ....... 532 
I. As to Normal Constituents, . . . . . . . ... 532 
II. As to Abnormal Constituents, ........ 533 
Diagnosis in Cases of Enteric Fever, ........ 533 
Tabular Statement of the Leading Diagnostic Points in Contrast, . . 534 
[Certain Phenomena met with in Typhoid Fever, from which a certain and 
timely Diagnosis can be made], ........ 534 
Prognosis in Cases of Enteric Fever, ........ 535 
Circumstances under which Death may occur in Cases of Enteric Fever, . 536 
(1.) By Blood-poisoning, .......... 536 
(2.) By Implication of Excretory Organs, ....... 536 
(3.) By Congestion of Important Organs, ....... 536 
(4.) By Hemorrhages, . . . • . . . . . . .. . 536 
(5.) By the Exhaustion of Diarrhoea, ........ 536 
(6.) By Peritonitis, ........... 536 
Origin and Propagation of Typhoid Fever, . . , . . • . . 537 
■Elementary Facts regarding the Propagation of Enteric Fever, . . . 538 
Preventive Measures, or Measures for Checking the Spread of Enteric Fever, 539 
Details of Procedure for Checking the Spread of Typhoid Fever,. . . 540 
Question as to a Specific Poison and Origin of Enteric Fever, . . . 540 
Pythogenetic Fever of Dr. Murchison, ......... 541 
[Chief Determining Causes of Typhoid Fever in the United States Armies 
during the Rebellion], ........... 542 
Treatment of Enteric or Typhoid Fever, . 543 XXXIV 
CONTENTS OF VOLUME I. 
PAGE 
Question of Checking the Diarrhoea, ........ 545 
Good Effects of Calomel in Enteric Fever, ....... 546 
Necessity of Attending to Diet in Cases of Enteric Fever, .... 549 
[Great Care and Vigilance necessary during Convalescence], . . . 550 
Eelapsing Fever, 550 
Definition of Eelapsing Fever, . 550 
Pathology and Historical Notice of Eelapsing Fever, ..... 550 
[History of Eelapsing Fever in the United States], ..... 552 
Phenomena of Eelapsing Fever, ......... 554 
The Primary Paroxysm in Eelapsing Fever, . . . . . . 554 
The Crisis of Eelapsing Fever, . . . 555 
Diagram of Temperature in a Case of Eelapsing Fever (Herman), . . 556 
The Eelapse or Eecurrent Paroxysm in Cases of Eelapsing Fever, . . 557 
Protracted Convalescence from Eelapsing Fever, . . . . < . 557 
Tendency to the Occurrence of Sudden Death, ...... 557 
Duration of the Fever and Prolonged Duration of Convalescence, . . 558 
Sequelae of Eelapsing Fever, .......... 558 
Post-febrile Ophthalmitis (Mackenzie), ........ 559 
Treatment of Eelapsing Fever, ......... 559 
Simple Continued Fever, 560 
Definition of Simple Continued Fever, ........ 560 
Pathology of Simple Continued Fever, ........ 560 
Seasons for Detaining this Name as the Name of a Disease, .... 560 
Anomalous Forms of Continued Fever, ....... 561 
Febricula, 562 
Definition of Febricula, ........... 562 
Pathology of Febricula, ........... 562 
Diagram of Typical Eange of Temperature in a Case of Febricula, . . 563 
Typical Eange of Temperature in a Case of Protracted Febricula, . . 563 
Diagnosis of Febricula, ........... 564 
Treatment of Febricula, .......... 564 
[Specific] Yellow Fever, 564 
Definition of Specific Yellow Fever, . . . . • . . . 564 
Pathology and Symptoms of Specific Yellow Fever, ..... 564 
Necessity of Separating and Distinguishing the Specific from the Malarious 
Forms of Yellow Fever, . ... . . . . . . . 565 
History of the "Eclair" Epidemic, 567 
Incubation of Specific Yellow Fever, . . . . . . . 567 
Importation of Specific Yellow Fever, ........ 568 
History of its Importation into St. Nazaire, ....... 568 
Propagation of Specific Yellow Fever, ........ 569 
[Facts Favorable to the Doctrine of the Transmissibility and Portability of 
Yellow Fever], ........... 571 
Symptoms of Specific Yellow Fever, . . . . . . . 572 
Types, Groups, or Forms of Specific Yellow Fever, ..... 573 
Several Types of Specific Yellow Fever, ....... 573 
Condition of the Urine in Specific Yellow Fever, ..... 574 
White and Black Vomit in Yellow Fever, ....... 575 
Prognosis in Cases of Specific Yellow Fever, . . . . . .576 
Treatment of Specific Yellow Fever, ........ 576 
Composition of Chlorodyne [Note), . . . . . . . .578 
[Prevention of Yellow Fever], ......... 579 
Plague, 580 
Definition of Plague, ........... 580 
Pathology and History of Plague, ......... 580 
Morbid Anatomy in Cases of Plague, 581 
Symptoms of Plague, ........... 582 
Progress of the Bubo in Plague, ......... 582 
Varieties of Carbuncle in Plague, ......... 582 
Diagnosis in Cases of Plague, ......... 583 CONTENTS OF VOLUME I. 
XXXV 
PAGE 
Cause of Plague, ............ 583 
Modes of Propagation of Plague, . . . . . . . . 584 
Treatment of Plague, ........... 584 
Quarantine, ............. 585 
Ague-Syn., Intermittent Fever. 585 
Definition of Ague, ........... 585 
Symptoms of Ague-The Paroxysm or Fit, ....... 585 
[Number of Cases of Intermittent Fever in the United States Armies dur- 
ing the first two years of the Civil War (Vote)], ..... 585 
Varieties or Types of Intermittent Fever, . . . . . . . 587 
[Congestive Form of Intermittent Fever], ....... 587 
Temperature in Cases of Intermittent Fever, ...... 588 
Diagram of Typical Range of Body-temperature in Intermittent Fever of 
Quotidian Type, 588 
Diagram of Typical Range of Body-heat in Intermittent Fever of Tertian 
Type, 589 
Condition of the Urine in Ague, ......... 590 
Treatment of Intermittent Fever, ......... 591 
Remittent Fever, 594 
Definition of Remittent Fever, ......... 594 
Symptoms of Remittent Fever, ......... 594 
Varieties of Type of Remittent Fever, 596 
[Prevalence of Remittent Fever in the Middle, Southern, and Western Re- 
gions of the United States, ......... 596 
Malignant Congestive or Pernicious Remittent Fever], .... 598 
Treatment of Remittent Fever, ......... 599 
Professor W. C. Maclean's Treatment of Remittent Fever [Note), . . 601 
[Chronic Malarial Toxemia, 603 
Definition of Chronic Malarial Toxaemia, ....... 603 
Morbid Anatomy of Chronic Malarial Toxaemia, ...... 603 
Morphological Changes in the Blood in Malarial Fever, .... 604 
Treatment of Chronic Malarial Toxaemia], ....... 606 
[Typho-Malarial Fever-Syn., Ciiickahominy Fever; American Fever, 607 
Definition of Typho-malarial Fever, ........ 607 
History of Typho-malarial Fever, ......... 607 
Symptoms of Typho-malarial Fever, ........ 607 
Anatomical Character of Typho-malarial Fever, ...... 608 
Treatment of Typho-malarial Fever], 608 
Malarious Yellow Fever-Syn., Febris Icterodes Remittens, . . 608 
Definition of Malarious Yellow Fever, ........ 608 
Pathology of Malarious Yellow Fever, . . . . . . . 608 
Nature of the Soil in Relation to Malarious Yellow Fever, .... 610 
Malignant Cholera-Syn., Serous Cholera; Spasmodic Cholera; Asi- 
atic Cholera, 611 
• 
Definition of Malignant or Asiatic Cholera, 611 
Pathology of Malignant or Asiatic Cholera, ' . . 611 
Theories Explaning the Pathology of Malignant or Asiatic Cholera, . .611 
Mr. Simon's Views regarding the Pathology of Malignant Cholera, . . 612 
Second, Third, Fourth, and Fifth Theories, 617 
Sixth Theory regarding the Pathology of Malignant Cholera, . . . 618 
Seventh and Eighth Theories-those of Pettenkoffer and Macnamara-as to 
the Nature of Malignant Cholera, ....... 618,619 
Ninth Theory-Conclusions of Dr. Beasley, as expressed by Dr. Bryden, . 619 
Conclusions regarding the Several Theories, ....... 620 
Quite as many False Facts as False Theories regarding Cholera, . . . 620 
Earliest Knowledge of the Progress of Cholera due to the late Sir James 
Clark, . 620 
Two points in which all the Theories Agree, . . . . . .' 620 XXXVI 
CONTENTS OF VOLUME I. 
PAGE 
Differences between the Epidemic of 1866 and Former Epidemics, . . 621 
Evidences of Importation or Transmission of the Disease, .... 621 
Infection of England in 1866 at many different parts, . . . . . 622 
Occasional Circumstances which Facilitate and give Energy to the Spread of 
Malignant Cholera, ........... 624 
(1.) Meteorological Conditions, . 624 
(2.) Local Causes, ............ 627 
Views of Bayer, Barton, Carpenter, Pettenkofer, and Snow, regarding Local 
Influences, ............ 628 
Impure Water the Main Local Agent of Importance, ..... 628 
Precise Conditions which Aggravate Epidemics of Malignant Cholera, as 
determined by Dr. Greenhow, ........ 629 
Propagation of Cholera by Human Intercourse, ...... 630 
Communication of the Disease from Excreta, ...... 631 
Propagation through the Excreta of the Premonitory Diarrhoea, . . 633 
[Prevalence of Cholera in the United States Army in 1866, . . . 633 
Instances of the Portability of Cholera, ....... 633 
The Organic Theory as a Cause of Epidemics, ...... 635 
Conclusions of Dr. Lionel S. Beale], ........ 635 
Endemic Area and Epidemic Spread of Cholera, ...... 636 
Routes followed by Malignant Cholera, ....... 637 
Countries which have remained Free from Cholera, ..... 639 
Dr. Macnamara's Characteristics of Malignant Cholera, .... 639 
Morbid Anatomy in Cases of Malignant Cholera, ...... 641 
External Appearances, ........... 641 
Condition of the Intestinal Canal, ......... 641 
Condition of the Visceral Organs, ......... 641 
Condition of the Lungs, .......... 642 
Dr. Johnson's Diagram of the State of the Heart and Lungs, . . . 642 
Post-mortem Appearances in Cases of Reaction after Cholera, . . . 643 
Chemistry of the Blood in Asiatic Cholera, ....... 643 
Microscopy of the Body in Cholera, ........ 646 
Question of Specific Fungi in Cholera Excreta, ...... 646 
Hallier's, Thome's, Klob's, and Parke's Account of Fungi in Rice-water 
Stools of Cholera, . . . . . . . ... . . 646 
Explanation of Engraved Plate, . . . . . . . . 649 
Special Inquiry as to Fungi in Cholera, suggested by the Professors of the 
Army Medical School, to be carried out in India, and the Scheme pro- 
posed by them, ........... 651 
Conclusions since arrived at regarding the so-called Cholera Fungi, . . 653 
Chemical Changes Undergone by the Body in the Progress of Malignant 
Cholera, ............. 654 
Question as to Epithelium in the Stools of Malignant Cholera, . . . 654 
Composition of Malignant Cholera, Intestinal Contents and Rice-water-like 
Evacuations, ............ 665 
Symptoms and Various Forms of Cholera, ....... 657 
Stages of Malignant Cholera, ......... 657 
Period of Incubation of Cholera, ......... 657 
Usual Course of the Disease as seen in this Country, ..... 658 
Termination of Cases of Malignant Cholera, ....... 659 
Hours at which Death takes place, . 660 
Typhoid Symptoms after Reaction, . . . . . . . 661 
The Blood and Urine in Malignant Cholera, . ...... 661 
Seven Stages of Cholera distinguished by Thudichum, . . . *• . . 662 
Body-temperature in Malignant Cholera, ....... 662 
Duration of Malignant Cholera, ......... 664 
[Relation of Vomiting and Purging to Algid Symptoms, .... 664 
Evidences of Reaction after Malignant Cholera, ...... 665 
Circumstances Predisposing to Malignant Cholera, as well as those which 
present Resistance to the Attack, . . . . . . . 666 
Prognosis in Cases of Malignant Cholera, ....... 667 
Treatment of Malignant Cholera, 668 
Three Periods to be specially Provided for, ....... 668 
Conditions to be attended to in the Management of Cases of Malignant 
Cholera, ............. 668 
Circumstances Regulating the Dose of Opium, ...... 668 
Formula for Antispasmodic Pills, ......... 668 CONTENTS OF VOLUME I. 
XXXVII 
PAGE 
Beneficial Influence of Opium, 668 
Management of Large Bodies of Men in Armies, Factories, or Offices, with 
a view to the Prevention of Cholera, ....... 669 
Elimination Treatment of Cholera by the Promotion of Purging and Vom- 
iting, ............. 671 
Dr. George Johnson's Treatment of Malignant Cholera by Castor Oil, . 671 
Fallacies of the Theory of Elimination, on which Dr. Johnson's Treatment 
is Based, ............. 672 
Dr. Macnamara's Experience as to Castor Oil, ...... 673 
Aim of Treatment in the Algid Stage, ........ 673 
Formula of Medicines to promote Reaction in Cholera and Diarrhoea, . . 673 
Question as to Use of Calomel in Reaction, ....... 673 
Treatment during the Reaction Stage, by Dr. Andrew Clark, . . . 674 
[Mode of Treatment by Drs. Leclere and Barrant], ..... 674 
The Kind of Cases Benefited by Calomel, . . . . . . . 674 
Use of Water and Cold Compresses, ........ 674 
Drinks recommended, ........... 674 
Injection of Medicated Fluid into the Veins, . . . . . .675 
Stimulants not to be used, . 675 
Prevention of Cholera, ........... 676 
Use of Disinfecting Agents, .......... 676 
[Cholera Morbus-Syn., Sporadic Cholera; Simple Cholera; Cholera 
Biliosa, 678 
Definition of Cholera Morbus, ......... 678 
History of Cholera Morbus, .......... 678 
Nature and Pathogeny of Cholera Morbus, ....... 678 
Symptoms and Diagnosis of Cholera Morbus, ...... 678 
Comparison of the Symptoms of Cholera Morbus with those produced by 
Irritant Poisons, ........... 680 
Treatment of Cholera Morbus], ......... 680 
[Cholera Ineantum-Syn., Summer Complaint; Ineantile Cholera, . 680 
Definition of Cholera Infantum, ......... 680 
History of Cholera Infantum, ......... 680 
Symptoms of Cholera Infantum, ......... 681 
Causes and Nature of Cholera Infantum, ....... 682 
Effective Causes,-Age, High Temperature, Humidity, and Malnutrition, . 682 
Malnutrition due to Several Sources, ........ 682 
The Necroscopic Characters of Cholera Infantum, ..... 683 
Treatment of Cholera Infantum], ......... 683 
Diphtheria, 685 
Definition of Diphtheria, .......... 685 
Historical Notice of Diphtheria, ......... 685 
Pathology and Morbid Anatomy of Diphtheria, . . . . . . 686 
Condition of Urine in Diphtheria, ........ 688 
Albumen in the Urine of Diphtheria, ........ 688 
Phenomena and Symptoms of Diphtheria, ....... 690 
Varieties of Diphtheria, as Grouped by Sir William Jenner, . . . 690 
Diagnosis in Cases of Diphtheria, ......... 691 
Prognosis in Cases of Diphtheria, ......... 692 
Sequelse after Cases of Diphtheria, ........ 692 
Peculiar Paralysis Subsequent to Diphtheria, ...... 692 
Propagation of Diphtheria, .......... 693 
Treatment of Diphtheria, .......... 694 
Topical Applications, ........... 695 
Question of Tracheotomy in Diphtheria, ....... 695 
Importance of Feeding the Patient, ........ 696 
Hooping-cough, 696 
Definition of Hooping-cough, ......... 696 
Pathology and Morbid Anatomy of Hooping-cough, ..... 696 
Symptoms of Hooping-cough, .......... 697 
Phenomena Comprehended in a " Fit " or " Paroxysm " of Hooping-cough, 698 XXXVIII 
CONTENTS OF VOLUME I. 
PAGE 
Complications in Cases of Hooping-cough, ....... 699 
Diagnosis in Cases of Hooping-cough, ........ 700 
Cause of Hooping-cough and Modes of Propagation, ..... 700 
Period of Latency of Hooping-cough, . . . . . . . . 701 
Prognosis in Cases of Hooping-cough, ........ 701 
Ages of Fatal Cases, ............ 701 
Treatment of Hooping-cough, ......... 701 
Dietetic and General Management of Cases of Hooping-cough, . . . 704 
Mumps, 704 
Definition of Mumps, ........... 704 
Pathology of Mumps, ........... 704 
A symptomatic Parotitis as distinguished from the Idiopathic Parotitis of 
Mumps, 704 
Spread of the Disease by Contagion, 704 
Symptoms of Mumps, 705 
Treatment of Mumps, 705 
Influenza, 705 
Definition of Influenza, 705 
Historical Notice of Influenza, 706 
Pathology of Influenza, 706 
Symptoms, Course, and Complications of Influenza, ..... 707 
Special Pulmonary Complications, ......... 707 
Causes and Modes of Propagation of Influenza, ...... 709 
Susceptibility to Influenza exhausted to a certain extent, not absolutely, . 709 
Prognosis in Cases of Influenza, ......... 709 
Treatment of Influenza, 709 
Glanders, 711 
Definition of Glanders, 711 
Pathology of Glanders, ........... 711 
Morbid Anatomy in Cases of Glanders, 712 
Symptoms of Glanders, 713 
Special Eruption in Cases of Glanders, 713 
Acute and Chronic Glanders or Farcy, 714 
Causes of Glanders, ........... 714 
Transmission of Glanders from the Horse to Man, ..... 715 
Inoculation of the Poison of Glanders, ........ 715 
Period of Latency in Cases of Glanders, . 715 
Prognosis in Cases of Glanders, ......... 716 
Diagnosis in Cases of Glanders, 716 
Treatment of Glanders, 716 
Preventive Treatment of Glanders, ........ 716 
I 
Farcy, 717 
Definition of Farcy, ........... 717 
Pathology of Farcy, 717 
Morbid Anatomy-" Farcy Buds " and " Farcy Buttons," .... 717 
Equinia Mitis, 718 
Definition of Equinia Mitis, 718 
Pathology of Equinia Mitis, 718 
Affection known as " Grease " in Horses, 718 
Morbid Anatomy-"Grapes" and other Lesions Produced by " Grease," . 718 
Symptoms of Equinia Mitis, 718 
Treatment of Equinia Mitis, .......... 718 
Malignant Pustule (Vesicle), 718 
Definition of Malignant Pustule, ......... 718 
Pathology and Historical Notice of Malignant Pustule, . . . .719 
Propagation of Malignant Pustule, ........ 720 
[Malignant Pustule occasionally of Spontaneous Origin, .... 720 CONTENTS OF VOLUME I. 
XXXIX 
PAGE 
Diversity of Opinion regarding the Risk of Eating the Flesh of Animals 
affected with Malignant Pustule (Note)], ...... 720 
Phenomena and Symptoms of Malignant Pustule, ..... 720 
[Malignant (Edema of the Eyelids, ........ 721 
Anatomical Characters of Malignant Pustule], ...... 721 
Treatment of Malignant Pustule, ......... 722 
Phagedena, 722 
Definition of Phagedena, .......... 722 
Pathology of Phagedena, .......... 722 
Treatment of Phagedena, . . . . . . ... . . 723 
Sloughing Phagedena, 723 
Definition of Sloughing Phagedena, ........ 723 
Pathology of Sloughing Phagedena, ........ 723 
Hospital Gangrene, 723 
Definition of Hospital Gangrene, ......... 723 
Pathology of Hospital Gangrene, ......... 723 
Cases Prone to Hospital Gangrene, ........ 723 
Erysipelas, 724 
Definition of Erysipelas, .......... 724 
Pathology of Erysipelas, .......... 724 
Lesions in Erysipelas not limited to the Skin, ...... 724 
Probable Origin and Seat of Erysipelas in the Absorbents, .... 725 
Suppurative Process and Effusion in Erysipelas, ...... 725 
Morbid Anatomy in Cases of Erysipelas, . . . . . .' 726 
Symptoms of Erysipelas, .......... 726 
Diagnosis in Cases of Erysipelas, ......... 727 
Typical Range of Body-temperature in Cases of Erysipelas of the Face, . 727 
Local Symptoms of Erysipelas, ......... 728 
Phlegmonous and Gangrenous Erysipelas, ....... 729 
Cause of Erysipelas, ........... 730 
Internal Lesions Associated with Erysipelas, ...... 730 
Propagation of Erysipelas by Inoculation and Fomites, .... 730 
Identity with some Forms of Puerperal Fever, ...... 731 
Period of Latency of Erysipelas, ......... 731 
Prognosis in Cases of Erysipelas, ......... 731 
Treatment of Erysipelas, .......... 732 
Local Applications in Cases of Erysipelas, ....... 733 
Pyaemia, 734 
Definition of Pyaemia, ........... 734 
Pathology of Pyaemia, ........... 734 
Pyogenic Fever, ............ 735 
Difference of Pyogenic Fever from True Pyaemia, ..... 736 
Metastatical Dyscrasiae and their Nature, ....... 736 
Literal Meaning of Pyaemia, . . . . . . . . . 736 
Composition of Pus, ........... 737 
Results of the Decomposition of Pus, ........ 737 
Pyaemia a Collective Name for several different Lesions, .... 738 
Morbid Anatomy-Secondary or Metastatic Abscesses, . . . 740 
Difference of Pyaemic Abscesses from Ordinary Purulent Collections, . . 740 
Symptoms of Pyaemia, ........... 741 
Body-temperature in Cases of Pyaemia, ........ 742 
Diagram of Body-temperature in a Case of Pyaemia (Ringer), . . . 743 
Diagnosis in Cases of Pyaemia, ......... 744 
Prognosis in Cases of Pyaemia, ......... 744 
Treatment of Pyaemia, ........... 74c 
[Chronic Pyaemia, 741 
Description of Chronic Pyaemia, ......... 741 XL 
CONTENTS OF VOLUME I. 
PAGE 
Prognosis in Chronic Pyaemia, . . . . . . . . . 746 
Treatment of Chronic Pyaemia], ......... 746 
Puerperal Fever, 746 
Definition of Puerperal Fever, . . . .' . . . . . 746 
Pathology of Puerperal Fever, ......... 746 
Alliance between Puerperal Fever and Erysipelas, ..... 747 
Origin of Cases of Puerperal Fever, ........ 747 
Dr. Hicks's Experience as to the Origin of Puerperal Fever, . . . 747 
Morbid Anatomy in Cases of Puerperal Fever, ...... 748 
Symptoms of Puerperal Fever, ......... 748 
Treatment of Puerperal Fever, ......... 749 
Puerperal Ephemera or Weed, 750 
Definition of Puerperal Ephemera, ........ 750 
Pathology of Puerperal Ephemera, . . . . . ... . 750 
Symptoms of Puerperal Ephemera, ........ 750 
Treatment of Puerperal Ephemera, ........ 750 
CHAPTER X. 
Pathological Summary regarding the Nature op the General Dis- 
eases DESCRIBED UNDER SECTION A, 750 
Groups of those Diseases according to Natural Alliances, .... 750 
Nature of Contagion and Infection, ........ 751 
Nature of the Poison-causing Particles, ....... 751 
Form is that of a Minute Germ or Granule, ....... 751 
Distinction to be made between Poison-reproducing General Diseases and 
those which do not Reproduce the Poison, 752 
CHAPTER XI. 
Detailed Description of the General Diseases comprehended in Sec- 
tion B, 752 
Explanation of the Term Diathesis, . . . . . . . . 752 
Acute Rheumatism-Syn., Rheumatic Fever, 752 
Definition of Acute Rheumatism, . . . . . . . . .752 
Pathology of Acute Rheumatism, ......... 753 
Circumstances which point to the Constitutional Origin of Rheumatism, . 753 
Parts affected in Acute Rheumatism, . . . • . . . . . 754 
Results of Acute Rheumatism, ......... 755 
Heart Affection in Acute Rheumatism, . . . . . . . .756 
Lesions from which the Heart is apt to suffer in Acute Rheumatism, . . 756 
Complex Lesions in Acute Rheumatism, ....... 757 
Morbid Anatomy in Cases of Acute Rheumatism, ...... 758 
Symptoms of Acute Rheumatism, . . . . . . . . .758 
The Urine in Cases of Acute Rheumatism, ....... 759 
Body Temperature in Acute Rheumatism in a Severe Case, .... 759 
Diagram of the Typical Range of Body-temperature in a Case of Acute Rheu- 
matism affecting many Joints (Wunderlich), ..... 762 
Symptoms of Heart Complications in Rheumatism, ..... 764 
Pain and " Pains" in Chronic Rheumatism in relation to " Malingering," . 765 
Diagnosis in Cases of Acute Rheumatism, . . . . . . . 765 
Prognosis in Cases of Acute Rheumatism, ....... 765 
Indications of Acute Rheumatism from Urinary Excreta, .... 766 
Causes of Acute Rheumatism, ......... 766 
Treatment of Acute Rheumatism, ......... 767 
Aim and Object of Purgative Remedies, ....... 769 
Composition of the Remedy known as the 11 Chelsea Pensioner" . . . 770 
Neutralizing and Eliminative Methods of Cure, . . ' . . . . 773 
[Constant Galvanic Current in Chronic Rheumatism], ..... 774 CONTENTS OF VOLUME I 
XLI 
PAGE 
Gonorrhoeal Rheumatism, 774 
Definition of Gonorrhoeal Rheumatism, ........ 774 
Pathology of Gonorrhoeal Rheumatism, . 1 . . . . . . 774 
Theories regarding the Nature of Gonorrhoeal Rheumatism, . . . 774 
Symptoms of Gonorrhoeal Rheumatism, ....... 775 
Treatment of Gonorrhoeal Rheumatism, ........ 776 
Synovial Rheumatism, 776 
Definition of Synovial Rheumatism, ........ 776 
Pathology of Synovial Rheumatism, ........ 776 
Treatment of Synovial Rheumatism, ........ 776 
Muscular Rheumatism, 777 
Definition of Muscular Rheumatism, ........ 777 
Pathology of Muscular Rheumatism, ........ 777 
Lumbago, .............. 777 
Stiff-neck and other Forms of Muscular Rheumatism, ..... 777 
Treatment of Muscular Rheumatism, ........ 777 
Chronic Rheumatism, 777 
Definition of Chronic Rheumatism, ........ 777 
Pathology and Symptoms of Chronic Rheumatism, ..... 777 
Treatment of Chronic Rheumatism, ........ 778 
Acute Gout, 779 
Definition of Acute Gout, .......... 779 
Pathology of Acute Gout, .......... 779 
Constitutional Origin of G-out, ......... 779 
Theories regarding Excess of Uric Acid in the Blood, ..... 781 
Niemeyer's Theory regarding Gout, ........ 781 
Natural History of Acute Gout, ......... 782 
Causes of Acute Gout, 783 
Most important Factors in the Production of Gout, ..... 783 
Varieties of Gout, ............ 784 
Morbid Anatomy in Cases of Acute Gout, ....... 784 
Urate of Soda (Fig. 84) (Wedl), 784 
Symptoms of Gout, 784 
Diagnosis of Gout, ............ 786 
Prognosis in Cases of Acute Gout, ......... 787 
Treatment in Cases of Acute Gout, ........ 787 
Chronic Gout, : 790 
Definition of Chronic Gout, .......... 790 
Pathology and Symptoms of Chronic Gout, ....... 790 
Nature and Course of Retrocedent Gout, ....... 791 
Gout as Affecting Internal Organs, ........ 791 
Treatment of Chronic Gout. .......... 792 
Mineral Springs which Exercise the most Favorable Influence on Gout, . 792 
Rules regarding the Use of such Springs, ....... 792 
Properties and Constituent Elements of the Mineral Waters at the Differ- 
ent Springs, 792 
Gouty Synovitis, 796 
Definition of Gouty Synovitis, ......... 796 
Pathology of Gouty Synovitis, . . . . •. • • • • 796 
Treatment of Gouty Synovitis, ......... 796 
Chronic Osteo-arthritis-Syn., Chronic Rheumatic Arthritis, . . 796 
Definition of Chronic Osteo-arthritis, . . . . . . . . 796 
Pathology and Symptoms of Chronic Osteo-arthritis, ..... 796 
Table Exhibiting the Differential Diagnosis of Gout, Rheumatism, and 
Chronic Osteo-arthritis (Dr. Garrod), ....... 797 
Treatment of Chronic Osteb-arthritis, ........ 798 XLII 
CONTENTS OF VOLUME I. 
• PAGE 
Syphilis, 799 
Definition of Syphilis, 799 
Pathology and Morbid Anatomy of Syphilis, . . . . . . 799 
History of Syphilis in Soldiers, ......... 800 
Reduction of Venereal Diseases in the Army, ...... 801 
Special Returns called for in the Army regarding this Disease, . . . 802 
Nomenclature of Syphilis, .......... 802 
Professor Longmore's Directions for Drawing up a History of Cases of 
Syphilis, 803 
Conclusions regarding the Venereal Poisons, ...... 804 
How the Vaccine Virus may Carry Syphilis, ...... 805 
Nature of the Syphilitic Poison, ......... 805 
Anatomy of the Induration of a Syphilitic Sore, ...... 805 
Characters of the Venereal Sores, and especially of the " Infecting Sores," 806 
History of the Identification of the several Venereal Poisons, . . . 806 
Several Venereal Infections, .......... 806 
Forms of Syphilitic or Infecting Sores, ........ 808 
Clinical Characters of the Syphilitic Sore, ....... 810 
Characters of True Syphilis and Pseudo-syphilis Contrasted, . . . 810 
Period of Incubation of Syphilis, ......... 810 
Contamination of the System and General Course of Syphilis, . . . 811 
State of the Blood in Syphilis, ......... 811 
Fever of Syphilis, ............ 811 
Order of Evolution of Syphilitic Lesions, ....... 812 
Succession of Phenomena in Syphilis, ........ 813 
Characteristics of Specific Induration, ........ 814 
Tabular Order of Events regarding the Specific Lesions of Syphilis, . . 815 
Cutaneous Affections in Syphilis, ......... 815 
The Early Affections of the Fauces,, ........ 815 
Second Attacks of Syphilis, .......... 815 
The Soft or Suppurating Chancre, . . . . . . . . .816 
Vehicles or Media by which the Specific Infecting Virus may be Inoculated, 817 
Herpes Preputialis-its Characters, and how the Lesion is to be distin- 
guished from Syphilis, .......... 817 
Modes of Syphilitic Contamination, ........ 818 
Morbid Anatomy of the Secondary Lesions of Syphilis and of the Local 
Growths in the Internal Viscera, . . . . . . . .818 
Gummata the Basis of the Characteristic Lesions of Syphilis, . . . 819 
Development and Course of the Syphilitic Node, or Gummy Tumor, . . 820 
(a.) In the Skin, ........... 820 
(b.) Syphilitic Lesion of Mucous Membrane, ...... 821 
(c.) Affections of the Nails, ......... 822 
(d.) The Syphilitic Lesions of the Testicles, 822 
(e.) In the Substance of the Heart, . ....... 822 
(f.) In the Bones, ........... 823 
(g.) In the Brain and Nervous System, ....... 825 
(h.) In the Lungs, ........... 826 
(i.) In the Liver, . . . . . . . . . . 826 
(k.) Lesions of the Tongue, ......... 827 
Hints for the Investigation and Description of Syphilitic Ulcers, . . 827 
Syphilization : its History and Nature, . ....... 828 
. Description of the Process of Syphilization, ....... 829 
Treatment of Syphilis, ........... 829 
Question of Mercury in Syphilis, ......... 830 
Forms of Syphilis for which Mercury is Unsuitable, ..... 832 
[Beneficial Effects of Mercury when Properly Administered], . . . 833 
Preventive Treatment of Syphilis, ......... 836 
[Hereditary Syphilis, 837 
Pathology of Hereditary Syphilis, ......... 837 
Syphilis may affect the Foetus at an Early Period, ..... 838 
Coryza the Earliest and most Striking Symptom of Inherited Syphilis, . 838 
Diagnosis of Inherited Syphilis, ......... 839 
Appearance of the Teeth in Hereditary Syphilis, ...... 839 
Several Affections of the Eye of Interest in the History of Hereditary 
Syphilis], • 840 CONTENTS OF VOLUME I. 
XLIII 
PAGE 
Cancer-Syn., Malignant Disease, 841 
Definition of Cancer, 841 
Pathology of Cancer, . . . . . . . . . . . 841 
Constitutional Origin of Cancer, ......... 842 
[Opinion as to the Local Origin of Cancer independently of a Constitutional 
Cause], 842 
Very little known of the Conditions giving rise to Cancers, . . . . 845 
Normal Course of Cancerous Tumors, . . . . . . . . 845 
Idea of Cancers being due to Entozoa, ........ 845 
Composition of the Local Exudations of Cancer-growths, .... 845 
Characters of the Cancer-cell, . . . 846 
Practical Questions to be Solved with reference to Growths supposed to be 
Cancers, . . . . . . . . . . . . 846 
Malignant Tumors indicated by certain Characters Described, . . . 847 
(a.) Structure, 847 
(b.) Grouping, 847 
(c.) Infiltration, ........... 847 
(d.) Tendency to Ulcerate, ......... 847 
(e.) Progressive Growth towards Death, ...... 847 
Microscopic Characters of Cancer-growths, ....... 848 
Microscopic Distinction of Cancer-elements, ....... 848 
Mode of Extension of Cancer-growths, ........ 849 
Varieties of Cancers described under various names, ..... 850 
(a.) Constituents and Definition of Scirrhus or Hard Cancer, and figure 
showing the Cancer-cells of Scirrhus, ...... 851 
(b.) Elements of Medullary Cancer and Definition of it, ... 852 
Constituents related to Firmness and Softness, ..... 852 
Process of Softening, .......... 854 
Characters of Epithelial Cancer or Cancroid Epithelioma, . . . 855 
Sites of Epithelioma, .......... 855 
Question of Classifying Epithelioma with Cancers, .... 855 
Essential Characteristic Elements of Melanotic Cancer, . . . 856 
Characters of Melanotic Cancer or Melanosis, 856 
Fungus Hsematodes, 856 
Woodcut showing the varied Elements of Epithelial Cancer, . . . 857 
Osteoid Cancer and Villous Cancer, ........ 858 
Elements of Melanotic Cancer, 858 
Causes of Cancer, 858 
Theories or Hypothesis regarding Causes of Cancer, ..... 858 
Diagnosis of Cancer, 859 
Prognosis in Cases of Cancer, 859 
Treatment of Cancer, 859 
Colloid-Syn., Colloid Cancer, Alveolar Cancer, 861 
Definition of Colloid, 861 
Pathology of Colloid, 861 
Doubtful Affinity with Cancer, ......... 861 
[Form of Colloid which belongs to the True Cancer Group, Anatomically 
and Clinically], 862 
Lupus, . 862 
Definition of Lupus, 862 
Pathology of Lupus, 862 
Symptoms of Lupus, ........... 863 
Diagnosis of Lupus, 863 
Prognosis in Cases of Lupus, 863 
Treatment of Lupus, 863 
Rodent Ulcer, 865 
Definition of Rodent Ulcer, 865 
Pathology of Rodent Ulcer, 865 
True Leprosy-Syn., Elephantiasis Gr^corum, 865 
Definition of True Leprosy, 865 XLIV 
CONTENTS OF VOLUME I. 
PAGE 
Pathology of True Leprosy, . . . . . . . . . 865 
Report by the College of Physicians regarding True Leprosy, . . . 865 
Hereditary Nature of True Leprosy, ........ 865 
Leprosy now Unknown in this Country, . 865 
Prevalence of Leprosy in this Country during the Middle Ages, . . . 866 
Present Geographical Distribution of True Leprosy, ..... 867 
Forms of True Leprosy described, ......... 868 
Acute and Chronic, Tuberculous and Anaesthetic, ...... 868 
Morbid Anatomy in Cases of True Leprosy, ....... 869 
A. Analyses of Venous Blood in Norwegian Tuberculous Elephantiasis, by 
Danielssen and Boeck, .......... 870 
B. Analyses of Venous Blood in Anaesthetic Elephantiasis, by Danielssen, . 871 
Minute Anatomy of the Infiltration of True Leprosy, ..... 871 
Chemical Analysis of the Exudation, . . . . . . . . 871 
Symptoms of True Leprosy, .......... 871 
Summary of Symptoms in the Two Forms of Leprosy, ..... 872 
Duration of True Leprosy, .......... 873 
Causes of True Leprosy, .......... 873 
Diagnosis in Cases of True Leprosy, ........ 874 
Prognosis in Cases of True Leprosy, 874 
Treatment of True Leprosy, 874 
Scrofula, . 875 
Definition of Scrofula, 875 
Pathology of Scrofula, ........... 875 
Specific Forms of Scrofulous Disease, ........ 875 
Growth of the Peculiar Substance named " Tubercle," . . . . . 875 
Constitutional Conditions associated with Scrofulous Disease, . . . 875 
Original Meaning of the terms " Phthisis," " Consumption," . . . 875 
Predisposition to Scrofulous Growths, ........ 876 
Nature of the Constitutional State leading to the Development of Scrofula, . 876 
Strumous Dyspepsia, ........... 878 
Diathesis expressive of the Latent Existence of Scrofula, .... 878 
Morbid Anatomy of Tubercle, ......... 879 
Opinions entertained regarding the Nature of Tubercle, .... 879 
Definition of Tuberculization, ......... 880 
Relation between Tuberculosis and Scrofulosis, ...... 880 
Forms and Conditions under which Tubercle appears, . . . . . 880 
Gray and Yellow Tubercle-their Structure and Relations, .... 880 
Microscopic Structure of Tubercle, ........ 880 
Fatty Degeneration of Tubercle, ......... 882 
Basis of Tubercle-structure, .......... 882 
Development of Tubercle from Connective Tissue, ..... 882 
Tubercle in Earliest Stage of Growth, ........ 883 
Cheesy Metamorphosis of Tubercle ........ 883 
Retrograde Changes in Tubercle, ......... 884 
Cretification-Calcification of Tubercle, ....... 884 
Chemical Composition of Tubercle, ........ 884 
Nomenclature of Tubercle, .......... 885 
Seat of Scrofulous Inflammation in Peritoneum and Mucous Membrane, . 885 
Forms of Tubercle Ulceration, ......... 885 
Inflammation of Tubercle, . . . . . . . . . . 885 
Relation of Bloodvessels to Tubercle and Cancer, ...... 885 
Distinction between Tubercle and Cancer, ....... 886 
Softening of Tubercle not constant, ........ 886 
Healing of Local Lesions in Scrofula, ........ 886 
Spontaneous Cure of Tubercle Lesions, ........ 886 
Symptoms of Scrofula or of the Cachexia which precedes and accompanies 
the Growth of Tubercle, .......... 886 
The Dyspepsia of Tuberculosis, ......... 887 
Cases of Scrofula referable to Impaired Assimilation of Nutrition Processes, 887 
Strumous Dyspepsia of Tweedy Todd, ........ 887 
Conclusions regarding Dyspepsia in Phthisis, ...... 887 
Characters of the Scrofulous Organization by Miller and Canstatt, . . 888 
Scrofulous Constitution of Children, ........ 889 
Type of Inflammation in Scrofulous Subjects, ...... 889 
Duration of the Phthisis Pulmonalis of Scrofula, 889 CONTENTS OF VOLUME I. 
XLV 
PAGE 
Causes of Scrofula, . . . • . . . . . . . . . 889 
Development during Infancy, .......... 890 
Age in relation to Scrofula, . . . . . . . . . 890 
Deficient Ventilation and Abeyance of Normal Exercise, .... 890 
Influence of Occupations in causing Scrofula, . . . . . . 891 
Moisture and Damp as a cause of Scrofula, ....... 892 
Morbid States of the Parent, a cause of Scrofula in Children, . . . 892 
Hereditary Prevalence of Scrofula, ......... 892 
Manifestation of Scrofulous Constitution in Children, ..... 893 
Influence of Race in the Production of Phthisis, ...... 893 
Influence of Depressing Passions in producing Phthisis, .... 893 
Is a Predisposition to Scrofula demonstrable anatomically or otherwise? . 894 
Assemblage of Phenomena characteristic of Scrofula, ..... 894 
Great Care necessary in Physical Training, ....... 894 
Average Weight of Full-grown Men at twenty-five years of age, . . 894 
Average Height of a Growing Lad at eighteen years of age, . . . 894 
Correlation of Age, Weight and Height in the Growth of the Human Body, 
from eighteen to thirty years of age, ....... 895 
Correlation of Age, Stature, and Weight of Boys from nine to nineteen years 
of age, 896 
Correlation of Height and Circumference of Chest in 1270 Young Persons, . 896 
Year of greatest Increase in Stature, ........ 896 
Year of greatest Increase in Weight, . . . . . . . . 896 
Certain Individual Peculiarities suspicious, ....... 896 
Vital Capacity of Chest, ........... 896 
Indications of Functional Incapacity, ........ 897 
Relation of Ana3mia to Scrofula, ......... 897 
Physical Training-Use of the Lungs, ........ 897 
Evil Effects of Vitiated Air and Over-exertion, ...... 898 
Progressive Atrophy indicative of Scrofula, ....... 899 
Necessity for Weighing Men to determine Ratio to Age and Height, so as 
to furnish a Standard for determining Progressive Loss of Weight, . 899 
Progressive Reduction in Weight in Phthisis, ...... 899 
General Treatment of the Scrofulous Cachexia, ...... 899 
Beneficial Influence of Cod-liver Oil, ........ 900 
Modes of its Administration, .......... 901 
Its Immediate Action upon the Blood, ........ 901 
Influence of Animal Fats and Oils, . ........ 902 
Question of Bloodletting in the Inflammations of Tubercular Exudations, . 902 
Tonic Treatment of Scrofula, ......... 903 
Details of Hygienic Measures regarding Prevention and Management of 
Scrofula, 903 
Rickets, 905 
Definition of Rickets, ........... 905 
Pathology of Rickets, ........... 905 
Changes in the Bones in Rickets, ......... 905 
Symptoms of Rickets, ........... 905 
Treatment of Rickets, ........... 907 
Cretinism, 908 
Definition of Cretinism, ........... 908 
Pathology and Phenomena of Cretinism, ....... 908 
Varieties of Cretinism, . . . . . . • . . . . . 908 
Cretins generally subjects of Goitre, ........ 908 
Geographical Districts where Cretinism Abounds, ..... 908 
Stature of Cretins, ............ 908 
Virchow's Dissections of Cretins' Heads, ....... 908 
Relation of Cretinism and Goitre to Soil, . . . . . . . 909 
Symptoms of Cretinism, . . . . . . . . . . . 910 
Hygienic Measures for the Prevention of Cretinism, ..... 910 
Diabetes, 911 
Definition of Diabetes, ........... 911 
Pathology of Diabetes, 911 
Diabetes Mellitus a Constitutional Affection, ...... 911 XLVI 
CONTENTS OF VOLUME I. 
PAGE 
Glycogenesis, 911 
Generation of Sugar by the Liver, 911 
Prevention of Sugar Formation, ......... 912 
Intermittent Diabetes, ........... 913 
Influence of Diet on Formation of Sugar, ....... 913 
Distinction of Sugar in the Blood in Health, ...... 913 
Formation of Sugar in the Liver, ......... 913 
Beflex Excitement of Medulla Oblongata a Cause of Diabetes, . . . 914 
Bernard's Experimental Production of Diabetes, . ..... 914 
General Circumstances under which Melituria is Developed, . . . 914 
Relative Occurrence of Diabetes in Males and Females, . . . .914 
Hereditary Origin and Transmission of Melituria, ..... 914 
Morbid Anatomy in Diabetes, ......... 914 
Secondary Lung Lesions, . . . . . . . . . .915 
Question as to their being Tubercular, . . . . . . . .915 
Symptoms of Diabetes, ........... 915 
Progressive Emaciation in Diabetes, ........ 915 
Condition of the Urine in Diabetes, ........ 916 
Tests for Sugar in the Urine, . ... . . . . . . . 916 
Crystals of Diabetic Sugar from Diabetic Urine, ...... 916 
Trommer's Test for Sugar in the Urine, ....... 916 
Fehling's Test for Sugar in the Urine, ........ 916 
Sources of Sugar in the Urine in Diabetes, ....... 917 
Influence of Sugar, Starchy and Nitrogenous Food in producing Melituria, 917 
Relation between Food and Sugar in Diabetes, . . . . . .917 
Sugar-formation at the Expense of the Muscles of the Body, . . . 918 
Inosite or Muscle-sugar Crystallized, ........ 918 
Relation of Urea and Sugar-formation in Diabetes, ..... 918 
Chronic Nature of Diabetes, .......... 919 
Duration of 100 Cases of Diabetes collected by Griesinger, .... 919 
Complication of Diabetes with Pulmonary Lesion and with Defective Vision, 919 
Cataract in Diabetes, ........... 919 
Amblyopia in Diabetes, ... ........ 920 
Prognosis in Diabetes, ........... 920 
Treatment of Diabetes, ........... 920 
Management of Diabetes by Diet, .... ..... 921 
Animal Diet in Diabetes, .......... 921 
Mixed Diet in Diabetes, ........... 921 
Abstinence from Sugar and Starch, . 922 
Milk Diet in Diabetes, ..... ...... 922 
Bran Cakes and Bread in Diabetes, 922 
Cod-liver Oil, ............. 923 
General Conclusions regarding Management of Diabetes, .... 923 
Purpura, 925 
Definition of Purpura, ........... 925 
Pathology of Purpura, ........... 925 
Varieties of Purpura, 925 
Simple Purpura, 925 
Hemorrhagic Purpura, ........... 925 
Examination of Blood in Purpura, . . . . . . . 925 
Symptoms and Causes of Purpura, ........ 926 
Diagnosis between Purpura and Scurvy, ....... 926 
Treatment of Purpura,............ 927 
Scurvy, 928 
Definition of Scurvy, 928 
Pathology and Historical Notice of Scurvy, ....... 928 
Circumstances under which Scurvy has Prevailed, . . . . 929 
Prevalence of Scurvy in the British and American Armies, . . . 929 
Morbid Anatomy of Scurvy, .......... 929 
Chemical Pathology of Scurvy, 981 
Symptoms of Scurvy, ........... 932 
Extravasations of Blood in Scurvy, 932 
Sites of Scorbutic Ulcers, .......... 933 
Duration of Cases of Scurvy, ......... 933 
Scorbutic Dysentery, 934 CONTENTS OF VOLUME I, 
XLVII 
Night-blindness in Scurvy 934 
Tendency to Swoon in Scurvy, 934 
Intercurrent Chest Affections in Scurvy, 934 
Diagnosis of Scurvy, 934 
Prognosis in Scurvy, 934 
Causes and Conditions under which Scurvy is Developed, .... 935 
Summary of Conditions producing Scurvy, 936 
Treatment of Scurvy, ........... 937 
Prevalence of Scurvy in the Merchant Service, ...... 938 
Prevention of Scurvy, ........... 940 
Anemia, 941 
Definition of Anaemia, ........... 941 
Pathology of Anaemia, ........... 941 
Results of Deficiency of Red Corpuscles in the Blood, ..... 941 
Symptoms of Anaemia, ........... 942 
Cardiac, Arterial, and Venous Murmurs in Anaemia, ..... 942 
Characters of Anaemic Murmurs, ......... 943 
Condition of the Urine in Anaemia, . . . . . . . ■ 944 
Causes of Anaemia, ........... 944 
Treatment of Anaemia, ........... 945 
Tonic Treatment of Anaemia, ......... 945 
Suggestions for the Use of Iron in Anaemia, ....... 945 
Formula for the Preparation of Syrup of the Phosphates of Iron, Quinine, 
and Strychnia, ............ 945 
Chlorosis, 947 
Definition of Chlorosis, ........... 947 
Pathology and Symptoms of Chlorosis, ........ 947 
Implication of the Nervous System in Chlorosis, ...... 947 
Disorder of Digestion in Chlorosis, ........ 947 
Condition of Respiratory, Generative, and Vascular System in Chlorosis, . 948 
Causes of Chlorosis, ........... 948 
Diagnosis of Chlorosis, ........... 948 
Treatment of Chlorosis by Food and Medicine, ...... 948 
General Dropsy, 950 
Definition of General Dropsy, ......... 950 
Pathology and Symptoms of General Dropsy, ...... 950 
A Form of Universal (Edema or Anasarca, . . . . . . 950 
Phenomena of " Pitting " under Pressure, ....... 950 
Diagnosis of General Dropsy, . . 950 
Treatment of General Dropsy, . . . ... . . . . 950 
Beriberi, 950 
Definition of Beriberi, ........... 950 
Pathology and Historical Notice of Beriberi, ...... 951 
Morbid Anatomy in Cases of Beriberi, . . . . . . . 952 
Symptoms of Beriberi, ........... 952 
Forms of Beriberi, ............ 952 
Causes of Beriberi, ............ 954 
Diagnosis of Beriberi, ........... 955 
Prognosis in Cases of Beriberi, ......... 955 
Sudden Death in Beriberi, .......... 956 
Treatment of Beriberi, ........... 956 
Composition of the Eastern Remedy called " Treeak Farook," . . . 956 
CHAPTER XII. 
Influence of Food on some Constitutional Diseases described in the 
Previous Chapter, 957 
Principles of Construction of Dietaries for Large Bodies of Men, . . 958 
Amount of Food consumed by a Man, ........ 959 XLVIII 
CONTENTS OF VOLUME 1. 
Relation of Food to Body-weight, ......... 960 
Relation of Food and Disease, ......... 961 
Table of Nutritive Value of Foods (Parkes), in 100 parts, .... 960 
Table of Dietaries and their Nutritive Values (Letheby), .... 961 
Table of Nutritive Value of Foods (Letheby), 962 
Mean Amount of the Four Classes of Aliments (Playfair), .... 962 
Effects of Over-feeding, ............ 963 
Pathology of Corpulence, .......... 963 
Dietary of Mr. Banting, . . . . . . ' . . . . 964 
Effects of Deficient Food, \ 964 
Death from Starvation, 965 
The " Truck-system " and its Evil Effects, 966 
CHAPTER XIII. 
General Management ok the System Liable to Constitutional Dis- 
eases, 967 
Prevention, Control, and Arrest of Farther Development the Basis of Man- 
agement, ............. 967 
General and Individual Hygienic Management, ...... 967 
Three Periods in the Development of Constitutional Diseases relative to 
their Management, ........... 968 
Intervals of Abeyance of Disease or of Comparative Freedom from Disease 
to be taken advantage of in their Management, ..... 968 
Management of Disease by Regulation of Diet, ...... 968 
Management of Disease by the Use of Water, ...... 970 
Management of Disease by the Aid of Wines and Alcoholic Beverages, . 970 
Properties of Wines and Alcoholic Beverages, ...... 970 
Medicinal Substances contained in Wines, ....... 970 
Rules for the Administration of Alcohol in Disease, . . . . 970 
Determination of the Amount of Alcohol in Wine, ..... 971 
■Determination of the Amount of Acidity in Wines, . . . . . 972 
Determination of the Amount of Sugar in Wines, ..... 973 
Determination of the Amount of Solids in Wines, ..... 973 
Use of Wine and Alcoholic Beverages generally in Constitutional Diseases, 974 
CHAPTER XIV. 
General Nature oe Local Diseases, 975 
Diseases comprehended under this head, ....... 975 
Constitutional Symptoms of Local Affections, . . . . . . 975 
Secondary Symptoms of Lesions, ......... 975 
Anatomical Forms of the Local Lesions, . . . . . . .975 
CHAPTER XV. 
Diseases oe the Nervous System, 976 
Section I.-Introduction to the Pathology oe the Diseases oe the 
Nervous System, . 976 
How the Varied Phenomena of the Nervous System aro to be viewed, . 976 
Constituents of Brain and Nerves, . . . . . . . . 977 
Chemical Composition of the Brain and Nerve-tissue, ..... 977 
Weight of the Brain and its Parts, 977 
Absolute Weight of the Brain, ......... 977 
Table of Relative Averages of Body-weight, and the Weight of Cerebral 
Organs as to Age and Height,......... 978 
Bulk of the Encephalon, .......... 978 
Specific Gravity of the Healthy Brain, ........ 978 
Specific Gravity of Central Ganglia, ........ 979 
Pathological Relations of the Nervous Organs and Textures, . . . 980 
Cardinal Facts in the Physiology of the Nervous System illustrative of its 
Pathology, 980 CONTENTS OF VOLUME I. 
XLIX 
PAGE 
Phenomena of Isolated Conduction, 980 
Phenomena of Sympathy or Irradiation, ....... 981 
Phenomena of Intelligence, 981 
Nervous Force from Gray Matter, ........ 981 
Section II.-Guides to the Diagnosis of Diseases of the Nervous 
System, . . . . • 982 
I. As to Locality or Site of Lesion, ........ 982 
Indications of the Cerebrum being Affected, ..... 982 
Indications of the Meninges being Affected, ..... 982 
Indications of the Spinal Cord being Affected, ..... 982 
General Grounds on which a Diagnosis may be made, . . . 982 
Characters of Cerebral and Meningeal Diseases contrasted, . . 983 
Characters of Gastric or Hepatic Vomiting contrasted with Cerebral 
Vomiting, ........... 984 
II. As to the Nature of the Affection, ....... 984 
(a.) Acute but Non-febrile Symptoms of Diseases of the Nervous 
System, 984 
(6.) Characters of Chronic Diseases of the Nervous System, . . 984 
Symptoms of Loss of Function, 984 
Symptoms of Irritation, ........ 984 
III. As to the Anatomical Condition, ........ 985 
IV. As to Urea in the Blood and Brain, ....... 985 
Detection of Urea-(1.) In Serum; (2.) In Brain, .... 986 
V. As to Morbid Textural Changes in the Brain, ..... 986 
Principles on which Diseases of the Nervous System may be Arranged 
and Considered in Groups, ........ 987 
Definition of Words in Common Use in Describing Diseases of the 
Nervous System, .......... 987 
VI. As to Physical Conditions, ......... 988 
(a.) Perversion of Sense of Touch and Power of Discrimination, . 988 
Dr. Sieveking's JEsthesiometer and its Use, ..... 988 
Normal Distance Limits of Sensitiveness, ..... 988 
Rules for the Use of the ^Esthesiometer, ..... 989 
(b.) Perversion of Muscular Power, 990 
(c.) Perversion of Body-heat, ........ 991 
(d.) Perversion of the Power of Expressing Thought, . . . 991 
Theories of the Localization of Brain Lesion in Aphasia, . . 992 
Section III.-Diseases of the Brain and its Membranes, . . . 993 
Encephalitis, 993 
Definition of Encephalitis, .......... 993 
Pathology of Encephalitis, . . . . . . . . . 993 
Causes of Encephalitis,........... 993 
Morbid Anatomy in Cases of Encephalitis, ....... 993 
Symptoms of Encephalitis, .......... 994 
Cerebral as Distinct from Meningeal Symptoms,...... 995 
Premonitory Symptoms of Cerebral Softening, ...... 995 
Diagnosis of Encephalitis, .......... 995 
Treatment of Encephalitis, .......... 995 
Meningitis, 995 
Definition of Meningitis, .......... 995 
Pathology and Morbid Anatomy of Meningitis, ...... 996 
(1.) Inflammation of the Dura Mater, ........ 996 
(2.) Inflammation of Pia Mater and Arachnoid,. ..... 996 
Phenomena of Arachnitis, ......... 996 
Serum in Arachnoid Cavity, ......... 996 
Suppurative Arachnitis, ......... 996 
Characters of Chronic Arachnitis, ....... 997 
(3.) Tubercular Meningitis (Acute Hydrocephalus), ..... 997 
Causes of Meningitis, .......... 998 
Symptoms and Diagnosis of Meningitis, ...... 998 
(a.) Simple Meningitis, . . . . . . . . . . 998 
Mental, Sensorial, and Motorial Phenomena, ..... 999 L 
CONTENTS OF VOLUME I. 
PAGE 
(6.) Tubercular Meningitis in the Child, 1000 
Mental, Sensorial, and Motorial Phenomena, ..... 1000 
(c.) Tubercular Meningitis in the Adult, ....... 1001 
Mental, Sensorial, and Motorial Phenomena, ..... 1001 
General Characteristics of Tubercular Meningitis, .... 1001 
(d.) Acute Meningitis in the Aged, ........ 1002 
Mental, Sensorial, and Motorial Phenomena, ..... 1002 
(e.) Chronic Meningitis of the Aged, ........ 1003 
Mental, Sensorial, and Motorial Phenomena, ..... 1003 
Diagnosis of Meningitis, ......... 1003 
Treatment of Meningitis, ......... 1003 
Tubercular Meningitis, 1004 
Definition of Tubercular Meningitis, .... ... 1004 
Pathology of Tubercular Meningitis, ........ 1005 
Acute Hydrocephalus, ........... 1005 
Morbid Anatomy in Acute Hydrocephalus, . . . . . . 1006 
Symptoms of Acute Hydrocephalus, . . . . . . . 1006 
Earliest Signs of Acute Hydrocephalus, ....... 1007 
Diagnosis of Acute Hydrocephalus, ........ 1007 
The Vomiting Characteristic of Acute Hydrocephalus, .... 1007 
Spurious Hydrocephalus or Hydrocephaloid, ...... 1008 
Diagnosis of this Form of Hydrocephalus, ....... 1008 
Prognosis in Hydrocephalus, . >. . . . . . . . 1008 
Treatment in Acute Hydrocephalus, ........ 1008 
Bloodletting in Tubercular Meningitis, ....... 1008 
Use of Medicines in Tubercular Meningitis, ...... 1009 
Management of Diet in Tubercular Meningitis, ...... 1010 
Inflammation of the Brain, 1010 
Definition of Inflammation of the Brain, ....... 1010 
Pathology of Inflammation of the Brain, ....... 1011 
Morbid Anatomy in Inflammation of the Brain, ..... 1011 
Results of Inflammation of the Brain,. ....... 1011 
Symptoms of Inflammation of the Brain, . . . . . . . 1011 
Mental, Motorial, and Sensorial Phenomena, ...... 1012 
Treatment (see Encephalitis and Meningitis}, ...... 1012 
Red Softening of the Brain, 1012 
Definition of Red Softening of the Brain, ....... 1012 
Pathology of Red Softening of the Brain, . . ... . . . 1012 
Several Morbid Conditions to be Distinguished within the Cranium, . . 1012 
Symptoms of Red Softening of the Brain, . . . . • • 1014 
Mental, Sensorial, and Motorial Symptoms of Softening of the Brain, . 1014 
Combination of Symptoms indicative of Softening, ..... 1014 
Duration of Life in Ramollissement of the Brain, ..... 1015 
Diagnosis of Red Softening of the Brain, ....... 1015 
Prognosis in Cases of Red Softening of the Brain, ..... 1616 
Treatment of Inflammatory Softening, ....... 1016 
Yellow Softening of the Brain, 1017 
Definition of Yellow Softening of the Brain, ...... 1017 
Pathology of Yellow Softening of the Brain, ...... 1017 
Symptoms of Yellow Softening of the Brain, ...... 1018 
Conditions under which Softening (post-mortem) is seen, .... 1018 
Conditions producing Softening, 1018 
Diagnosis of Softening, .....••••• 1018 
Treatment of Softening, 1018 
Abscess of the Brain. 1019 
Definition of Abscess of the Brain, ....•■•• 1019 
Pathology of Abscess of the Brain, ......•• 1019 
Morbid Anatomy in Cases of Abscess of the Brain, ..... 1019 
Locality of Abscesses in the Brain, 1020 
Causes of Cerebral Abscess, 1020 CONTENTS OF VOLUME I. 
LI 
PAGE 
Symptoms of Cerebral Abscess, ......... 1020 
Diagnosis of Cerebral Abscess, . . . . . . . . 1020 
Apoplexy, 1021 
Definition of Apoplexy, . . . . . . . . . 1021 
Pathology of Apoplexy, .......... 1021 
Group of Symptoms Characterizing Apoplexy, ...... 1021 
Local Lesions Inducing Apoplexy, ........ 1021 
Theories to Explain the Apoplectic State, ....... 1022 
Morbid Anatomy in Cases of Apoplexy, ....... 1022 
Changes in the Blood Effused, ......... 1023 
Position of Blood Effused in Apoplexy, ....... 1024 
(a.) Superficial or Ventricular Extravasation, ...... 1024 
(&.) Extravasation in the Substance of the Hemispheres, .... 1025 
(c.) Extravasation in the Pons Varolii and other Parts, .... 1026 
Comparative Liability of Parts of the Brain to Extravasation, . . 1027 
Circumstances under which Extravasation Occurs, .... 1028 
Symptoms of Apoplexy, . . . . . . . . 1028 
I. Symptoms of Apoplexy from Congestion, . . . . . . 1028 
Mental, Sensorial, and Motorial Phenomena, ..... 1029 
Precursory Symptoms or " Warnings " of Apoplexy, ... * 1029 
Special Nervous Symptoms Characteristic of Congestive Apoplexy, . 1029 
Diagnostic Value of Symptoms Combined in Groups, .... 1030 
II. Symptoms of Apoplexy from Hemorrhage, ...... 1030 
A. Into the Cerebral Substance of the Hemispheres, . . . . 1030 
The " Stroke of Apoplexy," ........ 1030 
Mental, Sensorial, and Motorial Phenomena, ..... 1030 
Combination of Symptoms Characteristic of Hemorrhage in the 
Hemispheres,........... 1031 
b. Symptoms of Hemorrhage into the Ventricles, .... 1032 
Mental and Motorial Symptoms, ....... 1032 
c. Symptoms of Arachnoid Hemorrhage, ...... 1032 
Combination of Symptoms Characteristic of Subarachnoid Hemor- 
rhage, ............ 1032 
Causes of Apoplexy, ........... 1033 
Anatomical Lesions, ........... 1033 
Connection of Apoplexy with Heart and Kidney Disease, .... 1033 
Influence of Temperature in causing Apoplexy, ...... 1034 
Influence of Moral Causes in producing Apoplexy, ..... 1034 
Influence of Mechanical Obstruction and Violence, ..... 1034 
Occurrence of Apoplexy in Childhood, ....... 1034 
, Influence of Sex, Progress of Digestion, and Conditions of the Body Pre- 
disposing to Apoplexy, . . . . . . . . . 1034 
Prognosis in Cases of Apoplexy, ......... 1034 
Treatment of Apoplexy, 1036 
Question of Bloodletting in Apoplexy, ....... 1037 
Purgation in Apoplexy, . . . . . . . . . . 1038 
Turpentine, Castor Oil, and Croton Oil Enemata, ..... 1038 
Dietetic Treatment of Apoplexy, ......... 1038 
Hematoma of the Dura Mater, 1039 
Definition of Haematoma of the Dura Mater, ...... 1039 
Pathology of Haematoma of the Dura Mater, ...... 1039 
Morbid Anatomy of the Blood Extravasation, ...... 1039 
Symptoms of Haematoma, .......... 1040 
Treatment of Haematoma, 1040 
Sunstroke 1040 
Definition of Sunstroke, . 1040 
Pathology and Symptoms of Sunstroke, ....... 1040 
Circumstances under which Sunstroke has Occurred, . . . . . 1041 
Sunstroke occurring on the March or in the Field, ..... 1041 
Influence of Vitiated Air in producing Sunstroke, ..... 1043 
Condition of the Atmosphere and as to Heat, ...... 1043 
Sunstroke occurring " in Quarters " or in Tents, ...... 1043 
Premonitory Phenomena of Sunstroke, ....... 1044 LII 
CONTENTS OF VOLUME I. 
PAGE 
The Urine in Sunstroke, 1044 
Periods of Attack in Sunstroke, ......... 1045 
Constant Symptoms of Sunstroke, ........ 1046 
Body-temperature in Sunstroke, . . . . . . . . . 1046 
Heart's Action in Sunstroke, ......... 1046 
Symptoms of a Fatal End, .......... 1047 
Mortality from Sunstroke, .......... 1047 
Symptoms of a Favorable End, . 1047 
Morbid Anatomy in Cases of Sunstroke, ....... 1048 
Condition of the Blood in Sunstroke, ........ 1048 
Theories regarding Mode of Action of Heat in producing Sunstroke, . 1048 
Modes of Death in Sunstroke, ......... 1049 
Causes of Sunstroke, ........... 1050 
Treatment of Sunstroke, .......... 1050 
Measures for the Prevention of Sunstroke, ....... 1052 
APPENDIX TO VOL. I. 
Circumstances connected with the Origin of Specific Yellow Fever, . . . 1054 LIST OF ILLUSTRATIONS IN VOL. I. 
FIG. PAGE 
1. Dilated Bloodvessels in Inflammation (after Paget), ..... 72 
2. Parenchymatous Inflammation, or Cloudy Swelling, as seen in a Convoluted 
Urinary Tubule taken from the Cortex of a Kidney in Bright's Disease 
(after Virchow), ............ 79 
3. Diagram showing Records of Temperature in a Case of Hectic Fever (Croft), 100 
4. Lymph Cells from Inflamed Pleura (Paget and Turner), .... 101 
5. Nuclei in Fibrinous Product of Inflammation Developing into Fibres (Ben- 
nett), 102 
6. Fibro-plastic Cells of Lymph developing into Fibres (Bennett), . . . 102 
7. Perfect White Fibrous Tissue from Lymph (Bennett), ..... 102 
8. Pigment from an Apoplectic Cicatrix in the Brain (Virchow), . . . 113 
9. Crystals of Haematoidin in different forms (Virchow), .... 113 
10. Hepatic Cells-(1.) Normal; (2.) Affected with Hypertrophy; (3.) Affected 
with Hyperplasy-Numerical Increase or Adjunctive Hypertrophy (Vir- 
chow), 121 
11, 12. Rokitansky's Representations of the Minute Structure of Cysts, . 138, 139 
13. Slightly Magnified Cyst of Trichina Spiralis (Virchow), .... 154 
14. Trichina Spiralis removed from the Cyst (Virchow), ..... 154 
15. Diagram of the Head or Anterior end of the Guinea-worm (Bastian), . . 166 
16. Various Forms of the Caudal End of the Guinea-worm (Busk, Carter, and 
Greenhow), ............. 166 
17. Dissection of a Guinea-worm (Bastian), ....... 167 
18. Dissection of Anterior Extremity of Guinea-worm (Greenhow), . . . 167 
19. A. Transverse Section of Adult Guinea-worm (Bastian), .... 168 
B. Young of the Guinea-worm more or less Spirally Curved (Bastian), . 168 
20. Head of the Bothriocephalus Latus. ........ 178 
21. Operculated Ova of Bothriocephalus, . . . . . . . . 179 
22. Bothriocephalus Cordatus, Natural Size and Magnified, .... 179 
23. Head and Neck of Tasnia Solium, showing Circle of Hooks, . . . 180 
24. Circle of Hooks in Head of Taenia Solium, highly Magnified (Leuckart), . 181 
25. Proglottis of Taenia Solium, Magnified (Rokitansky), ..... 182 
26. Proglottides of Taenia in Various Stages of Contraction (Leuckart), . . 182 
27. Development of the Ovum of Taenia Solium, . . . . . . 183 
28. Head of the Taenia Mediocanellata,' ........ 186 
29. Groups of Echinococci (Erasmus Wilson), ....... 189 
(1.) and (2.) Singly Pediculated in Groups, ....... 189 
30. Echinococci from a " Hydatid Tumor," ........ 189 
31. A. Transverse View of the Head of an Echinococcus, showing Suctorial Disks 
and Booklets, ............ 190 
32. b. Circle of (34) Booklets seen on its Under Surface, ..... 190 
c. Lateral Views of Separate Booklets, ........ 190 
33. Two Specimens of Cysticercus Mediocanellata. Natural Size, taken from a 
Specimen of Ration-beef sent from the Punjaub, ..... 194 
34. Bead of one of these Specimens Magnified 65 Diameters, .... 195 
35. Bead of Cysticercus Celluloses, to contrast with the Taenia Mediocanellata, . 195 
36. (a.) Operculated Ovum of Distoma; (6.) Opalina, ..... 203 
37. (1.) Ovum of Distoma Haematobium ; (2.) Embryo (Ciliated! from Ovum 
Capsule; (3.) Embryo attached to the Ovum Capsule from Haematobia, at 
the Cape of Good Bope (Dr. John Barley), ...... 206 
38. Small portion of the Lung of an African Soldier with a Pentastoma Constric- 
tum curled up in its Cyst (Dr. Humphry C. Gillespie), .... 208 LIV 
LIST OF ILLUSTRATIONS IN VOL. I. 
FIG. , PAGE 
39. Two Specimens of Pentastoma Constrictum removed from their Cysts, and 
of the Natural Size (Dr. Humphry C. Gillespie), ..... 208 
40. Two Specimens of Pentastoma Constrictum, Magnified from 3 to 5 Diameters 
-(a.) the Shorter ; (5.) and (c.) Posterior and Anterior Aspects of the 
Longer Parasite (Dr. Humphry C. Gillespie), . . . . . 2Q9 
41. Anterior Aspect of the Flattened Head of the Parasite, to show its five spots 
or marks (Dr. Humphry C. Gillespie), ....... 209 
42. Portion of Liver containing Encysted Specimens of Pentastoma Constrictum, 
from a Private in a West India Regiment, in the Museum of the Army 
Medical Department since 1854, Drawn by Dr. H. C. Gillespie, . . 211 
43. Larva or Grub from Bulama Boil (Dr. Albert Gore), ..... 212 
44. Larva or Grub from Boil, Magnified, showing-a, a, Hollow Suction Tubes; 
(6.) Fine Red Spots and Hooklets over Body (Dr. A. Gore), . . . 212 
45. Hooklets, highly Magnified (Dr. A. Gore), ....... 212 
46. The Crab-louse, X 10 Diameters (Dr. T. Anderson), ..... 213 
47. (a), Pediculus Capitis (male); (6), Trachea and Stigmata; (c), Antennae (Dr. 
T. Anderson), ............ 214 
48. Nit, or Egg Capsule of the Louse, fixed to (b) a hair by a Glutinous Secre- 
tion (c, c, a), ............ 214 
49. Pediculus Corporis-Female-(Dr. T. Anderson), ...... 215 
50. Acarus Scabiei-Female (Dr. T. Anderson), ....... 216 
51. Acarus Scabiei-Male (Dr. T. Anderson), . ' . . . . . 217 
52. Development of the Acarus Scabiei-a, b, c, d, e, Egg in Different Stages of 
advancement (Dr. T. Anderson), ........ 218 
53. Larva or Young of Acarus Scabiei (Dr. T. Anderson), ..... 219 
54. Demodex Folliculorum (Dr. T. Anderson), ....... 219 
55. Crystals of Margarine (Robin and Verdeil), ....... 229 
56. Fat Cells, inclosing Crystals of Margarine (Wedl), ..... 229 
57. Margaric Acid (Beale), ........... 230 
58. Cholesterin Plates-(a.) Regularly Laminated; (5.) Irregularly Laminated 
and Injured Forms, x 300 Diameters (Wedl), ...... 230 
59. Crystals of Uric Acid-(re.) Rhomboidal, Truncated, Hexahedral, and Lami- 
nated ; (5.) Rhombic Prisms; (c.) Barrel-shaped Prisms; (d.) Cylindrical 
Forms, x 300 Diameters (Wedl), ........ 231 
60. (a.) Urate of Ammonia in Globules; (6.) As a Fine Sandy Concretion in 
Kidney Tubes of a Child; (c.) Angular Molecules, ..... 231 
61. Crystals of Oxalate of Lime (Wedl), . . . . . . 232 
62. Usual Forms of Triple Phosphate of Magnesia and Ammonia (Wedl), . 232 
63. Double Embryo from a Fowl's Egg after sixteen to eighteen hours' Incu- 
bation, Magnified four times-(re.) Germinal Area of Cicatricula; (6.) 
Transparent Area, containing two Primitive Traces of Embryos; (c, c.) 
Primitive Grooves of the Double Embryonic Trace, on each side of which 
are seen the Laminae Dorsalis (after Dr. Allen Thomson), . . . 238 
64. Double Embryo from a Goose's Egg after five days' Incubation, Magnified 
four times; (<;.) The Common Heart; (A.) Rudiments of the Superior; (i.) 
Of the Inferior Extremities; (A.) The Common Cephalic Fold of the Am- 
nios ; (I.) The Caudal Folds (after Dr. Allen Thomson), .... 238 
65. Curved Clinical Thermometer for Reading in situ the Bodily Temperature in 
the Axilla, ............. 244 
66. Phillips's Registering Maximum Thermometer for Clinical Investigation, . 244 
67. Changes said by Dr. Halford to occur in the Blood-corpuscles subsequent to 
the Bite of the Cobra di Capello, X 1050, ....... 365 
68. Similar appearance X 400, .......... 365 
69. Diagram of the Typical Range of Body-temperature in a Case of Natural 
Small-pox (Wunderlich), .......... 381 
70. Diagram of Typical Range of Body-temperature in a Case of Small-pox 
Modified by Vaccination (Wunderlich), ....... 389 
71. Diagram Representing the Range of Body-temperature in a Severe Case of 
Measles (Wunderlich), .......... 426 
72. Diagram Typical of Body-temperature in a Case of Scarlet Fever (Wunder- 
lich),' 439 
73. Diagram Typical of Body-temperature in Typhus (Wunderlich and Mac- 
lagan), .............. 467 
74. Range of Body-temperature in a Severe and Prolonged Case of Enteric Fever 
(Wunderlich), ............ 530 
75. Diagram of Range of Body-temperature in a Case of Relapsing Fever (Her- 
man), .............. 556 LIST OF ILLUSTRATIONS IN VOL. I. 
LV 
FIG. PAGE 
76. Diagram of Typical Range of Body-temperature in a Case of Febricula 
(Wunderlich), ............ 563 
77. Diagram of Typical Range of Body-temperature in a Case of Protracted Feb- 
ricula (Wunderlich), ........... 563 
78. Diagram of Typical Range of Body-temperature in a Case of Intermittent 
Fever or Quotidian Ague (Wunderlich), ....... 588 
79. Diagram of Typical Range of Body-temperature in a Case of Intermittent 
Fever of Tertian Type (Wunderlich), . . . . ' . . . 589 
80. Diagramatic Representation of the State of the Heart, Lungs, and Great 
Vessels, after Death, in Collapse of Cholera (after Dr. George Johnson), . 642 
81. Diagram of Typical Range of Body-temperature in a Case of Erysipelas 
affecting the Face (C. L. Fox), ......... 727 
82. Diagram of Body-temperature in a Case of Pyaemia (Ringer), . . . 743 
83. Diagram Typical of Body-temperature in a Case of Acute Rheumatism affect- 
ing many Joints (Wunderlich), . . . . . . . . . 762 
84. Urate of Soda in Stellae-form Crystals (Wedl), ...... 784 
85. Appearance of the Teeth in Hereditary Syphilis, ...... 839 
86. Cancer-cells of Scirrhus filling the Interstices among Bundles of Connective 
Tissue in the Skin of the Breast (Paget), ....... 851 
87. Varied Forms of the Elementary Cells of Scirrhus Cancer (after Wedl and 
Paget), ............... 852 
88. Varied Forms of the Elements of Soft or Medullary Cancer (after Paget and 
Wedl), 853 
89. Various Typical Epithelial Cancer-cells and their Arrangement (after Paget 
and Rokitansky), ............ 857 
90. Various cells of Melanotic Cancer from the Orbit (after Wedl), . . . 858 
91. Development of Tubercle from Connective Tissue in the Pleura-300 Diame- 
ters (after Virchow), ........... 882 
92. Crystals of Diabetic Sugar from Diabetic Urine (after Beale), . . . 916 
93. Inosite, or Muscle-sugar, Crystallized partly from Alcohol and partly from 
Water (after Funke), ........... 918 
94. Nitrate of Urea (after Beale),. ......... 986 
95. ^Esthesiometer of Dr. Sieveking, ......... 988 
96. Dynamometer of Mathieu for measuring the Strength of Paralyzed Muscles, 991 
Engraved Plate, showing Forms of Fungi as described by Hallier and others in 
Rice-water Stools of Cholera, to face page ....... 649 THE 
SCIENCE AND PRACTICE OF MEDICINE. 
PART I. 
TOPICS RELATIVE TO PATHOLOGY. 
CHAPTER I. 
OF MEDICINE AS A SCIENCE AND AS AN ART; ITS OBJECTS AND ITS 
EXTENT. 
The study of Medicine is prosecuted under two relations, namely, as a 
Science and as an Art. 
Considered as a Science, Medicine takes cognizance of all that relates to 
our knowledge of diseases ; and, especially, of the circumstances under which 
they become developed, of the conditions of their existence, of their nature 
and of their causes, in the widest sense of these terms. 
Considered as an Art (in so far as Medicine has that practical value), its 
object and aim is to distinguish, to prevent, and to cure diseases; to alleviate 
human suffering, and to lengthen out human existence, by warding off or by 
modifying disease " as the greatest of mortal evils," and by restoring health, 
and even at times reason itself, " as the greatest of mortal blessings." 
In general terms, the practical view required to be taken of Medicine is, 
that " it is the art of understanding the nature of diseases, in order to appre- 
ciate their causes, and to prevent their occurrence when possible; to promote 
their cure, or to relieve those who suffer from them." 
Many branches of human knowledge are combined in the constitution and 
elucidation of the Science of Medicine. The practice of the Art ought to be 
founded on principles and facts of universal applicability. 
A consideration of the different topics of human knowledge which together 
make up the Science of Medicine suggests its division into the following 
departments, namely: 
(1.) Physiology, which embraces the study of the healthy functions of 
which the human body is the seat or instrument; 
(2.) Pathology, subdivided into Special Pathology and General Pathology, 
which together embrace a consideration of everything relative to the existence 
and nature of diseases; , , 50 
TOPICS RELATIVE TO PATHOLOGY. 
(3.) Therapeutics, which expounds the various actions of remedies upon 
the diseased economy, or the means by which Nature may be aided in her 
return to health; 
(4.) Hygiene, which embraces a consideration of the means of preventing 
disease, or, in other words, of preserving health. 
Physiology, General Pathology, Therapeutics, and Hygiene are sometimes 
designated indifferently by the titles of the "Institutes," the "Institutions," or 
the "Theory of Medicine." 
These departments of science are all preliminary subjects of study, and 
constitute a necessary and appropriate introduction to the Practice of Physic, 
in which Special Pathology and the treatment of special diseases are the 
leading topics of consideration. 
Each of these departments has grown or expanded itself into a great branch 
of science; and any single section is sufficient of itself to occupy the lifetime 
of an individual in working out and studying it in detail. It is, therefore, 
not possible for the human mind to embrace all of these departments in their 
whole extent or relations to each other; and, setting aside the consideration 
of theories and systems, it has been truly observed, " that no man possesses 
all the pathological knowledge contained in the records of his art" (Chomel). 
Still less possible is it to embrace in any single treatise a complete and con- 
nected view of the Science of Medicine in all of these departments. 
For the purpose of teaching the Science of Medicine in its application to 
practice, its elementary principles, as developed in the departments of Pa- 
thology, are the most useful guides to the student; and the aim of the follow- 
ing chapters, relative to Pathology, is to elucidate these principles. 
CHAPTER II. 
HOW THE PROVINCE OF PATHOLOGY IS MAPPED OUT. 
An inquiry into the nature of diseases embraces a consideration of the fol- 
lowing topics: 
(1.) The accurate observation and correct registration of Facts in Pathology. 
On the efficiency of the machinery devised for these important ends will 
rest our power to curb the invasion of our science by the guesswork of 
theory; and eventually to root out the traditional errors which so largely 
pervade medical literature. 
(2.) Descriptive Pathology, embracing General and Special Pathology. 
Special Pathology is intended to comprehend a consideration of the essential 
nature and origin of particular diseases as they occur in man and animals, 
and General Pathology to include those more general facts or principles which 
result from a comparison of particular diseases with each other. Although 
Special Pathology comes first in the order of Nature, yet, wherever the ar- 
rangements for medical education are complete, General Pathology is taught 
as an introduction to, or conjointly with, the special study of diseases, just as 
in other sciences; for example, in chemistry it is found convenient to give a 
general view of the principles which have been established by experiment and 
observation, before entering upon the particular details of the science. All 
theory in Medicine, all Descriptive Pathology, all grounds for rational specu- 
lation regarding the nature of diseases, and for the framing of experiments, as 
well as all maxims of practice which aim at the prevention or cure of diseases, 
must rest ultimately on observed and recorded facts. Accuracy of observation 
is therefore the first lesson the student has to learn in all methods of investi- THE PROVINCE OF PATHOLOGY. 
51 
gation, and the lesson is one of paramount importance. The best observa- 
tions, however, will avail but little unless the observed facts are recorded in 
such a way as to secure their preservation; and Descriptive Pathology mainly 
concerns itself, in the first instance, with the Registration of Facts, as em- 
braced,- < 
(a.) In the History of cases of disease from their origin to their end. 
(6.) In the Statistics of disease. 
Such registration includes methods for preserving, in an authentic and per- 
manent form, the memory of Facts in Pathology as they occur. It thus 
eventually furnishes materials upon which future pathologists and statists will 
build a comprehensive and definite system of scientific Medicine. It will 
furnish the means of teaching all that is necessarily involved in our notions 
regarding the nature of diseases. The Descriptive Pathology, so arrived at, 
considers diseases as they exist, or have existed in man, in the lower animals, 
or in plants. It considers the conditions under which diseases originate; it 
considers how far certain conditions are fulfilled before disease establishes 
itself; and it aims at demonstrating how far such conditions are inconsistent 
or incompatible with the maintenance of health. Subsequently, with ex- 
tended information, Descriptive Pathology may undertake to assign the con- 
ditions which give rise to certain diseases rather than to others. It will 
eventually define the elements necessary to establish, to originate, or to con- 
stitute particular diseases; and will show how the same disease, or class of 
diseases, may assume various forms, but in all of which definite elements are 
recognizable. Descriptive Pathology thus aims at determining and describ- 
ing the essential elements of a disease. 
(3.) Speculative Pathology assumes that we know what a disease is-that we 
know the effects it produces-that we know the conditions necessary for its 
existence-that we know its relations to other diseases. It seeks to inquire 
how certain conditions or circumstances will operate in bringing about dis- 
ease. It seeks to determine the tendency in the future of a diseased state 
from certain observed facts in its course, or in the course of similar diseases. 
Statistical data are thus the main basis of its operations. 
(4.) Pathology dictates the maxims of rational practice. It is in the nature 
of the science of Pathology that it always ought to be in advance of our certain 
knowledge regarding the treatment of diseases. It is the basis of rational 
medicine; for it is rational to know the nature of a disease, in order (1.) To 
enable us to prevent .it; (2.) To understand the principles which ought to 
guide us in the management of it. Such are the main divisions which the 
province of Pathology embraces. 
It is intended, however, in the first part of this handbook merely to guide 
the student to appreciate,- 
(1.) The relative nature of the terms "Life," "Health," "Disease." 
(2.) How the nature and causes of diseases may be elucidated. 
(3.) The nature of morbid phenomena, symptoms, and signs of disease. 
(4.) The means and instruments of investigation into the nature and causes 
of disease. 
(5.) Some of the more elementary constituents of disease. 
(6.) Some complex morbid states associated with individual diseases, or 
with conditions of ill-health (cachexise). 
(7.) The modes by which diseases terminate fatally; the types of disease, 
and their tendency to change. 
(8.) The general treatment of the more complicated morbid states of the 
system comprehended under the name of General Diseases. 
In the subsequent parts of this work it is intended to consider some of the 
details of the Science and Practice of Medicine: to furnish the student with,- 
(1.) A nosological system by which to classify and name diseases. 
(2.) A detailed description of characteristic diseases in the respective classes 52 
TOPICS RELATIVE TO PATHOLOGY. 
of that nosological arrangement. In this part a definition (provisional) and 
a history of the nature of each disease will be given; the probable course and 
succession of events in the progress of each disease will be described, and 
the grounds on which an accurate diagnosis may be made, or a prognosis 
expected; and, lastly, a detailed account of those rational modes of treat- 
ment which are consistent with the established principles of the Institutes of 
Medicine. 
(3.) An account of what is known relative to the geographical distribution 
of diseases. 
CHAPTER HI. 
RELATIVE NATURE OF THE TERMS LIFE, HEALTH, DISEASE. 
The word Disease is used in a general and also in a specific sense; as when 
it is said that a person is diseased, without the nature of the affection being 
stated; or, that he suffers from a particular disease, such as small-pox. 
Attempts to give a precise definition of the term Disease have all been unsuc- 
cessful. The relations of the morbid state to the condition of health, and of 
health to the performance of the vital functions, are of such a kind that they 
can merely be described in connection, comparison, or contrast with each 
other, but not defined. 
If Life is understood to imply an active state, resulting from the concur- 
rent exercise of the functions of the body, then there are conditions of activity 
and of mutual adaptability of functions and of parts, both as regards body 
and mind, which are necessary to healthy existence. Our notions of the con- 
ditions of health have thus considerable latitude; and Health is merely a name 
we give to that state or condition in which a person exists fully able, without 
suffering, to perform all the functions and duties of life. Many degrees of 
Health are therefore at first sight obvious, from the possession of a feeble 
existence to the most robust condition of the body; and there are even many 
degrees of feebleness and delicacy of Health without any disorder of the 
system. Our notions of normal life are thus so extremely indefinite that it is 
only by a forced abstraction the normal can be separated from the abnormal. 
Hence also our idea of Disease is very indefinite; it cannot be separated by 
any well-defined boundary from our idea of normal life, and the two condi- 
tions are connected by a kind of debatable border land. 
When we regard, therefore, the phenomena of the living state and the con- 
ditions of health, we can readily observe when and how Disease is but A de- 
viation FROM THE STATE OF HEALTH, CONSISTING FOR THE MOST PART IN A 
CHANGE IN THE PROPERTIES OR STRUCTURE OF ANY TISSUE OR ORGAN, WHICH 
RENDERS SUCH TISSUE OR ORGAN UNFIT FOR THE PERFORMANCE OF ITS 
ACTIONS OR FUNCTIONS ACCORDING TO THE LAWS OF THE HEALTHY FRAME. 
It is now a received pathological doctrine that Disease does not consist in 
any single state or special existence, but is the natural expression of a combi- 
nation of phenomena, arising out of impaired function or altered structure. 
All attempts, therefore, to define disease by the use of such terms as " derange- 
ment," " modification," " alteration," " change," from the pre-existent state of 
health, show, in the first instance, that, in use, various ideas are attachable to 
the terms or to the state to which they are meant to apply, and, secondly, that 
these terms point to a nosological division into structural and functional 
diseases, rather than to a state common to all forms of disease. 
A definition of any state of disease ought, therefore, to include all the cir- 
cumstances, whether functional or organic, which constitute the deviation MORBID PHENOMENA, SYMPTOMS AND SIGNS OF DISEASE. 
53 
from health ; and for obvious reasons such a definition can only be approxi- 
mately expressed, very incompletely circumscribing the subject by shadowy 
outlines. 
CHAPTER IV. 
HOW THE NATURE AND CAUSES OF DISEASES MAY BE ELUCIDATED. 
The nature of the derangements to which the human body is liable may be 
studied under the three following aspects : 
(1.) As diseases present themselves in individual cases, becoming thereby 
the subjects of Clinical Investigation and Instruction-a method of 
teaching in which the Natural History of the disease ought to be a special 
subject of study. 
(2.) As they constitute particular genera or species of disease, forming the 
topics of Special Pathology. 
(3.) As they may be reduced to and studied in their primary elements, 
forming thereby the science of General Pathology. 
But, in whatever aspect we may view disease, there is invariably presented 
to the student the same subjects for investigation, namely,-First, The morbid 
phenomena or symptoms by which we become aware that derangements have 
taken place in the economy. It is by a mental effort that either the student 
or the physician converts these symptoms into signs of disease; and hence 
arises the necessity of studying Symptomatology or Semeiology. Second, The 
agents by which derangements and diseases are produced, generated, or brought 
about, constituting the department of Etiology. Third, The seats or localities 
of disease, or of derangements, constituting Pathogeny. Here the peculiar 
nature, general forms, and types of disease must be studied, together with va- 
rieties in their course, duration, and termination. Fourth, The morbid altera- 
tions discoverable in the structure of the body before, but more especially 
after death, constituting Morbid Anatomy. These alterations must be studied 
in connection with the symptoms, the causes, and the course of the disease. 
Lastly, The elementary constituents of disease-products, constituting Morbid 
Histology, must be recognized in the first instance, and contrasted with analo- 
gous constituents of the body in the healthy state. 
CHAPTER V. 
OF MORBID PHENOMENA, SYMPTOMS, AND SIGNS OF DISEASE. 
It has been stated- that only by a mental effort is the student or physician 
able to convert symptoms into signs of disease. Therefore the idea associated 
with "sign" is of a much more comprehensive kind than that which is con- 
nected with the word " symptom: " the former implies the possession of more 
extensive knowledge-a knowledge such that comparisons may be instituted 
amongst the symptoms which present themselves. Certain symptoms of' 
disease, or of disordered function, are thus recognized to be peculiar, charac- 
teristic, or significant of a particular morbid state. A symptom is thus con- 
verted into a sign, and what is called a diagnosis of the disease is made. 
Symptoms and signs of disease derive their importance from the fact that 
they are capable of being connected with lesions of structure or disorders of" 54 
TOPICS RELATIVE TO PATHOLOGY. 
function; and both of these conditions mutually act and react upon each 
other. Thus it is that such mutual reaction greatly aggravates any general 
disease. In place of the concurrent exercise of function, and the mutual co- 
operation of parts in a state of health, both as regards mind and body, we 
have symptoms of disease expressed in various ways, characteristic of the func- 
tion at fault, and incompatible with the normal existence of the part or organ 
affected, or of the body generally. From such phenomena the physician 
makes up his mind,-(1.) As to whether or not disease exists (2.) How far 
the condition of the patient is removed from the state of health usual to him. 
(3.) As to the nature of the disease, and how it is distinguished from other 
ailments, or in what respects it may differ from the same ailment in other 
people in similar circumstances. Thus a diagnosis is made by the art of con- 
verting symptoms into signs of disease. 
But the physician at the same time generally carries his mental exertion a 
little further. He tries to arrive at a just estimate of the probable result or 
event of the malady, and so makes up his mind,-(4.) As to whether the ill- 
ness will terminate in the death of the patient, in permanent organic mischief 
of greater or less extent, in persistent impairment of the general health 
(cachexise), or in complete recovery. As in Politics, so in the Science of 
Medicine: the Politician and the Physician have each to deal with the future, 
as well as with the present. Both endeavor to forecast events; and thus, in 
the Practice of Medicine, we are said to make or give a prognosis. (5.) The 
Physician must be able also to appreciate with reasonable rapidity those 
symptoms which are peculiar, and to recognize them when associated together 
as the signs of particular or definite morbid states. Such symptoms are then 
said to furnish pathognomonic signs of disease. (6.) The Physician must further 
discriminate, and try to put a fair and just value or interpretation upon, those 
symptoms which are only experienced by the sensations (subjective) of the 
patient himself, as contrasted with those which may be seen or appreciated by 
others-such as objective phenomena or physical signs. 
The interpretation of symptoms can only be successful after a close observa- 
tion of the patient-often prolonged, and repeated for more complete investi- 
gation-so as to connect the results arrived at with his previous history. The 
utmost logical acumen is required for the due interpretation of symptoms. 
The individual Value of each ought to be duly weighed ; one symptom must 
be compared with another, and each with all; while the liability to variation 
of a similar symptom in different cases of a like kind must not be forgotten ; 
and the occasional absence of the usual pathognomonic signs may be some- 
times calculated upon. Thus only can the nature of a disease be clearly deter- 
mined-its severity and dangers fully appreciated-its treatment indicated, 
and the probability of recovery foretold. 
A close observation of the general symptoms of diseases, in all their details, 
is absolutely necessary; and the investigation is aided practically by the 
improved instruments of the present day, and the better methods of examina- 
tion of patients. Above all things, methodical examination is essential for the 
student, if he would acquire the habit of carefully and accurately learning the 
nature of the cases of disease with which he will have to deal. Patients must be 
examined methodically, in order that the symptoms of disease may be correctly 
interpreted, and that nothing be overlooked or neglected. Directions have 
been given by many authorities for acquiring and habitually following a defi- 
nite system of examining patients, as to what are the essential data to be 
obtained and recorded in case-taking; and although, as Dr. Acland justly 
remarks, a skilful practitioner can learn the truth of most cases in any order, 
or in no order, yet it is highly desirable that a regular order should be fol- 
lowed by learners; and all cases observed by the student should be methodi- 
cally entered in a note-book for the purpose. This habit will thus eventually MORBID ANATOMY AND PATHOLOGICAL HISTOLOGY. 
55 
become a necessity, and will be found most useful in after-life, and especially 
in consulting practice. 
The following works are recommended for study, and as guides for acquir- 
ing the best methods of observing and recording cases: (1.) A Manual of 
Medical Diagnosis, third edition, by A. W. Barclay, M.D.; (2.) A Handbook of 
Hospital Practice; or, an Introduction to the Practical Study of Medicine at the 
Bedside, by Robert D. Lyons, M.B., Professor of Medicine in the Catholic 
University of Ireland; (3.) An Introduction to Clinical Medicine, by John 
Hughes Bennett, M.D., Senior Professor of Clinical Medicine in the Univer- 
sity of Edinburgh ; (4.) " Suggestions for taking Cases," by Dr. Beale, Archives 
of Medicine, vol. iii, p. 47. 
CHAPTER VI. 
MORBID ANATOMY AND PATHOLOGICAL HISTOLOGY: THE SPECIAL MEANS 
AND INSTRUMENTS BY WHICH THE NATURE OF DISEASES MAY BE INVES- 
TIGATED. 
Morbid, or, as it is also sometimes called, Pathological Anatomy, is 
that department of medical science which treats of the changes produced by 
disease in the solids and fluids of the body; while Morbid or Pathological 
Histology treats of the origin, development, growth, and decay of the new 
products or new formations which are the elementary constituents of structu- 
ral or organic lesions. The anatomy of diseased parts stands in the same rela- 
tion to the development of morbid phenomena and conditions of disease that 
the anatomy of healthy structures and tire histology of the textures do to the 
natural functions and processes of development, growth, and nutrition in the 
healthy body. 
The vestiges left by the prolonged existence of a morbid state, whether in 
the body of man or of the lower animals, have always claimed from the physi- 
cian a large share of attention. In proportion also as the knowledge of healthy 
anatomy and physiology has become extended, so has pathology and morbid 
anatomy gradually but steadily acquired an important and prominent position 
among those branches of study on which Medicine rests its claims as a science. 
Morbid Anatomy is a department of medical science which has gradually 
grown out of the accumulated experience and observation of ages; but 
Pathological Histology, as a science, is of modern origin. It is but yet 
in process of development, although its foundations may be traced in the works 
of the earliest medical writers of antiquity. All of them refer to changes 
which they merely supposed had taken place in the internal organs; and they 
were doubtless led to this assumption by observing the connection that existed 
between structural lesions of the external parts and their accompanying symp- 
toms. Hippocrates describes the deposit of tubercles in the lungs, the symp- 
toms occasioned by them in a crude state, and those which attend their soft- 
ening and discharge. 
The science of Morbid Anatomy is a record of facts. In its relation to 
the progress of Medicine it is a living record-a history whose pages must be 
ever open to receive the observations which are constantly being made by 
those engaged in pathological pursuits-a record from which one may ascer- 
tain at any time the conditions under which morbid changes or new forma- 
tions in the body have taken place. The pages of this history show that at 
the present day the department of pathology is in a transition state; and the 
position of Medicine, as a science, must eventually result from a rearrange- 
ment of the innumerable details which the sciences of morbid anatomy 'and 
histology may disclose and unfold. It is necessary, therefore, and often advan- 56 
TOPICS RELATIVE TO PATHOLOGY. 
tageous, to look back upon the past, and see what has already been done, so 
that its venerable facts may not be lost sight of, but grouped in series with the 
extensively verified experiments and observations, of the present day. In so 
doing, if we pause and contemplate the steps which have been taken to arrive 
at our present position, such a contemplation may stimulate the youthful 
student to the noblest exertions of his intellect, as he cannot fail, with exten- 
sive study, to see before him, and on every side, much unlabored but produc- 
tive soil. Such a retrospect will at the same time have the effect of placing 
in a prominent aspect the varied influences which Morbid Anatomy has had 
on the Science of Medicine, the conditions under which it has flourished, and 
the legitimate objects of its investigations. 
The art of printing had not been long invented when books on morbid an- 
atomy began to issue from the press; and although the early period of the 
fifteenth century has left little enduring literature of any kind (but has been 
mainly distinguished by the number of colleges then founded), yet about this 
time pathological anatomy in the medical school of Florence shows the earliest 
evidences of an existence. 
The facilities for study which the art of printing introduced soon stirred up 
ardent students; and the sixteenth and seventeenth centuries produced much 
that will ever remain famous in the annals of medical science. Eustachius, 
Tulpius, Ruysch, Harvey, Malpighii, and Leuwenhoeck are names familiar 
as household words to the student of Medicine. The earlier attempts of this 
period to form a system of pathological anatomy are characterized by abortive 
endeavors to explain all results upon some exclusive and general principle. 
A spirit of speculation marks the character of the age. The men of that time 
had observed but few facts; and on these facts they preferred to speculate 
and dogmatize, rather than prosecute the further interpretation of nature, or 
record more observations. Accordingly, theories in abundance successively 
led captive the minds of the medical world, and, disappearing one after the 
other, demonstrated the unstable foundations on which the science of Medicine 
had been placed. The leader of each sect founded his so-called school or 
system, all of them distinguished by a due amount of arrogance and con- 
tempt for predecessors and contemporaries-a feeling unhappily not yet quite 
extinct. The " vital agency," the " influence of the humors," and of the " solid 
organs," have each been considered by turns as the only orthodox belief; and 
each has had their school and sect respectively designated as the Vitalists, the 
Humoralists, and the Solidists. The theories of Galen, of Paracelsus, and 
others, have all been famous in their time, but are now unheard of, and 
almost unknown. The same fate awaits the false theories and absurd con- 
ceits of more recent times, although, as in the case of Stahl, Cullen, Brown, 
and Broussais, they have had a wide prevalence in the schools of Europe, 
and made impressions on the sentiments of the profession which yet influ- 
ence their modes of practice and the reasons of their belief. Broussaiswn, 
Hahnemanmsm, and some other systems, " the fruits of a luxuriant fancy 
and of few facts," must all descend, as others have done, the same inev- 
itable slope to oblivion; but the vast collection of facts which the founders 
and followers of such systems eventually accumulate and bring to notice, 
remain unchangeable, and will continue to recur in the daily experience of 
our profession, just as they appeared to the venerable fathers of medicine 
centuries before the Christian era. The practice of medicine, as based upon 
rational principles and a knowledge of the nature of diseases, has thus oscil- 
lated through these varied systems and innumerable theories, and the science 
of Morbid Anatomy has been marked throughout by unmistakable periods of 
progress, of stationary existence, or even of retrogression, according as one or 
othei* exclusive system had the ascendency, or as each principle or theory of 
practice challenged for itself a supreme importance. 
The modern doctrines relative to the nature of diseases and the practice of PHYSIOLOGY THE BASIS OF PATHOLOGY. 
57 
Medicine are guided' by the dictates of Physiology, and of what is known 
regarding the development and growth of the human body. Ordinary dissec- 
tions alone, or post-mortem examinations of the body, have long since ceased 
to furnish us with facts before unknown; and new modes of extending obser- 
vation and research, by taking advantage of every physical aid to the senses, 
are diligently looked for by the modern anatomist, physiologist, and physi- 
cian ; and the means and instruments which advance the science of physiology 
are well able to advance our knowledge regarding the nature of disease- 
processes. 
A belief is now rapidly gaining ground, and acquiring a hold on the pop- 
ular mind, that advances in the science of Medicine in future years will be 
mainly due to a better appreciation of the causes of disease; and just in propor- 
tion as our knowledge of physiology and pathology becomes more exact and 
extended, so will the causes of disease be appreciated, and the occurrence of disease 
on a large scale prevented. An amiable and large-minded physician, the late 
Sir John Forbes, emphatically recorded the observation, more than twenty 
years ago, that " here the surest and most glorious triumphs of medical science 
are achieving, and are to be achieved." He himself lived to see great and good 
results; to see improvements in social and sanitary matters which continue 
to be realized, and whose rapid progress is characteristic of the present period. 
Within the last half century land-draining and town-sewering have ripened 
into sciences. From rude beginnings, insignificant in extent, and often in- 
jurious in the first instance, the systematic sewering of towns and draining of 
land have become of the first importance. Land has thus, in not a few in- 
stances, doubled its value. Town-sewering, with other social regulations, have 
contributed to prolong human life from 5 to 50 per cent, as compared with 
previous rates in the same district. Agues and typhoid fevers are reduced in 
the frequency of their occurrence. Since 1840 an annual mortality in English 
towns of 44 in 1000 has been reduced to 27; an annual mortality of 30 has 
been reduced to 20, and even as low as 15. Not less remarkable reductions 
have taken place in the mortality and loss of strength in the army and navy; 
so that generally it may be said that human life has now more value in Eng- 
land than in any other country in the world-a result entirely due to better 
sanitary arrangements (Rawlinson " On Sewering of Towns," Soc. of Arts 
Journal, vol. x, p. 276). 
The political economist, therefore, cannot now regard Medicine in any 
other light than as a productive art; and the labors of the physician, whether 
in civil or in military life, cannot be regarded as unproductive labor. 
But the science of Physiology (on which much of our sanitary improve- 
ments are based) has immeasurably outstripped the science of Pathology in 
the comprehensiveness of its views and in the value of its results; while Pa- 
thology, in its turn again, has always been, and ought to be, in advance of 
Therapeutics. The best physiologists have distinctly recognized that the basis 
of their science must include not only a knowledge of animals below man, 
but a knowledge of the entire vegetable kingdom. Without such an exten- 
sive survey of the whole realm of organic nature, we cannot possibly under- 
stand human physiology, and far less comparative physiology. The science 
of Pathology, therefore (whose aim is to expound the nature of all diseases'), 
must be, a fortiori, very far behind Physiology. The diseases of the lower 
animals, for instance, rarely form any part of the study of the student of 
Medicine. The diseases of plants are almost entirely neglected. Yet it is clear 
that until all these have been studied, and some steps taken to generalize the 
results, every conclusion in pathology regarding the nature of diseases must 
be the result of a limited experience from a limited field of observation. How 
do we know that the blights of plants, or the causes of them, are not commu- 
nicable to animals and to man? We know how intimately related the dis- 
eases of man and animals are with famines and unwholesome food; and of 58 
TOPICS RELATIVE to pathology. 
famines with the diseases of vegetable and animal life, as much as with the 
destruction and loss of food. 
To Physiology, therefore, in its most comprehensive sense, and to a knowl- 
edge of the natural and normal development of animal and vegetable beings, 
we must look for future progress in pathology; while the means and instru- 
ments which advance physiology will simultaneouly advance our knowledge 
regarding the nature of diseases-a sound knowledge of which can alone enable 
us to " appreciate their causes," and so arrange measures for the prevention of 
many of them, based on the great truths of science. 
Organic chemistry, the microscope, the ophthalmoscope, the sphygmograph, the 
laryngoscope, and such-like instruments, have opened up new fields of labor, 
which are being diligently cultivated; and while alterations in the ultimate 
tissues and organs are more especially attended to, the first beginnings of dis- 
ease, the development of new formations, and the examination of excretions, 
and of specific products, claim a large share of attention. 
Histology, or the study of the development and arrangement of the tissues 
in the formation of normal and healthy organs, is characteristic of the ana- 
tomical investigations of the present day ; while the histology of morbid prod- 
ucts and chemico-physiological investigation into the nature of morbid 
changes is characteristic of the pursuits of the science of modern Pathologi- 
cal Anatomy. 
It is also a significant fact that now, in the nineteenth century, some of the 
leading doctrines of the humoral pathology which prevailed in the seventeenth 
are again revived. The experience and learning of that erudite period are 
now being made available for modern uses. By the improved means, instru- 
ments, and methods of research of modern times, important truths may be 
sifted from the errors and theories with which they are mixed up in the 
ancient chronicles of medical science; and when we get analogous conditions 
of disease with which the phenomena described by the ancients may be com- 
pared, " not a few of the apparently modern beliefs are daily found to have a 
time-honored reputation unappreciated before." 
The chemist and the histologist now combine their researches, and, working 
hand in hand, we regard them as the most inquisitive anatomists of the time. 
They lend assistance of the most important kind in laying the foundation of 
our knowledge regarding the nature of diseases, the details of which can only 
be made more certain and perfect by taking advantage of every kind of scien- 
tific knowledge which can be brought to bear upon medical research, and 
more especially,-(1.) By physical aids to the senses, extending our means 
for the actual inspection and appreciation of phenomena. The use of the 
thermometer, the sphygmograph, microscope, ophthalmoscope, laryngoscope, 
the stethoscope, and specula of various kinds, aided by a careful study of the 
writings and labors of the men who have more particularly devoted their 
attention to observations by such means, may be quoted as examples (Laen- 
nec, Louis, Walsh, Stokes, Hope, Bennett, Quekett, Virchow, Wun- 
derlich, Traube, Vogel, Beale, Graefe, Czermak, and others). (2.) 
By the knowledge (gradually being made more extensive) of the textures, 
organs, and functions of the body, whose normal exercise constitutes a healthy 
existence (Longet, Muller, Sharpey, Valentin, Allen Thomson, Car- 
penter, Kirkes, Paget, Kolliker). (3.) By an intimate knowledge of 
the normal development of the human textures, as well as those of plants and 
animals from the fecundated ovum (Bischoff, Costa, Allen Thomson, 
Huxley, Newport, and Kolliker). (4.) Besides these kinds of investiga- 
tions, the science of practical medicine has been, and is being, advanced by 
operations and experiments upon the internal organs of living animals, oppro- 
briously termed vivisections. At some of our great schools of medicine such 
investigations are now being actively but judiciously prosecuted and taught. 
Successful inquiries into Pathology, or the nature of diseases, cannot be said now THE SCIENCE OF PATHOLOGY HAS BEEN ADVANCED. 
59 
to have commenced till the middle of the eighteenth century, when the great 
work of Morgagni issued from the press. It was the work of his lifetime. In 
the eightieth year of his age, and not till then, did he consider himself war- 
ranted to publish his observations, De Sedibus et Can.sis Morborum (1761); a 
work whose material and circumstances of publication read us the practical 
lesson, that the more frequently a disease occurs, the more necessary it is that 
its phenomena should be carefully investigated. And when we think of the 
prudent reserve, the anxious and the conscientious delay exhibited by Har- 
vey, Morgagni, and Jenner, in the publication of their respective researches, 
we cannot but contrast the circumstances with those under which the exuber- 
ance of medical publications are now given to the world. Morgagni modified 
and corrected many of the views entertained and promulgated by his prede- 
cessors ; and the study of the nature of diseases was carried into the com- 
mencement of the present century by Cullen, De Haen, William and John 
Hunter, Portall, and Bichat. 
Our knowledge regarding the nature of disease-processes has advanced 
simultaneously with that of general anatomy; and when the component parts 
of an organ, and of the human body, came to be distinguished, it was observed 
that membranes and tissues might be individually diseased, while neighboring 
membranes and tissues remained untouched. Bichat's idea, therefore, of de- 
composing the animal body into its elementary parts, must be regarded as 
the foundation of modern special pathology, and Morbid Anatomy. He 
pointed out the necessity of studying diseases with reference to the different 
tissues as separately and specially affected; and it has been since shown, in a 
remarkable manner, how general anatomy, deduced from the physical proper- 
ties of parts and crude observation, may coincide with more minute investiga- 
tions of a chemical and microscopical kind. The membranes and tissues of 
the human body, roughly torn asunder by Bichat, are now themselves being 
daily subjected to a more inquisitive analysis of an anatomical and chemical 
nature, which unravels them into still more minute histological elements. 
Although, therefore, Bichat entertained the view that each tissue had its 
own diathesis, it is to Cullen and the Hunters, in this country more especially, 
that the application of the distinction of tissues was made to illustrate the 
nature of disease-processes. 
Cullen's descriptions of diseases are descriptions of groups of phenomena 
which comprise complex morbid states. 
The written labors of the Hunters form but a small part of the memorials 
of what they did to elucidate the nature of diseases, and it is only those who 
have had the opportunity of carefully examining their museums, preserved in 
London and in Glasgow, that are able to form any conception of the compre- 
hensive nature of their labors, or to assign to them a proper place among 
those who have successfully advanced the science of Medicine. They hold a 
position in science at least one hundred years in advance of the age in which 
they lived. 
Bichat, Cullen, and the Hunters, in their respective countries, have thus 
reciprocally influenced and advanced the progress of our knowledge regarding 
the nature of diseases. And although it was reserved for Bichat to complete 
a more perfect system of general anatomy, it must not be forgotten that Dr. 
Carmichael Smith, in 1790, applied his knowledge of textural anatomy to 
elucidate the nature of disease-processes; and that Pinel, after him, in his 
Nosographie Philosophique, made the distinction between the membranous and 
other animal structures the foundation of his pathology. The classic work of 
Baillie (his Morbid Anatomy), published in 1793, closed the labors of the past 
century. 
If we look now to the tendency of the studies and researches of those men 
just named, including Bichat, the truth gradually asserts itself, that it was 
necessary to study alterations of structure so as to connect morbid changes 60 
TOPICS RELATIVE TO PATHOLOGY. 
with the symptoms of diseases during life, and with the operations of ascer- 
tained causes of morbid action. The nature of the morbid changes was ob- 
served to be more apparent in the progress of external diseases; and, therefore, 
surgical experience was brought to bear upon the elucidation of internal dis- 
ease-processes. One especially marked result of this nature is to be seen in 
the modern application of the ophthalmoscope, which reveals information the 
most important, for the diagnosis of many general diseases, from an examina- 
tion of the interior of the eye. 
Thus the progress of Morbid Anatomy is, in a great measure, a record of 
the history of Medicine; and we can trace the science of special morbid anat- 
omy, giving a character to the various systems of the healing art which have 
prevailed from time to time. 
All the writers up to the time of Bichat, Laennec, and Abercrombie, were 
pure morbid anatomists, who did not connect the effects of disease with their 
causes, and who recognized the changes of disease as important only in pro- 
portion to their magnitude as apparent to the senses. They are, therefore, 
regarded as pure solidists, whose researches doubtless contributed much towards 
a correct knowledge of the changes in the organs of the body, while the con- 
dition of the fluids was neglected, as well as the relations of the textures, 
organs, and fluids, in the combined exercise of their functions. Simple func- 
tional disturbances were thus wholly overlooked, and the constitutional con- 
nection of local affections entirely lost sight of. 
The contemporaneous surgery of the period previous to Bichat was marked 
by its unwillingness to recognize anything but material facts, mechanical 
processes, and contrivances. The surgeons of those days desired to know 
nothing but anatomy and mechanics; and, accordingly, it may be recognized 
as the period of pure anatomical and mechanical surgery, distinguished by 
the writings of men whose works bear ample testimony that the surgery of 
the period was founded on exact and even minute anatomical knowledge. 
No allusion is made, however, by them to medicine,-they make no applica- 
tion of physiological truths, and they encourage no therapeutic tendency apart 
from mechanical or instrumental interference. 
The purely solidist, as well as the purely humoral principles by which the 
nature of diseases have been explained, may be said to have died a natural 
death long ago; but, as already noticed, the remembrance of what is valuable 
in the - results of both are preserved in modern pathology, which takes its 
stand upon anatomical and physiological facts, connected by simple methods 
of inductive observation with the symptoms and signs of disease as seen and 
expounded to the student by the distinguished professors of Clinical Medicine 
and Surgery at most of our celebrated schools, where clinical instruction is 
given. 
In this field of instruction it would be invidious to mention here the names 
of men still living. For their own sakes, as well as for science, may they be 
long deprived of being thus honorably and respectfully mentioned. As teach- 
ers, they are in our own country familiar to every student. As recorders of 
what they observe at the bedside and in the post-mortem room, they are not 
less celebrated abroad than appreciated at home. 
Tested by extensive clinical observations, the character of the present period 
in the history of Practical Medicine is one of probation as well as of progress, 
marked by a close inductive examination of past generalization and classifica- 
tion of facts, however remotely connected, which illustrate the nature of dis- 
eases and their treatment. 
Side by side, since 1816 and 1819, the microscope and the stethoscope have 
advanced our knowledge of the nature of diseases with a regular and accele- 
rated velocity ; but they have only done so as assistants and in subordination 
to laws and facts whose knowledge we have acquired, by a close observation 
of general symptoms, of which such instruments have never been intended to CHARACTERISTICS OF MEDICAL RESEARCH. 
61 
take precedence. They have never accomplished, nor can they ever accom- 
plish, useful practical results, to the exclusion of such other methods of obser- 
vation as have just been noticed. We are not to confound relative smallness 
with absolute simplicity, and believe that because a simple organic cell is a 
small object-because we can see around it, through it, and on every side of 
it-the functions and conditions of its existence are less complex or less obscure 
on that account than are those of a more large and complex organ, or the 
functions of a living body. 
We are not to suppose that because the stethoscope enables us to detect a 
mitral murmur, or a crepitation in a lung, we are justified at once in adopting 
one, and only one, method of treatment. It is this exclusive use of instru- 
ments, to the disregard of general symptoms and signs of disease, derived from 
close observation and knowledge of the living functions, which leads to the 
repudiation of the use of such instruments by the sagacious and experienced 
physician, who sees the numerous errors not unfrequently committed by his 
younger brethren, who trust too exclusively to instruments in the diagnosis of 
disease. 
Like the stethoscope, the microscope has been unjustly and unnecessarily 
burdened with labor, and has been equally unjustly blamed, and brought into 
unmerited discredit, when it has failed to elucidate the nature or even pres- 
ence of a morbid state, the existence of which could not be doubted, but which 
the sense of sight could not appreciate, even when presented in small quanti- 
ties greatly magnified. In such instances the microscope has been applied to 
uses which it was not the nature or province of the instrument to detect. 
The gravimeter or hydrostatic balance, the microscope, the stethoscope, the 
ophthalmoscope, the laryngoscope, the pleximeter, the sphygmograph, and the 
thermometer, are merely instruments of pathological inquiry, each one adapted 
for the determination of particular classes of facts. They can only elucidate 
disease when they are brought to bear upon physical properties, the nature of 
which they are able to appreciate; and it is only from their combined and 
appropriate use, in connection with a history of the general signs and symp- 
toms of disease in each particular case, that our knowledge of the nature of 
diseases will be advanced. 
The industrious employment of these aids to diagnosis, and an intimate 
acquaintance with the results, are attended with this further advantage, that 
such practice and knowledge enable their possessor to appreciate the general 
symptoms of disease with infinitely greater certainty than heretofore. This is 
the usual consequence of training in all exact methods of observation. The 
thorough study of these aids to the senses in appreciating disease leads directly 
to the possibility of dispensing with them in many instances. By means of 
auscultation and percussion, for example, our attention has been drawn to 
numerous conditions of the thorax, which enable us to make the diagnosis at 
the first glance, which hitherto was not possible; because the conditions for 
diagnosis could'never have been recognized without such physical aid to the 
senses as that derived from auscultation and percussion. In many cases, from 
the mere inspection of a patient, a well-instructed clinical student may decide 
upon the existence of pleurisy, pneumothorax, emphysema, or pulmonary tubercle. 
The initiated are thus frequently enabled to dispense with percussion and 
auscultation; but if they had never acquired the practical knowledge of the 
subject-if they had never examined numerous patients by means of these 
instruments as physical aids to diagnosis-and so learned thus to determine 
with great exactness the significance of the various forms and movements 
exhibited by the thorax, they would never have been able to appreciate their 
significance. So, also, the physician well instructed in the use of the ther- 
mometer may, in hundreds of cases, without its aid, draw conclusions with great 
certainty, incomprehensible to others not so instructed; but if, led away by 
this skilfulness, he is induced to dispense with exact thermometrical control, 62 
TOPICS relative to pathology. 
he may soon fall into gross errors. So it is with the ophthalmoscope, sphyg- 
mograph, specula, and all other more or less exact physical aids to diagnosis. 
Let them be in constant and appropriate use, but the results must always be 
taken and compared in connection with other general symptoms of disease. 
In all the temperate regions of the world, histology, as applied to morbid 
products, has been cultivated, and has advanced our knowledge regarding 
disease ever since 1838. In warmer latitudes our knowledge of practical 
Medicine has been advanced by extensive observations on physical climate, 
medical topography, and by organic chemical analysis applied to obtain thera- 
peutic agents from the vegetable world. Those may be said to be the charac- 
teristics of the researches of our own country, Germany, France, and America, 
as contrasted with the nature of the observations mostly prosecuted in India. 
No exclusive doctrine will now stand the test of well-directed pathological 
inquiry, the main object of which is to connect all organic changes (lesions) 
and functional derangements, with their symptoms and causes, with the view 
of applying rational remedies and prophylactics. The too exclusive study of 
pure organic pathology and morbid anatomy leads to no distinction between 
the signs and causes of disease; and the obvious tendency of such exclusive 
study is to exaggerate the importance of the principles it may establish, to 
hold out no hopes of cure, and to undervalue the power of remedies and 
remedial measures. To obviate this tendency, it is necessary to have recourse 
to inductive reasoning, so as to connect all the morbid changes seen or appre- 
ciated after death with the signs and symptoms of disease observed during 
life. Thus it is that links in the chain of disease-processes which, from a 
one-sided or exclusive view, appear isolated and localized, are really found to 
be connected with each other. It may be, also, that they are connected with 
a long but intelligible series of processes developed during life through the 
metamorphosis of tissue, and going on in apparent health, or in an obviously 
morbid exercise of function. The constitutional origin of many local diseases, 
otherwise inexplicable, then becomes apparent. 
Among the more eminent exponents of this rational school of pathology, 
who at an early period in this country discerned and appreciated such doc- 
trines, we find the names of Allen, Golding Bird, Sir Robert Carswell, 
Gregory, Hope, Hodgkin, Marshall Hall, Prout, William Stark, 
John Thomson, Tweedy Todd, and many others, who, although now no 
more, have left behind them imperishable evidence of their labors. The 
younger pathologists of the present day, whose name is Legion, follow in the 
footsteps of these men, extending the fields of observation and the boundaries 
of the science of Medicine. By them the importance of morbid anatomy is 
sufficiently appreciated, and its province distinctly defined and limited as 
follows, namely: (1.) To detect the "stamps of disease," or the changes 
which have taken place during the course of diseases in the structure of tissues 
and organs of the body; (2.) To demonstrate the exact seat of these " stamps 
of disease," or local alterations which have become established during the 
progress of disease. 
The investigation and elucidation of the nature, course, and causes, of those 
changes, constitute the prominent objects of the science of pathology. By 
the aid of clinical observation during life, and morbid anatomy after the 
death of the body, pathology seeks to establish the relations of the changes 
which lead to the lesions, and so to connect the general progress of disease 
with its symptoms and signs. 
Morbid Anatomy goes beyond its province when it attempts to point out 
the nature of the proximate cause of disease. It is only by the application 
of inductive reasoning that the connections of causes and morbid effects can 
be shown, and such constitutes the main object, and is the highest aim, of the 
science of Pathology. 
The morbid anatomist finds a lesion or change for what ought to be the FORMS OF THE CONSTITUENT ELEMENTS OF DISEASE. 
63 
natural structure, appearance, or condition of a part. The pathologist seeks 
to connect such lesions with signs and symptoms during life, that the practical 
physician may suggest a remedy to the disease, and that the nosologist may give 
it a name, distinguishing characters, and a place in his classification. 
CHAPTER VII. 
THE ELEMENTARY CONSTITUENTS OF LESIONS AS SHOWN BY MORBID 
ANATOMY AND OTHER MEANS OF RESEARCH. 
Where the material effects or "stamps" of disease can be rendered obvious, 
they are found to consist, for the most part, of- 
1. Morphological changes in the elementary textures of the body generally, 
and altered conditions of the fluids. 
2. The presence of new formations foreign to the normal condition of an 
organ or system of organs. 
3. Change in the position or form of some of the organs or parts of organs. 
4. Deposits within or surrounding the elements of tissues, or changes of a 
degenerative or retrograde kind in them. 
The object of prosecuting the anatomy of disease is, therefore, in the first 
instance, to institute a comparison between the known appearances or standard 
of health, and an altered state of the parts as evidence of disease. Such a 
comparison is, in the first instance, founded on an intimate knowledge of the 
doctrines stated at p. 56. 
Means and Instruments of Research.-To institute investigations such as 
those indicated at p. 61, advantage must be taken of almost every branch of 
human knowledge. The methods of carrying on pathological research are 
therefore extremely varied, but may be shortly enumerated under the follow- 
ing heads: 
1. The opening of dead bodies, to ascertain the condition of their organs 
and tissues in all that relates to their structural, chemical, and physical prop- 
erties (Rokitansky, Hasse, Virchow). 
2. Application of various instruments, such as the microscope, and of means 
to ascertain the absolute and specific weight of organs or parts, the relations, 
size, form, and colors of structures, and the like (Quekett, Bennett, Beale, 
Peacock, Boyd). 
3. Application of chemical investigations to the diseased products (Vogel, 
Simon, Day, Lebert, Gluge, Beale, Garrod, Christison, Parkes, Vir- 
chow, Frerichs, Gairdner). 
4. Application of statistics to determine various points of interest in refer- 
ence to the nature, course, and complications of diseases (Wm. Farr, Guy). 
5. Means to preserve objects for further study by the microscope, or any 
other mode of examination (Tulk, Henfrey, Beale, Quekett, Van der 
Kolk, Lockhart Clarke). 
6. Experiments instituted on living animals, and, in certain cases, on man, 
with the view of artificially producing a morbid condition. A careful study 
of such experiments by the previously mentioned means affords valuable in- 
formation, for the causes in action are more under control than those which 
are spontaneously brought about by disease in the living body (Bernard, 
Harley, Pavy, Kuchenmeister, Zenker, and others). 
The immediate object of such investigations is to obtain information re- 
garding the material changes in the different parts of the body which accom- 
pany or produce morbid symptoms, and to connect these changes with symp- 64 
TOPICS RELATIVE TO PATHOLOGY. 
toms and signs of disease during life. We thus learn how morbid products 
are formed at first and gradually perfected; and by combining these two kinds 
of knowledge we learn the relative connection of two orders of phenomena- 
namely, how the perverted properties, disordered actions, or altered structures 
give rise to perverted or impaired secretions; disordered and irregular motions; 
deranged, impeded, or interrupted functions. In other words, the " order of 
invasion of disease-processes " is learned from such investigations; and we are 
thereby taught how parts, once the seat of morbid change, return by various pro- 
cesses of nutrition, growth, repair, or reproduction, to their normal condition. 
The questions arising out of such investigations are, or ought to be, the first 
object of thought to the conscientious medical practitioner. It is his duty, from 
an attentive consideration of the signs and symptoms of disease, to form an 
idea, as accurate as possible, of the nature and extent of the morbid action or 
change which is going on, or which may be set up, in the tissues, organs, and 
fluids of the living body. 
If, therefore, he does not avail himself of every means and instrument by 
which he can ascertain the existence of change in the dead body, and its 
alteration from some standard of health-if he does not embrace every oppor- 
tunity of making post-mortem examinations-if he contents himself merely 
with observing signs or symptoms of disease, without witnessing the changes 
of structure, if any, which may give rise to them-he can have little conscious 
satisfaction in the study of Medicine as a science, or in the practice of the 
healing art. In the words of Cruveilhier, he will, during his lifetime, "see 
many patients, but few diseases." Such a practitioner is not to be trusted. 
Forms of the Constituent Elements of Disease.-The histologist has now 
ascertained the various simple organic forms which compose the textures in 
their normal state, and the mode in which these textures are arranged and 
combined so as to form the organs and systems which carry on the healthy 
functions of the body. The pathologist has made out (although with less 
completeness), by the methods of observation and experiment already indi- 
cated, the various simple organic forms which constitute the elements of those 
material changes whose phenomena of growth, decay, and varied change are 
associated with the manifestations of disease. By classifying and arranging 
these forms, we obtain more or less clear ideas of lesions; and we ascertain 
that the morbid processes follow, in their development, a very definite order 
of change, but not yet determined with absolute certainty in each disease. 
An anatomical investigation of morbid parts, conducted with the aid of the 
microscope and other instruments of research, shows that the material of which 
their substance is macle up is of very various structure, sometimes combined in 
forms of one kind throughout, and sometimes varied by the development and 
combination of many elementary forms, more or less solid, soft, or fluid. 
An analysis of the morbid material, carried as far as scientific means at 
present enable us, shows that the elementary conditions in which morbid prod- 
ucts are found may be described as follows: 
1. Fluid matter and hyaline substance, more or less soft, soluble, and prob- 
ably nutrient to surrounding or imbedded morbid elements. 
2. Simple elementary forms of the nature of deposits, sometimes of a min- 
eral or inorganic character: e. g. (a) amorphous granules; (6) crystalline 
structures in a granular state. 
3. Simple, but organized products (minute rounded particles, nuclei, or 
germinal matter) capable of growth, i. e., which live, change, convert or ger- 
minate : e. g. (a) amorphous masses (plasm germs, bioplasm, protoplasm}; (b) 
nuclei or granules; (c) compound corpuscles; (d) simple cells; (e) fibres. 
The various appearances and conditions which these simple forms may 
assume in disease, as well as the functional states with which they are fre- 
quently associated, lead to a further enumeration and classification of morbid 
elementary products, as well as of more complex disease-processes, as below: MORBID ELEMENTARY PRODUCTS. 
65 
A.-Morbid Elementary Products. 
I. Exudations more or less soft, semi-fluid, or fluid, and formed 
of,- 
a. Germinal, plastic, and formed material, which has sometimes been called 
blastema, plasma, bioplasm, protoplasm, coagulable lymph, false membrane, or 
fibrin, as seen adhering to free surfaces. 
b. Aqueous matter, as seen in the morbid state termed "dropsy," and 
" oedema," of parts. 
c. Gaseous exudations, as seen in the various forms of pneumatosis; e. g., 
emphysema, flatulency, tympanites, pneumothorax. 
II. Exudations more or less consolidated, and consisting of,- 
a. Molecular or granular material, from the 800th of a line to an immeas- 
urably small size, and consisting chiefly of the simple forms of,- 
(1.) Forms of an organic kind capable of growth, which live, grow, con- 
vert, or germinate, and invariably take origin from a pre-existing structure, 
(bioplasm, protoplasm, &c.) 
(2.) Fatty molecules or granules. 
(3.) Deposits of an inorganic kind, generally calcareous salts. 
(4.) Pigment granules. 
b. Coagulable compounds, resisting the action of most reagents, such as are 
seen in the elements of tubercle, scrofula, oleo-albumino us formations, lardaceous 
degenerations. 
c. Exudations of a transitional nature, organized, which are capable of 
growth, which may become vascular, which grow from pre-existing structures, 
and which are composed of,- 
(1.) Consolidated homogeneous material, passing to 
(2.) A fibrilloid arrangement of the molecular or granular particles com- 
posing connective substance, and a subsequent formation of fibres in it or 
from it. 
(3.) The formation of pyoid cells, and fibro-plastic or connective tissue 
cells, passing into fusiform cells and fibres as the material becomes consoli- 
dated. 
(4.) The formation or exudation of fluid matter holding pus, or other more 
compound cells. ' 
III. Growths and Exudations of a specific kind. 
a. Lymph of small-pox and cow-pox, just removed from the vesicle, con- 
tains a great number of extremely minute particles. To these the active prop- 
erties of the lymph are entirely and solely due (Beale). 
b. Matter of glanders, of malignant pustule, and of the plague, contain 
similar particles. 
c. Fluid of infecting chancre, and of some forms of secondary syphilitic 
lesions, containing multitudes of living particles. 
d. Material of tubercle and scrofula. (?) 
e. Material of cancer. 
f. The growth in Peyer's glands during typhoid fever. 
g. The growth in Peyer's glands in cases of cholera. 
h. Melanotic or pigmentary germs. 
The minute elements of all of these resemble each other so much in their 
microscopic appearances, that they cannot be distinguished from each other, 
or from pus; and pus containing specific contagious properties cannot be dis- 
tinguished from ordinary pus, except in the matter of vital power or virulent 
specific properties, as evinced by its effects. The experiments and observa- 
tions of Dr. Burdon Sanderson tend to show that the specific material of each 
of these diseases consists of living germs; and many there are who now believe 66 
TOPICS RELATIVE TO PATHOLOGY 
that the day is not far distant when we shall be able to demonstrate the 
material poison of each specific disease, just as the chemist is able to show the 
active principle of substances like opium, cinchona, and the like. 
IV. Material of a complex kind. 
a. Media of repair and reproduction of injured or lost parts-substance of 
granulations and cicatrices. 
b. Hypertrophy of parts. 
rp (innocent. 
c. tumors, s v , 
' (malignant. 
d. Concretions. 
V. Parasitic Formations. 
B.-Complex Vital Morbid Processes whose Phenomena, more or 
LESS COMBINED, CONSTITUTE DISEASE. 
1. Catarrh. 
2. Inflammation, comprehending the following forms: 
(a.) Ulcerative. 
(b.) Suppurative. 
(c.) Plastic. 
(d.) Rheumatic. 
(e.) Gouty. 
(f.) Pyaemic. 
(g.) Syphilitic. 
(h.) Scrofulous. 
(i.) Gonorrhoeal. 
3. Gangrene. 
4. Passive congestion. 
5. Extravasation of blood-Hemorrhage. 
6. Dropsy. 
7. Fibrinous deposit. 
8. A Iteration of dimensions. 
(a.) Dilatation. 
(b.) Contraction. 
(c.) Hypertrophy. 
(d.) Atrophy. 
9. Degenerations. 
(a.) Fatty degeneration. dm. , p ,7 , 
v Aj ,• the components of atheroma and so- 
(b.) Mineral degeneration f n , 1 .p ... 
o 7 -F .• I called ossification. 
or Eetnfaction. ) J 
(c.) Pigment degeneration-Pigmentation. 
(d.) Fibroid degeneration. 
(e.) Lardaceous or albuminoid degeneration, lardaceous, waxy or amyloid 
disease. 
m rr (malignant. 
10. 1 umors, 1 J 
' ( non-mahgnant. 
11. Cyst. 
12. Parasitic disease. 
13. Calculus and concretions. 
14. Malformation. 
15. Functional diseases. 
16. Fever. 
Such a classification as the above is merely intended to bring before the 
student at a glance the variety of morbid material which is concerned in the 
expression of many phenomena seen in the course of disease, the distinctions 
made being mainly based on structural analyses. 
While it is more properly the province of the anatomist to describe the PATHOLOGY AND ANATOMICAL CHARACTERS. 
67 
MORBID ELEMENTARY PRODUCTS, it is the COMPLEX VITAL MORBID PROCESSES, 
WHOSE PHENOMENA, MORE OR LESS COMBINED, CONSTITUTE DISEASE, with 
which the Physician has more immediately to deal; and these complex states 
require special notice in the following chapter. 
CHAPTER VIII. 
COMPLEX MORBID STATES 
Catarrh. 
Latin Eq., Catarrhus; French Eq., Catarrhe; German Eq., Catarrh; Italian Eq., 
Catarro. 
Definition-Engorgement of the bloodvessels of any region of the mucous 
membrane. An abnormal secretion of fluid oozes out and flows from the surface. 
The tissue is succulent and swollen; and there is a copious generation or prolifer- 
ation of young cells, pushing their way to the surface, and so causing the flux. 
Pathology and Anatomical Characters.-The regions of the mucous tract 
most prone to catarrh are the nose, mouth, pharynx, larynx, bronchii, stomach, 
intestines, gall-ducts, urinary bladder, urethra (male and female), uterus, and 
vagina. These several regions give names to the catarrhal disease: e. g., 
acute or chronic bronchial catarrh; virulent or non-virulent catarrh of the urethra; 
uterine catarrh; vaginal catarrh, and so on ; and these several forms of catarrh 
will be considered under the respective local diseases under which they are 
classified. 
A graduaj flow of fluid secretion from the mucous surface is characteristic 
of catarrh, and hence the name. Under the microscope, numerous transpar- 
ent cells may be seen, called mucus-corpuscles, which are detached young 
epithelial cells from the deeper layers, or from the mucous glands. The sub- 
stance of the mucous tissue is swollen, moist, and flabby; and the submucous 
tissue may become the seat of considerable serous infiltration (cedema),-a 
condition of great danger when the mucous membrane of the larynx is in- 
volved. The redness of the membrane is sometimes diffuse, due to uniform 
injection of the bloodvessels; sometimes mottled, when it is due to ecchy- 
mosis. The texture is softened so as to be easily torn. 
When the catarrh has become chronic, the evidence of this chronicity is 
seen in the extensive pigmentation of the mucous surface which has been so 
frequently implicated in the morbid process. It has a brownish color, from 
the pigment derived from oft-repeated ecchymosis in its substance. The sub- 
mucous tissue becomes thick, firm, and hypertrophied ; the bloodvessels, vari- 
cose and gorged with blood. The mucous secretion is now made up of an 
opaque, yellow-colored, tenacious substance, composed of cells indistinctly 
granulated, and containing divided nuclei-a " muco-purulent " secretion- 
where the mucus cannot be distinguished from the pus cell. 
The results of catarrh are seen in ulcerations, polypus growths from the 
long irritation of the surface, thickening and induration of the submucous 
tissues. 
There seems to be a certain predisposition, or structural development, of 
the individual, prone to catarrhal attacks. They are prone to occur in con- 
ditions characterized by poverty of blood and nutrition, in which the walls of 
the capillary vessels have a feeble power of resistance; while the tissues 
through which such vessels pass, are at the same time soft and yielding. The 
predisposition to catarrh is strongly marked in scrofula and rickets; and, as 68 
TOPICS RELATIVE TO PATHOLOGY. 
bronchial catarrh, the morbid condition is a frequent attendant on typhoid 
fever, measles, and small-pox. Effeminate habits also augment the liability 
to catarrhal affections. 
The first effect of catarrh is marked by an increase of the secretion of the 
mucus proper and normal to the part,-a peculiar viscid, ropy, pellucid sub- 
stance, without any visible corpuscles or organized particles. With an in- 
crease of this material there comes the mixture of epithelial particles from 
the mucous membrane, or corpuscles from the follicles and follicular glands 
imbedded in its substance. These particles vary in shape and properties ac- 
cording to the part of the mucous tract whence the catarrhal secretion flows; 
and they increase in number from premature desquamation, while their char- 
acteristic local shapes are less and less perfectly preserved. With such in- 
crease of flow, there is afflux of blood to the part, and infiltration of its sub- 
stance with fluid material, making the membrane thick and spongy. It is 
swollen also by the increased production of the corpuscles which may arise 
from nuclear multiplication, both within the epithelial cells on the surface of 
the membrane, or within its follicles and in the corpuscles of the subepithelial 
connective tissue, for a greater or less depth, according to the degree of the 
irritation or inflammation in the part (Paget, Turner, Remak). These 
corpuscles are commonly called mucus-corpuscles; and they differ only from 
the corpuscles formed from a serous membrane in a state of inflammation in 
the greater viscidity of the fluid in which they lie (Paget and Turner). 
Inflammation. 
Latin Eq., Inflammation; French Eq., Inflammation; German Eq., Entundung; 
Italian Eq., Inflammazione. 
Definition.-A complex morbid process characterized- i(1.) By a suspension 
of the concurrent exercise of function among the minute elements of the tissue in- 
volved; (2.) By stagnation of the blood and abnormal adhesiveness of the blood- 
discs in the capillary vessels contiguous to the tissue-elements whose functions are 
suspended; (3.) By contraction of the minute arteries leading to the capillaries of 
the affected part, with subsequent dilatation and paralysis of the contractile tissue 
of the affected bloodvessels. The nutritive changes between the blood and the 
minute component elements of the affected tissue become visibly altered, and if it 
persists, an appreciably excessive interstitial exudation infiltrates the affected tissue, 
with a constant tendency to a profusion of growth to which this interstitial exuda- 
tion ministers abundant nutrition. This excessive exudation which follows, as a 
result of the inflammatory state, is apt to be associated with an unhealthy condition 
of the blood, and of the blood-plasma, giving rise to varied forms of inflammation, 
and associated with varied forms of new growth, according to,-(1.) The elemen- 
tary structure in ivhich it occurs; (2.) The specific, constitutional, or local disease 
with which this complex morbid process may coexist; and (3.) According to the 
progress of the inflammation, the amount and suddenness of the effusion, the extent 
of tissue involved, the diminished vascularity, and the powers of absorption of the 
surrounding parts. 
Pathology.-As it is not possible clearly to define the limits of natural pro- 
cesses, it is not possible to give a correct definition of inflammation. It is a 
process the most important of all morbid states; and a knowledge of its phe- 
nomena (at this very time-1870-undergoing an extensive reconsideration), 
the laws which regulate its course, and the relations which its several events 
bear to each other, have been always considered as " the keystone to medical 
and surgical science," and the " pivot upon which the medical philosophy of 
the time has revolved." 
It is not wonderful, therefore, that much has been written on the subject of PATHOLOGY OF THE INFLAMMATORY PROCESS. 
69 
inflammation, more especially since microscopic research has been brought to 
aid in the investigation of its phenomena. Among the many who have inves- 
tigated this morbid process with success, and by whose original observations 
its study may be said to have begun, the names of Wilson Philips, John 
Thomson, Gendrin, Kaltenbrunner, Gerber, and Muller; and more recently, 
those of Alison, Lebert, Gulliver, Addison, C. J. B. Williams, Bennett, Whar- 
ton Jones, Henle, Virchow, Paget, John Simon, Joseph Lister, Stricker, Cohn- 
heim, Prussak, and Recklinghausen, are well known; and no account of in- 
flammation can be complete which does not embrace the results of the labors 
of these men. 
The early experiments which illustrate the nature and phenomena of inflam- 
mation have been made chiefly on the web of the frog's foot, and the folds of 
the frog's mesentery. The phenomena in both are found to correspond, in all 
essential points, with the results of experiments performed on the more or less 
transparent parts of warm-blooded animals; such, for example, as the wings 
and ears of bats, the ears of rabbits, the mesenteries of these animals, the brains 
of rabbits and of pigeons, and the legs of dogs, upon the bones of which com- 
pound fractures have been inflicted. As a general result of such experiments 
and observations, it may be stated that the chief constituents of the inflam- 
mation-process are to be found in altered conditions of the healthy nutritive 
changes-the phenomena of the abnormal state becoming more or less obvious 
by the redness, swelling, heat, pain, impairment of function on a large scale, 
and sometimes exudation in the part affected. 
Phenomena and Theory of the Inflammatory Process.-The process of 
inflammation is one in which many stages of morbid action are passed through, 
and which reaches its acme when the serum of the blood and the liquor san- 
guinis, and even the corpuscles of the blood itself, transude or permeate the 
walls of the bloodvessels of the inflamed part, without rupture, into the sur- 
rounding texture. This has been termed " exudation." 
The series of complex changes through which the inflammatory process is 
seen to proceed, as observed in the transparent parts of animals under the 
microscope, are found to occur nearly in the following order: 1st. The beau- 
tiful experiments and observations of Mr. Joseph Lister, Professor of Clinical 
Surgery in the University of Edinburgh, clearly prove that a suspension of 
the concurrent exercises of function among the minute elements of the tissue 
involved is the primary lesion in the. congestion of inflammation, and which 
immediately leads to-2d. Inflammatory derangement of the blood, which, in 
the vicinity of the impaired tissue-elements, tends to assume the same charac- 
ters as blood always assumes when it is in contact with ordinary solid matter, 
and which renders it unfit for transmission through the bloodvessels. But a 
return of the tissue-elements to their usually active state will be associated 
with a restoration of the blood to the healthy characters which adapt it for 
circulation (Royal Society, June 18', 1857); and thus the normal essential re- 
quirements of blood and tissue mutually counterbalance each other. If blood 
is depraved, tissue must suffer; and if tissue is morbid, blood becomes morbid 
too, and may remain so if depuration is not completed. 3d. The arteries of the 
affected part are narrowed, and the blood flows through them with greater rapid- 
ity. 4th. The same vessels subsequently become enlarged, and the current of 
blood is slower. 5th. The flow of blood becomes irregular. 6th. All motion of 
theblood ultimately ceases, and complete stagnation ensues. 7th, and lastly. The 
liquor sanguinis may be exuded through the walls of the bloodvessels, some- 
times accompanied by the exudation or permeation of blood-corpuscles. 
These different phenomena are associated with the production of the more 
obvious symptoms (and to some extent they physically account for them), 
namely, redness, pain, heat, and swelling. But although these changes are 
here mentioned consecutively, it is not to be understood that in every instance 
of inflammation such changes can be traced in distinct succession. The 70 
TOPICS RELATIVE TO PATHOLOGY. 
changes are to be studied as nearly concurrent, rather than as a distinct series 
of events, of which each stands in the relation of a consequent to one or more 
of its antecedents ; so that, starting from impaired function of the elements of 
tissue, to stagnation of blood in the capillary vessels, we must observe the 
various stages in the process almost as concurrent phenomena, which, for the 
purposes of study, are here enumerated in sequence. 
An analysis of these concurrent phenomena has shown that the conditions 
for the healthy nutrition of the part are materially changed, being somewhat 
as follows: 
I. The supply of blood to the part is altered,-(1.) By the changes in the 
bloodvessels, especially the narrowing of the arteries and subsequent enlarge- 
ment of the capillaries; (2.) By the mode in which the blood moves through 
them. 
The narrowing of the arteries, in the first instance, may be demonstrated 
under the microscope, by the application of warm water simply to the web of 
the frog's foot; and the same phenomena are presumed to occur in man, for 
the following reasons : Sudden operations of the mind, and the application 
of cold, produce paleness of the skin-an effect which can only arise from con- 
traction of the minute arteries, and the diminution of the quantity of blood 
thereby conveyed by them. The subsequent enlargement of the capillaries is 
presumed to be a constant event in the inflammation of a part. It usually 
extends to some distance around what may be considered as the chief seat, cen- 
tre, or focus of diseased action, but in some textures the enlargement and red- 
dening are peculiar to the vascular parts in the vicinity. To this condition of 
the blood and bloodvessels is to be ascribed the usually first observable symp- 
tom of inflammation in a part, namely, the redness. But there are also many 
circumstances under which inflammation has existed, and yet no redness is 
apparent in the part itself. We often find the cartilages of the joints ulcera- 
ted, and yet not a trace of a red vessel. In cases of bronchitis, with purulent 
expectoration, if the lungs be washed so as to remove the morbid product, the 
most experienced anatomist may be unable to determine whether the parts are 
in a state of health or disease. Take the arterial system, and how often do we 
find the aorta thickened and thinned, softened and indurated, ulcerated, and 
its elasticity entirely destroyed, and yet not a red vessel to be seen; and when 
the patient has neither complained of the slightest sensation of pain, nor of 
any feeling of heat in the part during life ? A large abscess may form in the 
brain or areolar tissue, or pus may be effused into the cavity of the abdomen, 
without any appearance of redness, or even evidence of having been preceded 
by any suffering. Although in certain parts-extra-vascular tissues, as the 
cornea and the articular cartilages, and the arterial tissues-the previous 
existence of inflammatory action is obvious from the effects produced, and 
where no bloodvessels existed obvious to the eye, assisted or not by the micro- 
scope, yet it is, for the most part, found that enlargement of the bloodvessels 
of the adjacent parts, and especially of those from which the diseased part 
derives its nutrient supply, is a constant phenomenon, purely functional, and 
which appears to be developed indirectly through the medium of the nervous 
system. In inflammation of the cornea, for instance, the bloodvessels of the 
sclerotic and conjunctivae are enlarged. In ulceration of the articular carti- 
lages, the surrounding synovial membrane and the articular extremities of the 
bones are more fully pervaded with enlarged bloodvessels. The vasa vasorum 
of the aorta round the morbidly thickened part are also the subject of enlarge- 
ment, and the channel of increased supply of blood,-a series of vascular 
changes ministering to the act of inflammation in each of these extra-vascular 
parts. There is, therefore, no doubt that the conditions favorable to the exist- 
ence of redness are always present to a greater or less degree at the early period 
of inflammation; and whether the redness be always present or only slightly 
perceptible, the same impairment of function among the minute elements of PATHOLOGY OF THE INFLAMMATORY PROCESS. 
71 
the tissue, and increased adhesiveness of the blood-discs, not only to each other, 
but to the tissue of the capillaries, take part in the development of the inflam- 
matory process. 
The enlargement of the bloodvessels varies. It may be hardly perceptible, 
or it may increase their diameter to two or three times their natural size. 
John Hunter established this stage of the inflammatory process in the ear of 
a rabbit, by thawing it after it had been frozen: the rabbit was killed during 
the process, and the head being injected, the two ears were removed and dried. 
Woodcuts representing the comparative conditions of the two ears may be 
seen in the first volume of Paget's Surgical Pathology, p. 295, or at p. 221 of 
the edition edited by Professor Turner. The bloodvessels of the inflamed ear 
became greatly larger than those of the healthy one, and it was found that 
arteries before invisible, in the healthy state of the rabbit's ear, were brought 
clearly into view during the stage of the inflammatory process. 
The redness of an inflamed part is of various intensity and shade, according 
to the degree of the inflammation, its stage, and the structure (especially as 
to bloodvessels) of the part affected. Its shades pass from a light rose-color 
to a deep crimson, or even purple. If assumes the form of points where con- 
geries of minute bloodvessels are concerned; or streaks, as where the vessels 
of fibrous structures are inflamed, as in tendon ; or a series of minute and fine 
ramifications, as in synovial structures; and generally, it may be stated that 
the form of the redness derives its character from the normal arrangement of 
the capillaries of the part. The redness is most intense towards the centre of 
diseased action, gradually softening down towards the circumference, where 
the conditions of health exist. This gradual shading off serves to distinguish 
the redness of inflammation from the redness of extravasation. The margin 
of an extravasation is defined, its redness cannot be removed by pressure; 
while the disappearance of inflammatory redness under pressure is, to a certain 
extent, a measure of the activity of the circulation in the part. The brighter 
hues generally attend ordinary active inflammation;-the darker hues of in- 
flammatory action are generally associated with some specific cause of disease, 
a feeble action of the parts, or a tendency to gangrene. The increased depth 
of color is mainly due, in the first instance, to the congestion and stagnation 
of blood in the existing vessels, and not in any measure to the formation of 
new ones. The redness, however, always appears more than proportionate to 
the enlargement of the bloodvessels; and we find that the red corpuscles are 
intensely adherent in the enlarged capillaries. 
The dilated vessels of an inflamed part appear crammed with red corpuscles, 
which lie or move as if no fluid intervened between them, or as if they were 
imbedded in a hyaline substance due to the solidification of the fibrin of the 
liquor sanguinis. Au increase of redness is sometimes seen to depend upon 
extravasation of blood, the distended and softened capillaries breaking from 
the pressure of the blood, or the effusion of the coloring matter of the blood- 
corpuscles, as well into the spaces between the blood-corpuscles as into the 
adjacent tissue through the walls of the bloodvessels. Lastly, the redness is 
sometimes intensified (as Hunter first suggested, and microscopic examina- 
tion subsequently proved) by the passage of the blood, unchanged, from the 
arteries into the veins. No new formation of bloodvessels is necessarily con- 
cerned in the redness of inflamed parts; but as inflammation continues and 
advances, new bloodvessels gradually develop themselves, and which, like the 
old ones, become filled with blood. When inflammation has subsided, these 
new vessels pass into any new growth of tissue which may have arisen, as if 
for its nutrition, development, and continued growth, or to effect its subsequent 
removal, degeneration, decay, or absorption. 
Peculiar changes of shape are associated with enlargement of the blood- 
vessels, consisting chiefly of tortuosity of distribution and aneurismal or vari- 
cose dilatation. The aneurismal or varicose state is seen to take place, most 72 
TOPICS RELATIVE TO PATHOLOGY. 
frequently in the soft textures, as in the brain, where it is a frequent condition 
of the inflammatory red softening (Kolliker and Hasse) ; and in subcuta- 
neous tissue, the points of what appears to be extravasated blood are aneur- 
ismal dilatations of capillary vessels filled with the red corpuscles (Lebert), 
as shown in the woodcut. 
Fig. 1. 
Dilated bloodvessels in inflammation, after Paget. 
These varied conditions of the bloodvessels affect the motion of the fluid 
in the part; and consequently the supply of blood for the purposes of nutri- 
tion. Generally it may be stated that there is stagnation of the blood in the 
focus or centre of severe inflammation. This stagnation is surrounded by a 
state of fulness of vessels and slow movement of the blood, while farther around, 
and more distant still, there is fulness of the vessels, with a rapid, movement of 
the blood. From the discrepancy existing among observers regarding the 
statement as to whether the motion of the blood is slower or quicker when 
the vessels are contracted or dilated, there is evidence that the contraction 
alone of a vessel, or its dilatation alone, is not always sufficient to cause the 
current of blood to be either slow or quick. Other conditions are at work 
which contribute in no small degree to accelerate or to slow the rate of move- 
ment in the vessels. Besides the force of the heart's action, there is a mutual 
relation which subsists between (a) the blood, (6) the bloodvessels, and (c) 
surrounding tissue, which materially influences the active motion of the blood. 
In the healthy body this mutual functional relation between the minute ele- 
ments of tissue and the blood is necessary to maintain it in a state fit for 
transmission through the vessels. The mere contraction of the arteries leading 
to a part does not tend to stagnation of the blood in the capillaries of the 
inflamed part; on the contrary, the movement onwards of the blood in the 
vessels is influenced or modified by the vital functional processes going on 
between the capillary vessels and the surrounding elements of tissue, and 
which has been variously named the "capillary force," the "vital force," the 
"nutritive force;" it is also mainly influenced by the action of the heart itself, 
and by the physical condition of the vascular tubes through which it has to 
pass. Accordingly at first, with contraction of vessels, the current has been 
described as being quickened. It also sometimes slackens, or even retrogrades 
for a time, and not unfrequently oscillatory movements may be noticed. But 
when dilatation is complete, the blood flows with rapidity, and a greater 
quantity passes during a given time than in the unexcited state of the parts. 
This is known as the state of " determination of blood to a part," or " active PASSAGE OF BLOOD-CORPUSCLES THROUGH VESSELS. 
73 
congestion." The natural function of the part thus becomes simply exalted ; 
and it may be said that a step beyond this will pass the confines of that 
neutral ground which exists between health and disease. With an increased 
circulation, and such "determination of blood to a part," functional activity 
is not only maintained, but is promoted and increased; and unusual transu- 
dation of the nutrient material may take place, chiefly of the serum of the 
blood. Hence the oedema which surrounds an inflamed part. After a time 
the motion of the blood becomes slower, while the volume propelled is in- 
creased, and the retardation gradually increases till the blood-corpuscles are 
no longer propelled, floating in their liquor sanguinis ; but, accumulating in 
masses, they advance by a jerking intermittent motion, till at last complete 
stagnation takes place. The blood-corpuscles now detained exhibit a marked 
tendency to adhere alike to the walls of the vessels and to each other; thus 
accumulating together and sticking in the capillaries, while the liquor san- 
guinis flows onwards. To this condition the term " stasis" has been applied. 
In the immediate neighborhood, and surrounding the part which is in the 
condition of stasis, the circulation of the blood goes on with increased rapidity: 
it may even pulsate in the arteries and oscillate in the veins, while it moves 
with a uniform but rapid flow through highly distended but less turgid vessels. 
When these conditions exist simultaneously, and the true morbid process is 
completely established, the capillary vessels may burst, causing hemorrhage 
or extravasation into the surrounding tissue, or the serum and liquor sanguinis 
may transude through their walls, without rupture, into the surrounding 
texture. But not only does the serum and liquor sanguinis make way without 
rupture through the capillary walls (whose texture is peculiarly permeable), 
but the observations of Professor Stricker conclusively show that capillary 
canals undergo changes of calibre, while the red blood-corpuscles sink into 
and through the substance of the unbroken capillary wall. Sometimes these 
blood-corpuscles will remain with half their volume within and half their 
volume without the bloodvessels, having an hour-glass constricted shape, the 
wall of the bloodvessel in this case having an amceba-like capacity for being 
protruded or impressed upon, permitting the corpuscles to permeate or pass, 
as the swimmer passes through fluid without leaving a trace of his way. Dr. 
William Addison, in 1842, also published, in Transactions of Provincial Medical 
Association and in subsequent writings, that white corpuscles not only accu- 
mulate in the vessels of inflamed parts, and adhere to their walls, but that 
they seem to become incorporated with the substance of the vessel, and to 
pass through it (without permanent solution of continuity), into the sur- 
rounding tissue, where they constitute the corpuscles of inflammatory lymph, 
pus, or mucus. The red corpuscles act similarly. Dr. Augustus Waller re- 
corded similar observations in 1846 (Philosophical Magazine, vol. xxix). In 
1868, Cohnheim, of Berlin, also came to the conclusion, from experiment and 
actual observation, that not only the white but the red corpuscles pass through 
the walls of capillaries and veins of irritated and inflamed parts; and that 
they may even migrate to some distance from the vessel through which they 
have permeated-their movements being like those of an amoeba; that is, 
having a power of spontaneous movement by various changes of form, as by 
sending out processes, blunt or thread-like, to be again withdrawn, and the 
spheroidal form resumed. Thus, by repetitions of these changes of form, the 
blood-corpuscles change from place to place. He believes the white corpuscles 
become pus-cells. 
Two novel features have now therefore been slowly demonstrated since 
Addison's observations on the phenomena of inflammation, namely-first, 
the yielding permeability of the soft, nucleated protoplasm which forms the 
walls of the living capillaries; and, second, the spontaneous amoeboid move- 
ments possessed by the corpuscles of the blood. Any visible pores, or stomata, 
are not found to exist in the walls of the capillaries. Recklinghausen, in 74 
TOPICS RELATIVE TO PATHOLOGY 
Berlin, and Professor Bastian, of the London University, have each con- 
firmed these observations. 
" The determination of blood to a part," characterized by dilatation of the 
arteries with increased flow of blood through the capillaries, must be distin- 
guished from the "passive congestion," characterized by the accumulation and 
stagnation of red and white corpuscles in the vessels, tending to be abnormally 
adherent to each other and to the vessels, associated with low vital activity. 
Both of these phenomena, namely, " determination " and "congestion," may 
result from irritation. .The dilatation of the arteries seems to be immediately 
developed through the medium of the nervous system, while the accumula- 
tion of the blood-discs and stagnation of the blood is the immediate and 
direct result of impaired or suspended function of the minute tissue-elements 
contiguous to the capillary vessels. 
The "determination of blood" and dilatation of the arteries lead to no 
change in the quality of the blood itself; on the other hand, accumulation 
and stagnation of blood, in the congestion of an inflamed part, are associated 
with increased adhesiveness of the red and white discs. Mere determination 
of blood becomes obliterated after death by the post-mortem contraction of the 
arteries, whereas passive congestion is persistent. It is an evidence of organic 
lesion declaring itself as distinctly in the dead as in the living; and thus the 
most important, if not the only sign, of the early stage of inflammation having 
occurred during life, is recognizable, on dissection, by the intense redness due 
to the accumulation of red discs adherent to each other in the minutest rami- 
fications of the vessels, and not due to distension of the vessels merely. 
Such is a statement of the facts ascertained regarding the early phenomena 
of the inflammatory process; and they are of such a kind that, with the 
facilities of study which ought now to be within the reach of every student 
of medicine, he ought to make such experiments as have been already noticed, 
or see them made by others, and thus really appreciate the steps of that mor- 
bid process which he requires to treat so extensively in practice, and of which 
he can form but a faint conception from the most lucid description. 
II. The constitution of the blood is altered as regards its adaptability to 
nourish the part. 
The nature of this alteration cannot be chemically expressed; but micro- 
scopical observation has established a fundamental fact, namely, that the tis- 
sues through which the blood flows have such special relations to the living 
fluid that, in the healthy state, the functional activity of the minute tissue- 
elements maintains the blood in a state fit for transmission through the blood- 
vessels ; and the first change observed in the blood, subsequent to impaired 
function of tissue-elements, is an increase of adhesiveness of the red as well 
as of the white corpuscles; but the white corpuscles are now known to be sus- 
ceptible of much greater adhesiveness than the red; so that slight irritation, 
leading to impairment of function, causes stagnation of the white sooner than 
of the red discs. The blood is not thus altered in the first instance through- 
out its whole mass; but the change is a local one, confined to the seat of the 
inflammatory process. At one time it was believed that the blood was altered 
in its constitution chiefly by an -increase of the fibrin and the white cor- 
puscles ;* but it is now found that the white or rudimental corpuscles of the 
blood cannot be separated from the fibrin by any known process; conse- 
quently the relative amount of fibrin cannot be correctly stated in relation 
* Andral and Gavarret showed that the proportion of fibrin in the blood was aug- 
mented in inflammations, when sufficiently severe or extensive to affect the system. 
In health the average proportion is three parts in 1000, and in cases of severe inflam- 
mations it has been found to rise as high as eight, nine, or ten parts in 1000. This 
increase commences as soon as the inflammation is established, and ceases when the 
process begins to decline. APPEARANCES OF THE BLOOD IN INFLAMMATION. 
75 
to the blood. And, as in many inflammations these corpuscles are increased, 
as well as in many conditions, such as pregnancy, in which no inflammatory 
process exists, the blood is similarly altered, it is not known how much of 
change is due to fibrin or how much to the white corpuscles. The generation 
and accumulation of large numbers of white corpuscles in the vessels of an 
inflamed part is not now received as a fact. The phenomenon may be true 
as regards some frogs, but not as regards warm-blooded animals; and it is 
consistent with the experience of three most eminent pathologists who have 
experimentally examined this subject - namely, Mn Wharton Jones, Dr. 
Hughes Bennett, and Mr. Paget-that an especial abundance of white cor- 
puscles in the vessels of an inflamed part is neither a constant nor even a fre- 
quent occurrence. Dr. Hughes Bennett's researches relative to leucocythaemia 
have shown that even the most extreme abundance of white corpuscles in the 
blood has no tendency either to produce or to aggravate inflammations. 
A remarkable phenomenon presented by the red blood-corpuscles in inflam- 
mation was first observed in 1827 by Mr. Lister, Sen., and by Dr. Hodgkin, 
and afterwards accurately described by Mr. Wharton Jones. 
They observed that when healthy blood is received on a glass plate, or the 
clean surface of a polished lancet, and immediately examined, the corpuscles 
lie diffused in the liquor sanguinis, but in about half a minute they run 
together into piles or rouleaux, which arrange themselves in small-meshed 
networks. But if a drop of blood from a patient with acute rheumatism, or 
with an inflammation, be similarly examined, piles of red corpuscles instantly 
form, and are clustered into masses, leaving a network with wide interspaces. 
This appearance of itself, however, is not a sure sign of inflammation. It 
may be observed in the blood of the chlorotic female as well as in the pregnant 
one; in those also in whom a plethoric condition as regards the blood exists; 
in persons in health whose circulation has been much accelerated, as by vio- 
lent exercise; and it appeal's to be the natural state of the blood of horses. 
It is a phenomenon resulting from an increased tendency to aggregation of the 
blood-corpuscles, and gives a granular appearance to a thin layer of blood 
when viewed with the naked eye. When blood is drawn off* in quantity, the 
phenomenon is associated with the formation of what is termed the "buffy 
coat," as the clustered blood-corpuscles, rapidly sinking, subside to some dis- 
tance below the surface before the fibrin and the white corpuscles begin to 
coagulate. The connection is now well established between the yield of fibrin, 
as expressed by a buffy coat, and the existence of acute inflammation. 
It has been found greatly increased in rheumatic fever, pneumonia, pleurisy, 
bronchitis, peritonitis, quinsy, erysipelas ; and the buffy coat over the contents 
of the bleeding-basin was wont to be an ordinary element in diagnosis, and a 
justification for the bloodletting (Simon). 
However indefinite and uncertain the changes may be, as observed upon a 
small portion of the blood, it cannot be doubted that the blood stagnant or 
retarded in an inflamed part undergoes important alterations; and by a con- 
stant succession of such changes the whole fluid may come at length to be 
materially altered, as indicated by the general effects and constitutional dis- 
turbance, extending throughout the nervous and the vascular system, and 
which may ensue in the train of an inflammation of purely local origin. It 
is probable that local changes ensue in the blood similar to those we shall 
have to notice as taking place in the products of growth in and amongst the 
elements of tissue during the inflammatory process. There is no doubt, as 
Wharton Jones has shown, that fibrinous coagula occasionally form, and even 
degenerate, within the bloodvessels. When the stagnation of the blood is not 
constant, these fibrinous coagula are carried away into the general circulation, 
giving rise to the phenomena of embolism (to be afterwards described) in the 
capillary vessels of some of the more solid viscera, such as the brain, lungs, 
liver, spleen, or kidneys. By the degeneration of such coagula the whole 76 
TOPICS RELATIVE TO PATHOLOGY. 
mass of blood may be infected, and constitutional disturbance excited, pro- 
ducing sometimes various and widespreading suppuration,-as when purulent 
infection is consequent on local injury, or when a blood-clot passes upwards, 
and, becoming lodged in the cerebral vessels, induces the state known as soft- 
ening of the brain. 
There are many points or questions deserving of attention regarding the 
theory of the inflammatory process; but it is also obvious that, in a text-book 
such as this, any mere analysis of speculative doctrines ought not to take up 
much space. The following statement will therefore merely embrace as much 
as possible of those topics of special interest which a more extended and accu- 
rate physiological knowledge of the process of inflammation has shown to be 
the proper objects of more extended inquiry. 
In the first place, as to the primary seat of the inflammatory process, there 
can be little doubt, from the phenomena already described, as well as 
from the results of dissection, which show the progress and effects of the 
process, and from the experimental researches of Hunter, Thomson, Wilson 
Philips, Hughes Bennett, Wharton Jones, John Simon, Paget, Lister, and 
other observers, that the vital morbid process known as "inflammation" is 
connected with the minute capillaries, and the most minute elements of tissues 
which they nourish. Questions relative to the theory of the process are there- 
fore found to be intimately connected with the histological and physiological 
relations of these parts; and especially with more recent knowledge as to the 
structure of the capillaries, and the movements through their walls of cor- 
puscles of the blood. 
During the earliest period of the process-the period of increment, or of 
incubation, as it has been termed-it appears to be the inherent properties of 
the minute component elements of tissues which first undergo a change, and, 
combined with the reflex actions of the nervous system, seem to maintain, to 
promote, or to increase the activity of the subsequent stages. 
The simplest effects upon the minute elements of tissue, and upon the blood- 
vessels, are seen to follow the application of the mildest or slightest physical 
or chemical agents, but which, operating powerfully, are also capable of extin- 
guishing altogether the life of these elements of tissue. When the action 
induced is mild and gentle, the tissues become incapable of performing their 
wonted functions ; and, provided the mechanical or chemical agency has not 
been too severe, the impairment of function may subside, and the tissues will 
return to their normal state of functional activity. This is "resolution" of 
the inflammation. 
Such irritant causes acting either immediately from without, or through the 
blood, or through the instrumentality of the nerves, each component texture 
of the part becomes affected as soon as it is brought in contact with the irri- 
tant. A gradual contraction of the arteries takes place-the contraction 
following at some interval after the application of the stimulus-is slowly 
accomplished, and persists for a variable length of time. Relaxation then no 
less gradually ensues, when the capillaries open up and slowly dilate, till 
they acquire a size larger than they had previous to the application of the 
stimulus. 
The minute arteries have been shown by the histologist to possess in abund- 
ance the structural elements of the n on-striated contractile tissue ; and in this 
respect they closely resemble the constitution of the muscular fibre of the 
intestine. Accordingly, the contractions they undergo have been considered 
as analogous to spasms (as Cullen first suggested); while the succeeding dila- 
tation may be of the nature of relaxation, and ultimately of paralysis. This 
paralyzed state is shown from the fact that the same vessels now dilated will 
not contract upon a reapplication of the same stimulus which before made 
them contract. If the stimulus is made with a needle upon the vessels in the 
transparent parts of an animal, the needle may be repeatedly drawn over THEORIES OF INFLAMMATION. 
77 
such dilated vessels and no contraction will follow; but with a stronger stimu- 
lus, such as that of heat, they may be made to contract again, and even close ; 
and this state of contraction may persist for a whole day, before the vessels 
again open up and permit the blood to flow (Paget). 
On the other hand, the true capillaries seem totally destitute of any special 
structure known to be contractile. They merely consist of a delicate, yield- 
ing, homogeneous, contractile protoplasm, beset with occasional nuclei, and, 
like protoplasm, having the power of developing processes or outgrowths. A 
film of collodion is not more homogeneous nor more continuous than the mem- 
brane of a capillary (Virchow). Whereas the minute arteries (some of them 
less even in calibre than capjllaries) possess distinct coats, one of them con- 
sisting of a single layer of muscular (or contractile) fibre-cells, wound spirally 
round the internal membrane of the bloodvessel, so as to encircle it from one 
and a half to two and a half times. The arteries, to their smallest branches, 
are sometimes contracted to absolute closure, and at other times are widely 
dilated; whereas the capillaries are never entirely closed, nor do they present 
any variations in diameter which are not due to the elasticity or yielding per- 
meability of their parietes (Lister, 1. c.). 
The most interesting point in the whole process is perhaps that which em- 
braces an inquiry into the cause of the " stasis," or stoppage of the blood, the 
exudation of the liquor sanguinis, and the permeation of blood-corpuscles 
through the yielding walls of the capillaries. This is a point which I think 
the observations of Professor Lister have so very beautifully illustrated; but 
the explanations of other eminent pathologists and experimentalists, if not 
universally satisfactory, serve to present the subject in a variety of aspects to 
the mind, which cannot fail to be both interesting and practically instructive. 
Henle, Simon, Bennett, Williams, Addison, Rokitansky, Paget, Stricker, 
Cohnheim, and Bastian, have all helped to elucidate the process by the fol- 
lowing theories: 
The theory of Henle, or, as it is sometimes called, the " neuro-pathological 
theory," assumes that the stimulus, acting on the sensory nerves of the part, 
excites in them a state which, being communicated to the spinal nervous 
centre, is reflected on the vascular nerves, occasions their paralysis, and there- 
with paralysis also of the contractile coat of the bloodvessels. Various modi- 
fications have been made upon this theory; but, as the phenomena have been 
seen to take place in the case of absence of a spinal cord, and in division of 
the roots of the nerves, and in section of the lumbar and sciatic nerves, such 
facts are subversive of the hypothesis. Henle considers the stasis as a neces- 
sary physical consequence of this dilatation of the bloodvessels, and this stasis, 
together with the relaxed and dilated state of the vessels, favors the exudation 
of serum, the consequence of which is, that the plasma of the blood in the part 
becomes inspissated by a preponderance of albuminoid matter over the salts. 
This inspissation of the plasma determines endosmotic changes in the red cor- 
puscles, in consequence of which they are disposed to aggregate. 
Simon propounds the view that the phenomena are due, not to a reflex 
action, but to a direct change effected by the living molecular structure of 
the part on the blood which traverses it, or on the vessels which convey that 
blood. 
Bennett ascribes the change as due to a vital force actively operating 
through the tissues which lie outside the vessels, and which is the only active 
agency causing the approach of the colored particles to the capillary walls of 
the bloodvessels, and the passage through them of exudation. 
Paget and Lister suppose a mutual relation to exist between the blood, its 
vessels, and the parts around, which, being natural, permits the normal 
transit of the blood, but being disturbed, increases the hindrances to its 
passage. 78 
TOPICS RELATIVE TO PATHOLOGY. 
Dr. C. J. B. Williams considers that an essential part of inflammation is 
the production of numerous white globules in the inflamed vessels, and that 
the obstruction of these vessels is mainly due to the adhesive properties of 
these globules. 
Rokitansky is of opinion that the condition of stasis proceeds,-1st. From 
the sticking together of the blood-corpuscles, the heaping up and wedging of 
them in the capillaries, while the plasma in part flows off towards the veins; 
2d. From the inspissation of the plasma, occasioned by the exudation of serum 
through the dilated and attenuated walls of the vessels, and its saturation 
with fibrin and albumen; 3d. From the heaping up of the colorless cor- 
puscles, i. e., the nucleus and cell-formations, together with blood-globules; 
from their sticking together, and from the delicate hyaline, fibrinous coagula 
which develop themselves among them. Rokitansky considers this to be the 
most important moment in the inflammatory process, since on the one hand 
it very specially throws light upon the phenomena of stasis, and on the other 
hand it comprehends the plastic processes which take place in the heaped-up 
and stagnant blood. It separates in this way the process of inflammation 
from a merely simple one of exudation. The elementary formations above- 
mentioned are not merely swept together towards the place of stasis, but they 
originate as new formations in the stagnant blood, which generally presents 
remarkable alterations. 
Wharton Jones describes the progress of stasis as consisting,-1st. Of the 
adhesion of collapsed and dark-red blood-corpuscles to the walls of the ves- 
sels ; and, 2d. The adhesion of other blood-cells to these. The first adhesion 
of the blood-cells usually takes place at a bifurcation, and the stagnation of 
blood is seen to begin in those capillaries which are least in the direct course 
from the artery to the vein, depending in a great measure upon the inspissa- 
tion of the plasma, or its increased quantity of fibrin and albumen. 
Whatever explanation may be given or accepted as to how the phenomena 
of inflammation in a part are brought about, our views regarding the essential 
nature of the process have been hitherto modified according as this complex 
morbid state has been studied by its effects as seen on the dead rather than 
on the living body. 
While Dr. Bennett regards an exudation from the bloodvessels as the neces- 
sary constituent of inflammation, Alison and Virchow, on the other hand, rec- 
ognize the morphological changes of the living tissues, such as have been 
described in inflammation, as betraying merely a tendency in a part to such a 
local change as exudation amongst its structure. That local tendency may be 
so slight that hardly any difference can be appreciated between the healthy 
changes attendant on normal nutrition, and those changes between the blood 
and the minute tissues which are of such a kind that a morbid change (inflam- 
mation) is established in the elementary components of the tissues themselves, 
without any appreciable exudation having taken place either amongst the 
interstices or upon the free surfaces of membranes. To such a condition Vir- 
chow gives the name of parenchymatous inflammation, meaning thereby that it 
is a process established locally between the capillaries, the blood, and the 
component elements of tissue, and expressed 'by a tendency merely to the 
effusion from the bloodvessels of such plastic material as may eventually take 
place. 
Inflammation may thus exist as a local morbid process, characterized by an 
abnormal condition of the nutritive changes between the capillaries, the 
blood, and the component elements of a texture, without any appreciable ex- 
udation. Such an abnormal condition will, under proper regimen and proper 
remedies, in a case of simple inflammation, seen from the first, completely 
subside, no interstitial exudation ever taking place. 
Examples of this simple form of inflammation have been fully illustrated PARENCHYMATOUS INFLAMMATION. 
79 
by Goodsir and Redfern in this country, by their demonstrations of what 
takes place within the large cells of cartilage. The 
cells become larger, the number of nuclei increases, and 
some, or all of them, may undergo fatty metamorphosis 
under the influence of this, the simplest form of inflam- 
mation ; and which is only manifested by this abnormal 
nutritive process between the blood and the cells. 
These changes within the cell-elements of tissue are 
described by Virchow as a "cloudy swelling" (triibe 
Schwellung, Fig. 2) of the parts, and are seen, for exam- 
ple, in the cells of the uriniferous tubes, and those of 
the mucous membrane in the state of catarrh. In this 
abnormal nutritive process, however, there is a constant 
tendency to the interstitial exudation of a hyaline ma- 
terial, which may become fibrous or filamentous, and 
ultimately soft and gelatinous. Virchow, Weber of 
Bonn, and His, have demonstrated similar changes in 
the cells of the cornea. 
Thus the minute and penetrating observations of 
Virchow have given a more comprehensive meaning to 
the process of exudation than it has hitherto, in this 
country, been understood to signify; and such alterations as he and others 
have described in the elements of the tissues of an inflamed part have been 
in a great measure overlooked, except by Dr. Alison and Mr. Simon. The 
latter especially states that the irritation of the inflammatory process is inde- 
pendent of the nervous influence, but is a direct change operated by the living 
molecular structure of the part on the blood which traverses it, or on the vessels 
which convey that blood. Dr. Alison, also, long ago recognized the tendency to 
interstitial exudation as attending such vital changes in the constituent ele- 
ments of a part, and which entitled it to be considered inflamed. The accurate 
observations of Virchow, Goodsir, and Redfern have shown that such primi- 
tive changes do take place before those more palpable phenomena occur which 
constitute the excessive exudation as described by Bennett, namely, the exu- 
dation of decolorized lymph into the interstices between the constituent ele- 
ments of a texture. Both sets of phenomena alike show that inflammation 
is only one of the various shades of deviation from the normal process of nutri- 
tion,-a diseased action tending to a local lesion (British, and Foreign Medico- 
Chirurgical Review, January, 1854). That the irritation of inflammation is 
in some measure independent of the nerves, the following interesting experi- 
ment, related and performed by Mr. Simon, may be quoted in proof: 
" A patient had complete anaesthesia of the fifth nerve, dependent (as a post- 
mortem examination subsequently showed) on its organic disease ; the con- 
junctiva, as well as the integument of the face, was utterly insensible; not 
only was the function of the nerve destroyed, but those reflective nutritive 
changes, of which I have already spoken, had taken place, and had exhausted 
themselves; showing that the nerve was spoiled for participation in the acts 
of nutrition (whatever they may be) no less than for its more obvious uses as 
a medium of conscious sensation; the cornea had undergone ulceration, and 
had healed again. The following experiment was carefully made: The lids 
being held open, a single granule of cayenne pepper was laid upon the insen- 
sible conjunctiva; in a few moments it had become the centre of a very dis- 
tinct circle of increased vascularity, the redness of which slowly became more 
and more distinct as long as the stimulus was suffered to remain, so that, on 
its removal, there was a very evident circumscribed erythema on the surface 
of the membrane. I consider myself justified in believing that this change 
occurred without any intermediate nervous excitement; not only because the 
Fig. 2. 
1000th of an inch X 350 diam. 
Convoluted urinary tubule 
from the cortex of a kidney 
in Bright's disease (after Vir- 
chow) (a.) Tolerably nor- 
mal epithelium ; (6.) State of 
" cloudy swelling (c.) Com- 
mencing fatty degeneration 
and disintegration. 80 
TOPICS RELATIVE TO PATHOLOGY. 
history of the case would lead me to consider the fifth as annihilated; not 
only because the experiment was totally unattended with sensation ; but like- 
wise because there was the very remarkable absence of that sympathetic phe- 
nomenon which the faintest remnant of nervous excitability would have 
produced-namely, there was not the slightest trace of lachrymation " (Lectures 
on General Pathology, p. 76). 
Further evidence might be submitted from the papers of Mr. Joseph Lister 
to the Royal Society, already referred to. 
Such being the essential nature of inflammation, it is easy to understand 
how reasonable is that doctrine which teaches " that the process of inflamma- 
tion is susceptible, at all times and in all countries, of very great variety as 
to extent or intensity, and especially as to the constitutional affection associa- 
ted with it or consequent upon it." 
Products, Effects, or Events of Inflammation.-Care must be taken not to 
put the products of inflammation in place of the symptoms of inflammation. 
When the local impairment of function of the minute elements of tissue in 
process of inflammation is confined to a small space, or is carried on upon a 
minute scale, or rapidly abates, the inflammation is said to terminate by resolu- 
tion as a general principle; that is, the abnormal action ceases, interstitial 
exudation does not take place, the tendency to further impairment of func- 
tion is subdued and passes off' and the part is left apparently as it was before. 
If, however, interstitial exudation has taken place, and resolution is to be 
effected, the return of the part to health may be followed, for some time, by 
some impairment of its structure and function. 
After the process has thus gone a certain'length, an increased local growth of 
cells, and their liquefaction or reduction to a state capable of absorption (what 
Dr. Addison calls cell-therapeutics}, are essential to the restoration of the part. 
Before the process has attained such a length, however, resolution may be 
simply effected by a gradual return of all the parts to a natural state: a mere 
retracing of the steps by which the natural actions had been departed from 
sufficiently describes the process (Paget). 
The process of resolution has been closely watched by Mr. Paget. He has 
seen, in those cases where impairment of function and actual lesion had taken 
place, that fragments of fibrin, washed from the blood in the vessels of the 
injured parts, were borne along and floated into distant vessels. The observa- 
tions of Dr. Kirkes, also, leave no doubt that similar changes may occur in 
warm-blooded animals, and may be the source of great evils ; may be, indeed, 
productive of some of those constitutional effects yet to be noticed, by carrying 
the materials of diseased or degenerate blood from a diseased organ to one 
that was previously healthy. When the disappearance of the inflammation 
is unusually sudden and rapid, the event is technically called " delitescence 
and if at the same time the symptoms of inflammation appear at another part 
not anatomically connected with the part first diseased, the event is called a 
" metastasis." 
When the process does not confine itself to the simple expression of altered 
nutritive changes between the constituent tissues of a part and the blood ; but 
when the tendency to exudation amongst the interstices of texture continues, 
.and does not subside, as already explained,-namely, by resolution,-then it 
is that (1) such a material is separated from the blood as will become a me- 
dium or nidus-substance, in which many changes connected with the growth of 
new particles, granules, or cell-forms will take place, and the phenomena of 
which have been so well described by Bennett, Gluge, Paget, Virchow, Beale, 
and John Simon; and (2) coincident with this exudation, and the changes 
which it undergoes, the tissue of the part itself sustains serious alterations. 
For in all such inflammations, especially of the more vascular parts, when 
.there is increased exudation from the bloodvessels, there is a great deteriora- SEROUS, FIBRIN, AND BLOOD EFFUSIONS. 
81 
tion of the surrounding elements of tissue. The texture is rendered soft and 
easily torn, and by such changes of cohesion the elasticity of parts (a circum- 
stance often of very primary importance) becomes greatly altered and im- 
paired. 
These changes, therefore, Mr. Paget happily describes as consisting of,- 
(1.) Productive effects-that is, effects resulting from the growth of new parti- 
cles, granules, or cell-forms, from pre-existing germinal elements of tissue, and 
which are susceptible of further development, and also of degeneration; (2.) 
Destructive effects, such as softening, degeneration, absorption, ulceration, and 
death of tissue. 
Productive Effects of Inflammation-Inflammatory Effusions or Exuda- 
tions-These consist of,-1. Serum; 2. Blood ; 3. Fibrin; and, 4. Mucin. 
These last two are the only true inflammatory exudations. 
1. Serous Effusions.-The effusion of pure serum is said to be very rare. 
In Inflammation of a serous membrane, as the pleura, the fluid effused is not 
only greater in quantity than natural, but is also greatly altered in quality. 
In health, the serous secretions are little more than pure aqueous vapor, with 
a trifling addition of saline matters ; but when they occur in an inflamed part,, 
they contain a considerable quantity of albumen, sometimes a portion of fibrin^ 
and at other times the secretion appears to be the pure liquor sanguinis which 
is effused, entirely unchanged in its physical properties. The quantity effused 
varies, according to the part affected, from perhaps a portion of an ounce to a 
few pints, or even more than a gallon. 
This product of inflammation, but mixed with fibrin, may be seen in the 
fluid contained in blisters raised by counter-irritants in a healthy person;, 
also in the fluid of peritonitis; of pleurisy and of pericarditis: such also is the 
fluid that fills the early vesicles of herpes and eczema, and other cutaneous 
eruptions. It is also seen in the fluid which surrounds an acute,, deep inflam- 
mation beneath the skin. The fluid of a common hydrocele is another exam- 
ple of serous effusion. The phenomena associated with the production of such, 
a secretion may be often seen surrounding a phlegmon or boil of large size- 
While the centre or core of the boil is hard, it is surrounded by textures into' 
which the effusion that has taken place is serous. Such serum is seen to a 
great extent in pelvic cellulitis in its first stage,. A very demonstrative and. 
interesting example of this is given by Professor Simpson, of Edinburgh, in 
the Medical Times and Gazette for 1859, p. 27, July 9. In such cases the fluid 
fills the areolar tissue which immediately surrounds the inflamed parts ; and 
when the finger is pressed firmly on the part,, the fluid is displaced into the 
adjoining areolar spaces, which yield to receive it.. When the finger is with- 
drawn, the fluid does not immediately return, but an impression is left in the 
shape of a pit. The part which is the seat of serous effusion is then said to.- 
pit on pressure, or to be oedematous. 
The fibrin of inflammatory serous effusions remains in solution for weeks 
or months within the body, during life, but will coagulate readily when with- 
drawn. This delay of the fluid to coagulate within the body is a propitious 
event. So long as it is liquid, absorption may still ensue without its undergo- 
ing any ulterior change when the inflammation subsides. This subsidence of 
the inflammation, however, is necessary, for it is known, that so, long as inflam- 
mation continues, there is impairment of function, and absorption does not 
take place. 
One constant characteristic of the productive effects of inflammation is, that 
growing material is always developed from the pre-existing germinal elements 
of the tissue involved; and. the effusion that results from mere mechanical 
obstruction to the flow of blood is very different from the fibrinous effusion of 
an inflammation. In the former case the fluid effused from the blood is merely 
the serous part, as the fluids of anasarca and. ascites,, and will not coagulate... 82 
TOPICS RELATIVE TO PATHOLOGY. 
Such fluids, as a rule, neither present fibrin, nor are any granules, particles, 
or cell-forms developed in them from the elements of surrounding tissue. 
Fibrin can only be made to exude upon any surface or part in a state of 
irritation or inflammation. Such a local change is sufficient to cause the 
exudation of fibrin, independently of obstruction to the circulation; and the 
cause of the greatest differences in the nature of exudations is to be found in 
the special constitution of the irritated parts (Virchow). In some effusions 
there is a great yield of fibrin, e. g., the exudation of diphtheria, so also in 
the effusions of ortitis and of muscular rheumatism. 
It has been clearly shown (Simon, Lehmann, Beale) that there are two 
essential characteristics .of inflammatory effusion: (1.) It tends to contain 
certain ingredients in larger proportion than that in which they exist in the 
blood-excess of chloride of sodium and of phosphates and albumen; (2.) 
Organic forms find in it a suitable place for growth. 
The site of effusion resulting from inflammation is important, as sometimes 
constituting the chief element of danger-a danger sometimes immediate, 
from the mechanism of the parts affected. A large quantity of fluid is often 
poured out in a very short time. The cavity of the pleura may fill in a few 
hours, and the lung may be compressed by it to a half or third of its bulk; 
and if both pleural cavities become thus affected, constituting double pleurisy, 
the patient must die from suffocation, if not at once relieved by allowing free 
vent to the fluid. This operation is called tapping the chest, or, technically, 
"paracentesis thoracis.'" Serous effusion into the areolar submucous tissue of 
the glottis may also produce almost immediate death from suffocation, unless 
the cavity of the larynx is immediately opened to admit the air to the lungs 
(Watson). 
2. Blood Effusions, or Extravasations, chiefly occur from rupture of the new 
vessels developed in the newly-formed material, which has just become vascu- 
lar (Rokitansky) ; but Cohnheim has also shown that during the process of 
inflammation, at the same time that the white corpuscles permeate the veins, 
that red corpuscles make their way through the capillaries. In the ordinary 
course of internal inflammations, extravasations of blood are rare, and betoken 
an unfavorable state of the constitution generally, such as occurs in typhus 
fevers, in scurvy, in purpura, or in syphilis. The post-mortem evidence of 
such extravasations is the presence of a colored cicatrix at the spot of rupture 
and effusion, and the color is found to be due to,the presence of hsematoidin, 
generally in the form of a mass of aggregate crystals, composed of minute 
rhombic columns, and which may be considered as the regular typical ultimate 
form into which hsematin is converted in any part of the body where consid- 
erable masses of extravasated blood continue to lie for any length of time, e. g., 
apoplectic clots, ami coagula in the Graefian vesicle of the ovum after men- 
struation (Virchow). 
Mr. Paget correctly observes that we must not confound' with hemorrhages 
the cases in which the inflammatory products are merely blood-stained, i. e., 
have acquired a more or less deep tinge of blood, through the oozing of some 
of its dissolved coloring matter. The natural color of inflammatory new for- 
mations is grayish or yellowish-white, and even when they have become vas- 
cular, their opacity in the recent state prevents their having any uniform tint 
of redness visible to the naked eye. When inflammatory products present 
the tinge of redness, it is either because of hemorrhage into them, or because 
they have imbibed the dissolved coloring matter of the blood; and when this 
imbibition happens during life, or soon after death, it is important, as imply- 
ing a cachectic, ill-maintained condition of the blood, in which condition the 
coloring matter of the corpuscles becomes unnaturally soluble. 
3. Inflammatory Lymph or Fibrin.-This product is so named to distinguish 
it from the lymph in the lymphatic vessels, with which it is probably not 
identical (Paget). It is a characteristic primary product of the inflamma- TYPICAL FORMS OF GROWTH IN LYMPH. 
83 
tory process, and was called originally "lymph," or "coagulable lymph;" and 
more recently it has been called "exudation," or "fibrinous" or "inflammatory 
exudation." "It is at first," says Mr. Paget, "probably always a pellucid 
liquid exudation which passes through the bloodvessels"-"sweats through 
them," as Simon hath it,-" and especially through the capillaries of the' in- 
flamed part. Its most characteristic general properties are, that it may become 
a nidus-substance, capable of taking some share, or of assisting in promoting the 
growth of new elements like the natural connective tissue of the body." But 
the nature of the products of this development in the "inflammatory lymph" 
varies much, according to the part and the state of the constitution; and 
accordingly Bennett attempts to distinguish the products of simple exudation 
from those of tuberculous and cancerous exudations. The typical elementary 
forms which may grow amongst inflammatory lymph vary according to a 
much greater variety of circumstances. The circumstances which tend to 
modify the type of the inflammatory process, or impart to it a particular ten- 
dency in respect to the nature of the productive material, may be shortly 
stated as follows: 
1. The nature of the tissue in which the inflammation takes place. 
2. The period at which the product is examined after exudation has taken 
place and growth commenced. 
3. The state of the blood, and the nature of the zymotic or constitutional 
morbid state which may be associated with the inflammation. 
4. The amount of vascularity which the affected part retains. 
5. The amount of the local exudation, and the extent of healthy tissue 
implicated. 
6. The suddenness of the phenomena of exudation and of growth. 
7. The persistence of the inflammatory state in its vicinity. 
8. The amount of fluidity, serum, serous effusion, blood, or mucus, asso- 
ciated with the inflammatory lymph. 
These are the chief circumstances which determine and modify the elemen- 
tary forms which may grow amongst the "inflammatory lymph," and which 
may advance to further development, or to degeneration. These circum- 
stances, severally, or more or less collectively, influence the different stages 
of progression, by which the local lesion of the inflammatory process may 
ultimately terminate in resolution, in permanent organic mischief, in death of 
the parts involved, or in death of the patient. 
There are several typical forms, especially found growing amongst the "in- 
flammatory lymph," and in the growth of which the material of the lymph 
may take some share-namely, the granular, molecular, or fibrillated develop- 
ment of fibrinous products and corpuscular forms. 
Rokitansky describes these typical forms by the terms "fibrinous" and 
"croupous" and Dr. C. J. B. Williams by the names of "plastic" and "aplastic." 
Examples of each variety may illustrate the application of the terms. To the 
fibrinous or plastic variety belong the serous effusions already referred to, and 
perhaps also the granular, molecular, or fibrillated growths. The corpuscular, 
croupous, or aplastic forms of lymph are represented by those growths which 
never become consolidated, as in the early-formed contents of vesicles in vac- 
cinia and herpes; in the fluid of blisters raised in cachectic patients; in some 
instances of pneumonia; and in some forms of inflammation of serous mem- 
branes. In by far the larger number of inflammatory products these typical 
forms are mixed in various proportions; and the larger the proportion of cor- 
puscles in new growth, the greater is the probability of suppuration, or of some 
other degenerative process, and the more tardy is any process of development 
into tissue, such as that of adhesions, indurations, and the like. In other 
words, the preponderance of granules, molecules, and fibrillated material in 
the new growth, is generally characteristic of the "adhesive or lymphy inflam- 
mations the preponderance of corpuscles, or their sole existence in a liquid 84 
TOPICS RELATIVE TO PATHOLOGY. 
medium, is a general feature of the "suppurative inflammation." The hard- 
ness of inflamed parts is due to the former of these typical forms of inflamma- 
tion, and is exemplified in the case of a phlegmon or boil before it suppurates; 
as also in a lung in a state of hepatization, when its textures are inclosed by 
lymph, "just as the stones of a wall are by the cement;" also in the harden- 
ing of a chancre. 
On the surfaces of inflamed membranes the new fibrinous growth forms a 
layer of a membranous firmness or consistence, to which the name of false, 
adventitious, or pseudo-membrane has been given. By this new growth the 
naturally opposed surfaces of parts which are inflamed are apt to adhere. 
This is commonly seen to be the case between such serous surfaces as the 
pleurce, the pericardium, the peritoneum, or the edges of a wound. The inflam- 
mation associated with this organization is sometimes called " adhesive inflam- 
mation and Dr. John Thomson ascertained that this growth and organization 
might be effected between the surfaces of wounds in less than four hours after 
they were inflicted. 
On the surfaces of mucous membranes may generally be seen the " corpus- 
cular" typical form of new growth as a result of inflammation. It has little 
tendency to cohere, but grows in films, gelatinous masses, shreds, patches, or 
delicate casts of the surface upon which it was formed. The new growths in 
chronic catarrh of the intestines are an example; so are the membranes some- 
times passed from the cavity of the uterus, and called dysmenorrhoeal mem- 
branes. In the "adhesive" form of inflammation the new growth of granules 
or of molecules may ultimately assume the form of fibroxis tissue interstitial 
to the textural elements inflamed. Examples of this organization are seen in 
the laminated and nodular thickening of the capsules of the spleen, the thick- 
ening and induration of the periosteum, or the capsule of the hip-joint in 
chronic arthritis; and by virtue of the peculiar tendency to contraction which 
fibrinous products possess, the contractions of parts are to be explained which 
have been the seat of such a form of inflammation. 
There are instances also in which the new growth assumes the form of adi- 
pose tissue, elastic tissue, and epithelium (Kirkes, Virchow, Paget); and 
bone is a very frequent ulterior change which it assumes, especially when the 
new growth is interstitial to fibrous tissue; but these ulterior events only happen 
after the inflammatory process has ceased in the part. So long as the inflam- 
matory phenomena continue, the tendency of the new growth is to assume the 
corpuscular form, such as pus, rather than the more adhesive forms of organi- 
zation. Hence rapid organization accompanies, as a general rule, a minor 
degree of action; and by depressing the action of a part, we tend to prevent 
the threatened occurrence of suppuration. 
The existence of the inflammatory state, associated with an interstitial exu- 
dation, influences the simplest corpuscular forms of organization. Lymph-cells, 
or simple primordial forms, occur, which are represented by the corpuscles of 
chyle, lymph, the white corpuscles of the blood, and by those of granula- 
tions on the surface of a wound. These simple cells become developed amongst 
the lymph while it is still fluid, transparent, and apparently homogeneous. 
The first discernible organic form in the lymph of herpes, for example, is that 
of a mass of soft, colorless, or grayish-white corpuscles, about j-g^nith or 3-0'0 y-th 
of an inch in diameter, round or oval, pellucid, but appearing, as if through 
irregularities of its surface, dimly nebulous or wrinkled. It does not look 
granular, nor is it formed by an aggregation of granules; nor in its earliest 
state, can any cell-wall be clearly demonstrated, or any nucleus on adding 
water. In a few hours, however, a pellucid membrane appears to have grown 
over its surface, permeable by water, which raises up part of it like a clear 
vesicle, while the contained mass retreats or subsides to the lower part of the 
inclosure, and appears more nebulous or grumous than before. A nucleus ulti- 
mately forms, and can be distinguished in this mass (Paget). ABSORPTION OF LYMPH. 
85 
From these primordial cell-forms in the lymph either the adhesive or more 
corpuscular forms of organization may proceed; and all the various forms of 
corpuscles described by authors as plastic cells, fibre cells, caudate cells, or 
fibro-plastic cells, and some forms of filaments, are developed from the ger- 
minal matter of the surrounding tissue by continuous development. Also, 
from the development of the primordial granules, corpuscles, or cells, all those 
elementary forms proceed which are known as "pus-corpuscles," "granule-cells," 
"compound granule-masses or cells," "inflammatory globules," and much of the 
moleczilar debris-like matter that makes inflammatory effusions turbid. 
The modes of growth as well as of degeneration are well described by Mr. 
Paget, from whose work on Surgical Pathology the following examples and 
illustrations are chiefly taken : 
1. The lymph may simply wither or waste, as may be noticed in the vege- 
tations on the valves of the heart or large arteries, when they become yellow, 
stiff, horny, elastic, and nearly transparent; or in the lymph deposited over a 
compressed lung, associated with empyema or hydrothorax. 
2. The fibrin of lymph may undergo changes similar to what is known as 
fatty degeneration,-changes similar to those which occur in the primordial 
lymph-cell when it is transformed into pus. The two changes generally go on 
together. To the former change-namely, the fa tty-like degeneration of the 
fibrin-Mr. Paget gives the name of " liquefactive degeneration:" the solid 
fibrin of inflammatory lymph that becomes again liquid when suppuration 
takes place, as may be observed in a hard mass of inflamed texture when it 
becomes soft. 
This is a degeneration which brings the new growth into a state favorable 
for its absorption, or to the resolution of an inflammation. Examples of such 
an absorption may be seen in rheumatic iritis, and the observations of Dr. 
Kirkes on the rarity of adhesions of the pericardium in comparison with the 
frequency of pericarditis may also be explained in this way. 
3. Melanic degeneration of lymph and new growths is not unfrequent, as in 
peritonitis. 
Concurrent with these degenerations of the lymph-granules and molecules 
are the degenerations of the corpuscular elements. 
1. They may wither, as in the dried-up pus of chronic abscesses. 
2. The fatty degeneration of cells is said to be shown in their transition to 
the granule-cell, known also as the inflammatory globule of Gluge, or the exuda- 
tion-corpuscle of Bennett. The history of the formation or growth of these 
corpuscles is still doubtful. 
The description of them, as originally given by Gluge, in describing the 
alterations of blood in inflamed parts, is as follows : 
He observes "that the blood-globules lose their tegument and their color. 
Their inner substance alone remains, which, however, does not remain soli- 
tary ; but by means of a whitish connecting material the masses become 
agglomerated, and form dense, opaque, round groups, containing on an aver- 
age from twenty to thirty of the smaller bodies, which, examined singly, are 
quite light and transparent. By means of pressure or acetic acid the asso- 
ciated granules break down into the individual bodies, and we see that the 
opacity is merely owing to the association. The associated bodies have a 
diameter in the mass of from ^th to ^th of a millimetre; the single gran- 
ules are from -g-^^th to Tooth of a millimetre. These associated bodies," says 
Gluge, "I have seen in the bloodvessels, so that we have not here to do with 
a fluid which, transuding through the coats of the bloodvessels, is changed 
into granules. They escape by bursting the capillaries." 
That this cell or corpuscle is formed within as well as without the blood- 
vessels, is apparent from an examination of inflammatory lungs or brain-sub- 86 
TOPICS RELATIVE TO PATHOLOGY. 
stance. The corpuscles may be seen to coat the bloodvessels exteriorly and 
interiorly to their walls ; and the formation of the corpuscle of Gluge can also 
be traced through stages of development, as described by Vogel, Bennett, 
Kolliker, Hasse, and myself; as well as through stages of degeneration from 
the normal state of some corpuscular elements (textural or morbid), the occur- 
rence of which has been described by Reinhardt, Dr. Andrew Clark, Dr. W. 
T. Gairdner, and Mr. Paget. 
The essential ingredient of which the compound granule-cell is composed 
appears to be oily or fatty matter; and these cells vary considerably in their 
appearance, according to the fineness with which this matter is divided. In 
some the oil-drops are large, in others they are small and quite granular. 
They are by no means confined to inflammatory parts. Kolliker, in examin- 
ing morbid products in an animal, has seen oval blood-discs included in these 
corpuscles, showing that the cell-membrane may be in some instances a sub- 
sequent formation in their progressive development. This view of their na- 
ture would imply that a number of the original oil or fluid granules come 
into contact with each other, and cohere into a glomerulus, which subse- 
quently becomes invested with a membrane, and constitutes a cell, the con- 
tents of which gradually undergo some morphological process by which they 
are resolved, and ultimately pass into the circulation (Simon). 
My own observations on this point, published in 1849, and chiefly made 
upon inflamed pulmonary tissue, led me to express the same result, as to the 
nature of this compound corpuscular development, in the following statement; 
"1. The formation of clear, transparent, non-nucleated cells may be ob- 
served. 
" The formation of cells with a nucleus and nucleolus are seen, differing 
from pus-corpuscles in their large size, and in having a single nucleus. These 
are formed in the fluid of coagulated exuded matter, and become gradually 
filled by minute granules, which, when few in number, readily admit of the 
nucleus being seen. Subsequently, however, they conceal it; and the origi- 
nally smooth cell-membrane becomes rugged, the granular cell appearing as 
a spherical agglomeration of granules. Subsequently the cell-wall appears 
to vanish, the inclosed granules to separate from one another, and to fall into 
irregular heaps" (Edin. Med. Journal, No. 178, for 1849). 
The following are the general facts connected with the appearance of these 
corpuscles: 
"1. They are formed in greatest abundance during the first stage of the 
exudation (the second stage of pneumonia, according to Laennec). 
" 2. As long as the capillary circulation is going on, and before complete 
stagnation has taken place. 
" 3. When the redness and condensation are the greatest, the corpuscles 
begin to disappear, or are not seen. 
" 4. They disappear altogether as the red softening passes into gray, be- 
coming liquid. 
" 5. They are imperfectly formed, or not at all, in the deposits that occur 
during the progress of typhus fever .or typhoid fever." 
Associating these observations with the descriptions of Mr. Paget relative 
to the liquefaction of fibrin,-with those also of Zwicky and Gulliver, who 
found these corpuscles in the softened apex or centre of arterial clots,-with 
those of Simon, who states that they are often found in the fibrinous clots of 
veins,-with their occurrence in the mammary secretion, in the softened parts 
of encephaloid cancer, in the vicinity of apoplectic effusions, and that gen- 
erally they are extremely apt to be present where blood, or the products of 
exudation or secretion are undergoing absorption,-does it not appear proba- THE INFLAMMATORY TYPE OF FEVER. 
87 
ble, moreover, from the lucid description given by Mr. Paget (when he says 
that during the formation of these corpuscles " they present a gradual in- 
crease of shining black-edged particles, like minute oil-drops, which accumu- 
late in the cell-cavity, and increase in number, and sometimes in size also, till 
they fill it"), that these compound granular cells, when associated with in- 
flammatory products, fulfil a very important function, as the media through 
which the liquefied, softened, and disintegrated products of inflammation are 
gradually absorbed ? 
The observations of Reinhardt, Dr. Andrew Clark, Paget, and Gairdner, 
also place it beyond a doubt, that compound granular cells may result from a 
fatty degeneration of the textural cells of a part; just as calcareous or pig- 
mental degenerations occur, and which are common to primordial cells. 
While there can be no doubt, therefore, that/fatty degeneration of lymph or 
textural elements may lead to the appearance of compound granular cells, 
that process can scarcely be called degeneration which is associated with 
development, growth, and complete absorption, by which the indurated and 
confused parts of an inflammation, such as the solidified portions of a lung 
in pneumonia, are ultimately cleared up. 
Degenerate products are usually persistent, but the compound granule-cell 
is not. It seems to have an important function to perform in the removal of 
fluid, effete, or softened exudations, after which it too disappears. 
All these productive effects of inflammation, in the form of effusions or 
exudations, contribute, with the greater abundance of blood, to the swelling 
which attends inflammation of a part. The effusion may collect within a 
shut-sac, as in synovial and serous inflammations; or it infiltrates the solid 
organs. In mucous membranes the effusion is represented by the altered 
secretion which, as a catarrhal exudation, flows from its surface. The swell- 
ing in such cases is represented by the amplification of the epithelial layer; 
and hence the interference of respiration which belongs to the beginning of 
acute bronchitis, the blocking up of the kidney tubes with modified cell- 
growth in scarlet fever, and the diminished stream of urine during the severity 
of gonorrhoea (Simon). It is these products of effusion and exudation which 
render inflamed parts so extremely juicy, so oedematous, that a cut or punc- 
ture into them during life allows the fluid to drain away long after hemor- 
rhage has ceased. 
All these effusions of inflammation differ from the mere exudation of serum 
from liquor sanguinis in the nutrition of texture. " Their specific gravity is 
high. Their proportion of albumen is great; and, when they are not puru- 
lent, they probably give a fibrinous coagulum" (Simon). 
Local and General Symptoms of Inflammation. - Redness, or at least 
increased afflux of blood, swelling, or at least textural productivity, pain, 
throbbing, increased sensibility, disorder of function, arrest and change of 
secretion, are the phenomena which are associated with the local morbid 
state, or with the textures in its immediate vicinity. Under all circumstances 
the inflammatory process involves a local production of heat accompanying 
the increased vital effort and the increased textural changes of inflammation. 
This has been recently proved to demonstration by the ingenious experiments 
of Mr. Simon and his colleague, Dr. Edmund Montgomery (A System of 
Surgery, second edition, edited by T. Holmes, M.A., vol. i, p. 20). If the local 
process of inflammation, however, is carried on upon a minute scale, or in 
certain tissues, one or other or more of these symptoms may be absent; if, on 
the other hand, the local process proceeds on an extensive scale, and involves 
important and delicate textures of vital importance, then we have much more 
unequivocal expression given, not only to local symptoms, but to complex 
morbid processes, affecting the constitution generally. Of these the chief are: 
I. Inflammatory Fever.-Of the constitutional symptoms, as they are termed, 
the most prominent are those which indicate " inflammatory fever, symptomatic 88 
TOPICS RELATIVE TO PATHOLOGY. 
fever, or sympathetic fever." These constitutional symptoms are of the greatest 
importance, not only by indicating the nature of the disease, as when the 
inflammation is connected with an internal organ removed from sight and 
touch ; but they are highly important as a guide to treatment. The premoni- 
tory symptoms of coldness and shivering are usually very decided, but not of 
long duration. They are succeeded by a stage of reaction. The pulse is then 
hard and swift. There is thirst and greatly increased heat of surface. The 
secretions and the appetite may not at first vary much from the normal state, 
but on the whole are diminished. Exhaustion and emaciation do not proceed 
rapidly. This fever is pre-eminently one of strong reaction and vascular 
excitement, and these characteristics may be said to constitute its type. 
A most minute description of the disorder of the general frame by inflam- 
matory fever, according to its qffect on the systems of the body, is thus con- 
densed from the account given by the late Professor James Miller (Principles 
of Surgery, p. 39) : 
(1.) The Nervous System. There are aching, dull pains in the loins and 
limbs, restlessness, and much discomfort. The will and the power of exertion 
are diminished. Anxiety or foreboding of evil is felt and expressed upon the 
countenance. The head is generally hot, the face flushed, the eyes suffused, 
and the skin hot and dry. Special sensation is at first exalted, but after- 
wards the intellectual functions become more and more disturbed. Ulti- 
mately delirium is established, and coma may ensue. (2.) The Vascular Sys- 
tem. The pulse ranges from 80 to 130, or more, and the heart's action is 
proportionally rapid. The pulse is hard, rolling like a cord below the finger, 
and yielding but little to its pressure; or an irregularity of movement in the 
artery may exist, and thus a thrill or jar is imparted to the finger. There is 
increased fulness, as if the vessel were itself enlarged, and held a larger quan- 
tity of blood at each impulse; the heart is acting not only more rapidly, but 
more powerfully than in health, and the circulation is truly accelerated. 
Frequency, hardness, and thrilling, are seldom, if ever, absent; but fulness 
may be wanting, and the pulse may be small instead of full. This modifica- 
tion is chiefly observed during serous inflammatory action, affecting important 
internal organs situated in the abdominal region. Hence it is sometimes 
termed the abdominal pulse; the artery resembling a hard, thrilling thread, 
rather than a cord. This pulse always exists in connection with great nervous 
depression, and debilitated, though rapid, cardiac action ; to which circum- 
stance its smallness is probably due. In affections of the brain, on the other 
hand, producing coma, the pulse is commonly slow and full; the suspension 
of cerebral influence appearing to diminish the rapidity, without affecting 
the force, of the heart's action. There are idiosyncrasies also to be taken 
into account. The pulse may be naturally slow or rapid-fifty or ninety; 
and this must be allowed for, when previous inquiry has satisfied us that the 
patient is the subject of such peculiarity. (3.) The Respiratory. Respiration 
is quickened; the breath is felt to be hotter than usual; and an oppression is 
complained of in the chest. (4.) The Digestive. The tongue may be loaded, 
white, and moist; or the edges and central tip may be red and dry: the latter 
is probably the more frequent combination. (5.) The Secerning. The secre- 
tions and excretions in general are materially diminished. The bowels are 
constipated-mainly from want of mucous secretion from their lining mem- 
brane ; the skin is hot and dry; the mouth is parched; the urine is scanty, 
high-colored, generally acid, sparingly aqueous, and holding much saline 
matter, with comparatively little urea, in solution. (6.) The Nutritive. Diges- 
tion is interrupted; so is assimilation; as the fever advances, so does emacia- 
tion ; and strength is more and more prostrate. 
Chilliness, often amounting to shivering, marks the date of the febrile dis- 
turbance; and rigors more frequently attend the commencement of spontaneous 
inflammation than of inflammation caused by external injury. THE INFLAMMATORY TYPE OF FEVER. 
89 
The essential fact of inflammation fever is, that in proportion as any con- 
siderable part of the body becomes acutely inflamed, the patient's blood in- 
variably rises in temperature above 98° Fahr.; and regarding this constitu- 
tional febrile state characteristic of inflammation, some important general 
conclusions, especially insisted on by Dr. Alison and Dr. Watson, may be 
thus shortly stated: 
(1.) It is to be observed that there is no fixed relation between the degree 
or intensity of internal inflammations and the constitutional fever attending 
them; nor is the fever always proportioned in its degree of violence to either 
the size or importance of the part inflamed. In some cases, writes Dr. Alison, 
where we are sure that we have had inflammation going on under our inspec- 
tion, to extensive effusion of pus, the pulse has been feeble, the skin cool and 
damp, and the patient exhausted and faint on the slightest exertion; while 
in others there is high and more inflammatory fever, and in some of these 
the organ inflamed has been so to no extent, and its function comparatively 
little affected, but yet the patient has become comatose nearly as in typhus, 
and died so. Laennec makes an observation of a similar kind, and Dr. 
Watson observes that the fever may be high and very strongly marked in 
that common complaint, the quinsy, cynanche tonsillaris, or tonsillia, which 
can scarcely ever be said to imply much danger. (2.) The situation, the 
extent, and the degree of the local inflammation being the same, the fever 
commonly runs higher in young and in plethoric persons, and in those of 
sanguine temperament, than under opposite conditions. (3.) Inflammatory 
fever is modified in its expression, and especially in the characters of the 
pulse, by the nature of the part which is inflamed. This has been already 
alluded to in regard to inflammations of the abdomen, where the action of the 
heart is depressed, and the pulse is changed accordingly, tending to death by 
asthenia; and also in regard to the brain, when the mode of death tends to 
be by coma, the pulse being slow, labored, and full. (4.) The type of the 
inflammatory fever is very much modified by constitutional circumstances, 
such as the previous habits of the patient, and whether any zymotic disease 
is associated with the local inflammation. (5.) The inflammatory fever 
undergoes a further change of type (a).when suppuration takes place; (6) 
when it continues long; and (c) when mortification or gangrene occurs to a 
large extent. (6.) The febrile state follows generally the local disease; but, 
(7.) There is also good reason to believe that the pyrexial condition, and the 
condition of inflammation in a part, may be excited in some instances con- 
jointly ; or, at all events, their periods of commencement may correspond so 
closely that it is difficult to conceive that one is the effect of the other. Obser- 
vations are much wanted as to the exact ranges of temperature, as measured 
by the thermometer, in cases of inflammatory fever, and so to verify or set 
aside such general statements (see Bilroth, in Year-Book of Syden. Society for 
1861). 
When inflammation proceeds to suppuration, a severe paroxysm of shiver- 
ing is often the first indication of the formation of the pus, and the character 
of the fever undergoes a great alteration from that just described. The degree 
of the fever varies greatly even in this case, for a most copious formation of 
pus may take place from a mucous membrane, as that of the bronchi or 
urethra, and yet the constitution may hardly suffer in any appreciable degree; 
while a trifling amount of pus from a serous membrane may be associated 
with a fatal fever. 
In any case the character of the fever depends in a great measure on the 
constitution of the patient. If that be good, the fever is attended with a 
white tongue, with little tendency to become brown, also with much heat, and 
a full, strong pulse. On the contrary, if the patieit's constitution be broken 
or impaired, the fever is of a low type-asthenic, as it is called. The event 
of suppuration is generally marked by a rigor of greater or less severity, while 90 
TOPICS RELATIVE TO PATHOLOGY. 
the fever hitherto has been sthenic. It is the occurrence of the rigor in the 
course of the inflammatory febrile state which gives it prominence and im- 
portance. It generally attracts the attention of the patient, and indicates to 
the physician that pus has been produced in the part or organ inflamed. As 
soon as suppuration is complete, and the abscess ripens, or pus approaches a 
surface to be discharged, and especially if any important organ is its seat, the 
fever tends to become asthenic, with a brown tongue and a rapid pulse, while 
the local pain in a great measure subsides. At this period the abscess must 
open spontaneously, or be opened by art, otherwise the patient may be in 
danger. The opening of the abscess, though attended with much pain from 
the contracting of the inflamed walls, is usually followed by relief of all the 
constitutional symptoms; the pulse rises, the tongue cleans, the appetite 
returns, and a visible and immediate amendment takes place. If, however, 
the patient has been exhausted by his sufferings in the earlier stages of the 
disease, the relief afforded is but transient, the pus degenerates into sanies, or 
is altogether suppressed, the fever changes its type, and the patient sinks, too 
enfeebled to establish the reparatory process. 
II. Typhoid Fever.-The type of fever during inflammation, known by this 
name, is asthenic or adynamic. Feeble and more feeble the patient becomes ; 
the pulse sinks ; there is great impairment of the heart's action, and tendency 
to collapse ; the features become pinched, shrunken, damp, and ghastly ; and 
the skin is covered with a cold and clammy perspiration. Sometimes these 
adynamic characters may pass into that typhoid state in which nervous symp- 
toms, such as delirium, somnolence, and tremors prevail. These characters 
are known as nervous or ataxic. The tongue becomes dry, black, and tremu- 
lous, sordes cover the teeth, and harden on the lips and angles of the mouth. 
Low muttering delirium, stupor, or coma prevail; tremors affect the volun- 
tary muscles, and the faeces and urine pass unnoticed. This form of fever sets 
in as a consequence of some untoward or unhealthy tendency of the inflamma- 
tory process, such as when mortification of the part occurs. Any cause, how- 
ever, by which the system becomes extensively vitiated, will bring about this 
form of fever. It is not necessary that the part should die. Putrescence of 
the infiltrated exudations in the inflamed part poison the fluids circulating 
amongst them, and so, by absorption, may induce the typhoid state. If this 
happens with an internal organ, the event is generally indicated by a sudden 
cessation of all pain, at which the patient often appears very happy, and even 
joyous, while to the experienced physician its sudden cessation is assuredly an 
evil omen (Watson). The most important vital functions are deeply im- 
paired by a prolonged existence of this type of fever. It tends to death by a 
complete sinking of the circulation, and diminution and loss of animal heat; 
or deepening stupor, with oppressed respiration, supervenes ; or the patient dies 
by a combination of both conditions,-asthenia and coma. 
These are two distinct types or forms of fever, one or other of which is sure 
to be associated with inflammation. 
Causes of Inflammation.-These have been described by Mr. Simon as : 
(1.) Determining or exciting causes, arising from several sources, and hav- 
ing different modes of operation. 
(2.) Predisposing causes or influences. Inflammation does not take place 
without an irritating stimulus; irritation being the starting-point in every 
form of inflammation. The determining causes of irritation, classified accord- 
ing to the source whence they come, are: 
1. Acts of mechanical and chemical violence inflicted from without-e. g., cuts, 
stabs, bruises, lacerations, abrasions, fractures, dislocations, burns, the action 
of caustics, or other chemical agents. 
2. Lodgment of matters foreign to the tissue-e. g., splinters, bullets, morbid 
products, retained excreta-becoming irritant to parts and cavities containing 
them; a bladder imperfectly relieved of urine-as in chronic paralysis; re- DEFINITION OF ULCERATIVE INFLAMMATION. 
91 
tained and decomposing excrement in balls or knobs (scybalce), irritating the 
mucous membrane of the colon; concretions of blood-as in retro-uterine or 
pelvic hmmatocele; masses of tubercle; dead tissue; a dislocated crystalline 
lens; a sequestrum of dead bone: all tend by contact, as foreign bodies, to 
provoke inflammation within a certain radius of their influence. 
3. An altered state of the local nerves, as when injuries or diseases of the oph- 
thalmic division of the fifth nerve lead to injection and inflammation of the 
conjunctiva, clouding and ulceration of the cornea, final destruction of the 
globe of the eye, and sometimes to ulceration of neighboring integument. 
Similarly, lesions of the pneumogastric nerve may induce pneumonia. 
In explanation of how the nerve-influence acts, there are some grounds for 
belief that certain portions of the nerve cords consist of centrifugal fibres ex- 
ercising a special " trophic" function; and that it is probable they may be 
subject to some reflex action, as when a carious tooth produces superficial 
sloughing of the cheek, or ulceration of the neck (Salter, in Guy's Hospital 
Reports, vol. xiii, third series. Simon). 
4. Abnormal 'properties of the circulating blood, such as deficiencies in its 
constitution, or from being charged with some specific irritant. The 11 poor 
blood" of persons who are ill-nourished is popularly believed to be a source of 
inflammation. The tissues are badly nourished, so that wounds or injuries on 
them tend to inflame and fester, rather than to heal, and that out of proportion 
to their injury or hurt. Privation of food is therefore an active determining 
cause of inflammation ; leading, most probably, to a certain quantity of tex- 
tural death as the direct result of the privation. 
The action of specific irritants with which blood may be charged, and 
which lead to inflammation, may be exemplified in the fact, that arsenic ap- 
plied to an external sore produces its characteristic inflammation on the mu- 
cous membrane of the stomach, just as efficiently as if it had been swallowed. 
So will the application of a cantharides blister produce strangury. From 
the contact of blood thus poisoned, the stomach or the kidneys inflame; and 
so also serous inflammations flow from blood in Bright's disease, being poi- 
soned with the elements of uneliminated urine, acting as an irritant to the 
serous membranes. 
5. Direct contagion causes inflammation, as when the material secretion from 
a vaccine vesicle or a primary syphilitic sore, or from small-pox, is inserted 
into the skin by a scratch, and produces a train of inflammatory phenomena 
peculiar to each kind of inoculation. Also, when gonorrhoeal pus comes into 
contact with a healthy urethra, inflammation, with a flow of similar specific 
pus, forthwith commences. 
The predisposing causes of inflammation are certain influences which 
co-operate with the determining causes. They embrace those influences which 
make one man at one time apter than another to initiate an inflammatory 
disease, or special forms or varieties of inflammation. Examples of such 
influences, Simon states, are to be found in chronic inanition, exhaustive 
diseases of old age, local disease of arteries, local obstruction of veins, local 
defects of innervation, previous inflammation in a part, overfeeding of the 
body, overstimulation from alcoholic drinks, ingestion, by breathing or other- 
wise decomposing organic matters, climatic influences, such as heat. 
ULCERATIVE INFLAMMATION. 
Latin Eq., Inflammatio Exulcerans; French Eq, I. Ulcerative; German Eq., 
Geschwlirige Entzlindung; Italian Eq , Infiammazione Ulcerosa. 
Definition-A form of inflammation which, eventually approaching a cuta- 
neous or mucous surface, induces a breaking up of the surface, and the formation 
of what is termed an ulcer. 92 
TOPICS RELATIVE TO PATHOLOGY. 
Pathology,-When the process of inflammation takes place beneath a sur- 
face, eventually that surface gives way, or is directly transformed into a soft 
diffluent mass. A mode of suppuration or pus-formation is thus established, 
and granulations appear. These consist of a tissue, where, in a small quantity 
of soft intercellular substance, round cell-elements are imbedded, proportionate 
in quantity to the proliferation of the granulations. The nearer the surface 
is approached, the more do the cells present divisions in their nuclei, which, 
in the deeper parts, were mostly uni-nucleated before; and quite on the sur- 
face they cannot be distinguished from pus-corpuscles. If this mode of growth 
or proliferation continues abundant, the mass keeps constantly breaking up, 
the cells pour themselves out upon the surface, and a destruction takes place, 
which, making deeper and deeper inroads into the tissue, throws up more and 
more of its cells and debris upon the surface. Thus an open condition of the 
surface is brought about, to which the name of an ulcer is given. The term 
ulceration is now being restricted so as to express the removal of the superfi- 
cial or exposed particles of inflamed parts; but when epithelium or epidermis 
of an inflamed part is alone removed, and none of the vascular or proper tissue 
beneath it, then the result is a mere "abrasion" or "excoriation" (Paget). 
Three processes thus progress simultaneously in order to effect ulceration, 
namely : (1.) An exudation of inflammatory lymph and serum surrounds the 
mass of young cells, which constantly continue to grow and to break up (pro- 
liferation). (2.) Cells are thus continually growing on the surface, to be car- 
ried off by a fresh exudation. (3.) Liquefaction of the gelatinous interstitial 
material supervenes, and so destruction of tissue takes place continuously. 
Thus ulceration advances. 
Ulcerative inflammation is thus always attended by a loss of substance, a 
destruction of parts, and a more or less abundant secretion of a puriform, 
ichorous, fetid, sanious, or an otherwise variously-colored fluid; but in the 
midst of this destruction and death of parts, the growth of granulations may 
eventually predominate as inflammation subsides. Thus the ulcer heals by 
granulation. 
Granulation, therefore, is one of the modes in which a wound, or sore, or a 
part previously acutely inflamed, may heal. It is then said to do so by 
"second intention," and is always a reparative process. Granulation may 
occur with or without suppuration. The first mode is extremely common. 
The latter is occasionally seen in the healing of syphilitic maculse and ulcers 
of the cornea; and Mr. Hunter conceives he once met with it in the union of 
a broken thigh-bone. 
Granulation is associated with an exudation of inflammatory lymph, into 
which old vessels extend, and new ones are formed. A new surface thus 
results, which is " granular "-the granule or granulation being a small coni- 
cal tumor or growth, composed of a mesh of terminal loops, formed by capil- 
lary vessels shooting into the effused lymph. The figure and color of the 
granulation are determined by the state of the circulation ; when that is feeble 
and inclined to stagnate, the granulation is broad, flat, and spongy, and either 
pale or of a livid hue ; when, on the contrary, it is vigorous, the granulation is 
conical or acuminated, and of a bright-red tint (Travers). The vessels pro- 
longed into the granulation are more or less tortuous, and so numerous as to 
require a high magnifying power to exhibit their distinctness after successful 
injection. These vessels become contracted to obliteration as the period of 
cicatrization approaches. Granulation may take place from a surface, or from 
the sides of an abscess. If from the cutaneous tissue, the sore heals by a pro- 
cess of skinning; the skin always springing from the edges of the wound. 
Again, if granulations spring from the walls of an abscess, their opposite sur- 
faces may unite. Granulations sometimes form with great rapidity. Mr. 
Hunter has seen, after trephining a patient, the dura mater strongly united 
to the scalp in twenty-four hours. Granulations, however, have not in all SITES OF ULCERATIVE INFLAMMATION. 
93 
cases an equal disposition to unite. Thus the granulations of fistulous ab- 
scesses are little prone to adhere, their surfaces being often as difficult to unite 
as those of a mucous membrane; indeed, it is often impossible to produce ad- 
hesion except by exciting a considerable inflammation. A part having healed 
by granulation, uniformly contracts. This contractile force is so great, that 
although the sore made by the amputation of a thigh is seldom less than seven 
or eight inches in diameter, yet the cicatrix left on healing is hardly more 
than an inch or an inch and a half. From this cause we find, in parts that 
have been the seat of abscess, a marked depression at the point of cicatri- 
zation. 
The reproductive energy of parts which heal by granulation, however, is not 
great. It is rare that the original tissue is perfectly reproduced. No fat, for 
instance, is regenerated in ulcerated adipose tissues; a muscle being divided, 
unites by a cicatrix of connective tissue, no muscular fibre being reproduced ; 
and a divided cartilage unites by tough fibrous tissue, but not by a cartilagi- 
nous bond of union. The skin, when destroyed, may be reproduced, especially 
by the method of grafting or transplantation of germs of the rete mucosum, as a 
good imitation. After small-pox, the rete mucosum is either slow in forming 
or never forms at all, so that the cicatrix or pit remains whiter than natural. 
Neither the smooth muscular fibres, nor any of the glandular structures of the 
skin, are formed in its scars ; but its fibro-areolar and elastic tissues, its papil- 
lae, and epidermis, are all well formed in them. The reparation of the mucous 
membrane is equally imperfect, the villi being always wanting. The repara- 
tion of a flat bone, such as the cranium, is so slow, that ten, twenty, and even 
fifty years pass away before a small trephine hole is filled up with bony mat- 
ter. In like manner a healed cavity of the lungs is always marked by a cica- 
trix of areolar tissue altogether different from the original structure; neither, 
as far as we know, is the proper tissue of the liver, of the spleen, or of the kid- 
ney, restored. A nerve simply divided is united by nervous matter in about 
twelve months or more; and the union is quicker and better in all tissues if 
air is excluded from the healing of the part. 
It is a rule of all cicatrices that the newly-formed part is harder and of 
greater density than the original structure. Muscle, for instance, unites by 
coarse, dense, connective tissue; tendon most frequently by a harder and less 
pliant, but not tougher tissue, and sometimes by bone; and. bone after a frac- 
ture is a more compact substance, and contains more phosphate of lime than 
before the accident; but, notwithstanding this addition, the new bond of 
union is not so strong, nor the living actions so energetic, as in the original 
structure. For when the constitution becomes enfeebled by severe disease, of 
a scorbutic kind especially, an old sore has been known to open, and the ends 
of a once-broken bone again to separate. It is equally a rule that a part 
having been once inflamed, the liability of the part to that form of inflamma- 
tion is greatly increased; and also, when new membranes or tissues have 
formed, that these tissues are infinitely more prone to disease than the original 
membrane. 
The sites of ulcerative inflammation with which the physician has most 
frequently to contend, besides the skin, are especially the cervix uteri, duode- 
num, larynx, pharynx, oesophagus, stomach, intestines, bladder. The form 
and mode of ulceration in each of these parts is peculiarly influenced by the 
anatomical nature of the textures implicated. Sometimes a distinct and 
limited slough is first cast off and leaves the ulceration beneath-sloughing 
ulcers-as in those of dysentery, where the smallest and most superficial 
ulcers of the gut are preceded by the death and detachment of portions of the 
mucous membrane, with its epithelial investment (Baly). 94 
TOPICS RELATIVE TO PATHOLOGY. 
SUPPURATIVE INFLAMMATION. 
Latin Eq., Inflammatio Suppurans; French Eq., I. Suppurative; German Eq., 
Eiterige Entziindung; Italian Eq , Inflammazione Purulenta. 
Definition.-A form of inflammation, resulting in the formation of pus. 
Pathology.-One of the most frequent and important results of inflamma- 
tion is the formation of pus by the growth of pus-cells. If a phlegmon or 
boil be observed, when it is a firm, hard, aud solid mass of texture and exu- 
dation, we may feel in a few days that the solid mass has become fluid, and 
that it has not increased in bulk. The solidity and hardness are due to the 
inflammatory changes and effusion, the softening is due to the growth of pus- 
cells developed from the germinal elements of surrounding tissue (Virchow, 
Beale). So it is with the cells of vesicular eruptions which become pustular. 
The new cells there also become pus-cells-a change which may be accom- 
plished in twelve hours, or sooner (Paget). The following circumstances 
point to the development of pus from pre-existing germinal matter, namely, 
that,-(1.) A preliminary lymph-cell cannot always be discerned; (2.) The 
modification of the suppurative process, which occurs in the inflammation of 
mucous surfaces, where the formation of pus seems at once to take the place 
of the natural cell-growth, without any apparent distinction or alteration of 
the membranes of the mucous cells, corresponding in this instance to the most 
simple idea one can have of what Virchow terms parenchymatous inflammation, 
as described at p. 79. Ultimately the natural mucous secretion undergoes a 
change. The characteristic cells on its surface drop off in all stages of abor- 
tion. Impaired cohesion of parts results,-an invariable expression of the 
inflammatory tendency. The epithelial covering becomes less characteristic, 
and gradually declines to small and simple cells, mingled with many pri- 
mordial cells, which appear to have been hurried from the surface before 
they had time to undergo their legitimate development into the perfect 
mucous cells. From this sketch of what occurs, "it will be obvious," as Mr. 
Simon writes, "that the anatomical distinction between pus and mucus must 
be as useless as the so-called chemical tests. Infinite gradations between the 
two destroy all practical value in such criteria. Mucus, as a. copious fluid 
secretion, has no existence in health : the only natural secretion of a mucous 
membrane is its epithelium, which ought not to exist in quantity sufficient 
for any evident discharge. If the secretion be hurried, as in catarrh, it im- 
mediately begins to assume the forms and physical characters of pus, even to 
the splitting of its nuclei with acetic acid." In short, the essential process of 
inflammation has been established in the very cell itself, by the abnormal nutri- 
tive morphological relations which take place between it and the blood in the 
processes of life. 
Inflammations of mucous membrane with a mtidnous exudation (quite as 
characteristic of inflammation as fibrinous exudations) appertain to certain 
organs, e. g., the gastric catarrhal inflammations. Such mucus is loaded 
with mucin, as a characteristic product of the inflamed mucous membrane, 
and which gives the tenacious, stringy character to the discharge. 
Between healthy pus and healthy mucus there can thus be no confusion; 
but there are conditions between the two which yield neither "praiseworthy" 
pus nor healthy mucus. 
Formation of Pus-Suppuration.-Well-formed, perfectly elaborated pus 
is a smooth, viscid, yellowish or cream-colored fluid, specifically heavier than 
water, averaging generally about 1.030, having little or no smell, and of an 
alkaline reaction. Microscopically, it is seen to be composed of certain essen- 
tial constituents-namely, the pus-cell, and often minute clear particles, which 
seem to have some relation to the pus-cells as rudiments or nuclei of them. FORMATION OF PUS. 
95 
These constituents float in a fluid or serum called the liquor puris. Thepus- 
cells are about y^yth to ^Jogth of an inch in diameter, pellucid, filled with 
semifluid albuminous contents, and sometimes containing a few minute oil- 
globules, which give the cells a granular appearance. Their shape appears 
to depend upon the density of the liquor puris. Sometimes a distinct, circular, 
dark-edged nucleus may be seen in the paler corpuscles, and sometimes two, 
or even three particles, like a divided nucleus. The minute clear particles 
often seen are not more than of an inch in size. Such are the com- 
ponents of good, healthy, or praiseworthy pus-the pus laudabile of the older 
authors-literally, the pus to be commended, as showing a benign form of in- 
flammation, indicating that the process, though a morbid one-a disease-is 
going on regularly, and promises a fortunate, issue (Watson). It is the lauda- 
ble pus of surgical writers. When, however, the process deviates from the 
state of health-deviates from the usual and regular course of the morbid 
action in a person otherwise healthy-then we find not only variations in the 
pus-cells, but multiform mixtures of withered cells appear, with molecular and 
fatty matter, escaped and shrivelled nuclei, blood-corpuscles, and fragments 
of granular matter like shreds of fibrin. The liquor puris becomes unduly 
liquid, and the pus is then said to be watery or ichorous. It may even, in weak 
and tuberculous patients, consist chiefly of a thin serum, mixed with flakes or 
curdled, when it has been called serous pus. When the coloring matter of 
blood is mixed with it, it is called sanious pus. Chemical or vital changes of 
various kinds bring about a peculiar decomposition in pus while yet in contact 
with living parts, although it is probable that atmospheric air, or gases from 
an internal cavity, may have to do with the change; but hydrosulphate of 
ammonia is frequently developed, especially in abscesses about the alimentary 
canal, near the tonsils or the rectum. The stench is then most offensive when 
the fluid is set free. Pus, besides possessing certain chemical properties, may 
possess certain specific properties: thus, it may be impregnated with certain 
poisons, as that of syphilis, or of small-pox; it is also often, in certain consti- 
tutional states, loaded with foreign matters, such as urate of soda. 
The formation of pus is termed suppuration. It takes place under three 
conditions, namely,-(1.) Circumscribed ; (2.) Diffused; and, (3.) Superficial. 
As examples of the circumscribed formation of pus, may be mentioned an 
abscess, a boil, or phlegmon, in which the suppuration is inclosed within a 
cavity whose walls are composed of connective areolar tissue, and into which 
interstitial exudation of inflammatory lymph and serum has extended over a 
certain area. It happens that while the central portion of an area has become 
purulent (i. e., has. produced pus-cells as a result of the continuous premature 
proliferation of tissue), the peripheral part has maintained its firmness and 
solidity by activity of nuclear growth ; and sometimes a " thin, opaque, yellow- 
ish-white layer, easily detached," separates the suppuration area from the 
denser part. This has been called a "pyogenic membrane," from the supposi- 
tion that its function is to secrete the pus, whereas the nuclei and cells of the 
denser part are growing by continuous but premature development into pus- 
cells. Abscesses are sometimes formed without any of the usual accompany- 
ing signs of inflammation being present. They are generally slowly formed, 
and are named old or chronic abscesses. When suppuration happens in the 
natural cavities of the body, it is still circumscribed by the cavity. It is not 
then, however, called an abscess, but a purulent effusion into the cavity. 
Diffuse suppuration is exemplified in phlegmonous erysipelas, or the purulent 
infiltration of an organ. In such cases the inflammation extends through a 
wide extent of tissue, and from first to last the boundaries are ill-defined. 
The growth of pus-cells is distinctly interstitial. They are generally rapidly 
formed, and the tissue becomes thoroughly infiltrated, as if soaked in pus. 
The usual want of cohesion in the elements of tissue involved in inflammation 
prevails from the first, and ultimately large sloughs, or death of portions of 96 
TOPICS RELATIVE TO PATHOLOGY. 
texture, may take place. In some textures of a loose kind it is believed that 
the pus may spread about or infiltrate parts by its own gravity, thereby lead- 
ing to secondary destruction of tissue and the formation of what are called 
sinuses. 
The incipient progress of diffuse suppuration is probably not dissimilar to 
that of a phlegmonous abscess, but the inflammation is generally of a different 
type, and all the processes are less complete ; thus, no fibrinous lymph circum- 
scribes the limits of the abscess, nor does any membrane form to limit the pus. 
The process of suppuration is less perfect, so that the abscess often contains 
shreds, or even large portions of mortified and loose connective tissue. The 
pus is less healthy, is thinner, containing a larger portion of serum, and often- 
times portions of loose fibrinous lymph. The pointing of this form of abscess 
differs also from that of the phlegmonous abscess, for the pus readily passes 
from its original seat, by infiltration, and gravitating towards the most depend- 
ing position, presents a soft, broad surface, without any indications of pointing. 
Such collections of matter are always of greater extent than phlegmonous 
abscesses, for the free transmission of pus from part to part occasions a great 
extension of the original disease. When these diffused abscesses open, the 
phenomena which result depend very much on the nature of the opening, and 
how it has been effected. "I have seen," says Mr. Hunter, "large lumbar 
abscesses open of themselves on the lower part of the loins, which have dis- 
charged a large quantity of matter, then close up, then open anew, and so go 
on for months, without giving rise to any disturbance; but when opened, so 
as to give a free discharge to the matter, inflammation has immediately suc- 
ceeded, fever has come on, and, from the situation of the inflamed part, as 
well as from the extent of the lesion, death in a very few days has been the 
consequence." The same result has also occurred from liberating collections 
of the diffuse suppurative process in other parts. In erysipelas, however, 
which so often gives rise to this form of abscess, a free opening is often neces- 
sary, to allow of the escape of the portions of loose areolar tissue they contain. 
Superficial suppuration may be observed in gonorrhoea, purulent ophthalmia, 
and generally in inflammation of mucous and cutaneous surfaces. There the 
growth of pus can be clearly traced where stratified, as well as columnar, 
epithelium naturally exists. Upon the skin the development of pus may be 
seen to proceed from the rete Malpighii, as a growth by continuous premature 
development of cells from this part of the young cuticle. In proportion as 
these young cells give birth to younger germs (proliferate), a separation of 
the harder layer of epidermis ensues, and a vesicle or pustule is the result. 
The exact spot where the growth of pus occurs corresponds to what would be 
the superficial layer of the rete Malpighii; and if the membrane of the vesicle 
be stripped off, the cells of the rete, in process of conversion into pus, in place 
of epithelium, will adhere to the epidermis, and be stripped off' with it (Vir- 
chow). In the deeper layers the cell-elements, which originally have only 
single nuclei (centres of nutrition, growing or germinal centres), divide, so 
that their nuclei (or centres of growth) become more abundant. Single cells 
have their places taken by several, which in their turn again provide them- 
selves with dividing nuclei, and so the process of multiplication goes on. 
Dr. D. R. Haldane, of Edinburgh, has observed and recorded the contin- 
uous development of pus-cells from the cylindrical .variety of epithelium. In 
a case of small-pox he found the larynx and trachea coated over with a soft, 
dirty-looking deposit, which was found to consist of pus-cells. On gently 
scraping the surface, the cells were found enlarged, and, in place of contain- 
ing a single nucleus, each contained several-three, four, or more. These 
were derived from the proliferation of the original nucleus. External to the 
cells were young ones in all stages of development (Edinburgh Medical Journal, 
Nov., 1862, p. 439). 
The more completely the epithelium is of the stratified kind, the less is the GROWTH OF PUS-CELLS. 
97 
surface liable to ulceration (e. g., the urethra in gonorrhoea); but those mucous 
surfaces where the epithelium is of the cylindrical form scarcely ever produce 
pus without ulceration (e. g., the intestines). Pus-cells, mucous cells, and 
epithelial cells are now regarded pathologically as equivalent elements, which 
may replace one another; but physiologically they are not equivalent ele- 
ments, inasmuch as they cannot perform each other's functions. Deeply seated 
pus-formation may proceed from connective tissue, or from the nuclei of vessels 
or sheaths of tissue. An enlargement of the connective tissue germs occurs 
(Otto Weber), which divide and subdivide, and so multiply excessively by 
divisions of the larger germinal masses or cells. Round about the irritated 
or inflamed parts, where single cells lay, masses or groups of cells are formed, 
a large new formation grows, and towards the interior of this growth heaps 
of little cells accumulate. These little accumulations occur at first as diffuse 
"infiltrations" of roundish masses, encircled by an intermediate growth, which 
continually liquefies as proliferation of the cells extends. Virchow regards 
this liquefaction as of a chemical nature; the intermediate substance (which 
yields gelatine), becomes transformed into mucus, and being ultimately con- 
verted into an albuminous fluid, is thus rendered liquid. Thus two different 
modes of pus-formation are distinguished, according as (1) the growth of the 
pus-cells proceeds from the germs of superficial tissue, like epithelium, or (2) 
from connective tissue; and two forms of inflammation can in like manner be 
separated from each other, namely: (1.) The parenchymatous inflammation 
(p. 78, ante), where the process runs its course in the interior of the tissue- 
elements (e. g., connective tissue cells or germ masses, hepatic cells), without 
our being able to detect the presence of any free fluid which has escaped 
from the blood, but where softening and fluidity are due to the process above 
described. (2.) The secretory (exudative) inflammation of superficial tissue- 
elements, where an increased escape of fluid takes place from the blood, and 
conveys the new products of growth and altered secretion along with it to the 
surface. 
The parenchymatous inflammation has from its outset a tendency to alter the 
elements of tissue and their special functions. Whereas the secretory inflam- 
mation, with a free exudation, in general affords a certain degree of relief to 
the part. Witness the relief which follows the free flow of mucus in catarrh. 
It conveys away a great mass of noxious matter, and the part appears to 
suffer much less than a part which is the seat of a purely parenchymatous in- 
flammation. In gonorrhoea, also, we have an example of how the pus result- 
ing from the secretory form of inflammation is carried away by that trans- 
udation of fluid (exudation) which removes the pus-cells from the surface, 
without the slightest appearance of ulceration (Virchow). 
The description here given regarding the formation of pus is based on the 
great fact, demonstrated originally by Goodsir, that all new cells proceed 
from "centres of nutrition," from other cells, or from the nuclei of them; 
and, as Dr. Haldane justly observes, "We must not expect to be able, in the 
case of every abscess or purulent discharge, to trace thus distinctly (as has 
been done in the preceding paragraphs) the origin of the pus-cells. There is 
only a certain stage in pathological as in physiological growth in which the 
actual mode of development can be followed. We might as well expect to 
be able to discover, by an examination of the mature foetus, the different steps 
by which its organs had been formed, as to be able, in a ripe abscess, to deter- 
mine in what way normal had been converted into abnormal tissues." 
There are especially three events which, with more or less frequency, accom- 
pany or follow inflammation in a part. These are softening, ulceration, and 
mortification. 
Softening, or diminished cohesion of tissue, is an almost constant result. 
It may be due not merely to mechanical separation by infiltration of the 
component elements of tissue, but to a loss of the vital cohesive properties, 98 
TOPICS RELATIVE TO PATHOLOGY. 
and impaired function of the tissues themselves, which tend towards their 
liquefaction and degeneration. Examples of this may be seen in the inflam- 
mation upon mucous surfaces already referred to, also in the inflammatory 
red softening of the brain and spinal cord, and in the lungs, where a peculiar 
brittleness and rottenness is imparted to their fibrous substance or skeleton 
texture. Such softening is due to vital changes in the proper tissue, often 
independent of any interstitial infiltration. The most remarkable example 
of inflammatory softening is that which occurs in bones. An acutely inflamed 
bone is so soft that it may be cut with a knife (Stanley, Paget). 
But while some parts are softened, others are removed altogether by the 
process of interstitial absorption, as it has been termed. This phenomenon is 
best seen in bones which have been inflamed. Such absorption gradually 
precedes the extension of the inflammatory process, and leads, in the case of 
abscesses, to their spontaneous evacuation, commonly called the "pointing of 
an abscess." The inflammation continues, and the growth of pus moves along 
in a definite direction, towards the cutaneous or mucous surfaces of the body 
in its vicinity ; but as the integuments are generally the more prone to inflam- 
mation, it is probable that they thus become soft, and yield sooner than the 
mucous surfaces do. 
Hectic Fever.-If suppuration continues beyond the powers of the consti- 
tution to supply the process with material to form inflammatory lymph and 
pus-if the inflammation continues, and becomes chronic as to time, inflam- 
matory lymph continuing to be exuded, and pus continuing to form in profuse 
quantity, especially if an internal organ is its site-a characteristic type of 
febrile symptoms is apt to supervene, constituting hectic fever. 
It is not to be supposed, however, as was once believed and taught, that 
hectic fever is due in every case, to the continued formation of pus. There are 
forms of hectic fever unconnected with suppuration anywhere, but associated 
with some analogous wasting of the bodily substance; for example, a pro- 
longed secretion of milk in mothers who suckle their infants beyond the natural 
period. In all cases where a drain upon the system is established beyond its 
means, such a complex morbid condition of the body as hectic fever may be 
thus induced, and the mischief may not be revealed by any other symptoms. 
This type of fever is particularly distinguished from the inflammatory and 
typhoid forms of fever (described at pp. 88 and 90), by its remarkable inter- 
missions, which are usually periodical; a period of remission and a period of 
exacerbation occurring once, and sometimes twice, in the twenty-four hours. 
It is also characterized by an excessive waste of the tissues of the body; and 
the sweating which attends the paroxysms causes great exhaustion. The 
assimilative and nervous functions are comparatively unimpaired, so that it is 
a febrile condition generally of very long continuance. The mind. remains 
perfectly clear-often vigorous and active-even when the body is debilitated; 
and if the intervals between the paroxysms are tolerably free from febrile ex- 
citements, the hectic type of fever may be protracted much beyond what at first 
sight might appear credible. Thus it is sometimes within our power to alle- 
viate greatly this condition. If, however, the fever does not abate during the 
remissions of the excessive paroxysms, when sweating continues profuse, and 
when suppuration or other wasting discharge is excessive, the fatal termina- 
tion approaches rapidly. 
The leading symptoms of this form of fever have been watched and de- 
scribed minutely by many observers, non-professional as well as professional. 
The fever creeps on insidiously, and almost imperceptibly ; and the physician 
is at first led to suspect its existence only by a very slightly increased fre- 
quency of pulse, and a small degree of heat of skin, occurring generally towards 
evening, and subsiding before the beginning of the next day. The pulse is 
subject to temporary quick excitement from slight causes, such as by exertion, 
by emotion, or by food, as after meals. The heat is especially felt in the palms THE HECTIC TYPE OF FEVER. 
99 
of the hands and soles of the feet. The excitement of the pulse gradually 
begins to be more and more easily induced throughout the day, daily loses in 
power and increases in frequency; and towards evening the general exacer- 
bation of the febrile state becomes regular, and is unmistakable. Periodic 
exacerbations or febrile paroxysms occur almost invariably towards evening, 
and remissions now become distinctly marked. The exacerbation reaches its 
height about midnight, and terminates by a profuse perspiration or sweating 
stage towards the morning. This sweating is sometimes called colliquative, 
and may be replaced or accompanied by diarrhoea. Occasionally a second 
paroxysm occurs in the morning after breakfast (Wood), or at noon, as de- 
scribed by Cullen; and as a midday meal was common in his day, it is prob- 
able that these slighter paroxysms may be attributed to such causes as the 
simple taking of food. Generally, however, in the earlier periods of this type 
of fever, the interval from morning till towards the afternoon and evening is 
free from fever; but in the advanced stage the fever becomes nearly constant, 
while the evening exacerbations and the morning sweats remain character- 
istic to the end. The following diagran shows records of temperature in a 
case of suppuration of knee-joint and abscesses in kidney, described by Mr. 
John Croft (Holmes's System of Surgery, vol. i, p. 288). The pulse of the 
hectic patient is scarcely ever so hard and full as the pulse in inflammatory 
fever; nor is it so soft and compressible as the pulse of the typhoid patient. 
It expresses a middle condition between the two, of very variable character, 
both as to quickness and strength, according to the degree of exhaustion of 
the patient and the amount of febrile reaction. Often during the paroxysm, 
or during temporary excitement from slight causes, it reaches 120 beats in the 
minute, the beat being performed with a jerk, as if the result of irritation upon 
a weakened heart (Wood). 
The heat of skin during the paroxysm is often considerable, and always 
distressing, so that little more than the slightest covering can be endured. 
The respirations are quick and short. The appearance of the face is so char- 
acteristic by its florid circumscribed suffusion, that this hectic flush of the 
cheek, limited to a spot in its centre, is now well known. The delicate 
bright-red color and circumscribed form of the flushed spot contrast strongly 
and often beautifully with the pale cheek, and the bright and sparkling eye, 
with its sclerotic of pearly whiteness. The surface of the skin is harsh and 
dry, and towards the close of life the region of the ankles is apt to become 
oedematous. The patient loses flesh rapidly, and as death approaches he 
becomes exceedingly emaciated. It is then that diarrhoea is apt to super- 
vene, and to aggravate the sweating, so as completely to exhaust the remain- 
ing strength. The mind, unclouded before, gently wanders now, and the 
functions of life cease, generally without a struggle. It is often one of the 
closing symptoms, most strongly marked, in pulmonary consumption; and 
the non-professional pen of the great novelist, Charles Dickens, has beauti- 
fully portrayed its more striking features in the death of Smike: 
" But there were times, and often too, when the sunken eye was too bright, 
the hollow cheek too flushed, the breath too thick and heavy in its course, the 
frame too feeble and exhausted, to escape their regard and notice. There is 
a dread disease which so prepares its victims, as it were, for death; which so 
refines it of its grosser aspect, and throws around familiar looks unearthly 
indications of the coming change,-a dread disease, in which the struggle 
between soul and body is so gradual, quiet, and solemn, and the result so 
sure, that day by day and grain by grain the mortal part wastes and withers 
away, so that the spirit grows light and sanguine with its lightening load; 
and feeling immortality at hand, deems it but a new term of mortal life,-a 
disease in which death and life are so strangely blended that death takes the 
glow and hue of life, and life the gaunt and grisly form of death." 100 
TOPICS RELATIVE TO PATHOLOGY. 
Line 
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Days of 
Disease 
Feb. 
IS 
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Fig. 3.-DIAGRAM SHOWING RECORDS OF TEMPERATURE IN A CASE OF HECTIC FEVER ('Croft') CHANGES IN THE ELEMENTS OF LYMPH. 
101 
PLASTIC INFLAMMATION. 
Definition.-A form of inflammation in which the material produced not only 
tends to solidify as fibrin, but is loaded with elementary colorless corpuscles; and 
is, for the most part, peculiar to serous surfaces, to the cut-surfaces of wounds, and 
flaps of amputated parts. 
Pathology.-In the early stages of inflammation of a serous membrane, the 
free surface, which ought to be smooth and glistening, becomes covered with 
a soft " lymph," capable of being moulded into form, and hence described as 
plastic. It is seen in most characteristic perfection in some forms of peri- 
carditis. On the free surface of any serous membrane so inflamed the epi- 
thelial cells become swollen, opaque, and loosened. They fall off altogether 
into the cavity of the serous sac. A rapid multiplication of their contained 
nuclei ensues, set free by the breaking down of the inclosing cells. 
Productive changes at the same time occur in the corpuscles of the sub- 
epithelial connective tissue, and groups of rudimentary corpuscles appear, by 
germination from the nucleated protoplasm. Continuing the description, the 
best ever given, in the words of Mr. Paget, it is found that, " as the inflam- 
mation advances, these rudimentary cells multiply with great rapidity, so that 
adjacent groups run together and form masses of immature corpuscles, which 
are so numerous in the focus of the inflammation that the part seems to be 
altogether composed of these new productions, and all trace of its natural 
structure is lost. Not unfrequently the more superficial layers of this corpus- 
cular lymph become detached and fall into the liquid exudation, which is 
formed with more or less abun- 
dance into the serous cavity, where 
they may be mingled with the 
fibrinous coagula which usually 
form in that fluid" (Surgical 
Pathology, p. 247). It is impos- 
sible, without isolation of the 
cells composing the thick layer 
of corpuscular lymph, to recog- 
nize their forms. Towards the 
free surface the cells are usually 
pale round corpuscles, possessing 
a well-marked nucleus, invested 
by soft, faintly granular proto- 
plasm. Beyond these the nuclei 
tend to subdivide, and the cells 
to elongate into fibre-cells. In 
the subepithelial tissue proliferation in the corpuscles of the connective tissue 
goes on with an activity proportionate to the inflammatory action. An en- 
largement first takes place of the single nucleated cells; then the nuclei divide, 
and for some time multiply excessively. These changes are very soon followed 
by divisions of the cells themselves; so that round about the inflamed part, 
where single cells only were found, pairs, or even multiple groups of cells, are 
subsequently found. This process is name proliferation, and is well shown in 
Fig. 4, from an inflamed pleura, but the appearances are similar from below 
any serous surface; or in connective tissue, as in the flap of an amputated 
limb (Virchow, Paget, Turner). 
In addition to this local multiplication of material derived from the elemen- 
tary structures of the part, it is at present a subject of inquiry how far the 
observations of Cohnheim give grounds for belief that much of the purely cor- 
puscular forms on the free and soft parts of the lymph may not have migrated 
from the bloodvessels. 
Fig. 4. 
From inflamed pleura (after Paget and Tuknek). 102 
TOPICS RELATIVE TO PATHOLOGY. 
Examined under the microscope, the lymph of plastic inflammation usually 
possesses two distinct elements-namely, a filamentous basis, composed of 
very delicate threads crossing one another in all directions. Amongst these 
are entangled the cell or corpuscular elements of the lymph. These elements 
are described as plastic-cells, fibre-cells or fibro-cells, caudate or fibro-plastic 
cells; all of which may become so elongated and condensed as to assume the 
appearance of white fibrous tissue. Figs. 5, 6, and 7, after Bennett, show 
nuclei (Fig. 5) in the fibrinous product developing into fibres; fibro-plastic 
cells (Fig. 6) developing into fibres; and into (Fig. 7) white fibrous tissue. 
Fig. 5. 
Fig. 6. 
Fig. 7. 
Nuclei in the fibrinous product, develop- 
ing themselves into fibres (Bennett). 
Fibro-plastic cells developing them- 
selves into fibres (Bennett). 
Perfect white fibrous 
tissue (Bennett). 
Eventually this new matter becomes organized; that is, it becomes supplied 
with blood and bloodvessels, and is vascular in proportion to the amount of 
such supply. New bloodvessels sprout up in loops from the vessels of the 
adjacent texture. When these fibrinous products form on free surfaces like 
the pericardium or peritoneum, or on a mucous surface, as in croup or dysen- 
tery, the film of lymph is usually called a false membrane. 
RHEUMATIC INFLAMMATION. 
Latin Eq., Inflammatio Rheumatica; French Eq., I. Rheumatique; German Eq , 
Rheumatische Entziindung; Italian Eq., Inflanimazione Reumatica. 
Definition.-Inflammation concurrent with an attack of rheumatism; or in a 
person liable to such attacks. 
Pathology.-As the subject of rheumatism will be afterwards fully con- 
sidered, a notice merely of the peculiarities of rheumatic inflammation is all 
that is required here. Certain textures are especially liable to rheumatic 
inflammation-namely, the fibrous tissues of the joints, aponeuroses of muscles, 
sheaths of tendons, neurilemma, periosteum, muscles, and tendons. The in- 
flammation is attended with great pain (but not so great as in gout), and its 
severity is probably owing to the dense and unyielding nature of the textures 
especially implicated, and which are subjected to stretching and pressure in 
their elements by the dilated capillary vessels and local inflammatory oedema. 
Such inflammation is generally held to be rheumatic when these fibrous tissues 
are implicated in an idiopathic way, and independent of any traumatic origin. 
There is also a great tendency for the inflammatory lesion in rheumatism to 
pass from the part first affected to others of analogous structure and function. 
In rheumatic inflammation of joints, the synovial capsule of one or more is 
generally the texture most deeply implicated; but the inflammation seldom 
reaches a great degree. Fluid exudation into the cavity of the joint is not 
apt to be copious, nor fibrinous, nor very purulent. Inflammatory oedema of PATHOLOGY OF GOUTY AND GONORRHIEAL INFLAMMATION. 
103 
the connective tissue round the joint accounts for any visible swelling. A 
predisposition to rheumatic inflammation is certainly inherited, and those who 
have had an attack are very liable to others. Recovery is the usual termi- 
nation, by a gradual and not always regular diminution of symptoms. 
GOUTY INFLAMMATION. 
Latin Eq., Inflammatio Podagra; French Eq., I. Goutteuse; German Eq., Gicht- 
ische. Entziindung; Italian Eq., Inflammazione Gottosa. 
Definition.-A form of inflammation characterized especially by the intensity 
of pain, by oedema of the part, and desquamation of the cuticle when superficial 
structures are attacked; and occurring in those predisposed to gout. 
Pathology.-As the nature of gout will be afterwards fully considered, the 
character of the inflammation attending that general disease alone requires a 
short notice here. The pain of the inflammation is very intense, and differs 
from that produced by injury. The oedema also is peculiar, and may not at 
first be obvious on account of the great tension of parts, when inflammation 
is violent, and the skin is distended and shining. When the inflammation 
begins to subside, pitting is then easily produced, and the presence of fluid 
made evident. In this respect it differs from rheumatic inflammation, in 
which oedema is not local. After complete subsidence of the gouty paroxysm, 
desquamation of the cuticle takes place. It is most usually observed from 
about the feet and hands, and but rarely from the knees; and, according to 
Dr. Garrod, the desquamation seems to bear some relation to the amount of 
the previous oedema, and consequent distension of the skin. Now and then 
the nails have been shed after a severe attack of gout. The presence of much 
excrementitial matter in the blood of gouty people tends to influence the 
products of inflammation; but it is rare indeed that inflammation in gout is 
followed by suppuration, although, at first sight, when the disease is most 
intense, and the part is swollen, red, hot, and tender, suppuration looks as if 
it were inevitable. 
The cases which come to suppuration are those in which the gouty concre- 
tions (of urate of soda), acting as a foreign body, or local irritant, establish 
suppuration. The inflammation of gout is indeed "characterized by an 
explosive local appearance of uric acid; and on consideration of the circum- 
stances under which this explosion occurs, the inference suggests itself, that 
materials transformable into uric acid were previously accumulated in the 
texture which inflames" (Simon). 
Latin Eq , Inflammatio Gonorrho'ica; French Eq.,Z. Blennorrhagique; German Eq., 
Gonorrhoische Entziindung, Tripperartige Entziindung; Italian Eq., Ivflamma- 
zione BlennoVragica. 
GONORRHOEAL INFLAMMATION. 
Definition.-A form of inflammation arising about five days after the direct 
contagion of gonorrhoeal pus within the orifice of the urethra. 
Pathology.-Although the process of inflammation in the mucous mem- 
brane of the urethra, which constitutes a gonorrhoea, is not different from the 
process of inflammation in any other portion of a mucous membrane, and is 
an example of a catarrh, yet as the inflammation is peculiar in being due to 
a specific cause, and gonorrhoea, therefore, is a specific disease, the inflamma- 
tion requires a short notice here. 
The peculiarities of gonorrhoeal inflammation are: 
1. Its cause distinguishes it from all other catarrhs which affect the mucous 104 
TOPICS RELATIVE TO PATHOLOGY. 
membrane of the urethra or of other regions, and the disease never arises 
otherwise than by contagion. 
2. The nature of the specific poison is as little known as that of small-pox, 
or other communicable poison; it is only certain that it produces a specific 
result, invariably the same, case after case. The vims is a something fixed 
and specific, conveyed in the secretion of a diseased mucous membrane, by 
contact with which secretion, in those susceptible of infection, a similar com- 
plaint is transmitted from person to person. 
3. Between the period of contagion and the obvious expression of the dis- 
ease, there is a certain interval-three to eight days-known as the period of 
incubation; earlier or later periods are exceptional. 
4. The susceptibility to gonorrhoeal inflammation varies greatly in different 
persons; and the causes of increased or diminished susceptibility are quite 
unknown. 
5. Certain portions only of mucous membrane seem susceptible of gonor- 
rhoeal inflammation. These are,-the urethra, the female genitals, the con- 
junctiva, and the rectum; all other parts of the mucous membrane remain 
incapable of undergoing the specific inflammation of gonorrhoea. Different 
portions of the urethra also are more susceptible to the influence of the poison 
than others; and although the infecting secretion acts first upon the orifice of 
the urethra, the chief site of the gonorrhoeal inflammation is in the fossa navic- 
ularis. During the first and second week of the disease, the anatomical 
changes are entirely confined to this portion of the urethra, a portion which 
is very vascular, and very richly furnished with glands. Many complica- 
tions may be associated with gonorrhoeal inflammation, all of which will be 
fully noticed when the disease is treated of in a subsequent part of this work. 
GANGRENE. 
Latin Eq., Gangrcena ; French Eq., Gangrene; German Eq., Brand-Syn., Gan- 
gran; Italian Eq., Gangrena. 
Definition.-Incomplete mortification, or death of a portion of a soft organ or 
tissue, while the rest remains alive. 
Pathology.-When complete death of the part is accomplished, the condi- 
tion is termed sphacelus. In the hard parts, as in bones, a somewhat similar 
distinction obtains in using the terms caries and necrosis. Necrcemia means a 
corresponding death of the bloo,d. Particular names are also given to the 
dead parts. A dead piece of tissue is called a slough. A dead piece of bone 
is called a sequestrum. Progressive gangrene of soft parts is usually called 
sloughing. 
Mortification of the soft parts may be white or black in appearance, humid 
or dry. The mortified part has a black aspect when the blood is extravasated 
through the walls of the bloodvessels into the affected tissues, giving to the 
part a purple or dingy hue, while to the touch it is soft, inelastic, and doughy. 
It may appear white, when, by the action of cold, the blood has been driven 
from the part before its death commences, which subsequently freezes per- 
fectly white. 
Humid mortification occurs when the blood transudes in a fluid state, and 
after its exudation separates into its constituent parts, so that the serum, set 
free, dissolves in it the red globules, raises up the cuticle in bladders, and 
forms what are termed " phlyctence." Air, generated by a process of com- 
mencing putrefaction, is not unfrequently contained in the phlyctence, and 
gives, to the finger touching the part, a sensation of crepitation. 
Dry mortification is rare, and has sometimes been caused by the ergot of 
rye, or other diseased grain, used as food, giving rise to the condition known pathology of passive congestion. 
105 
as ergotism. In the year 1716, dry mortification appears to have been to a 
certain extent epidemic at Orleans, fifty cases having been treated at the 
Hotel Dieu of that city. Dodard described it as beginning generally in one 
or both feet, with pain, redness, and a sensation of heat or burning like that 
produced by fire. At the end of some days the part became cold, as black as 
charcoal, and as dry as if it had been passed through fire. Sometimes a line 
of separation was formed between the dead and the living parts, and the com- 
plete separation of the limb was effected by nature alone. In one case the 
thigh separated in this manner from the body at the hip-joint. In other cases 
amputation was necessary. Mr. Solly has given an interesting case of this 
description, which occurred in the practice of Mr. Bayley, of Odiham. The 
patient was a child three years and seven months old, from whom, by this 
spontaneous process of nature, both arms were removed above the elbow, the 
left leg below the middle of the thigh, and the right foot above the ankle- 
joint, being a remarkable instance, in modern times, of this destructive disease 
(see "Ergotism," and Med.-Chir. Trans., vol. xxii, p. 23). 
The bones, the brain, the lungs, the liver, the spleen, and the kidney, are 
all liable to sphacelus and gangrene; so are the different tissues, as the areolar, 
cutaneous, nervous, and serous. The muscles, tendons, aponeuroses, and blood- 
vessels, are likewise all liable, but in a less degree. 
It is necessary to distinguish the incomplete death of soft parts, or gangrene, 
from the condition afterwards to be described as degeneration; and which 
sometimes precedes complete death of the degenerate part. 
The degeneration of a part is to be distinguished from gangrene, or actual 
death, by this,-" that the degenerate part never becomes putrid ; and that 
no process ensues for its separation or isolation, such as we can see in the 
case of a dead part" (Paget). A tissue, however degenerate, remains in con- 
tinuity with the parts around it, or is absorbed. If the tissue were dead, the 
parts surrounding it would separate from it, and the dead portion would be 
ejected from them. 
But there are also some conditions of parts where it is impossible to say 
whether they are dead or alive; a condition which may be termed "suspended 
animation." Thus, the end of a finger, in a case of diseased heart, may be 
cold, livid, insensible, and shrunken for three days; or the foot of an old man 
cold, livid, purple, mottled, and numb for a whole week; and during these 
times it could not be told whether the parts were alive or dead. But, as both 
parts afterwards regained all the signs of life within the days mentioned by 
Mr. Paget, time alone showed that both parts had been in a state of " sus- 
pended animation." In the same way parts that are frozen, as by the mode 
of inducing local anaesthesia by the ether-spray, introduced by Dr. Richard- 
son, ot parts that are crushed or otherwise severely injured, have their "ani- 
mation" or vitality "suspended" for a time. 
PASSIVE CONGESTION. 
Latin Eq., Congest™ Passiva; French Eq., Congestion Passive; German Eq., Passive 
Congestion; Italian Eq., Congestione Passiva. 
Definition.- Overfulness of blood in the capillary vessels of a part; associated 
with impairment of the vital relations between the blood and minute elements of 
the texture, as the cause of the sluggish flow of the blood in the capillaries. 
Pathology.-The term congestion, or hypercemia-meaning, literally, a mere 
excess of blood in a part, or over-bloodedness-has always been regarded as of 
two kinds, namely, active and passive. The former, or active congestion, cannot 
be separated from inflammation of a texture, of which it forms a stage or part 
of the morbid process, as already described, and, in fact, leads up to it; while 106 
TOPICS RELATIVE TO PATHOLOGY. 
the latter, or passive congestion, merely predisposes to inflammation from trifling 
injuries, obstructs recovery, tending to molecular degeneration of tissue, and 
to atrophy; and, further, it leads to dropsy. 
Much confusion exists as to the use and interpretation of the term conges- 
tion; and as no one has put the subject in a clearer light than Professor 
Rokitansky, and also Dr. Moxon, in his very interesting Lectures, at Guy's 
Hospital, on Analytical Pathology, the account here given is based mainly 
on his exposition, in Med. Times and Gazette, July 16, 1870, and that of 
Rokitansky, in vol. i, p. 107. 
The relations between active and passive congestion have been described as 
simply, that, too much blood being brought into a part, active congestion, or 
hypercemia, is established; on the other hand, when too little blood passes out 
of a part in proportion to what passes into it, the state of passive congestion 
is established. But, in the first case, the description falls short of the truth, 
inasmuch as too much blood passes out of the part as well as into it; and the 
congestion is not only active, as regards the flow of blood to the part, but also 
as regards its flow out of it. In the second case, the description of passive con- 
gestion involves two forms of congestion, differing in their causes, and also in 
their results. The causes of one form are purely mechanical, the causes of the 
second are truly passive. 
Examples of purely mechanical congestion are to be studied in the following 
morbid conditions: Narrowing of the mitral orifice of the heart, by the mechan- 
ical stoppage of the blood at the obstructed valve, inducing a very intense 
congestion of the lung. Condensation of the tissue of the lung is the conse- 
quence of the persistence of the mechanical obstruction; and, at last, some of 
the minute vessels of the lung tissue may burst, causing pulmonary apoplexy. 
The results of congestion due to mechanical obstruction of the venous cur- 
rent are,- 
(«.) Distension of the veins behind the obstruction, leading to stretching 
and straining of their walls, and so, apparently, to leakage of serum through 
the distended veins into the tissue, producing oedema in connective tissue, or 
dropsy into serous cavities. Habitual use of a tight garter will occasion such 
results of mechanical congestion of the leg; so will a tumor in the popliteal 
space or the groin, or habitual distension of the lower bowel by feculent 
matter. 
(6.) Effusion of blood, either from rupture of overdistended vessels behind 
the obstruction; or, reasoning from the observations of Addison, Waller, 
Cohnheim, and others, who contend that the blood-corpuscles find their way 
through the tissue of capillary vessels without any rupture of them, those cases 
are capable of explanation where a free and fatal hemorrhage may come from 
the stomachal mucous membrane, without any trace of a ruptured vessel or 
solution of continuity of the mucous surface. 
Examples of effusions of blood from vessels behind the mechanical obstruc- 
tion are to be seen in pulmonary apoplexy, in the free escape of blood into the 
stomach in cases of cirrhosis of the liver obstructing the portal vein, or in cases 
of obstructive heart disease, in the cerebral hemorrhage that results from infan- 
tile convulsions, and in hemorrhage from varicose veins. 
(c.) A thrombus or coagulum of blood may form during life in the obstruct- 
ed vein. Such clots or thrombi are to be found in the portal veins in cases 
of cirrhosis of the liver ; and in the veins of the bend of the thigh, and pros- 
tatic plexus, in cases of cardiac dropsy. These clots begin to form behind 
the valves of the mechanically distended veins, in the stagnant eddies of blood 
which occupy the hollows behind the valves. Portions of clots so formed in 
these veins may break away and pass into the current of the circulation, and 
passing up the veins through the right side of the heart, may lodge in the pul- 
monary artery, and cause either sudden death or pulmonary apoplexy. This 
is one form of thrombosis; and the primary formation of the clot in this RESULTS OF MECHANICAL CONGESTION. 
107 
form is to be distinguished from formation of the clot in veins during life, 
which is due to inflammation of the vein, or close to its wall. Such inflam- 
matory coagula constitute another form of thrombosis. . They form wherever 
veins are subjected to irritation, such as in cerebral sinuses, in cases of trau- 
matic or other inflammation of the cranium, the veins of unhealthy stumps 
after amputation, such clots being sometimes mixed with true pus; and when 
such clots pass into the lung, inflammation of the part of the lung supplied 
by the artery is the result. 
(d.) Gangrene may be a result of mechanical congestion, as in the limbs and 
scrotum, from obstructive disease of the heart, or the too tight bandaging of 
a limb may lead to gangrene of finger or toe. 
These four results of congestion succeed each other as the results of suc- 
cessive increments of mechanical force, and are the natural consequences of 
such mechanical obstruction. 
Passive congestion differs from this mechanical congestion both in its cause 
and in its seat. Severe emphysema of the lungs and chronic bronchitis fur- 
nish examples of passive congestion of different parts of the body. In emphy- 
sema there is a general lividity of the surface-so constant that it constitutes a 
valuable sign in diagnosis between emphysema and heart-disease, especially 
when the presence of a tricuspid murmur in emphysema, or bronchitis in 
mitral disease, makes the one very like the other. In the case of mitral 
disease, there is free entry of plenty of air into the lungs, but there is little 
blood passing through them. The flow through the mitral orifice is a small 
stream; but it is well aerated blood, and as such freely passes through the 
capillary vessels and into the veins, where it begins to meet the first mechan- 
ical impediment to its farther progress, and is detained in the veins, then in 
the right heart, and then in the lungs. These being the parts congested, and 
not the systemic capillary vessels, lividity is generally absent in mitral dis- 
ease. On the other hand, in emphysema of the lungs, the blood circulates 
freely through the lungs; but not so the air. It is with difficulty, and 
in an imperfect way, that air is renewed in the lungs. The blood, therefore, 
is insufficiently aerated, and so passes to the systemic capillaries in an impure 
state, where a true passive congestion is the result. The normal vital relations 
between the impure blood and the minute elements of tissue are impaired, by 
the unfitness of the blood to nourish the textures. Hence the skin becomes 
livid, as the capillaries are gorged with a slowly moving purple current of 
blood. 
Thus the seat and the cause of true passive congestion are different from the 
seat and cause of mechanical congestion. The seat of passive congestion is the 
capillaries of the part, and is largely due to deficient activity in the vital in- 
terchanges between blood and texture of the part. In mechanical obstruc- 
tion, the seat of the congestion is in the veins, and the cause is not vital, but 
mechanical. 
The two forms may be combined in cases of general languid action of the 
heart, where imperfect circulating force is at the same time a mechanical 
obstacle to the current of blood, and congestion is at the same time both pas- 
sive and mechanical. 
Other examples of passive congestion are seen in the blueness of cold hands, 
redness of the extremities, ears, and noses of people with languid, weakly, or 
feeble circulation; in the prolonged redness or lividity of fauces following 
severe tonsillitis; hypostatic hypersemia of the dependent parts of the lungs in 
fever, where the air fails to pass into the air-vesicles during the imperfect 
respiration. .In all these cases the congestion is passive, and secondary to 
local inactivity in the vital changes between the tissue-elements and the 
blood. Rokitansky believes passive congestion to depend upon direct palsy 
of the nervi vasorum, wherewith is commonly associated a depressed energy in 
the remainder of the nervous system. Such palsy may originate in the nerve- 108 
TOPICS RELATIVE TO PATHOLOGY. 
centres, or it may be peripheral, and is often determined by a morbid condi- 
tion of the blood, especially by its decomposition. The passive congestion of 
asthenic inflammation in organs exhausted by excess of functional activity, 
enfeebled by active congestion, or paralyzed-so also hypostatic hypersemia 
of the lungs, abdominal and pelvic organs, and the common integuments of 
dependent parts; developed under diminished impulse from the heart-are 
examples of such paralysis, causing congestion. 
The direct results of such passive congestion. are, that the tissue becomes 
depraved, becoming atrophied, with more or less molecular change of a de- 
generative kind, and such texture is thereby greatly predisposed to fall readily 
into inflammation under trifling injuries, when the passive congestion will be 
replaced by the active congestion of inflammation, and the power to recover 
from such lesions is very greatly reduced. 
The redness of passive congestion is always of a dark or livid hue. Little 
or no heat is felt in the part; a sense of weight or dulness is experienced 
rather than pain ; and there is neither obvious tension, induration, nor in- 
creased proliferation in the part. 
The causes of passive congestion may be thus shortly stated, as-(1.) Pre- 
vious perverted vascular function, such that vital interchange between the 
textures and the blood is diminished. It may thus come to be a result of 
previous inflammation or active congestion. Thus local debility of a part 
from any cause favors the depression of textural vital function, and therefore 
to passive congestion. (2.) Diminution of the normal proportion of fibrin in 
the blood renders its fluid portion more transudable, and so favors passive con- 
gestion in dependent parts, as in the lungs in fever. (3.) General debility is 
favorable to passive congestion. 
EXTRAVASATION OF BLOOD-HEMORRHAGE. 
Latin Eq., Svffusio Sanguinis, Hcemorrhagia; French Eq., Extravasation de Sang; 
German Eq., Blutextravasation, Hcemorrhagie; Italian Eq., Stravaso di Sangue, 
Emorragia. 
Definition.-Any discharge, transudation, or effusion of blood in its entirety 
from the bloodvessels along which it ought to flow. 
Pathology.-Hemorrhage may be spontaneous or traumatic. The first kind 
of hemorrhage concerns the physician, the second concerns the surgeon. 
Blood escapes from the containing vessels amongst the interstitial elements of 
an organ or tissue, either by rupture of a bloodvessel, by solution of its con- 
tinuity from disease, such as an ulcer, an abscess, or from injury. As a rule, 
there is effusion, hemorrhage, or extravasation of all the blood-constituents; 
except, perhaps, in those cases of transudation or sweating through the capil- 
laries, as the old term " exhalation" was meant to express, and which may 
now be explained by the experiments of Cohnheim, Bastian, and others. 
Virchow's description of a capillary being as homogeneous as a layer of collo- 
dion, abundantly testifies to its capacity for "exhalation" in the sense of 
Cohnheim's experiments. 
These recent experiments, reviving those of Waller and Addison, point to 
hemorrhages from the capillary vessels of a part taking place without any 
rupture of vessel or visible breach of surface. Such hemorrhages, where no 
breach of surface could be found, were wont to be described as hemorrhages 
by exhalation, and were believed to occur in ninety-nine cases out of a hun- 
dred. 
Congestions due to mechanical stoppage of the various currents are amongst 
the most frequent causes of hemorrhage, probably from rupture of overdis- 
tended vessels; and when the hemorrhage takes place into the substance of CAUSES OF PASSIVE HEMORRHAGE. 
109 
any'organ, or into any texture interstitial to its elements, the lesion receives 
the name of apoplexy. 
But there are also hemorrhages from free mucous surfaces under various 
morbid conditions. For example, the free escape of blood into the stomach 
in cases of cirrhosis of the liver obstructing the portal vein, or in cases of 
obstructive heart disease, are hemorrhages from rupture of vessels behind 
mechanical obstructions. Also cerebral hemorrhages (or apoplexy) sometimes 
result from infantile convulsions, and are due to rupture of vessels from ob- 
struction ; and so are hemorrhages from varicose veins. These are all exam- 
ples of hemorrhage from mechanical obstacles to the circulation. Valvular 
disease of the heart; hypertrophy of the left ventricle of the heart, with 
capillary impediments to the passage of blood ; affections of the liver, like cir- 
rhosis, which obstruct the flow of blood through the portal vessels, producing 
congestion of the whole portal system, cause hemorrhage in the stomach and 
bowels. " Time was," says Dr. Moxon, " when we could speak strongly con- 
cerning these hemorrhages. Thus, the notion of blood passing through the 
walls of a vessel without a lesion of the latter, is one that could only belong 
to times when the structure of minute vessels was unknown. Capillaries 
naturally possess delicate but perfectly solid and continuous walls; and it is 
just as possible for a single blood-corpuscle to get through that wall without 
a hole being made for it, as it would be impossible for the entire man to sink 
through the floor of an apartment without an aperture of his own size existing 
for his passage. But all this is changed now. If the femoral vein of a frog 
be tied or pinched in forceps, and the capillaries of the foot well watched, 
corpuscles of blood are seen to make their way through the capillary walls. 
They evidently go through holes much smaller than themselves, so that in the 
middle of their passage they are hour-glass-shaped, half in and half out of the 
vessel, constricted much where actually passing. Whether the walls of the 
capillaries are composed of cells, adapted to each other so as to leave pores 
between them ; or whether, rather, our minute tissues, during their life, pos- 
sess some of that yielding and closing capacity that one sees in the amoeba, 
which can take in a fellow-creature of its own size through its skin, and then 
close over it, so that there is no remaining opening,-I think we don't know." 
" It is, indeed, very surprising to find a very free and even a fatal hemorrhage 
from the stomach while the mucous membrane from which the blood must 
have come is entire; yet no doubt this sometimes occurs. Nevertheless, its 
occurrence must not be accepted without very careful search over the mucous 
surface, for the opening of a vessel must be very small." Dr. Moxon instances 
a case where cirrhosis of the liver led to total obstruction of the portal vein, 
by ante-mortem coagulation in it; and in consequence of this obstruction, a 
varicose oesophageal vein ruptured close to the cardiac orifice of the stomach. 
A small hole was found leading into the vein channel, from which the patient 
had bled to death. The occurrence was equivalent to rupture of oesophageal 
piles, and is an interesting link, connecting common small hemorrhoids, that 
arise from hepatic obstruction, with the dilated vessels on the cheeks and in 
the mouth-all signs of obstructed hepatic circulation-and which were 
really facial hsemorrhoids {Med. Times and Gazette, July 16, 1870, p. 58). 
Hemorrhages have also been distinguished into active and passive; and, 
according to Broussais, all spontaneous hemorrhages are active-i. e., they are 
due to increased action and excess of irritation of the bloodvessels of the 
part. Those, on the other hand, are considered passive which result from 
external lesion of the vessels, as when hemorrhage takes place from a blow, 
which impairs the vitality of the part and allows the escape of blood into the 
surrounding tissues. Active hemorrhages are typified in the menstrual flow 
of the female, which is natural, and in vicarious hemorrhage and epistaxis, 
common in the young and plethoric. The predisposing causes are,-good 
living, the excessive use of fermented drinks, excessive exercise, as well as a 110 
TOPICS RELATIVE TO PATHOLOGY. 
too sedentary life. Heaviness and increased pulsation, which makes itself 
sensibly felt in the part, commonly precedes the flow of blood, owing to the 
local congestion, and also coldness of the feet. The blood evacuated is gen- 
erally of a florid red color. 
There are a number of passive hemorrhages which acknowledge some 
general cause, and which seem to result from some constitutional weakness, 
combined with an altered state of the blood. Protracted disease of kidneys, 
heart, liver, or spleen ; degeneration of vessels, poor diet, or unsuitable food; 
long watching, excessive evacuations, previous active hemorrrhage in excess, 
scurvy, purpura, are instances of conditions under which such passive hemor- 
rhages are apt to occur. Hemorrhage from the laceration of vessels and parts 
of organs diseased in texture, pulpy and friable, as in laceration of the heart, 
are of this kind. Hemorrhages are also common when the blood contains 
less fibrin than in health, as in typhus and in scurvy, while they are rare in 
diseases in which the blood contains an excess of fibrin. In hemorrhage 
from plethora, the fibrin remaining the same, or being diminished, the blood 
contains a larger proportion of red globules than in health; while in scurvy, 
or other depressed states of the system, the fibrin is alone diminished, the red 
globules remaining in normal proportion. In general, in hemorrhage, the 
blood is not buffed, has a large soft clot, and if the hemorrhage has been con- 
siderable, with difficulty coagulates, showing a diminished quantity of fibrin. 
Many substances also which directly contaminate the blood seem to have the 
power of inducing hemorrhage. A solution of subcarbonate of soda injected 
into the veins of animals deprives the blood entirely of the power of coagu- 
lating, and disposes to hemorrhages. Many morbid poisons, also, as that of 
typhus fever and of small-pox, have a similar tendency. Hemorrhage, there- 
fore, may be caused by an altered state of the blood as well as by a diseased 
condition of the tissue, and in many instances, perhaps, is referable to both 
causes. Such passive hemorrhages are not preceded by any signs of local 
congestion or excitement of an active kind. They are usually associated with 
pallor of the countenance, feeble pulse, and a tendency to faintness. 
Plethora and anaemia are thus alike proved to be conducive to hemorrhages. 
In youth, plethora is apt to predominate, and then the seat of hemorrhage is 
generally the mucous Schneiderian membrane, and is named epistaxis. In 
adult age, hemorrhages from the lung and bronchial tubes are called haemop- 
tysis ; from the stomach, hcematemesis; and from the urinary passages, haema- 
turia; from the uterus, menorrhagia. In old age, apoplexy and hsemorrhoidal 
discharges of blood prevail especially from fifty to the end of life. If such 
hemorrhages are not suddenly fatal, as may be the case with apoplexy, 
repeated hemorrhages from piles, often occurring, tend to embitter existence. 
The effects, and even the appearance of hemorrhages, are generally alarm- 
ing. The effects must be estimated after due consideration of the cause and 
the seat of the hemorrhage. The signs of danger and grounds for anxiety are 
as follows: 
(a.) Depression, restlessness, deep inspirations (expressed by the term 
anxietas), with rapidity of pulse. 
(6.) Pallor of countenance. 
(c.) Loss or imperfection of vision. 
(d.) Syncope, on attempting to sit up. 
(e.) Coldness of the extremities. 
(/.) Wandering or delirium. 
Ease or contentment, with, de- 
sire to be left alone and un- 
disturbed. 
Secondary Hemorrhage.-Effusions of blood are also apt to occur in connec- 
tion with the inflammatory process ; but such hemorrhages are generally from 
rupture of the vessels of the inflammatory products which have recently 
become vascular (Rokitansky). These new vessels are peculiarly delicate, 
and being apt to rend, like the vessels of new granulation, with a very slight CONSTITUTIONAL TENDENCY TO BLEEDING. 
111 
force, especially when they are made turgid or dilated by an attack of inflam- 
mation of the newly-formed material in which they lie, they may be sources 
of considerable bleeding, especially in the stages of congestion and of stasis 
(Paget). Such is probably the explanation of the conversion of a hydrocele 
into a hcematocele; the inflammatory products of the hydrocele becoming vas- 
cular, and being subjected to slight violence, the new vessels are ruptured, and 
blood pours into the sac. Hemorrhagic pericarditis acknowledges a similar 
mode of causation. To these effusions of blood Mr. Paget gives the name of 
Secondary Hemorrhages. Primary effusions of blood in inflammation, i. e., 
the effusion of blood direct from the ruptured vessels of inflamed parts, min- 
gling with the inflammatory products, are common in pneumonia, in which the 
extravasated blood gives the sputa their characteristic rusty tinge in that 
disease. In the inflammatory red softening of the brain, the blood is also 
effused direct from the vessels of the inflamed part. 
Other morbid conditions are also liable to hemorrhage; for example, such 
as are highly vascular, as encephaloid and other cancers, and the highly vas- 
cular walls of cysts. In all these, the hemorrhage is generally capillary. 
Hemorrhagic Diathesis-a disposition or liability to habitual hemor- 
rhage-has been described under the names of hcemophilia, hoemorrhophilid, 
hcemorrhophilis, and occurs in some persons as a constitutional peculiarity. 
The tendency is congenital, and is sometimes made manifest immediately 
after birth by the difficulty with which bleeding from the umbilical cord can 
be subdued, and in some cases death of the infant takes place from such loss 
of blood. In after-life, and shortly after dentition-after the sixth or eighth 
year-the tendency is expressed by the obstinacy of traumatic hemorrhages, 
profuse and dangerous bleeding from very slight wounds, by spontaneous 
bleedings from the gums, nose, bronchi, stomach, intestines, or kidneys; also, 
as ecchymosis into the texture of the skin and subcutaneous areolar tissue. 
Such spontaneous hemorrhages, however, do not usually occur till after the 
patient has suffered repeatedly from traumatic hemorrhages-the frequent 
loss of blood tending to hypinosis (diminution of fibrin of the blood), and to 
impair its coagulability. Such spontaneous hemorrhages are generally pre- 
ceded by certain phenomena moving or struggling towards the crisis (molim- 
ina) which eventuates in the hemorrhage. Such phenomena constitute the 
"molim.ina hwmorrhagicum" and are expressed by cardiac palpitation, tend- 
ency to stupor or indifference, signs of cerebral congestion, pains in the limbs, 
and, in some cases, painful tumefaction of the joints, especially of the wrists, 
knees, and ankle-joints (Niemeyer), with ecchymosis, and fever (Miller),- 
symptoms which continue about a fortnight. The accidents of a traumatic 
kind which give rise to these alarming hemorrhages are usually extraction of 
a tooth, a leech-bite, biting the tongue, puncture, slight cut, abrasion, or 
laceration, as of the hymen ; and sometimes the slighter the apparent wound, 
the more obstinate and dangerous is the bleeding from it. The blood oozes 
from the surface, or wells up from the puncture or cut, as if from a sponge, 
or like a continuous- spring of water, although no bleeding vessel can be dis- 
covered. No styptic can stanch the flow; and the bleeding may persist for 
days, and many cases even prove fatal by syncope. At first the blood may 
appear normal, but gradually it grows thin and watery, and coagulates loosely,, 
if at all. The complexion becomes pallid, waxy, and anaemic; color passing 
from the lips and mucous membrane of the mouth. 
When the bleeding ceases, as it may after a few days, the patient is left in a 
state of the most extreme exhaustion, approaching collapse, and recovery is 
very slow, from the effects of the enormous loss of blood which sometimes 
amounts to many pounds. 
The slightest contusion, bruise, or pressure on the skin of such hemorrhagic 
patients, sometimes leads to extensive extravasations beneath the skin. 
This peculiar state of the system is either congenital or becomes developed 112 
TOPICS RELATIVE TO PATHOLOGY. 
afterwards as life advances. Those born with the diathesis have usually in- 
herited the constitution chiefly through the male line. It usually descends 
from a family, one of the members of whom, in previous generations, has 
suffered from the same affection. In its hereditary transmission it furnishes, 
like gout, instances of atavism-i. e., it may in transmission through four gen- 
erations, skip over or miss one, the grandchildren inheriting the disease, but 
not the children. Thus, lost in one generation, the disease reappears in the 
next. But all cases are not so inherited, and even when an inheritance, it is 
rare for every member of the family to be affected, the males being more 
liable than the females of the family. 
Many cases die young, and if the tendency is great, the period of childhood 
is rarely survived. On the other hand, cases disclose themselves at a very 
early age, and, abating as age advances, the tendency to bleeding ceases alto- 
gether, and the patient lives to a good old age. The tendency to bleeding 
also seems to fluctuate; the least abrasion or scratch may at one time threaten 
fatal loss of blood; at another time bleeding from any similarly slight injury 
will scarcely attract attention. 
Distinct periods of remission and exacerbation are also experienced. The 
" molimina hwmorrhagicum," already noticed, marks the periods of exacerba- 
tion, which continue about a fortnight. 
The diathesis has points of resemblance on the one hand to scrofula, and 
on the other to scurvy; but with marks sufficiently characteristic to separate 
it from both. The most prominent are an obviously delicate constitution- 
usually a fair complexion-a thin transparent skin, irritability of the circula- 
tion at all times, occasional attacks of fever. But the cause does not lie in 
the constitution of the textures only, for there is a morbid condition of the 
blood as well as of the bloodvessels. There is a preternaturally delicate and 
vulnerable structure of the coats of the vessels associated with a thin and 
watery condition of the blood. It is deficient in the due proportion of fibrin, 
and in the power of coagulation. Even when wholly at rest, it is incapable of 
forming a dense firm coagulum. An undue tendency to congestion of the capillary 
vessels is a consequence of these changes in the blood and in the vessels; so 
that when they are cut, not only do they contain too much blood, upon which 
they are unable to contract, remaining open and uncontracted, passively pour- 
ing out their thin contents; but that blood is deficient in the most important 
of Nature's hemostatics,-the power of coagulation. The minute arterial 
twigs seem to be devoid of any middle substance. They are of a thin feeble 
appearance, and unusually capacious, impaired in contractile power and tone. 
They are friable and easily torn; hence slight bruises produce serious and ex- 
tensive ecchymosis; coughing may induce a dangerous haemoptysis, a sneeze 
may bring on uncontrollable epistaxis, and extravasations within internal 
cavities not unfrequently follow a very slight cause. 
But it is necessary in all such cases to find out, if possible, the source of the 
■depraved blood and constitutional impairment of texture. Some of the organs 
having to do with nutrition, may be contributing a permanent supply of nox- 
ious material to the system. Hence it is of importance to discover the defi- 
nite tissue or organ from which the derangement in the constitution of the 
blood proceeds. Numerous instances of the hemorrhagic diathesis have 
pointed to a definite organ as its source-namely, either a morbid condition 
of the spleen or the liver; and in cases of leukaemia,, usually towards the close 
of life a genuine hemorrhagic diathesis is developed, and hemorrhages ensue, 
occurring with .special frequency in the nasal cavity (as an exhausting epis- 
taxis), and also in or from other parts of the body, as in apoplectic clots in 
the brain, or melsena from the intestinal canal. 
The liver, spleen, and lymphatic system of glands require special investiga- 
tion in all cases of hemorrhagic diathesis. FORMS AND EFFECTS OF HEMORRHAGES. 
113 
The following are the special hemorrhages, extravasations of blood, or hem- 
orrhagic lesions, which call for special notice in this text-book; namely,- 
1. Cerebral hemorrhage, or the sanguineous form of apoplexy. 
2. Spinal hemorrhage, or spinal apoplexy. 
3. Choroidal hemorrhage, or choroidal apoplexy. 
4. Epistaxis, or hemorrhage from the nose. 
5. Haemoptysis (a) from passive congestion; (6) from pulmonary extrava- 
sation, or pulmonary apoplexy. 
6. Hemorrhage into the pericardium. 
7. Hannatemesis, or hemorrhage from the stomach. 
8. Intestinal hemorrhage. 
9. Haemorrhoids, internal and external. 
10. Hemorrhage from the rectum. 
11. Hematuria renalis, or hemorrhage from the kidneys. 
12. Hematuria vesicalis, or hemorrhage from the bladder. 
13. Hematocele, or hemorrhage into the tunica vaginalis. 
14. Hemorrhage into ovary. 
15. Peri-uterine, or pelvic licematocele, or hemorrhage underneath the peri- 
toneum, or within the fold of the broad ligament of the uterus. 
16. Pelvic luematocele, hemorrhage into the areolar tissue of the pelvis. [1'5 
and 16 are sometimes described under the name of retro-uterine 
hsematocele.] 
17. Uterine hemorrhage, and menorrhagia. 
18. Hemorrhagic cysts. 
Each and all of these forms of hemorrhage will be considered in detail un- 
der the respective organs implicated in the lesion. 
Fig. 8. 
Eig. 9. 
Fig. 8.-Pigment from an apoplectic cicatrix in the brain (Virchow's Archiv., vol. i, pp. 401, 454, plate 
iii, Fig. 7). (a.) Blood-corpuscles which have become granular, and are in process of decolorization; (6.) 
Cells from the neuroglia, some of them provided with granular and crystalline pigment; (c.) Pigment- 
granules ; (d.) Crystals of haematoidin; (/.) Obliterated vessel, with its former channel filled with granular 
and crystalline red pigment: 300 diameters (Virchow, Cellular Pathology, p. 144). 
Fig. 9.-Crystals of haematoidin in different forms: 300 diameters (1. c., p. 143). 
There remains now to be noticed, the results of-blood extravasations. 
The immediate effects of hemorrhage, besides the amemia consequent upon 
great effusion, either out of the body or into its cavities, are lesions of contin- 
uity in textures, impairment or destruction of function, paralysis of the organ 
affected, as in cerebral and muscular hemorrhage. The irritation, too, of the 
extravasated blood, acting as a foreign body, may set up inflammation of sur- 
rounding textures, with eventual organization t»f the effused products, result- 
ing in a callous condensation of texture surrounding the lesion, and the isola- 
tion, by inclosure of the hemorrhagic clot in a more or less dense capsule. It 
is rare for the hemorrhagic lesion to become purulent. 
A slight hemorrhage is usually cured by absorption of the effused fluid, so 114 
TOPICS RELATIVE TO PATHOLOGY. 
that the injured and distended textures recover their resiliency. The liberated 
red pigment, however, frequently resists absorption, even in slight hemorrhages, 
remaining in a state of minute molecules, scattered over a membrane, or be- 
tween the minute elements of a texture, as a minute or black pigment. Every 
extravasation may also leave behind it a contingent of hsematoidin crystals 
(Fig. 9), which, when once formed, remains in the interior of the organ in 
the shape of compact bodies endowed with the greatest powers of resistance. 
From the numbers of such remains any number of old apoplectic attacks may 
be counted, with remains like Fig. 8. 
Prognosis in cases of hemorrhage is unfavorable under the following condi- 
tions : 
(a.) Into serous cavities, unless limited by other lesions. 
(6.) Into the substances of organs. 
(c.) Under the influence of the hemorrhagic diathesis. 
Treatment.-As the details for treatment of each of the hemorrhages already 
named will be considered under the account of the respective diseases, there 
only remains to indicate here the treatment suitable for cases of the hemorrhagic 
diathesis, which only finds a place here. 
Nutritious diet, outdoor life, and tonic remedies generally, express the line 
of treatment. 
Medicinal tonics are of first importance, and must be patiently persevered in, 
consistently with the capacity to assimilate food with them. Smart purgative 
doses of sulphate of soda are of benefit in two ways: first, as a purgative and 
hydragogue, diminishing the amount of serum in the blood; second, as a chemical 
salt, which has the effect of increasing or promoting the firm coagulation of 
the blood. Acetate of lead and opium also favor coagulation, and tend to calm 
the circulation. They must be administered in full and sustained doses. 
Opium seems to have a tonic and astringent effect on the capillary vessels, 
and tends to sustain life under the great depression from loss of blood. 
Sulphate of alum and sulphate of potass, in doses of fifteen to twenty grains; 
or gallic acid, in doses of twelve grains, frequently repeated, i. e., every two, 
four, or six hours; or infusion of matico or oil of turpentine, may each be used 
by turns, and according as the stomach will tolerate one rather than another; 
but the sulphate of soda must not be given in conjunction with the acetate of 
lead. The efficacy of gallic acid is increased by combining it with fifteen or 
twenty minims of aromatic sulphuric acid. It may also with benefit be com- 
bined with alum. Gallic acid should have a fair trial, before giving acetate of 
lead. From two to five grains of ergot of rye (secale cerealef or the liquid ex- 
tract, in doses of twenty or thirty minims, frequently repeated, say every hour 
or half hour, has been of use. The oil of turpentine, to the extent of ten to 
twenty drops, is to be given in mucilage every two or three hours. 
Nutritive but non-stimulant food must be given in small quantities, and 
frequently. It is best given as animal jelly, coagulated soups, or soup in the 
jelly form, rather than in the fluid watery form. Alcoholic stimulants are to 
be avoided. One well-selected plan must be persevered in, so as to avoid 
capriciously and rapidly shifting from one remedy to another. 
As to local remedies, the actual cautery should never be employed, but 
every trust must be placed in gentle pressure over applications of strong tinc- 
ture of matico, and solution of the perchloride of iron. 
As a last effort in a case apparently hopeless, transfusion of blood may still 
be tried. 
Consult also the articles on Scurvy and Purpura. 115 
DEFINITION AND PATHOLOGY OF DROPSY. 
DROPSY. 
Latin Eq., Hydrops; French Eq., Hydropisie: German Eq., Wassersueht; Italian 
Eq., Idropisia. 
Definition.-Dropsy is a contraction for Hydropsy, and signifies the accuyiu- 
lation of a watery fluid in one or more of the serous cavities; or a diffusion of watery 
fluid through the areolar tissue of the body, or its organs; or a combination of all 
these conditions. 
Pathology-The distinctive characteristic of dropsy is in the nature of the 
fluid which forms the accumulation. The fluid is not liquor sanguinis, but 
water containing more or less constituents of the blood-serum. 
In the preceding pages, 81 to 83, the nature of the results are described, 
when liquor sanguinis, and blood, are effused as products of the inflammatory 
process. In dropsies, however, the fluid seems to be devoid of all coagulating 
elements, or of elements tending to growth or development. The liquid is 
clear, like the serum of the blood; and in the so-called " fibrinous dropsies," 
where the fluid contains coagulated fibrin in greater or less amount, the fluid 
is not the fluid of dropsy, but is generally the result of more or less inflamma- 
tion, involving the texture of the serous sac in which the fibrinous fluid is 
found. In all true dropsies the texture of the part where the fluid exists is 
unimpaired by inflammatory changes; and the lesions giving rise to the 
dropsy must be sought for generally in some other organs of the body. The 
fluid collections in the pleura of pleuritis and hydrothorax contrast in these 
respects. The fluid of the former is the result of inflammation, and generally 
contains flakes of coagulated fibrin; the fluid of hydrothorax is a true drop- 
sical effusion. The prefix hydro or hydrops is used to express the fact that the 
lesion is a true dropsy of a serous sac; and dropsies receive different names 
according to their situation. Thus, dropsy of the belly, where the peritoneum 
is distended with watery fluid, is sometimes called hydroperitoneum, but is 
usually now called ascites; dropsy of the brain or head, where the ventricles 
are distended with watery fluid, is called hydrocephalus; dropsy of the chest, 
where the pleural sac is filled with serous fluid, hydrothorax; dropsy of the 
pericardium, where that sac contains the fluid, hydropericardium; dropsy of 
the eye, hydrophthalmia; dropsy of the womb, hydrometra; dropsy of the tunica 
vaginalis testis is termed hydrocele; dropsy of the areolar tissue of a part is 
termed oedema, and is a lesion common to the areolar tissue of internal organs, 
as well as to the subcutaneous areolar tissue of the body generally. Hence 
there is oedema of the lungs and of the liver, and when fluid effusion exists in 
the tissue of these organs, they are said to be oedematous. When oedema of the 
subcutaneous areolar tissue is general over the body, this dropsy receives the 
name of anasarca; and the combination of anasarca, with dropsy of one or 
more of the large serous sacs, is usually named general dropsy. There are 
also dropsies of other parts, which receive characteristic names. Thus, dropsy 
of the lachrymal sac is called a fistula lachrymalis, or lachrymal hernia. 
The water of dropsy has the serum of serous membranes as the basis of the 
fluid accumulation; but the exact constituents of the dropsical fluid differ in 
different cases as regards the ingredients held in solution; and, generally in 
all, more of the water of the blood than of the solids of the serum passes out 
of the vessels in these dropsies. The specific gravity of the fluids also varies 
in different parts, the fluid of hydrocephalus and spina bifida being the least, 
pericardial and ovarian dropsy the greater. 
The following table gives the results of Dr. Marcet's analysis, but it greatly 
wants verification: 116 
TOPICS RELATIVE TO PATHOLOGY 
In 1000 Grains of Fluid. 
Specific 
Gravity. 
Total Solid 
Contents. 
Animal 
Matter. 
Saline 
Matters. 
Fluid of Spina Bifida, 
" Hydrocephalus, 
" Ascites, 
" Ovarian Dropsy, 
• " Hydrothorax, 
" Hydrops Pericardii, .... 
" Hydrocele, 
" A Blister, 
" Serum of the Blood, .... 
1007.0 
1006.7 
1015 0 
1020.2 
1012 1 
1014.3 
1024.3 
1024.1 
1029.5 
Grains. 
11 4 
9.2 
33.5 
26 6 
33.0 
80.0 
loo.o 
Grains. 
2.2 
1.12 
25.1 
18.8 
25 5 
71.5 
90.8 
Grains. 
9 2 
8 08 
8.4 
8.0 
7.8 
7 5 
8 5 
8.1 
9 2 
Generally, the fluid of hydrothorax will be lighter than that of pericardial 
fluid; and the fluid of dropsy is but an augmentation of the kind of effusion 
or secretion natural to the part, and not merely a sweating dr escape of serum. 
In its reaction, the fluid of dropsy is mostly alkaline, but may be faintly acid 
or neutral: in its purity it is colorless, or pale straw color, and of a clear and 
limpid appearance, and in the quality of its ingredients it is analogous to the 
serum of the blood, although in consistence it is thinner. Chemically, it con- 
sists of water, albumen, fat (generally as cholesterin), pigments, extractive 
matter, and salts (chloride of sodium preponderating over the carbonates and 
phosphates of alkalies), and of alkaline earths. Urea is sometimes present 
when the kidneys are at fault. The albumen is subject to the greatest fluc- 
tuation ; and is generally pure as the albumen of blood-serum, or it exists 
as an albuminate of soda or other well-known forms, as well as in forms and 
modifications as yet unknown. The fluid of pleural dropsy (hydrothorax) is 
richer in albumen than the fluid of ascites (Lehmann) ; and there is still less 
albumen in the fluid of arachnoid dropsy, or that of the cerebral ventricles 
(hydrocephalus) than in the fluid of ascites. The fluid of dropsy into the sub- 
cutaneous areolar tissue (anasarca) is the poorest of all in albumen. When 
the albumen is in great abundance (as in the ascites from ovarian disease), 
the fluid becomes viscid and adhesive, like synovia. A red coloration is due 
to blood-pigment; a yellow or yellowish-green, generally to bile-pigment; a 
milky whiteness, opalescence, or whey-like turbidity, may be due to accidental 
mixture with epithelium or fat, as fine cholesterin crystals (often seen glis- 
tening in the fluid of old hydroceles), or it may be due to albumen precipitated 
by an excess of water relative to the saline contents. 
The origin of dropsy is due to several causes, acting singly or in two or more 
combinations ; and, like congestion, it may be sometimes purely mechanical, as 
(1) when it is the result of retention of blood in the veins through mechanical 
hindrance to the circulation. The interruption to the venous circulation as a 
chief cause of dropsical effusion was first experimentally demonstrated by 
Lower, who tied the vena porta of a living dog, thereby causing its death by 
dropsy. The extensive distribution of the dropsical effusion varies in accord- 
ance with the site of the obstruction; and is great in proportion as the cen- 
tres of the circulation are implicated. The fluid also will be in abundance 
proportionally to the fluidity or excessive wateriness of the blood (hydrcemia), 
and is exuded mainly from veins. (2.) In dropsy resulting from general de- 
bility, hydrcemia in parts that are paralyzed, effusion takes place mainly from 
capillary vessels. 
Thus three important conditions may act singly or in combination in the 
production of dropsy; namely,-(a) Mechanical impediment to the circula- 
tion, and especially the free passage of blood through one or other of the great 
organs, namely, the heart, lungs, or liver; (b) Altered condition of the 
blood, by excess of water diminishing the density of blood-serum; or, by un- ORIGIN OF DROPSY. 
117 
eliminated excreta, such as biliary or urinary elements in hepatic or renal 
diseases; (c) A poor, watery, exhausted blood. 
Dropsy is never a primary affection, or substantive disease, but only a 
symptom of disease, and always dependent on some antecedent morbid condi- 
tion, the mechanism of whose action is implied in the physical conditions just 
mentioned. 
Au important distinction is made between general dropsy and local dropsy. 
In the former, more or less extensive anasarca is associated with effusion of 
fluid into one or more serous cavities, especially the peritoneum or the pleura. 
The subcutaneous appearance of the fluid is generally expressed first by a 
puffiness of the face, especially in the morning, under the eyelids, and next in 
the feet and ankles in the evening, or in the hands and forearms, particularly 
the left; or it appears at once in all of these seats, and gradually extends 
throughout the body, associated with which the accumulation in the serous 
cavities may be also considerable. 
All such cases of general dropsy at ohce point either to obstructive lesions 
affecting the central organ of circulation, or to a morbid condition of the 
blood, or to both combined. 
Associated with the first condition, it is a symptom of disease of the heart, 
and is then known by the name of cardiac dropsy. It is attended with great 
difficulty of breathing (dyspnoea), labored action of the heart, and livid con- 
gestion of the skin. Although called generally cardiac dropsy, it arises from 
obstruction to the current of blood through the heart, lungs, or liver ; either 
primarily in the heart-as in valvular disease of the left side-or primarily 
in the lungs, and secondarily in the heart-as in emphysema and chronic 
bronchitis, one or both producing dilatation and inefficient action in the right 
heart, and a consequent retrograde effect throughout the venous system. 
Associated with the second condition, general dropsy is usually a symptom 
of disease of the kidney; and it is then known by the name of renal dropsy. 
Drs. Bright, Christison, and Gregory were the first to furnish numerous proofs 
of the frequency of structural lesion of the kidneys with dropsical effusions. 
The lesion of the kidney is generally some one of the varied forms of Bright's 
disease, in which the serum of the blood becomes greatly altered, being 
deprived of its albumen, which passes in the urine, and rendered impure by 
retention of excreta such as urea. The countenance and skin are especially 
pale in such cases. 
Associated with changes in the blood, general dropsy is sometimes a conse- 
quence of severe malarious poisoning, giving rise to protracted intermittent 
fever, in which the blood becomes greatly altered, as in extreme anaemia; and 
a similar general dropsy has been known to attend the anaemia of over-pro- 
longed lactation, aud in chlorosis after large hemorrhages, or other exhausting 
discharges, also in starvation from deficient, watery, vegetable, or unwhole- 
some diet, as in the dropsy often prevalent among the poor in times of scarcity. 
In local dropsy, one serous cavity, or one organ, or one part of the subcuta- 
neous areolar tissue, is the seat of the dropsical accumulation. The perito- 
neum is the most frequent serous sac so affected, and the accumulation is gen- 
erally the result of obstruction to the circulation through the liver by the vena 
porta, a result of hepatic disease generally in the form of the complex lesion 
known as cirrhosis, under which this form of dropsy will be more particularly 
described. But it may be here stated that the effect of the obstruction in the 
liver, as in cardiac dropsy, is carried back till its effects are felt in the remotest 
capillaries of this section of the venous system; and hence the ascites which is 
the usual expression of such hepatic obstruction. An example of local dropsy 
may also be seen in the oedema of the lungs, resulting from the cardiac lesion 
of mitral obstruction. Fibrinous concretions obstructing the vena cava and 
internal iliac veins, or tumors, or a psoas abscess pressing upon these vessels, 118 
TOPICS RELATIVE TO PATHOLOGY. 
are also sometimes causes of local dropsy. Disease, by enlargement of the 
spleen, gives another cause for local dropsy, and is often the result of malaria. 
Special details regarding dropsies will be found under the several lesions 
of which dropsy is a result.* 
FIBRINOUS DEPOSIT. 
Latin Eq., Fibrina Deposita; French Eq , D^pbt Fibrineux: German Eq., Faser- 
stoffablagerung-Syn., Fibrinose Ablageruny, Italian Eq., Deposito Fibrinoso. 
Definition.-A morbid condition in tvhich a great tendency exists for fibrinous 
matter to separate from the blood, more or less rapidly, and to be deposited in va- 
rious parts. 
Pathology.-The exact nature of this form of lesion is not well known, but 
if the quantity of fibrin be considerable at any one time, it forms a solid 
mass, of which, perhaps, the best examples are those large yellow pyramidal 
blocks often seen in the spleen. If, on the other hand, as is more common, a 
slow and gradual separation occurs, a formation of fibroid tissue takes place, 
causing thickening of membranes, or similar changes in more solid parts (H. 
Jones, Path. Trans., vol. vi, p. 96). These fibrinous deposits present a light 
red or yellowish white color, and occur in a more or less wedge-shaped form, 
with the apex centripetal and the base of the wedge towards the periphery of 
the organ. Miscroscopically the deposit consists of a granular material. 
Two views are entertained regarding the production of such deposits- 
namely, either that they result from minute particles of fibrin being continu- 
ously detached at points of the circulating system, more or less remote from 
the local deposit, but carried there by the current of the circulation; or they 
have been regarded as an exudation of fibrin from the capillary circulation. 
(See Path. Trans., vols. iii, viii, xiii.) 
There are cases where a tendency, either on the part of the blood to pre- 
cipitate its fibrin, which seems increased in quantity, or there is a tendency 
* Pneumatoses, or the accumulation of various gases, both within textures, and more par- 
ticularly in every cavity of the body and of its organs, ought to find some notice here. 
It does not find a place in the new nomenclature of the College of Physicians. Roki- 
tansky describes the inodes in which gas accumulations originate, as follows: 
(a.) Gas accumulated in the textures or in cavities is generally atmospheric air, which 
has penetrated from without. For example, most kinds of emphysema, gas accumu- 
lations in the pleural sac, gas accumulations in the stomach, and perhaps also, the more 
rare instances of gas collections in the uterus and urinary bladder; also gas in the 
blood, after injury to veins, particularly those of the neck, are collections of at- 
mospheric air. Interstitial emphysema and pneumothorax are results of lesions of 
continuity, through wounds or ulcerations in the bronchial passages, or in the lungs. 
If air be long retained in any of those situations, it undergoes changes similar to what 
it undergoes in the lungs. Its oxygen becomes exchanged for carbonic acid, with the 
superaddition of aqueous vapor. 
But some gaseous accumulations are the products of decomposition; as, for example 
gaS development in stomach and intestines, the result of impaired and imperfect 
digestion. Its morbid increase constitutes flatulency and tympanitis ; the former term 
implying movement of the gas (borborygmus), and its final expulsion by mouth or 
by anus; the latter term implies its retention, causing distension, with augmented 
resonance on percussion of the abdomen. This tympanitis is sometimes witnessed to a 
painful extent in cases of lientery, where the great bowel gets so distended with gas and 
paralyzed by distension, that death has ensued with symptoms similar to intestinal 
obstruction. The mucous membrane itself is also believed to secrete gas. 
Such putrefactive gas development also takes place out of blood mass; or from 
decaying normal textures or morbid products, such as sloughing cancers. 
It has also been observed that the subcutaneous areolar tissue, when slightly inflamed, 
may secrete air in such abundance as to produce emphysema. Dr. Graves relates a 
case in which gas was secreted to a considerable amount in the cavity of the pleura. FIBRINOUS DEPOSITS 
119 
to the spontaneous coagulation of the fibrin, it being natural as to quantity, 
but thus altered in quality. Instances of this exist in cases of phlegmasia 
dolens, especially those occurring as a sequence to typhoid fever. The ten- 
dency also exists in those cases where decomposing clots of fibrin are found 
at times in the cavities of the heart, especially in the appendices of the auri- 
cles (J. W. Ogle, Path. Trans., vol. vi, p. 32). 
Fibrinous deposits, or concretions of fibrin, within the heart, are called 
polypi or fibrinous vegetations. When such fibrinous deposits are found in blood- 
vessels, having been carried from a distance into them, and not formed where 
they are found, the term Emboli has recently been applied to denote such 
deposits. 
ALTERATION OF DIMENSIONS. 
Latin Eq , Magnitude) Mutata; French Eq., Alterations de Dimension; German 
Eq , Veranderungen der Gestalt und Grosse; Italian Eq., Cangiamenti di Dimen- 
sions. 
Definition.-Alteration of dimension is expressed by an increase or decrease 
in the volume or bulk of an organ when compared with the normal volume as ex- 
pressed by the cubic inches of water it will displace. 
Pathology.-Such alterations of dimensions are comprehended under the 
following lesions-namely, dilatation, contraction, hypertrophy, atrophy. The 
terms dilatation and contraction are usually applied to hollow organs, such as 
the heart; while hypertrophy and atrophy have reference to an increase or 
diminution of the specific texture composing any organ or part. 
(«.) DILATATION. 
Definition.-Expansion of the walls of a cavity, so as to inclose greater con- 
tents. 
It is generally coupled with hypertrophy of the walls of the dilated organs, 
when it is known as active dilatation. When the inclosing walls of the cavity 
are of normal thickness, the dilatation is known as simple dilatation ; conjoined 
with thinning, attenuation, or atrophy of walls, it is known as passive dilata- 
tion. 
The causes of dilatation of hollow organs may be expressed as follows: 
1. Mechanical impediments, obstructing the free passage and egression of the 
contents of the different canals and reservoirs, and occasioning dilatation 
either beyond or behind the impediment. 
They are expressed in the following lesions ; namely : 
(a.) Constriction of calibre, through pressure from without; e. g., by ab- 
scess or tumors. 
(b.') Coarctation or stricture, consequent upon hypertrophy and change of 
texture in the walls of the organ. 
(c.) Foreign bodies, or secretions obstructing canals. 
2. Paralysis of the contractile elements in the walls of the organ. 
3. Degenerative lesions. 
4. Inflammations. 
Dilatation tends to destroy life through paralysis, simply, or by the con- 
currence of asthenic inflammations, or by gangrene, the retained contents of 
dilated cavities contributing, by decomposition, to pneumatoses and farther 
dilatation, as in paralysis with distension of the large intestine and urinary 
bladder. 120 
TOPICS RELATIVE TO PATHOLOGY. 
(b.) CONTRACTION. 
Definition.-Contraction, coarctation or stricture, are also terms applied to 
diminished capacity or calibre of hollow parts or passages,-such, for example, 
as local contraction of bile-ducts, or of urethra, or oesophagus, stomach, or any part 
of intestinal canal. 
(c.) HYPERTROPHY. 
Definition.-A lesion in which the enlargement of a part is effected by in- 
crease, growth, or development of its natural tissue, with proportional retention of 
its natural form, and with increase of power in proportion to increase of growth 
(Paget). 
Pathology.-Hypertrophy of the heart is a common example; and, in its 
genuine form, the muscular tissue is developed to more robustness. Its fibres 
become not only larger or more numerous, but firmer, more highly colored, 
and stronger. It is an instance in which the individual elements of the 
structure take up a considerable amount of matter, and thereby become 
larger; by which, and in consequence of the simultaneous enlargement of a 
number of elements, at last the whole of an organ may become swollen or 
enlarged. When a muscle becomes thicker, all its primary fasciculi become 
thicker. So also a liveT becomes enlarged by hypertrophy, simply in conse- 
quence of a considerable enlargement of its individual cells. It is a genuine 
hypertrophy without new formation (Virchow). In the pregnant uterus 
also, such fibres are formed as are not seen in the unimpregnated state. They 
are not a new kind of fibre, but they differ in size and shape, and are much 
more powerful than those which compose the uterus in its unimpregnated 
condition. It is an enlargement of the organ effected through increase by 
development of its natural tissue. It is the hyperplasia of Virchow. Such 
hypertrophy of pregnancy is natural; but it is imitated in disease, when, by 
the growth of fibrous tumors in the uterus, the womb attains the size, the 
structure, and full capacity of action of the pregnant organ, so that even the 
course of labor is imitated, and the fibrous tumor is expelled by the con- 
tractile power of the uterus, as if it had been a foetus (Paget). Hypertrophy 
involves an abnormal activity of nutrition, and also at the same time pre- 
serves the proportional natural form of the part. Thus simple hypertrophy 
is scarcely to be distinguished from the results of nutritive irritation; but, on 
the other hand, mere nutrition increase, without irritation (which is equiva- 
lent to exercise), will not produce hypertrophy. Mr. Paget, therefore, has 
well stated the essentials for hypertrophy to consist of the following condi- 
tions, namely: 
1. Increased exercise of a part in its healthy functions (or irritation short of 
exciting inflammation'). 
2. An increased accumulation in the blood of the particular materials which a 
part appropriates to its nutrition or in secretion. 
3. An increased afflux of healthy blood. 
As examples of the first, the arm of a strong blacksmith, whose muscles 
acquire bulk and power from constantly recurrent and vigorous contraction 
from exercise in the use of the hammer, or the great robust heart of a man 
who has suffered from some disease producing an obstacle to the movement of 
the blood. In the great majority of cases of hypertrophy of the heart, the 
lesion is due to valvular disease, which presents an obstacle to circulation of 
blood through the organ. So also is the urinary bladder hypertrophied in 
consequence of stricture of the urethra. "The bladder," says Mr. Hunter, 
"in such cases having more to do than common, is almost in a constant state 
of irritation and action, by which, according to a property in all muscles, it DEFINITION AND PATHOLOGY OF HYPERTROPHY. 
121 
becomes stronger and stronger in its muscular coat; and I suspect that this 
disposition to become stronger, from repeated action, is greater in the involun- 
tary muscles than the voluntary; and the reason why it should be so is, I 
think, very evident, for, in the involuntary muscles, the power should be in 
all cases capable of overcoming the resistance, as the power is always per- 
forming some natural and necessary action; for whenever a disease produces 
an uncommon resistance in the involuntary parts, if the power is not propor- 
tionally increased, the disease becomes very formidable; whereas, in the vol- 
untary muscles there is not that necessity, because the will can stop whenever 
the muscles cannot follow; and if the will is so diseased as not to stop, the 
power in voluntary muscles should not increase in proportion" (Mr. Paget's 
Catalogue of College of Surgeons, vol. i, p. 3; and Hunter's work, vol. ii, p. 
299). Thus it is that the oesophagus, the stomach, the intestinal canal (as 
often as any portion is the seat of stricture) becomes hypertrophied as to its 
muscular coat above the seat of stricture. 
Diagrams of hepatic cells.-(A.) Their simple, physiological appearance. (B.) Hypertrophy a,,sim>- 
ple ; b, with accumulation of fat (fatty degeneration, fatty liver). (C.) Hyperplasy (numerical increase 
or adjunctive hypertrophy): a, cell with nucleus and divided nucleolus; b, divided nuclei; c, c, divided 
cells. (After Vikchow.) 
It is still undecided whether, in muscular hypertrophy, the increase of size 
is owing exclusively to enlargement of primitive fibrillae, or whether new fib- 
rillae are produced. If new fibrillae are produced, the enlargement, accord- 
ing to Virchow, would be hyperplastic ami not hypertrophic. In hyperplasia 
new or more numerous anatomical elements are generated, which contribute 
to the enlargement of a part, by real increase of new material, and which 
must be distinguished from that enlargement of a part which is a genuine 
hypertrophy. It will thus appear obvious that mere enlargement of a part is 
not necessarily hypertrophy of the part; and, therefore, it is important patho- 
logically to distinguish real hypertrophy from apparent or false hypertrophy.. A 
liver or spleen enlarged\by lardaceous degeneration furnish examples of false 
hypertrophy; such liver or spleen, as to structure, being really in a state of 
atrophy from wasting of the normal elements. 
Cases in which an enlargement takes place in consequence of an increase in 
the number of the elements, are examples of hyperplasia. Thus, a liver may 
become enlarged by a very abundant development of a series of small cells 
in place of the ordinary cell development (c, Fig. 10, ante). Hyperplasia may 
therefore be considered as a numerical hypertrophy, due to a proliferation or 
reproduction of tissues similar to the original part, and the condition of the 
pregnant uterus is thus one of hyperplasia rather than genuine hypertrophy.. 122 
TOPICS RELATIVE TO PATHOLOGY. 
(d.) ATROPHY. 
Definition.-A deficiency of the formative process, by which a part simply wastes 
and is reduced in size, with little or no change of texture, or with gradual and con- 
tinuous degeneration (Paget). 
Pathology.-As there are two forms of hypertrophy-the one with growth, 
the other with development (the hyperpdasia of Virchow)-so there are two modes 
of atrophy; the one with simple decrease, the other with gradual and continuous 
degeneration of tissue. In both forms, there is invariably a loss of functional 
power in the part: but, in the one form-that of simple decrease-the loss is 
due to deficient quantity; in the other form-that of degeneration-the loss is 
due to deteriorated quality of the tissue. Atrophy does not necessarily imply 
diminution in the bulk of an organ. The atrophied organ may, in reality, 
be increased in size, as in the false hypertrophies already noticed, especially 
fatty and lardaceous degenerations. Atrophy is sometimes a natural process, 
as in the decline of gland textures, when the need for their existence, or 
natural term of their special life, has ceased; for example, the thymus gland, 
Peyer's patches after forty or fifty years of age, the ovary, testicles, and gen- 
ital parts generally in old age. Progressive atrophy of all the organs and tex- 
tures is incident to old age, and is called senile atrophy. In some instances cer- 
tain tissues waste continuously or progressively; for example, the muscles in 
that form of disease which will be described as "progressive muscular atrophy" 
and where the volume of the affected muscles is markedly diminished, as they 
become successively implicated in the disease. Atrophy, with diminution of 
volume, is also illustrated in certain chronic diseases of the kidneys, marked 
by contraction of their bulk; and also in cirrhosis of the liver. The emacia- 
tion of scrofula, with or without tubercle, is an example of atrophy affecting 
the fatty or adipose tissue especially; and it is especially expressed by the 
terms phthisis, consumption, marasmus. It is thus a general atrophy; and its 
effects exhibit themselves in the wasted appearance of the body as a whole. 
The conditions giving rise to atrophy may be shortly stated as the opposite 
or reverse of those producing hypertrophy, already noticed. 
Latin Eq., Degeneratio; French Eq., Degenerescence; German Eq., Degeneration- 
Syn , Entartung; Italian Eq., Degenerazione. 
DEGENERATION. 
Definition.-Degeneration of tissue implies such a departure from the normal 
state as gives rise to a granular disintegration or detritus within its minute ele- 
ments, or to any deterioration by exudation or deposit, which, by the functional 
actions of repair in the normal state, could not have been left in the texture. 
Pathology.-The separation of degenerations from substantive diseases is 
one of the greatest advances in modern Medicine, as Sir William Jenner has 
well shown in the address to the British Medical Association at Leeds, July 
28, 1869. 
By degeneration is meant,- 
(1.) Retrograde metamorphosis; and what is that? Shortly, it may be 
stated, that we are always changing, therefore something is always being 
removed and replaced; but in degeneration a passive change goes on, distinct 
from living processes. The result is a granular disintegration of tissue. 
This is especially expressed in the form of fatty degeneration, rotting and 
■calcification, or petrifaction. These same changes occur post mortem, and after 
tissues are removed from the body and preserved in the bottles of the museum. 
(2.) Changes accompanied by thickening by hyperplasia generally, and 
diminished elasticity of certain tissues, occurring especially in advancing life. IMPORTANCE OF RECOGNIZING DEGENERATIONS. 
123 
The general diffusion of these degenerations is characteristic of advancing 
age. The circumstances under which degenerations occur are of the nature 
of decay and death. For example, degeneration occurs to an immense extent 
in the tissues of the aged, especially in the heart and arteries, and to a less 
extent in the voluntary muscles and the hard textures. Towards the close of 
the life of a part of the body, degeneration takes place; as, for example, in 
the textures of the placenta, when utero-gestation is nearly complete. To 
such degenerations Virchow has given the name of necrobiosis, because death 
and degeneration seem to be brought about by altered life at the close of 
natural existence. In this respect it may be truly said, that "As we begin to 
live we begin to die." " To degenerate and die is as normal as to be developed 
and live." A spontaneous wearing out of living parts goes on, so that de- 
struction and annihilation are immediately consequent upon life. 
Alterations in consistence are marked characteristics of degeneration. Elas- 
ticity is impaired, and softening is often the ultimate result of such degenera- 
tion, which becomes palpable chiefly by the decided friability of the parts. 
The minute elements of tissue lose their coherence, and at last really liquefy, 
so that pulpy or fluid products take their place. When it is remembered, 
also, how abundantly a granular fatty transformation occurs after death, the 
nature of degenerations becomes more intelligible; and my friend Dr. Lyons, 
Professor of Medicine in the Catholic University of Ireland, instituted a series 
of observations which beautifully demonstrated a process of morphic changes 
of tissues through dissolution and decay, till the mortal parts of our body 
return " ashes to ashes " and " dust to dust." To these morphic changes he 
has given the name of " Histolysis." To the same end are the demonstrations 
of Dr. Quain, regarding the conversion of muscle into fat, and of crude flesh 
generally into aclipocere, accounting for the enormous fattiness of certain geo- 
logical strata in which animal remains are abundant (Michalis, quoted by 
Simon). Such experiments and observations as those of Panum, Meisens, Asch- 
erson, Gluge, Lyons, Simon, Burdach, Wagner, Michaelis, and others, and in 
which granules, vesicles, and cell-forms appear to rise spontaneously out of 
homogeneous albuminous fluid, will go far to explain many of the conflicting 
accounts which are given of the nature of the inflammatory products just 
described, and of the degenerations. Such forms may undoubtedly arise, as 
these observers show ; and having arisen, they decompose and advance through 
changes such as Dr. Lyons has described under the name of histolysis. On the 
other hand, the productive results of inflammation undoubtedly grow from pre- 
existing tissue-elements, as already described. From this point of view, struc- 
tural changes in the valves of the heart are the result of one of three con- 
ditions : 
(a.) Imperfect development. 
(b.) Endocarditis. 
(c.) Degenerative changes. 
These last rarely occur till middle life; not usually till advanced life in civ- 
ilians. They seem to be frequent in soldiers at early ages. 
Our knowledge of such degenerations enables us to appreciate lesions of 
cerebral textures following such degeneration of arteries and the capillaries of 
the brain. 
Degenerative changes in coats of larger arteries can be traced in series up 
to aneurisms through all stages of local dilatations. They do not occur in 
childhood or early youth ; they are concomitants of old age especially, but are 
seen at early ages amongst soldiers. 
All the degenerations are examples of atrophy with changes of texture 
(Paget), as distinguished from atrophy resulting from simple decrease of bulk, 
the organ or tissue otherwise retaining its usual form, and to some extent its 
function. To recognize the following degenerations of tissue after death, the 
employment of the higher powers of the microscope is essential. 124 
TOPICS RELATIVE TO PATHOLOGY. 
The recognition of the following degenerations has very much modified our 
practice and opinions of recent years, e. g., the diagnosis and treatment of 
degenerative heart diseases, also of certain forms of apoplexy. In illustration 
of this, Sir William Jenner gives the following apt illustration in one of the 
most terse and suggestive lectures of the time : 
" Although with regard to the virtues of this or of that particular drug, and 
to the mode of action of this or of that particular class of remedies, there is, 
and always will be differences of opinion-the evidence that satisfies A. being 
insufficient from the constitution of his mind to satisfy B.-with regard to the 
value of drugs in the abstract, with regard to the value of treatment, there is 
really little difference of opinion among physicians equally well informed as 
to the present state of medical knowledge, and equally experienced in 
practice. 
" I say, among men equally well informed. Let me illustrate my mean- 
ing. I was one of three who met in consultation concerning a case of apo- 
plexy. In the opinion of one of my colleagues and myself, the only treatment 
to be adopted was as follows : To place the patient in the recumbent position, 
with head and shoulders raised, to enforce absolute rest, to keep the bowels so 
far loose as to prevent excitement and straining; to apply cooling substances 
to the head in the event of any heat of the part occurring; to support the 
patient with light nutritive food, having regard to his habits. The third gen- 
tleman protested against the modern system of doing nothing ; he was anxious 
to bleed, to purge, to blister; and, when opposed, was not sparing of the term 
skeptic, &c. 
"Now, the difference of opinion in this case was not due to skepticism on the 
one side and justifiable faith-i. e., faith justified by knowledge-on the other; 
but to knowledge on the one side, and absence of knowledge on the other. 
" The case was one of degenerative change, retrograde metamorphosis, of the 
arteries; one had become so rotten that its wall had given away, its contents 
had escaped, a clot had formed, and by its mechanical effects had given rise 
to the symptoms. The heart shared in the degenerative changes ; the bleed- 
ing had ceased. To those who understood the real nature of the case the lesions 
present, and the mode in which they had been produced-in short, the pathol- 
ogy of the case-belief in the efficacy of so-called active treatment appeared 
to be not merely unjustifiable faith, foundationless faith, faith without knowl- 
edge, but to be faith in opposition to knowledge, which in Medicine is the worst 
form of skepticism, inasmuch as it is doubt of truth and belief in error-doubt 
which may prevent the saving of life, and belief which, embodied in practice, 
may kill" {The Practical Medicine of To-day, p. 4). 
(a.) Fatty Degeneration. 
Amongst the degenerations which are brought about by the spontaneous 
wearing out of living parts, the most widely spread, and the most important, 
is unquestionably fatty degeneration. It is attended by a continually increas- 
ing accumulation of fat, which replaces the minute elements of tissue in dif- 
ferent organs ; and Simon concludes generally, regarding the presence of such 
oil or fat in textures uninflamed, that it is essentially a sign of weakness or of 
death, representing decomposition of effective material. In such necrobiosis 
the elements of the normal tissue completely perish, and are replaced by fat- 
granules. 
Examples of this degeneration may be seen in the minute elements of 
muscle, especially of the heart; in the acini of the liver, contiguous to the 
capillaries into which the branches of the portal vein break up. In such 
degeneration the cells ultimately disappear, leading to loss of substance and 
atrophy of the gland. It may be seen in the bloodvessels, in the corpora lutea CAUSES OF FATTY DEGENERATION. 
125 
of the ovaries, in the renal epithelium, and in many pathological products, 
such as pus, tubercle, cancer, and the like, when in process of decay; and, in 
short, in nearly all cell-structures, this degeneration is known to occur. 
In every texture this degeneration becomes evident in a similar manner. 
Isolated, extremely minute globules of fat appear in the substance of the cells, 
and becoming more abundant, they gradually replace the normal cell-ele- 
ment. Usually the fat-granules appear at some distance from the nucleus; 
but ultimately they lie as close to each other as in the colostrum corpuscles of 
milk. At last the nucleus is no longer visible, and the membrane of the cell 
finally disappears-probably by a species of solution. If the degeneration 
occurs in the more rigid structures-as, for example, in the walls of arteries 
-the fatty granules retain the form of the cell-structure which they replace. 
Such degeneration in arteries is first seen in the tissue composing the inner- 
most layer of the internal coat. Afterwards the intermediate substance 
softens, the degenerate fat-granule masses fall asunder, and the current of 
blood may carry away the particles of fat with it. Thus a number of uneven 
places (cicatricial-like loss of tissue) may be produced upon the surface of the 
larger vessels without any appearance of ulceration (Virchow). 
In fatty degeneration of the substance of the heart there is discoloration 
of its whole substance. It assumes generally a pale yellow hue, with peculiar 
spots on the papillary muscles. Short yellow streaks, which communicate 
with each other, are to be seen in the direction of the primitive fasciculi, and 
pervading the substance of the papillary muscles. 
Yellow softening of the brain is a form of fatty degeneration; and the 
yellowness is due to the accumulation of finely granular fat. At every point 
where fatty degeneration attains a high pitch, great opacity always presents 
itself. The primitive cells of tissues are always transparent in their normal 
state; but fat in excess renders them opaque. Thus a transparent part 
becomes opaque, as in the cornea, where the fatty clouding marks the arcus 
senilis, described by the late Mr. Canton, in persons past middle life, and 
regarded by him as an index to the existence of fatty degeneration of other 
more important organs, although the importance of the sign may have been 
exaggerated. In some form of Bright's disease the uriniferous tubules become 
filled with fattily degenerated epithelium, which appear as opaque spots on 
the surface of the kidney. 
Additional examples of this fatty degeneration are to be seen in the fatty 
liver, and in mollities ossium, atrophied renal capsules, and thymus gland, and 
the muscles-voluntary as well as involuntary-the fatty degenerations of the 
placenta, of cartilage, of bone, and of morbid growths; indeed, there is no 
kind of tissue, healthy or morbid, which may not undergo fatty degeneration. 
When the normal structure of the part is thus transformed into fat, it is 
ultimately destroyed, and the place of the histological elements is gradually 
occupied by a purely emulsive mass-a kind of milk or fatty debris-that is, 
an amorphous accumulation of fatty particles in a more or less highly albu- 
minous fluid (Virchow). 
Practically it is of importance to know what leads to such degeneration. 
The conditions are mainly as follows: 
(a.) Impediment to the flow of blood to the textures, due to calcification 
or petrifaction of the coats of arteries. Anything damaging to nutrition of a 
part favors such degeneration. 
Thus the hypertrophied heart ceases in time to yield the proper physical 
signs of hypertrophy. Degeneration comes on, and the signs of hypertrophy 
are obscured and ill-expressed, being overlaid by those of degeneration. 
Thus, in hypertrophied hearts, degeneration is really a preservative lesion. 
From this point of view we ought always to discriminate clinically valve- 
lesions arising from endocarditis, as distinguished from degenerative changes 126 
TOPICS RELATIVE TO PATHOLOGY. 
due to old age and other causes, and also distinguish the results of changes 
due to structures damaged from acute inflammation. 
Fatty heart and fatty arteries are concomitants. 
With reference to fatty degeneration in particular organs, see the account 
given of local diseases. 
(b.') Mineral Degeneration-Petrifaction. 
The process followed by tissues undergoing this form of degeneration is very 
similar to that described in the previous paragraphs; but it is necessary to 
distinguish forms of mineral degeneration as distinct from ossification. 
Formerly every kind of tissue condensed to the same degree of hardening 
as a bone was considered to be ossified, and the condition was described as 
" ossification." But although a part may have lime in its intercellular sub- 
stance, and although stellate cells may be present in it, yet it may be merely 
" calcified" or "petrified " tissue, and this condition Virchow briefly described 
as "petrifaction." 
Pathological ossification presupposes that the tissue or part which ossifies is 
called into existence by growth, and not that a previously existing tissue or 
part merely assumes the form or hardness of bone by absorbing calcareous 
salts. Ossification always begins by a growth of new tissue; and deposition 
of calcareous salts in its substance does not take place till a comparatively 
late period. 
Calcification or Petrifaction is a degeneration comparatively more frequent 
in the peripheral arteries, and occurs most commonly in cases where there is 
a tendency to calcifications generally, and where calcareous salts are set free 
at other points in the system, to circulate with the juices (Virchow). 
The lesion, in its purity or genuine form, is to be distinguished from athe- 
roma of the arteries, which implies a combination of the fatty with the cal- 
careous material-the so-called ossification. In both conditions the artery 
may be felt to be a hard and rigid tube, with a calcareous feel to the knife or 
the touch. A careful examination microscopically will show that the degen- 
eration is in the middle coat, that calcification or petrifaction of the minute 
muscular cell-elements has taken place, and that the fibre-cells of the circular 
fibre coat are transformed into calcareous spindle-shaped bodies, mixed with 
more or less fat. The degeneration may also invade surrounding parts, while 
the internal coat of the artery may be unchanged. The larger arteries are 
often brittle, from the mineral degeneration of their tissue-associated with 
fatty degeneration (atheroma'). Patches or plates of the mineral substance 
may be seen imbedded in the middle coat after the inner membrane is stripped 
off. When the smaller vessels undergo the mineral degeneration, the deposit 
resembles particles of oil; and the nature of such an appearance can only be 
determined by the microscope after the application of mineral acids, which 
will dissolve the mineral matter with effervescence. 
Nerve-cells, the fibrous membrane of the brain, the pia mater, and the 
choroid plexus, are all liable to undergo the mineral degeneration. Exu- 
dations and new growths are similarly liable. Dr. Bennett has seen the gall- 
bladder converted into a calcareous shell, and the pericardium into an un- 
yielding box of mineral matter inclosing the heart. The cardiac valves are 
thus often covered with mineral incrustations. Cancer and tubercle-grow'ths 
may be transformed by the mineral degeneration; and Dr. Bennett has shown 
how the calcareous transformation of tubercles is the natural mode of arrest- 
ing their advance. 
The degeneration may follow upon the metastasis of calcareous salts, not 
excreted by the kidneys, in cases of caries of the bones, necrosis, or osseous 
cancer. I have seen specimens in the most interesting collection of Professor PIGMENT DEGENERATION. 
127 
Virchow which show that metastatic deposits of bone-earth have taken place 
in the lungs and in the stomach under such circumstances. Considerable 
portions of the pulmonary tissue were calcified or petrified, without any appar- 
ent injury to the permeability of the respiratory passages. The lesion in the 
lung looked like a portion of fine bathing sponge. The mucous membrane 
of the stomach was in like manner transformed into a calcified or petrified 
mass. It felt like a rasp, and grated under the knife, so that the stomach- 
tubes seemed imbedded in a stiffened mass. The basis of such degeneration, 
in which the lime-salts find a resting-place, are the fine fibrous or connective 
tissues; and hence the degeneration is seen to occur in fibrous tumors, in 
serous membranes, in the parenchyma of lungs and stomach (as in the in- 
stance just mentioned), in cicatrix tissue on the skin, in the valves of the 
heart, in the connective tissue of muscle sheath, as well of the heart as of 
common muscle; in the tunica albuginea, in the fibrin coagula in the heart's 
cavities, in aneurismal sacs, qnd in the thyroid and pineal glands. The creti- 
fication of fibrin, of pus, of tubercle, of cancer, of vegetations, of coagula, all 
pertain to this form of degeneration ; and the process may be traced through 
all stages of progressive degeneration, from the pulp-like condition to cement- 
like, compact, calculous concretion, as in the phlebolite of veins ; also in the 
turbid, chalky, speedily condensing juice of the cysts of the choroid plexus, 
and the cell-incrustations of the pineal gland concretions, as well as in the 
calcification of sarcomata and cancers. With regard to the degeneration as 
seen in tumors, Mr. Paget describes two methods by which it advances- 
namely, a peripheral and an interstitial calcification. The former is the rarer 
of the two. In this form of degeneration the fibrous tumor is seen to be 
coated with a thin, rough, nodulated layer of chalky or bone-like substance. 
In the interstitial form the degeneration is interspersed throughout the tumor, 
and so arranged that by maceration a heavy hard mass is obtained, variously 
knotted and branched, like a lump of hard coral (Paget, Surgical Pathology, 
vol. ii, p. 139). 
(c.) Pigment-Degeneration-Pigmentation. 
In this degeneration pigment takes the place of the minute tissue-elements, 
as fat or lime did in the previously-described conditions. It is seen in mucus- 
corpuscles, as in catarrhal pneumonia, in the pulmonary epithelium, in the 
acini of the liver, in the epidermic tissue, in the corpuscles of the blood in 
ague and melancemia. As in the former degeneration, so in this one, a dis- 
tinction must be carefully made between fat granule-cells and pigmentation, 
for in both cases apparently the same image is offered to view. 
The fat granule-cells appear as brownish-yellow corpuscles, but their indi- 
vidual particles have no positive color; whereas the pigment-cells contain 
unquestionable gray, brown, or black molecules of pigment, which are opaque 
(Virchow). The diagnosis between the two is important, as in the brain,, 
for example, where both sorts of granule-cells, namely, pigment-cells and fat- 
cells, may exist side by side. The former points to apoplexy having existed,, 
the pigment originating probably in a solution of the coloring matter of the 
effused blood, the fat to cerebral softening. Therefore it is of importance for 
the pathological interpretation of the diseased condition to distinguish between 
pigment and fat in the granular form. Such pigment or coloring matter is 
insoluble in potash and acids-even in nitric acid. 
In mucus-corpuscles or catarrhal cells the pigment exists in the form of 
grayish-black granules. They give rise to the smoky gray spots which are 
brought up in great quantity in the sputa in catarrhal states of the pulmonary 
passages; and to an extreme degree where accumulating masses of prolifer- 
ating epithelium take place, as in catarrhal pneumonia and in the phthisis of 128 
TOPICS RELATIVE TO PATHOLOGY. 
colliers, so well described by Dr. Wm. Thomson (Med.-Chir. Trans., vols. xx 
and xxi). 
In the condition known as melanazmia (which, like leukcemia, has cells cir- 
culating in the blood, having made their way into it from definite organs) 
the cells contain black pigment; in the latter case (leukemia') the cells are 
colorless. In melanannia colored elements are met with in the blood which 
do not belong to it (Stiebel, Virchow, Schonlein, Heinrich, Meckel, 
Frerichs, and Tigri). These pigment-cells in the blood were first seen to 
occur in melanotic tumors, and were supposed to be due to the passage of 
particles from the tumors into the blood. This is not yet verified by obser- 
vation. On the other hand, it is to enlarged spleens pervaded by black pig- 
ment that the change in the blood is to be ascribed in such cases, the color 
being due to the absorption of colored particles from the spleen. The class 
of cases which are the most fruitful source of black pigment in the blood are 
those of malarious diseases, e. g., intermittent fevers, and especially in persons 
who have been long afflicted with a considerable enlargement of the spleen. 
In such cases, Virchow, found iu the blood of the heart cells containing such 
pigment; and the cells that bore the color resembled in size and form the 
colorless blood-corpuscles; but there were also other cells of an oblong form 
and nucleated, within which a greater or less number of large black granules 
were to be seen. It is in the more severe forms of intermittent fever that 
such pigment-degeneration occurs. Such pigment is seen to accumulate in 
the minute capillaries of the brain, attaching to the points of division of the 
small vessels, and sometimes associated with the comatose and apoplectic 
forms of intermittent fever. Such pigment is also seen in the minute hepatic 
vessels (Frerichs), where it ultimately gives rise to atrophy of the paren- 
chyma of the liver. In a specimen of liver preserved at the museum of the 
Military Medical School, a deposition of melanotic pigment in a granular 
form is visible amongst the interlobular connective tissue, following mainly 
the course of bloodvessels in an irregular manner; and this case, like all the 
others yet recorded, was associated with a large black spleen. The contami- 
nation of the blood in these cases seems due to a degeneration commencing in 
the spleen. 
In post-mortem lesions the textures are thus seen to be very variously tint- 
ed, red, yellow, brown, green, or black, generally resulting from chemical 
alteration in the coloring matter of the blood or bile. The red pigments, as 
a rule, are due to the altered luematin, originally of a yellow color; and 
which is the common origin of three different kinds of crystals : (1.) Crystals 
of Hcematoidin are the most frequent products of blood-degeneration (Vir- 
chow). (Fig. 9, p. 113, ante.) These are formed spontaneously in the body 
out of hsematin; and in their most perfect form present the shape of oblique 
rhombic columns, of a yellow-red color, or, in thicker pieces, of a deep ruby- 
red. In little plates it frequently bears a considerable resemblance to uric 
acid. In the majority of cases the crystals are of extreme minuteness-diffi- 
cult to see clearly, even with a power of 300 diameters. They are insoluble 
in alcohol, ether, dilute mineral acids, and alkalies; and exhibit a peculiar 
play of green, blue, rose-tint, and yellow colors, under the action of concen- 
trated mineral acids. If large masses of extravasated blood continue to lie 
for any length of time, this is the substance into which the blood is trans- 
formed. An apoplectic clot in the brain, for example, is repaired by a large 
portion of the blood undergoing this transformation, and the color of the re- 
:sulting cicatrix is due to the crystals of hcematoidin. When a young woman 
menstruates, also, the cavity of the Graefian vesicle, from which the ovum 
escaped, becomes filled with coagulated blood, and ultimately hcematoidin 
■crystals are the last memorials of the event (Virchow). Hcematoidin is also 
.allied to the coloring matter of the bile. 
(2.) Crystals of Hcemin, arising out of hoematin, differ from hcematoidin in DEFINITION OF LARDACEOUS DISEASE. 
129 
this, that hitherto they are only known as artificial products which have not 
yet been seen in the human body. They are of a dark-brown color. (3.) 
Rectangular crystals or spicules of Hoemato-crystalline. 
The yellow pigments are due to blood very much dissolved or dispersed, as 
in ecchymosis, or to bile, when it is absorbed in the blood and tinges all the 
textures. Coloring matter due to bile may be recognized in the urine by the 
play of colors it gives with nitric acid. A small quantity of acid gives a green 
hue; and, as more acid is added, blue, purple, violet, and a red or brown- 
yellow color will ultimately appear. Of the brown and dark pigments there 
are two kinds. One kind loses color on the addition of nitro-muriatic acid or 
chlorine water; the other resists not only these agents, but even the action of 
the blow-pipe. This latter pigment consists of carbon. The former is a pecu- 
liar secretion formed within cells, or is a transformation of the coloring matter 
of the blood (Bennett). Blue and purple pigments have been seen in urine 
containing uroxanthin, or the Indican of Schunk ; and illustrate the close con- 
nection subsisting between animal and vegetable coloring matters (Parkes On 
Urine, p. 198). For much more interesting observations on the nature of 
pigmentation, consult Bennett's Principles and Practice of Medicine, p. 249. 
(d.) Fibroid Degeneration. 
Definition.-A very gradual transformation of tissue, with scarcely any percep- 
tible exudation of material capable of growth, into a material having a fibre-like 
appearance. 
Pathology.-This fibroid transformation is chiefly found in membranous 
structures. It takes part in the gradual thickening of serous membranes and 
areolar tissue ; and on the surface of such organs as the spleen and pericardium 
covering the heart (white spot), it very much resembles cartilage, by its dead 
white appearance, as if the capsule of the spleen or covering of the heart had 
undergone cartilaginification (Rokitansky). But there is no resemblance 
beyond appearance between the degenerate formation and cartilage. The 
capsule of the liver is sometimes similarly thickened, and so are the sheaths 
of the vessels composing the capsule of Glisson similarly impaired in some 
forms of cirrhosis. The degeneration is the result of long-continued pressure 
(condensation), perhaps with friction ; or may be a sequence of chronic inflam- 
mation with an exudation. It is a form of sclerosis telce celluloses of new-born 
children (hide-bound f It takes part in the wheals and knolls of skin in 
elephantiasis, and constitutes cicatrix tissue. In synovial membranes it ap- 
pears first as a fibro-serous plate, of milk-white hue, from which the serum is 
ultimately expelled, leaving a dense fibroid band of union, or a thickened, 
opaque, bluish-white, tough patch, as in the arachnoid, pleura, peritoneum, 
pericardium, and endocardium. It is especially so on the heart's valves, which 
become rough, indurated, and thickened under the influence of this degenera- 
tion. 
LARDACEOUS DISEASE-SYN., AMYLOID DISEASE, WAXY DISEASE. 
Latin Eq , Morbus Lardctceus-Idem valent, Morbus Amyloides, Morbus Cereus; 
French Eq., Lardacie-Syn., Maladie Amyldide; German Eq., Speckige oder- 
Amyloide od.er Wachsartige Degeneration; Italian Eq., Lardacea.-Syn., Malattia 
Amiloidea. 
Definition.-A lesion in which the normal textural elements of many organs 
and tissues are transformed into, or infiltrated with, a peculiar substance, sug- 
gesting, on the one hand, an alliance (in some respects only) with the chemical 
characters of amyloid compounds, and, on the other hand, with albuminous sub- 
stances similar to those which pervade the tissues of foetal life. 130 
TOPICS RELATIVE TO PATHOLOGY. 
Pathology.-The London College of Physicians no longer regards this 
lesion as a degeneration, but classes it with other local lesions as a substantive 
disease. 
Professor Virchow, of Berlin, was the first to collect the facts regarding 
this peculiar form of disease, and to put them prominently forward. He 
proved the frequent occurrence in the animal economy of a degeneration, 
distinguished by the production of the peculiar substance to be described, 
which gradually takes the place of normal elements in the tissues so diseased. 
But Drs. Gairdner and Sanders, of Edinburgh, had anticipated many of the 
views and descriptions of the Berlin Professor, and, quite independently of 
Virchow, they initiated in this country the first steps in the elucidation of 
this very remarkable disease. They showed that the waxy condition of the 
liver and kidney was due to the same change as that which was seen to take 
place in the spleen. These valuable communications were made to the Phys- 
iological Society of Edinburgh; and an account of them may be read in the 
Edinburgh Monthly Journal of Medical Science for Feb., 1854, p. 186, and also 
in May of the same year. Notwithstanding these researches, and those of 
Drs. Harris, Aldridge, and others in this country, we have much still to learn 
regarding (1.) The conditions under which this disease occurs; (2.) The 
forms in which it exists; and (3.) The symptoms of the lesion. 
This disease or degeneration has been long known by a variety of names. 
For many years the morbid anatomist has been familiar with a "bacon-like" 
or "lardaceous" infiltration of several solid organs of the body, and especially 
of the spleen and the liver. Portal and Abercrombie described the morbid 
condition in the liver as a "lardaceous degeneration;" and Hodgkin and Bright 
described the same disease as an "albuminous infiltration." In 1842 Rokitan- 
sky was the first to give a clear account, and to describe in detail the "lar- 
daceous" infiltration of the kidney with an "albuminous" transparent sub- 
stance. The lesion so described constitutes his eighth form of " Bright's disease." 
But Rokitansky made no chemical examination of the infiltrated material. 
He simply assumed, from its general appearance, that it was of an albumi- 
nous nature, and he rightly recognized its pathogenetic relations to certain 
cachexias. Budd has described the disease as "scrofulous enlargement of the 
liver." Oppolzer and Schrant have described the lesion by the name of 
"colloid," and Baron by the name of "carnification." The pathologists of 
this country have hitherto described organs so diseased under the term of 
"waxy degeneration." 
Such are the names, derived from appearances generally, under which the 
peculiar disease has been described before microscopic examination demon- 
strated the condition of the structures implicated. 
Chemistry and micro-chemical investigations have modified the views 
regarding the nature of the disease, and now and then have led to modifica- 
tions in the nomenclature. Under this kind of inquisitive investigation it 
has been described (1.) By Virchow under the name of "animal amyloid," 
he believing, from the behavior of the transformed substance with iodine 
and sulphuric acid, that the substance must be classified with the vegetable 
carbodiydrogens-cellulose and starch. (2.) Meckel retains the name of 
"lardaceous" or "cholesterin disease," believing that the essential character 
of the degeneration consists in the development of a peculiar fatty or larda- 
ceous matter, of the nature of cholesterin. (3.) The more extended and 
definite examinations by Friedreich and Kekule have shown that the sub- 
stance of the purest amyloid degeneration more closely resembles the albumi- 
nous principles than any other substance we know of; and (4.) Schmidt has 
arrived at the same conclusion. The question, therefore, is not yet defini- 
tively settled as to the exact nature of the substance into which the tissues 
are transformed, but the weight of evidence points to its being albumen in 
some form; and the albuminoid deposits in the spleen of children, so well NATURE OF LARDACEOUS DISEASE. 
131 
described by Dr. Jenner, must be classed as examples of this disease, and 
probably also the special lesions in rickets. 
Investigations relating to lardaceous disease have taken especially three 
directions. Pathologists have endeavored- 
(1.) To trace the extension of the process of disease or degeneration 
throughout various tissues and organs of the body. 
(2.) To determine the essential nature of the material into which the tissue 
is converted. 
(3.) To determine the conditions under which the disease is brought about. 
Virchow first stated that the large Malpighian sacculi in the spleen (which, 
in some instances, looked like boiled grains of sago) were sometimes com- 
posed of a substance which gave the chemical reactions of cellulose, as seen 
in plants. Cellulose and starch are both vegetable constituents-"isomeric" 
forms of some common material; and what gave special interest to the obser- 
vation of Virchow was the discovery that cellulose is also an element in the 
covering or skin of the "Tunicata"--a genus of acephalous mollusca-and 
therefore not a constituent of only vegetable organization. Dr. Robert 
McDonnell, of Dublin, has also shown that the bloodvessels of the foetus, at a 
certain stage of development, are of the same albuminoid matter. 
This discovery of cellulose in animal tissue induced Virchow to look for it 
or its analogue-namely, " starch"-in the human subject. He recognized it 
in the corpora amylacea of the brain. These contain a substance chemically 
related to starch or cellulose; and these bodies were first seen and named by 
Purkinje, who gave them the name they have, not on account of chemical 
characters, but because he observed them to be laminated like starch. Of 
these corpora amylacea there are two kinds, namely,-(1.) Mineral bodies 
with concentric circles more or less soluble in mineral acids; (2.) Others 
which assume a blue tint with iodine, and a violet color on the subsequent 
addition of sulphuric acid. The relations of these two kinds to each other 
are still unknown. The first are the calcareous particles known as brain- 
sand ; and both were at first described under the name of " corpora amylacea" 
by Virchow, which has led to some confusion. The term ought to be restricted 
to those bodies which, by physical and chemical characters, are assimilated 
to starch. The mineral bodies erroneously described as corpora amylacea are 
chiefly found in the cysts of the choroid plexus and in the pineal gland. On 
the other hand, the starch-like bodies have been found by Virchow, Rokitan- 
sky, Scherer, Kblliker, Busk, and other observers, in the ependyma of the 
ventricles, the septum lucidum, the fornix, the auditory and the optic nerves, 
and also in the prostatic ducts. Concentric lamination of these bodies is not 
always present; nor is the reaction with iodine and sulphuric acid constant.' 
For these reasons Virchow began to examine those organs whose morbid state 
was described by the names already mentioned as having been given to the 
fatty or waxy spleen. He applied solutions of nitric acid, which, when hot, 
gave a yellow hue; he applied caustic ammonia, which gave a brown color; 
and from behavior with reagents generally, he concluded that the substance 
was "albuminoid" in its nature. Iodine and sulphuric acid were subse- 
quently tried. Iodine alone gave a strong yellow-red; sulphuric acid being 
added, developed a blue color, passing into a strong violet hue. An excess 
of acid destroyed the violet hue, causing a dark brown-red color, passing into 
yellow. Meckel, subsequently to these observations of Virchow, came to the 
conclusion that there were four forms of this waxy material-that the basis of 
them all was a peculiar fat allied to cholesterin rather than to starch-that 
various saponaceous products are formed, ending in the development of choles- 
terin ; and although he did not sustain his statement by anything like suf- 
ficient proof, he made the important discovery that it was the system of small 
arteries and capillaries which first suffered in this disease. 
The inquiry into the chemical nature of the lesion becomes still more inter- 132 
TOPICS RELATIVE TO PATHOLOGY. 
esting when connected with the observations and discoveries of Bernard, Pavy, 
and others, on the " sugar-producing" functions of the liver, and on the 
material so formed, which may be separated by chemical processes, and has 
been recently shown by Dr. Robert McDonnell to be a substance which enters 
largely into the constitution of most of the tissues of the embryo (Proceed. 
Royal Society, vol. xii, p. 476). The results of these inquiries bring the 
" starchy substances" of animals in very close physiological alliance, and also 
in alliance with morbid results. The material so found has been called indif- 
ferently " glycogene," " amyloid matter," " zoo-amyline," or " animal-starch." 
It owes it origin, not to any direct function of the organ, but its formation 
seems to take place almost immediately upon contact with albuminous mat- 
ter, when this remarkable product is the result, and which may be obtained 
as a white powder. It seems capable of being produced in greatest abun- 
dance by the hepatic tissue; but its formation may proceed at any part of 
the vascular capillary system. If, therefore, it is thus formed normally, it 
may also be formed, retained, or transformed in a morbid way. In diabetes 
we have an instance of the transformation of the product into sugar at the ex- 
pense of the tissues at large; and which sugar is so discharged by the urine. 
The disease now under consderation has thus had various names to denote 
its presumed chemical nature, namely,-(1.) Cellulose degeneration; (2.) 
Amyloid degeneration; (3.) Cholesterin disease; and now (4.) Albuminoid 
degeneration. 
The analysis of the pure matter is very defective. Such as it is, it shows 
the substance to be albuminoid, and combined with nitrogen rather than 
starch; and those who describe the reaction of cellulose and starch with iodine 
and sulphuric acid, seem only to agree with each other in giving singularly 
diversified descriptions of color, which, perhaps, to those familiar with the 
writings of the late Dr. George Wilson, on color-blindness, may be accounted 
for. Such diversity may be explained in some measure, also, by the fact that 
the degree of concentration of the reagents materially concerns the results; 
for, as Virchow correctly observes, the blue coloration is only got after a con- 
siderable period, and in practiced hands, and it may pass from a bright pur- 
ple to a very blue or even black color; in fact, the blue-black color is an 
error resulting from the decomposition of the iodine solution, by excess of sul- 
phuric acid, throwing down the iodine, which blackens the tissue. Neverthe- 
less, the action of iodine solution on the lardaceous tissue is peculiar and 
definite, independently of a blue color. It is of the nature of a chemical 
reaction. 
The appearance of a chemical reaction, which gives a hue different from 
the mere dyeing with the iodine, and which suddenly deepens in tone, from 
the moment it begins to take effect, to a deep brown-red color, is sufficiently 
characteristic. When this takes place with the solution of iodine alone, it 
distinguishes at once the substance from cellulose and cholesterin. 
By way of chemical analysis very trustworthy results seem to have been 
arrived at by Friedreich and Kekule. On submitting the white amyloid 
matter to ultimate analysis, they obtained the following composition in 
equivalents per cent. (Med.-Chir. Review, 1861, p. 59). 
C. H. N. 
Amyloid, = 53.58 7.0 15.04 
But the composition of albumen, according to Dumas and Cahours, Lieber- 
kuhn, and Ruling, is as follows : 
C. 
H. 
N. 
Albumen, . . . . = 
( .53 5 
. . . . 7.1 .... 
15 8 
Dumas and Cahours, 
? 53.4 
. . . . 7.2 .... 
15.7 
53.5 
. . . . 7 3 .... 
15 7 
Lieberkuhn, . . . 
53.5 
. . . . 7.0 .... 
15 6 
Billing, 
53.8 
. . . . 7.1 .... 
15.5 ANATOMICAL CHARACTERS OF LARDACEOUS DISEASE. 
133 
These results show an almost perfect chemical identity between albumen 
and the morbid substance found in the so-called waxy or lardaceous spleen; 
and demonstrate that the waxy disease, in the spleen, at least, is due to a 
peculiarly modified albuminous material, and not to starch. On the other 
hand, the chemistry of the corpuscular variety of the corpora amylacea occur- 
ring as a deposit in various parts-e. g., in the brain, the prostate, and the 
ependyma of the ventricles-shows a reaction almost identical with starch. 
The corpuscles also have concentric laminae, and, according to some, resemble 
starch-granules when polarized. As regards the corpuscles of the prostate, 
sugar has been chemically produced from them, and demonstrated by Trom- 
mer's test. 
Many of these corpuscular varieties of amylaceous bodies are no doubt of 
the same nature as starch; and therefore the direction which inquiry ought 
now to take will be to determine "whether or not there is any chemical 
affinity on the part of the formless matter of lardaceous disease with the cor- 
puscular variety of the amylaceous concretions?" Such an affinity has been 
assumed hitherto; but, so far as observation has gone, the evidence of any 
affinity seems to be getting less and less. On the other hand, the modifying 
effects of admixture and of growth are very remarkable as regards these pros- 
tatic concretions. Some of them iodine will not color blue, not even after 
sulphuric acid has been added; and as growth proceeds, any starchy matter 
they contain gradually disappears. Many admixtures of organic and inor? 
ganic substances give various shades of color; and the yellow-brown colored 
deposits failed to give forth sugar to Paulizky's attempts. 
General Characters and Anatomical Description of Tissues affected with 
Lardaceous Disease.-The cut surface of an organ so affected has a semi- 
transparent appearance. It feels like a piece of soft wax, or of wax and lard 
combined (Wilks). It cuts into portions of the most regular shape, with 
sharp angles and smooth surfaces; and the thinnest possible slices may be 
removed by a sharp knife for microscopical examination without any special 
preparation. The tissue is abnormally translucent. Water, alcohol, and 
acids do not produce any change upon the transformed parts, which may be 
kept for a length of time without decomposition. The organs affected are 
increased in volume, in solidity, and in weight, absolute and specific. Anaemia 
is predominant; but the color of blood or of tissue shines through the semi- 
transparent morbid substance. 
Lardaceous disease is generally widely diffused; so much so, that a consti- 
tutional state of ill-health seems associated with its production; and in cases 
preceded by a local disease, such as caries of a bone, the lesion may be found 
in the adjacent lymphatic glands only (Billroth). This is the earliest 
appearance of the disease yet recognized. 
The small vessels of the tissue-the more minute arteries in particular- 
are, as a rule, the first structures attacked. The coats of the arteries become 
granular and thickened, apparently by exaggeration of their transverse fibres, 
and at last pellucid, transparent, and hyaline. Their calibre is reduced, and 
their cut section remains patulous. 
It is the transverse fibres of the middle or muscular coat of the vessels 
which first change. Each fibre-cell becomes a compact hyaline, pellucid, 
transparent particle, with an indistinct outline, and all the tissue involved 
becomes at last uniform, clear, and transparent. The diseased artery looks 
like a compact, homogeneous, silvery cord or thread, of a clear and glassy 
appearance, with a lustre like molten glass without polish, or like rough ice. 
This colorless, hyaline, diseased tissue is very tough, but not hard nor brittle, 
like the calcareous degenerate parts. All degenerations tend to obscure the 
original texture, by making it more opaque. This disease, on the contrary, 
renders the affected tissue more transparent and pellucid. The specific cells 
of the functional parenchyma, when the disease affects a solid organ like the 134 
TOPICS RELATIVE TO PATHOLOGY. 
liver or kidney, next undergo the change, which finally spreads to the nutrient 
vessels amongst the connective tissue. According to Dr. Dickenson, the mor- 
bid matter penetrates the coats of the minute vessels, and gradually works its 
way into the surrounding tissue; and the changes which thenceforth result 
vary according to the organ affected. In the solid viscera the lardaceous 
material remains about the vessels, and fills the interstices of the texture. 
Thus, the organs so affected, especially the liver and spleen, increase in size, 
becoming hard, gray, and semitransparent, as if uniformly infiltrated with 
wax. The kidneys, suprarenal capsules, and lymphatic glands are all apt 
to assume the same firmness and wax-like translucency. In the spleen the 
deposit often exaggerates the Malpighian sacculi, till they are larger even 
than grains of boiled sago-more like tapioca, I have seen them in many 
instances. In the mucous membranes of the small intestines the vessels are 
similarly altered in appearance; but Dr. Dickenson believes that the exuda- 
tion, instead of being retained, is passed off by diarrhoea; or, if the stomach is 
affected, by vomiting. 
When a solution of iodine is brought in contact with the affected part, a 
very deep violet-red color is produced. This deep-red color seems to be alone 
a sufficiently characteristic test of the existence of the disease, especially when 
in a few seconds the color increases in depth from the moment it begins to 
take effect. The morbid material seems to have a strong affinity for the 
reagent, "absorbing it readily, holding it tenaciously, and assuming its full 
color," while the healthy parts take only a faint and superficial yellow tinge. 
Hence the contrast which the deep reddish-brown of the morbid parts pre- 
sents, against the uniformly faint yellow of the normal tissue in which it may 
be placed (Dickenson). It is of the nature of a chemical reaction which 
ensues between the iodine solution and the morbidly degenerate part. The 
best test-solution is composed as follows: Twelve grains of Iodine is to be dis- 
solved with twenty-four grains of Iodide of Potassium, and mixed with three 
ounces of Water. Such a test-solution ought always to be at hand in the 
dead-house, or on making a post-mortem examination anywhere. 
Elements of Tissue in which Lardaceous Disease has been demonstrated. 
1. Nervous System: Ligamentum spinale cochlese: atrophied parts of brain 
and spinal cord : gelatinous softening, and tumors. 
2. Spleen: Cells of the Malpighian sacculi and pulp : thickened walls of the 
arteries in all stages : the trabeculse. 
3. Liver: The hepatic cells and intralobular vessels, and intercellular 
tissue. 
4. Kidneys: Malpighian tufts and afferent vessels, the walls of which 
become enormously thickened: areolar tissue in the vicinity of the papillary 
ducts. 
5. Muscular tissue of the heart and the uterus. 
6. Bloodvessels of the villi and mucous membrane of the alimentary canal. 
7. Osseous tissue. 
8. Lymphatic glands. 
9. Old deposits in serous membranes, having lost their fibrous character, 
becoming dense, more vascular, and semitransparent, undergo this metamor- 
phosis (Gairdner). 
10. Tubercle also becomes lardaceous (Gairdner). 
11. The cancerous nodules in a waxy liver also become lardaceous 
(Gairdner). 
12. In some cases of inflammation with exudation on the mucous membrane, 
the exudation has become lardaceous (Virchow). 
13. The fibrin of a hsematocele (Friedreich). 
The extensive range of organs in which this remarkable lesion has now been 
demonstrated clearly shows that it cannot be regarded as merely of local im- 
portance. Its occurrence seems rather to point to some general pathological RESULTS OF LARDACEOUS DISEASE. 
135 
state of which the lesion is the expression. In the first instance it is found 
more particularly affecting the functional capillaries of the most important 
organs of the body-e. g., the kidney, the liver, the spleen, the intestines, as 
well as the minute arteries of nutrition of those organs, and of the pia mater, 
bone, and lymphatic glands. The results of such a disease must therefore be 
sooner or later destructive,-(1.) To the function of the invaded organ ; (2.) 
To its nutrition ; and we can only arrive at a correct pathology of this degen- 
eration by a close observation of the circumstances, condition, relations, and 
symptoms under which the lesion manifests itself. These must be studied 
especially in relation to the functional or physiological anatomy of the organs 
implicated. As yet the lesion has been recognized with certainty only in the 
dead-house. There it has been found associated with certain diseased states ; 
and all the cases agree in this particular, namely, that the constitution of the 
patients has been broken up by ill health (cachexia) of some considerable 
duration before death. So it has been amongst the soldiers dissected at Fort 
Pitt and at Netley; and the following statement is a summary of diseased 
conditions, in the order which furnishes the greatest number of cases of larda- 
ceous diseases: 
Diseased States with which Lardaceous Disease has been found associa- 
ted. or upon which it is engrafted. 
1. Diseases of the bones, especially caries and necrosis in scrofulous subjects. 
Rickets also leads to the amyloid liver and spleen, as observed by Glisson, Por- 
tal, Rokitansky, Lam be, Loeschner, Frerichs, and Jenner. 
2. Syphilis, especially in its ulcerative forms, the cachexia having been 
prolonged. Syphilitic children have been the subject of it when newly born. 
3. The malarious cachexia, especially intermittent fever. 
4. Mercurial cachexia and marasmus. 
5. Pulmonary and intestinal forms of tubercle. 
6. Albuminuria and anasarca. 
7. Diseases of large arteries. 
It has been more recently urged by Dr. Dickenson that the degeneration is 
always the result of extensive purulent formation of long duration. He 
believes that its mode of origin has to do with the removal of alkalies from 
the system; which long-continued suppurations tend to do, leaving a relative 
increase of fibrin. Five-sixths of the cases recorded by him were connected 
with suppuration. Hence he proposes the term depurative infiltration as sig- 
nificant of its pathology. Pus is an albuminous fluid rich in alkaline matter, 
containing about 1 per cent, of alkaline and earthy salts, in the proportion of 
ten of alkaline to one of earthy salts. Next to suppuration, albuminuria, when, 
connected with nephritis, is the most frequent antecedent of lardaceous disease; 
the long-continued discharge of albumen carrying alkali with it. 
As to the origin of the lesion or degeneration, Frerichs has propounded two 
questions, namely,-(1.) Is the lesion due to deposits from the blood of the 
albuminoid matter in some primordial form, and which is generated in the 
blood in consequence of a local disease, such as caries of the bones or other 
suppurative processes ? (2.) Is the albuminoid matter developed locally in 
the affected tissue by the transformation or degeneration of the tissue into 
albuminous matter ? 
Arguments are put forward by Virchow and Frerichs to show that the lesion 
may be due to a deposit from the blood; and Dr. W. H. Dickenson comes to 
the conclusion that the deposit essentially consists of an exudation of a pecu- 
liar material differing from the proper constituents of the body. He considers 
the substance essentially fibrous; and so deposited in consequence of the 
absence of alkali necessary to hold it in solution. Hence he names it " de-al- 
kalinized fibrin," and not a form of albumen. He believes it to be fibrin, 
rather than albumen, on account of the strong tendency it shows to undergo 
contraction after its deposition. It becomes converted into fibroid, tissue as a 136 
TOPICS RELATIVE TO PATHOLOGY. 
coagulum in the arachnoid or as vegetations on the valves of the heart. In 
certain cases also it is identical in appearance and reaction with the hyaline 
casts of the kidney tubes, believed to be fibrinous. Fibrin can be also con- 
verted into the lardaceous substance by removing the alkali it naturally con- 
tains, or only neutralizing it. Conversely, if potash or soda be added to the 
morbid matter, it ceases to give the characteristic reaction with iodine. It 
will not decompose the color of sulphate of indigo, as healthy tissues contain- 
ing alkali will do. Analysis of lardaceous livers show a diminution by one- 
fourth of alkaline salts, and the earthy salts exist in larger quantity than in 
health. 
But there is also undoubted evidence to show in some parts it is of the 
nature of a degeneration. For (1.) In cases where the lesion follows affec- 
tions of the bones, the lymphatic glands adjoining the diseased bones are im- 
plicated before the kidneys, liver, or mucous membrane of the intestines. 
(2.) General causes of ill-health (cachexia), pointing to impoverished blood, 
are in operation, and organs situated in different parts of the body are simul- 
taneously affected. (3.) The fibrin of the blood itself has been observed to 
undergo the degeneration; for Friedreich found a substance which gave the 
amyloid reaction with iodine in the old fibrinous layer of the sac of a hsema- 
tocele. 
In this remarkable lesion or degeneration an acquaintance with a new fact 
in pathology must be recognized-i. e., since 1854-associating itself with 
grave constitutional disease, and distinguished from every other morbid condi- 
tion hitherto known, by the physical, chemical, and physiological characters 
just described. 
The Clinical History of Lardaceous Disease is remarkably deficient. The 
effect of the degeneration is to interfere with function of organs and nutrition 
of parts; and the injurious effects are the more marked as the lesion extends 
through many important organs. For example, hepatic cells cease to take 
part in the formation of sugar or the secretion of bile. Bloodvessels lose their 
power of transmitting fluid through their walls, and become impervious as to 
their canals. Hence those who suffer from lardaceous disease have an appear- 
ance of general ill-health, denoted by paleness of the surface, by symptoms of 
anaemia, hydraemia, or by leukaemic affections of the blood; and the more so as 
the constitution is enfeebled by such morbid processes as suppurative ulcera- 
tion of bones, syphilis, tuberculosis, albuminuria, or malaria. The sequence 
in which the different organs degenerate is uncertain. In most cases of caries 
and necrosis the kidneys seem to be first attacked after the lymphatic glands. 
In cases of intermittent fever, it is usually the spleen which is first affected; 
and generally it seems rare to find several or all the organs affected to the 
same extent. 
Signs or Symptoms associated with this Degeneration discoverable dur- 
ing Life.--On these points data are wanting upon which to found any state- 
ment. The pathological change is of so recent discovery, that well-recorded 
cases, terminating in death, with verification of the symptoms by post-mortem 
inspections, are very few indeed. There is no subject, therefore, more full of 
interest, or one more likely to repay close observation and well-directed patho- 
logical inquiry, than the diagnosis of lardaceous degeneration. Cases in hos- 
pital ought to be most carefully noted, and especially such ambiguous cases 
as those where marasmus, anaemia, or dropsy are primary symptoms, and 
which are not to be accounted for even after the blood has been examined mi- 
croscopically during life, and the condition of the liver, heart, spleen, and 
lymph-glands carefully inquired into, without evincing signs of disease. In a 
remarkable case recorded by Friedreich and Kekule, and quoted in the 
Medico-Chirurgical Review for October, 1860, diarrhoea and vomiting were 
of frequent occurrence, with a systolic murmur of the heart, and high-col- 
ored and albuminous urine, with a specific gravity of 1.019. The patient, a DEFINITION AND PATHOLOGY OF CYSTS. 
137 
female, after suffering from tertian ague for twelve months, became dropsical 
and emaciated. The intestines throughout, the stomach, the colon, the jeju- 
num, and especially the capillary vessels of its villi, were affected, as well as 
the vessels of the kidneys. The urine should be watched as to albumen, or 
deposits, and its amount in relation to body-weight should be recorded. 
When albumen appears, it goes on gradually increasing; and hyaline gases 
increase with the increase of albumen. 
Dr. Stewart, of Edinburgh, records twenty cases and nine dissections in 
cases of Bright's disease, where he considered lardaceous disease to have been 
present {Edinburgh Medical Journal for February, 1861). He records that 
large quantities of urine were passed in the early stage of supposed waxy de- 
generation, and of a specific gravity from 1.005 to 1.015.- In all the cases 
there was a striking general correspondence in the other symptoms; and Dr. 
Stewart thinks that from this similarity of symptoms, and from other consid- 
erations, he is warranted in believing that lardaceous disease existed in the 
eleven cases that did not die. The history of all Dr. Stewart's cases is markedly 
different from that of the fatty kidney which Dr. Bright figured in his first 
plate, and illustrated in his first case. Almost all of the cases were associated 
with long-continued wasting disease; and it has been long known that the 
form of renal affection accompanying phthisis, syphilis, and other wasting 
maladies, is this lardaceous disease. Of the twenty cases related by Dr. 
Stewart, six were associated with phthisis, six with syphilis, two with caries, 
two with intemperance, one with cancer, one with chronic rheumatism, and 
two with no particular disease. 
The lesion is much more common than is generally supposed. It has been 
observed very frequently amongst the soldiers who have been dissected at the 
Military Hospital for Invalids, formerly at Fort Pitt, and now at Netley. The 
microscope and iodine test can alone determine its presence; and without 
microscopic examination the absence of the degeneration cannot be deter- 
mined. For a detailed account of lardaceous disease in the various organs, 
see the descriptions given under Local Diseases. 
CYST. 
Latin Eq., Cystis; French Eq., Kyste; German Eq , Cyste; Italian Eq., Ciste. 
Definition.-A cyst, sac, or bag (to the exclusion of capsules or sheaths forming 
round foreign bodies, extravasations, or parasites'), filled with some substance 
which may be regarded as entirely, or for the most part, its product, whether as a 
secretion or as an endogenous growth. 
Pathology.-Many theories have been put forward to explain the forma- 
tion of cysts; but no single hypothesis has yet been sufficient to account for 
their formation in all situations where they have been found. It has been 
extensively taught that the structure of a cyst consists of an excessive augmen- 
tation of volume of the alveoli of the areolar tissue, composed of condensed 
and modified filamentous tissue. Bichat urged many objections to this view, 
and held that cysts, being in many respects analogous to serous sacs, they 
ought to have the same origin. He held that cyst-growths were aberrant 
forms resulting from unnatural growth of germs in and amongst areolar tissue, 
and that the contents increased with the enlargement of the cyst by growth. 
Rokitansky subsequently followed very much the idea of Bichat, regarding 
the cyst, from its organization and secretory function, as a definite hollow 
structure, whose essential rudiment is a definite functional elementary germ or 
granule. But there are no doubt some cyst formations due to the dilatation 
and growth of natural ducts, sacculi, or follicles, as well as others which form 
by the enlargement and fusion of areolar spaces in connective tissue. 138 
TOPICS RELATIVE TO PATHOLOGY. 
Thus there are three modes in which cysts may be formed, namely: 
(1.) Cysts which are a substantive new growth, having a distinct elementary 
groundwork, derived from cells or the nuclei of cells, pursuing a morbid course 
of growth from their origin, and reaching an enormous development. 
Fig. 11. 
(2.) Cysts which are formed by obstruction, dilatation, and growth of natural 
ducts or sacculi. Examples of such cyst-formations are seen in sebaceous or 
epidermal cysts formed from enlarged hair follicles, and the cysts formed by 
dilated mucous tubes; also certain cysts, containing milk, from enlarged parts 
of lactiferous tubes; ovarian cysts from overgrown Graefian vesicles; and 
lastly, cysts formed from dilated bloodvessels shut off from the main stream. 
(3.) Cysts formed by enlargement and fusion of the areolar spaces in con- 
nective tissue. The tissue of the wall of such cysts becomes condensed, and 
the inner surface secretes fluid like a serous sac. 
Although the observations of Rokitansky and Simon point to the growth 
of cysts in the kidney from the original primary cell elements, yet the obser- 
vations of Drs. Gairdner and George Johnson equally explain their forma- 
tion by local obstruction of uriniferous tubules, and their dilatation into cysts 
above or between the points of obstruction. But whatever may be the source 
of their formation, we have yet to learn, as Mr. Paget specially notes, why 
they tend continually to grow. 
The Figs. 11 and 12 are Rokitansky's representations of the minute struc- 
ture of cysts of the kidney. They represent "nests" of delicate vesicles, 
from a size just visible by id to |th lens to the size of a millet-seed, imbedded 
in a red-gray whitish substance. 
They represent proliferous cyst-formations from the cortical substance of the 
kidney, as a sequel to Bright's disease. The two figures illustrate well Roki- 
tansky's history of proliferous cyst-development, and at the same time what 
he understands by the often-occurring expression, "alveolar type or arrange- 
ment." CLASSIFICATION OF CYSTS. 
139 
In Fig. 11 we have the cyst in all its phases, a is a simple cyst, arising out 
of the expansion of the elementary granule, first into the nucleus, from this 
into the cell, and progressively into the cyst. But it has remained barren, 
and contains only a diaphanous viscid serum within a simple cyst-membrane. 
b represents a parent 
cyst, the early history of 
which accords with that 
of the barren cyst; within 
it, however, new granules 
have formed, and gradu- 
ally became developed 
into vesicles or cysts con- 
taining other nuclei, un- 
til the parent cyst has 
become replete with 
them, and, from being 
spherical, they are ren- 
dered polyhedrical by 
mutual compression. In 
an adjoining parent cyst, 
many of the filial cysts 
have remained barren; 
others contain nuclei in 
the act of splitting, c, c, 
c, c, represent another 
form of development of the parent cyst. Here, again, the parent cyst has 
gone through the same phases, from the elementary granule upwards. But, 
as the cell dilates into the cyst, a granule forms centrally to the latter and 
expands into a filial cyst, centrally to which a third granule opens out in the 
same manner; and so on., These intracystic cysts in their dilatation ulti- 
mately close upon the parent cyst, forming secondary, tertiary, and ulterior 
layers, to which an external fibrous layer is generally added out of the sur- 
rounding blastema. Or this fibrous coat occurs in the alveolar shape. Fig. 
11 affords several examples of this. It is, however, better seen in 
Fig. 12-Where a is the fibrous sheath in progress of development out of 
d, the elongated and caudate nuclei coursing around the parent cyst or aggre- 
gation of parent cysts. They eventually break up into the requisite fibres. 
e is to represent the point-molecule, within an amorphous blastema, out of 
which the nuclei (b) form. They are at first spherical, afterwards elongated, 
and ultimately broken into fibrillation. This constitutes what the author 
designates as the " alveolar type or arrangement." 
Rokitansky teaches that the nucleus grows to be the cyst, whether it be 
simple or barren; and that the outside layers of the cyst-walls, if they are 
complex and thick, are made up of endogenous growths, of nuclei, of cells, or 
of any other structures. 
Thus, a classification of cysts has been conveniently arranged into 
(a.) Simple or barren; and into 
(6.) Compound or proliferous. 
Simple or barren cysts contain fluid or organized matter; compound or 
proliferous cysts contain variously organized bodies (Paget). 
The simple or barren cysts may occur singly or many together (when they 
are called "multiple cysts"), and contain a fluid like that of a serous sac 
(mammary cysts, choroid. plexus cysts, synovial cysts). Some are full of 
blood, or colloid stuff (glue-like), or other peculiar or abnormal fluid. Others 
(transitional between barren and proliferous cysts) contain specific secretions, 
such as milk, semen, mucus, saliva; and they are thus named, according to 
Fig. 12. 140 
TOPICS RELATIVE TO PATHOLOGY. 
contents, as lactiferous, seminal, mucous, salivary, colloid, sanguineoxis, synovial, 
serous. 
The simple or barren cysts contain one or other of the following materials: 
(a.) Gaseous cysts (examples of pneumatoses, see p. 118, ante) are mentioned 
by Mr. Paget, on the authority of Hunter, Jenner, and Cavendish, and the 
preparation is preserved in the Museum of the College of Surgeons, No. 153-4; 
but beyond the description of Plate xxxvii in Hunter's Works, vol. iv, p. 
98, nothing is known concerning such gaseous cysts. 
(b.) Serous cysts, or hygromata, are the most frequently seen. They include 
nearly all which have thin liquid or honey-like contents, of a yellow or brown 
color. They are most frequently found near the secreting or vascular glands ; 
and there is scarcely a part of the body in which they may not be found. So 
common are they in and amongst gland-structures, that they are believed to 
arise from the same germinal elements of membranes that furnish the per- 
petual growth of glandular or secreting elements. Thus, in such sites they 
are held as examples of perverted epithelial or gland-cells. But they are no 
doubt independent of such origin, as in bones, connective tissues, muscles, 
nerves, and fibrous tumors, where their origin is quite independent of gland- 
cells. So complicated are the contents of some cysts, as in bone, that perfect 
ciliated epithelium has been observed in them (Wedl). 
Serous cysts occur chiefly in the neck, the mammary gland, and the gums. 
In the neck they are sometimes described as " hydroceles of the neck." They 
may be single or multiple to the extent of hundreds, having many cavities, 
either separate or communicating. A case of this description proved fatal at 
Netley Hospital in November, 1870. The patient was a young soldier, only 
eighteen years of age, and of five years' service. The left side of the neck 
was enlarged from many cysts, which had been opened into during life, and 
which, at death, were in a state of active suppuration, so that the original 
connection of the cysts was not traceable. On the right side of the neck a 
smooth tumor, about the size of a turkey's egg, occupied the la'tcral region, 
extending beneath the yilatysma myoides, and lying between the fibres of the 
deep muscles of the neck, from an inch and a half below the ear to an inch 
and a half above the clavicle. Commencing small cysts were seen posterior 
to the tissue of the left tonsil, and the pressure of the diseased parts, especially 
from the left side, caused extensive oedema of the pharyngeal and laryngeal 
mucous membrane. The cysts had no connection either with the thyroid or 
lymphatic glands of the neck. Another mass of cystic growths occupied the 
entire pelvis, and was apparently divided into four large lobules. These 
growths pushed the bladder over to the right side, pressing upon it anteriorly, 
and from the left. There was also another development of large cysts in the 
soft parts about the left hip, and upper part of thigh, but the joint was in no 
way implicated. Some of the cysts had been opened in the thigh by a trocar, 
and had commenced to suppurate. The cysts, which were entire, contained 
clear serous fluid, highly albuminous, of a straw color, and having a specific 
gravity of 1.017. The fluid was frequently examined during life, several pints 
having been removed from time to time, but neither during life nor aftpr 
death were any evidences of parasitic development (such as echinococcus) 
discoverable. 
The cysts were obviously developed in and amongst the areolar tissue of 
the neck, pelvis, and thigh ; but the origin of the cysts is extremely obscure. 
It is most probable they had their origin in the corpuscular elements of the 
connective tissue or juice canal system, which permeates that tissue. The 
subject of this cystic disease had been considered to be suffering from scrofula, 
and had been 129 days in hospital at Gibraltar. The exciting cause of the 
swellings was attributed to sleeping in a wet tent, when encamped with his 
regiment at Windmill Hill. Thence he was invalided to Netley, where the 
cystic nature of the tumors in the neck and hip was recognized. On admis- EXAMPLES OF SEROUS CYSTS. 
141 
sion, there was enormous swelling of the left neck from the ear to the clavicle, 
and from the region of the left parotid gland to the ligamentum nuchas. Several 
small openings existed, from which a thin watery discharge exuded. He 
complained of pains in the left hip, simulating rheumatism, accompanied with 
a moderate general swelling of the joint. Respiration sounds were normal. 
He was a spare anaemic lad, badly nourished, and of unhealthy aspect. For 
two months after admission to Netley, the swelling in the neck progressively 
increased in size, and the patient continued to lose flesh, and became more 
and more cachectic. A puncture was made with a small trocar, in two places, 
by Staff Surgeon-Major Mackinnon, C. B., and serous fluid, to the extent of 
six ounces, escaped. The fluid, however, accumulated again very rapidly; 
and ten days later, about half a pint of blood-serum was removed and care- 
fully examined for parasite developments, but with a negative result. At 
this time swelling about the hip-joint was observed. It was of a uniformly 
rounded contour; and the circumference of the upper part of the left thigh 
was five inches in excess of the corresponding part of the opposite limb (right 
side, 15| inches; left side, 20^-). There was much tenderness on pressure 
over the joint; but pressure on the condyles of the femur, in an upward direc- 
tion, did not cause pain in the hip-joint, neither was there lengthening or 
shortening of the limb. Five days later, sixteen ounces of fluid were evacua- 
ted from the facial tumor, and eleven ounces on the following day. After 
another five days, Mr. Mackinnon made an incision over a tumor at the lower 
part of the neck, and exposed a dense glistening membrane-the wall of 
another cyst-from which serous fluid escaped as from, the others. Five days 
afterwards, another tumor was observed on the right side of the neck, rounded, 
smooth, and fluctuating, and this gradually continued to increase till death. 
It was left unopened. The openings by trocar, into the cysts in the left side 
of the neck, led to a depth of several inches; and two of the cysts communi- 
cated ; two others opened into were isolated. Much pain was subsequently 
experienced in the region of the left hip, and in eighteen days the circumfer- 
ence of the thigh had increased three inches. An opening was now made by 
trocar into one of the swellings over the hip, and a pint of fluid evacuated: 
five days later, twenty ounces more escaped. The fluid was of the consistence 
of very thin arrowroot, and with a tendency to stringiness between the fingers, 
consisting almost entirely of an albuminous solution, coagulating into a solid 
white mass on boiling. Soon after, a large tumor, firm and round, containing 
fluid, was detected in the pubic region, giving a sensation to the hand similar 
to a contracted uterus. It was tender on pressure, and much pain was expe- 
rienced on micturition. The excessive daily discharges from the several open- 
ings and cyst surfaces, combined with the acute pain in the hip, and the onset 
of laryngeal irritation from oedema and pressure on larynx and trachea, eventu- 
ally terminated fatally. 
In young children such serous cysts are often congenital (hygroma coUi cys- 
ticum congenitum). Some are connected with the thyroid gland, others are 
transformations of vascular tumors, such as erectile vascular growths or nsevi 
(Paget )» 
Cysts in or near the gums, with contents of a thick honey-like consistence, 
and generally sparkling with crystals of cholesterin, are usually found lying 
behind the reflection of the mucous membrane from the gum to the cheek. 
From their tough thick walls in that situation, they are apt to simulate dis- 
ease of the antrum. 
Cysts in the mammary gland are often due to dilated ducts, portions of 
which assume a cystic form. They may contain milk. Mr. Birkett records 
numerous cases of this kind, from one of which he evacuated ten pints of 
milk. Some contain the remains of milk, such as fat and epithelial scales ; 
or they may be filled with transparent watery fluid, uncoagulable. More 
commonly they contain serous fluid, pure or tinged with blood. They may 142 
TOPICS RELATIVE TO PATHOLOGY. 
also originate (like those of the kidney) independently of the gland-tubes 
(Birkett, Paget). 
Mr. Paget lays down the general rule that the cysts which contain the 
simplest fluids, and which have the simplest walls, are apt to grow to the 
largest size. 
Synovial cysts acknowledge three methods of formation: (a.) From widen- 
ing of spaces in areolar tissue, forming, by condensation, bursae as the result 
of pressure; (6.) Cystic transformation of cells inclosed in the fringe-like 
processes of the synovial membrane of the sheaths of tendons, such as those 
near the wrist-joint, forming ganglions, as they are called. They resemble 
the cysts of the choroid plexus, which grow from the villi at the margins of 
the plexus (Rokitansky), (c.) The mouths of subsynovial follicles, which 
normally open into the cavity of the joint, become obstructed, and the folli- 
cles undergo such dilatation as converts them into subsynovial cysts (Gosse- 
lin, quoted by Paget). Such synovial cysts vary as to contents, being some- 
times serous, gelatinous, or honey-like. 
Mucous cysts are formed in connection with simple mucous membranes, or 
ducts of mucous glands, such as those about the cervix uteri, giving rise to 
Nabothian cysts; or connected with Cowper's glands in the male, forming 
Cowperian cysts. Similar cysts form in connection with cutaneous follicles. 
Examined microscopically, such cysts contain epithelial scales, free fat, tables 
of cholesterin, crystals of triple phosphate, and small hairs in various pro- 
portions. 
Many abscesses projecting into the vagina have their origin in glands near 
the orifice (Bartholino), which become cystic (Paget). 
Mucous cysts are recorded also in the antrum; in the mucous membrane of 
the stomach and other parts of the alimentary canal; in the uterus; in the 
posterior wall of the trachea, forming cystic tumors lying between the trachea 
and (esophagus (Virchow); in the back of the epiglottis, and covering the 
upper orifice of the larynx (Durham). 
Ranula is an analogous affection of the duct of the sublingual gland. 
Sanguineous cysts contain blood, and are probably the result of hemorrhage 
into the cavities of serous cysts, like the transformation of pericarditis into 
hemorrhagic pericarditis, or of a hydrocele into a hcematocele. Such blood-con- 
tents are generally coagulated or thick. Others have their origin in vascular 
noevi. 
Cysts containing oil or fat are rare, except as the residue of fatty degenera- 
tion of other matters. Colloid cysts embrace cysts containing all those mor- 
bid materials described as "pellucid," "jelly-like," "flickering," "half-solid," 
"glue-like." Such material is common in the cysts of bronchoceles and in 
kidney cysts. The density of such contents varies from that of serum to that 
of a firm jelly, and in color it may be of any hue. 
The second kind of cysts are the proliferous or compound cysts, and are so 
named from the occurrence of secondary growths in the interior of the origi- 
nal cysts-cysts growing within cysts, or upon their walls, as in complex ova- 
rian cysts. These secondary growths may hang pendulous from the walls; 
and immense proliferous power exists in ovarian cysts from Graefian vesicles. 
On this subject the student must consult Mr. Spencer Wells's treatise On Dis- 
eases of the Ovaries. 
The mammary and thyroid glands are also often the seat of similar prolif- 
erous cysts; and there are proliferous cysts described by Mr. Paget as recur- 
ring and as cancerous; while there are others developing skin structures 
(sebaceous), and others developing teeth (dentigerous). 
For more details regarding those, the student must consult Mr. Paget's 
Lectures on Surgical Pathology, a work which has mainly furnished the mate- 
rials for this account of cysts. DEFINITION AND PATHOLOGY OF PARASITIC DISEASES. 
143 
PARASITIC DISEASE. 
Latin Eq., Morbus Parasiticus; French Eq., Mala,die Parasitaire; German Eq., 
Parasitiche Krankheit; Italian Eq., Malattia Parasitica. 
Definition.-Forms of disease in which a great variety of lesions, and of 
symptoms of organic disorder, are brought about by the presence of animal or 
plant life, finding a subsistence within or upon some tissue, organ, or surface of 
the human body, or of other animals or plants. 
Pathology.-Parasitic diseases may be considered as due either,-(1.) To 
the existence of parasites from the animal kingdom; or (2.) To parasites from 
the vegetable kingdom; any one or more of which may live either upon some 
surface, or within a cavity of the body, or within the substance of some of 
its tissues or organs. 
From the animal kingdom we have the entozoa and the epizoa, and from 
the vegetable kingdom the parasitic diseases are due to epiphytes and entophytes. 
It is only recently that we have been able to point with distinctness to a vege- 
table parasite finding its way actually into the substance of animal tissues, 
and there progressing in development. Dr. H. V. Carter, the Professor of 
Anatomy and Physiology in the Grant Medical College of Bombay, has 
described a '"fungus disease' of the foot, in which numerous minute tubercles, 
resembling fish-roe, lie beneath the muscles," and affect the tissues from the 
bones to the skin (Trans, of the Med. and Phys. Society of Bombayf 
Plants, as well as man and animals, have their peculiar parasites and para- 
sitic diseases. The mistletoe is a familiar example of a vegetable parasite; 
and the oak apple, or gall-nut, is a familiar example of an animal parasite 
affecting a plant. 
It is known, and in many instances it is capable of experimental proof, 
that some of these parasitic diseases (vegetable as well as animal) may be 
transmitted or communicated indifferently from animals to man, and from 
man to animals. The tape-worms, the encysted, vesicular, and round worms, 
are examples of parasites intercommunicable among animals; and Tinea, 
from the "Dartre tonsurante" of the horse, ox, and cat, having been commu- 
nicated from these animals to man, are instances of vegetable parasites inter- 
communicable among animals. It may be that the so-called blights of plants, 
or the causes of them, are also communicable to animals and to man. We 
know that some of the diseases of man and animals are intimately related 
with famines and unwholesome food, and that famines are due more often to 
diseases of vegetable and animal life than to destruction or loss of food. 
The records of history furnish numerous examples of periods of blight in 
the vegetable kingdom, associated with epizootics among the lower animals, 
and with epidemics affecting the human family. (See Sir William Wilde's 
History of Ireland, compiled in connection with the census taken twenty 
years ago [1871].) The relative connection of these events has scarcely yet 
attracted the attention of pathologists, in human or comparative anatomy. 
Here, indeed, is a wide field for investigation-a territory almost yet unex- 
plored. The medical service of Her Majesty's British and Indian armies 
gives golden chances for observation, if the chances are seized at the moment, 
and the observations connected with facts already known. To the more 
salient of these facts the attention of the student is here directed. 
Since the beginning of the present century, when Rudolphi published his 
systematic work on the entozoa (1808), almost every year has contributed 
new and important facts, which render the subject of Parasitic diseases one of 
increasing interest to the pathologist and the physician. The subject abounds 
with most puzzling riddles in natural history and pathology, especially con- 
cerning the reproduction, the development, and the propagation of parasites. 144 
TOPICS RELATIVE TO PATHOLOGY. 
So long as 180 years ago (1691), the independent nature of such structures 
as the "hydatid cyst" was established by Tyson {Phil. Trans., cxciii, p. 506); 
and it was stated by Pallas, in 1766, that all the cystic worms were forms of 
tape-worms belonging to one species-namely, the cystic or hydatid tape- 
worm ; but it was not then known how their generation and propagation was 
effected. For a very long time the received doctrines regarding the genera- 
tion and development of living beings were tacitly set aside in behalf of such 
"existences." They were believed to arise spontaneously. Inquiry was thus 
set at rest, curiosity seemed satisfied, or investigations followed a fruitless 
direction-as when observations were made on such cysts, in the hope of dis- 
covering in them some evidence of the existence of organs of generation, or 
evidence of some process of generation analogous to what prevails in other 
animals. Ova were looked for, and organs of generation were looked for, 
where neither ova nor organs of generation existed. The calcareous particles 
visible in the tissues of those animals were at one time mistaken for eggs, and 
described as such, in the membrane of the Cysticercus (1841). At last, in 
1842, a great insight was obtained regarding the nature of the generation and 
development of these and other parasites by the publication of facts which 
showed that amongst a certain class of minute Cercarice (worms of a microscopic 
size found in stagnant water), the generation of them was carried on through 
a series of broods produced from one parent, each brood differing from the 
parent and from each other. The discovery of this fact was due to Steenstrup. 
He described the phenomena under the name of " alternation of generation " 
amongst these Cercarice which ultimately live within the body of different 
mollusca {Planorbis and LymnwuP). 
These observations gave quite a new direction and impetus to investigation ; 
and Steenstrup himself foretold that the hydatid cysts would be proved to be 
undeveloped tape-worms, each cyst capable of producing a tape-worm after 
its kind. This view was at once taken up, and independently worked out, 
by Eschricht, Nordmann, Von Siebold, Kuchenmeister, Kraemar, Zenker, 
Leuckart, Wein land, in Germany; Von Benedin, in Belgium; Dujardin, 
Blanchard, and Robin, in France. 
Many physiologists and physicians of this country have been no less accurate 
observers. Barker, Bristowe, Nelson, Erasmus Wilson, Gulliver, Gull, Jenner, 
Busk, Rainy, Cobbold, and Bastian, may be particularly noticed ; and many 
valuable records have been published in isolated papers by officers of the 
Army Medical Department. The conjoint researches of these extensive 
workers have found most philosophical expositors in this country in Dr. E. A. 
Parkes, the Emeritus Professor of Clinical Medicine in University College, 
and now Professor of Hygiene in the Army Medical School {Brit, and For. 
Med. Review, 1853); in Dr. Allen Thomson, Professor of Anatomy in the 
University of Glasgow {Glasgow Med. Journal, No. x, July, 1855); and 
lastly, in Dr. William Brinton, in the Brit, and For. Med.-Chir. Review for 
1857. From these and many other later sources the following account is 
given relative to parasitic diseases, and their rational treatment. 
Kuchenmeister and Von Siebold were the first to prove by experiment that 
the hydatid or vesicular worms were the young or larval states of tape-worms; 
and they demonstrated- 
(1.) That each parasite had an independent life of its own. 
(2.) That most animals have each their own peculiar parasites ; that even 
parasitic animals are themselves infested with parasites. 
" So naturalists observe a flea 
Has other fleas on him to prey, 
And these have other fleas to bite 'em, 
And so proceed, ad infinitum." 
(3.) That some parasites pass or migrate from the body of one animal ELEMENTARY FACTS IN PARASITIC SCIENCE. 
145 
into that of another (including man), or from one part of the same animal 
to another cavity or viscus in it. Such migrations are required for the intro- 
duction of the entozoa or their ova into the animals they inhabit, and where 
they undergo those series of changes about to be described, by which they 
reach maturity. 
(4.) That thus, through food or drink, or both, or by bathing in impure 
water, entozoa pass into the human body, finding their way into the most 
delicate tissues, as minute ova or embryos, or as fecundated females like the 
Guinea-worm. 
(5.) That they undergo progressive changes of development towards matu- 
rity in each of the new localities where they find subsistence and protection. 
These are elementary facts in parasitic science; and the student of Medi- 
cine cannot now rest satisfied with a mere knowledge of the general appear- 
ance of these so-called " worms " as they are found in man and animals. It 
behooves the physician to ascertain their origin, their source, and their mode 
of entrance into the body they inhabit. The easy but unsatisfactory hy- 
pothesis of "spontaneous generation" can no longer be entertained. On the 
contrary, it is now clearly established that all the parasitic entozoa are pro- 
duced more or less directly from fecundated ova. The general and minute 
anatomy of these " worms " must be studied, as well as their modes of gene- 
ration, reproduction, and phases of progressive development; the various met- 
amorphoses of their individual forms; and, their transmigrations from one 
animal into another. We must become acquainted with their existence even 
in and upon plants, as well as in other animals besides man, especially in such 
animals or plants as constitute the food of man-fish, flesh, fowl, mollusca, 
and Crustacea,-and especially also all fresh-water plants, or plants which 
grow on moist ground. 
But domestic animals which are not generally eaten, but which, being the 
companions of man, come, like him, to be infected with parasites, and so tend 
to promote their propagation alike in man and other animals, require atten- 
tion, as to their feeding and habits. 
A knowledge of details relative to the generation and reproduction of para- 
sites is also absolutely necessary in order to appreciate the nature of parasitic 
diseases. Indeed, without such knowledge no advance is likely to be made 
in the prevention of these diseases. It is this kind of knowledge which has 
recently led to most important practical results in the history of animal para- 
sites ; and which most of all seems capable of extending our knowledge of 
parasitic diseases, especially in relation to human pathology, to the rational 
treatment of parasitic diseases, and especially their prevention. 
Parasites of animal organization exist in man and animals in every grade of 
development; and the first lesson for the student to learn is,-how to distin- 
guish entozoa which are sexually complete from those parasitical productions 
which are destitute of sexual organs, which are immature larvae, or 
non-sexual parasites, but which have long been regarded as distinct animals. 
The following is a classified list of Human Parasites, as given by the Royal 
College of Physicians of London, in the Appendix to their Nomenclature, 
p. 232. 146 
TOPICS RELATIVE TO PATHOLOGY. 
HUMAN PARASITES. 
The Parasites are to be returned as registered under Local Diseases. 
SUBDIVISIONS. 
1. Entozoa. 
2 Ectozoa. 
3. Entophyta and Epiphyta 
ENTOZOA. 
CLASSES. 
a. Ccelelmintha. English synonym, Hollow worms. Definition: Worms with 
an abdominal cavity. 
B. Sterelmintha. English synonym, Solid worms. 
c. Accidental Parasites. Definition: Internal parasites, having the habits, 
but not referable to the class, of entozoa. 
1. Ascaris lumbricoides. (Linnaeus.) Habitat: Intestines. 
2. Ascaris myst^x. (Rudolphi ) Habitat: Intestines. 
3. Trichocephalus dispar. (Rudolphi.) Habitat: Intestines. 
4. Trichina spiralis. (Owen ) Habitat: Muscles. 
5. Filaria medinensis. (Gmelin.) Synonym, Dracunculus medinensis. English 
synonym, Guinea-worm. Habitat: Skin and subcutaneous tissues. 
6. Filaria oculi. (Nordmann.) Synonym, Filaria lentis. (Diesing.) Habitat: Eye. 
7. Strongylus bronchialis. (Cobbold.) Habitat: Bronchial tubes. 
8. Eustrongylus gigas. .(Diesing ) Habitat: Kidney and intestines. 
9. Sclerostoma duodenale. (Cobbold.) Synonym, Anchylostomum duodenale. Habi- 
tat: Duodenum. 
10. Oxyuris vermicularis. (Bremser.) English synonym, Thread-worm. Habitat: 
Rectum. 
Class A. Ccelelmintha. 
Class B. Sterelmintha. 
11. Bothriocephalus latus. (Bremser.) T. lata. (Linnseus.) Habitat: Intestines. 
The broad tape-worm endemic to man in some localities only. Its embryo is 
ciliated and developed in water (Knock). 
12. Bothriocephalus cordatus. (Leuckart ) Habitat: Intestines. Recently found in 
North Greenland. 
13. Taenia solium. (Linnseus.) Habitat: Intestines. 
14. Cysticercus of the Taenia solium. Synonym, Cysticercus telae cellulosae. (Rudol- 
phi.) The larva or scolex of the T. solium. 
15. Taenia mediocanellata. (Kiichenmeister.) Habitat: Intestines. 
16. Taenia acanthotrias (Weinland.) Habitat: Intestines. 
17. Taenia tlavopuncta. (Weinland.) Habitat: Intestines. 
18. Taenia nana. (Siebold.) Habitat: Intestines. 
19. Taenia lophosoma. (Cobbold.) Habitat: Intestines. 
20. Taenia elliptica. (Batsch.) Habitat: Intestines. 
21. Cysticercus of the Taenia marginata. Synonym, Cysticercus tenuicollis. 
22. Echinococcus hotninis, or Hydatid of the Taenia echinococcus. (Siebold.) 
23. Fasciola hepatica. (Linnaeus.) Habitat: Liver. 
24. Distoma crassum. (Busk ) Habitat: Duodenum. 
25. Distoma lanceolatum. (Mehlis.) Habitat: Hepatic duct; intestines. 
26. Distoma ophthalmobium. (Diesing.) Habitat: Eye. 
27. Distoma heterophyes. (Siebold.) Habitat: Small intestines. 
28. Bilharzia haematobia. (Cobbold.) Habitat: Portal and venous blood. 
29. Tetrastoma renale. (Della Chiaje.) Habitat: Tubes of the kidney. 
30. Hexathyridium venarum. (Treutler.) Habitat: Venous blood. 
31. Hexathyridium pinguicola. (Treutler.) Habitat: Ovary. 
32. Pentastoma denticulatum. (Siebold.) Habitat: Liver; small intestines. 
Class C. Accidental Parasites. MIGRATIONS OF PARASITES. 
147 
33. Pentastoma constrictum. Habitat: Liver and lung; Negroes on West Coast of 
Africa. 
34. (Estrus hominis. (Say.) English synonym, Larva of the gad-fly. Habitat: In- 
testines. 
35. Anthomyia canicularis. (A. Farre.) Habitat: Intestines; and exciting causes 
of boils by their larva. 
3(5 Phthirius inguinalis. (Leach.) English, synonym, Crab-louse. 
37. Pediculus capitis. (Nitzsch.) 
38. Pediculus palpebrarum. (Le Jeune in Guillemeau.) 
39. Pediculus vestimenti (Nitzsch.) English synonym, Body-louse. 
40. Pediculus tabescentium. (Burmeister.) 
41. Sarcoptes scabiei. (Latreille.) Synonym, Acarus. English synonym, Itch-insect.* 
42. Demodex folliculorum. (Owen.) 
43. Pulex penetrans. (Gmelin.) English synonym, Chigoe. Habitat-. Skin and cel- 
lular tissue. 
Ectozoa. 
44. Leptothrix buccalis. (Wedl. Robin.) English synonym, Alga of the mouth. 
45. Oidium albicans. (Link.) English synonym, Thrush fungus. Habitat: Mouth 
in cases of thrush, and certain mucous and cutaneous surfaces. 
46. Sarcina ventriculi. (Goodsir.) Habitat: Stomach. 
47. Torula cerevisise. (Turpin.) Synonym, Cryptococcus cerevisise. (Kiitzing.) 
English synonym, Yeast-plant. Habitat: Stomach, bladder, &c. 
48. Chionyphe Carteri. Definition: A cotton fungus occurring in the disease called 
Mycetoma. Habitat: Deep tissues, and bones of the hands and feet. 
49. Achorion Schonleini. (Remak.) Habitat: Tinea favosa.f 
50. Puccinia favi. (Ardsten.) Habitat: Tinea favosa.f 
51. Achorion Lebertii. (Robin ) Synonym, Trichophyton tonsurans. (Malmsten.) 
Habitat: Tinea tonsurans.j- 
52. Microsporon Audouini. (Gruby.) Habitat: Tinea decal vans, f 
58. Trichophyton sporuloides. (Von Walther.) Habitat: Tinea Polonica.f 
54. Microsporon furfur. (Eichstadt.) Habitat: Tinea versicolor.f 
55. Microsporon mentagrophytes. (Gruby.) Habitat: Follicles of hair in Sycosis or 
Mentagra.f 
The foregoing list might be extended by the addition of various parasitic vegeta- 
tions, which have been reported under the names of Algse, Fungi, Mycoderms, 
Leptomiti, &c., but the characters or the existence of which are still the subject 
of inquiry. 
The distinction between mature and immature parasites has not been main- 
tained in the classification; but in the description about to be given, it is 
necessary that this distinction shall be maintained. 
The sexually mature entozoa inhabit either the alimentary canal of animals 
or the cayities of the lungs; or, to express it generally, they inhabit such 
parts of the body as are in immediate or free communication with the exter- 
nal air. On the other hand, the non-sexual or immature entozoa, while para- 
sitic, all live inclosed in cysts; such cysts being situated either in the 
parenchyma of organs, like the liver or lung, or in close internal cavities- 
e. g., the peritoneum, pleura, pericardium, or eye, within secreting tubes, blood- 
vessels, and the like. In such places these non-sexual parasites are all 
proved to be incomplete animals. They are the embryos, larvae, or early 
forms of entozoa, which only attain to sexual maturity by migration from the 
place of their earlier abode into the alimentary canal, or pulmonary, or other 
open cavity of different animals. Or, leaving their encysted parasitic state 
in the condition of larvae, they reach maturity in a free state (i. e., liberated 
from their encysted condition), when they are developed in water, in earth,, 
mud, or upon moist plants, or in other conditions favorable for them. 
Entophyta and Epiphyta. 
* The disease Scabies to be returned amongst the parasitic diseases of the skin, 
f To be returned amongst the parasitic diseases of the skin. 148 
TOPICS RELATIVE TO PATHOLOGY. 
The cystic or vesicular entozoa (established by Rudolphi as a separate 
order of parasites) are to be distinguished from those which are not vesicular, 
but which are also inclosed in cysts. Some of the early parasitic forms of 
round worms, as well as others, are thus inclosed in cysts ( Trichina spiralis); 
but they are not cystic or vesicular. Fig. 33, is an example of a cystic 
parasite-e. g., Cysticercus tomia'mediocaneUata; Fig. 13, p. 154, of an en- 
cysted round worm-Trichina spiralis. All entozoa so encysted, whether they 
be cystic or round worms, are found to be immature; and in no instance has 
the encysted entozoon been known to attain sexual completeness, however 
well grown it may appear to be, so long as it remains inclosed in a cyst. 
Sometimes cysts only are found, which may be identified as pathologically 
altered conditions of cystic or encysted entozoa. When free, all these entozoa 
come at last to acquire sexual organs, and, when they have arrived at matu- 
rity, they exercise the function of sexual reproduction. The number of fecun- 
dated ova which most of them produce is enormous. In a tape-worm or ascaris, 
there are many millions; but " the struggle for existence" consigns the greater 
part of them to death as the food of others, such as birds, or fish, or animals 
unfavorable to their growth as parasites. 
The process of fecundation and the development of the embryo from the 
ovum have now been actually observed in a considerable number of the para- 
sitic entozoa; and it is to be remembered, as a general fact, that the develop- 
ment of the ova rarely takes place in the same animal, or in the same part 
of an animal, where the parent parasitic entozoon has passed its life and has 
exercised the generative function. There is either a migration from a para- 
sitic to a free condition for a time (e. g., Guinea-worm, Ascarides, Cercarice) ; 
or from one animal into another animal, the free condition intervening (e. g., 
Bothriocephalus) ; or, lastly, the migration may take place from one part to 
another of the same animal who is the unfortunate host (e. g., Trichina spi- 
ralis; and cases of tape-worm giving rise to Cysticercus). Some entozoa, known 
only as incomplete or immature animals in the parasitic mode of life, attain 
to sexual maturity in the free state; others again, and perhaps the greater 
number, after living free for a time, become sexually complete in the parasitic 
condition (e. g., the Ascarides and the Bothriocephalus). 
" The migrations or changes of habitation of the entozoa, or their ova or 
embryos, appear to take place in a variety of ways: first, by their being 
passed out of the body of the inhabited animal with the faeces or other excre- 
tions ; second, by their being introduced into the bodies of inhabited animals 
with their food or drink; third, by their directly piercing the integument or 
other tissues; fourth, by their piercing the membranes and parenchyma, en- 
tering the bloodvessels, being distributed through them, and subsequently 
piercing their coats to attain other situations. 
"Some of these entozoa are directly developed from their ova, without 
undergoing more remarkable changes than those which are known usually 
to accompany the process of embryonic evolution in many other animals. 
Other entozoa are subject to individual metamorphoses, or the embryo passes 
through successive stages of development of so remarkable a character as to 
mark the regular sequence of the phenomena of progressive formation. There 
are others of the entozoa which are subject to still greater changes in the 
progress of their existence,-changes upon which great light has recently 
been thrown by the remarkable researches of Steenstrup and others, in regard 
to what has been called alternate generation or metagenesis. Thus some of 
the entozoa, by a non-sexual process, undergo that peculiar form of multipli- 
cation in which the immediate progeny of development from the ovum is dis- 
similar from the parent, but produces, without the aid of sexual organs, 
another progeny, which either itself, or by repetition of an analogous process, 
returns to the parental form. This is a process of the nature of an internal or MIGRATIONS OF PARASITES. 
149 
external gemmation, which is often attended with a prodigious multiplication 
of the number of individuals. In some entozoa, again, metamorphosis and 
metagenesis are combined. It is obvious that the external conditions neces- 
sary to maintain these varieties of the vital states must be different" (Allen 
Thomson, Glasgow Med. Journal, 1. c.). 
The lesions and diseases caused by the existence of parasites rather tend to 
embitter existence' than to cause death; and they are especially frequent 
amongst soldiers. With one exception-namely, in the case of the immature 
cystic parasites-the disorders induced are, as a rule, not severe; indeed, it 
is a condition of parasitism that it should not actually destroy the life of the 
animal from which it derives its own subsistence. 
It is the immature parasites which tend to destroy the life of their host, by 
the severe lesions they induce, and the destruction of the parts which they 
cause, when they pass from one place to another, or from one state to another 
onwards to maturity. Thousands of mature worms infest children, yet they 
do not appear ill. But such is not always the innocent history even of the 
mature worms,-undefined illnesses, violent and sudden pains, febrile phe- 
nomena like typhoid or rheumatic fever, chronic inflammations, wastings, 
convulsions, chorea, epilepsy, amaurosis, apoplexy, giddiness (staggers in 
sheep and horses), are the grave results which sometimes befall human or 
other animals who may become the unfortunate hosts of such undesirable 
guests, as mature or immature parasites. Dr. Heslop, of Birmingham, has 
especially called my attention to the fact, that the accounts given of the cere- 
bro-spinal symptoms of worms are remarkably defective ; and he kindly sent 
me part of an essay of his on the subject, originally printed in the Dublin 
Quarterly Journal, No. 55. The following are his conclusions: 
" 1. That in the great majority of cases of tape-worm, and, though with 
lesser frequency, in cases of other intestinal worms, more or less serious and 
peculiar nervous disturbances are apt to arise. 
"2. That the most frequent of these are headache, giddiness, various 
troubles of the special senses, especially singing in the ears, flashes and dark 
spots before the eyes, imperfect amaurosis, and trembling of the limbs. 
" 3. That various anaesthetic, and, on the contrary, neuralgic phenomena, 
are very frequent, usually connected with general lassitude and sense of mus- 
cular feebleness. 
" 4. That, though less frequent than those previously cited, convulsive 
seizures, partaking of the nature of epilepsy or acute eclampsia, or sudden 
attacks of insensibility, mixed with syncope, and, in the female sex, severe 
forms of hysteria, are also often directly traceable to worms. 
"5. That the last symptoms (No. 4) are more common in childhood and 
the earlier periods of life than afterwards, and are more frequently caused by 
the round and thread-worms than by tape-worm. 
" 6. That chorea does not appeal- to be often excited by the irritation of 
worms. 
" 7. That a feeble state of the general health generally accompanies the 
presence of worms; often, in cases of tsenia, proceeding to marked anaemia, 
so as even to lead to the suspicion of the possible existence of Bright's disease. 
" 8. That the irritative phenomena of the digestive tube, even when asso- 
ciated with various symptoms referred to the functions of that tract, do not 
warrant the diagnosis of the presence of taenia; and that their absence does 
not absolutely indicate the absence of the parasite. 
"9. That the frequent appearance of the nervous symptoms above related, 
without a well-marked relation to any special lesion of the nervous system, 
especially if alternating with periods of perfect or nearly perfect freedom, 
should engender the suspicion that worms are present. If to these symptoms 
are added, various ill-defined disturbances of the functions of assimilation, 150 
TOPICS RELATIVE TO PATHOLOGY. 
including occasionally colicky pains, without marked vomiting, pain after 
food, or decided emaciation, it is in the highest degree probable that worms 
are the source of the symptoms. 
"10. That it is probable that many of the symptomatic phenomena of ver- 
mination are connected not with their direct irritation of the mucous mem- 
brane with which they are in relation, but with a general disorder of the sys- 
tem, partly resulting from the parasites, and partly the cause of their main- 
tenance and development in the intestinal tract." 
Sometimes even death is the result. But in any case the prevalence of 
parasitic disease in animals comes in the end to be a national loss, affecting 
the health and wealth of nations, by rendering the flesh of many animals used 
as food innutritions, or altogether unfit for use. 
Following out the arrangement in the Table at pp. 146-147, a detailed de- 
scription of those parasites will now be given, and of the lesions associated 
with them, commencing with- 
I.-Entozoa. 
CLASS A.-CCELELMINTHA, OR HOLLOW WORMS. 
Definition.- Worms of an attenuated cylindrical form, with an abdominal 
cavity, in which an intestinal canal is suspended free. They are possessed of a 
mouth and anus, and have the sexes distinct. 
Pathology.-In their mature state these worms inhabit the alimentary- 
canal, the pulmonary tubes or areolar tissue of man and animals. In their 
immature state some are encysted in the human body, and others come to 
maturity in the open waters. In the human subject they are represented by 
the Ascarides, the Oxyurides, the Trichinae, the Sclerostoma, the Strongylus, 
the Speroptera, and the Filariae. 
A knowledge of the generation of these round worms is of the utmost impor- 
tance for preventing their occurrence in man. The generative organs of these 
nematoid worms are adapted for the reproduction of an enormous number of 
fertile ova. They are male and female; but the males, as a rule, are scarcer 
and smaller than the females. 
The fertility of these animals is enormous. Dr. Eschricht has made an 
elaborate calculation regarding the A. lumbricoides, the commonest parasite 
of man. The ova being arranged like flowers upon a stem in the ovary tubes, 
he has counted fifty in a circle, or in every transverse section. The thickness 
of each ovum he estimates 5-J^th of a line (= -j^ffth of T3th = go^nth of an 
inch); so that in every line of length of the worm there would be 500 wreaths 
of 50 eggs each, = 25,000 eggs. 
The length of each horn of the uterus is taken at sixteen feet, which gives 
2304 lines; and for the two horns it will give 4608 lines. The eggs, how- 
ever, gradually get as large as /oth of a line, so that only sixty wreaths of 
eggs come to be on one line, or about 3000 ova; and an average gives 14,000 
ova in a line-i. e., sixty-four millions of ova in every mature female Ascaris. 
What becomes of all these ova? The embryo is not developed within the 
body of all of these parasites; and the source of the various Ascarides which 
inhabit man is not yet fully known. 
The ova being discharged by millions, many of them in large cities are 
carried into streams of water. An extremely small proportion is ever likely 
again to find their way into the alimentary canal of the animal which was 
the dwelling-place of the parents of these ova. Thus they become food for 
numerous inhabitants of the water, and therefore stand in the same relation 
to many of these animals as the cerealia in the vegetable kingdom to the INCUBATION OF OVA OF ROUND WORMS. 
151 
higher animals on land. Indirectly they thus contribute to the sustenance of 
man and animals. 
But on the other hand, there are many circumstances which tend to show 
that the A. lumbricoides is most frequently introduced as a minute embryo 
with water, or with fresh uncooked vegetable food. 
Dr. Paterson, an eminent physician in Leith, observed that certain families 
who drew water from a public well in a particular street there, were very 
subject to the A. lumbricoides; while towards the other end of the same street 
the families were supplied by the pure water which supplies Edinburgh and 
its vicinity; and these families were free from the parasite. The water of the 
well came from a dirty pond or lake in the vicinity (called Lochend), and in 
its water numerous vermiform animalcules existed, such as the Anguilhda 
fluviatilis, perhaps the embryonic form of an Ascaris. 
Another point to be remembered in all inquiries of this kind is the intense 
tenacity of life, and revival from a state of apparent death, exhibited by these 
parasites; and in no class of animals has the origin by spontaneous genera- 
tion been more strenuously contended for than in regard to these entozoa. For 
example, there is a minute worm of a nematoid kind which is a parasite upon 
wheat grains (the Vibrio tritici) ; some of these being dried, and then remoist- 
ened after a lapse of four to seven days, they resumed their living active state 
(Bauer, in Phil. Trans., 1823, p. 1, quoted by Owen). Dr. Blainville has 
given other similar instances of revival after desiccation; and mature entozoa 
will even resist the effects of such destructive agents as extremes of heat and 
cold, to a degree beyond the endurance of any other minute animals. Owen 
relates that a nematoid worm has been seen to exhibit strong contortions- 
evident vital movements-after having been subjected above an hour to the 
temperature of boiling water with a codfish which it infested. Rudolphi 
mentions of some entozoa which infest herrings annually sent to Berlin hard 
frozen and packed in ice, that they do, when thawed, exhibit unequivocal 
signs of restored vitality (Owen, Lectures on the Invertebrata, p. 80). Ligulce 
are often found alive in undercooked codfish. Rudolphi found individuals of 
Ascarides (spiculigera) stiff and hard in the gullet and stomach of a bird 
(cormorant) kept in spirits of wine for eleven days, and which returned to life 
in warm water. Miram has seen individuals of the Ascarides (acus) from the 
pike become dry, and remain sticking to a board, where they would revive 
again by being placed in water, and in some instances they would move a 
part of the body which had imbibed the fluid, while the remaining part con- 
tinued shrivelled up, and adherent immovably to the board. I have seen the 
same results in the Ascaris which infests the peritoneal covering of the mack- 
erel. Such being the tenacity of life on the part of the mature animal, how 
much more do the ova possess the powers of endurance? Without losing 
latent life, they even develop themselves under circumstances of the most im- 
probable kind. Dr. Henry Nelson and Dr. Allen Thomson have observed 
the development of the ova of the A. mystax to proceed for several days, while 
the parent bodies containing them were immersed in oil of turpentine. I 
have once seen the same occurrence; and also I have seen the development of 
the embryo proceed in spirits of wine for about three weeks before signs of 
vitality had ceased. 
Periods of Incubation of the Ova.-The eggs are ovoid, and covered by a trans- 
parent envelope or chorion, which, after fecundation and segmentation, becomes 
tuberculated. Hence the various accounts given as to their surface appear- 
ance. They are expelled with the faeces in the case of the A. lumbricoides. 
They have been placed in water and taken care of for various lengths of time, 
and Richter records, that at the end of eleven months each ovum contained a 
living embryo. In August, 1853, Verloren and Richter put a fragmennt of 
a mature female Ascaris (marginata of the dog) into water, so as to keep the 
ova moist merely; and he examined them from time to time with the micro- 152 
TOPICS RELATIVE TO PATHOLOGY. 
scope. Segmentation having commenced, the development of the young was 
completed in fourteen days. They moved with great briskness within the 
egg-shells, bid did not break through them. In this imprisoned or encysted 
state they continued throughout autumn and winter; the movements of the 
embryos gradually diminishing, and at last entirely ceasing during the winter 
months, to recommence in the following spring, and become again distinct in 
summer. But, they never broke through the shell. 
The condition of these Ascarides from the encysted state of inclosure within 
the egg is only changed under favorable circumstances-namely, when the 
animals are liberated and carried on to further development; and now it is 
known that the embryo of nematoid worms may pass the winter in a torpid 
state, floating about in the open waters, or lying in moist places. The fully- 
formed embryo is cylindrical, its length y-^th of an inch; the mouth is not 
furnished with the three characteristic papillae of the genus, and the tail ter- 
minates suddenly in a point. It is highly probable, from the evidence, that 
the embryos are directly transferred to the alimentary canal of man from 
river and pond-water. 
1. The Ascaris lumbricoides, or round worm, is perhaps the most anciently 
known, and is the most common of human entozoa. It is now regarded as 
specifically distinct from the A. megalocephala of the horse and the A. suilla of 
the hog (Dujardin, Moquin-Tandon, Cobbold). It is much more common 
in children and adults than in old people. The body is long (six to sixteen 
inches), round, elastic, and attenuated towards both extremities, but more 
attenuated towards the anterior end. It is of a grayish-red color, and suf- 
ficiently translucent to permit its viscera to be seen through its coverings. 
The Ascarides inhabit chiefly the small intestines, but may pass up into the 
gall-ducts, the stomach, the oesophagus, the nostrils, the mouth, or frontal 
sinuses ; and there are cases on record and specimens in museums where the 
worm has evidently penetrated the coats of the intestine, and got into the peri- 
toneum or into the pleura. It sometimes makes its way by the bile-ducts into 
the liver, and leads to hepatic abscesses. An interesting example of this may 
be seen in a preparation in the museum of the Army Medical Department at 
Netley. In some cases they are so numerous as absolutely to obstruct the 
intestines ; in others only a solitary worm, or a pair, may be found. Three 
distinct tubercles surrounding the mouth characterize the genus. The pos- 
terior end is obtuse; but is straighter and thicker in the female than in the 
male. It is abruptly acute and curved in the male. An anus is situated in 
both sexes close to the tail, and in form is like a transverse fissure. In the 
female the body presents a constriction at the junction of the anterior with the 
middle third; and here the vulva is situated. The parasite throughout is 
marked with transverse furrows and with fine striae. Longitudinal equidis- 
tant lines run from the head to the tail, and are independent of the exterior 
envelope. 
2. The Ascaris mystax, which infests every domestic cat, must now be 
regarded as a human parasite (Pickells, Bellingham, Cobbold). It varies 
from an inch and a*half to two or three inches long, its head end being spear- 
shaped, in consequence of two lateral processes, from which it has been named 
A. alata. The ova have the embryo developed within them before they escape 
from the parent, and in this respect they resemble the Oxyuris vermicularis. 
(See description of the Oxyuris vermicular is.) 
3. The Trichocephalus dispar occurs in the caecum and colon, and was first 
noticed by Morgagni. A little more than a hundred years ago (1760-61) a 
student of Gottingen was dissecting the valve of the colon of a girl five years 
of age. He accidentally opened the gut, and several of these entozoa came out. 
Wrisberg and other students considered the worm a new one; but the demon- 
strator of anatomy maintained that it was an Ascaris or an Oxyuris, and a dis- 
pute arose. At last the new parasite got a name as a new worm, and was DESCRIPTION OF THE TRICHINA SPIRALIS. 
153 
called a Trichinalis or hairtail. But it afterwards turned out that its head was 
hair-like, and. not its tail, so it has been since called Trichocephalus. About 
this same time an epidemic raged in the French army stationed at Gottingen, 
and the disease was described under the name of the Morbus mucosus. This 
entozoon was frequently found in the bodies of the soldiers who died during 
the epidemic of this mucous flux. 
It is said to be very common in persons attacked with typhus fever; 
and is found in those dying with excessive discharges from the bowels, as in 
cholera and diarrhoea. 
It is found in France, England, Egypt, Ethiopia, and rarely in Italy; 
abounding particularly in the caput caecum. It is generally thought to be 
scarce in England-a persuasion which Dr. Cobbold thinks has probably 
arisen from " the negligence of pathologists, whose arduous duties connected 
with the superintendence of post-mortem examinations have, perhaps, left 
them little time for these inquiries." On the other side of the Channel this 
parasite is so abundant in some localities, that not less than one-half the 
inhabitants of Paris are affected by it (Duvaine). 
These parasites are males and females, in separate sexes, varying from one 
and a half to two inches. 
The anterior extremity, carrying the head, is the narrow hair end, and it is 
usually buried in the mucous membrane of the intestines, while the remainder 
of the body moves freely in the midst of the mucous secretion, generally coiled 
upon itself. 
The males are shorter than the females, and less thick posteriorly, with a 
long spiculum. The eggs are oval, with resisting shells yf^th of an inch in 
length. 
4. The Trichina spiralis was first seen by Tiedemann in 1822, and de- 
scribed by Mr. Owen in 1835 from a specimen taken to him by Mr. Paget. It 
has since been often recognized chiefly as a dissecting-room curiosity. The 
student tries in vain to clean the fibres of the muscle he is dissecting, which, 
however clearly displayed, still looks as if it were "sprinkled over with the 
eggs of some insect." 
Instances of the T. spiralis in the muscles of the human body are of much 
more frequent occurrence than has generally been supposed. Most probably, 
from their very minute size, they have hitherto been overlooked, and the 
symptoms of illness produced by their presence been mistaken for enteric fever 
and rheumatism. Virchow had not seen a case before 1859, after which he 
met with no less than six in one year. It is perhaps more common in man 
than even the Cysticercus. Zenker, of Dresden, found Trichinae in four out of 
136 dissections-i. e., one in thirty-four. 
Of late, however, much interest has been excited in this subject; for, in 
place of the T. spiralis being quite a harmless parasite, as has been hitherto 
the belief, Zenker has lately shown that it is the source of a new and most 
alarming form of disease; that, in place of remaining harmless and encysted 
in its capsule, only to cretify or degenerate, it may free itself from this cyst, 
and, migrating amongst the muscles, may give rise to symptoms of the most 
serious kind, causing death in a strong and healthy person after a few weeks 
of painful suffering. 
It seems, indeed, to be the most dangerous of all parasites-not even ex- 
cepting the Echinococcus; and it behooves the physician to know something 
about the nature, origin, and development of this entozoon, seeing that its 
pathological relations are now known to be of extreme importance and interest. 
Hitherto the T. spiralis has been known as a minute round worm, inclosed 
in a more or less transparent capsule, lying between the sarcolemma of the 
primitive muscular fibres (Figs. 13, 14); but when the parasite is free, it finds 
its way within that sheath. It forms the type of a distinct genus of nematodes, 
having no genetic relations with the Trichocephalus dispar, as was supposed; 154 
TOPICS RELATIVE TO PATHOLOGY. 
but is reproduced viviparously. The non-encysted Trichina may exist in the 
flesh of animals without being visible to the naked eye. In the encysted state 
they are difficult of detection without the aid of a lens, if cretification has not 
commenced in the cyst. The cysts are round or elongated, and appear, 
according to their shape, like small round dots, granules, vesiculse, or streaks, 
Fig. 13. 
Fig. 14. 
Slightly magnified cyst of Trichina 
spiralis (after Virchow). 
The Trichina spiralis removed from its 
cyst (after Virchow). 
100th of an inch X 300. 
grayish-white or opaque, and quite distinct from the red transparent muscle. 
When the cyst has become calcareous, its limey material may be dissolved 
away by acetic or hydrochloric acid with the evolution of gas, and the para- 
site is then seen coiled up within (Fig. 13). 
The following account of this parasite is given by Dr. Cobbold, from his 
own observations and those of Leuckart: 
" (1.) The Trichina spiralis, in its mature state, is an extremely minute 
nematode helminthe; the male, in its fully developed and sexually mature 
condition, measuring only ygth of an inch, whilst the perfectly developed 
female reaches a length of about ; body rounded and filiform; usually 
slightly bent upon itself, rather thicker behind than in front, especially in 
the males; head narrow, finely pointed, unarmed, with a simple central minute 
oral aperture; posterior extremity of the male furnished with a bilobed caudal 
appendage, the cloacal or anal aperture being situated between these diver- 
gent appendages; penis consisting of a single spicula, cleft above, so as to 
assume a V-shaped outline; female shorter than the male, bluntly rounded 
posteriorly, with the genital outlet placed far forward, at about the end of the 
first fifth of the long diameter of the body; eggs measuring from pole 
to pole ; mode of reproduction viviparous. (2.) The sexually mature trichina 
inhabits the intestinal canal of numerous warm-blooded animals, especially 
mammalia (also of man), and constantly in great numbers. (3.) At the second 
day after their introduction, the intestinal trichinae attain their full sexual 
maturity, lose their spiral figure and become stretched, whilst they grow rap- 
idly, and their generative organs are developed. (4.) Most females contain 
from three to five hundred ova. In six days the female parasites will contain 
perfectly developed and free embryos in the interior, and these, on attaining 
full size, pass out at the vaginal opening. The eggs of the female trichina 
are developed, within the uterus of the mother, into minute filaria-like em- 
bryos, which from their sixth day are born without their egg-shells. (5.) The DESCRIPTION OF TRICHINA SPIRALIS. 
155 
new-born young soon afterwards commence their wandering. They pene- 
trate the walls of the intestines, and pass directly through the abdominal 
cavity into the muscles of their bearers, where, if the conditions are otherwise 
favorable, they are developed into the form hitherto known. (6.) The direc- 
tion in which they proceed is in the course of the intermuscular connective 
tissue. (7.) The majority of the wandering embryos remain in those sheathed 
muscular groups which are nearest to the cavity of the body (abdomen and 
thorax), especially in those which are smaller, and most supplied with con- 
nective tissue. (8.) The embryos penetrate into the interior of the separate 
muscular bundles, and here already, after fourteen days, acquire the size and 
organization of the well-known Trichina spiralis. (9.) Soon after the intru- 
sion of the parasite, the infested muscular fibre loses its original structure. 
The fibrillae collapse into a finely granular substance, whilst the muscular 
corpuscles change into oval nucleated cells. (10.) The infested muscular 
bundle retains its original sheathing up to the time of the complete develop- 
ment of the young trichime, but afterwards its sarcolemma thickens and be- 
gins to shrivel at the extremities. (11.) The spot inhabited by the rolled-up 
parasites is converted into a spindle-shaped widening, and within this space, 
under the thickened sarcolemma, the formation of the well-known lemon- 
shaped or globular cysts commences by a peripheric hardening and calcifica- 
tion. One cyst may have from one to three trichinae. (12.) The migration 
and development of the embryos also take place after the transportation of 
impregnated trichinae into the intestines of a new host. (13.) The further 
development of the muscle trichinae into sexually mature animals is altogether 
independent of the formation of the calcareous shell, and occurs as soon as 
the former have reached their completion. The male and female individuals 
are already recognizable as sexually distinct in their larval state." (Entozoa: 
an Introduction to the Study of Helminthology, with reference more particularly 
to the Internal Parasites of Man, by T. Spencer Cobbold, M.D., F.R.S. Lon- 
don, 1864.) 
The symptoms of the disease induced by this parasite are at first of a febrile 
nature, having a close resemblance to some forms of specific fevers. Dr. Philip 
Frank, lately Assistant Surgeon on the Staff of Her Majesty's Army Medical 
Department, was the first to send an account of this remarkable disease from 
Germany to this country. He described a case of its occurrence in the Medical 
Times and Gazette of May 26,1860; and recently Dr. Parkes has given a short 
notice of trichina disease in the Sanitary Report of the Army Medical Depart- 
ment for 1860, p. 351. The history of the case referred to by Dr. Frank is as 
follows: 
In January, 1860, a servant girl about twenty years of age died in the 
Dresden Hospital from the effects of the T. spiralis; and the muscles of her 
body furnished materials for numerous observations and experiments, which 
have thrown much light on the origin and development of this parasite. The 
illness of the patient commenced about Christmas, 1859; and the symptoms 
may be arranged into two sets: (1.) Extreme lassitude, depression, sleepless- 
ness, loss of appetite, and eventually febrile phenomena which were well ex- 
pressed, so much so, that the case was set down as one of typhoid fever; but 
grave doubts prevailed, for (2.) A new train of symptoms developed them- 
selves-namely, the whole muscular system became the seat of excruciating 
pain, especially in the extremities. Contractions of the knee and elbow joints 
supervened, and associated with such extreme pain as to render extension of 
the limbs impossible. (Edema of the legs followed; and the case terminated 
fatally by pneumonia, about the twenty-eighth or thirtieth day after the first 
symptoms of illness. 
A post-mortem examination of the body showed the muscles moderately 
developed, of a pale reddish-gray color, and dotted over with specks, which 
turned out to be groups of non-encapsuled Trichinae, lying free upon and within 156 
TOPICS RELATIVE TO PATHOLOGY. 
the sheaths of the muscular fibres. They were alive-some coiled up and 
others lying straight; and they appeared to be in all stages of development, 
diffused throughout all the striated muscles of the body, not even excepting 
the heart itself. They abounded in such vast numbers that as many as 
twenty Trichinae were seen in the field of view through a low magnifying 
power, the muscular tissue being everywhere in a degree of very marked de- 
generation. In the jejunum were found sexually mature Trichinae. Death 
was due to the development of the T. spiralis, whose existence fully explained 
the anomalous symptoms which attended the case. 
On looking into the history of the girl, it was found out that she had been 
a servant in a farm-house, and had been taken ill very soon after the killing 
of two pigs and an ox-animals which it is customary to kill about Christmas. 
Pigs are known to be infested with the T. spiralis-so are oxen; and Professor 
Zenker went to the master's house, and found some ham left of the identical 
pig that had been there killed, and also some sausages. The flesh of the pig 
wTas examined microscopically, and every specimen examined showed that the 
pig's flesh was infested with Trichinae in the encysted state. At same time 
Professor Zenker learned that, soon after the girl had been taken ill, the 
housekeeper also became unwell, with similar symptoms, but in a less severe 
degree; and all the servants about the farm became more or less ill about the 
same time. The house of the butcher who had killed the pig was then visited 
by Professor Zenker, who was informed by the wife of the butcher that he had 
been very ill since that event. He had been three weeks in bed, suffering 
from rheumatic pains in the limbs, and had been as if paralyzed over his body 
-unable to move his arms, legs, or neck. He had never suffered anything 
of the kind before, but had always been a healthy and strong man. He 
thought he had caught cold the day he killed the pig; but when it is 
known to be a habit of German butchers to taste the meat they kill, in the 
raw condition, the history of these cases, to Professor Zenker, became a history 
of trichinatous disease-the development and growth to maturity of the T. 
spiralis in the muscles of those who lived at the farm-house, as well as of the 
butcher who had killed the pig, and who no doubt had eaten some of its 
flesh. 
Numerous experiments were made with the flesh of the girl who died in 
this remarkably morbid state. Portions of the flesh were sent by Zenker to 
Professor Virchow at Berlin. He fed a rabbit with some of it, and this 
rabbit died about a month after the feeding, with symptoms of general muscular 
paralysis, and myriads of young Trichinae were seen in its muscles. Other 
rabbits were fed with the flesh of the first rabbit, and they too died with 
similar phenomena. 
Virchow found the villi of the intestines of the rabbits loaded with the ova 
or prospermice of the entozoa; and he found mature Trichinae of both sexes 
moving freely in the mucus of the intestine. The males were filled with 
sperm corpuscles, while the females were densely stocked with ova and their 
germs, and with young ones in the eggs, coiled up like little snakes. 
Another observer had before made similar experiments. Herbst, in 1852, 
fed three young dogs with the flesh of a badger whose muscles were saturated 
with Trichinae. The dogs in their turn became trichinatous; being killed after a 
few months, the parasites were seen in their flesh. Pigeons also were fed 
with moles' flesh known to be trichinatous; and free Trichinae were found in 
the flesh of the neck, the wings, and the thighs of the pigeons in eighteen days. 
But Herbst did not examine into the relation between the capsuled and the 
free Trichinae, as Virchow and Zenker have done. 
The Trichina spiralis is now well known not to be limited to the muscles of 
man. It occurs in eels, cats, dogs, badgers, hedgehogs, pigeons, moles, and 
swine. It has been found in the horse, ox, sheep, and other ruminants; also 
in rabbits, rats, mice, and guinea pigs fed with trichi nous flesh. Thus the EXPERIMENTS WITH THE TRICHINA SPIRALIS. 
157 
debris of an animal eaten by carnivora may become fatal to rodents, or a car- 
cass near a marsh or rivulet may communicate the parasites to man or ani- 
mals drinking such water (Devaine). 
In the summer of 1860, a subject was received into the dissecting-room of 
the University of Edinburgh; and the muscles of that subject contained 
numerous flesh-worms. Dr. Turner (then Demonstrator of Anatomy, and 
now Professor) took the opportunity of verifying the experiments of the Ger- 
man professors. He fed kittens with portions of the human flesh containing 
the worms, which were observed to move, though somewhat languidly, on 
rupturing the cysts. To one cat, on the 7th, 13th, and 16th of July, he gave 
portions of the flesh, and in the intervals fed it on bread, milk, and fish. He 
killed the cat on the 24th of the month. Nothing could be seen with the 
naked eye in the fluid of the small intestines; but on placing a drop below 
the microscope, thread-like worms were seen actively moving about in it, or 
coiling themselves up in a spiral form. Every drop of fluid taken contained 
one or more. Each of these thread-like worms was about ^th of an inch 
long, and -y^^tli of an inch broad, with a pointed and a rounded end, and 
about two-thirds smaller than the mature flesh-worms met with in the muscles 
of the cat. These had migrated from the intestines, and after working their 
way between the fibres of the muscles, had become encapsulated-the cap- 
sules being perfectly transparent. Herbst and Virchow have found the flesh- 
worms both in the mesenteric glands and in the mesentery, and therefore, 
presumably, in transitu between the intestines and the muscles. All the 
phenomena described occurred within the space of a single month; and even 
as early as three weeks after feeding, Virchow found the young brood equal 
in size to those administered at the commencement. The genesis, develop- 
ment, and migrations of these flesh-worms are thus proven to be astonishingly 
rapid. Dr. Thudichum has also very recently verified these experiments; 
and at the conversazione of the British Medical Association, held at Downing 
College, Cambridge, on 4th August, 1864, he exhibited the parasite, 
living, in various stages of development, which he obtained from the muscle 
of a rabbit infested with them, and also from some pork chops {Brit. Med. 
Journal, August 13, 1864). 
Thus the T. spiralis has been shown to be a bisexual parasite, producing 
its young alive in the intestines of the animal whose muscles it may infest. 
So long, as it remains in the capsule, it is immature and non-sexual, and so 
far they are harmless. 
In the mucus of the intestines the mature Trichinae find a suitable place for 
growth and breeding, their progeny finding their way to the muscles, where 
they eventually become encysted; and their favorite haunt there seems to be 
the small muscles of the larynx (Zenker). According to Virchow's conclu- 
sive testimony, all these phenomena occur within the space of a single month; 
and, in his experiments, even as early as three weeks after ingestion, the young 
were found to equal in size those that he administered at the commencement; 
but even in the seventh and eighth week, living Trichinae have been found in 
the intestines, filled with eggs and embryos, rendering it not improbable that 
the intestinal Trichinae bear young repeatedly, which pass into the muscles at 
different times ; hence also the exacerbations of the disease. The genesis and 
migrations of Trichinae are therefore astonishingly rapid, and probably with- 
out parallel in this class of parasites (Cobbold). 
Since the discovery by Leuckart of the round worm, of which the T. spiralis 
is the immature condition, since the case recorded by Zenker, and since the 
more complete knowledge that has been acquired by experiments of the won- 
derful migrations of the young Trichinae, attention has been especially 
directed to the possibility of the trichinatous disease in man being much more 
common than was anticipated. In December, 1860, Professor Wunderlich 
met with a case of prolonged fever, which did not correspond in its course 158 
TOPICS RELATIVE TO PATHOLOGY. 
with any of the well-known specific fevers. The patient was a butcher. He 
eventually got quite well, and so far negatived the diagnosis of acute tuber- 
culosis which had been made. A second butcher, from the same establish- 
ment, came into the hospital with the same symptoms of high fever, with 
immense depression; but the course of the disease again did not correspond 
with any of the known fevers. Here, as in the first case, the muscles were 
particularly implicated, but in a less degree. There was not only muscular 
pains, but absolute soreness of the muscles on pressure. This man, too, 
eventually got well. A third and a fourth butcher, from the same house, 
were also taken ill with similar severe febrile symptoms, but they were not 
seen by Wunderlich. 
These men had been killing a number of pigs; and, as is the custom, they 
ate of the raw flesh. Eight men so ate, and four of them were afterwards 
attacked with these anomalous but severe febrile symptoms. Unfortunately 
none of the pork had been preserved, and the possibility of Trichince existing 
in it had therefore not been proven. Moreover, none of these men died, and 
no evidence of the parasite existing in their muscles was obtainable. But 
looking to the undoubted fact that the use of the raw meat brought on the 
disease, and to the great probability that the wanderings in large numbers of 
the Trichince will produce these symptoms, Professor Wunderlich deems him- 
self justified in thinking that there are some grounds for considering these 
febrile attacks to have been due to trichinatous disease. That individuals 
enjoy good health, although the muscles are infested with the encapsuled 
Trichinae, is now well known, from the number of cases that have been seen 
in dissecting-rooms. Cases are also referred to by Mr. Curling, of its being 
recognized in the muscles of men killed by accident, when engaged in severe 
manual labor (London Med. Gazette, Jan., 1838; also Turner, in Edin. Med. 
and Surg. Journal, 1860, p. 209). The distinguished teacher of clinical sur- 
gery at Berlin, Professor Langenbeck, related to the Medical Society there, 
in 1863, the case of a man from whom he had recently removed an epithelial 
cancer situated in the neck. During the operation, the platysma myoides 
exhibited a singular appearance, which, on careful inspection, was found to 
arise from the presence in the muscle of innumerable dead Trichince, con- 
tained in calcified capsules. On inquiry, the following facts were elicited: 
In the year 1845 there was a "church visitation" (whatever that may mean, 
and it seems to imply some jovial meeting), in which eight persons took part, 
and of these, seven afterwards sat down to a breakfast consisting of ham, 
sausages, cheese, roast veal, and white wine. In the course of three or four 
days every one of the seven persons was seized with diarrhoea, pains in the 
neck, oedema of the face and extremities. Of the seven, four died, and the 
three who survived (among whom was the man operated upon eighteen years 
afterwards by Professor Langenbeck), remained ill for long afterwards. The 
suspicion arose that poisoning, through the agency of white wine, had taken 
place; and an investigation was made, but without any result. The innkeeper, 
however, at whose house the breakfast was given, being still under suspicion, 
was obliged to give up his business and emigrate. The importance of such a 
case in its forensic aspects cannot be overrated; and it becomes an important 
subject of inquiry whether some of our cases of death from suspected but un- 
proved poisoning may not be due to trichina disease, which is now known to 
be much more prevalent than has hitherto been supposed, both in this country 
and in Germany. 
Very recently attention has been again awakened on the subject by an 
occurrence almost tragical. About the middle of October, 1863, there was a 
festive celebration at Pleltstiidt, a small country town in Prussia, near the 
Hartz Mountains, numbering from 5000 to 6000 inhabitants. One hundred 
and three persons sat down to an apparently excellent dinner, mostly men 
in the prime of life. Within a month more than twenty persons had died, OCCURRENCE OF TRICHINA SPIRALIS IN MAN. 
159 
and more' than eighty persons were then suffering from the fearful malady, 
while those who were apparently unscathed were in hourly fear of an outbreak 
of the encapsuled flesh-worms. The dinner had been ordered at a hotel, and 
it was arranged that the introduction to the third course should consist of 
" Rostewurst." The sausage-meat was therefore ordered at the butcher's the 
necessary number of days beforehand, in order to allow of its being properly 
smoked. The butcher, on his part, went to a neighboring proprietor of pigs, 
and bought one of two pigs from the steward of the pig-farm. The steward 
unfortunately sold a pig which his master intended should not be sold, because 
it was not considered to be in good condition. Nevertheless, for this time, at 
least, the butcher got "the wrong sow by the ear." The ill-conditioned pig 
was the one that was killed and worked up into sausages. These were duly 
smoked and delivered at the hotel; and after being toasted before the fire (so 
as to be warmed through merely), they were served to the guests at the 
dinner-table. 
On the day after, several persons who had eaten the dinner were attacked 
with great irritation of the bowels, loss of appetite, great prostration, and 
fever. The number of persons attacked rapidly increased; so much so, that 
great alarm was felt in so small a town lest an epidemic of typhoid fever was 
about to set in. But one of the physicians at last conjectured that some 
poison must be at the bottom of the outbreak, and an active inquiry into all 
the circumstances of the dinner was instituted; and when the muscles of the 
calves of the legs of some of the sufferers began to be affected, the description 
of Zenker's case (already described, pp. 155, 156, ante) was at once remem- 
bered. The remnants of sausages, and of pork employed in the manufacture 
of them, were examined with the microscope, and found to be literally swarm- 
ing with encapsuled flesh-worms. From the muscles of several of the suffer- 
ing victims small pieces were excised, and under the microscope they were 
seen to be charged with Trichina in all stages of development. It could 
therefore no longer be doubted that as many of the 103 persons as had dined 
together and partaken of the " Rostewurst" were affected with trichinous dis- 
ease by eating the trichinous pork, the flesh-worms of which had not been 
killed by the smoking and toasting. On the contrary, the subdued heat of 
toasting would rather foster their vitality. 
This catastrophe awakened sympathy and fear throughout the whole of 
Germany. Most of the leading physicians were consulted in the interest of 
the sufferers; and some visited the neighborhood where most of the affected 
patients were. None could bring relief or cure. Case after case died a slow 
and lingering death, by exhaustion from nervous irritation, fever, loss of muscu- 
lar power, inflammation of the lungs, or of organs essential to life. The cases 
have been observed with great care and chronicled with skill. All the fea- 
tures of the remarkable disease have been registered in such a manner that 
hereafter there can be no difficulty in recognizing the disorder. 
The disease begins a few days after eating the meat in which there were 
Trichina, with loss of appetite, general discomfort after eating, irritation of 
the stomach, vomiting, and diarrho3a. These symptoms last from four to 
eight days, till the progeny are born. Severer symptoms may set in, and 
continue till the parasites are encapsuled, if not previously fatal. These 
symptoms are,-continued diarrhoea and fever; oedema of the eyelids; also 
pain, or at least painful sensation of weakness in the limbs; oedema of the 
joints, sometimes of the whole body; difficulty in moving the tongue; profuse 
clammy perspiration; and those patients who do not become convalescent die 
either unconscious, with symptoms of typhoid fever, or, in a few cases, remain 
conscious to the end, complaining of inability to breathe freely. The suf- 
ferer generally lies on his back, with his legs drawn up, unable to move or 
speak. The only important symptom of typhoid fever said to be absent in 
the disease is the enlargement of the spleen; and it is very probable that 160 
TOPICS RELATIVE TO PATHOLOGY. 
some of the so-called epidemics of typhoid fever in former days were caused 
by the propagation of TrichincE in the human body. But the epistaxis, the 
pains and gurgling on pressure in the right iliac region, the rose-colored erup- 
tion, characteristic of typhoid fever, cannot exist in trichinous disease; while 
the earlier irritation of the stomach and bowels, with oedema of the face and 
severe muscular pains, especially on motion, with breathlessness increasing to 
dyspnoea, or almost asphyxia, ought to render the parasitic disease easy of 
diagnosis from enteric fever. Pneumonia or peritonitis may be suddenly fatal 
in mild cases. 
Since the disease has become better known, a great many cases have been 
observed in Germany, and several cases in the United States. On this sub- 
ject, Dr. Clymer records, in the second American edition of my book, that- 
" In 1859, 1860, and particularly in 1862, many cases were noticed at 
Blankenbourg, chiefly amongst the soldiers. In 1862, of 60 attacked, 2 died 
(Scholz). Two cases were seen by Wunderlich in Leipsic in 1861; and 
Wagner describes 5 cases which occurred there in 1863 (Archiv. der Heil- 
kunde, 1854). Landois met with 12 cases in the island of Rugen in 1861, 
and Wentzel with 20. In that year, at Cosbach, 3 persons of the same 
family; who had eaten of fresh pork, and in whose muscles Zenker found 
trichinae, were affected. In the same year, 300 fell ill with the disorder in 
Magdebourg, and 2 died. In the summer of 1862, at Calbe, 30 persons, in a 
population of 1200, were attacked-9 males, 25 women and 4 children; and 
8 died-1 male, 6 women, and 1 child. In the spring of 1862 there was an 
outbreak at Plauen, in Saxony, and several died (Bohler). In the autumn 
of 1863 the Heltstadt epidemic occurred, already described. There was an 
outbreak at Hedersleben in 1865 (300 cases and 40 deaths) ; at Zittau, in 
1866 (57 cases); and at Gorlitz (80 cases and 1 death). 
" But few cases of the trichinous disease have been recognized in the United 
States. The first cases reported are believed to be those of Dr. Joseph Schnet- 
ter, of New York; 2 cases after eating underdone pork-steaks; neither were 
fatal (January, 1864) ; and 5 cases and 1 death (February, 1864), of persons 
who had eaten raw ham, in which trichinae were subsequently found.* About 
the same time, Dr. Voss, of New York, had 4 cases on board one of the Bre- 
men steamers, then in the harbor. Dr. Voss verified his diagnosis by cutting 
down on the deltoid muscle of one of the affected persons, and removing a 
portion for microscopical examination ; it proved to be filled with trichinae.f 
Dr. J. R. Lothrop, of Buffalo, has reported a case.| Nine cases have hap- 
pened in 1866 in one family at Marion, Iowa, and been reported by Dr. 
Joseph H. Wilson.§ About the 5th of May, six persons in the family of Mr. 
Bemiss, of that place, were taken ill, with the characteristic symptoms of the 
trichinous disease, which was not, however, at first recognized, and the disorder 
was looked upon and treated as typhoid fever. On the 14th of May, three 
other members of the family, became similarly affected. It appeared that 
towards the end of April a couple of smoked hams had been bought, and 
from that time until the 5th of May all the nine had eaten of it sliced raw, 
and all had been taken ill in from five to ten days. Five of the nine died. 
Two post-mortem examinations were made, and trichina? were found in large 
numbers, and very active, in the muscles, in the lungs, and spleen. All the 
organs appeared healthy to the eye. It is stated that one of the family ate 
some of the meat 'rarely done,' and was affected but slightly, and another, 
* Observations on Trichina Spiralis, by John C. Dalton, M.D. The Transactions 
of the New York Academy of Medicine, vol. iii, 1864. 
f Dalton, I. c. 
| A Treatise on the Principles and Practice of Medicine, by Austin Flint, M.D., 1866. 
§ St. Louis Medical Reporter, July 15,1866; Chicago Medical Journal, August, 1866 CASES OF TRICHINA SPIRALIS IN THE UNITED STATES. 
161 
when well cooked, who was unaffected. No portion of the offending ham was 
got for examination; but it was shown that some of it had been given to a 
healthy sow, who died on the 1st of June, 'with all the symptoms of hog- 
cholera ; and on some of her meat being examined, it was found swarming 
with trichinae.' Dr. H. Ristine, of Marion, Iowa, has also reported six cases,* 
happening in the same country, in four families living in the same neighbor- 
hood, all children, their ages ranging from seven to seventeen years. It 
appears that on the 25th of April, 1866, they had all eaten chips of raw 
ham. 'On the 27th they were, most of them, seized with diarrhoea, followed 
in two or three days by the other characteristic symptoms. In the oldest 
girl the order of succession was reversed, the muscular pains preceding the 
diarrhoea.' The 'counterpart of the eaten ham, put up in brine, was examined 
and found to contain trichinous cysts.' The same meat, it is stated, was eaten 
by the family of the owner, when well cooked, and with no bad effects. We 
have no data at present to estimate the degree of prevalence of trichinous 
disease amongst the hogs of this country. 
" The symptoms of the disorder in the pig are said to be loss of appetite, a 
hoarse voice, and aversion to movement, particularly to running; and when 
this is attempted there is dragging of the extremities (Cobbold). Still it is 
positively asserted that the animal may be infested, and yet show no signs. 
Cobbold mentions an instance where a pig appeared remarkably healthy, and 
yet the butcher who ate his flesh died of the disease. Delpech says, in his 
Report to the French Government: 'It is rare that any symptoms are spon- 
taneously developed in the infected animal which would lead to any suspicion 
of the disorder: it has the appearance of perfect health. The butchered 
meat, too, looks well.'j" Dr. H. Jardine states (loo. citj that, in his vicinity, 
the opinion prevails that the trichina spiralis exists in the flesh of animals 
affected with hog-cholera, the symptoms of this disorder being diarrhoea, 
swelling of the neck, stiffness of the limbs, debility, and cough; but the 
opinion has not been yet verified by microscopic examination. 
"The Chicago Academy of Sciences appointed in the spring of 1866 a com- 
mittee of physicians, 'to examine into the facts concerning the supposed 
existence of trichinae in pork raised in this country.' The results of their 
well-conducted observations were, that having procured and examined por- 
tions of muscles taken from 1394 hogs in the different packing-houses and 
butcher-stalls of Chicago, they found trichinae in the muscles of twenty-eight 
hogs; from which they conclude, that in the hogs brought to that city, 1 in 
50 is affected with trichiniasis in a greater or less degree; which would indi- 
cate that trichiniasis in pork is even more common in this country, or in that 
of the Northwestern States, than in Germany. In the town of Brunswick, 
North Germany, where a most careful inspection of 19,747 hogs was made in 
the years 1864-65, only two were found to have trichinae in their muscles; 
'the proportion being 1.10000 to 1.50 in the Chicago pork.'J Oue of the 
tables of the Chicago committee shows the great variation in the number of 
helminthes infesting the several muscles examined. An approximation only 
to the number existing in a cubic inch of a given muscle could be obtained. 
The method adopted was to count the trichinae existing in several different 
portions of a muscle, each a cubic 75th of an inch in size, and to multiply 
the average number to a cubic inch. Of twenty-eight specimens examined 
with this view, only three of them contained over 10,000 to the cubic inch,- 
18,000, 16,000, and 15,000 respectively. The remaining twenty-five were 
infested to a much less degree-from 48 to 6000 in the cubic inch. It was 
* The Medical Record, New York, August 6, 1866 
f See the Report officially made to the French Minister of Commerce by MM. Del- 
pech and Raynal, Bulletin des Academie de Medecine, May, 1866 
J Chicago Medical Examiner, April, 1866. 162 
TOPICS RELATIVE TO PATHOLOGY. 
calculated that a person eating an ordinary meal of the pork from which the 
specimen containing 18,000 to the cubic inch was taken, would soon become 
infested with not less than 1,000,000 of young trichinae.* 
"With regard to the muscles of the hog which are the most common site of 
trichinae, the observations of the Chicago committee do not agree with those 
of European observers. In Germany, the inspectors of pork are instructed 
to examine microscopically nine different sets of muscles,-namely, those of 
the diaphragm, tenderloin, shoulder, front and back of neck, extensors of the 
fore-arm, flexors of the leg, and the muscles of the larynx. In the trichinous- 
infested muscles examined by the Chicago committee, more than one-half 
were spinal muscles, which are not named in the German list. 
"In conducting an examination of the trichinatous pork, the tendinous 
extremities of muscles should be selected, as here they are usually most 
numerous. The cysts are visible to the naked eye as whitish, round, or ovoid 
specks, sprinkling the surface of the muscle. If a very small piece of muscle 
is cut off with scissors, and then torn in shreds with a needle, freeing the cysts 
from the flesh, and these are touched with a drop of hydrochloric acid, the 
lime is dissolved and the white coloring disappears; or a piece of the sus- 
pected flesh may be put into a watch-glass with liquor potasse (1 part to 8 of 
water), when it becomes changed to a mucus-like, clear mass, and the cap- 
sules will be seen as sharply defined minute white specks (Leuckart). But 
it is always better, if possible, to use the microscope, and trichinae not yet 
encysted can only be recognized by the microscope. A thin layer of the sus- 
pected flesh should be cut out with a sharp knife, and spread over a glass 
plate, moistened with a drop of water, covered with a thin piece of glass, and 
examined by a magnifying power of -50. Their intimate structure cannot be 
recognized with a less power than 200 (Althaus)."! 
The vitality of the Trichina is not destroyed in the meat or in other sub- 
stances, such as sausages, in which they may be located, below the tempera- 
ture of boiling water; and it is fully proved that if subjected for a sufficient 
time to insure that every particle has been acted upon by that degree of heat, 
they are found incapable of further development, and are, in fact, destroyed. 
Salting, smoking, and toasting trichinous meat, as is usually done, does not 
appear to be sufficient to destroy the worms in all parts of the meat. 
Picric acid (acidum picro-nitricum) has failed. In trichinous pork of a pig 
killed with picric acid the worms were found alive (W. Muller, of Hom- 
berg). Benzine, too, has failed. 
Carbolic acid has also been recommended; and any of these may kill or 
render the parasite inert if it is still in the stomach; but if its progeny have 
bred, and commenced to penetrate the tissues, nothing seems able to remedy 
the evil till the parasite becomes encapsuled. A few doses of calomel and 
castor oil repeated occasionally, even although diarrhoea may be present, is 
advised by Ruprecht to remove intestinal Trichina. He also recommends 
wet-sheet packing, to relieve the sleeplessness and the copious sweats. 
When this flesh-worm was seen more than thirty years ago, it was little 
thought that the bit of muscle sent to Owen contained the germs of a disease 
* As many as 2,000,000 trichinae have been estimated in the muscles of a man who 
died of the disorder; and Prof. Dalton counted in a piece of muscle (in one of Dr. 
Schnetter's cases) ^th of an inch square, and ^th of an inch thick, where they were 
in average abundance, twelve trichinae, which would give in round numbers over 
85,000 to the cubic inch ; and in the portion of muscle taken from the living subject, 
in Dr. Voss's case, they numbered a little over 7000 to the cubic inch (Dalton, I. c.). 
In one of Dr. Wilson's cases, which proved fatal, 104 trichinae were counted in a piece 
of the rectus femoris muscle measuring T^th of an inch square, and j2th of an inch 
thick, which would give nearly 180,000 to the cubic inch (Clymer). 
f On Poisoning by Diseased Pork; being an Essay on Trichinosis or Flesh-worm 
Disease; its Prevention and Cure. By Julius Althaus, M.D. London, 1866. DESCRIPTION OF GUINEA-WORM. 
163 
which might be carried in a living pig from Valparaiso to Hamburg, and 
then kill almost the entire crew of a merchant vessel. It has been recently 
related that a pig so diseased was shipped at Valparaiso, and killed a few 
days before arrival at Hamburg. Most of the sailors ate of the pork in one 
form or another. Several were affected with the flesh-worm, and died. One 
only escaped being ill. Numerous cases of fever, and epidemics of inscruta- 
ble peculiarity, are now claimed by medical writers, with much show of 
reason, as outbreaks of the flesh-worm disease. 
Professor Eckhardt, of Giessen, has obtained permission to produce the 
disease in a criminal condemned to die, and to try various remedies on him. 
(For a very interesting account of Trichinous or Flesh-worm disease, the 
reader is referred to the recent work of Dr. Althaus on this subject.) 
For the diagnosis of Trichinae, in the muscles of man, Kuchenmeister has 
proposed to harpoon the muscles; but this seems a very severe operation. 
Weicker believes that the best place to look for them is under the tongue, 
close to the fraenum: in cats they can be easily seen in this situation. 
Whether it is so in man is not yet known (Virchow's Archiv., 1861, p. 453, 
quoted by Dr. Parkes, 1. c.). 
5. The Filaria medinensis, commonly called Guinea-worm, or Dracunculus, 
lives amongst the connective tissue of man and of some animals. In this situa- 
tion it is only known as a female, containing in its germinal sac an enormous 
quantity of young Filaria, and resembles a long piece of uniformly thick 
white whip-cord. In this country few are familiar with its appearance, or 
with the lesions it produces ; and we therefore look for our knowledge regard- 
ing the main points in the natural history of this parasite to be furnished to 
us by observers in Africa or Asia; who we hope will fill up the gaps which 
still exist. 
The Guinea-worm is essentially a tropical parasite. It is endemic in the 
hot intertropical regions of Asia and Africa, extending from Egypt, about 23° 
or 24° north latitude, to Sumatra and adjacent islands, as far as 103 or 12° 
south. But it is only in some districts within these tropical limits that the 
parasite abounds. For example, it is endemic in Arabia Petrea, the borders 
of the Persian Gulf and of the Caspian Sea, the banks of the Ganges, Upper 
Egypt, Abyssinia, and Guinea. Its occurrence in Guinea (although it has its 
common name from this place) is extremely capricious. In some districts 
every native who comes off to the ships seems to be affected by it; in other 
places in Guinea it is very rarely seen. 
The F. medinensis is unknown in America, unless the person in whom it 
exists has been in the places where the Dracunculus is endemic. The only 
exception is the Island of Curagao. It is sometimes so extensively dissemi- 
nated that it has been said to prevail after the manner of an epidemic. 
Although this parasite rarely causes death, still it is often the cause of 
great distress and loss of strength to regiments quartered in those places where 
it is epidemic. 
In the Statistical Sanitary and Medical Reports of the Army Medical Depart- 
ment for 1860, the admissions for Dracunculus into the hospital mav be shown 
as follows: 
I.-EUROPEANS. 
Stations. 
Average Strength. 
Total Admissions. 
Ratio per 1000. 
Home Stations,* . . 
97,703 
28 
.3 
Mauritius, .... 
1,886 
17 
9.0 
Bengal, 
42,371 
51 
1.2 
Madras, 
10,696 
19 
1.7 
Bombay, 
11,388 
114 
10.0 
* It is of course to be inferred that these men had served abroad in countries where 
Dracunculus is endemic. 164 
TOPICS RELATIVE TO PATHOLOGY. 
II.-BLACK TROOPS AND ASIATICS. 
Stations. 
Average Strength. 
Total Admissions. 
Ratio per 1000. 
Sierra Leone, . . . 
379 
1 
2 6 
Gold Coast, .... 
313 
77 
246 0 
South China, . . . 
2611 
73 
26.0 
In India, the average number of clays which those affected with the Guinea- 
worm remain in hospital increases progressively with advancing years. During 
the first period of life (18 and under 20 years of age), the average number of 
days under treatment-during which period each person was rendered ineffec- 
tive-was 14.8; during the second period (20 and under 25 years), it was 
16.188 days; during the third period (25 and under 30 years), it was 18.001 
days; during the fourth period (30 and under 35 years), it was 22.718 days ; 
during the fifth period (35 and under 40 years), it was 24.290 days; during 
the sixth period (40 and under 45 years), it was 31.620 days (Ewart). 
Dr. Leith, in the Bombay Mortuary Reports, records 133 deaths from Dra- 
cunculus in eight years (from 1848 to 1857). A fatal result generally takes 
place from hectic (Lorimer) and exhaustion, consequent on the copious dis- 
charges which sometimes follow the presence of the parasite, or from abscesses 
forming and bursting into the abdominal cavity (Ewart). Death has fol- 
lowed from tetanus (Drs. Minas and McKenzie, Trans, of Hydrabad Med. and 
Phil. Society). Great destruction of tissues sometimes results from sloughing ; 
and deep-seated inflammation may attend its existence, with the formation of 
abscesses and deep-seated sinuses. The death of one person is recorded by 
Dr. Minas at Sirsa, in whom the whole body and skin was a network of 
Guinea-worms. As a rule, however, the patient is unconscious of the presence 
of the Dracwtcuhis till it is matured and ready to make its exit. 
The Number of Worms observed in any one individual is very various. In the 
majority of cases only one is present, or known to be making its exit at one 
time. But there are remarkable exceptions to this rule. Mr. Forbes men- 
tions that most of those affected have had two worms extracted; but many 
have had four, five, and six; and when he wrote he was then treating a man 
in hospital in whom no less than fifteen were exposed to view, and many of 
these were extracted. Dr. A. Farre mentions that as many as fifty worms 
have been met with in one person. Such cases, however, are confessedly rare 
even in India, where fifteen worms is about the greatest number observed. 
Seat or Locality of the Parasite.-The lower extremities are by far the most 
frequently affected-or rather, the parasite most frequently tends to make its 
exit there;-98.95 per cent, of the parasites do so. Two cases are recorded 
by Lorimer, remarkable in this respect, that one gave vent to seven and the 
other to thirteen parasites. In the case where seven parasites were extracted, 
two were from the left foot, three from the left leg, one from the right leg, and 
one from the left forearm. In the case where thirteen parasites were extracted, 
four were taken from the left foot, two from the right foot, two from the left 
leg, one from the right leg, one from the right thigh, and three from the right 
forearm. 
The Dracunculus has made its appearance in the socket of the eye, in the 
mouth, in the cheeks, and below the tongue (Scott). Dubois records its exit 
from the nose, the ears, and the eyelids. Dr. Kennedy records cases in which 
the parasite made itself apparent in the back and muscles of the loins. One 
preparation exists in the Museum of the Army Medical Department, in which 
a great number were removed from beneath the scalp. Instances are recorded 
in which the worm has been found in the internal viscera. All such cases 
are regarded as extremely rare. It is of importance to notice, however, that GUINEA-WORM IN HORSES AND DOGS. 
165 
both Dr. Scott and Dr. Van Someran agree in stating that the men who 
carry water in India, in leathern bags on their back, are infested by the Dra- 
cunculus on all that part of the skin that has often been wetted; while Drs. 
Chisholm and Scott state that the legs of persons who walk among grass 
(especially during the rainy season, and particularly gardeners and agricul- 
turists, and those who are obliged to wet themselves frequently) are at all 
seasons liable to Dracunculi. Some animals are said to be affected by the 
parasite. Forbes says that horses and dogs are so affected, and relates that a 
"tatoo" (a small Indian horse) was exhibited at Dharwar, having a Dra- 
cunculus protruding from its right hind fetlock. The parasite was of the 
usual size, and made its appearance as a boil; and no difference could be 
perceived in any respect in it from the Dracunculus which infests man. Clot 
Bey remarks that dogs are also sufferers; but on this head information is 
greatly to be desired. Assistant Surgeon Adam Taylor, of the 1st Goorkha 
Light Infantry, wrote me from Bootan, in 1866, that during the rains of 
August, 1862, he being in medical charge at Hissar, a sandy district about 
seventy miles from the desert of India, he saw a favorite bull-terrier with 
swollen feet. From a fluctuating tumor in one of the hind feet he liberated 
four ounces of serum, and eighteen inches of a Guinea-worm; four inches 
more the next day; and the remainder, about fifteen inches, was wheedled 
out by a native barber the following day. The worm was exactly the same 
as those found in man; and he has repeatedly seen Dracunculus in horses, 
and heard of their existence in camels. He believes the habitat of the para- 
site is sandy soils and not water. 
Migratory Powers exhibited by the Guinea-worm before Extraction.--Dr. 
Smyttan relates the cases of two officers, in one of whom the Dracunculus 
could be felt, and traced with the fingers like a cord under the skin at the top 
of the shoulder. By and by it made its way to the elbow, where it was 
equally distinct; and in a few weeks it gradually worked its way to the wrist, 
whence it was extracted. In the other case the Guinea-worm jvas observed 
under the skin inside the biceps, and about the middle of the upper arm. It 
then passed round the elbow-joint and down to the middle of the forearm, 
then back to the region of the inner condyle of the humerus, whence it was 
extracted. It was three months engaged in this migration. Dr. Paton 
records similar cases (Edin. Med. and Surg. Journal, 1806, vol. ii, p. 151); 
and Dr. Morehead says of his men, that when they had felt the Guinea-worm 
in the thigh, in the first instance, it had subsequently been ejected from the 
foot. He has distinctly noticed the corded feeling of the worm below the 
skin, and observed that it was entirely gone the next day he examined the 
part. Dr. L. W. Stewart, of the Madras Medical Service, relates a very dis- 
tressing instance of this kind which happened to an officer, from whose scro- 
tum a Guinea-worm fifteen inches long had already been extracted. Ten 
days afterwards he experienced an unpleasant sensation in the posterior 
aspect of the left thigh. Day by day the sensation shifted lower down, till it 
reached the popliteal space. A few days later the sensation was experienced 
in the calf. Hitherto nothing was visible; but at the end of sixteen days 
from the first sensation in the thigh, the convolutions of a Guinea-worm could 
be distinctly traced at the outer side of the ankle-joint. Dr. Stewart now 
wished to cut down and extract the parasite, but the evening was too dark, 
and he delayed till the following morning. By the morning visit, however, 
the parasite had again fled, and had taken up a position in the deeper muscles 
of the foot. Not a trace of the worm could be recognized in the place which 
he had evacuated. Many abscesses now formed, and severe inflammation of 
the foot resulted, which coufined the patient for three months before he was 
free of this wandering parasite. Dr. Ewart says he has seen the worm change 
its position from the upper part of the lateral aspect of the thorax to the 166 
TOPICS RELATIVE TO PATHOLOGY. 
groin m the course of twenty-four hours; but he has never seen the creature 
travel from below upwards {Indian Annals, vol. vi, p. 490, July, 1859). 
Structure of the Dracunculus.-It is often a matter of extreme difficulty to 
extract the whole worm without breaking it, and on account of its remarkable 
elasticity (for it may be extended to twice its apparently natural length), 
good measurements of any large number of worms are not easily obtained 
(Busk). Of forty Indian specimens, Ewart gives the average length at 25.25 
inches, the shortest being 12f inches, the longest 40 inches. Clot Bey records 
their length at from 6 inches to 4 feet, in Egypt. Carter gives their dimen- 
sions in India at about 28 inches long, -gth of an inch in diameter. He has 
dissected five. Busk gives the dimensions at from 4 to 6 feet, and y^th of an 
inch in diameter; and he has made out that it grows in 
the human areolar tissue at the rate of about an inch a 
week. 
H. C. Bastian, Professor of Pathology, University 
College, has recently read an account of the anatomy 
of this parasite at the Linnaean Society; and from the. 
records of these excellent observers we have now a very 
complete account of the anatomy of the Guinea-worm. 
The anterior end of the worm (Fig. 15) may be recog- 
nized by a "punctum" in its centre, y^^th of an inch 
in diameter, surrounded by rugae in circles, the external 
of which was 2^-T of an inch in diameter. Above and 
below are two papillae opposite each other, with a trans- 
parent area in the centre of each. These are rather 
oval, ^--th of an inch in diameter, with a transparent 
area of °f an inch. Besides these, two lateral 
tubercles exist, much smaller, more indistinct, and farther from the punctum 
than the upper and lower papillae. They are j^o^th of an inch in diameter. 
It is difficult to obtain a good view of the head; for, as it is the first part 
to protrude through the skin, it is usually rubbed off* or destroyed by the 
treatment adopted for extraction. 
Great varieties in form are presented by the tail or posterior end of the 
worm (Fig. 16). The remains of the attenuated extremity of the young 
Filaria, being more or less persistent in the form of a hook or spikelet, was 
Fig. 15. 
Diagram of the head or 
anterior end of the Guinea- 
worm ; showing (a.) Puncti- 
form mouth l-2300th of an 
inch in diameter; (6.)Upper 
large papillae; (c.) One of 
small lateral papillae; (d.) 
One of four crucial white 
lines meeting at the mouth, 
and occupying intermuscu- 
lar spaces (H. C. Bastian). 
Fig. 16. 
Various forms of the caudal end of the Guinea-worm: (a, b, c.) After Busk-all of them proligerous 
(d.) After,Carter ; (e.) After Greenhow. 
believed at one time to be the penis of a male; and such specimens as showed 
such spikelets have been mistaken for male Guinea-worms. All these forms, 
as Busk showed, have been found in specimens containing living young ones 
(proligerous). All are females that have yet been found, and no males are 
known to exist in the human body. The strength of the tissue of the Dra- 
cunculus is such that a loop of the parasite will suspend a weight of Ilf 
ounces (Scott), and it is elastic to a remarkable degree. On opening the 
body, two longitudinal muscular bands are seen on the dorsal, and two on the STRUCTURE OF THE GUINEA-WORM. 
167 
ventral aspect, running from end to end; while circular or transverse, rugse 
mark the whole extent of the worm; and these are approximated or apart as 
the worm is contracted or extended. The body of the worm (Fig. 17) contains 
an alimentary canal, which commences at the " punctum" and terminates in 
the concavity of the tail end. It is of a yellow color, nearly uniform in size 
throughout its extent, and in its course through the body winds several times 
round the genital tube (Bastian). No outlet has yet been detected. It is 
distinct from the tube containing the young (Forbes). 
The genital organs consist of a large uterine sac or tube, occupying nearly 
the whole length of the worm, and terminating abruptly at either extremity 
in a much smaller tube (probably ovarian), about three-quarters of an inch 
in length. No vagina or vulva can be discovered (Bastian). The whole 
extent of this uterine sac or capsule is crowded with innumerable young, and, 
with the exception of a transparent half inch or so of the worm, the whole 
extent of the parent seems to be a uterus, a matrix, or a proligerous capside, 
carrying a countless offspring, to which no parturient female of anv animal 
can be compared for productiveness; and 
from the fact that no inlet has ever been dis- 
covered to the genital organs, and from va- 
rious other circumstances, Mr. Bastian has 
endeavored to show that this innumerable 
progeny has been produced by a process of 
parthenogenesis similar to that with which we 
are so familiar in the Aphis. 
If a living worm recently extracted be 
well lit up by an argand lamp, the hair-like 
filaments may be seen in motion with a good 
simple lens ; and if a section be made across 
the parasite after it has been hardened in 
glue, the young may be demonstrated in situ 
(Fig. 19). 
When the animal is mature, and present- 
ing its head through the skin, it protrudes 
the extremity of the proligerous capsule 
through one of the small papillee or puncta. 
carrying forward a prolongation of something 
in the form of a loose corrugated sheath (Fig. 
18). It gradually assumes the form of a di- 
lated vesicle filleel with limpid fluid-the 
contents of the proligerous capsule-contain- 
ing flocculent granular matter and young 
Guinea-worms. Carter tells us that, if kept 
moist, the full-grown parent will live many 
hours; and in this state the young will live 
till the parent begins to decompose; and 
when the head end of the worm during its 
extraction may have been dried up foi 
several days outside the wound, the remain- 
ing part with the young still remains alive. 
Mr. Busk says that the young survive aftei 
having undergone a considerable degree oi 
drying up. They are exceedingly numerous 
and constitute the bulk of the contents of the 
parent's body; but are less numerous towards 
the tail end. Each young one may be said 
to consist of a body and a tail, hair-like and finely pointed. The body con- 
stitutes 4ths, and the tail i-ths of the whole length. The anterior extremity 
Fig. 17. 
Fig. 18. 
Fig. 17.-A. Anterior extremity of worm, 
slit open and magnified, showing, (a.) Up- 
per and lower cephalic papillae in profile ; 
(6.) Junction of oesophagus with intestine, 
and constriction of peritoneal sheath; (c.) 
Anterior termination of uterus, with short 
ovarian tube. B. Posterior extremity of 
worm, slit open and magnified in same 
way,showing its hook-like termination; 
and (a.) Posterior termination of uterus 
with ovarian tube; (&.) Termination of 
intestine (Bastian). 
Fig. 18.-Anterior extremity. The ovisac 
(a) is protruded, dilated, and contains 
young: (b.) A funnel-shape sheath sur- 
rounding the protruding ovisac (Green- 
how). 168 
TOPICS RELATIVE TO PATHOLOGY. 
has a- blunt end, with a rounded oval orifice communicating with a cavity 
occupying about one-half of the whole length of the body, and terminating 
ccecally. 
Symptoms of the Guinea-worm in the Human Body.-As a parasite in the 
human body it may be studied during two periods of existence ; but from the 
beginning to the end of its cycle of development its history embraces at least 
three, if not/oar, phases of existence or forms of life: 
Fig. 19. 
lOOths of an inch X 5 diameters. 
lOOths of an inch X 50 diameters. 
A. Appearance of transverse section of adult Guinea-worm, as seen throughout the greater part of 
its length.-(a, a, a, a.) Sections of the/our longitudinal muscles; (6.) The intestine flattened, and lying 
along the edge of one of the longitudinal muscles; (c.) Walls of the uterine sac, often adherent to the 
parietes of the body. B. Young of the Guinea-worm more or less spirally curved (Bastian), 
(1.) During the first period of its existence in the human body the Guinea- 
worm parasite is latent, residing in the connective tissue, at variable depths 
from the surface. During this period it does not exert any irritating influ- 
ence on the surrounding tissue, as has been shown by dissections (Busk). 
(2.) The second period of existence comprehends that of ripening or matu- 
ration of the worm and its progeny, when the worm makes itself felt, and be- 
gins its exit through the skin. This period is marked by characteristic 
symptoms. Drs. Scott, Forbes, Morehead, Lorimer, and Van Someran all 
agree in stating that the earlier symptoms are a pricking, itching heat, which 
is felt at the part where the worm exists, seldom amounting to pain till after 
the lapse of three or four weeks. A small vesicle forms over the part, which 
immediately precedes the appearance of the anterior end of the worm. Dr. 
Scott was himself a sufferer, and writes feelingly on this point (see Med.-Chir. 
Review, 1823). This itching may happen before any vesicle forms; and when 
the vesicle forms, it rapidly enlarges-so rapidly that in a few hours it attains 
the size of a good large filbert (Lorimer). If this vesicle is opened early, it 
is seen to contain a clear and limpid fluid (the fibrinous serum of irritation ?); 
but if untouched for a day or two, its contents become turbid, and sometimes 
bloody, from the rupture of the proligerous sac, and the discharge of the 
young Filaria amongst the serum. These greatly add to the irritation; so 
much so, that when the cuticle is removed, an angry-looking ulcer is exposed, 
in the centre of which the parasite may be seen presenting itself, with a thin 
transparent tendril about an inch in length hanging from its point. 
After the appearance of the vesicle or blister, it is sometimes weeks before 
the worm protrudes itself. 
The contents of the blister, when turbid, are a discharge from the tube of 
the animal; as Wilkins, of 4th Light Dragoons, first surmised, and as shown 
afterwards by the independent observations of Forbes, who found that the 
best way to procure the young Guinea-worm for microscopic examination was 
to lay open this vesicle before the delicate membrane of the proligerous cap- 
sule burst. After the escape of the serum from the vesicle, the delicate trans- 
parent membranous tube or cut de sac is sometimes protruded from the extrem- PERIOD of incubation of the guinea-worm. 
169 
ity of the worm; and if cold water is gently poured in a constant stream upon 
this protrusion, the dilatation and protrusion increase, till an innumerable 
quantity of young is ejected from the ruptured orifice of the dilated tube. 
Forbes says that he has often repeated this experiment; and in one instance 
the transparent tube was again retracted within the limb, after three emis- 
sions of young Guinea-worms. On the following day the tube was found 
again protruding as before; and the same result (namely, emission of young) 
followed the gentle application of the stream of water. The animal will emit 
its young daily in this way for some time; and when it ceases to emit them, it 
is then time to begin the extraction of the parasite (Forbes). 
The Period of the Year when Dracunculus is most prevalent seems to vary con- 
siderably in different parts of India, and the probable causes of these differ- 
ences are of great interest in regard to the origin and spread of this parasitic 
affection. 
At Madras and its vicinity Guinea-worm annually appears with greater 
prevalence during the hot season (Lorimer), comprehending February, 
March, April, May, and June. At Dharwar and its vicinity the admissions 
to hospital for Guinea-worm generally commence in April and May. At this 
time water is scarce, every tank is dried up, wells yield a scanty supply, and 
the natives are obliged to remain at the bottom of the wells by turns, till the 
required supply is obtained; and when the monsoon sets in (rainy season), 
the admissions gradually increase through June, July, August, and September. 
The increase of the disease amongst soldiers or residents seems to advance 
with length of residence, generally during the rainy season. In the Bombay 
and Matoongha districts the admissions to hospital begin in May or June 
(irrigation of fields by the natives being common at this time), but it chiefly 
prevails during the rainy months of June, July, August, and September, and 
is rare after October (Smyttan). Dubois, a missionary at Sattimungalum, 
says that its annual endemic prevalence in the Carnatic villages is in Decem- 
ber, January, and February, during which time more than half the inhabi- 
tants are affected. Dr. Morehead's experience at Kirkee and vicinity gave 
March, April, May, June, and July as the months of gradual increase and 
prevalence; and September, October, November, December, and January as 
those of comparative exemption. 
In the Bheel districts Guinea-worm begins to increase in frequency in Feb- 
ruary ; it is four times as frequent in March, and six times as common in April, 
as in February. It reaches the monthly maximum of prevalence in May. It 
prevails to a great extent in June, and continues to be common throughout 
the monsoon months of July and August. During September, October, No- 
vember, December, and January it is least of all prevalent. The half of the 
year comprising the hot and rainy season is, therefore, the period when Dra- 
cunculus abounds, abruptly commencing with the initiation of the former, and 
terminating more abruptly still with the exhaustion of the monsoon in Sep- 
tember (Ewart). 
All the records agree in assigning to this parasite-(1.) An annual periodic 
recurrence; (2.) Periods (annual) of progressive increase and subsidence; (3.) 
A probably fixed latent period of residence in the connective tissue-a period 
of incubation-of not le^s than twelve months (Lorimer, Mitchell) ; or of 
twelve to eighteen months (Busk). 
The Guinea-worm never makes itself manifest in the human body before 
the second season of residence in the places where it is endemic, a complete 
season being requisite to mature the worm. 
There are some remarkable cases which fix the period of incubation of the 
Guinea-worm in a very decided way. For example, in some excellent remarks 
on this subject by J. Mitchell, Esq., in the supplement to the Madras Times, 
of December 18, 1861, and January 13, 1862, it is related of a gentleman, 
well known to be extensively acquainted with natural history, that when he 170 
TOPICS RELATIVE TO PATHOLOGY. 
was travelling in the Northern Circars, the tents were pitched near a tank, of 
bad repute. He was accompanied by five friends, who, against his advice, 
bathed in the tank. Each of these five persons subsequently became affected 
with the Guinea-worm. In the Indian annals many accurate accounts are 
given which fix the period of incubation at about twelve months. 
Geological Features of Locality and Soil where the Dracuncuhis is Endemic.- 
Evidence of a circumstantial kind tends to connect the parasite with some- 
thing geologically characteristic in the soil, mud, moisture, or water of the 
places where the parasite is endemic; yet information is still very imperfect 
on these points. Morehead believes that all the districts where Dracunculus 
prevails are composed of the secondary trap rock-i. e., of igneous forma- 
tion, as in the villages of the Deccan and Northern Concan, where the para- 
site is indigenous. In the country between the Western Ghauts and the sea- 
coast, where the parasite is rare, the soil is a conglomerate ironshot clay, of a 
red color. 
Chisholm's investigations on this point led him to the conclusion that the 
districts where Guinea-worms abound (i. e., in man) are of volcanic origin, 
with an argillaceous soil, holding much moisture, impregnated with salts or 
percolated by sea-water. Dr. Carter's evidence as to soil is, that the para- 
site abounds where the soil is a decomposing trap, of a clayey consistence, and 
of a yellow color. 
Every regiment which has occupied the lines at Secunderabad, "near the 
large tank called the 'Hausen Saughur,'" has suffered from the Dracunculus 
(Lorimer). The cause of the disease exists in or near the lines at that place; 
and the soil is marshy which borders on the tank. The experience of the 19th, 
the 4th, 5th, 1st, and 35th Regiments of Native Infantry all fix the locality 
of the Guinea-worm germs to be 11 in or near these lines." For example, the 
19th Regiment arrived at Vepery on the 20th May, 1838. It had been 
free from Dracunculus for five years before: twelve months after its arrival 
twenty-eight cases of Guinea-worm appeared, and several cases amongst the 
followers and children. The 45th Regiment occupied the same lines previous 
to the arrival of the 19th Regiment; and the disease appeared amongst them 
at the same season of the year and after twelve months' residence. The 
Guinea-worm had not been amongst them for many years before. At Peram- 
pore (in the 1st Regiment, N. I.) it manifested itself, after twelve months' 
residence, in March, April, and May. For many years previously Guinea- 
worm had been unknown in the regiment. Those who suffer most in canton- 
ments are those who use water of the filthiest kinds. 
On the authority of Scott, Smyttan, Chisholm, and Duncan, Guinea-worms 
are said to have been found in the earth or soil, and that they have been dug 
out of moist earth. There can be little doubt, however, but that the worms so 
found were specimens of the Gordiacece. 
In some form or another the Guinea-worm has an existence in moist earth 
and mud; and it is probable that the hair-like worms found by gardeners in 
India coiled up together may be the young filaria of the Guinea-worm in 
sexual congress; whose progeny, as Zoosperms, or as filiform female worms in 
process of parthenogenesis (like the Tank-worm of Carter), make their way 
into the body. It is known that the Gordius aquations, when young, enters 
the bodies of large water-beetles, and at a certain stage of life it leaves its 
abode in the beetle and goes into the water, where it becomes a variety of 
TanAworm. It appears that there are white and brown Tank-worms-nay, 
that there are no fewer than seventeen species of minute Filaria (Carter, 
Mitchell) ; and some say that all Tank-worms are white at first, but become 
black after a time in the water (Gunther). Observations are greatly wanted 
on these points. According to observations collected by Pallas and quoted 
by Vogel, it appears that even in Europe thread-worms like the G. aquations, SPONTANEOUS EXPULSION OF THE GUINEA-WORM. 
171 
common in stagnant water and moist earth, can in certain cases infest the 
human subject (De Infestis Viventibu's intra Viventia, p. 11). 
The most obscure and incomprehensible parts of the history of this parasite 
are-(1.) The phase of its existence and that of its young after it leaves the 
body of man; and, (2.) The future life of the young, and their sexual differ- 
entiation. 
The parasite may be removed in several ways by surgical interference- 
either by cutting down upon it, or, after it begins to show itself, to commence 
winding it on a stick, gently pulling a portion of it out every day. But there 
is a natural termination to all diseases; and it is a fair subject of inquiry as 
to what becomes of the Dracunculus if left to itself, and its expulsion unaided 
by art. How would it be expelled, and what becomes of the progeny? Is it 
probable that they would ever be placed in circumstances where they could 
lead an independent existence, becoming sexual and multiplying their kind ? 
In reply to these questions it is to be observed that there are undoubted ex- 
amples of the spontaneous evolution or expulsion of the Guinea-worm. Scott 
once observed about five inches of the worm to start suddenly out, firm, 
elastic, and spirally twisted like a cork-screw, showing evidence of resistance 
to a progressive force from behind. So firm was the parasite that it supported 
itself for a little time perpendicularly to the limb. It is only when the animal 
dies that great mischief happens to the part where the parasite is. Then and 
there it acts as a foreign body; but alive it does not cause disturbance (John 
Hunter, On the Blood, 4to, 1794, p. 208). The part first protruded is the 
head; and its future progress, though slow and invisible, becomes in time very 
obvious (Scott). 
As an example of its spontaneous evolution or expulsion, Dr. Forbes relates 
that on one occasion eight Sepoys were admitted with Guinea-worm, and all 
of them had a characteristic vesicle on the ankle. These vesicles were opened 
on the fourth or fifth day. The loose skin was cut away with scissors, and a 
stream of cold water was poured daily on the part. Under these circum- 
stances the young were daily ejected from the proligerous tube of the parent 
parasite, and continued to be so for fifteen to twenty days. After this time a 
watery fluid only was emitted, without any young, but sometimes containing 
particles of a white flaky appearance, which continued two or three days 
longer. The Guinea-worm then became flaccid, and was discharged spon- 
taneously, without pain or swelling. The only exception was in one case, 
where the worm was constricted by the pressure of a band of areolar tissue, 
which led to retention of the young, and sloughing. 
Dr. Kennedy relates an anecdote which has an interesting bearing upon 
the spontaneous evolution and the probable future of the Guinea-worm after 
expulsion. "In 1791, when marching up the Ghauts with a Sepoy battalion, 
an African stepped out of the ranks and requested permission to go to a rapid 
running stream of water near by, in order to relieve himself, after his own 
fashion, of a worm in his ankle. The man unbound a bandage from his foot, 
loosened the worm (of which a part was extracted) from the cloth round 
which it was secured, and plunged his naked foot into the current of the 
stream. The constant but gentle force of the running water was sufficient to 
stimulate the worm to come forth, and it was extracted almost immediately." 
Another custom, recorded by Dr. Lorimer, illustrates the spontaneous evolu- 
tion, and points, at the same time, to the probable future of the Guinea-worm.. 
He says, "Many people belonging to the bazaars in the vicinity of the lines,, 
affected with the parasite, came for the express purpose of extracting the worm 
to the same tank where the men of the regiment bathe. The people so infested 
swim about in the water with the worm hanging loose, drawing the limb 
quickly backwards and forwards through the water, and from side to side, 
till expulsion is effected." The natives do not believe that they get the para- 
site from bathing in the water. 172 
TOPICS RELATIVE TO PATHOLOGY. 
In these and similar cases the parent, being carried away in the stream, 
finds a place to die, and so gives freedom to her immense brood of young. 
The water seems congenial to the parent Guinea-worm, and sooner than any- 
thing else induces her to leave her position in the human body, and so to 
extricate herself, perhaps by stimulation of the muscular structures. This 
w'ater method of extraction was also recommended by Dr. Helenus Scott, of 
Madras (Edin. Med. and Surg. Journal, vol. xviii). 
Vitality of the Parasite in Water.-It has been stated that young Dracunculi 
die in four, five, or six days, if placed in pure water from well or tank (and 
that is the case with many animals), simply for want of food. Water not 
pure is, no doubt, the proper element for them (Mitchell). Those artificially 
kept in impalpable red clay, partially covered with water, and exposed to the 
sun, were found alive after fifteen, eighteen, and twenty-one days, burrowing 
into the fine soft and ochry mud. 
Forbes experimented on two pups five or six months old. He poured down 
their throats water containing the young Guinea-worm Filarice. After three 
minutes the first pup became uneasy, sick, and vomited; the watery part of 
which was found to contain the animal still alive. Four hours after this the pup 
was killed, when abundance of Filarice were seen in the mucus of the stomach 
and duodenum; but none showed signs of life. The other pup was killed 
twenty-four hours afterwards, but none were alive, although abundant in the 
mucus. Lorimer tried upon himself and others if the parasite could be prop- 
agated by inoculation of the young Filarice emitted from the parent's orifice. 
Five besides himself were inoculated. He naively remarks that he is sorry to 
say they did not hatch in any, although in his own case he put them in their 
favorite place-namely, the/oof and ankle. Such experiments were not likely 
to succeed, from the delicate nature of the young Filarice, and because they 
were introduced under unnatural circumstances. Inflammation and pus are 
inimical to the life of the worm. Besides, it is most probable that they enter 
the body in some other form. They seem to go through another stage of 
existence, and become sexual; for it is only females, and these impregnated 
ones, which are found in the body of man. 
The impregnated females only of the progeny of sexual Filarice would 
therefore seem to be the Dracunccdus of man. 
Dr. Ewart, iri his able paper on the vital statistics of the Mey war Bheel 
corps, writes as follows: "I am inclined to believe that Guinea-worm is prop- 
agated by a female and impregnated Zoosperm, and not directly from either 
the young of the full-grown female Guinea-worm or from tank-worms" 
(Indian Annals, vol. vi, July, 1859). Its generation is another example of 
parthenogenesis. 
Examination of Water, Mud, and Tanks.-In the months of August and 
September, 1837, Dr. Forbes examined several of the tanks in the vicinity of 
Dharwar, and found the mud on their banks, and in half-dried beds, abun- 
dantly supplied with animalcules (Filarice), some of them very much resem- 
bling those produced by the Guinea-worm when infesting the human limb. 
Their vermicular motion in the water is exactly the same; their general 
appearance is the same; and they are active and equally numerous. The 
point of a penknife inserted into the mud will raise up abundance for exami- 
nation. They are most numerous where the water assumes a variegated ap- 
pearance, with a pellicle floating on its ochry surface; and the fine, soft, 
impalpable mud just above water-mark contains most, and the best time to 
find them is about three or four o'clock in the afternoon. Two kinds may 
generally be detected in the soft mud: one kind is seven or eight times the 
size of the Guinea-worm young Filarice, the other exactly resembles them. 
The larger one may be the more mature form of the progeny after becoming 
sexual. The smaller one may be the first generation born of that sexual THE TANK-WORMS OF INDIA. 
173 
progeny-whose females, being fecundated, enter the body of man in this 
young and minute condition. 
Dr. Carter had medical charge of a school containing nearly 400 children. 
" One morning a case of Guinea-worm in a child little more than four years 
old was reported to him. There having been only two cases of this disease in 
the school during the previous eight years, Dr. Carter, who had before noticed 
the resemblance of the aquatic Filaria of Bombay to the larva of the Guinea- 
worm, was led to make inquiries, when he learned that the child was the son 
of the sergeant of the Industrial School, situated about three miles off, and 
had been only a little more than three months in the school. Upon further 
inquiry, he found that the sergeant's wife had then a Guinea-worm in her 
ankle, and that twenty-one out of fifty boys had been affected with Guinea- 
worm during the past year. Some boys had had as many as five extracted, 
and ten more were then suffering from the disease, all of whom had been in 
the school more than a year. None of those who had been less than twelve 
months in the school had been admitted to hospital on account of Guinea- 
worm. 
" The boys were living in an embanked inclosure that had been taken in 
from the shore, the fourth side of which was formed by a cliff of the mainland, 
on which resided the sergeant and his family. In this inclosure were two 
small tanks, ten feet square, sunk in decomposing trap, one being six feet, the 
other three feet deep: the first furnished drinking-water, in the latter the 
boys bathed. The sergeant also obtained his bathing-water from these tanks, 
but the drinking-water from a well at some distance. 
"These tanks contained Confervce; and every small piece as large as a pea 
contained twenty or thirty of the tank-worms. At the Central Schools, where 
there had been no cases, or only two in eight years, the Confervce of the tanks 
failed to yield worms after the closest scrutiny. Hence he argues, and with 
apparently good reason, No tank-worm-No Guinea-worm; but that persons 
who bathe in water in which the former is found may expect to have the 
latter. 
" Dr. Carter further states that the Industrial School is situated near an 
old artillery barrack, now in ruins and overgrown with weeds, which had to 
be abandoned in consequence of the havoc made among all ranks, officers as 
well as men, by this fearful parasite" (Mitchell, 1. c.). 
The habit of the tank-worm is to bury itself under any organic debris that 
may be in the water in which it is found; and if it be disturbed, it will imme- 
diately seek a hiding-place, nor rest until again covered. This implies that 
its proper habitat is the bottom of tanks, wells, or other reservoirs, among the 
decayed and decaying organic matter. It may be assumed that the water- 
carriers referred to by Dr, Morehead were Army Bheesties, who as such 
probably had access to good puckah wells (Dr. Morehead having found that 
Guinea-worm was not more common among them than among other people), 
and as the tank-worm, habitually resident in the mud at the bottom, would 
only be disturbed when the water became very low, and would get back again 
to its retreat, if possible, the fact of water-carriers being as little affected with 
Guinea-worm in the upper part of the body as other people does not carry so 
much weight as at first it would seem to do, and as it would in reality if the 
tank-worm was in the habit of swimming at the surface like many other 
aquatic animals. It has not been said that the worm finds its way into the 
body by any of the natural cavities of the body, such as the alimentary canal. 
On the contrary, it is supposed that the water may be drunk with impunity, 
as known by experience, and from the experiments of Forbes already noticed. 
The young Filaria can work its way into a proper receptacle by its pointed 
extremity, " which is a long cone, ending in a point so inconceivably fine that 
the point of a cambric needle is a large marlinspike in comparison with it." 
But notwithstanding its exceeding tenuity, it appears tolerably rigid; and as 174 
TOPICS RELATIVE TO PATHOLOGY. 
the proper receptacle referred to is one of the sudoriparous ducts, a ready-made 
aperture exists for a distance quite long enough to contain so small a creature; 
and it is by no means inconceivable to one who has seen its active exertions, 
that it should be able thus to hide itself in a foot or leg kept for some time in 
the water. It is unnecessary perhaps, to do more than allude to the well-known 
native custom of going into a tank to take water. In these tanks water-car- 
riers may often be seen standing for five or ten minutes at a stretch, chatting 
and washing themselves. They of course stir up the bottom mud, and if the 
tank-worm be there, and is the origin of the Guinea-worm, they certainly 
afford it every opportunity to effect a lodgment. One circumstance which 
makes this the probable mode of entry is, that natives are much more subject 
to attack than Europeans. 
Thus the evidence is very strong which refers the entrance of the parasite 
to bathing, walking, or lying on moist places where the tank-worms abound. 
Greenhow states that the sepoys of the Maiwara Battalion bathe in and 
drink the water of a well sunk in the limestone rock, which generally contains 
about twenty-eight feet of water, clear and sweet; while the prisoners of the 
jail at Beaur use similar water from another well; but they never bathe, which 
the sepoys do every day. The result is, that Dracunculus is much more preva- 
lent among the sepoys, compared with the prisoners, in the proportion of three 
to two. Again, amongst " Puchallies" the numbers affected are four times as 
great as among the men of the regiments. The former frequent the tanks 
more than the men of the regiments. 
Generation and Propagation of the Guinea-worm.-1The following periods 
may be recognized in its natural history: 
(1.) It is probably got by bathing in tanks or places where the young and 
impregnated females abound. 
(2.) A period of maturation in the human body takes place. 
(3.) A time favorable for extraction comes, when the animal seems to seek 
delivery from its imprisonment, to fulfil a new law of its existence. The 
adult animals perish annually. It is necessary they should die, that the 
young may live; and, indeed, the Guinea-worm of the human body is not 
adapted to live. It has no functional arrangements for life. 
Men being exposed to the cause about the same time, the period for extrac- 
tion will arrive about the same time in all, but with just sufficient variation 
(as to time) as to suggest the idea of contagion (Scott, Med. and Surg. Jour- 
nal, vol. xvii, p. 99). But the idea of contagion or infection from one man to 
another (as Bruce, McGrigor, and Paton wished to establish) is quite untena- 
ble. The evidence is all the other way. In Paton's cases on board Her Maj- 
esty's ship "Cirencester," from 30th May, 1805, to 9th August of the same 
year, the origin of the disease is quite traceable to the preceding July and 
August, when the ship lay in Bombay harbor {Med. and Surg. Journal, 1806, 
vol. ii, p. 151). Sir J. McGrigor's cases in the 88th Regiment, and the 
absence of Guinea-worm among the artillery on shipboard, related in his 
medical sketches, were not fully investigated. We have no account of the 
water supply previous to embarkation. Afterwards he wrote a paper, or rather 
an account of the sickness in the regiment from all diseases, in the Edin. Med. 
Journal, vol. i, p. 270, and from this it appears that the regiment had been 
quartered in the Fort of Bombay, which is partly surrounded by a wet ditch; 
and several months after leaving this place most of the cases of Guinea-worm 
occurred. Bombay is well known to be extremely infested with Guinea- 
worm. 
Mosely is reported to have said that " there is as much foundation for believ- 
ing Dracunculus to be contagious as that a thorn in the foot is contagious." 
As observed by Rudolphi, the parasite is known to occur in persons who have 
neither eaten nor drank in the countries where it is endemic, but who have 
■exposed themselves to its moisture and its mud. The moisture contained in CONTAGION OF GUINEA-WORM IMPROBABLE. 
175 
native canoes is sufficient to have carried to a ship off the coast the germs of 
the Guinea-worm, which find their way into the seamen of the ship, who are in 
the habit of going into these canoes with bare feet. 
Negative evidence, which would attempt to show that tank-worm doesnot 
exist, cannot be received. Most of the examinations on which such negative 
evidence rests have been imperfect; having been made with instruments 
confessedly imperfect, and perhaps by men not accustomed to use the instru- 
ment. I speak only of written and published statements, and on the authority 
of Dr. Lorimer. 
Problems for Solution.-Forty years ago Dr. Scott suggested that a patient 
and careful investigation of soils and waters ought to be made wherever Dra- 
cunculus is known to be endemic, and especially the soil round brackish wells 
and the beds of tanks. Morehead, in 1833, recommended that the following 
points be attended to, namely: (1.) Geological structure of the ground and 
nature of the site generally; (2.) Nature of soil, wells, and well-water; (3.) 
Nature of rocks through which wells are sunk; (4.) Abundance or scarcity 
of water; (5.) Seasons of increase or decrease of the disease; (6.) Opinions 
of natives. 
I desire very much to obtain specimens of Guinea-worm taken from the 
dead body long before the parasite arrives at maturity. 
The occurrence of Gninea-worm is sometimes defined by a distance of a few 
miles. So it is with many algae and minute water animals and plants as to 
habitat.* 
6. Filaria oculi. Length, T30ths to -j60ths; width, --^j-tli of an inch. The 
body is thick posteriorly, filiform, and ending in a pointed tail, transparent, 
and partly coiled up in a spiral form. The alimentary canal is surrounded by 
the folds of the oviduct. 
This Filaria ^F. lentis) is very imperfectly known, and the female only has 
been seen. It was detected by Nordmann in the liquor Morgagni of the cap- 
sule of a crystalline lens of a man whose lens had been extracted for cataract 
by the Baron Von Grafe. In this instance the capsule of the lens had been 
extracted entire; and upon a careful examination half an hour after extrac- 
tion, there were observed in the fluid two minute and delicate Filarice coiled 
up in the form of a ring. One of them presented a rupture in the middle of 
its body (probably made by the extracting needle), from which rupture the 
intestinal canal was protruding. The other was entire, and measured about 
Y^ths of an inch in length. It presented a simple mouth, without any 
apparent papillae, such as are seen to characterize the large Filaria which 
infests the eye of the horse; and through the transparent integument could 
be seen a straight intestinal canal, surrounded by convolutions of the oviducts, 
and terminating at an incurved anal extremity (Owen, p. 64). 
* My friend, H. C. Bastian, Esq , M.B., Professor of Pathology in University Col- 
lege, London, has recently furnished a most interesting account of the anatomy of the 
Guinea-worm to the Linnsean Society, and has been kind enough to furnish me with 
drawings of his observations. He writes to me as follows : " Since I saw you last I have 
discovered several species of Carter's ' tank worms' in soft mud, &c. (at Falmouth); 
that is, small Nematoids, agreeing in almost every respect with those found by him in 
Bombay. The more I see of these, the more thoroughly am I convinced of the 
undoubted relationship existing between them and the Guinea-worm, coinciding as 
they do in their anatomy even to minute details, and in many respects where there is 
a salient distinction between the anatomy of the Dracunculys and that of the Ascari- 
des. One which I sketched to-day had an exsertile rigid, sharp-pointed oesophagus. 
" The great difficulty in the theory is to account for the fact of the localization of 
the disease, whilst these animals are probably so widely spread; and I suppose it is one 
particular species which is limited in its diffusion ; but I suspect that many of those 
others will hereafter be discovered as parasites in animals or vegetables. The Vibrio 
tritico I have examined, and find it to be a worm essentially similar ; and Dr. Cobbold 
tells me that he has found a long thread-like worm in the subcutaneous tissue of the 
back of a water-bird. The whole question wants working out." 176 
TOPICS RELATIVE TO PATHOLOGY. 
A Filaria oculi vel lachrymalis lias been described as not uncommon among 
the negroes on the Angola coast, where it is called loa; also at Guadaloupe, 
Cayenne, and Martinique. Its length is lT40ths to lT9aths of a line. It is a 
filiform, slender worm, pointed at one end, obtuse at the other, tolerably firm, 
and of a white-yellow color. 
This parasite has been considered a Strongylus by some, by others a young 
Guinea-worm, and by others as an Oxyuris vermicularis. 
7. The Strongylus bronehialis was first discovered by Treutler, in 1791, 
infesting the enlarged bronchial glands of an emaciated man. The parasite 
is cylindrical, slightly narrowed anteriorly, filiform, but somewhat compressed 
at the sides, semitransparent posteriorly, and of a blackish-brown color. It 
measures from half an inch to three-quarters of an inch in length. 
8. The Eustrongylus gigas is fortunately rare in man, though common in 
a great variety of animals, such as weasels. It inhabits the kidney, destroy- 
ing the substance of the organ, the walls of which become the seat of calcare- 
ous deposits. 
9. The Sclerostoma duodenale is known to be tolerably common throughout 
Northern Italy; and, according to Pruner, Bilhartz, and Griesiuger, it is so 
remarkably abundant in Egypt, that about one-fourth of the people are con- 
stantly suffering from a severe anaemic chlorosis, occasioned solely by the 
presence of this parasite in the small intestines. 
" Its length is about one-third to half an inch, its width about one-twentieth 
of its length. Its head has a round apex, and its extremity, which is bevelled 
at the expense of its posterior surface, is provided with booklets that occupy 
converging papillae. The mouth contracts, to open into a thick muscular 
pharynx, which, widening as it passes downward, ends, after occupying one- 
seventh of the body, in the intestine. The sexual differences of the male and 
female are very interesting. Its pathological significance is chiefly due to the 
hemorrhage caused by these parasites, which are often present in thousands 
between the valvula conniventes of the duodenum, jejunum, and ileum, and 
not infrequently in the submucous areolar tissue. In short, the physician 
practicing in Egypt must never forget that the chlorosis of this climate is often 
the result of repeated and small hemorrhages from the intestine, caused by 
these parasites. Turpentine, as Griesiuger points out, promises to be the best 
remedy both as a styptic and as a vermifuge" (Brit. and For. Med.-Chir. 
Review, 1. c.). 
10. The Oxyuris vermicularis was known to Hippocrates, and is one of the 
most troublesome parasites of children, and occasionally of adults. It is a 
minute, white, thread-like worm, the male being about a line and a half in 
length, and the female five or six lines. They inhabit chiefly the rectum, 
where they are often found in clusters, rolled up in balls of considerable size, 
and from the rectum may creep into the vagina or urethral orifice. Some- 
times they give rise to profuse and exhausting bloody discharges from the 
vagina. 
The eggs of this parasite have embryos developed within them prior to their 
escape from the parent; and in this respect they differ from the A. lumbricoides 
and the Trichocephalus on the one hand, and from the viviparous Dracunculus 
on the other. In this character, however, they resemble the A. mystax. 
In all probability the young escape from the eggs soon after the latter are 
expelled, or migrate per rectum, and, like others of the Nematelmia, gain access 
to the human body with our vegetable food or water whilst still in a sexually 
immature condition. 
Treatment of those Infested by the Round Worms. 
The habitat of the Ascarides being for the most part a collection of mucus, 
the means used for their expulsion are such as may expel mucus. Four grains REMEDIES FOR EXPULSION OF ROUND WORMS. 
177 
of compound scammony powder, with five grains of aromatic poxvder; or two to 
three grains of calomel and ten grains of jalap, taken at bedtime, are useful. 
In weakly children, small doses of Epsom salts will ultimately effect the same 
object, and with less distress to the patient. Many persons place great confi- 
dence in calomel as a medicine capable of destroying round worms ; but it does 
not appear to act beneficially except as a purgative, expelling the mucus. 
The day after the administration of the purgative, the patient ought to be 
kept on low diet, without solid food ; only a little beef tea being taken ; and 
on the second day-the day succeeding the purgative-from five to ten grains 
of the ethereal extract of santonin may be given during the day ; or from three 
to four grains of santonin itself.* 
About three doses are sufficient; one every second night, followed by a 
brisk cathartic the morning after each dose. It may be compounded as troches, 
containing one or two grains in each ; or two to six grains may be dissolved 
in one ounce of castor oil, and a teaspoonful given every hour till the oil ope- 
rates. A santonate of soda is also recommended by Kuchenmeister in doses of 
two to four grains. Santonin seems to be a specific for the destruction of Ascaris 
lumbricoides; but it may be necessary to state to the patient or his friends, that 
the sight sometimes becomes perverted as to color, after a few doses, and color- 
less objects may be seen to be blue or yellow. 
The Oxyurides, or small vermicular Ascaris, being situated so near the rec- 
tum, enemata have at all times been much used in the treatment of these 
cases; and injections of oil have been much commended, especially of castor 
oil, olive oil, or sweet oil. But these animals will live from thirty-six to forty- 
eight hours in castor oil. Indeed, very little benefit has been derived from 
any such local treatment. Warm water injections tranquillize the intestine, 
and give more temporary relief than anything else. The Oxyurides are killed 
by cold; and injections of cold water, with a little vinegar, are very effica- 
cious. If the child is a vigorous child, large injections of very cold water may 
be administered, with vinegar or a few drops of ether or of alcohol. In obsti- 
nate cases, a weak solution of corrosive sublimate, in the proportion of one 
quarter of a grain to two ounces of enema. Injections of the following bitter 
substances have been found very useful in the treatment of the Ascaris ver- 
micularis: Three or four ounces of a strong infusion of quassia repeated three 
or four times, or of steel and quassia and aloes, or a solution of common salt in 
gruel, or a similar quantity of lime-water, has been found of service. At the 
same time it is also well to administer internally some bitter medicines ;-for 
example, half an ounce (or any dose suitable to the age and strength of the 
child) of compound decoction of aloes, taken in the morning fasting, once or 
twice a week; and three ounces (or other suitable dose) of infusion of quassia 
may be taken every morning that the aloes is not taken. 
Chloride of sodium, to the extent of an ounce in a pint of quassia infusion, 
has also been found a useful injection; so also has an enema composed of 
aloes, carbonate of potash, and mucilage of starch. But whatever local reme- 
dies are used, it is necessary to attend to the general health, which usually is 
at fault, and to persevere in the use of enemata twice a week for several 
months. The digestion is generally slow and imperfect, the secretions from 
the mucous membrane of the alimentary' canal being abnormal. For this 
condition, small doses of the extract of nux vomica, with sulphate of iron, in 
extract of gentian or aloes, or in rhubarb or colocynth pill mass, taken twice a 
day, will be found of great service. 
* Santonin is a crystalline neutral principle obtained from the Artemisia Santonica, 
or Semen Contra,-which is not a seed, but is the unexpanded flower-head of a species 
of Artemisia imported from Russia, and is the only so-called worm-seed which yields 
Santonin in quantity worth extracting. It is a tasteless and pleasant vermifuge for 
children (Squire). 178 
TOPICS RELATIVE TO PATHOLOGY. 
From what has already been written, it will be seen how important it is, in 
the treatment of all these parasitic diseases, to take every means of utterly 
destroying, by burning or by chemical agents, all debris or excreta which may be 
passed by patients suffering from these parasites, and also how necessary it is to 
look well to the purity of all water supply used either for the purposes of food, 
drinking, or bathing, and to the quality of pork or bacon, especially in connec- 
tion with the Trichina spiralis; the use of bad flour in connection with the 
eggs or larvae of Ascaris or Oxyuris (Stein). 
11. Bothrioceplialus latus.-Although classed with tape-worms, Bothrio- 
cephali differ essentially from Twnia. Two species have been found in man, 
namely,-(1.) Bothrioceplialus latus; and (2.) Bothrioceplialus cordatus. 
The Bothrioceplialus latus is endemic chiefly in the north of Europe, and is 
found more especially in Russia, Sweden, Norway, Lapland, Finland, Poland, 
and Switzerland. The inhabitants of the French provinces adjoining Switz- 
erland are infested with both species. 
Instances of Bothrioceplialus latus are said to have occurred both in Eng- 
land and France; but, when carefully inquired into as to their history, it will 
be found that this parasite maintains a very fixed geographical distribution. 
For example,-of the six specimens in the College of Surgeons of England, 
one is from a native of Switzerland; one from a Russian, belonging to the 
Russian embassy in London; one from a person who had been travelling in 
Switzerland; a fourth happened in the practice of Dr. Gull, in the person of a 
little girl from Woolwich, where there is always a number of foreign ships 
and sailors, bringing with them native food and water; another was passed 
by a native of Russia, who, after a long residence in England, paid a tempo- 
rary visit to his birthplace, and returned to England with this parasite as a 
pleasant memento of his native country. 
The liability to this form of parasitic disease appears to be greatest towards 
the seacoasts and along river districts. Huss, of Sweden, describes it as 
extremely common on part of the Lapland frontiers, in Finland, and on the 
shores of the Gulf of Bothnia. On the extreme coast there is scarcely a 
family together free from it-old and young, rich and poor, native and emi- 
grants, alike suffer from this worm; and in one or two large towns on the 
mouths of rivers, at least two per cent, of the population experi- 
ence its attacks. On passing inland the frequency of the disease 
diminishes, until, eight or ten leagues from the coast, rivers, or 
lakes, it almost ceases to Joe found. The natives believe it to be 
hereditary. Dr. Huss attributes it to the use of salmon (Brit, 
and For. Med. Review, 1. c.). 
The head of the Boihriocephalus latus is peculiar, and very 
different from the T. solium. It is of an elongated form (Fig. 20), 
compressed, with an anterior obtuse prominence, into which the 
mouth opens; an opaque tract extending from the mouth separates 
two lateral transparent parts, which are supposed to be depres- 
sions. There are no traces of joints till about three inches from 
the head; and throughout the entire body the segments have more 
length than breadth. The whole length of the mature parasite 
varies from six to twenty feet. It is of a grayish-white or yellow 
color; and the ova are very brown, giving the mature segments a 
very marked appearance. The neck is not always obvious, for 
the worin has the power of making it long and thin or thick and short; and 
there are no joints or segments to be seen in it, but merely prominent ridges. 
The segments, when they become first apparent, are nearly square: but after- 
wards they become much wider than they are long. There are two orifices 
CLASS B.-STERELMINTHA, OR SOLID WORMS. 
Fig. 20. BOTHRIOCEPHALUS CORDATUS. 
179 
on one of the flat surfaces of each segment; the anterior orifice is connected 
with a male organ of generation, the posterior is connected with 
the female. The proglottides are never passed singly, but always 
in chains of many links, and particularly in February, March, 
October, and November. The ova (Fig. 21) arc always discover- 
able in the faeces, of an ovoid form, with a perfectly translucent 
operculated capsule, through which the segmented yolk is dis- 
tinctly visible ; and at the period of discharge of the proglottides 
the ova show merely the stage of segmentation of the yolk. The 
six-hooked embryo, cased in a mantle studded with vibratory cilia, 
develops itself after segmentation, protected by the capsule in fresh 
water, for several months after the expulsion of the proglottides. 
When so far matured, the lid of the capsule opens up, and the cili- 
ated embryo escapes (Fig. 21a), and becomes globular in shape, 
and moves actively about for a considerable period (a week). If 
during this period they do not succeed in obtaining access to the intestine of 
an animal adapted for their development, they lose 
the ciliated mantle, and perish. When these em- 
bryos are introduced by experiment into the intes- 
tines of mammals, the scolices and mature Bothrio- 
cephalus were found. Experiments in which living 
embryos were introduced by implantation between 
the brain and dura mater, and into the eyes of dogs, 
also under the skin of frogs, and by injection into the 
bloodvessels of mammals, give a negative result; 
quoad the development into cysticerci or scolices. So, 
also, feeding experiments with the scolices of the 
Bothriocephalus found in various fish lead to negative 
results; just as the feeding of fish with the eggs 
themselves. It is therefore justifiable to assume that 
drinking-water from lakes and rivers is the medium 
through which the living embryos of the Bothrioceph- 
alus latus find their way into the intestines of men 
and of mammals (Dr. J. Knoch, Petersburger Medi- 
cinische Zeitschrift, 1861; Cobbold, 1. c.). 
12. Bothriocephalus cordatus.-This species (Fig. 
22, a) is new to science, and has only very recently 
been described by Leuckart, who received about 
twenty specimens from Godhaven, in North Green- 
land, one of which was from the human intestine. 
The parasite measures about a foot in length, and 
exists in dogs in considerable abundance. It differs 
from Bothriocephalus latus in the form of the head, 
which is heart-shaped (Fig. 22, b and b'f or obcor- 
date, short, and broad, and set on to the body with- 
out the intervention of a long neck. The segments 
are distinct from the very commencement, near the 
head ; and so rapidly do they increase in width, that 
the anterior end of the body becomes lancet-shaped. 
About fifty joints are immature; and in the largest 
example Leuckart counted a total of 660 joints. It 
displays a greater number of the calcareous corpus- 
cles, and a greater number, of lateral uterine pro- 
cesses (Leuckart ; Cobbold, " Remarks on the 
Human Entozoa," in Proceedings of Zoological 
Society, Nov., 1862). 
13. Taenia solium.-In their mature condition the 
Fig. 21a. 
Fig. 21. 
Fig. 22. 
(a.) Bothriocephalus cor dolus, 
natural size; (b.) Head, back 
view, magnified five diameters ; 
(b'.) Upper part of body and head, 
magnified two diameters. 180 
TOPICS RELATIVE TO PATHOLOGY. 
tape-worms are all more or less jointed entozoa, of a riband-like form, marked 
with bands, or girdled. Each mature joint or segment is of hermaphrodite 
conformation, containing at once male and female reproductive organs, which 
produce fecundated ova. In their immature condition the embryo penetrates 
the tissues, and becomes encysted. In this stage of development they are 
known as the " cystic entozoa," because they terminate in a bag or cyst. 
Eight varieties of true tape-worms have been found in man, and the two 
varieties of the Bothriocephalus already noticed. 
But two only of the true tape-worms are of frequent occurrence-namely, 
the T. solium and the T. mediocanellata. The former is the one endemic in 
this country; the latter is the more common tape-worm on the Continent, in 
South Africa, and India. 
These tape-worms have been known for a very long period; but they have 
not always been distinguished from each other. Indeed, the distinguishing 
characters are but recently known. They have often been confounded together 
under the name of "solitary worm," because it was believed they lived singly. 
This, however, is a mistake. 
The T. solium and T. mediocanellata appear at first sight to be very similar 
to each other in general appearance. The latter is much the larger of the two. 
It is only in the alimentary canal-the small intestines of man and other 
animals-that Tcenice become sexually mature, in natives and native animals 
of all countries. The Tomia is very common 
in natives of Abyssinia;-so common is it 
there, that its absence is the exception to the 
rule. The affection is there looked upon as 
a natural occurrence ; and so general is this 
belief, that when a slave is sold into Abyssinia 
he provides himself with a plentiful supply 
of kousoo-the local remedy for expelling 
the parasite. 
The Tomia solium is a common tape-worm 
of this country. It is composed of segments 
of variable size, numbering from 800 to 1000; 
and these being endowed with considerable 
contractile power, the length of tape-worms 
varies greatly, and so also does the width 
and thickness. Nine to thirty-five feet may 
be quoted as average measurements of length. 
The body narrows from the posterior to the 
anterior extremity, till towards the head it 
becomes a mere thread. The parenchyma 
is soft and white, with microscopic calcareous 
particles, sometimes mistaken for ova (because 
they are round or oval), scattered through 
nearly every part. 
The Head (Fig. 23) is very small, but it 
may be seen with the naked eye to be of a 
globate or triangular form, with black pig- 
ment ingrained into its substance, which may 
be the remains of blood. On the most ante- 
rior part of the head, with the aid of a lens 
magnifying twenty-three or twenty-five di- 
ameters, four circular projections, equidistant 
from each other, may be seen. Each has a 
circular disc or cup, surrounded by a rim of 
dense tissue. The parasite is able to elongate 
and retract these projections ; so that, while opposite ones are put forward, 
Fig. 23. 
Head and neck of Tcenia solium, 
{a.) Circle of hooks. ANATOMY OF TAPE-WORM SEGMENTS. 
181 
the two others are kept back. Between the suckers, and anterior to them, is 
a convex protuberance or rudimentary proboscis, which is impervious, and 
surrounded by a double row of hooks (Fig. 22, a, also Fig. 23). These are 
siliceous, and number twelve to fifteen in each row. The shape of these is 
peculiar. They consist of a straight stem or handle, a middle nob, and a dis- 
tinct hook or claw, surrounded by a sheath or sac. Bremser believes that a 
taenia loses these as it gets old ; or it may shed them periodically by rows ; 
and being lost, they may not be renewed, and so the parasite may be got rid 
of in the course of nature. 
The head terminates a long and slender neck, on which there are trans- 
verse markings, but no visible joints or articulations. Such joints distinguish 
the body ; and these joints, segments, or zoonites are united end to end in a 
single linear series. 
The characters of the segments vary at different parts of the body. They 
are square or oblong; and in the mature part of the animal the length of them 
is equal to twice the width. The anterior border of each segment unites with the 
anterior or previous segment, and is thinner than the posterior border, and also 
narrower. The posterior border is thick, and projects or overlaps the border 
of the segment next in order, and is undulating or indented. The lateral 
margins incline to each other anteriorly. The two surfaces are flat or slightly 
elevated towards the centre. 
Each mature segment contains male and female organs of generation. The 
opening at the side of each segment is the 
sexual aperture, indicated by a prominent 
papilla. These openings are sometimes at 
one edge, and sometimes at the opposite 
edge. Two, three, or four consecutive seg- 
ments may have them on the same edges, or 
on opposite ; but there is no regular alterna- 
tion. With a lens a cup-shaped depression 
may be seen, showing two mesial apertures. 
From one of these a lemniscus or rudimen- 
tal penis projects, connected with a horizon- 
tal (deferent) canal (sometimes indicated 
by a dark pigmentary material) from a vesic- 
ular body in the middle of the posterior 
end of the segment (Owen). 
Behind this male orifice is the opening to 
the female organs, by a canal leading to a 
lobulated organ, which is the ovary or germ- 
stock. These parts are more distinctly developed the farther the segments 
examined are from the head end of the worm. While the head continues to 
adhere, by its circles of booklets and oscula, to the mucous membrane of the 
intestine, the last or caudal joints, when they have arrived at sexual maturity, 
are separated one by one, or in numbers together, and new joints are at the 
same time gradually formed behind the head. The total number of joints in 
a taenia, ten feet long, has been counted, and found to number upwards of 
800 ; and the joints appear to be sexually mature about the four hundred and 
fiftieth segment from the head. Thus growth and development take place 
mainly towards the neck of the parasite, by a process of transverse fission; and 
thus a segmented individual or compound animal appears to grow. This seg- 
mentation of individual links by transverse fission ceases when the organs of 
generation begin to develop themselves in them; and when those are com- 
plete, the segment or link has arrived at sexual maturity or completeness. It 
is now called a proglottis. Thus all the new segments come to be developed 
between the head and those which are advancing to sexual completeness; and 
if the charactei's of complete sexual development be taken as the distinctive 
Fig. 24. 
Circle of hooks more highly magnified 
(after Leuckabt). 182 
TOPICS RELATIVE TO PATHOLOGY. 
mark of individuality, then each segment of the tape-worm may be looked 
upon as a distinct animal; and this separation^by fission or segmentation may 
be considered as analogous to what takes place in the medusae or polypes-a 
kind of alternate generation, in which, 
the segments, zoonites, or proglottides 
may be regarded as making up a col- 
ony of animals. It is only in the ali- 
mentary canal of man and other ani- 
mals that the tape-worms, or cestoid 
entozoa, attain to sexual maturity; 
and in all of them the ova are fecunda- 
ted before being discharged, and may 
often in the T. solium be perceived to 
have undergone the first stage of their 
development before they are excluded 
from the oviduct of the mature seg- 
ment. The expulsion of the ova oc- 
curs in some one of the following ways : 
(1.) The impregnated segments sep- 
arate from each other, and passing out 
of the body singly or in numbers with 
the faeces or without any fecal .evacua- 
tion, become decomposed, and so the 
eggs are set at liberty. The activity of 
these separate segments is retained for 
a considerable time after passing out 
of the body-a circumstance which led 
to their being at one time taken for a 
distinct species of worm, to which the 
name of Vermes cucurbitini (from re- 
semblance to a pumpkin-seed) was ap- 
plied. The contracted appearancesofa 
segment during its movements out of 
the body are represented by the forms 
shown in the accompanying woodcut 
(Fig. 26). 
One may readily observe the activ- 
ity displayed by these beauties of na- 
ture as they disport themselves on the 
recently extruded excrement of almost 
every constipated dog. The expelled 
joints may be seen to become violently 
contracted shortly after their expul- 
sion, as if the stimulus of physical cli- 
mate in their new situation provoked 
excessive contortions. The long single 
joints thus expelled become still more elongated by contractions of their trans- 
verse fibres, while the alternate contractions of these fibres with the longitu- 
dinal ones cause shortening of the joint to such an extent that its breadth ex- 
ceeds its length. Such a sequence of contractions produces movements which 
simulate those of progression in a worm, and thus these segments may be seen 
to move some little distance from the spot on which they may have first fallen, 
discharging ova during their march from the interior of the segment. Thus 
they may move about for a time; but the growth of the myriads of embryos 
in the interior of the proglottis causes it sooner or later to burst, when the 
embryos become scattered over grass or ground, dispersed in drains, sewers, 
ditches, surface water, or waste places, while wind and insects help to diffuse 
them still farther. 
Fig. 25. 
Proglottis of Tcenia solium magnified.-(a.) Geni- 
tal pore, with its preputial cover or sheath-skin; 
(6.) Lemniscus or penis ; (c.) The oviduct; (d.) 
The seed-vessel ; (e.) The uterus; (f.) The water 
vascular system of vessels (after Rokitansky). 
Fig. 26. 
Proglottides. of a Tcenia (medioeanellata) in va- 
rious stages of contraction (after Leuckart). STRUCTURE OF TAPE-WORM OVA. 
183 
,(2.) Eggs are thus discharged through the genital pores of the mature seg- 
ments ; and if the segment be slightly squeezed, the ova may be pressed out. 
(3.) The mature joints of the adult tape-worm seem, in some instances, to 
undergo a disintegration within the intestine of the animal they live in. 
Thus, Kuchenmeister on one occasion found the wall of the large intestine of 
a dog occupied by a white sandy powder, the particles 
of which, on examination under the microscope, turned 
out to be innumerable ova of a T. serrata which lived 
higher up the bowel, accompanied by its separated 
joints. 
Such contingencies, as in (2) and (3), are not un- 
likely to happen within the rectum, when, by constipa- 
tion or otherwise, the matured joints are retained, and 
constitute one of the most serious dangers which the 
matured tape-worm inflicts on the animal it inhabits, 
and one of the strongest indications for its removal. 
It has been recently ascertained that in one or two in- 
stances the presence of a Cysticercus telce celluloses (the 
embryo of the T. solium) has been found to coexist with 
the previous prolonged existence of a T. solium in the 
intestinal canal of the human subject. 
The mature segments are often expelled from the 
human rectum at the rate of six or eight a day, some- 
times with the excreta, and sometimes per se; and they 
exhibit evidence of very active vitality for some time. 
Moisture is favorable for maintaining their existence, 
and for favoring the spread of the eggs over herbs, 
grass, ground, fruit, or vegetables, which may become 
the food of man or of cattle. 
The structure of these ova (Fig. 27) is peculiar; and 
the provisions possessed by their coverings for preserv- 
ing the embryo are important points for consideration 
in connection with their transmissions through ap- 
parently impossible conditions into the bodies of ani- 
mals, where they become further developed; and in 
connection with their powers of resistance to therapeutic 
agents (which have been called anthelmintics or vermi- 
fuges) administered for their removal. 
It is only in their earlier stages of development that 
they are really the analogues of ordinary ova. In the 
blind extremities of the oviducts of the mature joint of 
the tape-worm the shells of the ova appear to be com- 
posed of a calcareous transparent substance; and by 
the time the ova reach the central segments of the tube 
their hitherto transparent calcareous shell becomes not 
only much thickened, but is converted into a dark- 
yellow or brown mass, in the interior of which the em- 
bryo is formed. The egg at flrst is of the simplest 
structure, and very minute, being only about y^th 
part of an inch in size. The admixture of these or- 
ganic elements with the calcareous shell imparts to it 
that extraordinary power of resistance to chemical, and 
even mechanical, violence which it certainly possesses. 
Dilute acids and alkalies have little immediate effect 
on this leathery husk; and even after hours of immer- 
sion in them, scarcely more than a slight swelling and transparency is pro- 
duced upon the shell. It is, therefore, no matter of surprise that after 
Fig. 27. 
Development of the ovum 
of Tcenia solium.-(1.) Previ- 
ous to segmentation ; (2,3,4, 
5.) Segmentation in the im- 
pregnated ovum; (6.) Ap- 
pearance of the early em- 
bryo, with its three pairs of 
siliceous spikelets; (7.) Ma- 
ture condition of the ovum 
containing the embryo in- 
closed within its leathery 
case (after Leuckart). 184 
TOPICS RELATIVE TO PATHOLOGY. 
months of exposure to warmth and moisture, or to cold and dry air, the 
pulpy, putrid, or dried-up mature segments of tape-zvorms should yield ova 
which show no sign of degeneration or decay. 
A more or less speedy death of the expelled segments is followed by their 
putrefaction, hastened, it may be, by warmth and moisture. The eggs in their 
interior are then set free, to be carried by winds, waters, or other agents, 
wherever accident may determine. Thus they may lie to rot upon the soil, or 
they may be consumed as food by various animals which feed on such minute 
particles of food. The minority of these eggs, after many and long wander- 
ings of this passive nature, may at length be engulfed unconsciously by some 
unfortunate animal with its food. 
Within the alimentary canal of the animal which is thus so unfortunate 
as to eat the egg, a small embryo of most simple form is set free from the 
ovum by the rupture of the calcareous husk which incloses it. Such rupture 
is absolutely necessary to liberate the embryo, and may be effected by 
mechanical violence, such as friction, or crushing by the teeth in mastication 
of the food, rather than by solution or digestion in the stomach. Animal 
heat does not seem to be alone sufficient, nor is mere moisture sufficient, to 
liberate the embryo; which when set free consists of little more than a 
highly contractile vesicle about the same size as the yolk of the ovum, measur- 
ing only about the y^oth of an inch. It is peculiarly armed for progression 
by boring its way through the most delicate tissues. On one side of it are 
placed three pairs of spikelets; one pair points forwards, and the two other 
pairs are so placed that a pair is towards opposite sides of the embryo, or at 
right angles to the anterior pair. These spikelets are shown in the last two 
drawings of Fig. 27. 
The embryo when free is named a "proscolex" and commences life on its 
own account by efforts at active migration. By the vigorous exercise of the 
spikelets it makes a passage through membranes, walls of vessels, and textures 
of solid viscera, so as to reach localities where it becomes encysted, and passes 
another phase of existence. The first portion of its path is pierced by bring- 
ing close together the several pairs of spikelets so as to form a kind of wedge- 
shaped stiletto. The lateral pairs of these spikelets are then brought back- 
wards to a rectangular position, and so they thrust the embryo forwards in 
the direction in which the anterior pair of spikelets pointed. Similarly 
repeated actions eventually accomplish progression to a resting-place; and 
the action may be aptly compared to the movements of the arms and attitude 
of the head of a swimmer. But this active migration is not the sole means 
by which the embryo Tcenia is enabled to traverse the animal body. The 
embryo may penetrate a mesenteric vein, when it will at once be swept onwards 
by the current of the blood to the portal vein, and passing into the minute 
ramifications of the portal system, may find a resting-place in the liver. 
Leuckart has found the embryos of tape-worms in the blood in such large 
numbers that he inclines to regard the currents of the blood in the vessels as 
the ordinary and more usual channels for the migration of the embryos. It 
also explains the wide diffusion of tape-worm embryos as cysticerci or echinococci 
in various stages of development throughout viscera of the body, where they 
become encysted, and especially their very frequent site in the liver, perito- 
neum, and mesentery. Thus far completed and encystic, the embryo is called 
a "scolex" and as such in Cysticercus telce celluloses was first described by 
Rainey. The embryos of Echinococci and Coenuri give rise to numerous scolices, 
which complete their development into tape-worms in the alimentary canal 
of another animal, when that animal happens to eat the liver or brain con- 
taining the cysts of such Echinococci or Coenuri; but the embryos of such 
echinococci or coenuri tape-worms find their way into man or animals with 
drinking-water, or with raw, uncooked articles of vegetable diet from moist T2ENIA MEDIOCANELLATA. 
185 
soils, such as salads, roots, fallen fruit, all of which may be doubtless so ex- 
posed as to receive the germs or ova containing the embryos, passed along 
with fecal excrement of dogs especially, and which, after being dried, are 
carried by wind or water in all directions. 
The third stage of development consists in the formation of segments, which 
are first seen in the form of marks, like girdles, surrounding that portion of 
the entozoon next to its oscula and booklets, and which terminate in a caudal 
vesicle. It is now an incomplete segmented Tcenia, and in scientific nomen- 
clature is called a Strobila; and the development to this stage may occur 
while the entozoon is still within the closed cyst which has formed round it. 
It is only in the alimentary canal of animals that the last and perfect stage 
of development is attained, by the tape-worm reaching sexual maturity. The 
segments or links marked off* by the bands, joints, or girdles, in the encysted 
'Strobila embryo become mature segments by the development of sexual organs 
within them. This only takes place after the Strobila embryo has passed into 
the alimentary canal of an animal which can afford it a place to live and 
spend the rest of its days as a fixture attached by its hooks to the mucous 
membrane. The human alimentary canal is an oft-chosen place of the T. 
solium and T. mediocanellata. Here the tape-worm forms complete sexual 
segments or links, each being hermaphrodite, and tending to separate when 
completely mature. 
After living for some time in this prolific condition, and having produced 
often a very large number of joints and an enormous quantity of ova, the 
existence of this troublesome parasite is terminated by the separation of the 
animal from its attachment to the intestinal membrane. When this separa- 
tion occurs spontaneously, it may be that the circlet of booklets being shed peri- 
odically, or being lost, they are not renewed, and so the prolonged life and 
romantic vicissitudes of a tape-worm may be thus brought to a natural termi- 
nation. The whole length of the beast is then ignominiously expelled, while' 
some reputed vermifuge, however innocent, may get the credit of its death. 
The apparent success of many such parasiticides is recorded and measured by 
yards of tape-worms, which, being ingeniously bottled by worm-doctors and 
charlatans, are duly advertised to have been passed by John Smith or Sarah 
Brown, after they had been dosed with the "infallible" remedy. 
The length of the tape-worm in the human body has been known to exceed 
thirty feet, and there are grounds for believing that the T. solium may attain 
to this size in the human intestine in about three or four months. 
15. Taenia mediocanellata.-This is a hookless, flat-headed tape-worm, the 
cysticerci and embryos of which are developed in the muscles and internal 
organs of cattle (Leuckart) ; and man becomes infested with tape-worm by 
eating imperfectly cooked veal and beef in which the cysticerci abound. It 
was first discovered by Kuchenmeister in 1855, and then shown by him to be 
different from the T. solium. Its head (Fig. 28), is large, obtuse, and trunca- 
ted, and carries no hooks. Its sucking discs are much larger than those of the 
T. solium, as if to compensate for the want of the hooks. Its segments, when 
mature, separate easily. The ovaries are simple, giving off sixty lateral par- 
allel branches. The eggs are similar to those already described. 
The T. mediocanellata has been found in several instances of invalid soldiers 
who died at Fort Pitt, and at the Royal Victoria Hospital at Netley. In one 
instance three very large and long worms existed in the small intestines, each 
of them precisely similar in all respects. The soldier in whose intestine they 
were found died of diabetes mellitus, and he had been a cook for many years 
to a military mess at the Cape of Good Hope; another case was that of a 
soldier who had been also a long time at the Cape. 
16. Taenia acanthotrias, like the T. marginata, is only known in man as an 
embryo or cysticercus. From twelve to fifteen of them were found in the 186 
TOPICS RELATIVE TO PATHOLOGY. 
muscles of a woman about fifty years of age, by Dr. Jeffries Wyman, in 1845. 
The woman was a subject in the 
dissecting-room at Richmond, 
Virginia. The rostellum of this 
parasite is furnished with three 
rows of hooks, fourteen in each 
row. 
17. Taenia flavopunctata meas- 
ures about eight to twelve inches 
long. The proglottides are short, 
and there is a yellowish spot, 
clearly visible to the naked eye, 
situated about the middle of each 
joint, which reminds one of the 
color and situation of the genital 
organs as seen in the Bothrioceph- 
alus. The reproductive orifices 
occur all along one side of the 
worm, and the eggs are unusual- 
ly large. Only one instance of 
the occurrence of this parasite is 
on record; it was obtained in 
considerable numbers by Dr. Ezra 
Palmer in Massachusetts, in 1842, 
from an infant nineteen months 
old. They were expelled without 
medicine, their presence not hav- 
ing been suspected (Weinland, 
Cobbold). 
18. Taenia nana, when fully 
grown, attains a length of eight 
or ten lines, and carries from 150 
to 170 joints. Its hooks are essentially the same in form as those of other 
Tcenia, only they are very minute, and have a peculiar form, owing to the 
close approximation of the claw and of the anterior root-process (Leuckart), 
which gives them a "bifid" appearance. Its head is comparatively large and 
obtuse, with a long neck. It was first described by Bilharz in 1851, having 
been found in Egypt in the intestine of a young man. 
20. The Taenia elliptica, whose cysticercus, or embryotic condition, is not 
yet known, is common to cats and dogs, and sometimes infests man (Esch- 
richt, Leuckart). Weinland believes that the cysticercus will be found in 
flies, and that dogs obtain the larvae by snapping at dipterous insects. 
Fig. 28. 
Head of the Tcenia mediocanellata, drawn from the cam- 
era lucida, by Assistant-Surgeon B. J. Jazdowski, from 
one of three specimens, all of which were removed from 
the small intestines of a soldier who died at Eort Pitt in 
1860, and who had been for many years a cook at the 
Cape of Good Hope. The specimens are in the Museum 
of the Army Medical School at Netley. 
l-100th of an inch X 23 diameters. 
The tape-worms just noticed are all mature parasites, and for that reason 
they have been considered together. It therefore comes that number 14 of 
the list, at page 146, has been left to take its place amongst- 
The Immature Tape-worms, Non-sexual, Cystic, or Vesicular Parasites. 
These entozoa are variously spoken of by the older, and even by many 
recent writers on medical subjects, under the vague terms of hydatids, cysts, and 
acephalocysts. They all inhabit the closed cavities of animals, or they are 
inclosed in cysts in the more solid parenchyma of their organs. They are 
represented by the scolices or second stage of the tape-worm embryo, and con- 
sists of a Tcenia head, provided with a similar circle of booklets, or absence VARIOUS KINDS OF CYSTICERCI. 
187 
of booklets, as the case may be, according to the variety of the Tccnia, and 
four oscula, and this head is united by a neck to a vesicular body of variable 
size. These are now known to be as already described, varied forms of Teenies 
embryos, of which the following infest various parts of the human body, or of 
animals used as food, or of domestic animals not so used: 
14. The Cysticercus of the Taenia solium (synonym, Cysticercus teles cellu- 
loses) is the larva or scolex of the Tccnia solium, and as seen in man, in the pig, 
in the ox, horse, calf, camel, sheep, and roe deer, it consists of a vesicle-con- 
ical, glistening, and white-containing fluid; to this a head is attached by a 
narrow pedicle or neck, which is transversely lined-the lines approaching 
to rugae towards the vesicle. Its size varies in solid viscera from that of a 
small pea to a large marble; but in free cavities, such as in the ventricles of 
the brain, it attains a larger size. The smallest measles (sconces) measured 
'has been 23-th of an inch in diameter from the brain, liver, and intermuscular 
septa of a pig, thirty days after feeding with proglottides; and the complete 
development is usually accomplished within ten weeks, when the cyst measures 
|th to ^d of an inch, or from the size of a pea to that of a kidney bean. The 
cyst is more dense nt the side or edge where the head and neck are growing, 
than at the great vesicular part, which is the vesicular or bladder-like end. 
The head and neck can be drawn, as if into the vesicle, so that the form and 
appearance of the parasite may thus be very much altered. An external 
cyst incloses the parasite when it inhabits a solid viscus, such as the substance 
of the liver, or amongst the connective tissue of muscle; but in close cavi- 
ties, such as the eye or the ventricles of the brain, there is no enveloping cyst, 
and the parasite floats free within the cavity. In these more free conditions 
it tends to grow more like the form of a tape-worm; and if it happens to be 
in the eye, it may soon destroy it, by fixing its hooks in some of its delicate 
textures. The cyst which envelops the parasite is developed at the expense 
of the tissue in which the parasite imbeds itself. They have been thus seen, 
in man as well as in animals, in the heart, liver, choroid plexus, the brain, in 
the tissue between the sclerotic and the conjunctiva, in the anterior and pos- 
terior chambers of the eye (Mackenzie), and in the retina (Graefe). The 
head resembles that of the T. solium, and carries thirty-two hooks in two rows, 
and the neck varies greatly in length. The parasite is especially frequent in 
domestic swine, and in them it produces the appearance known as the 
"measles," or "measly pork." 
15a. The Cysticercus ex Tsenia mediocanellata is to be found in the mus- 
cles and internal organs of cattle. For our knowledge of the larval state of 
the T. mediocanellata we are mainly indebted to Professor Leuckart, of Giessen. 
He has artificially reared them in the flesh of calves, from the eggs of a T. 
mediocanellata; and recent experimental researches incontestably prove that' 
the " measles" of cattle give rise to the T. mediocanellata. He fed two calves 
with the fresh eggs of the T. mediocanellata, by giving them the proglottides 
of this parasite. The first animal be experimented on died from a violent at- 
tack of the measle disease; and on dissection the muscles were found filled 
with measles, or vesicles containing imperfectly-developed scolices. On the 
second occasion a smaller number of proglottides (in all about fifty) were ad- 
ministered, and the febrile symptoms again appeared with such virulence that 
Leuckart thought this animal would die also. Fortunately, after the lapse of 
a fortnight from the commencement of symptoms, some abatement of the 
disease took place, and this gradually continued until the animal was per- 
fectly restored to health. Eight-and-forty days subsequent to the earliest 
feeding experiments (which were continued at intervals for eighteen days) 
Professor Leuckart extirpated the left cleidomastoid muscle of the calf,, and 
whilst performing the operation he had the satisfaction of seeing the cysticercus 
vesicles lodged within the muscles. They were larger and more opalescent 
than those of the Cysticercus tccnia celluloses, but nevertheless permitted the 188 
TOPICS RELATIVE TO PATHOLOGY. 
recognition of the young worms through their semitransparent coverings. 
The heads of the contained cysticerci exhibited all the distinctive pecularities 
presented by the head of the adult Strobila (the T. mediocanellata). Taking 
the results of this experiment in connection with previously ascertained facts, 
the most unequivocal evidence is brought together that man becomes infested 
with the T. mediocanellata by eating imperfectly-cooked veal or beef in which 
the cysticerci abound. 
21. The Cysticercus of the Tsenia marginata {Cysticercus tenuicollis) is 
rarely found in man, but it has occasionally been found in the mesentery and 
in the liver. Eschricht and Schleissner have shown that these Cysticerci are 
sometimes associated with the Echinococcus in Iceland (Cobbold, 1. c.). It is 
only in this immature state that it is known to infest man as a cysticercus. 
The full-grown tape-worm is found in the dog and wolf, and is often con- 
founded with the T. serrata, from which it differs in its comparatively bulky 
size and the peculiar form of its hooks. The proglottides nearly equal in size 
those of the T. solium. In its scolex or immature condition this parasite has 
a very wide distribution ; for, in addition to its occasional presence in man, it 
has likewise been found in various monkeys, in cattle and sheep, reindeer, and 
in many other ruminants ; in horses, swine, and even in squirrels. Its habitat 
is for the most part the peritoneum (Rose and others). The cysticerci occa- 
sionally attain an enormous size. 
22. The Echinococcus hominis is the larva of the T. echinococcus; and the 
first accurate description of the immature form of the parasite was published 
by Bremser in 1821. These parasites have been, and are still often indiffer- 
ently named "hydatids" or "echinococcus cysts;" but English writers have 
restricted the term " hydatid " to designate the enveloping cyst, and the term 
" echinococcus" to signify the contained entozoon. The Echinococcus is an ex- 
tremely common parasite of the human body. It has been found in the kid- 
neys, lungs, liver, brain, heart, spleen, ovaries, breasts, tissue of the throat, 
and the bones; and they are not unfrequently discharged with the expectora- 
tion, or by stool. In the Icelandic endemic disease due to this parasite there 
is scarcely a part of the body in which it has not been found ; and its occur- 
rence in Iceland is a remarkable example of the prevalence of cystic entozoa 
in the human subject. It appears that the people of that country have been 
for some time suffering to a great extent under this very remarkable hydatid 
disease, which mainly affects the liver, peritoneum, and subcutaneous texture. 
Eschricht, writing to Von Siebold, says, "The disease has extended itself to such 
an alarming degree, that about a sixth of the whole population of Iceland are 
affected with it, and that it is attracting considerable attention at Copenha- 
gen." It produces a long, protracted illness, terminating with a painful 
death, and means of cure have not yet been discovered. Von Siebold con- 
siders it " probable that this disease arises from the immense quantity of dogs 
kept in Iceland, for the purpose of herding sheep and cattle" (Scldeissner, 
Medical Topography of Iceland; Allen Thomson, 1. c.; also Leared, in 
Medical Times, 1863). 
In some cases only a single " hydatid tumor" is developed in an organ or 
part; but occasionally two, three, or more tumors may be found. These " hydatid 
tumors" consist externally of a firm fibrous capsule, of a tint which varies with 
the organ in which it may be developed. In the liver they are white, or of a 
yellowish tinge. The capsule adheres intimately to the surrounding tissue, 
..and is abundantly supplied with bloodvessels. Bands of connective tissue 
■may be seen stretching outwards from the capsule, and incorporating it with 
■the tissue in which it is imbedded. Within this capsule, and completely fill- 
ing it, are-(1.) A gelatinous, translucent gray bladder or bladders, composed 
of numerous concentric hyaline layers, giving a laminated appearance to a 
section. It is finely granulated in some parts (degeneration?) and highly 
elastic. (2.) A very thin and delicate membrane is spread over the interior DESCRIPTION OF ECHINOCOCCUS EMBRYO. 
189 
of this elastic hyaline bladder, as the innermost layer of the "hydatid tumor." 
This membrane is the mother sac of the Echinococcus embryo (Huxley), and 
corresponds with the germinal membrane of Professor Goodsir. It is studded 
with innumerable transparent cells, varying in extremes of measurement from 
tffo troth to ^oVoth °f an inch* If is the seat of the development of innume- 
rable Echinococci; and to this membrane, in a fresh hydatid tumor, they are 
found connected by a delicate membrane, either singly or (more commonly) 
in clusters, the number of individuals on the cluster varying from ten to a 
hundred or more, as shown in the annexed woodcut (Fig. 29). 
Fig. 29. 
Groups of Echinococci, showing-(1) The pedunculated connection between these parasites and the 
germinal membrane ; (2.) Their occurrence in groups, enveloped by a very delicately thin membrane, 
continuous with the germinal membrane (after Erasmus Wilson). 
On close examination with the naked eye these groups present the appear- 
ance of a number of delicate white particles upon the inner surface of the 
germinal membrane; and when the aggregation into groups consists of many 
individual embryos, they may be seen through a transparent cyst. They are 
the scolices or embryos of the T. echinococcus in various stages of development. 
The "hydatid tumor" is Hl led and distended with a clear watery fluid, with 
numerous large and small vesicles, more or less clear and transparent, float- 
ing free, or so closely packed together that they cannot be removed without 
some degree of pressure. Some of them, particularly the smallest, adhere \ o 
the germinal membrane. They vary in size from that of a millet-seed to a 
size as large as a goose's egg, and their number not unfrequently amounts to 
several hundreds (560, Pemberton), or even thousands (7000 and 8000, 
Allen, quoted by Ploucquet and Frerichs). The larger of these free vesi- 
cles sometimes contain smaller ones of a third generation, and occasionally 
they in their turn contain others of a fourth generation. The size of the 
" hydatid tumor " and the germinal membrane must increase and grow accord- 
ing to the number and size of the daughter-vesicles, and in proportion to the 
quantity of contained fluid, which is sometimes 
rendered slightly opaque by the quantity of em- 
bryo Echinococci floating free in it. From the 
rotundity and distension of these inclosed vesi- 
cles it is difficult to fix them for examination ; 
and when they are punctured, their fluid con- 
tents issue from the vesicle in a jet of considera- 
ble force, impelled by the contractile power of 
the elastic tissue; and if the incision be of a 
sufficient size, the vesicle will roll up, and turn 
itself inside out. The Echinococcus embryo va- 
ries in size from Jgth to ^th of a line in length 
in the contracted state, and from ^th to T]Kth 
of a line in its elongated form. These varia- 
tions in length are according as the head of the 
parasite is extruded or retracted within the vesicle. The contracted state, in 
which the head is retracted within the vesicle, is the form most commonly seen 
Fig. 30. 
Two Echinococci from a " hydatid 
tumor." The one has the head re- 
tracted within the vesicle ; the other 
has the head extruded. 190 
TOPICS RELATIVE TO PATHOLOGY. 
in the "hydatid tumor," after removal from the organ in which it was devel- 
oped. In this state it is usually globular or oval, and slightly flattened at the 
opposite poles. In the elongated state, when the head is extruded and the 
hooks appear outside, the parasite is usually larger at the cephalic end, where 
there may be seen four suctorial prominences and the circlet of booklets. 
The Echinococci vary much in regard to the number of cephalic booklets 
they display at certain intervals of growth, but not sufficiently to give ground 
for specific distinctions to be made amongst them; and 
while the number of hooks fluctuates in all the forms of 
Echinococci that have been described, the alleged dif- 
ferences in the size and character of these booklets have 
reference to the degree of development of the parasite 
(Leuckart, Cobbold). These hooks are arranged in 
a double festoon, round a membranous disc (Fig. 31, 
A), and vary from twenty-eight, thirty-four, forty-six, 
or even fifty-two. They are arranged in two rows (Fig. 
32, B}, one row containing longer hooks than the 
other; the longer ones measuring about yog-oth of an 
inch. They each possess a gentle curve, so that there 
is a concave and a convex border, and a base (Fig. 32, 
b, c) which encroaches on the concave border for nearly 
half its length. The base is broader than any part of 
the hook, and has a bifid end. These booklets move on the central bifid 
process as on a pivot (Fig. 32, f, g, k}. Hook sacs may be distinguished with 
a sufficiently powerful lens. These booklets are 
of so minute a size, and at the same time so ex- 
tremely characteristic and important in diagnosis, 
that the annexed woodcuts (Figs 31 and 32, after 
Erasmus Wilson) may give an idea of their shape 
and arrangement. 
The head of the worm is separated from its body 
by a groove, and at its opposite pole is an um- 
bilical depression, which gives insertion to the 
peduncle which fixed it to the germinal membrane 
(Fig. 30, a). 
As the growth of the " hydatid tumor " ad- 
vances, the external enveloping capsule gradually 
loses its uniform thin and smooth character. It 
becomes rigid, fibrous, or even cartilaginous, while 
its inner surface becomes rough and uneven, cov- 
ered here and there with laminated deposits. Fre- 
richs, of Berlin, has seen such capsules completely 
surrounded by a calcareous shell; and the thicker 
and more rigid the capsule becomes, the greater 
is the resistance opposed to the further growth of 
the Echinococci, which may even be thus arrested, 
so that the parasites die, and a spontaneous cure 
results (Cruveilhier, Frerichs). 
Compound " hydatid tumors " have been found 
in which the cavity is multilocular. Outgrowths 
or buds form, which give an alveolar character to 
the lesion (Buhl, Virchow, Frerichs); and 
such occurring in the liver (as in several specimens 
in the museum at Netley), show on section a most peculiar alveolar appear- 
ance, the alveoli varying in size from that of a pin-head to a pea, and lined 
by the characteristic cyst. 
It has been usual to consider that there are two distinct forms of Echino- 
Fig. 31. 
(A.) An Echinococcus 
viewed transversely, the 
head being directed to- 
wards the observer ; s, s, 
suctorial discs. The hook- 
lets are seen to encircle a 
membranous disc. 
Fig. 32. 
(R.) The circle of booklets seen 
upon its under surface ; thirty- 
four in number, seventeen long 
and seventeen short. (C.) b, c, 
Lateral views of the separate 
booklets-b, The base ; c, The 
•central extremity, or bifid pro- 
cess of the base; c, Hooklets 
viewed upon the concave or in- 
ferior borderg, k, A diagram 
illustrating the movements and 
position of the hooklets. The 
•dotted line represents the outer 
rsurface of the neck, and runs 
through the fixed point of the 
three hooks. NATURE OF ACEPHALOCYSTS. 
191 
coccus cysts severally referable to different tape-worms; but they are now re- 
garded as one and the same. The cysts so prevalent in Iceland are known to 
occur indifferently in men and oxen; and are sometimes so prevalent that 
about one-eighth of all the cases of disease' are referable to this cause; and 
generally several members of one family suffer (Leaked). The Tcenia echi- 
nococcus is very often seen in Iceland. It is a very small one, consisting of 
not more than three or four segments, and not much longer than a line, 
and carrying twenty-eight to thirty-six booklets. It is found in large numbers 
in the intestines of dogs. 
Acephalocysts require some notice here. They were first described by 
Laennec as growths of membranous cysts. In the present state of science 
they are regarded as abortive Cysticercus or Echinococcus cysts-parasites of 
one or other of those kinds in whic)i the development has been arrested. Re- 
mains of booklets have been found in them; and the structure of the cyst 
may sometimes be seen to be precisely similar to that of the Echinococcus cyst. 
They have been found in all those places where the Cysticerci and Echinococcus 
cysts are known to abound-e. g., liver, spleen, kidney, bladder, and in exos- 
toses of bones. 
Thus we have seen that each kind of Tcenia has not only its own definite 
vesicular embryo, but each Tcenia has a definite Cysticercus or Echinococcus; 
and all of them are capable of being developed or reared into Tcenia when 
transferred into the alimentary canal of a suitable animal; and conversely, 
the development of Cysticercus and Echinococci occurs in man and other ani- 
mals in consequence of segments of tape-worms, or the ripe ova they contain, 
being eaten with their food. 
The experimental proof of these statements it is the principal scientific merit 
of Kuchenmeister to have established, by experiments which date so far back 
as 1851; and they have since been repeated and confirmed by many other 
observers (Siebold, Nelson, Zenker, Leuckart, Weinland, Knock). 
The experiments of Kuchenmeister were made on a variety of animals, and 
in one instance on the human body. The following is a short summary of 
his observations, together with those of Von Siebold and others, condensed 
from Dr. Allen Thomson's valuable paper in the Glasgow Medical Journal, 
No. x, July, 1855, which demonstrates the 
Relation between the Cystic and the Cestoid Entozoa. 
Experiments to determine this relation mainly consist in observing the 
effects of feeding an animal with the ova or larvae with which it is designed to 
affect it and other animals with the cysts. 
The first experiment of this kind was performed by Kuchenmeister in 1851. 
He caused young dogs to eat with their food a n amber of the Cysticercus pisi- 
formis of the rabbit and hare, and found that after some weeks these Cysticerci 
were converted, in the intestine of the dogs, into the T. serrata. 
The more important of the experiments devised and performed by Von 
Siebold confirm these results, and are described by him in his Essay on Tape- 
worms. They may be arranged as follows: 
First Series.-Ten young dogs were fed with the C. pisiformis from the 
rabbit, and being killed and opened at different successive periods afterwards, 
the gradual progress of conversion of the Cysticerci into Tcenice was carefully 
observed in their intestines. It appeared that, by the action of the gastric 
fluid in digestion, first the cyst and then the caudal vesicle of the Cysticercus 
were dissolved in the dog's stomach ; but the head and neck, resisting entirely 
the solvent action, passed into the duodenum. Here they soon became attached 
to the mucous membrane: and after an interval of only two or three days 
they were seen to enlarge, the head and neck undergoing little change, but 
the body elongating and transverse grooves appearing, which afterwards 192 
TOPICS RELATIVE TO PATHOLOGY. 
became more marked, and divided the body into segments. In less than two 
months these Taenic/e had attained a length of ten and twelve inches; in three 
months they were from twenty to thirty inches long, and the reproductive 
organs were fully developed in the last or caudal segments, which then began 
to separate as proglottides. 
Second Series.-These experiments were made by feeding young dogs with 
the C. tenuicollis, which is common in domestic cattle, and of which the vesicle 
often attains a large size. Having found that the vesicle was invariably de- 
stroyed by digestion, Von Siebold contented himself thereafter with giving the 
heads only to the dogs, removing artificially the vesicle. Six young dogs 
were the subjects of this experiment, which was conducted in a manner similar 
to the first, and with the same result-namely, the formation of tape-worms, 
which reached their full development in forty-eight days, and corresponded 
exactly with T. serrata. 
Third Series.-In this set of experiments the C. celhdosce, from the flesh of 
the hog, was employed. Four young dogs received at different times a num- 
ber of these Cysticerci with their food, and on being opened at different inter- 
vals afterwards, tape-worms, which resembled exactly the T. serrata, were 
found in their intestine, in various stages of advancement corresponding to 
the length of time that had elapsed. Von Siebold was struck with the close 
resemblance of this T. serrata of the dog to the common T. solium of man, and 
after an accurate comparison of various examples of these entozoa, concludes 
that they are identical, and not to be specifically distinguished, or that at 
most they are varieties of the same species, dependent only on the difference 
of their parasitic habitations. 
Similar experiments have since been made by Leuckart, and repeated by 
Cobbold, as to the cysts in cattle-the Cysticercus Tcenia mediocanellata. 
Fourth Series.-This series of experiments was performed in the same man- 
ner as the last, but with the heads or scolices of the Coenurus cerebralis, the 
entozoon so well known in connection with the disease called "sturdy" and 
"staggers," which it produces when infesting the brain of sheep and cattle. 
In order that the Coenurus might be procured alive, the dogs experimented 
on were carried to a part of the country where a number of sheep were 
affected with the "sturdy." In the intestine of five out of seven dogs fed with 
the Coenurus, great numbers of Tcenioe were found, at successive periods and 
in different degrees of advancement; in thirty-eight days the Toenice had 
arrived at maturity, and appeared, like those in the previous experiments, to 
correspond exactly with T. serrata and T. solium; in two other dogs the ex- 
periment was rendered nugatory by the dogs being ill of distemper at the time. 
Fifth Series.-The last of the experiments related by Von Siebold were 
made with the Echinococcus animalcules of domestic cattle, which are not 
specifically different from those of man. As many as twelve young dogs, 
and also a fox, received a quantity of the small Echinococci in milk; and on 
being examined at various periods from the commencement up to twenty-six 
days, there were found, in all different stages-of development, small Tcenioe 
totally different from any observed in the previous experiments, or indeed 
from any accurately distinguished or described by helminthologists. Von 
Siebold proposes to call this variety T. echinococcus. It is remarkable for its 
very small size-not much longer than an inch; and for the small number of 
its joints-which never amounted to more than three; and for the circum- 
stance that the reproductive organs are confined to the two last segments, and 
the caudal joint separates as a proglottis at a very early period. 
The Experiments on Man may be looked upon as the most interesting of all. 
Having the opportunity of repeating on a condemned criminal the experi- 
ments which he had previously performed on animals, Kuchenmeister con- 
trived to give to this man, at seven successive times, between 130 hours and 
12 hours previous to his execution, mingled with various articles of food, a EXPERIMENTS OF LEUCKART AND COBBOLD. 
193 
number of Cysticerci from the hog and some from the rabbit. "They appear 
to have been partly disguised by their resemblance to the grains of rice in 
warm rice soup; partly by their likeness to the small bits of paste in a kind 
of vermicelli soup; and partly foisted on the unhappy wretch by being sub- 
stituted for the small lumps of fat in blood-puddings" (Brit. and For. Med.- 
Chir. Review, Jan., 1857, p. 119). After death, a number of young Tcenice, 
in different stages of advancement, were found in the intestine; the greater 
number of them loose, but a few attached to the mucous membrane. The 
form of the booklets, and other circumstances, induced him to regard these 
tape-worms as the T. solium. There were no traces of the Cysticerci last 
swallowed; and Kuchenmeister was of opinion that those only which were 
first taken, and which were quite fresh, had been converted into Tcenice, and 
that those taken later, being dead, had been digested with the food. Leuckart 
made a similar experiment. He fed a man thirty years of age with Cysticerci 
from a pig, and in two months the man had Tcenice. But the enthusiastic 
and skeptical Germans were not yet content with the proof. M. Humbert, 
of Geneva, experimented on himself. On the 11th December, 1854, he 
swallowed fourteen fresh Cysticerci in presence of MM. Vogt and Moulinie! 
Early in March of 1855 he felt the presence of Tcenice, and discharged seg- 
ments of them. 
With regard to the converse experiments, the following facts may be related: 
Kuchenmeister, having previously caused the production of the T. serrata 
in a dog, by feeding him with the C. cerebralis from a sheep, gave to young 
lambs some of the ripe joints or proglottides of this Tcenia, and by the 
fifteenth day the usual symptoms of sturdy began to appear in the lambs. 
Kuchenmeister sent some of the same Tcenice to Van Beneden at Louvain, to 
Eschricht at Copenhagen, and to Leuckart at Giessen, all of whom, in sepa- 
rate experiments, caused lambs in the same manner to take the Tcenice seg- 
ments with their food, and in all the cases the same result followed-namely, 
the occurrence of the symptoms of sturdy at a period of from fifteen to 
eighteen days after the mature segments of Tcenice were given. Twenty-four 
hours after administration, the blood of the portal and other abdominal veins 
contained numerous cestode embryos. On the fourth day, semitransparent 
vesicles, g^th of an inch, appeared in the liver, and in six days they measured 
A; th part of an inch. The same experiment had likewise been performed by 
Dr. Haubner, of Dresden. He caused six young lambs to swallow the living 
and mature segments of a T. serrata. They all died of the vertiginous disease; 
and the Ccenurus cysts were found in the brains, heart, lungs, and voluntary 
muscles. The symptoms commenced by the fifteenth day; and in point of 
time their appearance was curiously constant, the vertigo being obvious 
between the fifteenth and eighteenth days in all the experiments. 
Several of these experimenters, having examined carefully the lambs so 
affected, were able to detect the progressive stages of formation of the Ccenurus 
in the cortical substance of the brain, where alone these entozoa seemed to 
attain the true Ccenurus form. There were abundant traces of them in the 
heart, diaphragm, and other muscles, and also under the skin, in some of the 
experiments; but in these situations they appeared to be abortive; while in 
the brain they gradually grew, and in some instances the vesicle had there 
attained the size of a hazel-nut. The brain was in all instances marked with 
inflamed grooves over its surface, indicating probably the track of the Tcenia 
embryos; for at the end of each of these tracks, in the early stages, were 
found the minute Ccenurce. 
Another confirmation of the fact of the conversion of the ova of Tcenia into 
cystic entozoa has been afforded by an experiment of Leuckart's, which merits 
separate mention. It gives the complement of the relation between the C. 
fasciolaris of the mouse and the T. crassicollis of the cat. Having in his pos- 
session a family of white mice, which he had employed for various experi- 194 
TOPICS RELATIVE TO PATHOLOGY. 
ments, and in none of which had the Cysticercus of the liver been perceived, 
he gave to six out of twelve, with their food and drink, the ova of the T. 
crassicollis, obtained by breaking up the ripe joints or proglottides of this tape- 
worm from a cat. Four months afterwards he found, on opening these mice, 
that four of them were affected with the C. fasdolaris of the liver; and he 
ascertained that in none of the mice which had not received the Tcenia ova 
was there any production of these entozoa. Similar experiments have been 
made with Tcenia solium and T. mediocanellata. 
From the whole series of observations and experiments that have now been 
made, and of which a summary has been here given, the following general 
conclusions maybe drawn and elementary facts stated, namely: (1.) That 
entozoa are always introduced into animals from without; (2.) That some 
obtain access to the body of animals from water, or other matters in which 
they have previously lived in the free condition, while others are taken along 
with animal food in which the entozoa have lived parasitically; (3.) That 
entozoa, when reaching sexual perfection in their parasitic condition, require 
to be in a situation which communicates with the external air-the most 
common position being the alimentary canal, and more rarely the pulmonary 
cavities; (4.) That almost all the entozoa inhabiting close cavities, or other- 
wise encysted in the bodies of animals, are only imperfect and earlier forms 
of other entozoa, which may attain maturity in the open cavities of the same 
or of different animals, or in the free condition, that is, liberated from their 
cysts; (5.) That entozoa rarely propagate themselves in the same animal in 
which they have arrived at sexual maturity, but require a different habita- 
tion, which they reach by migrations in the various modes before referred to; 
(6.) That the cystic entozoa are the imperfect states of different Tcenice; (7.) 
That Tcenice are almost invariably introduced, in their earlier condition, into 
the bodies of animals with flesh or other animal food; (8.) That if the ova of 
Tcenice be introduced into the alimentary canal of a suitable animal, through 
water, vegetable food, or fruit, their tendency is, after penetrating the tissues, 
to become encysted, and to assume the form of a cystic entozoon, such as that 
of a Cysticercus, Coenurus, or Echinococcus; (9.) That if these cystic entozoa 
again are taken by certain animals with their animal food, the head part 
(which corresponds with that of a Tcenia) resists digestion, and has a tendency 
to establish itself, and become developed into some form of Tcenia in the 
alimentary canal, by the formation of segments after attachment to the 
mucous membrane. 
The prevalence of cysts in the ration-beef served by the Commissariat 
throughout the Punjaub, especially at Peshawur, Meean Meer, and Jullun- 
dur, has, for many years, challenged the attention of the authorities. I have 
had a sample recently sent me from Meean Meer of this beef, containing as 
many as 100 cysts in the pound of flesh; and the medical officer who sent it 
me has taken out as many as 300 to the pound of ration-flesh. The largest 
percentage of cyst-infected cattle occurred in the Lahore division of the Pun- 
jaub, in January, 1869, namely, at Meean Meer, where it was as high as 
33.15 per cent.; and next in Peshawur, in February, 1869, when it was 17.99 
per cent. But all statements regarding the number of slaughtered cattle 
rejected as food, on account of being cyst-infected, are 
extremely variable, and are totally worthless as to 
scientific value. No two inspectors are equally care- 
ful, and great differences exist as to the practical 
knowledge and experience of examiners individually; 
while the general ignorance on the subject of such para- 
sites and their propagation is almost incredible. The 
natural size and appearance of these cysts are repre- 
sented (Fig. 33) by a and b. The head of one of these 
is magnified in Fig. 34, to the extent indicated by the scale attached, and is 
Fig. 33. 
(a. and b.) Two specimens 
of Cysticercus Tomia medio- 
canellata, natural size. CYST-INFECTED RATION-BEEF IN THE PUNJAUB. 
195 
shown to be the characteristic head of Tcenia mediocanellata in its embryo 
state. It may be contrasted with the embryo head of Cysticercus telce cel- 
lulose of measly pork (Fig. 35). Up to August, 1868, a great destruction of 
Fig.34. 
Head of Cysticercus Tcenia mediocanellata from ration-beef. 
ration-beef had taken place in India, on account of these cysts; and 17,428 
pounds of meat had been destroyed in 1868 and 1869. The Government 
then appointed Assistant-Surgeon Cleghorn to investigate into the whole 
question. The extensive condemnation of meat on account of cyst thus in- 
curred great expense to the Government, so 
great that the Commissary-General feared 
a difficulty might be experienced in pro- 
curing the number of cattle required for 
rations. The Inspector-General of Hospi- 
tals, Dr. Muir, also expressed his belief that 
the danger of eating cyst-infected beef had 
been much exaggerated, and that it might 
be eaten with safety, provided it was thor- 
oughly cooked. The Commander-in-chief in 
India concurred in this view, and orders 
were accordingly issued by the Government 
to this effect. Further special inquiry was, 
however, suggested, but was deferred; till a 
Report, dated June 1, 1870, by Assistant- 
Surgeon Oliver, R. A., on the prevalence of 
cysticercus in ration-beef at Jullundur, was 
considered by Dr. Muir to confirm his 
opinion, and was no doubt satisfactory to 
the authorities, and especially to the Commissary-General {Abstract of Pro- 
ceedings of the Sanitary Commissioner with the Government of India, August, 
1870, p. 236). 
Dr. Oliver reports that the whole of the meat was well-fed, and of excellent 
Fig. 35. 
Head of D. Cysticercus cellulose from measly 
pork, v. contrast with the Tania mediocanel- 
lata. 196 
TOPICS RELATIVE TO PATHOLOGY. 
quality; and the objects of his inquiry were,-(1.) As to the sources whence 
the cattle obtained the Tcenia ova; (2.) As to whether or not any evil results 
followed the consumption of cyst-infected meat when properly cooked. 
Regarding the source of the Tcenia ova, it was found,- 
(1.) That the infected cattle had been purchased by native dealers from 
various parts of the district, not from any particular locality. 
(2.) That when brought in they were lean, and, on an average, required 
from two to three months' feeding at the Commissariat cattle-yard before they 
were fit for the shambles. 
(3.) That their food consisted of the grass they could pick up on the grazing- 
grounds of cantonments, supplemented by such an allowance of grain and 
bhusa as their condition required. 
(4.) They were supposed to be watered at a trough with water drawn from 
a well, but it transpired that they very frequently were taken to a large dirty 
tank near the yard for their water. 
There can be no doubt, from the above statements, that both the grazing- 
grounds of the cantonments and the dirty water of the tank were plentiful 
sources of Tcenia ova. The tank was close to the huts of the camel-drivers, many 
of whom were infected with Tcenia mediocanellata. Human filth was often to be 
seen on the banks of the tank, and microscopic examination of such, and of stag- 
nant water taken from the margin, exhibited Tcenia ova. 
Dr. Oliver also says, that, a few months after means were taken to secure a 
good supply of well-water for the cattle, cysticerci entirely disappeared from 
amongst them. The cysts are most abundant in the flesh at the root of the 
tongue, also in the flesh of the rump, and the psoas muscles, the gluteal and 
lumbar regions; but it is not possible to detect them for practical purposes 
before death in any of these situations. 
Besides the ration-beef cyst, the watery-bag or hydatid cysts largely infest 
the animals killed at the Commissariat slaughter-house. Of the livers, 70 per 
cent, were so infected (Oliver and Cleghorn). As these cysts or watery- 
bags are only seen in the internal parts, the attention of medical officers has 
not been so much directed to them. Hence a prominence has been given to 
ration-beef with cysts, rather than to the abundant existence of watery-bags 
or hydatids, which have been in some measure overlooked. The liver and the 
lungs are the parts generally infected. The larger of the hydatid cysts are 
found in the liver,-from a pea to a man's head in size. They are the inclos- 
ing bags of the embryo echinococcus-a little tape-worm, which infests the dog 
tribe (see p. 188, ante) ; and considering the immense number of Pariah dogs 
which Dr. Oliver says are fed on the refuse of animals infected with hydatids, 
there can be no doubt about the source of the water-bag infection of cattle. 
The ova of the Tcenia echinococcus passed by the dogs must be extensively 
disseminated over the pastures on which the cattle graze. The refuse of 
animals infected with watery-bags ought to be burned. No dog should be 
allowed even a smell of such offal. 
Dr. Oliver's experiments as to eating beef infected with cysts show, as the 
experiments of others have long ago shown, that if the vitality of the cysts is 
destroyed by a high temperature, it will not produce tape-worm; but if the 
flesh is underdone, or if " scolices " of cysticerci are surreptitiously introduced 
into the food of a Hindoo boy of low caste (or any other boy), the chances 
are, that between three and four months afterwards, that boy will apply (as 
the Hindoo boy did), for tape-worm medicine. Surely such experiments are 
not now required ? 
Tcenia mediocanellata is acknowledged to be very common amongst the 
Mussulman population of the Punjaub, the lower classes of whom are in the 
regular habit of eating half-cooked beef-indeed, prefer it so.' It is amongst 
these people that tape-worm is so prevalent. Dr. Oliver is of opinion, from 
his experiments and observations, " that the question as to the safety or other- POWER OF PREVENTING CYST-INFECTION OF BEEF. 
197 
wise of eating cyst-infested beef, simply depends upon the manner in which it 
is cooked. If this meat is thoroughly done, and presents no rawness when cut 
into, the measles appear like little nodules of coagulated albumen, are doubt- 
less perfectly inert, and may be eaten with impunity. But," continues Dr. 
Oliver, " it is not only thorough cooking that is required to guard soldiers in 
India from the ill effects of eating measly meat. There is a want of cleanli- 
ness in the general arrangement of the kitchens, and serving of meals, which 
must offer great facilities for the introduction into the food of cysticercus; bar- 
rack cooks, unless constantly looked after, are utterly careless as to the 
washing of chopping-blocks, tables, dishes, &c. The dish or pot cover on 
which the meat is placed when raw is often used without washing for serving 
the piece up for dinner; and I have myself picked up a cysticercus from the 
table on which a cook was preparing food." The dangers, too, of the parasite 
being conveyed by the cook's unwashed hands to the plates in which the 
meals are served, and the common practice of using the same knife for cutting 
up meat, and afterwards (without washing it) for other culinary purposes, 
must not be overlooked. 
With , good selection and careful feeding, there seems to be every proba- 
bility that cysticercus would soon almost or completely disappear from our 
commissariat cattle. If they were entirely stall-fed, and watered from wells, 
there could scarcely be a possibility of infection after their purchase, and no 
possibility whatever if all ova-infested excreta were also destroyed. 
Notwithstanding the very excellent Report by Dr. Oliver, of June 1, 1870, 
the Sanitary Commissioner with the Government of India does not rise to the 
occasion. He merely observes that "it is very desirable that the special 
attention of the Executive Commissariat officers should be drawn to the great 
importance of being careful about the water used by slaughtered cattle." 
Moreover, he writes that " very little is yet known of these cysts or their con- 
nection with tape-worm," and suggests a careful inquiry, without arousing 
any alarm or suspicion. But with all due deference to the opinion of the 
Sanitary Commissioner with the Government of India, there is no fact in 
medicine more clearly and securely established, alike by experiment and 
observation, than the connection of such cysts with tape-worm, and of the ova 
of tape-worm with such cysts. Knowing this, and having seen every year, for 
the last ten or twelve years, the deficiency of practical acquaintance with the 
great facts of parasitic disease amongst medical men, I am compelled in duty 
to teach doctrine opposed to the practice prescribed for adoption in India. 
By the evidence contained in the abstracts of proceedings of the Sanitary 
Commissioner, it appears that so soon as the feeding and watering of the 
cattle are cared for in the proper manner, the cyst-infection of beef disap- 
pears. It is to this careful feeding and watering, therefore, that the Execu- 
tive ought to turn its attention and endeavors. Because the Executive fails 
to secure this cleanliness, is it politic that the cyst-infested beef-ration should 
be ordered to be used as food even when thoroughly cooked ? It is by no means 
a settled question what amount of heat or cold is necessary to destroy the 
vitality of cysts like the cysticercus or echinococcus (see Owen and Rudolph's 
observations at pp. 151,152, ante}. It is generally believed that the boiling 
temperature of 212° Fahr, is sufficient to destroy the vitality of these cysts, 
and to convert them as Dr. Oliver describes, into nodules resembling albu- 
men. But the boiling-point is not the ordinary temperature at which good 
wholesome meat is usually cooked, if it is well cooked so as to retain the 
nutritive juices in its interior. The outside may approach that temperature, 
and may even reach it in baking or roasting; but 158° to 1703 Fahr, is about 
the usual range of temperature at which meat is cooked in perfection, so as 
not to be hard or shrunken. Apart from the disgust, discomfort, and disease 
to the soldier, the mere permission to use cyst-infested ration, and far more, 
the authoritative order that it must not be condemned, but eaten when 198 
TOPICS RELATIVE TO PATHOLOGY. 
thoroughly cooked, open a door for the wide extension and continuous propa- 
gation of these parasites-a door that ought to be most rigidly closed. The 
tendency undoubtedly is to undercook animal food rather than thoroughly 
to cook it, or overdo it. Thus greater facilities are afforded for such cysts to 
live and become tape-worms, capable in their turn of shedding myriads upon 
myriads of ova, which may find their way into other cattle and herbivora 
grazing on foul cantonments, and drinking the taenia,-ova-infested water of 
the tanks. Compare the ultimate and inevitable consequences of this policy 
with the policy of destroying all cyst-infected meat, and the incidental loss at 
first of 8000 or 10,000 pounds of meat in a year (the average yearly amount 
destroyed for 1868 and 1869) at Qd., or even Is. a pound, and the certainty 
that every year the loss would be less, and such parasites eventually stamped 
out, if care be taken as to the feeding and watering of the cattle, and destruc- 
tion of ova-infested excreta. 
Cyst-infested ration-beef, and all hydatids or watery-bags, ought to be un- 
compromisingly condemned to destruction by fire; for there can be no doubt that 
parasitic disease has a firm hold, and is most disgustingly prevalent, among 
the inhabitants of India (both man and beast), and especially in the district 
of the Punjaub (see subsequent remarks by Dr. Gordon). I believe it to be 
increasing, not only from accounts I receive from India, but from the preva- 
lence of tape-worm (ymediocanellata variety) in the intestines of invalids from 
India who happen to die at Netley, and in whom the existence of a tape- 
worm during lite was unknown. As a rule, patients do not complain of tape- 
worm ; and unless they happen to be in hospital for other diseases, the medical 
officer has little chance of knowing how prevalent tape-worm may be among 
the men of a regiment. If the medical officer desires to know this, he must 
make a special inquiry, and with his own eyes must look for the presence of 
tape-worm links (proglottides) in the daily fecal evacuations of every man. 
A medical officer who did this amongst the patients in the hospital writes me, 
that he found six men out of thirty (one-fifth) suffering unknowingly from 
tape-worm when he examined specially to determine the point. How many 
cases were outside hospitals in India, there are no records to show. The prac- 
tical importance of this fact is obvious. All such ova-infested excreta ought 
to be as uncompromisingly destroyed by fire as the cyst-infested ration or 
hydatid. If such excreta are not destroyed, the ova inevitably find their way 
on the grazing-grounds of cantonments, or by surface conduits and drains into 
the water of tanks. 
If, on the one hand, cyst-infested beef is suffered to be eaten, and, on the 
other hand, the excreta of tape-worm infested men are allowed to go unde- 
stroyed, the propagation of parasitic disease broadcast over the land of India 
must be the inevitable result. Prophylaxis, therefore, is all-important; and 
the entrance of the scolices must be prevented. 
With prophylaxis in view, therefore, the following remarks are not less re- 
volting than suggestive. Dr. Gordon, of the Army Medical Department, 
thus writes: 
"Taenia appears to be of very frequent occurrence among the white troops 
in Upper India, and especially the Punjaub; and I have been told by some 
medical officers who have been stationed at Peshawur, our nearest canton- 
ment to Affghanistan, that they firmly believe every third soldier has had 
tape-worm during the two years regiments remain there. 
" From what I have been able to ascertain on the subject, natives are not 
particularly liable to tape-worm, and certainly not more so in the northwest- 
ern parts of India than in Lower Bengal. This is generally attributed to their 
almost total abstinence from animal food; and when we consider that both 
Hindoos and Mussulmans-all except the very lowest classes-abhor pigs' 
flesh, /while our own countrymen are very partial to it, and the common sol- 
dier probably not very particular regarding the early history of the animal CUSTOMS IN INDIA FAVORABLE TO PARASITISM. 
199 
that is converted into pork for his use, an additional circumstance in favor of 
the transformation of the Cysticercus constituting the 'measles' of pork into 
Taenia is thus disclosed to us. 
" Those who have escaped the misfortune of having had to pass some years 
in India can form no idea of the vast herds of lean, half-starved pigs that 
roam over the fields and waste grounds in the vicinity of villages ; neither can 
they have any conception of the nature of the food on which these pigs subsist. 
" The natives of India perform their ordinary natural functions in the open 
air on a piece of waste ground, left for the purpose on the outskirts of every 
village, and where, morning and evening, men, women, children, and pigs dot 
the ground at short intervals from each other. In an incredibly short space 
of time after the villagers have left the field it is as clean as if they had never 
been there, while the herd by which the clearance has been effected may be 
found in some shady place near or close to a tank, with the exception of a few 
of the more insatiable, that have gone to hunt for dead dogs, cats, cattle, and 
Hindoos that have paid the debt of nature since the previous meeting, and 
have been thrown or left on the plain to be devoured by domestic animals or 
vultures. 
" Pigs, however, are not the only animals that live in this filthy manner in 
India; cattle and sheep, that are so particular in their food in Britain, 
acquire degenerate tastes in India ; and it is needless to enter into similar par- 
ticulars regarding ducks, fowls, turkeys, and pigeons, all of which are more or 
less used as food by our countrymen there. 
" I have thus alluded to these matters with a view to indicate some circum- 
stances that most unquestionably tend to vitiate the quality of the animal 
food upon which our troops in India must subsist, and I think I have at least 
shown a sufficient cause for almost any amount of disease in the bodies of 
these animals ; as also why their flesh should be more liable to become diseased 
in Upper India than in Lower Bengal " (Med. Times, No. 357, May, 1857). 
Abstinence from the practice of eating raw meat is to be strenuously recom- 
mended ; and cases closely inquired into will often be found to take their ori- 
gin from the habit of taking animal food imperfectly cooked or underdone. 
Children have been affected with Taenia on being weaned, from the custom of 
giving them pieces of pigs' flesh to suck in an uncooked state, and containing 
Oysticerci. Cooks and butchers are known to be more liable than other peo- 
ple to be infested with tape-worms ; and in countries where raw or uncooked 
meat in the shape of fish, flesh, or fowl is much used, there tape-worms greatly 
abound, e. g., Abyssinia. By contrast, this is remarkably brought out in that 
country. It is observed that those who abstain from flesh altogether in those 
countries are altogether free, e. g., the Carthusian monks of Abyssinia. 
Vegetables eaten green, such as salads, ought to be scrupulously clean; for 
it is through green vegetable food and fruits that the ova which lead to the 
growth of Cysticerci and Echinococci make their way into our bodies. Hence 
these immature forms of parasites are most common in cattle; while the 
mature tape-worms are mostly found in the carnivora. Man, being more or 
less omnivorous, is doubly hospitable, entertaining as a host both forms of 
unwelcome guests, the tapes and the cysts. 
In place of burying the excreta of animals known to be affected with Taeniae, 
all such excreta ought to be burned. If they are simply buried, or merely allowed 
to drop and lie on the ground, multitudes of minute embryos escape destruc- 
tion ; and may ultimately find their way into the human body. All entozoa 
(not preserved for scientific investigation and experiment) should be thoroughly 
destroyed by fire when practicable, and under no circumstances should they be 
thrown aside as harmless refuse (Cobbold). 
Many of the immature entozoa pass their whole life as encysted parasites, 
and a few even acquire the jointed form, or become partially divided into seg- 
ments, while still within their closed cysts. A well-known example of this is 200 
TOPICS RELATIVE TO PATHOLOGY. 
afforded by the C. fasciolar is, which inhabits cysts in the liver of the rat 
and mouse, and has been the means of leading Von Siebold and Dr. Henry 
Nelson (independently of each other's observations) to the discovery of the 
remarkable relation now proved to exist between the cystic or vesicular entozoa 
and the cestoidea or tape-worms. These observers found the cystic entozoa in 
the liver of the mouse and rat in every stage of development, from the sim- 
plest vesicular form of the true Cysticercus to that which (from the number of 
the joints and their external form) has all the appearance of a true tape- 
worm, and from which, in fact, it only differs in the absence of sexual organs 
within the segments. A careful comparison of the form of the head, its circle 
of booklets, the four oscula or suckers, and other parts in the Cysticercus of 
the rat or mouse, with those of the T. crassicollis, which inhabits the intestine 
of the cat, has shown an exact resemblance between them. Dr. Allen Thom- 
son has repeated and confirmed these observations (Art. " Ovum," Cyclopaedia of 
Anatomy). The conclusion such observations lead to is now generally regarded 
as established-namely, that the cat receives its T. crassicollis with the flesh 
of the mouse or rat which it may have eaten. 
Symptoms of the Presence of Tape-worm and Cystic Parasites. 
From what has been stated, it is obvious that these must be very variable, 
determined by the form of the parasite and the locality in which it exists. 
Almost every case has some special symptoms of its own, local, reflex, or 
general. 
In the alimentary canal the tape-worms occasion uneasiness, or pain in the 
abdomen, sometimes spasmodic, gnawing, or biting, but more frequently a dis- 
tressing feeling which cannot be described. Irritation at the mucous orifices 
(mouth, nose, and anus) are also characteristic accompaniments. The bowels 
may be constipated or relaxed; the stools exceedingly dark or white; the 
appetite sometimes lost and sometimes voracious ; sleep disturbed, and temper 
fretful; and often, as a result of so many combined irritating causes, a remit- 
tent fever occurs, which has received the name of " worm fever." The mind 
is also often so much depressed as to amount to hypochondriasis. 
The symptoms of the existence of worms in the small intestine, such as 
Taenia, are often exceedingly obscure, and simulate many other diseases; so 
that, until a patient has passed a portion of the parasite worm, we are unable 
to predicate its existence with any certainty; and at no time till we actually 
see the parasite can we determine its species. 
Prevention and Treatment of the Tape-worm and Vesicular Parasites. 
The preceding history points out very clearly the means to be adopted for 
the prevention of tape-worm and of cyst-infected meat. At the same time, 
it is probable that there may be other accidental means by which the larvse 
of the tape-worm may be introduced; and it will be easily understood how 
this may more particularly happen in the cases of butchers, cooks, or others 
in the habit of handling affected meat. 
The instances in which the human body is affected with the Cysticercus or 
other cystic entozoa, though not rare, are by no means so frequent as those of 
tape-worm; but they are much more serious in their effects, more obscure in 
their origin, and in the meantime, therefore, more difficult to prevent. Scarcely 
any attention has yet been given to the source from which the various indi- 
viduals of the cystic entozoa infesting the human body may have derived their 
origin; but the observations already referred to make it extremely probable 
that the explanation of their introduction is to be sought for in the same 
causes which have been shown to operate in the lower animals. Thus, it MEDICINAL REMEDIES FOR TAPE-WORM. 
201 
appears to have been demonstrated that the Coenurus of the sheep proceeds 
from the ova or first embryos of Tcenia, and it is most probable that those are 
obtained from the excreta of the dog. The only mode, therefore, of removing 
this affection from a flock in which it may have become prevalent, and in 
which it is well known sometimes to cause very great losses, must be the care- 
ful separation of the dogs from the sheep for a certain time; for such time, 
indeed, that the dog shall find no more Coemcri in the offal of sheep which 
die of staggers, in eating which it receives the larvae of its Taenia; and 
that the dog, being free from this Tcenia, shall not furnish, by his excreta, 
the ova or embryos which, being taken accidentally with the pasture or water 
by the sheep, establish themselves in them as encysted Coenuri. Von Siebold 
states the important fact, that those flocks which are entirely without dogs, 
and are stall-fed, are never affected with the " sturdy." 
Medical Treatment. 
For the ejection of Taenia from the small intestines a great many remedies 
have been recommended; but in the present day medical men very generally 
limit themselves to one or two methods, or to the action of a purgative. The 
celebrated Swiss remedy, purchased by one of the kings of France, was 
a purgative composed of twelve grains of calomel and twelve grains of scam- 
mony, followed shortly after by half an ounce to an ounce of the sulphate of 
magnesia. In many cases such a purgative has been efficient. 
The oleum terebinthince alone has been found to act well. Half an ounce 
to two ounces of this medicine makes the patient slightly tipsy, but is less 
likely to cause strangury than a smaller dose, and produces three or four 
motions. In one of these the worm is usually found, the animal having, it is 
supposed, a great antipathy to this substance, lets go its hold, and actively 
attempts to escape. This medicine maybe repeated twice a week, if the first 
dose is not efficient. Three-fourths of the inhabitants of Cairo are said to be 
infested with Taeniae, and the native remedy is twenty to thirty drops petro- 
leum-an agent not greatly dissimilar to turpentine. The Grenadine bark 
has acquired much reputation in this disease in the West Indies; but it has 
not supported the hopes that have been entertained of it, at least in this 
country. 
Drs. Christison, Jenner, Gull, and others, have employed, with great suc- 
cess in tape-worm, the ethereal oleo-resinous extract of the male shield fern 
(Lastroea Filix-mas) in doses of twenty to twenty-four grains-a remedy 
which by many is still believed to be the most efficacious. Dr. Gull's dose is 
one and a half to two drachms. The liquid extract of fern root is the offici- 
nal remedy of the British Pharmacopoeia. It is made from the rhizoma or 
rootstalk of the Aspidium or Nephrodium Filix-mas, according to the formula : 
Fern root, in coarse powder, 1 part; ether, 2 parts, or a sufficiency; percolate 
and distil off the ether, and the liquid extract remains. The dose is 30 to 
n^60, in milk, or with mucilage, and should be given on an empty stomach. 
Mr. Squire finds the extract of the unexpanded frond equally effective with 
that of the rhizome. The powder may be used alone in doses of one to three 
drachms. 
A remedy sometimes used in Germany is Chabert's bandwurmbl, or the 
" oleum Chaberti contra Tceniam." It is obtained by the distillation of twelve 
ounces of oil of turpentine mixed with four ounces of the oleum animate faeti- 
dum, which is the crude oil obtained from hartshorn and animal bones. 
A remedy of Abyssinian origin, called Kousso or Cusso, the flower of the 
Brayera anthelmintica, has recently been much recommended; and has doubt- 
less been of great efficacy in some instances. It is administered in the form 
of powder, of which half an ounce is mixed with half a pint of warm water, 
and the infusion, with the sediment, is to be taken at two or three draughts, in 202 
TOPICS RELATIVE TO PATHOLOGY. 
the morning, on an empty stomach. If the bowels fail to be moved, a brisk 
cathartic ought to be given in three or four hours. 
Another remedy of more recent recommendation is Kameela or Reroo, the 
Rottlera tinctoria of the natural order Euphorbiacece, and sub-order Crotonece. 
It has been highly lauded by Dr. Gordon, Surgeon to the 10th Regiment of 
Foot. He writes: 
" The success and rapidity of effect of the kameela in removing tape-worm 
in the cases of soldiers of the 10th Regiment, to whom I administered it, were 
such that I did not consider it worth my while to keep notes of them after the 
first two or three ; nor, indeed, were the men to whom it was administered 
latterly taken into hospital, for they soon became aware of the wonderful effi- 
cacy of the remedy, asking of their own accord for a dose of it, after which 
they invariably parted with the worm in the course of a few hours, and then 
went on with their military duty as if nothing had happened; while, as 
I afterwards ascertained, considerable numbers did not think of 'troubling 
the doctor at all,' but, on suffering from the characteristic symptoms of the 
worm, applied for the kameela to the apothecary, and always with the same 
effect. 
" We prepared a spirituous tincture by adding Oj of alcohol to ^iv of the 
powder, and then filtering. We never succeeded in obtaining more than ^vj 
in this wray; and of this jj in a little mint-water was generally found to be a 
sufficient dose, Jij being in some cases required, and perhaps in one or two, 
Jiij; but I have never seen the remedy fail in removing the worm in a case 
where there were unequivocal symptoms of its presence. 
" With kameela there is no unpleasant effect. It is not even pecessary to 
take a dose of purging medicine as a preparative; and beyond a trifling 
amount of nausea and griping in some instances, no unpleasant effects are 
experienced ; while by far the greater number of persons to whom it is admin- 
istered suffer no inconvenience whatever, beyond what they would from a dose 
of ordinary purging medicine" {Med. Times, 2d May, 1857). 
One to three drachms of the powder, suspended in gruel, mucilage, treacle, 
or syrup, will of itself expel the worm. Dr. Clymer suggests the following 
formula: 
Rottlerse, Ji; Oleo Resime Fil icis, fjss.; Mucilag. Acaciee, Syrupi Aurantii, 
aa fgii; Misce et signa. One-half at bedtime, and the remainder the next 
evening-the patient fasting ten or twelve hours before. Should it not operate 
adequately, a dose of castor oil should be given. 
The duration or life of the parasite within the human intestine varies from 
a few months to thirty-five years (Wauruch) ; and although it is considered 
by some absolutely necessary that the head of the animal should be expelled 
before the treatment can be considered successful, yet there are good grounds 
for believing that there is considerable chance of destroying the parasite if 
large masses near the head are brought away. The worm is then likely to 
perish, the most actively growing and important portions being discharged. 
The head of the worm ought always to be sought for during treatment; at 
the same time, not being easily found, the physician is not to be discouraged 
by not finding it. Out of 100 patients treated for Taenia by Bremser, he only 
once found the head in the dejections; yet all are said to have been cured. 
In the list given at p. 146, numbers 23, 24, 25, 26, 27, and 28 comprehend- 
Fluke-like Parasites.-They are of a flattened oval form, smooth, soft, and 
yellowish, or yellowish-brown, and not jointed nor segmented. They are pro- 
vided with two discs; one, situated at the pointed head extremity, forms a 
funnel-shaped depression leading to the oval orifice of a ramifying or bifurca- 
ting alimentary canal, which has no anal aperture. The other disc is situated DEVELOPMENT OF DISTOMATA. 
203 
on the abdomen, and terminates by a blind concavity. The opening of the 
sexual organs lies between the two discs. Male and female sexual organs are 
embodied in one and the same individual; and (as in parasites generally) 
they pervade a very large portion of the body of the mature adult animal. 
A study of these parasites is of practical importance, chiefly in relation to 
their ova and early embryotic forms, 'which are now known to be developed 
in the open waters, or in minute water animals. It is therefore incumbent 
on us to be able to recognize them, and to know something of their natural 
history. 
The generation of some of these trematode parasites constitutes one of the 
most remarkable parts of the history of the process of reproduction among the 
Invertebrata. Two states or forms are known to exist-namely, a mature and 
an immature form-encysted and free. 
It is only in the mature form that the generative organs are found. Such 
mature Distomata have their habitat in the biliary passages, especially of the 
Ruminantia, as well as in man. Among sheep the disease induced by Trema- 
todes often commits great devastation, and is commonly known by the name 
of " the rot." These fluke-like parasites are found in all grazing cattle, also 
in the horse, ass, hare, rabbit, squirrel, antelope, deer, beaver, and man. 
These fluke-like parasites are chiefly injurious to man, indirectly, by their 
prevalence in the lower animals, causing meat to be unfit for food; although 
such meat is largely eaten by poor people. 
The odor of sheep with rot is peculiarly offensive; the flesh is wasted, flabby, 
and watery; and hundreds of thousands of sheep die every year, especially in 
marshy districts, from the effects of the liver fluke. 
It is only very recently that the facts connected with the natural history 
of these parasites have been ascertained, and their general result may be 
stated as follows: The fully grown and 
sexually mature Trematodes (as exemplified 
in the Distomata) are parasites of the higher 
Vertebrata, and are oviparous. The egg is 
7^-nth of an inch long, and °f an 
wide. 
When the egg of the Distoma opens (by 
the springing open of a sort of hood, which 
gives it the operculated appearance at one 
end), it gives vent to an embryo which moves 
rapidly by means of cilia, as is the case with 
many infusorise, and especially of the Opa- 
lina, now regarded by Schultze, Agassiz, 
and Stein as the earliest embryonic form of a Distoma. The discovery was 
made by Agassiz that a genuine Opalina (Fig. 36, b) was hatched from the 
egg (Fig. 36, a) of the Distoma. As such, they are found in sewage water 
(see A. H. Hassall's Reports on the Water of London); also in the faeces of 
animals infested with liver flukes, their ova passing out with the bile. The 
eggs continue to develop in water, and each egg finally produces an embryo 
which swims freely by cilia. They die in pure water, as many vermicular 
animals do who wpuld be more fortunate in water which is dirty, full of 
organic impurities, and abounding in food fitted for them. 
From each of these ova is formed an embryo, in which no resemblance to 
the parent Trematode is to be recognized; but presenting the simple structure 
of a ciliated animalcule, like a polygastric infusorian known as the Opalina. 
This embryo is not itself converted by any direct process of development or 
metamorphosis into a perfect Distoma, but has a progeny gradually formed from 
germ-cells within it, and consisting sometimes of one, but more frequently 
of a number of bodies which, when they arrive at maturity, present each one 
an external form and internal structure and locomotive powers entitling them 
Fig. 36. 
Egg of Distoma. 
Opalina. 204 
TOPICS RELATIVE TO PATHOLOGY. 
to be considered as independent animals. Nor are these directly converted 
into Distomata; a new progeny of animals is formed as before, nearly similar 
to those producing them, and equally differing from the complete Distomata. 
Each individual of this new progeny, as it increases in size, has formed within 
it, by development from germ-cells, the third progeny of the series and last of 
the cycle. These are different from their immediate parents, and in their 
internal organization soon manifest the type of the true Trematoda. They are 
endowed for a time with very active locomotive powers, to which a long 
caudal appendage contributes. Their progenitors have been confined in the 
parasitic condition; but these are in general freed from confinement, and 
move about with great vivacity for a time in the water surrounding the ani- 
mals which their progenitors infested. 
In this state they have been long known as Cercarice, having the appear- 
ance of minute worms with tails, and were classed by Mueller, the Danish 
zoologist, with the Infusories. Regarding the history of the development of 
these animals, information is only fragmentary; yet so different periods have 
been observed in the development of different species of these Trematodes, 
that by analogy a tolerably connected history has been obtained of the whole 
process. 
These Cercarice in water are observed to be exceedingly lively and active, 
both as to body and tail; and after moving about free in the water, they begin 
to go through a metamorphosis of a most extraordinary kind. They either be- 
come inclosed like a chrysalis in a pupa case, or penetrating the bodies of soft 
animals, or embryos of the animals, inhabiting the water-e. g., snails, fish, 
larvae of insects, and the like-they become encysted within these bodies. They 
thus become parasites, for example, in the mussel family {Mytilus edulis}; in the 
ovisacs of the Gammarus, or sandhopper (a small crustacean abounding on 
our sandy shores, and which may be seen leaping up in myriads from the 
beach); also in snails, frogs, newts, and the like. 
In the cavities of these animals it lives as a ciliated animal, and multiplies 
by division of its body. 
The next change in these parasites is that the cilia vanish. They fix them- 
selves, and become by and by oval motionless bodies (Steenstrup, Prichard, 
p. 270), which continue to grow, and in which a germinal mass becomes visi- 
ble, of an elongated form, and out of which the first form of a Cercaria arises. 
It is a single-mouthed parasite, and is known as the Monostoma mutabile, in- 
habiting the intestinal cavity of water birds. 
In the interior of this parasite arises another embryo, which becomes free, and 
passes out of the bird into the water again; and being yet furnished with cilia, 
it makes its way especially into the aquatic larvae of insects-e. g., ephemera, 
caddice worms (Phryganida?), the dragon-fly {Libellulidce); and into the soft 
embryos of fishes like those of the cod kind; in snails, mussels, and such kinds 
of water animals, all used as bait and food for fishes. 
Out of this ciliated embryo a germ pouch, as it has been called, makes its 
way; and from this germ pouch the Cercarice broods are developed. In the 
eyes of the fishes, they inhabit the aqueous humors. Thus it seems probable 
that Distomata enter the human intestinal canal as Cercarice, and pass thence 
into the biliary passages (Frerichs) ; and according to the observations of 
Giesker and Frey, they may also penetrate directly into the skin, and undergo 
development in the subcutaneous cellular tissue. Two Distoma were found 
in the interior of a tumor on the sole of a woman's foot; and in all probability, 
as Frerichs remarks, the Cercarice had entered the sole of this woman's foot 
while she was bathing in stagnant portions of the lake at Zurich. In another 
instance it was found in a cyst behind the ear of a sailor, aged thirty-nine, 
and in an abscess in the head of a boy twenty-five months old (Murchison, in 
Translation of Frerichs's Diseases of the Liver, vol. ii, p. 488). The eating of 
uncooked fish, whelks, shell-fish, and uncooked garden snails, are all obvious LESIONS FROM BILHARZIA HAEMATOBIA. 
205 
modes in which the Cercarice of the Trematoda may find an entrance into the 
bodies of man and other animals. 
Nine species of fluke-like parasites have been found in man. They have 
been named as follows (the numbers correspond to the list at p. 146): 
23. Fasciola hepatica, in its full-grown condition, measures from eight to 
fourteen lines in length, and from three to six lines in breadth. 
24. Distoma crassum.-In 1843 Mr. Busk found fourteen of these Distoma 
in the duodenum of a Lascar who died on board the "Dreadnought" hospital 
ship in the Thames. They are thicker and larger than those of the sheep, 
varying from one and a half to nearly three inches in length. 
25. Distoma lanceolatum.-Very few (only three) instances are known of 
its occurrence in man. The eggs are gJoth of an inch long, and ^g-gth wide. 
26. Distoma ophthalmobium.-It is recorded that four specimens have 
been found in the eye of a child five months old, born with lenticular cataract. 
No one of them exceeded half a line in length; and they were situated between 
the lens and its capsule, where they could be recognized as so many dark 
spots on the surface of the lens (Cobbold). 
27. Distoma heterophyes was found by Dr. Bilharz, of Cairo, in 1851, in 
the small intestine of a boy; and on a second occasion he collected several 
hundred specimens under very similar circumstances. The parts infested 
displayed a multitude of reddish points, due to the presence of dark-colored 
ova in the interior of the worms. The length of the largest specimens did 
not exceed three-fourths of a line (Siebold, Cobbold). 
28. Bilharzia haematobia is so named by Dr. Cobbold in honor of its dis- 
tinguished discoverer. It is, however, a bisexual parasite. The body of the 
male is thread-shaped, round, white, and flattened anteriorly. The oral sucker 
is triangular; the abdominal sucker at the end of the trunk is circular. Below 
this, at the curved margin of the abdomen, a furrowed canal exists for the 
reception of the female. This canal is peculiar and distinctive, and renders 
this Distoma generically distinct from the Distomata already noticed. The 
genital pore lies between the abdominal sucker and the commencement of the 
canalis gynwcophorus. The female is very thin and delicate; its tail is not 
provided with any canal. The suckers resemble those in the male; but the 
genital pore and the abdominial sucker are in contact. The length of the 
animal amounts to three or four lines, and the male is broader than the 
female (Frerichs, Murchison, Cobbold). Another name has therefore 
been given to it-namely, the (Dyncecophorus hcematobiiis (Diesing) ; but by 
whichever name it is known, it is of remarkable interest, not only from its 
peculiar anatomical structure, but from its great prevalence on the borders 
of the Nile, and from the grave and characteristic symptoms and appearances 
to which it gives rise. According to Griesinger, it is met with in Egypt 177 
times in 363 necropsies-i. e., equal to 33 per cent. 
The first specimens were discovered by Bilharz, of Cairo, in the portal 
vein and its branches, and likewise in the walls of the urinary bladder. It 
has been since observed by Griesinger, Reinhart, and Lautner in the veins of 
the mesentery, urinary bladder, ureters, and pelvis of the kidney, giving rise 
to a formidable and very prevalent disease. In the larger vessels, such as 
those of the liver, this Distoma gives rise to no derangements equal to those 
which result when it exists in the lining membrane of the urinary passages 
and the intestinal canal. There it induces hemorrhage and inflammation. 
In the intestine they are often associated with appearances resembling those 
of dysentery, with congestion, extravasation of blood, deposit upon and 
beneath the mucous membrane, fungoid excrescences, and croupy exudations 
that occupy ulcerated patches of the bowel. In many of these cases the eggs 
of the creature may be found wedged in long rows within the intestinal 
vessels, or in and beneath exudations on the free surface of the mucous 
membrane. Hence it has been suspected whether the dysentery endemic to 206 
TOPICS RELATIVE TO PATHOLOGY. 
Egypt may not have to the presence of these Distoma, the same relation as 
the itch has to the Acarus. Such a conclusion receives a strong confirmation 
when we turn to the lesions produced in the urinary apparatus. Here the 
mucous membrane appears swollen in places which are covered with a soft, 
sandy, rotten mass, that is firmly fixed to the subjacent tissue. The micro- 
scope shows this mass to consist of the full and empty shells of the parasitic 
ova, imbedded in a mixture of blood, exudation, modified epithelium, and 
crystals of uric acid. The thickening of the submucous tissue often produces 
stricture of the ureter, which is followed by retention of urine and all its dan- 
gerous consequences,-degeneration of the kidneys, pyelitis, dilatation of the 
pelvis, or atrophy of the renal substance; or the masses themselves become 
the nuclei of calculous deposits, and thus aid in the chlorotic exhaustion 
these creatures produce in the person they inhabit, by the consumption and 
loss of blood they imply. Lastly, it seems not unlikely that the dislodgment 
of clots into the general circulation sometimes brings about pneumonia, in 
the way described by Virchow, and illustrated by the ^clinical researches of 
Kirkes (Brit, and For. Med.-Chir. Review, 1. c., p. 125). Professor Virchow 
was good enough to show me a specimen, in his museum, of lesions in the 
bladder effected by the existence of this Distoma. The entire trunk of the 
portal vein is sometimes filled with this parasite, while their ova are found in 
the tissue of the liver; but the symptoms to which the D. haematobium gives 
rise are more referable to the urinary organs than to the liver. The urine is 
bloody, and sometimes contains the ova of the Distoma; and a state of pro- 
found cachexia supervenes (Frerichs, Cobbold, Moquin-Tandon). Dr. 
John Harley, of King's College, London, has recently directed the attention 
of the profession in this country to the remarkable prevalence of hcematuria 
at the Cape of Good Hope-a condition which he found associated with the 
fertile ova of this entozoon passed in the urine. After micturition, a little 
blood, never exceeding a teaspoonful, or some dark coagula, like " veins," 
appear with the last half-ounce of urine. The urine itself is never bloody. 
Sometimes the blood-coagula will block up 
the urethra, and cause obstruction for a few 
minutes. These are all the symptoms which 
appear in connection with the urinary appa- 
ratus : and numbers of people of both sexes 
are affected in precisely the same way in 
certain parts of the Cape-as endemic hsema- 
turia-especially at LTitenhage and Port 
Elizabeth. In various samples of urine sent 
to him by a person suffering from this affec- 
tion, he invariably detected the ova of this 
entozoon. Of these he was kind enough to 
give me specimens, and a copy of the wood- 
cut (Fig. 37). The eggs measure joTj-th of 
an inch long, and 3-5-5 th of an inch broad. 
He was successful in observing the perfect 
ciliated embryo after its escape from the 
shell; Fig. 37 (2) and (3). 
Dr. Cobbold has discovered the same Distoma in the portal system of an 
African monkey. 
29. The Tetrastoma renale, as its name implies, infests the tubes of the 
kidney, and was discovered in 1833 by Lucarelli and Della Chiaje. It 
attains a length of five lines, has an oval, flattened body, and is furnished 
with four suckers disposed in a quadrate manner at the caudal extremity. 
The reproductive organs are situated near the mouth. 
30. Hex'athyridium venarum has been found in venous blood, and from the 
sputa of persons suffering from haemoptysis (Treutler, Chiaje, Follina). 
Fig. 37. 
(1.) Ovum of Distoma hcemalobium from 
haematuria of the Cape of Good Hope ( Dr. 
John Harley); (2.) Embryo (ciliated) 
from ovum capsule; (3.) Embryo attached 
to the ovum capsule. DESCRIPTION OF ACCIDENTAL PARASITES. 
207 
It attains a length of three lines, is cylindrico-lanceolate, with six suckers 
biserially disposed on the under side of the so-called head (Cobbold). 
31. Hexathyridium pinguicola was once found in a diseased ovarium. The 
parasite attains a length pf eight lines (Treutler, Owen). 
Symptoms.-The symptoms to which Distomata give rise in the human sub- 
ject must of course vary with the site of the parasite; but nothing definite is 
known regarding them, except in the cases of hematuria and dysentery, already 
noticed. In sheep their presence occasions dilatation and catarrh of the bil- 
iary passages, accompanied by atrophy of the hepatic tissue. Jaundice rarely 
shows itself, and then only lasts a short time; but ultimately a condition of 
anaemia is developed, under which numbers of sheep die. The disease is known 
as " the rot " among sheep; and it prevails to a considerable extent among 
flocks feeding on marshy and wet land near the shores of rivers. 
In the human liver bodies have been found like the ova of entozoa, so fre- 
quently met with in the liver of rabbits (Gubler, quoted by Frerichs). 
CLASS C.-ACCIDENTAL PARASITES. 
Definition.-Internal parasites, having the habits but not referable to the class 
of entozoa. 
32. Pentastoma denticulatum lias been conclusively shown by Leuckart's 
experiments to be the larva. or sexually immature condition of Pentastoma 
toenoides, and is found in the liver and small intestines. 
33. Pentastoma constrictum.-The author had two portions of lung and 
three portions of liver, each containing an unusual parasite, sent to him from 
Jamaica, in August, 1865, for the Museum of the Army Medical Department 
at Netley. Staff Assistant-Surgeon Edward Barrett Kearney, Esq., is the 
donor of the specimens; and from his history of the patient's fatal illness, the 
following account has been drawn up: 
On the 11th of January, 1865, private Isaac Newton was admitted into the 
hospital of the 5th West India Regiment, at Up Park Camp, Jamaica, for an 
attack of tonsillitis. He was an African, enlisted about eight months pre- 
viously from the slave depot at Rupert's Valley, St. Helena, where all slaves 
captured in slave-ships are kept until disposed of. He appeared to be about 
twenty-one years of age, and of a thin spare habit of body. 
On admission the tonsils were inflamed and enlarged, but not ulcerated ; 
and there were aphthous ulcers about the tongue. He suffered from headache 
and pain across the back. 
On the morning of the 14th he complained of great pain in the abdomen, 
which became tympanitic. His tongue was clean, but vividly red at the edges 
and tip, and it felt dry to the touch. The skin was very hot and dry and 
harsh, and his pulse 100. The pulse continued to increase in quickness; 
sordes soon began to appear about the mouth and teeth, and the tongue 
became furred and cracked. Large moist crepitation was heard over the 
whole surface of both lungs. He became low, and disinclined to be spoken 
to, and by six o'clock in the evening his mind appeared to be confused. He 
passed his urine and his stools involuntarily in bed. 
On the 15th there was no improvement in his condition, and at ten o'clock 
at night he appeared to be in much the same state as before, and the bowels 
were confined. 
On the 16th he appeared livelier in the morning, the skin cooler, but still 
dry. He was thirsty, and sordes were still about the lips and teeth. The con- 
junctivae of both eyes were stained of a vivid yellow color. 
About nine in the evening he became suddenly worse. His pulse became 
very weak and almost indistinct, the skin cold, the countenance sunken, and 208 
TOPICS RELATIVE TO PATHOLOGY. 
covered with a copious perspiration. He appeared to be sinking, and he died 
at half-past ten that night. 
Post-mortem Examination Fourteen Hours after Death - The general appear- 
ance of the body was that of emaciation, with yellowness of the conjunctiva. 
Thorax.-The subcutaneous areolar tissue over the chest and abdomen was 
of a deep yellow color. The pericardium contained about four ounces of deep 
amber-colored fluid. 
The Heart was large and pale, but its substance was otherwise normal, and 
its valves healthy. The Lungs were both highly congested; and when cut 
into, a bloody frothy fluid exuded in quantity. The substance of both was 
very friable and yellowish in color. " On the anterior surface of the right 
lung, and near the edge of its lower lobe, one or hvo yellow specks appeared. 
They were about the size of a spangle, and when cut 
into, worms were seen regularly encysted in its sub- 
stance." On the posterior surface of both lungs 
there were numerous adhesions of long standing. 
Abdomen.-The Liver was very large, extending 
into the left hypochondrium. " Its surface was 
dotted over, both posteriorly and anteriorly, with about 
twenty or thirty yellow specks similar to those seen in 
the lung." The hepatic substance appeared paler 
and rather more soft than natural. 
Stomach.-It was distended with air and fluid, 
containing about a pint and a half of dark-green-colored fluid. The mucous 
membrane was congested in patches, in the stomach, and along the whole 
tract of the intestines. There was no ulceration; and no appearance of 
Tcenice, either continuous or in proglottides, could be discovered. Other organs 
were healthy. 
Description of the Parasite and the Lesions it produced.-Fig. 38 repre- 
sents a small portion of the lung, with the little worm seen at a curled up in 
its cyst. The pleura has been removed, so as to expose the "rings," "mark- 
ings," or " constrictions," which are characteristic of the body of this para- 
site. The pleura wras opaque and considerably thickened, probably from the 
irritation of the parasite. 
The appearance of the parasite on the surface of the liver was exactly 
similar to that in the lung, and therefore it is unnecessary to give another 
drawing; and wherever the serous covering of the organ was sufficiently 
transparent, the constrictions of the parasite could be seen distinctly shining 
through. 
Fig. 39 represents twro specimens of the parasite removed from their cysts. 
They are of the natural size, and one of them, a, is much shorter than the 
other, the constrictions being closer together: a measures five lines 
in length, b measures about eight lines. In diameter they are 
about o.ne line. About twenty to twenty-three rings or constric- 
tions can be counted on the elongated body, at tolerably regular 
intervals, and somewhat spirally arranged. 
Fig. 40 represents the two specimens of the parasite slightly 
magnified (about three diameters) : a is the shorter; b and c are 
the posterior and anterior aspects of the longer of the two worms. 
The head end appears compressed, so as to be flat and square- 
shaped at the end. It is seen to be marked with'/w spots on the anterior 
aspect, as shown at c. The posterior aspect of the flattened head, as shown at 
b, is comparatively smooth. The elongated body is rounded, and the caudal 
end terminates in a blunt-pointed cone. The constrictions appear like folds 
of the outer covering of the worm, each fold overlapping the one which follows, 
from the head to the tail. The body of the parasite is rounded, and not flat, 
as the tape-worms or cysticerci. 
Fig. 38. 
Fig. 39. PENTASTOMA CONSTRICTUM IN THE LUNGS AND LIVER. 
209 
Fig. 41 represents the anterior aspect of the flattened head end (cephalo- 
thorax} of the parasite. It is so highly magnified as to show the nature of 
the five spots or marks shown in Fig. 40. 
The dotted lines from a and b point to two 
pairs of hooks or claws-one pair on each side of 
a pit or mouth, c. The points of the claws, in- 
dicated by a, are seen nearly in profile; those at 
b are directed more towards the observer. These 
claws appear to be implanted in socket-like hol- 
lows or depressions, surrounded by much loose 
integument. These socket-like hollows appear 
to be elevated on the summit of the mass of tissue 
which lies underneath the folds of integuments 
surrounding the base of the hooks. These parts 
are regarded as the feet of the parasite, and the 
hooks are the foot claws. 
The pit or mouth (indicated by the dotted line 
to c) is of an oval shape, the long axis of the oval 
lying in the direction of the length of the worm. 
The lip or outer margin of the pit is marked by 
a well-defined thin line. There are no spines nor hooks on the integument of 
the elongated body. 
From the description and the drawings here given, it will be seen that the 
parasite corresponds in its specific char- 
acters with the larval condition of the 
" Pentastoma constrictum." It belongs to 
the family acantliotheca of Diesing, and 
has no structural connection with the 
true helminth parasites found in the 
bodies of man and other animals. 
The parasite now described, when 
compared with the descriptions of penta- 
stomata given by Frerichs, Cobbold, and 
other observers, demonstrates clearly 
that at least two species of petastomata 
infest the human body; the Pentastoma 
constrictum being by far the larger, the 
more dangerous, and fortunately the 
more rare, of the two species. It is also 
still more satisfactory to know that, as 
a human parasite, neither of the two 
species has (ever been detected in this 
country ; and according to the researches 
of Dr. Cobbold, it is only in the encysted 
or larval conditions that the pentastomata 
are met with in the human body. As 
an embryo it becomes encysted. The 
cyst is composed of condensed connective 
tissue, and is lined by layers of loose 
flakes, which are evidently the remains 
of repeated castings of the skin of the 
parasite; and during the intervals of 
these successive moultings the worm 
makes considerable growth, so as to 
reach the size in which it is finally found. 
In this pupa or larval condition it occurs 
in the solid organs of the abdominal and thoracic cavities of man in certain 
Fig. 40. 
Fig. 41. 210 
TOPICS RELATIVE TO PATHOLOGY. 
geographical districts in Europe, Egypt, and the West Coast of Africa, and 
much more frequently in various herbivorous animals, such as the sheep, deer, 
antelope, peccary, porcupine, Guinea pig, hare, rat, and domestic cat (Cob- 
bold). In all these animals, and in man, the larvse usually occupy cysts 
immediately underneath the serous covering of the liver and the lungs; and 
Dr. Cobbold mentions that he has occasionally found the Pentastoma denticu- 
latum free in the cavities of the abdomen and pleura of animals. 
Our knowledge of the natural history of these parasites is mainly derived 
from descriptions of the Pentastoma denticulatum, the larval or sexually im- 
mature condition of the Pentastoma tcenoides of Rudolphi. We are told by 
Frerichs {Clinical Treatise on Diseases of the Liver, vol. ii, p. 276) that Pruner 
was the first observer who pointed out, in 1847, the existence of the pentastoma 
as a parasite in the human subject. On two occasions he found pentastoma in 
the liver of negroes at Cairo. He does not seem, however, to have determined 
accurately the nature of the parasite he observed ; and he also subsequently 
found two specimens of the worm preserved in the Pathological Museum at 
Bologna, which had been removed from the human liver (Cobbold). Bilharz 
has since repeatedly detected in the livers of negroes at Cairo the parasite 
discovered by Pruner in 1847. Bilharz and Von Siebold made this parasite 
the subject of careful study ; and they recognized in it a variety of pentastoma 
quite different from that which prevailed in some parts of Germany. They 
gave this new variety the name of Pentastoma constrictum-the parasite which 
has proved fatal in the case whose history Dr. Kearney has sent to me from 
Jamaica. It is the form of pentastoma endemic in Egypt, and hitherto it has 
only been found in the African negro. It differs from the Pentastoma dentic- 
ulatum (the larval form of the Pentastoma tcenoides), " in not being furnished 
with any integumentary armature of spines, and in its being a much larger 
worm" (Cobbold, p. 402). The Pentastoma constrictum seems to be from 
eight to twelve times larger than the Pentastoma denticulatum, and therefore 
is all the more dangerous from its actual size (nearly an inch long) ; and 
when it occurs in great numbers, as in the present instance, it cannot fail to 
prove an extremely irritant " foreign body," when it escapes into a serous 
cavity like the pleura or peritoneum-a mode in which it seems to cause 
death. The latter parasite (P. denticulatum) has been fully described by 
Frerichs, and figureci by him in his Atlas, plate xi, Fig. 9, as endemic in Ger- 
many in the human liver-in which organ it is considered to be far more 
common than the echinococcus.* Frerichs, however, regards the pentastoma 
endemic in Germany as devoid of clinical importance, because it does not 
give rise to any functional derangement. Not so, however, is such the inno- 
cent history of the Pentastoma constrictum as it affects the negro; and after 
the history of the case now given, the clinical importance of this parasite can- 
not be disregarded. 
As to the mode in which it tends to cause death, the evidence in this case, 
from symptoms and post-mortem examination, seems to point to pneumonia 
and sudden collapse from peritonitis. The author is able also to verify this 
point in the pathology of this parasitic disease still more clearly from a prepa- 
* u In Germany," says Frerichs, " the pentastoma was first found in the human liver 
by Zenker in 1854: it occurs, however, not only in this gland, but also in the kidneys, 
and in the submucous tissue of the small intestine (Wagner). The parasite is by no 
means rare with us. Zenker, at Dresden, succeeded in finding it 9 times in 168 autop- 
sies (or, according to Kuchenmeister, 30 times in 200 autopsies). Heschl, in Vienna, 
met with it 5 times out of 20 autopsies; Wagner, at Leipsic, once in 10. According 
to Virchow, it is more common in Berlin than in Central Germany. During six months 
at Breslau, I (Frerichs) met with it in 5 out of 47 dead bodies. As a rule there is only 
one present; in rare cases there are only two or three. It presents the form of a some- 
what prominent nodule, from 1 to lj lines in length, which is formed by a firm fibrous 
capsule, easily detached from the surrounding parts. The animal lies coiled up in the 
interior of this capsule " (On Diseases of the Liver, vol. ii, p. 276). PENTASTOMA IN THE HUMAN LIVER. 
211 
ration which has been in the Museum oi the Army Medical Department since 
1854, but the nature of which he could not understand till the history of the 
case now published was so thoughtfully furnished by Dr. Kearney, together 
with the specimens of the parasite in situ which he sent. 
The preparation in the Museum (hitherto a puzzle to all who have examined 
it) consists of four pieces of liver (Fig. 42, a, b, c, d), and appears in the Cata- 
logue with the following description: 
" Portions of liver, containing numerous small cysts (evidently some jointed 
entozoon), taken from Private George Sutton, 1st West India Regiment, who 
died at Bathurst, Gambia ; and for the history of the case reference is made to 
the annual report of sick and wounded from that station, dated March, 1854." 
The author is now able to identify this preparation 
as an example of lesions produced by the Pentastoma 
constrictum. At a, in the cyst where the larva has been, 
there is contained the debris of integumentary exuviae; 
at b, the head end of the parasite is seen peering out of 
an ulcerated opening in the serous covering of the liver. 
The edge of the opening is rounded and indurated, as if 
a good deal of local irritation had been maintained at 
the part previous to penetration of the serous covering. 
At c, the ring-like constrictions of the parasite are seen 
shining through a very thin portion of serous membrane; 
and the portion of liver at d represents an empty cavity 
-whence one of these larvae has passed out, probably 
into the peritoneum. The cicatricial-like contraction 
and puckering of tissue in the vicinity shows that con- 
siderable irritation has existed previous to the exit of 
the parasite. 
We have no information as to how the Pentastoma 
constrictum finds its way into the human body as an em- 
bryo and subsequent larva. Although in this instance 
the negro was stationed in Jamaica, it is most probable 
that he had the germs of these parasites within him when 
he left his native shores in some part of Africa; and 
that this parasite is neither endemic in St. Helena nor 
in Jamaica. Reasoning from what is known regarding 
the propagation and development of the Pentastoma 
denticulatum, it is probable that the ova with the contained embryos are in- 
troduced into the human stomach along with uncooked vegetable food (fruits 
or salads), in regions where the mature animals are endemic. From the 
stomach the embryos, escaping from the ova, bore their way, and find a rest- 
ing-place in the liver or other solid viscus, exactly like the embryo of the 
taenia. In solid organs (like the lungs and liver) they become encysted, and 
undergo the pupal transformation so well described by Leuckart and Cobbold 
in the case of the pentastoma endemic in Germany. 
The drawings which illustrate this paper were made by Staff Assistant Sur- 
geon Dr. Humphrey C. Gillespie, from the preparations which are now in the 
Pathological Museum of the Army Medical Department at Netley. 
34. (Estrus hominis.-Various insects and their larvae are apt to infest 
man, such as "bots," the (Estrus bovis, and the larva of a species of musca 
in Africa (Kirk). Five cases of the (Estrus hominis are recorded in man. 
They are the larvae of the oestridce, the bot-flies, breeze-flies, or gad-flies. The 
females deposit their eggs on the bodies of different herbivorous animals, and 
each species of fly keeps to its own particular species of animal. 
35. Anthomyia canicularis are known as exciting causes of boils by their 
larvae; and under this head, it may be convenient to notice that my friend Dr. 
Albert A. Gore, Staff Assistant Surgeon on the West Coast of Africa, has 
Fig. 42. 212 
TOPICS RELATIVE TO PATHOLOGY. 
kindly favored me with the following account of a larva or grub which is 
the exciting cause of Bulama boil: 
"This small larva or grub is of a white color, a line or two in length, and is 
the exciting cause of a boil occasionally seen in the Island of Bulama and its 
neighborhood (Fig. 43). When magnified under a 
low power (Fig. 44), it appears to be divided into a 
series of joints, and covered with minute bulbous hairs. 
On the anterior division are placed four or five red 
spots (6), and from either side project two hollow suc- 
tion-tubes (a, a). The posterior extremity seems to be 
terminated by a blunt hook. In applying a higher 
power the bulbous hairs turn out to be a number of 
beautiful black booklets (Fig. 45), which have a very 
pretty appearance on the white surface. A faint out- 
line of a central cavity can be discerned. The hook- 
lets are directed anteriorly. 
"Symptoms, Treatment, &c.-Attention is first at- 
tracted to the part by feeling an extreme itchy sensa- 
tion. On examination, a small red pimple is seen. 
After a while a small serous discharge oozes from its 
centre, which sometimes seems to pulsate. If allowed 
to progress, it becomes a regular inflamed boil, very 
painful, and often causing an erysipelatous blush, with 
inflammation in the neighboring lymphatics, and ten- 
derness of the glands to which they run. On the evac- 
uation of the small abscess in the boil these symptoms 
gradually disappear, but a persistent red mark remains 
at the original seat of the disease. The treatment con- 
sists in poulticing until the little animal appears, when 
it can be withdrawn. If allowed to suppurate, it must 
be treated in the usual way of a boil under similar cir- 
cumstances. The natives put in a mixture of salt and palm oil, which takes 
out the little grub. 
"Etiology and Pathology.-This little worm cannot be the chigoe or Pulex 
penetrans of the West Indies, although it may result from the ova deposited 
by some similar aphanipterous insect. The chigoe chiefly attacks the toes or 
intervals between them, and causes a series of painful ulcers. It is also of a 
black color. This small grub is white, causes a boil or two in any portion of 
the body, most commonly in the thigh, arm, or abdomen; it is sporadic, 
although endemic. They have one symptom in common-viz., the extreme 
itchiness. But this is complained of in nearly every case of disease resulting 
from insect or other living organisms." 
Fig. 43. 
Natural size of larva or grub, 
the exciting cause of Bulama 
boil. 
Fig. 44. 
The same grub magnified 
by a low power, (a, a.) Hol- 
low suction-tubes; (&.) Fine 
red spots. The other dots on 
the body are booklets. 
Fig. 45. 
Two of the booklets highly 
magnified. These drawings 
were furnished by Dr. Gore. 
II.-Ectozoa. 
Definition.-Animals living upon the skin and hair. 
Pathology.-These parasites are of three kinds-namely, lice, mites, ticks 
or spielers, and fleas. 
1. The first kind belong to the family of "lice" (Pediczdidce), of the class 
Insecta, amongst the annzdose or artiezdated animals. They belong to the 
order Anoplura, all of which are parasites and destitute of wings. They un- 
dergo no regular metamorphosis, as most other insects do; but in their growth 
to maturity they shed their skin a certain number of times, which may to 
some extent explain the irritation and forms of lesion to which they give rise. 
Almost all animals-man, quadrupeds, birds, and reptiles-are liable to be 
infested with these parasites; and were it not for our instinctive feelings of THE INGUINAL AND HEAD LOUSE. 
213 
disgust with regard to them, as opposed to our notions of cleanliness and pro- 
priety, the study of their forms and habits is of considerable interest to the 
pathologist. Upwards of 500 species of lice have been described-universally 
diffused over the animal kingdom in different climates of the world. Their 
superabundance upon the persons of the human race is associated with some 
severe lesions of the skin; and authentic cases are related of death from lousi- 
ness. A technical name has been given to this condition, namely: 
Phthiriasis.-Lousiness is a morbid state in which lice develop themselves 
to such an extent that a pruriginous eruption is produced {Prurigo pedicu- 
laris). The skins of persons liable to constitutional skin diseases in which 
watery or secreting eruptions (such as eczema) prevail, are those most favor- 
able for the development of lice. 
Five forms of lice infest the skin of man. One variety is met with on the 
hair of the head-the Pediculus capitis; a second variety infests the other 
hairy parts of the body, but especially the pubis; and hence its name-Pe- 
diculus pubis; the third form lives on the general trunk of the body-the 
Pediculus corporis; a fourth is the Pediculus palpebrarum; and a fifth the 
Pediculus tabescentium. 
The first four species, although they live in close proximity to one another, 
yet strictly limit themselves to the regions mentioned. In a clinical point of 
view the P. corporis is the most important. 
2. The second kind of animals associated with diseases of the skin belong 
to the family of "mites" or "ticks" {Acaridce), of the class Arachnida, 
amongst the anmdose or articulated animals. Some of these are free, others are 
parasitic, and vary somewhat in their structure accordingly. Those which 
live a parasitic life have the mouth in the form of a sucker. Such are the 
"ticks," which fasten upon dogs, cows,sheep, horses, and other animals. They 
bury their suckers so deep in the skin that it is impossible to detach them 
without tearing the skin to which they fix themselves; and they multiply so 
rapidly that oxen and horses attacked by them have been known to die of 
mere exhaustion. The harvest ticks {LeptidP), one species of which, the 
Leptus autumnalis, well known as the harvest bug, is common in autumn in 
grass and herbage, from which it gets on the body of man, and, though ex- 
ceedingly small, produces extreme irritation of the skin. One only of these 
parasitic Acari has been found to live entirely in the skin of man-the Sarcoptes 
galli vel Acarus scabiei-producing the disease called the itch. 
(3.) The third kind includes the common flea, Pulex irritans, and the 
Pulex penetrans or chigoe. 
36. Phthirius inguinalis, or the Crab Louse (Fig. 46), has a shield-shape, 
and a much broader body in proportion to its size than any other form of 
louse; and there does not appear to be any distinct 
separation between its thorax and abdomen. It has 
been met with on all the hairy parts of the body 
except the head, but more especially on the hair of 
the pubis. It does not run about like other lice, 
but grasps the stems of the hairs with its fore legs, 
and adheres so firmly that it is difficult to remove 
it without pulling out the hair. The nits or egg 
capsules are attached to the hairs in the same way 
as on the head. Pruriginous or eczematous erup- 
tions, which may become pustular, are the results 
of their existence (Anderson). 
37. Pediculus capitis, or the Head Louse (Fig. 47), is considerably smaller 
than the body louse. Its legs are larger in proportion to the size of the body 
than those of the P. corporis; and the abdomen is more distinctly divided into 
seven segments, separated from each other at the margins by deep notches. 
They propagate with astonishing rapidity, and by their irritation produce 
Fig. 46. 
lOOthsofan inch X 10 diameters. 
The Crab Louse (after An- 
debson). 214 
TOPICS RELATIVE TO PATHOLOGY. 
an eczema, from which the fluid exudes abundantly, and crusts are formed, 
involving the cuticular debris or exuviae 
of the lice and the remains of epidermis. 
The hairs become glued together; partly 
by the fluid from the eczema and partly 
by the secretions of the insects as they 
deposit their ova in the capsules which 
they fix to the hairs (Fig. 48). These 
capsules are commonly called nits; and 
they adhere with great tenacity to'the 
hairs. 
38. Pediculus palpebrarum, the Louse 
of the Eyebrows, is a doubtful variety. 
39. Pediculus vestimenti.-The Body 
Louse (Fig. 49) is of a whitish color, and 
varies from half a line to two lines in 
length; the body elongated and the ab- 
dominal portion broad, its margins lobu- 
lated and covered with little hairs. The 
thoracic portion is very narrow, and car- 
ries three legs on each side. The legs, 
are hairy, jointed, and terminate in claws. 
The insect secretes itself amongst the folds 
of the clothing, and causes extreme itchi- 
ness of the skin where it comes to feed. Between the irritation of the insect, the 
Fig. 47. 
(a) Pediculus capitis (male); (6) Trachea and 
stigmata; (c) Antenna (after Anderson). 
Fig. 48. 
Nit, or Egg Capsule of the Louse, fixed to (&) a hair, by the glutinous secretion (c, c, c, c). 
lOOths of an inch X 200 diameters. 
debris of its exuvite, and the scratching of the skin by the patient,papulae arise, 
the summits of which being torn off, give rise to a pruriginous eruption, which TREATMENT OF LOUSINESS. 
215 
may even become pustular. This eruption is met with most frequently on 
the neck, back, and shoulders, and round the waist-the parts most tightly 
embraced by the clothing; and where the clothes 
are most frequently gathered into folds, between 
which the lice are imbedded, and where they de- 
posit their eggs, or egg capsules, which are crystal- 
line, shining, yellowish, opaque bodies. The lice 
seem to multiply fastest where eruptions, such as 
eczema, prevail. A case is reported by Mr. Bryant 
as having occurred in Guy's Hospital, in which the 
whole of the body was literally covered with lice. 
The patient had been a governess, about thirty 
years of age; and the irritation was so great that 
excoriations and scabs were produced. On admis- 
sion into hospital she was put into a warm bath, 
her clothes were destroyed, and every precaution 
taken to remove all the insects; but in two hours 
afterwards her body was again covered with lice, 
although she had been laid in a clean bed. She 
was again thoroughly washed, but the vermin re- 
appeared immediately. Some of the insects and 
their ova no doubt remained adhering to the skin, hidden amongst the scabs 
of the excoriations; and they are known to multiply with a rapidity propor- 
tioned to the favorable nature of the soil afforded by the morbid condition of 
the skin of the affected person (Anderson, 1. c., p. 108). Bernard Valentin 
relates the history of a man, forty years of age, afflicted with unsupportable 
itching over the whole body, and having his skin covered with little tuber- 
osities. The physician, unable to assuage the itching, made an incision into 
one of the small tpmors, and gave exit to an enormous quantity of lice of 
different forms and sizes. The same operation was performed on the other 
tumors with a similar result (quoted by Anderson, p. 110). The following 
instance is related by Dr. Whitehead, in his work On the Transmission from 
Parent to Offspring of some Forms of Disease, p. 173, and quoted by Dr. 
Tanner: A farmer forty-three years of age, strong, and of sanguine com- 
plexion, contracted syphilis in April, 1840. Seven months afterwards he 
suffered from secondary symptoms. At the end of 1841 he became so an- 
noyed by the presence of lice about his person, chiefly on the trunk, that he 
sought again medical aid and advice. He was scrupulously clean in his 
habits, and had never before been troubled with these vermin. They in- 
creased in number, and produced such mental distress that fears were enter- 
tained for the integrity of his intellect. An examination of the skin showed 
a multitude of irritable-looking points on the front and sides of the chest, 
from which nits could be detached by lateral pressure. At this period the 
generation of the lice was so considerable and rapid that a flannel vest put on 
clean in the morning was crowded with them by the end of twenty-four hours. 
The usual remedies had only a temporary effect, till iodide of potassium and 
prussic acid, taken internally, seemed to render the system unsuitable for the 
further development of the vermin. 
40. Pediculus tabescentium, or Distemper Louse, is of a pale yellow color, 
having a rounded head and long antennse; the thorax is large and quadrate, the 
abdomen large, and the segments intimately united. It is doubtfully British. 
Treatment of Lousiness consists in the destruction of the insects and sooth- 
ing the irritation. To accomplish the death of the parasites the following sub- 
stances are efficient-namely, carbolic acid, sulphur, mercury, staphisagria, 
sabadilla, pyrethrum, the essential oils, and alcohol (Anderson). 
Carbolic acid may be used as a soap (Calvert's or Macdougal's), or oint- 
ment, or as a lotion, in the following proportions: 
Fig. 49. 
lOOthsof an inch X 10 diameters. 
Pediculus corporis-female (after 
Anderson). 216 
TOPICS RELATIVE TO PATHOLOGY. 
Crystallized carbolic acid, two drachms; Spirits of Rosemary, one ounce; 
Rectified spirit, half an ounce: Distilled water, to make up a lotion to six 
ounces, with which the parts are to be sponged night and morning. 
Sulphur is used in the form of vapor baths or fumigations, or the simple or 
compound sulphur ointment of the Pharmacoposia. 
Mercury may be employed as simple mercurial ointment, or by fumigations 
with cinnabar, or in solution of the bichloride, in the proportion of two to 
three grains to an ounce of water, to which some alcohol has been added. 
Staphisagria is employed as an ointment in the proportion of an ounce of 
staphisagria with four ounces of lard ; or an infusion of staphisagria may be 
made with vinegar. 
Sabadilla may be used in powder or as an ointment; an ounce of lard being 
used to incorporate a drachm of sabadilla. 
The hair should be cut short when lice infest the head ; and a lotion of the 
bichloride of mercury, or some of the ointments above named, applied at once 
to cause the death of the insects. The nits may be dissolved away by alcohol or 
dilute acetic acid (Hebra). The scalp should afterwards be repeatedly washed 
in warm water with soap, and the eruptions treated according to their nature. 
Sometimes the nits and the debris of the lice are involved in the substance 
of these eruptions, so that care must be taken to kill any insects that may 
remain and be so hidden. 
With regard to body lice, it is necessary either to destroy the clothes or to 
expose them to a temperature of at least 150° Fahr., by steaming them, or 
ironing them over with a sufficiently hot iron, or to boil them. In extreme 
cases, such as those related at p. 215, it has been found that a mixture of 
iodide of potassium and prussic acid in full doses cured the diseased state of 
the system which favored the development of lice in such numbers. After 
sixteen or eighteen doses in the case recorded by Whitehead, the cure was 
permanently completed. , 
The Pediculus pubis is best got rid of by rubbing a lotion of bichloride of 
mercury amongst the roots of the hairs, taking care that it is brought in con- 
tact with every insect. The 
application should not only 
be applied to the hair of the 
pubis, but to that in the 
neighborhood, such as that 
of the scrotum, perinceum, and 
anus; and the application 
should be continued twice a 
day for a week at least. Mer- 
curial ointment is equally ef- 
ficacious ; but care must be 
taken not to induce saliva- 
tion : the hairs, rather than 
the skin, are the parts on 
which the lotion or ointment 
ought mainly to be applied. 
41. Sarcoptes scabiei.- 
The full-grown itch spider or 
Acarus is of a whitish-yellow 
color, and is just visible to the 
naked eye. The female (Fig. 
50) varies in size from 7th to 
^th of a line in length, and 
from Toth to ^th of a line in 
breadth. It is of an ovoid 
form, broader anteriorly than 
Fig. 50. 
Acarus scabiei.- 1female (after Dr. T. Anderson). DESCRIPTION of the itch spider. 
217 
posteriorly. The anterior segment carries the head and four limbs, two on 
each side of the head, which are set very close to it. The head projects con- 
siderably beyond the body, is of a rounded form, and marked by a central 
fissure provided with mandibles. The limbs are altogether eight in number, 
the four posterior limbs being placed about the middle of the under surface of 
the body. These limbs are of a conical form, tapering towards a point. They 
are each composed of several jointed segments; and the four anterior limbs 
are each provided with a stalked sucker. The extremity of each of the hind 
limbs terminates in a long curved hair; and several short hairs spring from 
beside the root of each sucker on the anterior limbs. The body is marked by 
numerous regularly disposed wavy lines; the dorsal surface is convex, pro- 
vided with numerous little angular spines and little round tubercles, from 
each of which also springs a short conical spine. From each side of the body 
two hairs project; and four project posteriorly; so that, including those 
springing from the hind legs, the posterior half of the body is provided with 
twelve long hairs. 
The male Acarus scabiei (Fig. 51) is considerably smaller than the female; 
and the innermost pair of posterior limbs are provided with stalked suckers 
as well as the anterior limbs; while the parts corresponding to the genital 
organs are very distinctly marked (Hebra, 
Anderson). 
It is now impossible to say who discovered the 
itch insect. Avenzoar hinted at the existence 
of an insect in the vesicles of itch; but Moufet, 
in his Theatrum Insectorum, first mentioned it in 
a particular manner in 1663. Hauptmann first 
published a figure of it, and represented it with 
six feet. Redi Lorenzo, Cestoni, and Bonomo ex- 
amined numbers of them, having removed them 
from the papules or vesicles of the skin. They dis- 
covered also the eggs of the parasite, and even ob- 
served their extrusion. Morgagni, Linmeus, De 
Geer, Wichmann, and Waltz confirmed these ob- 
servations ; but, nevertheless, the existence of the 
parasite up till 1812 was still called in question. 
About this time, therefore, a considerable prize 
was offered by the Parisian Academy of Sciences 
for its demonstration ; and M. Gales, an apothe- 
cary of the St. Louis Hospital, tempted by the reward, is said to have defrauded 
the Academy and gained the prize (Anderson). His investigations are re- 
ported to have been witnessed by many members of the Institute ; but never- 
theless, he managed to conceal beneath the nail of his thumb the common 
cheese-mite, and having opened with a lancet the pustule of a patient affected 
with scabies, he dexterously produced the cheese-mite from beneath his nail, 
pretending to have removed it from the patient (Anderson). Many others 
attempted to find the Acarus in the pustules or vesicles ; and the circumstance 
of such men as Galeoti, Chiarugi, Biett, Lugol, and Mourouval having failed 
in finding the animal, occasioned fresh doubts regarding its existence. Their 
failures arose from having followed the cue given them by M. Gales in search- 
ing for the parasite in the papules or vesicles. Moufet had long before stated 
that they were not to be found in the pustules, but by their sides. Casal 
made nearly a similar observation; and Dr. Adams remarks that they are 
not found in the vesicles, but in a reddish line going off from one of its sides, 
and in the reddish firm elevation at the termination of this line, a little dis- 
tance from the vesicle. Seventeen years after Gales's demonstration the 
Academy discovered, through Raspail, that they had been defrauded; and 
in 1834 M. Renucci, a medical student from Corsica, showed the physicians 
Fig. 51. 218 
TOPICS RELATIVE TO PATHOLOGY. 
of Paris the mode of discovering the Acarus, which is the same method as 
that which had been formerly mentioned by Dr. Adams. Since that time, as 
Ray er remarks, the existence of the A. scabiei has been placed beyond a 
doubt; and after the demonstrations of MM. Lemery, Gras, and Renucci 
(all of whom showed him the method of detecting it), Rayer has been able to 
extract it several times himself. Raspail has given an excellent description 
and figure of the parasite. M. Albin Gras enters into researches as to the 
share it has in producing the eruption, and he instituted experiments on the 
Acarus itself, which have an important bearing on the treatment of scabies. 
The habits and natural history of the parasite have been carefully investi- 
gated by Hebra; and Dr. Anderson has given an excellent account of these 
investigations, from which this description of the parasite and the disease is 
mainly taken. 
The discovery of the male Acarus is claimed by several observers. Accord- 
ing to Hebra, it was first discovered by Danielssen and Boeck in Norwe- 
gian scabies. According to Dr. Anderson, M. Bourgogne, the maker of 
microscopic preparations in Paris, claims to be the discoverer. According to 
Devergie, the honor is due to M. Lanquetin, a pupil of St. Louis. 
It is the female only which burrow's in the epidermis of the human skin. 
All the male Acari go free on the surface of the epidermis, where sexual in- 
tercourse between male and female Acari is said to take place. When an 
impregnated female is placed on the surface of the skin, it seeks a suitable 
spot to penetrate, and raising its head at right angles to the surface, it digs, 
burrows, or eats its way between the scales into the deep layers of the epider- 
mis, where it imbeds itself, derives nourishment, and goes through the process 
of paturition till she dies. Having found a suitable place, an egg is laid, and 
each day another, the animal penetrating a little further each time, leaving 
its deposited eggs to occupy the space previously inhabited by itself. The 
direction of the canal is oblique, the portion first formed being of course, 
nearest the surface. As the old epidermis is thrown off, new layers of cuticle 
being formed from the deeper strata, the first-laid eggs are gradually thrust 
upwards to the surface, where they are finally extruded, while the recently 
deposited ova remain in the canal close to the parent female, whose instincts 
lead her to make the canal in such a way that her eggs reach the surface 
about the time the young ones are ready to come out of the shell. The newdy- 
hatched Acari (males and females) having arrived at the surface, crawl about 
the skin, and enter into sexual congress. The females in due time become 
impregnated, and, like their parent, repeat the process of burrowing and par- 
turition just described. The length of time which intervenes between the 
laying and hatching of an egg is said to be fourteen days; and as the Acarus 
is found to lay one egg daily, there are rarely more than fourteen eggs in one 
Fig. 52. 
(a.) Egg in the first stage; (&.) In the second stage, their grannlar contents being yellow; (c.) Egg in 
the third stage, the form of the Acurus becoming apparent; (d.) The egg in the fourth stage, the lew 
having broken the shell; (e.) Eggshell after the escape of the Acarus (after Dr. T. Anderson). 
canal at a time. The canals (cuniculi) which the female Acari burrow have 
a serpentine shape, and vary from half a line to three lines long. Hebra and 
Dr. Reid, of Glasgow, have seen them three or four inches in length; and 
Hebra mentions that they sometimes completely surround the wrist like a DEVELOPMENT OF THE ITCH SPIDER. 
219 
bracelet. These canals have generally a whitish dotted appearance, the dots 
corresponding to the ova in the canals; and at the extremity of each canal is 
a little whitish elevation, which corresponds to the site of the parturient or 
defunct female Acarus. This whitish elevation is generally about a quarter of 
a line distant from the papule or vesicle; and the skin should be cleaned 
before endeavoring to detect it. After the death of the mother Acarus, the 
epidermis which covered in the canal gives 
way, as the cuticle grows and desquamates; 
there is then left at first a depression, or open 
rugged furrow bounded on each side by a rag- 
ged edge of epidermis; and as these edges 
become dirty, the remains of the canal present a 
dirty ragged line. Besides the Acarus and its 
eggs, numerous little oval or rounded blackish 
spots are seen in these canals, which are supposed 
to be the excreta of the parasites; and after the 
female has once entered its canal it is unable to 
recede, owing to the spines on its body, which 
project backwards. It therefore dies in the canal 
when parturition is finished. The eggs of the 
Acarus vary much in size, according to their age 
and development; and just before the larva has 
burst its shell the egg is almost as large as the male Acarus. In the earliest 
stages the egg is very small, and filled with a granular-like matter (Fig. 52, a). 
It grows in the canal; and as it increases in size its con- 
tents seem to shrink and recede from the shell, and to have 
a distinct enveloping membrane. The bright yellow color 
of the embryo contrasts strongly with the clear, almost color- 
less, walls of the eggshell (Fig. 52, b, c, d). The head and 
legs of the embryo soon become distinctly visible, and at 
last the whole form of the Acarus (Fig. 52, c, d). Finally, 
the shell bursts, and the young Acarus escapes, leaving its 
shrivelled envelope (e) behind. The larva or young (Fig. 
53) differs from the full-grown insect in the possession of two 
hind limbs only, in place of four. By and by, however, 
it casts its coat, and then appears with eight legs; and 
sometimes even the full-grown Acarus, with its eight legs, 
may be seen inside of its old six-legged skin, and thus ren- 
ders the history of its development complete. 
42. Demodex folliculorum is found inhabiting the sebace- 
ous sacs and hair-follicles of the human skin (Fig. 54). By 
some naturalists this parasite is referred to the Acaridce, but 
by recent investigations it is considered to be more nearly 
related to the Rotifer a, its parasitic habits causing it to 
resemble some of the numerous forms of the Crustacea. It 
is not known to cause disease or any specific lesion. 
43. Pulex penetrans, Chigoe or Jigger, is a species of flea, 
and one of the greatest pests in tropical countries, and espe- 
cially in South America and the West Indies. The female 
burrows in the skin of the feet till quite out of sight, pre- 
ferring the bare spot between the toe and the nail, and 
there remains to rear a numerous progeny. It sets about 
its work so quietly, and insinuates itself so gently, that the 
only perceptible sensation is a slight, but not unpleasant, 
irritation (Rev. J. G. Wood). When the female has com- 
pletely penetrated under the skin, the vast number of ova 
begin to undergo development, and so enlarge the parent-abdomen of the 
Fig. 53. 
Larva or young Acarus scabiei- 
having only two hind legs (after 
Dr. T. Anderson). 
Fig. 54. 
Demodez follieulo- 
rum (after Dr. An- 
derson). 220 
TOPICS RELATIVE TO PATHOLOGY. 
Chigoe to about the size and shape of a pea. Even when so large, the only 
external sign is the swelling, with livid bluish color surrounding it, and up to 
this time it may escape observation. Those, however, who live in Chigoe-in- 
fested districts are careful to examine their feet every day, and dislodge the 
insect at an early period with the point of a needle. It is very difficult to 
extract them when fully swollen; for if the distended abdomen bursts, and a 
single egg is suffered to remain, the larva will be hatched in the wound, severe 
inflammation results, and a painful, festering, troublesome sore remains. If 
such a consequence supervene, oil of turpentine dropped into the wound is the 
most efficient, though painful remedy, but preferable to the long-continued and 
future painful sores. The negroes use red pepper, which they rub well into' 
the hollow after extracting the rest of the Chigoe from the feet of children; 
and the children are so afraid of being peppered that they soon learn to apply 
early to have the Chigoe removed before it has completely penetrated the skin. 
III.-Entophyta and Epiphyta. 
These mainly consist of fungi; but as fungi are often confounded with algae 
and confervas, the following three definitions may be given : 
Definition I.-Algos are represented by sea-weeds and multifarious green vege- 
table forms of simple cell-structure. They are met with in all streams, ditches, 
ponds, or even in the smallest accumidation of water standing for any length-of 
time in the open air. They are common also on damp walls, or on the ground in 
all permanently damp places. 
They are represented by the following groups: 
(a.) Floridece; (bf Fucoidea; (c.) Confervoidece. 
The following were once classed as algse, but are now regarded as the mycelia 
of various fungi, and not independent organisms, namely : 
Cryptococceae; Leptomitecs; and Phaeonemece. 
Definition II-Confervas or Confervoid Algos are chiefly marine; and con- 
sist of plants having unbranched filaments, composed of cylindrical cells, the 
length and diameter of which have a very variable relation in different species. 
They are produced from Zoospores, having two or four cilia. 
Definition III-Fungi are a class of cellular floiverless plants, growing in or 
upon damp mould; in or upon the wood and herbaceous parts of living or dead 
plants; upon living or decaying animal substances, or in solutions containing 
organic matter. 
They do not appear capable of assimilating inorganic food, and are in this 
respect distinguished from healthy specimens of all other plants, as also by 
the total absence of color, depending on the presence of chlorophyll or of its 
red modifications. They are allied by certain forms with the algce and with the 
lichens; but are distinguished from all outwardly similar forms of algos by the 
spore-bearing fruit always being elevated into the air, when mature, although the 
thallus or mycelium may be aquatic. 
The lichens possess green gonidial cells in the thallus, which fungi have 
not. They are entirely aerial incrusting plants, while the fungi have their 
vegetative structures immersed in the medium in which they grow. 
As influencing disease, fungi have certain peculiarities : 
(1.) They all absorb oxygen, and give off carbonic acid. They have great 
powers of decomposing salts of metals, as well as of destroying organic sub- 
stances. 
(2.) All of them contain a greater or less proportion of poisonous alkali 
entering into their composition. 
(3.) Yeast formations produce diarrhoea (Pereira's Materia Medica, p. 588). 
The Structural Elements of Fungi are-(1.) Mycelium (thallus fibrils), or 
vegetative structure, consisting of threads of various shapes and sizes, com- STRUCTURAL ELEMENTS OF FUNGI 
221 
posing a mass of exceedingly delicate, sometimes jointed and branched, col- 
orless, interlacing filaments. Some are large convoluted tubes, sometimes sep- 
tate, and they form together a cottony or felt-like mass when growing in or 
upon any permeable structure; or cloudy flocks when growing in liquids 
undergoing fermentation or putrefaction. The contents of the tubes and 
threads are granules or cells. 
(2.) Reproductive structures or fruit of fungi differ extremely in appearance 
in the various tribes. A filament rises up from the general body of the myce- 
lium, and at its terminal end is borne the fruit, composed of a modification of 
.one or more terminal cells. Thus the fruit may either be an enlarged, termi- 
nal, solitary cell; or a shortly-jointed tube; or a clustering of minute cells 
seated upon a receptacle; or a radiate arrangement of minute cells; or a large 
sac filled with minute cells. 
Reproductive cells or fruit may be of at least three different forms in conio- 
mycetous fungi. 
(a.) Conidia (naked spores), rising direct from the mycelium, or from the 
stroma found on the mycelium. 
The stroma consists of an indefinite number of minute cells, and is the early 
condition or nuclear form of the fully developed fungus. It accompanies all 
fungi in a state of active growth. The nuclear cells sometimes exhibit a molec- 
ular movement of their contents. 
(6.) Conceptacles, or hollow cells (organized immediately on the mycelium), 
the inner wall of which is lined by filaments (stylospores) terminating in 
minute cells or spores; or by spermatia, which are much smaller than the 
stylospores, and of a linear form (ultimately confused into a gelatinous mass). 
The functions of these spermatia are unknown, but are supposed to be fer- 
tilizing. 
(c.) Another form of spore is found inclosed in asci. 
Structure of the Spores of Fungi.-They are round or oval, solitary or 
arranged in rows, single or many-piled, or in groups of various sizes. They 
often show a dark spot, or a nucleus or nucleolus, in their interior. 
The spore has an outer coat composed of cellulose, and an inner coat or 
utricle inclosing a liquid containing floating granules, which are colored blue 
by iodine. 
Spores may be confounded with many other cells, such as fat, blood- 
disks, corpuscles of various fluids, nuclei of epithelial cells, pus, earthy 
particles. 
They are unaffected by ether, chloroform, alcohol,-all of which dissolve 
fatty cells, and render epithelium transparent. 
Ammonia renders the spores a little more colorless. It also dissolves pus 
and the secretions of eruptive diseases (which often contain granules and cells 
very like spores), converting them into a gelatinous mass. 
A hot solution of potash with alcohol dissolves impetiginous crusts, fat, pus, 
hair, and epithelium. 
Earthy particles, in granular, duplicate, or quaternate forms of carbonate 
and phosphate of lime, are destroyed by acids. 
The greatest care must be taken to distinguish fat-cells from spores, and 
diffused molecular fat from sporules, or nuclear forms of fungi. Beware also 
of taking minute fibres from handkerchiefs or towels for mycelia. 
The following are the most useful reagents for determining the character 
of fungi: 
Iodine (solution for granules of spores), Ether, Chloroform, Spirits of Wine 
(absolute alcohol), Ammonia, Potash, Acids (to dissolve earthy carbonates), 
Glycerin, Sulphuric Acid. 
The use of reagents is absolutely necessary in determining fungi, to escape 
from constant sources of fallacy. 222 
TOPICS RELATIVE TO PATHOLOGY. 
Although much has been written on the influence of fungi in the production 
or aggravation of disease in the animal as well as in the vegetable kingdom, 
and also as to their influence in the transmission, propagation, or portability 
of disease, yet the subject is involved in much confusion; because, in a few 
instances only, have the persons recording their experience been sufficiently 
acquainted with the botanical nature of fungi, on the one hand, and with the 
nature of diseases, on the other, so as to give anything like a complete history 
of the cases which have fallen under their observation. Mere mycelia have 
been described as perfect plants, and mistakes have been made in impor- 
tant points of structure. Productions of an undoubted fungic nature have 
been referred to algce, although agreeing with them neither in habit nor in 
physiology. The commonest moulds have received new names; and several 
conditions of the same species have been recorded as productions differing in 
their mechanism and physiological laws (Berkeley). 
Fungi are the most numerous of all plants in regard to genera and species, 
and their growth may be associated with most extensive injury to animal and 
vegetable life; and as they are now proved to be capable of propagation by 
implantation from animals and vegetables to man, they demand from the 
physician a most careful study. The epiphytic diseases of plants as well as 
animals have hitherto been almost neglected by the pathologist; yet how do 
we know that the blights of plants, or the causes of them, are not communi- 
cable to animals and to man ? It is known how intimately the diseases of 
man and animals are related with the occurrence of famines and the prevalence 
of unsound or unwholesome food, and of famines with the diseases of vegetable 
and animal life, as much as with the destruction and loss of food. The black 
sporules of Ustilago hypodytes, which cause disease in grasses in France (the 
grass smut), and those of Ustilago vittata, which cause similar disease in the 
grasses of India, are known to produce most injurious effects upon the 
haymakers in the former country (Leveille). In places favorable to the 
multiplication of fungi they often commit extensive ravages. Among the silk- 
worms in the silk manufactories of Italy, fungi are the cause of more exten- 
sive destruction of such animals than we have any correct idea of. Under 
the names of "mildew," "blight," "smut," "brand," and the like, fungi are 
described as committing extensive damage among living plants, as the farmer 
and orchardist know too well. It has been asserted that/wu/i are uncommon 
in tropical countries; but it is doubtful if this is true; and the fungus disease 
of the foot in India, so well described by the two Carters, shows that fungi 
are capable of giving rise to a disease almost dangerous to life in that country. 
It therefore behooves the pathologist to study carefully the nature of those 
epiphytic diseases in animals and vegetables, as well as in man, whenever he 
has an opportunity, and especially in India. It is not in all cases easy to 
determine whether they are the cause of morbid states, or whether, as some 
think more likely, the diseased tissues has merely afforded a suitable nidus 
for their development. It is certain that wherever the normal chemical pro- 
cesses of nutrition are impaired, and the incessant changes between solids and 
fluids are less active, then, if the part can furnish a proper soil, the crypto- 
gamic parasites will appear. The soil they select is for the most part com- 
posed of epithelium or cuticle, acid mucus or exudation. Acidity, however, 
though favorable for their growth, is not indispensable; since some of the 
vegetable parasites grow upon alkaline or neutral ground, as on the ulcera- 
tions of the trachea, or in fluid in the ventricles of the brain. Certain atmos- 
pheric conditions seem favorable to the occurrence of those vegetable parasites. 
For example, Tinea tonsurans maybe quite absent for years in places such as 
workhouses, where it commonly exists, and then for several months every 
second or third child in the place gets the disease. It has been observed that 
some of these parasitic diseases can be propagated by transference of the plant, PATHOGNOMONIC SIGN OF FUNGIC LESIONS. 
223 
as in various forms of tinea, and that the disease can be cured with the greatest 
readiness by the chemical agents which are most destructive to vegetable life. 
Parasites of the nature of fungi, associated with the skin diseases described 
as "ringworm," have been shown to be capable of transmission from animals 
to man. It has been proved by Devergie that T. tondens, for example, is 
transmissible by contagion from horses and oxen to man, and that the para- 
site has given rise either to the same form of tinea disease or to another; but 
he ascribes both species of parasitic disease to the growth of one and the same 
parasite-namely, the Trichophyton. Von Barensprung, of Berlin, bears sim- 
ilar evidence. He rubbed on his forearm some of the scales of tinea from one 
of the lower animals, containing abundance of the spores and mycelium of 
the fungus Trichophyton. No effect was produced for several days; but after 
a longer interval considerable itching called his attention to the part, which 
he found occupied by a well-marked spot of T. circinatus about the size of a 
sixpence. In three weeks the patch increased to the extent of a crown-piece 
(Brit. and For. Med.--Chir. Review, July, 1857, p. 263). 
Instances have been noticed of grooms being attacked by T. circinatus and 
sycosis after grooming horses affected by T. tonsurans. " A dragoon came to 
the Dispensary of the St. Louis Hospital affected with T. circinatus on the 
front of the right forearm. He stated that five or six of his comrades had 
contracted this affection as well as himself from grooming diseased horses. A 
visit to the barracks showed three horses with round patches absolutely iden- 
tical with T. tonsurans. These were situated on the withers, shoulders, back, 
and belly. The hairs in the centre of each patch were broken off close to 
the skin, and there was a whitish, squamous, crust-like production, which was 
traversed by the hairs. The presence of sporules was detected by the micro- 
scope. The dragoon who showed the horses showed also his daughter, a girl 
of eight or ten years of age, the side of whose nose exhibited a patch of T. 
circinatus " (Bazin, quoted by Dr. Anderson, On the Parasitic Affections of 
the Skin, p. 51). 
With regard to the transmission of favus from the lower animals, I am 
informed by Dr. Anderson that, in the Dispensary practice of Glasgow, the 
physicians often find it traceable to contagion from mice, cats, and dogs simi- 
larly affected ; but that mice especially are the animals which seem to be the 
ultimate source of the disease. 
On the other hand, it is shown that animals may contract parasitic diseases 
of the skin from human beings similarly diseased. Dr. Fox mentions an 
instance of a white cat, a great pet with the children of a family of nine, 
which contracted the mange and T. tarsi from T. tonsurans affecting five of 
the children. The fungus of the mange in the cat is the same fungus as that 
of Tinea in man-namely, the Trichophyton. 
The principal vegetable parasites associated in man with special morbid 
states are enumerated at p. 147, ante; but it would have been better if these 
fungi had been described in the first instance without specific names. The 
fact of specific names having been assigned to each of them has drawn atten- 
tion from the important part which these fungi perform in the work of de- 
composition. They may be forced to fructify by placing them in a globule of 
water surrounded by air, and placing them in a closed cell; and until the 
fungus has thus come to maturity, it is worse than useless to give them names; 
so many different forms in an undeveloped state being all capable of refer- 
ence to one common mould (Berkeley). 
The plants forming on mucous membranes, or in the contents of cavities 
lined by mucous or serous membrane, are in most cases secondary forma- 
tions only, and their exact pathological significance is unknown. 
The pathognomonic sign of all the fungic parasitic lesions of the surface 
(cutaneous or mucous) in man and animals is the infiltration or destruction of 
hairs (twice) and epithelial textures (muguet, thrush, oidium) by the sporules 224 
TOPICS RELATIVE TO PATHOLOGY. 
of a fungus, and which, by union or by growth, form elongated branches, or 
mycelium* 
The diagnosis of such fungi on the skin, hair, or epithelium, can only be 
effected by a careful and skilful microscopic examination; and it is always 
absolutely necessary to use liquor potasses and other reagents, mentioned at p. 
221, ante, in the examination of all tonsurant appearances of the hair, of all 
idiopathic bald patches, and of all brown or yellow-colored scurfs, for sporules 
are frequently detected which had escaped observation before liquor potasses 
had been used (Bazin, Fox, Anderson). Sufficient time must also be al- 
lowed for the parts to become transparent under the action of this reagent. 
The parasitic lesions of the skin are, as a rule, unsymmetrical, and hence 
they differ materially in this respect from syphilitic cases. They differ also 
no less essentially from the eruptive diseases of the skin. An eruption is no 
necessary part of these parasitic lesions; but, from the irritation established 
in the true skin, eruptions of various kinds may occur. Eruption thus often 
precedes the detection of a fungus, and, as a rule, very often follows its exist- 
ence ; and they who dispense with the microscope in the diagnosis of skin affec- 
tions cannot avoid confounding severe eruptive with parasitic lesions, because 
they disregard the pathognomonic evidence of such lesions already indicated 
(Fox). The term herpes, therefore, as applied to these parasitic affections, 
is an objectionable term; because it has been already used to indicate a vesic- 
ular eruption, namely, herpes zoster, which invariably exhibits large typical 
vesicles. 
There seems to be a peculiar condition of nutrition best fitted for parasitic 
growths of a vegetable nature, just as some constitutions and states of the 
system are best suited for the propagation and development of entozoa; but 
the exact circumstances which predispose to the growth of these entophytic 
fungi upon the human body are not better known than those which predis- 
pose the body to receive and develop certain morbid poisons of a specific 
kind, known to multiply during the course of the disease, and to throw off 
material capable of propagating and spreading the same kind of disease. 
With regard to the parasitic diseases of the skin and hair, a failure of the 
vital powers to carry on the healthy processes of life seems ordinarily to be 
one of the inviting causes of such a development of true fungi as would con- 
stitute a disease. A special nidus or soil is necessary, just as a predisposition 
is necessary in the case of the spread of miasmatic diseases; yet care must be 
taken in both instances not to confound the co-operating cause with the special 
or peculiar poison or germ. Both Robin and Bazin recognize a condition of 
the hairs (dependent, perhaps, on constitutional causes) which appears to be 
essential for the growth of the plant; for sometimes the disease disanpears 
spontaneously, and the fungus dies without its being destroyed by any specific 
treatment. 
Varied opinions still prevail regarding the nature of vegetable parasitic 
affections, and especially as to whether several distinct fungic growths are 
conceived in the production of the parasitic affections of the skin; or whether 
those affections are due to one and the same parasite. It has been shown 
that all the forms of ringworm are due to the same parasite,-namely, the 
Trichophyton (Bazin, Anderson) ; but there are not a few who hold that 
there is only one parasite productive of all the vegetable parasitic affections 
of the skin, amongst whom are the names of Hebra, Tilbury Fox, Lowe, and 
Jabez Hogg. 
There are numerous facts which seem to them to justify the belief that 
there exists but one essential fungus, whose sporules find a soil for develop- 
ment and growth upon the surface, or even within more secluded portions of 
* These fungi have sometimes been popularly but erroneously termed conferva;. 
The confervce for the most part grow in salt or fresh water. NON-IDENTITY OF PARASITIC FUNGI. 
225 
the human body; and that varieties in the growth of that fungus are due to 
differences in the constitution of the individual, to the moisture, exudation, 
soil, or temperature under which the development of the fungus takes place. 
The exact nature of these differences is not yet understood; but the produc- 
tion of irritant acids and gases are constant accompaniments of the growth of 
such parasites, by the chemical action of the vegetable cell; for it does not 
undergo development without exciting a chemical decomposition in the pabu- 
lum on which it feeds; and the different stages in its growth give rise to alco- 
holic acid and putrefactive fermentation. Of the latter there is ample evi- 
dence in many of these parasitic skin diseases, and especially in favus, the 
odor of which closely resembles that of some methylamine compound (Lowe). 
Thus their irritant action very soon may establish an eruption. But the ratio 
of eruption to parasite is not constant; for an amount of fungus which will 
simply produce death of hair in one person or part of the body, may in 
another produce irritation, eruption, or violent inflammation. These different 
results may be due to two causes,-(1.) Constitutional peculiarity in different 
individuals; (2.) Peculiarity of structure of a part as regards density, heat, 
moisture, and chemical and anatomical composition of the part. 
On the other hand, Dr. Anderson contends that the fungi met with in 
favus, tinea tonsurans, and pityriasis versicolor, are each different; in other 
words, that the Achorion Schonleini, the Trichophyton, and the Microsporon 
furfur, are not identical. The following is a summary of the proof he adduces 
in favor of their non-identity : 
" (1.) In all cases of successful inoculation with the Achorion, Trichophyton, 
and Microsporon furfur, the same parasitic disease has been produced as that 
from which the parasite was taken. 
" (2.) Of the innumerable cases occurring in the human subject illustrative 
of the contagious nature of favus, tinea tonsurans, and pityriasis versicolor, 
which have been recorded, there is no authentic case in which one of these 
diseases gave rise to one of the others. 
" (3.) The difference in the appearance of favus, tinea tonsurans, and pityr- 
iasis versicolor, when fully developed, is so very striking, as to lead to the 
belief that they are produced by separate parasites. 
" (4.) There is no authentic instance on record of the transition of one of 
these diseases into one of the others. 
" (5.) The difference in the appearance of the achorion, trichophyton, and 
microsporon furfur, is sufficiently striking to enable the observer in many 
cases to form a correct diagnosis from the microscopic examination alone. 
" (6.) Of the numerous instances on record of the transmission of favus and 
tinea tonsurans from the lower animals, by contagion or inoculation, favus has 
always giv6n rise to favus, and tinea tonsurans to tinea tonsurans." 
It is not to be hastily concluded that a disease is non-parasitic because a 
fungus has not been demonstrated in the part where it was expected to exist. 
The minuteness of the sporules, and the care required in the investigation, 
sufficiently explain the very various opinions which have prevailed on the 
nature of these parasitic lesions (Lowe). ho appreciate the ravages which 
may be produced by such minute cells, the reader may be reminded of the 
immense force which the growth of such cells is capable of producing through 
continuous and gradual development; for, being of so minute a form, and its 
agency so apparently invisible, its intrinsic power is apt to be underrated. 
An Agaric growing under a stone of more than a hundred pounds' weight 
will eventually raise it from its bed to the height of several inches; and the 
cells of that Agaric are not widely different from the sporules of a fungus. 
Again, the mycelium of a fungus (probably identical with that found in skin 
diseases) has been known to raise a cask of wine, the fungus feeding on. the 226 
TOPICS RELATIVE TO PATHOLOGY. 
wine as it leaked from the cask (Harvey, quoted by Lowe in Lancet of 
August 13, 1859). 
The variations of form in these different vegetable parasites, associated with 
the skin diseases to be afterwards described, are obviously so slight that they 
seem insufficient to warrant different species being made out of them. They 
may all be initial or undeveloped forms, referable to the Aspergillus glaucus 
or Penicillium; the initial forms of both of these being isomorphous (Lowe) ; 
and both of them are also equally indifferent about the matrix where they 
grow, as long as the conditions for their growth are fulfilled (Berkeley). 
Peculiarities have also been observed in the growth of the fungus, which may 
be explained as due to the stage of development and conditions of growth at 
the time it was examined {Path. Society Trans., xA. vii, p. 395). The same 
fungi during their growth are known to assume very different forms and 
appearances. It thus happens that the same species has not only been de- 
scribed under different specific names, but even referred to different genera. 
Fries states that he has traced no fewer than eight genera of different authors 
to mere degenerations or imperfect states of one particular fungus ( Thelephora 
sulphur id); and Nees von Fsenbeck states that the same fungoid matter which 
develops a certain fungus in winter (the Sclerotium mycetospord) will develop 
another fungus in summer (the Agaricus volvaceus). Professor Henslow showed 
that some of the supposed species of Uredo are forms of Puccinia, Aregma, 
and the like. 
Thus the Di-morphism of fungi presents a difficulty at the outset in connec- 
tion with the identification and interpretation of the structures seen ill textures 
which are believed to be infested with fungi. 
In many fungi of the coniomycetous kinds (where spores are the principal 
part) the same fungus appears under two or more distinct forms-so distinct, 
that some have been regarded as different species belonging to different genera, 
far removed from each other, and bearing different names. 
The golden-colored tumeric-like powder on the under surface of the rose 
leaves has its mycelium penetrating the tissue of the leaves, and the powder 
on the surface is composed of the spherical spores. The plant fungus was 
believed to be here complete, and has had the name of Uredo Hosoe given to 
it. But later in the season there are produced on the same mycelium certain 
dark-brown spots, which have been found to be aggregations of complex fruits 
of the same plant. These brown spores are borne on long stalks, and are 
septate or divided by transverse partitions into a complex fruit, to which the 
name of Puccinia Rosce has been given. 
Thus Uredo Bosse (the yellow spores), and afterwards the Puccinia Rosse 
(the brown fruit), were believed to be distinct and different fungi. Now they 
are knwn to be different forms of fruit on the same plant. 
Multiplicity of form is thus characteristic of the fructification of fungi. 
These forms are one or other of the following: 
(1.) Naked spores, or "conidia" (of which there are at least four forms), 
growing on the external cells of stroma, and reproducing only torula-like 
forms or promycelium. 
(2.) Naked spores or conidia, becoming sacs or pycnidia, and containing true 
minute spores (sporiferous), sometimes septate or bead-like, or moniliform 
strings, associated with true spores, and named stylospores. 
(3.) Spermatia, or minute bodies, produced in cysts or spermogones, and not 
known to germinate. 
(4.) Conceptacles, containing "sporidia," in hyaline sacs. These "sporidia" 
are secondary sporules, and are thus produced, within asci or sporangia, on the 
germinating threads from the true spores. 
In such fungi the mycelium or root-part consists of fine thin filaments, 
spreading through all parts of the plant infested by the parasite; and the dis- 
tinctions are taken from the characters and forms of the true spores. ARTIFICIAL CULTIVATION OF FUNGI. 
227 
The artificial cultivation of fungi has lately attracted attention, and it has 
for its object to distinguish the species of fungus under observation. The iden- 
tification of fructification and fruit is necessary to distinguish the species; and 
the only safe method is,- 
First. To identify the germ to be cultivated (the individual 11 micrococcus," or 
larger globule, or spore). 
Second. To take a specimen of " the micrococci," or one or more globules 
or spores, and isolate them in a closed cell, containing suitable food, to germi- 
nate in; /and with a pellicle of air surrounding the food and the germs, into 
which, as they grow, they may throw out their aerial forms of fruit or other 
reproductive parts by which they may be identified. My friend, Dr. Maddox, 
recommends the following solution for cultivating microscopic fungi (on glass 
slides) : " Dextrin, phosphate of soda and ammonia, microcosmic salt, of each 
two grains; grape sugar, sixteen grains; saturated solution of acetate of pot- 
ash, twelve drops; distilled water, one ounce, placed in an ounce and a half 
vial set in a saucepan, with sufficient water to come to the shoulder, and 
boiled for half an hour or longer. Surround the bottle very loosely with bits 
of rag or hay. If wished to increase the temperature, add salt to the water, 
or use a dense fluid, as oil. When cold, pour off into clean Jij stoppered 
bottles. I find most of the fungi grow well, keeping their color in this fluid. 
Placing the growing slide in a porous (battery) cell, and setting this in a 
vessel with an inch depth of water, keeps the object moist. This cell can be 
opened or covered from the light." * This is the only way to determine what 
originates from such bodies as are termed "micrococci." 
Third. To take care that the menstruum contains no other germs than those 
to be cultivated. 
The growth of moulds on moist substances ought first to be made a subject 
for the practical study of beginners. 
The pastes of wheat or of rice flour, where such moulds grow, should be 
examined at different depths, when it will be seen that numberless different 
modifications of form are assumed by the same fungus in different parts of the 
matrix. 
The general unsatisfactory character of cultivation-experiments are mainly 
due to two elements: (1.) The difficulty of the work, and the loose mode of 
identifying what has been called " micrococci," or even the larger " yeast-like 
cells." (2.) The uncertain methods of cultivation of these, and their uncer- 
tain identification with known forms of fungi. 
When a spore is taken for artificial cultivation, it is almost sure to carry 
* Further particulars, accompanied with two plates of figures, showing the results 
obtained with the Aeroconiscope, described in the Monthly Journal of the Royal Micro- 
scopical Society, June, 1870, on 155 days' exposure, are given in the February num- 
ber of the same Journal, 1871. The following is a brief summary of the method 
adopted: A narrow lined square, |ths of an inch diameter, open at one corner, being 
drawn on a slightly warmed microscope slide, with a sable-hair pencil, dipped in a 
preparation of mastic, wax, chloroform, and turpentine; a droplet of the following 
solution, which, after many trials, was also, by preference, employed for collecting 
the atmospheric particles on the thin glass covers, was placed in the centre of the 
square; the thin cover, with the collected substances, was then laid on this and gently 
pressed down. The slides thus prepared were set in a thin box, made from a new 
large writing-slate, one surface of the frame being slightly deepened by an extra one. 
This surface of the slate, covered with thick white blotting-paper, damped with dis- 
tilled water, had placed over it a clean sheet of pierced zinc plate, on which the slides 
were laid ; the thin box was then covered by a plate of glass, made to slide in the addi- 
tional framing, so as to convert the same into a narrow, flat, moist chamber, in which 
the slides were exposed to ordinary daylight. The solution was made from thick trea- 
cle, 1 drachm ; saturated solution of acetate of potash, 40 minims; distilled water, 5 
drachms, boiled in a narrow, covered test-tube until reduced to 4 drachms, the tube 
closed whilst hot, and when cooled and settled, a portion of the liquid poured into a 
2-drachm stoppered bottle, previously washed out with alcohol, and drained. 228 
TOPICS RELATIVE TO PATHOLOGY. 
with it germs of Bacteria schizomycetes, or other germs, as these exist in great 
abundance wherever fungi are, and they rapidly develop into an immense 
number of individuals. 
Spores of certain fungi will endure the moist heat of boiling water without 
losing powers of germinating; their behavior is similar with regard to the 
power of resisting frost; so that their endurance of high and low temperatures 
is very remarkable (Berkeley's Fungology, p. 32). Hence the very inde- 
structible characters of spores. The smallness of the reproductive cells or 
germs of fungi, and their facility of distribution, are important to be remem- 
bered in connection with their relation to disease-propagation. Some species 
are constantly recurring in the same places; but there is nothing like chance 
about their characters and growth. So rapid are they in development, that 
their appearance seems to favor the idea that they cannot have grown from 
seeds, germs, or spores. But notwithstanding the recent revival of the ques- 
tion of spontaneous generation, and of Professor Bastian's and Huxley's 
results, the belief in such generation is surely exploded,-all the more surely 
after the recent repetition of the experiments by Professor Frankland, of St. 
Bartholomew's Hospital. The most careful experiments show that without 
pre-existent germs no organized beings are ever produced from solutions con- 
taining material fit to nourish animal or vegetable life. Where experiments 
are not careful, and proper precautions are not taken to exclude germs, they 
grow and will exist in myriads. Observations on the growth of germs must 
be made very often, in some cases hourly. Only very little material should 
be employed at a time (a single germ only, if possible), in order that the field 
of observation may be well known and clear. 
The object is to see actually that a given growth proceeds from a given 
origin ; and not to conclude that when two or more forms exist in the same 
preparation, that they necessarily have a developmental relation to each other 
or a common origin, even although, at the beginning of the experiment, there 
appears to be only one kind of element present. Mere coexistence without 
organic connection affords no grounds for such a conclusion. 
The apparatus required for culture-experiments must be of such a kind as 
will afford-(1.) Means'of protection from dust; (2.) Means of applying 
heat; (3.) Means of growing in the dark ; (4.) Means of frequent observation. 
An account of the parasitic diseases of the skin will be found under " Dis- 
eases of the Cutaneous System." 
CALCULUS AND CONCRETION. 
Latin Eq., Calculus et Concreta; French Eq., Calcul et Concretion; German Eq., 
Stein und Concretion; Italian Eq , Calcolo e Concrezione. 
Definition.-(a) Calculus is a formation brought about by the deposition of 
all or of certain components of a fluid in which they are naturally held in solution 
or suspension; (b) Concretion is a formation (1) arising ord of a liberation of 
lime or other salts (phosphates and carbonates) from their normal combinations, so 
as to incrust or penetrate parts and sever minute textures (Rokitansky), or (2) 
a formation arising from stagnation of a secretion, when mineral and protein 
compounds alike become solid. 
Pathology.-Calculi are especially prone to form in secreted fluids, and 
either consist purely of specific ingredients proper to the secretion, or these 
ingredients blended with other elements. Numerous causes contribute to 
their separation : for example,-(a.) Extreme concentration of the fluid from 
loss of water; (b.) Inspissation and exsiccation of secreted and exuded mat- 
ter, such as mucus, ear-wax, smegma preputii, bile, pus; (c.) Chemical con- 
version of the fluid, as when the free acid of normal urine retains the phos- 
.phatic earths in solution, and when such urine is rendered alkaline, as by the CONCRETIONS OF PROTEIN SUBSTANCES AND FATS. 
229 
presence of mucus, or of pus, or of exudation, or by conversion of urea into 
carbonate of ammonia, the phosphatic earths becoming precipitated. If 
lithates present in the urine become decomposed by excess of acid in the 
urine, uric acid, being less soluble, is thrown down as concretions or minute 
calculi. The soluble phosphate of magnesia also becomes a concrete precipi- 
tate the moment it enters into combination with ammonia, as ammonio-phos- 
phate of magnesia. 
The principal and best-known elementary substances which, either in their 
purity or in combination with others, compose the more bulky calculi-concre- 
tions or concrements, are as follows: 
1. Concretions of Protein Substances emerge from their solutions as a struc- 
tureless or clod-like lump, or mass in various degrees of coagulation, or as 
elementary granules, represented under the highest magnifying powers by a 
concrete dot or point. Whatever undergoes spontaneously rapid and firm 
coagulation is described as fibrin; that which coagulates more slowly and less 
perfectly, under the influence of heat, is known as albumen. 
The protein deposits are insoluble in ether and mineral acids. Acetic acid 
renders them translucent, and ultimately dissolves them. Caustic potash and 
fuming hydrochloric acid slowly dissolve them, the latter with a lilac tint. A 
watery solution of iodine colors them yellow. 
2. Concretions of Fats occur in the elementary form of drops, or as amor- 
phous solid particles, granules, or crystals. There are different kinds of fats, 
recognizable by their forms and chemical relations, namely: 
(a.) Elain or olein, occurring in variously-sized drops, either free or within 
cells. The fat is usually set free out of emulsion-like compounds; and as 
elaic acid, out of saponaceous compounds; or out of combination with other 
fats, as in exudations or in medullary cancers. The drops resist the action of 
water and of acids, but dissolve on being boiled with potash, and still more 
readily in ether or heated alcohol. 
(6.) Margarine and margaric acid occur as microscopic, needle-shaped crys- 
Fig. 55. 
Fig. 56. 
(A.) Fat-cells, inclosing crystals of marga- 
rine (Wedl). 
(A.) Crystals of margarine (after 
Robin and Verdeil). 
tals, generally aggregated so densely in stellate groups or bundles as to 
appear as round, almost black, spherical masses (Fig. 55). Margarine 230 
TOPICS RELATIVE TO PATHOLOGY. 
emerges in these shapes from its solution in elain after cooling either within 
fat-cells (Fig. 56) or free. Crystals of margaric acid, soluble in concentrated 
heated alcohol, are developed out of the margarine of the fat by free acid, 
and are usually products of decomposition. They are found in gangrene, 
and are apt to take up coloring matter. Margaric acid (Fig. 57) crystallizes 
in minute tufts, composed of very small and much-curved crystals. 
(c.) Cholesterin occurs in flat tubular crystals or laminated plates (a) 
(Fig. 58), representing rhombic planes. It also occurs in the form of granules 
of fat. It almost always occurs with other fats, and often in great abun- 
dance. It is always present in bile; and colorless gall-stones consist almost 
entirely of this substance. It is also found in the atheroma of arteries; in 
the serous fluid of ovarian and other serous cysts; in the fluid of old hydro- 
celes. In general terms it may be stated that wherever tissues are in a state 
of fatty degeneration, there cholesterin may be found as the product of 
decomposition of their elements. Thus cholesterin is found in exudations, 
Fig. 58. 
Fig. 57. 
Fig. 57.-Margaric acid (Beale). 
Fig. 58.-Cholesterin plates-(a.) Regularly laminated, and viewed obliquely; at +, in the middle soli- 
tary plate, one edge is truncated; (&.) Irregularly laminated, partially injured forms: X 300 diameters 
(after Wedl). 
tubercle, stratiform coagula in the inner coats of arteries, epithelial cells of 
the air-passages, in bronchitis (Beale), epithelium and oil-globules in 
coats of uriniferous tubes in fatty degeneration of the kidneys. It may be 
extracted from many tissues in health,-e. g., crystalline lens of the eye 
(Beale). It is non-saponifiable, and is colored dark red by the action of 
sulphuric acid. 
These crystalline fatty concretions are frequently found in morbid growths, 
such as lipoma, and very commonly in various fluids and solids of the body. 
3. Pigment Concretions from blood, urine, or bile, assume the following 
forms: 
(a.) Black, brown, russet-yellow molecular granules, often adherent to micro- 
scopic crystals of ammonio-phospliate of magnesia. 
(6.) Bile-pigment, as a finely granular precipitate of a yellow-brown color, 
insoluble in water and in most acids-soluble in a boiling potash solution, 
with a greenish-brown tint. Nitric acid destroys it, after causing it to pass 
through phases, first, of green, then of blue, and lastly of red coloration. 
4. Concretions of Uric Add and Urates, simply or in the following combi- 
nations : CONCRETIONS OF LIME SALTS. 
231 
(a.) Uric Acid.-The fundamental type of this crystal (Fig. 59) is the rhom- 
boid prism-often cut down to a rhombic plane. Frequently the crystals are 
Fig. 59. 
Fig. 60. 
Fig. 59.-Crystals of uric acid.-(a.) Rhomboidal truncated, hexahedral, and laminated crystals. (6.) 
Rhombic prism ; horizontally truncated angles of the rhombic prism ; imperfect rhombic prisms; on the 
last crystal in this row is seated a group of rectangular crystals, (c.) Prism, with a hexahedral basic sur- 
face-barrel-shaped figure ; prism, with a hexahedral basal surface, (d.) Cylindrical figure ; stellate and 
superimposed groups of crystals: X 300 diameters (Wedl). 
Fig. 60.-(a.) Urate of ammonia in the form of globules; (&.) Urate of ammonia as an orange-yellow, fine, 
sandy concretion in the tubes of the kidney of a child, forming divergent, hard, irregular, black streaks, 
with'lateral branches and twigs imbedded in the tubular substance: X 60 diameters; (c.) Angular mole- 
cules of urate of ammonia, aggregated into black concretions. 
seen grouped into concretions as rosettes, and are difficult of solution in water. 
They are insoluble in acids, alcohol, and ether. Potash causes their gradual 
solution, and they are generally soluble in alkaline fluids. It occurs: 
(1.) As a sediment in the urine. 
(2.) As concretions of minute crystalline grains, of a gritty feel, but indis- 
tinctly visible. Such concretions are commonly known as " gravel." 
(3.) As amorphous or crystalline concretions, from a size clearly visible to 
a very large size, when they are named " calculi." 
(5.) Urate of Ammonia (Fig. 60) occurs as a finely-granular precipitate, 
colored of a dingy yellow, yellow-red, russet or rose-tint. It also occurs in 
the form of globules. It is difficult of solution in cold water; less so in hot. 
Acids will separate the uric acid, which, under the microscope, will be seen 
to assume their characteristic form, as shown in the previous figure. 
5. Concretions of Lime Salts are composed of the following forms : 
(a.) Basic Phosphate of Lime occurring as a gelatinous granular mass, solu- 
ble in acids, both in fluids and in solidified formations ; a soluble combination 
of protein substances with gluten, out of which it separates,especially in putre- 
factions and ossifications, in the form of molecules. 
(6.) Carbonate of Lime in a granular deposit in cell incrustation or stratifi- 
cation, either alone or in combination with the former. It is soluble in acids 
with effervescence. 
(c.) Oxalate of Lime occurs in octahedral crystals, sometimes remarkably 
minute. They are insoluble in water, alcohol, ether, and acetic acid; but 
soluble in hydrochloric acid. They are found in urine and in the urinary 
bladder (Fig. 61). 
6. Concretions of Ammonio-phosphate of Magnesia are composed of crystals 232 
TOPICS RELATIVE TO PATHOLOGY. 
of various shapes (Fig. 62). When rapidly formed, they cluster together in 
stellate groups, of needle-shaped crystals, or represent denticulate leaf-like 
forms. When slowly developed, they constitute trilateral prisms, in which 
both angles, corresponding to the same lateral edge, are truncated. These 
crystals are readily soluble in acids, even acetic acid. Wherever a develop- 
ment of ammonia takes place, the wide dissemination of phosphate of mag- 
nesia determines the formation of the insoluble triple phosphate. 
Fig. 61. 
Fig. 62. 
Fig. 61.-(a.) Quadratoetahedrals of oxalate of lime; (&.) The basal plane of an octahedron forming a 
rectangle; (c.) Compound forms ; (d.) Imperfect forms (dumb-bell crystals): X 300 diameters (Wedl). 
Fig. 62.--The more usual forms of triple phosphate of magnesia and ammonia; various metamorphic, 
hemihedral forms of the fundamental figure-the rhombic vertical prism : X 300 diameters (Wedl). 
In the formation of calculi and concretions these elementary constituents 
are classed by Rokitansky under two series, namely : 
(1.) Those made up essentially of protein substances; or into such as consist 
of gluten and fat, with the phosphates and carbonates of lime and magnesia. 
In this series are included the following: 
(a.) Protein concretions, as coagula within bloodvessels (vegetations); free 
bodies in serous cavities. 
(6.) Gluten-like colloid substances, commonly encysted, or conified concre- 
tions, as the valve-vegetation of the heart. 
(c.) Fat, as in the contents of fatty cysts, or accumulations of fat in serous 
cavities, or in combination with- 
(d.) Bone-earth concretions, as in cretification and ossification of fibroid 
and cartilaginous textures (see " Mineral Degeneration," p. 126, ante). 
(2.) Into such as have a more varied composition, and are especially 
marked by the specific substances which they contain, e. g., bile, urine, &c. 
In this second series of concretions there are two varieties: 
(a.) Genuine stony concretions or calculi, which when diminutive, are termed 
"gravel" or "sand," resulting from the precipitation of one or of several of the 
specific components of a secretion, the animal matter entering into their compo- 
sition as a bond of union or cement. The size of such calculi are extremely 
varied, from a fine but just perceptible sand-grain to that of a concretion fill- 
ing up the largest secretory canals and reservoirs. The smaller are usually 
spherical; the larger have their shape in some measure determined by the 
form of the canals or reservoirs in which they occur-as, for example, gall- 
stones in the bile-ducts, and calculi in the urinary bladder. 
Where many concretions coexist, they acquire more or less smooth facets 
from reciprocal pressure and friction-as, for example, numerous calculi in 
the gall-bladder or in the urinary bladder. 
The consistence and specific weight of calculi depend on their composition. 
They may be free in a cavity, or firmly impacted, or glued to a surface by 
the medium of a fibrinous exudation. DEFINITION AND PATHOLOGY OF MALFORMATIONS. 
233 
In structure they are extremely varied. A nucleus is sometimes recogniza- 
ble, composed of an amorpho-granular precipitate, round which concentric 
strata or crystalline formations form ; or they may be altogether crystalline, 
as the lithic acid calculus, or of cholesterin, as the white gall-stones. Some- 
times a foreign body may form a nucleus, introduced from without, as into 
the urinary bladder; or a coagulum of blood or fibrin, or inspissated bile, or 
bile-pigment, to a cholesterin calculus in the gall-bladder. Examples of such 
calculus formations will be found described in calculi of the urinary bladder, 
salivary calculi, calculi of the lachrymal sac, prostatic calculi, gall-stones, 
and intestinal concretions. 
(6.) Inspissation and desiccation of some fluid of secretion. The ingredients 
of the secretion form the substance of concretion or calculus, including a con- 
siderable amount of animal matter, combined with the specific elements of 
secretion. In proportion to the inspissation is the hardness of the concretions. 
Cyst-like dilatation of follicles gives space for such concretions to accumulate; 
for example, the follicles of the skin, mucous follicles, the tonsils, nasal and 
pharyngeal cavities, glands and prepuce, intestinal concretions, especially in 
diverticula of the intestines, inspissation of colloid or other cyst-contents. 
A microscopical analysis of concretions is essential for a determination of 
their source and character, and ought never to be omitted. (See Wedl, p. 
121, for an instructive illustration of this part, too long for quotation.) 
MALFORMATIONS. 
Latin Eq., Deformitas Ingenita; French Eq., Vice de Conformation; German Eq., 
Missbildung; Italian Eq., Vizio di Conformazione. 
Definition.-Deviations from the normal development of the organism of the 
body occurring in the earlier period of gestation, or at least previously to the termi- 
nation of foetal existence. 
Pathology.-The imperfections consequent on such primitive malformations 
result in more or less permanent deformity, to which the harsh name of mon- 
strosity has been given; and the doctrine of such congenital deformity is now 
comprehended under the scientific name of "Teratology" (Tipa^, signifying 
monster). The superstitions, absurd notions, and strange causes assigned to 
the occurrence of such malformations are now fast disappearing before the 
lucid expositions of those famous anatomists who have made the development 
and growth of the ovum a subject of special duty. It is sufficient to mention 
here the names of J. Muller, Rathke, Bischoff, St. Hilaire, Burdach, Allen 
Thomson, G. and W. Vrolik, Wolff, Meckel, Simpson, Rokitansky, and Von 
Ammon, as sufficient evidence that the truths of science will in time dispel 
the mists of ignorance and superstition. Nevertheless, much mystery still 
enshrouds the origin of malformations; and opinions concerning the origin of 
them may be considered in the two main issues, namely,-(1.) Are they due 
to original malformation of the germ? (2.) Or, are they due to subsequent 
deformities of the embryo by causes operating on its development ? 
With regard to the first issue, it is believed that the germ may be origin- 
ally malformed or defective, owing to some influence proceeding either from 
the female or from the male; as in the case of the repeated procreation of the 
same kind of malformation by the same parents, deformities on either side being 
transmitted as an inheritance. Farther evidence of original germ-defect is 
held to exist in the hereditary deformities extending over more than one 
generation; such, for example, as harelip, excessive number of fingers, hypo- 
spadias, and the like. 
With regard to the second issue, namely, whether subsequent deformation 
may not follow an originally well-formed germ, it has been said,- 
(1.) That such deformation maybe produced by mental impressions on 
pregnant women; but of this there is an absence of positive proof. 234 
TOPICS RELATIVE TO PATHOLOGY. 
(2.) It has been proved that external injury, suffered by women during 
pregnancy, will bring about deformation, as in the congenital deformity of 
hydrops ventriculorum cerebri. 
(3.) The late Sir James Simpson has shown how diseases of the ovum and 
foetus will bring about deformation of the child. The diseases are chiefly acute 
and chronic inflammation of the placenta, attachment of pseudo-membranes 
to the foetus, and adhesions of the foetus to the placenta. Self-amputations 
are thus also explained. Moles, mother's marks, and cutaneous spots, are 
ascribed to morbid states of the coats of the ovum. 
(4.) A very generally recognized cause of malformation consists in im- 
peded development of the foetus, the cause of which is not always obvious, 
but is for the most part concealed. The impediment may be confined to one 
part or extended to many, to more than one region of the body, for example, 
and to more than one apparatus. 
To understand the results of impeded development, the student requires to 
know the natural forms through which the several parts of the foetus pass in 
their normal development to completeness. If he does not know these, he 
cannot appreciate an "arrest of development" where it ceases at a certain 
point, and advances no farther. The increased growth and progressive nutri- 
tion of the normal portions of the body also impart important modifications 
to the final result. Transient forms of the human foetus are comparable to 
persistent forms of many lower animals; hence, malformations resulting from 
arrest of development often acquire an animal-like appearance. Many are 
unfit for life after birth. 
The following elementary facts in "teratology" are essential to a proper 
understanding of malformations: 
1. Dissimilar parts are never fused or united; only parts that are not origin- 
ally dissimilar, but which are developed from a common mass. 
2. Malformed parts are restricted to their determinate place. 
3. No malformed organ ever loses entirely its own character, nor a mal- 
formed animal its generic distinction-a distinct gradation and natural order 
are observable throughout. Thus, there are different degrees of malformation 
in the same deformity, varying from the greatest possible degree to the very 
least. 
4. Deformities do not take place by chance, and double deformities are 
always of the same sex. 
No suitable classification of deformities can yet be given; but taking embryo- 
genesis as a basis, a grouping may be made, useful alike for physiological and 
medical practice. Such is that originally given by F. A. Von Ammon and 
W. Vrolik. The same principle seems to have guided the College of Physi- 
cians in the following grouping of malformations (p. 237, Appendix to Nomen- 
clature of Diseases}: 
I.-Malformations resulting from Incomplete Development or 
Growth of Parts. 
Head absent, or rudimentary. (Nine types are described by Vrolik.) 
Cranium defective. 
(a.) OF THE BODY GENERALLY. 
Lower jaw absent or defective. 
Upper and lower extremities absent. 
Lower extremities absent. 
One lower extremity absent. 
Hands and feet articulated to scapulae and pelvis. 
Fingers and toes deficient in number. 
Referable to very- 
early periods 
of develop- 
ment. CLASSIFICATION OF DEFORMITIES. 
235 
(b.') OF THE NERVOUS SYSTEM. 
Brain absent, with exposure of base of skull. 
Brain rudimentary or incompletely developed-several types, accord- 
ing to incompleteness. 
Spinal cord absent or imperfect, with more or less exposure of spinal 
canal. 
Continuity of nerves with nerve-centres incomplete. 
(C.) OF THE ORGANS OF SPECIAL SENSE. 
Eyes absent. 
Eyes imperfect. 
Eyelids incomplete. Eyelids remaining united. (Symblepharon.) 
External ear absent. Pinna adherent. 
Meatus externus closed. 
Internal ear imperfect. 
Nose absent. 
Nose imperfect. 
Nose resembling a proboscis. 
(d.') OF THE VASCULAR SYSTEM, 
Heart absent. 
Cavities of heart deficient in number. 
a. One auricle and one ventricle. 
b. Two auricles and one ventricle. 
Septa incomplete. 
a. Auricular. 
b. Ventricular. 
Orifices obstructed or imperfect. 
a. Right auriculo-ventricular aperture. 
b. Pulmonic aperture. 
c. Left auriculo-ventricular aperture. 
d. Aortic aperture. 
Foramen ovale prematurely closed. 
Ductus arteriosus prematurely closed. 
Origins of aorta and pulmonary artery transferred. 
Origin of ascending aorta from left ventricle, and of descending aorta 
from right ventricle, through the ductus arteriosus. 
Commencement of descending aorta contracted or obliterated. 
Foramen ovale persistent. 
Ductus arteriosus pervious. 
Cardiac valves imperfect. 
Pericardium absent. 
(e.) OF THE RESPIRATORY SYSTEM. 
Lung (one or both) absent. 
Pulmonary lobes deficient in number. 
Larynx and trachea absent or imperfect. 
(/.) OF THE DIGESTIVE SYSTEM. 
(Esophagus impervious. 
Intestine impervious, or deficient in various regions. 
Anus impervious. 
Anus in unusual situations. 
Liver preternaturally small. 236 
TOPICS RELATIVE TO PATHOLOGY. 
Gall-bladder absent. 
Biliary ducts impervious. 
Urachus patent. Vitelline duct patent. 
Kidney (one or both) absent. 
Kidney lobulated. 
(</.) OF THE URINARY SYSTEM. 
Ureters absent or impervious. 
Urachus persistent. 
(7l) of the male organs of generation. 
Penis diminutive, resembling clitoris. 
Prepuce abbreviated-elongated. 
Testicle (one or both) absent. 
External organs absent. 
(l.) OF THE FEMALE ORGANS OF GENERATION. 
Ovary (one or both) absent. 
Uterus absent. 
Vagina absent. 
Vagina impervious. 
Vagina a cul-de-sac. 
External organs absent. 
[Hymen imperforate.] 
II.-Malformations resulting from Incomplete Coalescence of the 
Lateral Halves of Parts which should become Conjoined. 
(a.) on the anterior median plane. 
Fissure of the face. 
" " iris. Coloboma. 
" " lip. 
a. Single harelip. 
b. Double harelip. 
" " palate. 
a. Harel palate. 
b. Soft palate. 
" " nose. Naso-buccal fissure. 
" " sternum. 
" " diaphragm. 
" " abdominal walls. 
" " pubic symphysis. 
" " anterior wall of urinary bladder (with extroversion of 
the posterior half). 
Epispadic fissure of the urethra. 
Hypospadic fissure of the urethra. 
Fissure of the scrotum. 
(b.) on the posterior median plane. 
Fissure of the skull. 
" " spinal column. Spina bifida, 
a. Complete. 
b. Partial. 
1. Cervical region. 
2. Lumbar " 
3. Sacral " 
Fissure of the spinal cord. classification of deformities. 
237 
III.-Malformation resulting from Coalescence of the lateral 
Halves of Parts which should remain Distinct. 
Lower extremities conjoined. Sy reniform foetus. 
Fingers or toes conjoined. Coalescence-webs. 
Monoculus. Cyclops. 
Double kidney. 
IV.-Malformations resulting from the Extension of a Commis- 
sure BETWEEN THE LATERAL HALVES OF PARTS (CAUSING AP- 
PARENT Duplication). 
Double uterus. 
Double vagina. 
V.-Malformations resulting from Repetition or Duplication of 
Parts in a Single Fcetus. 
Supernumerary fingers and toes. 
" cavities to heart. 
" valves. . 
VI.-Malformations resulting from the Coalescence of two Fce- 
TUSES, OR OF THEIR PARTS. 
Foetus, more or less perfect, contained within another foetus (foetus in 
Foetus, more or less perfect, constituting a tumor covered by integument. 
Double foetus. 
a. One perfect. The other an appendage. 
b. Both more or less perfect. 
1. The middle parts united. The upper and lower distinct. 
2. The upper parts united. The lower distinct. 
3. The lower parts united. The upper distinct. 
VII.-Congenital Displacements and Unusual Positions of Parts 
OF THE FCETUS. 
Transposition of viscera.-[Influence of foetus as always developed 
lying on left side, as a rule, to be considered here.] 
Hernia or ectopia of the brain. 
" " " heart. 
" " " lungs. • 
" " " intestines. 
Varieties: 
Through diaphragm. Syn., Diaphragmatic hernia. 
Through abdominal walls. Syn., Abdominal hernia. 
Through umbilicus. Syn., Umbilical hernia. 
Extroversion of posterior wall of bladder. 
Testis retained in abdomen. 
" " inguinal canal. 238 
TOPICS RELATIVE TO PATHOLOGY. 
In the case even of double or duplex deformities only one germ seems to be 
concerned. In illustration of this, Dr. Allen Thomson has given the following 
demonstrations (Figs. 63 and 64). He has shown that on one yolk, and on 
one germinal membrane or blastodermic vesicle, two primitive grooves may be 
Fig. 63. 
Fig. 64. 
Fig 63.-From a fowl's egg, after sixteen or eighteen hours' incubation, magnified four times. («.) The 
germinal area of the cicatricula; (&.) The transparent area, containing two primitive traces of embryos; 
(c, c.) Primitive grooves of the double embryonic trace, on each side of which are seen the lam hue dor- 
sales (after A. Thomson). 
Fig. 64.-Double embryo removed from a goose's egg, after five days' incubation, magnified four times, 
(g.) The common heart; (h.) Rudiments of the superior; (i.) Of the inferior extremities; (A.) The com- 
mon cephalic fold of the amnios ; (I.) The common folds (after A. Thomson). 
formed, which, in their ulterior development, shall probably (certainly, if they 
live ?) form a double monster, as may be seen in Fig. 64, taken from a goose's 
egg after five days' incubation. The formation of such a primitive groove in a 
single ovum is sufficient to explain the origin of the principal types of double 
monsters. Such malformations of the ovum have been overlooked by the Col- 
lege of Physicians, and are omitted in the table just quoted. 
These are the earliest examples of double deformity that have ever been 
recorded ; and no student of Medicine should remain ignorant of thein. 
FUNCTIONAL DISEASES. 
Latin Eq., Vitia Naturalium Actionum ; French Eq., Maladies Functionelles; Ger- 
man Eq, Functionelle Krankheiten oder Affectionar; Italian Eq., Malattie di 
Funzione. 
Definition.-All those diseases in which the concurrent living action of the 
parts or organs (i. e., the concurrent exercise of function) is not maintained, or 
in which the contractility, tonicity, nutrition, secretion, sensation, or motion of 
parts may be increased, diminished, or perverted, and that without fever or inflam- 
mation. 
Pathology.-Hitherto the complex morbid processes which have been 
described embrace nearly all the important forms of disease which affect the 
various organs which the eye can appreciate, assisted or not by the micro- 
scope, or which can be appreciated by other physical aids, such as by chemical 
analysis or reagents; all of which are now comprehended in the science of 
morbid anatomy, and demonstrated by anatomical investigations. Morbid 
changes which are not visible, or which are not yet ascertained by any physi- 
cal means of observation, are described as functional or dynamic. They em- PATHOLOGY OF FUNCTIONAL DISEASES. 
239 
brace all those diseases in which the action, the secretion, or the sensation of 
a part is impaired, without any primary alteration of structure of the organ 
or tissue affected, so far as our imperfect means of research can ascertain. It 
is possible, however, as physical aids to the senses increase and become more 
practical, thereby improving the means of observation, that the now so-called 
functional changes may eventually be shown to depend upon some concomi- 
tant anatomical change or alteration of structure (molecular it may be), which 
at present is not appreciable. The appreciable morbid forms of disease which 
have been described, and which are either permanent or more or less persistent 
after they are formed, are described in the science of morbid anatomy as lesions. 
They are common to a greater or less number of individual diseases, hereafter 
to be considered and described in this Text-book of the Practice of Medicine. 
It will then be seen that such lesions do not essentially constitute the disease, 
but are rather the results of disease, and are serious or otherwise according to 
their nature, their site, and the amount of the structural change involved. It 
is the duty of the pathologist and the physician to connect them with signs 
and symptoms of disease, with the object of adopting remedial measures for 
their prevention, or cure, or for the relief of such inconveniences as they may 
cause. • 
But the class of complex morbid states, known as "functional," are often 
not less strikingly formidable in their symptoms than those attended with 
obvious lesions; they are, in many instances, the cause of much suffering. 
They are usually, also, of long duration, without fever, generally difficult of 
cure, having a strong tendency to recur, and to terminate eventually in organic 
changes capable of demonstration. 
The occasional exciting causes of such diseases act upon the vital functions, 
or the usual manifestations of life and action in the various organs and struc- 
tures. They will be considered in detail under the various organs whose 
functions are thus specially implicated. They have hitherto been described 
under the name of " Neuroses;" but, year by year, ag a knowledge of morbid 
anatomy has extended, the number of these functional diseases has diminished. 
They were so named because "functional" diseases were believed to have 
their origin in the nervous system, and were indicated by disordered sensa- 
tion, volition, or mental manifestation, without any evident lesion in the struc- 
ture of the part, and without any material agent producing them. Broussais 
attributed them to a state of irritation of the brain and spinal marrow. In 
the Nomenclature of the College of Physicians of London, the functional 
diseases of the nervous system constitute a group which embraces all affec- 
tions, of which the cause is either undefined or variable, whether its probable 
seat be the brain, the cord, or the nerves. Its components are so far hetero- 
geneous as to include such discordant elements as hydrophobia, epilepsy, 
neuralgia, tetanus, cramps, chorea, shaking palsy, hysteria, catalepsy, trance, 
and hypochondriasis. 
At present the following are functional diseases, which, comprehended under 
" Neuroses," are of unknown anatomical origin : 
Functional diseases of the heart; of the nervous system, such as chorea, 
tetanus, epilepsy, acute epilepsy of infants and children, hysteria, catalepsy, 
hypochondriasis; while colic, vomiting, diarrhoea, constipation, have been 
regarded as " neuroses," or functional diseases of the alimentary canal. 
But when it is remembered that every function of the animal body consists 
of one or more, sometimes of several individual but concurrent and successive 
actions (actiones) ; that each action is performed by one or more organs con- 
structed for the purpose ; that each organ consists of certain elementary tissues, 
arranged in a certain form; that each elementary tissue not only possesses a 
definite arrangement of its minute particles or constituent atoms, but is en- 
dowed with certain physical and vital or physiological properties (facilitates), 
by virtue of which it is enabled, with its particular arrangement and the me- 240 
TOPICS RELATIVE TO PATHOLOGY. 
chanical form in which it is disposed, to concur in the accomplishment of the 
actions assigned to it; then, every derangement of function (i. e., every func- 
tional disease) depends on the derangement of some of its constituent actions. 
But it is doubtful how far any action can be deranged without some change 
in the properties of the elementary tissue of the organ; and it is still to be 
determined to what extent these properties can be impaired, disordered, or 
annihilated, without some corresponding change in the elementary atoms 
which constitute the intimate structure of the organ (Craigie). At present, 
the pathological explanation of these so-called functional diseases is, to a very 
great extent, a matter of theory merely. 
Of the morbid states named at p. 66 as elementary forms of disease, there 
remains to be considered one very complex condition, implying variations 
of functional tension to an extreme extent, and which will be found to take 
part in the expression of many diseases, both local and general: namely,- 
FEVER. 
Latin Eq , Febris; French Eq., Figure; German Eq , Fieber ; Italian Eq., Febbre. 
Definition-A complex morbid state which accompanies many diseases as part 
of their phenomena, more or less constantly and with a defined regularity, but va- 
riously modified by the specific nature of the disease which it accompanies. It 
essentially consists in elevation of temperature, which must arise from an increased 
tissue-change, and have its immediate cause in alterations of the nervous system 
(Virchow, Parkes). 
Pathology.-In describing the nature of fever, the following statements are 
principally compiled from the Gulstonian Lectures of Dr. Parkes, delivered 
before the College of Physicians in 1855, and from a review by Dr. Jenner, 
" On the Proximate Cause of Fever," in The British and Foreign Medico- 
Chirurgical Review for 1856. Knowing how difficult it is to convey an ortho- 
dox account of the nature of fever ; fully impressed with the great importance 
of the subject; and believing " that so consistent a theory of the nature of 
fever, and one so largely supported by facts, has not been placed before the 
profession as that developed by Dr. Parkes, I only hope I may be able to do 
it justice in the attempt to lay it before the student of Medicine in the follow- 
ing form. In the eloquent language of Dr. Parkes, ' I shall have to allude 
to inexplicable phenomena, to vast spaces still unfilled by solid facts, to spots 
unknown to observation, and to regions lighted only by the dim and treacher- 
ous ray of speculation.' " 
The practical object aimed at in the exposition about to be given, is to fix 
the scientific principles which ought to guide clinical investigation in determi- 
ning the Natural History of fevers generally ; and especially the scientific 
principles which must define the differences which subsist among specific fevers; 
and so aid in determining the conditions under which they are generated or 
propagated-their development, course, or progress, and their defervescence. 
" A hot skin, a quick pulse, intense thirst, scanty and high-colored urine," 
are phenomena common to many diseases ; and when they are present it is said 
that the patient is feverish, or that he suffers from fever or joyrexia. There aye 
.some diseases in which such symptoms constitute the prominent, and almost 
the only appreciable phenomena, and which run a more or less definite course, 
without the necessary development of any constant local lesion. Such diseases 
have been emphatically termed " fevers," or sometimes specific, primary, or 
idiopathic fevers. When diseases marked by local lesions-such, for instance, 
as the local inflammations-are attended by the symptoms just stated, then 
the pyrexia, fever, or feverish symptoms which attend them, are said to be 
secondary or symptomatic; and the physician is accustomed, when he deals NATURE OF FEVER. 
241 
with such cases, to abstract the symptoms of fever from the other symptoms 
proper to the special affection. In other words, he prescribes for, and tries to 
cure the special affection, and not the fever, because he knows that when he 
has subdued the local disease the fever will subside. Not so, however, with 
the fever of specific diseases like small-pox, typhus, or enteric fever. The physi- 
cian cannot cure such a fever; but he may guide its course, by judicious 
management, as an experienced pilot may guide a ship and preserve it through 
a storm ; and this is true of all specific fevers. 
It is to the nature of fever (whether primamj and specific, or secondary and 
symptomatic), considered in its abstract relations, that the attention of the 
student is here directed, and not to any particular fever, such as ague, typhus 
fever, traumatic fever, or the like. 
It is to fever in general, or in the abstract, that the following observations 
apply. It is to the pyrexial symptoms which are common to many diseases 
(such as to small-pox, scarlatina, measles, typhus, agree, pneumonia, nephritis, 
meningitis), and which, " like shadows to substance, are necessary to the very 
existence of such diseases, but yet are not, per se, any one of these diseases," 
that the following description refers. 
Galen defined fever as a preternatural heat-"Color preeter naturam." 
Subsequently many other additional clauses were added to this definition, 
such as a " quick pulse," " turbid urine," and the like; but still, the improved 
definition would not meet the requirements of every case; and now it is fully 
recognized that of all the clauses and phrases in the usual definitions of fever, 
"preternatural heat" is the only one whose accuracy is unimpeachable. In 
all cases, therefore, where fever is present, there are two points to be deter- 
mined ; namely,-(1.) The amount of the preternatural heat determined by ac- 
curate measurement; (2.) The amount of the tissue-change, as represented by 
an estimation of the amount of all the excreta relative to the body weight. 
It is the exact sequence of phenomena we desire to know in every case 
where pyrexia is present, as well as the meaning and correlation of the phe- 
nomena : and symptoms sufficiently characteristic usually become developed 
and superadded to the febrile phenomena, by which the physician is able to 
define the specific nature of the disease or fever as a whole, and to say of this 
case or of that, " It is an enteric fever," or " It is an ague," or " It is a rheu- 
maticfever," or " a pneumonia," or "a dysentery," or any other form of illness 
where pyrexia is present, which we are able clinically to recognize. It is not 
very long since we were able to do this. Up till within a comparatively short 
time ago the classification and diagnosis of " Fevers" was not such as to dis- 
tinguish and separate their varied forms and varieties from each other. 
" Common continued fever," for example, was a comprehensive name which 
included many very different types of fever; and no means of observation 
have been of late so exactly discriminating, so as to distinguish one form of 
disease from another where fever coexists, as accurate observations on the 
temperature of the patient, determined by the thermometer. In acknowledg- 
ing this great fact, it is important to observe that the absence of such exact 
observation, and the trusting to general signs alone, have hitherto led to great 
confusion-a confusion which has been unfortunately increased by a pernicious 
system-becoming too common-of naming " Fevers " from the place or 
locality where supposed varieties of fever have prevailed as epidemics; or by 
the use of local or provincial native names. For example, the Walcheren 
Fever, Levant Fever, Mediterranean Fever, Crimean Fever, Bulam Fever, 
African Fever, Fernando Po Fever, Lisbon Fever, Bengal Fever, Pucca 
Fever, Gall-sickness of the Netherlands, Hong Kong Fever, and other names 
not less barbarous, may be quoted. Except as matter of history, and as bea- 
cons to warn us from a great danger to science, let these and such-like names 
be consigned to oblivion. With the exact means at the disposal of the physi- 
cian as aids to diagnosis (and which are about to be described), every variety 242 
TOPICS RELATIVE TO PATHOLOGY. 
of illness where fever takes a part may be accurately distinguished, its type 
recognized, and its place fixed in nosology; or, if it should be anomalous, its 
exact departure from the type may be not less accurately defined and described. 
The phenomena which thus call for special investigation are those which 
are strictly related to the development and progress of the febrile state. 
They ought to be determined by clinical observation in all cases of disease 
where fever may be present. The facts to be ascertained are not less sig- 
nificant of the abatement, subsidence, or " defervescence" of the febrile state 
than of the advent of local lesions. The term " defervescence," in fever, is a 
comparatively new one in English pathology. It was first used by Professor 
Wunderlich, and subsequently adopted in this country by Dr. Parkes. It 
signifies the period during which the temperature of the fevered body is de- 
clining to its normal amount from that intense degree of heat attained in the 
state of accession of the febrile phenomena. This " defervescence" may be 
sudden, when it is regarded as a "crisis;" or it may be gradual, and is then 
described as a "lysis"-the "insensible resolution" of the older authors; or it 
may be partly sudden and then slow, when it may be described as "wave-like," 
with gradual and sometimes regular alternations of high and low temperature, 
as Dr. Parkes was the first to point out {The Composition of the Urine in 
Health and Disease, p. 270). 
The Usefulness of the Thermometer at the Bedside in the Diagnosis of Pyrexia. 
One hundred and seventeen years ago (1754), Antonius de Haen (the first 
teacher of clinical medicine in the Hospital of Vienna) impressed his pupils 
with the necessity of attending to the temperature of the body in disease, as 
measured by a thermometer, instead of being estimated merely by the sensation 
of heat imparted to the hand laid on the skin of the patient. He showed 
that even in the cold stage of ague, with the teeth chattering and the body 
shivering, the temperature of the blood is rapidly rising, although the pallid 
skin may really be colder than usual-its supply of blood being diminished 
by the contraction of the bloodvessels. He first demonstrated with measured 
accuracy how much the heat of the blood, ami therefore of the body, is aug- 
mented under the influence of the febrile state; and when the crude appli- 
ances and the rough instruments of a hundred years ago are compared with 
the delicacy and refinements of "the instruments of precision" of the present 
day, it may be of interest now to observe how the progress of knowledge and the 
powers of modern research have not suffered the valuable pathological lessons 
to be lost sight of which are to be learned from the clinical use of the ther- 
mometer, as De Haen taught a hundred and seventeen years ago. When the 
hand of the physician alone is used to judge of the temperature of a patient, 
or when the feelings of the patient are alone taken as a measure of his tem- 
perature, it can easily be understood how such kinds of observation are 
extremely fallacious, doubtful, and unsatisfactory. The determination of the 
amount of heat in fever cases is stamped by a much more early appreciation 
of its importance and value than even since the time of De Haen; for, ever 
since the days of Hippocrates, the physician and the surgeon have been in the 
habit of applying the hand to the skin of the patient, to appreciate the pres- 
ence of abnormal heat. But the practical application of tlie thermometer in 
place of the hand, while it is obviously a more accurate method, has never 
come into general use, mainly on account of the difficulty of getting instru- 
ments sufficiently sensitive and trustworthy-instruments, in fact, of sufficient 
precision. The time and trouble required to work with crude and inefficient 
instruments soon brought them into disuse and discredit; but now the in- 
struments required may be obtained so delicate and accurate, and the time 
taken to apply them is so insignificant, that the student of medicine and the METHODS FOR RECORDING THE FEVER-HEAT OF THE BODY. 
243 
physician have no excuse for neglecting to use them. When it is remembered, 
also, that Galen's definition of fever is still the one whose accuracy remains 
not only unimpeachable, but fully demonstrated and recognized; that it de- 
scribes fever to consist in "a preternatural heat,"-it is obviously essential that 
we should be able to measure this heat, and so learn the significance of such 
increase of temperature in every case of disease where fever may be present. 
The careful physician counts the pulse and the respirations in all cases of ill- 
ness; it is not less incumbent on him to measure the amount of heat. By 
means of a delicate thermometer he has in every case of fever an accurate meas- 
urer of its amount; and the student of medicine, as one of the earliest clinical 
lessons in hospital wards, should be taught to look to the excreta, and to the 
various physiological conditions of the patient, for the products of the meta- 
morphosis of tissue equivalent to the amount of heat in each disease. 
Ever since the publication of the second edition of this work, when the 
thermometer as a means of measuring the heat in cases of fever was first ex- 
pounded in any text-book for students, I have been greatly pleased to see that 
the importance of the thermometer, as an instrument in the diagnosis and 
prognosis of disease, has become more and more apparent. There is ample evi- 
dence of this in the contributions to the literature of this subject from the pens of 
Albutt, Bseumler, Compton, Findlayson, Cornelius Fox, Grimshaw, Maclagan, 
Miller, Ogle, Perry, Prior, Sidney Ringer, Stevenson Smith, Reginald E. 
Thompson, and others, since the second edition of this text-book appeared. 
The thermometer is now as much of a necessity and as much of a companion 
to the medical man as the stethoscope. 
The thermometry of disease is thus practically shown to be important from 
two points of view, inasmuch as,-(1.) The continuous daily use of the ther- 
mometer greatly facilitates the clinical recognition of diseases, and aids us in 
acquiring an accurate knowledge of various diseases. It aids the busy practi- 
tioner in coming to more certain and safe conclusions than heretofore; and so 
relieves him of much anxiety of mind in doubtful cases. (2.) The use of the 
thermometer tends to elucidate the course, tendencies, and results-in short, the 
Natural History-of all diseases where fever is present. 
It is proposed, therefore, to illustrate this subject under the following four 
heads: 
I. The Instruments, Methods, and Practical Pules for Observing and Recording 
the Temperature of the Human Body in Diseases where Fever may be present. 
Animal heat has been determined in two ways-namely, either by the ordi- 
nary mercurial thermometer, or by the thermo-electric apparatus. The latter 
may indicate fractions of a degree, and in this respect surpasses the powers 
of the most delicate mercurial thermometers. MM. Becquerel and Breschet 
employed such an apparatus to determine the temperature of internal parts. 
The apparatus consisted of two wires, of different metals, soldered together, 
and having their free ends brought into communication with a thermo-electric 
multiplier, having an index showing tenths of a degree. The fine points of 
the wires being passed through different parts of the body (like acupuncture 
needles) indicated the temperature of the tissues at the point of contact of 
the two metals. For example,-passing the wires an inch and a half into 
the calf of the leg, the temperature was found to be 98° Fahr., while at the 
depth of the third of an inch it was only 94° Fahr., showing some cooling of 
the body towards the surface compared with the interior. The superficial 
fascia of the biceps was nearly 3° Fahr, lower than the temperature of the 
muscle itself. But notwithstanding the greater delicacy of the thermo-electric 
apparatus, a sensitive mercurial thermometer, finely graduated and compared 
with a standard one, is the only instrument of practical usefulness, as yet, 
for ordinary clinical purposes; and for obvious reasons. 
Whatever thermometer is used, it is necessary to compare it with a standard 
one, and note the differences between every degree. A thermometer is bad, and 244 
TOPICS RELATIVE TO PATHOLOGY. 
all but useless, if the differences between various degrees are unequal; but it 
is quite serviceable if the same sum is to be added or subtracted for each 
degree. The price of such an instrument need 
not now render it difficult nor expensive for a 
student to acquire a competent practical knowl- 
edge of " the thermometry of disease." 
It is necessary to have an instrument which 
will determine the temperature in the mouth, 
axillae, rectum, or other parts of the body. Such 
an instrument is named a "clinical thermometer;" 
and it must be of unquestionable veracity. If the 
instrument is not absolutely accurate, its errors 
require to be known. Differences in the diameter 
of the bore (in calibration), throughout the entire 
length of thermometer, seem to be almost una- 
voidable, as yet, in their manufacture. 
The majority of the instruments at present made 
seem to indicate a temperature sometimes higher 
and sometimes lower, at different parts of the scale, 
than is correct. For example, Dr. C. Fox quotes 
a certificate of verification from the Kew Obser- 
vatory of one in his possession, as follows : 
At 52° Fahr. + 0.1 
" 62° " -0.1 
" 72° " 4- 0.1 
That is to say, at 52° Fahr. must be added, at 
623 Fahr. requires to be subtracted; and again, 
at 72°, must be added. As no two faces are 
alike, so no two thermometers seem to be alike. 
Dr. Prior of Bedford, in comparing five instru- 
ments, one with another, found that "no two of 
them precisely corresponded at any one time;" 
and, as Dr. C. Fox very justly observes, the want 
of complete agreement between the observations 
of physicians on temperature is doubtless partly 
due to the differences of the readings of the ther- 
mometers employed, and also to the fact that all 
observers do not take the temperature of the same 
parts of the body. The rectum is about two- 
fifths of a degree of Fahr, warmer than the mouth ; 
and the mouth four-fifths of a degree warmer than 
the axilla or the groin (Fox), unless precautions 
are taken, as afterwards shown, to render the axilla 
a closed cavity. 
In meteorological observations, only those ther- 
mometers are employed which have been verified 
by means of a comparison with the standard 
instruments in the Greenwich or Kew Observato- 
ries. How much more important is it that clinical 
thermometers (where life or death may hang on 
the difference of a degree) should be verified and 
certified to in the same way, so that the proper corrections may be made for 
errors which seem to be inevitable? Although the accuracy of the instru- 
ment, or delicacy of it, may be guaranteed by the manufacturer, it cannot 
be depended on. Dr. Fox gives an illustration, among several, in which the 
Fig. 65. 
Fig. 66 MODE OF USING THE CLINICAL THERMOMETER. 
245 
following results were returned in the certificate from the Kew Observatory,- 
namely, at 85°, must be subtracted; at 90°, ; at 95°, Ts0; at 100°, T40; and 
at 105°, t40 must be deducted-errors varying from T30 to T5^, or half a degree. 
The only safe rule, therefore, is, that each instrument ought to be sent to Kew 
for verification, to be returned to the owner with a certificate containing the 
corrections for its several readings, if any are requisite. A fee of half a crown 
is charged at Kew for this certificate of verification; and if the makers would 
do this, and charge the fee to the price of the instrument, it would save a 
great deal of trouble.* 
A good clinical thermometer ought to have a uniform and correct scale, 
having a range from 90° to 112° Fahr., exhibiting also fifths Fahr, of degrees, 
and be one-fifth of an inch apart from each other. It ought to be a sensitive, 
mercurial maximum self-registering (Fig. 66) one (known as "Phillip's maxi- 
mum ") ; which does not require to be read in situ, but may be removed from 
contact with the part, and read when convenient. The bulb of mercury 
should be as thick as the diameter of the stem, and not more, so as to expose 
a sufficiently large surface to the part of the body whose temperature is to be 
determined. 
An Ordinary but very Sensitive Thermometer (Fig. 65), made with a curve, 
in order that its bulb may be the more easily and perfectly fitted into the 
axilla, while the stem, being carried upwards, renders the reading in situ 
more easy, is a useful instrument for teaching students to observe in clinical 
classes; but is less useful in general practice than the maximum self-register- 
ing instrument. 
Directions for Use. I. The Curved Thermometer (Fig. 65).-Its bulb must 
be well fitted into the arm-pit, being introduced below the fold of the skin 
covering the edge of the pectoralis major muscle, and so kept in close contact 
with the skin, completely covered and firmly surrounded by the soft parts. 
In very thin or very old persons this adjustment requires special care. The 
instrument must be retained in situ during a period of not less than four 
minutes; and the height of the mercury in the graduated stem must be read 
while the thermometer is still undisturbed in the axilla, care being taken that 
the axis of vision falls perpendicularly on the column of mercury in the tube. 
II. The Straight Thermometer (Fig. 66), which is self-registering, must have 
its index set before commencing to take an observation. 
[N.B.-The Index is the bit of mercury detached from the column in the stem 
of the instrument.] 
1. This index is to be set by bringing the bit of detached mercury down 
into the clear part of the stem, just below' the lines which indicate the de- 
grees. This is done by taking the bulb and stem of the instrument firmly in 
the hand, and then by a single rapid swing of the arm the index will come 
down the stem; and this swing of the arm must be repeated till the top of the 
index is at least below the lines which indicate the degrees. 
2. After the index has thus been set, the bulb of the instrument may then 
be applied to the axilla, or between the thighs, or any part which is com- 
pletely covered; and being retained in close apposition (by strapping, if 
necessary) with the surrounding soft parts for a sufficient length of time, the 
instrument is to be carefully and gently removed, wdien the top of the index 
-i. e., the end farthest from the bulb-will denote the maximum temperature 
during the period the instrument has been in perfect contact with the parts. 
The patient should have been at perfect rest in bed for at least one hour be- 
* Cassella of Hatton Garden, Hawksley of Blenheim Street, London, and Harvey 
and Reynolds of Leeds, are the most careful makers of clinical thermometers, in my 
experience. 246 
TOPICS RELATIVE TO PATHOLOGY. 
fore observations on temperature are made, and he ought to lie on the side, so 
as to completely close the axillary space which is the seat of the thermometer, con- 
verting it into a close cavity. 
III. The Observations ought to be continuous daily, and regularly taken 
at the same hour every day, throughout the whole period of sickness. The 
most useful periods for observation are-(1.) Between 7 and 9 o'clock in the 
morning; (2.) At noon ; (3.) Between 5 and 7 o'clock in the evening; (4.) 
At midnight. For most practical purposes, it is sufficient to note the tem- 
perature twice daily,-morning and evening, with an occasional observation 
at midnight. 
IV. In all observations of temperature the pulse and the respirations 
should be noted at the same time. 
In less important cases, the physician may make at least one observation 
daily himself, and leave the others to the friends of the patient or the nurse, 
if either of them are sufficiently intelligent. This arrangement, however, is 
only justifiable so long as the observations correspond with those typical of 
the particular disease, and so long as they are in harmony with the other 
general signs of its course; but as soon as notable deviations from these con- 
ditions are observed, the physician ought to make the observations for him- 
self. A difference of 2° Fahr, is not of any practical importance unless it is 
persistent. 
In prolonged and severe cases an examination of the records of temperature 
made during the course of the disease will recall to mind the nature of the 
case more effectively than the most detailed written history. For this pur- 
pose it is desirable to exhibit on paper the daily thermometric changes, in 
the form of an angular line or a curve, and to note in the proper places short 
memoranda of the more important incidents or therapeutic events which 
have taken place during the progress of the disease. Details illustrative of 
the changes in the pulse and the respiration, and amount of excreta, ought 
to be entered in the same sheet, as exhibited at pp. 248 and 249 following.* 
* Some thermometers are graduated to Centigrade as well as to Fahrenheit on the 
same glass stem ; and some have the Centigrade scale marked on the wooden tubes 
which inclose the thermometer. The presence of two scales on one thermometer is 
too confusing for delicate observation ; and it is better to have only one, converting 
that one scale into the other, if necessary, by calculation or by means of the tables 
commonly employed for this purpose; the form for filling up giving (as at pp. 248. 
249) the double scale of Fahrenheit and Centigrade. 
Fahrenheit Scale Compared with Centigrade and Reaumur's. 
Fahr. 
Cent. 
Beau. 
Fahr. 
Cent. 
Reau. 
112.0 
44.44 
35 55 
101 0 
38.33 
30.66 
111.2 
44 0 
35.2 
100.4 
38.0 
30.4 
111.0 
43.88 
35.11 
100 0 
37.77 
30.22 
110.0 
43.33 
34.66 
99.0 
37.22 
29.77 
109.4 
43 0 
34.4 
97.6 
37 0 
29 6 
109 0 
42.77 
34.22 
97.0 
36.11 
28.88 
108.0 
42 22 
33.77 
96.8 
36 0 
28 8 
107.6 
42.0 
33.6 
96 0 
35.55 
28.44 
107.0 
41.60 
33.33 
95.0 
35 0 
28 0 
106.0 
41 11 
32.88 
94.0 
34.44 
27.55 
105.8 
41.0 
32.8 
93 2 
34 0 
27.2 
105.0 
40.55 
32 44 
93.0 
33.88 
27.11 
104.0 
• 40.0 
32.0 
92.0 
33.33 
26.66 
103.0 
39.44 
31.55 
91.4 
33 0 
26.4 
102.2 
39 0 
31.2 
91.0 
32.77 
26 22 
102.0 
38.88 
31.11 
90.0 
32.22 
25.77 SCALES OF TEMPERATURE COMPARED. 
247 
In chronic cases, when febrile attacks and their'concomitant dangers may 
be expected, as well as in acute cases, after return of the normal blood-heat, 
one daily observation will be found sufficient. This single observation may 
be best made in the afternoon, evening, or midnight. 
It is advisable to induce nurses, friends, or other attendants on the sick 
(whenever they seem apt pupils), who may make notes of any considerable 
excitement or restlessness, or take notice of hot hands, or increased heat of 
head, rather to consult at once the thermometer than trust to their sensations. 
They may thus, perhaps, tranquillize the patient and his friends when the 
instrument' does not indicate any material increase of heat; but the sudden 
appearance of any considerable increase of temperature would always be (as 
stated) a fact of vital importance. 
It has been recommended by some to place the thermometer under the 
tongue, as the best place. On the contrary, the cavity of the mouth is the 
worst place in which the thermometer can be put, in patients not accustomed 
to such obstructions, because the temperature there is continually varying 
according to the quantity and temperature of the air used in respiration; and 
if the atmosphere is cold, and deep inspirations are made, large differences 
may be observed, compared with the temperature in the axilla. Therefore 
observations made with the thermometer in the mouth are not generally trust- 
worthy, unless verified by observations in the axilla, groin, rectum, or bladder. 
Five minutes is found quite sufficient for the application of the thermometer, 
if certain precautions are taken. The simplest and most convenient way is to 
heat the instrument before inserting it into the patient's axilla, just as the 
surgeon heats the catheter before he introduces it into the urethra. Neglect 
of this precaution is apt to lead to an under statement of temperature. It 
may be heated by holding the thermometer in the warm hand till the mer- 
cury shows a temperature of 98°; and after the instrument is properly placed, 
be satisfied if two observations at intervals of one to two minutes give exactly the 
same result. 
Cent., . . . 
0.1 
0.2 
0 3 
0.4 
0 5 
0.6 
0.7 
0.8 
0.9 
1.0 
Fahr., . . . 
0.18 
0.36 
0 54 
0.72 
0.9 
1.08 
1.26 
1.44 
1.62 
1.8 
Reau., . . . 
0.08 
0.16 
0.24 
0.32 
0.4 
0.48 
0.56 
0.64 
0.72 
0.8 
Fahr., . . . 
0.1 
0.2 
0.3 
0.4 
0.5 
0.6 
0.7 
0 8 
0.9 
1.0 
Cent., . . . 
0.06 
0 11 
0 17 
0.22 
0.28 
0.33 
0.39 
0.44 
0.5 
0.56 
Reau., . . . 
0.04 
0.09 
0.13 
0.18 
0.22 
0.27 
0.31 
0 36 
0.4 
0.44 
Reau , . . . 
0 1 
0 2 
0.3 
0.4 
0.5 
0 6 
0.7 
0.8 
0.9 
1.0 
Fahr., . . . 
0.22 
0 45 
0.67 
0.9 
1.12 
1.35 
1 57 
1.80 
2.02 
2.25 
Cent., . . . 
0.12 
0.25 
0.37 
0.5 
0.62 
0.75 
0.87 
1.00 
1.12 
1.25 
Comparison of.the Scales for each Tenth of a Degree 
To convert degrees Centigrade above zero to degrees Fahrenheit: multiply by 1.8, 
and add 32, or multiply by 9, divide by 5, and add 32. To convert degrees Centigrade 
below zero to degrees Fahrenheit: multiply by 1 8, and subtract from 32. To convert 
degrees of Centigrade into those of Reaumur: multiply by 4, and divide by 5. To 
convert degrees Reaumur above zero to degrees Fahrenheit: multiply by 2 25, and 
add 32. To convert degrees Reaumur below zero to degrees Fahrenheit: multiply by 
2.25, and subtract from 32. To convert degrees Reaumur into those of Centigrade : 
multiply by 5, and divide by 4. To convert degrees of Fahrenheit into those of Cen- 
tigrade : deduct 32, multiply by 5, and divide by 9. To convert degrees of Fahren- 
heit into those of Reaumur : deduct 32, divide by 9, and multiply by 4. In De Lisle's 
thermometer, used in Russia, the graduation begins at boiling-point, which is marked 
zero, and the freezing-point is 150. 248 
TOPICS RELATIVE TO PATHOLOGY. 
RECORDS OF TEMPERATURE, PULSE, 
In the case of. 
^Etat. 
Occupation 
Ward 
□ATES OFK? 
OBSERVATIONS 
DAYS OF 
DISEASE 
TEMPERATURE 
CENTIGRADE 
TEMPERATURE 
FAHRENHEIT 
TIME 
AM-PM 
TIME 
AM' PM 
TIME 
AM- PM 
TIME 
AM' PM 
TIME 
AM- PM 
TIME 
AM • PM 
TIME 
AM - PM 
TIME 
AM-PM 
TIME 
AM • PM 
TIME 
AM ■ PM 
TIME 
AM - PM 
TIME 
AM - PM 
TIME 
AM ■ PM 
TIME 
AM - PN 
41 o 
106 0 
8 
6 
2 
8 
6 
4 
2 
40° 
- 105° 
- 104° 
8 
6 
4 
2 
i i r i 
" 103° 
8 
6 
2 
• 
102° 
8 
6 
4 
2 
5 
I 
38° 
o 
Illi II 
8 
6 
4 
2 
8 
6 
2 
; 
- 
- 100° 
- 99° 
8 
6 
2 
• 
37° 
- 
8 
6 
TEMPERATURE 
~ 98 D 
2 
- 97° 
8 
6 
2 
- 
- 96° 
8 
6 
4 
2 
PULSE PER MINUTE 
RESPIRATIONS 
PER MINUTE 
URINE 
HOURS 
CTION OF 
RE/ 
CIF.GR.OF 
SPE 
LOUR OF 
CO 
CLEARorTURBID 
UREA (amount) 
3AR in 
s u 
UMEIN IN 
ALB 
□ S IN 
SOL 
MICROSCOPIC 
SEDIMENTS 
STOOLS NUMBER 
2k CHARACTER RECORDS OF TEMPERATURE, ETC. 
249 
RESPIRATION, AND EXCRETA (See p. 246). 
Disease 
Termination 
Register 
Folio... 
TIME 
TIME 
TIME 
TIME 
TIME 
TIME 
TIME 
TIME 
TIME 
TIME 
TIME 
TIME 
TIME 
TIME 
TIME 
TIME 
TIME 
AM-PW 
AM- PM 
AM'PM 
AM' PM 
AM ■ PM 
AM' PM 
AM' PM 
AM' PM 
AM- PM 
AM • PM 
AM ■ PM 
AM • PM 
AM ■ PN 
AM' PM 
AM - PM 
AM • PV 
AM • PM 
J 
i 
' • 
1 
■ 
> 
i 250 
TOPICS RELATIVE TO PATHOLOGY. 
The rapidity with which the mercurial column rises depends on the degree 
of temperature present. The rapidity of the rise of temperature ought to be 
noted, as well as the maximum height. If the temperature be above the nor- 
mal standard, a sensitive thermometer will indicate that fact within the first 
minute; and as the quickness of the rising depends upon the existing tem- 
perature, the physician is able, after some experience in the use of a particular 
instrument, to form an approximative judgment of the amount of rising of tem- 
perature to be expected in any particular case from the slowness or rapidity 
of the rise of the mercury after half a minute. 
II. Fluctuations of Temperature within the Limits of Health; and the Corre- 
lation of the Animal Heat with the Pulse and the Respiration. 
Several observers in Germany, France, England, and the Tropics, have 
now determined these fluctuations with great accuracy, so that ample and 
sufficient data are on record to furnish a standard for comparison in cases of 
disease. 
The temperature of the body is the result of the opposing action of two 
factors: 1st, Development of heat from the chemical changes of the food, and 
by the conversion of mechanical force into heat, or by direct absorption from 
without; and 2d, and opposed to this, Evaporation from the surface of the 
body, which regulates internal heat (Parkes's Hygiene, p. 432). 
With reference to the normal range of temperature, our most trustworthy 
information is mainly,due to Valentin and Traube, in Germany; to Edwards, 
Becquerel, Breschet, and Bernard, in France; to Dr. William Ogle, in Eng- 
land; and to Dr. Alexander Rattray, Surgeon in the Royal Navy, in tropical 
and temperate climates. It is generally agreed that the ranges tof tempera- 
ture vary in different parts of the human body; but, as a general practical 
result, it is equally agreed that in temperate regions the normal temperature, 
at completely sheltered parts of the surface of the human body, amounts to 98.4° 
Fahr., or a few tenths more or less at different times of the day; and a rising 
above 99.5°, or a depression below 97.3° Fahr., are sure signs of some kind of 
disease, if the increase or depression is persistent. 
Valentin proved by many experiments that all warm-blooded animals sur- 
rounded by an atmosphere of 50° Fahr, to 68° Fahr, have a temperature of 
about 99.5° in the back of the mouth, the rectum, or other accessible internal 
parts; and at completely sheltered parts of the surface it is about 97.5° to 98.4° 
or .5°. According to Ringer and Stewart, in persons under twenty-five, the 
average maximum temperature is 99.1°; over forty years of age, it is 98.8°. 
In the second childhood of old age it again rises (Albutt). Dogs have a 
temperature similar to that of men. A knowledge of thermometry, there- 
fore, in the diseases of animals, will prove not less valuable in veterinary 
pathology than in human, and perhaps more so, inasmuch as animals de- 
prived of speech are unable to express their feeling. In the cattle plague of 
1866-67, the use of the thermometer was found of great practical value in 
diagnosis. 
The observations of Dr. John Davy, originally communicated to the Royal 
Society, have been shown by Dr. William Ogle to be so full of errors, that 
they are really without value. The following records are believed to be the 
most trustworthy: 
The minimum temperature is from 1.30 a.m. to 7.30 a.m. (Jurgensen). 
The lowest temperature occurs about daybreak, about 6 a.m. At this time a 
rise begins, which continues till late in the afternoon, and it commences while 
yet the body is in complete repose, and when no food has been taken for ten 
or twelve hours; but coincidently with this rise there is an increase in the 
exhalation of carbonic acid (Ogle) and of urea; so that the rise is doubtless 
due to increased chemical change or resumed activity of organic functions, as 
the intensity of sleep diminishes towards morning. 
The highest range of daily temperature is maintained between 9 a.m. and NORMAL TEMPERATURE OF THE HUMAN BODY. 
251 
6 p.m. After this time the temperature falls slowly and continuously, if no 
alcohol be taken; but if alcohol be taken with the evening meal, the fall is 
more sudden (Ogle). Otherwise food seems to have little influence on nor- 
mal temperature, except, perhaps, with infants. Although the records may 
vary somewhat, yet one elementary fact stands clearly out-namely, that in 
a healthy man the limits of fluctuation, under various conditions, are very 
narrow, and independent of external temperature. This constancy of the 
bodily temperature is a consequence of the remarkable regulation of evolu- 
tion and loss of its heat, and is the expression of their difference. The 
average variation in the course of twenty-fours is about 1.5° Fahr. A 
general average for the day may be stated as follows: 
Before 
Breakfast. 
11 A.M. 
2 P.M. 
3 P.M. 
5 P.M. 
6.30 P.M. 
7.30 P.M. 
9 P.M. 
10 P.M. 
12 P.M. 
12.30 a.m. 
12.30 a.m. 
1 A.M. 
3 A.M. 
5 A.M. 
5.30 A.M. 
6.30 a.m. 
8 A.M. 
9 A.M. 
97.73° 
98.2° 
98 36° 
98.63° 
98° 
97.96° 
97.9° 
97.5° 
97 2° 
97.6° 
Dr. Rattray's observations were made by placing an ordinary Fahrenheit 
thermometer nnder the tongue thrice a day during a voyage from England 
to Bahia (lat. 11° S.) and back-i. e., across the Equator-extending over 
sixty days (fifty-three in the tropics, and seven in the latitude of England, 
51° N.). During this period the temperature of the air in the shade on the 
verge of the tropics was 72° Fahr.; at the equator, 84° Fahr.; and the 
average of the tropics generally, 76.9° Fahr. The atmospheric humidity 
ranged from 0° to 7.5°; the average being 3.8° of a Mason's hygrometer. 
In England, with a temperature ranging from 60° to 70° Fahr., the average 
temperature of the body was 98.3° Fahr.; it rose in the tropics to 98.6°, and 
in the equatorial doldrums to 99° Fahr., and occasionally even to 100° Fahr. 
In the tropics the temperature of the body is greatest during the afternoon, 
when the sun is high, and the body most active, and least in the morning. 
The pulse is likewise highest and lowest at these times. The totals show 99° 
Fahr, to be the most frequent bodily temperature, while 99.5° and 100° Fahr, 
form 22 per cent, of all the observations, and the range of temperature about 
2° Fahr, daily {Proceedings of Royal Society, No. 122, p. 513, June 16, 1870). 
The following are the collateral circumstances which mainly influence 
animal heat in our daily life, and which require to be remembered, in order 
that erroneous conclusions may not be drawn: (1.) Active exercise (not carried 
to the extent of exhausting fatigue) raises the temperature proportionally to 
the degree of muscular exertion made. (2.) Exposure to cold without exercise 
lowers the temperature. (3.) Sustained mental exertion reduces the tempera- 
ture about half a degree. Lombard states the reverse to be the fact. (4.) 
The amount of heat is also at first reduced after a full meal and after alcohol; 
but it rises again as digestion advances. According to Dr. William Ogle, it 
causes a rise most marked after breakfast, less so after lunch, and which is 
reduced after dinner to a mere retardatio'n of the fall, which without it would 
occur. (5.) Alcohol (claret) causes an immediate rapid fall, which is tempo- 
rary, and a reaction occurs by which the temperature is carried to as high a 
point, or even higher, than it would have reached if no alcohol had been 
taken. Tea causes an elevation of temperature. (6.) Sex, race, latitude, 
seasons, weather, habits of life, and idiosyncrasies go for very little in influ- 
encing the temperature of healthy persons, fl f On the other hand, the tem- 
perature in disease is more readily and rapidly affected-more sensitive, so to 
speak-than either the pulse or the respiration, and the increase or variations 
are persistent as long as disease exists. 
The amount of abnormal increase of temperature is usually proportionate 
to the degree of frequency of the pulse, and to the other signs of general 252 
TOPICS RELATIVE TO PATHOLOGY. 
disease. Yet such congruity of phenomena is sometimes in part or wholly 
absent or incomplete; and in the cases in which a disproportion or incongruity 
exists between the increase of temperature and the pulse, or other febrile phe- 
nomena, it is the accurate measurement of the temperature which is most of 
all to be relied upon. 
As a general rule, the correlation of pulse and temperature may be stated 
as follows, namely: An increase of temperature of one degree above 98° 
Fahr, corresponds with an increase of about eight beats of the pulse per minute, 
as in the following table: 
A temperature of 98° . . Corresponding with a pulse of 72 (Health) 
" 99° . . Ought to correspond with a pulse of 80 
" 100° . . " " " 88 
" 101° . . " " " 96 
" 102° . . " " " 108 
" 103° . . " " " 112 
" 104° . . " " " 120 
" 105° . . " " " 128 
" 106° . . " " " 136 
This statement is, however, in some respects arbitrary, and is given for the 
convenience of comparing different diseases with some standard. In some 
diseases a high temperature is found with a low pulse, and a low temperature 
with a high or rising pulse. The pulse, too, sometimes rises in rapidity when 
the temperature falls, or falls when the temperature rises. 
Dr. John Beddoe, Physician to the Bristol Royal Infirmary, records a pecu- 
liar case of enteric fever, in which the most notable point was the coexistence 
of an elevated temperature with an abnormally slow pulse, and but a mode- 
rate rate of wasting. 
In children the records are contradictory. For example: According to 
the observations of M. Roger and Dr. Holland, the temperature of children 
is somewhat higher than adults, when placed in conditions favorable to suste- 
nance. At birth the temperature of the infant is the same as that of the 
mother, but quickly falls to 93.4°, or 95.5°, rising in the course of twenty- 
four hours to 97.7°,-i. e., more than half a degree below adult heat (Mac- 
lagan). Between four and six years of age, M. Roger found the tempera- 
ture to be 98.9° Fahr.; and between six and fourteen years, 99.16° (Carpen- 
ter). Dr. Bennett states generally, that in children the heat of the body is 
about 2° higher than in adults. 
On the other hand, among numerous written statements sent me on this 
subject, from actual observation, I find results are varied,-many opposed to 
the preceding statements. For example, during an epidemic of measles in 
Glasgow, in 1866, Mr. James P. Cassels, while using the clinical thermometer, 
was much struck with the low temperature recorded in some cases after com- 
plete recovery. The following shows the result of six observations on a baby, 
16| months old, and in perfect health since birth, taken when asleep, and every 
source of error carefully avoided. His observations show results below those 
of adult life: 
Date of 
Observation. 
Hour. 
Tempera- 
ture of 
Room. 
Temperature of Body. 
Respi- 
rations 
per 
Minute. 
Pulse 
per 
Min- 
ute. 
Time during 
which Thermo- 
meter was in 
close contact 
with Skin. 
Phillip's 
Thermo- 
meter. 
Curved 
Thermo- 
meter. 
July 3, 1866. 
10.20 P.M. 
65° Fahr. 
96|° 
964° 
23 
106 
25 minutes. 
July 5, 1866. 
10 20 p.m. 
65° Fahr. 
96j° 
96|° 
22 
106 
30 minutes. 
Julv 6, 1866. 
10 30 p.m. 
64° Fahr. 
962° 
96|° 
22 
100 
25 minutes. 
July 11, 1866. 
10.30 p.m. 
69° Fahr. 
974° 
964° 
22 
112 
40 minutes. 
July 28,1866. 
10.20 p.m 
68° Fahr. 
974° 
974° 
25 
100 
25 minutes. 
July 30, 1866. 
12 midnight 
68° Fahr. 
974° 
974° • 
22 
120 
20 minutes. USEFULNESS OF THE CLINICAL THERMOMETER. 
253 
III. Ranges of Temperature in Disease. 
Having satisfied ourselves as to the delicacy and accuracy of the thermom- 
eter, and obtained a standard for comparison, we are prepared to appreciate 
the ranges of temperature in febrile diseases as measured by such an accurate 
instrument. 
The maintenance of a normal temperature, within the limited fluctua- 
tions just noticed, under all these varying influences, gives a complete assur- 
ance of the absence of anything beyond local and unimportant disturbances; 
and, long before the subject was worked out so thoroughly as it has been, it 
was often casually observed that any acute disease, however slight, elevates 
abnormally the temperature or animal heat; "and its undue degree of eleva- 
tion (as Dr. Davy clearly enunciated) is some criterion of the intensity of the 
diseased action" {Phys. Researches, vol. i, p. 56). In short, it is now placed 
beyond a doubt by the observations of Gierse, Roger, Valentin, Von Bseren- 
sprung, Wunderlich, Friedlander, Virchow, Traube, Jockmann, Greisinger, 
Billroth,and others, in Germany; by MM. Becquerel, Breschet, and Bernard, 
in France; by Parkes, Jenner, and Ringer, in this country, that while this 
preternatural heat varies in amount in different diseases, in different persons, 
and at different times of the same day, it is this preternatural heat which is 
the essential symptom in fever, which proves fever to be present, and which 
exists to the extent of 4°, 6°, or even 8° Fahr, over the natural limits of 
health, and must be estimated by the temperature in the axilla or rectum, as 
indicated by the thermometer. This preternatural heat is never absent in 
fever, and without it fever cannot be said to exist. Rigor, which is also some- 
times present, is a mere peripheric phenomenon. The coldness of the skin, 
so much complained of by the patient, is usually a subjective sensation,, pro- 
duced by the state of the peripheral nerves, and is not due to any actual 
decline of temperature; for even " while the outer parts feel cold to the by- 
stander, the inner parts are abnormally warm. While the outer parts freeze, 
the inner burn" (Virchow, Parkes, Jenner). 
There are many cases now on record in which the physician, without ther- 
mometric observation, does not appreciate the existence of fever or of danger. 
AVunderlich gives numerous examples of this; but long before he brought 
this subject so forcibly to the notice of medical men, we have the testimony 
of Dr. John Davy in this country, given quite incidentally, and therefore all 
the more valuable as an unbiassed testimony of the usefulness of the ther- 
mometer in detecting latent disease not otherwise indicated by general symp- 
toms. When Dr. Davy was collecting his extensive observations on the 
normal temperature of the body, he was surprised to find that one person 
exhibited for many weeks a persistent temperature of 104° Fahr. This person 
was a lunatic soldier; and Dr. Davy remembered that the insane do not seem 
to suffer from cold nor heat like ordinary individuals, and that there are 
certain organic lesions which are apt to occur in them unaccompanied by the 
usual symptoms. For example, tubercle and cavities of the lungs occur with- 
out cough or difficult breathing ; and although no warning nor any indication 
may be given, the disease runs its course, terminating in death as certainly and 
as rapidly as if indicated by the ordinary train of symptoms. Discovering, then, 
as it were by accident, that the temperature in this lunatic was as high as 104.5° 
Fahr., and that his pulse was rapid, Dr. Davy's attention was more particu- 
larly aroused; and although the man made no complaint, but had a good 
appetite, with his digestive functions, so far as was known, acting well, yet 
disease of the lungs was thus discovered; and was confirmed by the examina- 
tion of his chest yielding the usual physical signs of disease. The lunatic died 
in a month, of acute tuberculosis, not otherwise expressed by symptoms 
beyond the great, persistent, and continuous elevation of temperature thus 
incidentally noticed. There were ulcers of the larynx found after death, but 
there had been no affection of the voice; there were vomicce and tubercles in 254 
TOPICS RELATIVE TO PATHOLOGY. 
the lungs, but there had been no cough; there were ulcerations of the intestines, 
but there had been no diarrhoea; there was disease of the testes, vesicular 
seminales, and prostate, of a severe kind, but these lesions had been equally 
latent during life, except hardening and enlargement of the testicle without 
pain,-all which conditions were only casually observed. 
In this very instructive case a temperature of six degrees Fahr, above the 
normal standard was the earliest indication of disease {Researches, Physiologi- 
cal and Anatomical, vol. i, p. 206). 
But it is mainly to Wunderlich, the Professor of Medicine in Leipsic, that 
we are indebted for an elaborate exposition and persevering advocacy of the 
usefulness of daily records of the temperature of fever patients, and the con- 
stant employment of the thermometer as a means of diagnosis at the bedside. 
On this subject he has written much, from an extensive experience, embra- 
cing at least half a million exact thermometric observations, following the 
continuous progress of individual diseases, the results of which he has com- 
pared in more than 5000 patients. He constantly employs the thermometer 
in his private practice, and bears unqualified testimony to its sterling value 
in the early detection of disease, and as often furnishing an important guide 
to treatment. When the physician once becomes accustomed to the investi- 
gation of disease by the thermometer, he regards its daily employment as in- 
dispensable, for it imparts a certainty to his observations, attainable by no 
natural penetration, and which no other method of investigation can convey 
{Medical Times and Gazette, June 19, 1858, and September 28, 1861). 
Wunderlich gives some striking instances of disease being indicated by 
thermometric observation before it could be detected by any other means : 
In ague, several hours previous to the paroxysm, the temperature of the 
trunk of the patient's body begins to rise ; and when the disease seems to have 
disappeared, an increase of temperature may be detected periodically, unac- 
companied by any other symptom. So long as this periodic rise of tempera- 
ture continues, the patient is only apparently, but not really cured. 
In enteric fever, during the exacerbations especially, the rise of temperature 
or its abnormal fall may indicate what is about to happen three or even four 
days before any change in the pulse, or other sign of mischief, has been 
observed. A sudden and marked reduction of temperature has thus denoted 
hemorrhage from the sloughs of Peyer's patches in typhoid fever several days 
before it appeared in the stools. A case of this kind is recorded by Dr. 
Parkes. It occurred in a female twenty-five years of age. Diarrhoea was 
considerable, and blood was largely passed in fluid stools the night before the 
seventeenth day of the fever. On the morning of that day the temperature 
was as low as 93° Fahr., rising in the evening to 101° Fahr. 
It is rare, however, that a definite diagnosis or prognosis can be based on a 
single observation; but sometimes certain conclusions may be arrived at, as 
in the following instances : 
When the temperature is increased beyond 98.5° or 99° it merely shows 
that the individual is ill, and suffering from some disease; and that wl^en 
considerably raised, as with a temperature of 101° to 105° Fahr., the febrile 
phenomena are severe ; that when a great height is reached, as at temperatures 
above 105° Fahr., the patient is in imminent danger ; and that with a rising 
temperature above 106° Fahr., to 108° or 109° Fahr., a fatal issue may almost 
without doubt be expected in a comparatively short time. The highest tem- 
peratures before death have been observed in cases of scarlet fever and of 
tetanus. 
A definitive diagnosis may also be based on a single observation, under the 
following circumstances : 
A person who yesterday was healthy, but exhibits this morning a tempera- 
ture above 104° Fahr., is almost certainly the subject of an attack of ephem- 
eral fever or of ague; and should the temperature rise up to or beyond USEFULNESS OF THE CLINICAL THERMOMETER. 
255 
106.3° Fahr., the case will certainly turn out one of ague, or some other form 
of malarious fever. 
A girl eighteen years of age, supposed to be suffering from hysteria, but 
simulating a case of cerebro-spinal meningitis. A temperature of 103.5° con- 
firmed the diagnosis of meningitis and negatived that of hysteria. The case 
terminated fatally (Compton). Again, in a patient whose temperature rises 
during the first day of illness up to 106° Fahr., it is certain he does not suffer 
from typhus nor enteric fever; and of a patient who exhibits the general 
typical signs of pneumonia, but whose temperature never reaches 101.7° Fahr., 
it may be safely concluded that no soft infiltrating exudation is present in 
the lung. 
Again, if a patient suffer from measles, and retains a high temperature 
after the eruption has faded, it may be concluded that some complicating 
disturbance is present. 
Single observations of temperature, combined with a careful consideration 
of all the symptoms, will often determine whether the disease is one of danger 
or not. 
In enteric fever a temperature which does not exceed on any evening 103.5° 
Fahr, indicates a probably mild course of the fever-and especially if the 
increase of temperature takes place moderately, towards the beginning of the 
second week. A temperature of 105° Fahr, in the evening, or of 104 Fahr, 
in the morning, shows that the attack is a severe one, and forebodes danger 
during the third week; on the other hand, a temperature of 101.7° Fahr, and 
below, in the morning, indicates a very mild attack, or the commencement of 
convalescence. In pneumonia a temperature of 104° Fahr, and upwards 
indicates a severe attack. In acute rheumatism a temperature of 104° Fahr, 
is always an alarming symptom, foreboding danger, or some complication, 
such as synovial or pericardial inflammation. In a case of jaundice otherwise 
mild, an increase of temperature indicates a pernicious turn. In a puerperal 
female an increase of temperature indicates approaching pelvic inflammation. 
In tuberculosis an increase of temperature shows that the disease is advancing, 
or that untoward complications are setting in. 
In short, a fever temperature of 104° to 105° Fahr, in any disease indi- 
cates that its progress is not checked, that complications may still occur, and 
that the case is a precarious one. 
But it is by continuous daily observations that the most important results 
have been arrived at, especially in the hands of Wunderlich, Greisinger, 
Traube, Billroth, Parkes, Jones of Augusta, Ringer, and others who are now 
working most actively in this field of labor. 
Certain febrile diseases have been found to have typical ranges or daily 
fluctuations of temperature throughout their course. In pure unmixed and 
uncomplicated cases this is found to be so constant that the differential diagno- 
sis may be established by accurate observation of the temperature continuously 
from day to day. This has now been determined, especially in cases of mala- 
rious fever, typhus, enteric fever, small-pox, scarlatina, measles, rheumatism, 
pyaemia, pneumonia, acute tuberculosis.w In each of these diseases the tem- 
perature is one of the most certain (although not the only) means for deter- 
mining the real state of the patient as regards morbid disturbances or complica- 
tions ; and a careful observation of temperature from day to day, considered 
in relation with other signs, is indispensable for judging as to the prognosis. 
Frequently it affords the only ultimate means of deciding in doubtful cases, 
and often it is the best corrective of a too hasty conclusion: for example, the 
characteristic variations of the temperature, in a typical case of enteric fever, 
are of such a kind that they are not found in any other disease. Intestinal 
catarrh, severe forms of pneumonia, malarious fever, acute tuberculosis, men- 
ingitis, some stages of Bright's disease, may each simulate enteric fever, and 
may exhibit some of its most characteristic symptoms ; but observation with. 256 
TOPICS RELATIVE TO PATHOLOGY. 
the thermometer as to the patient's temperature from day to day, will at once, 
or after a very few days at most, establish the distinction with certainty. 
In the course of many diseases, whose diagnosis has been accurately deter- 
mined, if the temperature departs from its normal or typical range, the ther- 
mometer will furnish the best and the earliest indication of any untoward 
event, such as the additional development of disease, or of visceral complica- 
tions in its course. 
When once the typical range of temperature (normal to the particular 
disease) is determined, an important point in its natural history has been fixed, 
and a basis is laid for appreciating irregularities or complications in its course 
in particular cases. For example, a patient exhibits symptoms of fever of 
the typhoid type, but during the progress of the first week his temperature 
becomes normal, for however short a space of time ;-the occurrence of this 
event proves that the fever is not what it w,as supposed to be. Again, a patient 
may suffer from all the general symptoms of incipient pneumonia; but there 
still is a doubt as to whether infarction of the lung has taken place. The 
sputa being suppressed, or not procurable, does not assist the diagnosis. If, 
however, the temperature is found to be normal, it is certain that no croupous 
exudation has taken place in the lung, and that there is no pneumonia. 
Again, if a tuberculous patient has a sudden attack of htemoptysis, and if the 
temperature of his body is normal during and subsequent to the attack, no 
reactive pneumonia, nor any exacerbation of the tuberculous exudation, need 
be expected. This is a new field open for investigation in cases of phthisis. 
Again : In all cases of convalescence, so long as the defervescence proceeds 
regularly as measured by the temperature, no relapses need be feared : on the 
other hand, delayed defervescence in pneumonia, the persistence of a high 
evening temperature in general diseases, and the incomplete attainment of 
normal temperature in convalescence, are signs of great significance. They 
indicate incomplete recovery, supervention of other diseases, or local lesions, 
unfavorable changes in the products of disease, or the continuance of other 
sources of disturbance requiring to be carefully examined into. The onset of 
even a slight elevation of temperature during convalescence is a warning to 
exercise careful watching over the patient, and especially for the maintenance 
of a due control over his diet and actions. 
Continuous daily observations by the thermometer show the typical ranges 
of temperature in particular forms of fever, and supply the grounds or basis 
by which it is determined whether any individual case is progressing as it 
ought to do. Such knowledge can only be acquired by repeated observation 
of numerous cases; and deviations from the normal temperature in certain 
diseases are stable in proportion to the typical character and full development 
of the particular disease. But even in such diseases we may have an increase 
or decrease of temperature proper to the disease brought about by accidental 
influences. Such instability, however, is only temporary, and of short dura- 
tion, when the accidental influences act but transitorily. For example, the 
temperature proper to the disease may be lowered under the influence of a 
profound sleep, bleeding, epistaxis, the relief of constipation or of the reten- 
tion of urine, and the like; or it may be raised after excitement of a mental 
kind. But any such alterations, unless they are dependent upon a change in 
the disease-process itself, will become effaced after twelve or twenty-four hours 
at the most, when the temperature again resumes the typical character diag- 
nostic of the particular disease. In continued fevers the temperature is gen- 
erally less high in the morning than in the evening. 
Stability of temperature from morning to evening is a good sign; on the 
other hand, if the temperature remains stable from evening till the morning, 
it is a sign that the patient is getting or will get worse. 
When the temperature begins to fall from the evening to the morning, it is USEFULNESS OF THE CLINICAL THERMOMETER. 
257 
a sure sign of improvement; on the other hand, a rise of temperature from the 
evening till the morning is a sign of his getting worse. 
When it is found, in a bad case of enteric fever, that some morning about 
the third week the temperature has fallen to 99.5°, the reparative stage has 
begun-the healing of Peyer's patches; and when a similar fall of tempera- 
ture is observed in the evening, convalescence has commenced. 
In pneumonia, when a marked fall of temperature occurs in the evening, 
the period of crisis has arrived. 
In measles, when the maximum severity of the eruptive stage has been 
reached, the temperature falls. 
A sinking from a considerable height down to a normal temperature sud- 
denly (within twenty-four hours), occurs in a few eruptive fevers,-measles, 
variola, rarely in pneumonia, typhus, and pyaemia. 
In scrofula, especially in its acute form, with deposition or growth of tuber- 
cle, the persistent maintenance of a uniformly high temperature will alone 
show that no arrest in the progress of the disease has occurred. 
The correlation of pulse, respiration, and temperature is of great importance 
to be determined in many acute diseases; and especially in pneumonia, if the 
mean of the temperature is not above 104° Fahr., and (hat of the pulse is not 
above 120 in a minute, and the mean of the respirations not over 40 in the 
same time, the case must be considered a slight one; and if the patient is 
otherwise healthy, he will surely begin to get well in from eight to twelve 
days, without any medical treatment beyond attention to antiphlogistic 
regimen. 
In typhus fever, a falling temperature with a rising pulse forebodes danger. 
Convalescence is known to commence when the disease-process ends; and 
this precise point can only be fixed by continuous thermometric observation. 
The morbid process does not end till the normal temperature of the body 
returns, and maintains itself unchanged through all periods of the day and 
night. 
Regularly continuous observations of the temperature exhibit the precise 
point at which the disease-process terminates, and the degree of its complete 
development. When this point has been determined on, a retrospective view 
may be taken of the character of the disease, as to the purity of its typical 
form or its complexity, and a prognosis may be hazarded as to the probability 
or doubtfulness of recovery. The morbid process has not terminated till the 
normal temperature of the body returns, and remains unchanged in the eve- 
nings and throughout all periods of the day. The transition'from the febrile 
state into defervescence being either slow (lysis) or rapid (crisis); and regu- 
larly continuous defervescence is always a sure sign of convalescence. Irreg- 
ular defervescence, on the contrary, indicates a disturbed and । protracted 
course of convalescence, which requires careful watching and judicious 
nursing. 
It is of practical importance to know that the fall of temperature during 
the period of recovery, in cases of considerable morning remissions, as well as 
in those of continued defervescence, may be abnormally large, and sink as 
low as 2$° R. = 95° Fahr., oi' even lower. Such events constitute collapses 
during defervescence, which must be counteracted by artificial heat, the 
administration of warm drinks, or even of such stimulants as wine or camphor, 
unless some unexpected new danger should interfere with an otherwise favor- 
able course of the disease. 
During convalescence the recurrence of a high temperature is generally 
the first sign of an approaching relapse, or the onset of a new disease, the 
characteristic symptoms of which it may precede by several days. The per- 
sistence of even an inconsiderable degree of abnormal temperature after 
apparent return to health, is a certain, and frequently for a long time the 
only, sign of incomplete recovery, or the existence of some lingering secondary 258 
TOPICS RELATIVE TO PATHOLOGY. 
disease. The temperature should therefore be closely watched during conva- 
lescence; and the thermometer should be applied every alternate evening at 
the very least. As long as the temperature remains normal, nothing need be 
feared; but every rise of temperature should act as a warning. It may be 
due to mere error in diet, or to leaving bed too early; but in such cases the 
temperature soon sinks again, on greater precautions being taken. 
Regularly continuous observations on the temperature alone, or in connec- 
tion with other symptoms, may enable the physician to predict a fatal issue 
with certainty, or the probably near approach of death. On this point one of 
two conditions may be observed. (1.) The temperature may rise continuously 
and considerably above 106.2° Fahr., when it is a bad sign; or it may even 
reach 110° Fahr., when a fatal issue is almost certain; and it not unfrequently 
happens that, after the apparent occurrence of death, the temperature still 
continues to rise one or two-tenths Fahr., or even a degree, the cooling of the 
body taking place very slowly. Wunderlich records a case of spontaneous or 
rheumatic tetanus in which the temperature exceeded the maximum that has 
ever yet been observed in any disease. The heat only began to increase 
within the last twenty-four hours before death; but the other symptoms before 
that time had been very violent, the respirations being accelerated, and the 
pulse at 102. During the night previous to death the temperature suddenly 
rose 3.3° Fahr., while the velocity of the pulse and the frequency of the respi- 
rations diminished, and the other symptoms did not increase in severity. 
Shortly before death, the heat rose to 110.75° Fahr., the pulse being then at 
180; and at the moment of death the thermometer was at 112.5° Fahr. 
After death the temperature still rose, and was found to be 113.8° Fahr, an 
hour after the fatal event. It then slowly diminished; and thirteen and a half 
hours after death the temperature had not yet fallen to the normal average of 
the living body. 
(2.) The temperature may become more or less moderated, while the pulse 
is increased in frequency, and the other symptoms become more and more 
threatening. Such diminution of temperature, amidst conditions which do 
not harmonize with it, must be regarded as a pretty certain sign of approach- 
ing dissolution (see cases published by Dr. Muller of Dundee in Brit, and For. 
Med. and Chir. Review, Oct., 1868). 
But, on the other hand, there are cases in which the observation of the 
temperature yields the most favorable signs for prognosis. For example, 
when it is found, in a bad case of enteric fever, that the temperature has fallen 
some morning to 99.5° Fahr., we know that the reparative stage is entered 
upon; and when a similar fall of temperature is observed in the evening, con- 
valescence has commenced. In pneumonia, when a marked fall of tempera- 
ture occurs in the evening, it shows that the period of crisis has arrived. 
When the temperature falls in measles, the maximum severity of the eruptive 
stage has been reached; and when, in the first stage of variola, ^nq observe a 
quick return to the normal temperature, we may feel certain that a slight 
form of the disease, free from danger, is likely to ensue. 
A decrease of temperature below the normal is rare. It happens sometimes 
transitorily, anouncing thereby a favorable crisis, by preceding the feturn to 
a normal temperature. It is also met with sometimes during the morning 
remission of remittent fever; also during the apy rexia of intermittents; in acute 
collapse, preceded or not by fever; in chronic wasting diseases; and sometimes, 
also, on the approach of death, especially in typhus fever, in which the car- 
diac symptoms have been dangerous. 
A remarkable inequality in the distribution of the temperature over dif- 
ferent parts of the body (face, hands, feet, &c.) may occur during the shiver- 
ing preceding fever, in collapse, and in the agony of approaching dissolution. 
Sometimes, also, such unequal distribution may occur in disorders of the chest 
and abdomen, in some local skin diseases, and in partial paralysis. This fact CORRELATION OF BODILY HEAT WITH EXCRETA. 
259 
is not of importance or utility for diagnosis or prognosis; but it requires to be 
known, in order that erroneous conclusions may not be drawn. 
IV. Of the Ranges of Temperature in Diseases where Fever is present, as related 
to the Amount of the Excreta. 
The particular degree of heat and the waste in every febrile disease are 
represented by-something. The physician sees the fevered patient wasting 
before his eyes. Every tissue is wasting, and, in correlation with the exces- 
sive generation of heat, how is this waste expressed ? As a rule, it is expressed 
by the amount of excreta. 
To Dr. Parkes, in this country, to Dr. Jones of Augusta (in cases of mala- 
rious fever), to Virchow and Wunderlich in Germany, is the merit mainly 
due of having demonstrated, by clinical and experimental observation, that 
the morbid development of heat, as measured by a thermometer, is associated in 
some cases with more abundant, in other instances with less abundant excreta 
from the body than in health;-that the temperature and the amount of the 
excretions bear some undetermined relation to each other;-and that the loss 
of weight of the patient is due to increased and rapid elimination of material 
with increased tissue-change, associated with the increase of temperature. 
. So far as physiological facts have elucidated the normal generation of heat 
in the healthy body, so far has the abnormal generation of heat essential to 
the febrile state been clearly made out. In health the normal temperature 
produced by chemical change in the body is represented in the excretions by 
so much urea, sulphuric acid, carbonic acid, excretive volatile acids of the skin, 
and the like; but in the febrile body a higher temperature is represented in 
the excretions, in some cases by a larger, and in others by a smaller quantity 
of urea, sulphuric acid, and probably carbonic acid (Parkes). 
In the study of special diseases the student ought frequently to estimate the 
quantity of excreta passed by the urine, as one of the best methods for ena- 
bling him to appreciate the changes which go on in the body during disease. 
To aid him in prosecuting such researches, he is recommended to consult the 
work of Dr. Parkes On the Composition of the Urine, and to follow the direc- 
tions given on the Examination of the Urine, towards the end of the second 
volume of this text-book, for obtaining quantitative results by the volumetric 
method. Here the following general results may be given: 
Average quantity of Urine passed in twenty-four hours, . . 52 j to 56 ounces. 
" amount of Solids, " " " . . 954 grains. 
" " Urea, " " " . . 512 " 
" " dblorine, " " " . . 126 76 " 
" " Free Acid, " " " . . 33 " 
" 11 Phosphoric Acid, " " . . 48.80 " 
" " Sulphuric Acid, " " . . 31.11" 
" " Uric Acid, " " . . 8.5 " 
" Specific gravity, ........ 1.020 
Two grains of urea per pound weight of the body is the minimum given by 
Haughton and others, eliminated as the product of vital work alone. The 
urinary solids may be estimated by multiplying the number of ounces of urine 
passed in the twenty-four hours into the number representing the specific 
gravity-the product being the weight of the solids in grains. A convenient 
table (see pp. 260, 261) is given by Dr. Houghton, founded on many observa- 
tions of urine both in health and in disease, of specific gravities from 1003 to 
1028. The results are approximations to the daily excretion of urea in all 
cases where sugar and albumen are absent. The table is one of double entry, 
and is used by finding the daily excretion of urine in fluid ounces and its 
specific gravity by means of a carefully graduated urinometer. These data 
being found, and the corresponding columns referred to in the table, at the 
intersection of the columns, the excretion of urea is given in grains. 
The most opposite statements have thus been made regarding the amounts 260 
TOPICS RELATIVE TO PATHOLOGY. 
Ounces. 
SPECIFIC 
GRAVITY. 
Fluid 
1003 
1004 
1005 
1006 
1007 
1008 
1009 
1010 
1011 
1012 
1013 
1014 
1015 
1016 
1017 
1018 
1019 
1020 
1021 
1022 
1023 
1024 
1025 
1026 
1027 
1028 
20 
35 
36 
43 
57 
71 
85 
100 
103 
106 
119 
130 
136 
142 
151 
160 
196 
233 
241 
249 
257 
265 
274 
276 
278 
279 
280 
21 
37 
38 
45 
59 
74 
89 
105 
108 
111 
124 
136 
142 
149 
158 
168 
205 
245 
253 
261 
269 
278 
288 
290 
292 
292 
294 
22 
38 
40 
47 
62 
78 
95 
110 
113 
116 
130 
143 
149 
156 
166 
176 
215 
257 
265 
274 
282 
292 
301 
303 
305 
306 
308 
23 
40 
41 
49 
65 
81 
97 
115 
118 
121 
136 
149 
156 
163 
173 
184 
225 
268 
277 
286 
295 
305 
315 
317 
319 
320 
322 
24 
42 
43 
51 
68 
85 
101 
120 
123 
127 
142 
156 
163 
170 
181 
192 
235 
280 
28.1 
299 
308 
319 
329 
331 
333 
334 
336 
25 
43 
45 
53 
71 
88 
106 
125 
129 
132 
117 
162 
170 
177 
188 
200 
245 
291 
301 
311 
321 
332 
342 
345 
347 
348 
350 
26 
45 
47 
55 
73 
92 
110 
130 
134 
137 
153 
169 
176 
184 
196 
208 
254 
303 
313 
324 
334 
346 
356 
359 
360 
362 
364 
27 
47 
49 
57 
76 
95 
114 
135 
139 
143 
159 
175 
183 
191 
213 
216 
264 
314 
325 
336 
347 
359 
369 
372 
374 
376 
378 
28 
48 
50 
59 
79 
99 
118 
140 
144 
148 
165 
182 
190 
198 
221 
224 
274 
326 
337 
349 
360 
372 
383 
386 
388 
390 
392 
29 
50 
52 
61 
82 
103 
122 
145 
149 
153 
171 
188 
197 
205 
228 
232 
284 
337 
349 
361 
373 
386 
397 
400 
402 
404 
406 
30 
52 
54 
64 
85 
106 
127 
150 
155 
159 
177 
195 
204 
213 
226 
240 
294 
349 
361 
374 
386 
399 
411 
414 
416 
418 
420 
31 
55 
55 
66 
87 
109 
131 
155 
160 
164 
182 
201 
210 
220 
233 
248 
303 
361 
373 
386 
398 
412 
425 
428 
429 
432 
434 
32 
55 
57 
68 
90 
113 
135 
160 
165 
169 
188 
208 
217 
227 
241 
256 
313 
373 
385 
398 
411 
425 
438 
442 
443 
446 
448 
33 
57 
59 
70 
93 
116 
140 
165 
170 
175 
194 
214 
224 
234 
249 
264 
323 
384 
397 
411 
424 
438 
452 
455 
457 
460 
462 
34 
58 
61 
72 
96 
120 
144 
170 
175 
180 
200 
221 
231 
241 
256 
272 
333 
396 
409 
423 
437 
451 
466 
469 
471 
474 
476 
35 
60 
63 
74 
99 
124 
148 
175 
180 
185 
206 
227 
238 
248 
264 
280 
343 
407 
421 
436 
450 
464 
479 
483 
485 
488 
490 
36 
61 
64 
76 
102 
127 
153 
180 
185 
191 
212 
234 
244 
255 
271 
288 
352 
419 
433 
448 
462 
477 
493 
497 
499 
502 
504 
37 
63 
66 
78 
105 
130 
157 
185 
190 
196 
218 
240 
251 
262 
279 
296 
362 
430 
415 
461 
475 
490 
507 
510 
513 
516 
518 
38 
65 
68 
80 
108 
134 
161 
190 
195 
201 
224 
247 
258 
269 
286 
304 
372 
442 
457 
473 
488 
503 
520 
524 
527 
530 
532 
39 
67 
70 
82 
111 
138 
166 
195 
200 
206 
230 
253 
265 
276 
294 
312 
382 
453 
469 
486 
501 
516 
534 
538 
541 
544 
546 
40 
69 
72 
85 
114 
142 
170 
200 
206 
212 
236 
260 
272 
284 
302 
320 
392 
465 
482 
498 
514 
530 
548 
552 
555 
558 
560 
41 
71 
73 
87 
116 
145 
174 
205 
211 
217 
241 
266 
278 
291 
309 
328 
401 
477 
494 
510 
527 
543 
562 
566 
568 
571 
574 
42 
74 
75 
89 
1 19 
148 
178 
210 
216 
227 
247 
273 
285 
298 
317 
336 
411 
489 
506 
523 
540 
557 
575 
580 
582 
585 
588 
43 
75 
77 
91 
122 
152 
182 
215 
221 
228 
253 
279 
292 
305 
324 
344 
421 
500 
518 
535 
553 
570 
589 
593 
596 
599 
602 
44 
76 
79 
93 
125 
156 
186 
220 
226 
233 
259 
286 
299 
312 
332 
352 
431 
512 
530 
548 
566 
584 
603 
607 
610 
613 
616 
45 
78 
81 
95 
128 
160 
191 
225 
231 
238 
265 
292 
306 
319 
339 
360 
441 
523 
542 
561 
579 
597 
616 
621 
624 
627 
630 
46 
80 
82 
97 
130 
163 
195 
230 
236 
243 
271 
299 
312 
326 
347 
368 
450 
535 
554 
573 
592 
611 
630 
635 
638 
641 
644 
47 
82 
84 
99 
133 
166 
199 
235 
241 
249 
277 
305 
319 
333 
355 
376 
460 
546 
566 
586 
605 
624 
644 
648 
652 
655 
658 
48 
84 
86 
101 
136 
170 
203 
240 
246 
254 
283 
312 
326 
340 
362 
384 
470 
558 
578 
598 
618 
637 
657 
662 
666 
669 
672 
REV. SAMUEL HAUGHTON'S TABLE FOR THE DETERMINATION OF UREA IN URINE (See p. 259.) TABLE FOR THE DETERMINATION OF UREA IN URINE. 
261 
49 
85 
88 
103 
139 
174 
207 
245 
251 
259 
289 
318 
333 
347 
370 
392 
480 
569 
590 
611 
631 
651 
671 
676 
680 
683 
686 
50 
87 
90 
106 
142 
178 
212 
250 
257 
265 
295 
325 
340 
355 
377 
400 
490 
581 
602 
623 
644 
665 
685 
690 
694 
697 
700 
51 
88 
92 
108 
144 
181 
216 
255 
262 
270 
301 
331 
346 
362 
385 
408 
499 
593 
614 
635 
656 
678 
699 
704 
708 
710 
714 
52 
90 
94 
110 
147 
185 
220 
260 
267 
276 
307 
338 
353 
369 
393 
416 
509 
605 
626 
648 
669 
692 
712 
718 
721 
724 
728 
53 
92 
96 
112 
150 
188 
225 
265 
272 
281 
313 
344 
360 
376 
400 
424 
519 
616 
638 
660 
682 
705 
726 
731 
735 
738 
742 
54 
94 
98 
114 
153 
192 
229 
270 
277 
286 
319 
351 
367 
383 
408 
432 
529 
628 
650 
673 
695 
718 
740 
745 
749 
752 
756 
55 
95 
99 
117 
156 
195 
233 
275 
283 
292 
325 
358 
374 
390 
415 
440 
539 
639 
662 
685 
708 
732 
753 
759 
763 
766 
770 
56 
96 
100 
119 
159 
199 
238 
280 
288 
297 
331 
364 
380 
397 
423 
448 
548 
651 
674 
698 
720 
745 
767 
772 
776 
780 
784 
57 
98 
102 
121 
162 
202 
242 
285 
293 
303 
337 
371 
387 
404 
430 
456 
558 
662 
686 
710 
733 
758 
781 
776 
790 
795 
798 
58 
100 
104 
123 
165 
206 
246 
290 
298 
308 
343 
377 
394 
411 
438 
464 
568 
674 
698 
723 
746 
772 
794 
800 
804 
808 
812 
59 
102 
106 
125 
168 
209 
251 
295 
303 
314 
349 
384 
401 
418 
445 
472 
578 
685 
710 
735 
759 
785 
808 
814 
818 
822 
836 
60 
104 
108 
128 
171 
213 
255 
300 
309 
319 
355 
391 
408 
426 
453 
480 
588 
697 
722 
748 
772 
798 
822 
828 
832 
836 
840 
61 
106 
109 
130 
173 
216 
259 
305 
314 
324 
360 
397 
414 
433 
460 
488 
597 
708 
734 
760 
784 
811 
836 
842 
845 
850 
854 
62 
108 
110 
132 
176 
220 
263 
310 
319 
329 
366 
404 
421 
440 
468 
496 
607 
719 
746 
772 
797 
824 
849 
856 
859 
864 
868 
63 
109 
112 
134 
179 
223 
267 
315 
324 
335 
372 
410 
428 
447 
475 
504 
617 
730 
758 
785 
810 
838 
863 
869 
873 
878 
882 
64 
110 
114 
136 
182 
227 
271 
320 
329 
340 
378 
417 
435 
454 
483 
512 
627 
742 
770 
797 
823 
851 
877 
883 
887 
892 
896 
65 
112 
116 
138 
185 
230 
276 
325 
335 
345 
384 
423 
442 
461 
490 
520 
637 
754 
7S2 
810 
836 
864 
890 
897 
901 
906 
910 
66 
114 
118 
140 
187 
234 
280 
330 
340 
351 
390 
431 
448 
468 
498 
528 
646 
766 
794 
822 
849 
877 
904 
911 
915 
920 
924 
67 
115 
120 
142 
190 
237 
284 
335 
345 
356 
396 
437 
455 
475 
505 
536 
656 
778 
806 
835 
862 
891 
918 
925 
929 
934 
938 
68 
116 
122 
144 
193 
240 
288 
340 
350 
361 
402 
443 
462 
482 
513 
544 
666 
790 
818 
847 
875^ 
904 
931 
939 
943 
948 
952 
69 
118 
124 
146 
196 
244 
292 
345 
355 
367 
408 
449 
469 
489 
520 
552 
676 
802 
830 
860 
888 
917 
945 
953 
957 
962 
966 
70 
120 
126 
149 
199 
248 
297 
350 
361 
372 
414 
456 
476 
497 
528 
560 
686 
814 
843 
872 
901 
930 
959 
966 
971 
976 
980 
71 
121 
127 
151 
201 
251 
301 
355 
366 
377 
419 
462 
482 
504 
536 
568 
695 
826 
855 
884 
913 
943 
973 
980 
984 
990 
994 
72 
122 
128 
153 
204 
255" 
305 
360 
371 
382 
425 
469 
489 
511 
544 
576 
705 
838 
867 
896 
926 
956 
986 
994 
998 
1004 
1008 
73 
124 
130 
155 
207 
258 
310 
365 
376 
388 
431 
475 
496 
518 
551 
584 
715 
849 
879 
909 
939 
969 
1000 
1007 
1012 
1018 
1022 
74 
126 
132 
157 
210 
262 
314 
370 
381 
393 
437 
482 
503 
525 
558 
592 
725 
861 
891 
921 
951 
982 
1014 
1021 
1026 
1032 
1036 
75 
128 
134 
159 
213 
266 
318 
375 
386 
398 
443 
488 
510 
532 
566 
600 
735 
872 
903 
934 
964 
995 
1027 
1035 
1040 
1046 
1050 
76 
130 
136 
161 
216 
269 
323 
380 
39! 
404 
449 
495 
516 
539 
573 
608 
745 
884 
915 
946 
977 
1008 
1041 
1049 
1054 
1060 
1064 
77 
132 
138 
163 
219 
273 
327 
385 
396 
409 
455 
501 
523 
546 
581 
616 
755 
895 
927 
959 
989 
1021 
1055 
1062 
1068 
1074 
1078 
78 
134 
140 
165 
222 
276 
331 
390 
401 
414 
461 
508 
530 
553 
588 
624 
765 
907 
939 
971 
1002 
1034 
1068 
1076 
1082 
1088 
1092 
79 
136 
142 
167 
225 
280 
336 
395 
406 
420 
467 
514 
537 
560 
596 
632 
775 
918 
941 
984 
1015 
1047 
1082 
1090 
1096 
1102 
1106 
80 
139 
144 
170 
228 
284 
340 
400 
412 
425 
473 
5-21 
544 
568 
604 
640 
785 
930 
964 
996 
1028 
1060 
1096 
1104 
1110 
1116 
1120 
1003 
1004 
1005 
1006 
1007 
1008 
1009 
1010 
1011 
1012 
1013 
1014 
1015 
1016 
1017 
1018 
1019 
1020 
1021 
1022 
1023 
1024 
1025 
1026 
1027 
1028 262 
TOPICS RELATIVE TO PATHOLOGY. 
of the excretions in fever, compared with the amounts excreted in health; and 
at present many excellent observers hold that these excretions are always, and 
of necessity, increased; others, no less exact, affirm that they are invariably, 
or almost always, diminished. Such discrepancy of statement is due, in the 
first instance, to the difficulty of collecting and measuring exactly the amount 
of all the excretions. "Two of the excretions, the cutaneous and the pul- 
monary, cannot be collected and measured with anything like the accuracy 
necessary in such an inquiry: even in health such an inquiry is difficult, and 
in fever it is almost impossible." By careful and accurate observation at the 
bedside, however, Dr. Parkes has been able to obtain very close approxima- 
tive data to found his conclusions upon relative to the increase or diminution 
of the excretions. He assumes that when the respirations are not quickened 
(i. e., about eighteen times a minute, or about one act of respiration for every 
four beats of the pulse), and when the skin is not evidently sweating, the excre- 
tions by these two organs are not increased; and, on the other hand, an in- 
creased excretion by these organs may reasonably be inferred if the exercise 
of their function is unusually active, and if there are tolerably copious per- 
spirations. The other two excretions-namely, the urine and intestinal dis- 
charges-can be measured with accuracy, and the urine in particular is a 
valuable index of the metamorphoses of tissue. The urea alone represents 
two-thirds of the whole quantity of nitrogen which passes off; the sulphuric acid 
(the sulphates of the food being accounted for) represents almost entirely the 
oxidation of sulphur; and the oxidized phosphorus of the body passes out in 
great measure, though not altogether, as urinary phosphoric acid. Therefore 
a careful examination of the urine, and of the intestinal discharges, with an 
approximative estimate of the pulmonary and cutaneous excretions, give suffi- 
ciently extensive and accurate materials for the question at issue. 
The products excreted are thus of such a kind as to be eliminated, some by 
the lungs, some by the skin, some by the bowels, and some by the kidneys, and 
rarely by two or more modes of excretion; for when the discharges from the 
skin or bowels are profuse, those by the kidneys are deficient, as in the last two 
cases recorded in the following Table I, in which the augmented excretions 
are printed in italics. The facts thus so carefully observed by Dr. Parkes, 
confirmed by Alfred Vogel, Heller, and others (but chiefly in regard to the 
excretion of urea only), justify the conclusion-"That increase of temperature 
may be attended with increased elimination; and therefore presumably with 
increased tissue-changed 
The abstract given in Table II shows that another conclusion is equally 
legitimate, namely,-"That the products of metamorphosis, as judged of by the 
excreta, may be diminished in febrile cases. These statements, apparently dis- 
cordant, are capable of explanation in various ways. In the first place, it is 
evident that more chemical change may go on in the body than is represented by 
the excreta. The metamorphosis of blood or of tissues may not be carried to 
the point of forming those principles which can alone pass through the elimi- 
nating organs. A vast amount of imperfectly organized compounds may be 
formed and retained in the system, circulating with the blood or thrown upon 
certain organs." Thus there may be increased metamorphosis with lessened elimi- 
nation. Several pathological facts point to such a conclusion. 
1. It is in such febrile cases, with diminished excreta, that, at a later period 
of the disease, copious discharges from one or other of the eliminating organs 
occur. Thus, in the case of pneumonia referred to in Table II, severe spon- 
taneous diarrhoea came on; and many other cases are quoted, with similar 
diminution of the excretions at the period of increased febrile heat, in which 
violent purging, sweating, or diuresis, with increase of urea and of sulphuric 
acid, subsequently occurred. Such discharges occurring during the progress 
and towards the termination of a febrile disease have been termed critical, the 
occurrence being called a crisis; and the particular day on which it happens, RELATION OF EXCRETA TO FEVER-HEAT. 
263 
counting from the day of seizure, has been called a critical day. The term crisis 
or critical is applied because the occurrence of such discharges is usually coin- 
cident with more or less sudden fall of temperature, and general improvement 
Table I.-Abstract of Cases in which some of the Excretions are 
Increased in consequence of the Febrile State (Dr. Parkes). 
Disease. 
Average 
Temperature 
above 98°. 
Condition of 
Pulmonic 
Function. 
Condition of 
Cutaneous 
Function or 
Skin. 
Condition of 
Intestinal 
Function. 
Condition of Urinary 
Excretion. 
Rheumatism 
Fahr. 3°. 
Not noted. 
Sweating 
profusely. 
Discharge 
as usual 
Solid matter excre- 
ted greater than in 
health by 100 grains, 
and due to urea and 
sulphuric acid. 
Rheumatism. 
Fahr. 3°. 
Not noted. 
Sweating 
profusely. 
Discharge 
not 
diminished 
Solid matters excre- 
ted greater than m 
health by 200 grains, 
and due to urea and 
sulphuric acid. 
Typhoid 
Fever. 
Several 
degrees. 
Rapid. 
Moist. 
Not 
increased. 
Increased by 60 
grains. 
Erysipelas of 
Head and 
Face. 
Quick. 
Moist. 
Unaltered 
Considerably 
augmented. 
Febricula. 
Fahr. 3°. 
Normal. 
Enormously 
augmented. 
Confined. 
Solids less than nor- 
mal by 91 grains. 
Typhoid. 
Fahr. 3°. 
Not noted. 
Sweating and 
Sudamina. 
Diarrhoea 
profuse. 
Solids less by 73 
grains. 
Table II.-Cases in which there was Diminution of the Excretions (Dr. 
Parkes). 
Disease. 
Average 
Temperature 
above 98°. 
Condition of 
Pulmonic 
Function. 
Condition of 
Cutaneous 
Function or 
Skin. 
Condition of 
Intestinal 
Function. 
Condition of Urinary 
Excretion. 
Bronchitis 
of both 
Lungs. 
Fahr. 2.6°. 
20 Respira- 
tions per 
minute. 
Not 
increased. 
Not 
increased. 
Less by 112 grains. 
Pneumonia 
Acute 
Sthenic. 
Fahr. 5°. 
30 per 
minute; ex- 
pectoration 
scanty. 
Slightly 
moist. 
Confined. 
Less by 220 grains. 
Typhoid 
Fever. 
Consider- 
able. 
No sweating. 
No 
diarrhoea. 
Below normal 
amount. 
Acute 
Rheumatism. 
Fahr. 4°. 
Tranquil 
breathing. 
Inconsider- 
able. 
Bowels 
quiet. 
Very small amount 
of urinary solids. 
in the condition of the patient, whose convalescence 
day; when, in common language, his disease is said 1 
> dates from the critical 
to have "got the turn." 264 
TOPICS RELATIVE TO PATHOLOGY. 
In such cases, therefore, a large amount of partially metamorphosed substances 
are retained until they are suddenly discharged, and the system freed from 
the noxious compounds. Coincident with the critical discharge, the tempera- 
ture is found to fall. 
Table III.-Table of Cases to show Local Lesions coincident with 
Sudden Retention of the Excretions in Fever (Dr. Parkes). 
Disease. 
Average 
Tempera- 
ture 
above 98°. 
Condition of 
Pulmonic 
Function. 
Condition of 
Cutaneous 
Function or 
Skin. 
Condition of 
Intestinal 
Function. 
Condition of Urinary 
Excretion. 
Rheumatic 
Fever. 
Observed 
on the 
5th, 6th, 
and 7 th 
day of the 
disease. 
Fahr. 2°. 
Fahr. 2°. 
No record. 
Sweating 
profuse. 
Lessened on 
the 8th day. 
No intestinal 
discharge. 
While 400 grains 
more than in health 
were being daily ex- 
creted, suddenly on the 
8th day a diminution 
of the solids took place 
by 602 grains; and 
coincident with this 
diminution a local le- 
sion became developed 
(angina faucium). The 
next day the excretion 
augmented, and the lo- 
cal affection subsided. 
Typhoid 
Fever. 
Fahr. 5°. 
Fahr. 5°. 
No record. 
Great 
sweating. 
Lessened 
much. 
Diarrhoea 
profuse. 
Diarrhoea 
ceased. 
While the average 
daily excretion for 8 
days was 422.348 grs., 
a gradual diminution 
continued for 3 days, 
to the daily extent of 
78 grains, when pleu- 
risy came on. 
Rheumatic 
Fever. 
No record. 
Sweating 
moderately. 
Unchanged. 
Considerable quan- 
tity of urine passed, 
containing an excess of 
solids : a sudden and 
great diminution both 
of the solids and fluids 
of the urine took place, 
when the joints again 
began to suffer, and 
pleurodynia s u p er- 
vened. 
2. But in another class of febrile cases, retention of the products of meta- 
morphosis is not followed by such a fortunate critical issue. At a later period 
in the history of some febrile cases, with diminished excreta, it is not uncom- 
mon for secondary inflammatory affections to occur, as if the blood were more 
contaminated; and it is sometimes observed that in a patient whose excreting 
organs are acting copiously, that there occurs a diminution of excretion when 
a simultaneous or subsequent development of local disease becomes manifest. 
The preceding Table of Cases is interesting from the exactness of the obser- 
vations and the coincidence of the local lesions with suppression and retention 
of excreta during febrile states. 
Thus it is evident, from'these carefully recorded observations, "that dimin- 
ished excreta in fever are to be referred to retention of such excreta, and not to a 
want of formation; and that while the amount of excreta (capable of being RELATION OF EXCRETA TO FEVER-HEAT. 
265 
measured) may in fact be small, the amount of tissue-change may nevertheless be 
great." The practical lesson so often insisted on by the older physicians,- 
" never to lock up the excretions,"-is thus demonstrated with scientific exact- 
ness. Another general and practical conclusion is, that the febrile heat cannot 
be measured even by the amount of the. excretions as a whole, nor yet by any 
ingredient of them in particular; but must be estimated in correlation with 
them and with age and body-weight. Under the same degree of animal heat, 
and in the same disease, different patients pass very different quantities of 
urea, uric acid, sulphuric acid, phosphoric acid, cutaneous and intestinal excre- 
tions. The same observations may be made regarding men in health. No 
two persons pass exactly the same amount of excretory products. 
The nature of these excretory products shows that it is the albuminous or 
nitrogenous tissues of the body which are being destroyed in the febrile state; 
for the excretory products of the urine are the representatives of the azotized 
structures. The amount of these excretory ingredients varies considerably 
from day to day in fever exactly as in health. Often there is a regular gra- 
dation of increase and decrease: the urea, for instance, may, for two or three 
days, slightly but regularly diminish in amount) and then suddenly augment 
to its highest point, again slowly to fall. The same fact may be observed 
with the sulphuric acid; and Dr. Parkes is led to believe that, both in health 
and in disease, a certain periodicity, having a range of three or five days, is 
connected with these gradations of increase and diminution. 
The largest amount of urea excreted in twenty-four hours in the febrile 
state is recorded of a case of pyaemia by Alfred Vogel, namely, 1235 grains. 
The largest amount observed by Dr. Parkes was in a case of typhoid fever, in 
which it amounted to 885 grains. The largest amount of sulphuric acid re- 
corded by the same observer, when no medicine was taken, was in a case of 
rheumatic fever. It amounted to 52.668 grains; and under the influence of 
liquor potassae in the same disease, he has known this excretion rise to 70 
grains-more than twice as much as in health. The largest amount of uric 
acid excreted during a febrile disease in twenty-four hours, as recorded by 
Drs. Parkes and Garrod, has been 17.28 grains. 
"The amount of tissue destroyed in order to furnish such quantities of 
excreta must be enormous; and if it is recollected that little or no food is 
taken by the feverish patient, and, therefore, that no materials are supplied 
for the reconstruction of the textures thus melting away, three times more 
quickly than in health, the rapid loss in weight in fever, and the impaired 
nutritive condition of every organ at its close, will be at once evident." 
It is not yet determined where the increased destruction of the albuminous 
textures takes place; that is, whether it occurs in the blood or in the organs 
themselves. It is only known that both the albumen and the red corpuscles 
of the blood are lessened in amount at the end of a febrile disease; and of 
the various tissues none appear to waste so fast as the muscles, and especially 
the involuntary ones (e.g., the heart in typhus fever). The fat of the body is 
rapidly absorbed in fevers; and Virchow asserts that the bones also become 
lighter. While it is known that much of the metamorphosis of these tissues 
takes place in the normal way, it is also probable that there is an unhealthy 
or perverted metamorphosis which leads to the appearance of compounds in 
the excretions, either altogether foreign to the body or foreign in respect of 
place and time. There is evidence of this in the peculiar smell of the perspi- 
ration, in the peculiar coloring matter of the urine, as well as in the occasional 
excretion by it of hippuric as well as of lactic, valerianic, and other organic 
acids. 
Next to the occurrence of preternatural heat in fever, the excessive retention 
of water in the febrile system is perhaps the most remarkable and constant 266 
TOPICS RELATIVE TO PATHOLOGY. 
phenomenon. Notwithstanding the large amount of water frequently taken 
to quench the extreme thirst, the quantity of the urine is lessened, and is even 
scantiest when the skin is driest. The "concentration of the urine which 
results, appears to be almost as good an index of the amount of fever as the 
temperature itself." The excretion of water by the skin is also, as a rule, 
diminished; and it is a well-known clinical fact that the skin is drier than 
usual in febrile affections. Very early in the febrile state the buccal mucous 
membrane also becomes sticky, and the amount of saliva diminishes; and the 
decrease in the quantity of the gastric fluid during fever has been proved by 
the well-known experiments of Beaumont on Alexis St. Martin. The intesti- 
nal juices, like the gastric, are also probably diminished, for the stimulus of 
food is taken away, constipation prevails, and the faeces are dry (Parkes). 
This retention of water in the system cannot at present be explained; but 
Dr. Parkes has suggested that it may possibly be due to the presence in the 
blood (or tissues generally) of some intermediate waste product of the febrile 
body, of some substance which (like gelatine) has a powerful attraction for 
water. 
Besides water, there is reason to believe that chloride of sodium is retained 
to a certain extent in fever, or that it passes off less readily with the urine; 
but much has yet to be learned of the nature of fever from investigations 
regarding the chemistry of the excretions, of the secretions, of the blood, and of 
the organs. 
The Urine in Fever.-The general characters of this excretion proper to 
the febrile state are, deficiency of water, increase of solids, if they are not 
retained, and especially of the urea, the uric, the sulphuric, the phosphoric, and 
the hippuric acids. The pigments also are increased; and the chloride of 
sodium is diminished. The deep color of febrile urine has usually been attrib- 
uted to its concentration; but if febrile urine be diluted to the usual amount 
of fluid contained in healthy urine, it is still darker than normal urine. The 
coloring matter has been shown by Vogel to be increased sometimes fourfold, 
and it appears to contain more carbon than usual. This coloring matter in 
febrile urine is peculiar, and does not give any of the reactions of the bile- 
pigment. It may, according to Dr. Parkes, be considered as a measure of the 
metamorphosis of the blood-globules, which in some cases may thus be four 
times as rapid as in health. 
Another important fact connected with the chemistry of the urine in fever 
is the augmentation of its free acidity, as measured by its neutralization with 
soda. 
The Blood in Fever.-The most trustworthy and interesting facts connected 
with the chemistry of the blood in fever are,-(1.) A diminution of the alka- 
line salts, as shown by Becquerel and Rodier in inflammation; (2.) A dimin- 
ution of alkalinity of the serum, as shown by Cohen; (3.) The diminution of 
the albumen after the fever has lasted for some time, with a commensurate 
increase in the water of the serum; (4.) A diminution in the numbers of the 
red corpuscles of the blood; (5.) In certain specific fevers the presence of uric 
acid has been detected; for instance, in the fever of rheumatism, by Dr. 
Garrod. 
Of the Pulmonary Excretion, in the febrile state, little is known. Some 
have found the carbonic acid augmented, others have found it diminished. 
Dr. Wilks, of Guy's Hospital, found that the ratio of respirations to the pulse 
is always increased, and that the pulse may be descending while the respira- 
tion remains high. Such phenomena he considers indicative of a positive 
increase of function of the lungs. 
It is important to determine when the blood becomes affected in fever. It 
has been, and still is, a favorite opinion to refer the origin of fever to primary 
disease of the blood; and in almost all general (specific) diseases a fever- 
making cause appears to enter the blood; at least, writes Dr. Parkes, it may CONDITIONS PRODUCING THE PHENOMENA OF FEVER. 
267 
be proved to enter in several cases; and a strong analogical argument can be 
maintained as to its entrance in others. The fever-making cause also repro- 
duces itself in the blood, or in some organs; and it is now generally admitted 
that the first action of the febrile cause is on the blood. 
The Nervous System seems to play so important a part in fever that Vir- 
chow, in his definition, states that the essential phenomena must have their 
immediate cause in changes of the nervous system. 
It is very difficult to substantiate this position, but the following general 
results prove the great influence of the nerves in febrile affections. Taken 
individually, they, no doubt, will impress different minds with different de- 
grees of force, while, collectively, they cannot fail to furnish an argument in 
favor of the essential participation of the nervous system in fever: 
1. There is the generally received physiological law, that nerves regulate 
the metamorphosis of tissue and the production of heat, both of which are 
altered in fevers (Helmholtz, Ludwig, Bernard). 
2. There are those experiments on the vagus nerve which bring about 
febrile phenomena, such as increased cardiac action, pulmonary congestion, 
anorexia, and nausea (Bernard, Pavy). 
3. There are those arguments derived from the various symptoms which 
announce, accompany, or terminate fever, (a.) The remarkable depression, 
apathy, sense of exhaustion and debility, which usher in the febrile state. (6.) 
The shiverings, the contraction of the superficial vessels and of the skin, (c.) 
The increased rapidity of the heart's action, and the relaxation of the vessels, 
which soon follows the stage of contraction just noticed, or occurs without it. 
(d.) The congestion of the lungs, (e.) The periodicity of some of the phenom- 
ena of fever, and the occurrence of death or recovery on so-called critical 
days. (/.) The abnormal state of the secretions. 
4. The fearfully rapid death which sometimes ensues in the early stage, 
from some unknown cause, may with justice be referred to profound nervous 
lesions; for there is great prostration, a galloping and early-failing pulse, and 
an excessively rapid respiration. 
5. The effect of certain remedies, such as quinine, upon periodical febrile 
phenomena. 
Conditions which combine to produce the Complex Phenomena of Fever. 
-1. The entrance into the blood of a morbific agent, and the alteration of 
the blood to a certain extent under its influence, come first in the order of 
events. Perhaps this occurs under the incubative period, when often there is 
no rise of temperature, no fever; that is, when no appreciable alteration of 
the general health can be discovered. The nature of the change in the blood 
is unknown. 
2. When the change in the blood has reached a certain point, the nervous 
system, or rather that part especially connected with nutrition and organic 
contractility, begins to suffer changes in composition, which probably paralyze, 
impede, or destroy the normal molecular currents. When this occurs, the ner- 
vous symptoms of weakness, depression, rigors, contraction of some parts and 
vessels, speedily followed by relaxation, mark the stage of invasion. 
3. Various parts, simultaneously, especially the muscles, and probably some 
of the organs, deprived in greater or less degree of nervous influence, begin 
rapidly to disintegrate, and by their disintegration preternatural heat is pro- 
duced. Little or no fresh material is assimilated to compensate for the loss; 
great muscular prostration ensues; and destruction of tissue is increased by 
the accelerated action of the heart. 
4. This metamorphosis is aided, in most cases, by the condition of the vagus 
and vasi motor nerves, which cause increased action of the heart and dilata- 
tion of the vessels. 
5. The contamination of the blood, already produced by the morbid agent, 
is increased by the check which the normal extra-vascular currents experience, 268 
TOPICS RELATIVE TO PATHOLOGY. 
by the pouring into the blood of the rapidly disintegrating tissues, and by the 
continued action of the morbid agent, which in almost all cases appears to act 
more rapidly and more powerfully in blood rendered impure in any way, 
either (as shown by Dr. Carpenter) by retention of excretions, absorption of 
septic substances, or, as in fever, by the too rapid metamorphosis of tissue. 
6. The various organs suffer (apart altogether from specific changes), and 
must produce increased deterioration of the blood. Thus the lungs are con- 
gested in so many cases that we can scarcely suppose proper aeration to go on ; 
the liver would seem, from Frerichs's observations, to be, in some cases at any 
rate, in a most abnormal condition, and to produce compounds (such as leucin) 
unknown in health; and the spleen in many fevers, if not in all, enlarges (in 
persons of a certain age), and is congested, possibly even to extravasation. 
7. Food being almost withdrawn, the various alkaline and neutral salts no 
longer pass into the system. 
8. Non-elimination of the products of tissue-metamorphoses may give rise to 
cerebral symptoms and local inflammation. 
9. On the elimination of the fever poison and of the products of the tissue- 
metamorphoses, the nerves resume their normal functions, the undue consump- 
tion of tissue is checked, and the patient regains strength and weight. 
10. When coma, delirium, or stupor present themselves in the course of 
fever, it is the custom to refer these symptoms to the action of the fever poison 
on the brain ; but the cerebral functions are more probably deranged not alone 
by the fever poison (which was the first and the necessary link in the patho- 
logical chain), but by the accumulation in the blood of the products of tissue- 
metamorphosis, and by the perverted and defective nutrition of the brain 
itself. Hence the symptoms in the advanced stage of many fevers are closely 
assimilated, although the primary poisons have been perfectly distinct (Parkes, 
Murchison). 
All these events tend to render the febrile state an extremely complex one, 
and its investigation difficult. Our science is often spoken of as an exception 
to the exactness or comparative certainty of the (so-called) physical sciences ; 
but nothing can demonstrate more clearly the claims of the Science of Medi- 
cine to exactitude and certainty than the advances made in recent years in 
our knowledge of the natural history of febrile diseases-their causes, their 
modes of propagation-their development, natural course, and termination. 
Improved methods and instruments of research, with more extensive clinical 
instruction at our schools of medicine, have contributed to this end; and per- 
haps nothing demonstrates this exactness and certainty better than the ad- 
vances made in our knowledge of the thermometry of disease, and the correlation 
of body-heat with other morbid phenomena. By numerous careful observa- 
tions it is now clearly established that the determination of the correlation of 
the pulse, the respiration, and the temperature of the body, is of the greatest 
practical importance, and especially when regarded in relation to the amounts 
of excreta. By such observation the natural course and termination of many 
diseases can be predicated with great certainty; and so our knowledge becomes 
more exact as to their nature and treatment. The pulse, the respirations, and 
the temperature, all and each of them, represent forces at work in the living 
body, all of which are capable of being measured with great exactness; and 
such measurements show how closely such expenditure of forces is related to 
the excreta, which represent the waste of our tissues in health and disease. 
The student or physician who continues to disregard the aid of thermometry 
in the diagnosis of febrile disease, or the military medical officer who ignores 
its value in the appreciation of feigned diseases, may be compared to the blind 
man guiding himself. By means of great practice and intelligence, the blind 
man will often proceed rightly; but the advantages of being able to see clearly 
are proverbially above all price. The necessity of using the thermometer will 
also soon become known to the general public, and patients will become dis- TYPES OF DISEASE AND THEIR TENDENCY TO CHANGE. 
269 
satisfied, if all known means of investigation are not employed in appreciating 
the nature of their malady. For many years the German student and physi- 
cian has been familiar with its use; but, until Dr. Parkes, and the pupils he 
taught when Clinical Professor in University College Hospital, began to use 
the thermometer, its usefulness in recognizing febrile diseases does not seem 
to have been hitherto sufficiently appreciated in the medical schools of this 
country. The author is pleased to learn, from the numerous communications 
he receives, that this chapter, in previous editions, has led many to use the 
thermometer invariably in clinical work ; and within the past two years (since 
1868), the use of the thermometer in practice has steadily increased. 
Before stating the principles which ought to guide the treatment of the va- 
rious complex morbid processes described in the previous pages, and of indi- 
vidual diseases in particular, it behooves the student, first, to make a separate 
study of the varying types of disease, their prevailing peculiarities, and the con- 
stitutional tendency to change of type which they assume at varying intervals of 
time; and, second, to observe and learn to recognize the various modes by 
which diseases terminate fatally. 
CHAPTER IX. 
TYPES OF DISEASE AND THEIR TENDENCY TO CHANGE. 
Definition-The type or form of disease is the order of succession observed 
to obtain among certain morbid phenomena; and admits of modification from 
various causes, without the intrinsic nature of the phenomena being essentially 
affected (Copland). 
In describing, appreciating, or ascertaining the type of a disease, our atten- 
tion must be directed to a variety of phenomena and conditions; and the type 
of the disease only becomes characteristic and distinctive when some one or 
other of those conditions becomes predominant, or manifests itself more de- 
cidedly than others. The hereditary or natural constitution of the individual 
may be regarded as an important element in determining and modifying the 
type of the disease. Town life, as compared with country life, also exercises 
an influence in modifying the type of many diseases; and there are good 
grounds for believing that the town life and artificial habits of the present 
period are more prejudicial to the strength of the constitution than those 
which prevailed when large towns were but rural villages, and the inhabitants 
more simple in their mode of life, and less artificial in their habits. 
The occupation of the individual in many instances exercises an influence 
over the complex processes of disease ; and there cannot be a doubt that some 
diseases have altogether disappeared, while* others have been so much modi- 
fied that their resemblance to the original form or type can with difficulty be 
recognized. 
With regard to Edinburgh and its vicinity, Professor W. T. Gairdner 
observes that the changes of type which have occurred in epidemic fever, and 
especially in typhus fever, during the ten years previous to 1862, or since the: 
cessation of the great epidemic of 1847-8, are not less remarkable than the: 
diminution in the amount of this class of cases. The relapsing fever or synocha, 
which formed so large a part of the epidemics of 1843-4 and 1847-8, has for 
the time absolutely disappeared ; and in 1870 it again reappeared in several 
places (especially London) as an epidemic. Typhus fever has become less 
fatal to those attacked than it was from 1843 to 1848; while its general type 
and some of its leading characters have been remarkably modified. This is. 
especially noticeable in the diminished mortality; the earliness of the appearance 270 
TOPICS RELATIVE TO PATHOLOGY. 
of the eruption; the earliness of the crisis (tenth to fourteenth day as a rule, 
and rarely prolonged into the third week)-a great cause of the diminished 
mortality; for a day's delay of the crisis, in a case of any degree of severity, 
is an immense addition to the risk {Clinical Medicine, 1862, p. 156, et seq.f 
Nevertheless, it is the rule that diseases preserve their essential characters and 
nature from age to age, although the opinions of the profession respecting 
them and their treatment may change from year to year, or from one period 
of time to another. For example, small-pox, measles, typhus fever, typhoid or 
intestinal fever, dysentery, diphtheria, and the like, always remain the same as 
to their essential characters, and unchanged in their special symptoms; but it 
must be remembered that they are also very often modified in their phenomena 
by the existence of such constitutional ill-health (cachexia) as may arise from 
syphilis, mineral, vegetable, or alcoholic poisoning of the system, as well as from 
gout, rheumatism, scrofula, tuberculosis, and scorbutus; also from epidemic 
causes, and especially also by the artificial mode of life in towns, as compared 
with the more natural habits of rural villages. These are the diseases and con- 
ditions of existence which are the main sources of deterioration of the human 
race, in all physical attributes, among such civilized communities as our own. 
Diseases also have arisen which appear to be more or less new to us, in 
some instances resulting from a hybrid combination of various pathological 
phenomena to be noticed presently. While this is undoubtedly the case, 
there is abundant evidence to prove that we now have in some respects a more 
healthful enjoyment of our life (although the constitution may not be so 
strong) than formerly; and that the duration of man's life of late years has 
been prolonged. While it is the lot of " all men once to die," that final 
change is more frequently deferred than was wont, to beyond that period when, 
in the words of the inspired Psalmist, it is recorded that " the days of our 
years are threescore years and ten; and if by reason of strength they be four- 
score years, yet is their strength labor and sorrow." 
It has been observed by a popular writer that there never were any specifics 
discovered against the plague, the sweating sickness, or the leprosy; and yet 
these diseases, 'so far as regards this country, are now amongst the things that 
were, and are almost unknown. They have disappeared, not before any mar- 
vels of medicine, or any perfection of chemical science, but as a consequence 
of the gradual amelioration of the conditions of our mode of life through sani- 
tary improvements. Observe, also, what sanitary science has done, in a com- 
paratively short space of time, to ameliorate the condition of the British army. 
The Right Honorable the Secretary of State for War (the late Sir George C. 
Lewis, Bart.), in moving the Army Estimates for the year 1862, in the House 
of Commons, said: 
" Improvements have been introduced with a view to ameliorate the social, 
moral, and sanitary condition of the private soldier. Much expenditure has 
been incurred for the sake of enlarging and improving barracks, and in car- 
rying out various recommendations of the House of Commons with respect to 
barracks and the hospitals connected with them. I am happy to say," con- 
tinues the Right Honorable gentleman, " that these efforts have not been un- 
attended with important results, as will appear from authentic returns of the 
mortality in the service. These returns have been prepared by the Director- 
General of the Army Medical Department, and I believe they are perfectly 
.authentic, though it is certainly difficult to believe that so great a change can 
have taken place in so limited a period. It is possible that the greater youth 
of some portions of the army may, to a certain extent, affect the returns, but 
I believe the difference is mainly to be explained by improvements in the 
sanitary conditions under which they are now called on to serve. RESULTS OF SANITARY SCIENCE. 
271 
"Deaths among the Troops serving in the United Kingdom annually per 
1000 of Men. 
From 1830 to 1836. 
1859 to 1860. 
Generally throughout, . 
14 
5 
Cavalry of the Line, 
15 
6 
Royal Artillery, 
15 
7 
Foot Guards, 
21 
9 
From 1836 to 1846. 
1859 to 1860. 
Infantry of the Line, 
17 
8 
From 1837 to 1856. 
1859 to 1861 
Gibraltar, 
22 
9 
Malta, 
18 
. 14 
Ionian Islands, 
27 
9 
Bermuda, 
35 
11 
Canada, 
20 
. 10 
Jamaica, 
128 
. 17 
Ceylon, 
74 
. 27 
"Similar Returns for the Colonies are as follows: 
" I have other returns from other colonies," continues the Right Honorable 
gentleman, " and I believe that these returns are authentic; and certainly 
they show how very considerable a diminution has taken place in the mor- 
tality of the army" (Times, March 4, 1862). 
The late Lord Herbert was the main agent in accomplishing this great 
work, which, as years pass on, will become better appreciated, more widely 
known, and more energetically followed up. 
Professor W. T. Gairdner has happily observed, that in proportion as we 
are getting rid of the severer forms of epidemic disease (e. y., fever, dysentery, 
scurvy, influenza, all more or less preventible), which had deteriorated the 
health of the population previously to 1848, we are also getting rid of the 
more severe and unmanageable types of acute inflammation. Inflammatory 
diseases, like fevers, he therefore justly considers to be subject to epidemic 
causes of increase and diminution, both as regards frequency and severity; 
and he believes that the acute inflammations are nearly as much under the 
influence of the sanitary reformer as the more obviously epidemic fevers; and, 
further, that some even of the chronic organic diseases have already yielded, 
and may be expected still further to yield, to the improved habits, the better 
clothing, the greater abundance of food, and the diminished destitution of the 
population generally (Clinical Medicine, p. 42). 
The Art of Medicine, guided by Sanitary Science, must now, therefore, be 
regarded as a productive art; for, by diminishing the occurrence of preventi- 
ble disease, and thereby lessening mortality, the average duration of human 
life has been extended to an age nearer that which has been ordained for man. 
Nevertheless, it behooves the physician to* remember that the sphere of his 
professional exertions is limited, and surrounded by insurmountable barriers;- 
that death will eventually come alike to all, " reminding us that we ourselves 
must become victims to the incompetency of our art." 
Dr. Pollitzer, of the Children's Hospital at Vienna, has expressed the opin- 
ion, that while the duration of mortality at early ages is diminishing in all 
civilized countries, under the various influences of extended hospital accom- 
modation, care of the sick, vaccination, and general sanitary regulations, there 
is no corresponding increase in the strength and vigor of the human race. On 
the contrary, the boundaries between health and disease are becoming less and 
less marked. There are now to be observed numerous conditions which are 
undoubted deviations from the healthy standard, which it is impossible to 
delineate or accurately to define, because they make their appearance during 
a state of "relative health." The physician is not always even able to name 272 
TOPICS RELATIVE TO PATHOLOGY. 
the disease; and while the patient maintains that he is not feeling in health, 
and not looking in health, but wasting away, his food doing him no good, he 
has no alternative but to call himself ill. Such is the insidious mode in which 
many of these truly constitutional diseases, which have yet to be described, 
and degenerations which have been already described, make their appear- 
ance, and which may be regarded as constituting a peculiarly characteristic 
feature in the diseases of our times. These conditions are known by the various 
names of anosmia, spancemia, leucocythcemia, chlorosis, to which we must also add 
such degenerations as those described in the previous pages, namely, larda- 
ceous degeneration, pigmentation, fatty degeneration, and the ill-health • (ca- 
chexia) of malaria and of syphilis. 
The poorness of the blood, peculiar to the class of diseases mentioned, 
furnishes the soil in which the feebleness and deterioration of race is most 
unmistakably evident. The nervous system is, moreover, extensively involved 
in the diseases of the age. Feebleness and debility constitute a dominant 
characteristic of the prevailing type of disease. This physical deterioration is 
held to be a " sad memorial of modern civilization." In this respect the obser- 
vations of Dr. Pollitzer coincide with those of Dr. Forbes Winslow. "A con- 
stant stretch of the mental powers, a restless excitement of the passions, a per- 
petual struggle for advancement, the fresh wants of every day (science, and 
the arts themselves, being subservient even to the luxury and demoralization 
of the times), the destruction of all moral harmony and peace, are evils which 
undoubtedly prevail, and which react especially upon the younger genera- 
tion." The sins of the fathers are thus being visited upon the children. The 
demands made upon the youth of eighteen or twenty of the present day, by 
competitive examinations on the one hand, and rapidity of work on the other, 
would formerly have been considered a sufficient tax for the strength of a man 
of upwards of five-and-twenty. It is the pace that kills. Many features, also, 
which characterize the pathology of our age have arisen out of the treatment 
of infancy and childhood ; and much of the deterioration of the race at large 
may be shown to date its origin from infancy. Thus, after seventeen years' 
observation in children's disorders, Dr. Pollitzer writes, that anaemia and chlo- 
rosis occur alone or associated with rickets, hypertrophy of the lymphatic glands, 
and of the spleen and liver, to an incredible extent even from the first month 
of life. In the children's hospital at Vienna, from seventy to eighty per cent, 
he found to be thus affected. Wherever the nutrition of the child had been 
imperfect, the constitutional diseases associated with poverty of the blood 
became widely diffused. The stomach and intestinal tract first suffer, consti- 
tuting the prevailing morbid condition of childhood-materially influencing 
the mortality at an early age, and if the age of childhood is survived, affect- 
ing the future health of youth .and manhood, and doubtless of subsequent gen- 
erations (Med.-Chir. Review, Report on Medicine, p. 261, July, 1857). 
The types of disease are also evidently modified by complication with other 
diseases, now more widely spread. The doctrine of the incompatibility of two 
or more contagious diseases concurring in the same subject has been clearly 
proved to be erroneous; so that one form of disease complicates or overlays 
another in a manner that at one time was not thought of. Dr. Murchison, in 
an admirable paper on this subject in the British and Foreign Medico- Chirur- 
gical Review for July, 1859, has clearly shown the coexistence of variola and 
scarlatina; also of variola and rubeola. Dr. F. J. Brown, of Rochester, has 
recorded a case of variola concurring with measles and purpura. The coexist- 
ence of variola and roseola or erysipelas, of variola and pertussis, of variola and 
varicella, of variola and vaccinia, of vaccinia and scarlet fever, of vaccinia and 
rubeola, of vaccinia and pertussis, of vaccinia and varicella, of rubeola and per- 
tussis, of variola, rubeola, and pertussis, of scarlatina and rubeola-the rbtheln 
of the Germans-of scarlatina and enteric or intestinal fever, of typhus and en- 
teric, intestinal, or typhoid fever, have all been more or less clearly shown. AGENCIES MODIFYING THE TYPES OF DISEASES. 
273 
Virchow relates a case of typhoid fever, combined with striking symptoms of 
cholera, occurring at Wurzburg. Typhus fever and the marsh fevers have been 
observed to occur together (Pringle). Bilious remittents have prevailed 
with small-pox in the West Indies, forming, as an old but outspoken writer 
remarks, "the most infernal combination that ever affected the human 
frame." Yellow fever has been found associated with putrid typhus; while 
specific yellou) fever and marsh fever, with phenomena similar in many respects 
to specific yellow fever, undoubtedly occur together. 
There are good grounds for believing that as we approach certain well- 
marked geographical regions of the earth, where characteristic types of dis- 
ease prevail, the confines of these disease-realms are found to mingle their 
types of disease together, so that the diseases of one region merge into and 
participate in many of the characters peculiar to the other. Cholera has 
extended its ravages over the earth, and is now a disease whose germs are 
endemic in our land; and the system under its influence, especially in the 
early cases of an epidemic, becomes rapidly depressed, to the speedy extinc- 
tion of life. The furuneuloid epidemic which prevailed about eleven years 
ago was one of a novel variety. The black death of the fourteenth century 
seems to have revived in India, and is described by the name of the Indian 
pali plague; and it may be that the formidable disease which laid waste our 
country in the thirteenth century may have arisen in these districts, and pro- 
ceeded thence to our land, passing apparently in the same way that cholera 
has done (Dr. Allen Webb). 
Our modern treatises on medicine justly and properly deal, largely and 
minutely, with the descriptions of individual diseases, as far as their nature 
can be discerned; and the languages of all civilized nations attempt to define 
and describe them clearly. Now only are we beginning to profit by an ex- 
tended inquiry into the diseases of nations; and to find that as man wanders 
from his native home, the type of the diseases to which he is liable also 
changes. ' In this field of science an unmeasurable and still unexplored 
country extends on every side. The more minutely, also, that individual 
diseases can be defined and described, the more useful will such descriptions 
be for comparison in future ages; and it will be seen, on comparing the de- 
scriptions of diseases in time past with accurate descriptions of the same dis- 
eases now, how, at various periods and under various circumstances, the 
expression of certain sets of symptoms becomes sometimes strongly developed, 
while at other times the same classes of symptoms were mild and subdued; 
but the really essential characters of specific diseases and morbid processes 
remain as persistent as the specific characters of a plant or an animal. 
It will be seen how, in epidemics, many diseases have been characterized 
by the expression of malignant phenomena scarcely perceptible before. The 
small-pox nowadays is not the malignant small-pox of the time of Sydenham. 
Nevertheless, it is small-pox. And although it may be said that such an 
example does not illustrate a change in .the type of a disease, because the 
change has been effected by artificial means, yet it must appear evident that, 
in effecting this change, natural results have only been imitated; and who 
can tell what modifying influences of a similar kind are going on, although 
the science of medicine can as yet take no cognizance of them ? We know 
that certain diseases confer immunity on the individual from future attacks; 
may it not be, therefore, that immunity to individuals from some diseases is 
conferred by agents and processes of which we as yet know nothing; and that 
ultimately the types of complex morbid states may still come to be very much 
changed from what they are now ? They appear to be changed, according 
to the best authorities, from what they were fifty years ago. " Many of the 
symptoms, and particularly the constitutional fever usually attending internal 
inflammations, and resulting from cold, or from other causes independent of 
the application of morbific poisons, are liable to variation in like manner,. 274 
TOPICS RELATIVE TO PATHOLOGY. 
although not so decidedly nor so rapidly as the epidemic diseases, in the 
course of time, and from causes not yet known. .They have in fact under- 
gone very considerable change since the early part of the present century" 
(Alison). 
Such changes in the types of diseases were formerly observed and much 
insisted upon by Sydenham, especially in the progress and recurrence of con- 
tinued fevers; and it is now a fact well recognized, that not only does the 
prevalent mode of fatal termination during epidemic diseases vary, but so 
also do the types, peculiarities, and morbid constitutional tendencies vary in 
these diseases. It is chiefly with regard to the local, sporadic, or intrinsic 
diseases, and especially inflammations, such as the cephalic, the pulmonic, or the 
enteric, that any doubt exists as to whether or not they vary in their type. 
Distinct statements as to this fact, however, have now been made by many 
accurate observers, whose experience is of the utmost value to science. Dr. 
Alison and Dr. Bennett both agree as to the fact, "that of late years, and 
apparently also in different parts of the world, inflammation, the most important 
of all forms of local diseases, seldom shows itself with such general symptoms 
as demand or would justify, in the opinion of the practitioners treating them, 
or indeed could bear, the large bleedings which were formerly regarded as the 
appropriate remedy, and which accordingly are now seldom practiced." There 
are not only also fewer examples of violent inflammation of the lungs to be 
met with, but the usual (highly inflammatory) type of fever attending such 
inflammation has materially changed, as occurring in the present day. This 
change which has taken place in the type of the usual phenomena character- 
istic of inflammatory fever, cannot be explained merely by the circumstance 
that a previously enfeebled or diseased state of the system has brought it about 
in the individual. The inflammations of internal parts, such as pneumonia, 
now occur often without much febrile reaction, and neither demanding nor bear- 
ing full bleedings, as described by Cullen and other authors. It is consistent, 
moreover, with the extensive experience of Drs. Alison, Christison, Watson, 
and many other physicians of the greatest eminence and long experience, that 
inflammations now seldom occur with such severe symptoms of inflammatory 
fever as have been described at page 87, and which were the rule in the time 
of Cullen and of Gregory. The constitutional symptoms now attending such 
inflammations partake more of the type of the so-called typhoid state, and inde- 
pendent of any epidemic influence or poison having acted on the body. 
The constitutional symptoms for many years past accompanying pneu- 
monia, for instance, in this country, have been of the following kind: An 
enfeebled circulation; softness of the pulse, and easiness of depression by 
depiction, or even by taking the erect posture; tremors and feebleness of vol- 
untary muscular motion, approaching to subsultus; indifference to surrounding 
objects; sickness and vomiting in some cases, with dryness of tongue and lips 
in others; complete anorexia or depraved appetite; in all, the symptoms gen- 
erally tend to assume those of the so-called typhoid state rather than of inflam- 
matory fever. Nevertheless, in the treatment of such cases, blood taken 
sufficiently early, if breathing is difficult, is distinctly beneficial; and although 
it may show the huffy coat, this has neither the thickness nor the tenacity of 
the fine huffy coat seen and described in former days; faintness supervenes on 
the loss of a quantity small in comparison of what was formerly well borne, 
and there is no such encouragement to a repetition of the bleeding, from the 
pulse speedily regaining its strength, or from the local symptoms abating and 
quickly recurring, as was formerly noticed by Cullen, Gregory, Christison, 
Alison, and other veterans in the practice of medicine. Dr. Gairdner also 
points out the great distinction to be drawn between the doctrines of Alison 
and of Todd iu this respect. Dr. Alison recognized the disuse of bloodlet- 
ting, and the increased necessity for stimulants, as a consequence of the changes 
he observed in the character of diseases. Dr. Todd, on the other hand, dis- EXAMPLES OF CHANGE OF TYPE IN DISEASE. 
275 
owned entirely the idea of such a change, and came to regard the adminis- 
tration of stimulants as a matter of routine. The former recognized the 
altered type of disease, the changes observed in its physiological manifesta- 
tions, and the gradual disappearance of those forms of acute inflammation 
which before had appeared to require and to bear bloodletting. Dr. Todd 
did not recognize or acknowledge these changes (Clinical Medicine, 1862, 
P- 34)' 
The mode of fatal termination is also different. The tendency to death is 
most usually either by coma or by asthenia, as in typhus fever. The tendency 
to gangrene is said to have become more frequent in various inflammations of 
internal parts, and particularly in the lungs, within the last fifty years, than 
it was in the time of Cullen and of Gregory. Such are the records of expe- 
rience, as stated by the late Dr. Alison in a series of papers published in The 
Edinburgh Medical Journal in 1855, 1856, and 1857; than whom the opinion 
of no one is more entitled to respect and consideration; and, "although dead, 
he yet speaketh." 
Dr. Handheld Jones, physician to St. Mary's Hospital, London, observes, 
"that instances of impaired action of the heart, sometimes amounting to 
serious danger, are met with at the present time with an absence of all condi- 
tions which require or justify venesection. This is associated with other 
symptoms of depressed nervous power, which appear to be most reasonably 
attributed to some kind of epidemic influence much resembling that of mala- 
rious diseases." 
The type of disease which reigns at present is believed by some to have 
prevailed more or less since the appearance of pestilential cholera in 1832. 
There is now little of sthenic indammation; bleeding and tartar emetic are 
but sparingly needed, while quinine, strychnine, and other tonics, with opium, 
and cod-liver oil, are continually in requisition in our efforts to raise and 
maintain failing power (Medical Journal, March, 1857). According to the 
experience of obstetric practice, the observations of Mr. Sidey, of Edinburgh, 
are to the same effect. 
In 1782, when Dr. Hamilton published his memoirs on the "contagious 
catarrh," or influenza, he records distinctly his belief that " our constitutions 
are considerably changed within the last century in Great Britain. Diseases," 
he remarks, " in their nature phlogistic (e. g., measles), have appeared within 
the thirty years previous to 1782 less inflammatory than they formerly 
were, and accompanied with a considerable degree of putridity;" and blood- 
letting in the " contagious catarrh," he states with emphasis, cannot be toler- 
ated. There seems, therefore, to have been even then an increasing belief 
that the degeneracy of the human race, as a whole, was in some respects 
advancing; and, that there seemed to be some visible evidence of this more 
or less traceable through the past four generations. 
Dr. Graves, in the course of an interesting and able argument in favor of 
the change in type or constitution of disease, describes how the epidemic 
of influenza exhibited phenomena different from the typical phenomena of 
sthenic inflammatory catarrh. 
Morel especially directs attention to the apparent increase in Europe of 
mental alienation, and of those abnormal states of existence which have 
special relations with the occurrence and existence of physical and moral 
degeneracy in the world ; and if a comparative increase in the number of the 
insane cannot yet be proven, there would seem to be a tendency to more fre- 
quent complications among them of those morbid states which diminish the 
probability of cure, such as general paralysis, epilepsy, and a marked depression 
of all the intellectual and physical forces, which depression is consistent with 
the asthenic phase of present existence. Hysteria and hypochondriasis, formerly 
almost the exclusive appanage of the rich, the indolent, and those of a wasted 276 
TOPICS RELATIVE TO PATHOLOGY. 
life, are known to attack in great proportions the working and the agricul- 
tural classes, among whom suicidal tendencies are also apt to prevail. 
Dr. Forbes Winslow writes, with regard to nervous diseases, that cases of 
disease of the brain and nervous system are now not only of more frequent 
occurrence, but that a certain unfavorable type of cerebral disorder develops 
itself in the present day at a much earlier age than was formerly observed. 
Softening of the brain, for instance, often manifests itself at the early age of 
thirty and thirty-five. The brain in the present day is overworked, its 
physical functions are unduly exercised, strained and taxed in the great 
effort required in the severe struggle and battle of life to obtain intellectual 
supremacy, professional emolument, and status (Journal of Psychological Medi- 
cine, July, 1857). 
Morel again shows how imbecility, congenital or early acquired idiocy, and 
other more or less complete arrests of development of the body, and of the 
intellectual faculties, indicate the existence of children who have acquired 
the elements of their degeneracy during intra-uterine life. It behooves, then, 
all civilized governments anxiously to inquire into and to consider such facts 
as show,-(1.) A continued increase of suicide. (2.) A continued increase of 
crimes against order and law, or against the person. (3.) The monstrous 
precocity of young criminals. (4.) The abnormal conformations of the skull, 
and tendency to early union of the cranial sutures, which prevail among 
criminals. So much is this the case, that in large towns, or in penal settlements 
and convict prisons, the physiognomy and general aspect of the " criminal 
population" are characteristic of a class, as their photographs show. (5.) A 
general diminution of the intellectual powers, with the manifestation of the 
most depraved immoral tendencies. (6.) An increase in the inmates of 
asylums and prisons. (7.) The etiolation, blanching, anaemic or cachectic 
condition of the population, and any relative increase of such constitutional 
diseases as anaemia, chlorosis, gout, Bright's disease, rheumatism, melituria. 
(8.) Any increased development of paralytic and convulsive affections. 
(9.) Prevalence of degeneration, as distinguished from diseases. These are the 
main directions in which the degeneracy of the human race is demonstrable; 
so much so, that in some localities the inhabitants can no longer fulfil the 
conditions required for military service (Traiti des Degenerescences Physiques, 
Intellectuelles et Morales de I' Espice Humaine, et des. Causes qui produisent ces 
Varictes Maladives. Par le Dr. B. A. Morel, de 1'Asile des Alienes de S'Yon, 
1857). 
The principal sources of degeneracy which appear at present to be most 
active in their influence for evil on large masses of mankind may be stated as 
follows: (1.) Degeneracy from Toxaemia, as from the abuse of alcoholic fluids, 
opium, preparations of Indian hemp (hachiscli), tobacco, and the like; also from 
the effects of mineral poisons, such as lead, mercury, arsenic, phosphorus; and 
from the use of unwholesome vegetable food, such as diseased rye, maize, 
wheat, and the like. (2.) Degeneracy from the persistent and pernicious 
influence of malaria. (3.) Degeneracy from certain peculiar geological for- 
mations, soil, and water, as in the development of goitre (Maclellan, Wat- 
son). See Paper on Hygiene of India, in Med.-Chir. Review. (4.) Degene- 
racy from the effects of epidemic diseases which now and then afflict large 
populations, profoundly influencing the system, and engendering those morbid 
temperaments whose types are more fully expressed in the generations which 
follow the one that has suffered from such epidemic pestilences. Many of 
such-like epidemics act like toxic agents on the nervous system. (5.) Degene- 
racy from the effects of the "great town system," as the phrase is. The chief 
elements of such degeneracy are, (a) unhealthy situations; (6) a noxious 
local and general atmosphere; (c) insufficient air; (d) insufficient and im- 
proper nourishment; (e) deleterious avocations; (/) moral and social misery, 
wretchedness, and crime. (6.) Degeneracy from fundamental morbid states, ACTIVE SOURCES OF DEGENERACY. 
277 
congenital or acquired, as seen in the numerous malformations whose nature 
has been described at p. 233 et seq., imperfect cerebral developments, deaf mutism, 
blindness, constitutional diseases, and diathesis (implanted, hereditary, or ac- 
quired), such as syphilis and scrofulosis. (7.) Degeneracy from mixed causes, 
from marrying in and in; and from other causes not included in the above 
(Med.-Chir. Review, Jan., 1858). 
By far the most active sources of degeneracy are thus seen to be those 
direct and repeated influences upon the blood, the brain, and the nervous system, 
which give rise to special morbid conditions; and which often place those who 
periodically expose themselves to the influence of toxic agents in a condition 
verging on or equivalent to insanity. The effects of chronic alcoholism, for 
instance, in giving rise surely and progressively to the mental and bodily degen- 
eration of the individual, are mainly demonstrable by the induction of the 
following states, namely: persistent loss of appetite, indigestion, nausea; occa- 
sional diarrhoea, progressive emaciation, and cachexia; the appearance of 
pustular eruptions; the occurrence of eructations associated with offensive 
breath; serious disturbance of the functions of the stomach, liver, kidneys, 
and heart, and the production of organic lesions in these organs, and in 
the structures of the bloodvessels, followed by fatal serous effusions, dropsy, 
hemorrhages, extravasations, or apoplexies. Intercurrent with these morbid 
conditions, there occur at variable periods, "fits of drunkenness," with 
sexual 'incompetency, different forms of psychical aberration, delirium tremens, 
suicidal melancholy, and such-like morbid phenomena. Finally, epileptiform 
seizures, general paralysis, drivelling or slavering idiocy, may close the scene. 
Those who become thus degenerate by alcoholic poison are arranged by Morel 
into two classes, namely,-First, Individuals who arrive at length, by a series 
of well-marked nervous lesions-physical and intellectual-at general paral- 
ysis. Second, Individuals who, although profoundly affected as regards ener- 
vation, still remain stationary at a certain state, leading a miserable existence, 
characterized physically by a special condition of ill-health (cachexia and 
marasmus), and morally by a manifestation of the worst tendencies, and of the 
lowest animal propensities. The serious degenerative effects thus detailed in 
their extreme forms, resulting from the poison of alcohol, ultimately influence 
the procreative functions; first, by diminishing the vital standard of the 
offspring; and second, by annihilating the generative power altogether. When 
such results are coupled with the moral and social aberrations which ensue 
from bad example, misery, and want, in families and masses of men, they 
become ample sources of the degeneracy and degradation of the population. 
This they do, not only throughout the existing but succeeding generation; 
and not only is the vice of alcoholic-abuse thus hereditarily transmissible 
(Morel), but it also frequently leads to insanity in the offspring of the 
drunkard (Whitehead, Adams). In cases of this description, where the 
tendency to alcoholic excesses has a hereditary origin, the cure of the dipso- 
maniac is generally impossible. Morel gives- the following example, in which 
a well-marked succession of morbid phenomena became developed in different 
descendants of a family throughout four generations. The great-grandfather 
of the family was a dipsomaniac; and so complete was the transmission of the 
disease, that the race became totally extinct, under the well-marked phenom- 
ena of alcoholic poisoning and degeneracy. The effects entailed were: in 
the first generation, alcoholic excesses, immorality, depravity, brutish disposi- 
tion; in the second generation, hereditary drunkenness, attacks of mania, 
general paralysis; in the third generation, sobriety prevailed, but hypochon- 
driases, lypomania, persistent ideas of persecution, homicidal tendencies, were 
expressed; in the fourth generation, intelligence was but feeble, mania became 
developed at sixteen years of age, stupidity running on to idiocy, and to a con- 
dition involving the extinction of the race. The late Sir James Clark also 
made the observation, many years ago, as the result of his experience, that 278 
TOPICS RELATIVE TO PATHOLOGY. 
the constitutions of the past three generations had deteriorated progressively 
from father to son (Treatise on Pulmonary Consumption, p. 11). 
The persistent pernicious influence of the marsh poison will be fully noticed 
in subsequent pages; but there are other abundant sources of constitutionally 
morbid influences; and, whatever the explanation may be, it certainly is a 
matter of fact, as the late Dr. Alison wrote, that the constitutional affections, 
going along with the same extent of inflammation and its local effects, are 
extremely various in different persons previously alike in good health, or even 
in the same person at different times; and that we are not entitled to deny 
that what happens in this way in different individual cases may not happen 
also in nations and in seasons. We are still very imperfectly informed as to 
the mode in which any local inflammation excites constitutional fever, and 
we have no reason to doubt that the constitutional reaction consequent on the 
excitement of a certain degree of inflammation of the lungs may vary, equally 
as that which is consequent on the introduction of a certain quantity of the 
poison exciting typhus fever, measles, scarlatina, or cholera; in all of which the 
previous muscular strength goes for nothing in determining the degree or 
danger of depression or debility which may ensue. 
Dr. Christison has recently communicated to the Medico-Ohirurgical Society 
of Edinburgh his experience relative to the changes which have taken place 
in the constitution of fevers and inflammations in Edinburgh during the forty 
years previous to 1857. His experience, as well as that of many of the older 
physicians of Edinburgh, shows that a transition had (and did every now and 
then) taken place from an inflammatory or sthenic form of fever to one of an 
asthenic type; that it was necessary, on the outburst of any epidemic, to watch 
carefully the early cases, to observe the mode in which the fatal cases termi- 
nate, and to observe generally the constitutional tendency or type of individual 
cases, in order to form an accurate judgment of the general character of the 
epidemic about to prevail. It will be seen also, on referring to the most 
approved and recent works on the diseases of India, that the descriptions of 
inflammations as well as fevers now seen there, when compared with the state- 
ments of Dr. Johnson, Mr. Twining, and others, twenty-five or thirty years 
ago, may be held to indicate that there has been a change in the usual form 
of reaction in inflammatory diseases in that climate as well as here. Such con- 
clusions may be inferred from the experience of Dr. Morehead, recorded in 
his Clinical Researches on the Diseases of India (vol. ii, pp. 71, 72, and 359); 
and the experience of Sir Ranald Martin, expressed in his recent classic work 
on Climate, bears out the same observation. Consult also Graves's Clinical 
Medicine, vol. i, p. 303, for the doctrines of Autenrith and Graves on the 
change of type in disease; and for evidence regarding the deterioration of 
race, see p. 105 of Mr. Simon's Third Report on the Health of Towns. 
It appears evident, therefore, that the human body is capable of undergoing 
various alterations as regards not only its physical, but also what has been 
termed its " Medical Constitution," from causes known as well as unknown. 
Fevers are known to change their types; epidemics to assume new tendencies; 
and inflammations and local lesions to affect in no constant manner the consti- 
tution of individuals at the same period, or at different times and in different 
countries. This view of the subject may be summed up in the eloquent lan- 
guage of Dr. Watson, when he writes,-" I am firmly persuaded, by my own 
observation, and by the records of medicine, that there are waves of time 
through which the sthenic and the asthenic characters of disease prevail in suc- 
cession, and that we are at present living in one of its adynamic phases " 
(Edinburgh Monthly Journal, June, 1857). It must be admitted, however, 
that much of what is written and here quoted regarding changes of type is 
based on the uncertain impressions of individual men, sometimes handed down 
by tradition, rather than based on the results of a deliberate deductive inquiry 
from statistics applied to the question by men agreed as to the meaning of DEATH BY EXTREME OLD AGE. 
279 
terms. On the other hand, I think Dr. Markham, in his very able Gulston- 
ian Lectures on " The Uses of Bloodletting in Disease," puts the evidence 
regarding change of type in disease on much too narrow a basis-not to say 
an erroneous one-when he holds that it is merely an excuse put forward for 
a change of practice in inflammations, and that the only argument in favor 
of such a theory rests upon the assumed conclusion that venesection produces 
different effects now from what it formerly did. 
A somewhat similar view of this important subject has been ably advocated 
by Dr. J. H. Bennett, of Edinburgh. He contends that inflammation is the 
same now as it has ever been-that the analogy sought to be established 
between it and the varying types of fevers is fallacious-that we cannot place 
reliance on the recorded experience of the past-and that our recent changes 
in therapeutics are solely due to an advanced knowledge of diagnosis and 
pathology {Principles and Practice of Medicine, p. 267). 
The local phenomena of inflammation are undoubtedly constant; but the 
question of change of type has reference to the constitution of the individual, 
and to the constitutional modes by which the inflammatory state is expressed 
in a given number of persons. Much of the argument of Drs. Markham and 
Bennett appears to me to be beside the question; and there are certainly good 
grounds for believing that elements of constitutional degeneration exist in such 
abundance, especially in the communities of large towns, that Dr. Watson 
has, I think, happily expressed the consequence of such deterioration in the 
sentence quoted from his writings on the subject. 
CHAPTER X. 
MODES BY WHICH DISEASES TERMINATE FATALLY. 
Our knowledge on this subject is derived chiefly from three sources, namely, 
from the examples and illustrations afforded by the study of-(1.) Death from 
old age; (2.) Death from fatal injuries; (3.) The powers and actions of all 
our best remedies. Such study leads to the important practical conclu- 
sion, that the same lesions of important organs may prove fatal in very dif- 
ferent ways, both in acute and in chronic disease, and the fatal event may be 
averted by very different and very opposite remedies (Alison). It is also to 
be observed, that in constitutions which are unimpaired, and, indeed, in every 
morbid process, there may be recognized a tendency to a spontaneous favora- 
ble termination. 
Death happens either from the decay of life, as in old age; or from rapid 
sinking of the vital powers in acute diseases, as in adynamic fevers. It may 
happen, also, as an accident caused by some of those untoward lesions or 
derangements of the vital organs which occur in the course of the various 
diseases and injuries to which mankind is liable; as, for example, from fatal 
hemorrhage before exhaustion has reached its utmost, as in some diseases of 
the lungs and digestive canal. 
Death by extreme old age may be considered in many instances as the desira- 
ble end of a long-continued and, perhaps at the end, a dreary journey. The 
sufferer appears to fall asleep as he might do after severe fatigue; and the 
long and weary pilgrimage of life is thus often brought to a close with little, 
apparent derangement of the ordinary mental powers. The final scene is often 
brief, and the phenomena of dying are almost imperceptible. The senses fail, 
as if sleep were about to supervene; the perceptions become gradually more 
and more obtuse, and by degrees the aged being seems to pass into his final 280 
TOPICS RELATIVE TO PATHOLOGY. 
slumber. We scarce can tell the precise instant at which the solemn change 
from life to death has been completed. Sensation fails first, then voluntary 
motion ; but the powers of involuntary muscular contraction, under the excite- 
ment of some external stimulus, may continue for some time longer to be 
feebly expressed. The blood at first generally ceases to be propelled to the 
extremities. The pulsations of the heart become less and less efficient. 
The vital fluid fails to complete its circuit, so that the feet and hands 
become cold as the blood leaves them, and the decline of temperature 
gradually advances to the central parts. Thus far the act of dying seems to 
be as painless as that of falling asleep ; and those who have recovered after 
apparent death from drowning, and after sensation has been totally lost, assert 
that they have experienced no pain. What has unfortunately been called the 
agony of death may therefore be presumed to be purely automatic, and there- 
fore unfelt. The mind at that solemn moment may be absorbed with an 
instantaneous review of those impressions made upon the brain in bygone 
times, and which are said to present themselves with such overwhelming 
power, vividness, and force, that, in the words of Montaigne, " we appear to 
lose, with little anxiety, the consciousness of light and of ourselves." At such 
a time the vivid impressions of a life well spent must constitute that euthanasia- 
that happy death-so much to be desired by all. 
The untoward lesions or derangements of vital organs, which occur during 
the progress of disease, terminate the life of man by various modes of dying. 
While it is ordained that eventually all must die, yet it is possible sometimes 
to avert, for a time, the tendency to death. To know by what agents this 
may be properly accomplished, it is necessary to know the modes in which 
death may approach in disease. Dr. Watson has happily observed that life 
rests upon a tripod, whose three vital supports are, the heart, the brain, and 
the lungs. Through the impaired functions of some one or more of these 
organs the tendency to death is expressed. The mode of dying may begin at 
the head, the heart, or the lungs (Bichat). But inasmuch as the functions of 
these organs are mutually dependent upon each other, so impairment of func- 
tion in any one of them may ultimately lead to death, while the mode of dying 
is expressed chiefly through the functions of another. The mode of dying in 
disease is usually a complex one, for many parts thus mutually dependent on 
each other are more or less immediately involved. Therefore it is of the 
greatest practical importance to observe how and when the different functions 
begin to languish, and how they may be best sustained in their exertions to 
maintain life. 
Death by Syncope.-When a person loses blood to such an extent that he 
faints, as from a wound, or by hemorrhage occurring in disease, and if the flow 
of blood is not arrested, the state of faint or syncope continues, is not recovered 
from, and the heart's action ceases; not because it is unable to contract, but 
because its natural stimulus, the blood, is withdrawn from it, or does not arrive 
in sufficient quantity to be of use. This is called death hy anaemia. In such 
cases, if blood can be timeously supplied to the heart (as by the operation of 
transfusion from a healthy person into the patient who is losing blood), the 
suspended function of the heart may be restored, and a supply of blood, suffi- 
cient to maintain life for a time, may be thus obtained. 
The symptoms of approaching death by this mode of dying are paleness of 
the countenance and lips, cold sweats, dimness of vision, dilated pupils, vertigo, 
a slow, weak, irregular pulse, and speedy insensibility. If the hemorrhage 
has been sudden, in large quantity, as from the uterus in " flooding," there 
may be nausea, or even vomiting, restlessness, tossing of the limbs, irregular 
sighing, breathing (anxietas), delirium, and one or two convulsions before 
death ensues. 
Death by Asthenia.-But another mode of death may be more immediately 
connected with the heart itself, and be independent of the supply of blood. DEATH BY SUFFOCATION OR APNCEA. 
281 
In other words, the stimulus from blood may be sufficient, but the contractile 
power of the organ may fail. Such a mode of death is by asthenia. Many 
poisons act in this way, and many diseases which are due to morbid poisons in 
the blood tend to prove fatal by this mode of dying. Cases of extensive mor- 
tification of parts, of acute inflammation of the peritoneum, and of malignant 
cholera, die in this way. 
The signs of death approaching by asthenia consist in the pulse becoming 
feeble and frequent, and ultimately failing altogether to be perceived. The 
muscular debility becomes extreme, but the senses remain perfect, often pain- 
fully acute, and the intellect clear to the last. 
Those who die by anosmia or by asthenia are often spoken of as having died 
in a faint, or by syncope. 
Death by Starvation.-There is still a mode of dying intermediate between 
the two, the type of which is seen in death by starvation. 
In cases of very gradual starvation an urgent feeling of hunger is not a 
prominent symptom, and even when it exists at first, it usually soon diminishes, 
and is succeeded by a feeling of exhaustion and faintness, and even loathing 
of food, if abstinence has been long protracted (R. B. Holland). The men- 
tal condition connected with poverty may in part account for this deficiency 
of appetite. A depression produced on the nervous system is very early mani- 
fested in the impaired energies of all the vital functions, the weakened condi- 
tions of the intellectual faculties and moral feelings, and diminution of the 
general sensibility. Disturbance of the cerebral functions is at first shown by 
an unnatural languor, despondency, and listlessness, slowness and hebetude of 
intellect, with an inability to employ the thoughts steadily and profitably on 
any subject. Notwithstanding all this general languor, however, the patient 
sometimes manifests a highly nervous state ; he is startled by any sudden noise, 
and hurried by the most trifling occurrences. He is liable to attacks of giddi- 
ness, " swimming in the head," staggering, dimness of sight, with temporary 
delirium, and either falls as in an apoplectic fit, or lapses gradually from a 
lethargic state into one of stupor, or even of complete coma. In many respects 
the symptoms in these cases have a considerable resemblance to the effects of 
exposure to cold. In consequence of the torpor of the brain and intellectual 
faculties, it is often extremely difficult to obtain the requisite information from 
patients. Instead of showing any anxiety to communicate the symptoms and 
cause of their illness, or to relate the privations they have undergone, they 
generally have an unwillingness to be questioned, lie in a listless or lethargic 
state, without taking any notice of what is going on, and seem desirous only 
not to be disturbed. Such listlessness and torpor of the mental faculties, the 
tendency to fainting or to perfect syncope, and, finally, a state of cerebral 
oppression, amounting in some cases to coma, are among the most character- 
istic symptoms of defective nutrition, and the surest indications of its existence 
to a serious extent. 
In February of 1862 a man, thirty-six years of age, was discovered in a 
stack, near Morpeth, dying from starvation. All attempts to rally him failed, 
and he ultimately died. He was an intelligent man, and had been editor and 
proprietor of a penny journal called the " Falkirk Liberal." A diary was 
found in his possession, containing entries of his condition from the 8th to the 
25th of February; from which it appeared that during seventeen days he had 
twice tasted a piece of bread; but for the last thirteen days he had been entirely 
without food. During the first ten days of the thirteen he was able to obtain 
water, but on the eleventh day he found his legs were useless, and he lost all 
motor power in the lower extremities, so that " one-half of his body appeared 
to be dead." The case is of interest to the pathologist, as showing the length 
of time during which existence can be maintained if water alone be taken. 
Death by suffocation or apnoea may be produced by the suspension of the 
functions of respiration, as when access of air to the lungs is prevented by a 282 
TOPICS RELATIVE TO PATHOLOGY. 
direct obstruction, either to the air-passage, in choking, or to the action of the 
chest, so as to prevent its expansion; or when the actions of the muscles of 
respiration cease, in consequence of disease or injury to the brain producing 
insensibility. The first of these modes by which the respiratory functions are 
suspended is that known as suffocation, technically expressed by the term 
apnoea, or privation of breath. Examples of this mode of dying may be 
referred to in cases of drowning, smothering, choking, strangulation, throttling, 
and closure of the rima glottidis by foreign bodies. In Dr. Allen Thomson's 
anatomical museum at Glasgow there is a larynx preserved in which a piece 
of coal is wedged between the rima glottidis. A collier thus died by apnoea 
or suffocation produced by the piece of coal dropping into the larynx while he 
lay on his back in the mine excavating the coal from the roof of the coal pit. 
Forcible pressure upon the chest, as sometimes happens in crowds during a 
continued crush of people, or occurs to workmen who have been buried by 
falls of earth and rubbish; in short, whatever causes an immovable condition 
of the lung-case beyond a period of three minutes and a half, will thus produce 
a fatal result. Tetanus, and the influence of strychnine, sometimes prove 
fatal in this way. Morbid states produced by disease, and which terminate 
fatally by apnoea, are oedema of the glottis; disease of the spinal cord above 
the origin of the respiratory nerves (phrenic, intercostals, and spinal acces- 
sory) ; effusion of serum into the pleural cavities; sudden infiltration of the 
lungs by inflammatory exudation, or collapse of the lung in bronchitis. 
The symptoms of approaching dissolution by this mode of dying are strong 
but ineffectual efforts to contract the respiratory muscles, and struggling 
efforts to respire, amounting to agony, of short duration, followed by vertigo, 
loss of consciousness, and convulsions; at last all effort ceases, twitchings or 
tremors of the limbs alone remain, the muscles relax, and the sphincters yield. 
The heart and the pulse, however, still continue to act after all other signs of 
life are past. The recent experiments instituted by the Medico-Chirurgical 
Society of London show that, on an average, the heart's action continues for 
three minutes fifteen seconds after the animal has ceased to make respiratory 
efforts. On this last circumstance rests our hope of resuscitating persons so 
suffocated, if artificial respiration be timeously resorted to, and persevered in. 
This prolonged action of the heart circulates blood, which is dark, venous, 
and not arterialized, and accordingly the face, at first flushed, becomes turgid, 
and then assumes a livid and purple hue; the veins of the head and neck 
swell, and the eyeballs protrude from their sockets. At length the heart 
ceases to beat, and life is extinct (Watson). 
Death by coma occurs when there is a loss of consciousness first, with the 
appearance of profound sleep, from which the patient may be partially roused. 
The symptoms of approaching death by this mode of dying consist in a 
gradual blunting of sensibility to outward impressions, slowness of respiration, 
the inspiratory effort being often delayed, and then performed with a sudden 
noise and jerking effort, technically known as stertorous breathing. All vol- 
untary attention to the act of breathing is lost, but the influence of a reflex 
stimulus to its performance continues. At length this function fails also. 
The chest ceases to expand, the blood is no longer aerated, and thenceforward 
precisely the same changes occur as in death by apnoea. 
Such are the several modes by which death tends to approach; and "to 
obviate the tendency to death*' is a doctrine which was often and strenuously 
inculcated by Cullen. After him, no less earnestly has it been impressed on 
many by my respected teacher, the late Professor Alison, whose interesting 
Lectures on Fevers and Inflammation furnished numerous illustrations. To 
his Outlines of Pathology and Practice of Medicine, and to the first volume of 
Dr. Watson's Lectures on the Principles and Practice of Physic, the student is 
referred who would seek further information-sources whence the preceding REDUCTION OF HEAT BY THE USE OF COLD WATER. 
283 
observations have been mainly compiled relative to the modes by which death 
may approach: 
11 Many are the ways that lead 
To his grim cave, all dismal; yet to sense 
More terrible at the entrance than within." 
" It is as natural to die as to be born 
and thus, in 
" Passing thro' Nature to Eternity, 
The sense of death is most in apprehension. 
CHAPTER XI. 
PRINCIPLES WHICH DICTATE THE TREATMENT OF THE TWO COMPLEX MORBID 
PROCESSES,-FEVER AND INFLAMMATION. 
I. As regards Fevers or the Febrile State. 
To avert the tendency to death in the febrile state, it is necessary to observe 
how fevers naturally terminate favorably. Four modes are enumerated by 
Dr. Parkes, namely: 
1. By crisis, in which the temperature falls suddenly in a few hours, and 
usually with some abundant excretory discharge, in which, possibly, much of 
the water which has been retained in the system is poured out. 
2. By lysis, in which the fall of temperature is gradual from day to day, 
till the normal standard is attained. The decline may thus occupy many 
days, the thermometer being known to take seven days in falling from 102° 
to 98° Fahr. 
3. By a combination of these two modes, namely, by a sudden fall of temper- 
ature to a certain point, and then a gradual decrease to the normal heat. 
4. By a somewhat irregular alternation of febrile and non-febrile periods, as 
shown by the temperature and the issue. 
When fever terminates by any of these modes, convalescence commences, 
normal nutrition is renewed, and the body begins to gain in weight. The 
blood is poor in albumen and in red particles; and there is now a danger that 
the rapidity of metamorphoses of tissue will exceed the healthy standard, as 
shown by the great tendency to lose heat which convalescents from fever have. 
The temperature may fall, and the excretions may diminish below their 
healthy amount. Great care, constant attendance, and watchfulness are 
required when the patient begins to convalesce, if the fever has been long and 
severe; and the treatment of the febrile'state itself maybe thus generally 
stated as consisting in a combination of measures, -(1.) To reduce excessive 
heat; (2.) To insure sufficient but not excessive excretion and elimination of 
the excretions; (3.) To act restoratively on the exhausted and semiparalyzed 
nerves; (4.) To neutralize any specific poison which may have set up the 
fever, and so to improve the state of the blood; (5.) To relieve distressing 
symptoms; and lastly, To obviate and counteract local complications (Parkes, 
Murchison). 
(1.) To reduce excessive heat.-To accomplish this, the first indication, Dr. 
Robert Jackson, "the patriarch of Military Medicine," and after him Dr. 
Currie, of Liverpool, in 1797, practiced to an extreme degree the application 
of cold water; a therapeutic agency which is now again challenging attention, 
so that Medicine, like History, constantly repeats itself. Jurgensen, Lieber-' 
meister, Hagenbach, and Kuchenmeister, are the most recent advocates and 284 
TOPICS RELATIVE TO PATHOLOGY. 
exponents of the application of cold water in the treatment of fevers. In 
health such an application tends to increase the metamorphoses of tissue, as 
shown by Lehmann and Sanderson; and therefore its use in the febrile state 
requires the greatest care and caution. It is interesting to notice that Kuch- 
enmeister confirms the accuracy of Currie's own observations. To be of use, 
it must be employed very early in the fever-before the third or fourth day. 
As soon as the temperature rises above 102.5° Fahr., or higher (104° 
Fahr.), the treatment by cold bath is to be commenced, and continued as long 
as the temperature remains so high. The effect and object of the bath is to 
lower the temperature-a lowering which does not reach its minimum imme- 
diately after the use of the bath. Hence the great caution required in its use. 
The diminution of bodily heat appears to be largely due to the excitement of 
skin transpiration-a condition brought about when the bath has a favorable 
influence. If the skin be moist and perspiring, the use of a cold water bath is 
not required. 
Among the many different ways of applying cold water in fevers, Kuchen- 
meister gives the preference to Currie's cold affusion,-the patient merely 
sitting in an empty tub, and having from four to six buckets of cold water 
(40° to 50° Fahr.) poured over him, from a height of about two feet. This 
form of administration is especially useful where cerebral symptoms are 
severe, with depression of the motor energy of the brain and cord, threatening 
paralysis of the heart, or severe degrees of bronchial complication with pas- 
sive collection of large quantities of thick secretion in the tubes.. In the 
unconsciousness of " sunstroke " it is thus useful. If the sitz or shallow bath 
be used, the patient must have his whole chest, front and back, well rubbed 
with towels till the skin becomes red, as he sits in the tub. It has been so 
used with benefit at an early period of enteric /ever and scarlet fever (The Prac- 
titioner, July, 1869, p. 45). The frequent and careful use of a thermometer 
for determining the temperature of the patient's body is required as affording 
the only correct measure of the severity of the fever. " It is as necessary to 
the physician as the compass is to the mariner at sea." 
Sometimes the patient may be laid bodily in a bath of a temperature of 
about 95° Fahr., which is gradually cooled down to 86° Fahr, or 77° Fahr.; 
as patients get stronger the bath is used colder and colder-77° or 68° 
Fahr. After the immersion, lasting from three to fifteen minutes, or even an 
hour, and regulated by effects as indicated by the thermometer, the patient is 
dried at once and put to bed and covered as usual; and if the feet are cold, 
warm bottles, or a hot brick enveloped in flannel, may be applied. This 
method, now being carried out in some parts of Germany, does not recom- 
mend itself at first sight, but it may have advantages which we in this country 
have not yet learned to appreciate. The proper time for the use of the remedy 
must not be later than the first few days of the fever; and in scarlet fever, 
when the skin is hot and the rash bright and red. The patient being stripped 
should have four or five gallons of very cold water poured over him (affu- 
sion) ; and when the heat of the surface returns, the application may be 
repeated and renewed again and again. Its good effect is to lower the tem- 
perature, to lessen the frequency of the pulse and the respiration, to render 
the tongue moist and soft, to diminish or remove stupor, to procure sleep, and 
sometimes it may bring about perspiration, which brings relief. But if there 
be much nervous irritability, and especially in delicate females, the shallow 
bath, as less exciting than the cold affusion, is to be preferred. The patient 
then sits or is supported in an open bath, about six feet long, in a depth of 
water from six to twelve inches, having a temperature from 60° Fahr, to 80° 
Fahr. The extremities and trunk must be well rubbed by the assistant, while 
jvater of the same temperature as the bath is generally poured over the head. 
The patient may remain in this shallow bath from five to forty minutes, till 
the temperature of the body is reduced. In cases of delirium, with a high METHODS OF REDUCING THE HEAT OF FEVER. 
285 
bodily temperature (104° Fahr.) and prolonged sleeplessness, while the patient 
is held in a warm bath (92° Fahr, to 98° Fahr.) ten, twenty, thirty, or more 
bucketfuls of cold water (40° Fahr, to 60° Fahr.) are to be poured slowly 
over the head, hot water being constantly added to the immersion bath, so as 
to maintain its temperature at 92° to 68J Fahr. A refreshing sleep is some- 
times the result. 
By using the douche, the cold water is made to impinge on some part of the 
body (head and shoulders, or individual joints, or any part in succession, for 
instance) with considerable force, and the nervous impression produced is 
correspondingly great-too great and uncontrollable to admit of its frequent 
employment in this way. Where delirium is furious it may sometimes be so 
quieted, and its good effects become visible if the pulse and breathing im- 
prove, or even continue as they were before commencing the douche. One 
good method of applying it is to place the patient in a warm bath, and then 
apply the cold douche to the head as described (Ringer). 
Great relief may also be obtained from the severe headache which is met with 
in acute specific fevers, if the water be employed as recommended by Professor 
J. Hughes Bennett: " A wash-hand basin should be placed under the ear, 
and the head allowed to fall over the vessel, by bending the neck over the 
edge. Then, from a ewer, a stream of cold water should be poured gently 
over the forehead, and so directed that it may be collected in the basin. It 
should be continued as long as agreeable, and be repeated frequently. The 
hair, if long, should be allowed to fall into the cold water, and to draw up 
the water by capillary attraction." 
Sucking of ice, also, is most grateful to fever patients; it allays thirst. 
Cold sponging, or by tepid water, of the body is also resorted to with great 
relief in fevers. Sponging with very hot water is similarly useful. It will 
sometimes bring about relief by perspiration; while at the same time it 
soothes the restlessness and favors sleep (Ringer). 
Bloodletting or hemorrhage also tends to reduce temperature; but blood- 
letting can never be tolerated in specific fevers, such as typhus, typhoid, scarla- 
tina, and the like. 
Infusion of digitalis has been found by Wunderlich to have a wonderful in- 
fluence in reducing and moderating the temperature in many febrile states, 
such as enteric fever. Its most obvious action in small doses is to depress the 
force of the heart. The dose should therefore be cautiously regulated: it 
must not be repeated too soon, nor be increased, if it should not operate at 
once. 
Alcohol is another agent, shown by the experiments of Professors C. Binz, 
Parkes, and Assistant Surgeon the late Count Wolowitz, capable of reducing 
temperature; but only in a very unimportant degree, so that its power as an 
antiphlogistic is very slight, and such enormous doses must be taken, that 
harm can only come by any attempt at reduction of temperature from the use 
of alcohol. Dr. Ringer has made many observations on this point, and is 
convinced that little can be hoped for from alcohol as a means of diminishing 
the preternatural heat of fever patients. This much seems certain, however, 
that its anti-febrile influence is best expressed in the removal of conditions 
which induce paralysis of the brain and heart, and when the temperature of 
the body is high, as indicated by the thermometer. In this respect it ap- 
proaches quinine in its action, but at the same time possesses in addition its 
well-known stimulating action on the central nervous system and upon the 
heart. Depression is generally found associated with a high temperature of 
the blood, and passes off when it falls. But, in giving alcohol, it must be re- 
membered that two circumstances may contraindicate its use, namely, (1.) Its 
effect on the pulse. (2.) Its influence on the tone and diameter of the vessels. 
It increases the heart's beats as well as the strength of the contractions of ■ 
the heart. If such effects are to be feared, of course alcohol is not proper to 286 
TOPICS RELATIVE TO PATHOLOGY. 
be employed either in fevers or inflammation. Certain precautions must 
therefore be observed in the administration of alcohol, and its effects on the 
different functions carefully watched, to learn whether we obtain from the 
employment of alcohol good or harm; and although the pulse and heart 
afford the greatest and most reliable information on this point, yet the influ- 
ence of the alcohol on the other organs must not be overlooked, as it may 
happen that while one system is benefited, others are injured, and with some 
good, the alcohol on the whole may do much harm (Ringer). 
The following rules regarding the use of alcoholic stimulants in fever were 
laid down by Dr. Armstrong; and they have been indorsed by many expe- 
rienced physicians. 
During the administration of alcohol: 
1. If the tongue becomes more dry and baked, alcoholic stimulants 
generally do harm. If it becomes moist, they do good. 
2. If the pulse becomes quicker, they do harm. If it becomes slower, they 
do good. 
3. If the skin becomes hot and parched, they do harm. If it becomes 
more comfortably moist, they do good. 
4. If the breathing becomes more hurried, they do harm. If it becomes 
more and more tranquil, they do good. 
" In judging also of the influence of the alcohol on the pulse," says Profes- 
sor Ringer, " its compressibility is of more importance than its volume. 
Under the action of alcohol, a soft and yielding pulse of large volume often 
becomes much less compressible and smaller, changes which show an increase 
in the tonicity of the arteries and in the strength of the heart." .... Other 
circumstances also afford information as to the employment of alcohol, namely, 
" At the two extremes of age, the powers of the body are easily depressed, 
and hence, with such persons, stimulants are early called for, and must be 
freely used. In such, and especially the aged, it is of the greatest importance 
to anticipate prostration by the early employment of alcohol, as when once 
this occurs, the greatest difficulty is experienced in restoring the patient to his 
former state. Young children, when weak, take stimulants even in large 
quantities with benefit. And with the stimulant some easily digested food 
should always be given." 
Sulphurous acid has also been proposed as an agent for the reduction of 
temperature by Dr. R. Bird, in Indian Medical Gazette for February, 1869. 
In drachm doses, every two, three, or four hours, according to intensity of 
febrile heat, a fall of temperature has followed its administration, continued over 
twenty-four hours. In remittent fever he considers it especially beneficial, and 
in "internal fever"-a native name. 
(2.) To insure sufficient but not excessive excretion, and to promote its elimina- 
tion in fever, is much more difficult than to reduce temperature; which, for 
obvious reasons, it is not always judicious to attempt, either by cold water, 
bloodletting, digitalis, or alcohol. 
The system ought to be supplied with an abundance of alkaline salts, if the 
urinary excretions are not eliminated. 
Chloride of sodium, the alkaline salts of soda and of potash, tend to aid the 
formation of urea and its elimination. Purgatives generally, and especially 
salines,-i. e., salts of the alkaline and earthy metals-tend to insure a proper 
excretion, probably by removing from the blood some of the abnormal prod- 
ucts formed in fever, and great relief may follow their intelligent use. Where 
urea is retained, they promote its elimination, because it is known that urea 
sometimes passes off by the mucous membrane of the intestines. 
Dr. Armstrong strongly recommended purgatives to be freely administered 
to fever patients during the first few days of their illness, and before exhaustion 
had set in, so as to produce several evacuations in the day. By free purgation 
in scarlet fever the severe sore throat and swelling of the glands can be pre- RESTORATIVE AGENTS IN THE FEBRILE STATE. 
287 
vented, as well as many other of the disagreeable sequelae of this disease, such 
as discharge from the nose and ears. I have found the following formula of 
great benefit as a purgative for this purpose: 
B. Magnesias Sulphatis, 5VF solve in aqua, ^viii; adde Pulv. Guaiaci, 
Jiss.; Pulv. Gum Tragacanth. Co., gr. xl. Misce bene. One-sixth part of 
this mixture given every four hours till the bowels are freely moved gives 
great relief to the congested throat and swollen glands. 
But in some fevers, as in typhus, purgatives must be very cautiously and 
sparingly given, and always in mild doses. So also elimination by the skin, 
to the extent of diaphoresis, is to be dreaded in typhus fever (see " Treatment 
of Typhus Fever"). 
(3.) Restorative agents.-The most important indication, however, in the 
management of the febrile state, is to find some substance which, being " re- 
storative" in its action (Headland), will so act upon the blood and on the 
nervous system at the same time, as to restore the exhausted energies of the 
nervous centres. 
Food, mild stimulants, and quinine are all more or less employed; and 
quinine especially may be employed with benefit. Infusion of coffee as a medi- 
cine has been given by Dr. Parkes, with the beneficial effect of relieving 
heada'che. Bocker and Lehmann have shown that the use of coffee, in health, 
delays the metamorphosis of tissue, and excites the nervous system. As a 
nerve-restorative, phosphorus merits some notice. And first, as iron is given 
where the blood requires nourishment and restoration, so phosphorus seems to 
nourish and restore the nervous system, especially in cases of fever, where 
much phosqjhoric acid has been passing by the urine. The forms in which it 
is given are (1) in pill, ^th or -^th of a grain of finely divided phosphorus, 
melted with fat, and the pill covered with an impermeable coating; (2) in 
the form of a hypophosphite of potash, soda, or lime, given in camphor water, to 
the extent of five grains of the salt, three or four times a day. The potash 
salts seem to have a resolvent and liquefacient action so strongly marked, that 
great mischief may result from its incautious administration to persons affected 
with tubercular deposit in the lung. For the same reason it is of great value 
in chronic bronchitis, with thick fetid expectoration and congestion of lungs 
(Dr. Thorowgood, in Practitioner, July, 1869, pp. 14-20). Camphor has been 
also found of use in the adynamic type of fevers. It acts beneficially in 
strengthening the pulse and reducing its frequency. At the same time it 
moistens the skin and subdues delirium, especially the low muttering form. 
Twenty grains or more every two or three hours are required for this result, 
and its effects must be watched (Graves). Counter-irritation by blisters have 
been largely employed by Graves and other physicians as mere stimulants in 
fever, under the following conditions, described by Dr. Ringer, as follows: 
" With acute diseases, such as the idiopathic fevers and inflammations, it not 
unfrequently happens that persons already weak and much prostrated have 
their dangers greatly aggravated by the following mental state,-they become 
apathetic and unobservant, which condition increases till it even reaches 
partial insensibility or coma, and they can only with difficulty be roused, and 
then wear a stunned, stupid, and vacant look, and understand very imper- 
fectly what is said to them. The body generally sympathizes with this de- 
pressed condition of the mind, and its functions are more and more languidly 
performed, till those necessary to life altogether cease. It is a condition 
which may not inaptly be compared to one produced by poisoning with opium, 
where there is partial coma, which produces a lethargy in the functions of the 
body, whose activity grows less as the coma continues and deepens. But there 
is no true and refreshing sleep, while it is a condition in which sleep is most 
urgently needed. With patients in such a precarious state, it is of all things 288 
TOPICS RELATIVE TO PATHOLOGY. 
necessary to rouse them from their state of lethargy, and with the restoration 
of consciousness and activity of mind, there occurs renewed vigor in the func- 
tions of the body, and the patient is removed from a state of imminent danger 
to one of comparative safety. To accomplish this, blisters of large size, in 
quick succession, and for a short time, should be applied to different parts of 
the body, for instance, to the chest, to the abdomen, and to the thighs and 
calves. I have seen very satisfactory results follow their application to the 
nape of the neck under such circumstances." Dr. Ringer considers that more 
good is obtained by an opiate and plenty of stimulants, carefully given to pro- 
duce sleep, out of which the patient wakes strengthened and much improved. 
No fixed rule can be laid down ; each case must stand on its merits. 
The treatment of any special febrile state depends on the disease of which 
it forms a part, and by which it is more or less modified-forming a special 
topic for consideration in the part which treats of special diseases. But it is 
above all necessary to guard against the habit of trying always to be doing 
something. As a routine system, nothing can be laid down as a rule, either in 
the direction of depletion, or of evacuants, or of stimulation or restoration. 
The febrile state is in many diseases part of the essence of the morbid condi- 
tion, which cannot be cut short nor materially subdued by remedies. There 
is no specific remedy for the cure of any fever; and in the present state of 
our knowledge regarding specific febrile diseases, there can be no specific 
remedy for their cure. 
Every disease where fever is present, and every case of specific febrile disease, 
must be studied so that its management or treatment may be regulated on the 
merits of the individual case; and must be regulated by the state of each 
particular function as determined by clinical investigation daily. 
No remedial agent here mentioned can "cut short" a specific fever. Judici- 
ously employed, they may render them less dangerous, and may in some cases 
save life. 
II. As regards Inflammation. 
It is necessary clearly to understand and to bear in mind that, in the first 
instance, it is not the lesion which may attend the inflammatory process as a 
result, which is to be attended to; but it is the diseased action tending to the 
lesion which it is the object of the physician to overcome, to subdue, and turn 
aside; and that the occurrence of any lesion is, if possible, to be prevented. 
It is the strictly vital action-the irritation and subsequent excitement of tissue- 
which tends to the organic lesion, to which remedies must be applied, in order 
to avert the tendency to lesion, expressed by the symptoms of a local and con- 
stitutional kind already referred to. 
The treatment which will subdue this tendency has been technically called 
"antiphlogistic treatment." Its mode of action depends upon the regulation 
and adoption of every agent, plan, or circumstance most favorable to the sub- 
sidence of the irritative agency and the phenomena of inflammation, and 
which will favor the influence of remedies, and oppose the advance and per- 
sistence of the inflammatory state. The treatment embraces,- 
(1.) Antiphlogistic regimen; 
(2.) Antiphlogistic remedies-means for counteracting in a direct way the 
complex morbid phenomena of inflammation. 
The regimen consists in,-(1.) A sparing allowance of diet; but there is, at 
the same time, a necessity for fresh and rapid supplies of nutriment in small 
quantities. The foul tongue and anorexia of the fever of inflammation (p. 
88, ante) must not be allowed to go without nourishing drinks, such as those 
which have Liebig's extract or beef tea as a basis, with ice in it if the patient 
desires cool drinks. Abstinence from anything but plain water must be pro- 
vided for. The indications for treatment conveyed by the disordered state BLOODLETTING. 
289 
of the sensations of a patient in the acute pyrexia, or fever of an inflamma- 
tion, are not to be relied upon as a guide to treatment. Small but frequent 
support by liquid or gelatinous food, ice-cold or warm, is a necessity not less 
than the administration of bland, simple, and cooling drinks, given often, and 
in small quantities; (2.) Absolute rest of body and mind; (3.) Residence in a 
well-ventilated apartment, maintained at an equable temperature, day and 
night, of about 62° Fahr.; and in cases where the lungs are inflamed, a tem- 
perature of not less than 70° Fahr, to 80° Fahr., and as dry and pure a state 
of atmosphere as possible. 
The remedies comprehend bloodletting, purgatives, antimonials, mercurials, 
iodide of potassium, opium, aconite, alkalies, and saline drugs. 
Bloodletting.-The most important and the most efficient of so-called anti- 
phlogistic remedies is undoubtedly bloodletting; while it must at the same time 
be remembered that it is not every case of inflammation that requires or war- 
rants the abstraction of blood. It is a spoliative remedy, powerful for good 
and for evil. In the treatment of inflammation, it has been well observed by 
Dr. Watson that " each case requires its special study, speaks its proper lan- 
guage, furnishes its peculiar indications, and reads its own lessons." The care- 
fully recorded facts of well-conducted though empirical observation, for hun- 
dreds of years, have attested the immediate sanative influence of bloodletting 
in incipient inflammation; and the most eminent physicians of bygone modern 
times have recorded, in unmistakable language, how potent is this remedy for 
good, and the reasons for their belief. 
Our forefathers well knew when the body suffered from an inflammation in 
the " inward parts;" and in saying this we give them credit for far less scien- 
tific knowledge than they really possessed. Against such inflammations, 
whether in the head, the chest, or the abdomen, they learned, by "watching 
and not by counting," the sanative efficacy of early venesection; and they 
obtained most trustworthy evidence and experience of its power to control 
inflammation. Following up such doctrines will be found those veteran phy- 
sicians who hold the foremost rank in the science of medicine of the present 
day in this country. The doctrine generally taught and universally acted 
upon with reference to bloodletting in inflammations is, "so to bleed as to 
secure the advantages of the remedy, and to avoid its disadvantages" (Watson). 
The standard examples of what bloodletting can do soon become apparent 
to every surgeon's apprentice, or hospital pupil, if he does not himself swoon 
the first time he sees the blood flow from the patient whom his master and 
teacher may wish to relieve. He may see the apoplectic sufferer roused to 
consciousness while the blood yet flows from the vein; and he may observe, 
also, that the stounding pains of the head in cephalic inflammations are imme- 
diately relieved, that the impatience of light and sound, the frequent, sharp, 
intermittent pulse, with vomiting or nausea on assuming the erect posture, 
the tendency to squint,-in short, all the urgent symptoms of incipient en- 
cephalitis at once, or one by one, disappear as the blood continues to flow. He 
may also notice in thoracic inflammation that the pain, the dyspnoea, the 
tightness of the chest, all disappear. Dr. Alison, as regards pleurisy, and 
Dr. Watson, as regards inflammation of the bowels, bear personal testimony 
to the good effects of bloodletting. They experienced its sanative influence 
in their own persons, and the practice undoubtedly saved their valuable lives 
from these respective diseases. Testimony from such personal experience has 
also been borne by the late Dr. Gregory, of Edinburgh, and before him by 
the celebrated Dr. Radcliffe. Such also is the testimony of many who, having 
experienced the benefit of the remedy once, imagine that, when again attacked 
with inflammation, they may be again relieved by its use. Of any one .of 
these illustrious examples from personal experience it might be said, as Dr. 
Gregory said of Dr. Radcliffe, that " he was at least no fool; and we may 
depend upon it he would not have allowed a hundred ounces of blood to be 290 
TOPICS RELATIVE TO PATHOLOGY. 
taken from him in one day without good reason for it" (Edin. Med. Journal, 
March, 1857). 
" Although much has been done," writes Dr. Alison, " particularly by the 
French pathologists, to enable us to judge of the texture within the chest which 
is the subject of inflammation, and although this is a matter of real impor- 
tance, because we know that the history of the changes to be expected from 
inflammation in the bronchise, substance of the lungs and pleura, is materially 
different, and of course the diagnosis of these gives us a great advantage in 
studying the progress of any individual case,-yet as to the specific questions 
of bloodletting or not, the quantity, or the repetition of the bloodletting, our 
predecessors were very nearly as well-informed as we are. It is an important 
practical error," he also continues, " to fix the attention, particularly of stu- 
dents of the profession, too much on those characters of disease which are 
drawn from changes of structure already effected, and to trust too exclusively 
to these as the diagnostics of different diseases; because, in many instances, 
these characters are not clearly perceptible until the latest and least remedia- 
ble stage of diseases. The very object of the most important practice, more- 
over, in many cases, is to prevent the occurrence of the changes on which these 
lesions depend. After these lesions are once established, the cases are very 
often hopeless, or admit only of palliative treatment. In those diseases in 
which most can be done by art, our practice must always be guided in part by 
conjecture, becaqse, if we wait for certainty, we very often wait until the time 
for successful practice is past; and therefore, although an accurate knowledge 
of the whole history of each disease is essential to its proper treatment, yet, 
in a practical view, the most important part of its history is the assemblage and 
succession of symptoms, by which its nature at least, if not its precise seat, may 
often be known before any decided lesion of structure has occurred. Accord- 
ingly, when this department of pathology is too exclusively cultivated, the 
attention of students is often found to be fixed on the lesions to be expected 
after death, more than on the power and application of remedies, either to 
control the diseased actions or relieve the symptoms during life." 
The immediate effects of loss of blood as a remedy in inflammation are,- 
(1.) A sedative result on the heart's action, by diminishing the pressure on 
the vessels, by diminishing the quantity and altering the quality of the blood. 
The withdrawal of a considerable amount of stimulus from the central organ 
has thus a depressing effect, greater in proportion to the sudden loss of blood ; 
the excitability of the nervous system being thus also reduced. (2.) The loss 
of blood generally has a derivative influence upon the blood in the part about 
to become the seat of effusion. This has been seen to occur in experiments 
upon the transparent parts of animals. (3.) Bloodletting facilitates by pro- 
moting absorption, probably, the action of other remedies. (4.) While the 
effect of bloodletting is well known, by the observations of Louis and Alison, 
not always to check the extension of the sphere of inflammation, yet it essen- 
tially modifies its character sometimes, (a) by limitation of its sphere to a cer- 
tain extent, (b) by diminishing the quantity of blood from which the inflamed 
part is nourished, (c) by rendering the fibrinous exudation more liable to 
reabsorption. 
Of late the medical profession has proclaimed with no uncertain sound, 
especially from the metropolis of Scotland, as to the good effects of bloodlet- 
ting in the judicious treatment of inflammation. But it ought to be well known 
that no remedy demands a more careful study of its application, or a more 
delicate adjustment of its powers; and therefore some general rules may be 
here stated as a guide in the use of the lancet, especially as it is now so 
rarely used. 
1. The utility of bloodletting varies with the variations in the type of 
disease. A change in the type of inflammatory diseases (i. e., in their usual BLOODLETTING. 
291 
symptoms, local and general, in their tendencies to certain local and general 
results rather than others, or a change in their mode of tending to a fatal ter- 
mination), demands a special study and fresh adjustment of the remedy in 
each particular case, country, locality, and epidemic. 
2. There is no truth, perhaps, in medicine more conclusively determined 
than that we ought not to bleed, or, if we do so, we must bleed sparingly, 
when the inflammation depends on or is associated with the action of a mor- 
bid poison. In epidemics, therefore, of every kind, we should not hastily have 
recourse to the lancet, but should remember that the disease probably depends 
on a poison, has a definite course to run, and is not amenable to the mere 
abstraction of blood. 
3. It is necessary to observe carefully, and to watch the combination and 
succession of the constitutional and local symptoms from the commencement of 
the febrile attack, and so to judge as to the propriety of bloodletting. 
4. In order to obtain the good effects of the remedy by a full bleeding, it 
must be done prior to fibrinous effusion or new growth; seeing that it is the 
diseased action which tends towards the lesion-namely, effusion or growth of 
new material-which the physician desires to control by this remedy. 
5. When the symptoms of inflammatory fever are little complicated and seen 
early, in persons previously healthy, the more violent the symptoms are, the 
more intense and rapid the constitutional reaction (if it does not indicate 
exhaustion), and the more decided the change on the function of the part 
affected, the more confidently we may depend on the effect of full bloodletting 
in relieving them. 
6. When the symptoms of inflammatory fever have been uncertain and 
insidious in the beginning, so that the early stage has passed over unchecked, 
or modified by previously existing constitutional disease, or complicated with 
organic local disease, or when they denote debility, exhaustion, or the so-called 
typhoid state, they generally prove improper cases for bloodletting even when 
seen within the first few days. 
7. Generally, it may be stated, that when the fever is high (above 104° 
Fahr.), when we may be sure that over a part of the inflamed organ there is 
congestion, stagnation of blood, distension of vessels, commencing extravasa- 
tion, and change of the constitution of the blood-but these latter changes 
still partial and not far advanced-the power of bloodletting to control the 
disease has been clearly established. It will lessen hypersemia, and engorge- 
ments of the venous system, the result of impeded circulation through the 
lungs and the left side of the heart. A feeble arterial pulse will not in such 
cases contraindicate bloodletting; and stimulants are not incompatible with 
its practice. 
8. The nature of the membrane or organ affected must always be considered 
in estimating the propriety of bleeding. If a serous membrane, for instance, 
be actually inflamed, the patient, for the most part, bears bleeding well, and 
is usually greatly relieved by it. With respect to organs, it is found that in- 
flammation of the brain is less influenced by bleeding than inflammation of 
the liver, and inflammation of the liver than inflammation of the lungs. The 
gist of the evidence brought forward in Dr. Markham's very able and inter- 
esting Gulstonian Lectures establishes the special efficacy of venesection in 
those inflammations which are accompanied with obstructions of the cardiac 
and pulmonary functions, but do not prove it to be useless nor injurious in 
the cure of acute inflammations generally, if its remedial functions are prop- 
erly used, and the advantage gained be duly followed up by appropriate 
remedies, such as are to be presently noticed. The symptoms which demand 
a full bloodletting in pneumonia are also those which indicate the greatest 
danger - namely, violent pyrexia, usually beginning suddenly, with full, 
strong, hard, and quick pulse-urgent dyspnoea, even orthopnoea-swelling and 
flushing of the face, frequency and violence of cough, with scanty or truly pneu- 292 
TOPICS RELATIVE TO PATHOLOGY. 
monic expectoration, aggravating the pain which extends through the chest. When 
such symptoms are seen within three days of their commencement, especially in 
those of robust and full habit in the prime of life, bloodletting is the remedy to 
be used,-everything else is trifling, and it is not safe to dispense with it. The 
nearer a case answers this description, the more sure we may be that the 
effect of bloodletting will be satisfactory, and its repetition, if the symptoms 
shall recur, will be well borne (Alison). But if the inflammation be so 
limited that it produces little or no appreciable impediment to the respiratory 
or cardiac functions, when the temperature does not exceed 104° Fahr., when 
the pulse does not exceed 120, and when the respirations do not exceed 40 in 
the minute, such cases of pneumonia will get well by regimen and absolute 
rest alone. 
9. It is found in practice, also, that this most powerful of therapeutic agents 
in the cure of inflammation requires the greatest caution in its repetition, for 
there is a line beyond which bleeding becomes destructive instead of remedial. 
Two indications are of great use in determining as to the propriety of a second 
bloodletting, namely,- 
(a) As to hoic the first bleeding is borne-a test first suggested by the late 
Dr. Marshall Hall. If much blood flow from an ordinary-sized opening, be- 
fore any tendency to syncope manifests itself, venesection is then considered 
to be well borne; if, on the contrary, the patient soon faints after a vein is 
opened, the judicious practitioner desists from further depletion. The urgent 
symptoms, being thus relieved for the moment, may again return, after a 
longer or shorter interval, and thus demand a repetition of the remedy, to be 
now judged of (6) by the reaction of the system generally, as-indicated by 
the state of the local symptoms, their urgency for relief, the character of the 
pulse, and the appearance of the blood first drawn. The reaction may be of 
such a kind that a sthenic state of inflammatory fever still continues, or returns 
after temporary subsidence. The inflammatory process having been inter- 
rupted, so far modified, but not arrested, the remission proves transient, and 
the reaccession may be more fierce than the onset. A repetition of bloodlet- 
ting is demanded so soon as such reaction has declared itself. On the con- 
trary, the reaction may be asthenic, or of nervous character, the pulse being 
rapid, soft, and jerking, the breathing oppressed, headache and tinnitus au- 
rium present, with general nervous excitement; bleeding under such circum- 
stances, is not to be repeated. A full opiate will allay the nervous excitement. 
10. The next consideration is, "What indications for bleeding are to be 
drawn from the state of the blood ?" The blood offers certain indications, 
either for bleeding or refraining from it, when the symptoms would otherwise 
demand or forbid this operation. The firmness of the coagulum, for example, 
has been considered at all times as a mark of the tonic state of the system, 
and as a warranty for repeating the bleeding when the part is as yet unre- 
lieved, and the reaction continues of the sthenic type. 
The thickness, and especially the firmness, of the buffy coat, if lifted on a 
pin, was -one of the leading characteristics of the existence of acute inflam- 
mation, amongst others already noticed, and was much founded upon by Dr. 
Gregory, as guiding his practice in the treatment of inflammation. On the 
contrary, a looseness of texture of the clot is a sure sign of great debility, so 
that, unless other circumstances strongly indicate the necessity of bleeding, it 
ought not to be repeated when the yellow or buffy substance on the surface is 
loose and not thick and firm. 
11. The proportion of the serum to the clot, and also its occasionally altered 
characters, are arguments for or against bleeding. When the quantity of 
serum is unusually large, unless the clot be very firm, bleeding ought not to 
be repeated. Also, when the properties of the serum are so altered that it 
coagulates and forms one mass with the clot, bleeding is constantly prejudi- 
cial ; and, lastly, it has been observed that when the serum, which has little METHODS OF BLOODLETTING. 
293 
or no affinity for the red globules in health, readily dissolves them, and as- 
sumes a red color (red-colored serum), it is an unerring sign that further 
bleeding should be avoided. In some of the febrile *diseases the fibrin never 
augments, remains often in normal quantity, and is also often diminished. 
In the acute inflammatory fever, on the contrary, there is a constant aug- 
mentation of this principle, compared with the red globules, as observed by 
Andral. It is this excess of fibrin which gives firmness to the clot, and is the 
cause of its being "buffed" and "cupped." The immediate effect of bleeding, 
according to the same high authority, is to reduce the red globules, but not 
so with the fibrin; for a reduction of the fibrin does not take place till after 
a certain time. Such is the state of the blood in the sthenic inflammatory 
states. There are many reasons, however, for not esteeming the buffed and 
cupped state of the blood, denoting an excess of fibrin, as a sufficient warranty 
for bleeding; for these conditions are often present in erysipelas, phthisis, or 
the early stages of typhus fever; and in either of these cases the loss of a 
moderate quantity of blood might hurry the patient to his tomb. Again, in 
acute rheumatism the blood is not only buffed and cupped, but contains a 
maximum quantity of fibrin ; yet the best practitioners seldom think it neces- 
sary to take blood, considering that mode of treatment as neither affording 
present relief nor shortening the course of the disease. The fact, then, of the 
blood being buffed and cupped does not in all cases warrant venesection. It 
is also well known that the sthenic or buffed characters of the blood are often 
greatly modified by the manner in which the blood is drawn; thus, if an in- 
dividual be bled in both arms, and the blood allowed to flow with different 
velocities-that is, in a full stream from one and slowly from the other-the 
blood drawn is identically the same; yet a thick buff will be wanting in the 
latter and be present in the former. And if the apertures be of different 
sizes, the same differences will result; the blood from the larger orifice will 
be buffed, while no such effect is seen in the blood drawn from the smaller 
one. Again, the form of the vessel which receives the blood, as to whether 
it be flat or conical, and also its temperature, or whether the blood be re- 
ceived into one that is cold or warm, will also affect the phenomena of its 
coagulation. 
There are many circumstances, therefore, which prevent the blood from 
being an unerring guide for bleeding in cases of inflammation; but the assem- 
blage and succession of symptoms must decide as to the propriety of bloodletting 
in doubtful cases. 
12. An improvement in the character of the secretion or excretion from the 
inflamed part contraindicates the repetition of bloodletting; for instance, in 
pneumonia, if the character of the expectoration, from being scanty, tenacious, 
and tinged with blood, becomes copious and free, much may be expected from 
this natural tendency to cure. 
13. It is an object to effect the sanative result with as little expenditure of 
blood as possible; but the amount to be taken can only be judged o.f by the 
effects produced. The patient should be bled, if possible, in the upright posi- 
tion, and a full stream of blood allowed to flow from a sufficiently large ori- 
fice in a vein. To accomplish this fully, it may sometimes be necessary to 
open a vein in each arm, so that the flow may be from both at the same time. 
Bloodletting may be employed either generally or locally. General bleed- 
ing is best adapted to subdue acute inflammation of visceral organs, because 
it makes a more decided and rapid impression upon the system. Local blood- 
letting, by leeching, scarification, or cupping, is more useful in chronic inflam- 
mation and in inflammations affecting membranes, such as the pleura, perito- 
neum, meninges, and articular membranes, by diverting the blood through 
the superficial vessels from the deeper arteries which supply the inflamed parts 
(see the observations of Struthers and Turner in Edinburgh Monthly Jour- 
naif It is sometimes advantageous to combine the two methods of taking 294 
TOPICS RELATIVE TO PATHOLOGY. 
blood. In the case of external visible inflammation, the direct abstraction of 
blood from the inflamed part during the congestive period of the inflammatory 
process, is seen to exercise a benign influence over the progress of the inflam- 
mation. 
Purgatives.-The next most important class of antiphlogistic agents in the 
treatment of inflammation consists of purgatives, especially the resinous cathar- 
tics, likeJaZap, scammony, and gamboge. (1.) They free the stomach and intes- 
tines from accumulated food and faeces, or other irritating and acrid matters. 
(2.) They subdue the inflammatory tendency by the discharge of a large quan- 
tity of serous fluid, charged with albumen, from a large extent of mucous 
membrane. Thus they tend to check effusions and diminish the force of the 
heart's action. Their use is especially indicated in encephalic inflammations 
and hepatic congestions ; but they are less efficient in subduing thoracic inflam- 
mation ; while in the enteric inflammations they ought not to be pushed 
beyond merely unloading the alimentary canal. Combined with diaphoretics, 
they promote the elimination of morbid material through the glands. 
Mercury varies in its influence with its mode of administration and the 
constitution of the patient. It is followed, in large doses, by an increased 
flow of watery evacuations from the bowels, and an increased flow of saliva.* 
If the use of the remedy is continued, especially in small and repeated doses, 
combined with opium, so that it is not passed off by the bowels, this mineral 
induces salivation-that is, saliva flows profusely, the gums become tender, red, 
swollen, and ulcerated on the margins in contact with the teeth. The patient 
gets rapidly thin during its use. The blood is decomposed, the red corpuscles 
are rapidly destroyed to the extent of one-sixth or more ; the fibrin is dimin- 
ished by one-third of its amount; the albumen by one-seventh; and, at the 
same time, it may become loaded with a fetid matter, the product of decom- 
position (Wright). "Thus it is an agent of terrible activity, and we may 
well be cautious how to handle it " (Headland). Its sanative power is 
believed to consist in controlling or preventing the coagulation of lymph; and 
for this purpose it is used as an auxiliary to bloodletting, and next to that 
as a remedy, and superior to purgation. It is only useful in the sthenic forms 
of inflammatory action. Bichloride of mercury is certainly of great use in 
iritis, and in inflammations of the deeper seated parts of the eye. It is also of 
service in the inflammations of serous membranes, in which it appears not only 
to subdue the inflammation, but to promote the absorption of the effused prod- 
ucts of the disease. Wherever coagulable lymph is effused, or about to be 
effused, wherever adhesive inflammation exists, gluing parts together, and 
" spoiling the texture of organs," there mercury is of service. The system 
should then be brought as speedily as possible under its specific influence-a 
result which is known by its effects on the gums and on the breath of the 
patient. The gums grow red and spongy, and the patient complains of their 
being sore, and that he has a metallic taste-a taste like copper-in his mouth. 
At the same time, an unpleasant and very peculiar fetor is to be smelt in his 
breath; and which, when once experienced, is easy of recognition again. 
Beyond this physiological point the effects of mercury ought not to be allowed 
* Concerning the action of mercurial salts in the secretion of bile, the most oppo- 
site statements have been made. The experiments of Dr. George Scott, of Southamp- 
ton, throw considerable doubts on the hitherto generally received opinion that calomel 
in large and purgative doses increases the flow of bile; on the contrary, suqh doses 
■seem, in the first instance, to diminish the flow of bile; and it is a matter for further 
experiment to determine whether small and frequent doses of calomel, continued for a 
length of time, so as to produce the specific action of mercury upon the system, will 
really ultimately augment the biliary secretion (Beale's Archives, vol. i, p. 209). Since 
then many experiments have been made on animals and on healthy men, from which 
it would appear that the secretion is rather diminished than increased. Nevertheless, 
the experience of generations speaks as strongly in support of the assertion that in some 
diseases the flow of bile is increased by mercury. ANTIPHLOGISTIC REMEDIES. 
295 
to advance; but these symptoms may require to be maintained for some time. 
Such results are best obtained by giving small equal and repeated doses of 
calomel, combined with just as much opium as will prevent its passing off by 
the bowels. Two or three grains of calomel with a third or a quarter of a grain 
of opium, given every three, four, or six hours, according to the necessity of the 
case, will effect the results indicated in the course of 36 or 48 hours. Previous 
bloodletting renders the body more readily susceptible of the influence of 
mercury, and the two remedies will accomplish, by their joint power, what 
neither of them might be able to accomplish singly. If the inflammation has 
been slow and chronic, the influence of mercury must be also slowly brought 
about, as the lymph can only be slowly and gradually taken up again by the 
specific action of the drug, sustained for a considerable length of time (Wat- 
son, Simon). It is decidedly hurtful in cases of erysipelas disposed to gan- 
grene, in scrofulous states of the system, in debility, and in cases where the 
nervous system is in an irritable condition, and the condition of the patient 
tending to the so-called typhoid state. The specific influence of mercury is 
recognized by the tenderness of the gums which it induces, by the increase in 
the quantity of saliva, and by the peculiar mercurial fetor of the breath. 
This is the utmost action which should ever be induced, and salivation espe- 
cially ought to be avoided. 
Mercury thus employed tends to prevent effusion and to favor absorption 
of effused products. It is advantageously employed in membranous inflam- 
mations, and such as go on slowly. 
Iodide of Potassium, by its administration, in addition to mercury, removes 
more quickly the inflammatory effusions, such as occur in pleurisy, and in the 
inflammatory thickening of organs. 
Antimony is antiphlogistic, by tending to increase all the secretions ; but 
particularly those from the skin and lungs. It is especially useful in those 
sthenic inflammations which are rapid, and in which a sudden and powerful 
action is desired ; and also where the direct sanative influence of bloodletting 
is to be maintained. It is thus indispensable in croup, extremely efficacious 
in sthenic pneumonia, and highly useful in bronchitis. As an agent to keep 
up the sanative influence obtained by bloodletting, the action of antimony is 
invaluable; for when bloodletting has weakened the force of the heart, by 
diminishing the pressure on the vessels, then antimony maintains this dimin- 
ished pressure in proportion as it weakens the force of the heart. A perse- 
verance in its use produces a watery condition of the blood, diminishing 
especially the amount of fibrin. The production of nausea is an indication 
that it has taken sufficient effect. 
Opium is one of the most important antiphlogistic remedies at present 
known. In various forms of inflammation of the abdomen and chest, it is a 
universal remedy; and if administered less in affections of the pulmonary 
mucous membrane, it is only because there *is a fear that by lowering the 
respiratory process, it may tend to prevent expectoration. Sore throats, bad 
colds, and ulcers heal rapidly under its influence. As soon as a cause of in- 
flammation begins to operate, treatment by opium ought to be commenced; 
a grain every three, four, or six hours, according to the indications, so as to 
keep the patient under its narcotic influence by renewed doses of the drug. 
Aconite is now also proven to be a powerful agent in counteracting inflam- 
mation and in subduing the inflammation, and its tendency seems rather to 
arrest dr cut short an inflammation than to remove the products of inflamma- 
tion when they are formed. It requires, therefore, to be used very early ; but 
so long as the inflammation is extending, aconite will do good. Acute inflam- 
mation of any of the tissues may be subdued by the early administration of 
the tincture of aconite (two to five drops every three hours, according to age). 
In the inflamed parts, like the tonsils or the mucous membrane of the throat, 
the good effects of aconite may be seen, and its good results are most apparent 
when the inflammation to be subdued is not extensive or severe, as in the 296 
TOPICS RELATIVE TO PATHOLOGY. 
catarrh of children, tonsillitis, or acute sore throat. Under its influence the 
large, livid, dry, and glazed tonsils will have their appearance completely 
altered in a day, so that the mucous membrane is moist and bathed with 
mucus or pus, after which a little glycerin of tannin applied to the part will 
complete the cure. The remedy ought to be given at the earliest stage, when 
the chill is yet upon the patient. " In a few hours," says Professor Ringer, 
" the skin, which before was dry, hot, and burning, becomes comfortably moist, 
and in a little time longer it is bathed in profuse perspiration, which may be 
so great that drops of sweat run down the face and chest. With this appear- 
ance of sweat, many of the distressing sensations, such as the restlessness, the 
chilliness, or heat and dryness of the skin, are removed. At the same time 
the quickened pulse is much reduced in frequency, and, in a period of twenty- 
four or forty-eight hours, it and the temperature have reached their natural 
state. It is rare that a quinsy or sore throat, if caught at the commencement, 
cannot be disposed of in twenty-four or forty-eight hours by its use. The 
sweating may continue for a few days after the decline of the fever, on slight 
provocation, but it then ceases." Aconite has had for a long time a reputa- 
tion as a depressant of the heart's action, and capable, as such, of lowering 
the force, or slowing the circulation. The admirable account of the physio- 
logical properties of aconite given in the inaugural dissertation of Dr. Flem- 
ing, of Birmingham, brought its usefulness more to the notice of the profession ; 
but still it has never come into general use, chiefly on account of its highly 
poisonous nature, and from the want of precise rules as to the class of cases 
demanding its administration. For a long time several eminent members of 
the profession have attributed the very highest value to aconite as an anti- 
phlogistic, and Mr. Liston highly advocated its use in the treatment of ery- 
sipelas. Dr. Wilks, of Guy's Hospital, has been in the habit of using it for 
many years, when favorable cases occurred, that is, cases seen at the very 
commencement of an inflammatory process. He has used it in pneumonia, 
acute rheumatism, hooping cough, and chronic catarrh, in doses varying from 
three to five drops of the tincture of aconite every four hours (The Practitioner, 
vol. i, p. 334). Dr. Ringer has used it with success in cases of catarrhal 
croup, severe colds, tonsillitis, pharyngitis, and in pericarditis; when the heart 
throbs violently, thus producing extreme pain, aconite will quiet the heart 
and ease the pain. Dr. Ringer gives of the tincture half a drop or one drop in 
a teaspoonful of water every ten minutes or a quarter of an hour for two hours, 
after which to be continued hourly. 
Alkalies dissolve the fibrin of the blood and retard its formation; and the 
ingredients of the urine produced out of the destruction of the albuminous 
compounds of the body are increased largely in amount by the administra- 
tion of alkalies. They generally pass out of the body as salts, having com- 
bined with acids in the system, and tending to leave behind them an excess 
of alkali in the blood. 
All treatment ought to be judiciously regulated by the knowledge of the 
tendency of the disease to a spontaneous favorable termination-the acci- 
dental symptoms of urgency requiring treatment and control in many cases, 
rather than the disease itself. In every case, details of treatment must be 
considered and fixed upon; for general principles of treatment must so result 
to have any practical value. It is not possible to lay down one rule based on 
general principles applicable to every case. Every case must be studied and 
managed in accordance with its individual requirements; and it is especially 
the duty of the clinical teacher to instruct the student in this kind of knowl- 
edge, because it is a kind of instruction which must be seen to be appreciated. 
To teach the art of applying remedies is the duty of the clinical instructor. 
The text-book of practical medicine can only faintly indicate the principles 
by which treatment ought to be guided. When individual diseases are con- 
sidered, whether involving fevers of a specific kind or inflammations, the 
details of treatment applicable to each will be set forth in detail. THE 
SCIENCE AND PRACTICE OF MEDICINE. 
PART IL 
METHODICAL NOSOLOGY-SYSTEMATIC MEDICINE, OR THE 
DISTINCTIONS AND DEFINITIONS, THE NOMENCLA- 
TURE AND CLASSIFICATION OF DISEASES. 
CHAPTER I. 
THE AIM AND OBJECTS OF NOSOLOGY. 
Nosology, regarded as a distinct department of the Science of Medicine, 
embraces three separate objects of consideration-namely, First, the Distinc- 
tion and Definition of particular diseases, or of the genera and species of 
diseases; Secondly, The Nomenclature of diseases, or the assignment of the 
names by which they are to be designated, so that each disease may be dis- 
tinguished and known by an appropriate name; and, Thirdly, The Arrange- 
ment or Classification of diseases in some methodical and convenient 
order, by which they may be distributed into classes, orders, genera, or 
species. These three divisions of Nosology are respectively known as the 
Definition, the Nomenclature, and the Classification of diseases. Of 
these in their order. 
I. The Definitions of Diseases.-The first .object of Nosology is to obtain 
such brief enumerations of the peculiar characters of diseases as are sufficient, 
provisionally, to define them; and the practice of attempting to define dis- 
eases so as to lead to their being easily recognized was begun before the time 
of Galen. In modern times the great advantages that have arisen from 
establishing definitions in natural history upon fixed and determinate princi- 
ples, not only of its various objects individually, but also of the groups under 
which it was found possible to arrange them, suggested to medical men the 
idea that much advantage might also result to the Science of Medicine from 
defining diseases, and such groups of diseases as might be found expedient to 
recognize, under general terms or common names, based upon some fixed and 
determinate principles. Sydenham recommended that definitions or brief 
descriptions of diseases should be framed after the model of those that are 
given of plants; and he lays down various judicious rules for the proper exe- 
cution of this object in the preface to his work On Acute Diseases, first pub- 
lished in 1675. The precepts of Sydenham were never reduced to practice in 298 
METHODICAL NOSOLOGY-SYSTEMATIC MEDICINE. 
his clay; but about fifty-seven years after his work On Acute Diseases was 
published, the idea was taken up and acted upon by Franciscus Boissier de 
Sauvages, a distinguished physician and eminent professor of medicine at 
Montpellier. He attempted to arrange diseases, as botanists have done 
plants, into classes, orders, and genera. He endeavored to lay down the 
characteristic phenomena of each, and to enumerate their principal varieties. 
The outlines of his nosological system were first published in 1732, and 
followed, thirty years afterwards, by his Nosologia Methodica-a work which 
marks an important era in the history of Medicine, as having led to much 
greater accuracy in the distinction of diseases than was previously observed. 
At present the only useful method of defining diseases seems to be an artifi- 
cial one. It is assumed by nosologists that the proper foundation for the 
distinction of particular diseases is the occurrence of constant and uniform 
combinations of morbid phenomena or symptoms, presenting themselves in 
concourse or in succession. Thus some of the essentials of a definition are 
obtained, so that each disease may be marked out by such a brief enumeration 
of its leading characters as might serve to distinguish it from every other. A 
series of nosological definitions, more or less correct, may be thus provisionally 
established, so that the same things are designated by the same terms. Ob- 
jections have been urged to methods of this kind, on the ground that diseases 
are unsteady and variable in their character; but the aids to science are now 
so numerous that physicians are becoming more and more able to distinguish 
diseases from one another, and to tell by what marks, or upon what grounds, 
they do so distinguish them. Such are the marks or grounds of distinction 
by which each disease ought to be defined; and as often as we attempt to es- 
tablish a distinction among diseases, either the deficiencies or the errors of 
our definitions will be the more easily perceived; and the attempt will lead 
to a more accurate consideration of observations previously made, as well as 
to a greater degree of accuracy in subsequent observations. Definitions of 
diseases are therefore not only of much service to methodical nosology, but 
they help to render the diagnosis of diseases more perfect. Pathologists, how- 
ever, are not agreed as to whether the definitions of diseases should be derived 
from the external phenomena that present themselves in their course, or from 
the internal pathological conditions on which these phenomena are supposed 
to depend; and particularly such of these conditions as consist in lesions or 
structural alterations discoverable after death, or a combination of all. 
Cullen was in favor of definitions derived from symptoms of diseases; but 
he believed that the information derived from pathological anatomy might 
guide to more correct and definite distinctions among them. Defining diseases 
by their supposed proximate causes may lead to error, inasmuch as in many 
cases these causes are disputable, and may long continue to be so. Whatever 
principle of defining diseases be adopted, it is absolutely necessary that it 
should be independent of every theoretical view; for any theory employed, 
however specious, however much we may be persuaded of its truth, may not 
appear in the same point of view to others, and may therefore occasion end- 
less confusion (Cullen). If no uniform principle can be laid down for 
arriving at precise definitions of disease, we must be content with such 
methods of definition as will serve the main purpose of coupling intelligible 
general notions regarding the disease with given modes of expression. For 
example, although we cannot give such a definition of many a disease as will 
embrace even all the leading phenomena of every case, we may assuredly 
give such a definition as shall apply with reasonable accuracy to the disease 
we intend to designate, so that no one may suppose we mean' thereby either 
small-pox or the gout when we mean typhus fever or dysentery: and, in a pro- 
gressive science like medicine, definitions must always be provisional. " They 
are, indeed, not for the present state of medical science. They can only in- PRINCIPLES INFLUENCING THE NAMES OF DISEASES. 
299 
completely circumscribe their subject, and must have shadowy outlines" 
(Paget). 
II. The Nomenclature of Diseases.-This, the second object of Nosology, 
has given rise to many disputes, and has furnished much scope for the display 
of classical erudition. From the earliest periods of medicine, the names im- 
posed upon diseases have been derived from several different sources; but the 
following considerations have generally regulated the naming of a disease: 
First: Some names have been taken from the part affected-e. g., peripneu- 
monia, podagra, ophthalmia, dysentery. Secondly: The most characteristic 
symptoms have furnished the name-e. g., ileus, tenesmus, paralysis, diarrhoea, 
dyspnoea, coma. Thirdly: Some names have been taken from these two cir- 
cumstances combined-e. g., cephalalgia, otalgia, cardialgia, odontalgia, hyster- 
algia. Fourthly: An alteration of tissue upon which subsequent changes 
depend being recognized as the essential element of the disease, it is named 
accordingly-e. g., pleuritis, peritonitis. Fifthly: Such alteration not being 
discovered, the first tangible link in the chain of causation has been used 
instead-e. g., melancholia, cholera, typhus. Sixthly: When a lesion tending 
to sudden death, at once follows the application of a cause, that cause may 
name the disease-e. g., lightning, prussic acid, arsenic, burn, scald, sunstroke, 
cut, stab, frost-bite, &c. Seventhly: A considerable number of names of diseases 
have been derived from some imaginary resemblance to external objects-e. g., 
elephantiasis, cancer, polypus, anthrax, &c. Lastly: There are still many 
names the origin of which it is not now easy to trace. 
It is obvious from these statements, that the names of diseases must change 
as our knowledge changes and becomes more precise; and many diseases 
which were once named after their symptoms are now named according to 
the lesion from which most of those symptoms proceed. An apt illustration 
of this is to be found in paralysis, which is no longer regarded as a disease 
per se, but is merely a symptom of several structural alterations of the brain 
and spinal marrow. 
The progress made in our knowledge of disease from time to time rendered 
it obvious that some diseases, now only sufficiently recognizable, are different 
from any other diseases hitherto known. In separating them it became neces- 
sary to invent new names for the distinct diseases, or a choice had to be made 
from amongst those names previously in use. Hence the jumble of Greek, 
Latin, and mongrel names which hitherto has pervaded medical nomencla- 
ture. The idea also of rendering medical nomenclature uniform, by deriving 
the names of diseases from one source only, or from a certain or mixed com- 
bination of sources, has caused many to attempt the reform of medical nom- 
enclature, and especially since morbid anatomy has been so much prosecuted 
that it might serve as a useful guide in distinguishing the disease or dictating 
its name. 
By some it is maintained that "the name of each disease or species should 
be so characteristic and significant that a person slightly acquainted with the 
language and the subject should, on hearing it, immediately understand what 
is the nature of the disease it designates " (Ploucquet). In this respect the 
name ought to be composed out of the same elements as the definition of the 
disease-in fact it ought to be the definition converted into a name, and 
derived either from the symptoms of the disease or from the supposed proxi- 
mate cause. But a name which is expressive only of the nature, seat, or 
proximate cause of a disease may be erroneous in respect of each of these 
facts singly, or of all of them together. The history of the nomenclature of 
fever, especially enteric, would amply illustrate these statements-e. g., putrid 
fever, adynamic fever, bilious fever, pythogenic fever, typhoid, meningogastric 
fever, nervous fever, gastric fever. The example of lardaceous disease (see 
that article, p. 133, ante) may furnish another illustration. Both are very 
mild examples of nomenclature and of confusion, which ought to make a 300 
METHODICAL NOSOLOGY-SYSTEMATIC MEDICINE. 
man pause before he attempts to construct a new name. Naming diseases, 
such as fevers, from the names of places (for example, Crimean fever, Bulam 
fever, Mediterranean fever), is also extremely objectionable. 
It is inexpedient, also, to abandon (except when unavoidable) the names of 
distinct diseases received and recognized by our forefathers in the science; or 
to substitute new ones in their place, without an extreme necessity. Sauvages 
insisted much on this point, and Cullen entertained the same opinion. 
"Words," says the former, "are good only in respect of their signification." 
In dealing, therefore, with ancient nomenclature, which, for the time being, 
may appear objectionable, it is surely better to extend, if possible, the signi- 
fication of the word, name, or term, than to alter it. At the same time it 
must always be permitted to give new names to new diseases, and to select 
the best out of those which are in use, when a great number have been used 
to designate one and the same thing. There are some principles, therefore, 
which it is well to recognize as influencing the judicious choice of a name. 
Such names, for example, as involve or attempt to indicate a proximate cause, 
are more liable to lead to error than those which are derived from leading 
symptoms. If names were to be based on supposed causes, new names of 
diseases would be required whenever a new hypothesis is started. Look, for 
example, at the names of enteric fever, already mentioned, and the systems 
of Linnaeus, Vogel, Pinel, and even Mason Good, will show that medical 
nomenclature has been repeatedly changed without any urgent necessity; 
and great inconvenience has especially resulted from incorporating particular 
and often peculiar pathological doctrines with the language and nomenclature 
of diseases. So much has this been the case that the language of medical 
science has been in danger of becoming " a curious mosaic of the chief specu- 
lations of ancient and modern times." The passion for inventing new terms 
retards also, in a wonderful degree, the progress of the student of medicine, 
and tends to involve him in difficulty and doubt. It will, therefore, be well 
for the student of medicine and for the science if the teachers of the various 
schools will absolutely adhere, for at least the next ten years, to the definite 
form of nomenclature as at present agreed to, and published by the London 
College of Physicians, and given in this Text-book. 
III. The Classification of Diseases From time to time physicians have 
considered it advisable or advantageous to arrange the whole of the diseases 
they are able to define, and to name, under more or less comprehensive 
groups. A consideration of the different plans which may be pursued in such 
arrangements, and of the advantages to be derived from them, forms the third 
object of Nosology. 
It is obvious that any single character, or combination of characters, in 
respect of which diseases agree with or differ from each other, may be made 
the basis of methodical arrangement, under a larger or smaller number of 
divisions, or of higher or lower genera (language of logicians), or of classes, 
orders, and genera (language of naturalists). By ingenious devices of the 
mind the physician or the statist may classify and arrange his knowledge so 
as to bring it all more readily within his reach for any special purpose,-so 
as to make it, in fact, more at his disposal-to facilitate and pave the way for 
further investigation. Such are the legitimate objects and the results of all 
methodical arrangements. Classification, therefore, being only a method of 
generalization, there are, of course, several classifications of disease which 
may be used with advantage for special purposes. The physician, the pathol- 
ogist, the jurist, the hospital statist, the army or navy medical officer, may 
each legitimately classify diseases from his own point of view, and for his own 
purposes, in the way that he thinks the best adapted to facilitate his inquiries, 
and to yield him general results. The medical practitioner may found his 
main divisions of diseases on their treatment, as medical or surgical; the 
pathologist, on the nature of the morbid action or product; the anatomist or PRINCIPLES OF CLASSIFYING DISEASES. 
301 
the physiologist, on the tissues and organs involved; the medical jurist, on 
the suddenness, slowness, violent, or unnatural mode of the death ; the hos- 
pital statist, on the kind of diseases which are treated in its wards; and all 
of these points of view may give useful and interesting results (Farr). 
There is thus no question on Which more diversified opinions are legiti- 
mately entertained than on that of classification. Although it is the aim of 
all systematic writers and observers to arrange the objects of study in the 
most natural order possible, and although diseases are named as if they were 
individual entities, yet they present so great varieties that they will not admit 
of that definite and, in many respects, natural species, of classification which 
can be made with objects of natural history. Manifest reasons of convenience 
and facility for work can therefore be assigned as the great incentive to classi- 
fication ; and numerous reasons exist for classifying diseases in various ways : 
(1.) Men differ in their estimation of the characters on which different 
arrangements may be founded. (2.) The facts and phenomena of diseases 
on which classifications may be made are not all regarded from the same 
point of view. Most systems are avowedly artificial, being arranged with the 
view to elucidate or support a theory, or otherwise to effect a definite end. 
For example, by classifying diseases and recording the causes of death, the 
most valuable information is obtained relative to the health of the people, or 
of the unwholesomeness and pestilential agencies which surround them. " We 
can take this or that disease," says Dr. Farr, "and measure not only its de- 
structiveness, but its favorite times of visitation; we can identify its haunts 
and classify its victims." We are able to trace diseases also as they percep- 
tibly get weaker and weaker, or otherwise change their type, as some have 
done from time to time. We know from the valuable returns of the Regis- 
trar-General, prepared periodically by Dr. Farr, that certain diseases are 
decreasing, or growing less and less destructive; that certain other diseases 
have ceased in some measure; while other severe diseases have exhibited a 
tendency to increase. The advantages, therefore, of adopting some system of 
classifying diseases, which can be put to such useful practical purposes, must 
be obvious to every one. 
To some extent, other systems are natural in their arrangement, in sp far as 
they attempt to express or exhibit some of the natural relations which subsist 
among diseases; but the mere expression of one man's interpretation of peculi- 
arities of disease of the same species, and the elevation of such diseases in a 
classification as specifically distinct, are apt to be based on insufficient evidence 
as regards natural relations. 
Principles of Classification-Many systems of Nosology have been adopted 
from time to time; and as valuable general principles have been adduced from 
some, the grounds on which diseases have been classified may be briefly 
described under the following ten divisions, namely: 
I. The nature of the ascertained causes of disease. On this principle two 
classes of diseases are recognized, namely,-(1.) Diseases arising from general 
causes; (2.) Diseases arising from specific causes. 
II. The pathological states or conditions which attend diseases. The principle 
of this classification consists in determining alterations of the structure or the 
chemical composition of parts, from which names are given to the disease- 
e. g., pleuritis, pneumonia, &c. The distinctions of Sauvages were generally 
derived from symptomatic and pathological characters, or external symptoms 
alone; Cullen, following (1792), adopted similar grounds of classification; but, 
with much more comprehensive views than Sauvages, a more lucid order, and 
a happier simplicity, he excelled in accuracy of definitions all who had gone 
before him. His descriptions of disease received no coloring from his theories. 
They are faithful to nature, consistent with the knowledge of his day; and, 
greatly in advance of his time, his original and inventive mind dwelt much 
on the causes of disease in all his reasonings and explanations upon medical 302 
METHODICAL NOSOLOGY SYSTEMATIC MEDICINE. 
subjects. Aware, however, of the imperfections of the Art of Medicine, he 
did not attempt to arrange diseases according to their proximate causes, but 
according to a method founded partly on their symptoms, partly on their 
causes, and partly on their seats (Currie). A methodical arrangement of 
this kind has generally been considered the most desirable, as being likely to 
bring together diseases corresponding not only in some very important relations 
as regards their symptoms, but also in the indications and means of treatment 
which they suggest and require. But it is obvious that such an arrangement 
must vary according to the progress of knowledge and of opinion; for a disease 
which may at present be supposed to depend upon one pathological condition 
may be found at a future time to proceed from another. Besides, the arrange- 
ment involves a principle which tends to separate diseases bearing a striking 
resemblance to one another in their external phenomena, though depending 
on different pathological conditions; for example, different species of apoplexy 
and epilepsy. It is an arrangement, also, bringing together diseases which 
though belonging to the same natural family, may be respectively charac- 
terized by groups of symptoms that do not bear any very obvious resem- 
blance. Thus the hemorrhages at once bring together apoplexy and haemop- 
tysis in this classification. 
III. The properties, powers, or functions of an organ or system of organs being 
deranged, dictates a classification in which the most prominent effects or phe- 
nomena of morbid states are considered as the disease-e. g., palpitation, 
diarrhoea. It is an arrangement which brings diseases into approximation 
with one another according to the part of the body principally affected and 
the function principally disturbed. 
When disease consists in perverted powers or functions, it is then denomi- 
nated a dynamic affection or disorder. When it depends on change of struc- 
ture, it is termed an organic lesion or disease. 
This third basis of classification is Physiological, and was adopted by Drs. 
Young and Mason Good, in imitation of Ploucquet, of Tubingen. It has 
been the most popular arrangement of diseases, and perhaps the best adapted 
for lectures, or for treatises on the practice of physic, because it brings together 
the different diseases of the same organ, and of those organs most intimately 
related to one another; but, to profit by the arrangement, the student must 
be previously instructed in the general doctrines of disease. 
IV. The diseases comprehended under the two latter principles of classifi- 
cation are sometimes inaccurately and loosely brought together under the 
heads of Structural and Functional diseases. The diseases of function, for 
instance, being made to embrace the neuroses, hemorrhages, and dropsies; 
while inflammation, tubercle, cancer, melanosis, hypertrophy, and atrophy are sub- 
ordinate classes of the diseases of structure. The diseases of function embrace 
all those diseases in which the action, the secretion, or the sensation of a part 
is impaired, without any primary alteration of structure of the organ or tissue 
affected, so far as our imperfect means of research can ascertain. Thus mania, 
catalepsy, neuralgia, are neuroses of the brain or other portions of the nervous 
system. Colic, vomiting, diarrhoea, and constipation, are neuroses of the alimen- 
tary canal; and so on of other parts. Hemorrhage, or the effusion of blood, 
and dropsies, or an effusion of water into the shut cavities of the body, as that 
of the head, chest, or abdomen, are also instances of functional disease. Such 
are the grounds of classification adopted by the late Dr. Williams, of St. 
Thomas's Hospital, London. 
V. A basis of classification has been adopted, founded on the pathological 
nature of the different morbid processes, but the arrangement of the orders and 
subdivisions is determined by the anatomical arrangement of the textures and 
organs of the animal body, as originally developed by Bichat. 
Such is the principle and mode of classification adopted by Dr. Craigie 
(1836). SYSTEMS OF CLASSIFICATION OF DISEASE. 
303 
VI. A ground of classification exists, having reference to the general nature 
and localization of the morbid states. It comprehends three classes,-(1.) Dis- 
eases which occupy the whole system at the same time, and in which all the 
functions are simultaneously deranged. These have been nhmed general dis- 
eases, such as fevers. (2.) Constitutional affections, meaning thereby diseases 
which display themselves in local lesions in any part, or in several parts of the 
system, but not in all parts at the same time-e. g., rheumatism, gout. (3.) 
Local morbid processes. 
Such is the classification adopted by Dr. Wood, of Pennsylvania (1847). 
VII. Applying the principles of a yourely, humoral pathology, we have a 
classification consisting of: 
a. Fevers, b. Dyscrasite-e. g., tabes, chlorosis, scorbutus, dropsy, diabetes, 
pyaemia, tuberculosis, carcinoma, c. Constitutional diseases, induced by-(1.) 
Specific agents; (2.) Vegetable substances. Such is Wunderlich's arrange- 
ment of diseases (1852). 
VIII. M. de Savignac, Professor of Clinical Medicine at the Naval School 
of Toulon, propounded (1861) a Nosological arrangement founded on what he 
believes to be the " elements" of disease. To each of the classes he so defines, 
the question would at once suggest itself, and require solution, as to what the 
" element" may be on which the particular class is made to stand alone. He 
merely subjoins the word " element " to an adjective formed from the name 
of each class of diseases. Thus the class Neuroses is distinguished as the 
neurosic element; the class Rheumatalgim, as the rheumatic element; and so 
on to the number of fourteen classes. In the formation of orders, genera, or 
groups of diseases under this classification, no fixed principle can be recognized. 
IX. Dr. Stark, of Edinburgh, proposed (1864) an arrangement embracing 
sixteen classes, namely: (1.) Fevers; (2.) Diseases of the brain, &c.; (3.) 
Diseases of the heart and organs of circulation; (4.) Diseases of organs of 
respiration; (5.) Diseases of organs of digestion; (6.) Diseases of urinary 
organs ; (7.) Diseases of organs of generation ; (8.) Diseases of organs of loco- 
motion ; (9.) Diseases of skin and cellular tissue ; (10.) Diseases of uncertain 
seat; (11.) Malformation; (12.) Debility at birth, and premature birth; 
(13.) Old age; (14.) Sudden deaths; (15.) Violent or unnatural deaths; 
(16.) Causes not specified. 
X. Upwards of thirty years ago a classification was proposed by Dr. Wil- 
liam Farr, of the Registrar-General's Office, which recognized the following 
five large classes of disease, namely: 
1. Epidemic, endemic, and contagious diseases. 
2. Sporadic diseases of uncertain or variable seat. 
3. Sporadic disease of special systems and organs. 
4. External causes, poisoning, asphyxia, injuries. 
5. Developmental diseases. 
To the first of these classes he assigned the name of Zymotic diseases, to 
express the fact that a materies morbi was introduced into the body, and which 
remained for a time unperceived in the system, and that, after an indefinite 
period of incubation, leavened the whole mass of the circulating fluid; a 
pathological series of facts, however, which cannot be asserted positively of 
each form of disease comprehended in the class. Moreover, the larger number 
of diseases strictly preventible by efficient sanitary arrangements are compre- 
hended in this class, so that the so-called zymotic diseases came to be synony- 
mous with preventible diseases, and for statistical purposes it has become com- 
mon to point to a large number of deaths from zymotic diseases, or zymotic 
sickness in any locality, as an index of faulty sanitary arrangements. In that 
class were comprehended typhus, thrush, diarrhoea, rheumatism, syphilis, a group 
of diseases each one of which is now known to be composed of very different 
pathological elements, and, as a group, impossible to represent the existence 
of any definite or even similar cause. The class zymotic was thus made to 304 
METHODICAL NOSOLOGY - SYSTEMATIC MEDICINE. 
include diseases of which the origin and mode of propagation are wholly 
dissimilar; and the group was subdivided into " miasmatic, enthetic, dietic, and 
parasitic dseases," a subdivision involving no common principle. Even the 
miasmatic groups, implying diseases due to miasm (on which many medical 
men are at one as to the main features) is not a congruous group. Thus 
quinsy, a simple inflammation of the fauces, is placed next to scarlatina; ery- 
thema, simple redness of the skin, stands as a subordinate variety of erysipelas, 
which it is not. Diarrhoea stands between dysentery and cholera, and has no 
place among diseases of the intestinal canal, and the order concludes with ague 
and rheumatism, ignoring alike the malarious origin of the one, and the con- 
stitutional origin of the other-gout standing at the head of constitutional dis- 
eases. As to parasitic diseases being zymotic, it is now getting more and more 
difficult to understand even the analogy to such a pathological process (Med.- 
Chir. Review, O, 1869). 
None of these methods lead to a perfectly philosophical or purely natural 
classification, because diseases are not yet sufficiently understood to permit us 
to see clearly their mutual relations; and the best recommendation of any 
one of them would be a negative one-namely, that of doing the least possible 
violence to our very imperfect knowledge regarding the natural affinities or 
alliances of diseases, of which we have at present only a sort of instinctive 
recognition. But the tendency of modern investigations by the varied instru- 
ments and methods of research tends to prove -that many diseases hitherto 
supposed to be altogether functional are really accompanied with changes of 
structure of an anatomical, physical, or chemical kind. It is therefore not 
unreasonable to anticipate that all the so-called functional maladies will be 
found to depend upon some concomitant alteration of structure; and when 
we are unable to detect an alteration either of the solid or fluid parts of the 
body, in cases where the existence of disease cannot be doubted, we may 
attribute our failure to the imperfection of our means and instruments of 
observation, or our modes of using them. 
In the present imperfect state of our knowledge, therefore, diseases cannot 
be philosophically classified, nor arranged according to natural or true patho- 
logical relations, dependencies, or alliances. Nevertheless, a great advan- 
tage inevitably results from the institution of nosological classification, on 
account of the necessity which every such attempt imposes on those who en- 
gage in it, of marking very accurately the characteristic phenomena of partic- 
ular diseases; and every one acquainted with the progress of natural history 
must know that the study of details, and the repeated attempts to systematize 
them, have mutually promoted and supported each other. It is the same 
with regard to diseases; and if a Methodical Nosology cannot be rendered 
perfect, it is a certain proof that, for the time being, the details of which it 
must be composed are neither accurate nor complete, and are not likely to 
be so till attempts to observe, investigate, and systematize have made further 
progress. Every attempt to reduce to system tends to enlarge our stock of 
facts; and though we may fail to obtain a perfectly philosophical arrange- 
ment, yet the very attempt to attain it must be of advantage, by leading to 
useful discussions regarding the Pathology and History of diseases (Cullen). 
No one could be more convinced than Cullen was that "perfect division and 
definition is the summit of human knowledge in every department of science, 
and requires not only the clearest, but the most comprehensive views, such as 
(with respect to diseases) we can arrive at only by often-repeated attempts and 
much study." A no less distinguished pathologist-M. Bayle-in discussing 
the difficulties connected with classification, recommends us " to follow the 
plan which presents fewest imperfections, remembering that the determination 
of specific characters is what is most essential in Nosology, arrangement being 
the least important; for each arrangement will have its defects, will present 
its deficiencies, and exhibit some forced approximations." Every plan of PRESENT STATE AND AIM OF NOSOLOGY. 
305 
arrangement ought, therefore, to be accepted for what it is worth, and appre- 
ciated at its true value; namely, as to how far it fulfils the object for which 
it was mainly devised. Cullen, also, in his lectures and in his writings on 
this subject, everywhere speaks with the utmost modesty and diffidence, and 
endeavors at all times to impress upon the mind the fact that Nosology, like 
other branches of medical science, must necessarily be progressive in its ad- 
vancement ; and that it is only by frequent and multiplied trials that it can 
be brought to any degree of perfection. A perfectly philosophical or natural 
system of classification aims at having the details of its plan to agree in every 
respect with all the facts as they exist in nature. To effect this end, arrange- 
ments, as they naturally exist, require to be traced out, not devised. The 
tracks in which such a pursuit must be followed up, and in which our knowledge 
is as yet deficient, may be shortly indicated under the following heads, namely: 
(1.) The affinities or alliances of diseases with each other. (2.) The morbid 
anatomy of diseased parts. (3.) The communication, propagation, inocula- 
tion, generation, development, course, and spontaneous natural termination 
of diseases. (4.) The connection of the phenomena recognized during life 
with the facts .of morbid anatomy. (5.) The geographical distribution of 
diseases. (6.) The succession of diseases, so far as they can be traced through 
past ages ; the peculiarities they have exhibited at different periods in the 
world's history, or within comparatively recent cycles of years. But the time 
has not yet come for a classification on a basis so comprehensive-simply be- 
cause the material does not yet exist; and attempts to make so-called natural 
systems of arrangement must end in disappointment, on account of the uncer- 
tain and fluctuating data on which they must be based. Such attempts are 
apt to suggest the serious question, "Whether such Nosology promotes or 
retards the progress of Medicine ?" 
Present State and Aim of Nosology.-The most distinguished physicians 
and statists have recently lent their aid to obtain a nomenclature and classi- 
fication of diseases which can be applied to the wants of the civil and military 
population in every country. Dr. William Farr devised a system of Nosology 
which was discussed at several meetings of the Statistical Congress of the 
Great Powers of Europe, convened for the purpose, amongst other business, 
of devising and adopting a uniform system of nomenclature for recording 
diseases and the causes of death from them. The Congress met in Paris on 
the 10th of September, 1855, when a nomenclature of the causes of death was 
agreed upon, essentially the same as that used in England and Geneva. At 
a third Conference, held at Vienna in 1857, a nomenclature substantially uni- 
form was agreed upon for adoption in all the states of Europe; and fatal 
cases were to be registered on a uniform plan. Dr. Farr's system of nomen- 
clature has been in use now for many years by the Registrar-General of this 
country, and more recently by the Army Medical Department. It was also 
adopted in previous editions of this Text-book; and although it had many 
imperfections and defects, it was still practically the most useful and authori- 
tative Nosology. " In the English list of names," proposed and adopted by 
the College of Physicians, " it seemed desirable that as little deviation as pos- 
sible should b^ made from those employed by the Registrar-General of Eng- 
land ; otherwise his settled plans, and his forms of returns, which have been 
followed for years, would require to be remodelled ; the comparison of future 
years with past returns would be made difficult and perplexing, if not impos- 
sible ; and a damaging break would be caused in evidence which becomes 
more and more trustworthy and valuable in proportion as it is prolonged and 
continuous." 
The important task of devising a " Provisional Nomenclature and Defini- 
tion of Diseases," consistent with the progress of medical science, engaged the 
attention of a committee of the Royal College of Physicians of London during 
the ten years from 1857 to 1867. After many interruptions and much con- 306 
METHODICAL NOSOLOGY-SYSTEMATIC MEDICINE. 
sideration, the committee at last completed their work, and submitted a Pro- 
visional Nomenclature to the College on the 3d of August, and again on the 
28th of November, 1867, when it was unanimously adopted.* 
* The circumstances of the origin and progress of this great work are of historical 
importance, and are thus recorded by the College: " The idea which led to the forma- 
tion of a general Nomenclature of Diseases originated in a correspondence between 
Dr. Dumbreck, of the Medical Department of the Army, and Dr. Sibson, respecting 
the need of such a nomenclature for use in the Army Medical Service. But at the 
Comitia majora of the Royal College of Physicians, held on the 9th July, 1857, it was 
resolved, on the motion of Dr. Nairne, in consequence of a letter addressed to the Col- 
lege by the Hospitals' Committee of the Epidemiological Society, ' That a committee 
be appointed to prepare a Nomenclature of Diseases, and that such committee have 
full power to co-operate with other bodies.' 
" The following Fellows of the College were appointed members of the committee 
by the President of the College : Drs. Mayo, Alderson, Hawkins, Jeaffreson, Pitman, 
Bence Jones, Risdon Bennet, Munk, Babington, Addison, Nairne, Barker, Budd, 
Gull, Baly, Barclay, Sibson, Parkes. At the first meeting of the committee Dr. Sib- 
son was appointed Secretary. 
" The following representative members afterwards consented to co-operate in car- 
rying into effect the objects of the committee : Mr. Stanley, President of the Royal 
College of Surgeons; Dr. Druitt, Representative of the Master of the Worshipful 
Society of Apothecaries ; Sir John Liddell, Director-General of the Medical Depart- 
ment of the Navy; Dr. Logan, Director-General of the Medical Department of the 
Army ; Sir Ranald Martin, Representative of the East India Company ; Dr. Farr, 
Representative of the Registrar-General ; Mr. Simon, Medical Officer of the Privy 
Council; Mr. Holmes, Secretary of the Hospitals' Committee of the Epidemiological 
Society. 
" The meetings of the committee were suspended in 1858, in consequence of the 
passing of the Medical Act of that year, and of the alterations thereby rendered 
necessary in the constitution and regulations of the College. They were resumed 
in 1863, and the following members were then or subsequently added to the com- 
mittee : 
"Sir Thomas Watson, Bart., President of the College of Physicians; Mr. Luke, 
President of the Royal College of Surgeons ; Dr. Bryson, Director-General of the 
Medical Department of the Navy ; Dr. Balfour, Deputy Inspector-General of Hospi- 
tals and Head of the Statistical Branch at the Army Medical Board ; Dr. Stark, 
Representative of the Registrar-General of Scotland ; Dr. N. M. Burke, Representa- 
tive of the Registrar-General of Ireland; Dr. Mackay, R.N., Deputy Inspector-Gen- 
eral of Fleets ; Mr. Moore, Surgeon to the Middlesex Hospitals ; and Drs. C. J. B. 
Williams, Barlow, Arthur Farre, Black, Frederick Weber, Charles West, Chambers, 
Monro, George Johnson, Quain, Kirkes, Wilks, Bristowe, Henry Thomson, Hermann 
Weber, Gueneau de Mussy, McWilliam. 
" A Classification Sub-Committee was formed, consisting of-Sir Thomas Watson, 
Bart. (Chairman), Drs. Farr, Barclay, Balfour, C. J. B. Williams, Quain, Sibson, Mr. 
Simon, and Mr. Holmes. 
"A Definition Sub-Committee was also formed, consisting of-Drs. Barlow, Arthur 
Farre, West, Chambers, Monro, George Johnson, Barclay, Sibson, Parkes, Kirkes, 
Wilks, Bristowe, Balfour, Mr. Moore, and Mr. Holmes. 
" Mr. Gaskill and Dr. Nairne (Commissioners in Lunacy) attended the meetings of 
the committee when the subject of Insanity was under consideration. 
"Mr. Cartwright and Mr. Tomes attended the meetings when the diseases of the 
Teeth were under consideration. 
" The Latin Nomenclature was prepared by Dr. Henry Thomson, and revised by 
Dr. Black. 
"The French Nomenclature was prepared by Dr. Gueneau de Mussy. 
"The German Nomenclature was drawn up by Dr. Hermann Weber, and revised 
by Dr. Frederick Weber. 
"The Italian Nomenclature was drawn up by Dr. Frederick Weber. 
" The List of Deformities was drawn up by Dr. Arthur Farre. 
"The entire work has been edited by the Secretary, Dr. Sibson ; with whom Dr. 
Barclay took part in editing more especially the Medical portion. The Surgical por- 
tions of the Nomenclature were prepared and, in conjunction with the Secretay, edited 
by Mr. Moore and Mr. Holmes. 
"Official changes during the period of the existence of the committee led also to 
the introduction into it of the following additional members: Mr. Partridge, as 
President of the Royal College of Surgeons ; Drs. Birkett, Owen Rees, Handfield 
Jones, Basham, Herbert Davies, Guy, Peacock, Wegg, as Censors of the College of ORIGIN OF THE NEW NOMENCLATURE. 
307 
This is a great achievement. The Registrars-General of England, Scotland, 
and Ireland, the chiefs of the Medical Department of the Army and Navy, 
and of the British troops in India, have all concurred with others in framing 
the Nomenclature; and therefore it is not unreasonably expected that greater 
accuracy, certainty, and uniformity, for comparison, than heretofore will char- 
acterize the statistical records of disease, alike in civil life arid in the public 
services. To facilitate the work becoming international, the College has trans- 
lated its nomenclature into Latin, French, German, and Italian equivalents. 
The methods of gradually improving the Nomenclature of Diseases in 
Medicine have some analogy to the methods of gradually improving Repre- 
sentative Reform in Politics. A nomenclature of diseases and a policy of 
parliamentary representation, judicious and proper a quarter of a century ago, 
must each eventually give place to the influence of progressive knowledge and 
power, which invariably come with the rapid movements of the age in which 
we live. But reform, whether of political representation or of medical nomen- 
clature, to be generally acceptable, cannot be the work of one man, nor the 
accomplishment of a limited period of time. To be on a broad basis and free 
of prejudice, each work ought to be the combined result of the best men of 
the time-each man being willing to yield, adapt, and mould his convictions 
on entering into a mutual arrangement to achieve a common end. Men thug 
brought together, who differ very seriously as to certain points, may yet, by 
mutual discussion and concession, come to a definite and reasonable agree- 
ment for practical purposes-the terms of the compromise being settled, 
doubtless, at the expense of some personal bias, which often has a firmer hold 
the more imperfect the information of the holder, but which mutual delibera- 
tion clears away. Knowing how biassed in opinion individual members of 
professional and political bodies are apt to be, the unanimous adoption of a 
Provisional Nomenclature by the London College of Physicians is undoubt- 
edly a great and a bold achievement; and although essentially a compro- 
mise of conflicting, and sometimes even of opposing views, the result is a work 
beyond all praise. It is thus, and thus only, that, in an uncertain science 
like medicine, any approach to truth can be attained. 
The plan of the "Nomenclature" is, first, "to give an English name to the 
disease, employing the terms in popular use whenever they are not absolutely inac- 
curate; and to use only one word, or as few words as possible, in naming a dis- 
ease" Definitions have been attached to the English names in some instances 
only, as where there might be some .ambiguity as to the signification which the 
College desires to attach to them. Thus the definitions have been framed for the 
purpose of identification only, not as explanations of the phenomena of disease. 
Secondly, the classification adopted is based upon anatomical considerations, on 
this principle,-General Diseases, or such as affect the whole frame, subdivided 
into Sections A and B; and Local Diseases comprehend the classification. 
" Section A comprehends those disorders which appear to involve a morbid 
condition of the blood, and which present, for the most part, but not all of 
them, the following characters: They run a definite course, are attended with 
fever and frequently with eruptions on the skin, are more or less readily com- 
municable from person to person, and possess the singular and important 
property of generally protecting those who suffer them from a second attack. 
They are apt to occur epidemically." 
Some of the so-called Zymotic diseases of Dr. Farr are comprehended in 
this classification. 
Physicians. Dr. Alderson's first official act after his election as President of the Col- 
lege was to appoint Sir Thomas Watson chairman of the committee." 
These names are the names of men who hold, or have held, the highest place as 
representative men in the Science of Medicine; and are at once a guarantee of the 
intellect and practical knowledge which have been brought to bear upon the work. 
The preface to the Nomenclature, from the pen of the,chairman of the committee, is 
extremely suggestive; and the work ought to be in the hands of every student of Medi- 
cine, and the handbook of every one who has to do with the Registration of Diseases. 308 
METHODICAL NOSOLOGY-SYSTEMATIC MEDICINE. 
" Section B comprises for the most part disorders which are apt to invade 
different parts of the same body simultaneously or in succession. These are 
sometimes spoken of as constitutional diseases, and they often manifest a 
tendency to transmission by inheritance." 
Some of the Constitutional diseases of Dr. Farr are comprehended in this 
classification. 
Many older physicians may regret the absence of those classes of disease 
familiar to them ever since they commenced the study of medicine, and 
which they learned from Cullen's Nosology-then the safest guide to classifi- 
cation which the student could follow. But the conflict of opinion rendered 
it impossible, we are told, for the Committee of the College to subdivide into 
smaller groups the larger divisions of diseases which have been adopted. To 
each individual, therefore, and especially to each teacher of medicine, must 
be left the formation of such groups as may facilitate to himself and to his 
pupils the study of the science from that particular standpoint which forms the 
groundwork of his study or his teaching (Med.-Chir. Rev., O, 1869). No fact 
could be predicated of any number of diseases which was not either too wide 
in its comprehensiveness, or too narrow in its exclusiveness, or which did not 
imply a theory which might have been found to be true of certain members 
of a group, but could only be applied theoretically to the remainder. There- 
fore the committee abandoned all attempts to subdivide the diseases into 
groups, beyond arranging under the two Sections A and B all that ought strictly 
to be called general diseases. To give any definition of either section was also 
found impossible, because no definition would absolutely embrace the whole 
of its members, and yet seem to exclude those belonging to the other division. 
A conception of the dominant character of each section would be more readily 
found by a simple enumeration of its constituent members than by any expo- 
sition of it in the set terms of a definition. 
Thus the general diseases of the College embrace the original classes 1 and 
2 of Dr. Farr's classification. The local diseases follow nearly the same 
order as Class 3 of Dr. Farr (p. 303, ante). The primary distinction between 
the general and local diseases is recognized in this: that the first comprehend 
those which more or less pervade the whole system, and in which any local 
affection, whether essential or accidental, is due to the previous existence of 
some general malady; while the second, or local diseases, are those which 
affect certain organs, and in which, when any other part of the body is 
involved, it is so only as a consequence of the primary disorder or local lesion. 
In studying the Science of Medicine systematically, a methodical nosol- 
ogy ought to be regarded as a table of reference to aid the student in naming 
diseases, and so preserving uniformity in his records and diagnosis, and a 
system to guide him generally in acquiring a knowledge of his profession, 
especially with reference to the practical questions of the day. The Nosology 
of tlie Royal College of Physicians of London ought, therefore, to be accepted 
simply as a contrivance to aid us in giving the same name to similar condi- 
tions of disease, and "for perfecting the statistical registration of diseases, 
with a view to the discovery of statistical truths concerning their history, 
nature, and phenomena." The nomenclature takes no note of causation, it 
deals only with the pathological fact, and the arrangement is really, in its 
main features, anatomical,-the organs are viewed as portions of tissue, which 
have deviated from the healthy standard. Such a nomenclature of diseases 
as that now recommended for general adoption, is a great boon alike to the 
medical profession and to the public; and as it will still enable future regis- 
tration to be compared with the past registration of the Registrar-General, it 
will gradually and eventually supersede that system for the registration of 
disease in Civil Hospitals, and in the Public Services. Numbers are intro- 
duced with each disease for the purpose of easy reference in double entries. 
But practically there is sometimes a difficulty here, as shown by my friend 
Dr. Steele, in the application of the nomenclature and classification to the THE FUTURE PROSPECTS OF NOSOLOGY. 
309 
registration of diseases in Guy's Hospital. In framing the report of that 
hospital for 1868, and in the attempt to adhere to the numerical arrangement 
in the construction of the statistical tables, Dr. Steele found himself frequently 
at a loss for a numerical indicator corresponding to the particular complaint. 
This arose from two causes: the first depending on the exclusively anatomical 
character of the terminology, which does not provide for diseases of a dupli- 
cate or multiple character, such as broncho-pneumonia, pneumonia-typhus, 
pleuro-pneumonia, disease of joint, &c.; and the other attributable to the too 
rigid definitions which, in many cases, and then not always, could only hope 
to be revealed by post-mortem examination. Many obscure affections of the 
heart, brain, &c., can only be entered as " disease of heart, or brain," as the 
case may be, without corresponding numbers to escape the possibility of " reck- 
less conjecture" in the absence of a post-mortem examination. In the regis- 
tration of disease in an hospital, a column should be added to the disease 
table, to be filled in from the post-mortem register (as has been done by Dr. 
Steele), indicating the more immediate cause of death. Such is especially 
useful where a difficulty has been experienced during life in selecting, fixing, 
upon, or specifying any one particular form of disease, where two or more 
have contributed to the fatal issue. Dr. Steele's statistical tables, which have 
been annually published for the past twenty years, relative first to the Glas- 
gow Infirmary, and subsequently to Guy's Hospital, London, are models of 
the construction of such tables for hospital registration, and of the resulting 
information to be obtained from them. 
The Science of Pathology, we know, is yet too young to base a scientific 
classification upon ; and as the Science of Pathology and the Art of Practical 
Medicine advance, so must Nosology. But there are many nice questions 
which always will arise, relative to the nature of diseases, on which it is in 
vain to expect physicians and statists to agree unanimously ; and therefore 
no system even of naming, far less of classifying, the diseases of mankind can 
we hope to see, otherwise than as a provisional one, ready to assimilate itself 
to the progressive advance of the Science of Medicine, which is a plant of 
slow but of sure growth. There is every reason to hope, however, that, by the 
numerous inquisitive researches of the day, Pathology and Nosology will grow 
even more rapidly than hitherto. The mere enumeration of diseases has almost 
doubled since Cullen's Nosology was written; while our knowledge of facts 
relating to disease has greatly more than doubled. Cullen's Nosology became 
effete and useless at last, under the pressure of increasing knowledge acquired 
and effected with resources very inferior to those we now possess, and far less 
extensive. The nomenclature and classification thus adopted by the College 
is therefore strictly provisional, being " subject to decennial revision," as stated 
on the title-page. It would be well, then, if the Colleges of Physicians and 
Surgeons in Scotland and in Ireland (who unfortunately do not seem to have 
taken part in the preparation of the nomenclature) would unite with that of 
London in this eminently practical work, and appoint committees to commu- 
nicate with each other in revising and readjusting such nomenclature at the 
end of every ten years ; and so stamp with their united authority the progres- 
sive improvements in the Science of Medicine which are capable of being indi- 
cated or expressed in the Nomenclature and Definitions of diseases. Such 
systematic arrangements, if consistent with existing knowledge, never cramp 
or hamper a man in carryingout scientific investigations ; on the contrary, they 
enable him to see more clearly in what direction his labor must be advanced, 
and demonstrate more forcibly than otherwise the deficiencies of his knowledge. 
The "Provisional Nomenclature" of the Royal College of Physicians of 
London, comprehended in the following list, has therefore been adopted in the 
text of this edition (sixth); while the synonyms, equivalents, and definitions 
have also been incorporated at the places where the diseases are described in 
the text, throughout both volumes. 310 
THE NOMENCLATURE OF DISEASES. 
CHAPTER II. 
TABULAR VIEW OF "THE NOMENCLATURE OF DISEASES" DRAWN UP BY A 
' JOINT COMMITTEE APPOINTED BY THE ROYAL COLLEGE OF 
PHYSICIANS OF LONDON (1869). 
A. 
1. Small-pox. 
Group A (unmodified). 
Group B (modified).1 
Varieties, applicable to both 
groups: 
a. Confluent. 
b. Semi-confluent. 
c. Distinct. Syn., Discrete. 
d. Abortive. Syn., Varicel- 
loid. 
Subordinate Varieties: 
e. Petechial. 
f. Hemorrhagic. 
g. Corymbose. 
2. Cow-pox. 
3. Chicken-pox. 
4. Measles. 
5. Scarlet fever. Syn., Scarlatina. 
Varieties : 
a. Simple. 
b. Anginose. 
c. Malignant? 
6. Dengue. 
7. Typhus fever. 
8. Cerebro-spinal fever. Syn., 
Malignant purpuric fever; 
Epidemic cerebro-spinal me- 
ningitis. 
9. Enteric fever. Syn., Typhoid 
fever; and in children is 
often named Infantile re- 
mittent fever.3 
10. Relapsing fever. 
11. Simple continued fever. 
12. Febricula. 
GENERAL DISEASES. 
13. Yellow fever. 
14. Plague. 
15. Ague. Syn., Intermittent 
fever. 
Varieties: a. Quotidian. 
b. Tertian. 
Sub-variety: 
Double tertian. 
c. Quartan. 
Sub-variety: 
Double quartan. 
d. Irregular. 
(101b.) Brow Ague. 
16. Remittent fever.4 
17. Simple cholera. 
18. Malignant cholera. Syn., Ser- 
ous cholera; Spasmodic 
. cholera; Asiatic cholera. 
a. Choleraic diarrhoea. 
19. Diphtheria. 
a. Diphtheritic paralysis. 
20. Hooping-cough. 
21. Mumps. 
22. Influenza. 
23. Glanders. 
24. Farcy. 
25. Equinia mitis. Syn., Grease. 
26. Malignant pustule. 
27. Phagedeena. 
28. Sloughing phagedeena. 
29. Hospital gangrene. 
30. Erysipelas. 
Varieties: 
a. Simple. Syn , Cutaneous. 
b. Phlegmonous. Syn., Cel- 
lulo-cutaneous. 
c. Diffuse inflammation (of 
cellular tissue).5 
31. Pyremia? 
32. Puerperal fever.1 
33. Puerperal ephemera. Syn., 
Weed. 
B. 
34. Acute rheumatism. Syn., 
Rheumatic fever. 
(a.) Subacute rheumatism. 
35. Gonorrhoeal rheumatism. 
36. Synovial rheumatism. 
37. Muscular rheumatism. 
Local varieties: 
a. Lumbago. 
b. Stiff neck. 
38. Chronic rheumatism.8 
39. Acute gout, 
40. Chronic gout. 
41. Gouty synovitis.9 
42. Chronic osteo-arthritis. Syn., 
Chronic rheumatic arthritis. 
43. Syphilis. 
a. Primary syphilis. 
Varieties: 
Hard chancre. 
Indurated bubo. 
Soft chancre. 
Suppurating bubo. 
Phagedeenic sore. 
Sloughing sore. 
b. Secondary syphilis.10 
C. Hereditary syphilis. 
1. Local syphilitic affections.11 
1 The definitions are omitted in this table, because they are given in the text, with the description of 
each disease. 
2 Scarlet fever occurs occasionally without any rash or sore throat being observed. 
3 Fevers symptomatic of worms, teething or other sources of irritation, should not be included under 
this head. 
4 The malignant local fevers of warm climates are usually of this class. 
5 In slight er cases, occurring on the surface of the body, diffuse inflammation is identical with phlegmo- 
nous erysipelas. In registering cases of phlegmonous erysipelas, and of diffuse inflammation arising 
from injury, surgical operation, or local disease, the cause should be specified. 
6 In returning cases of pyaemia, specify the affected organs. 
1 In returning cases of puerperal fever, the more important local lesions, such as peritonitis, effusions 
into serous and synovial cavities, phlebitis, and diffuse suppuration should be specified 
8 Cases attended with deposit of urate of soda are to be returned as chronic gout, and those in which 
there is marked distortion as chronic osteo-arthritis. 
9 Retrocedent gout is a term applied to cases of gout in which some internal organ becomes affected on 
the disappearance of the disease from the joints. It should be referred to acute or chronic gout. 
10 Tertiary syphilis is a term sometimes applied to the later symptoms, when separated by an interval 
of apparent health from the ordinary secondary syphilis. 
11 In returning local syphilitic affections, specify whether the case be one of primary syphilis, secondary 
syphilis, syphilitic deposit, or syphilitic inflammation. Local syphilitic affections, local cancer, local 
colloid, and local scrofulous affections are to be returned in the following order: 
1. Brain. 
2. Spinal cord. 
3. Nerve. 
4. Eye. 
5. Eyelid. 
6. Orbit. 
7. Auricle. 
8. Internal ear. 
9. Face. 
10. Nose. 
11. Pericardium. 
12. Heart. 
13. Lymphatics. 
14. Lymphatic glands. 
15. Bronchial glands. 
16. Thyroid gland. 
17. Thymus gland. 
18. Suprarenal capsule. 
19. Larynx. 
20. Bronchi. 
21. Lungs. 
22. Pleura. 
23. Mediastinum. 
24. Lips. 
25. Mouth. 
26. Cheek. 
27. Jaws. 
28. Gum. 
29. Tongue. 
30. Fauces. 
31. Tonsils. 
32. Salivary glands. 311 
THE NOMENCLATURE OF DISEASES. 
44. Cancer. Syn., Malignant dis- 
ease.1 
Varieties: [cer. 
a. Scirrhus. Syn., Hard can- 
b. Medullary cancer. Syn., 
Soft cancer.3 
c. Epithelial cancer. Syn., 
Cancroid epithelioma. 
d. Melanotic cancer. Syn., 
Melanosis. 
e. Osteoid cancer.3 
1. Local cancer.4 
45. Colloid. Syn., Colloid cancer; 
Alveolar cancer. 
1. Local colloid.5 
Arrangement of non-malig- 
nant Tumors and Cysts.6 
Fibrous tumor.1 
Fibro-cellular tumors.8 
Fibro-nucleated tumor. 
Fibro-plastic tumor.9 
Myeloid tumor. 
Fatty tumor. Syn., Lipoma. 
Osseous tumor. 
a. Of bone. Syn-., Exostosis, 
Varieties: 1. Ivory. 
2. Cancellated. 
3. Diffused. 
b. Of the soft parts. 
Cartilaginous tumor. Syn., 
Enchondroma. 
Fibro-cartilaginous tumor. 
Glandular tumor. Syn., Ade- 
nocele. 
Vascular tumor. 
Naevus. 
Sebaceous tumor. 
Cholesteatoma. 
Molluscum. 
Warty tumor and warts. 
Condyloma. 
Cheloid. 
Villous tumor. 
Simple or barren cysts. 
a. Serous. 
b. Synovial. Syn., Bursal. 
c. Mucous. 
d. Suppurating. 
e. Sanguineous. 
f. Hemorrhagic. 
g. Aneurismal. 
h. Oily. 
i. Colloid or gelatinous. 
j. Seminal. 
Compound or proliferous 
cysts. 
a. Complex cystic tumor. 
Syn., Cysto-sarcoma. 
1. With intracystic 
growths. 
b. Cutaneous or piliferous 
cyst. Syn., Dermoid. 
c. Dentigerous cyst. 
46. Lupus. 
Varieties : 
a. Chronic lupus. 
b. Lupus exedens. 
47. Rodent ulcer. 
48. True leprosy. Syn., Elephan- 
tiasis Graecorum. 
49. Scrofula.10 
Varieties : 
a. Scrofula with tubercle. 
b. Scrofula without tuber- 
cle. 
1. Local scrofulous affections.11 
Tubercular meningitis. 
Scrofulous ophthalmia. 
Tubercular pericarditis. 
Scrofulous disease of glands. 
Phthisis pulmonalis. 
Hsemoptysis.13 
Acute miliary tuberculosis. 
Tabes mesenterica. 
Tubercular peritonitis. 
50. Pickets. 
51. Cretinism. 
Varieties : 
a. Complete cretinism. Syn., 
Incurable cretinism. 
b. Incomplete cretinism. 
Syn:, Curable cretinism. 
52. Diabetes. Syn., Diabetes mel- 
litus. 
(935a.) Ergotism.13 
53. Purpura. 
Varieties: 
a. Simple. 
b. Hemorrhagic. 
54. Scurvy. 
55. Ansemia.13 
56. Chlorosis. Syn., Green sick- 
ness. 
57. General dropsy.14 
58. Beri-Beri. 
LOCAL DISEASES. 
Catarrh. 
Inflammation. 
ARRANGEMENT OF LOCAL DISEASES.14 
Ulcerative inflammation. 
Suppurative inflammation. 
Plastic inflammation. 
(31.) Pycemic inflammation.13 
33. Pharynx. 
34. Oesophagus. 
35. Stomach. 
36. Intestines. 
37. Rectum. 
38. Anus. 
39. Liver. 
40. Hepatic ducts and 
gall-bladder. 
41. Pancreas. 
42. Spleen. 
43. Peritoneum. 
44. Mesenteric glands. 
45. Kidney. 
46. Bladder and urethra. 
47. Prostate gland. 
48. Penis. 
49. Scrotum. 
50. Testicle. 
51. Ovary. 
52. Fallopian tube. 
53. Uterus. 
54. Vagina. 
55. Vulva. 
56. Female breast. 
57. Male mammilla. 
58. Bone. 
59. Skull. 
60. Joint. 
61. Spine. 
62. Muscle. 
63. Tendon. 
64. Fascia. 
65. Cellular tissue. 
66. Skin. 
1 In returning cases of cancer in more than one organ, specify in which the disease is primary, and in 
which secondary. State also the kind and duration of the disease in each case, and the nature of all 
operations, with their dates and results. 
3 Fungus hsematodes is a term applied to some cases of medullary cancer, which are more than usually 
vascular. Hard encephaloid is a designation sometimes applied to medullary cancers of unusually firm 
consistence. These two forms of the disease should be returned under the title of Medullary cancer. 
3 Cancer in mucous membranes, when covered by a villous growth, has received the name of Villous 
cancer. 
4 In returning cases of local cancer, specify the variety of cancer, by adding, after "44," the letter a, b, 
c, d, or e, according to the nature of the case (as above). They are to be returned in the order specified 
in the fooGnote (") of previous page. ' 
5 Cases of local colloid are to be returned in the order specified in the foot-note (") of previous page. 
s In order that the malignant and non-malignant growths may appear together, the non-malignant 
tumors and cysts are inserted here. They should, however, be returned among the local diseases, under 
"Non-malignant tumors," and they are not, therefore, numbered at this place. 
' When the tumor contains cysts, it has received the name of Fibrocystic. When it contains earthy 
matter, it has been named Fibro-calcareous. When it grows from bone, and is partly ossified, it consti- 
tutes the non-malignant form of the disease known as Osteo-sarcoma. When it contains involuntary 
muscle, as when growing in the uterus, it has received the name of Fibro-muscular. When it contains 
fat, it has been named Fibro-fatty. Other fibrous tumors have been named according to their seat, e.g., 
Neuroma. Painful subcutaneous tumor. 
8 When occurring as a pendulous outgrowth from a mucous surface, it constitutes the chief varieties 
of Polypus. 
8 When the fibro-cellular or fibro-plastic tumor, but more especially the latter, slowly involves the 
adjacent soft structures, and returns after removal, it has received the name of Recurrent'fibroid. 
10 The constitutional tendency which has received the name of the Scrofulous Diathesis, when unat- 
tended by local lesions, is not to be returned as a disease. 
11 These and all other cases of local scrofulous affection are to be returned in the order specified in the 
foot-note (") of previous page. 
13 When the cause of this affection has been ascertained, the case should be returned under the head 
of the primary disease, the secondary affection being also specified. 
13 The diseases printed in italics are to be returned, not among the local diseases, but under the head- 
ings referred to by number. 
11 Local dropsies, such as ovarian, and effusions into the serous cavities, as hydrothorax or ascites, when 
not connected with anasarca, should be returned as local diseases. 
15 The Local Diseases have been drawn up in accordance with the following arrangement, and the 312 
THE NOMENCLATURE OF DISEASES. 
Rheumatic inflammation. 
Gouty inflammation. 
(43*.) Syphilitic inflammation. 
(49*.) Scrofulous inflammation. 
Gonorrhceal inflammation. 
Gangrene. 
Passive congestion. 
Extravasation of blood. 
Hemorrhage. 
Dropsy. 
Fibrinous deposit. 
Alteration of dimensions. 
Dilatation. 
Contraction. 
Hypertrophy. 
Atrophy. 
Degeneration. 
Fatty and calcareous. 
Syn., Atheroma. 
Ossification. 
Fibroid. 
Lardaceous disease. Syn., 
Amyloid disease. Waxy 
disease. 
(43*.) Syphilitic disease. 
(44*.) Cancer. 
(45*.) Colloid. 
Non-malignant tumors. 
Cyst. 
(49*.) Scrofula. 
(49*a.) a. With tubercle. 
(49'b.) b. Without tubercle. 
Parasitic disease. 
Calculus and concretion. 
Malformation. 
(992, &c.) Injury. 
(1014, &c.) Foreign body. 
Functional diseases. 
Diseases of the Brain and its 
Membranes. 
59. Encephalitis.2 
60. Meningitis. 
1. Inflammation of the dura 
mater3 
2. Inflammation of the pia 
mater and arachnoid. 
(491.) 3. Tubercular meningitis. 
Syn., Acute hydroceph- 
alus. 
(8.) Cerebrospinal fever. 
61. Inflammation of the brain. 
62. Red softening (of the brain). 
63. Yellow softening (of the 
brain). 
64. Abscess (of the brain). 
65. Apoplexy. 
Varieties : 
a. Congestive. 
b. Sanguineous. Syn., Cer- 
ebral hemorrhage. 
66. Sunstroke. 
67. Chronic hydrocephalus. 
68. Hypertrophy (of the brain). 
69. Atrophy (of the brain). 
70. White softening (of the brain). 
Syn., Atrophic softening.4 
(43'.) Syphilitic disease. 
(44*.) Cancer. 
71. Fibrous tumor. 
72. Osseous tumor. 
(49*.) Tubercular deposit. 
a. Miliary or granular tu- 
bercle! 
b. Yellow tubercle. 
73. Parasitic disease. 
Return cases of this class ac- 
cording to the list at pp. 146 
to 148. 
73*. Malformations. 
Return such cases here ac- 
cording to the list at pp. 234 
to 238. 
74. Diseases of the cerebral ar- 
teries. 
a. Fatty and calcareous de- 
generation. Syn., Ather- 
oma, Ossification. 
b. Aneurism. 
DISEASES OF THE NERVOUS SYSTEM.1 
c. Impaction of coagula. 
1. Thrombosis. (Local 
coagulation.) 
2. Embolism. (Coagula 
conveyed from a dis- 
tance.) 
Diseases of the Spinal Cord 
and its Membranes. 
75. Inflammation.6 
Varieties: 
a. Spinal meningitis. 
b. Myelitis. 
76. Hemorrhage (Spinal). Syn., 
Spinal apoplexy. 
77. Atrophy (Spinal). Syn., Tabes 
dorsalis. 
78. White softening (of the Spinal 
cord). 
(441.) Cancer. 
79. Non-malignant tumors. 
Return such tumors here ac- 
cording to the list atp. 311. 
80. Malformations. 
Return such cases here ac- 
cording to the list at pp. 234 
to 238. 
a. Spina bifida. 
Diseases of the Nerves. 
81. Inflammation. 
82. Atrophy. 
(44*.) Cancer. 
83. Neuroma. 
84. Paralysis.7 
(108.) 1. Paralysis of the insane. 
Syn., General paralysis. 
85. 2. Hemiplegia.7 
86. 3. Paraplegia.7 
87. 4. Locomotor ataxy.7 
(797.) 5. Progressive muscular atro- 
phy. 
88. 6. Infantile paralysis.7 
89. 7. Local paralysis.7 
a. Facial paralysis. 
b. Scrivener's palsy. 
(19a.) 8. Diphtheritic paralysis! 
(908b.) 9. Lead palsy. 
(966a*.) 10. Paralysis from Lathyrus. 
Functional Diseases of the 
Nervous System. 
90. Tetanus. 
91. Hydrophobia. 
92. Infantile convulsions. 
93. Epilepsy. 
a. Epileptic vertigo. Syn., 
Petit mal. 
94. Convulsions7 
95. Spasm of muscle. 
96. Laryngismus stridulus. Syn., 
Spasm of the glottis, Spas- 
modic croup. Child-crow- 
ing. 
97. Shaking palsy. 
(907a.) Mercurial tremor. 
98. Chorea. Syn., St. Vitus's 
dance. 
a. Acute. 
ft. Chronic. 
99. Hysteria. 
100. Catalepsy. 
(243.) Syncope. 
101. Neuralgia. 
Principal Varieties: 
a. Facial. Syn., Tic dou- 
loureux. 
b. Brow ague. Syn., Hemi- 
crania. 
c. Sciatica. 
d. Pleurodynia.7 
e. Irritable stump. 
102. Hyperaesthesia.7 
103. Anaesthesia.7 
(938a.) Delirium tremens. 
104. Hypochondriasis. 
Disorders of the Intellect. 
105. Mania. 
a. Acute mania. 
b. Chronic mania. 
106. Melancholia.8 
107. Dementia. 
a. Acute dementia. 
b. Chronic dementia. 
108. Paralysis of the insane. Syn., 
General paralysis. 
109. Idiotcy (Congenital). 
110. Imbecility (Congenital). 
Diseases of the Conjunctiva.8 
111. Conjunctivitis. Syn., Oph- 
thalmia. 
DISEASES OF THE EYE 
112. Catarrhal ophthalmia. 
113. Pustular ophthalmia. 
114. Purulent ophthalmia. 
1115. Purulent ophthalmia of in- 
fants. Syn., Ophthalmia 
neonatorum. 
nature of the lesions comprehended in such local disease has been described in the first part of this Text- 
book, from p. 67 to the end of Part I, as "Topics relative to Pathology." 
1 The diseases printed in italics under this heading are inserted for the sake of local classification only, 
and are not to be registered here, but at the place referred to in each instance by number. 
2 This term is to be used only when the precise seat of the inflammation has not been ascertained by 
post-mortem examination. 
3 This form of inflammation is almost invariably the result of injury or disease of the bones of the 
skull; in such cases the injury or disease by which it is caused ought to "be specified. 
4 This form of disease is the result of imperfect nutrition, owing to deficient supply of blood, and is in 
most instances dependent upon mechanical obstruction, or degeneration of the cerebral arteries. 
6 To be referred to tubercular meningitis. 
6 This term is to be used only when the precise seat of the inflammation has not been ascertained by 
post-mortem examination. 
' When the cause of this affection has been ascertained, the case should be returned under the head of 
the primary disease, the secondary affection being also specified. 
8 Cases of so-called monomania are to be classed under chronic mania or melancholia, according to 
their character. 
8 Register the diseases printed here in italics, not under this heading, but at the place referred to in 
each instance, by number. THE NOMENCLATURE OF DISEASES. 
313 
(491.) Scrofulous ophthalmia. Syn., 
Strumous ophthalmia. 
116. Exanthematous ophthalmia. 
117. Gonorrhoeal ophthalmia. 
118. Chronic ophthalmia. 
119. CEdema of the subconjunc- 
tival tissue. Syn., Chemosis. 
120. Pinguecula. 
121. Pterygium. 
122. Fatty tumor. 
123. Parasitic disease. 
Return cases of this class ac- 
cording to the list atp. 146. 
124. Metallic stains. 
a. From nitrate of silver. 
b. From lead. 
Diseases of the Cornea. 
125. Keratitis. 
126. Chronic interstitial keratitis. 
127. Keratitis with suppuration. 
Syn., Onyx. 
128. Ulcer. 
129. Opacity. Syn., Leucoma. 
130. Conical cornea. 
131. Arcus senilis. 
132. Staphyloma. 
133. Parasitic diseases in the an- 
terior chamber. 
Return cases of this class ac- 
cording to the list atp. 146. 
Diseases of the Sclerotic. 
134. Sclerotitis. 
135. Staphyloma. 
Diseases of the Iris. 
136. Iritis. 
137. Traumatic iritis. 
138. Rheumatic iritis. 
139. Arthritic iritis. 
(431.) Syphilitic iritis. 
(491.) Scrofulous iritis. 
140. Gonorrhoeal iritis. 
141. Sequelae of iritis. 
142. Malformations. 
Return such cases here ac- 
cording to the list atp. 234. 
Diseases of the Choroid and 
Retina. 
143. Choroiditis. 
144. Retinitis. 
145. Choroidal apoplexy. 
146. Amaurosis. 
147. Impaired vision. 
148 Muscae volitantes. 
149. Albinism. 
Diseases of the Vitreous Body. 
150. Synchysis. 
151. Various morbid deposits. 
Diseases of the Lens and its 
Capsule. 
152. Cataract. 
Varieties: 
a. Hard. 
b. Soft. 
c. Fluid. 
153. Parasitic disease. 
Return cases of this class ac- 
cording to the list atp. 146. 
154. Malformations. 
Return such cases here ac- 
cording to the list atp. 234. 
a. Congenital cataract. 
155. Traumatic cataract. 
General Affections of the 
Eye. 
156. Glaucoma. 
157 Hydrophthalmia. 
(44'.) Cancer. 
(491.) Scrofulous deposit within the 
eyeball. 
158. Total disorganization of the 
eye from injury. 
158*. Malformations. 
Return such cases here ac- 
cording to the list atp. 234. 
Various Defects of Sight. 
159. Short sight. 
160. Long sight. 
161. Faulty perception of colors. 
Syn., Color blindness. 
162. Hemeralopia 
163. Nyctalopia. 
164. Astigmatism. 
Diseases of the Lachrymal 
Apparatus. 
165. Lachrymal obstruction. 
166. Abscess and fistula. 
167. Dacryolith. 
168. Diseases of the lachrymal 
gland and its ducts. 
Diseases of the Eyelids. 
169. Inflammation. 
170. Hordeolum. 
171. Abscess in the Meibomian 
glands. 
172. Epicanthis. 
173. Entropium. 
174. Ectropium. 
175. Trichiasis. 
176. Madarosis. Syn., Loss of the 
eyelashes. 
177. Tarsal ophthalmia. 
178. Blepharospasmus. 
(441.) Cancer 
179. Cyst of the lids. 
(895.) Phthiriasis. 
179*. Malformations. 
Return such cases here ac- 
cording to the list alp. 234. 
Diseases within the Orbits. 
180. Abscess in the orbit. 
181. Strabismus. 
182. Protrusion of the eyeball. 
Syn., Proptosis. 
(282.) Exophthalmic bronchocele. 
(250.) Orbital aneurism. 
(441.) Cancer. 
183. Non-malignant tumors. 
Return such tumors here ac- 
cording to the list at p. 311. 
184. Parasitic disease. 
Return cases of this class ac- 
cording to the list at p. 146. 
185. Affections of the orbital 
nerves. 
Injuries of the Eye are given 
atp. 324. 
Diseases of the Auricle. 
186. Gouty and other deposits. 
187. Haematoma auris. 
(441.) Cancer. 
188. Non-malignant tumors. 
Return such tumors here ac- 
cording to the list atp. 311. 
(827, &c.) Cutaneous affections. 
189. Malformations. 
Return such cases here ac- 
cording to the list atp. 311. 
(1012.) Injuries. 
Diseases of the External 
Meatus. 
190. Inflammation. 
a. Acute. 
b. Chronic. 
191. Abscess. 
192. Accumulation of wax. 
DISEASES OE THE EAB 
193. Polypus. 
194. Sebaceous tumor. Syn., Mol- 
luscous tumor. 
195. Osseous tumor of bone. Syn., 
Exostosis. 
195*. Malformations. 
Return such cases here ac- 
cording to the list atp. 234. 
(1014.) Foreign bodies. 
Diseases of the Membrana 
Tympani. 
196. Inflammation. 
197. Ulceration. 
198. Perforation. 
(1012.) Injuries. 
Disease of the Eustachian 
Tube. 
199. Obstruction. 
Diseases of the Tympanum. 
200. Disease of the mucous mem- 
brane. 
201. Disease of the ossicles. 
202. Disease of the mastoid cells. 
Diseases of the Internal Ear. 
203. Organic disease. 
204. Necrosis of the petrous bone. 
205. Deafness. 
Varieties: 
a. Functional or nervous. 
b. From disease. 
c. Deaf-dumbness. 
(44l.) Cancer? 
205*. Malformations. 
Return such cases according 
to the list at p. 234. 
206. Hypertrophy. Syn., Lipoma. 
207. Wart. 
218. Sebaceous cyst. 
(441.) Cancer of the skin. 
(46.) Lupus. 
DISEASES OF THE NOSE.i 
209. Ozeena. 
210. Ulceration of the pituitary 
membrane. 
211. Abscess of the septum. 
212. Perforation of the septum. 
213. Epistaxis.3 
214. Hypertrophy of the pituitary 
membrane. 
(441.) Cancer. Syn., Malignant po- 
lypus. 
1 Register the diseases printed here in italics, not under this heading, but at the place referred to in 
each instance by number. 
2 When any of these affections implicate the brain, carotid artery, or lateral sinus, the fact should be 
stated. 
3 When the cause of this affection has been ascertained, the case should be returned under the head of 
the primary disease, the secondary affection being also specified. 314 
THE NOMENCLATURE OF DISEASES 
215. Polypus nasi. 
Varieties : 
a. Gelatinous. 
b. Fibrous. 
1. Naso-pharyngeal polypus. 
216. Non-malignant tumors of the 
septum. 
217. Rhinoliths. 
217*. Malformations. 
Return such cases here ac- 
cording to the list at pp. 
234 to 238. 
(1015.) Foreign bodies. 
218. Loss or perversion of the 
sense of smell.1 
DISEASES OF THE CIRCULATORY SYSTEM.2 
Diseases of the Heart and its 
Membranes. 
DISEASES OF THE PERICARDIUM. 
219. Pericarditis. 
220. Suppurative pericarditis. 
(491.) Tubercular pericarditis. 
221. Adherent pericardium? 
222. Dropsy. 
(441.) Cancer. 
223. Malformations. 
Return such cases here ac- 
cording to the list atp. 234. 
(1056.) Injuries. 
DISEASES OF THE ENDOCARDIUM. 
224. Endocarditis.4 
225. Valve-disease. 
1. Aortic. 
2. Mitral. 
3. Pulmonic. 
4. Tricuspid. 
Varieties: 
a. Vegetations. 
b. Fibroid thickening. 
c. Fatty and calcareous 
degeneration. Syn., 
Atheroma, Ossifica- 
tion. 
d. Aneurism. 
e. Laceration. 
f. Simple dilatation of 
orifice. 
g. Malformations. 
Return such cases here 
according to the list 
atp. 234. 
Obstruction to the 
circulation and 
Regurgitation should 
be specially noted 
when they accom- 
pany the valve- 
disease. 
226. Fibrinous concretions in the 
cavities of the heart? 
DISEASES OF THE MUSCULAR 
STRUCTURE OF THE HEART. 
227. Myocarditis. 
228. Abscess? 
229. Hypertrophy. 
a. Of left side. 
b. Of right side. 
230. Dilatation. 
a. Of left side. 
b. Of right side. 
231. Atrophy. 
232. Excess of fat. 
233. Fatty degeneration. 
234. Fibroid degeneration. 
235. Aneurism. 
236. Acute aneurism? 
237. Rupture? 
(441.) Cancer. 
238. Parasitic disease. 
Return cases of this class ac- 
cording to the list atp. 146. 
239. Disease of the coronary ar- 
teries. 
240. Malformations. 
Return such cases here ac- 
cording to the list at pp. 234 
to 238. 
241. Cyanosis. 
(1056-58.) Injuries of the heart. 
242. Angina pectoris? 
243. Syncope? Syn., Fainting fit. 
244. Palpitation and irregularity 
of the action of the heart1 
Diseases of the Blood- 
Vessels.9 
DISEASES OF THE ARTERIES. 
245. Arteritis. 
246. Fatty and calcareous degen- 
eration. Syn., Atheroma, 
Ossification. 
247. Narrowing and obliteration. 
248. Occlusion. 
a. From compression. 
b. From impaction of co- 
agula. 
1. Thrombosis (local co- 
agulation). 
2. Embolism (coagula 
conveyed from a dis- 
tance). 
249. Dilatation. 
250. Aneurism. 
In returning such cases, 
state whether the aneurism 
be- 
a. Fusiform, 
b. Saccular, or 
c. Diffused (sac formed 
by the surrounding 
tissues).10 
251. Rupture of artery. 
a. From disease of artery. 
b. From disease external to 
artery. 
252. Partial rupture of artery. 
Syn., Dissecting aneurism. 
253. Traumatic aneurism. 
254. Arterio-venous aneurism. 
255. Aneurismal varix. 
Varieties: 
a. Traumatic. 
b. Spontaneous. 
256. Varicose aneurism. 
Varieties .• 
a. Traumatic. 
b. Spontaneous. 
257. Cirsoid aneurism. Syn., Ar- 
terial varix. 
258. Aneurism by anastomosis. 
259. Malformations. 
Return other cases of this 
class here according to the 
list alp. 234. 
a. Commencement of the 
descending aorta (con- 
tracted or obliterated). 
(1009, &c.) Injuries of arteries.11 
Contusion. 
Laceration. 
a. Of the whole vessel. 
b. Of the outer coat. 
c. Of the inner coat. 
Wound. 
DISEASES OF THE VEINS. 
260. Phlebitis. 
Varieties: 
a. Adhesive. 
b. Suppurative. 
261. Phlegmasia dolens. 
262. Fibrinous concretions in the 
veins. 
263. Obstruction. 
264. Obliteration. 
265. Phlebolithes. 
266. Varicose veins. 
267. Naevus vascularis. 
268. Parasitic disease. 
Return cases of this class ac- 
cording to the list atp. 146, 
Nos. 28 and 30. 
(109, &c.) Injuries of veins.11 
Rupture, without external 
wound. 
Wound of vein, with en- 
trance of air. 
DISEASES OF THE ABSORBENT SYSTEM.'2 
269. Inflammation of lymphatics. 
270. Suppuration of lymphatics. 
271. Inflammation of glands. 
1 When the cause of this affection has been ascertained, the case should be returned under the head 
of the primary disease, the secondary affection being also specified. 
3 Register the diseases printed here in italics, not under this heading, but at the place referred to in 
each instance by number. 
3 This term includes partial adhesions and calcareous and ossific deposits. 
4 In returning such cases, state, if possible, the valve or valves affected. 
5 Cases are to be returned under this head only when the condition has evidently existed during life, 
and is believed to have been the cause of death. 
6 Abscess dependent on pyaemia should be referred to that disease. 
1 This term has been applied to those cases in which blood becomes effused into the substance of the 
heart, owing to inflammatory softening and rupture of the endocardium and muscular tissue. 
8 In returning cases of aneurism and rupture, the situation ought to be stated. 
9 The vessel affected should in all cases be specified. 
10 When the aneurism has burst, state the part or viscus into or through which the rupture has taken 
place. 
11 Return these among the Local Injuries under the Injuries of Vessels, and in the order here employed. 
(See Nos. 1009,1013, 1043, 1057, 1072, 1087, 1095, 1119.) 
13 Register those diseases printed here in italics, not under this heading, but at the place referred to in 
each instance by number. THE NOMENCLATURE OF DISEASES 
315 
272. Suppuration of glands. 
273. Hypertrophy of glands. 
a. Chronic enlargement of 
glands. 
274. Atrophy of glands. 
275. Lymphatic fistula. 
(1142.) Foreign bodies and concre- 
tions. 
276. Obstruction of the thoracic 
duct.1 
277. Obstruction, obliteration, and 
varicosity of lymphatics. 
278. Bursting of lymphatics. 
(43l.) Syphilitic bubo. 
(431.) Syphilitic inflammation of 
glands. 
(441.) Cancer. 
(491.) Scrofulous disease of glands. 
(491.) Suppuration. 
(1143.) Wound of lymphatics. 
Diseases of the Bronchial 
Glands. 
(340.) Inflammation. 
(341.) Aoscess. 
(342.) Enlargement. 
(441.) Cancer. 
(343.) Non-malignant tumors. 
(49'.) Tubercle. 
DISEASES OF THE DUCTLESS GLANDS.2 
Diseases of the Thyroid 
Gland. 
279. Inflammation. 
a. Acute. 
b. Chronic. 
280. Goitre. 
281. Cyst. 
282. Exophthalmic bronchocele. 
283. Pulsating bronchocele. 
(441.) Cancer. 
Diseases of the Thymus Gland. 
284. Hypertrophy. 
(44'.) Cancer. 
285. Non-malignant tumors. 
Return such tumors here ac- 
cording to the list atp. 311. 
Diseases of the Suprarenal 
Capsules. 
(441.) Cancer. 
(49'.) Tubercular degeneration. 
286. Addison's disease. Syn., 
Bronzed skin. Melasma 
Addisoni. 
DISEASES OF THE RESPIRATORY SYSTEM.2 
Diseases of the Respiratory 
System not Strictly Local. 
287. Hay asthma. 
(22.) Influenza. 
(20.) Hooping-cough. 
288. Croup. 
(19.) Diphtheria. 
(995.) Asphyxia.3 
Disease of the Nostrils.4 
289. Coryza. Syn., Nasal catarrh. 
Diseases of the Larynx. 
290. Inflammation of the epi- 
glottis. 
291. Ulceration of the epiglottis. 
292. Laryngeal catarrh. 
293. Laryngitis. 
a. Acute. 
b. Chronic. 
294. Ulcer.5 
296^ Gidema of the glottis. 
297. Necrosis of cartilage (see the 
previous note). 
298. Contraction. 
(44lc.) Epithelial cancer. 
299. Warty growth. 
300. Polypus. 
301. Cyst. 
301*. Malformations.3 
Return such cases here ac- 
cording to the list atp. 234. 
(992-1039.) Injuries. 
(1044.) Foreign bodies in the larynx. 
302. Aphonia.3 
303. Paralysis of the glottis.3 
304. Spasm of the glottis.3 
(96.) Laryngismus stridulus. 
Diseases of the Trachea and 
Bronchi. 
305. Bronchial catarrh 
306. Bronchitis. 
a. Acute. 
b. Chronic. 
307. Ulcer. 
308. Casts of the bronchial 
tubes.3 
309. Necrosis of the cartilages of 
the trachea.3 
310. Dilatation. 
311. Contraction. 
(441.) Cancer. 
312. Non-malignant tumors. 
Return such tumors here ac- 
cording to the list atp. 311. 
(49l.) Tubercle. 
313. Parasitic disease. 
Return cases of this class ac- 
cording to the list at p. 146, 
No. 7. 
313. Malformations.3 
Return such cases here ac- 
cording to the list atp. 234. 
(1044.) Foreign bodies in the bronchi. 
314. Asthma. 
Diseases of the Lung. 
315. Pneumonia. 
Variety: 
a. Lobular.' 
316. Abscess. 
(31.) Pycemic inflammation and ab- 
scess. 
317. Gangrene. 
318. Passive congestion.3 
a. Haemoptysis.3 
319. Pulmonary " extravasation. 
Syn., Pulmonary apoplexy.3 
a. Haemoptysis.3 
320. CEdema.1 
321. Cirrhosis. 
322. Emphysema. 
a. Vesicular.3 
b. Interlobular.3 
323. Atelectasis. 
324. Collapse.3 
(431.) Syphilitic deposit. 
(44*.) Cancer. 
(491.) Phthisis. 
(49l.) Acute miliary tuberculosis. 
325. Acute pneumonic phthisis. 
326. Chronic pneumonic phthisis. 
327. Parasitic disease. 
Return cases of this class ac- 
cording to the list at p. 146. 
327. Malformations.3 
Return such cases here ac- 
cording to the list at pp. 234 
to 238. 
(1054-1058.) Injuries. 
(1044.) Foreign bodies. . 
328. Millstone makers' phthisis. 
329. Grinders' asthma. 
330. Miners' asthma. 
Diseases of the Pleura. 
331. Pleurisy. 
332. Chronic pleurisy. 
333. Empyema. 
334. Adhesions, including thick- 
ening and ossification. 
335. Hydrothorax.3 
336. Pneumothorax. 
(411.) Cancer. 
337. Non-malignant tumors. 
Return such tumors here ac- 
cording to the list atp. 311. 
(491.) Tubercular pleurisy. 
(1053-1054.) Injuries. 
Diseases of the Mediastinum. 
338. Abscess. 
(44'.) Cancer. 
339. Non-malignant tumors. 
Return such tumors here ac- 
cording to the list alp. 311. 
(284-285.) Diseases of the thymus 
gj.and. 
Diseases of the Bronchial 
Glands. 
340. Inflammation. 
341. Abscess. 
342. Enlargement. 
(441.) Cancer. 
343. Non-malignant tumors. 
Return such tumors here ac- 
cording to the list atp. 311. 
(491.) Tubercle. 
1 The cause of the obstruction should be stated. 
3 Register the diseases printed here in italics, not under this heading, but at the place referred to in 
each instance by number. 
3 When the cause of this affection has been ascertained, the case should be returned under the head 
of the primary disease, the secondary affection being also specified. 
4 For the diseases of the nose, see p. 313. 
5 When chronic laryngitis, ulcer of the larynx, or necrosis of cartilage, is due to phthisis or syphilis, 
the terms (431.) syphilitic or (49phthisical should be prefixed to the designation of the disease, and the 
case ought to be returned under the head of the primary affection. 
3 When this affection is due to phthisis or syphilis, the terms (431.) syphilitic or (49'.) phthisical should 
be prefixed to the designation of the disease, and the case ought to be returned under the head of the 
primary affection. 
' The term secondary has been applied to Pneumonia when it occurs as a complication of some other 
disease; such cases ought to be returned under the head of the primary affection. 316 
THE NOMENCLATURE OF DISEASES. 
Diseases of the Lips. 
The affected lip ought to be specified. 
344. Ulcer. 
(43*.) Syphilitic ulcer. 
345. Fissures. 
(44'.) Cancer. 
(59*.) Scrofulous hypertrophy. 
346 Cyst. 
347. Malformations. 
Return such cases here ac- 
cording to the list atp. 234. 
a. Hare-lip. 
Diseases of the Mouth 3 
348. Stomatitis. 
349. Ulcerative stomatitis. 
350. Thrush. Syn., Aphtha, Vesic- 
ular stomatitis. 
351. Abscess of the cheek.3 
353. Cancrum oris. Syn., Gan- 
grenous stomatitis. 
354. Cyst of the cheek. 
355. Ranula. 
(44*.) Cancer. 
356. Parasitic disease. 
a. Parasitic thrush. Syn., 
Parasitic aphthae.4 
Return cases of this class ac- 
cording to the list atp. 146. 
Diseases of the Jaws, includ- 
ing the Antrum.6 
357. Adhesion of the jaws by cica- 
trix. 
358. Abscess of the antrum. 
(44*.) Cancer. 
359. Fibrous tumor. 
360. Myeloid tumor. 
361. Osseous tumor. 
a. Hypertrophy of the bones 
of the face. 
362. Cartilaginous tumor. 
363. Vascular tumor. 
364. Cyst. 
(1016.) Foreign bodies in the antrum. 
Diseases, Malformations, and 
Injuries of the Teeth, Gums, 
and Alveoli. 
365. Teething.6 
Diseases of the Dental Tissue. 
366. Caries. 
367. Necrosis. 
368. Exostosis. 
369. Absorption. 
Diseases of the Dental Pulp. 
370. Irritation. 
371. Inflammation. 
372. Ulceration. 
373. Gangrene. 
Diseases of the Dental 
Periosteum. . 
374. Granulation or polypus. 
375. Calcification. 
376. Inflammation. 
377. Gum-boil. 
378. Chronic thickening. 
379. Rheumatic inflammation. 
Diseases of the Gums. 
380. Inflammation. 
381. Ulceration. 
382. Hypertrophy. 
DISEASES OF THE DIGESTIVE SYSTEM.! 
383. Atrophy. 
384. Induration (in infancy). 
(44*.) Cancer. 
385. Non-malignant tumors. 
Return such tumors here ac- 
cording to the list atp. 311. 
a. Polypus. 
b. Cartilaginous tumor. 
c. Vascular tumor. 
386. Epulis. 
Diseases of the Alveoli. 
387. Inflammation. 
388. Necrosis. 
389. Caries. 
390. Exostosis. 
391. Dentigerous cyst. 
392. Absorption. 
Specific Diseases affecting 
the Dental Periosteum, 
Gums, or Alveoli. 
393. Mercurial inflammation. 
394. Phosphoric inflammation and 
necrosis. 
(908c.) Blue gum from lead. 
(54.) Scurvy. 
Irregular Dentition. 
Irregularity in the time of erup- 
tion of the- 
395. Temporary teeth. 
396. Permanent teeth. 
Irregularity in the position of 
the- 
397. Temporary teeth. 
398. Permanent teeth. 
Irregularity of the number of 
the- 
399. Temporary teeth. 
400. Permanent teeth. 
Irregularity in the form of the- 
401. Temporary teeth. 
402. Permanent teeth. 
Abnormal development of the- 
403. Dental tissue. 
404. Enamel. 
405. Dentine. 
406. Cementum. 
407. Alveolar portions of the 
jaws, in size. 
408. Alveolar portions of the 
jaws, in form. 
409. Defective growth of lower 
jaw. 
410. Mechanical injuries of the 
alveoli and dental perios- 
teum. 
a. Hemorrhage. 
b. Fracture. 
411. Mechanical injuries of the 
teeth. 
a. Fracture. 
b. Dilaceration. 
c. Dislocation. 
d. Friction. 
Diseases of the Tongue. 
412. Glossitis. 
413. Ulcer. 
414. Aphthous ulcer. 
415. Abscess. 
416. Hypertrophy. 
(43*a.) Primary syphilis. 
(43*b.) Secondary syphilis. 
(44*.) Cancer. 
417. Vascular tumor. 
418. Tongue-tie. 
(89.) Paralysis.1 
Diseases of the Fauces and 
Palate. 
419. Sore throat. 
420. Relaxed throat. 
421. Ulcerated throat. 
422. Quinsy. Syn., Cynanche ton- 
sillaris. 
423. Tonsillitis. 
424. Sloughing sore throat. Syn., 
Putrid sore throat. Cyn- 
anche maligna.8 
(19.) Diphtheria. 
425. Enlarged tonsils. 
(441.) Cancer of the tonsils. 
(49*.) Scrofulous disease of the 
tonsils. 
426. Elongated uvula. 
427. Perforation of the palate. 
428. Stricture of the fauces. 
(43'.) Syphilitic affection of the 
fauces and tonsils. 
(44*.) Cancer. 
429. Non-malignant tumor. 
Return such tumors here ac- 
cording to the list atp. 311. 
a. Fibro-cellular tumor. 
b. Fibro-cystic tumor. 
430. Malformations. 
Return such cases here ac- 
cording to the list atp. 234. 
a. Cleft palate. 
Diseases of the Pharynx. 
431. Pharyngitis. 
432. Ulcer. 
a. Superficial ulcer. 
b. Perforating ulcer. 
433. Abscess. 
434. Sloughing. 
435. Adhesion of the soft palate. 
436. Dilatation.1 
(43*.) Syphilitic affection. 
(44*.) Cancer. [stances. 
(1047.) Injury by corrosive sub- 
(1045.) Foreign bodies. 
(89.) Paralysis.1 
Diseases of the Salivary 
Glands. 
437. Inflammation. 
438. Salivation. Syn., Ptyalism.1 
439. Abscess. 
440. Salivary fistula. 
(21.) Mumps. 
(44*.) Cancer. 
441. Non-malignant tumors. 
Return such tumors here ac- 
cording to the list atp. 311. 
442. Salivary calculus. 
Diseases of the (Esophagus. 
443. (Esophagitis. 
444. Ulceration. 
445. Perforation.1 
446. Stricture.1 
(44 *.) Cancer. 
(1046.) Foreign bodies. 
447. Malformations. 
Return such cases here ac- 
cording to the list at p. 234. 
(1047.) Injury by corrosive sub- 
stances. 
(89.) Paralysis.1 
448. Dysphagia. 
* Register the diseases printed here in italics, not under this heading, but at the place referred to in 
each instance by number. 
2 Whenever any of the affections of the mouth, throat, or parts connected therewith, depend on syph- 
ilis, scurvy, local irritants, or anv other specific cause, the fact should be stated. 
3 352 has been accidentally omitted. 
4 The name of the Thrush parasite is given at p. 147, No. 45. 
6 The affections of the alveoli are to be returned with those cf the teeth. 
G Any affection, such as convulsions and paralysis, induced by this condition should be specified. 
1 When the cause of this affection has been ascertained, the case should be returned under the head 
of the primary disease, the secondary affection being also specified. 
8 This affection must be distinguished from malignant scarlet fever. THE NOMENCLATURE OF DISEASES 
317 
Diseases of the Stomach. 
449. Gastritis. 
(906, &c.) a. From irritant poisons. 
{For the list of poisons, see p. 
323.) 
450. Chronic ulcer. 
451. Haematemesis? 
452. Perforation? 
453. Dilatation? 
454. Stricture? 
455. Gastric fistula. 
456. Hernia. 
(44?) Cancer. 
(45?) Colloid. 
457. Non-malignant tumors. 
Return such tumors here ac- 
cording to the list atp. 311. 
458. Parasitic disease. 
Return cases of this class ac- 
cording to the list at p. 147, 
Nos. 46, 47. 
(1065-1071.) Injuries. 
(1074.) Foreign bodies. 
459. Spontaneous laceration. 
460. Dyspepsia. 
461. Gastrodynia. 
462. Pyrosis. 
463. Vomiting? 
Diseases of the Intestines. 
464. Enteritis. 
465. Typhlitis. 
466. Dysentery. 
467. Ulceration. 
468. Perforation. 
469. Abscess in the subperitoneal 
tissue. 
470. Fecal abscess. 
471. Fistula. 
a. Fecal fistula. Syn., Arti- 
ficial anus. 
(561.) Vesico-intestinal fistula. 
472. Hemorrhage. 
473. Melama. 
474. Dilatation? 
475. Tympanites? 
476. Obstruction? 
477. Stricture. 
478. Intussusception. 
479. Internal strangulation. 
a. Mesenteric. 
b. Mesocolic. 
480. Hernia. 
a. Reducible. 
b. Irreducible. 
c. Obstructed. 
d. Inflamed. 
e. Strangulated. 
1. Diaphragmatic. 
2. Epigastrib. 
3. Ventral. 
4. Umbilical. 
5. Lumbar. 
6. Inguinal. 
a. Oblique. 
b. Direct. 
c. Incomplete. 
d. Scrotal. 
e. Congenital. 
f. Infantile. 
7. Femoral. 
8. Obturator. 
9. Perineal. 
10. Pudendal. 
11. Vaginal. 
12. Ischiatic. 
481. Diseases of hernial sacs. 
a. Inflammation. 
b. Fibrinous effusion with 
closure. 
c. Suppuration. 
d. Dropsy. 
e. Movable bodies. 
f. Laceration. 
(44?) Cancer. 
(45?) Colloid. 
482. Non-malignant tumors. 
Return such tumors here ac- 
cording to the list atp. 311. 
a. Polypus. 
483. Parasitic disease. 
Return cases of this class ac- 
cording to the list at pp. 146 
to 148, Nos. 1-3, 8-13,15-20, 
24, 25, 27, 32, 34, 35. 
(1075.) Concretions. 
483*. Malformations. 
With the exception of hernia, 
which will appear under 480, 
return such cases here ac- 
cording to the list atp. 234. 
(1075.) Foreign bodies. 
(1066-1071.) Injuries. 
484. Diarrhoea. 
(17.) Simple cholera. 
(18.) Malignant cholera. 
a. Choleraic diarrhoea. 
485. Paralysis? 
486. Colic. 
(908a.) Lead colic. 
487. Constipation. 
Diseases of the Rectum and 
Anus. 
488. Ulceration. 
489. Abscess. 
490. Fistula in ano. 
(562.) Recto-vesical fistula. " 
(630.) Recto-urethral fistula. 
(676.) Redo-vaginal fistula. 
491. Haemorrhoids. 
a. Internal. 
b. External. 
492. Hemorrhage from the rec- 
tum. 
493. Fissure of the anus. 
494. Prolapsus. 
495. Stricture? 
(43l.) Syphilis of the rechtm. 
496. Condyloma of the anus. 
(44'.) Cancer of the rectum. , 
(44l.) Cancer of the anus. 
497. Non-malignant tumors of the 
rectum. 
Return cases of this class here 
according to the list at p. 
311. 
4971. Parasitic disease. 
Return cases of this class here 
according to the list al p. 
146, see No. 10. 
497. Malformations? 
Return such cases here ac- 
cording to the list atp. 234. 
(1081-1082.) Injuries. 
(1089.) Foreign bodies in the rectum. 
498. Neuralgia. 
499. Spasm of the sphincter ani. 
500. Pruritus ani. 
Diseases of the Liver. 
501. Hepatitis. 
502. Abscess.3 
(31.) Pycemic inflammation and ab- 
scess. 
503. Acute atrophy. 
504. Simple enlargement. Syn., 
Congestion of the liver. 
505. Thickening of the capsule. 
506. Cirrhosis. 
507. Fatty liver. 
508. Fibroid deposit. 
509. Lardaeeous liver. Syn., Amy- 
loid disease of the liver. 
Waxy liver.4 
143'.) Syphilitic deposit. 
(44l.) Cancer. 
(45*.) Colloid. 
510. Non-malignant tumors. 
Return such tumors here ac- 
cording to the list alp. 311. 
511. Cyst. 
(491.) Tubercle. 
512. Parasitic disease. 
Return cases of this class ac- 
cording to the list atpp. 146, 
147, Nos. 14, 21-23, 25, 23- 
34, 35. 
512s. Malformations. 
Return such cases here ac- 
cording to the list atp. 234. 
(1066-1071.) Injuries. 
513. Jaundice. Syn., Icterus. 
514. Obstruction of the vena por- 
tee. 
Diseases of the Hepatic Ducts 
and Gall-Bladder. 
515. Inflammation. 
516. Ulcer. 
517. Perforation. 
a. Biliary fistula. 
518. Obstruction. 
(441.) Cancer. 
519. Parasitic disease. 
Return cases of this class ac- 
cording to the list at p. 146, 
No. 25. 
520. Gallstones. 
a. Passage of gallstones 
through the duct. 
520*. Malformations. 
Return such cases here ac- 
cording to the list at p. 234. 
(1066-1071.) Injuries. 
Diseases of the Pancreas. 
521. Abscess. 
522. Obstruction of the duct. 
(44'.) Cancer. 
(45l.) Colloid. 
523. Calculi. 
Diseases of the Spleen. 
521. Splenitis. 
525. Abscess. 
(31.) Pycemic inflammation and ab- 
scess. 
526. Congestion. Syn., Ague cake. 
527. Fibrinous deposit. 
528. Hypertrophy. 
a. Leucocythsemia. 
529. Lardaeeous spleen. Syn., 
Amyloid disease. Waxy 
spleen. 
(441.) Cancer. 
(451.) Colloid. 
(49'.) Tubercle. 
530. Parasitic diseases. 
Return cases of this class ac- 
cording to the list at p. 146, 
No. 22. 
(1066.) Rupture. 
Diseases of the Peritoneum. 
531. Peritonitis. 
(719.) a. Metro-peritonitis. Syn., 
Puerperal peritonitis. 
b. Chronic peritonitis. 
c. Suppurative peritonitis. 
1 When the cause of this affection has been ascertained, the case should be returned under the head of 
the primary disease, the secondary affection being also specified. 
2 The cause of the perforation, when ascertained, should be stated. 
3 When abscess of the liver is associated with dysentery, injury, or any other condition, the fact should 
be stated. 
4 Such cases have been described under the name of Scrofulous disease of the liver. 318 
THE NOMENCLATURE OF DISEASES. 
(49*.) d. Tubercular peritonitis. 
e. Adhesions of the perito- 
neum. 
532. Ascites? 
532*. Non-malignant tumors.4 
Return such tumors here ac- 
cording to the list at p. 311 
(441.) Cancer. 
(45'.) Colloid. 
533. Parasitic disease. 
Return cases of this class ac- 
cording to the list at p. 146, 
Nos. 4, 14, 22. 
(1067-1070.) Injuries. 
Diseases of the Mesenteric 
Glands. 
534. luflammation. 
535. Abscess. 
536. Enlargement. 
(441? Cancer. ' 
537. Non-inalignant tumors. 
Return such tumors here ac- 
cording to the list atp. 311. 
(49'.) Tubercle. 
(491.) Tabes mesenterica. 
Diseases of the Kidney. 
538. Bright's disease. Syn., Albu- 
minuria. 
1. Acute Bright's disease. 
Syn., Acute albuminu- 
ria. Acute desquama- 
tive nephritis, Acute re- 
nal dropsy. 
2. Chronic Bright's disease. 
Syn., Chronic albumin- 
uria. 
Subdivisions: 
a. Granular kidney. Syn., 
Contracted granular 
kidney, Chronic des- 
quamative nephritis, 
Gouty kidney. 
b. Fatty kidney. 
c. Lardaceous kidney. Syn., 
Amyloid disease. Waxy 
kidney. 
539. Suppurative nephritis. 
540. Abscess. 
541. Pyelitis. 
542. Fibrinous deposit. 
543. Hydronephrosis. 
544. Hypertrophy. 
545. Atrophy. 
(441.) Cancer. 
546. Non-malignant tumors. 
Return such tumors here ac- 
cording to the list at p. 
311. 
547. Simple cyst. 
548. Urinary cyst (from injury). 
(491.) Tubercle.' 
549. Parasitic disease. 
Return cases of this class 
according to the list at p. 
146. 
550. Calculus. 
551. Calculus in the ureter. 
552. Malformations. 
Return cases of this class 
according to the list at p. 
234. 
(1066-1071.) Injuries. 
553. Haematuria renalis? 
554. Suppression of urine. Syn., 
Ischuria renalis? 
(52.) Diabetes. Syn., Diabetes mel- 
litus. 
555. Diuresis? 
556. Movable kidney. 
DISEASES OF THE URINARY SYSTEM.3 
Diseases of the Bladder. 
557. Cystitis. Syn., Catarrh of the 
bladder. 
a. Acute. 
b. Chronic.1 
558. Ulceration. 
559. Suppuration. 
560. Sloughing. 
561. Vesico-intestinal fistula. 
562. Recto-vesical fistula. 
(660.) Utero-vesical fistula. 
(675.) Vesicovaginal fistula. 
563. Hypertrophy. 
564. Distension? 
a. Sacculated bladder. 
6. Rupture. 
565. Inversion. 
566. Extroversion. 
567; Hernia. 
(44'.) Cancer. 
568. Fibrous tumor. 
569. Villous tumor. 
570. Calculus. 
a. Urie acid. 
b. Urate of ammonia. 
c. Uric oxide. Syn., Xan- 
thic oxide. 
d. Oxalate of lime. 
e. Cystic oxide. 
f. Phosphate of lime. 
g. Triple pHbsphate. 
h. Fusible. 
i. Carbonate of lime. 
k. Fibrinous. 
I. Urostealith. 
m Blood calculus. 
Foreign bodies. 
571. Haematuria (Vesical).1 
571*. Malformations. 
Return such cases according 
to the list at pp. 234 to 238. 
(1083, 1091.) Injuries. 
572. Paralysis? 
573. Irritability? 
574. Spasm? 
575. Neuralgia? 
576. Incontinence of urine? 
577. Retention of urine? 
Diseases of the Prostate 
Gland? 4 
578. Inflammation. 
a. Acute. 
b. Chronic. 
579. Ulceration. 
580. Abscess. 
581. Atrophy. 
(441.) Cancer. 
582. Non-malign ant tumors. Syn., 
Enlarged lobe of the pros- 
tate. 
582*. Chronic enlargement. 
583. Cyst. 
(491.) Tubercle. 
584. Calculi. 
Gonorrhcea and its Complica- 
tions.1 4 
585. Gonorrhoea. 
a. In the male. 
b. In the female. 
586. Balanitis. 
(841.) Herpes preputialis. 
587. Phimosis. 
588. Paraphimosis. 
589. Bubo. 
590. Lacunar abscess. 
(580.) Prostatic abscess. 
591. Epididymitis. Syn., Gonor- 
rhoeal orchitis. 
a. Abscess. 
592. Abscess of the spermatic 
cord. 
593. Condyloma. 
a. In the male. 
b. In the female. 
594. Gleet 
(631.) Inflammation of ovary. 
595. Abscess of the vulva. 
(117.) Gonorrhoeal ophthalmia. 
(140.) Gonorrhoeal iritis. 
(35.) Gonorrhoeal rheumatism. 
Diseases or the Male Urethra. 
595*. Urethritis. 
596. Stricture.5 
a. Organic. 
b. Traumatic. 
c. Spasmodic. 
d. Inflammatory. 
597. Ulcer. 
598. Urinary abscess. 
599. Urinary fistula. 
600. Recto-urethral fistula. 
601. Extravasation of urine. 
601*. Impacted calculus. 
a. Foreign bodies. 
601f. Malformations. 
Return such cases according 
to the list atp. 234. 
(1078-1091.) Injuries. 
DISEASES OF THE GENERATIVE SYSTEM.3 
DISEASES OF THE MALE ORGANS OF GENERATION.6 
Diseases of the Penis. 
602. Inflammation. 
603. Abscess. 
I (505») Gonorrhoea. 
Con^oma. 
I 604- Gangrene. 
605. Priapism? 
(43'.) Syphilis. 
(441.) Cancer. 
1 When the cause of this affection has been ascertained, the case should be returned under the head of 
the primary disease, the secondary affection being also specified. 
2 Non-malignant tumors in the abdomen of uncertain seat must be returned under this heading. 
3 Register the diseases here printed in italics, not under this heading, but at the place referred to in 
each instance by number. 
4 These diseases, which rank properly under the Diseases of the Generative System, are inserted here 
on anatomical grounds. 
6 When the cause of the stricture is known, it should be stated. 
6 It has been found convenient, on anatomical grounds, to place the Diseases of the Prostate and Gon- 
orrhoea, which rank properly under Diseases of the Generative System, between the Diseases of the Blad- 
der and those of the Urethra. THE NOMENCLATURE OF DISEASES 
319 
a. Of the prepuce. 
b. Of the body. 
606. Non-malignant tumors. 
Return such tumors here ac- 
cording to the list atp. 311. 
(1078.) Injuries. 
607. Malformations. 
Return such cases according 
to the list atp. 234. 
a. Phimosis-congenital. 
Diseases of the Scrotum. 
608. Sloughing. 
609. (Edema. 
610. Elephantiasis. 
(834.) Prurigo. 
(431.) Syphilis. 
(441.) Cancer. 
(44'.c) Epithelial cancer. Syn., 
Chimney-sweepers' cancer. 
611. Non-malignant tumors. 
Return such tumors here ac- 
cording to the list atp. 311. 
611*. Malformations. 
Return such cases here ac- 
cording to the list atp. 234. 
Diseases of the Cord. 
612. Hydrocele. 
Varieties : 
a. Encysted. 
b. Diffused. 
613. Varicocele. 
614. Non-malignant tumors. 
Return such tumors here ac- 
cording to the list atp. 311. 
615. Neuralgia. 
Diseases of the Tunica 
Vaginalis. 
616. Inflammation. 
617. Hydrocele. 
Variet ies: 
a. Congenital. 
b. Infantile. 
c: Encysted. 
618. Heematocele. 
619. Loose bodies. 
Diseases of the Testicle. 
620. Orchitis. 
a. Acute. 
b. Chronic. 
620*. Epididymitis. 
621. Abscess. 
622. Protrusion of tubuli. Syn., 
Hernia testis. Fungus testis. 
623. Atrophy. 
(431.) Syphilitic disease. 
(441.) Cancer. 
624. Non-malignant tumors. 
Return such tumors here ac- 
cording to the list atp. 311. 
625. Cystic disease. 
(491.) Tubercle. 
(1078.) Injuries. 
626. Malformations. 
Return such cases according 
to the list atpp. 234 to 238. 
a. Foetal remains in the 
testicle. 
6. Malposition. 
627. Spermatorrhoea. 
628. Impotence. 
629. Neuralgia. 
DISEASES OF THE FEMALE ORGANS OF GENERATION IN THE UNIMPREGNATED STATE 
Diseases of the Ovary. 
630. Inflammation. 
631. Abscess. 
632. Hemorrhage. 
633. Atrophy. 
634. Hypertrophy. 
(441.) Cancer. 
635. Fibrous tumor. 
636. Encysted dropsy. 
637. Complex cystic tumor. Syn., 
Alveolar, gelatinous, and 
colloid tumor. Cystosar- 
coma. 
a. With intracystic growths. 
638. Cyst, containing tegumentary 
structures. 
a. Cutaneous or piliferous 
cyst. Syn., Dermoid cyst. 
b. Dentigerous cyst. 
(49*.) Tubercle. 
639. Parasitic disease. 
Return cases of this class ac- 
cording to the list atp. 146. 
640. Dislocation. 
a. Transplantation. 
641. Hernia. 
642. Malformations. 
Return such cases according 
to the list atp, 234. 
Diseases of the Fallopian 
Tube. 
643. Abscess. 
644. Dropsy. 
645. Stricture. 
646. Occlusion. 
(411.) Cancer. 
647. Cyst. 
(491.) Tubercle. 
648. Dislocation. 
649. Hernia. 
Diseases of the Broad 
Ligament. 
650. Inflammation. 
a. Pelvic peritonitis. 
b. Pelvic cellulitis. 
651. Abscess. 
652. Cyst. 
653. Periuterine or pelvic hsema- 
tocele. 
Diseases of the Uterus, 
INCLUDING THE CERVIX. 
654. Catarrh. Syn., Leucorrhcea. 
a. Hydrorrhcea. 
655. Inflammation. 
656. Granular inflammation. 
657. Abrasion. 
658. Ulcer. 
658*. Rodent ulcer. 
659. Abscess. 
660. Utero-vesical fistula. 
661. Stricture of the orifice. 
662. Stricture of the canal. 
663. Occlusion of the orifice. 
664. Occlusion of the canal. 
665. Hypertrophy. 
a. Elongation of the cervix. 
666. Atrophy. 
(44l.) Cancer. 
a. Scirrhus. 
b. Medullary cancer. 
c. Epithelial cancer. 
667. Non-malignant tumor. 
a. Fibrous tumor.1 
b. Polypus.2 
(491.) Tubercle. 
668. Displacements and distor- 
tions. 
a. Anteversion. 
b. Retroversion. 
c. Anteflexion. 
d. Retroflexion. ♦ 
e. Inversion. 
f. Prolapsus. 
1. Procidentia. 
g. Hernia. 
669*. Malformations. 
Return such cases according 
to the list atpp. 234 to 238. 
Diseases of the Vagina. 
670. Catarrh. Syn., Leucorrhcea. 
671. Inflammation. 
672. Abscess. 
(585b.) Gonorrhoea. 
673. Cicatrix or band. 
674. Vaginal fistula. 
675. Vesico-vaginal fistula. 
676. Recto-vaginal fistula. 
677. Hernia. 
a. Cystocele. 
b. Rectocele. 
(441.) Cancer. 
678. Non-malignant tumors. 
a. Polpyus. 
679. Laceration. 
679*. Malformations. 
Return such cases here ac- 
cording to the list at pp. 234 
to 238. 
Diseases of the Vulva. 
680. Inflammation of the labia. 
681. Pruritus. 
(843.) Eczema of the labia. 
682. (Edema of the labia. 
683. Abscess. 
684. Gangrene. 
685. Hypertrophy.3 
686. Occlusion. 
687. Imperforate hymen. 
(266.) Varicose veins. 
(431.) Syphilis. 
(441.) Cancer. 
688. Vascular tumor of the meatus 
urinarius. 
689. Mucous cyst. 
(5936.) Condyloma. 
689*. Malformations. 
Return such cases here ac- 
cording to the list at p. 234. 
Functional Diseases of the 
Female Organs of Generation. 
690. Amenorrhoea. Syn., Absent 
menstruation. 
Varieties: 
a. From original defective 
formation. 
6. From want of develop- 
ment at the time of 
puberty. 
c. From mechanical ob- 
struction. 
d. From temporary sup- 
pression. 
691. Scanty menstruation. Syn., 
Deficient menstruation. 
692. Vicarious menstruation. 
693. Dysmenorrhoea. Syn., Pain- 
ful menstruation. 
1 Letters have been here substituted for the omitted numbers. 
2 Under this head should be returned all pedunculated tumors growing from the cavity or neck of the 
uterus, whether mucous, cellular, or fibrous. 
3 Specify the part. 320 
THE NOMENCLATURE OF DISEASES 
694. Menorrhagia. Syn., Exces- 
sive menstruation. 
694*. Hemorrhage. 
(56.) Chlorosis. Syn., Green sick- 
ness. 
Disorders of the Nervous 
System.1 
Neuralgia. 
Varieties : 
a. Odontalgia. 
b. Cephalalgia. 
c. Mastodynia. 
Chorea. 
Convulsions. 
Hypochondriasis. 
Mania. 
Diseases of the Circulatory 
System.1 
Varicose veins- 
a. Of the lower extremities. 
b. Of the labia. 
c. Of the rectum. Hemor- 
rhoids. 
Serous exudation. 
Varieties : 
a. Ascites. 
b. GMema of the labia. 
c. CEdema of the lower 
extremities. 
AFFECTIONS CONNECTED WITH PREGNANCY. 
Syncope. 
Palpitation. 
Disorders of the Respira- 
tory System.1 
Dyspnoea. 
Orthopnoea. 
Cough. 
Disorders of the Digestive 
System.1 
Salivation. 
Depraved and capricious ap- 
petite. 
Nausea and vomiting. 
Cardialgia or Heartburn. 
Pyrosis. 
Intestinal cramp-colic. 
Constipation. 
Diarrhoea. 
Jaundice. 
Disorders of the Urinary 
System.1 
Albuminuria. 
Dysuria. 
Incontinence of urine. 
Retention of urine. 
Disorders of the Generative 
System. 
695. Metritis. Syn., Hysteritis. 
696. Discharge of watery fluid 
from the uterus. Hydror- 
rhoea. 
697. Rheumatism of the uterus. 
698. Hysteralgia. 
699. Spurious pains and cramps. 
(670.) Catarrh of the vagina. Syn., 
Leucorrhoea. 
700. Sanguineous discharge. Syn., 
Menstruation. 
701. Hemorrhage. 
702. Displacements of the uterus. 
Varieties: 
a. Prolapsus. 
b. Hernia. 
c. Retroversion. 
(681.) Pruritus of the vulva. 
703. Abortion. 
704. Premature labor. 
705. Extra-uterine gestation. 
706. Atony of the uterus. 
707. Over-distension of the uterus. 
a. From excess of liquor 
amnii. 
b. From twins, triplets, &c. 
708. Mechanical obstacle to the 
action of the uterus. 
a. From occlusion of the os 
uteri. 
b. From rigidity. 
(1.) Of the os uteri. 
(2.) Of the vagina. 
(3.) Of the perineum. 
c. From cancer of the cervix 
uteri. 
d. From narrowness of the 
vagina. 
e. From cicatrix or band in 
the vagina. 
f. From vaginal cyst. 
g. From prolapsus of the 
bladder. 
h. From stone in the blad- 
der. 
i. From distended rectum. 
k. From prolapsus of the 
rectum. 
I. From tumor. 
AFFECTIONS CONNECTED WITH PARTURITION. 
Varieties: 
1. Uterine. 
2. Ovarian. 
3. Pelvic. 
4. Of external parts. 
m. From polypus. 
n. From fractured pelvis. 
o. From exostosis. 
p. From distorted or con- 
tracted pelvis. 
q. From dislocated lumbar 
vertebrae into pelvis. 
Syn., Spondylo listhe- 
sis. 
r. From anchylosed coccyx. 
s. From diminutive pelvis. 
t. From extreme antever- 
sion of the uterus (with 
pendulous abdomen). 
u. From excessive size of 
the foetus. 
v. From malposition of the 
foetus. 
w. From malformation of 
the foetus. 
x. From enlargement of the 
foetus from disease. 
y. From unusual thickness 
of the fcetal mem- 
branes. * 
z. From unusual shortness 
of the funis. 
709. Hemorrhage. 
a. From placenta preevia. 
Syn., Unavoidable hem- 
orrhage. 
b. From accidental detach- 
ment of the placenta. 
Syn., Accidental hem- 
orrhage. 
c. From thrombus of the 
cervix uteri or labium. 
710. Rupture or laceration of the- 
uterus. 
711. vagina. 
712. urinary bladder. 
713. perineum. 
714. Retention of the placenta. 
a. From atony of the uterus. 
b. From irregular or hour- 
glass contraction. 
c. From preternatural ad- 
hesions. 
715. Inversion of the uterus. 
716. Convulsions. 
AFFECTIONS CONSEQUENT ON PARTURITION. 
717. Post-partum hemorrhage. 
(33.) Puerperal ephemera. 
718. Milk fever. 
(32.) Puerperal fever. 
719. Metro-peritonitis. Syn., Puer- 
peral peritonitis. 
a. Metritis. 
(531.) b. Peritonitis. 
(260.) Phlebitis. 
(261.) Phlegmasia dolens. 
(650b.) Pelvic cellulitis. 
720. Iliac and pelvic abscesses. 
721. Sloughing of the cervix uteri. 
722. " " vagina. 
723. Sloughing of the perineum. 
724. " " bladder. 
725. " " rectum. 
(660.) Uterovesicalfistula. 
(675.) Vesicovaginal fistula. 
Recto-vaginal fistula. 
(729.) Inflammation of the female 
breast. 
(730.) Abscess of the female breast. 
726. Puerperal mania. [tion. 
a. Connected with parturi- 
b. " " lactation. 
727. Puerperal convulsions. Syn., 
Eclampsia. 
728. Sudden death after delivery. 
a. From shock or nervous 
exhaustion. 
b. From impaction of coag- 
uli in the heart and 
pulmonary artery. 
1. Thrombosis. 
2. Embolism. 
c. From entrance of air into 
veins (from separation 
of the placenta). 
(902.) Still-born. 
(903.) Premature birth. 
729. Inflammation. 
a. Acute. 
b. Chronic. 
730. Abscess. 
731. Sinus. 
DISEASES OF THE FEMALE BREAST 
732. Galactorrhoea. 
733. Deficiency of milk. 
734. Hypertrophy. 
735. Atrophy. 
736. Depressed nipple. 
737. Chapped nipple 
738. Ulcerated nipple. 
(441.) Cancer. 
a. Scirrhus. 
b. Medullary cancer. 
1 These affections are secondary, and are therefore not numbered. THE NOMENCLATURE OF DISEASES 
321 
c. Epithelial cancer. 
(451.) Colloid. 
739. Non-malignant tumors? 
a. Fibrous tumor. Syn., 
Painful subcutaneous 
tumor. 
b. Fibro-plastic tumor. 
c. Fatty tumor. 
d. Osseous tumor. 
e. Cartilaginous tumor. 
Syn., Enchondroma. 
f. Chronic mammary tu- 
mor. Syn., Adenoid 
tumor. 
g. Vascular tumor. 
746. Cyst. 
747. Complex cystic tumor. Syn., 
Cysto-sarcoma. 
748. Parasitic disease. 
Return cases of this class ac- 
cording to the list atp. 146. 
749. Hyperaesthesia. 
750. Mastodynia. Syn., Neuralgia. 
DISEASES OF THE MALE MAMMILLA.2 
751. Inflammation. 
752. Hypertrophy. 
(44'.) Cancer. 
753. Non-malignant tumors. 
Return such cases according 
to the list atp. 311. 
754. Cyst. 
Diseases of Bones? 
755. Ostitis. 
a. Periostitis. 
1. Nodes. 
756. Diffuse periostitis. Syn., 
Acute periosteal abscess. 
a. Acute necrosis. 
757. Osteo-myelitis. 
758. Chronic abscess. 
759. Caries. 
760. Necrosis. 
761. Mollifies ossium. 
762. Hypertrophy. 
763. Atrophy. 
764. Spontaneous fracture. (The 
cause, if known, should be 
stated.) 
(431.) Syphilitic disease. 
(44*.) Cancer. 
765. Non-malignant tumors. 
a. Fibrous and fibro-cystic. 
b. Myeloid. 
c. Cartilaginous. Syn., En- 
chondroma. 
d. Osseous tumor. Syn., 
Exostosis. 
Varieties: 
1. Ivory. 
2. Cancellated. 
3. Diffused. 
766. Cyst. 
(50.) Rickets. 
(49.) Scrofulous disease. 
767. Parasitic disease. 
Return cases of this class ac- 
cording to the list atp. 146. 
767*. Malformations. 
Return such cases here ac- 
cording to the list at pp. 234 
to 238. 
Diseases of Joints.4 
768. Acute synovitis. 
769. Chronic synovitis. 
a. Pulpy degeneration of 
synovial membrane. 
(491.) b. Scrofulous disease of the 
joints. 
(491.) 1. Morbus coxce. 
770. Ulceration of cartilage. 
771. Abscess. 
(31a.) Pycemic abscess. 
772. Anchylosis. 
a. Deformity from anchy- 
losis. 
773. Dropsy of joints. 
(35.) Gonorrhoeal rheumatism. 
DISEASES OF THE ORGANS OF LOCOMOTION 
(36.) Synovial rheumatism. 
(41.) Gouty synovitis. 
(42.) Chronic osteo-arthritis. Syn., 
Chronic rheumatic arthritis. 
774. Degeneration of cartilage, 
and of the articular sur- 
faces of bones. 
775. Perforation of joints.5 
776. Loose cartilage. Syn., Loose 
body. 
777. Relaxation of ligaments. 
778. Displacement of articular 
cartilage. 
779. Knock-knee. 
780. Bow-leg, or out-knee. 
(441.) Cancer. 
781. Non-malignant tumors. 
Return such cases here ac- 
cording to the list at p. 311. 
782. Neuralgia of joints. 
Diseases of the Spine. 
783. Ulceration of ligaments and 
cartilages. 
784. Caries and necrosis. 
a. Spontaneous fracture of 
the odontoid process. 
785. Psoas, lumbar, and other 
abscesses. 
786. Angular deformity. Syn., 
Kyphosis. 
787. Lateral curvature. Syn., 
Skoliosis. 
788. Anterior curvature. Syn., 
Lordosis. 
(50.) Rickety curvature. 
789. Anchylosis. 
(42.) Chronic osteo-arthritis. 
790. Non-malignant tumors. 
Return such cases here ac- 
cording to the list atp. 311. 
(44'.) Cancer. 
791. Parasitic disease. ♦ 
Return cases of this class ac- 
cording to the list atp. 146. 
792. Malformations. 
Return such cases here ac- 
cording to the list atp. 234. 
a. Deformity from malfor- 
mation. 
(80a.) b. Spina bifida. 
Diseases of the Muscular 
System.6 
diseases of the muscles. 
793. Inflammation. 
794. Abscess. 
795. Gangrene. 
796. Atrophy. 
797. Progressive muscular atrophy. 
798. Fatty degeneration. 
799. Ossification. 
(43l.) Syphilitic deposit. 
(441.) Cancer. 
(45l.) Colloid. 
800. Non-malignant tumor. 
a. Erectile tumor. 
801. Cyst. 
(1144.) Rupture. 
(88.) infantile paralysis. 
802. Parasitic disease. 
Return such cases here ac- 
cording to the list at p. 146, 
No. 4. 
a. Trichinosis. 
(95.) Spasm. 
803. Exhaustion? 
(89b.) Scrivener's palsy. 
(19a.) Diphtheritic paralysis. 
DISEASES OF TENDONS. 
804. Inflammation. 
(865a.) Thecal abscess. 
805. Adhesion of tendons. 
(441.) Cancer. 
806. Non-malignant tumors. 
807. Contraction of tendons, fas- 
ciae, or muscles. 
808. Club-foot. 
a. Talipes varus. 
b. " valgus. 
c. " equinus. 
d. " calcaneus. 
e. " calcaneo-varus. 
f. " equino-valgus. 
Syn., Flat-foot. 
809. Club hand. 
810. Contracted palmar fascia. 
811. Wry-neck. 
(1145.) Rupture. 
DISEASES OF THE APPENDAGES OF 
THE MUSCULAR SYSTEM. 
812. Enlarged bursa patellae. Syn., 
Housemaid's knee. 
813. Enlargement of other bursae 
(specify which). 
814. Bursal tumor. 
815. Bursal abscess. 
816. Bunion. 
817. Ganglion. 
a. Diffused palmar ganglion. 
1 Letters have been here substituted for the omitted numbers. 
2 Register the diseases printed here in italics, not under this heading, but at the place referred to in 
each instance by number. 
3 In all cases the bone affected must be specified. 
4 In all cases the joint affected is to be specified. 
5 This refers to perforation by disease, and in returning it the original affection should be stated. 
6 lu all cases the affected muscle or muscles should be stated. 
7 When the cause of this affection has been ascertained, the case should be returned under the head of 
the primary disease, the secondary affection being also specified. 322 
THE NOMENCLATURE OF DISEASES. 
818. Inflammation. 
819. Abscess. 
820. Inflammatory induration in 
the newly born. 
821. Slough. 
(30b.) Phlegmonous erysipelas. 
(802.) Carbuncle. Syn., Anthrax. 
DISEASES OF THE CELLULAR TISSUE.1 
822. Obesity. 
823. Hemorrhage.9 
(653.) a. Pelvic hcematocele. 
824. Non-malignant tumors. 
Return such cases according 
to the list atp. 311. 
(441.) Cancer. 
825. Parasitic disease. 
Return cases of this class ac- 
cording to list atp. 146. 
(1146.) Foreign substances. 
826. Emphysema.9 
DISEASES OF THE CUTANEOUS SYSTEM.13 
(30.) Erysipelas. 
827. Erythema. (This term in- 
cludes 
1. Erythema teve. 
2. Erythema fugax. Syn.,L. 
volaticum. 
3. Erythema marginatum. 
4. " papulatum. 
5. " tuberculatum. 
6. " nodosum.) 
828. Intertrigo. 
829. Roseola. (This term includes 
1. Roseola sestiva. 
2. " autumnalis. 
3. " symptomatica. 
4. " annulata.) 
830. Urticaria. Syn., Nettle rash. 
a. Urticaria acuta. 
• b. a chronica. 
(Under one or other of these 
heads are included 
1. Urticaria febrilis. 
2. " evanida. 
3. " perstans. 
4. " conferta. 
5. " subcutanea. 
6. " tuberculata.) 
831. Pellagra. 
832. Acrodynia. 
833. Asturian rose, 
834. Prurigo. 
835. Lichen. (This term includes 
1. Lichen simplex. 
2. " pilaris. 
3. " circumscriptus. 
4. " agrius. 
5. " tropicus. Syn., 
Prickly heat.) 
(The so-called Lichen lividus 
is really a form of Purpura.) 
836. Strophulus. Syn., Red gum. 
Tooth rash. (This term 
includes. 
1. Strophulus intertinctus. 
2. " confertus. 
3. " candidus.) 
, (Strophulus albidus is referred 
to Acne. 
" volaticus to Ery- 
thema.) 
837. Pityriasis. (This term in- 
cludes Pityriasis capitis. 
Syn., Dandriff.) 
(Pityriasis versicolor is re- 
ferred to Parasitic Affec- 
tions as a Synonym of Tinea 
versicolor.) 
838. Psoriasis. (This term in- 
cludes Lepra.) 
a. Psoriasis vulgaris. Syn., 
Lepra vulgaris. 
b. Psoriasis guttata. 
c. Psoriasis diffusa. 
d. " gyrata. 
e. " mveterata. 
4840. Miliaria. 
a. Sudamina.5 
841. Herpes.6 
a. Herpes phlyctenodes. 
b. " circinatus. 
c. " iris. 
d. " zoster. Syn., 
Shingles. 
842. Pemphigus. Syn., Pompho- 
lyx. 
a. Pemphigus acutus. 
b. " chronicus. 
c. " solitarius. 
843. Eczema. 
a. Eczema simplex. 
b. " rubrum. 
c. " impetiginodes. 
d. " chronicum. 
844. Impetigo. 
a. Impetigo sparsa. 
b. " confluens. 
1. Figurata. 
2. Larvalis. Syn., Porrigo 
larval is. 
845. Rupia. 
a. Rupia simplex. 
b. Rupia prominens. 
c. Rupia escharotica. Syn., 
Pemphigus gangrseno- 
sus. 
846. Ecthyma. 
847. Acne. 
a. Acne punctata.' 
b. " indurata. 
c. " rosacea. 
d. " strophulosa. Syn., 
Strophulus al- 
bidus. 
848. Sycosis. Syn., Mentagra.8 
849. Stearrhoea. 
a. Stearrhoea simplex. 
b. " nigricans. 
850. Ichthyosis. 
a. Ichthyosis vera. 
b. " cornea. 
851. Xeroderma. Syn., Sclero- 
derma, Scleriasis. 
852. Leucoderma. (This term in- 
cludes Vitiligo.) 
853. Albinismus. 
854. Canities. 
855. Melasma. 
(286.) Melasma Addisoni. English 
name, Addison's disease. 
Syn., Bronzed skin. 
856. Lentigo and Ephelis. Syn., 
Freckles. 
857. Chilblain. 
858. Frostbite. 
859. Ulcer. 
860. Fissures. 
(353.) Cancrum oris. 
861. Boil. 
862. Carbuncle. Syn., Anthrax. 
(26.) Malignant pustule. 
863. Onychia. 
864. Onychia maligna. 
865. Whitlow. 
a. Thecal abscess. 
866. Gangrene. 
866a. Senile gangrene. 
866b. Bed sore. 
867. Hypertrophy. 
868. Corn. 
(816.) Bunion. 
869. Elephantiasis Arabum. Syn., 
Barbadoes leg, Elephas. 
(48.) True leprosy. Syn., Elephan- 
tiasis Grcecorum. 
870. Atrophy. 
a. Linear atrophy. 
b. Alopecia. 
c. Atrophy of nails. 
(441.) Cancer. 
871. Fibro-cellular tumor. 
872. Fatty tumor. 
(267.) Naums vascularis. 
873 Najvus. Syn., Port-wine stain. 
874. Najvus pilaris. Syn., Mole. 
875. Sebaceous tumor. 
a. Steatoma. 
876. Cornua. 
877. Warts. 
878. Condyloma. 
879. Molluscum. 
880. Cheloid. 
881. Framboesia. Syn., Yaws. 
882. Delhi boil. 
883. Aleppo evil. 
(46.) Lupus. 
(49.) Scrofulous disease. 
884. Ingrown nail. 
(912'.) Silver stain. 
(992.) Burns and scalds. 
884*. Cicatrices (state the cause).9 
(102.) Hypercesthesia. 
885. Pruritus. 
(103.) Ancesthesia. 
886. Ephidrosis. 
887. Anidrosis. 
PARASITIC DISEASES OF THE SKIN.10 
888. Tinea tonsurans. Syn., Ring- 
worm. Parasite, Achorion 
Lebertii. Syn., Trichophy- 
ton tonsurans. 
889. Tinea decalvans. Syn., Alo- 
pecia areata, Porrigo decal- 
vans. Par., Microsporon 
Audouini. 
1 Register the diseases printed here in italics, not under this heading, but at the place referred to in 
each instance by number. 
9 When the cause of this affection has been ascertained, the case should be returned under the head of 
the primary disease, the secondary affection being also specified. 
3 Where the disease is local, its situation should be specified. 
4 No. 839 has been accidentally omitted. 
5 This affection is almost invariably symptomatic. 
6 All the varieties which have been named from their locality only are to be included under the term 
Herpes. 
i When the Demodex folliculorum is discovered, its presence should be stated. 
8 When the Microsporon mentagrophytes or the Demodex folliculorum is discovered, its presence 
should be stated. 
9 Under this heading are only to be returned cases presenting a definite morbid character. 
10 For a list of the parasites found in the parasitic diseases of the skin, all of which are to be returned 
here, see pp. 146 to 148. (Nos. 5, 36-43, 45, 48-55.) THE NOMENCLATURE OF DISEASES 
323 
890. Tinea favosa. Syn., Favus, 
Porrigo favosa. Par., Acho- 
rion Schcenleinii; Puccinia 
Favi. 
891. Tinea versicolor. Syn., Pity- 
riasis versicolor. Par., Mi- 
crosporon furfur. 
892. Tinea Polonica. Syn., Plica 
Polonica. Par., Trichophy- 
ton sporuloides. 
893. Mycetoma. Syn., Madura 
foot. Par., Chionyphe 
894. Scabies. Syn., Itch. Par., 
Sarcoptes scabiei. 
895. Phthiriasis. 
896. Irritation caused by 
a. Pediculus capitis. 
b. " palpebrarum. 
c. " vestimenti. 
d. " tabescentium. 
e. Phthirius inguinalis. 
897. Irritation caused by Pulex 
penetrans. EnglishSyn., 
" Pulex irritans. [Chigoe. 
898. " Cimex. 
899. " Leptothrix autumnalis. 
English Syn., Harvest- 
bug. 
900. " Wasps, bees, and other 
stinging insects. 
(985a3.)1 [ing plants. 
901. " Nettles and other sting- 
CONDITIONS NOT NECESSARILY ASSOCIATED WITH GENERAL OR 
LOCAL DISEASES. 
902. Still-born. 
903. Premature birth. 
Metals and their Salts. 
906. Arsenic. 
907. Mercury. 
a. Mercurial tremor. 
(393.) b. Mercurial inflammation of 
the dental periosteum. 
908. Lead. 
a. Lead colic. Syn., Paint- 
er's colic. 
b. Lead palsy. 
c. Blue gum. 
(124>>.) d. Stain of the conjunctiva 
from lead. 
909. Copper. 
910. Antimony. 
911. Zinc. 
912. Silver. 
a. Silver stain. 
(124».) ft. Stain of the conjunctiva 
from nitrate of silver. 
913. Iron. 
914. Bismuth. 
915. Chromium. 
a. Bichromate of potash. 
Caustic Alkalies. 
916. Potash. 
917. Soda. 
918. Ammonia. 
919. Alkaline salts. 
Metalloids. 
920. Phosphorus. 
(394.) a. Phosphoric inflammation 
and necrosis of the alveoli. 
921. Iodine. 
Acids. 
922. Sulphuric acid. 
923. Nitric acid. 
924. Hydrochloric acid. 
925. Phosphorous acid. 
926. Oxalic acid. 
927. Tartaric acid. 
Vegetable Poisons. 
928. Savin. (Juniperus sabina.- 
Linnaeus.) 
929. Croton oil. (Croton tiglium. 
-Linnaeus.) 
930. Elaterium. (Ecbalium offici- 
narum.-Rich.) 
931. Colchicum. (Colchicum au- 
tu mnale.-Linnaeus.) 
932. Black hellebore. (Hellebores 
niger.-Linnaeus.) 
933. White hellebore. (Veratrum 
album.-Linnaeus.) 
a. Veratria. 
934. Squill. (Scilla maritima.- 
Linnaeus.) 
935. Ergot of rye. (Sphseria pur- 
purea.-Fries.) 
a. Ergotism. 
904. Old age? 
POISONS? 
936. Opium. (Papaver somnife- 
rum.-Linnaeus.) 
937. Indian hemp. Cannabis 
Indica. (Cannabis sativa. 
-Linnaeus.) 
938. Alcohol. 
a. Delirium tremens. 
939. Ether vapor. 
940. Chloroform vapor. 
941. Henbane. Hyoscyamus. 
(Hyoscyamus niger.-Lin- 
naeus.) 
942. Deadly nightshade. Bella- 
donna. (Atropa belladonna. 
-Linnaeus.) 
a. Atropa. 
943. Thorn apple. Stramonium. 
(Datura stramonium.-Lin- 
naeus.) 
944. Prussic acid. 
a. Oil of bitter almonds. 
b. Laurel water. 
945. Cyanide of potassium. 
946. Nitro-benzole. 
947. Wourali. Curara. Woorara. 
(Strychnos toxifera.- 
Schomburgk.) 
948. Hemlock. Conium. (Conium 
maculatum.-Linnaeus.) 
949. Monkshood. Aconite. (Acon- 
itum napellus.-Linnaeus.) 
a. Aconitia. 
950. Foxglove. Digitalis. (Digi- 
talis purpurea.-Linnaeus?) 
a. Digitalin. 
951. Tobacco. (Nicotiana taba- 
cum.-Linnaeus.) 
a. Nicotia. 
952. Hemlock drop wort. (CEnanthe 
crocata.-Linnaeus.) 
953. Nux vomica. (Strychnos nux 
vomica.-Linnaeus.) 
a. Strychnia. 
6. Brucia. 
954. Upas tieute. (Strychnos 
tieute.-Leschenhault.) 
955. Upas antiar. (Antiaris toxi- 
caria.-Leschenhault.) 
956. Calabar bean. (Physostigma 
venenosum.-Balfour.) 
957. Fool's parsley. (2Ethusa cyn- 
apium.-Linnaeus.) 
958. Water hemlock. (Cicuta 
virosa.-Linnaeus.) 
959. Camphor. (Cinnamomum 
camphora.-F. Nees and 
Obermaier.) 
960. Coeculus Indicus. (Anamirta 
cocculus.- Wight and Ar- 
nott.) 
961. Darnel. (Lolium temulen- 
tum.-Linnaeus.) 
962. Indian tobacco. Lobelia. 
(Lobelia inflata. - Lin- 
naeus.) 
905. Debility? 
963. Laburnum. (Laburnum vui- 
gare.-Griesbach.) 
964. Yew. (Taxus baccata.-Lin- 
naeus.) 
965. Poisonous fungi. 
a. Mouldy bread. 
966. Poisonous grain. 
a. Lathyrus. (Lathyrus sati- 
vus.) 
1 Paralysis from Lathy- 
rus. 
Animal Poisons. 
967. Spanish fly. Cantharides. 
968. Decayed and diseased meat. 
969. Poisonous meat. 
a. Sausages. 
970. Poisonous cheese. 
971. Poisonous milk. 
972. Poisonous fish. 
a. Mussels. 
Gaseous Poisons. 
973. Ammonia. 
974. Nitrous acid vapor. 
975. Chlorine. 
976. Carbonic acid. 
977. Carbonic oxide. 
978. Coal gas. 
979. Cyanogen. 
980. Sulphuretted hydrogen. 
(939.) Ether vapor. 
(940.) Chloroform vapor. 
981. Putrid and morbid exhala- 
tions. 
982. Other noxious effluvia. 
Mechanical Irritants. 
983. Pounded glass. 
984. Steel filings. 
' Poisoned Wounds. 
Varieties: 
985. a. By venomous animals. 
1. Snakes. 
2. Scorpions. 
985*. 3. Stinging insects. 
(900.) Cases of death from stinging 
insects should be entered 
here, and those of irritation 
only from that cause at 
No. 900. 
b. By animals having infectious 
disease. 
(23.) Glanders. 
(24.) Farcy. 
(25.) Equinia mitis. 
(26.) Malignant pustule. 
(91.) Hydrophobia, Rabies. 
(2.) Cow-pox. 
986. c. By dead animal matter. 
1 Cases of irritation from stinging insects should be entered here, and those of death from that cause 
under poisoned wounds. 
3 This mode of return is only to be employed when the cause of death is not traceable to definite 
diseases. 
3 When the cause of this affection has been ascertained, the case should be returned under the head of 
the primary disease, the secondary affection being also specified. 
' In returning cases of poisoning the precise agent should be stated. 324 
THE NOMENCLATURE OF DISEASES 
987. d. By morbid secretions. 
988. e. By vegetable substances. 
I 989. 1. Poisoned arrows. 
| (947.) Wourali. 
990. 2. Subcutaneous injection.* 
991. /. By mineral substances. 
General Injuries. 
992. Burns and scalds.2 
993 Lightning stroke. 
994. Multiple injury. (The cause 
and extent to be stated.) 
995. Asphyxia. Syn., Apnoea. 
Injuries of the Head and Face. 
A.-OF THE HEAD. 
1000. Contusion. 
a. Cephalheematoma. 
1001. Scalp-wound; bone not ex- 
posed. 
1002. Scalp-wound; bone exposed. 
1003. Concussion of the brain. 
1004. Fracture of the vault of the 
skull.8 [pression. 
a. Simple, without de- 
ft. " with depression. 
c. Compound, without de- 
pression. 
d. " with depression. 
1005. Hernia cerebri. [skull. 
1006. Fracture of the base of the 
1007. Wound of the skull.6 
1008. Laceration of the brain, 
without fracture. 
1009. Injuries of vessels.'8 8 (Spe- 
cify which.) 
1010. Injuries of the cerebral 
nerves. 
B.-OF THE FACE. 
1011. Contusion. 
1012. Wound.' 
1013. Injuries of vessels.'8 9 (Spe- 
cify which.) 
1014. Foreign bodies in the ear. 
1015. " " nose. 
1016. " " antrum. 
1017. " " soft parts. 
1018. Fracture of the facial bones. 
1019. " " lower jaw. 
(410, 4U.)10 
1020. Dislocation of the jaw. 
Injuries of the Eye. 
1021. Contusion. 
1022. Contusion, with rupture of 
the sclerotic. Syn., Rup- 
tured globe. 
1023. Contusion, with dislocation 
of the lens. 
1024. Contusion, with hemorrhage 
into the globe. 
1025. Foreign bodies in the cornea 
or conjunctiva. 
1026. Foreign bodies in the cavity 
of the eye.8 
1027. Wound of the eyelid. 
1028. " " conjunctiva. 
1029. " " sclerotic. 
1030. " " cornea. 
1031. " " lens. 
1032. " " iris. 
a. From Drowning. 
b. " Hanging. 
c. " Strangling. 
d. " Plugging of air- 
passages; e. g., 
With bread; with 
e. " Overlying, [blood. 
LOCAL INJURIES.4 
1033. Dislocation of the globe. 
(158.) Total disorganization of the 
eye from injury. 
1034. Wounds and injuries of the 
parts within the orbit. 
1035. Chemical injuries of the eye- 
lids and eye. 
1036. Burns and scalds. 
Injuries of the Neck. 
1037. Contusion of the soft parts. 
1038. Fracture of the hyoid bone. 
1039. " " cartilages of 
the larynx. 
1040. Rupture of the trachea. 
1041. Dislocation of the hyoid bone. 
1042. Wound. 
a. Superficial. 
b. Cut throat.' 
c. Gunshot.' 
d. From the mouth. 
1043. Injuries of vessels.' 8 9 (Spe- 
cify which.) 
(992.) Burn and scald of the larynx. 
1044. Foreign bodies in the air- 
passages. 
1045. " " pharynx. 
1046. " " oesophagus. 
1047. Injury of the pharynx and 
cesophagus by corrosive 
substances. 
Injuries of the Chest.' 
1048. Contusion. 
1049. Fracture of the ribs (includ- 
ing costal cartilages), with- 
out injury to lung. 
1050. Fracture of the ribs (includ- 
ing costal cartilages), with 
injury to lung. 
1051. Fracture of the sternum. 
1052. Wound of the parietes. 
1053. Perforating wound of the 
chest.'8 
1054. Penetrating wound of the 
pleura or lung.'8 
1055. Wound of the anterior me- 
diastinum.8 
1056. Wound of the pericardium 
and heart.'8 
1057. Injuries of vessels.'8 8 (Spe- 
cify which.) 
1058. Rupture of the heart or lung 
without wound or fracture.' 
Injuries of the Back. (Includ- 
ing the whole spinal region.) 
1059. Contusion. 
1060. Sprain. 
INJURIES. 
f. From Crushing. 
g. " Gaseous poisons. (See 
list at p. 323.) 
996. Privations.3 Syn., Starvation. 
997. Exposure to cold.3 
998. Infant exposure.3 
999. Neglect.3 
1061. Wound.'8 
1062. Fracture and dislocation of 
the spine.11 
1063. Injury of the cord, without 
known fracture. 
Injuries of the Abdomen. 
1064. Contusion. 
1065. Contusion with rupture of 
muscles.' 
1066. Contusion with rupture of 
viscera. 
1067. Wound of the parietes.8 
1068. Wound of the parietes, with 
protrusion of uninjured 
viscera. 
1069. Wound of the parietes, with 
protrusion of wounded 
viscera. 
1070. Wound of the parietes, with 
wound of unprotruded 
viscera. 
1071. Wound of viscera without 
wound of parietes.8 
1072. Injuries of vessels.'8 8 (Spe- 
cify which.) 
1073. Foreign bodies in the peri- 
toneal cavity. [ach. 
1074. Foreign bodies-in the stom- 
1075. Foreign bodies and concre- 
tions in the intestine. 
1076. Fistula from injury, and ar- 
tificial anus. 
Injuries of the Pelvis. 
1077. Contusion. 
1078. Wound of the male perineum, 
scrotum, and penis.8 
1079. Wound of the female peri- 
neum and vulva. 
1080. Wound of the vagina and 
internal female organs.' 
1081. Wound of the rectum.' 
1082. " " anus. 
1083. " " bladder. 
1084. Rupture of the bladder with- 
out wound. 
1085. Rupture of the bladder from 
fracture.12 
1086. Injuries of the pregnant 
uterus. 
1087. Injuries of vessels.'8 9 (Spe- 
cify which.) 
1088. Foreign bodies in the va- 
gina. 
1089. Foreign bodies in the rec- 
tum. 
(570, 601*.) Foreign bodies in the 
bladder and urethra.13 
1 In returning such cases, specify the agent employed. 
2 Including explosions. When limited to one part of the body, the part is to be specified; e.g., Scald 
of the larynx. 
3 Any affection that may have been induced by this cause ought to be stated. 
' In all cases of injury specify whether accidental, judicial, homicidal, self-inflicted, or in battle. 
5 In such cases state the main features in the fewest words possible. 
8 If from gunshot, to be so stated, 
' In such cases state the main features in the fewest words possible. 
8 Specify when from gunshot. 
9 Return such cases in the order given at pp. 310 and 311. 
10 Injuries of the alveoli and teeth are to be returned with the other affections of those parts. 
11 The seat of the injury and the existence and extent of paralysis to be stated. 
12 Rupture of the bladder from accumulation of urine is usually from stricture, and must be returned 
under the appropriate heading (592). 
13 Return such cases with calculus in the bladder and urethra. THE 
NOMENCLATURE OF DISEASES. 
325 
1090. Fracture and dislocation of 
the pelvis. 
1091. Fracture and dislocation of 
the pelvis, with rupture of 
the bladder or urethra. 
Injuries of the Upper 
Extremities. 
1092. Contusion. 
1093. Sprain. (Specify which 
joint.) 
1094. Wound.13 
1095. " of joint. 
1096. Injuries of vessels.1 3 3 (Spe- 
cify which.) 
1097. Foreign bodies imbedded.3 
1098. Separation of ejpiphyses. 
1099. Greenstick fracture, or 
bending of bone. (Specify 
which bone.) 
1100. Fracture. (State whether 
simple or compound.) 
1101. Fracture of clavicle. 
1102. " scapula. 
1103. " humerus. 
1104. " forearm. 
1105. " carpus, meta- 
carpus, and 
phalanges. 
1106. Ununited fracture, or false 
joint. (Specify which bone.) 
1107. Dislocation. (When com- 
pound, to be so stated.) 
1108. Dislocation of the sterno- 
clavicular joint. 
1109. Dislocation of the acromio- 
clavicular joint. 
1110. Dislocation of the shoulder. 
1111. " " elbow. 
1112. " " wrist and 
carpus. 
1113. " " thumb. 
1114. " " phalangeal 
joints. 
Injuries of the Lower 
Extremities. 
1115. Contusion. 
1116. Sprain. (Specify which 
joint.) 
1117. Wound.33 
1118. " of joint. 
1119. Injuries of vessels.1 3 3 (Spe- 
cify which.) 
1120. Foreign bodies imbedded.3 
1121. Separation of epiphyses. 
1121*. Fracture. (When com- 
pound, to be so stated.) 
1122. Fracture of the femur. 
1123. " cervix femoris. 
1124. " Intracapsular. 
1125. " trochanter ma- 
jor. 
1126. " patella. 
1127. " leg, both bones. 
1128. " tibia alone. 
1129. " • fibula alone. 
1130. " bones of the 
foot. 
1131. Ununited fracture, or false 
joint. (Specify which bone.) 
1132. Dislocation. (When com- 
pound, to be so stated.) 
1133. Dislocation of the hip. 
1134. " patella. 
1135. " knee. 
1136. " head of fibula. 
1137. " foot, at the 
ankle. 
1138. Dislocation of the foot, at 
calcaneo-astragaloid, and 
scapho-astragaloid joints. 
1139. Dislocation of the foot, at 
astragalus. 
1140. Dislocation of the foot, at 
os calcis. 
1141. Dislocation of the foot, at 
other tarsal bones. 
1142. Dislocation of the foot, at 
metatarsus, and phalanges. 
Injuries of the Absorbent 
System. 
1142*. Foreign bodies and concre- 
tions. 
1143. Wound of lymphatics. 
Injuries not Classified. 
1144. Rupture of muscle. 
1145. Rupture of tendon. 
1146. Foreign substances in the 
cellular tissue. 
1 Return such cases in the order given at pp. 310 and 311. 
3 In such cases state the main features in the fewest words possible. 
3 Specify when from gunshot. 
The topics of the Appendix-namely, Human Parasites and Congenital Malformations-have 
been already described at pp 146 to 148, and 234 to 238, where the lists are printed under the subjects 
which they embrace as topics relative to Pathology. THE 
SCIENCE AND PRACTICE OF MEDICINE. 
PART III. 
THE NATURE OF DISEASES-SPECIAL PATHOLOGY AND 
THERAPEUTICS. 
It is my object in this part of the Text-book to treat of the diseases compre- 
hended in the two groups or classes into which the London College of Physi- 
cians has arranged diseases-namely, into General and Local. 
The first, namely, General Diseases, comprehend the two sections, A and 
B, as defined at p. 307. 
Section A commences with what are generally known as specific or mias- 
matic fevers ; terms which may be sufficiently understood, but are far from un- 
objectionable. Next come the malarious fevers, and then follow the epidemic 
disorders, which differ more or less distinctly from the previous members of 
the group. Lastly, come those febrile affections which are either solely or occa- 
sionally excited by the introduction of some animal matter in a state of 
change. 
In section B, constitutional diseases are described, together with those forms 
of disordered nutrition in which the affection, whether localized or not, has 
a tendency to invade more organs than one in the same individual, either si- 
multaneously or in succession. 
In the following series of chapters on topics relative to the pathology of the 
General Diseases, it is intended to describe, Firstly, The common proper- 
ties or characters peculiar to specific or miasmatic diseases. Secondly, The 
nature of malarious diseases. Thirdly, The nature and management of epi- 
demics of disease. Fourthly, The nature of constitutional diseases; and 
Fifthly, To describe in detail the several diseases individually, their general 
nature and causes; pathology and morbid anatomy; symptoms, course, and com- 
plications; diagnosis, prognosis, and treatment. 
The employment of the words miasmatic and zymotic, as they are terms in 
common daily use, expressive of preventible diseases, whose causes are remova- 
ble, ought not to be understood as signifying more than this, and not express- 
ing scientifically any rigidly defined group of diseases. The terms are used 
to bring together those diseases which possess the peculiar character, in com- 
mon, of suddenly attacking great numbers of people, at intervals, in unfavora- 
ble sanitary conditions. In the language of Dr. Farr, the " diseases of this 
class distinguish one country from another-one year from another ; they 
have formed epochs in chronology; and, as Niebuhr has shown, have 
influenced not only the fall of cities, such as Athens and Florence, but of em- 
pires ; they decimate armies, disable fleets; they take the lives of criminals 
that justice has not condemned; they redouble the dangers of crowded hospi- 
tals ; they infest the habitations of the poor, and strike the artisan in his NATURE AND ORIGIN OF SPECIFIC DISEASES. 
327 
strength down from comfort into helpless poverty ; they carry away the infant 
from the mother's breast, and the old man at the end of life ; but their direst 
eruptions are excessively fatal to men in the prime and vigor of age. They 
are emphatically the morbi populares." 
The name Zymotic (first suggested by Dr. William Farr, to designate 
scientifically such a class of diseases) is not to be understood now as implying 
the hypothesis that these diseases are fermentations, which the derivation of 
the term would lead one to believe. It has become extensively used of late 
as applied to the diseases whose characters as a class are already indicated, 
and for which some convenient term was required. The class, then, to which 
the term zymotic has been applied was intended to comprehend all the prin- 
cipal diseases which have prevailed as epidemics or endemics,-all those which 
are due to paludal or animal malaria, and those which are due to specific dis- 
ease poisons, capable of propagation from one human being to another, and 
communicable either by direct contact, or indirectly through various channels of 
human intercourse, contaminating drinking-water or infecting the air, or by 
animals in a state of disease, as well as dietic and parasitic diseases. 
For reasons already stated at p. 307, the general diseases of section A can- 
not be subdivided into groups, scientifically distinct from each other, to 
permit of their being defined. "So many points of contact exist among them, 
that there is no one fact that could be predicated of any number which was 
not either too wide in its comprehensiveness, or too narrow in its exclusive- 
ness, or which did not imply a theory which might have been proved to be 
true of certain members of the group, but could only be applied theoretically 
of the remainder." The term zymotic, in the returns of the Registrar-General, 
has been made to include diseases of which the origin and mode of propaga- 
tion are wholly dissimilar. The class, as originally described by Dr. Farr, 
comprehend "diseases that are either epidemic, endemic, or contagious, 
induced by some specific body, or by the want or bad qualities of food," 
which incongruous group was subdivided into miasmatic, enthetic, dietic, and 
parasitic diseases,-a subdivision having no common principle involved in 
details of their description. Even the miasmatic group (concerning which 
there is a more general agreement among medical men as to the characters of 
diseases due to a miasma than regarding others) include diseases of very 
doubtful origin, and others altogether incongruous. Quinsy, a simple inflam- 
mation of the fauces, is placed next to scarlatina; erythema, a simple redness 
of the skin, is associated as a subordinate variety of erysipelas. Diarrhoea 
stands between dysentery and cholera, and has no place among diseases of the 
intestinal canal; and the order concludes with ague and rheumatism, "ignor- 
ing the malarious origin of the one, and the cpnstitutional character of the 
other." 
The following chapters are therefore intended to set forth the salient points 
in the Pathology of Class A of the General Diseases, so far as they can be 
conveniently grouped together. 
CHAPTER I. 
ON THE NATURE OF THE SPECIFIC OR GENERAL DISEASES, COMMONLY CALLED 
MIASMATIC. 
"In a rude manner, the General Diseases may be classed as the first 
section of local diseases-the blood itself being regarded as the organ affected." 
In the greater number of the diseases of the group to which the name spe- 328 
SPECIAL PATHOLOGY - SPECIFIC DISEASES. 
cific or miasmatic may be given, the blood is generally more or less changed, 
and by some is presumed to be the primary seat of diseases which result from 
specific poisons, of organic origin, either derived from without or generated 
within the body. These specific poisons tend to produce in the blood an 
excess of those decomposing organic compounds which physiology teaches us 
are always present in the circulating current. 
The diseases of this kind, which are to be first described, constitute a group 
of diseases sometimes termed "acute specific" (Walshe), or "general dis- 
eases" (Wood), because they primarily and essentially implicate the entire 
system; and all of them may be comprehended under the term "general 
diseases." Throughout their course, and from the first, they each variously 
modify the composition of the blood, the calorification and the innervation of 
the body. Each and all of them, also, during their progress, give rise to 
some lesions in the textures, of a special anatomical character, when the 
disease is not too rapidly fatal to allow of these pathological features to 
become developed, as is sometimes the case in yellow fever, typhoid fever, 
plague, cholera. These maladies run an acute and rapid course; they are 
attended with more or less fever; and in the majority of instances, the fever 
which accompanies them has a fixed duration. The greater number of them 
are contagious, or capable of being propagated from person to person, under 
certain conditions not yet well understood; and, lastly, all of them are pro- 
duced by an extrinsic poison, either of a miasmatic or specifically contamina- 
ting nature, or by the implanting of a specific virus. 
The specificity, so to speak, of these diseases, consists in certain characters 
which distinguish each of them from any other disease, and in the constancy 
by which, from time immemorial, such characters have continued to distin- 
guish them. Although medical opinions regarding their pathology may 
change, yet the essential characters of these "specific diseases" are not known 
to change. Each of these diseases observes a constancy and regularity of 
plan in the construction and development of its morbid processes (Paget). 
Each of them has some essential character or characteristics by which they 
are severally distinguishable. The course of the febrile phenomena is found 
to be distinctive, the duration of the febrile state not less so, as well as the 
anatomical signs which distinguish the local lesions, the development of which 
are concurrent with the general or constitutional phenomena. Of all truths 
relating to the phenomena of disease, the most important are those which 
relate to the order of their succession. 
Specificity cannot be denied to those diseases in which, during their natural 
course, we find that every phenomenon is related (in a uniform manner, so 
far as exact investigation has extended) to certain phenomena that coexist 
with it, and to others that have preceded and will follow it. When it is 
found that a series of phenomena occur in (thousands, millions) x number of 
instances in the same order, within similarly uniform periods of time, and 
altogether with so much regularity that those who are instructed, on visiting 
a patient for the first time, can not only affirm what has gone before, but may 
predict what is to come after (the highest achievement of science)-it is impos- 
sible to avoid concluding that such an invariable sequence has as constant a 
cause. This conclusion flows from the very constitution of our nature, and is in- 
evitable ; and on our knowledge of the facts relating to such order of succession 
is founded every reasonable anticipation of future events, and whatever power 
we possess of influencing those phenomena in the management of the disease, 
to the advantage of our patients and the. community at large. When it is 
found, moreover, that there are many series of these phenomena, which may 
be called A, b, c, d, &c., occurring in different persons, and at different times, 
all perfectly distinguishable, and never by any chance capable of being con- 
founded by a properly trained person, it is impossible to avoid concluding 
that the causes of A, b, c, d, &c., are not identical, and must be in fact dis- NATURE AND ORIGIN OF SPECIFIC DISEASES. 
329 
similar. Moreover, mere uniformity in the sequence of such phenomena as 
obtains in the natural course of the respective diseases is of itself enough and 
sufficient (to most minds) to warrant the belief that the diseases they represent 
are specific. 
This view of the specificity of each of these diseases may be held indepen- 
dent of the causation of them being also specific; but the term "specific," 
from this point of view, necessarily means that such unlike effects must have 
unlike causes; and the term " specific," as we use it, is derived simply from 
the fact that (following the analogy of natural history) the different diseases 
just named A, b, c, d, &c., have been considered as so many different species, 
preserving their individuality through all time, as the rose, the apple, the 
dog, the whale, or any other animal or plant preserves theirs. Like animals 
and plants, also, such specific diseases may disappear from off the face of the 
earth, when they can no longer "struggle for existence" against the well- 
directed measures of sanitary science. These measures may eventually be 
capable of rendering the existence of many specific diseases an impossibility 
-as much so as the existence of a megatherium or even a wolf would now 
be an impossibility in this country. 
The origin of all specific diseases, or "how their respective first eontagia 
arose," is alike unknown. "This in Pathology is just such a question as in 
Physiology is 'the origin of species.' Indeed, it is hardly to be assumed as 
certain that these apparently two questions may not be only two phases of 
one. Hourly observation tells us that the contagium of small-pox will breed 
small-pox, that the contagium of typhus will breed typhus, that the contagium 
of syphilis will breed syphilis, and so forth; that the process is as regular as 
that by which dog breeds dog, and cat cat,-as exclusive as that by which 
dog never breeds cat, nor cat dog; and prospectively we are able to predict 
the results of certain exposures to contagion as definitively as the results 
of any chemical experiment. But retrospectively we have not the same sort 
of certainty; for we cannot always trace the parentage of a given case of 
small-pox or measles" (Simon, Sixth Report on Public Health, p. 54). The 
same may be said of animals; given any individual calf, cat, dog, or child, 
we cannot always trace its parentage.* 
* "And here," says Mr. Simon, " notwithstanding the obvious difficulties of proof 
either way, some persons will dogmatize that there must have been an overlooked 
inlet for contagium, while others will dogmatize that there must have been in the 
patient's body an independent origination of the specific chemical change. Presuming 
(as may pretty confidently be presumed) that in the history of mankind there was once 
upon a time a first small-pox case, a first typhus case, a first syphilis case, &c., and admit- 
ting our entire ignorance as to the combination of .circumstances under which those 
first cases respectively came into existence, we have no scientific reasons for denying 
that new 'spontaneous generations' of such eontagia may take place. But, as regards 
some of the diseases, there are conclusive reasons against supposing that this is of 
frequent occurrence. Where we can observe isolated populations, we find very long 
periods elapse without any new rise of certain 'species' of disease. For instance, in 
1846, the contagium of measles was imported by a sick sailor into one of the Faroe 
Islands, and led to an epidemic which attacked more than 6000 out of the 7782 inhabi- 
tants; sparing only the persons who previously had had the disease, and 1500 who 
were kept out of reach of contagion; but before that time there, had not for sixty-five- 
years been, in those islands, a single case of measles. And the statistical return to which 
I have already often referred (Parliamentary Paper, 1864, No. 12) contains another 
very striking illustration of the same sort of thing: England has 627 registra- 
tion districts. During the ten years 1851-60, scarlatina, small-pox, and measles were 
(as usual) prevailing more or less throughout the country, producing among children- 
under five years of age an average annual mortality of 802 per 100,000; i. e., by scar- 
latina 419. by small-pox 103, and by measles 280 In 626 of the registration districts 
there were deaths (and, for the most part, in not inconsiderable quantity) from one 
or more of those causes; not quite invariably from all of them ; for forty-three of the 
626 (thanks, no doubt, to vaccination) had not any death by small-pox, and among 
the forty-three districts which thus escaped mortality by small-pox, there was one 330 
SPECIAL PATHOLOGY SPECIFIC DISEASES. 
With regard to their causes, therefore, each of them appears to be produced 
by some distinct morbific agent-some morbid poison-a poison or virus which 
is capable of being multiplied in the body during the development of the 
particular disease. In this respect they are capable of self-augmentation 
(Paget). No evident fresh cause is applied, and yet the disease increases 
(e. g., syphilis, small-pox, vaccinia, glanders, hydrophobia, and malignant pustule). 
The theory of each of them, expressed in the most general terms, is, that each 
of them depends upon a definite specific virus, which induces a morbid condi- 
tion of the blood; and that, during the development and course of the disease, 
the system endeavors to discharge or transform in some way the peculiar 
morbific agents which have given rise to the symptoms, or which have multi- 
plied in the body during the course of the affection. The whole blood then 
seems to be diseased, and nearly every function and sensation in the frame is 
impaired or disturbed from the state of health before any local lesion is 
developed. Sometimes, indeed, the severest constitutional disturbances of a 
specific kind may coexist with the smallest local development of any specific 
lesion (Paget); and Dr. Robert Williams has justly observed, and numerous 
examples have been noticed, in which "it may be laid down as a general law, 
that when a morbid poison acts with its greatest intensity, and produces its 
severest forms of disease, fewer traces of organic alterations of structure will 
be found than when the disorder has been of a milder character." Time, 
duration, or chronicity, is a peculiarly important and characteristic element 
in the nature of these diseases. They run a definite course; and we know of 
no specific remedy which will at once effect a cure and prove an antidote to 
the poison. The nearest approach to an antidote is that of quinine in the 
malarious fevers. They have all-'(1.) A more or less defined period of incu- 
bation or latency; (2.) A period of development towards the fasiigium or acme 
of the disease; (3.) A period of defervescence, during which the febrile phenom- 
ena abate; (4.) Etiologically they are quite distinct from one another; and, 
lastly, they have a period of convalescence. 
The causes, then, of A, b, c, d, &c., being thus specifically different, it still 
remains to be determined what these causes are. This is now being done by 
the principle of exclusion chiefly-i. e., that such and such an alleged cause 
cannot produce such and such effects. Thus, it is now certain that cold, a 
chill, or sudden change of temperature, never cause a specific disease such as 
any of those described ; that mere moisture in the air does not; that such and 
such gases do not, and so on. The question seems now narrowed to this point, 
-that in the case of many specific diseases (probably in all) the cause is 
something quite special, and, in fact, as yet, of unknown origin. Neverthe- 
less, there are some, such as small-pox and syphilis, concerning which organic 
chemistry may yet (and perhaps so.on) enable us to learn more definitely the 
" active principle" (to use a pharmaceutical phrase) by which they are propa- 
gated; just as we have learned that strychnine is the active principle of nux 
vomica; or that morphine is of opium; or digitaline of digitalis. 
which also had not even a single death by measles; but, with these exceptions, all the 
626 districts had deaths from the three diseases-deaths by measles, deaths by small- 
pox, deaths by scarlatina. But the 627th district had an entire escape. In all the ten 
years it had not a single death by measles, nor a single death by small-pox, nor a single 
death by scarlet fever. And why? Not because of its general sanitary merits, for it 
had an average amount of oth°r evidence of unhealthiness Doubtless, the reason of 
its escape was that it was insular. It was the district of the Scilly Isles; to which it 
was most improbable that any febrile contagion should come from without. And its 
escape is an approximative proof that, at least for those ten years, no contagium of 
measles, nor any contagium of scarlet fever, nor any contagium of small-pox had arisen 
spontaneously within its limits. I may add that there were only seven districts of 
England in which no death from diphtheria occurred, and that of those seven dis- 
tricts, the district of the Scilly Isles was one. Still, to say that a disease is contagious is 
not to say that it may not arise without contagion" (Simon, 1. c.). CAUSES OF SPECIFIC DISEASES. 
331 
We are as certain as we can be of anything that such an " active principle " 
exists in the pus or juice of certain pustules or papules in some of those specific 
diseases which are capable of being propagated by inoculation. " Thus the 
different ferments by which they severally are communicated have respective 
peculiarities of their own,-peculiarities which are primarily governed by the 
nature and anatomical relations of the morbid process in which each particular 
ferment originates. All of them are essentially unstable and transitory ; but, 
while some of them tend under ordinary circumstances to undergo a rapid 
extinction, others of them can with comparative ease retain their power for 
long periods of time, and some apparently have not their full force till some 
time after they have left the diseased body; e. g., cholera. Some of them 
associate themselves indistinguishably with one or more of the common excre- 
tions and exhalations of the body, others are separately tangible in vesicles 
and pustules, or at ulcerating or suppurating surfaces, and may or may not 
also exist in other products of the body ; some of them are evolved in small 
quantity, others in very large quantity, or with very large natural admixture ; 
some of them are fixed, others but very scantily volatile, others as volatile as 
if they were vapors; some of them operate easily on a second body by mere 
contact (more or less prolonged) with the outer or inner surface to which they 
are applied, others are not found to act unless they come into contact with 
accidentally abraded surfaces, or be thrust into the bodily substance by 
inoculation. Thus, in vaccine lymph and in the matter of chancres respectively, 
there is a contagium which we know only in a fixed form, and only as com- 
municable by intentional or accidental inoculation. Also ophthalmia and 
gonorrhoea and glanders are communicable by the fixed contagium which their 
pus contains ; but this contagium does not need inoculation to infect the mucous 
membrane to which it is applied ; and as regards ophthalmia, there are reasons 
for suspecting that to some extent the contagious pus may retain its activity 
when dry enough to float as dust in the air. In some forms of milzbrand 
(including, probably, the so-called ' malignant pustule,, which is the best-known 
human form of the disease) the highly virulent fluids can, it is alleged, infect 
by soakage through the cuticle. In diphtheria the characteristic exudation is 
capable of infecting by contact; and though often the disease is communicated 
from person to person without any manifest transplantation of matter, it may 
be that in such cases particles of the decomposed false membrane are con- 
veyed as a volatile contagium. Cholera and typhoid fever send forth their 
respective contagia for the most part, if not exclusively, as matter dissolved 
or suspended in the evacuations which pass from the patient's bowels; and 
probably these evacuations (which, at least in cholera, gradually develop 
their full infective force after their discharge from the body), can, under some 
circumstances, bring into similar contagious fermentation the excrement with 
which they are mingled in privies, drains, and cesspools, and can thus convert 
the effluvia and leakage from such sources into means of extensive secondary 
infection of air and water. The volatile contagium of hooping-cough is proba- 
bly disengaged in large quantities by the air-passages, and as it forms, is sent 
forth with the breath. In typhus, small-pox, measles, and scarlatina, the diffu- 
sion of volatile contagium occurs to a vast amount, probably with all exhala- 
tions from the body; and in addition to this, contagium, more or less fixed, 
collects abundantly about the patient's person and bedding; and, in a far less 
degree, something of the same sort probably occurs in erysipelas" (Simon, 1. c.). 
As regards the spread or modes of propagation of these diseases, each of them 
" has its own laws of communicability,-laws which must be properly under- 
stood if the danger of contagion is to be guarded against. The communication 
of some diseases (of scabies, for instance, and favus) is not by any true product 
of the human body, but consists in the migration of parasites, or germs of para- 
sites, animal or vegetable, from one person's body to another,-a migration 
which, of course, the recipient may to any extent facilitate by dirty personal 332 
SPECIAL PATHOLOGY-SPECIFIC DISEASES. 
habits, and which, as regards some parasitic diseases, can scarcely be con- 
ceived to occur otherwise than in consequence of such habits " (Simon). 
The communication of the specific diseases, on the contrary, takes place by 
that process which is distinctly called zymotic :* in the first affected body, 
and by or with a specific chemical transformation of some of its material, there 
is generated or multiplied a specific zyme, contagium, or ferment; which, if 
transferred while active to a second (not accidentally insusceptible), will there, 
according to the common law of ferment, excite the same morbid phenomena, 
the same chemical changes, as those amid which itself was begotten (Simon, 
1. c., p. 53). 
CHAPTER II. 
THEORY OF SPECIFIC DISEASES. 
The theory regarding the nature of specific or general diseases is thus 
expressed by Mr. Paget: 
" Each of them depends on a definite and specific morbid condition of the 
blood ; and the local process by which each is made manifest is due to the 
disorder produced by the morbid blood in the nutrition of one or more tissues ; 
and generally this disorder is attended with the accumulation, and leads to 
the discharge or transformation, of some of the morbid constituents of the 
blood in the disordered part. It is held, also, that in some of the Specific 
* " Some of these expressions," says Mr. Simon, " are meant to hesitate between two 
particular assertions. In this respect they correspond to the uncertainty which at 
present prevails as to the exact nature of some or all morbid ferments. A few years 
ago it might have seemed permissible to describe without reserve the contagion of the 
zymotic diseases, as but some changing organic material of the first affected body. At 
present, however, reserve on that point is necessary. That the power of contagious- 
ness is associated with such changing organic material is certain ; but whether the 
power be proper to the material, or be only contingently its attribute, seems to require 
further investigation. The recent very interesting experiments of Professor Schroe- 
der in Germany, and of M. Pasteur in France (published respectively in Wohler and 
Liebig's Annalen der Chemie, and in the Comptes Rendus de l'Academie des Sciences), 
aim at proving, most extensively, an essential dependence of specific fermentatory and 
putrefactive changes on the presence, in each case respectively, of some characteristic 
molecular living thing ; and they give it to be understood that, if certain fermenting 
or putrefying organic matters tend by their contact to bring a given quiescent 
organic compound into chemical excitement like their own, this contagious power of 
theirs depends on their carrying with them those distinctive microscopical animal or 
vegetable forms which in each case respectively are the true agents of change. The 
conclusiveness of those experiments in the field to which hitherto they have been con- 
fined is still matter of the warmest scientific controversy ; and while, therefore, it 
would be at least premature for me to insist upon them as evidence even in that field, 
it would be yet more premature for me to speculate on the possible results of an exten- 
sion of similar researches to the pathology of zymotic diseases. But it is impossible to 
ignore their very important bearing in that direction. It may be that broad distinc- 
tions will have to be drawn among the diseases which I here speak of as zymotic, or at 
least between them and some or all of the traumatic infections. Indeed, I gather from 
Canstatt's last Jahresbericht that already M. Monoyer, of Strasburg, in a recent work 
on Fermentation, has attempted a beginning in this matter. As connected with the 
argument in my text, it may be worth while to mention here that the different sorts 
of vibriones which M. Pasteur describes as the essential powers in putrefaction are, 
according to him, not only independent of atmospheric air, but are killed by it; so 
that, for instance, when butyric acid is forming in a saccharine solution, the butyric 
fermentation may at will be stopped by a current of atmospheric air, which kills the 
vibrionic ferment; though, on the other hand, a current of carbonic acid may traverse 
the solution for an indefinite time without affecting that infusorial life." DISTINGUISHING ELEMENTS OF SPECIFIC DISEASES. 
333 
Diseases the morbid condition of the blood consists in undue proportions of 
one or more of its normal constituents-in others, again, some new morbid 
substance is added to or formed in the blood. In either case the theory main- 
tains that the phenomena of each Specific Disease depend chiefly on cer- 
tain corresponding specific materials in the blood, and that, if characteristic 
morbid structures be formed in the local process, these morbid materials are 
incorporated in the organs which are formed as the products of the inflam- 
mation." 
In the Section A of the general diseases to be presently described, the 
chief or essential constituent of the specific morbific agent enters the body from 
without; while in the second Section, B, the essential constituent of the morbific 
agents appears to be inbred in the body, and makes itself manifest by various con- 
stitutional indications previous to the development of local lesions, or the charac- 
teristic expression of the disease by other phenomena. There is sufficient circum- 
stantial evidence with regard to all of these diseases, and absolute proof with 
regard to some, that there is-(1.) A morbid condition of the blood; (2.) 
That the nature of that condition is, in many, definite and specific, inasmuch 
as it may be produced at will by the introduction of a definite substance into 
the blood, which then manifests itself by establishing a local disease, and 
which, within certain limits, has constant characters ; (3.) That the morbid 
matter or poison by which the condition of the blood is changed may accumu- 
late or augment in quantity and virulence, and at length may be discharged 
in various ways from the body, and under a variety of organic forms, chiefly 
through the excretory products. But some are also discharged at the seats of 
local lesions which are set up, the morbid poisons being for the time accumu- 
lated in the morbid structures. 
• As far as some of the specific or miasmatic diseases are concerned, such as 
typhus and typhoid fevers, erysipelas, scarlet fever, cholera, and the like, there is 
undoubted evidence of a morbid material in the blood, although it has never 
been isolated nor proved to exist in the products of the local morbid processes 
or specific lesions.- In many of the constitutional diseases, too, similar evidence 
exists of a morbid matter inbred in the blood. 
It will soon appear obvious to the student that the diseases about to be con- 
sidered differ very materially in their nature from the purely local diseases to 
be noticed lastly. While the Local Diseases may be regarded as common 
or simple diseases, those general diseases are so very distinct from them, and 
are possessed of such constant features by which they may be distinguished 
from the local, common, or simple diseases, that they are described under the 
term "specific." 
Certain types of morbid local action, however, are common to both; and 
therefore the specific diseases have some constant and characteristic modi- 
fication, or something in addition which distinguishes them. These additional 
elements appear to consist- 
1. In a certain constancy and regularity of development, metamorphosis, 
duration, and decline, during which certain common morbid processes become 
modified according to the special nature of the disease. " In some the most 
evident specific characteristics are peculiar affections of the movement of the 
blood, as in the cutaneous exanthemata; in some, affections of certain parts of 
the nervous centres, as in tetanus, hydrophobia, hooping-cough; in some, pecu- 
liar exudations from the blood, as in the inoculable diseases; in some, peculiar 
structures formed by the exuded materials, as in variola, vaccinia, and other 
cutaneous pustular eruptions; in some, destruction of tissues, as in the ideers of 
syphilis, the gangrene of ergotism, and the sloughs of boils and carbuncles; in 
some, peculiar growths, as in cancers; in some, or indeed in nearly all, pecu- 
liar methods of febrile general disturbance" (Paget). 334 
SPECIAL PATHOLOGY-MIASMATIC FEVERS. 
In the specific diseases the phenomena of these local and general morbid 
processes are concurrent. 
2. The most striking feature (assuming specific diseases to be due to the 
presence of morbid poisons in the blood, which, by a morbid process, is again 
separated from it, and eliminated from the system during the progress of cure) 
is, that "the whole blood for a time seems diseased, and nearly every function 
and sensation is more or less disturbed from its health; and the patient feels 
'ill all over' before the local disease appears" (Paget). 
In the common or local diseases, on the other hand, the local phenomena 
precede the general or constitutional disturbance. 
3. There exists in the specific diseases an apparent want of proportion 
between the cause and the effect. Thus, in small-pox, measles, hydrophobia, bites 
of poisonous serpents, or syphilis, the severity of the disease does not bear any 
proportion to the amount of poison applied; and numerous diseases have been 
described in which the morbid poison appeared to act with so much intensity, 
and produced such severe forms of disease, that the patient died before local 
lesions had time to become developed-e. g., in typhus fever, specific yellow fever, 
paludal fevers, scarlatina, and the like. 
The student is referred for more information on these important topics to 
Lecture XX, on " Specific Diseases," by Mr. Paget, in his valuable work On 
Surgical Pathology. 
Of the two forms of specific diseases described by Mr. Paget, those which 
have been described as constitutional or inbred appear to be, in their origin, 
essentially blood diseases, the disturbance due to their development being in- 
dicated by what has been termed a cachexia. 
Those of the miasmatic or acute specific kind, again, recognize the intro- 
duction of materies morbi from without, and symptoms arise which indicate 
much constitutional disturbance. But, in whichever way these diseases are 
brought about, their specific nature is such as has been described. Under the 
term dyscrasice, the specific condition of the blood in such diseases was wont 
to be described by many continental pathologists, implying a defective or- 
ganization or elaboration of the circulating fluid. We cannot yet, however, 
associate particular diseases with definite and particular morbid states of the 
blood, however certain we may be that changes of a morbid nature do so 
exist; and therefore the term dyscrasice, as applied to designate such states, 
is premature in application, and has not come into general use, because, like 
the term zymotic, it takes for granted more than is known. 
CHAPTER III. 
THE PHYSIOLOGICAL MODES IN WHICH POISONS ACT ILLUSTRATE BY ANALOGY 
THE SPECIFIC OR MIASMATIC FEVERS. 
If the reader will now consider the following statements as to the modes 
in which poisons act physiologically, he will be prepared to appreciate the 
effects of those conditions which, like poisons, induce diseases of the kind 
termed specific or miasmatic. The actions of poisons are subject to certain 
general laws,-the most important of which are, first, that they have all cer- 
tain definite and specific actions ; second, that they all lie latent in the system 
a certain but varying period of time before those actions are set up; and 
third, that the phenomena resulting from their action vary, in some degree, 
according to the dose and to the receptivity of the patient. These laws are PHYSIOLOGICAL ACTIONS OF POISONS. 
335 
common to all poisons, but some are peculiar to individual poisons or classes 
of poisons ; and it may be necessary to notice a few of them. 
The first law, or that of the definite and specific actions of the poisons, can- 
not be doubted; for, if it be supposed that agents acting on the human body 
do not produce their effects according to certain definite laws, we can neither 
determine the seat nor the course of any disease, nor direct nor judge of the 
operation of remedies. No one, for instance, has seen castor oil produce 
tetanus, or colchicum intoxicate the brain, or opium inflame the spleen. The 
physician perfectly well knows that the first of these substances acts on the 
intestines, the second on the ligaments, and the third on the nervous system 
generally. The action of poisons, therefore, is not accidental, but determined 
by certain definite laws. 
The action of poisons, though definite, is variously limited. Some poisons, 
for instance, act on one membrane, or on one organ, or on one system of or- 
gans ; while other poisons extend their action over two or more membranes, 
or organs, or systems of organs, or even over the whole animal frame. We 
have examples in aloes and jalap of substances that act mainly upon the mu- 
cous membrane of the alimentary canal. In digitalis we have an instance of 
a medicine that principally acts on the heart, greatly reducing or even stop- 
ping its action; while strychnine is an example of a medicine acting on the 
parts supplied by the spinal cord, producing powerful and sometimes fatal 
tetanic action of every voluntary muscle in the body. 
It is seldom, however, that the action of poisons is limited to one mem- 
brane, or organ, or system of organs. The greater number of these noxious 
agents more usually act on two or more membranes, or organs, or systems of 
organs. Elaterium, for instance, acts on the mucous membrane of the intestinal 
canal, and on the kidneys. Tobacco nauseates the stomach, intoxicates the 
brain, and affects the action of the heart. Antimony has an equally extensive 
range; it induces cutaneous perspiration, acts cathartically and emetically, 
and in large doses appears to cause gangrene of the lungs. Alcohol and opium 
are examples of substances acting still more generally, affecting not only the 
action or secretion of every organ or tissue of the body, but even in some 
instances altering their structure. Thus alcohol, in its most limited action, 
has been shown to cause structural disease of the liver, of the stomach, and 
of the coats of the arteries. From the circumstance of these substances 
acting not only generally, but inducing local lesion, they resemble in their 
specific effects those of many so-called morbid poisons, as that of typhus fever, 
of scarlet fever, of small-pox, or of syphilis. 
The second important law of poisons is, that they lie latent in the system for 
a period of time, which varies in different indiyiduals, before they set up their 
specific actions. Rhubarb, for instance, produces no immediate result, but 
lies dormant in the system six or eight hours before its action is sensible on 
the bowels; opium, in the usual dose, is generally thirty minutes before it 
subdues the brain. The convulsions from strychnine do not follow till twenty 
minutes after its administration; and perhaps every substance has a more or 
less sensible period of latency. 
When a medicine acts on more parts than one, a considerable space of time 
may elapse after it has affected one organ before it affects another; thus, 
digitalis frequently occasions emesis before it acts on the heart, and the 
action of mercury on the bowels is frequently sensible for many weeks before 
the gums and salivary glands are affected. The doctrine of the latency of 
poisons is indeed so generally admitted, that the actual period has been a 
point on which the condemnation or acquittal of a prisoner tried for murder 
has turned in our courts of justice, when certain poisons have been supposed 
to have been given. 
The third great law of poisons is, that their effects are modified by the dose, 
the temperament, and the existing state of the constitution, mentally and 336 
SPECIAL PATHOLOGY MIASMATIC FEVERS. 
bodily, of the recipient. The effect of the dose in modifying the pathological 
phenomena of disease may be exemplified in the actions of oxalic acid and of 
arsenic. The specific action of oxalic acid is to inflame the mucous membrane 
of the stomach; but to insure this effect the dose must be limited so that this 
poison may lie in the system many hours. On the contrary, if the dose be 
excessive, and rapidly absorbed, the poison so disorders all the functions of 
the three great nervous centres, that life is destroyed in a few minutes. 
Arsenic, likewise, is a poison which inflames and ulcerates the mucous mem- 
brane of the alimentary canal, but it requires some hours to set up its specific 
actions; for, when the dose is large, it, in like manner, destroys by general 
irritation, and before traces of morbid change of structure can be appreciated 
after death. It follows from this law, that the larger the dose, or the greater 
the intensity of the poison, the more rapid its action, and the less the proba- 
bility of findihg any trace of specific lesion induced by it. 
In studying the effects of dose on the constitution, we find some poisons are 
absorbed and are cumulative, while others are not absorbed into the system; 
or they are so rapidly removed that no cumulative effect is produced. Thus, 
in persons predisposed to the effects of digitalis, a dose so small as to produce 
no sensible effect whatever, will, if frequently repeated, at last destroy the 
heart's action. This cumulative property of poisons, however, is by no means 
universal. There is no instance of jalap or of castor oil proving cumulative; 
and if a frequent repetition of either of them produces an increased effect, it 
is, perhaps, in consequence of the nervous papillae with which they are 
brought in contact being more easily irritated by each application, and hence 
they induce a more violent result. That the habitual ingestion of decompos- 
ing matter in the water used as drink is capable of inducing conditions favor- 
able to the development of specific diseases, admits of no doubt. Cogent 
instances of this are to be found recorded in the bitter experience of epidemics 
of cholera. 
Temperament is a circumstance which greatly influences the action of 
poisons. There are a few persons-rare exceptions-altogether insensible to 
the action of mercury, so that no quantity will affect their gums, or increase 
the secretion of the salivary glands. There are others, in like manner, the 
action of whose heart no quantity of digitalis will control. On the contrary, 
there are some constitutions-and these not so rare-so morbidly susceptible 
of these remedies, that it is scarcely possible to administer even a fractional 
dose of these drugs without giving rise to their specific effects. 
Besides natural temperament, habit, which may be termed an artificial tem- 
perament, has a powerful influence in reconciling us to particular classes of 
poisons, and of making them even sources of enjoyment. Thus tobacco, alco- 
hol, opium, are all substances which are productive, in the first instance, to 
many persons of great discomfort; but by frequent repetition they cease to 
have any unpleasant effects, and their stimulus at length becomes a necessary 
indulgence. Still there are many poisons to which no repetition can habit- 
uate us. On the contrary, each repetition only the more debilitates the con- 
stitution, and renders it more susceptible of the action of the poison. 
A peculiar existing state of the constitution has also a powerful influence 
on the action of poisons; and it would seem proved, with some exceptions, 
that these agents act with an intensity proportioned to the debilitated state of 
the patient. There is indeed no duty more imperative on the physician than 
that of adjusting the dose to the strength of the patient; ayd nothing is more 
common than to forbear administering a medicine because the patient's 
strength will not admit of it. As a general principle, therefore, medicines or 
poisons may be said to act with a power proportionate to the debility of the 
patient. 
Still, there are states of disease which render the constitution of the patient, 
though greatly debilitated, insusceptible to the action of even powerful reme- CONSTITUTIONAL SUSCEPTIBILITY TO POISONS. 
337 
dies. Thus, in typhus fever, the patient will often bear a considerable quantity 
of vinous stimuli without being affected by it. In tetanus, or hydrophobia, no 
quantity of ojmim will tranquillize the symptoms or procure sleep. Fallopius 
mentions a singular instance of the constitution being armed against the 
action of a poison. He states that in his day a criminal was given up to him- 
self and other anatomists, to be put to death in any manner they might think 
proper. To this man, therefore, they administered two drachms of opium; 
but, laboring under a quartan ague, and the fit just coming on, the "opium 
was hindered of its effect." The man, therefore, having survived this dose, 
begged that he might take a similar quantity, earnestly entreating, if he 
escaped, that he might be pardoned. The same dose was repeated, but it was 
in the interval of the attacks, and the man died. 
The experiments of Magendie may be referred to as affording many curious 
proofs of the state of the constitution in accelerating or retarding the action 
of poisons. He has shown that if a poison be introduced into the system, of 
such potency as usually will destroy life in two minutes, on bleeding the 
animal the same result will follow in half a minute, or in one-fourth of the 
time; and this experiment has often been repeated. Magendie also brought 
to light the curious fact, that if, after having poisoned the animal, and even 
after the poison has begun to act, we inject an aqueous fluid into its veins in 
such quantity as to cause an artificial plethora, as long as this artificial 
plethora can be maintained, the action of the poison is superseded. No 
sooner, however, does the plethora cease, from the general effusion of fluid 
into every cavity of the body, than the poison acts in the usual time, and 
with even perhaps more than its accustomed severity. 
Mr. Hunter thought that no two poisons could coexist in the same system 
together, or that, coexisting, they could not set up their specific actions at the 
same time. This hypothesis, however, is unquestionably erroneous; for we 
constantly see opium and digitalis, jalap and mercury, as well as many other 
combinations of medicines, producing their respective effects in the same sys- 
tem, and at the same time. There is no truth better established in medicine 
than that a combination of Epsom salts and senna produces a much more 
efficient and pleasant action than the administration of either remedy sepa- 
rately; and opium is an agent possessing a modifying or controlling power 
over every organ or tissue, without which it would be impossible, on many 
occasions, to reconcile the system to the introduction of many necessary and 
essential remedies. Poisons, therefore, are capable of coexisting together, and 
of so influencing the system that they reciprocally accelerate or retard each 
other's actions. The coexistence of two or more specific diseases has been 
already noticed at p. 272. 
The general laws observable in the actions of medicinal substances are for 
the most part precisely similar to those which govern morbid poisons, or only 
differ in a few minor points; for these latter poisons have their specific actions 
and their periods of latency, while their phenomena are not less variable, 
although the conditions of their varied actions are not yet clearly determined. 
The Specific Action of Poisons which Produce Specific Diseases is dis- 
tinctly proved by the fact that we are enabled to determine, within certain 
limits, the course, symptoms, and pathological phenomena which result from 
the presence of any given morbid poison. No man, for instance, can con- 
found the phenomena of small-pox with those of intermittent fever, or those of 
intermittent fever with syphilis, or those of syphilis with cholera: each of these 
poisons has its separate and peculiar origin, course, development, and mode 
of propagation, and consequently their actions are so far definite and specific. 
The actions of morbid poisons, like those of medicinal substances, are vari- 
ously limited, some affecting only one membrane, or organ, or system of 
organs. Thus, tinea is an example of a noxious vegetable germ acting on 
one tissue of the body, and even then partially. In some parts of the world, 338 
SPECIAL PATHOLOGY-MIASMATIC FEVERS. 
for instance, in Switzerland, in the Brazils, in the Andes, and some of the 
northwest provinces of India, a poison exists, associated with limestone and 
sometimes magnesian geological formation, whose action is limited to the 
undue ossification and thickening of the base of the cranium, tending to 
diminish the size of the foramina for the bloodvessels, and so leading to cretin- 
ism, and to growth of the thyroid gland in goitre (Kolliker and Reviewer 
in B. and F. Med.-Chir. Review, 1861, p. 43). Mr. Ceely, mentioning the 
fact that at Aylesbury, where goitre prevails, the soil is mainly limestone, 
incidentally states that solid aggregations of calcareous particles are also 
found in the thyroid gland. The contagion of hooping-cough and the virus 
of hydrophobia affect all the organs supplied by the eighth pair, or pneumogas- 
tric system of nerves. Instances of morbid poisons acting on several mem- 
branes, or organs, or systems of organs, are still more common, and form the 
great body of this class of diseases. The poison of measles, for instance, ex- 
presses itself no less on the mucous membrane of the eyes, nose, fauces, and 
perhaps on the mucous membranes generally, than on the skin; that of scar- 
latina, not only on the mucous membrane of the fauces, and on the skin and 
the kidneys, but also on the serous membranes of the joints and the abdomen. 
The paludal and the syphilitic poisons have a still more extensive range, 
hardly any organ or tissue of the body being exempt from the destructive 
ravages of these poisons. 
Morbid, like other poisons, have their periods of latency; and, generally 
speaking, a much longer time elapses before their specific actions come into 
operation than with medicinal substances. The virus of natural small-pox lies 
dormant from sixteen to twenty days before it produces any constitutional 
disturbance; and a still further period elapses, of three or four days, before 
the specific eruption appears on the skin. The poison of scarlatina lies latent 
from seven to ten days after exposure to the contagion; that of measles from 
ten to fourteen; while the poison of malarious fever has been said to lie dor- 
mant for a twelvemonth, and that of hydrophobia for a still longer time. 
These are examples of periods of latency far beyond anything that has been 
observed in the action of medicinal substances; and syphilis, in its remote 
effects upon the organs and the constitution generally, is still more remarkable. 
When morbid poisons act on more tissues or organs than one, their actions 
are sometimes simultaneous, but more commonly they are consecutive, and 
frequently long intervals of time elapse between each successive attack. Thus, 
the poison of typhus and enteric fever may affect the lungs, the membranes of 
the brain, and the mucous membrane of the alimentary canal, and all these 
may be attacked contemporaneously, but more often consecutively; or first 
the alimentary canal, then the brain, and lastly the lungs, several days elaps- 
ing between the commencement of each successive affection. 
It occasionally happens that morbid poisons which usually act on a plurality 
of membranes, exhaust their influence on one or more without affecting others. 
In scarlatina simplex the poison sometimes exhausts itself entirely on the skin, 
without affecting either the mucous or serous membranes of the body. The 
rubeola sine catarrho is a similar example of the poison exhausting itself on 
the skin. In intermittent fever, when the dose of the poison is limited, and the 
disease properly treated, it is seldom that a lesion occurs in any organ or 
tissue; yet, left to run a slow course, with constant exposure to the morbid 
influence, scarcely any organ or tissue would escape being affected, and having 
its function impaired. 
Sometimes, when the morbid poison acts on many membranes, the usual 
order of attack is inverted. In scarlet fever the affection of the skin may precede 
that of the throat, or the reverse may take place. 
It has been seen that the period of latency of medicinal substances having 
passed over, the effects vary in a considerable degree, according to the dose, 
temperament, or present state of the constitution of the patient. With SPECIFIC ACTION OF MORBID POISONS. 
339 
respect to the dose of a morbid poison, we rarely possess any direct measure 
of its strength. The paludal poison of tropical climates, to which malarious 
fevers are due, unquestionably greatly exceeds in intensity that of more tem- 
perate climates, and its effects are proportionally marked. Thus, in the West 
Indies, the severe remittent fevers occur with hardly a trace of organic lesion 
after death, so rapid is their course; in Holland, a paludal fever of less severity 
exists, but it is followed by enlarged livers or spleens, or by dropsy ; while, in 
this country, the same fever is comparatively mild, and, if properly treated, 
for the most part terminates without any visceral affection. With respect to 
the influence of temperament in modifying disease, small-pox offers very strik- 
ing instances. Different persons inoculated or poisoned from the same source 
have suffered in every degree from this formidable malady-from the horn, 
the distinct, the confluent, and the bloody small-pox; while, in the worst cases, 
children have died in the primary fever, and even before the specific action 
on the skin had time to be developed. It may therefore be laid down as a 
general law, that the more intense the dose of the morbid poison, the more 
severe the form and rapid the course of disease; and that fewer traces of 
organic alteration will be found after death when the poison is severe and 
abundant, than when the poison, or the disorder it produces, has been of a 
milder character, and the course of the disease more prolonged. Thus, en- 
larged livers, disorganized spleens, and dropsy, marked every case that died 
of the so-called Walcheren fever: while in the West Indian and African 
fevers, though resulting from the same poison, scarcely a trace of disease was 
to be found. 
The existing state of the constitution also influences the event. Thus, per- 
sons of a good constitution, but ignorant of their danger, are often seen to pass 
through a mild form of typhus fever, while the nurses and others contaminated 
by the same poison, but more alive to their critical state, have sunk in a short 
time. A presentiment of death is a very unfavorable circumstance in the 
progress of remittent fever, especially in tropical climates. A soldier will 
sometimes say to the medical officer, "You have been very kind to me, sir; 
but this time I shall not get over it." There may be no appearance of abso- 
lute or immediate danger at the time-yet the man generally dies (Sir 
Ranald Martin). As a general principle, therefore, it may be stated that 
morbid poisons act with an intensity proportioned to the enfeebled or depressed 
state of the constitution ; but this law is not universal. Want of a sufficient 
amount of food is most powerful among the conditions which predispose or 
help to bring about specific diseases, and most constant in operation. It is a 
popular belief that the lowering of all the vital forces by deficiency of food 
constitutes the particular condition which renders a starved population so 
peculiarly open to the invasion of these diseases; but it is also a curious 
phenomenon of starvation that a state of general putrescence supervenes 
during life, as if the want of material for the generation of new tissue were an 
obstacle to the deportation of that which has become effete (Carpenter). 
The hardy mountaineer is a surer victim, whether he visits the low countries 
of the tropics or the marshes of a more temperate climate, than the feebler 
natives of those countries. The immunity the latter enjoys is probably owing 
to his habit of living in the noxious atmosphere; for let him remove to a more 
healthy climate, and then return to those regions of pestilence, and he will be 
found as susceptible of the poison as the hardier stranger. 
Peculiarities in the Action of Poisons which induce Specific Diseases 
The principal points in which the effects of poisons which induce specific 
diseases agree with those of poisons generally having been stated, it will now 
be necessary to state those circumstances in which they principally differ. 
Many medicinal poisons have the property of accumulating in the system, and 
acting with an intensity proportioned, not to the last dose, but to the aggre- 
gate of the whole quantity that has been administered. Thus, the last few 340 
SPECIAL PATHOLOGY MIASMATIC FEVERS. 
minims of digitalis may stop the action of the heart, or the last few grains of 
mercury salivate the patient, or the last minute dose of strychnine become fatal. 
There is, however, no well-authenticated fact which can be arranged under 
this law in the whole circle of morbid poisons, except, perhaps, the cumulative 
and persistent pernicious action of paludal malaria. The actual quantity re- 
quired to establish disease, according to the experiments of Dr. Fordyce, is 
probably extremely small. That physician, in the hopes of mitigating the 
small-pox, inoculated with virus greatly diluted, and although the disease was 
not always produced, yet when produced, it assumed every form, character, 
and degree of severity that small-pox has ever been known to assume. In 
accordance with Burdon-Sanderson's experiments, such dilution tends to sepa- 
rate and diffuse more widely apart the organic particles (germs), which are 
the efficient carriers of the poison ; hence, the greater the dilution or diffusion, 
the more likely one would be to inoculate a portion of the fluid destitute of 
the specific organic particles or germs. 
The puerperal female is not only highly susceptible of specific disease poi- 
sons, but she is proved to favor their further development; and forms of 
puerperal fever seem capable of generation by materies morbi of a kind other 
than that which might be considered peculiar to it. It is a well-known fact, 
unhappily not,of rare occurrence, that a medical practitioner or a nurse from 
a case of puerperal fever going to attend on other cases of labor, the chances 
are that these will be attacked with the disease. I was recently called in 
consultation to see a lady within a few hours of her death, from puerperal 
fever. I found the nurse in charge of the patient had been in attendance, 
four mouths before, on a case of puerperal fever-the wife of a medical man- 
which terminated fatally. The nurse had not attended any case between the 
two ; and both cases died under similar morbid conditions. Further, the 
practitioner or nurse may go to cases of labor from attendance on cases of 
scarlatina, typhus, erysipelas, or small-pox, and the parturient patients may 
then become the victims of puerperal fever. In the Vienna Lying-in Hos- 
pital, it is on record that a mortality of 400 to 500 in an average of 3000 de- 
liveries per annum appeared traceable to the introduction of cadaveric matters, 
through the uncleanliness of the attending students ; these matters being 
especially potent when derived from the bodies of those who died from the 
adynamic forms of specific disease. Students of practical midwifery should 
bear in mind this fact. They ought not to attend cases of labor while they 
are engaged with practical anatomy in the dissecting-room; and no nurse 
ought to be allowed to go from a puerperal fever case to attend other cases 
of labor without destroying all clothes she has had in use in attendance on 
the fever case, and otherwise purifying herself. 
Another peculiar law of morbid poisons, and one wholly unknown in medi- 
cinal substances, is the faculty which the human body, during the progress of 
the specific disease, possesses of generating to an immense extent a poison of 
the same nature as that by which the disease was originally produced. A 
quantity of small-pox matter not so big as a pin's head will produce many 
thousand pustules, each containing fifty times as much of the specific pesti- 
lent matter as was originally inserted; and, moreover, the blood and all the 
secretions of the body are equally infected with the specific poison of the 
pustules. The miasmata from one child laboring under hooping-cough are 
sufficient to infect a whole city. 
There is still perhaps a more remarkable law of morbid poisons, which is, 
that many of them possess the extraordinary property of exhausting the con- 
stitution of all susceptibility to a second action of the same poison. This is 
the case with syphilis, scarlatina, measles, typhus fever, small-pox, hooping- 
cough, and, indeed, with a considerable number of others. Still, it would 
seem that a temporary protective influence is imparted by most morbid poi- 
sons, for it is certain that few persons suffer a second attack of the same CONDITION OF THE BLOOD IN SPECIFIC FEVERS. 
341 
specific epidemic disease; and, consequently, it follows that the previous 
action of the poison must for a time impair the susceptibility of the constitu- 
tion to its attacks. This beneficent law is of great importance in social life ; 
it enables those that have recovered to attend on those that are sick, and 
allows a mother fearlessly to nurse her child in a dangerous and contagious 
distemper she has herself passed through, if such an inducement is ever neces- 
sary to strengthen the moral courage of a mother. 
The laws of poisons are not more important than their modus operandi; 
and this part of the subject has been deeply investigated by modern physiolo- 
gists, and deserves some consideration. The great and striking alterations 
which often take place in the blood, led from a very remote period to the 
doctrine of humoralism, or, that a morbid state of the fluids was the great and 
primary cause of disease. On the contrary, when anatomy began to be culti- 
vated, and nerves traced into every organ and tissue, it was supposed that 
disordered actions of these prime agents of motion, and of the great phenomena 
of animal life, were the great causes of disease, the morbid state of the fluids 
being secondary. Fontana, attempting to prove this latter theory, found, to 
his surprise, on laying bare the sciatic nerve in a great number of rabbits, 
that neither the venom of the viper nor hydrocyanic acid, when applied to it, 
produced the phenomena of poisoning, and that no other consequence resulted 
beyond what would have been produced by a similar mechanical injury. 
Having thus shown that the phenomena of poisoning do not result from the 
application of the deleterious agent to the trunk of the nerve or to the solids, 
he determined to ascertain whether they followed after absorption, and conse- 
quent contamination of the fluids. He injected the venom of the viper, hydro- 
cyanic acid, and other poisonous substances, directly into the veins of different 
animals; and he found that although the nerves of a part may be steeped in 
these poisons with impunity, yet no sooner did the substance enter the veins 
than the animal, after uttering a few horrible shrieks, struggled and almost 
instantly died, and thus demonstrated a morbid state of the fluids, as well as 
the existence of a tissue of extreme sensibility, with which the poison being 
brought into contact, accounted for the death of the animal. Fontana pur- 
sued this subject one step further, and showed, if poisons acted by absorption, 
that this absorption was in many instances extremely rapid. He submitted a 
number of pigeons to be bitten in the leg by a viper. He then chopped the 
wounded limb off at different intervals after the introduction of the venom, 
and found, as the result of an extensive series of experiments on several 
dozens of pigeons, that none recovered when the poisoned leg was removed at 
a later period than twenty-five seconds, though the phenomena of poisoning 
did not occur till several minutes later. 
The experiments of Fontana had shown (supposing a poison to be intro- 
duced into the veins) that all the phenomena of poisoning were accounted for; 
but still it might be said that to prove the fact of absorption something was 
wanting in strict demonstration. For the further prosecution of this subject 
we are indebted to Segalas, who showed that if the arteries and veins of the 
mesentery of a dog be tied, a quick-acting poison would lie in harmless con- 
tact with the corresponding portion of the intestine for many hours; but no 
sooner were these ligatures removed than poisoning took place in a few 
minutes. Magendie has carried this proof, of the veins absorbing, even still 
further. He amputated the leg of a dog, having first introduced a portion of 
quill into the femoral artery and vein, in such a manner that, on dividing 
these vessels, the leg hung connected with the trunk solely by means of the 
quill, all continuity by means of the solids being cut off. The poison was now 
introduced into the tissues of the paw, and in four minutes the animal was 
under its influence. 
By these experiments it is believed that Fontana, Segalas, and Magendie 
have completely demonstrated the absorption of poisons by the veins, and 342 
SPECIAL PATHOLOGY-MIASMATIC FEVERS. 
consequently of their circulating with the blood; and that no doubt may 
remain on the subject, modern chemistry has demonstrated the actual pres- 
ence of many medicinal substances either in the blood itself or in the secre- 
tions formed from it. Thus, after the free use of soda, large quantities of 
uncombined alkali have been found in the serum. Alcohol has been obtained by 
distillation from the blood; while iodine, rhubarb, the nitrate of potash, and a 
large number of other substances taken into the stomach, have been found in 
the urine. It follows, then, that poisons are absorbed and mingled with the 
blood, and are conveyed directly to the parts on which they act, passing with 
impunity over others for which they have no affinity. 
The fact of morbid poisons in like manner being absorbed, and mingling 
with the blood, has been shown by many continental writers ; but perhaps the 
experiment made by Professor Coleman is the most satisfactory. " I have 
produced the disease (the glanders') by first removing the healthy blood from 
an ass, until the animal was nearly exhausted, and then transfusing from a 
glandered horse blood from the carotid artery into the jugular vein. The 
glanders in the ass was rapid in its progress, violent in degree, and from this 
animal I afterwards produced both glanders and farcy." Scarlatina, measles, 
and syphilis have now been produced by inoculation from the blood of patients 
laboring under these diseases. 
The circumstance of the presence of a poison in the blood is supposed by 
Andral to produce, besides its toxic states, certain alterations in its physical 
condition. Thus a specific cause has a tendency to destroy or reduce the 
quantity of fibrin in the blood, which he has found in some instances to be 
only one part in a thousand. Hence he adds, whatever may be the nature 
of the specific pyrexia, the blood always exhibits the following characters, 
whether it be taken from a vein or collected from the heart and arteries after 
death,-namely, that the serum and clot are incompletely separated the one 
from the other, so that the clot is consequently large, and often appears to fill 
almost entirely the bleeding-basin. Its edges are never raised, and its con- 
sistence is inconsiderable, so that it is easily torn, broken down, and reduced to 
a state of diffluence: in this state it becomes grumous, and discolors the serum. 
It is also remarkable for the absence of all buff, which is rarely met with in 
typhus, in measles, in scarlatina, or in small-pox, unless there has been some 
inflammatory complication; and even when it does exist, as in confluent 
small-pox, with large collections of pus, the buff is soft and gelatinous, and, by 
expression of the serum, is easily reduced to a thin pellicle. This defect of 
fibrin he conceives to be the cause of the great tendency to hemorrhage, and 
to that stasis or congestion so remarkable in typhus fever, scarlatina, and other' 
diseases dependent on morbid poisons. 
The facts and arguments which have been adduced prove that morbid 
poisons act in all instances not capriciously, but according to certain definite 
and specific laws, modified by the influence of climate, temperament, or the 
magnitude of the dose: also, that they mingle with the blood, with which 
they continue in latent combination a certain but varying period of time; and 
likewise that many of them are capable of coexisting together in the same 
system. A knowledge of these facts is necessary to the proper understanding 
of this class of diseases, and it is hoped that by their application many of the 
difficulties which have hitherto obscured the doctrines of fever, of syphilis, of 
hydrophobia, and of many other diseases incident to this class of morbid 
poisons, may be removed, and that this portion of medical science may be 
placed on a surer foundation, if not on a permanent basis. 
Deaths from Specific or Miasmatic Diseases.-The average annual rate 
per cent, of mortality in Great Britain for the past seventeen years is repre- 
sented by 2.245 ; i. e., nearly 22 per 1000, or 1 in 45 of the population. This 
statement is given as a fact by which the student may compare the numerical ENDEMIC AND EPIDEMIC INFLUENCES. 
343 
statements which are made in estimating the fatal nature of individual 
diseases, or of diseases considered in classes. 
With regard to diseases of a specific or miasmatic kind, it may be stated 
generally, that from 21 to 26 per cent, of the total number of deaths which 
take place in Great Britain during a year are due to them. Generally speak- 
ing, also, they may be arranged in the order of their greatest fatality, as follows, 
namely: (1.) Cholera, typhus, and other forms of continued fever; (2.) Scarlatina, 
hooping-cough, measles, croup, small-pox, erysipelas; (3.) The other diseases of 
this kind are less fatal; and it has been observed that of late years small-pox, 
influenza, and typhus fever are less fatal than they used to be. 
Specific Disease Poisons.-The matter by which the specific miasmatic 
diseases are communicated and propagated is solely derived from the body 
of the similarly diseased human or animal being ; for there, during the course 
of the specific disease, is the soil in which the specific poison is bred, to mul- 
tiply and propagate its kind. It is not yet clearly established how far the 
bodies of animals may not be a soil for the propagation of diseases communi- 
cable to man. (See the Sections on "Small-pox" and "Cow-pox.") 
The diseases of the lower animals are not sufficiently studied by us. The 
diseases of plants are almost entirely neglected. Yet it is clear that until all 
these have been studied, and some steps taken to generalize them, every con- 
clusion in pathology regarding the nature of the propagation and dissemina- 
tion of specific miasmatic, and even of parasitic, dietic, and enthetic diseases 
must be the result of a limited experience from a limited field of observation. 
How do we know that the blights of plants, or the causes of them, are not com- 
municable to animals and to man ? We know how intimately related the 
diseases of man and animals are with famines and unwholesome food ; and of 
famines with the diseases of vegetable and animal life, as much as with the 
destruction and loss of food. 
Dr. Carter, of Bombay, has shown that there is in India a very singular, 
and although strictly endemic disease, yet a very prevalent one, which occurs 
in the hands and feet, especially the latter, and which it is probable is really 
of the nature of a " blight," in so far as it is owing to the implantation in the 
tissues of " sporules or germs," which in the progress of development commit 
irremediable ravages on the affected parts, leading ultimately to entire disor- 
ganization of the tissues. It is known as the " fungus disease of India," 
originally described by Dr. Carter in the Transactions of the Medical and 
Physical Society of Bombay, No. 6, new series for 1860. (See the account of 
"Parasitic Diseases" near the end of this volume.) 
On the relations between the diseases of man and animals, and especially 
in connection with food, the reader is referred to a series of papers by the 
author, in the Medical Times and Gazette for.1857. 
Dr. William Budd, of Bristol, has also recently directed attention to the 
occurrence of malignant pustule in England, in a paper read at the great 
meeting of the British Medical Association in London, in August, 1862. He 
has shown that the disease has not been so uncommon in England as had 
been supposed-that it is common and very fatal to oxen and sheep in this 
country-that in man and in sheep the disease is identical-that it is com- 
municable to man by direct inoculation, and also by eating the flesh of the 
animals affected-that it may be conveyed and disseminated by the bites of 
insects, such as gnats-and that the disease may be recommunicated from 
man to animals (Brit. Med. Journal, January 24, 1863). 
There are some peculiar and characteristic features especially pertaining 
to specific diseases of a Miasmatic kind which require special notice as intro- 
ductory to a description of the individual diseases: First, They suddenly 
spring up in a locality-under unfavorable sanitary conditions. Second, They 
may rapidly spread at irregular intervals, so as to incapacitate or destroy great 
numbers of people. These two marked and striking features are technically 344 
SPECIAL PATHOLOGY-MIASMATIC FEVERS. 
described as being due respectively to Endemic and Epidemic influences, the 
nature of which will be considered in a subsequent chapter. 
[The following summary of Dr. Murchison on the Pathology and Treat- 
ment of the specific Pyrexim is so clear and of such practical value, that it 
is given nearly unabridged. 1. Pyrexia is a morbid condition of the blood, 
due to the entrance of some poisonous matter from without or generated 
within the body; or to some local injury or inflammation exercising a para- 
lyzing influence on certain portions of the nervous system, and particularly on 
the sympathetic or vagus. 2. Increased rapidity of the heart's action is one 
of the earliest results. 3. A second result is a rapid disintegration of the 
nitrogenous tissues into substances of a simpler chemical construction, while 
little or no fresh material is assimilated to compensate for the loss. Increased 
temperature, great muscular prostration, and loss of weight are the natural 
consequences. 4. The non-elimination, from any cause, of the products of 
this disintegration gives rise to cerebral (typhoid) symptoms, or local inflam- 
mations. 5. The impaired nutrition of the heart itself and of the rest of 
the body, in conjunction with the polluted state of the blood and the nervous 
paralysis already referred to, induces in severe cases of fever great weakness 
of the cardiac contraction and stagnation of blood in the capillaries in differ- 
ent parts of the body. 
With regard to treatment, the indications are: 1. To remove, when possi- 
ble, the cause on which the fever depends. 2. To promote elimination, not 
merely of any morbid poison, but of the products of exaggerated metamor- 
phosis in the blood and tissues. 3. To reduce the temperature and the fre- 
quency of the action of the heart. 4. To maintain the nutrition of the tissues 
and stimulate the action of the heart by appropriate food and stimulants, 
taking care not to excite congestion or increase the work of the already over- 
tasked glandular organs. 5. To obviate and counteract secondary complica- 
tions. 
The elimination of any morbid poison may be attempted by diaphoretics, 
purgatives, emetics, and diuretics. The old practice of giving a purgative to 
unload the portal circulation and promote the action of the liver, is a good 
one. Salines, as citrate of potash, a plentiful supply of fresh air, and the free 
use of diluents, aid in the elimination of the poison. Bloodletting is now dis- 
carded, because it is found to increase one of the great dangers, failure of the 
heart's action. The external use of cold water has come to be again much 
employed (particularly in Germany), and cases of recovery from its use when 
the body heat was as high as 110° Fahr, (usually fatal), have been reported 
by Dr. Wilson Fox. Quinine in large doses is of value when a pyrexia is 
at its crisis, and when the temperature is rising and not falling ; digitalis, 
veratria, aconite, and antimony are of great service. The nutrition of the 
body should be maintained by milk and beef tea. Dangerous symptoms, as 
stagnation of blood in the pulmonary capillaries, is to be met by stimulants, 
as alcohol, carbonate of ammonia, and ether. Digitalis, by strengthening 
the heart's action, and turpentine, which seems to stimulate the capillary 
circulation, are useful in this state; while mustard and linseed poultices to 
the chest, and warm applications to the feet may be employed. When 
uraemic symptoms predominate the action of the skin and bowels is to be pro- 
moted ; digitalis and saline diluents may be given to increase the flow of 
urine, sinapisms over the loins, cold affusion to the head, or blistering the' 
scalp with aqua ammonia, and sinapisms to the feet. Secondary complica- 
tions are to be counteracted as far as practicable, and two errors must be 
avoided : 1. The remedial measures should not thwart the natural modes of 
recovery or favor the natural modes of death. 2. Pyrexia should not be 
treated on a purely expectant plan, since a natural termination is death as 
well as recovery {British Medical Journal, vol. i, 1872).] EFFECTS OF MALARIA POISON IN THE BODY. 
345 
CHAPTER IV. 
ON THE NATURE OF MALARIA AND MALARIOUS FEVERS. 
Three varieties or forms of malarious fever are understood to exist, having 
many essential features in common. These are intermittent fever or ague, re- 
mittent fever, and that variety of yellow fever characterized by periodicity of 
febrile recurrence. The specific or contagious form of yellow fever is now 
understood to be a different fever from remittent and intermittent fever, and 
it has been considered separately in this Text-book as a continued fever sui 
generis. The malarious form of yellow fever is, on the other hand, the same in 
kind as the intermittent and remittent fevers, but varies greatly in the ex- 
tremes of its severity. So great, indeed, are the differences induced by the 
common malarious poison, that " if any one had seen only the milder forms of 
remittent fever, and had no opportunity of tracing up its several grades, he 
might well believe, when he saw suddenly the severest variety, that he had 
before him a distinct affection" (Alison). Such a belief is entertained by 
not a few. All of the three fevers, however, which are now about to be con- 
sidered, are similar pathologically; while all seem to take their origin from 
terrestrial aeriform emanations, which are sometimes rendered more active or 
dangerous in connection with human beings congregated together, and in cer- 
tain relations as to physical climate, and particularly as to temperature. 
In these forms of fever a malarial poison of an unknown kind, generated 
in paludal regions or littoral districts, is absorbed, and affects the blood, as 
cholera, typhus, and other miasmatic poisons do. The poison in the absence of 
any better name, is known as "malaria;" and as physicians have merely 
inferred the existence of such a poison, no exact knowledge has yet been 
obtained as to its nature and source. Indeed, it still remains to be shown 
that malaria has a substantial existence. No poisonous principle has yet been 
chemically demonstrated in the air of malarious regions. But many other 
acknowledged disease poisons are in a similar predicament as to proofs of their 
substantial existence; and the general impression with regard to malaria is 
that it is presumed to exist in the atmosphere of certain regions. On this 
point the late Professor Felix von Niemeyer writes: "I have no hesitation in 
saying decidedly that marsh miasm-malaria-must consist of low vegetable 
organisms, whose development is chiefly due to the putrefaction of vegetable 
substances. It is true, these low organisms have not actually been observed. 
No one has seen vialarious spores." 
This poison arises from marshy land in particular conditions, such as 
decomposition under the influence of partial moisture, and of heat above 60° 
Fahr. If the land is perfectly dry, or perfectly flooded, or frozen, the poison 
is not generated. It is believed to be a material poison. It may be wafted 
along with the wind, and so induce fever at a distance from the place where 
the poison is generated. It may also be intercepted by a belt of trees. It 
appears to be most intense near the surface of the ground. The diseases usu- 
ally attributed to this endemic source, and which were formerly so destructive, 
have almost disappeared from this country. The reason of this may fairly be 
ascribed to the improved drainage both of the towns and of the agricultural 
districts. The fact may be proved, did space permit; and the practical infer- 
ence leads one to hope for still more immunity from diseases arising from this 
source, if the " proper authorities " direct further efforts in this direction. 
"Within the last half-century laud-draining and town-sewering have ripened 
into sciences. From rude beginnings, insignificant in extent, and often inju- 
rious in their effects in the first instance, they have become of the first im- 346 
SPECIAL PATHOLOGY-MALARIOUS FEVERS. 
portance. Land has, in many instances, doubled in value; and town-sewer- 
ing, with other social regulations, have not unfrequently prolonged human 
life from 5 to 50 per cent., as compared with previous rates in the same 
district." "Agues (and malarious cachexise) are reduced. Since 1840 an 
annual mortality in English towns of 44 in 1000 has been reduced to 27; an 
annual mortality of 30 has been reduced to 20, and even as low as 15; and 
human life has now more value in England than in any other country in the 
world-a result entirely due to better sanitary arrangements " (Rawlinson, 
Journal of Society of Arts, March 21,1862, vol. x, p. 276). 
• The time, indeed, appears to have arrived when accurate sanitary statistics 
should not only be kept for all branches of the public service, but also by all 
corporations, municipalities, boards of commissioners, and parish vestries, for 
the population within their respective jurisdictions. Such statistics should 
be publishsd at least once every year, as the natural history of the popula- 
tion {Sanitary Statistics, B., International Statistical Congress. .London, 1860. 
Second Section.) 
The specific action of malaria poison is made apparent in its effects upon 
the body. After a period of latency, more or less long, functional disorders 
of the great nervous centres are brought about, terminating in the phenomena 
either of intermittent, remittent, or yellow fever of the malarious type. These 
fevers may exist without any alteration of structure being set up, and the 
patient often dies from the severest forms, with hardly a trace of disease being 
discoverable. In the milder forms of these fevers, however, a greater number 
of organs and tissues are morbidly altered than perhaps in any other disease, 
as the liver, spleen, lungs, heart, brain, and the serous and mucous membranes 
of the body generally. The specific action of the malarial poison, within 
certain limits, may be said to be in the inverse ratio of the intensity of the 
fever which attends its action. The affections of the liver and spleen also 
vary greatly according to the country; for in some parts of India the spleen 
is the organ chiefly affected, while in other districts it is .the liver; the nature 
of the country, perhaps of the soil, impressing evidently some peculiar 
character on the poison. 
Patients laboring under intermittent fever in this country generally recover 
under medical treatment, without any manifest derangement either of struc- 
ture or of function of any organ or tissue. When, however, the disease 
is neglected, the liver may suffer, the disordered function of that organ being 
generally indicated by jaundice; or inflammation of the liver may ensue, of 
which jaundice may or may not be a symptom; and this inflammation may 
be acute or chronic, diffuse or limited to one place. If a liver, previously 
healthy, becomes the seat of diffuse inflammation, it is of the deepest hepatic 
tint, and loaded with blood; and we find it often greatly hypertrophied, fill- 
ing the abdominal and pelvic cavities, and, according as the inflammation is 
acute or chronic, either greatly indurated or so softened as to be easily broken 
down. In a few instances this inflammation may terminate in abscess, gen- 
erally of the usual phlegmonous character. On the contrary, if the liver be 
previously diseased, its color, even when the seat of abscess, or otherwise most 
acutely inflamed, may be of the palest yellow, and its texture sometimes so 
soft and broken down that the larger bloodvessels may be dissected out with 
the fingers, or so indurated as to form a shapeless mass of varying magni- 
tude. When abscess forms, it may rupture into the duodenum, or into the 
cavity of the abdomen, or it may point externally. 
The paludal poisoning also often produces structural alteration of the 
spleen. In these cases that organ has been found sometimes so enlarged as 
to wreigh from ten to thirty pounds, greatly exceeding the liver in size (ague 
cake), while in other cases it is sometimes even less than natural. In con- 
sistency, also, it varies from a state of almost fluidity, a mere bag of blood, 
to a hardened mass with a distinct indurated edge. It is sometimes the seat PERSISTENT PERNICIOUS INFLUENCE OF MALARIA POISON. 
347 
of abscess; or its parenchyma is transformed into a soft mass of pigment of an 
extremely dark color. 
The functions of the peritoneum may be alone deranged, so as to produce 
dropsy; but every form of peritoneal inflammation may precede or accom- 
pany the ascites,-as the serous or the purulent, with diffuse or partial local 
adhesions. 
These are the most usual alterations of function and of structure in the 
mild paludal fevers of the present day; and in estimating the relative 
frequency of these secondary affections, ascites is the most common, then jam- 
dice; while peritonitis, hepatitis, and splenitis are less frequent, and occur, per- 
haps, in nearly equal proportions. 
The pathological phenomena which attend severe intermittent and remittent 
fever are much more severe, and extend over a greater number of organs. 
The information afforded us by the dissections of Davis, and the observations 
of Sir Gilbert Blane, in the cases of the Walcheren remittent; of Jackson in 
those of the West Indies; of Burnett in the Mediterranean, enable us to 
understand at least the tendency of the morbid action. Sir Gilbert Blane, 
in his observations on the Walcheren fever, remarks that the structural 
derangements were more frequent (especially swelling of the liver and 
spleen), which then occurred in a very few weeks. Such results seldom 
occur in England, except under a long continuance of the disease, or after 
frequent relapses. The morbid changes also extended to the mucous mem- 
brane of the stomach, which, in a few instances, became inflamed and ulcer- 
ated, and the ulcers had generally a sharp perpendicular edge, as if made 
with a punch. In cases which died dysenteric, the large intestines, and more 
particularly the sigmoid flexure and the rectum, were always much con- 
tracted, thickened, inflamed, and ulcerated; the ulcers being often so numerous 
and so confluent that the whole inner surface of the gut appeared in a state 
of granulation. There is a marked tendency in the phenomena of these 
paludal fevers to become inflammatory, the congestion of some organ proceed- 
ing at once to exudation from the bloodvessels into its parenchyma, which 
appears to be the cause of prostration and of fatal results. " The significant 
term bilious," writes Sir Ranald Martin, "as applied to these fevers of the 
East, is not an accidental or a misapplied term, as modern statistics fully show. 
A severe disturbance of the hepatic function is almost universal in the prog- 
ress of the remittent fevers in the East." 
There is another remarkable specific tendency to be noticed in the persistent 
effects produced by malaria-namely, that it impresses a character of periodi- 
city to subsequent ailments, especially neuralgic affections; and the disposi- 
tion to the recurrence of these diseases seems to last for life. Susceptibility 
to the action of the paludal poison does not diminish, but rather increases by 
continued residence where it prevails, so that a chill, or the opposite, such as 
exposure to great heat, will alike bring on the specific expression of malarious 
fever in some of its typical forms. The returns published by the War Office 
and Army Medical Department show such a result in the West Indies. Thus, 
while the annual mortality among the troops resident one year in Jamaica 
was 77 per 1000 mean strength, in those resident two years it was 87 per 
1000, while of those still longer resident it was no less than 93 per 1000. 
" In making calculations of efficient force," writes Sir James Macgrigor, 
" this description of men could not be relied on for operations long continued 
in the field" (speaking of men who had suffered from an attack of paludal 
fever), for " we found that in those who were convalescent or lately recovered 
from ague, the causes next prone to reproduce the disease were exposure to a 
shower of rain, or wetting the feet, full exposure to the direct rays of the sun, 
or to cold, with intemperance, irregularity, or great fatigue. There are many 
instances also of the same person being repeatedly attacked with the West 
Indian malarious fever. Sir Ranald Martin writes, with regard to himself, 348 
SPECIAL PATHOLOGY-MALARIOUS FEVERS. 
that " after a residence of ten years in Europe, I happened to pass three nights 
at the best hotel in Strasburg, at a time when ague prevailed in the garrison 
amongst the French soldiers who had served in Algeria ; and two days after 
quitting the town I was seized with ague at the hour of eleven a.m. (the hour 
at which ague used to commence with me in India), and I was the only person 
of the party who was so affected." 
The opinion regarding the pathology of yellow fever, which holds that it is 
" an intense form of the bilious remittent of the tropics," has given rise to much 
discussion. 
The investigation of this point, however, is attended with extreme difficulties, 
and is to be carried out with reference to two questions especially,-namely, 
(1.) The type or mode of progress of the symptoms in mild and severe cases, 
compared with cases of remittent fever in all grades of severity and stages; 
(2.) The pathological characters of the morbid processes which take place in 
severe forms of yellow fever, compared with those of remittent. 
Three opinions have thus been held regarding the essential nature of yellow 
fever. These are,-(1.) That there is a malarious form of yellow fever which 
is an intense and virulent form of remittent, and which becomes more or less 
a continued fever (Cleghorn, Lind, Hunter, Alison, Craigie, Martin). 
(2.) That it is a continued fever of a specific kind, different from all other 
continued fevers (Cullen, Chisholm, Blane, Wood, Hirsch, Arnold, 
Maclean). (3.) That it is a mixed fever, of a type variable between the 
remittent and continued forms (Jackson, Moseley). 
The grounds upon which the first of these opinions is accepted are-that in 
the symptoms and effects, progress and pathology, of remittent fevers and 
ordinary cases of yellow fever, we are unable to discover any essential differ- 
ences, but merely what is due to intensity of morbid action, degree, and rapidity 
of progress. Comparisons have been drawn in this way between the summer 
and autumnal remittents of the south of Europe, the remittent fever of the 
Mediterranean, the tropical remittent of the East and West Indies and Central 
Africa, the Bulam fever, or the fever of Sierra Leone and Fernando Po, on 
the one hand; and between some of the cases of the yellow fever of Cadiz, 
Gibraltar, Malaga, Carthagena, Leghorn, Vera Cruz, Havana, Jamaica, 
St. Domingo, the West Indies generally, and the United States, on the other. 
There are also cases in which no distinction can be drawn between the symp- 
toms, the effects, or the rapidity of action, if the case (considered to be a re- 
mittent) is compared with some cases of so-called yellow fever. In other 
words, it is not possible to distinguish some cases, and say with certainty that 
they are cases of remittent rather than of yellow fever, or of yellow fever and 
not remittent. 
Causes and Modes of Propagation-Facts tending to establish the con- 
currence of certain terrestrial, gaseous, or meteorological phenomena, as 
necessary to the generation and development of these fevers, are of a very 
conflicting nature. The concurrence of some, however, are sufficiently obvi- 
ous, and are applicable to the littoral and paludal fevers generally. 
By numerous observations it has been established that some aeriform mate- 
rial, probably of a poisonous nature, is exhaled from marshy or wet grounds 
in the progress of drying. Agues have always been observed to be the diseases 
of moist or marshy districts; and to prevail most in low, swampy, and humid 
countries, where seasons of considerable heat occur. The vicinity of marshes, 
or of a district that has at some recent time been under water; the banks of 
great lakes, and the shores of great rivers and seas, where the water flows 
slowly, and in some places stagnates, in shallow rivers over land alluvial, low, 
and flat; extensive flat tracts of wood, where much moisture is constantly 
present, where the process of drying is uninterrupted, and yet the surface 
constantly exhaling humidity;-these are some of the terrestrial physical 
conditions in which the paludal and the littoral fevers are found to abound. CONDITIONS FOR DEVELOPMENT OF MALARIOUS FEVERS. 
349 
It must also be admitted, however, that these diseases do not prevail in all 
marshy districts, and they cannot, in some cases, be traced to a residence in 
the vicinity of marshes. Dr. Wood gives an interesting example of the occur- 
rence of ague from an irritant cause, combined with the force of habit. " For 
seven successive nights M. Brachet bathed, at midnight, in the river Saone, 
towards the close of October, when the water was cold. Retiring to bed after 
each bath, and covering himself warmly, considerable reaction took place, 
which terminated in perspiration. At the end of the seventh day he ceased 
to bathe, but was, nevertheless, nightly, about the same hour, attacked with a 
regular intermittent paroxysm, consisting of the cold, hot, and sweating stages, 
which returned for about a week, when it ceased spontaneously on the occur- 
rence of an event which kept him out of his bed at the hour of paroxysm, and 
induced him to take a ride on horseback, which excited and warmed him." 
Cases having their origin in such causes, however, are of exceedingly rare 
occurrence, so far as the records of medicine show. 
The concurrence of circumstances under which paludal and littoral fevers 
have been observed to become developed may be shortly stated as follows: 
(1.) A certain degree of heat. A high temperature is especially favorable to 
the production of malaria, and the more so when acting on moist alluvial soil. 
(2.) A certain relation as to season, variable with the geography of the 
locality in which such fevers prevail. . The season of the year most marked 
in tropical climates is that which immediately succeeds the cessation of the 
rains, or, as it is called, " the drying up of the rains." (3.) Low swampy 
grounds and extensive rice fields are well-known sources of malaria. In such 
districts clouds of mist are often seen, wafted along the earth's surface for 
miles; and it is believed that malaria, whatever be its nature, clings to such 
mists. But although it has been observed that absolute marshes do not always 
produce agues, nor that agues are always due to obvious marshes, yet it is 
generally found that in districts where such paludal fevers abound the surface 
is porous, penetrable, and retentive of moisture, although it does not appear 
on the surface of the ground; that the district had been at one time sub- 
merged ; and that it continued slowly but constantly to undergo the process 
of desiccation; or while at certain seasons it imbibes moisture from local or 
meteorological sources, at other seasons it undergoes the drying process under 
intense solar heat. Such are some of the most sickly and febriferous districts 
in Europe, India, and America. For example, the Maremma of Italy; the 
district of the lakes near Varna, in Bulgaria; many districts in Burmah ; 
many newly cleared tracts in North America; and many parts in the south 
of Spain. In most of these places the conditions of the surface of the ground 
are very much alike. While no obvious appearance of a marsh exists, the 
vigor of vegetation is extreme, amphibious animals abound, of the batrachian 
kind, plants and cephalopodous mollusca of notoriously marshy regions find a 
habitat, and the rich alluvial soil is so imperfectly cultivated that the process 
of vegetation is not adequately exhausted, and a surface of humid ground is 
exposed to the solar heat, and so exhales a material which exercises a persis- 
tent deleterious influence on the human frame. It is believed that the number 
of insects and some reptiles with which a place abounds are more significant 
of its insalubrity than almost any other circumstance; and that a mixture of 
animal and vegetable matters undergoing decay give rise to miasms much 
more noxious than those resulting from vegetable matter alone. Dr. Fergus- 
son, in The Edinburgh Philosophical Transactions, vol. ix, p. 273, was the first 
author who clearly proved that the drying of all porous soils, from which 
watery fluid readily evaporated, was the genuine source of exhalations capa- 
ble of producing the paludal fever; and that the febriferous activity of these 
exhalations was influenced by the character of the season, the moisture, the 
temperature, and the aerial movements of the atmosphere. 
The evidence regarding the geological nature of soil as a cause of ague is 350 
SPECIAL PATHOLOGY-MALARIOUS FEVERS. 
somewhat conflicting. It is a fact that the usual localities in which paludal 
fevers abound are those in which the soil consists of mineral, vegetable, and 
animal matters, mixed together in such proportions and of such constituents 
chemically as tend to absorb moisture and retain it, and subsequently to 
decompose. Such soils are known as alluvial. Paludal fevers abound, how- 
ever, where soils of a different nature predominate. Level plains of sand, or 
dry, loose, open gravel, are soils where malarial fevers have prevailed. 
" The first time I saw intermittent and remittent fever become epidemic in 
an army," writes Dr. Fergusson, "was in 1794, when, after a very dry and 
hot summer, our troops in the month of August took up an encampment at 
Rosendaal, in South Holland. The soil was a level plain of sand, with 
perfectly dry surface, where no vegetation existed, or could exist, but stunted 
heath plants. On digging, it was universally found percolated with water to 
within a few inches of the surface, which, so far from being at all putrid, was 
perfectly potable in all the wells of the camp." 
High grounds near exposed marshes are often more unhealthy than the 
places immediately adjoining, which are on a level with them. Rocky places, 
such as Ciudad Rodrigo, Gibraltar, and Malaga, have now and then been 
ravaged by epidemics of littoral and paludal fevers, and the rocky shores and 
islands of the Mediterranean-for instance, Minorca, Sardinia, Sicily, Cepha- 
lonia, and all the Cyclades-abound as much in these fevers as the most level 
parts of Holland; and the West India Islands, most of which, although coral- 
line rocks, are the native soil of these diseases. Soil composed of tenacious 
or stiff clay (argillaceous) is highly retentive of moisture, and is difficult 
either to dry or to drain. The basin of the Thames, comprehending Middle- 
sex, Essex, Surrey, and Kent, is almost entirely clay land, and is the district 
of England where agues most of all prevail, especially along the banks of 
the Medway and the Thames. In the days of Sir Gilbert Blane agues had 
almost entirely ceased to occur in London, and the cases which he treated he 
believed to have been imported from malarious districts around; and the 
same may be said of those of the present day. A hundred years before the 
time of Sir Gilbert Blane, however, we find that agues prevailed in situations 
in the town of London where they are now wholly unknown, such as Russell 
Street, Covent Garden, Fleet Street, Fetter Lane, Newgate Street, Paternoster 
Row, Cheapside, Smithfield, and Fenchurch Street. At the present time ague 
rarely occurs in London, except on the south side of the river, especially in 
Bermondsey and Rotherhithe, and chiefly in persons who have recently been 
exposed to malaria in Kent or Essex, and who have come from marshy dis- 
tricts, either quite recently or within a few months. The malarious influence 
still in the metropolis, seems, however, sufficiently powerful to imprint a 
periodic character upon various local affections, and occasionally to give rise 
to fevers of a remittent type. Recently (in 1856) such affections have been 
unusually prevalent; but the forms of ague now met with in London are 
more tractable and milder than those which formerly prevailed (Dr. Pea- 
cock). 
It is observed that the surface of the earth may be dried either by the 
direct rays of the sun, or by currents of hot dry air wafted over it, or by both 
combined; but it is principally by the direct rays of the sun that the delete- 
rious material of the soil is liberated; and it seems to be at a certain period of 
this " drying up" process that the exhalations are more potent than at another 
time in developing paludal fevers. The exposed grounds, after clearing off 
the copious vegetation from dense jungles, so as to admit the influence of the 
sun's rays in " drying up," is known to be a fertile source of malaria. 
There appears also to be a certain state of the human frame which renders 
it more than usually susceptible to this disease. The natives of warm and 
tropical climates are much less frequently and less violently attacked with CONDITIONS FOR DEVELOPMENT OF MALARIOUS FEVERS. 
351 
paludal or littoral fevers than settlers or visitors from other lands, such as the 
natives of Europe or the northern parts of America. In the Mediterranean, 
along the coast of Africa, in the East Indies, in West India Islands, in the 
Southern States of the Union, new-comers from the northern latitudes are 
almost invariably attacked, and suffer much more severely from the fever 
than those who have been long in the country. It has been also noticed that 
those who, after residing in a territory where paludal fevers abound, have 
been out of it for some time, an augmented susceptibility to renewed attacks 
of the fever becomes manifest on their return (Craigie). 
Other causes predispose to those fevers, and none more than laborious or 
fatiguing duty in military or naval operations, laboring in the sun, exposure 
to chill, or from great heat suddenly to cold, excess in eating or drinking, 
intellectual exertion combined with bodily fatigue, and a crowded state of 
the population. Indeed, sunstroke, or heat apoplexy, is regarded by many as 
a form of remittent fever (Johnston, Martin, Hill). 
When a remittent fever, or other paludal or littoral fever, has, under certain 
concurrent circumstances of weather, season, and physical peculiarities, made 
its appearance in any locality, it necessarily attacks all those who are by 
constitution, habit, and age, susceptible and predisposed; and the majority of 
these, especially if enfeebled by previous dynamic or organic disease, it 
destroys. The population, therefore, which outlives such an epidemic visita- 
tion are no longer equally susceptible, and are greatly less likely to be attacked 
during the ensuing season unless it is more febriferous than the past, which, 
though sometimes, is not generally the case. The effect of this, therefore, is 
that while the endemial disease continues for a season to attack and destroy 
its ordinary annual proportion of the population, it does not for several years 
attack the extraordinary proportion, because that proportion is not yet ready 
for, or susceptible of, its attacks. In the course of a few seasons, however, 
during which the young have grown up and become adult, the adult have 
become careless, and perhaps irregular and incautious by long immunity, and 
their constitutions have become less able to resist deleterious or morbific 
impressions, and the whole population of the place has become generally 
augmented by the arrival of persons from various other countries; a consid- 
erable number of susceptible persons is gradually accumulated; and at the 
end of five or six years a place of 25,000 or 30,000 inhabitants becomes aug- 
mented perhaps by an additional fifth, or even by a third. The majority or 
the totality of these persons are all more or less predisposed and susceptible; 
a season of excessive drought ensues, in which solar desiccation and little 
wind form conspicuous characters; fever appears, and spreads at first slowly 
and gradually, but afterwards, springing up in many points, rapidly coalesces; 
and in a short time is so general and fatal that it assumes an epidemic char- 
acter. The usual mortality in the meantime takes place; all the susceptible 
and predisposed subjects pass through the disease or are cut off; and the pop- 
ulation of the place is once more reduced to its state of epidemic insuscepti- 
bility and endemic or ordinary liability. This is the usual course of epidemics 
of paludal or littoral fevers in all countries within the tropics, and, indeed, 
within the 45th degree of north and south latitude (Craigie). 
A question of much interest in connection with malaria has given rise to 
considerable speculation. It relates to the varieties of the malarious poison. 
Is the poison which gives rise to a quotidian ague different from that which 
produces a tertian; and is this, in its turn, different from that which produces 
a remittent fever; and this, again, different from that which gives rise to the 
malarious form of yellow fever ? Our knowledge is not yet sufficiently pre- 
cise and extensive to settle these points. But when we see a large body of 
men placed under the same circumstances as to food, drink, and clothing, and 
labor, and exposed to the same causes of disease, in the same way and in the 
same place, some of whom are seized with quotidian ague, others with tertian, 352 
SPECIAL PATHOLOGY-PANDEMIC INFLUENCES. 
and others with remittent fever, the presumption is that the same cause has 
produced different diseases, according to its intensity, the constitution of the 
individual, and the predisposing causes to which he may be subjected. Other 
facts also favor this presumption-namely, remittent fevers are known to pass 
into quotidian agues; and these again into tertian agues. 
CHAPTER V. 
ON THE NATURE OF ENDEMIC, EPIDEMIC, AND PANDEMIC* INFLUENCES. 
Endemic Influences result from those conditions or agencies peculiar to a 
locality which favor the development of various miasmatic diseases, and may 
thus account for their sudden origin. Such diseases are then said to be 
endemic. These endemic influences, for the most part, are exerted by the geo- 
logical properties of a district, and are traceable to the constitution and state 
of the soil, water, and air ; to elevation above the level of the sea, vicinity of 
sea, rivers, or stagnant wrater, woods, and vegetation; variations of tempera- 
ture, prevalent winds ; in connection with avocations, modes of life, quality of 
food and quantity, as modified by moral agencies, such as indolence or 
activity; privation and comforts, filth or cleanliness of people ; together with 
their habits of life and employments, ignorance or mental culture; and lastly, 
their social, moral, religious, and political conditions. It may be shortly 
stated in illustration, that endemic influences become mainly active through 
the following conditions, namely : 1st. That the specific poisons by which the 
communicable diseases, such as small-pox or typhoid fever, propagate their 
kind are never totally in abeyance. 2d. The specific communicable diseases 
are constantly extant somewhere, and only under conditions favorable to their 
dissemination do they spread or become epidemic. Although their germs, 
specific gases, active principles, or media of propagation and development, 
may lie dormant or latent for a time, it is not to be inferred that they have 
ceased to exist. 3d. The history of all the specific communicable diseases 
demonstrates the same alternations of slumber and activity; of widespread 
prevalence in one place, while neighboring places may remain free ; and 
finally, the same successive invasion of neighboring places, such that the pre- 
vailing disease only begins to prevail in the new locality after it has already 
died out in the old. 4th. One element remains constant in the history of 
endemic influence, and that is the specific morbid poison which is the origin of 
each case. It is susceptible of transmission from place to place, gathering 
strength as it proceeds, again to die out or become dormant, so that its track 
is with difficulty followed or traced out. 5th. In large cities such specific 
poisons are always more or less active, and their diseases always present; but 
in the country districts they only now and then occur. The occurrence of 
long intervals of rural exemption is not traceable to any feebleness of the 
poison to act; for when the disease does become developed in these places, the 
ratio of persons or of animals attacked is incomparably greater1 than is ever 
seen in cities under like circumstances (see Professor Acland's account of the 
fever in Great Horwood, in 1857-58; and Dr. William Budd, of Clifton, 
* Deputy Inspector-General Dr. Lawson has recently called the attention of the pro- 
fession to what he considers to be oscillations of influences over the whole world, deter- 
mining febrile diseases. To such influences he gives the name of " Pandemic ''(Trans- 
actions of Epidemiological Society for 1862; also, Statistical, Sanitary, and Medical 
Reports of the Army Medical Department for 1861). ENDEMIC INFLUENCES. 
353 
regarding fever at North Tawton ; and his most instructive little book On the 
Propagation of Typhoid Fever). 6th. In large towns the sewers are constantly 
charged with the materies morbi of specific diseases always abounding in towns. 
In small villages, and other places where no sewers exist, the air only may be 
infected, or the water contaminated, by the direct or indirect importation of 
cases of specific disease or their equivalents-the poison itself-so that the 
organic impurities, the dung-heaps, the open soil which surrounds the dwell- 
ings of the patients, the cesspools, and the privies common to several houses, 
gradually but eventually become impregnated with the specific poison of the 
disease. Thus the atmosphere of the village may become incomparably more 
virulent than the atmosphere of the sick-chamber itself. Hence the rapid 
epidemic spread of the miasmatic diseases in the limited space of rural vil- 
lages ; and which gives rise to the popular error, that such diseases are inva- 
riably contagious in country places, and only rarely so, or by exception, in 
cities or large towns. 7th. All these specific diseases multiply their kind after 
similar modes of propagation. 8th. Each of them establishes a constant series 
of morbid changes and lesions, and always issues in the reproduction of its 
own specific germ, miasm, gas, morbid poison, or active principle by which it 
propagates its kind. Thus smcdl-pox propagates small-pox, measles multiplies 
measles; scarlatind reproduces scarlatina; typhoid fever breeds typhoid fever; 
typhus, typhus; and so on. In the terse language of Dr. William Budd,- 
" What small-pox and measles were in the Arab in the days of Rhazes, they 
still are in the London Cockney of our own time. What they are in the Lon- 
don Cockney, they are in the Wild Indian of the North American prairie, 
and in the Negro of the Gold Coast. To all the other specific communicable 
diseases, as far as our records go, the same remark applies. In races the most 
diverse, under climates the most various, age after age, through endless gen- 
erations of man, these diseases pass down through the human body (sometimes 
through animals-e. g., ovine small-pox?), perpetuating their own kind, and 
each maintaining its separate identity by marks as specific as those which dis- 
tinguish the ash from the alder or the hemlock from the poppy." Such being 
the case, it is difficult to conceive (as Drs. Watson and William Budd most 
justly observe), "that diseases of ivhose propagation this is the history can ever be 
generated in any other way." Most of these miasmatic diseases also are pecu- 
liar to man; while animals on their part are infested by a whole brood of 
communicable diseases, no less specific in their kind, each distinct from the 
other, and most of them, although some may be communicable to man, are 
incapable of multiplying in the human body. Cattle appear to be subject to 
a variety of malignant and communicable fevers from which man is altogether 
exempt. 9th. Certain receptive conditions, pr a predisposition (the nature of 
which is unknown), exists in individuals, which appear essential to the devel- 
opment of the specific poisons and the establishment of the disease ; and 
immunity against a repetition of the disease is generally conferred by one 
attack of the same disease-an immunity which has been proved by experi- 
ment on an enormous scale with regard to small-pox; and with regard to the 
other diseases of this kind, the belief in such immunity is deduced from exten- 
sive observation. But the immunity acquired by one attack of any of these 
diseases is of no avail against the rest. Measles, for example, renders the 
body proof against measles, but leaves it as open to small-pox as before, and 
so on of the rest. 10th. With regard to fermentation, putrescency, or decom- 
position, there is some reason to believe (as shown in the previous chapter) 
that it may quicken the activity or facilitate the development of specific mor- 
bid poison, in the way of a predisposing cause. Dr. Budd, however, believes 
that this effect has been much overrated, notwithstanding the observations of 
Dr. Carpenter referred to in the preceding pages. Nevertheless, there is no 
small amount of circumstantial evidence tending to show that endemic condi- 
tions may be thus far favorable to the propagation of specific diseases, even to. 354 
SPECIAL PATHOLOGY - PANDEMIC INFLUENCES. 
the extent of epidemics, in consequence of the predisposing agency of putrescent 
emanations; and on the other hand, both endemic and epidemic influences are 
often held in abeyance by the tendency to decay, decomposition, and destruction 
of the specific germs, miasms, gases, or disease poisons themselves. They are 
stamped with the tendency to change and to perish. Like all organic sub- 
stances which propagate from minute or invisible beginnings, myriads perish 
for one that is fruitful. This is especially demonstrable in respect of the Para- 
sitic diseases, whose germs would overrun the world if they all came to matu- 
rity ; but the extinction or the dispersion of the specific poisons is abundantly 
provided for through the operation of many natural causes ; and by imitating 
some of these operations of nature we may be able eventually to exterminate, 
or, at all events, greatly to modify the severity and reduce the mortality from 
many of these diseases. 
The belief in the spontaneous endemic origin of the specific miasmatic dis- 
eases rests on evidence entirely negative-namely, the fact that cases do Spring 
up in which it is impossible to trace the disease back to a personal source of 
specific propagation and dissemination-an event which is inherent in the very 
nature of these diseases. For the active principle of the poison is invisible, 
although the matter that is known to contain it may be capable of isolation and 
inoculation, as in small-pox; yet the existence of the specific disease poison is 
known to us by inference only. Again, we know that ample provision is 
made, and ways are open, for the dissemination of the active agent of propa- 
gation in a thousand unseen modes, so that it is obvious that the precise 
source of infection and its track must often baffle the wisdom of man to dis- 
cover or trace out. 
Cases thus constantly arise which appear to give countenance to the belief 
that the disease has had a spontaneous origin-sporadic, as it is termed. 
Numerous cases of small-pox occur which can never be traced to their source, 
or to communication with persons similarly diseased; yet the history of small- 
pox is decisive against the notion of its spontaneous origin; and if of small- 
pox, so for all the other specific diseases of the same nature. Dr. Watson has 
well observed, that "the small-pox never occurs except from contagion. It 
was quite unknown in Europe till the beginning of the eighth century. No 
mention of any such malady is to be found in the Greek or Roman authors of 
antiquity. Now, whatever may have been the deficiencies of the ancient 
physicians, they were excellent observers and capital describers of disease; 
and it is impossible that a disease so diffusive, and marked by characters so 
definite and conspicuous, should have escaped their notice, or have been 
obscurely portrayed (if known) in their writings. On the other hand, Mr. 
Moore, in his learned and interesting History of Small-Pox, has shown that it 
prevailed in China and Hindostan from a very early period-even more than 
a thousand years before the time of our Saviour. That it did not sooner ex- 
tend westward into Persia, and thence into Greece, may be attributed partly 
to the horror which the disease everywhere inspired, and the attempts that 
were subsequently made to check its progress, by prohibiting all communica- 
tion with the sick, partly to the limited intercourse which then took place 
among the Eastern nations, but principally to the peculiar situation of the 
regions through which the infection was diffused, separated as they are from 
the rest of the world by immense deserts and by the ocean" (Watson, Lec- 
tures on the Practice of Physic, 3d edition, vol. ii, p. 709). "If anything were 
wanting," writes Dr. Budd, "to show what is the true inference to be drawn 
from these events, it would be found in the fact that, once imported into the 
West, it spread with the most fearful rapidity and havoc; and that, while 
almost all men are prone to take the disorder, large portions of the world 
have remained for centuries exempt from it, until at length it was imported, 
and that then it infallibly diffused and established itself in those parts. In 
this country the (endemic) conditions for the spread of the disease existed in NATURE OF EPIDEMIC INFLUENCE. 
355 
the most intense degree, as was shown by the event when the disease was once 
introduced. The long lapse of ages during which we remained entirely free 
from small-pox showed, with equal clearnesss, that, until this introduction 
occurred, all the conditions favorable to the development of small-pox were 
powerless to cause a single case. The spectacle witnessed in Europe was 
repeated over again in the Western World in a still more striking way. Our 
knowledge of the events here is precise and sure. There was no small-pox in 
the New World before its discovery by Columbus, in 1492. In 1517, the dis- 
ease was imported into St. Domingo. Three years later, in one of the Spanish 
expeditions from Cuba to Mexico, a negro covered with the pustules of small- 
pox was landed on the Mexican coast. From him the disease spread with 
such desolation that within a very short time (according to Robertson) three 
millions and a half of people were destroyed by it in that kingdom alone." 
"Again, small-pox was introduced into Iceland in 1707, when sixteen 
thousand persons were carried off by its ravages-more than a fourth part of 
the whole population of the island. It reached Greenland still later, appear- 
ing there for the first time in 1733, and spreading so fatally as almost to 
depopulate the island" (Budd, 1. c., p. 35, et seq.f No common conditions 
of human life gave rise to such phenomena. Propagation from the actual 
poison of a pre-existing case was the one necessary and all-sufficient condition 
for these endemic outbreaks and their epidemic prevalence. The precise 
mode in which the miasmatic diseases, with their specific poisons, first came 
into existence is beyond our ken-hidden from us as yet by a veil, and re- 
maining an inscrutable, at least as yet an unpenetrated, mystery. But every- 
thing tends to show that once created, they all propagate only in one way- 
namely, by continuous succession. 
Defective ventilation, inasmuch as it is always injurious to health, always 
aggravates disease, and so promotes the endemic influence. With regard to 
any influence it may have on the development and spread of communicable 
disease, it may be noticed that it does not equally help all communicable dis- 
eases to develop themselves and to spread. Commonly it seems to operate in 
proportion as the specific miasmatic disease is one which imparts specific 
poison properties to the general exhalations of the sick. The significance of 
defective ventilation is not likely, therefore, to be quite the same where 
typhoid fever, cholera, or dysentery, is the prevailing disease, as where the 
disease is typhus fever, scarlatina, small-pox, or diphtheria. In the cases of 
typhoid fever, cholera, and dysentery, any defect of ventilation would be- 
come more and more important in proportion as the bowel discharges of the 
sick were not promptly removed from within doors, or as, from othex' causes, 
there were fecal effluvia or excrements suffered to remain in the dwelling 
(Simon, Third Report of the Medical Officer of the Privy Council, 1860, p. 10). 
Epidemic Influence.-The second characteristic feature peculiar to some of 
the miasmatic diseases is, that they sometimes spread rapidly, so as to inca- 
pacitate and destroy great numbers of the people. The disease is then said to 
be epidemic (ent, upon; and the people). No subject has afforded greater 
scope for speculation than the origin, cause, and progress of epidemics. It is 
in vain to speculate upon the subject; and, in the words of Dr. Wood, of 
Pennsylvania, "all we can say, with certainty, regarding epidemics, is, that 
there must be some distempered condition of the circumstances around us- 
some secret power that is operating injuriously upon our system-and to this 
we give the name of epidemic influence or constitution," and which is believed 
to predispose towards the receptivity of specific disease poisons. The obser- 
vations of Mr. Simon lead to the belief that the prevalence of external condi- 
tions, tending in certain localities to determine a specific decomposition of 
excrement, communicable to other organic substances and infecting the air, 
is an essential element in an epidemic period. 
The most recent speculation regards the discovery of a peculiar atmospheric 356 
SPECIAL PATHOLOGY PANDEMIC INFLUENCES. 
condition, ascribed to a principle called ozone, or osmazone ^^<vv, stink, or 
dapy, smell), of which, as yet, we know nothing definite, although many subtle 
instruments and apparatus are in use to detect and measure the amount of this 
principle in the air. (See Parkes's Hygiene, pp. 455 and 470, third edition.) 
A careful study of the effects of the epidemic influence appears to warrant 
the enunciation of certain laws which seem to regulate its operations. These 
laws may thus be condensed: 
Laws of Epidemic Influence.-(1.) This influence frequently predisposes to 
diseases, apparently independently of any other known cause, as in the case 
of influenza and cholera. It makes itself manifest by appearing to give in- 
creased energy to causes which produce particular diseases ; so that small-pox, 
scarlatina, typhus, and the like, sometimes rage with great violence as epi- 
demics. It also appears to predispose to new and anomalous forms of disease, 
as witnessed in the furunculoid epidemic which, recently prevailed both in 
Europe and America, from 1849 till 1852. (2.) Sometimes the epidemic influ- 
ence manifests itself by a certain type or direction which existing diseases 
appear to take. Thus, at one period diseases take a low, or what is called a 
typhoid type, so that depletion is not tolerated ; at another time an inflammatory 
tendency predominates, and antiphlogistic treatment is required. At one 
period there is a tendency in disease to complicate its course by a disposition 
to affect particular organs. At one time head affections predominate; at 
another time affections of the chest, or of the alimentary canal, complicate 
the course of a prevailing disease. Consequently the same disease may demand 
very different, and even opposite, modes of management. (3.) During epi- 
demics other diseases are apt to assume more or less of the prevailing epidemic 
features. Thus, when cholera prevails, looseness of the bowels often compli- 
cates the course of other affections. When influenza prevails, catarrhal com- 
plications increase the danger of other diseases. Ill-health of any kind, 
therefore, favors the action of the epidemic influence. (4.) Some change in 
the character of prevailing diseases of a constant and recurring kind often 
indicates the approach of an epidemic and the prevalence of the epidemic 
influence. (5.) The first effects of the epidemic influence are usually the most 
violent and marked, and the cases of the epidemic disease become mild as the 
epidemic influence passes away. (6.) The epidemic influence sometimes disap- 
pears entirely after a short prevalence; sometimes continues, with irregular 
intermissions, for two, three, four, or even six years, or longer. Influenza and 
cholera are examples. (7.) An epidemic tendency, after continuing for several 
years, may give place to one of a different kind, which, in its turn, may again 
give place to the first. Malarious fevers, yellow fever, and typhus illustrate this 
in America. The eruptive affections seem to run in somewhat similar cycles. 
After the introduction of vaccination the small-pox seemed for many years to 
be almost entirely subdued ; but more recently again the disease has seldom 
been entirely absent from among us, alternating as an epidemic now and then 
with measles, scarlet fever, and typhus. We look forward to the time when 
vaccination, enforced by law, will completely eradicate the disease. (8.) The 
lower animals are also subject to epidemic influences; and seasons of unusual 
fatality among them have coincided with those in which the human race have 
suffered. This fact has been well shown in an elaborate and erudite analysis 
of the census of Ireland, by Sir William R. Wilde, of Dublin, the diseases of 
the population having been recorded at the time. 
Pandemic Influences.-The expressions of the hitherto prevailing doctrines 
regarding endemic and epidemic influences appear so unsatisfactory to many 
minds, and leave so many circumstances regarding the spread of diseases 
unexplained, that attention is being directed to more comprehensive views and 
investigations of the questions involved in the preceding paragraphs. An 
ingenious theory has been propounded by Deputy Inspector-General Dr. 
Lawson, who has attempted to establish the occurrence, between 1817 and NATURE OF PANDEMIC INFLUENCE. 
357 
1836, of a series of oscillations of febrile diseases, following each other over the 
world with amazing regularity. The mode of occurrence of such febrile dis- 
eases he attributes to a cause or influence which, from its extent and progres- 
sive character, he names a "pandemic wave," to distinguish the influence from 
that usually understood as epidemic, referring to a single form of disease 
affecting a limited space. Under the influence of this pandemic wave Dr. 
Lawson believes that there is a constantly progressive tendency to the develop- 
ment of all endemic febrile diseases in the Atlantic and Western parts of the 
Indian Ocean, from south or southeast to north or northeast. 
But the facts and data on which this theory is made to rest are not of suf- 
ficient number, and many of them are not sufficiently trustworthy, to rest a 
judgment upon. In not a few instances a totally different interpretation may 
be given to that which Dr. Lawson has assigned to them. Although, there- 
fore, it may be premature to propound such a theory, especially as it is still 
open to the verdict of "not proven," yet the expression of it is calculated to 
do good, by drawing attention to the subject, and to the comprehensive 
world-wide range which must be given to such investigations; and to whom 
can Science look with more hope for results than to the medical officers of 
Her Majesty's British and Indian Army and Navy? 
A successful study of these peculiar and characteristic features of mias- 
matic diseases-namely, the endemic, epidemic, and pandemic influences-is of 
the utmost importance to the student. He will learn to appreciate how much 
and successfully mortality may be diminished by well-directed hygienic 
measures, such as cultivation and improvement of the soil, extension of com- 
merce, improvements in diet and the social circumstances of the lower classes 
-especially in • regard to cleanliness, ventilation, and domestic management 
of improved dwellings, and efficient sewerage; care in the separation and 
treatment of the sick when in numbers; and the use of strict measures of a 
prophylactic kind suited to the circumstances of the case. Next to large 
towns, the health of the army is of the greatest importance, especially when 
we consider the tendency that exists to a high rate of mortality in that 
service. In the military age (which is the age between eighteen and forty) 
the mortality of the general population in England is less than 1 per cent, 
per annum. The mortality of the British army is much above this. On 
Home service it has had a mortality double that of the civil population at 
the corresponding ages; and seven-ninths of the entire mortality among the 
infantry of the line has arisen from diseases of the specific preventible kind. 
Disease and mortality are much greater during campaigns, when more than 22 
per cent, are constantly on the sick list. The causes of high rates of mortality 
require constant investigation, by carefully observing, recording, and com- 
paring the facts over a sufficiently large area; thus arriving at certainty as 
to the causes, and whether they can be mitigated or removed. 
An observation of great interest in connection with animal malaria poison, 
as well as with epidemic influences, may be appropriately referred to here. It 
seems clearly proven, especially by the valuable and decisive observations of 
Dr. William Budd, of Bristol, that the communicable poisons of typhoid 
fever and of cholera are capable of being imported or carried from place to 
place by persons who have the disease. Dr. Budd's history of the North 
Tawton fever and its offshoots {Lancet, July 9, 1860) is most conclusive on this 
point. His arguments are also cogent to the general effect that specially the 
bowel discharges are means by which a patient, whether migrating or sta- 
tionary, can be instrumental in disseminating typhoid fever and cholera. 
Mr. Simon makes the important remark, however, that these bowel dis- 
charges may not be the sole means of multiplying and disseminating these 
diseases; although, provisionally, the conclusions of Dr. Budd must be acted 
upon in their present unqualified form; while it is of the greatest practical 
importance to learn, as exactly as possible, whether it is in all states of the 358 
SPECIAL PATHOLOGY - ANIMAL MALARIA. 
disease, and under all circumstances, that the bowel discharges of typhoid 
fever and cholera can communicate and multiply the means of dissemination. 
In illustration of such possible contingent results, Mr. Simon refers to some 
interesting and important experiments made in 1854 by Professor Thiersch, 
of Erlangen. These experiments seemed to show that cholera evacuations, in 
the course of their decomposition, either acquire the power of communicating 
or multiplying their specific poison, or that the specific poison inherent in 
them becomes intensified by decomposition (zymosis?). That the decompo- 
sition or change may begin even in the bowels, after the secretion and accu- 
mulation of the material in them, as well as in cesspools, seems to be 
possible; and perhaps, as Mr. Simon justly remarks, may furnish an expla- 
nation of the many cases in which human intercourse has apparently dissemi- 
nated the disease. For, according to the observations of Professor Petten- 
kofer at Munich, and Professor Acland at Oxford, it would seem that during 
cholera periods the immigration of persons suffering apparently only from 
diarrhoea has been followed by outbreaks of cholera in places previously 
uninfected; and Professor Pettenkofer ascribes this fact to an influence 
(zymotic?) exerted by the decomposing faeces of such diseased persons, in the 
cesspools and adjoining soil of ill-conditioned places to which they go. 
Specific poison-properties of this kind would thus arise, and probably extend 
to the pollution of well-waters of such soils, and might render them, if swal- 
lowed, capable of exciting cholera, or typhoid fever, or dysentery, by direct 
contagion; and so a-ny of these diseases would thus have all the appearance 
of having arisen de novo. It is encouraging to sanitary reformers, as Mr. 
Simon justly remarks, that cases of the apparent introduction of cholera 
contagion by human intercourse are essentially different from cases of the 
dissemination of such specific diseases as small-pox or measles. The multi- 
plication of the specific poison in the latter diseases takes place exclusively 
within the human body. The multiplication and dissemination of them have 
no immediate dependence on differences of medium; but wherever human 
beings can cross one another's path, to the susceptible or unprotected person 
these specific diseases may be communicated. On the other hand, it seems 
really to be the fact that the cholera poison (and probably, also, typhoid 
fever poison and dysentery), if it can at all be multiplied within the body, 
almost certainly has its great centres of multiplication elsewhere-namely, in 
those avoidable foci of corruption where excrement accumulates and decays. 
Military authorities ought to remember this fact. They have had abundant 
evidence of it in the old camping-grounds of the Indian army, as well as 
when following the route and encamping on the ground previously occupied 
by retreating armies in other countries, as in the Russian war of 1854-5. 
For disseminating the disease and multiplying the poison, foulness of medium 
seems indispensable; and it is no ordinary foulness which will impart to air, 
food, or water, the zymotic action of decomposing excrement. The taint is 
something' specific. Therefore, as regards cholera, it seems highly probable 
that the immigration of infected persons might occur to a very great extent 
without exciting epidemic outbreaks, if such immigration were only made 
into places of irreproachable sanitary conditions, especially as regards water 
supply and the continuous removal of house refuse or camp filth. (Compare 
Simon, in his Public Health Reports-especially second and third-relative 
to the people of England; also Pettenkofer, Acland, and Thiersch, as quoted 
by Simon, p. 3 of his third report, 1860.) MANAGEMENT OF EPIDEMICS. 
359 
CHAPTER VI. 
MANAGEMENT OF EPIDEMICS ; AND ON PROCEEDINGS WHICH ARE ADVISABLE 
TO BE TAKEN IN PLACES ATTACKED OR THREATENED BY EPIDEMIC DIS- 
EASES. 
The practical questions immediately involved in the exposition which has 
been given of the nature of the specific or miasmatic diseases in particular, is 
contained in the following statement, namely: That it is possible to ex- 
tinguish the greater number of epidemic diseases, however intense or abun- 
dant may be the atmospheric or other agencies which constitute their potential 
causes, by remembering,-(1.) That the living body of the diseased persons is 
the soil on which the communicable disease breeds the poison by which the 
specific disease is multiplied and propagated: (2.) That excretions from an 
infected person, especially such excretions as are immediately related to or 
flow from parts affected with specific lesions, probably contain the most active 
elements of the specific poison by which the disease may be disseminated: 
(3.) That such active elements, germs, poisons, miasms, gases, active principles 
or noxious agents, may contaminate the drinking-waters of a district, or may 
infect the atmosphere, or lie dormant for variable and unknown periods of 
time, just as seeds or ova dry up and preserve their vital properties: (4.) To 
follow out zealously'the hygienic measures which flow from these statements, 
and so prevent the propagation of specific diseases: (5.) To preserve as much 
as possible the blood of every individual in that state which shall prevent 
these poisons from finding the conditions of their development within the 
body: (6.) That these ends are to be attained on the one hand by preventing 
the production of fermentable matter in or out of the body; and on the other 
hand by promoting its removal and chemical destruction or decomposition, 
when it is inevitably generated, and by a free supply of pure air, and by the 
reduction of that air to the lowest temperature at which the condition of the 
individuals will allow it to be safely inhaled. Preventive measures based 
upon these principles are of the utmost importance,-so much so that the 
most eminent members of the medical profession in London and elsewhere 
concur iu the views and opinions of Dr. William Budd, unanimously cherish- 
ing the maxim, that, "except under the pressure of great military straits, no 
army ought ever to suffer on a large scale from this great group of communi- 
cable diseases, and especially such as are disseminated by intestinal dis- 
charges." 
The following detail of proceedings advisable to be taken in places attacked 
or threatened by epidemic diseases are given mainly from a memorandum 
drawn up by John Simon, Esq., the Medical Officer of the Privy Council, and 
published in his Third Report on the Public Health in England in 1860: 
1. Wherever there is prevalence or threatening of cholera, small-pox, diph- 
theria, typhus, or any other epidemic disease, it is of more than common im- 
portance that the powers conferred by the Nuisances Removal Acts, and by 
various other laws for the protection of the Public Health, be vigorously, but 
at the same time judiciously exercised by those in whom they are vested; and 
with regard to armies, that the instructions relative to the guidance of the 
Medical Officer in sanitary matters, contained in the Army Regulations, be 
duly carried out, on the principle that the executive should act under 
authority, in order to carry out the required measures efficiently. 
2. If the danger be considerable, it will be expedient that the local authori- 
ties in civil life, and the commanding officers of armies, brigades, divisions, 
and regiments in military life, avail themselves, as soon as possible, of the. 360 
SPECIAL PATHOLOGY EPIDEMIC DISEASES. 
medical advice within their reach, in taking measures of prevention and pro- 
tection against the spread of epidemic influences. 
3. Measures of precaution for prevention and protection are equally proper 
for all classes of society, civil and military. But it is chiefly with regard to 
the poorer civil population-therefore chiefly in the courts and alleys of 
towns, and at the laborers' cottages of country districts-that local authorities 
are called upon to exercise the utmost vigilance, and to proffer information 
and advice. Common lodging-houses, and houses which are sublet in several 
small holdings, always require particular attention. 
4. Wherever there is accumulation, stink, or soakage of house refuse or of 
other decaying animal or vegetable matter, the nuisance should as promptly 
as possible be abated, and precaution should be taken not to let it recur. 
Especially all complaints which refer to sewers and drains, or to foul ditches 
and ponding of drainage, or to neglect of scavenging, should receive immediate 
attention. The trapping of house drains and sinks, and the state of cesspools 
and middens, should be carefully seen to. In slaughter-houses, and other 
places where beasts are kept, strict cleanliness should be enforced. 
5. In order to guard against the harm which sometimes arises from disturb- 
ing heaps of offensive matter, it is often necessary to combine the use of chemi- 
cal disinfectants with such means as are taken for the removal of filth; and 
in cases where removal is for the time impossible or inexpedient, the filth 
should always be disinfected. Disinfection is likewise desirable for unpaved 
earth close to dwellings, if it be sodden with slops and filth. Generally, 
where cholera or typhoid fever is in a house or barrack, hospital or hut, the 
privies especially require to be disinfected. 
6. Sources of water supply should be carefully and efficiently examined. 
Those of them which are in any way tainted by animal or vegetable refuse- 
above all, those into which there is any leakage or filtration from sewers, 
drains, cesspools, or foul ditches-ought no longer to be drunk from. Where 
the disease is cholera, diarrhoea, or typhoid fever, it is especially essential that 
no foul water be drunk. 
7. The washing and lime-whiting of uncleanly premises (houses, huts, hos- 
pitals, barrack guard-rooms, and the like), especially of such as are densely 
or multifariously occupied, should be pressed with all practicable despatch. 
8. Overcrowding should be prevented. Especially where disease has begun, 
the sick-room should, as far as possible, be free from persons who are not of 
use or comfort to the patient. 
9. Ample ventilation should be enforced. Window-frames should be seen 
to,-(1.) That they may be made to open, if not so made; and (2.) That they 
be kept sufficiently open. Especially where any kind of specific disease, com- 
municable by infection of the air, has begun, it is essential, both for patients 
and for persons who are about them, that the sick-room and the sick-house or 
hospital be constantly and efficiently traversed by streams of fresh air. This 
is especially necessary at night, and steps should be taken to insure efficient 
ventilation even at some real or imaginary expense of comfort. 
10. The cleanest domestic habits should be enjoined. Refuse matters should 
never be suffered to remain or to linger within the dwelling, hospital, barrack- 
room, or hut. Such refuse must at once be removed, and at once disposed of, 
or cast into the receptacle provided for it. All things or utensils which have 
to be disinfected or cleansed should always be disinfected or cleansed without 
delay. 
11. With regard to material substances discharged or separated from the 
bodies of the sick, special precautions of cleanliness and disinfection are nec- 
essary. Among discharges or substances separated from the body which it 
is proper to treat as capable of communicating disease, are those which come, 
in cases of small-pox, from the affected skin ; in cases of cholera and typhoid 
fever, from the intestinal canal; in cases of diphtheria and scarlatina maligna, RULES FOR THE MANAGEMENT OF EPIDEMICS. 
361 
from the nose and throat, and the exhalations from the skin and the lungs 
saturating clothes; likewise, in cases of eruptive fevers, measles, scarlatina, 
rotheln, typhus, and the like, the general exhalations of the sick, and espe- 
cially so of the convalescing, probably in connection with the desquamation of 
the skin. The caution which is necessary with regard to such matters must 
of course extend to whatever may be imbued with them; so that bedding, 
clothing, towels, and other articles which have been in use by the sick, do not 
become sources of mischief, either in the house to which they belong, or in 
houses to which they are conveyed. Moreover, in typhoid fever and cholera, 
the evacuations should be regarded as capable of communicating a similarly 
specific and infectious property to any night-soil with which they may be 
mingled in privies, drains, or cesspools (Thiersch). This danger of multi- 
plying the sources of communicating disease must be guarded against by the 
chemical destruction, decomposition, or disinfection of all the intestinal evacua- 
tions as soon as they are passed from the bowels, and certainly before they are 
thrown away, and so " let loose upon the world." Above all, they must never 
be cast where they can run or soak into sources of drinking-water. 
12. All reasonable care should be taken not to disseminate disease by the 
unnecessary association of persons suffering from the specific communicable 
diseases, either with healthy persons, or in wards of hospitals where patients 
suffering with other diseases are being treated. This care is requisite, not 
only with regard to the sick-house, ward, hospital, or ship, but likewise with 
regard to day-schools, places of public resort, courts of justice, and other 
places where members of many different households are accustomed to meet. 
13. Where dangerous conditions of residence cannot be promptly remedied, 
it will be best that the inmates, while unattacked by disease, remove to some 
safer lodging. If disease begins in houses where the sick person cannot be 
rightly circumstanced and tended, medical advice ought to decide on the 
propriety or fitness of removing him to an infirmary or hospital. In extreme 
cases, special infirmaries may become necessary for the sick, or special houses 
of refuge for the endangered. 
14. The questions of quarantine ought to be decided by the circumstances 
of the special case, the preceding principles being kept in view. 
15. Privation, as predisposing to disease, may require special measures of 
relief. 
16. In certain cases special medical arrangements are necessary. For in- 
stance, as cholera in this country almost always begins somewhat gradually, 
in the comparatively tractable form of what is called " premonitory diarrhoea," 
it is essential that, where cholera is epidemic, arrangements should be made 
for affording medical relief without delay to persons attacked even slightly 
with looseness of the bowels. So again, where small-pox is the prevailing 
disease, it is essential that all unvaccinated persons (unless they previously 
have had small-pox) should very promptly be vaccinated ; and revaccination 
should also be offered, both to persons above puberty, who have not been vac- 
cinated since childhood, and to younger persons whose marks of vaccination 
are unsatisfactory. 
17. It is always to be desired that the people should, as far as possible, 
know what real precautions they can take against the disease which threatens 
them; what vigilance is needful with regard to its early symptoms; and 
what, if any, special arrangements have been made for giving medical assis- 
tance within the district. Especially in the case of small-pox or of cholera, 
such information ought to be spread abroad by means of printed bills or 
placards. In any case where danger is great, house to house visitation, or 
personal inspection of all by discreet and competent persons, may be of the 
utmost service, both in quieting unreasonable alarm, and in leading or assist- 
ing the less educated and the destitute parts of the population to do what is 
needful for safety. 362 
SPECIAL PATHOLOGY-EPIDEMIC DISEASES. 
18. These memoranda relate to occasions of emergency. The measures 
suggested must be regarded as of an extemporaneous kind. Permanent pro- 
visions for securing Public Health have not been in express terms insisted on. 
In proportion as a district or number of individuals, such as an army or a 
regiment, are habitually well cared for by its sanitary authorities, the more 
formidable emergencies of epidemic disease are not likely to arise. 
As addenda to these memoranda, the following rules, the observance of 
which is enjoined by the government of the London Fever Hospital, might 
well be adopted under similar circumstances in military and in civil hospitals: 
1. It is of the utmost importance to the sick and their attendants that there 
be a constant admission of fresh air into the room, and especially about the 
patient's bed, care being taken to prevent the wind from blowing directly on 
the patient. 
2. Attention to cleanliness is indispensable. The linen of the patient 
should be often changed, and the dirty clothes, &c., immediately put into 
fresh cold water, and afterwards well washed. The floor of the room must be 
cleansed every day with a mop, and all discharges from the patient immedi- 
ately removed, and the utensils washed. 
3. Nurses and attendants ought to endeavor to avoid the patient's breath 
and the vapor from the discharges. 
4. Visitors must not go near to the sick, nor remain with them longer than 
is absolutely necessary; they should not swallow their spittle, but clean the 
mouth and nostrils when they leave the room. 
5. No dependence must be placed on vinegar, camphor, or other supposed 
preventives, which, without attention to cleanliness and admission of fresh, 
air, are not only useless, but by their strong smell render it impossible to per- 
ceive when the room is filled with bad air or noxious vapors. 
Processes of Disinfection.-These processes have been recommended by the 
late Professor Miller, of King's College, London. They cannot supply the 
place of cleanliness, ventilation, and drainage. They are artificial, and are 
used for exceptional purposes, the great natural disinfectant being fresh air, 
abundantly and uninterruptedly supplied. 
1. For purposes of artificial disinfection, the agents which most commonly 
prove useful are, chloride of lime, quicklime, Condy's manganic compounds, 
and carbolic acid. Metallic salts, especially perchloride of iron, sulphate of 
iron, and chloride of zinc, are under some circumstances applicable. In 
certain cases chlorine gas or sulphurous acid gas may advantageously be 
used; and in certain other cases powdered charcoal or fresh earth. 
2. If perchloride of iron or chloride of zinc be used, the common concen- 
trated solution may be diluted with eight or ten times its bulk of water. 
Sulphate of iron or chloride of lime may be used in the preparation of a 
pound to a gallon of water, taking care that the water completely dissolves 
the sulphate of iron, or has the chloride of lime thoroughly mixed with it. 
Condy's stronger fluid (red) maybe diluted with fifty times its bulk of water; 
his weaker fluid (green) with thirty times its bulk of water. Where the 
matters requiring to be disinfected are matters having an offensive smell, the 
disinfectant should be used till the smell has entirely ceased. 
3. In the ordinary emptying of privies or cesspools, use may be made of per- 
chloride of iron, of chloride of zinc, or of sulphate of iron. But where disease 
is present, it is best to use chloride of lime or Condy's fluid. Where it is 
desirable to disinfect before throwing away the evacuations from the bowels 
of persons suffering from certain diseases, the disinfectant should be put into 
the night-stool or bed-pan when about to be used by the patient. 
4. Heaps of manure or of other filth if it be impossible or inexpedient to 
remove them, should be covered to the depth of two or three inches with a 
layer of freshly burnt vegetable charcoal in powder. Freshly burnt lime may 
be used in the same way, but is less effectual than charcoal. If neither char- PATHOLOGY OF THE ENTHETIC KIND OF SPECIFIC DISEASES. 
363 
coal nor lime be at hand, the filth should be covered with a layer, some 
inches thick, of clean dry earth. 
5. Earth near dwellings, if it has become offensive or foul by the soakage of 
decaying animal or vegetable matter, should be treated on the same plan. 
6. Drains and ditches are best treated with chloride of lime, or with Condy's 
fluid, or with perchloride of iron. A pound of good chloride of lime will 
generally well suffice to disinfect 1000 gallons of running sewage; but of 
course the quantity of disinfectant required will depend upon the amount of 
filth in the fluid to be disinfected. 
7. Linen and washing apparel, requiring to be disinfected, should, without 
delay, be set to soak in water containing, per gallon, about an ounce either of 
chloride of lime or of Condy's red fluid: the latter, as not being corrosive, is 
preferable. Or the articles in question may be plunged at once into boiling 
water, and afterwards, when at wash, be actually boiled in the washing water. 
8. Woollens, bedding, or clothing, which cannot be washed, may be dis- 
infected by exposure for two or more hours in chambers constructed for the 
purpose, and heated to a temperature of 210° to 250° Fahr. 
9. For the disinfection of interiors of houses, the ceilings and walls should 
be whitewashed with quicklime. The wood-work should be w7ell cleansed 
with soap and water, and subsequently washed with a solution of chloride of 
lime, about two ounces to the gallon. 
10. A room no longer occupied may be disinfected by sulphurous acid gas, 
or chlorine gas,-the first by burning in the room an ounce or two of flowers 
of sulphur in a pipkin; the second by setting in the room a dish containing a 
quarter of a pound of finely powdered black oxide of manganese, over which 
is poured half a pipt of muriatic acid, previously mixed with a quarter of a 
pint of water. In either case the doors, chimney, and windows of the room 
must be kept carefully closed during the process, which lasts for several hours. 
CHAPTER VII. 
PATHOLOGY OF THE ENTHETIC KIND OF SPECIFIC OR GENERAL DISEASES. 
Diseases of this kind have the common property of becoming developed 
in the system after the introduction by inoculation or implantation of specific 
poisons. The sources of such poisons are more distinctly traceable than those 
which produce the miasmatic diseases; in other words, the substance or ma- 
terial which contains the poisonous principle can be obtained in most instances, 
although the principle itself has not been isolated by any chemical process. 
The poisons which produce the diseases of this order may be introduced 
through thin or abraded cutaneous surfaces, or through mucous membranes 
by the process of absorption, although, in most instances, it is believed that 
some solution of continuity exists. Others are directly introduced by weapons 
which inflict a wound or abrasion, and which at the same time introduce the 
poison. "Poisoned wounds" thus indicate or name a disease defined as fol- 
lows : " Wounds inoculated with foreign matter, producing general symptoms, 
or propagating inflammation to other parts of the body" (see Nomenclature 
under "Poisoned Wounds"). In all instances the poison is received into the 
system by the processes of absorption, and the individual thus becomes inocu- 
lated. Thus, germs of a specific kind become directly implanted, and by a 
zymotic-like process become developed and increased in quantity or viru- 
lence till symptoms and effects are produced characteristic of the specific 
affections; and hence the name given to this order of diseases. No one has 364 
SPECIAL PATHOLOGY-INOCULATED POISONS. 
better illustrated the pathology of these diseases than Mr. Paget, from whose 
lectures On Surgical Pathology the following statement is given : 
When a morbid poison is inoculated, it produces a peculiar specific effect, 
according to its kind, both on the tissue at the place of insertion and on the 
blood, and on the nerve-centres, as soon as the poison, or any part of it, is 
absorbed; in other words, it produces both a .constitutional and a local 
change. In both these effects its history may be traced in the constancy of 
the recurring phenomena characteristic of each poison or venom. The specific 
local change is best seen in the implanting of certain animal poisons direct 
from the poison glands, such as those of venomous serpents and insects, and the 
results most rapidly follow the implantation of such poisons, or indirectly by 
squirting, the poison through the syringe ordinarily used for hypodermic 
injection. The bite of a bug, for example, is followed, within less than a 
minute, by itching in the bitten part, and very soon a wheal, or circum- 
scribed pale swelling, with a nearly level surface and a circumscribed border, 
gradually rises and extends in the skin. The swelling is produced by oedema 
of a small portion of the cutis at and round the bite. As the itching sub- 
sides, the pale swelling becomes less defined, and the more general vascular 
swelling of the surrounding and adjacent tissues gradually encroaches on the 
primary swelling at the bitten spot. In about twenty-four hours a papule or 
some form of secondary inflammation appears, with renewed itching at the 
site of the puncture. This, too, in the case of the bug-bite, gradually sub- 
sides. The primary swelling here described illustrates the immediate effects 
of the morbid poison on the tissue at and round the seat of inoculation; and 
within the area of such a swelling the tissues are, by the direct contact or 
influence of the venom, altered in their nutritive relation to the blood. Such 
specific alterations of the tissues at the seat of inoculation occur with the 
syphilitic, the vaccine, and such-like virus; but the direct influence is most 
rapidly shown in the effects of the bites of the viper, the rattlesnake, and the 
cobra di capello. In such cases sloughing of the areolar tissue is established 
immediately after the bite. The poison seems to operate at once on the tissue, 
neither in the direction of the nerves, nor of the absorbents, nor of the blood- 
vessels ; but the slough forms at the puncture, as if the venom had com- 
pletely and at once killed the tissue (Brodie, Paget). 
A secondary inflammation soon appears at the bitten or punctured part; 
and the occurrence of this new inflammation may be ascribed, in some 
measure, to an influence exercised by the virus on the blood; and it proves 
that the part does not return to health, although the first effects of the inocu- 
lation may subside. It proves that some material of the virus remains, or 
that the effects it has already produced upon the tissues at the injured part 
alter their relations to the blood, and render the part prone to specific disease. 
These specific effects upon the part may remain locally quiescent for a con- 
siderable length of time-during all that period of latency or incubation 
which intervenes between the inoculation and the appearance of the specific 
phenomena of the venom. But during all this interval-during all this 
period of incubation-the tissues at the site of inoculation are constantly 
changing; and the virus itself, like all organic matter, is probably in con- 
stant process of transformation till the zymosis is complete, and the specific dis- 
ease is fully developed and expressed by various constitutional phenomena. 
Dr. George B. Halford, Professor of Anatomy in the University of Mel- 
bourne, gave recently (Brit. M^d. Journal, July 20, 1867) an interesting 
account of the action of the poison of the cobra upon the blood. 
" When a person is mortally bitten by the cobra di capello, molecules of 
living 'germinal' matter are thrown into the blood, and speedily grow into 
cells, and as rapidly multiply, so that in a few hours millions upon millions 
are produced at the expense ... of the oxygen absorbed into the blood NATURE OF THE VENOM SECRETED BY SERPENTS. 
365 
during respiration; hence the gradual decrease and ultimate extinction of 
combustion and chemical change in every part of the body, followed by cold- 
ness, sleepiness, insensibility, slow breathing, and death. 
Fig. 67. 
Magnifying power X 1050. 
Fig. 68. 
Figs. 67, 68.-Changes in the blood-corpuscles subsequent to the bite of the cobra di capello. 
Magnifying power X 400. 
The cells which thus render in so short a time the blood unfit to support life, 
are circular, with a diameter, on the average, of j^^th of an inch. They 
contain a nearly round nucleus of 3^Tth of an inch in breadth,-which, when 
further magnified, is seen to contain other still more minute spherules of 
living ' germinal ' matter. In addition to this, the application of magenta 
reveals a minute colored spot at some part of the circumference of the cell. 
This, besides its size, distinguishes it from the white pus or lymph-corpuscle." 
From this account it is inferred that such changes take place in the blood 
when the person bitten is still alive; but in a paper read to the Medical Society 
of Victoria (a copy of which he sent to Dr. Fayrer of Calcutta), Dr. Halford 
says of these corpuscles,-"he had never seen those cells before death, but 
he believed the organic germinal matter of the serpents' poison to be the 
efficient agent, and the post-mortem changes in the blood to be in some way 
connected with a metamorphosis of the fibrin of that fluid, which, so far as 
coagulation was concerned, appeared destroyed by snake poison." As Dr. 
Halford's conclusions involve too hasty generalization, and have not been con- 
firmed by the careful observations of several other competent observers, it 
may be well to give here a summary of what has been recently determined by 
careful experiment and observation regarding the physiological action and 
pathology of specific venoms. 
Francisco Redi, from 1669 to 1675, was the first fairly to examine the 
poison or venom secreted by serpents. Charas wrote soon after him (New Ex- 
periments upon Vipers, London, 1673), setting at rest many popular fallacies, 
and preparing the way for the more elaborate work of Felix Fontana, first 
published in Lucca in 1767. Fontana made at least 3000 experiments on all 
classes of animals, with an amount of industry and scientific sagacity rarely 
equalled before or since. In the East Indies, Russell and John Davy have 
given an account of experiments with the venom of the cobra; and more 
recently (1868, to March, 1871) a most elaborate and exhaustive series of 366 
SPECIAL PATHOLOGY-SERPENT VENOM. 
experiments by Dr. Fayrer, "On the Venomous Serpents of the East Indies," 
and especially on the action of the poison of the cobra, the daboia, the bungarus 
and the ophiophagus elaps, demonstrate the nature of those specific poisons. 
Dr. Rufz has given an excellent account of the viperefer de lance of Martinique; 
and in America the toxicology of the rattlesnake and copperhead have been 
studied with all the advantages of modern research. In Australia, Professor 
George Halford has illustrated the pathology of the venom of the cobra di 
capello; and Dr. John Shortt, of Madras, has described the nature of the cobra 
poison. 
When it is considered that in the Madras Presidency of India alone the 
deaths during the four years, from 1866 to 1869 inclusive, have been 8361; 
that during the nine years, from 1860 to 1868 inclusive, the Commissioner of 
Burdwar reports to the Bengal Presidency a mortality of 9232 persons killed 
by snake-bite, out of a population of 5,701,072, it is no wonder that the sub- 
ject of snake-bite challenges attention. In the district of Midnapore, in 1865, 
there were 530 deaths, out of a population of 1,200,000 persons. In the last 
Oude Administration Report (1868-69), 1127 persons died from snake-bite 
during the year; and in the Central Provinces Administration Report, 1074 
had died from the same cause during the three preceding years. These figures, 
referring as they do to isolated districts of India, may afford some approxi- 
mate idea of the mortality arising from this cause throughout India and other 
serpent-infested countries of the East. The most deadly of the poisonous 
colubrine snakes are the Ophiophagus elaps and the Naja tripudians in the 
East Indies. Of the viperine forms, the most deadly are the Daboia Rnssellii, 
than which there is probably no more deadly viper; and of the Crotalidce, 
the most deadly in India is the Trimeresaurus; but of this family none are so 
formidable in India as are their congeners in Africa and America, such as 
the Crotalus horridus (rattlesnake), the Jararacaca, or Craspedocephalus Brazil- 
iensis, which arc much more deadly than any Crotalidce of India (Fayrer). 
The specific venom secreted in the poison-glands behind the eye and in 
front of the tympanic bones varies much in color and viscosity in the different 
snakes; but its general appearance is that of a clear, slightly viscid fluid, 
soluble in water, and slightly acid in reaction. That of the ophiophagus elaps 
is of a deep rich orange color, viscid-looking, and of the consistence of mucus. 
It manifests its deadly effects most powerfully when inoculated into the blood, 
when the snake which emits the venom is fresh and vigorous in the warm 
weather, and when it has not bitten for some time. The result of the numer- 
ous observations and experiments that have now been made tends to demon- 
strate that the poison acts through the circulation, paralyzing the nerve-centres, 
and thus destroying life. It has also been shown to be capable of absorption 
through the thin mucous membrane of the conjunctiva, though with much 
less dangerous effects than when it is introduced into the blood. 
There are certain well-marked differences in the action of the venom, 
according as it is derived from different families of snakes. Thus the poison 
of the Naja (cobra) kills without destroying the coagulability of the blood; 
whilst that of the viper-the Daboia, for example-produces perfect and per- 
manent fluidity. It would seem also that the venom of the Crotalidce-for 
example, the American rattlesnake-not only destroys the power of the blood 
to clot, and causes the blood to decompose more rapidly than blood not so 
poisoned, but it seems also able to pass through the tissues, softening and de- 
stroying the minute bloodvessels, so that they readily rupture under the con- 
tinuing force of the heart's action. Hence it is that by and by, after the 
venom of the rattlesnake has been absorbed, the altered blood begins to leak 
through the various tissues, escaping out of the vessels into the brain, lungs, 
or intestinal walls,.giving in each case specific symptoms, according to the part 
injured and the function disturbed. The following experiment may explain 
these points : " A young rabbit was made senseless and motionless with chloro- EFFECTS OF RATTLESNAKE VENOM. 
367 
form. Its abdomen was then opened, the omentum exposed, and a portion 
spread under a microscope was kept moist by an assistant, so that the circula- 
tion of the blood was distinctly seen in the healthy vessels. A drop of rattle- 
snake venom was then put upon the tissue under observation ; and for thirty 
seconds there was no change, when suddenly, a small vessel giving way, a rush 
of blood-discs obscured its view. A little way off another small vessel rup- 
tured, then a third, and a fourth, until within five minutes the whole field of 
vision was obscured by blood." The same phenomena may be seen on the 
surface of an open wound on which the venom has been placed; and that 
which happens in the wound, and in the experiment just described, goes on 
at last everywhere in the poisoned body of the bitten animal, so that in 
dozens of places vessels break down, while the blood is powerless to coagulate, 
and Nature's haemostatics fail. Such are some of the phenomena which 
attend the more chronic or prolonged cases of rattlesnake bite, as when a 
larger animal, a dog or a man, perishes after a few hours or days. Having 
lived over the first few hours of feebleness, a new set of symptoms begin. The 
blood and tissues become changed in the manner indicated by the experiments 
and observations on wounds just described. The vital fluid leaks from the kid- 
neys or the bowels, and oozes from the gums. The wounds made by the poison- 
fangs begin to bleed, and from the prick of a needle blood will drop for hoursi 
Thus exhausted, the dog or man may die, or he may slowly recover; and in 
the meantime the wounds made by the fangs of the snake have undergone a 
series of changes. A large and growing tumor first marks the site of penetra- 
tion, which, when cut into, is found to be a mass of fluid blood. By and by 
this soaks into or infiltrates every tissue in the neighborhood, and even stains 
the bones themselves. But the rapid cases of death give no time for these 
local and constitutional lesions. When death takes place within minutes or 
seconds, that may be counted by tens, sixty and ninety seconds are the most 
rapid examples of the action of snake poison Dr. Fayrer has seen-namely, 
in a half-grown fowl bitten by a daboia. He has since recorded death in a 
dog in seventy seconds ; and when the venom of a fresh cobra is injected 
directly into the jugular vein, to the amount of ten drops, with the hypodermic 
syringe, no trace or alteration can be seen in the blood or solid tissues. A 
direct power to injure the great nerve-centres which preside over locomotion, 
respiration, and the heart's action, has circulated with the rapidity of the 
blood's flow, and so caused death. Thus, a pigeon has been known to die 
under the influence of two drops of the poison of the rattlesnake injected under 
the skin. On a sudden, within sixty seconds of the insertion of the poison, the 
bird is dead, and the tissues reveal no cause of death. If half a drop only is 
used, in a few minutes after its insertion the bird staggers, and at last crouches 
down, too feeble to walk. The feebleness increases, vomiting occurs, breath- 
ing becomes labored, the head droops, a slight convulsion follows, and the 
pigeon is dead. 
In countries where such poisonous snakes abound, and cases of snake-bite 
are numerous and not fatal, it is notuncommon to find that those who survive 
may become the victims of blindness, skin disorders, and various forms of 
palsy. The absolute danger to life is directly as the amount of venom effi- 
ciently inserted into the vascular textures. 
Analyzing the symptoms of rattlesnake poison, the first effects of the venom 
are a dangerous depression of all the functions, exactly like what follows an 
overdose of tartar emetic; and the obvious treatment is to stimulate the man 
or animal bitten. But no stimulant will destroy the venom in the sense of an 
antidote : it only antagonizes its activity. Nearly all the most reputed anti- 
dotes and stimulants have been made the subject of experiment by Dr. Fayrer 
in India regarding Indian snake poison, and by others in America regarding 
the rattlesnake, by mixing the venom with the antidote or stimulant, and 
injecting both, either together or following up the antidote immediately after 368 
SPECIAL PATHOLOGY-SERPENT VENOM. 
the poison, without withdrawing the nozzle of the syringe, so that the antidote 
went immediately after, and in the same channels as the poison ; yet the sub- 
jects of all the experiments died, just as if no antidote had been administered 
(Atlantic Monthly and All the Year Round, March 28,1868, p. 372). Thus the 
poison of all snakes may be diluted with water, or ammonia, or alcohol, with- 
out destroying its deadly properties. It may be kept for months or years, dried 
between slips of glass (just as vaccine virus is kept on points or between glass, 
or as small-pox matter was wont to be kept), and still it retains its virulence. 
The Prince of Cassino, Lucien Bonaparte, wrote a short chemical paper on 
the subject of snake poison in 1843, and gave an analysis of the venom of the 
vipera (Pelias) Cerus (the adder), and pointed out the presence of a principle 
representing the ptyaline of saliva. This he called viperine. He also found 
albumen and mucous fatty matter, substances soluble in alcohol, yellow color- 
ing matter, and saline matters. But the elementary analysis of viperine has 
yet to be made. All that is really known regarding it is, that it is a very 
unstable substance, of neutral reaction, and that it kills through its influence 
on the nerve-centres (Fayrer in series of papers in Edinburgh Monthly Medi- 
cal Journal, 1868, 1869, and 1870). The terms echidine, crotaline, have been 
given to similar active principles derived from the venom of other snakes, and 
which are probably identical. 
The poison acts most rapidly on birds and mammals; less so on cold-blooded 
animals; but fishes, frogs, molluscs, and non-venomous snakes are destroyed 
by it, and often die very rapidly from its effects. Poisonous snakes seem to 
be insensible to their own venom or to the venom of others; but Dr. Fayrer 
believes that the poison of the more virulent snakes takes effect on snakes 
of a less deadly character; for example, the poison of the cobra or daboia 
will kill the bungarus. The non-venomous snakes die rapidly ; for example, 
the ptyas, a large, vigorous, and fierce snake, but non-venomous, succumbs 
within an hour or so to the bite of a cobra. 
The flesh of an animal dead from snake poison does not seem to be rendered 
unfit to eat. Animals and man may eat it with impunity. So may they also 
eat or swallow7 the venom. Pigeons have been fed with rattlesnake poison, 
day after day, in doses sufficient to have killed forty, had the venom been 
injected under the skin. When the excreta has been collected, and the con- 
tents of the intestines removed, after killing birds so fed, and after using the 
chemical means which would separate any venom existing, and using the fluid 
thus obtained to inject other pigeons, no injury follows,-showing that the 
poison by which the pigeon was fed has disappeared. It has been altered and 
rendered harmless by the process of digestion. 
On the other hand, the blood of an animal killed by snake poison is itself 
poisonous; and if injected into an animal, rapidly manifests its poisonous 
effects. Dr. Fayrer has thus transmitted the poisoned blood through a series of 
three animals with fatal effect. [Query: " Does it multiply its virulent proper- 
ties in the blood?"] " What," says Dr. Fayrer, " can more forcibly illustrate 
the extraordinary virulence and potency of the venom of the cobra than this 
experiment ? A few drops of the blood of a dog, poisoned by a cobra, diluted 
with water, and injected into a fowl's thigh, killed the bird in scarcely five 
minutes. Thus diluted and mixed with blood, the quantity must have been 
excessively minute." Dr. Fayrer has had no opportunity of studying the 
local effects of the poison, for death has always occurred so rapidly that there 
has been no time for secondary or local changes. With regard to the cobra 
venom, Dr. J. Ewart notes, in the case of a dog bitten by a full-grown spec- 
tacled cobra, when death took place in thirty-two minutes after the bite, there 
was "evidence that it took place through the nerve-centres, the heart continu- 
ing to beat after the respiration entirely ceases,-which can only be through 
its own inherent irritability and its own ganglionic supply, and quite inde- 
pendent of the medulla, which in all other respects was hors de combat from ACTION OF SERPENT VENOM. 
369 
three to four minutes before the heart actually ceased to pulsate." This im- 
pression on the nerve-centres is doubtless made through the medium of the 
circulation of the blood, and is not due to any organic changes in the germi- 
nal matter or cellular structures of the blood; but the change in the blood 
seems to be of a much more subtle character than can be detected by the 
microscope-not dependent on any structural change which can be seen by 
the very highest magnifying powers. Such is the experience of Dr. Fayrer, 
Professor of Surgery, Dr. Ewart, Professor of Physiology, Drs. Macnamara 
and Douglas Cunningham, and Mr. Sceva, of the Indian Museum, in oppo- 
sition to the statements of Professor Halford regarding the venom of the 
cobra effecting blood changes, which have been described at pp. 364, 365. 
When death is three or four hours after the bite of a cobra, the whole ve- 
nous system is distended with blood; but sections of the brain, through the 
central ganglia, are pallid in the extreme; and scarcely a vascular point is to 
be seen. Locally, a coagulum marks the entry of the fang, and surrounds 
the ecchymosis parts; the tissues, also, are discolored, from rapid local death 
of the parts, and commencing decomposition. Blood coagulates, with a firm 
coagulum in all the veins, within an hour after being opened; but, microscop- 
ically, the blood was not unnatural. Such were the appearances seen in a 
pig-an animal not so susceptible as a dog to the poison-the former dying 
in three hours, and the latter in less than half an hour after similar doses of 
the venom. In another instance, that of a mare, ante and post mortem, firm 
coagula exist in the heart and large vessels as well as in the veins,-death 
occurred in less than an hour and a half (eighty minutes). 
The venom of the cobra is slightly viscid, and a somewhat opalescent fluid, 
clear when pressed out of the poison-gland, but becoming slightly turbid 
afterwards, and with a slightly acid reaction. 
With regard to the venom of the Daboia Russellii (the large viper of India), 
it seems as if anaesthesia was the first effect produced on the bitten limb and 
part. In a dog which had obviously got very little venom, and where death 
was slow (eight hours after bite) and painless, a gentle lethargy seemed to 
steal over the animal, which gradually increased till death. There was no 
sign of pain-no convulsions but just before death, defecation was of a 
muco-sanguinolent character. Ecchymosis surrounds the wounds, and dis- 
coloration by dark bloody fluid, with coagula, corresponding to the points 
where the fangs have pierced. Blood, watched for fourteen hours after death, 
did not coagulate, but remained fluid ; but under the microscope presented no 
change from the normal condition. In another case, that of a large powerful 
dog (experiment No. 9), where death took place nearly three hours after the 
bite, the venom caused profuse mucous discharge from the stomach, and blood 
and mucus from the bowels. The blood, on examination after death, showed 
the corpuscles shrivelled and collapsed, but not otherwise changed. In other 
instances there was no tendency of corpuscles to run together. The blood 
appeared to be dead-to be in a state of necrsemia {Edinburgh Monthly Med- 
ical Journal, May, 1869, p. 1001). 
Convulsions do not occur when death is slow and the dose of venom small 
in amount; but they form a marked feature in rapid cases where, the daboia 
being vigorous, the venom is abundantly distilled from the fangs into the 
wound. In the case of a horse bitten by a daboia, death was slow, and life 
seemed to be dozed away until just at the last, when a few unconscious plunges 
terminated existence. The cardia cavities were empty of blood; blood gene- 
rally fluid, while the lungs and other viscera were congested. The first effect 
of the daboia venom on the nervous system is much more violent than that of 
the cobra. Paralysis follows more quickly, but actual death is longer-con- 
sciousness being annihilated early. 
With regard to the venom of the bungarus, it is neither so deadly nor so 
active as the cobra. Blood flowing from the wound is thin and watery. The 370 
SPECIAL PATHOLOGY SERPENT VENOM. 
bitten part is discolored, and when pressed, gas escapes in bubbles, evidence 
of decomposition setting in rapidly. In a dog that died in three hours and 
forty minutes after being bitten, and the body of which was opened an hour 
after death, the blood looked dark and grumous, and was imperfectly coagu- 
lated the following day. Microscopically, it was examined by Dr. Douglas 
Cunningham, and exhibited characters quite different from specimens (of cobra 
and daboia victims) which Dr. Cunningham had before examined. The re- 
action was faintly but permanently acid. The red corpuscles were in irregular 
masses, and had lost all distinctness of outline, and become, as it were, semi- 
fused. The coloring matter had dissolved out, dyeing the serum and white 
corpuscles brownish. The white corpuscles were in some places in large masses, 
visible to the naked eye; and the most remarkable thing about them was 
their extensive distension. Dr. Cunningham adds, that it would be interesting 
to know if the reaction was acid immediately after death. In some other 
cases of bungarus bites of dogs, the blood passed into a state of excessive crys- 
tallization of a needle-like and long tubular form. 
With regard to Antidotes, it is a well-known saying, that " diseases for 
which there are numerous remedies are either very mild or very fatal." Dr. 
Fayrer bases his opinion on sound pathological experience when he says, " I 
am skeptical on the subject of antidotes, and fear that the hopes of those who 
are most sanguine on the subject will not be realized." It appears to be im- 
possible to overtake the venom and neutralize it when once in the circulation, 
however rapid may be the inoculation of the supposed antidote. Dr. Fayrer's 
well-devised experiments clearly demonstrate this. He does not deny that a 
man, or an animal, when poisoned by snake venom, may be benefited by the 
use of stimulants; but such is very different from any such stimulants being 
an antidote in the sense of neutralizing the poison. Nothing can demonstrate 
more strongly the extremely subtle and virulent nature of the cobra venom 
than some of Dr. Fayrer's experiments; such, for example, as when a full- 
grown dog bitten in the fore-arm a ligature was instantaneously tightened 
round the limb above the bitten part, and a pointed steel, heated to a red heat, 
inserted into the bitten wounds within one minute after the bite, and thus 
thoroughly cauterizing them. Ammonia was also at once injected into the 
venous circulation, yet in forty-three minutes the dog was dead. "Nothing," 
writes Dr. Fayrer of such experiments, " is more significant of the improba- 
bility of anything proving to be an antidote. If the poison finds entry into 
the bloodvessels, and be carried to the nerve-centres, I am inclined to believe 
that nothing can prove of any avail, excepting in those cases where the bite 
is imperfect, the quantity or quality of the poison diminished or deteriorated, 
or the snake itself is young, weak, exhausted, or is one of less poisonous family ; 
such I believe are the only cases in which recovery occurs through the inherent 
vigor of the animal or person bitten, perhaps aided by stimulants and excite- 
ment. The favorable result is attributed, and naturally enough, by those who 
do not understand the modus Icedendi of the venom, to the treatment and so- 
called antidote. That we can aid in such recoveries, and that we may do 
much to help the sufferer through the troubles arising from general disorder 
and secondary blood-poisoning, I have no doubt; and I would offer every en- 
couragement to all to persevere in this attempt; but I must state my convic- 
tion, that nothing that can properly be called an antidote to cobra or viper 
venom exists ; and the more this is known the better; for mistaken notions on 
such an important matter can only do harm, and may be the cause of losing, 
rather than of saving life. 
" My belief is, that if an animal, and probably a man, be fairly bitten by 
a fresh and vigorous cobra or daboia, it or he will inevitably succumb, unless 
some immediate and direct method of averting the entry of the poison into the 
circulation be practiced. 
" That such may be done, I will not deny; but the experiments recorded, SPECIFIC DISEASE-POISONS DIFFER FROM VENOM. 
371 
performed with the greatest care and speed by two surgeons accustomed to 
such operations, show that, at the least, it is very difficult. The moment of 
time that intervenes between the injection of the snake poison by the powerful 
maxillary muscles, through the tube-like fang into the minute bloodvessels of 
the part, and the application of the ligature and actual cautery, is sufficient 
to allow of the entry of the poison into the circulation, and thus reaching the 
nerve-centres, even in a small quantity, may prove fatal. The ligature is evi- 
dently very unreliable when applied to large parts of the body, such as the 
limbs ; for it is almost physically impossible to compress the part so tightly 
as to stop the circulation ; and unless this be done to the depth of the pene- 
tration of the snake's fangs, it is obvious that it can only be of very partial 
effect in preventing the entry of the poison. On a finger or a toe, the ligature 
might be of more service, as the smaller part might be thoroughly strangula- 
ted ; but unless the ligature were applied immediately, it is obvious that it 
would be useless even there, for the poison would have already entered, and 
be on its course towards the nerve-centres. How quickly this occurs is proved 
by those experiments in which the poison was injected directly into the jugu- 
lar vein. What took place there with the hypodermic needle inserted into 
the jugular vein has its exact counterpart in the case of the cobra's fang in- 
serted, as it must be, when it penetrates a vascular part into the minute veins. 
The same may be said of the actual cautery. Unless the hot iron enter the 
puncture directly after the fang has been withdrawn, the poison is already far 
on its way towards the nerve-centres ; and the burning, though it destroys the 
tissues, and such of the poison as may not have entered the circulation, can 
have no influence on that which is already beyond its reach. But as the liga- 
ture, if tightly and quickly applied, and the actual cautery, if promptly and 
thoroughly inserted, must limit to a certain extent the entrance of the poison, 
both should be had recourse to as speedily and efficaciously as possible, in the 
hope that the amount of poison left to find, or that may have already found 
its way into the system, may be less than sufficient to cause death. 
" To conceive of an antidote, in the true sense of the term, to snake poison, 
one must imagine a substance so subtle as to follow, overtake, and neutralize 
the venom in the blood, or that shall have the power of counteracting and 
neutralizing the deadly influence it has exerted on the vital forces. Such a 
substance has still to be found ; and our present experience of the action of 
drugs does not lead to hopeful anticipations that we shall find it. 
" But I repeat, that where the poisonous effects are produced in a minor 
degree, or when the secondary consequences are to be dealt with, we may do 
much to aid the natural forces in bringing about recovery. This is not, how- 
ever, what is meant by an antidote " (Fayrer, Ed. Med. Jour., March, 1870, 
pp. 818-820). 
The changes which the absorbed virus of specific diseases undergoes in the 
living and infected body are,-(1.) Increase; (2.) Transformation ; (3.) Com- 
bination ; and (4.) Separation or excretion. Thus they differ from venoms in 
these physiological respects. 
The increase of the virus is shown in such inoculable diseases as vaccinia, 
glanders, malignant pustule, syphilis. In all of these diseases the inoculation 
of the minutest portion of virus is followed by the formation of one or more 
vesicular structures, containing fluid from which virus, similarly and equally 
potent, is produced in million-fold quantity. Thus the virus of any contagious 
disease developed in an infected person may render his exhalations capable 
of similarly affecting thousands of other people. And it is probably among 
azotized materials chiefly that morbid poisons, whether of animal origin or 
of disease, find the means of their increase (Carpenter, Paget, Simon). 
The transformation of the virus is indicated by the successive phenomena 
which supervene during the continuous course of a specific disease. For exam- 
ple, syphilis is followed by a series of secondary and tertiary phenomena, 372 
SPECIAL PATHOLOGY-SPECIFIC DISEASE-POISONS. 
which follow, on the whole, a uniform course in a great variety of patients; so 
that these regular syphilitic phenomena may be attributed to the transforma- 
tions of the morbid poison ; while the irregularities of the phenomena may be 
ascribed to constitutional peculiarities of the patient, either natural or acquired 
from treatment. Thus there are periods of incubation, of development, of 
maturity, and of degeneration in the material of the virus; and the various 
phenomena which constitute the symptoms and prodromata of the disease cor- 
respond to such periods of transformation ; while the increasing disturbance 
of the general health probably implies that the morbid poison is increasing 
while it is being transformed-that it grows or multiplies with its devel- 
opment. 
The combination of a morbid poison with some normal material of the blood 
is indicated by the circumstance, that when the same specific disease, produced 
by the inoculation of the same matter, affects many persons, the disease set up 
in each of them may present different peculiar features. The disease may have 
some peculiar and varied methods of expressing its development in different 
persons-"personal peculiarities," as Mr. Paget calls them, and which he con- 
siders due in some measure to the combination of the virus with one or more 
of those normal materials of the blood which have in each person a peculiar 
or personal character. By such combinations the following characters of 
specific diseases may be explained, namely: (1.) Changes in the disease, by 
transmission from one person to another; (2.) Some varieties of syphilitic 
sores, and varieties of their consequences in different persons inoculated from 
the same source; (3.) The change in the forms of secondary syphilis in trans- 
mission from parent to offspring. 
The separation or excretion of the virus may be accomplished in many dif- 
ferent ways, and may be regarded as the final purpose of the morbid process, 
or the continuance of illness or disease. It is evident in the inoculable prod- 
ucts of some vesicles and pustules. 
In all of these enthetic disease-poisons, the immediate or the ultimate effect 
of the poison is to induce deterioration of the blood, and at the same time the 
poison seems to multiply itself or to increase in power by some mode not quite 
well understood, and which has been likened to the zymotic action which is 
known to take place in fermentation. The process by which the poison is 
multiplied, or by which its virulence or strength is increased, varies much as 
to the time required for its completion. 
Some of the more intense and virulent poisons, such as that of the most ven- 
omous serpents, produce their deleterious and perhaps fatal effects in as short 
a time as it takes the blood to complete a circulation. The change in the 
blood at once commences, although incapable of recognition microscopically, 
and death rapidly follows. This sometimes happens with some forms of the 
cadaveric poison, as that which results from wounds received in the dissection 
of virulent cases of puerperal fever. 
Other poisons do not exert their pernicious influence till after a tardy pro- 
cess of incubation, the time of which is not constant, as in hydrophobia. 
In a third class of disease-poisons, a double process of the zymotic-like action 
seems to take place before the full effects which the poison is capable of pro- 
ducing are completed. The syphilitic poison is an example of this. The mul- 
tiplication of this venereal poison, and its effects upon the system, seem to 
become developed during the existence of the hardening process which sur- 
rounds the infecting venereal sore. 
This is the first zymotic-like process, and is attended with a local papule, 
and perhaps an ulcer. From this local sore the system becomes contam- 
inated ; and in the blood a second process (of zymosis?) appears to be com- 
pleted, by which the original poison becomes intensified, its pernicious influ- 
ence more complete, and its specific secondary and tertiary effects are then 
fully developed. NATURE OF CONSTITUTIONAL DISEASES. 
373 
Many of the diseases implanted by specific poisons claim the attention rather 
of the surgeon than the physician, and therefore they may be considered as 
not properly coming within the scope of this Text-book of Medicine. But for 
the sake of the pathological doctrines they illustrate, also because of the impor- 
tance of their effects upon the system, and in relation to other diseases, some 
of them will be considered here. 
Under the head of " Poisoned Wounds," the following varieties are compre- 
hended, namely: (a.) By venomous animals, comprehending snakes, scorpions, 
and stinging insects; (b.) By animals having infectious or communicable 
disease, comprehending glanders, farcy, equinia mitis, malignant pustule, hydro- 
phobia, cow-pox; (c.) By dead animal matter ; (d.) By morbid secretions ; (e.) 
By vegetable substances, comprehending arrows poisoned by wourali and sub- 
cutaneous injections of vegetable substances; (f.) By mineral substances. 
CHAPTER VIII. 
ON THE NATURE OF THE GENERAL DISEASES OF A SPECIFIC OR MIASMATIC 
KIND COMPREHENDED IN SECTION B. 
While the General diseases in section A, which have been classed, 
become developed in the human body under the direct influence of agents 
acting from without, the, Constitutional diseases which section B includes 
may be said, by contrast, to become developed under the influence of agents 
generated within the body itself, and acting through the continuous exercise 
of its functions. The original organization of the human body may be of 
such a kind that the continued and prolonged exercise of its functions, in 
place of preserving the system in a healthy state, ultimately brings about dis- 
eases of various kinds in the daily course of development and growth, which 
(from this mode of origin and development) have received the name of Con- 
stitutional Diseases. All of them are eventually attended with more or 
less local manifestations of disease, some of so fixed a character, and so 
strongly expressed, that the local lesions which may prevail are sometimes 
looked upon (although erroneously) as constituting distinct diseases; such, 
for instance, as the joint or heart affection in rheumatis^n, or the bone affection 
in rickets. 
The local manifestations of those diseases which belong to the constitutional 
class are invariably the expression and result of a pre-existing unhealthy state 
of the system, without which no outward, extraneous, or accidental condition 
could call them into existence; although such conditions might determine (as 
a stimulus would) the local development, external manifestation, or expres- 
sion of the constitutional disease. 
The Constitutional Diseases are, therefore, all associated with what is 
termed a cachectic state (cachexia), or, in common language, "a bad habit of 
body." They are sporadic diseases, and are sometimes discovered to be 
hereditary. The lesions which attend them are observed to be rarely limited 
to one part or organ; and, before death ensues, several organs, tissues, or 
apparatus, not necessarily contiguous to each other, become diseased, and new 
materials of a heterologous nature may grow up in their substance. 
In the local lesions are to be found those elements which mark the "ana- 
tomical characters" or "anatomical signs" of the several constitutional 
diseases. 
We do not yet know why one organ or texture should be either earlier or 
more constantly affected than another. It cannot be explained why tubercle 374 
SPECIAL PATHOLOGY-CONSTITUTIONAL DISEASES. 
selects at one time the bronchial glands for its main nidus, and the lungs at 
another; nor why cancer infests by preference the mamma and the uterus; nor 
why rheumatism affects the white fibrous tissues; nor why rickets affects the 
bones. The predilections of constitutional diseases to express themselves 
through lesions of certain organs rather than others are still unexplained. 
The course of constitutional diseases is generally a prolonged one; the ten- 
dency to repeated attacks or paroxysms of morbid action exists throughout 
life; and the local expressions of disease may ultimately assume a persistent 
or chronic type, complicated with and complicating diseases of another kind, 
and mutually overlaying or aggravating each other. 
The primary implication of the constitution is, in the greater number of 
cases, sometimes demonstrable; but sometimes it can be stated only as a 
matter of fair induction that the constitution is affected through the blood 
and the relation of the nutritive processes to it. Pyrexia, when present, is 
secondary, and generally dependent on the irritation produced by the effort 
to eliminate some morbid material. The reabsorption of the elements of this 
morbid material, or a persistence of its existence in the blood, tends to affect 
the blood secondarily; and this secondary blood affection tends to produce 
secondary changes in the solids. Thus the blood changes, and the changes 
in the solids continue to act and react on each other. Thus, also, the consti- 
tutional diseases are not traceable to the extrinsic action of a virus, and have 
none of the properties attached to infection. The constitutional diseases are 
thus apparently generated, developed, and sustained under the influence of an 
intrinsic blood poison, the result of perversion of the nutritive or assimilative 
functions of the individual, and are frequently determined by congenital con- 
stitution or hereditary tendency. "It seems strongly probable," writes Dr. 
Walshe, "that each member of the group has its specific morbid principle in 
the blood, uninterchangeable with the rest, just as any one virus is uninter- 
changeable with others; and that, further, there may exist for each constitu- 
tional disease its specific curative agent-an antidote for each poison. In the 
greater number of these diseases a more or less obvious disposition may be 
traced to symmetrical arrangement of the anatomical characters of the local 
lesions, whether these be external or internal." 
External physiognomical differences may generally be recognized as dis- 
tinguishing one man from another, and due to the peculiarities of his own 
constitution-"personal peculiarities." These are due to what have been 
called "temperament," combined with that character of the constitution which 
tends to the repeated expression of some form of ill-health, always in the same 
way, and to which the name of diathesis has been given. Such external dif- 
ferences between man and man-such personal peculiarities-are known to be 
transmitted from parent to child, and are then said to be due to hereditary 
transmission. The tendency to the expression of certain forms«of disease being 
thus born with such children, is said to be due to hereditary predisposition, 
and this tendency may be strong and evident, or it may be but feebly and 
faintly marked. In the former instance it will become expressed in the midst 
of circumstances even the most favorable to health. Another remarkable 
feature in the pathology of constitutional diseases requires special notice- 
namely, that the transmission of the hereditary tendency may fail to be ex- 
pressed in the children of a family liable to diseases known to be so trans- 
mitted, and yet the tendency may appear in the grandchildren. The tendency 
is thus expressed in alternate generations-the law of " atavism," as it has been 
called. The tendency, thus failing to appear in one generation, may lie dor- 
mant, and at last burst forth "in some collateral branch of the family tree;" 
thus proving that tendencies not obviously expressed by the parent may never- 
theless be transmitted by him. A person therefore cannot be considered free 
from the inheritance of constitutional maladies simply because his parents BLOOD DISEASES AND CONSTITUTIONAL DISEASES. 
375 
may not have suffered from any of them: and now it is admitted that, under 
at least three generations, the investigation of hereditary tendency is uncertain. 
When one only of the parents is the victim of constitutional disease, the 
tendency to similar constitutional disease is most obviously expressed in those 
children who most resemble that parent in physical conformation and appear- 
ance ; and it has been observed that, when both parents suffer, the tendency 
will sometimes be expressed more often in the daughters of the family than 
in the sons, or more often in the sons than in the daughters. 
It is especially to be noticed that a marked distinction ought to be made 
between those which are described as " Constitutional Diseases " and 
those which are sometimes called " Blood Diseases." The specific mala- 
rious diseases may emphatically be termed "blood diseases''-diseases in 
which a poison from without affects the blood and establishes a specific disease 
like small-pox; but the constitutional diseases are " blood diseases and something 
more." They not only exhibit an aptitude, possessed by those who suffer from 
them, to assume peculiar forms of morbid action, but their existence stamps 
upon every other morbid state with which they may be combined a most 
untoward effect. Exudations no longer proceed to healthy resolution. A 
chill, which otherwise in a healthy man would do no harm, is followed by 
rheumatic pains and swollen joints in one whose constitution tends to rheu- 
matism, which is an example of a constitutional disease; or the growth of 
tubercle may commence in the lungs of one whose constitution is tuberculous. 
A bruise is followed by inflammation and an unhealthy suppuration, which 
has been termed scrofulous, in those who are stamped with the diathesis of 
such a constitutional disease; while the influence of a constitution disposed 
to attacks of gout or rheumatism is very unfavorable for recovery from 
wounds, injuries, and other severe diseases. On the other hand, it is to be 
remembered that local inflammations depending on a constitutional cause are 
sometimes remarkably fugitive and transient. So much is this the case that 
an idiopathic inflammation, such as a pneumonia or bronchitis, lasts, as we 
know, for several days; but it occasionally happens that local affections 
having all the characters of inflammation will be suddenly established in 
persons laboring under constitutional diathesis or cachexias, and these inflam- 
matory affections will run their course and terminate in as many hours as the 
others may take days-may appear at first even more formidable-but the 
very fact that they occur in a person suffering from rheumatism or gout 
enables one to give a more favorable prognosis of the immediate result than 
would perhaps be warrantable in the case of a person otherwise healthy. 
This may appear paradoxical; but it is known as a matter of experience that 
when visceral inflammations appear in the train of rheumatism, for example, 
they run a materially more favorable course, as a general rule, than if gene- 
rated under some other influence (Graves, Walshe). This fact it is neces- 
sary to bear in mind during the examination of all cases of constitutional 
diseases, for it may help to explain many apparent anomalies amongst the 
diseases of this class. 
Dr. Walshe has specially called attention to the very complex and dan- 
gerous forms of disease which result when miasmatic and enthetic diseases 
(or, as he terms them, acute specific diseases) are complicated with the dia- 
thesis of constitutional diseases. He shows, further, that constitutional dis- 
eases and miasmatic diseases, when they coexist, exercise an unfavorable 
reciprocal influence upon each other (Med. Times, 1855). 
The reader will therefore be pleased to observe and remember that the 
term "Constitutional," applied to disease, as used in this Text-book, is not 
synonymous with General or Extensive, as used by some writers. 376 
SPECIAL PATHOLOGY SMALL-POX. 
CHAPTER IX. 
DETAILED DESCRIPTION OF THE GENERAL DISEASES 
Section A. 
SMALL-POX. 
Latin Eq., Variola; French Eq., Variole; German Eq., Blattern-Syn., Menschen- 
pocken; Italian Eq., Vajuolo. 
Definition Small-pox in man is the product of a specific and palpable morbid 
poison, which is reproduced and multiplied during the course of the malady. It 
is contained in the contents of the pustules and in the cutaneous and pulmonary 
excreta of small-pox patients. After a definite period of incubation (of about 
nine days, in cases of inoculated, and twelve to thirteen days by ordinary 
infection) a remittent fever is established, and followed by an eruption on the 
skin, and sometimes on the mucous surfaces, with other concomitant and occasion- 
ally succeeding affections. The eruption on the skin passes through the stages of 
papule, vesicle, pustule, scab, and leaves marks or cicatrices on its site. The dis- 
ease runs a definite course, and, as a rule, exhausts the susceptibility of the con- 
stitution to another attack. 
Pathology.-The theory regarding the development of small-pox is, that 
a specific poison is absorbed and infects the blood, and after a given period of 
latency gives rise to "primary fever," which lasts from two to four days, till 
the eruption appears, when the fever for the most part remits. The secondary 
or specific action of the poison of small-pox makes itself obvious by an erup- 
tion on the skin, and also sometimes on the mucous membrane of the eyes, 
nose, mouth, fauces, and great intestine. The eruption runs a certain defined 
course-namely, first a papule, then a vesicle, and finally a pustule-and when 
fully out, or at its height, the febrile phenomena, which had remitted, return, 
and give rise to what is termed the secondary fever. The occasionally suc- 
ceeding morbid conditions are inflammation of the various tissues of the lungs, 
of the urinary organs, and, lastly, of the areolar tissue of the body generally, 
which may become the seat of an endless number of abscesses. 
The occurrence of fever preceding the secondary or specific action of the 
poison, or the appearance of the eruption, has scarcely an exception; and, 
indeed, in some instances it has been of so severe a character as to have de- 
stroyed the patient on the first onset. The remission or subsidence of the 
fever is constant in mild cases, but in the severer forms of confluent small-pox 
it sometimes runs on, and is constant. The recurrence of the "secondary 
fever," and the exacerbation of the fever in severe cases at the time of the 
maturation of the pock, is also constant. The cause of this secondary attack 
has long been a difficulty in the pathology of small-pox. Some attribute the 
fever to the specific nature of the disease, while others consider it to result 
from the maturation of the pustules, and to be a suppurative fever-symp- 
tomatic, and dependent upon the local affection. 
Another constant phenomenon in the development of small-pox is, that the 
secondary actions of the poison occasion a peculiar eruption. There are a few 
rare exceptions, which constitute a variety of small-pox sometimes noticed as 
the "variolce sine eruptione." But the cutaneous eruption is a necessary part 
of the disease; its absence is an exception to the rule, and is generally of evil 
omen. The affection of the mucous membranes is often wanting in mild cases, 
though rarely absent in severe ones. The poison is also apt to set up many 
other lesions, such as inflammation of the lungs, of the urinary organs,' of the 
eye, and of the areolar tissue. Generally it may be mentioned that the state pathology and morbid anatomy of small-pox. 
377 
and appearance of the eruption depend in a great measure upon the type and 
character of the fever, while the type and character of the fever may be modi- 
fied by the organic functions and condition of the blood, especially as induced 
by vaccination. 
Morbid Anatomy.-The development of small-pox is traceable through cer- 
tain stages to be afterwards described; but as the eruption, or formation of 
the small-pox pustule, is undoubtedly a marked characteristic of the disease, 
it requires particular description first. It has certain definite stages in its 
development. It runs a given course of about eleven days, and in its progress 
undergoes many mutations. It is at first a papule, then a vesicle, then a 
pustule, and lastly it forms the scab or crust. These various changes form so 
many stadia of unequal duration. The first, or stage of papule, lasts from 
twenty-four to forty-eight hours; the second, or vesicular stage, four days; 
the pustular stage, three days; while the last stage, or that of scabbing, lasts 
three days more, making the whole duration of the normal pustule ten or 
eleven days. There are varieties, however, of this disease, in which the 
formation of the pustule is irregular, as in the confluent and horn small-pox. 
In the latter the two last stages are singularly shortened, or absent altogether. 
When the eruption in small-pox is of the "distinct variety" (Syn., "dis- 
crete"), its first appearance consists of a number of small red papules, about 
the size of a pin's head, more or less numerous, but separate and distinct from 
one another, and scarcely salient. They commence with a circumscribed 
hypersemia of the true skin (variolous dermatitis), extending into the subcuta- 
neous tissue. The cells of the rete Malpighii swell up, the papillae elongate, and 
the red spot of skin becomes a sharply-defined nodule, perfectly solid, and 
having a flattened top (Niemeyer). On the second or third day of the 
eruption the second stage towards the development of pustules commences. 
A small vesicle, which gradually enlarges, bound down and depressed in the 
centre, or umbilicated, forms on the apex of each pimple, by elevation of the 
outer layer of the epidermis, and contains a clear whey-colored fluid. This 
vesicular stage lasts about four days, when the vesicle maturates or "ripens" 
into a pustule. This process is so gradual, that, if you examine the pustule 
closely about the fifth or sixth day, you may see, at least in many, two colors, 
viz., a central whitish disc of lymph, set in, or surrounded by, a circle of yel- 
lowish, puriform matter. "In truth, there is in the centre a vesicle, which is 
distinct from the pus, so that you may puncture the vesicular portion, and 
empty its contents, without letting out any of the pus; or you may puncture 
the part containing the pus, and let that out without evacuating the contents 
of the vesicle. The vesicles have even, by careful dissection, been taken out 
entire" (Watson). The pus cells form from the young cells of thereto Mal- 
pighii. The adherence of the altered cuticle to the cutis at some points, and 
its separation at others, produces the little compartments or dissepiments 
spoken of by some writers. These cavities are usually irregular in shape; 
and all who have examined these multilocular cavities agree in describing 
the existence of a white substance in them, of the consistence of pulp or thick 
mucus, and which at first was supposed to be the specific exudation of small- 
pox. It is now ascertained that it is no pseudo-membrane, but is composed 
of the deeper and softened layers of the epidermis. This " disc " of softened 
epidermis covers the interior of the pustule, and extends from the centre to 
the raised circumference of the pustule in diverging rays, forming part of six 
or eight fan-like chambers of nearly equal size. In the structure of this disc 
the following elements are distinguishable from without inwards,-(1.) Large 
flat cells; (2.) Large cells not so flat, but more globular, with nuclei; (3.) 
Nearest the cutis are the cells and tissue of the rete mucosum (Gruby, Gluge, 
Layer, Gustav Simon, besides other observers of more early date). Will 
not some delicate process of organic analysis tell us what the active principle 
of the specific virus of small-pox is,-if it be capable of being so determined ? 378 
SPECIAL PATHOLOGY - SMALL-POX. 
The poison is believed to be most active just at the period when the clear 
contents of the vesicles begin to turn cloudy. While the maturation of the 
vesicle into a pustule is going on, a damask red areola forms round each pus- 
tule ; and as the vesicle fills, the whole face swells, and often to so great a 
degree that the eyelids are closed. While the maturation is complete, the 
"bride," which bound down the centre of the vesicle, ruptures, and the pus- 
tule now becomes spheroidal or acuminated. About the eighth day of the 
eruption a dark spot is seen on the top of each pustule. At that spot the 
cuticle ruptures, allowing matter to exude, which concretes into a scab or 
crust; and during this process the pustule shrivels and dries up. The crust 
is detached between the eleventh and fourteenth days, leaving the cutis be- 
neath of a dark reddish-brown hue-a discoloration which lasts many days, 
or even weeks. On the face, however, the pustule often penetrates or bur- 
rows, so as to cause ulceration of the rete mucosum, leaving a permanent cica- 
trix in the form of a depression or "pit." The cicatrix thus formed, though 
at first of a reddish-brown, ultimately becomes of a dead white color. 
The small-pox eruption does not appear over the whole body at once, but 
appears in three successive crops. The first crop covers the face, neck, and 
upper extremities, the second the trunk, while the third appears on the lower 
extremities. There is usually an interval of several hours between each crop ; 
and the later the papules are in appearing on the trunk and lower extremities 
than on the face and neck, by so much the later they are in maturating, and 
in disappearing from those parts. When the eruption on the face is declining, 
that upon the extremities has scarcely yet arrived at its height, so that the 
hands and feet are then considerably swollen. This is to be regarded as a 
favorable sign, in so far as it indicates a certain vigor of constitution. 
The number of pustules sometimes does not exceed five or six over the whole 
body; more commonly they number from one to three hundred, and occa- 
sionally amount to several thousands. It has been calculated, if ten thousand 
pustules be counted on the body, that two thousand at least will be found on 
the face; and accordingly, the number of pustules on the face being in pro- 
portion, those on the other parts of the body furnish a fair estimate of the 
extent of the disease, and of the danger of the patient. 
The pustule is subject to many irregularities, both as to its form and course; 
which give rise to two very marked varieties of the disease-namely, the 
confluent and the horn small-pox. The confluent small-pox differs from the 
distinct small-pox in the papules being small, less prominent, and so numerous 
that even on the first appearance of the eruption there is hardly any distinct 
separation between them. The vesicles which form on their apices appear 
earlier, and their diameters increase more irregularly than in the distinct forms, 
and often they run one into the other. The eruptive stage is usually shorter, 
and spreads over the body more rapidly, the contents of the vesicles become 
purulent sooner, and their confluence on the face makes it look " as if it were 
covered with one large bladder of matter." The pustules, likewise, which are 
confluent, either remain flat, and do not rise, or, the areolar tissue rupturing, 
they form large bullse or bladders in clusters like a bunch of grapes-a rare 
variety of the disease (variola corymbosa')-and are not encircled with the 
usual red areola round their base; neither do their fluid contents always 
acquire the yellow color and thick purulent consistency of the milder disease. 
Their crusts, moreover, are soft, and do not fall off till many days after the 
usual period, or not till the eighteenth or twentieth day, or even later. When 
the desiccation is completed and the crust detached, a deep scar or pit, some- 
times an extensive seam, remains, and shows the loss of substance that has 
taken place, and how destructive to the tissue of the true skin has been the 
process beneath these crusts. 
When the pustules remain separated by intervals of healthy skin, or just SYMPTOMS OF NATURAL SMALL-POX. 
379 
touch each other, the varieties are known respectively as distinct or discrete 
small-pox (variola discretes) and coherent small-pox (variola cohcerentes). 
The horn small-pox is a variety of the pustule, and is by much the mildest 
form of the disease. The pustule in this variety passes through the stages of 
papule and of vesicle, but on the fifth or sixth day of the eruption, instead of 
maturating, the pustule shrivels, desiccates, and crusts, and the disease termi- 
nates three or more days earlier than in the usual course, and without the 
occurrence of any secondary fever. This is the form of the disease which so 
usually follows after vaccination. Where the pocks do not pass beyond the 
first stage of papule, so that no vesicles form on the flattened papule, the 
variety is known as variola verrucosa. 
Many other varieties have been described by the older authors, which are 
seldom if ever now seen-for instance, black small-pox (Sydenham) ; a blood 
small pox, variola cruenta (Mead), or hemorrhagic, in which "blood is effused 
into the vesicles or pustulesa gangrenous small-pox (variola gangrenosa), 
when the vesicles fill with an ichorous matter, accompanied with gangrene of 
the skin; a siliquous small-pox (Friend), in which the pustule resembles a 
small hollow bladder, but contains no fluid (variola siliquosa seu emphysematica). 
There is one variety, however, which is not uncommon, called the crystalline 
or pearl pock (varioles crystallines,), in which the vesicle continues transparent, 
seldom maturates, and has a tendency to become confluent (variola lymphatica 
seu serosa). Every variety of the eruption, when the disease is severe, may 
be intermixed with petechise. Such are the chief features of the disease, so 
far as the development of the eruption is concerned. 
Varieties and Symptoms of Small-Pox.-The species of small-pox recog- 
nized in the Nomenclature of the College are: 
Group A (Unmodified). 
Group B (Modified). Definition : Pustules cut short in their development by 
vaccination or previous attacks of small-pox. 
The varieties applicable to both groups are: 
a. Confluent. Definition: Pustules running together over the greater part 
of the body. 
b. Semi-confluent. 
c. Distinct. Synonym, Discrete. Definition : All thepushdes separate. 
d. Abortive. Synonym, Varicelloid. Definition: Comparatively few pustules, 
the general eruption scarcely passing beyond the stage of vesicle. 
The subordinate varieties are: 
e. Petechial. 
f. Hemorrhagic. Definition: Blood effused into the vesicles or pustules, with 
a tendency to hemorrhage from the mucous surfaces. 
g. Corymbose. Definition: Some of the pustules assume the form of clusters, 
like a bunch of grapes (corymbus). This is a rare variety of the disease. 
The varieties of small-pox are here much more elaborated than those of 
other similar diseases in the Nomenclature of the College, chiefly to meet the 
wants of public institutions for the treatment of small-pox. 
Group -d--Unmodified or Natural Small-Pox. 
This species Sydenham and Frank have observed in every variolous epi- 
demic,-that some few persons who have not previously had the small-pox, or, 
according to Frank, have neither had the small-pox nor been vaccinated, are 
seized during the time the small-pox is raging, with all the symptoms of 
primary variolous fever, which having subsided, they have afterwards been 
found insusceptible of the disease. Sydenham states that he has seen fatal 
cases of this kind attended with purple spots and bloody urine,-and hence 
the "variolae sine eruptione" of authors,-which, when it occurs in the present 
day, is more usually regarded as a modification of small-pox, probably de- 380 
SPECIAL PATHOLOGY-SMALL-POX. 
pending on the influence of vaccination, the existence of which may have 
been overlooked; but when occurring in the unvaccinated, is generally sugges- 
tive of a fatal issue. 
Symptoms of Distinct Small-Pox.-The symptoms and development of 
variolas discretes, or of distinct small-pox, are traceable through, and may be 
divided into four stages. The first stage comprises the period of incubation or 
of latency-a period of time which varies according as the poison has been 
introduced by the mucous or cutaneous tissues. In the former case, or in 
natural small-pox, for example, the more usual time of latency is from ten to 
sixteen days; while in the inoculated small-pox the period of latency is from 
seven to nine days, the extremes, taking both forms of the disease, being from 
five to twenty-three days. Barensprung, of Berlin, has lately recorded a most 
interesting fact, which demonstrates, in a more striking and definite manner, 
the period of latency; and which appears to be similar in persons who have 
been vaccinated and in those who have not. He observed seven cases of small- 
pox, all of which were infected from the same source on the same day. In all 
of them the outbreak occurred between the thirteenth and the fourteenth day. 
Some of them were vaccinated and some were not (Annalen des Charite Kran- 
ken, vol. xix, p. 103). The second stage comprises the primary fever, the earliest 
expression of constitutional disturbance, and which generally terminates with 
the appearance of the eruption (stadium prodromorumf The third stage com- 
mences with the eruption, and terminates with the appearance of the secondary 
fever (stadium eruptionis). The fourth stage commences with the secondary 
fever, and includes the suppuration and maturation of the vesicles, with all 
the subsequent phenomena of desiccation, scabbing and convalescence (stadium 
suppurationis seu maturationis et exsiccationis). 
In the adult the symptoms of the second stage are mainly to be distinguished 
from those of the first stage of typhus, or other febrile affections, by the char- 
acteristic ranges of temperature. There is, however, a great tendency to 
vomiting, and to pain in the back, and the brain is oppressed, as indicated 
by drowsiness, stupor, or coma, followed occasionally by convulsions, especi- 
ally in children. The ordinary duration of this fever is four days; audit 
may be sudden in its attack, or be preceded by some days' illness, in which 
case the most prominent and characteristic symptoms in the adult are severe 
muscular pains simulating rheumatism, especially in the small of the back, 
the sacral and lumbar regions, and the frequent occurrence of obstinate vomit- 
ing, foreboding a severe form of the disease. 
The primary fever commences with a chill or repeated rigors, followed by 
the sensation of great heat; and the thermometer rising rapidly, may indi- 
cate a temperature of 104° to 106° Fahr., attaining its maximum when the 
eruption can be felt. The face is suffused with redness, and the carotids pul- 
sate strongly. There is usually much thirst, loss of appetite, and pains in the 
limbs. The tongue is coated, and the secretions of the mouth are slimy. 
Sometimes there is epistaxis. 
During the fever, and prior to the expression of the eruption, there is one 
symptom of great importance in small-pox, as especially pointing to what is 
about to happen,-that is, the pain in the back. It is a peculiar and striking 
symptom, and more intense than in any other form of fever. It is distin- 
guished from lumbago by its position: that in lumbago affects the muscles on 
each side of the spine, and is greatly aggravated by movement; while the 
pain of the back in small-pox is in the central part of the sacrum and the 
lumbar region, and is not influenced by movement. Three ideas prevail as 
to the source of this characteristic pain; namely, whether it may be due to- 
(1.) Hypersemia of the spinal medulla; (2.) Pressure on spinal nerves as they 
emerge from the lumbar and sacral regions by the distended venous plexus 
surrounding them in the bony outlets; (3.) Excessive hypersemia of the kidney, 
or incipient nephritis in the connective tissue of the kidney. TEMPERATURE IN NATURAL SMALL-PON. 
381 
On the evening of the third or morning of the fourth day, after the com- 
mencing of chill, the fever is usually at its height; and on the fourth day, 
sometimes sooner, and but seldom later, the eruption appears, and the third 
stage commences. The phenomena of the third stage are as a calm succeed- 
ing to a storm; for, on the appearance of the eruption, the fever remits, the 
heat abates, the affection of the head subsides, the vomiting ceases, and the 
pulse returns to its natural standard. The febrile phenomena seem to have 
altogether disappeared for the time, and the patient may think himself well. 
A temporary defervescence is thus well marked, the temperature falling, from 
perhaps 106° Fahr., progressively downwards to 100° Fahr. 
TYPICAL RANGE OF TEMPERATURE IN A CASE OF NATURAL SMALL-POX, COMMENCING WITH THE 
THIRD STAGE; THAT IS, FROM THE PERIOD OF THE ERUPTION, ON THE EVENING OF THE 
FOURTH DAY FROM THE BEGINNING OF THE SICKNESS. THE RECORDS INDICATE MORNING 
(a.m.) and evening (p.m.) observations (Wunderlich). 
Fig. 69. 
The number of pustules varies, according to the severity of the case, from 
about twenty to some thousands. They appear first in minute bright red 
specks on the face, neck, and upper extremities, then on the trunk, and lastly 382 
SPECIAL PATHOLOGY-SMALL-POX. 
on the lower extremities, and run their course in a succession of crops, devel- 
oping late as they appear late. They undergo the various mutations of papule, 
vesicle, and of pustule, already described. The eruption on the mucous mem- 
brane commences at this time also, but it is not generally recognized till its 
occurrence in the mouth increases the flow of saliva; or in the pharynx, caus- 
ing a difficulty in swallowing; or in the air-passages, causing cough, hoarse- 
ness, or altered timbre of the voice; or the conjunctiva, causing the tears to 
flow, and light to be avoided. There may be also difficulty of making water, 
and severe pains in the external genitals, symptoms which come on later after 
the others may have subsided. About the eighth day of the disease, however, 
or when the eruption is fully out over the whole body, and the pustules on 
the face begin to maturate, the whole face, head, and neck swell, particularly 
the eyelids, which often close and blind the patient; the swollen parts also 
throb, and are painful when touched. The intumescence of these parts lasts 
three days, during which the spaces between the pustules inflame, and are of 
a deep red or damask-rose color; and the closer this resemblance is seen to be, 
the milder will be the subsequent affections. 
It is during this period of intumescence, simultaneously with the renewed 
hyperaemia of the skin, and introductory to the change taking place in the 
contents of the pustule, that the fever, which had remitted, returns, and the 
fourth stage, or that of secondary fever, commences, sometimes called the Fever 
of Suppuration. This stage, in cases of ordinary intensity, is marked by a 
rise of temperature to a considerable height, by a frequent pulse, sometimes 
by a rigor, or repeated chills, and by slight delirium, from which the patient 
is easily aroused. If, however, the disease be of greater intensity, hsematuria, 
haemoptysis, or a hard dry cough, are added in proportion to the implication 
of the mucous membrane. In favorable cases the swelling of the face, the 
redness of the intervening spaces, and also this secondary fever, having lasted 
from the eighth to the eleventh or twelfth day, subside, and the pustule, now 
fully ripe, bursts and discharges a thin yellow matter, which, concreting into a 
crust, falls off on the fourteenth or fifteenth day, and the disease terminates. 
During this somewhat protracted defervescence, the temperature sinks grad- 
ually, to rise, perhaps, for the third time, when the final desiccation takes 
place. 
In the very mild variety of distinct small-pox which was wont to be named 
the " horn-pox," the primary fever is little more than a febricula ; the pustules 
do not exceed half a dozen to two or three hundred; and, having passed 
through the stages of papule and of vesicle, they, on the eighth day-i. e., 
about the usual time of maturation-shrivel, desiccate, and crust. The secon- 
dary fever, often so fatal in unmodified small-pox, when vaccination has not 
been done, does not recur; so that the convalescence usually commences on 
the eighth day, and the disease is terminated on the eleventh. 
It was once supposed that in such cases the pus of the pustules was absorbed; 
but it appears that pus does not form, the fluid always remaining serous in 
such cases. In cases of any degree of severity, even in the distinct small-pox, 
the poison acts not only on the skin, but also on the mucous membrane, as 
already indicated, and produces an exudation in several parts of that surface. 
This additional lesion, however, does not appear to aggravate the fever, or to 
occasion other inconvenience than what arises from the local mischief. The 
buccal eruption is usually preceded and accompanied by soreness of the throat 
and difficulty of swallowing, and sometimes salivation; but these symptoms 
do not exceed those of a common sore throat. The exudation upon the mucous 
membrane is generally resolved without the formation of ulcers, or anything 
that can be considered a scab or cicatrix. The exudations which form within 
the eyelids are not attended with much pain; and it is only when the 
swelling has subsided that the mischief which sometimes takes place is dis- 
covered. DESCRIPTION OF CONFLUENT SMALL-POX. 
383 
A peculiar faint and sickly odor, of a "greasy, disagreeable" kind, and 
quite sui generis, emanates from the small-pox patient during the period of 
maturation of the pustules. So much is this the case, that Dr. Watson says, 
" one might name the disease at once by the smell." When, however, the 
disease assumes an unfavorable character, and threatens a fatal termination, 
the face, which ought to have been intumescent on the eighth day, remains 
without increase of size, and the spaces which ought to have inflamed are pale 
and white. The pustules also, says Sydenham, look red, and continue ele- 
vated (even after death), and the saliva, which flowed freely up to this day, 
suddenly ceases. At this critical period the secondary fever, instead of its 
usual sthenic character, may assume one of two forms,-namely, either a form 
like the second stage of typhus, with brown tongue, frequent pulse, and delir- 
ium ; or the patient may be overwhelmed with the depressing influence of the 
poison, and sink almost without experiencing a reaction, the pulse being 
hardly increased in frequency, the heat of the body natural, and the intellect 
unimpaired. But the patient suffers from an indescribable restlessness, an 
inexplicable anxiety, some cough, with sickness, a frequent desire to pass 
urine ; and with such symptoms as these he dies. In its regular typical course 
the vesicles become larger at the period of maturation, and the skin around 
them swollen, and of a bright red color. With diffuse redness and swelling, 
the face becomes greatly disfigured, and the pulsating pain in the skin becomes 
severe, and the tension distressing. It is during the suppurative stage that 
the lesion of the mucous membrane causes the greatest distress, swallowing 
may become almost impossible, the saliva flowing from the mouth, and the 
nose being stopped, the voice inaudible, and the cough distressing. The eyes 
burn, and are extremely sensitive to light, being of a dark red, and full of 
muco-purulent secretion. 
The intensity of the fever of maturation seems to be in proportion to the 
intensity of the dermatitis, on which it seems to be secondary, and not directly 
due to the variolous poison, although, doubtless, its influence on the blood must 
tend to aggravate the fever. 
The confluent small-pox is described by Sydenham as beginning with symp- 
toms similar to those of the distinct small-pox, but more violent; the second 
stage, or primary fever, being attended with more sickness and vomiting, with 
a higher temperature, with rigors, with more severe muscular pain, with more 
considerable delirium, and in children often, on the evening before the erup- 
tion, by convulsions. This fever is not only more intense than in the distinct 
kind, but is of shorter duration, and more tumultuous-the eruption appear- 
ing more generally on the third day, or even earlier; and the sooner the pus- 
tules appear, so much the more confluents the disease that follows likely to 
be. The eruption is often preceded by an extensive erythematous or erysipela- 
tous inflammation, and the pimples come out irregularly, or in small clus- 
ters, like measles, and are less eminent than in distinct small-pox. " The pus- 
tules run together over the greater part of the body." 
When the third or eruptive stage is formed, the primary fever remits, but 
not so completely as in the distinct kind ; for the pulse often continues fre- 
quent (110 to 120 in a minute), and the temperature does not fall so distinctly, 
the tongue is white, and even the delirium may recur in the evening. This 
eruption also has some remarkable characters; for the pustules, especially 
those of the face, do not rise ; they are more irregular and flatter in their 
forms; and, from their greater number and contiguity, run into each other, 
or are confluent, sometimes forming bullae as large as a hen's egg, and some- 
times scarcely a portion of healthy skin is visible. 
Other symptoms, sometimes seen in the distinct small-pox, never fail to 
accompany the second stage of confluent small-pox-namely, sore throat and 
salivation. The tonsils and the fauces become tumid and red, the face begins 
to swell, and then the salivary discharge begins either with the eruption or 384 
SPECIAL PATHOLOGY-SMALL-POX. 
within a day or two afterwards. The discharge of saliva is at first thin and 
copious, resembling the ptyalism of mercury. About the eighth day, how- 
ever, it becomes viscid, and is expectorated with difficulty; while in bad cases 
it either ceases for a day or two, and then returns, or it disappears altogether 
abruptly ; and if the swelling of the face also subsides suddenly, the danger is 
great. Children are not so liable to this salivation as adults. In them, how- 
ever, a vicarious diarrhoea often appears, but not constantly; neither does it 
occur so early in the disease. It is frequently profuse, and often proceeds 
till the disease terminates. [The nasal cavities in children should be fre- 
quently examined, as the affection of the membrane is often severe.] Not 
unfrequently the larynx and trachea are implicated, even to the larger divis- 
ions of the bronchia. There is cough, with hoarseness, painful expectora- 
tion, and sometimes complete extinction of the voice. These are most danger- 
ous symptoms, when the eruption is confluent. 
It has been stated that, on the appearance of the eruption and the com- 
mencement of the third stage, although the fever is mitigated, it does not 
altogether subside, defervescence is incomplete, and the affection of the head, 
the frequency of the pulse, and greater heat of the surface, often continue. 
With these ominous symptoms still present, on the eighth day of the erup- 
tion, or the eleventh day of the fever, the fourth stage, or secondary fever, 
commences, bringing with it new sources of anxiety to the physician and of 
danger to the patient. Gregory and Watson both consider the eighth day of 
the eruption as the most perilous day of the disease. Blood often appears in 
the urine in slight and sometimes in large amount. Renal cylinders are not 
uncommon. The bladder is affected in a great number of cases, and there is 
increased mucus. If the urine be retained in torpid and semicomatose cases, 
it becomes soon ammoniacal, as in all cases with catarrhal cystitis (Parkes, 
On the Urine, p. 262). 
" The confluent small-pox," says Sydenham, " does not in the least endan- 
ger life in the first days of the illness, unless there happens a flux of blood 
from the urinary passages, or from the lungs. Yet, on the decline of the 
disease, or on the eleventh, fourteenth, seventeenth, or twenty-first days, the 
patient is often brought to such a state that whether he will live or die is 
equally uncertain." He is first endangered on the eleventh day by a high 
fever (and the highness of the temperature may indicate the danger), attended 
with great restlessness, and other symptoms which ordinarily prove destruc- 
tive, by adynamia and fatal paralysis, not unfrequently accompanied by an 
acute hemorrhagic condition, the contents of the pustules becoming bloody, and 
petechial on such parts of the skin as may be free from eruption-epistaxis, 
hcematuria, hcemoptysis, or hemorrhage of the uterus may also supervene. " But 
should the patient outlive this day, the fourteenth and seventeenth are to be 
apprehended, for a very vehement fit of restlessness comes on every day 
towards evening, and there is the greatest difficulty in saving him." The 
disease is apt to prove fatal by way of apnoea, after the eighth day; but after 
that period the characters of asthenia supervene. 
The fatal symptoms of the fourth stage are, the absence of the usual redness 
in the intermediate spaces, the non-intumescence of the face, the suppressed 
salivation, cough, with haemoptysis, or haematuria, and great restlessness. 
Sometimes other symptoms are added to these, as a brown tongue, delirium, 
petechiae, or a black spot in the centre of each pock, scarcely so big as a pin's 
head; or a disposition to gangrene round the larger vesicles. When these 
symptoms are present, few patients survive such a crisis, dying early with 
symptoms of great prostration; or if life continue longer, pleurisy or pneu- 
monia may be eventually fatal. In some cases, however, the event is favorable, 
and the patient is restored; but the struggle is sharp and the convalescence 
long. In the most favorable cases a slow and protracted convalescence is the 
rule. In its progress an endless series of abscesses may form, or inflammation SYMPTOMS OF INOCULATED SMALL-POX. 
385 
of a joint may take place, and produce lameness; ulceration of the cornea, 
blindness, otitis, or deafness may also ensue; while the deeply-scarred face is 
a lasting record of the severity of the disease, and of the great danger the 
patient has survived. It is the most malignant form of small-pox. A dark 
crust sometimes forms, which covers the face like a mask, which is constantly 
being added to by the continued suppuration beneath, until it falls off, leaving 
a cicatrix like that of a burn, and equally tending to induce deformity by 
contractions. 
[In some cases of small-pox certain nervous disorders are noticed, especially 
where there has been coma or delirium. On the subsidence of one or the 
other, or both, ataxic symptoms are developed. Speech is slow and broken, 
without modulation of voice, which is nasal. Lateral movements of the head 
are noticed, which cease when the head is supported, and are increased by 
mental excitement. Deglutition is temporarily affected. There is ataxy of 
both the upper and lower extremities, without paralysis of motion or any 
alteration of sensation (Westphal). Though these disorders of the motor 
system are distinct from the paralysis often consecutive to diphtheria and 
other specific diseases, yet it is not peculiar to small-pox, for it is met with 
after typhoid fever occasionally.] 
The Inoculated Small-Pox. 
Symptoms.-The phenomena which result from the introduction of the 
variolous poison by means of inoculation into the cutis differ in many respects 
from those that occur in the natural small-pox; and they are as follows: On 
the day after the operation is performed, little alteration is discovered in the 
punctured part. On the second day, however, if the part be viewed with a 
lens, and the operation has succeeded, there generally appears an orange- 
colored stain around the incision, while on the fourth or fifth day the part is 
hard, slightly inflamed, and itches, and a vesicle containing serum is formed 
on it. About the sixth day some pains and stiffness are felt in the axilla, 
symptoms which foretell the near approach of the fever and the favorable 
progress of the disease. On the seventh day the vesicle becomes more devel- 
oped and the red areola forms round its base. 
The operation having now been performed seven, eight, or nine days (the 
usual period of latency of the poison when so inoculated), and the vesicle 
having existed four days, the ordinary symptoms of primary fever appear. 
This fever lasts three or four days, when the general eruption follows, now 
called the secondary eruption, the pustules coming out, as usual, in three suc- 
cessive crops, on the face, trunk, and lower extremities. On the day of the 
general eruption the primary pustule, says Dr. Gregory, is distended with 
matter, and proceeds on its course, so that it has scabbed when the secondary 
eruption is only about to maturate. 
The most remarkable phenomena, however, of the inoculated small-pox are 
the singular mildness of the fever and the diminished number of the pustules 
of the secondary eruption. The mildness of the fever is thus instanced by the 
late Dr. Watson, of the London Foundling Hospital: "Of the seventy-four 
persons whose histories I have related, though inoculated with variolous matter 
in different states, although prepared in so different a manner, and a great 
number not otherwise prepared than by an abstinence from animal food, not 
one of them were disordered enough during the whole progress to occasion 
the least anxiety for the event; not one of them had their eyes closed a single 
day, from the pustules being upon the eyes or near them ; none continued in 
bed an hour longer than they would have done in their best health." 
The number of pustules of inoculated small-pox is subject to great varieties, 
but, with very few exceptions, is much less than in the natural small-pox. In 
some cases not more than two or three appear; occasionally only the primary 386 
SPECIAL PATHOLOGY-SMALL-POX. 
pustule is seen; but more generally the number varies from ten to two hundred, 
the mean being thirty or forty. Such is the general course of the inoculated 
small-pox. In a few instances, however, the disease that follows this operation 
is extremely severe, and in a still smaller number it is confluent; and in either 
case the patient is perhaps destroyed. Many theories have been propounded 
to explain the singular mildness of the inoculated small-pox, but none of 
them are satisfactory. 
Complications of Small-pox and Special Morbid Tendencies.-Small-pox 
having been chiefly studied previous to any sound knowledge of morbid anat- 
omy, or of morbid poisons, the occasional subsequent affections of the disease 
are still but imperfectly known. About the eighth day in the distinct small- 
pox, and the eleventh day in the confluent small-pox, a secondary fever is 
established, and at the same time a new series of phenomena (already indi- 
cated, but requiring more special notice) may present themselves in a few 
severe cases,-as affections of the lungs, of the pleurae, or of both ; of the 
urinary organs, or of the areolar tissue of the body generally. It is during 
the progress of this secondary fever that frequent opportunities occur for its 
degeneration into a fatal type. In such cases complete defervescence is never 
established ; but lesions become developed whose advent is capable of being 
appreciated by careful records of morning and evening temperature during 
the progress of this fever of suppuration. These are the tertiary affections, the 
eruptions and the fever being the secondary effects of the specific poison. 
The most frequent affection of the lungs is haemoptysis, but occasionally 
inflammation of these organs takes place, generally as a pleuro-pneumonia, 
indicated by a sharp pain in one side, increased dyspnoea, harassing cough, 
and bloody expectoration. The mucous membrane (for instance, of the 
trachea) is often found covered with a thick semipurulent, muciform matter, 
peculiar to small-pox, irregular or honeycombed at its free surface, and which 
being removed, the subjacent tissue is found diffusely inflamed. The sub- 
stance of the lungs also is occasionally found inflamed in every degree, even 
to purulent infiltration. The pleura also is peculiarly disposed to inflamma- 
tion, which comes on about the eleventh or twelfth day, for the most part 
very suddenly, and proceeds rapidly to empyema, sometimes destroying the 
patient in thirty-six hours. The inflammation of the pleura does not merely 
run into suppuration, but takes other forms of lesion, and especially hemor- 
rhagic exudation. 
The tertiary action of the variolous poison on the urinary and genital 
organs is seen in the frequent occurrence of haematuria, in the occasional for- 
mation of abscess of the kidney, in the occurrence of peripheric and paren- 
chymatous orchitis, and in ovaritis; while its action on the uterus is manifest 
from menorrhagia in the unimpregnated state, and by frequent miscarriage 
when the patient is pregnant The areolar tissue of the body generally is also 
frequently implicated. In some cases, examined a few hours after death, the 
bodies can with difficulty be laid on the table, the skin being detached by the 
pressure necessary to raise them; and the serous coat of the intestines sepa- 
rates from the mucous and muscular coats with the greatest facility for 
many feet, and apparently might be entirely peeled off. In some cases the 
finger can be thrust through the walls of the heart with ease, as if the muscle 
of that organ had become unnaturally soft and broken down. This affection 
of the areolar tissue generally is seen in the great tendency to the formation 
of abscesses on the subsidence of the eruption. Twenty, thirty, and even 
more small abscesses will sometimes form on a limb or other part of the body, 
in most formidable succession, and which, on being opened, are found to con- 
tain sanious, or, only in a few instances, laudable pus. 
Pyogenic Fever.-In a case of septicaemia, occurring during the course of 
confluent small-pox, examined by Dr. Parkes, the disease ran its course well 
till the eleventh day, when there was shivering; on the following day there PYOGENIC FEVER AFTER SMALL-POX. 
387 
was bilious vomiting; on the fourteenth day there was sudden pain in the 
right wrist, and swelling of many joints; and on the following day there were 
all the well-marked symptoms of pyaemia. A daily examination of the urine 
showed the remarkable fact that the amount of sulphuric acid passed con- 
tinued progressively to increase daily-rising from 23.8 grains to 44.4 grains 
(Parkes, On the Urine, p. 267). 
Sequelae.-The different lesions that have been mentioned are not the only 
miseries from which the patient may suffer; for these are often followed by 
sequelae even more formidable than the preceding phenomena, as blindness, 
deafness, or lameness. With respect to blindness, it is generally supposed 
that pustules form on the conjunctiva or cornea, the inflammation then ex- 
tending to the deeper-seated parts, and thus destroying the eye. Mr. Marson, 
formerly surgeon to the Small-Pox Hospital, says that, according to his 
experience, " The eye seems to possess a complete immunity from the small- 
pox eruption, and that although it sometimes extends to the inner margins of 
the eyelids, the particular local affection that causes the destruction of the 
organ of vision in variola begins generally on the eleventh or twelfth day, or 
later, from the first appearance of the eruption, and when the pustules in 
every other part of the body are subsiding. It comes on after the secondary 
fever has commenced, with redness and slight pain in the part affected, and 
very soon an ulcer is formed, having its seat almost invariably at the margin 
of the cornea. This continues to spread with more or less rapidity, and the 
ulceration passes through the different layers of the cornea, until the aqueous 
humor escapes, or till the iris protrudes. In the worst cases there is usually 
hypopion, and when the matter is discharged, the crystalline lens and vitre- 
ous humor escape. In some instances the ulceration proceeds very rapidly: 
I have, more than once, seen the entire cornea swept away within forty-eight 
hours from the apparent commencement of the ulceration; and, what is singu- 
lar, now and then the mischief goes on without the least pain to the patient, 
or his being aware that anything is amiss with his eyes." Hence the hypopion 
may be overlooked. Further, he calculates that in 1000 cases 26 had ophthal- 
mia, or about 1 in 39; and of these 11 lost an eye each, or 1 in about 100. 
The inflammation of the buccal membrane may extend to the Eustachian 
tube, causing suppuration of the ear, and sometimes permanent deafness. It 
may spread also to the glottis; and the patient has been known to die suffo- 
cated by effusion into the areolar tissue around it, causing occlusion of the 
aperture. Sometimes it has terminated in ulceration, with the loss of a por- 
tion of the nose, or in caries of the jawbone, or in enlargement of the glands 
of the neck. 
The soreness of the fauces and tonsils is often associated with pustules on 
these parts; and the tongue, the roof of the mouth, the inside of the cheeks, 
the uvula, and the velum palati may be covered with an eruption like pus- 
tules; and it has been much disputed whether the eruption forms on any 
other part of the mucous membrane. As a general principle, it does not: 
but Martinet found, in a man that died on the eighth day, the rectum covered 
with what he supposd to be variolous pustules. Rostan has seen the alimen- 
tary canal garnished with pustules similar to those of the mouth, from the 
oesophagus to the rectum. Sir Gilbert Blane also met with pustules on the 
mucous membrane of the intestines in two persons who died in the West 
Indies; and Rayer has given a plate representing pustules on the mucous 
membrane of the trachea. Dr. Mead's experience has made him state that 
"I myself have seen subjects in which the lungs, brain, liver, and intestines 
were thickly beset with pustules." Dr. Pitzholdt, in the Morbid Anatomy of 
Small-Pox, writes that he has seen the peritoneum covering the liver and the 
spleen presenting appearances which he felt justified in regarding as the 
product of small-pox. 
The pustules which form on the mucous membrane of the intestine, how- 388 
SPECIAL PATHOLOGY-SMALL-POX. 
ever, have not been very distinctly studied either as to their course or phe- 
nomena. Ray er terms them rudimentary pustules. A case of small-pox 
recorded by Dr. George Patterson, of Edinburgh, was examined by one of the 
most learned and discriminating pathologists of the day, Professor W. T. 
Gairdner. He observed pustules on the mucous membrane of the colon, 
identical with the pustules on the skin (Edinburgh Monthly Journal, 1849, p. 
549). Still it appears to be doubtful whether such eruption on the mucous 
membrane of the intestine is not the same as that seen in cholera cases, ex- 
tending (as I have frequently seen it do in cases I examined in the hospitals 
at Scutari, in 1855) throughout the whole intestinal tract. The appearance 
of eruption in such cases is due to the solitary mucous glands, which are 
filled with exudation, not of a purulent kind, but having all the external 
appearance of pustules. 
Such are the pathological phenomena which occasionally complicate small- 
pox. Death, however, not unfrequently anticipates their action, and destroys 
the patient during the primary fever, and before any of these lesions, not 
excepting the eruption, are set up. 
Group B.-Small-Pox after Vaccination- Varioloid, or Modified Small-Pox. 
Definition.-Pustules cut short in their development by vaccination or previous 
attacks of small-pox. 
Symptoms, Course, and Modifications.-It has been already noticed that 
during the epidemic prevalence of small-pox, even before vaccination was 
known, cases of small-pox occurred in a very modified form: such as the oc- 
currence of variolous fever without the eruption (variolce sine variolis vel erup- 
tione), or the occurrence of small-pox in which the eruption continued vesicu- 
lar (the crystalline pock), and lastly, the occurrence of small-pox in which the 
vesicle dried up instead of becoming a mature pustule, and known as stone- 
pock, horn-pock, wart-pock (variola verrucosa vel cornea). Modern pathology 
now regards these varieties as the result of the modifying influence of vacci- 
nation, where vaccination has been performed; and they may now be all de- 
scribed and classed under the common name varioloid. Comparative mildness 
of symptoms and course is their great characteristic, the pustules being "cut 
short in their development by vaccination or a previous attack of small-pox." 
There appears to be every variety in the nature of the modification, of which 
the principal are: 
1. A fever of three days, without eruption, affecting people during vario- 
lous epidemics. 
2. A high and severe fever, followed by a very mild eruption, sometimes 
only a single pock; the slight proportion which the amount of eruption bears 
to the severity of the preceding fever is perhaps the most marked character- 
istic of varioloid. 
3. The occasional appearance of a scarlet efflorescence like that of scarla- 
tina or roseola, preceding the appearance of the proper pimples, which occur 
as a very scanty crop. 
4. In some rare instances the eruption is confluent, but does not advance 
beyond the development of a pimple or vesicle, and begins to dry on the 
fourth or fifth day of the eruption, forming a small hard tubercle, which soon 
disappears. 
5. Sometimes the eruption is pimple, vesicle, and pustule at one time in the 
same case. 
6. Sometimes the eruption runs its regular course, but stops sooner, some- 
times on the sixth or seventh day, instead of the eighth or ninth. In general, 
it may be stated that the severity and fully developed state of the disease is 
in proportion to the length of time which elapses from vaccination (Copland). EXHAUSTION OF SUSCEPTIBILITY. 
389 
7. The varioloid eruption wants the peculiar odor of natural small-pox, and 
secondary fever is very rare. 
TYPICAL RANGE OF TEMPERATURE IN A CASE OF SMALL-POX MODIFED BY 
VACCINATION. THE RECORDS INDICATE MORNING (A.M.) AND EVENING 
(P.M.) OBSERVATIONS, COMMENCING ON THE EVENING O^ THE SECOND DAY 
(W underlich). 
Fig. 70. 
8. Other eruptive affections-such as measles, scarlatina, purpura-materi- 
ally modify the course and symptoms of small-pox. 
Generally, it may be stated that after an intense continuous fever, lasting a 
few days, a final exacerbation terminates the fever suddenly and simultane- 
ously with the development of the small-pox pimples. A rapid and perfect 
defervescence then ensues, the temperature decreasing seven or even more 
degrees (Fahr.) within thirty-six hours. From this event the patient remains 
entirely free from fever--provided there exists no serious complication-in spite 
of the continuous and progressive development of the small-pox pimples into 
pustules, and even in spite of the successive eruption of new pimples. 
Exhaustion of Susceptibility.-The small-pox has the property, in common 
with measles and scarlet fever, of exhausting, after one attack, the susccpti- 390 
SPECIAL PATHOLOGY-SMALL-POX. 
bility of the constitution for the rest of life to any future actions of the poison. 
The disease, artificially induced by vaccination with cow-pox matter, has a 
similar effect upon the constitution, and furnishes the basis of its protective 
influence. This law, however, is not without some exceptions, and in an epi- 
demic at Marseilles, Bosquet considered that one person in one hundred was 
attacked a second time with small-pox. In some few instances even a second 
attack has no protective influence. Dr. Roupel says he met with an instance 
in which small-pox occurred three times in the same person. The lady of a 
Mr. Guinnett had it five times. Dr. Matson speaks of a lady who had it seven 
times; while Dr. Baron mentions a surgeon of the South Gloucestershire Militia 
who was so susceptible that he took small-pox every time he attended a patient 
laboring under that disease. Hence, also, vaccination, while it invariably 
modifies small-pox, does not always absolutely prevent its occurrence in the 
person vaccinated, especially if they have been vaccinated early in life, and 
exposed late in life to infection. Hence vaccination ought to be repeated in 
adult life (eighteen to twenty years of age) after having been performed in 
infancy. 
Coexistence of Small-Pox with other Morbid States.-The variolous poison 
is capable of coexisting with many other poisons, and also of influencing their 
actions, and of being reciprocally influenced by them. Dessessarz has seen 
varioke coexist with scarlatina and with hooping-cough; Cruickshanks with 
measles; Frank with psora; and Dimsdale with syphilis. A patient was 
admitted into St. Thomas's Hospital with tertian ague, writes Dr. Williams; 
the ague subsided and small-pox appeared; small-pox having run its course, 
the ague immediately returned. Ring mentions a case of triple disease co- 
existing--namely, small-pox, measles, and hooping-cough-and that they all 
ran their course together. In the British, Medical Journal for May, 1868, an 
instance of the coexistence of small-pox and scarlet fever is related by Dr. 
Sansom. [Dr. Bugg, of London, has reported a similar case.] 
Cause.-The same obscurity hangs over the cause of small-pox as over that 
of many other diseases, such as of measles and of scarlatina. There is every 
probability, however, that these diseases have now no other mode of commu- 
nication than from one person to another. The source of contagion or infec- 
tion can always be traced where there is no peculiar obstacle in the inquiry. 
It spreads solely by contagion. There are some grounds for believing, how- 
ever, that small-pox, in common with some other distempers, originated in the 
lower animals, and extended from them to the human species by infection or 
contagion. Sheep, we know, are liable to a distemper of the nature of small- 
pox; and there is every reason to infer that the disease is perpetuated by its 
own specific poison, miasm, effluvium, or virus, which-spreads it about by the 
media of impalpable substances technically called "fomites," and which are 
capable of receiving, preserving, and carrying the germs of the disease. By 
such impalpable means the disease has been propagated since its first appear- 
ance in the world. The poisonous material of small-pox is given out from the 
mucous and cutaneous surfaces of a patient, especially from the lungs and skin, 
from the exhalations, the secretions, the excretions, the matters in the vesicles 
and pustules, and the scabs. These all contain the noxious germs of the dis- 
ease, which may attach themselves to bed-clothes, body-clothes, and especially 
to woollen, cotton, and felted articles. Such stuffs retain the specific poison 
for a very long but undetermined period: any number of years, so far as is 
known-just as the hat, cap, and coat worn in a dissecting-room retain the 
peculiar effluvia of that place for a very long period. The poison is most 
tenacious of vitality. Drying preserves it; and if protected from air it re- 
mains active for an unknown number of years. 
It is not yet determined at what period this poison is first generated by the 
patient's person, whether during the primary fever, or not till after the erup- 
tion has appeared ; but it probably begins to form and multiply in the patient PROGNOSIS AND CAUSES OF DEATH IN SMALL-POX. 
391 
during the primary fever. Generally, it may be stated that the poison is most 
powerful when it is most manifest to the sense of smell, and at the period when 
the clear contents of the vesicles begin to turn cloudy that the dried crusts of 
the pustules or scabs possess the power of communicating the disease, and re- 
tain this power for a very long time. It is unsafe for a susceptible person- 
i. e., a person who has not been vaccinated, or has not had small-pox-to be 
in the same room, or in the same house, with a patient laboring under the dis- 
ease. It has been caught by passing a child ill of small-pox in the street; 
and " to expose a person in the public highway, infected with this contagion, 
is considered a common nuisance, and indictable as such." The dead body 
of a variolated person is equally infectious, and students who have been near 
it when brought into the dissecting-room have in consequence had the disease 
communicated to them, although they may not have touched the body (Caesar 
Hawkins) ; and I have known students take small-pox from dissecting small- 
pox subjects. The infecting distance, therefore, must be many yards around the 
patient's person : indeed, with every precaution, there is great difficulty in pre- 
venting it spreading from ward to ward in large hospitals during the preva- 
lence of the disease. " There is no contagion so strong and sure as that of 
small-pox : none that operates at so great a distance" (Watson). 
The fact that small-pox is communicable has been fully demonstrated by 
the once general practice of inoculation. The poison by this operation has 
been proved to exist in the serum, in the pus, and in the crusts of the small- 
pox pustule. There is no law more singular and unexpected, in the whole 
range of morbid poisons, than that the introduction of the variolous poison, 
by means of the cutaneous tissue, should produce an infinitely milder disease 
than when the same poison is absorbed by a mucous tissue. Then the poison 
seems to be much more incontrollable in its operations, as in the case, when it 
affects a person who breathes an infected atmosphere, compared with one who 
has been inoculated with the small-pox poison inserted beneath his cuticle 
through a puncture of the skin. Several explanations are put forward, 
namely,-(1.) That the small quantity of the poison conveyed by inoculation 
into the blood may make the difference; an explanation opposed to known 
facts as to inoculated poisons. (2.) That the disease is milder when the poison 
is admitted through the cutaneous than through the mucous tissues; (3.) It 
may be held that in passing through the absorbent mucous membrane the poison 
is not only admitted in large quantity, but its potency may be increased and 
its amount multiplied by the living cells of the mucous membrane through 
which it passes. 
The causes which predispose to small-pox or increase the susceptibility of 
infection are,-(1.) A very early age. (2.) Not having had the disease be- 
fore. (3.) Not having been vaccinated: such are called "unprotected per- 
sons." (4.) Peculiarity of constitution-e. g., the negro and dark races. (5.) 
Fear of infection. (6.) Epidemic influence. 
It is gratifying to know that of recent years the prevalence and mortality 
of small-pox in this country are greatly less than was wont to be. Dr. Farr 
tells us that, for the three years previous to 1855, out of every 1000 deaths 
from all causes, only 7.607 were from small-pox. At present (1871) an epi- 
demic is extending in London, after having prevailed in Paris; and which 
not improbably had its commencement from the influx of Parisians to London, 
in consequence of the Franco-Prussian war and the siege of Paris by the 
Germans. 
Prognosis and Causes of Death.-The prognosis of the natural small-pox 
is always most grave. The danger may be measured, to a certain degree, by, 
-(1.) The quantity and confluence of the eruption; (2.) The state of the 
circulating fluids; (3.) The presence and nature of the complications, espe- 
cially those of the. respiratory organs and nervous centres; (4.) Age and 392 
SPECIAL PATHOLOGY-SMALL-POX. 
habit of body of the patient: (5.) Nature of the epidemic constitution which 
may prevail. 
Natural small-pox in unprotected persons is generally very fatal. The 
deaths average one in three. The fully-formed confluent small-pox is always 
very dangerous. About one in ten patients die of distinct natural small- 
pox ; and one to three per cent, of patients only of small-pox after in- 
oculation or after vaccination. The calculation of the proportionate number 
of deaths, however, appears to have greatly varied in different years, without 
any cause that can be found out. 
There are certain signs regarded as unfavorable,--for example, excessive 
lumbar pains continuing; the persistence of vomiting after the appearance 
of the eruption; the occurrence of delirium, convulsions, or coma in adults 
during the primary fever; great confluence and simultaneous appearance of 
the eruption over the whole body. Such unfavorable signs are not necessa- 
rily fatal; but unfavorable signs which appear during secondary fever fore- 
bode, with greater probability, a fatal end. These are: the absence of the 
usual redness of the skin in the intermediate spaces between the pustules; 
the distribution of petechise in the interstices; the development of a black 
spot hardly so large as a pin's head in the centre of each pustule; a livid or 
purple color of the pustule; a disposition to gangrene in the larger vesicles; 
imperfect development of the pustules, or their sudden subsidence, without 
remission of symptoms; sudden suppression of salivation ; sudden suppression 
of urine; haematuria ; cough with haemoptoe; absence of swelling in the hands 
and feet when the eruption is copious; tendency to the formation of abscesses 
(jpyogenic fever) after desquamation has commenced; congestive pneumonia, 
or bronchitis, with livid lips, face, or extremities, with hoarseness or complete 
aphonia. Recovery may take place even although the first-mentioned of these 
unfavorable signs exists; but convalescence is likely to be retarded by ulcera- 
tions of the cornea, asthenic ophthalmia, purulent deposits in the joints, ulcer- 
ation of cartilages, otitis, abscesses and suppuration in the areolar tissue under 
the skin. 
The development of scrofula and phthisis is apt to follow the disease, even 
though no unfavorable symptoms occur. In pregnant women the disease is 
always dangerous, often fatal, and almost always produces abortion ; and the 
foetus so parted with not unfrequently bears evidence of small-pox upon the 
skin. 
The most common causes of death are due to combinations of the unfavor- 
able signs already noticed; and, according to Dr. Gregory's observations at 
the Small-pox Hospital, in 1828-29, the greatest number die on the eighth 
day of the eruption ; or the eleventh day of the fever is the most fatal period. 
In private practice, Dr. Wood, of Pennsylvania, considers the period between 
the twelfth and eighteenth day as the most dangerous to life. The greatest 
mortality from small-pox is in the early periods of life,-for example, before 
the fifth year. Dr. Farr estimates that out of every 100 deaths from small- 
pox, 75 are below that age. 
Diagnosis.-It is not possible to distinguish, except by careful records of 
the temperature, the primary fever of small-pox from that incident to many 
other diseases with eruptions, or from the first stage of continued fever. It is 
for the most part characterized by excitement rather than depression; and in 
the adult the muscular pains and pains in the back and loins are more severe 
and intense than in ordinary fever. The pain of the back is central in its 
position-a spine ache-and is less affected by change of posture than the pain 
which is characteristic of lumbago, which affects the muscles at the side of 
the spine (often on one side only, and which is much aggravated by move- 
ment) (Barclay). If vomiting occurs, which cannot be ascribed to any ob- 
vious cause, and persists till a papular eruption appears on the third or fourth TREATMENT OF SMALL-POX. 
393 
day, with a remission of the febrile symptoms, little doubt can exist as to the 
variolous nature of the disease. 
The diseases with which small-pox may be, at first, confounded, are petechial 
eruptions, measles, and chicken-pox, and the secondary pustular eruptions of 
syphilis. 
Small-pox is to be distinguished from measles by the symptoms, as well as 
by the form and successive changes of the eruption. Crescentic patches, 
terminating in desquamation on the fourth day, characterize measles, as com- 
pared with small-pox, the eruption of which, even although it may be at first 
in efflorescent patches, never fails to become vesicular and pustular, proceed- 
ing to suppuration or blackening on the eighth day-a process which never 
fails to be attended by secondary fever. 
It is more difficult to diagnose between varioloid and varicella, or chick- 
en-pox. The chief difference consists in the eruption of chicken-pox present- 
ing a vesicular character, which it retains; and it does not proceed to suppu- 
ration, but completes its course, in five or six days, with a mild and short 
symptomatic fever. 
The combination of mercury, scrofula, and syphilis often gives rise to cuta- 
neous eruptions attended with fever, which may, in the first instance, be 
mistaken for commencing small-pox. The eruption, however, is more tedious 
in its development, irregular in its course, and is persistent. It is recognized 
by the history of the case, the long duration of the eruption, and the deep 
red or copper color it generally presents. 
Treatment.-Since the first accounts by the Arabian physicians of the 
ravages of small-pox in Mecca, the history of this disease may be arranged 
in three great eras, each of which is characterized by remarkable epochs, and 
a fourth may be said to be apparent now. 
The first of these eras is marked by an improvement in the treatment of 
small-pox. In few diseases has medical opinion undergone a more obviously 
beneficial change. To Sydenham is due the merit of this revolution in med- 
ical practice. 
The second era is marked by the discovery of the singular and beneficial 
phenomenon that the virulence of the poison of small-pox was greatly miti- 
gated by introducing or ingrafting the disease into the system, through the 
cutaneous tissue, thereby causing the transference of the disease from one 
person to another by inoculation. To Lady Mary Wortley Montague is due 
the merit of having introduced the practice of inoculation into this country 
in 1722--a deed which must be considered as one of great heroism, when 
measured by the knowledge possessed by the physicians of those days. 
The third great era in the history of small-pox is marked by the remark- 
able discovery which has rendered the name of Jenner immortal-namely, the 
modifying and protecting influence of vaccination. He found that a certain 
disease in the cow, known as the cow-pox, could be transferred to the human 
subject by inoculation; and that, having been so transferred, it modified, to 
a considerable extent at least, the course of the disease, if it did not altogether 
prevent in the human subject the occurrence of small-pox in its natural state. 
A fourth era may be said to have commenced in this country almost imper- 
ceptibly. It may be described as a period of transition marked by doubt and 
skepticism as to the efficacy of vaccination; tending to propagate an errone- 
ous popular belief; and consequently, the ineffective adoption of means which 
practically have been proved to be sanative in the highest degree. In other 
countries, on the contrary, and especially in Central Europe, this period is 
marked by implicit faith in the virtues of vaccination, and the successful 
legal enforcement of this sanative measure. The most plausible objection to 
vaccination must now give way before the one great fact that, during the last 
century, one-tenth of the population died of small-pox, while another tenth 
were disfigured for life by the disease; and that since the introduction of 394 
SPECIAL PATHOLOGY-SMALL-POX. 
vaccination, the general mortality from all diseases is less, and that of small- 
pox is reduced to a minimum. 
An account of the treatment of small-pox resolves itself, therefore, into the 
consideration of two topics, namely,-(1.) The usual therapeutic, curative, or 
sanative treatment of the disease; (2.) The sanitary treatment-i. e., the 
means of protecting individuals from the small-pox; or of modifying the 
influence of the malady by inoculation or by vaccination. Of these in their 
order. 
1. Therapeutic, Curative, or Sanative Treatment of Small-Pox. 
The main object, in the first instance, is to prevent, if possible, a copious 
eruption; for the severity and danger of the disorder may be measured, in 
some degree, by this. The vulgar belief, that "better out than in," does not 
apply in the case of small-pox. The great object is to reserve the strength 
of the patient; and the attentions of an experienced nurse are demanded. 
A third indication is to watch for and deal vigorously with intercurrent 
inflammatory action, which is apt to be set up. The disease is not under the 
influence of any specific or antidote. There is no remedy which will cut short 
the disease. It must run its course. But it is the business of the physician 
to assuage the untoward symptoms and avert the dangerous accidents which 
may arise, by all the most approved methods of treatment, in accordance with 
the science of medicine of the present day. 
Dietetic and General Treatment.-In the first instance, the course to be pur- 
sued is for the physician to act on the defensive, and simply protect his patient 
from certain injurious influences to which he may be exposed,-such as heat- 
ing drinks to force out the eruption, which are apt to be given by ignorant 
and officious friends. Throughout the whole course of the disease, the diet 
should be strictly limited to slops, sago, arrowroot, and ripe fruits, with cold 
water or lemonade for drinks, with or without ice. 
The chamber in which the patient lies should be cool, not above 60° Fahr., 
and freely ventilated. The bed-clothes should be light, the body linen daily 
changed; and, when the disease is long, the patient's back should be often 
examined to prevent sloughing. The scalp, likewise, should be examined, 
and if full of pustules, the hair should be cut off, to prevent its matting. If 
the disease be recognized early, however, it is proper to shave the scalp, 
because the irritation which attends the suppuration of the pustules is thereby 
diminished, and cold may be more efficiently applied to the head if necessary. 
In the early stage of the primary fever, in severe cases more especially, it is 
necessary to have the bowels well opened in the first instance, and to keep 
them regularly moved daily by saline medicine, or an enema of three parts 
water to one of vinegar. A cathartic pill, composed of the following ingre- 
dients, will be found to be efficient in most cases, especially if aided by a 
seidlitz power, given six or eight hours after the pill: 
Two grains of calomel, one grain of the compound extract of colocynth, one 
grain of gamboge, and one grain and a half of scammony, made consistent 
with a little aromatic oil. 
The bowels must be daily attended to afterwards, and castor oil, or rhubarb, 
or magnesia, &c., may sometimes be required. Saline diaphoretics, in the 
form of James's powder; or the aqua acetatis ammonice, to which a grain or 
two grains of tartar emetic has been added, so as to have -g-th or -pg th of a 
grain in every tablespoonful of the mixture, is an efficient and cooling dia- 
phoretic. Spirit of nitric ether, or the nitrate of potass, may be added if 
required. 
The surface of the body, over the hands, face, and feet, may be sponged 
several times a day with tepid water, with a view to relieve the intolerable TREATMENT OF SMALL-POX. 
395 
itching; but caution is necessary to prevent exposure to cold. Cold-cream, or 
a liniment of olive oil, glycerin, and lime-water, smeared from time to time 
over the itching surface, by means of a camel-hair pencil, may be found to 
afford relief; and chlorine lotions are highly spoken of by Eisenmann. With 
regard to the occurrence of convulsions in children, it is not found that opiates, 
as recommended by Sydenham and Cullen, are expedient. When the chil- 
dren are robust, or previously in good health, local bleedings, by means of one 
or two leeches to the temples, are more beneficial. Delirium, violent scream- 
ing, intolerance of light or sound, heat of head, all of which indicate a ten- 
dency to meningeal congestion, still more clearly warrant the application of 
leeches. 
With regard to the propriety of bleeding (general) in adults, it is now well 
ascertained that it will neither eradicate the fever nor diminish the amount of 
the eruption; moreover, experience has amply shown that loss of blood is 
badly borne in all infectious diseases. Bleeding is only warrantable if the 
pulse be full and strong, combined with evidence of inflammatory congestion 
in the lungs, causing dyspnoea. The persistent application of cold to the head, 
and repeated affusion of the body with cold water, is to be preferred, in cases 
where there is much cerebral excitement. 
When delirium, with restlessness, wakefulness, and a frequent pulse, is con- 
tinuous, an opiate is indicated; and, combined with tartar emetic, is most ad- 
vantageously given. A draught, composed of thirty minims of the solution of 
muriate of morphia, with half a grain of tartar emetic, will be found beneficial in 
such conditions, and especially when given at bedtime. 
If the temperature rise higher, large doses of quinine are to be given. 
Cooling drinks, with or without ice, of lemon-juice, tamarinds, neutral effer- 
vescing powders, are always agreeable to the patient, who ought also, for the 
sake of coolness, to be very lightly clothed. After the eruption has fully ap- 
peared, this is all which in ordinary cases requires to be done, and if, towards 
the tenth or eleventh day, there is much restlessness or sleeplessness, an opiate 
may be given. 
When the febrile symptoms do not abate, as they ought, in the regular 
course of the disease, cathartics may be daily required to keep the bowels open. 
The most approved are the saline infusion of senna, or the black draught, the 
compound powder of jalap, combined with calomel and some aromatic powder, 
such as ginger. In this disease the bed-clothes ought frequently to be changed, 
and abundance of cool fresh air supplied to the apartment. When the state 
of the skin alone seems to keep up the febrile irritation, an antimonial opiate 
may allay irritation and procure sleep, after which a cathartic may be given 
with advantage in the morning. 
In the complications which sometimes ensue, such as inflammation of the 
throat and base of the tongue, opiates are found to be injurious. The general 
treatment must be by cathartics or purgative clysters, if swallowing is difficult. 
In the other inflammations, however, opiates are of the greatest service, pro- 
vided the symptoms be not of cerebral oppression. In bronchitis, nauseating 
doses of antimony every hour sometimes procure relief; and if relief does not 
follow in the course of thirty to thirty-six hours, doses of calomel and opium 
ought to be given every second hour till three doses have been taken, each 
consisting of two grains of calomel and half a grain of opium. If the symptoms 
are not then relieved, this remedy need not be carried farther. 
[Hebra's practice is to keep his patients in a warm bath, sometimes for sev- 
eral days. Dr. Stokes (Dublin Journal of Medical Sciences, January, 1872), 
mentions a case in which great relief from pain followed a warm bath, in 
which the patient was placed for seven hours. The antiseptic treatment by 
the carbolates seems entitled to consideration. Dr. Foot, of Dublin, has used 
the carbolate of sodium, in doses of thirty or forty grains, every three hours, 
with decided advantage. He found it to deodorize the faeces, lessen the ten- 396 
SPECIAL PATHOLOGY-SMALL-POX. 
dency to decomposition of the urine, and to destroy the peculiar nauseous 
smell from the skin. 
Laryngitis, so constant a complication in the confluent form, may be treated 
by sponging with sulphuric acid, or with a solution of carbolic acid, five 
grains of the crystallized acid to the ounce of water. If the mouth and lips 
are much swollen, these may be used as spray.] 
In the advanced stage of the secondary fever the strength of the system re- 
quires maintenance and support; because the abundant suppuration and ex- 
tensive cutaneous irritation combine to exhaust the strength, as shown by the 
weakened pulse, the dark and dry tongue, blueness, paleness, or coldness of 
the extremities. Tonics, stimulants, and generally nutritious diet, are now 
called for. Quinine, mineral acids, malt liquors, especially the light bitter ales, 
wine, and even brandy, may be demanded. [Quinine should be largely given 
not only for its tonic as its antiseptic effect.] The diet should consist of milk, 
strong animal broths, eggs, raw or lightly boiled, according to the discretion of 
the physician, regulated by the digestive powers of the patient. 
The development of a severe eruption on the conjunctiva is to be especially 
guarded against, by the assiduous employment of cold water applications, or 
by compresses moistened with a weak solution of corrosive sublimate (one grain 
to six ounces of water) (Niemeyer). 
To prevent the face from being seamed, scarred, or " pitted " by the sup- 
puration of the pustules, has taxed the ingenuity of physiologists and physi- 
cians. It has been stated that the influence of the atmospheric air is essential 
to the development of the pustules, and, accordingly, anything which would 
effectually exclude this influence would prevent the occurrence of a scar. But 
it is evident that the chance of scars can only be diminished by those means 
which are calculated to allay the general violence of the disease. When the 
eruption is severe, it is almost impossible to prevent the formation of " pits," 
because the depression results from the expulsion of a small slough ; and the 
more mild the suppurative inflammation can be rendered, so in proportion 
will the chance of " pitting " be diminished. 
The local means adopted to prevent "pitting" maybe shortly stated as 
follows: 
1. To open each individual pustule after suppuration has commenced. 
2. To cauterize the pustules with nitrate of silver. 
3. To employ both methods-that is, to open each of the pustules when it 
becomes vesicular, and introduce a strong solution of nitrate of silver into the 
cavity of the vesicle. At the end of a week scales fall off, and no pit is left. 
Or, lastly, to paint the face with a solution of nitrate of silver, in the propor- 
tion of one drachm of the nitrate to the ounce of water. 
4. The application of a mercurial plaster, with the view of producing reso- 
lution of the papulce. The preparation in use for this purpose at the Children's 
Hospital in Paris consists of 25 parts of mercurial ointment; 10 parts of yellow 
wax; 6 parts of black pitch. With this plaster the face is to be covered, and 
so to remain for several days. 
5. Sulphur ointment applied several times a day. ■ 
6. Calamine mixed with olive oil, to form a coherent crust (Bennett). 
7. Tincture of iodine, painted over with a brush. 
8. Saturated solution of gutta percha in chloroform (Drs. Graves and 
Wallace). 
9. To smear the face over with common olive oil. 
10. Skoda prefers compresses moistened with solution of corrosive sublimate 
(two to four grains in six ounces of water') to mercurial plaster, which induces 
too much elevation of temperature. 
11. Hebra recommends cold water compresses only. PREVENTIVE TREATMENT OF SMALL-POX. 
397 
All of these applications are for the most part applied to the face, the hands, 
and the arms only. 
[The tendency to pitting is in proportion to cutaneous vascularity and heat 
(Stokes). To prevent or lessen this (1) air should be excluded from the 
pustulation ; (2) it should be kept in a permanently moist state. To meet these 
indications, light poultices may be applied, or a mask of lint wet with glycerin 
and water, over which oiled silk is laid, will be generally successful. Dr. Foot 
recommends carbolic oil-for fine skins one part in seven, and for coarse skins 
one part in three, disguising the odor with oil of origanum, one drachm to 
eight ounces of oil.] 
The severity and the mortality of small-pox have led many to think of 
means by which the disease might be completely extirpated. This leads to 
the consideration of- 
2. The Prophylactic, Sanitary, or Preventive Treatment of Small-Pox. 
More than half a century ago it was generally taught, among English phy- 
sicians, that small-pox attacked the same individual only once in the course 
of life, and that its double occurrence in the same person was either very rare 
or next to impossible. The observations of Drs. Willan, John Thomson, Mr. 
Cross, Dr. Barnes, Dr. Craigie, and others since the time of these eminent 
physicians, lead to the following general conclusions: 
1. Small-pox, though in general attacking the same individual only once 
during the course of life, may, however, affect him a second and even a third 
time. 
2. This happens much more commonly when the first attack has been one 
of mild distinct small-pox than when it has been severe; and if the first at- 
tack has been one of confluent small-pox, it is rare for the same individual to 
have a second attack. 
3. It is established by numerous observations, that an attack of any one of 
the varieties which have been named spurious small-pox, or abortive small- 
pox, or chicken-pox, by no means secures the same individual from an attack 
of confluent small-pox at a subsequent period. 
4. Small-pox produced by inoculation does not necessarily secure the indi- 
vidual against an attack of small-pox induced in the natural way. 
5. Every previous attack, however, of small-pox, whether natural or inocu- 
lated, exercises some modification on that which succeeds. This modification 
may be various in degree, from very slight and almost imperceptible to very 
conspicuous and remarkable. In this modification the symptoms of eruptive 
fever may be mild and of short duration; and the eruption may consist of ves- 
icles or hard pustules, which disappear without suppuration. 
6. The most powerful modifying agent on the course of small-pox is the 
action of the cow-pox on the constitution, or the disease produced by the ap- 
plication of vaccine lymph to the exposed skin. The specific disease so in- 
duced, in a large portion of cases, not only renders the individual less likely 
to be affected by the variolous effluvia, but, if he is affected, changes very 
much the characters of the disease which may supervene. Though the fever 
which precedes the eruption in cases of this class be similar in form and equal 
in degree to that by which the inoculated small-pox is attended, the eruption 
is either papuliform or tuberculated, without much surrounding inflammation. 
A similar eruption is produced when vaccine and variolous matter are inocu- 
lated at the same time in the same individual; or when a person who is ex- 
posed to the variolous contagion has been inoculated with vaccine lymph early 
enough to mitigate, but not wholly to supersede, the eruption of small-pox. 
In such circumstances the vaccine lymph and variolous matter restrain and 
counteract the operation of each other on the system and on the skin. To 398 
SPECIAL PATHOLOGY-COW-POX. 
these eruptions of modified small-pox the general name of varioloid eruptions 
has been applied. 
7. Cow-pox destroys the susceptibility to inoculated small-pox almost en- 
tirely; but the susceptibility to the natural disease, or that by inhalation, it 
does not entirely extinguish. This susceptibility, however, it diminishes in a 
much greater degree and much more effectually than inoculated small-pox 
does. 
8. The susceptibility to second attacks of small-pox,* and attacks of small- 
pox after vaccination, is principally favored by the existence of an epidemic 
constitution of the atmosphere, and by the circumstance of early life, or the 
age below ten years. If no epidemic influence exists, the occurrence of second 
attacks of the disease may not be observed for a long series of years. But if, 
on the other hand, the atmosphere should possess or acquire an epidemic or 
variolous constitution, then neither the circumstance of a previous attack of 
small-pox, nor vaccination, can insure many of those under ten years of age, 
and not a few between that and thirty, from attacks of small-pox. 
The preventive management of small-pox consists,-(1.) In the artificial 
production of the disease by inoculation or artificial variolation; (2.) In the 
modifying and protective influence of vaccination. 
Inoculation consists in the application of small-pox matter or virus to the 
surface of the corium, exposed by a puncture or scratch. The result is a local 
inflammation similar to small-pox, attended with an eruption and a fever, 
generally milder in form than small-pox acquired by breathing an atmos- 
phere contaminated with the specific poison of the disease; and which thus 
passes through the mucous membrane to infect the blood. This is called the 
" natural way " of contracting small-pox; and the course of the disease so 
induced has been already noticed. For obvious reasons, the operation of inocu- 
lating the poison of small-pox has been rendered illegal in this country, and 
the practice of vaccination has been attempted to be enforced by law. What 
remains to be said about inoculation will be considered under the next topic. 
COW-POX. 
Latin Eq., Vaccinia; French Eq., Vaccine; German Eq., Kuhpocken; 
Italian Eq., Vaccina. 
Definition.- Cow-pox is the product of a specific and palpable morbid poison, 
which is reproduced in the contents of the cow-pox pustule, and multiplied during 
the course of the malady in the cotv or in the human being. After a definite 
period of incubation (from the time that the specific virus is artificially implanted), 
a specific nodule or papule forms, which, at the point of inoculation, passes through 
the stages of vesicle, pustule, scab, and desiccation. On the fifth or sixth day it 
changes to a vesicle, which, by the eighth day, has attained the size of a lentil, hav- 
ing a central depression-an umbilication with dissepiments. On the ninth day 
the contents become cloudy and whey-like, and a broad dark-red halo becomes de- 
veloped around the vesicle. On the tenth day the contents are purulent; after 
which the pock begins to dry up, and the scab falls off towards the end of the third 
week or later, leaving a white cicatrix, with characteristic round pits over its sur- 
face. During the maturation of this specific lesion the adjoining lymphatic glands 
swell; a febrile state is induced, denoted by increase of temperature (104° Fahr.), 
constitutional disturbance of functions, acceleration of the pulse (which, to a cer- 
tain extent, has been observed to continue persistent in some cases); and a general 
lichenous, roseolar, or vesicular eruption may make its appearance on the trunk and 
limbs. The disease runs a definite course, affords immunity from another attack 
* The average number of second attacks of small-pox seems to be one per cent. (R. 
Acad, of Med., Marseilles, 1828; and B. and F. Med.-Chir. Review, Jan., 1848, p. 74.) PATHOLOGY OF COW-POX. 
399 
(for a considerable time at least), and exercises (during that period) a protective 
influence from human variola. 
Pathology and Symptoms.-The importance of a comprehensive knowledge 
of the pathology of variolous diseases generally, and of cow-pox in particular, 
lies in the relations of this latter disease to small-pox and to vaccination. Dr. 
Jenner named the disease " vario Ice vaccince," implying thereby that one genus 
at least of the animal creation is liable to a disease of a kindred nature with 
that which attacks man. The disease in the cow was observed to be generally 
mild ; in man it was observed to be most pestilential and sometimes fatal. It 
was observed, also, that the disease was communicable from the cow to man, 
and that persons so affected were protected from subsequent attacks alike of 
small-pox and of cow-pox. Dr. Jenner believed that the two diseases were in 
reality identical. It has now been shown by unquestionable evidence that 
cattle and horses have for centuries been known to be affected with a species 
of small-pox or variola. Every different writer who has seen the disease has 
given it a similar name. Previous to 1745 it was known and described in 
Italy (Fracastorius, Lancisi, Ramazini) as a malignant disease which 
destroyed cattle almost as extensively as small-pox did the human race. It 
was first observed in this country in 1745, and again in 1770, when it appeared 
among the horned cattle with so much severity that His Majesty George III, 
in his speech from the throne, at the opening of Parliament on the 9th of 
January of that year, called upon the Houses of Parliament to take the sub- 
ject into their serious consideration. The disease continued with more or less 
violence till 1780; and it was no doubt the expiring embers of this epizootic 
which Dr. Jenner found in Gloucester, and made the basis of his investiga- 
tions during that and subsequent years. Dr. Layard described the disease 
amongst the cattle in England, in that year, in a paper communicated to the 
Royal Society ; and he mentions that inoculation from cow to cow was success- 
fully practiced, to mitigate the severity of the disease; just as Mr. Simonds, 
of the Veterinary College, London, in 1862, successfully practiced inoculation 
of the variolous disease from sheep to sheep, or lamb to lamb, throughout the 
counties of Wilts, Hants, and Dorset, when ovine small-pox was epidemic. 
The great increase of mortality from small-pox among human beings which 
occurred during the latter part of the last century is a fact of some importance 
in connection with the epizootic disease; for at other times and places it has 
been observed that when the cattle were scourged by the variolous disease, 
mankind were in like manner great sufferers from a similar epidemic. In the 
interesting lectures "Introductory to the Study of Fever," by the late Dr. 
Andrew Anderson, of Glasgow, we are told that while small-pox was raging 
with great violence at St. Jago, on the west coast of New Granada-to which 
a town named David, in Chiriqui, was situated about sixty or seventy miles 
to leeward-a few days (four or five) before the disease appeared in this latter 
town the small-pox had attacked and destroyed many monkeys in the forest. 
Dying and dead monkeys were seen on the ground covered with the perfect 
pustules of small-pox ; and several sick monkeys were seen on the trees, mop- 
ing or moving about in a sickly manner. In the course of a fortnight one-half 
of the inhabitants of the town of David were stricken with small-pox (Ander- 
son, p. 70). 
It is also within the experience of many medical men, that during the 
prevalence of small-pox, cattle are apt to become affected with cow-pox. 
Horses, as well as cows and sheep, are liable to the affection ; and the coun- 
tries where the disease of late years has been found are those where it has 
formerly been known to have existed among cows or horses in its most viru- 
lent form. During the epidemics of small-pox previous to 1840 the variolous 
affections among the cows of the country were more observed than at any 
period for many years. In the dairies of Suffolk, of Gloucestershire, Dorset- 
shire, and Buckinghamshire, the disease has prevailed not only during epi- 400 
SPECIAL PATHOLOGY-COW-POX. 
demic small-pox, but when no cases of variola were known to exist in the 
immediate neighborhood. There are good grounds for the belief that the im- 
palpable emanations-the specific effluvia-from cases of small-pox in human 
beings, have been sufficient to communicate the variolous disease to cows. Mr. 
Ceely gives a most interesting history of such an occurrence in the tenth vol- 
ume of the Transactions of the Provincial Medical and Surgical Association. 
At the village of Oakley, about sixteen miles from the town of Aylesbury, 
small-pox had been epidemic from June to October, 1840. Two cottages, in 
which three persons resided during their illness, were situated, one on each of 
two sides of a long narrow meadow, comprising scarcely two acres of pasture 
land. One of these three patients, though thickly covered with pustules of 
small-pox, was not confined to her bed after the full development of the erup- 
tion ; but frequently crossed the meadow to visit the other patients-a woman 
and a child-the former of whom was in great danger, from the confluent 
malignant form of the disease, and died. According to custom, she was buried 
the same evening; but the intercourse between the cottages across the meadow 
was still continued. On the day following death the wearing apparel of the 
deceased, the bed-clothes and bedding of both patients, were exposed for puri- 
fication on the hedges bounding the meadow; the chaff of the child's bed was 
thrown into the ditch ; and the flock of the deceased woman's bed was strewed 
about on the grass over the meadow, where it was exposed and turned every 
night, and for several hours during the day. This purification of the clothes 
continued for eleven days. At that time eight milch cows and two young 
heifers (sturks) were turned into this meadow to graze. They entered it every 
morning for this purpose, and were driven from it every afternoon. Whenever 
the cows quitted the meadow the infected articles were again exposed on the 
hedges, and the flock of the bed was spread out on the grass, and repeatedly 
turned. These things remained till the morning, when the cows were read- 
mitted, and the contaminated articles were supposed to be withdrawn. It 
appears, however, that the removal of the infected articles was not always ac- 
complished so punctually as had been enjoined, so that, on one occasion at 
least, the cows were seen in the midst of them, and licking up the flock of the 
bed which lay on the grass. These cows were in perfect health when first put 
out to graze in this meadow; but in twelve or fourteen days five (out of the 
eight) milch cows appeared to have heat and tenderness of the teats. The 
teats became swollen, and small hard papules could be distinctly felt upon 
them, as if imbedded in the skin. These papules daily increased in magnitude 
and tenderness; and in a week or ten days they rose into blisters (vesicles), 
passing into brown or blackish scabs. When the teats were in this condition, 
and very tender, constitutional symptoms of ill-health became developed. 
Sudden sinking or loss of milk, drivelling of saliva from the mouth, frequent 
inflation and retraction of the cheeks, staring of the coat, " tucking up of the 
limbs," " sticking up of the back," and rapid loss of flesh, were tbe appear- 
ances which even the peasants themselves were able to appreciate. By the 
middle of the third week the pustules were mature, and the crusts and loose 
cuticle began to be detached. The simultaneous occurrence of the disease on 
all the animals increases the probability of the operation of one common cause. 
The whole of the cows were certainly affected within less than three days of 
each other; and another circumstance requires particular notice, namely, the 
occurrence of the disease in a young heifer (sturk), to which of course the 
disease could not have been communicated by those casualties which com- 
monly propagate the vaccine variola amongst milch cows. The cause which 
originated the disease amongst them at the same time affected the young heifer, 
which hitherto had not been considered liable to the vaccine disease, simply 
because no one had seen the animal affected by it. Now it is known, both in 
this country and in Germany, to be liable to the disease. 
The proprietor of the animals referred to in this narrative had the disease' PATHOLOGY OF COW-POX. 
401 
communicated to himself. He had never suffered from small-pox nor the 
vaccine disease; and it was his own spontaneous conviction " that his cows had 
been infected from human small-pox -effluvia," to which undoubtedly they had 
been exposed. He had not the remotest idea of the medical theories concern- 
ing the nature of the disease, and consequently had no prepossession in favor 
of the opinion he thus spontaneously expressed. His cattle had hitherto been 
in good health, and no vaccine variola had been known in the vicinity. 
Human small-pox has also been communicated to the cow by direct im- 
plantation of the specific virus from man. The efforts at first were numerous 
and unsatisfactory to inoculate directly the cow with human small-pox; and 
the experiment is said to have first succeeded at the Veterinary College in 
Berlin, so early as 1801. M. Viborg, of Copenhagen, about the same period 
communicated the disease to dogs, apes, and swine. In 1807, Gassner im- 
parted small-pox to the cow by inoculation. In 1830 or 1831, Dr. Sonder- 
land, of Bremen, communicated the disease to cows, by simply covering the 
animals with sheets and blankets on which persons suffering from small-pox 
had lain. In 1836, Dr. Basil Thiele, of Kasan, in South Russia, successfully 
inoculated some cows on the udder with the virus of human small-pox. Vesi- 
cles were produced bearing all the characters of the true vaccine vesicle in 
those animals. The lymph so produced from the variolation of the cow con- 
tinued to retain the specific properties of the vaccine variola throughout sev- 
enty-five successive transmissions in the human subject. In 1838, M. Thiele, 
repeated this interesting experiment with a similar success. It would there- 
fore seem that the constitution of the cow has the power of assimilating, of 
modifying, and of mitigating the human variolous virus, and of stamping it 
with the properties of the vaccine variola. Dr. Ceely, of Aylesbury, twice 
succeeded in accomplishing this object (so important pathologically), after 
many fruitless trials. The interesting papers by him in the eighth and tenth 
volumes, and the Reports of the Vaccination Section of the Provincial (now 
British) Medical Association in their Proceedings for 1839 and 1842, should 
be studied by every student of Medicine. The main points of the statement 
here given are taken from these sources. Very recently (1860) Martin inocu- 
lated some variolous matter, taken from a pock upon the body of a man who 
died of variola, into a cow's udder, and subsequently vaccinated about fifty 
persons with the matter derived from the cow. Most of those so inoculated were 
attacked with variola, and three died {Boston Med. Journal, 1860 ; New Syden. 
Society Year-Book for 1860). It would have been better, or at least more 
judicious, to have chosen a milder case than a fatal one to have inoculated 
from. Mr. Ceely has also often recommunicated the vaccine disease from 
man back to the cow (retro-vaccination, as it has been called); and he has 
observed that good human lymph, when re-transmitted in this manner, loses 
some portion of its activity. The phenomena appear later, smaller vesicles 
are produced, but ultimately, after successive re-inoculations on man, it regains 
its activity. Human small-pox has also been transmitted through the horse 
to the cow, and so to the child in the form of cow-pox (Fletcher). 
As the first origin of these specific poisons is as yet unknown, it cannot be 
now definitively determined whether man first had the disease communicated 
to him from the animal creation, or whether the lower animals, such as horses 
or oxen, had the disease communicated to them from man. The existence of 
small-pox in man is recorded in China as early as 1122 years before Christ 
(Moore). And it is certain that when variolous disease appears among the 
lower animals in a malignant form, it is capable of producing, by inoculation,, 
a disease of similar severity in man, if he has not already suffered from a 
similar affection; and that the direct inoculation of the cow with human 
small-pox produces a mild and mitigated form of disease-that such disease- 
being again reproduced in man by inoculation from the mitigated disease of 
the cow, accords entirely in its character, in its progress, and in its protecting 402 
SPECIAL PATHOLOGY-COW-POX. 
influence with the variolce vaccince, as described by Dr. Jenner. These and 
similar facts seem to lead to the conclusion that small-pox and cow-pox are 
not dissimilar diseases, but are identical in their nature. 
There are some remarkable circumstances which must at once arrest the 
attention of the student who carefully studies the accounts given of the experi- 
ments on men and animals, from which many of these statements are deduced. 
First, There seems to have been great uncertainty and difficulty often attend- 
ing the actual attempts to transfer the specific virus of these eruptive or vario- 
lous diseases from one animal to another. The very interesting experiments 
of Ceely, and of Thiele and others, demonstrate this in a remarkable manner. 
Second, These experiments show the marked improvement which sometimes takes 
place in the energy, and therefore in the quality of the specific virus, by subsequent 
removes or inoculations, in animals of the same kind, after the virus had been suc- 
cessfully implanted in one of them. This energy and improved quality was 
shown in the more perfect development of vesicles, and in the more active 
manifestations of the primary and secondary symptoms. The subsequent 
inoculations of such improved lymph seem to produce less severe and less 
dangerous local results-the virus seems less acrid, less virulent, and less mis- 
chievous-having apparently acquired increased specific activity combined 
with mildness of action, and a greater susceptibility of transmission from one 
animal to another of the same kind. 
Keeping, therefore, these facts in view, the history of the remarkable epi- 
zootic of variolce ovince which made its appearance in August, 1862, in some 
of the largest breeding flocks of sheep in the West of England, is of great 
interest to the pathologist. This variolous disease of the sheep allies itself 
very closely with small-pox in man, with cow-pox amongst cattle, and with 
the vesicular eruptive diseases of the horse, but undoubtedly modified by the 
constitution of the sheep, just as the variola of man is known to be modified 
or transformed by the constitution of the cow into the variolce vaccince of that 
.animal. 
The ovine variola is known as the clavelee of the French ; and although this 
kind of rot was not observed in this country till 1847, when it was imported 
from Spain, yet it is a disease by no means uncommon as an epizootic in the 
flocks of Italy, France, and Moravia. In 1803 the mortality was considerable 
in Moravia; but by a timely inoculation with the virus of the disease, the re- 
maining part of affected herds was preserved. The artificially affected animals 
seemed to pass through a milder disease. To this kind of inoculation the name 
of " clavelization" has been given, from clavelee, the French word for the tag- 
sore or rot. This variolous disease in sheep assumes one of two forms, namely, 
(1.) A virulent or malignant form; and (2.) A benign form. The virulent 
form (which would seem to have been the form epizootic in England) never 
produces pustules; and specific virus for safe inoculation (clavelization) can 
only be got from the benign form of the disease. When the disease is viru- 
lent, the sheep lose their eyes, their wool falls off, and their skin cracks in a 
zigzag manner. Their nostrils are so full of a fetid discharge that the shep- 
herds are under the necessity of constantly syringing them with medicated 
lotions, to prevent suffocation. When the disease is benign, genuine pustules 
form, and every pustule, after the scab falls off, leaves a cicatrix in the form 
of a pit. On this cicatrix the wool never grows again. Hence it can always 
be told what sheep have undergone the variolous disease, as easily as it can be 
seen that a human being has had small-pox, from being marked with the pits 
or cicatrices. 
The prevention or mitigation of this disease among sheep is a most impor- 
tant object in a sanitary point of view. 
In 1803, Dr. De Carro, of Vienna, tried the effects of the inoculation of 
variolce vaccince, but without success. The inoculation only produced small 
local sores. It is said, also, that this sheep-pox cannot be communicated PATHOLOGY of cow-pox. 
403 
directly to the cow, nor to children (Ceely, Simonds). Other observers 
state, however, that it is so communicable, and that ovination is protective 
against small-pox (Saccho). The ovination, or inoculation of the disease from 
sheep to sheep, was first proposed by Challette in 1762, and has been yearly 
practiced since that time in many parts of Italy, Prussia, Austria, and France. 
The practice of inoculation from sheep to sheep was practiced in England by 
Professor Simonds during the recent epidemic. Results accrue to sheep, from 
the communication of the disease to them by inoculation, not less beneficial 
(compared with the fatal effects which followed when they became affected 
with the disease in the "natural way") than the beneficial effects that accrued 
to man when small-pox was communicated to him by inoculation-as it rightly 
was-before the protective powers of vaccination were known. 
The ovine variola has been ascribed by some farmers to the communication 
of the virus from an eruptive disease of the horse (De Carro, Ring). Fontan 
relates that some mares being affected with a pustular eruption, the matter 
from the pustules was inoculated on the teat of a cow, where it produced 
several fine pustules. From these several infants were vaccinated, with the 
result of producing perfectly characteristic vaccine vesicles. Thirty infants 
have been vaccinated from this source at Toulouse, and in all the result has 
been most satisfactory (Z' Union Med., 1860; New Syden. Society Year-Book, 
1860). If this can be definitively established, then the successful inoculation 
of some animal, other than the sheep, with the virus from the specific eruptive 
disease of the horse, may give such energy and, at the same time, mildness to 
the morbid poison, by subsequent removes, that the implantation of the new 
virus (equination) may perhaps be followed by the same beneficial results to 
sheep, in respect of the malignant variolous disease to which they are liable, 
that vaccination has conferred on man in respect of small-pox. The question, 
then, at once suggests itself: " Has human small-pox ever been communi- 
cated to sheep, with the view of obtaining a modified lymph which may confer 
protection on them from the variolous disease to which they are liable?" 
From analogy, may we not indulge the hope that the practice of inoculating 
sheep from the small-pox of man might induce as mild and modified a disease 
in them, and prove as protective to them, as vaccine variola, through vaccina- 
tion, has been to man ? Or, having communicated the human variola to cows 
(as the experiments of Ceely and Thiele demonstrate that such inoculation 
may be effected), might- not sheep be tried with the resulting virus as a pro- 
tective agent ? The vesicular eruptive diseases of dogs, as well as of horses, 
should be similarly inquired into and experimented with, seeing that dogs are 
so much associated with sheep. 
The outbreaks of the variolous diseases amongst cattle and sheep seem to 
follow similar inexplicable paths to those which small-pox amongst human 
beings is observed to follow. Occasionally the disease is epizootic (equivalent 
to epidemic amongst men), or prevalent at the same time in several farms at 
no great distance. Cases spring up like small-pox, now and then, which 
appear to be solitary, and the source of which cannot be traced. It is rare, 
indeed, that the solitary cases of small-pox in human beings can be traced to 
a communicating source. In oxen it may be seen sometimes at contiguous 
farms; at other times, one or two farms, apparently similarly circumstanced 
amidst the prevailing disease, entirely escape its visitation. Sometimes it is 
introduced into a dairy by recently purchased cows. On the other hand it 
has been undoubtedly communicated to cows from the vesicular disease of the 
horse, through the hands of the common attendant on both animals. There 
can be no doubt, also, that the disease often exists, although it is not observed ; 
for the disease being mild, and the tempers of the animals good, little notice 
is taken of tenderness in milking, and so the existence of disease escapes 
detection. 404 
SPECIAL PATHOLOGY COW-POX. 
There are spurious forms of the disease, which it is very necessary to be able 
to distinguish. 
In the true cow-pox in the cow there is very slight manifestation of fever 
or constitutional disturbance. The secretion of milk may diminish ; but the 
animal continues to feed and to graze very much as usual. The local affection 
may be so mild that a single vesicle only may appear upon the udder; but 
where the udder is voluminous, flabby, and pendulous, and uncovered with 
hair, with a corrugated, thin, or fissured skin, then there is apt to be a copious 
eruption. The disease is very readily propagated from cow to cow by the 
milkers. It is also said to be communicated in the natural way; but the evi- 
dence on this point is not sufficient; at least there is no evidence to show that 
a healthy human being, or a cow, ever becomes infected with cow-pox by 
entering the atmosphere where a person or beast is suffering from vaccinia. 
The local symptoms of cow-pox in the cow are evinced by heat and tender- 
ness of the teats and udder for three or four days, followed by irregularity and 
nodular hardness of the surface, especially about the bases of the teats and the 
adjoining part of the udder. The nodules or papules assume a red hue when 
about the size of a vetch or pea, and are quite hard. In three or four days 
more they increase to the size of a horse-bean, milking becomes painful to the 
animal, and the pimples become vesicles, which are then apt to be broken by 
the hands of the milkers, giving rise to troublesome and dangerous sores on 
the udder and teats of the cow, and communicating the disease to the milker, 
if he is not already protected by having had the disease before. If the vesicle 
remains unbroken, it becomes a globular, oval, and ultimately a pointed (acu- 
minated) pustule. A central depression, with a marginal induration, is the 
form ultimately assumed ; and when punctured towards the centre, the vesicles 
yield a more or less viscid amber-colored fluid. Dark-brown or black, solid, 
uniform crusts eventually form on the site of the vesicles. Some of these 
crusts may be seen semi-detached, others entirely so, and exposing a raw sur- 
face with a slight central slough. The forms of the crusts are either circular 
or oval, some flatter, and others unguiform, some thin, and more or less trans- 
lucent. These varied appearances are seen in all stages at the same time, 
indicating the formation of new crops of vesicles at different periods. The 
period of incubation, after casual communication of the disease, seems to be 
from six to nine days, although it is said papules may be felt under the cuticle 
about the fifth day. When the vesicles are fully mature, they may measure 
from eight to ten lines in the largest diameter; the centre and edges of the 
intumescent margin being of a deep blue or slate-color, and the surrounding 
areola of a pale rose-color, and seldom more than four or five lines in depth, 
the integuments under it being deeply indurated. The lymph contained in 
the vesicle is now so copious that the cuticle over the central depression ap- 
pears raised up by it, and so gives rise to a globular or cone-like vesicle; or 
it spontaneously ruptures, when the lymph freely flows out, and concretes into 
a clear amber-colored crust or scab. 
If undisturbed, this crust or scab gradually becomes thicker, darker, and 
more compact, till the thirteenth or fourteenth day, and spontaneously sepa- 
rates about the twentieth or twenty-third day. A cicatrix or pit is thus left, 
which is shallow, smooth, oval, or circular, of a pale rose or whitish color, 
with some traces of induration surrounding it. The anatomical structure of 
the vesicle seems to be precisely similar to that of small-pox in man, as shown 
now by many observers (Gendrin, Ceely, and others). The cow-like 
children and the young of other animals, particularly high-bred dogs-is 
subject to a purely vesicular eruption, which makes its appearance about the 
ninth or tenth day of the vaccine disease. The vesicles of this eruption, 
within twenty-four hours, contain a pellucid serous fluid, raising the epidermis. 
On the following day they become turbid, the cuticle collapses or bursts, and NATURE OF PRIMARY VACCINE LYMPH. 
405 
a thin, brittle, flimsy crust forms, and speedily falls off. Successive crops 
continue to form and desiccate for three or four weeks. 
Primary Vaccine Lymph.-To procure primary liquid vaccine lymph 
direct from the cow, in a condition fit for use, is a task of no ordinary diffi- 
culty. Primary crusts should be sought for on the lower part of the udder 
and around the base of the teats; and during a search for these it is not im- 
probable that smaller vesicles of later growth may be found to yield efficient 
lymph. The best lymph is to be obtained from perfect vesicles, before they 
begin to point. After this period it is less to be depended on, particularly if 
very abundant, thin, or discolored. Pointed vesicles, when broken by vio- 
lence, are rarely to be relied on. Entire unpointed vesicles, or vesicles with 
central crusts, should be sought for on parts where they are least exposed to 
injury-namely, on the lower and naked parts of the udder and adjoining 
basis of the teats. It is impossible to exercise too much delicacy in the pro- 
ceeding. The puncture to liberate the lymph should be made with a sharp 
lancet, as near the centre of the vesicle as possible; and the epidermis may be 
gently raised to a moderate extent around the discolored or most depressed 
part. Slight pressure with the blade of the lancet, or between the thumb and 
finger, will enable the operator to charge a few points or capillary tubes with 
the slowly exuding lymph. Punctures at the elevated and indurated margin 
of the vesicle are utterly useless. They only give vent to blood. Vesicles on 
which the central crust has begun to form are the most productive, particu- 
larly if the crust be small, and the margin of the vesicle be tender, hot, and 
tumid ; and small superficial vesicles are often more yielding than contiguous 
larger vesicles, which are more deeply seated or confluent. 
Useful substitutes for liquid lymph, capable of communicating the vaccine 
disease, are-(1.) Amorphous masses of concrete lymph, found upon or in close 
proximity to broken vesicles. They ought to be colorless, like crystals of 
white sugar-candy; or of a light amber hue, resembling fragments of barley- 
sugar. (2.) Central crusts, irregular, rough, and more or less conical; the 
more transparent and nearer a dark-brown hue the better. (3.) Vesicular 
crusts or desiccated vesicles. These crusts should be carefully removed by the 
milkers before they are casually removed or spontaneously fall; and those 
only of primary formation, which are, as it were, the mould of a vesicle, of a 
dark-brown translucent appearance, should be retained. These three dry con- 
ditions of the specific vaccine virus may be reduced to a liquid state at any 
time for use. Glycerin is said to be the best solvent for such solid conditions 
of the lymph, which ought to be reduced to powder before the glycerin is 
added (Collins, Boston, Med. and Surg. Journal, 1858). 
Vaccination.-It is now (1871) at least seventy-one years since Jenner first 
promulgated his discovery to the world, that the eruptive vesicular disease 
which has now been described as occurring on the udders and teats of the cow, 
and which he named the cow-pox, was communicable directly to the human 
being, and thus conferred protection from the small-pox, so fatal to man. 
The operation for thus ingrafting the cow-pox on the human being has been 
named " vaccination and its discovery still remains one of the most inter- 
esting facts in the history of Medical Science. When an obscure apprentice 
with a surgeon at Sodbury, near Bristol, Dr. Jenner first caught a glimpse of 
this great truth, which he thoroughly investigated amongst the expiring em- 
bers of that epizootic disease which laid waste the herds of this country 
towards the end of the last century. He did not suffer the spark to be lost 
in the flame it had served to kindle. Amongst the gossip of the cow-herds he 
had heard of the vague, obscure, but popular belief regarding the possible 
communication of cow-pox to the milkers of the cows, and the protection from 
small-pox which the cow-pox conferred-a belief which undoubtedly prevailed 
in the rural districts of Gloucestershire, and, at the same time, curiously 
enough, on the continent of Europe, in some districts round Gottingen. These 406 
SPECIAL PATHOLOGY - COW-POX. 
things Jenner mentioned to the famous John Hunter, at the time he was an 
apprentice to that eminent surgeon ; but John Hunter, otherwise sagacious 
and far-sighted, pooh-poohed the notion as vague and improbable. Neverthe- 
less, Jenner had determined to examine into the truth of the tradition, and he 
commenced his earnest and painstaking investigations as soon as he had estab- 
lished himself as a surgeon at Berkeley, in Gloucestershire. In June, 1798, 
he published his observations in the form of a thin quarto, of scarcely more 
than seventy pages, dedicating it to his friend, the celebrated Dr. Parry, of 
Bath. Jenner seems to have felt almost a holy reliance in the truth of his 
great discovery; and in the face of much foolish opposition he modestly con- 
tinued to prosecute his inquiry, " encouraged," as he said, " by the hope of its 
becoming beneficial to mankind." Its importance to the welfare of the human 
race has since been clearly demonstrated ; and the acute observation of Jen- 
ner himself has been abundantly fulfilled-namely, that the keenest of all 
arguments for or against the practice of vaccination will be those which are 
engraved with the point of the lancet. We have, indeed, in this country, paid 
but tardy homage to his memory ; nevertheless, he has imprinted for himself 
imperishable "footprints on the sands of time," which wave after wave of 
scientific research appears only to deepen and to make more distinct. He has 
not only pointed out the means of subduing a loathsome disease, but the health 
of all civilized communities has improved; and, in proportion as vaccination 
has been efficiently carried on, the frequency of epidemics has been diminished, 
and the duration of human life has been extended. 
The subject of vaccination is one which demands a careful study, alike in 
its pathological and in its sanitary relations. Questions of great national 
importance are concerned; and the following account is mainly given from 
a notice of the subject, written by the author, in the pages of the Medico- 
Chirurgical Review for 1857: 
In 1841 the Vaccination Act was passed, which rightly made the practice 
of inocidation unlawful. In 1853 another act was passed, with the view of 
rendering the practice of vaccination compulsory,-an act which is known as 
Lord Lyttleton's Vaccination Act. During the interval between the first and 
second reading of the bill in the House of Commons, " The Small-Pox and 
Vaccination Committee of the Epidemiological Society completed a report on 
the prevalence and mortality of small-pox, and of the means taken to guard 
against it through vaccination." The conclusions they arrived at were deduced 
from the largest and most accurate mass of statistical evidence which had 
ever been brought to bear upon the question, and were eminently calculated 
to encourage Her Majesty's Ministers to pass an efficient measure to compel 
vaccination. A most valuable pamphlet was afterwards published by Dr. 
Seaton, which demonstrates the truth in a still more forcible manner, as to 
the protecting and.modifying influence of vaccination in small-pox. To this 
belief, indeed, the general assent of the medical profession appears to have 
been given more than half a century ago. Then, it would seem to have been 
all but unanimous; and now, one would think, at first sight, that it were 
almost an insult to human understanding to be obliged to collect statistics to 
prove that vaccination confers a large exemption from attacks of small-pox, 
and almost absolute security against death from that disease. But so it is, 
and independently of the information which such statistical inquiry is calcu- 
lated to convey to those who advise our lawgivers and public administrators, 
the inquiry is eminently useful in relation to everything which bears on the 
nature of vaccine and variolous disease. The general ignorance of the com- 
munity, and especially the prejudices of the lower orders, and not a few (even 
medical men) who ought to know better as to the value, the aim, and the 
object of vaccination, is lamentably great, and has still to be overcome. More- 
over, the highest medical authorities of late years recommend that all views 
and facts put forward as objections to vaccination should be rigorously inquired NATURE OF VACCINATION. 
407 
into, and that there should be published from time to time a true account of 
such inquiries, with an elucidation of what has seemed doubtful and contra- 
dictory (Sigmund, Alison). 
It is now well known that Lord Lyttleton's Vaccination Act (1853) has 
proved but a very imperfect measure-a piece of legislation which has fallen 
very far short of accomplishing all that is yet required. The inefficiency and 
imperfect working of the Act has been fully shown,-(1.) In the Reports of 
the Registrar-General for 1854; (2.) By the medical profession generally; 
(3.) By the medical registrars in particular; (4.) By the public, as expressed 
now and again in the newspapers of the day. To this state of things we owe 
a most valuable work on vaccination, written by the indefatigable medical 
officer (John Simon, F.R.S.) of the then (1857) General Board of Health. 
The aim of this publication was to lay before the Board such medical facts 
and considerations as might assist in estimating the hygienic value of vacci- 
nation, and the strength of any objections which may have been alleged against 
its general adoption. This work is especially valuable, because it brings 
together a body of evidence down to the day of its publication-evidence of a 
pathological and statistical kind-such evidence as Jenner would have rejoiced 
to see-records which have been engraved by the lancet's point. But evidence 
of the inefficiency of the Vaccination Act of 1853 still continues to be appar- 
ent, as may be seen from the yearly reports of the medical officer of the Privy 
Council. During three or four years previous to 1860, Mr. Simon writes, that 
" sometimes in one set of places, and sometimes in another, there have been 
occurring, almost generally throughout England, epidemics of small-pox more 
or less considerable." To such an extent has this been the case, that, in 1860, 
the Lords of Her Majesty's Most Honorable Privy Council deemed it nec- 
essary, with reference to local outbreaks of this disease, to enter into corres- 
pondence with the authorities responsible for public vaccination in several 
Unions of England where small-pox had been prevalent. Some of these dis- 
tricts were specially visited by competent medical officers, and in two adjoin- 
ing Devonshire Unions it was ascertained that the diffusion of small-pox had 
actually been to some extent wilfully promoted by the illegal practice of Inocu- 
lation ! Alarm was of course justly excited among educated persons in the 
endangered places, by the knowledge that this offence was being committed ; 
and in one case, where there was reason to believe that inoculation had been 
the cause of death, Secretary Sir George C. Lewis offered a reward of £50, to 
be paid to any person not actually concerned in the offence, who would give 
information and evidence leading to a conviction of the offender. 
The unsatisfactory working of the Vaccination Act of 1853, now amply 
proven, has led to the promulgation of an Order of the Privy Council (of date 
December 1, 1859), for the improvement of public vaccination. Their Lord- 
ships have seen fit to direct the commencement of a systematic inspection, 
with reference especially to the operation of vaccination, and its efficiency in 
Unions where the amount of infantine vaccinations, compared with the number 
of births, appeared to be especially low. These inquiries continue to show 
that the present law, " to extend and make compulsory the practice of vacci- 
nation," is so imperfect as to be almost inoperative; and the systematic inspec- 
tions instituted seem to have been so useful in promoting vaccinations, that 
their Lordships propose to continue them throughout all the Unions of Eng- 
land. 
The present position of our knowledge regarding vaccination is based upon 
evidence which demonstrates,-(1.) The protective influence of vaccination; and 
(2.) The causes which have combined to impair its protective power. Of these 
in their order. 
I. Of the Protection conferred by Vaccination-its Nature, and the Evidence 
of its Existence. 
The main features of the reports and works already mentioned amply illus- 408 
SPECIAL PATHOLOGY'-COW-POX. 
trate how small-pox diminishes in its mortality in proportion as efficient 
measures are adopted to insure perfect vaccination. To demonstrate this 
statement, the progress of vaccination in Great Britain and in Germany has 
been compared as to its influence on mortality generally; and more particu- 
larly, it has been shown, by comparing the statistics of vaccination from vari- 
ous German states with similar statistics from different districts in Great 
Britain and Ireland, that where vaccination is most perfectly carried out, 
small-pox is least mortal. The following are the general results which the 
Committee of the Epidemiological Society arrived at: 
1. To prove the influence of vaccination in England, it is shown that out 
of every 1000 deaths in the half century from 1750 to 1800 there were 96 
deaths from small-pox; and out of every 1000 deaths in the half-century from 
1800 to 1850 there were only 35 deaths from small-pox. 
2. To prove the influence of vaccination on the Continent, it is shown that 
in various German states sufficient evidence can be obtained to show that out 
of every 1000 deaths before vaccination was used, 66.5 were deaths from 
small-pox; but that out of every 1000 deaths after vaccination came into use, 
the deaths from small-pox were only 7.26. 
3. To prove that in countries where vaccination is most perfectly carried 
out small-pox is least mortal, it is shown that- 
(a.) In this country, where vaccination has been voluntary, and frequently 
neglected, the deaths from all causes being 1000, the deaths from small-pox 
were as follows: 
London, . . . . .16 
Birmingham, .... 16.6 
Leeds, ..... 17.5 
England and Wales, . . 21.9 
Perth, . . . . .25 
Paisley, . . . . .18 
Edinburgh, .... 19.4 
Glasgow,* . . . . .36 
Galway,* . . . . .35 
Limerick,* . . . .41 
Dublin, ..... 25.6 
Connaught,* . . . .60 
(6.) In other countries, where vaccination has been more or less compulsory, 
the deaths from all causes being 1000, the deaths from small-pox were as 
follows: 
All Ireland, .... 49 
Westphalia, .... 6 
Saxony, . . . . .8.33 
Rhenish Provinces, . . 3.7 
Pomerania, .... 5.25 
Lower Austria, . . .6 
Bohemia, . . . . .2 
Lombardy, 2 
Venice, ..... 2.2 
Sweden, . . . . .27 
Bavaria, . . . . .4 
Evidence corroborative of these results has been adduced by Dr. Balfour 
from the records of the Army and Navy Medical Departments, where every 
soldier or sailor is protected by vaccination, if he has not previously suffered 
from cow-pox or small-pox. 
1. For twenty years, namely, from 1817 to 1836 inclusive, it is shown that 
in Dragoon Regiments and Guards, with an aggregate strength during that 
period of 44,611 men, and a total mortality of 627, only THREE deaths were 
from small-pox. 
2. Among the troops at Gibraltar, the aggregate strength being 44,611 
* With regard to the high rate of smali-pox mortality in the towns marked by the 
-asterisks, it was clearly shown by Dr. Stark, in Edinburgh, and by Dr. J. G. Steele 
(the present Medical Superintendent of Guy's Hospital in London), that such mortal- 
ity was due to the neglect of vaccination. Dr. Steele, then resident in Glasgow Infir- 
mary, called attention to the great increase of small-pox in Glasgow, as mainly coming 
from the Highland and Irish population, among whom vaccination was rare. Dr. 
Stark showed that more than 80 per cent, of all the deaths from small-pox happened 
in children under five years of age. No country is now (1871) more efficiently vacci- 
nated than Ireland. BENEFICIAL INFLUENCE OF PERFECT VACCINATION. 
409 
men during that period, and a total mortality of 1291, only ONE death 
from small-pox occurred. 
3. In the West Indies several epidemics of small-pox prevailed during the 
period, but there were no deaths either among the British or white troops, of 
whom the aggregate strength was 86,661, and with a total mortality of 6803. 
Among the black troops on the same station, with an aggregate strength of 
40,934, and a mortality of 1645, there was not one case of small-pox. 
4. At Bermuda, Nova Scotia, New Brunswick, Cape of Good Hope, and 
the Mauritius, not a death from small-pox occurred during the twenty years 
mentioned; and the white troops of Western Africa wholly escaped this dis- 
ease, while the black unprotected population were dying by hundreds. 
5. In Malta, from 1818 to 1838 inclusive, the aggregate strength of the 
British troops being 40,826 during these twenty years, and the total mortality 
665, only TWO deaths were from small-pox. This is the more remarkable, 
inasmuch as small-pox raged as an epidemic all over the island in 1830, and 
again in 1838, destroying 1169 persons. In 1830 there died of small-pox 
1048, out of a total mortality of 3407; and in 1838 there were 121 deaths 
from small-pox, out of a total mortality of 2583. The disease was first intro- 
duced by His Majesty's ship " Asia." The mortality among those " not vacci- 
nated" was 1 in 4.7; among those "supposed to have been vaccinated" it was 
1 in 23.4; and, lastly, among those attacked a second time by small-pox the 
mortality was 1 in 10.8. The native population of Malta in 1830 was esti- 
mated at 100,839 persons, amongst whom it appears that 1 in every 12.1 
persons was attacked with the disease, and one in every 85 persons died. 
Amongst the military, including wives and children, the proportion attacked 
was 1 in 188, and the mortality only 1 in 682. 
6. The most important observations are those made at the Royal Military 
Asylum, in which the prevalence of variola among a vaccinated and unvacci- 
nated population, at the same ages, and in exactly similar circumstances, has 
been traced out by Dr. Balfour (see Med.-Chir. Trans, for 1852). 
One very obviously beneficial result of vaccination has not been so much 
appreciated and noticed as it ought to be-namely, that while the epidemic 
influence of small-pox greatly increased during the practice of inoculation, 
it has greatly diminished since vaccination has been adopted. Dr. Hebra, 
of Vienna, alludes to the fact, and incidentally remarks, "that epidemics of 
small-pox have been more rare, and are less malignant, since the introduction 
of vaccination." Definite data are to be gathered from the various reports 
already mentioned, which fully bear out the belief. The results may be stated 
as follows: 
1. During ninety-one years previous to inoculation, there are on record 65 
distinct and well-marked epidemics; which is equal to a ratio of 71.4 epi- 
demics in 100 years. 
2. During sixty-three years in which inoculation was practiced, and that to 
a very great extent, there were 53 distinct and well-marked epidemics; which 
is equal to a ratio of 84 epidemics in 100 years. 
3. During the fifty-five years since vaccination has been mainly practiced, 
there have been 12 distinct and well-marked epidemics of small-pox; which is 
equal to a ratio of 24 epidemics in 100 years. 
This kind of testimony is greatly enhanced by the fact, that epidemics 
never occur in the army or navy of our own country, nor in those countries 
where the soldiers and seamen are efficiently protected by vaccination. The 
details given with reference to the two Malta epidemics in 1830 and 1838 
afford a striking proof of the protective power of vaccination when tested by 
epidemic influence; and there are records of the Danish army and navy hav- 
ing altogether escaped during several epidemics of small-pox in Denmark. 
There is still another way in which the protective power of vaccination 
makes itself manifest-namely, by the mildness of the disease in the vaccinated 410 
SPECIAL PATHOLOGY-COW-POX. 
compared with the unvaccinated, and the almost absolute security against death 
from small-pox which perfect vaccination confers. With few exceptions, this 
appears to be the universal belief of the medical profession. At various times 
the opinions of large numbers of medical men have been specially asked for and 
obtained on this point. Three distinct and very comprehensive "polls" may 
be referred to, namely,-(1.) That by the College of Physicians in London, eight 
years after vaccination had been adopted. (2.) An almost national "poll" 
taken by the Epidemiological Society of London about the years 1852 and 1853. 
The written opinions of nearly two thousand medical men in this kingdom, as 
well as Bombay, Bengal, the Mauritius, the West Indies, and various other 
places, were here expressed; and they concurred in confirming the belief in 
the protective and modifying influence of vaccination in small-pox. (3.) A 
very extensive "poll," of which a list is published by Mr. Simon, comprehends 
not only members of the medical profession generally, but also the members 
of the Medical Department of the Army and Navy, together with the opinions 
of foreign governments. 
These "polls" may be held as completely decisive of the question, really 
practically decided in the affirmative fifty years ago. From such evidence 
the inference is so inevitable, "that he who disputes it is equally unreasonable 
as he who opposes in like manner any proposition in Euclid" (Alison). 
The actual extent of the security against death from small-pox enjoyed by vac- 
cinated, compared with unvaccinated persons, has been calculated by Mr. 
Simon from various sources; and it appears that the death-rate from small- 
pox amongst the vaccinated varies from an inappreciably small mortality to 
12^-per cent.; that amongst the unprotected the death-rate from small-pox 
ranges from 14^ to 534 per cent. 
The average percentage mortality from small-pox, stated by Mr. Marson 
to occur amongst the vaccinated, is 5.24; but when vaccination is known to 
have been perfectly performed, as shown by the cicatrices, the mortality is uni- 
formly found to be reduced to less than half of one per cent. 
Another very important and most interesting phase in which vaccination 
may be viewed as exercising a protecting influence indirectly over the health of 
the community, may be studied in those statistics which show that the general 
death-rates from other diseases have diminished, and more especially as regards 
scrofulous diseases, since vaccination became more universal. To Dr. Green- 
how and to Dr. Farr in this country, and to the statists of Sweden, we are 
indebted for any accurate knowledge existing on this subject. Not only has 
the grand total of the death-rates been diminished, but the death-rates of two 
special classes of diseases have diminished in a remarkable degree. These 
are,-(1.) Scrofulous affections, including phthisis or scrofula, with the deposit 
of tubercle in the lungs; and (2.) The continued fevers, especially typhoid 
fever. 
Another kind of historical evidence bearing out the protective influence of 
vaccination is to be seen by comparing the advertisements of old newspapers, 
especially those during the last portion of the seventeenth and early portion 
of the eighteenth centuries, with similar advertisements of the present day. 
At the former period the ravages of small-pox upon the population were 
beyond conception, testifying to the widespread epidemic influence. The 
description of every man or woman, as exhibited in "the villanous portraits 
of the Hue and Cry," showed them to have been more or less marked with 
small-pox, or "speckled with pock-holes." Nowadays it is the exception, and 
not the rule, to see such pits and scars amongst the population (Quarterly Re- 
view, July, 1855). 
It is thus clearly demonstrated how vaccination has thrown the aegis of pro- 
tection over the world; and how ample, how great, and how efficient that pro- 
tection may be. It has been shown to diminish mortality generally, and the 
mortality from small-pox in particular, both in civil and in military life, at impairment of the influence of vaccination. 
411 
home and abroad, and just in proportion as it is efficiently performed. It has 
been shown to diminish the epidemic influence; it has been shown to preserve 
the good looks of the people; it has been shown that it tends to render small- 
pox a mild disease compared with the same disease in the unprotected; it con- 
fers an almost absolute security against death from small-pox; and, lastly, it 
has been shown to exercise a protecting influence over the health of the com- 
munity generally. On the other hand, it is no less amply proven that " where- 
soever vaccination falls into neglect, small-pox tends to become again the 
same frightful pestilence it was in the days before Jenner's discovery; that 
wheresoever vaccination is universally and properly performed, small-pox 
tends to be of as little effect as any extinct epidemic of the middle ages" 
(Simon). Moreover, it has been clearly shown by the systematic inspections in- 
stituted by Her Majesty's Privy Council, under the direction of Mr. Simon, 
that it is hopeless to expect to be free from fatal epidemics of small-pox, of 
greater or less extent, so long as unvaccinated children are allowed to accu- 
mulate as they have been found to do. There is therefore the greatest neces- 
sity for vigilance on the part of every intelligent member of the community 
to prevent any reaccumulation of unvaccinated persons. 
Four conditions are absolutely necessary to be efficiently carried out before 
we can hope to see small-pox eradicated through vaccination, and the aim of 
Jenner accomplished. These are,-(1.) The vaccination of every child must 
be made compulsory within a certain time after birth. (2.) Systematic inspec- 
tions of two kinds must be constantly and periodically made by competent 
persons-namely, one to ascertain as to the effectual performance of the 
operation, as evinced by the kind of cicatrix visible. This inspection may be 
most conveniently made in public and private schools; and the School Boards 
now forming ought to keep this object in view. Another inspection should 
have for its object to ascertain the numbers vaccinated within a certain terri- 
tory compared with the numbers born in the same place. (3.) Every attempt 
at inoculation from small-pox ought to be made a penal offence. (4.) Every 
case of small-pox ought to be treated in strict seclusion, and be as completely 
as possible isolated, following out all the directions given with reference to 
the management of epidemics at pp. 359-363, as are applicable to the case. 
A quarantine regulation to enforce segregation of the sick from small-pox is 
of far more importance in this country than it is for yellow fever, which does 
not find a habitat with us. 
The Sanitary Commissioner of the Punjaub draws attention to the loss of 
life by small-pox which occurs annually in that district of India, which is yet 
practically unprotected by vaccination. With a population of 18,000,000, 
the deaths from small-pox there are never less than 20,000 a year. In 1869 
they numbered 53,195. Any person walking through the streets of a Punjaub 
city is struck by the immense proportion of persons blind of one or both 
eyes-a calamity caused in 99 cases out of 100 by small-pox. Europeans, 
protected by vaccination, suffer very little. 
We come now to consider- 
II. How the Protective Influence of Vaccination has been Impaired. 
Since vaccination has been generally practiced it has now and then seemed 
apparent that "the protective power of vaccination becomes gradually weaker, 
and at length dies out in the individual." Indeed, it seems now to be very evi- 
dent that "the protection against variola or human small-pox afforded by 
vaccination in cow-pox is for a far shorter period than is generally believed" 
(Niemeyer). No definite conclusion, however, has yet been arrived at as to 
the absolute duration of the protective influence; and the practical conclusion 
is, to advise revaccination of everybody (but especially adults up to twenty 
or thirty years of age) at the outbreak of any epidemic-no matter what 
length of time has elapsed since their last vaccination. This is what Mr. 
Simon, through the Privy Council, has at present (Feb., 1871) advised should 412 
SPECIAL PATHOLOGY-COW-POX. 
be done. Vaccination must be repeated from time to time, if we would pre- 
vent a return of the liability to small-pox, seeing that it is certain the pro- 
tective influence of vaccination is not persistent through a lifetime. The 
works and reports which have been mentioned seem to demonstrate the truth 
of this statement; but in justice to Dr. Seaton (one of the greatest authorities 
on the subject) it must be stated that he does not subscribe to this belief. 
Indeed, in his last Report (Appendix to Public Health Report for 1861, p. 64), 
he states that where uniform care in the selection of lymph, and in the per- 
formance of the operation, was practiced, the results did not favor the 
hypothesis that there had been any necessary deterioration of the lymph. 
He has seen several cicatrices, the results of the vaccinations of Dr. Jenner 
and Dr. Walker; but the work of the vaccinators to whom he refers (and 
mentions as having bestowed great care in the selection of their lymph and in 
the performance of the operation) will bear comparison with the results 
obtained by Dr. Jenner and Dr. Walker. 
In 1809, Mr. Brown, of Musselburgh, near Edinburgh, published the 
opinion that the protective virtue of cow-pox diminished as the time from 
vaccination increased. In 1818 and 1819, small-pox prevailed in Scotland 
as an epidemic, and many vaccinated persons passed through a mild form of 
variola. The terms " modified small-pox" and "varioloid disease" about this 
time came into general use; and two classic monographs on the subject made 
their appearance, one by Dr. Monro, in 1818, and another by Dr. John 
Thomson, of Edinburgh, in 1820. Dr. Copland also writes that he saw and 
described, as early as 1823, small-pox as it affected members of the same 
family at different periods after vaccination, and in young persons who had 
been vaccinated only ten or eleven years. Contrasting such cases, he found 
that the severity and fully developed condition of small-pox was generally in 
proportion to the length of time which had elapsed from vaccination (Dic- 
tionary of Practical Medicine, Art. "Small-pox," p. 815). 
Again, from the evidence contained in the bills of mortality of 1825-from 
the experience of epidemics of small-pox in France and Italy, in 1826, 1827, 
and 1829-from the experience of the epidemics of small-pox in Ceylon in 
1833 and 1834-and from the admissions into the London Small-pox Hos- 
pital in 1838, it has been rendered obvious that the susceptibility to small- 
pox, which in vaccinated persons is destroyed for some years, returns with 
advancing age, and becomes greater as life advances. 
Some of the phenomena, also, which the practice of vaccination itself has 
made known to us, tend to establish the doctrine of a gradual impairment of 
vaccine protection, due to lapse of time, and as a result of physiological changes 
in the healthy body. This is especially indicated by the fact, that in propor- 
tion (undetermined) to the distance of time that has elapsed from the first 
implanting of the vaccine virus, so is the better development of the vaccine 
vesicle produced by revaccination. It has been shown, however, from a care- 
ful analysis of cases, that the lesser protectedness of certain vaccinated persons 
bears at least some proportion to the number of years which had elapsed since 
vaccination. Any uniform rate of increased susceptibility to small-pox from 
year to year from the period of vaccination has not been demonstrated; but 
an increasing susceptibility to small-pox continues up to about thirty years of 
age at least, after which period of life it seems that the liability to contract 
small-pox continues to decline (Heim, Mohl, Retzius, Marson, Simon). 
Dr. Balfour, of the Army Medical Department, adverted some time ago to 
these important facts; and there can be no doubt of the practical result to 
which they point-namely, revaccination, as a most necessary supplemental 
measure to vaccination. A large reduction in mortality, and in the occur- 
rence of small-pox, can be shown to have taken place from the practice of 
revaccination, so as to leave no doubt of its practical efficacy. The records 
of the earliest experience of its usefulness date from Wirtemberg, 1829 to VACCINE VIRUS IS APT TO DETERIORATE. 
413 
1836. In 1833, between 40,000 and 50,000 adults were revaccinated in the 
Prussian army, and in about 33 per cent, of the entire number this revaccina- 
tion "took" with perfect success. Amongst Russian soldiers at Kasan, the 
rate of perfect success was about 18 per cent. In the army of Denmark, from 
1843 to 1847, nearly 20,000 revaccinations were practiced, of which more 
than a half were attended with perfect success, and more than a quarter with 
modified success. Since 1843 revaccination has been compulsory in the Bava- 
rian army. From that date till 1857 not even a single case of unmodified 
small-pox has occurred, nor a single death from small-pox. Similar good 
results have followed the institution of revaccination in the Danish army, the 
army of Sweden, of Baden, and in the British army also, according to Dr. 
Balfour's interesting report for 1859. So great, indeed, is the practical 
importance of revaccination, that in the British army a departmental order 
was issued by circular, of date 21st September, 1858, and is at present in 
force, which ordains that "every recruit, without exception, on joining the 
headquarters or depot of the corps or regiment to which he belongs, shall 
be vaccinated, even if he should be found to have marks of small-pox or of 
previous vaccination, and that a monthly return of the results (as to (1) a 
perfect vaccine pustule following the operation, or (2) a modified one, or 
(3) a failure) shall be forwarded to the Director-General" (Statistical Report 
for 1859, p. 21). 
On the other hand, it must be remembered, as Mr. Marson clearly shows, 
that " probably revaccination does not afford the same amount of protection 
that the first vaccination well performed does. The great object to aim at is 
to vaccinate well in infancy. This should be looked upon as the sheet anchor; 
and therefore a careless vaccination should be deprecated at all times, prac- 
ticed under the belief that, if it fails to take effect properly, it will be of no 
consequence, as the operation can be repeated. By such a proceeding the 
vaccination often takes effect badly, and will never afterwards take effect prop- 
erly, and the individual may take small-pox severely." 
It has been alleged (but sufficient proof has not yet been adduced to show) 
that the vaccine virus becomes deteriorated by its passage through numerous human 
bodies. In other words, it has been supposed that its protective influence is 
weakened by length of time or of use, in consequence of the long succession of 
subjects through whom it has been transmitted since its direct inoculation 
from the cow. This doctrine is opposed to the obvious pathological fact, that 
the specific virus of cow-pox, small-pox, and other similar diseases, multiplies 
and reproduces itself in the system of those who suffer in the natural course of 
these diseases. Considerable differences of theoretical opinion prevail upon 
the point. In the report of the National Vaccine Establishment for 1854 it 
is stated " that the vaccine lymph does not lose any of its prophylactic power 
by a continued transit through successive subjects." Such an unqualified be- 
lief is not, however, by any means universal, as shown in various parts of the 
evidence collected by Mr. Simon. It is certain that the vaccine lymph, when 
taken direct from the cow, seems to show an amount of infective power which 
is not usual in lymph of long descent; but how much of this effect is due to 
irritation simply, and how much to specific action, does not seem certain. 
Lymph direct from the cow " takes " (as the phrase is) in persons with whom 
lymph of long descent has failed. This is more often obvious in revaccina- 
tions. Lymph direct from the cow excites local changes of an intenser kind, 
so active, indeed, as to render caution necessary in its selection and use. The 
vesicle produced by it runs a full course, compared with which the progress of 
vaccine vesicles from lymph of long descent seems unduly rapid, and their 
termination premature. Also, the lymph direct from the cow renders more 
certain, and apparently more characteristic, that slight febrile disturbance 
which is proper to the action of cow-pox on the human system. This febrile 
disturbance is undoubtedly an essential pathological phenomenon, not at all 414 
SPECIAL PATHOLOGY-COW-POX. 
in proportion (or rather beyond all proportion) to the trifling extent and in- 
tensity of the local inflammation of the skin round the vaccinated part. This 
specific febrile state seems essential for the due protection of the vaccinated 
person and for the perfect development and local multiplication of laudable 
and efficient lymph at the spot where the specific vaccine virus was originally 
implanted. A temperature of 104° Fahr, has been observed where the local 
inflammation seemed to be very slight (Niemeyer). The more distinctly and 
typically this specific febrile action is expressed which follows the implanting 
of the vaccine virus, the more certainly is the person protected, and the more 
efficient is the local development of the lymph which has been multiplied at 
the site of implantation. The development of any other febrile state, such as 
from cold, or other disease, is apt to hinder the development and progress of 
the vaccine vesicle altogether. Referring to the records of revaccination in 
the Prussian army, an extremely interesting fact is brought out by Mr. Simon, 
tending to confirm the doctrine that, by transmission through a succession of 
persons, the vaccine virus has degenerated-namely, " that the revaccinations 
of 1836, as tested by eventual resusceptibility to cow-pox, were not half so stable 
as the vaccinations of 1813." 
On the whole, therefore, there appears to be still room to believe that any 
diminution of protective influence from vaccination may be due to personal 
carelessness-first, in the selection of lymph for use, as well direct from the 
cow as of lymph of long descent; and secondly, in the choice of cases to con- 
tinue the vaccinations from-cases, for example, being chosen where the lymph 
of the local vesicle at the site of vaccination has been developed in the absence 
of the constitutional specific febrile phenomena; and in which the lymphy 
contents of the vesicle are not only impotent, but the anatomical development 
and structure of the vesicle in respect of its dissepiments are at the same time 
incomplete and imperfect. The cicatrix, scar, or mark left by imperfect vac- 
cination is also an imperfect cicatrix, and is capable of recognition as such. 
To an almost incalculable extent, the protective power of vaccination has been 
impaired by imperfect vaccination, as shown by Mr. Marson-a fact which 
does not seem to be duly appreciated as yet, either by the medical profession 
or by the public. In the Contributions, by Dr. Elisha Harris, relating to the 
causation and prevention of disease, and published by the United States 
Sanitary Commission in 1867, the results of spurious vaccination are shown 
by large observations made by medical officers, alike of the United States and 
Confederate armies, during the American war. The following is a summary 
of these results: 
" (1.) There were three kinds of spurious vaccination prevalent in the 
American armies; (a) that which occurred in consequence of the loss of the 
specific property in the once good lymph or crust used; (6) that which re- 
sulted from the impairment or destruction of the vesicle as soon as it began 
to form, in the marching and excessive exercise of the soldier, and that re- 
sulting from the use of the sero-purulent matter of such destroyed vesicle in 
vaccinating other persons; (c) that resulting from the employment of matter 
from pustules or crusts that never had the genuine qualities of vaccine virus. 
"(2.) Scurvy and all the asthenic dyscrasise of army life, not only pre- 
vented or greatly impaired the normal operation and effect of genuine vaccinia 
when soldiers with such conditions were subjected to vaccination, but they 
frequently became the causes of certain morbid phenomena, as obstinate ulcers, 
&c., which caused the greater part of the evils from vaccination during the 
war. 
"(3.) In the armies it was never proved that the normal vaccine vesicle 
communicated any other than normal innocuous virus; but from carelessness 
in taking lymph at its perfection, and by neglecting to observe the rule never 
to use lymph or crusts not perfect in all respects, and free from blood or pus, OPERATION OF VACCINATION. 
415 
frequent instances of inoculation with purulent matter or unhealthy blood 
happened. 
"(4.) By the use of matter, fluid or concrete (purulent or morbid in either 
case), taken from sores of any specific and enthetic character, as (a) erysipel- 
atous and ecthymatous; (6) that of zymotic ulceration and destruction of 
tissues, and possessing the properties of a morbid poison; (c) syphilis, primary 
or secondary, whether communicated by a lancet, or contaminated vaccine 
points or crusts; or, as occasionally happened, the manifestation of syphilitic 
phenomena in connection with, or supervening upon, genuine or spurious 
vaccination. 
"(5.) The deterioration of genuine virus, by transmission through scorbutic 
and unhealthy persons, or where at the time of revaccination the protective 
power of a former vaccination was partly retained, or to the continued use of 
virus from adult soldiers, many of whom were suffering from unhealthy in- 
fluences, instead of using lymph from the primary vesicles of healthy infants. 
" (6.) The destruction or deterioration of originally good virus by heat and 
humidity. 
"These results substantiate the observations of Jenner as to the necessity 
of guarding against deterioration of the virus of cow-pox, which, losing its 
specific property, ceases to be prophylactic. Army experience would go to 
prove that genuine vaccination is an absolute safeguard against small-pox."* 
The Operation of Vaccination^ ought to be performed in childhood and it 
* [Reprinted from 2d Am. Edition, vol. i, p. 266; additions of the Editor.] 
f On February 13, 1871, Mr. W. S. Foster moved for a committee to inquire into 
the operation of the Vaccination Act of 1867, and to report whether such Act could 
be amended, which motion was agreed to. He considered it necessary to provide for 
vaccination by legislation. Statistics showed that the extent of small-pox epidemics 
had really gone up and down according as compulsory vaccination had or had not 
been enforced. In Scotland and in Ireland, where they had insured almost complete 
compulsion, the disease was formerly very prevalent, and now it was reduced almost 
to a minimum. In those districts, too, in England, where vaccination had been en- 
forced, small-pox had almost vanished. Nevertheless, some people in the country en- 
tertained conscientious objections to vaccination, on the ground that it would do their 
children harm ; and the evidence which would be adduced before such a committee 
would, Mr Foster believed, tend to convince such persons of their error. The follow- 
ing paper of advice and instruction has been issued by the Royal College of Physicians : 
" At the present time, when small-pox prevails extensively as an epidemic, and when 
much anxiety exists in the public mind respecting it, and questions have arisen as to 
the efficacy of vaccination as a preventive of that formidable disease, the Royal College 
of Physicians have thought it their duty to call public attention to the following facts 
and observations : Nothing in the history of vaccination, since its first introduction, 
has occurred to shake the confidence that has hitherto been placed by every well-in- 
formed physician in the power of vaccination to diminish the susceptibility to small- 
pox, and in its efficacy as a protective against both the mortality and the disfigurement 
occasioned by that disease. Small-pox occasionally occurs a second time in the same 
individual; it is not, therefore, surprising that small-pox does sometimes occur in 
those who have been vaccinated, more especially in those in whom the operation has 
been imperfectly performed. These facts were admitted by Dr. Jenner himself, the 
discoverer of vaccination. The mortality from small-pox occurring in the non-vacci- 
nated amounts to 35 per cent, of those attacked, whereas the mortality in those who, 
having been properly vaccinated, subsequently take small-pox, amounts to less than 1 
per cent. Disfigurement, more or less serious, is in the non-vaccinated the rule; in 
the properly vaccinated it is the exception. Experience has amply proved that re- 
vaccination of adults who have been vaccinated in childhood will to a very large ex- 
tent, protect against an attack of small-pox. Thus, to take one of many illustrations 
that might be adduced. For more than thirty years all the nurses and servants at the 
Small-pox Hospital, who had not previously had small-pox, have been revaccinated 
before entering on their duties; and not one case of small-pox has occurred among 
these persons, although living in an atmosphere of concentrated infection. The College 
therefore deem it right-1. That all persons who have not been vaccinated, or who 
have not already had small-pox, should at once be properly vaccinated by competent 
vaccinators. 2. That all persons who have passed the age of puberty, and have not 416 
SPECIAL PATHOLOGY-COW-POX. 
is ordained by law in this country to be performed within three, or in case of 
orphanage, within four months of birth. The infant ought to be at least from 
four to six weeks old, before a disease, sometimes attended with considerable 
febrile disturbance, is ingrafted upon the constitution. Under six weeks of 
age, infants should never be vaccinated, unless in cases of urgent necessity, 
such as small-pox being in the vicinity. The age of three months is on the 
whole to be preferred. The child ought to be in good health, free from any 
eruptive cutaneous disease, and free from disorders of teething, of the bowels, 
or other diseases peculiar to the age of childhood, otherwise the protective in- 
fluence of the vaccination cannot be depended on. Weakly children, inclined 
to scrofula, ought not to be vaccinated during their 'first year of life, and not 
till the second or third year, when the teeth shall have been developed. The 
future stability of the health of such children very much depends on the pro- 
tection of their first development from injurious influences (Sir James Clark, 
Combe, Niemeyer). 
Difference of opinion exists as to the number of vesicles it is proper to graft 
upon the arm, and the size of them. Some believe the person to be as thoroughly 
protected by a small vesicle, "the tenth of an inch in diameter, as if the arm 
were covered with inoculated points" (Cazenave, Andrew Anderson); and 
many vaccinators regard the multiplication of vesicles only as a safeguard 
against failure, and attach value only to one successful insertion of the vaccine 
lymph (Buchanan, Appendix to Fourth Report on Pxtblic Health, for 1861, p. 
111). On the other hand, the official instructions issued to vaccinators in 
England contain the following directions: "In all ordinary vaccinations, vac- 
cinate by four or five separate punctures, so as to produce four or five separate 
good-sized vesicles; or if you vaccinate otherwise than by separate punctures" 
(for some vaccinators prefer to make long scratches, side by side, or intersect- 
ingly, instead of punctures), "take special care to secure the production of 
four or five separate good-sized vesicles." This is considered necessary for secur- 
ing to those who are vaccinated the full amount of protection which good vac- 
cination confers. The superior value of several vesicles is especially insisted 
upon by Marson, Seaton, and Simon. They have shown a constant relation 
to subsist between the number of the sufficient cicatrices and the degree of pro- 
tection afforded. 
The skin covering the insertion of the deltoid muscle is the place generally 
chosen for implanting the specific lymph of variolse vaccime. The methods 
of operating are as follows: 
1. The part of the arm to be operated upon should be grasped with the left 
hand, and the thumb of that hand should draw the skin with sufficient tight- 
been revaccinated since infancy, should be revaccinated. 3. That all persons, of 
whatever age, who have not sufficient and characteristic marks, and are likely, as at 
the present time, to be exposed to the infection of small-pox, should be revaccinated. 
The advantages to be derived from revaccination may be best secured, both for the 
community and for the individual, by a systematic performance of the operation on 
every person upon passing the age of puberty. For the community, because a well- 
grounded confidence would replace the present recurring panics about small-pox ; for 
the individual, because the operation performed as part of a system would be done in 
the manner most certain to be efficient, and not, as at present too often happens, under 
conditions little conducive to a protective result. The local effects produced by re- 
vaccination vary with a number of conditions. A revaccination with well-chosen 
lymph (not taken from a revaccinated person), producing some indisputable local re- 
sult, may be regarded as affording evidence of efficient protection from small-pox. 
But on the other hand, where no local effect whatever is produced, the person can 
only be regarded as being in the same position as if the revaccination had not been 
performed. The practice of repeated or periodic revaccination does not appear to be 
generally necessary. But in instances where a person, after revaccination, has been 
subjected to serious constitutional or climatic changes, and is subsequently more than 
ordinarily exposed to the infection of small-pox, a further revaccination may properly 
be advised." SIGNS OF SUCCESSFUL VACCINATION. 
417 
ness so as to facilitate the introduction of the point of a lancet with the other 
hand. Three or four punctures should be made near each other, for each in- 
tended vesicle. These punctures should penetrate the cuticle to the extent of 
a few lines in an oblique direction, so as to make a minute valvular aperture, 
and so as to impinge upon or penetrate the cutis vera. The lancet used to 
make the punctures should be charged with the vaccine virus contained in 
lymph taken from a healthy child who had not been vaccinated before. Cer- 
tain it is that lymph taken from the vesicles of revaccinated persons is much 
less certain to produce normal pocks than that taken from persons vaccinated 
for the first time (Niemeyer). It should be taken on the seventh or eighth 
day after vaccination, from vesicles which are perfectly normal as to size, 
form, and areola. i 
Arm-to-arm vaccination ought to be the rule; but otherwise, the lymph pre- 
served in glass tubes, with the ends sealed, is the best. 
The part of the arm operated upon should be selected so as constantly to be 
covered, even when short sleeves are worn by children. 
* If vaccination is unsuccessful it ought to be repeated after an interval of a 
few months. 
Compresses, wet with lead lotion, are the best application, if much inflam- 
mation extend round the points of puncture. It should be allowed to remain 
in the punctures for several seconds, and, in the course of its removal, the site of 
puncture should be compressed for a moment or so, to prevent bleeding, and also 
to retain the virus from the lancet's point. About five punctures should be 
made, and sufficient space left between each to insure prevention of the pocks 
becoming confluent. 
2. Another mode of operation is often chosen-namely, to make an immense 
number of minute scratches over a very limited area of skin, and as close to- 
gether as possible. In this way the number of groups of scratches will corres- 
pond to the number of vesicles intended to be ingrafted. The scratches may 
be made with the point of a clean lancet, and may be either parallel to each 
other or crossed in two or any number of directions. The number of these 
groups of scratches will vary according as three, four, five, or more vesicles 
are considered necessary, and the length of the individual scratches will deter- 
mine the size of the resulting vesicle, and, to some degree, the soreness of the 
arm. It is necessary to remember these facts in dealing with young and deli- 
cate children, so as not to give rise to unnecessary suffering, torment, and 
danger. The scratches should be so slight as barely to result in the faintest 
possible exudation of blood, and that only after the lapse of a second or two. 
To the group of scratches from which blood first exudes, the "point" or lancet 
is to be applied, charged with the specific virus. The lymph containing this 
virus will be at once absorbed; and the blood with which the lymph is mixed 
should be smeared over and pressed into the other scratches in succession 
several times. 
3. Simple abrasion of the cuticle is sometimes resorted to with very good 
success-namely, by scraping off the cuticle with the lancet, used as an eraser 
is used to remove blots from paper {Fourth Report on Public Health, p. 107). 
Signs of Successful Vaccination.-By the end of the second day small 
spots appear elevated over the sites of the punctures, or over the groups of 
scratches or abrasions; and these, when examined by a simple lens, are seen 
to be vesicular, and surrounded by a slight redness. This stage continues for 
three to four days from the date of ingrafting the virus. About the third, but 
rather towards the fourth day, the elevation is more perceptible and more red; 
and by the fifth or sixth day a distinct vesicle is obvious upon it, of a whitish 
color, having a round or oval form, an elevated edge, and a depressed centre.. 
Late on the seventh, or early on the eighth day, an inflamed ring or areola 
begins to form round the base of the vesicle, and with it continues to increase 
during the two following days. This areola is of a circular form, and its 418 
SPECIAL PATHOLOGY-COW-POX. 
diameter extends from one to three inches. On the eighth day the vesicle ap- 
pears distended with a clear lymph. This is the day of its greatest perfection, 
and it is the proper period for obtaining the specific virus for continuing vaccina- 
tion on others. The vesicle is now circular and pearl-colored; its margin is 
turgid, firm, shining and wheel-shaped. 
Having reached its height on the ninth or tenth day, the development of 
the bright red areola is accompanied with considerable tumefaction of the 
skin, with hardness and swelling of the subjacent areolar tissue. This ery- 
thematous ring is often the seat of small vesicles. By the tenth day, also, the 
febrile symptoms of constitutional disturbance are well expressed, the lym- 
phatics of the arm are engorged, and sometimes a roseolous rash supervenes 
over the body. On the tenth or eleventh day the areola begins to subside, 
leaving, as it fades, two or three concentric circles of redness. The vesicle 
now begins to dry in the centre, and acquires there a brownish color. The 
lymph which remains becomes opaque and gradually concretes, desiccation 
commences, and tumefaction subsides, so that by the fourteenth or fifteenth 
day the vesicle is converted into a hard round scab of a reddish-brown color. 
This scab contracts, dries, and blackens, and about the twenty-first to the 
twenty-fifth day from the date of vaccination may fall off. It leaves a cica- 
trix which commonly is permanent in after-life. Indeed, the mark of a good 
cicatrix is indelible if it is not injured (Gregory, Marson, Ceely, Caze- 
nave, Simon). 
While these local changes are in active progress, febrile phenomena become 
established-first, so slightly from the fifth to the seventh day, that often the 
fact passes unobserved; and again, more considerably during those days wdien 
the areola is about its height. The patient is then restless and hot, with more 
or less disturbance of stomach and bowels. About the same time, especially 
if the weather be hot, children of full habit not unfrequently show on the ex- 
tremities, and less copiously on the trunk, a lichenous, roseolar, or vesicular 
eruption, which commonly continues for about a week. When vaccination is 
performed on such adults or adolescents as have not previously been vacci- 
nated, and likewise when lymph is employed which has recently been derived 
from the cow, the resulting phenomena, as compared with the preceding de- 
scription, are somewhat retarded in their course, and the areola is apt to be 
much more diffuse. There is also more feverishness, and eruption is less fre- 
quently seen (Simon, Health Report, 1859). 
Signs of Successful Revaccination.-When persons who have once been 
efficiently vaccinated are, some years afterwards, revaccinated with effective 
lymph, there sometimes result vesicles which, as regards their course and that 
of the attendant areolse, cannot be distinguished from the perfect results of 
primary vaccination. But far more usually the results are more or less modi- 
fied by the influence of such previous vaccination. Often no true vesicles 
form, but merely papular elevations surrounded by areolae; and these results, 
having attained their maximum on or before the fifth day, afterwards quickly 
decline. Or, if vesicles form, their shape is apt to vary from that of the 
regular vesicle, and their course to be more rapid, so that their maturity is 
reached on or before the sixth day, their areolae decline on or before the 
eighth day, and their scabbing begins correspondingly early. In either case 
the areolae tend to diffuse themselves more widely and less regularly, and with 
more affection of the areolar membrane, than in primary vaccination ; and the 
local changes are accompanied by much itching, often by some irritation of 
the axillary glands, and in some cases, on the fourth or fifth day, by consider- 
able febrile disturbance (Simon, 1. c.). 
Characters of the Cicatrix after Vaccination.-It seems now to have been 
agreed to arrange the characters of cicatrices after vaccination into the fol- 
lowing three classes: 
1. "Typical," ''excellent," "perfect," "good," or "first-rate" cicatrices are number and quality of vaccination-marks. 
419 
recognized by their circular form and pale or white appearance. They are 
somewhat depressed, and dotted, indented, or foveolated with minute pits or 
depressions over the base, supposed to indicate the number of compartments 
in the anatomical structure of the vesicle (referred to at pp. 377, 378). In 
some instances there are radiations from the centre. It has been considered 
that the normal diameter of a cicatrix produced by a single insertion is one- 
third of an inch ; that scars of larger measurement are generally of double or 
multiple origin. 
2. "Fair" "passable," or "vwdified" cicatrices possess the characters of the 
typical cicatrix, but they are less perfectly expressed, the contour being less 
regular, and the size just within the average above-mentioned. To irregularity 
of contour, however, it must be remembered that scars resulting from single 
insertions (as in the ordinary method of puncture) are notably uniform, so 
that irregularity of contour, when associated with a single puncture for vacci- 
nation, indicates that the progress of the vesicle has been irregular; but where 
the scar results from several contiguous insertions or scratches, no such infer- 
ence can be made. 
3. "Bad" cicatrices, which must be held as denoting "failures," are such 
scars as cannot be recognized as the product of vaccination, by any circum- 
stance beyond being found near the usual site of the operation. Scars also 
having a less diameter than a quarter of an inch ought to find a place amongst 
this class; and generally, all ill-defined, faint, scarcely discernible white 
patches, especially such as consist of large, flat, ill-defined shiny marks. 
Fruitless attempts at vaccination may be also recognized by the permanent 
traces left of the parallel or transverse scratches employed at the operation. 
It is, however, very difficult to describe the extent of differences between 
the results produced by different vaccinators. A large amount of bad, and a 
still larger amount of second-rate vaccination has been found to prevail in 
many districts, as the result of the inspections instituted by Mr. Simon in 1860 
and 1861 abundantly testify. Medical men are found to vary exceedingly in 
their estimate of a satisfactory vaccine vesicle and cicatrix, or the reverse, for 
the standard is comparative rather than absolute (Seaton, Sanderson, 
Buchanan). This is exactly what might have been expected, seeing that 
medical students 'are left to pick up their knowledge of vaccination where 
they can. In fact, practical medical education at our schools of medicine has 
hitherto, or until very recently, been entirely nil in regard to this most impor- 
tant subject; and no test of knowledge has ever been applied. Many men, 
whose estimate of the quality of the resulting cicatrices is of a low standard, 
can scarcely appreciate the typical character of marks which are the ordinary 
results of good vaccination (Seaton). Excessively small cicatrices are apt 
not to be perfect, and there are great varieties in the size of cicatrices of per- 
fect character, the results of puncture. It is therefore fairly presumed that 
cicatrices which thus vary cannot all have precisely the same value. The 
hand of different vaccinators can even be recognized by the kind of marks 
they leave behind them. The marks of some vaccinators are conspicuous for 
their excellence; the marks left by others are not so; and hence there are 
great differences between the vaccination of districts where different vaccinators 
are employed. In the schools, for instance, of large towns, Mr. Seaton informs 
us that "where the work of many vaccinators was seen together, it was fre- 
quently possible to fit the work to the vaccinator by the kind of cicatrix." 
With regard to the means of estimating the efficiency of vaccination, it 
seems established, that " a distinct connection subsists between the number and 
the quality of the cicatrices and the protection conferred by vaccination against 
small-pox; so that it may be confidently stated that that vaccination is the most 
efficient from which the most and the best cicatrices result." The evidence de- 
rived from the records of the Small-Pox Hospital, collected by Mr. Marson, 420 
SPECIAL PATHOLOGY-COW-POX. 
regarding the superior value of several rather than few vesicles, appears to 
be conclusive on this point. 
These facts have been tabulated by Mr. Simon in the following form, as the 
result of observations made during twenty-five years, in nearly 6000 cases of 
small-pox contracted after Vaccination, the persons having been vaccinated 
in different ways as regards the number and quality of the cicatrices: 
Cases of Small-Pox Classified according to the Vaccination Marks or 
Cicatrices borne by each patient respectively. 
Number of Deaths 
per cent, in each 
Class respectively. 
Class I.-Stated to have been vaccinated, but having no cicatrix, 
21f 
11 II.-Having one vaccine cicatrix,* 
tl III.-Having two vaccine cicatrices,^ 
" IV.-Having three vaccine cicatrices, ....... 
It 
" V.-Having FOUR or more vaccine cicatrices, 
t 
Un VACCINATED, 
35j 
Looking, therefore, to the characters or quality of the cicatrices, and to the 
number of the vesicles which have given rise to these cicatrices, four de- 
grees of protection conferred by vaccination may be specified, and the com- 
munity inspected may be arranged into the following four classes: 
Class I. Best protected-having more than two typical marks. 
Class II. Sufficiently well protected-having two typical marks. 
Class III. Moderately protected-having two or more passable, or one 
typical mark. 
Class IV. Badly protected-having bad marks, or having only one 
passable mark. 
Selection of Lymph for Vaccination.-The lymph used for vaccination 
ought to be taken from the vesicle on the eighth day-the, day-week after the 
operation-when the lymph is yet clear and the vesicle turgid, firm, shining, 
pearl-colored, and translucent, and before the vascular zone has reached its 
full development. The lymph ought not to be taken from any but perfectly 
"typical" vesicles. Inferior, or merely passable vesicles, ought not to be used 
to propagate lymph. Small vesicles, exhausted vesicles, or vesicles far ad- 
vanced (such as tenth or twelfth day) are to be avoided. Very early lymph 
appears, as a rule, to give the worst cicatrices. Thus "the careful vaccinator" 
does not indifferently vaccinate from the arms of all infants brought back on 
the eighth day, but exercises selection among them. The fresh lymph from the 
vesicle ought to be ingrafted directly upon the arm of the child about to be 
vaccinated-"arm-to-arm" vaccination, as it is called. Dry, or otherwise 
preserved lymph ought only to be used when fresh lymph cannot possibly be 
obtained. Properly dried lymph, however, seems capable of producing quite 
as good results as arm-to-arm vaccination; but it demands incomparably 
more care than it generally receives, first in its storage and afterwards in its 
use. It may be dried and stored on "points" of ivory or bone, or upon small 
pieces of glass glued together by the dried lymph, or on lancets. These 
should be well charged-i. e., coated twice or even thrice with the lymph, and 
rolled up in a covering of goldbeater's skin, and still further secured from 
* Among cases in which the one cicatrix was well marked or typical the death-rate 
was 4|. Among cases in which it was badly marked the death-rate was 12. 
j- Among cases in which the two cicatrices were well marked the death-rate was 2|. 
Among cases in which they were badly marked it was 7|. DEFINITION AND PATHOLOGY OF CHICKEN-POX. 
421 
atmospheric influences by an outer case of tinfoil hermetically sealed, or in a 
vial carefully corked, in which they may be packed, with cotton, if they 
require to be transmitted to any distance. Glycerin has been used with suc- 
cess to keep the lymph liquid. 
[In a Report on Animal Vaccination to the Trustees of the New York 
Dispensary (Jan., 1872), by Dr. Frank P. Foster, we find that animal vacci- 
nation has been largely tested by him. The lymph used was from calves 
inoculated with the Beaugency bovine virus. As to the asserted difficulty of 
susceptibility to the vaccine disease in the human subject from the animal 
virus, the results, as regards success, with the bovine and the humanized virus 
respectively, in primary vaccinations, were: 
Percentage with the long-humanized lymph in use in 1870, . . .78 
Percentage with humanized lymph of earlyremoves (the greater portion 
of not more than one remove) in use in 1871, 95 
Percentage with the bovine lymph in use in 1871, 93 
This objection to animal vaccination would appear groundless. 
With respect to the alleged danger of greater inflammation, Dr. Foster's 
experience goes to show that such is not the case, and that there is indeed less 
traumatism than with the humanized lymph. 
Of the positive advantages of animal vaccination, it is claimed that the risk 
of syphilitic contamination is eliminated, and this fear being set at rest in a 
community, the use of bovine virus will tend to secure a more general diffu- 
sion of vaccination. Moreover that it furnishes a valuable addition to our 
means of obtaining a constant supply of reliable virus. 
Whether animal vaccination secures as complete a protection against small- 
pox as humanized lymph is a question not yet determined, and dne that it is 
very important to have decided.] 
By proper care, complete and perfect vaccination may be attained under 
every variety of method; but bad vaccination, as it prevails at present, is 
almost always directly dependent on the careless employment of improperly 
preserved dry lymph, and indirectly associated with irregularity of inspec- 
tion, in consequence of which the vaccinator remains unaware of the number 
and extent of his failures, and loses all the advantages of experience. " The 
use of capillary tubes affords considerable advantages to the public vacci- 
nator, especially if his district be rural-Firstly, Because it furnishes him 
with an efficient means of maintaining his supply without having recourse 
to extraneous sources, and thus enables him to dispense altogether with the 
use of ' points,' ' glasses,' &c.; Secondly, Because in thinly populated neighbor- 
hoods, in which experience shows that it is impossible to assemble all the 
children at any particular station, it enables him with equal advantage to 
vaccinate from house to house." (Sanderson, in Public Health Report, 1861.) 
CHICKEN-POX. 
Latin Eq., Varicella; French Eq., Varicelle; German Eq., Windpocken-Syn., 
Wasserpocken, Varicellen; Italian Eq., Varicella. 
Definition.-The disease consists of a specific eruption, in a series of new 
crops, usually appearing for several days in succession; so that dried and fresh 
vesicles are often alongside of each other, on the breast, bach, face, and extremities, 
preceded by fever. The disease may be protracted for a fortnight or longer. 
Pathology.-This disease derives an importance which it does not of itself 
possess, in consequence of its resemblance to small-pox, with the modified 
form of which it has been considered by some to be identical. It is for the 
most part peculiar to childhood and early adult age; and its infectious origin 
may generally be traced; and, that it is communicable has been proved by 
inoculation. The theory of the disease, therefore, is, that a specific poison, 422 
SPECIAL PATHOLOGY-CHICKEN-POX. 
after a given period of latency, gives rise to primary fever, which lasts from 
twenty-four to seventy-two hours, when the eruption appears, and runs a 
course of eight or ten days. The fever is much mitigated on the appearance 
of the eruption, and entirely subsides with it. 
That fever precedes the eruption is a phenomenon observed so generally 
that no exception is to be found in the account given of the disease by any 
writer excepting Heberden. The febrile affection is of a mild character, and 
though for a few hours it may seem severe, yet it seldom passes into a stage 
so severe as to have the tongue of a brown and coated appearance. Never- 
theless there is general discomfort, gastric derangement, loss of appetite, and 
headache. The eruption has three stages,-that of papule, of vesicle, and of 
incrustation; and after the fever has lasted from twenty-four to seventy-two 
hours, a number of red papulae appear, which become vesicular, and perhaps 
in a few points pustular, on the first day. On the second day the vesicles are 
filled with a whitish or straw-colored lymph. On the third and fourth days 
they attain their greatest magnitude, when they become acuminated, and 
shortly afterwards they burst and shrivel, except those which contain purulent 
matter, and have much inflammation around their base. Pus, indeed, is so 
rarely found, that when it does appear, it may be secondary to some local 
excitement of inflammation surrounding a vesicle. Individual vesicles develop 
in from six to twelve hours; their contents becoming cloudy on the second 
day, and commencing to dry up on the fourth. On the fifth day they begin 
to crust, and in four or five days more the crust falls off, leaving for a time 
red spots on the skin, generally without, but sometimes with a "pit" or de- 
pression. The "pit" is permanent, and the cicatrix generally whiter than 
the original.tissue, and the patient consequently is marked or scarred. The 
eruption is not at first universal over the body, but usually consists of a series 
of crops, which succeed each other at intervals of twenty-four hours, and die 
away in the order of their occurrence. The first crop usually appears on the 
breast and back, where it is also generally most abundant, and afterwards on 
the face and extremities; but the face sometimes remains quite free. The 
number of crops may be limited to two or three, while in other cases a new 
succession will appear every twenty-four hours for ten, twelve, or fourteen days. 
Symptoms.-Of the varicella there were wont to be three forms recognized: 
the varicella lenticularis, the varicella conoides, and the varicella glob ata. The 
symptoms of these varieties are similar to each other, their only differences 
consisting in the size and form of the vesicle-that of the varicella globata 
being the largest. 
The fever which precedes this eruption is often as severe as that which 
precedes mild small-pox or measles; but it generally, though not constantly, 
remits on the appearance of the eruption, and does not return as the eruption 
approaches maturity. The urine, however, is usually little affected in the 
early stages, when it is often as limpid as in hysteria; but when the fever 
runs high, it assumes the usual febrile characters (Parkes). 
The globate chicken-pox is known as the swine-pox, or, vulgarly, " the hives." 
The eruption consists of large vesicles not quite circular in form, but often a 
little larger than the pustules of small-pox, surrounded with a red margin, 
and containing a transparent fluid, which, on the second day of the* eruption, 
resembles milk whey. On the third day they subside, shrivel, and present a 
yellow tint. Before the conclusion of the fourth day they are converted into 
thin blackish scabs, which dry, and fall off in four or five days more. 
Diagnosis.-Dr. John Thomson, who carefully studied this disease during 
the epidemics of 1815 to 1821, concluded that it was impossible to distinguish 
chicken-pox from modified small-pox; and as their identity is still a matter 
of opinion, the following statements (Craigie) embrace the most important 
pathognomonic characters derived from the respective phenomena of both 
diseases: DIAGNOSIS AND TREATMENT OF CHICKEN-POX. 
423 
1. Chicken-pox emits a peculiar odor, different from that of small-pox, and 
less decidedly partaking of the variolous fetor. 
2. Chicken-pox appears indiscriminately, and almost equally all over the 
person, beginning first on the trunk in general, and then appearing on the 
face and scalp; while small-pox appears first on the face and neck, and the 
pimples are more numerous on the face than on any other part. 
3. Chicken-pox eruption is generally completed in the space of twenty-four 
hours, or solitary vesicles come out irregularly afterwards in different points; 
but in small-pox the eruption begins in the evening of the third, or morning 
of the fourth day, and proceeds regularly for the ensuing three days, until it 
is completely established. 
4. While variolous pustules are on the first and second days of the eruption 
small, hard, globular, red, and painful, and communicate to the finger a sen- 
sation similar to that which would be excited by the presence of small round 
seeds under the cuticle in chicken-pox, every vesicle almost has on the first 
day a hard red margin, but communicates to the finger a sensation like that 
from a rounded seed flattened by pressure. 
5. On the second or third day of the eruption of chicken-pox, the individual 
bodies are vesicles containing serous fluid, and giving them a whitish aspect. 
6. These vesicles are surrounded by little or no inflammatory redness, and 
do not naturally, and independent of external violence, proceed to suppuration. 
"We often see," says Niemeyer, " especially when the eruption is very ex- 
tensive, that, besides numerous varicella vesicles running the usual course, a 
few filled with pus (varicellce pustuloses) acquire the appearance of variola pus- 
tules, and even leave cicatrices. Since the form of variola pustules is not 
specific [? See "Small-pox"], but exactly resembles that of some erythema 
pustules, we should not attach too much importance to the external resem- 
blance of some of the efflorescences in varicella to those in variola, and con- 
sequently consider the two diseases as identical." 
7. Chicken-pox may be confidently distinguished from small-pox on the 
third and fourth days by the state of the vesicles, some of which, being left 
entire, are shrivelled and wrinkled, while others, whose ruptured tops have 
been closed by incrustation of their fluid, are marked by radiating furrows. 
None present depressions on the apices; and as they do not suppurate, they 
incrust and' disappear sooner than variolous pustules. 
8. The marks left by chicken-pox, when they do leave marks, present a 
peculiar conformation, being round or elliptical, and less frequently irregular 
than those of small-pox, and in general smooth and shining. Lastly, it is said 
by Luders, that while small-pox is formed in the cutis vera or corion, the 
chicken-pox eruption is formed in the tissue situate between the corion and 
cuticle (Craigie, vol. i, p. 614). 
Against the identity of chicken-pox and small-pox, there stands the fact of 
the frequent occurrence of varicella, rather than small-pox, in children that 
have never been vaccinated, and that its occurrence does not prevent them 
taking small-pox, nor prevents successful vaccination. On the other hand, it 
is also known that children have been attacked by varicella who have been 
vaccinated, or had variola only a few weeks before,-all which are opposed to 
any pathological identity with small-pox. 
Varicella must therefore be regarded as a specific disease, sui generis. It 
usually occurs in more or less extensive epidemics, which occasionally accom- 
pany, precede, or follow small-pox epidemics, or may be coexistent with mea- 
sles or scarlet fever. 
Treatment.-It consists simply in abstinence from animal food, having 
recourse to a milk diet, and careful attention to the bowels. The patient is- 
to be kept cool, by light coverings, and by making him repose on a mattress 
rather than on a feather bed. 424 
MEASLES. 
Latin Eq., Morbilli; French Eq., Rougeole; German Eq., Maseru; Italian Eq., 
Rosalia. 
Definition.-J. purely contagious disease, in which an eruption, occurs in crops 
of a crimson rash, consisting of slightly elevated minute dots, about the size of 
millet-seeds, and having a small pajndar centre, scarcely perceptible to the touch, 
and without any sensation of hardness. Several of these may unite in irregular 
circular forms, or crescents, or they may be isolated. The eruption is preceded 
by catarrhal symptoms affecting the conjunctiva and air-passages for about four 
days, and accompanied with fever, which commences with repeated rigors following 
a period of incubation, which lasts from ten to fourteen days. Measles affects the 
system only once; and sometimes prevails as an epidemic. The eruption lasts six 
or seven days, and the whole duration of the disease is completed in from nine to 
twelve days. 
Pathology.-That a poison, probably organized, is absorbed in cases of 
measles, and infects the blood, there can be no doubt, inducing, after a period 
of incubation of ten or fourteen days, a specific continued fever. The fever 
thus established at the end of three, more generally of four, and in some few 
instances of five days, is followed by a secondary or specific inflammation of 
the skin and of the mucous membranes of the eyes, nose, mouth, fauces, and 
bronchia. In a few cases the poison has more remote effects, inducing inflam- 
mation of the substance of the lungs, or of the pleura, which may greatly pro- 
long the illness. , 
The fever may greatly vary in intensity, but it is uniformly present, and 
before the period of eruption the rise of temperature is very rapid, and often 
very great. The fever which precedes the local lesions is termed the primary 
fever; and the premonitory phenomena of cough, sneezing, and general malaise, 
are usually more prolonged than in other eruptive fevers. It does not always 
happen, however, that the functions of the mucous membrane are disordered, 
as well as the cutaneous surface. There are cases in which no catarrhal symp- 
toms exist, and such cases are described as "morbilli sine catarrho." Such cases 
occur during epidemics of the disease, and are but few in number. On the 
other hand, there are cases where the eruption is limited, very indistinct, or 
altogether absent-"morbilli sine exanthemate"-and which unmistakably re- 
sult from infection with measles-poison. They run the course of a very severe 
catarrh, and often not without considerable danger to life, especially in those 
cases afterwards to be noticed as asthenic septic measles, where patients die 
of increasing prostration before the appearance of eruption. 
The cutaneous eruption is one of the great characteristics of the disease; 
but the morbillous eruption being evanescent after death, we can only imper- 
fectly trace its morbid anatomy. It first appears as a circular spot or blotch, 
similar to a flea-bite, slightly prominent, and scarcely sensible to the touch. 
It is " quite free from the feeling of grittiness, so characteristic of small-pox," 
although it is a collection of inflammatory exudation at a circumscribed spot. 
Its color is of a pinkish red, or deep raspberry hue, and in rare instances, as 
in the morbilli nigri, is livid or black, from extravasation of blood in the cutis. 
In severe cases, especially if the patient be of tender age, the eruption assumes 
a papular form, and, when at its height, occasionally a vesicular form, the 
latter being most common on the arms, the neck, or the breast. The color of 
the eruption is evanescent on pressure, but returns on the finger being removed. 
In most of the spots, however, which have existed for a considerable time, a 
very slight escape of blood into the cutis complicates the hyperaemia ; and such 
spots only lose their color slowly and incompletely under pressure of the finger; 
and after the eruption has quite gone, dirty brown stains, or bright yellow dis- 
colorations, may be left on the skin. CHARACTERS OF THE ERUPTION OF MEASLES. 
425 
The patches of the eruption are extremely numerous, so that little of the 
healthy skin intervenes between them; and they not unfrequently become 
confluent, forming large maculae, sometimes of a semilunar form. The prin- 
cipal seats of the eruption are the face, back, and loins; the parts least affected 
are the pudendal and popliteal regions. The inflammation of the cutaneous 
texture extends in some degree to the subjacent areolar tissue, for the face is 
oedematous, tumid, and swollen, but not so much as to close the eyelids; other- 
wise the skin may retain its normal color between the spots. 
The eruption does not at once cover the whole body, but occurs in three 
crops, each of which follows the other at an interval of about twenty-four 
hours, the duration of each crop being from three to four days. The course 
of measles, then, in its most simple uncomplicated form, is, that on the third 
or fourth day of the primary fever, which is continuous, the first crop of the 
eruption appears on the face, especially about the mouth and eyes, spreading 
to the neck, the breast, and upper extremities. On the following day the 
second crop covers the trunk; and on the third day the third crop appears on 
the lower extremities, so that the whole body is covered with the eruption, 
which is then at its height. At this time the perspiration of the patient has 
a peculiar odor, strongly suggestive "of a freshly-picked goose" (Niemeyer). 
On the following day (the fourth of the eruption) it begins to decline from the 
face, neck, and upper extremities; and on the next day it fades from the trunk. 
On the sixth or seventh day it is evanescent over the whole body, and termi- 
nates by resolution, followed by a furfuraceous or bran-like desquamation of 
the cuticle generally. During the eruptive state the constitutional disturbance 
and catarrhal symptoms increase, and the maximum of the fever is reached, 
when the height of the eruption has reached its full extent, about the fifth 
day, and may last from twelve to twenty-four hours. The height of the 
fever is immediately followed by a rapid and almost complete defervescence, 
the temperature sinking in one night two or more degrees (Fahr.). It con- 
tinues to decrease throughout the following morning and day; and on the 
second day from the beginning of the defervescence the normal temperature 
is arrived at. It is only in very severe cases that this steady decrease is pro- 
longed beyond twenty-four or forty-eight hours more. In severe cases the 
decrease of temperature may be slower and more protracted; but if the defer- 
vescence be more prolonged, it is a fair ground for suspecting some untoward 
complication. 
A similar course of temperature, as regards defervescence, has been observed 
to obtain in cases of erysipelas of the face, but the fastigium lasts longer, and 
the epoch for the commencement of the defervescence vacillates between the 
fourth and eighth days. 
It is the amount of fever present-i. e., the increased bodily heat, as measured 
by the thermometer-which greatly aids in deciding diagnosis and prognosis. 
From this point of view slight, severe, and complicated cases are to be distin- 
guished. 
During the period of incubation there is generally no sign of disease, but 
slight feverishness, depression, and catarrh may be present in adults. When 
the disease is expressed, its commencement may be marked by violent shiver- 
ing, or merely by chilliness, characteristic of catarrhal fever. The inflamma- 
tion of the mucous membrane, of the eyes, and nasal fossae, indicated by more 
or less constant sneezing, and sometimes epistaxis, generally commences either 
with or before the primary fever, and consequently precedes the eruption by 
some days. There is increased frequency of pulse, and the local symptoms 
are very decided. The eyes burn and shun the light, which causes them to 
fill rapidly with tears. There is pain over the frontal sinus, and the nasal 
passages are stuffed up from the swollen mucous membrane in apposition, and 
the nose discharges a limpid salty secretion, which stiffens linen. This in- 
flammation, for a few hours, may be confined to fixed spots, and is marked by 426 
SPECIAL PATHOLOGY MEASLES. 
itching at the mitcous orifices; then it becomes diffuse, and quickly changes 
to mucinous discharge; for a profuse watery discharge from the eyes and nos- 
trils shortly follows, technically termed " coryza." This affection usually con- 
tinues till the decline of the eruption, and in some cases to a later period. 
Children, as a rule, are not anxious to seek their beds; even with a tempera- 
ture of 104° Fahr, they are still able to remain out of bed; but in cases of 
pneumonia, with the same temperature, they desire to lie down at once. 
THE FOLLOWING DIAGRAM REPRESENTS THE RANGE OF TEMPERATURE IN A 
CASE OF MEASLES, IN WHICH THE FEVER IS SEVERE. THE RECORDS 
INDICATE MORNING (A.M.) AND EVENING (p.M.) OBSERVATIONS, COM- 
MENCING ON THE EVENING OF THE FOURTH DAY OF THE DISEASE. 
Fig. 71. BODILY TEMPERATURE IN MEASLES. 
427 
The temperature rises rapidly towards the breaking out rtf the eruption, but 
is rarely severe enough to threaten life, as it is in scarlet fever. Its rise is 
steady to the fastigium, but if remissions are marked, they occur in the morn- 
ing. If the fever is high before the eruption for many days, it indicates a 
severe case, and is apt to be attended with such nervous derangements as are 
indicated by somnolency, jactitation, or delirium. The fastigium, or maximum 
of temperature, generally coincides with the period of the eruption; and simul- 
taneously with this increase of the fever the nervous symptoms are apt to pre- 
dominate. In the majority of uncomplicated cases the temperature falls within 
the first tiventy-four hours after the appearance of the red spots, and the fas- 
tigium in such cases does not extend beyond twelve, and in a few cases beyond 
twenty-four hours. Protracted fastigia are always connected with severe cases. 
In some cases the defervescence is completed within twenty-four hours-an 
example of complete crisis. But pauses sometimes occur to interrupt this rapid 
defervescence-pauses which may extend from twelve to thirty-six hours. Such 
are examples of protracted crisis, and are always anxious cases. With regard 
to prognosis, it is found that high fever, having small daily fluctuations, 
especially with the coexistence of nervous derangements, delirium, and the 
like, are very unfavorable symptoms. Prolific eruptions are always more 
favorable than scanty exanthema. Short duration of the fastigium, rapid 
defervescence, and speedy disappearance of the eruption, are the most favorable 
events. On the other hand, exacerbations are always more or less unfavorable. 
Of the complications of measles, the most important is catarrhal pneumonia; 
and a fatal issue, from such a complication, is apt to ensue in cases of young 
children. In such cases the pulse and respirations are enormously accelerated, 
the face is flushed, and the movements of the body are lively. The contrac- 
tions of the heart are then apt to abate in frequency, and the breathing to be- 
come very inefficient; while, simultaneously with diminishing expectoration, 
the breathing surface of the lungs becomes less and less, owing to the bronchiae 
being rendered more and more impervious, as capillary bronchitis extends to 
the alveoli of the lungs. Portions of lungs then collapse, and others become 
emphysematous. " If measles be accompanied by severe disease of the respira- 
tory organs, and the consequent difficulty of breathing or fever induce collapse, 
the eruption becomes pale, and may entirely disappear in a short time. This 
symptom is often wrongly interpreted, when the disappearance of the eruption 
is regarded as the cause, not the result, of the distress, the collapse, and bad 
symptoms in the organs of respiration" (Niemeyer). 
The mucous membrane of the mouth and fauces in most of the severe cases 
inflames, but the inflammation differs from that of the eyes and nose in not 
being accompanied by any discharge. In other respects it is exactly similar 
to the cutaneous eruption, for a number of exanthematous patches, more or 
less confluent, are seen upon the palate, uvula, tonsils, and velum pendulum 
palati, and they, equally, terminate by resolution. They appear also at the 
same time with the eruption on the face, neck, and upper extremities, but do 
not decline till the eruption fades from the body generally. 
The cough and expectoration, which indicate the attack of catarrhal pneu- 
monia, and accompany it, are constant, and the latter shows that it partakes 
of the same mucinous catarrhal character as that of the nasal and ocular 
membrane. 
When the substance of the lungs is thus affected, a serous exudation per- 
vades that tissue, and the quantity of fluid effused is frequently so considerable 
as to stream from the lung after death, as soon as its tissue is divided. In 
severe forms of the disease, either the red or gray hepatization of the lung 
may supervene; but these results are rare. The pleura does not at all times 
escape the morbid action ; and the diffuse, the serous, the adhesive, and even 
the purulent inflammation, may invade that tissue, and either destroy the 
patient or retard his convalescence. Few analyses of the urine in cases of 428 
SPECIAL PATHOLOGY-MEASLES. 
measles have been* made. Albumen is extremely common in some epidemics, 
and appears simultaneously with the eruption; it may then disappear, and 
reappear during the fading of the rash. Blood in small quantities is also 
common. In the Leith epidemic of 1854 the recoveries were most speedy 
when the albuminuria was the greatest (Parkes On the Urine, p. 262). 
Symptoms.-The symptoms of measles result from the fever and the con- 
secutive local lesions. The varieties of the disease, however, are extremely 
few, so that intensity of the disease merely has led physicians to consider the 
phenomena under two grades-namely, the " morbilli mitiores " and the " mor- 
billi graviores." 
The essential characters of morbilli mitiores are such as have been already 
described-namely, a primary fever, preceding a specific inflammation of the 
skin and mucous membranes,-the defervescence of the fever taking place 
while the eruption fades. 
The symptoms may be divided into three stages: the first embraces the 
primary fever, or the period before the eruption, and may last from three to 
five days; while the second stage embraces the period of the eruption, and 
lasts from six to seven days. These two stages very commonly comprise the 
whole disease, whose usual course is then from nine to twelve days. The third 
stage includes any inflammatory lesions which may be caused by the tertiary 
action of the poison, and only occasionally exists. • 
The early symptoms of the primary fever are seldom severe, and greatly 
resemble those of an ordinary acute catarrh ; so much so that, in the absence 
of any epidemic of measles, they could not be otherwise recognized. They 
are, shivering, alternated with heat, frequent pulse, headache, derangement of 
the bowels, sometimes accompanied by nausea and vomiting; and these affec- 
tions are so considerable that the patient usually takes to bed. At. the end of 
a few hours the fever becomes continued, and the specific action of the poison 
commences by the mucous membrane of the eyes and nose inflaming, so that 
the light is painful; the senses of smell and taste are lost, followed by a co- 
pious discharge of mucinous fluid from the nose and eyes, attended with more 
or less constant sneezing, and sometimes epistaxis. 
The buccal and bronchial membranes may become affected at the same 
time, and the patient is then troubled with a frequent cough, which has this 
peculiarity, that it occurs in paroxysms. The cough does not remit till about 
the seventh day, and is often accompanied by hoarseness, by a sense of con- 
striction across the chest, so that the cough is short and barking in its char- 
acter, by diarrhoea, and sometimes by ischuria. At night the breathing and 
cough may simulate an attack of croup. The duration of this first stage may 
be three, four, five, or even six days. 
The second stage commences with the appearance of the eruption, whose 
course and character have been described. On the appearance of the eruption 
the fever is often aggravated, but the distressing nausea and vomiting seldom 
last beyond the fourth day. The fever, therefore, together with the coryza, 
sneezing, coughing, hoarseness, and diarrhoea, continue with unabated severity 
till the eruption has reached its height, and is fully out over the whole body, 
which is on the third or fourth day after its first appearance. From this 
period, in favorable cases, all the symptoms begin to decline; and on the 
eruption disappearing, the cuticle desquamates, and the disease terminates on 
the ninth, tenth, or eleventh day from its commencement. 
In a few cases, however, on the subsiding of the eruption, or about the ninth, 
tenth, or eleventh day of the disease, and in some instances earlier, the pec- 
toral symptoms do not subside as they ought to do, but inflammation of the 
substance of the lungs or of the pleura takes place, prolonging the duration 
of the disorder, and endangering the life of the patient. The inflammation 
of the bronchial membrane is denoted by the expectoration either of a thick 
viscid mucus or of pus, and which may or may not be streaked with blood; DIAGNOSTS OF MEASLES. 
429 
while the mucous or sonorous rattle will point out the peculiar seat and extent 
of the mischief. If the substance of the lungs be inflamed, the breathing is 
more difficult, the cough more troublesome, and the countenance livid; but 
the loud mucous rattle which accompanies it seldom allows us to hear crepi- 
tation, or to determine the absence of respiration in any given portion of the 
lung. If the pleura be inflamed, we have, in addition to the cough, severe 
pain in the side, and an impossibility of filling the chest with air, except in 
a very limited degree. This condition is often accompanied by dulness on 
percussion, by bronchophony or segophony, assuring us that fluid is effused 
into the cavity of the chest. 
The main characteristic of the more severe form of measles, morbilli gravi- 
ores, is the eruption becoming, suddenly black, or of a dark purple, with a 
mixture of yellow. The early writers on measles describe this form of the 
disease as being much more common in their time than we find it to be in the 
present day. It is the asthenic typhous or septic form of measles. Sydenham 
considers this appearance as extremely formidable, and that persons so seized 
are irrecoverably lost, unless they are immediately relieved by bleeding and a 
cooler regimen. Willan writes that he has seen this discoloration, but thinks 
more lightly of it. 
The eruption is sometimes greatly delayed from causes not quite manifest. 
Excessive purging is thought to have this effect, or anything which greatly 
debilitates the system, hereditary or acquired unhealthiness of constitution, or 
the peculiarly malignant nature of the disease. The occurrence of the erup- 
tion is therefore to be looked for with anxious care, as the appearance of it, 
even though late, is in itself a favorable indication. 
If the eruption suddenly disappears, or " goes in," it is no less an unfavor- 
able omen, and is apt to be attended by other dangerous results-diarrhoea, 
dyspnoea, coma, convulsions-all which unfavorable signs may again disap- 
pear on the reappearance of the eruption. In these severe cases the eruption 
is irregular in its spread and appearance, and of various dark shades, as a 
result of hemorrhage into the cutis; and petechiie may appear on the skin 
interspersed amongst the eruption. In such forms of asthenic septic measles, 
the pulse, from a strong one, becomes small, weak, and so frequent that, when 
very small, it cannot be counted. There is great depression, with coldness of 
the hands and feet, while the body burns. The mind becomes confused, the 
tongue dry and crusted, and death ensues from prostration, sometimes in con- 
vulsions or stupor, even before the appearance of eruption. Great increase 
of bodily temperature 'from blood infection, or the blood-poisoning alone, are 
each, or both, set down as the source of this brain paralysis, in this asthenic 
septic form of measles; but the evidence is more in favor of high tempera- 
ture being the cause of the paralysis; and that remedies directed to lowering 
the temperature have a favorable effect on the symptoms (Niemeyer). 
[Camp Measles.-One of the most formidable of camp diseases are measles. 
During the civil war they prevailed epidemically to a great extent, both in 
the United States and Confederate armies ; mostly in recently organized regi- 
ments, at the State depots, or when moved to camps or barracks, and among 
recruits. The epidemics happened in the autumn, winter, and spring. The dis- 
order was most common in regiments from the rural districts. The mortality 
was large; in General Hospital No. 1, at Nashville, it was 19.6 in 100, and in 
the field hospital at Chattanooga, 22.4 in 100. Many died from the sequelae, 
or were permanently disabled for service. Nearly all the cases were in persons 
who had had no previous attack.] 
Diagnosis.-The diseases with which measles may be confounded are scar- 
let fever and some forms of syphilitic eruptions. The diagnostic symptoms 
between measles and scarlet fever are numerous; for there are many differ- 
ences, both in the general course of the fever, the ranges of temperature, and 
particular symptoms of these diseases, by which they may readily be distin- 430 
SPECIAL PATHOLOGY-MEASLES. 
guished from each other. Thus, the periods of the latency of the poisons are 
different-that of scarlet fever being from two to ten days, while that of 
measles is from ten to fourteen days. The eruption in scarlet fever seldom 
appears later than the second day of the primary fever; in measles it is 
delayed till the fourth day. In scarlatina the exanthematous patches are 
large, and the surface they cover ample; but in measles they are not larger 
than flea-bites, and when most confluent the clusters are small, sometimes 
forming crescentic patches. The color is also different, being of a bright red 
in scarlet fever, while in measles it partakes more of a pinkish-red or rasp- 
berry hue. The affections of the mucous membranes are also different in the 
two diseases. In scarlatina the tonsils are almost always greatly enlarged and 
ulcerated, while in measles they are little or not at all affected. ■ In scarlatina 
the eyes are free from coryza, while in measles this is the most prominent 
symptom. The tertiary actions of the poison are also different, being, in scar- 
latina, inflammatory affections of the joints, and dropsy; while in measles 
they are inflammations of the lungs or pleura; and, lastly, in measles the 
fever usually subsides on the disappearance of the eruption ; but in scarlatina 
the fever often continues many days or weeks after the eruption has run its 
course, or till the sore throat has healed. 
Prognosis.-The mortality from measles greatly varies in different years. 
During each of the four years previous to 1858 the proportion of deaths from 
measles in every 1000 deaths from other causes has been, in 1851, 24.107 ; 
1852, 14.599 ; 1853, 11.818; 1854, 21.463. Percival says, that out of 3807 
cases of measles, 91 died, or 1 in 40. Watson says, that in one year, at the 
London Foundling Hospital, 1 in 10 died; and in another 1 in 3. In the same 
establishment, in 1794, out of 28 cases none died; in 1793, out of 69 cases, 6 
died ; in 1800, out of 66, 4 died : and the aggregate of these data will give us 
an average of 1 death in 15: so that the prognosis in every case of measles is 
favorable in the first instance. The prognosis, however, is more favorable in 
the country than in large metropolitan towns; for it appears by the Registrar- 
General's reports that the proportion per cent, of the population that died of 
measles in London has been much greater than in England and Wales. 
The chief danger arises from bronchial and pulmonary inflammation, and 
the danger of this is greater after the disease has begun to decline than during 
its progress. An epidemic of measles occurred at Kiel in 1860. In the fatal 
cases the chief cause of death was a peculiar state of the lungs, which in part 
were collapsed, with foci of purulent infiltration in various parts, or a condi- 
tion of carnification. Intense bronchial catarrh was present, extending to the 
minuter ramifications of the air-tubes, but not of a croupal character (Vir- 
chow's Arch., vol. xxi, p. 65; New Sy den. Society Year-Book, 1861, p. 132). In 
strumous patients, measles may end in the development of miliary tubercles 
in the lungs; increasing cough, emaciation, and a harsh, dry skin being the 
symptoms of such an untoward result. The catarrhal affection during the 
desquamative stage forms generally the connecting link with the sequelse of 
measles; and the cough often remains for weeks or months after desquama- 
tion is over, and grows worse from the most trifling causes. It may depend 
on simple bronchial catarrh, or on severe disease of the lungs. The nature of 
that disease, however, is not always tubercle, but more often a caseous trans- 
formation and disintegration of the products of lobular pneumonia, with case- 
ous degeneration of the bronchial glands,-one of the most common compli- 
cations of measles. 
Croup sometimes supervenes, and cuts off young patients. It tends to be of 
the asthenic type, and is not unfrequently preceded by diphtheritic inflamma- 
tion of the fauces, which gradually passes down to the larynx. 
Diarrhoea is another danger to be encountered. During convalescence there 
is a tendency to looseness of the bowels, but which, if moderate, ought not to PROPAGATION OF MEASLES. 
431 
be counteracted, as it is commonly rather advantageous; but if suffered to 
continue, the consequences may be fatal. 
Catarrhal ophthalmia, otorrhcea, swelling of lymphatic glands, if the con- 
stitution be strumous, must also be watched for, and, if possible, prevented. 
Measles, in any of the malignant forms described, is highly dangerous ; 
and the danger is greater in the old than in the young-in cold than in warm 
weather. 
Causes.-Measles were first noticed at the same time and in the same coun- 
try with scarlet fever, and the two diseases have subsequently followed nearly 
the same course. They now prevail all over the world, are little influenced 
by season, are believed to be constantly in existence somewhere, and occasion- 
ally epidemic. 
Measles, though incidental to every period of life, are most frequently con- 
tracted in childhood, when it is difficult to trace the effects of accidental cir- 
cumstances, so that our knowledge of the predisposing causes is most imper- 
fect. Both sexes, however, appear to be equally liable to this affection. 
With respect to the influence of season, it is generally supposed that measles 
break out most readily in the beginning of winter, increase till the vernal equi- 
nox, and then tend to subside towards the summer solstice. The greatest num- 
ber and the largest epidemics occur in the winter and autumn, or in cold damp 
summers. The deaths, however, from this disease, registered in England and 
Wales, show that the influence of season is exceedingly trifling. 
Propagation of the Disease by Direct Communication and Infection.-It 
is admitted by all authors that a patient laboring under measles generates a 
poison which is organized, and which may be communicated directly, or which 
may contaminate the atmosphere with an impalpable poison. The poison 
seems to be most infectious when the eruption is out; and next, in the pro- 
dromal or catarrhal stage. Like scarlatina, measles is thus eminently com- 
municable ; and in like manner no susceptible person can remain in the same 
room, or even in the same house, with an infected person, without hazard of 
taking the disease. In the year 1824 it was imported into Malta by some 
children belonging to the 95th regiment, and spread extensively in that island, 
so that many natives died. This circumstance was the more remarkable, as 
measles had not been in the island for many years. The infecting distance of 
this poison, it will be plain from what has been stated, must be considerable; 
indeed, it is often very difficult to isolate the disease in public schools, or other 
large establishments, where it sometimes appears. 
The fact of measles being communicable has often been proved; but some 
difference of opinion exists as to the possibility of comumunicating the disease 
by inoculation. Healthy children have been inoculated, either by blood 
drawn from the arm of a patient suffering from measles, or with serum taken 
from the vesicles which are occasionally found intermixed with the eruption; 
an experiment which appears to have been first made by Dr. Home, with a 
view of producing a mild disease; but as no such result has been obtained, 
the practice has been abandoned. Many trials of this kind have failed to 
produce the disease, yet, on the whole, successes are sufficiently numerous 
and varied to warrant the statement that a specific poison communicates the 
disease. 
This disease is also propagated \yy fomites. The strictest demonstration of 
this fact is, that the disease has been communicated by direct application of 
substances impregnated with the virus in the attempts to inoculate the disease; 
it is also proved by the fact that children's clothes sent home in boxes from 
schools where the disease has raged, communicate the disease; and also by 
the same circumstance resulting when susceptible children have lain in the 
same beds, or in the same room, shortly after it has been occupied by patients 
suffering from the disease. Cold weather appears favorable to the develop- 
ment and propagation of measles. No age is exempt, from the foetus in the 432 
SPECIAL PATHOLOGY-MEASLES. 
womb to the second childhood of old age; but it is much more frequent in 
children than in adults, and there are few who have not had an attack of 
measles at some period of life. Children, however, under six months often 
escape during an epidemic of measles; and also very old persons rarely have 
the disease. It not unfrequently makes its appearance at the end of an acute 
disease. 
The morbillous poison having once produced its specific effects, as a general 
principle, leaves the patient exempt from all liability to a second attack. 
This law may be considered as proved both by Willan and Rosenstein-the 
former affirming that, after an attention of more than twenty years to eruptive 
complaints, he had not met with an individual who had twice had "febrile 
rubeola; " while the latter states that in a practice of forty-four years he had 
met with no instance of a second infection. There are, however, occasional 
exceptions to the rule. One variety of this disease-namely, the rubeola sine 
catarrho-is supposed to afford no protection against an attack of the rubeola 
vulgaris. There are many exceptions, however, to the non-susceptibility of 
persons who have passed through the rubeola vulgaris. Burserius, Robedieu, 
Home, Baillie, Rayer, and Holland, have all seen instances of a second 
attack of measles in the same individual. 
The period of latency of the poison of measles is determined to vary from 
ten to fourteen days. It seems also ascertained that the specific poison of 
measles is generated as soon as the primary fever is established, and before 
the eruption appears. 
Treatment.-The nature and course of measles differ from scarlet fever, 
not only in the fever being much less depressing, but in running a shorter and 
more certain course, and in having no tendency to terminate in ulcerations or 
mortifications of the skin. The constitution during measles is little impaired 
by the short continuance of the disease, and consequently admits of a more 
strictly antiphlogistic treatment. 
As no antidote is known to the poison of the measles, the disease must run 
its course. The rule, therefore, is to interfere as little as possible as long as 
the disease is pursuing its normal course, and merely to attempt to moderate 
and subdue symptoms when they threaten danger, knowing that the great 
majority of cases end in recovery without any medical treatment. 
The morbilli sine catarrho is usually of such a mild form as to require no 
other treatment than a milk diet, the customary attention to the bowels, and 
the prevention of exposure to cold and wet. Measles will not bear exposure 
of the surface of the body to cold so well as either scarlatina or small-pox, 
on account of the great tendency to bronchial and pulmonary inflammation. 
Children must therefore be watched night and day to prevent them lying 
uncovered, and special care must be taken to avoid exposure to cold during 
convalescence. An even and moderate temperature must be maintained in 
the room. The temperature ought to be regulated by the thermometer and kept 
at 60° to 65° Fahr. The room must also be regularly subjected to a current 
of fresh air daily, the patient being sufficiently protected at the time. 
In the morbilli mitiores the cough, the frequent vomiting, and the heavy 
catarrhal symptoms which so generally attend the primary fever, render medi- 
cal attendance necessary from the first moment of the attack. The treatment 
of these symptoms, however, and also of the eruptive stage, as long as the 
patient continues free from any serious inflammatory affection of the lungs, 
need not necessarily be active, it being sufficient to alleviate the cough, allay 
the vomiting, and check the catarrh by some of the large class of saline laxa- 
tives, linseed tea, or mucilaginous mixtures, to which antimonial wine may be 
added, if necessary, as a diaphoretic, and to subdue high vascular action. In 
making a selection from these, the physician must be principally guided by 
the state of the bowels and the condition of the stomach of the patient. If 
the bowels be constipated, the milder purging salts, as the sulphate of magnesia, TREATMENT OF MEASLES. 
433 
are to be preferred. Often however, a diet of stewed prunes or fruit will be 
sufficient. On the contrary, if the patient be purged, and the vomiting dis- 
tressing, a neutral mixture or effervescing draught will be found most bene- 
ficial. There are many persons in whom the cough and catarrh are the most 
urgent symptoms; and in such cases, if the stomach be quiet, the liquor am- 
monice acetatis, in half-ounce doses, combined with camphor mixture, from its 
more powerful action on the skin, is an excellent substitute. Another remedy, 
equally or perhaps still more useful, is ipecacuanha, of which from one to two 
grains may be given every four or six hours. Some practitioners prefer anti- 
mony to ipecacuanha, but antimony appears, at least in large doses, to act in 
some instances perniciously on the lungs. 
The treatment which has been specified is, in most cases, all that is neces- 
sary throughout the whole course of the disease; and the greatly extended 
experience of Willan hardly enabled him to enlarge it. He was of opinion, 
however, that an emetic, given on the second or third evening, somewhat al- 
leviated the violence of the catarrhal symptoms, and contributed to prevent 
the diarrhoea which usually succeeds measles. An emetic is especially useful 
if the disease be threatened with croup as a complication. During the erup- 
tion, he adds, "I have not observed any considerable effect from antimonials 
or other diaphoretics." Bathing the feet every evening seems a more bene- 
ficial application. Emulsions and mucilages afford but a feeble palliation of 
the cough and difficulty of breathing. With respect to opiates, they are not 
generally advisable; in the early stages especially, according to Willan, opium 
produces an increase of heat and restlessness, without conciliating sleep. 
The catarrhal symptoms are frequently accompanied, even in the very ear- 
liest days of the disease, with much bronchial inflammation, and sometimes 
with pneumonia; or these affections may occur at any later period, after the 
decline of the eruption, from the tenth to the twelfth day of the attack. 
"Oppressed breathing is common to many eruptive fevers; and if it were uni- 
versally to be considered as an indication for bleeding, the practice would 
often be more fatal than the disease" (Willan). In children, then, below 
ten years of age, we should be content with moderating the symptoms by reme- 
dies already mentioned; for, as the inflammation depends on a morbid poison, 
it has a course to run, and does not admit of a cure; and we have a right to 
look for a diminution of all the symptoms as the eruption naturally disappears. 
If pleurisy alone supervenes, mercury is best used in the form of friction with 
blue ointment over the chest, a little croton oil being added to promote its 
absorption (Andrew Anderson). In cases where miliary tubercle may be 
suspected to grow, good results have been obtained from quinine, nutritious 
diet, and wine. In the Kiel epidemic already noticed, leeching and emetics, 
employed moderately, were unsuccessful; but the alternate application of 
towels dipped in hot and cold water had very good effects, but required to be 
continued for hours or days. The disease was very prone to relapse, and 
never pursued the typical course of a simple pneumonia. 
During the whole course of measles it is necessary to enjoin an abstinence 
from all animal food, and to limit the patient to a low diet and to slops. The 
chamber should be of a moderate temperature (60° to 65° Fahr.), not subject 
to any sudden change from heat to cold, and the strictest cleanliness should 
be observed. With a view to protect the eyes, the room should be kept dark, 
so that the patient may be prevented reading or using his eyes. In large 
establishments separation is necessary to prevent the spreading of the disease, 
if possible. Should the eruption disappear or be retarded, and untoward 
symptoms appear, such symptoms must be carefully dealt with. On this 
point Niemeyer makes the following pertinent remarks: "Among the acci- 
dents that demand active treatment during measles, most authors place the 
'striking in of the eruption' in the first rank, and consider its 'restoration' as 
the most important point in treatment. We do not hesitate to say that it is 434 
SPECIAL PATHOLOGY SCARLET FEVER. 
just as unscientific as it is dangerous to carry out this indication; it is dan- 
gerous, because it induces rules which may have an injurious effect on the 
course of the disease. The disappearance of the eruption is not to be regarded 
as the cause, but as the result of a bad time of the disease, and due to the gen- 
eral collapse of the patient, in which the skin participates. But this bad time 
of the disease usually depends on the appearance of some complication, espe- 
cially pneumonia; and, if this fact be not remembered, but the patient be 
rubbed with irritating applications, or be placed in a hot bath, with or with- 
out mustard, or wrapped up in wet blankets with decoction of mustard, 'to 
bring the eruption out again,' we shall often do much harm, even if we succeed 
in our object, because these procedures do not generally act advantageously 
on the pneumonia and other complications, while they increase the fever " 
( Text-book of Practical Medicine). 
When convulsions occur in children, hot foot-baths sometimes give relief, 
as well as sinapisms to the limbs; after which, if they do not subside, blood 
must be taken by leeches from the temples; and it is in all cases necessary to 
determine the most probable source of the irritation giving rise to the convul- 
sions-i. e., whether they depend upon the specific poison of the disease, upon 
dentition, or upon intestinal irritation or cerebral disorder. Diarrhoea should 
not be checked suddenly, but kept under control. 
The patient ought to remain in bed so long as fever is present, while des- 
quamation is going on, and the cough is severe; and he ought to keep his 
room so long as catarrh is' present. 
SCARLET FEVER-Syn., SCARLATINA.* 
Latin Eq., Febris Rubra; French Eq., Scarlatina; German Eq , Scharlacbfieber; 
Italian Eq., Febbre Scarlattina. 
Definition.-Afebrile disease, the product of a specific poison, which is repro- 
duced during the progress of the affection. On the second day of the illness, or 
sometimes later, a scarlet efflorescence generally appears on the fauces and pharynx, 
and on the neck and face, which spreads over the whole body, and commonly ter- 
minates in desquamation from the fifth to the seventh day. The fever is accom- 
panied with an affection of the kidneys, often with severe disease of the throat, or 
of some internal organ, and is sometimes followed by dropsy. The disease runs a 
definite course, and, as a rule, occurs only once during life. 
Pathology and Morbid Anatomy.-After a period of latency or of incuba- 
tion, shorter than in measles, and lasting only eight or nine days, the peculiar 
poison of scarlet fever induces a disorder of the blood, which is, in the first 
* A considerable number of synonyms has been given by the College of Physicians 
in their Nomenclature, not with the view of sanctioning their employment, but that, 
in the registration of disease, whenever they occur, they are always to be rendered 
into the corresponding term sanctioned by the College. The Committee bad a two- 
fold object in mentioning these synonyms. First, There are several diseases which are 
commonly designated by an objectionable name, and when a preferable term could be 
found ; the other has been given as a synonym to indicate that exactly the same dis- 
ease was meant by the new name. A good instance of such a change is found in the 
substitution of "enteric" for "typhoid fever." Secondly, The enumeration of syno- 
nyms in common use seemed likely, in many cases, to give precision to the term 
adopted by the Committee, and in many instances served to identify it, and obviated 
the necessity of giving a definition-a matter always of considerable difficulty, and 
sometimes almost impossible in the compass of a few words, such as seemed suitable 
for a nomenclature of disease. As an instance of such an employment of synonyms, 
may be cited the subdivisions of Bright's disease, where a definition of the generic 
name having been given to avoid misapprehension, the simple addition of the names 
applied by different observers to each form of the disease seemed quite sufficient for the 
purposes of identification.-Med.-Chir. Review, Oct., 1869, p. 364. PATHOLOGY AND MORBID ANATOMY OF SCARLET FEVER. 
435 
instance, made manifest by a febrile state, and a disturbed condition of the great 
nervous centres. The primary fever having lasted for one, two, or three days, 
does not entirely subside, but the actions of the poison are set up as a peculiar 
eruption, preceded, followed, or accompanied by a sore throat, and also by 
intense hyperaemia and catarrh of the uriniferous tubules. The eruption runs 
a course of from six to eight days, but the duration of the affection of the 
throat is more indefinite, and varies from eight to twenty or more days. The 
fever continues during the eruption, and as long as the sore throat exists; but 
this being terminated, it subsides, and convalescence ought to advance. In 
a few instances, however, remote results succeed, as dropsy or inflammation 
of the joints, pleura, or pericardium, of the ear or cornea, lesions quite as 
formidable as any which had preceded them, and each or all of them localized 
expressions of the influence of the scarlet fever poison on the body. As in 
ordinary fever, the poison of scarlet fever acts on the brain and its membranes, 
often causing the usual forms of inflammation of those parts, modified in their 
course and effects by the nature of the specific febrile disease. 
That fever precedes the specific actions of the skin in this disease is so 
general a rule that it has few exceptions. Scarlet fever, indeed, of whatever 
description, essentially consists of a specific fever, and certain local inflamma- 
tions ; but among its more striking phenomena is the sudden and remarkable 
depression of the mental and physical powers of the body which the poison 
produces-a depression so great as sometimes to cause the death of the patient 
in a few hours, without any reaction, or any very sensible local lesion of the 
throat or other part being discoverable after death. On the contrary, there 
are a few instances in which the fever has been so great and so severe as to 
destroy the patient before the more specific lesions had time to appear, the 
affection of the skin being suppressed, and the sore throat wanting, the patient 
dies as if from the influence of an overwhelming poison. Death has taken 
place in six hours from the commencement of the disease-the child, in fact, 
dying poisoned (Dr. Andrew Anderson On Fever, p. 77). In such cases the 
patients seem to die of paralysis of the heart, preceded by symptoms of exces- 
sive adynamia (Niemeyer); and the question arises here, as in measles and 
diseases of this specific kind,-Has the poison through the blood a directly 
paralyzing effect on the nervous system, and especially on the nerves of the 
heart? or, Is the injurious effect due to the excessive increase of the heat of 
the blood alone-sufficient of itself to kill, or to induce the paralysis? In 
suddenness of danger it thus approaches yellow fever and cholera. Again, 
the rule that the great specific action of the poison is expended on the skin, 
causing the specific eruption, has very few exceptions. Of this eruption there 
are several forms, such as smooth, papulose, phlyctoenoid or vesicular. These 
are all evanescent after death. 
In the smooth eruption the surface of the inflamed skin presents no 
inequality either to the sight or touch. The scarlatina papidosa has an erup- 
tion in which the papillae of the skin are enlarged, by inflammatory exudations 
at circumscribed spots, and the appearance is that of roughness, or " goose- 
skinned." The third form is when the eruption is accompanied by numbers 
of vesicles of various size, filled with serum, or with limpid or cloudy yellow 
liquid, which ultimately shrivel up and desquamate. 
Whatever the ultimate form of the eruption may be, its first appearance is 
by innumerable small bright-red puncta, dots, or maculae, separated by inter- 
stices of healthy skin. These puncta or maculae are at first very minute points 
all over the affected parts of the skin, which are usually more or less rough to 
the touch; but they quickly become confluent, so that in a few hours the red- 
ness becomes general over the parts attacked. The anatomical change in the 
skin is that of a very extensive erythematous inflammation, consisting of very 
intense hyperaemia and an inflammatory oedema of the superficial layers of the 
cuticle. The color, in ordinary cases, is in the first instance a bright red, like 436 
SPECIAL PATHOLOGY-SCARLET FEVER. 
that of a boiled lobster, but on the decline of the disease it becomes deeper, 
and more resembles that of beet-root, while in severe cases it is of a pink 
blush, rather than a scarlet efflorescence, or it may be livid, and intermixed 
with petechise. But whatever tint the eruption may assume, it has this pe- 
culiarity, that it disappears on pressure, and again returns from the periphery 
to the centre on that pressure being removed. The color is also always 
brighter and more vivid in the flexure of the joints, and about the hips and 
loins, than over the rest of the body. A sign of scarlatina, in connection with 
the eruption, has been described by Bouchut, as pathognomonic. It consists 
in an enduring white stripe, produced by pressure with any hard substance on 
the skin occupied by the eruption. This phenomenon is ascribed to an increase 
of the contractile power of the capillaries, and which is proportionate to the 
intensity of the disease, the regularity of the eruption, and the amount of vital 
power (Syden. Society Year-Book, 1861, p. 130). As in the malignant cases 
of the previously described exanthematic fevers, so in scarlet fever, the hy- 
persemia of the skin is occasionally accompanied by more or less extensive 
hemorrhages, in the form of petechiee and extensive ecchymoses,-a most un- 
favorable sign. The termination of this specific inflammation of the skin is 
generally by desquamation of the cuticle. The desquamation begins with the 
decline of the eruption, and is usually completed by the end of the second 
week, unless it is longer delayed by successive crops of eruption, aud conse- 
quent succession of exfoliations. There is no fever in which this phenomenon 
is more conspicuous. A few days after the commencement of the desquama- 
tion, albumen may be detected in the urine in small quantity, which con- 
tinues to be given off for several days, along with a considerable amount of 
epithelium, resulting from the hypersemia and catarrh of the uriniferous 
tubules (Dr. J. W. Begbie). There are also cases in which the albuminuria 
is associated with anasarca; and three stages have been recognized in which 
this complication occurs: 
(1.) A febrile stage, characterized by fever of an intermittent character, 
and by rapid serous extravasation and infiltration. 
(2.) A chronic stage, in which the affection follows a slowly progressive 
course. 
(3.) A period of resolution (Hamburger). 
Such cases sometimes terminate by uraemic symptoms and convulsions. An 
unusual case of this nature has been recently recorded by Biermer. It hap- 
pened with a boy five years and a half old, and ended fatally on the thirty- 
fifth day. No urine was passed for 108 hours between the twenty-first and the 
twenty-sixth days of the disease, and extremely little for five days more. Yet 
during these ten days there were no uraemic symptoms, nor any notable dropsy. 
The uraemic symptoms first set in after the urine began to be secreted freely, 
and it was but slightly albuminous (Syden. Society Year-Book, 1861, p. 218). 
Occasionally the squamce of the cuticle are so large as to preserve entire the 
whole epidermis of the palms of the hands and of the soles of the feet. Fre- 
quently, however, the material of desquamation is furfuraceous or scaly. 
Frank has seen the cuticular squamae come away with the hair, nails, and 
even with verrucce attached. In a few instances the termination is by ulcera-x 
tion and sloughing of large portions of the integument. 
Symptoms.-Although several varieties of scarlatina are described by 
authors, it is not to be supposed that they are equally distinctly defined in 
nature. Yet it not unfrequently happens that the characters of each variety 
are tolerably well marked. The following varieties are to be distinguished, 
namely: 
(a.) " Simple Scarlet Fever." Definition: " A scarlet rash, with redness of 
the throat, but without ulceration." 
(6.) "Anyinose Scarlet Fever." Definition: "A more severe form of the SYMPTOMS OF SCARLET FEVER. 
437 
disease, with redness and ulceration of the throat, and a tendency to the 
formation of abscess in the neck." 
(c.) "Malignant Scarlet Fever." Definition: "The throat tends to slough; 
the scarlet rash is scarcely, if at all, visible; petechias are often seen on the 
surface, and the fever is of a low form." 
To this definition a note is added by the College of Physicians, to the effect 
that "scarlet fever occurs occasionally without any rash or sore throat being 
observed." If such cases could be always recognized, they ought to furnish 
a fourth variety-namely, Latent Scarlet Fever. 
The symptoms of scarlet fever under ordinary circumstances may be 
divided into three stages. The first stage occupies the period from the com- 
mencement of the disease till the appearance of the eruption, and is techni- 
cally termed the " primary fever;" the second stage, that from the appearance 
of the eruption till its entire subsidence; while the third stage is reckoned 
from the disappearance of the eruption till the termination of the disease. 
The duration of the first stage is one, two, or three days; that of the second, 
from six to eight days; while the third stage may either not exist, or vary 
from a few hours to two or three weeks,-making the whole duration of the 
fever to vary from eight to thirty or more days. These stages are not, as in 
typhus, usually marked by changes of the tongue; for, except in the more 
severe forms of the disease, it continues coated with a white creamy mucus 
throughout the whole course of the disease. In " scarlatina anginosa or ma- 
ligna," however, it becomes brown or black in the second, or at the commence- 
ment of the third stage. 
Simple Scarlet Fever.-It has been usual to give the name of "simple" or 
" benign " scarlet fever to those cases where the fever maintained an inflam- 
matory type, and where the perceptible localizations of the disease are 
expressed by the exanthema, severe catarrhal sore throat, and simple hyperm- 
mia, with catarrh of the kidneys. Simple though this variety may appear 
to be, it is a most serious affection. 
The primary fever may be sudden in its attack, or the patient may com- 
plain for some days of weariness and depression, or a feeling of sickness or of 
slight indisposition during the period of incubation. The early symptoms, 
whatever be the variety, are headache, pains in the back and loins, loss of 
appetite, sickness, and white tongue. The disease is, indeed, usually ushered 
in by vomiting-sometimes by very obstinate and troublesome vomiting. In 
slight cases it is sometimes the only noticeable symptom (Anderson). Still 
there are symptoms which distinguish it from other continued fevers; for the 
pulse, instead of being full and strong, is small, and weak, and rapid-120 
to 130 beats a minute; the heat of the skin is more ardent-104° Fahr, to 
105°, or higher; and with such ranges of temperature, these phenomena 
continue through the whole course of the disease. The fever, however, varies 
greatly in intensity, in height of temperature, and in duration. The charac- 
teristics of the fever are a rapid ascent, a very high maximum, and an inter- 
rupted defervescence. 
Simple Scarlet Fever has been also named Scarlatina mitis and Scarlatina sine 
angina; but these names ought not to be longer in use. 
The symptoms of this variety are sometimes extremely mild, so that the 
patient is frequently not confined to bed. The primary fever (except that 
the pulse is rapid) is little more than a mere febricula, and is not aggravated 
on the appearance of the eruption. The eruption appears at the end of 
twenty-four or forty-eight hours, and the crops follow each other according 
to the usual order of succession, that is, appearing first on the face and neck 
and upper extremities ; on the following clay on the trunk; and on the third 
day on the lower extremities, when the disease has reached its acme. On the 
fourth day the rash begins to decline, and fades from the face, neck, and 
upper extremities; on the fifth day it disappears from the trunk; and on the 438 
SPECIAL PATHOLOGY-SCARLET FEVER. 
sixth or seventh day it is evanescent over the whole body. The color of the 
rash is always more florid during the night than in the day; and on its declin- 
ing, desquamation takes place. With the disappearance of the rash the 
fever of this simple and benign variety ceases, and the disease terminates; 
but it often leaves the patient in a state of considerable debility for several 
days, and may be followed by albuminuria. 
Whatever may be the color or description of the eruption, it does not attack 
all parts of the body simultaneously, but appears partially, or in a succession 
of crops, the order of which maybe stated as follows: On the first day it spreads 
universally over the face, neck, and upper extremities; on the following day 
over the trunk, but is less general on the back than on the abdomen; and, 
lastly, on the third day, it has extended itself over the lower extremities. 
The duration of each crop is about three days, when it disappears, and in the 
order of attack, fading from the head and upper extremities on the fourth 
day; from the trunk on the fifth day; and from the lower extremities from the 
sixth to the eighth day. The order of attack, however, which has been men- 
tioned is not constant, for in some few instances the eruption appears first on 
the trunk and lower extremities, and only on the second day very faintly on 
the face and upper extremities. The period of eruption usually commences 
with an increase of the fever heat, while at the same time the general symp- 
toms increase, such as headache, weakness, restlessness; and convulsions are 
apt to occur in children. These early and severe symptoms are almost pathog- 
nomonic, as expressed by the fever and the pulse, such as are not often 
observed at the commencement of other diseases. If sore throat commences, 
there can be no longer any doubt. 
The disease attains its height, and the fever maintains its course, usually 
from the fifth to the ninth day, when, in favorable cases, a continuous but 
more often an interrupted defervescence sets in, and all the symptoms begin 
to decline. The fever does not subside on the appearance of the rash, as is 
the case with small-pox, but continues, with various degrees of violence and 
ranges of temperature, throughout its progress, until the eruption is fully 
developed. The maximum of temperature usually coincides with the maxi- 
mum point of eruption. The pulse is often 120 to 130 in a minute, and some- 
times beats with considerable force. The skin frequently indicates by the 
thermometer a temperature of 105°, or 106°, or even 112° Fahr.; and it is 
dry, with a sensation of burning heat till about the third day, when the maxi- 
mum of temperature is attained. From the third to the ninth day the range 
is maintained between 103.8° and 102.9°, and begins to subside about the 
tenth or twelfth day, after which the defervescence ought to be continuous. 
The difference in these respects between scarlatina and measles may be appre- 
ciated at once by a glance at the account and the diagram given of measles, 
and comparing it with the following diagram, which shows the typical range 
of temperature in Scarlet Fever. 
The temperature may be higher in this fever than in any other without a fatal 
issue; and is sometimes extremely high where the eruption is deficient or absent. 
There is no remarkable increase of fever heat preceding complete deferves- 
cence ; and after the exanthema has reached its maximum, the decrease of tem- 
perature proceeds by no means rapidly. The commencement of the decrease may 
be marked by a few decided and rapid falls; but its further fall is decidedly 
lingering, and is even sometimes interrupted by small increases of tempera- 
ture, like enteric fever, but with less exacerbation towards evening, so that 
the whole process of defervescence occupies, as a rule, from five to eight days. 
It is only in very mild or anomalous cases that the temperature rarely 
exceeds 101.8° Fahr.; and these cases sometimes show a rapid defervescence, 
completed in a single night. It is essentially a short fever, the ranges of 
temperature, according to Dr. Sidney Ringer, forming cycles composed of a 
variable number of days, generally of five; a fall of temperature taking place SYMPTOMS OF SIMPLE SCARLET FEVER. 
439 
on the fifth, tenth, or fifteenth day of the disease {Med.-Chir. Society Trans., 
28th January, 1862). 
TYPICAL RANGE OF TEMPERATURE IN A CASE OF SCARLET FEVER. THE 
RECORDS INDICATE MORNING (a. M.) AND EVENING (p. M.) OBSERVA- 
TIONS, COMMENCING ON THE EVENING OF THE SECOND DAY (Wunderlich). 
Fig. 72. 
The poison of scarlatina as frequently expresses itself on the mucous mem- 
branes of the eyes and nasal fossse, and excites a similar eruption over those 
parts as on the skin, at first consisting of a distinct punctated or dotted appear- 
ance, which changes in a few hours to one of diffuse redness. The inflamma- 
tion of the ocular membrane, however, has this peculiarity, that it does not 
distress the sight, for the eye bears light without inconvenience, and in no 
case of simple scarlet fever is it combined with coryza. Neither is sneezing a 
consequence of the affection of the nasal membrane; and only in a few severe 
cases is there any discharge from the nostril. As the eruption attacking these 
parts generally appears with the first crop of the exanthema of the skin, so 
does it generally die away with the cutaneous eruption. This inflammation 
usually terminates by resolution. 
The lingual and buccal mucous membranes are also often the seat of a 
similar exanthema, presenting nearly the same appearance as in other parts. 
The papillae of the tongue are singularly elongated and enlarged, and stand 
up salient and erect, and of a deep scarlet color, above the thick, white, 
creamy mucous fur which coats the lingual membrane; and hence the term 
"strawberry tongue," from the supposed resemblance to-the exterior of a 
strawberry, or " cat's tongue," from its resemblance to the rough surface of the 
tongue of the feline tribe. The tip of the tongue is of a vivid red, through 
development of the papillae. By and by the fur falls off, and the whole 
dorsum of the tongue is then left clean, red, and raw-looking. This affection lasts 
longer than that of the eyes and nose, and usually terminates by resolution. 440 
SPECIAL PATHOLOGY-SCARLET FEVER, 
The sore throat, or inflammation of the faucial membrane, though not so 
constant an affection as that of the skin, yet, when it does exist, it is often of 
much longer duration, and is a much more grave disease. It may either 
precede all the other symptoms, or it may occur at any period of the fever. 
This inflammation, at first punctated, then diffused, usually runs into ulcera- 
tion, and the character of the ulcer is so completely in unison with the state 
of the constitution as to enable us, according as it is slight or severe, to divide 
scarlatina into two great Varieties-namely, into the " anginose" and the 
"malignant." The first, or sthenic form, is marked by a greatly enlarged or 
swollen state of the tonsils, which are of a vivid or bright-red color; and, 
when ulceration takes place, the ulcers are seldom deep, or the sloughs slow 
to come away, but usually they separate about the fifth or sixth day; so that 
in mild cases the sore throat is healed about the eighth or tenth day, and in 
more severe ones about the fifteenth or twentieth. In malignant cases, the 
tonsils are much less tumefied and enlarged, but much more loaded with 
blood, and of a deeper, and sometimes of a livid color. The ulcers, also, are 
deep and formidable, and the sloughs are thrown off* later in the disease. They 
are likewise slow to heal, or not till the end of three weeks, and in severe 
cases not till four or even six weeks have elapsed, during which period the 
fever continues, and the patient remains in considerable danger. 
The inflammation of the throat is not limited to the tonsils, but extends 
over the fauces generally and uniformly, or symmetrically on either side, as is 
common with blood diseases. It may extend to all the neighboring parts, and 
an abscess may form in the pharynx, or pus may issue from the ears. The 
tympanum, in some cases, has been eroded, and in a few instances the inflam- 
mation has extended to the larynx, and the patient has died of croup. 
Besides these disorders, the glands of the neck often enlarge and occasionally 
suppurate, and, singular to say, sometimes not till after the sore throat has 
healed, and sometimes when there has been no previous affection of the throat, 
as if these parts were the seat of a specific action of the poison. Glandular 
swellings on both sides of the neck are not unfrequent, and have been 
described as "the scarlatinal bubo" (Trousseau). They may be the best 
and most accurate index of danger in the later period of scarlet fever, in so 
far as the danger depends on the sore throat, and on the putrid infection of 
the blood (septicaemia) which accompanies it (W. T. Gairdner, Clinical Medi- 
cine, p. 193). 
The inflammation of the cutis, as also of the buccal mucous membrane, is 
usually accompanied by some oedema of the submucous or subcutaneous 
areolar tissue. This affection takes place as soon as the rash appears, and 
causes the hands to swell, so that the patient is unable to bend his fingers, 
and his face becomes tumefied and painful. In mild cases, however, the 
serum effused is absorbed, and the disease terminates without any unpleasant 
consequences; in severe cases it has a tendency to terminate in ulceration or 
in mortification. In children the toes of one foot have been known to slough 
off; and in some the integuments of the leg have mortified from the knee to 
the foot; while in others, mortification, commencing in the upper lip, has 
been known to spread till one-half the cheek has been eaten away. Some 
have been known to die of mortification of the rectum, and others of a similar 
affection of the pudenda. 
Such are the primary and secondary affections of scarlet fever; but this 
poison has also more remote actions, giving rise to dropsy, as well as affecting 
the synovial membranes of the joints, the serous membranes of the pleura and 
pericardium. 
The dropsy which sometimes occurs after scarlet fever usually commences 
between the fifteenth and twenty-third days of the disease, and, almost 
uniformly, not till after all the other symptoms have subsided. The patient 
is liable to it during desquamation, as already mentioned, and for a consid- CONDITION OF THE URINE IN SCARLET FEVER. 
441 
erable time afterwards. It begins with anasarca of the face, and afterwards 
of the hands and feet. In some instances the anasarca is universal, the whole 
areolar tissue of the body filling so rapidly as sometimes to destroy the patient 
in a few hours, the cavities of the chest and abdomen frequently filling at the 
same time. According to the observation of Dr. Wood and many others, it 
has occurred more frequently after mild than severe cases. Its forms are 
anasarca, ascites, hydrothorax, hydropericardium, and even hydrocephalus; but, 
in whatever form, heaviness approaching to stupor is a common attendant. 
During the progress of the fluid effusion, oedema of the glottis must be watched 
for and relieved. The dropsy is generally accompanied with scanty and 
albuminous urine; and although the presence of albumen, without diminished 
secretion, is almost a regular phenomenon in the course of the disease, inde- 
pendent of dropsy, as shown by Dr. James W. Begbie, yet, if the urine be- 
comes highly albuminous and diminished in quantity, the dropsical complica- 
tions may be apprehended {Edin. Med. Journal, Jan., 1849, and Oct., 1852). 
More or less congestion of the kidneys occurs in every case of scarlet fever, 
although, like the sore throat, it may often be so slight as not to give rise to 
any prominent symptom (Begbie, Anderson). The scarlatinal dropsy is 
very generally considered as most intimately connected with the kidney dis- 
ease ; and when the kidney disease is well marked, the characters of the urine 
exactly resemble those in acute Bright's disease (Parkes). On the other 
hand, there is also evidence decidedly in favor of the opinion that albuminu- 
ria may be wanting in scarlatinal dropsy (see Parkes On the Urine, p. 264). 
The condition of the urine in scarlet fever ought to be ascertained daily in 
every case, especially during the period of convalescence. " It is of more im- 
portance," writes Dr. Andrew Anderson, " that you should examine the urine 
than that you should feel the pulse of a convalescent from scarlet fever." The 
urine has the ordinary febrile characters. During the first six days the 
amount of urine is small; the urea and uric acid are increased in amount, and 
sediments of urates occur. On the other hand, Dr. Edward Long Fox writes, 
that " urea is certainly not increased in the pyrexial period of scarlatina; but 
is diminished after the first few days of the disease, bearing no relation at all 
to the temperature." But he does not say if the amount he obtained was 
estimated in relation to the body weight of the patient, or by what standard 
he compares the results. (Under this head consult the article On the Urine.) 
The chlorine is sometimes greatly lessened, and augments during convales- 
cence. On the sixth to the eighth day, if the case goes on well, the urine 
becomes abundant, pale, and the reaction neutral or feebly acid. There is 
bile-pigment present during the first six days; and in a large proportion of 
cases, though not in all, the urine becomes albuminous. Dr. Warburton 
Begbie believes albumen to be present at some period in almost every case. 
It is usually associated with a large amount of renal, pelvic, and bladder 
epithelium, but not with renal cylinders (Begbie), unless there be dropsy. 
The albuminuria occurring during desquamation is usually transient; but it 
may continue till an attack of dropsy occurs-disappearing and reappearing, 
when dropsy conies on a fortnight or three weeks later. A rise of temperature, 
even to the maximum point of the original fever, marks the progress of acute 
tubal nephritis. In malignant scarlatina, as in malignant variola, there may 
be considerable haematuria or passage of dissolved haematin (Parkes On the 
Urine, p. 263). 
Intercurrent inflammations of the synovial membranes have been described 
by Withering, Sennertus, Heberden, and others. This disease may attack 
the wrist, ankle, or knee-joints, and usually terminates by effusion of serum; 
and in some cases the cavities of the joints contain pus. This inflammation 
seldom occurs till after the eruption has subsided, and is generally a tertiary 
phenomenon in the course of the specific disease. 
Such are the morbid phenomena which have been observed in the ordinary 442 
SPECIAL PATHOLOGY-SCARLET FEVER. 
course of scarlet fever, and with sufficient constancy to mark the disease as 
due to a specific poison; but these appearances are only to be found when the 
disease is of moderate intensity and the patient survives some days. In severe 
and rapid cases the patient may die, not from any organic lesion, but from the 
intensity of the shock, in the first instance, on the nervous system. Breton- 
neau, Tweedie, and Sims, all speak of having examined the bodies of persons 
who have died early in the disease, in which there was scarcely any appre- 
ciable lesion-coma, or other violent cerebral affection, carrying off the patient. 
Anginose Scarlet Fever.-In this form of the disease the specific action of 
the poison is mainly limited to one region-that of the throat-the eruption 
on the skin being altogether wanting, or appearing at a later period than usual, 
generally by one day; and, as a general rule, is less copious and less diffuse 
than in the other forms. It is "a more severe form of the disease than the 
simple variety, with redness and ulceration of the throat, and a tendency to 
the formation of abscesses in the neck." 
There is seldom a season in which scarlet fever has been in any degree 
epidemic, that cases have not occurred in which patients (not having previ- 
ously had scarlet fever) are seized with severe fever and sore throat, unac- 
companied by any eruption, and who, on subsequent exposure to the contagion 
of scarlet fever, have been found insusceptible of the action of the poison. 
Hence it is inferred that the disease they have passed through must have been 
a variety of scarlet fever or scarlatina sine eruptione, making itself manifest by 
a peculiar sore throat, associated with the febrile phenomena. 
This disease, therefore, essentially consists in fever and sore throat; and is 
only to be distinguished from simple sore throat from cold by its occurrence 
during an epidemic of scarlet fever, by the high fever, quick pulse, and great 
constitutional disturbance at an early period of the stage of incubation. It 
has been stated that the state of the throat is constantly in unison with the 
state of the constitution, and consequently this form of disease, according to 
its severity, may assume all the symptoms which accompany simple scarlet 
fever, or the more severe forms, with the exception of the absence of the erup- 
tion. 
In the simple form the essential character is, that the specific action of the 
scarlet fever poison falls on two tissues-on the skin, and on the mucous mem- 
brane of the eyes, nose, mouth, and fauces. The fever which precedes the 
eruption in such cases lasts from twenty-four to seventy-two hours. 
The symptoms, however, of the anginose variety are more violent than in 
the preceding species; for nausea or vomiting, great restlessness, headache, and 
some delirium, frequently occur as early as the second day. The heat of the 
skin also is more considerable, and often raises the thermometer as high as 
105°, while the pulse is quick, feeble, and fluttering, and shows the extreme 
debility the poison has occasioned. The primary fever having lasted its* period, 
the specific actions of the poison are set up, and the eruption may run the 
course which has been described in simple scarlet fever, but its color is more 
intense, its duration more variable, and its attack more partial. 
The angina, so marked a symptom in this affection, may precede the pri- 
mary fever, may commence with the eruption, or may occur at some later day 
in the disease. It has many grades, and in this form of scarlatina they are 
all of the sthenic or inflammatory type. Thus, in slight cases, the throat has 
merely the sensation of heat, dryness and roughness, with some pain, which is 
increased by deglutition; and then the mucous membrane of the tonsils and 
soft palate is seen to be dark-red and swollen. At a higher degree the tonsils 
are enlarged and ulcerated; while in cases of still greater severity they are 
swollen to a degree almost to occlude the fauces. In this latter case the act 
of deglutition is not merely painful, but in many instances impossible, and is 
impeded by a thick viscid mucus, which frequently requires the effort of vomit- 
ing to remove. The irritation of the fauces is sometimes propagated to the SYMPTOMS OF MALIGNANT SCARLET FEVER. 
443 
larynx, and the patient's voice is hoarse or inaudible, and perhaps he may ulti- 
mately die from this new affection. The parotid and submaxillary glands 
often enlarge, sometimes previously to the sore throat, more commonly about 
the fifth day, and again after the sore throat has healed. When the constitu- 
tional disturbance is very great, the sore throat may be of a diphtheritic char- 
acter, attended with an irregularly developed eruption, pale or livid, remain- 
ing expressed only for a short time, and accompanied by petechise, which 
continue after the eruption has disappeared. The fever continues high, the 
pulse weaker, and prostration greater. Such cases are generally attended 
with so-called "typhoid symptoms," the tongue, gums, and teeth covered with 
sordes. 
The degree of fever is usually proportioned to the severity of the angina, 
and is accompanied by headache and sometimes by delirium. It does not 
abate on the appearance of the eruption, but continues till the throat is 
healed. If the sloughs come away early, or on the fourth or fifth day, the 
throat heals, and the fever perhaps subsides within a day or two after the 
eruption. It sometimes happens, however, that the sloughs do not separate 
till the fourteenth or fifteenth day; and in this case the fever runs on with 
fequal violence after the disappearance of the eruption, and the whole disease 
is sometimes prolonged for three weeks or a month. In this case the tongue 
may become brown or dry, but it seldom continues so for more than a few 
hours. Observations as to body-temperature ought to be regularly and con- 
tinuously made. 
Malignant Scarlet Fever.-In the more severe forms of the scarlatina angi- 
nosa (and which have been described by some authors as the "scarlatina 
gravior, or malignant scarlet fever") the specific actions of the poison are the 
same as in the milder forms, but the symptoms, both local and general, are 
more severe, and the tertiary affections more frequent, and, consequently, the 
disease is more grave and the danger more formidable. 
The most remarkable symptom which distinguishes this form of the disease 
is the state of the tonsils. In the milder form previously noticed, it has been 
stated that the tonsils are either slightly affected or greatly enlarged, of a 
bright red, and the ulcers comparatively superficial; but in this severer form 
the tonsil, though less swollen, is more gorged with blood, more livid in color, 
while the ulcers are foul, deep, and burrowing: the secretions of the mouth 
are more copious, and generally impregnated with the offensive sordes of the 
sloughs; while deglutition, if less difficult, is perhaps infinitely more painful, 
and the mouth often so tender that the slightest touch excoriates it. The 
ulcers likewise are slow to granulate, and only heal after a tedious treatment; 
and in the worst cases they spread in every direction, the parts tending to 
vesicate and even to mortify previous to the death of the patient, which is 
almost certain to happen. 
This form is that which is known as the " malignant sore throat," or " pu- 
trid sore throat" of some authors; and is the name now generally applied to 
certain cases of extreme severity, into which some of the forms already de- 
scribed may pass, as if by insensible gradations. In this variety " the throat 
tends to slough ; the scarlet rash is scarcely, if at all, visible, petechise are 
often seen on the surface, and the fever is of a low form." In others, the vio- 
lence of the attack is so sudden that the patient is at once struck down by 
the force or virulence of the poison, the type of the attack being at once 
septic, adynamic, typhoid, and malignant. The extreme severity of the con- 
stitutional symptoms is marked by the smallness, feebleness, and irregularity 
of the pulse; the oppressed, short, and quick respiration; the appearance of 
early raving, stupor, and sometimes coma, alternating with fretfulness and 
violence, dulness, and suffusion of the eyes, flushing of the cheeks, and dark- 
brown furred tongue. The rash appears late, and is of uncertain duration, 
and soon assumes a dark or livid color, or disappears in a few hours, reap- 444 
SPECIAL PATHOLOGY SCARLET FEVER. 
pearing again after several days, if life is so far prolonged. Aphthous eleva- 
tions in the throat, surrounded by a livid base, also become dark, and, burst- 
ing, they expose a surface of an excoriated, gray, or dark and gangrenous 
appearance. The passages of the fauces are always clogged up with much 
viscid mucus or phlegm, which produces a rattling noise in breathing, and 
increases the pain and difficulty of swallowing. The discharges, often sanious, 
are remarkably acrid, which issue from the nostrils and posterior nasal pas- 
sages, causing soreness, excoriations, and even blisters on the surfaces and 
orifices over which, or through which, they flow. To this source the diarrhoea 
may be ascribed, which is sometimes severe at this period, and generally adds 
greatly to the sufferings of the patient. 
Such malignant sore throat not unfrequently occurs during what seems at 
first a simple or benign case of scarlet fever, and may not at first seem dan- 
gerous to life. But, insidiously, a diphtheritic inflammation may be seen on 
the throat, showing itself by dirty-white and firmly-adherent spots or points 
on the dark-red mucous surface. It soon spreads to the nasal cavities, whence 
there flows a discharge at first of an apparently bland fluid, but which soon 
becomes fetid. The dirty-white patches begin to separate as partially dif- 
fluent sloughs, which, being imperfectly detached, leave a gray unhealthy 
ulcer. The secretion flowing from nose and mouth then assumes a yellowish 
tinge, and is very fetid, and seems to corrode the skin of the cheek over 
which it flows. The lymphatic glands of the neck now become "scarlatinal 
buboes," forming hard lumps on each side of the neck. In such cases the 
pulse tends to become small and rapid, 140 to 160 per minute, and with a 
high temperature-105° to 106° Fahr. 
The eruption offers some peculiarities, being often later by some hours in 
coming out, its color darker and more livid, its duration more uncertain, and 
its distribution more irregular and capricious than in the milder form. The 
primary fever, likewise, is usually longer, the delirium earlier, and the de- 
pression more complete than in the milder forms; and towards the close of 
the disease the tongue becomes brown, and the symptoms closely resemble 
those of the last stage of typhus fever. 
Such are the more marked characters of the severer form of scarlatina ; but 
it often happens that the progress of this disease (unless the range of tempera- 
ture is regularly and continuously recorded) is silent, slow, insidious, scarcely 
marked by any prominent symptom, till the degree in which the constitution 
is subdued by this formidable poison is shown by the inflamed nasal membrane 
discharging its fetid ichor, causing mortification of the alee of the nose, or 
mortification of the lip or cheek; or it seizes on some remote part, as the toe, 
the leg, or the whole of a lower extremity, from which I have seen nearly the 
whole integument separate as a slough, and which, for the most part, termi- 
nates the life of the patient. 
The severity of the symptoms may produce death on the second, third, or 
fourth day of the disease, as from gangrene occurring in the course of the 
oesophagus or alimentary canal. In other instances in which the early symp- 
toms were not remarkably severe, the aphthous state of the throat has all at 
once assumed a sloughing aspect, and has carried off the patient at the close 
of the first week. When the disease is continued beyond this time,'death is 
foretold by the rapid, small, and weak pulse; by the rapid, languid, and op- 
pressed respiration ; frequent fluid acrid discharges issue from the bowels, and 
blood may be discharged from the nostrils, mouth, throat, bowels, or even 
from the kidneys; petechial or purpuric spots appear on the skin ; and the 
patient is at last destroyed with local manifestations of the morbid state in 
several different parts and organs. 
Latent Scarlet Fever.-The marked prevalence of anasarca in children has 
led to the discovery that such children have had previous attacks of scarlet 
fever, in such a mild form that it has escaped detection. In such cases the LOCALIZATION OF LESIONS IN SCARLET FEVER. 
445 
constitutional affection of scarlatina has been produced, but without any rash 
or sore throat being observed. On the kidneys alone the poison makes itself 
felt, and the dropsy which ensues is more severe, complicated, and fatal than 
that which follows the regular forms of the disease. 
Special Lesions (or Localization of them) in Scarlet Fever.-Under this 
head it is proposed to notice the more remote effects of the poison of scarlet 
fever. The effects produced in this way are often called by the people the 
" dregs" of the fever. The principal source of some of the formidable symp- 
toms is found to be the primary obstruction to which the functions of the kid- 
neys are so liable. Croupous nephritis is a frequent and important lesion, not 
necessarily due to cold or exposure during the eruption, but which is really a 
localization of the blood-poison of the specific disease. It is a more frequent 
lesion in some epidemics than in others. 
Another most important form of lesion is due to the effect produced by an 
extension of the original affection of the throat towards the internal ear, by 
the Eustachian tubes. When this takes place it not unfrequently happens 
that the small bones of the ear are completely destroyed, the tympanic cavity 
becomes iuflamed, ulceration of the membrane takes place, perforation follows, 
and deafness for life is the result. 
This morbid state is most difficult to remedy: a chronic discharge from the 
ear is established, which is of the most offensive kind, and which may con- 
tinue till the whole of the internal ear is involved in the destructive and in- 
flammatory processes; till the delicate and soft tissues in the cochlea and 
semicircular canals arc destroyed, and the petrous portion of the bone itself 
dies; till the mastoid process, with its capacious osseous areolse, becomes the 
seat of an obstinate carious process; or even till the brain itself, or the mem- 
branes, are involved in the unhealthy inflammatory process. Such a combi- 
nation of effects occasions great and protracted sufferings, and sometimes in 
the end a fatal result (Bruce, Anderson). A similar inflammation may 
destroy the tissues in the back part of the pharynx, extending towards the 
base of the cranium and upper cervical vertebrae. 
A frequent form in which the remote action of the poison of scarlatina is 
manifested consists in inflammation of the joints, and dropsy; and it is sin- 
gular that these diseases are oftener set up after mild than after the more se- 
vere forms of this fever. In such cases, about the time of the disappearance 
of the rash, the joints of the wrists or fingers, of the knees, or other articula- 
tions, become swollen and inflamed, and present all the phenomena of an 
attack of acute rheumatism. This affection keeps up the fever, and prolongs 
the whole duration of the disease for many days beyond the usual period. 
Again, in a given number of cases, not exceeding 3 per cent, in general, 
but in different seasons, or under different epidemic types of fever, sometimes 
amounting to 20 per cent., the remote action of the poison produces dropsy. 
This affection usually occurs about the twenty-second or twenty-third day, or 
about the time when the patient is convalescent, and more often after a mild 
than after a severe disease. Dropsy more commonly begins with pallor of 
the countenance, and with oedema of the face; then the hands and feet swell, 
and, in a few cases, the areolar tissue of the trunk and lower extremities be- 
comes enormously distended. When the areolar tissue is thus slightly or more 
generally distended with fluid, effusion may take place into the cavities of the 
head, chest, or abdomen. When the brain is threatened, the effusion is com- 
monly preceded by the usual hydrocephalic headache, by convulsions, and 
sometimes by blindness. Effusion into the cavity of the chest or of the ab- 
domen causes the usual symptoms of hydrothorax and of ascites, which have 
been described. In the former' instance, however, the watery fluid is some- 
times poured out so rapidly as to destroy the patient in a few minutes or in a 
few hours. 
The first appearance of the oedema or effusion is usually preceded or accom- 446 
SPECIAL PATHOLOGY - SCARLET FEVER. 
panied by an accelerated pulse, by the urine being scanty, commonly turbid, 
and passed with pain : the quantity, however, is shortly increased ; and if ex- 
amined when passed copiously, it is found to be of low specific gravity, or 
from 1.011 to 1.017, and to contain albumen, sometimes blood, renal epithe- 
lium, and cylindrical casts of the tubes (croupous nephritis). 
Diagnosis.-The only diseases with which scarlet fever can be confounded 
are the acute forms of roseola and measles. Roseola, though usually accom- 
panied by fever and sore throat, is distinguished from scarlatina by the erup- 
tion being confined generally to the chest. The diagnosis between measles and 
scarlatina will be better understood after the disease noticed in a note to this 
article has been described-namely, the hybrid form sometimes assumed by a 
concurrence of the two diseases; and by a careful study and observation of 
the ranges of temperature in each. 
Cause and Propagation of the Disease.-"The origin and nature of the 
scarlet fever poison are unknown; but its ordinary.sources, the way in which 
it is diffused abroad, and the means by which it may be destroyed, are known 
with entire certainty. It is impossible to say that it may not now and again 
be produced anew in the laboratory of nature ; but such a renewed production 
is not required for the explanation of any established fact. It is unquestiona- 
bly contained in everything that proceeds from the body of a patient laboring 
under the disease, and it is contained in special energy in the skin, which 
peels off at the close of the attack, and is scattered to the winds in the form 
of tiny scales, or even as absolute powder. Such portions of dried skin may 
settle down in undusted corners, or may become entangled in clothing or bed- 
ding, in either case preserving their virulence for an unknown period of time, 
and always liable to be disturbed from their resting-places, and sent forth to 
reproduce the fever." The earliest source of the poison is distinctly traceable 
to Arabia ; and the disease has now spread over the whole world. It prevails 
at all seasons of the year, is always in existence somewhere, and often epi- 
demic. Scarlet fever has been found to spread more extensively, and with 
greater fatality, among the poorer than among the wealthier classes of society. 
Both sexes are attacked in nearly equal proportions. 
All ages are probably liable to the disease ; but it is most common to child- 
hood-the feebleness of this early period of life facilitating, perhaps, the re- 
ception of the poison; and as children grow older, the less liable are they to 
be attacked. In a clinical essay On the History of Scarlet Fever, most care- 
fully worked out by Dr. B. W. Richardson, it is shown that scarlet fever 
attacks most frequently in the third and fourth years of life. The chances of 
attack decline rapidly after the fifth year. 
The seasons also seem to influence its prevalence and intensity. The 
months of October, November, and December, furnish in England the maxi- 
mum amount of the disease-the months of April, May, and June, the 
minimum. 
The specific fever being established, the patient generates a poison which 
may be communicated directly, as shown by a few cases of successful inocu- 
lation, or which may contaminate the atmosphere. The disease is eminently 
communicable, so that no susceptible person can remain in the same room, 
and hardly in the same house, without contracting it, unless special care be 
taken to isolate the sick. That scarlatina is capable of being directly com- 
municated is shown by the fact that children have been inoculated with the 
serum found in the vesicles which sometimes accompany the rash, and have 
taken the disease; but the inoculated disease not having proved milder than 
the natural, the practice has been properly abandoned. Another proof of the 
directly communicable nature of scarlatina is, that it has often been propa- 
gated by fomites, as by the clothes and boxes of boys returning from school. 
Susceptible persons also sleeping in a room lately occupied by patients labor- 
ing under scarlatina, and before the furniture has been washed and the bed- CAUSE AND PROPAGATION OF SCARLET FEVER. 
447 
ding and walls well ventilated, have often taken the disease. The virus is 
destructible by heat at the boiling-point, or it may be disinfected artificially, 
as by the fumes of nitrous acid. 
In the Lancet, of October 29, there is a very instructive history, by Pro- 
fessor Bell, of a succession of cases of scarlet fever that occurred in a College 
connected with the University of St. Andrews. Servants were the first suffer- 
ers, then students. Some of the latter went away, carrying contagion with 
them, and occasioning fresh outbreaks; but the succession of cases in the 
College, where isolation and disinfection had been practiced, was at first very 
perplexing. Scattered cases occurred in the town also, in families having no 
communication either with the College or with one another. At last it was 
found that the infection had been brought from the farm that supplied the 
several habitations with milk. This farm was a small one. The farmer's 
wife, with one child, visited a distant place where they were exposed to scarlet 
fever, and brought it home with them. The wife appears to have suffered 
very slightly. She nursed the child and fliilked the cows. A second child 
took the disease, and continued the infection. The boy who carried out the 
milk was next infected; and in him the fever was so slight that it never pre- 
vented him from accomplishing his daily round. On making out a list of the 
houses in which scarlet fever showed itself in St. Andrews, and on asking the 
farmer for a list of those to which he sent milk, the two were found to be iden- 
tical. With one exception, the inmates of every house supplied with the milk 
had been attacked by the disease, and twenty-six cases and two deaths were 
directly traceable to this centre of contagion. 
In the same communication, Professor Bell mentions having seen a child 
with sharp scarlet fever in a small crowded room. Upon inquiry he found 
the following facts: " The father had charge of an extensive society's bread 
shop ; the mother was a washerwoman, taking clothes to her house to wash ; 
the eldest girl attended, throughout the day, the children of a lady's family, 
and came home to sleep at night; the other children attended, some an infant 
school, some a large mixed school, where hundreds of other children met. 
The youngest played with young children in a house on the opposite side of 
the passage." Among the most common sources of the spread of scarlet fever 
may now be reckoned the movements of the dwellers in infected houses, the 
dispersion of schools in which the disease has appeared, and the unchecked 
going to and fro of the friends of the sick. It is less clearly proved that con- 
tagion is the only mode of propagating the disease; and that scarlet fever 
never develops itself spontaneously. But, on the other hand, this negative 
proposition is barely susceptible of proof; for although it is certain that epi- 
demics occur in places where it seems improbable that the disease had been 
imported, reasoning thus is surrounded by fallacy, inasmuch as there are 
facts which render it probable that the material of contagion is carried by 
persons not themselves infected by the disease. It has been attempted to be 
shown that the decomposition of the offal of slaughter-houses is capable of 
breeding scarlet fever; but the evidence is not conclusive. On this point, 
Dr. Ballard, the able medical officer of health for Islington, writes most dis- 
tinctly (and with him I fully agree) that " thus much is certain, it does twt 
arise spontaneously,-no disease of its class ever does. The seeds of the malady 
-sometimes given off by a patient suffering from it-are always present; 
isolated cases are never wanting in the metropolis." 
Dr.'Willan says, that out of 2000 cases that he attended, he witnessed no 
instance of a second attack. Still, there are some exceptions to the statement 
that an attack of scarlatina gives an immunity from a second attack. Dr. 
Binns has seen instances of scarlet fever occurring twice in the same person, 
while Sir Gilbert Blane met with an instance of its occurring thrice in a young 
lady, without the least suspicion of ambiguity or possibility of mistake in diag- 
nosis. Dr. B. W. Richardson shows that it may recur once or even twice in 448 
SPECIAL PATHOLOGY SCARLET FEVER. 
the same person. But these events are rare; and death from a second attack 
is unknown as a fact. 
Scarlet fever has often coexisted with the vaccine disease, and with erysip- 
elas, and this poison is consequently capable of coexisting in the system, not 
only with those diseases that have been mentioned, but probably with all other 
disease-poisons. 
The poison of scarlet fever is absorbed by the mucous membranes; and ab- 
sorption is also evident from the fact of inoculation having been effected 
through the skin. Children have been born laboring under this disease. 
The period of latency varies from a few hours to ten days. In one case in- 
oculated by Rostan the disease appeared on the seventh day; and the specific 
poison is probably capable of communication from the patient to others as 
soon as the primary fever has formed, and perhaps continues to be so till the 
sore throat has perfectly healed, supposing that affection to continue after the 
eruption has died away. 
Prognosis.-The mortality from scarlet fever varies greatly according to 
the season, and also, perhaps, according to the fatality of the epidemic. In 
some years the proportion of deaths is not greater than 3 per cent.; but Sir 
Gilbert Blane says his practice gave one in four. He was consulted probably 
only in the worst cases, for in the same year it appears, from the reports of 
other practitioners, the deaths varied from one in six to about one in thirty. 
There is perhaps no disease in which the progress is so capricious: for it is 
found to vary with the several forms, types, complications, epidemic constitu- 
tion, and with the treatment, in a most remarkable degree. The mortality is 
greatest in the period of infancy and childhood-from one to five years. In 
relation to mortality, it seems second in this country as to severity, typhus 
fever standing first (Richardson). It is twice as fatal in towns as in the 
country. "There is one condition in which the disease is almost invariably 
fatal; that is the puerperal state. No precaution ought, then, to be neglected, 
no precaution ought to be thought excessive, which tends to prevent a woman 
from receiving the poison of scarlatina while pregnant or recently delivered" 
(Dr. Andrew Anderson). Fever during the pregnancy most certainly 
ends in abortion and death. If the woman be recently delivered, the disease 
will be of the most malignant type, and almost always fatal. 
"The continued prevalence and the great fatality of scarlet fever in Eng- 
land and Wales, and especially in the London registration district, are such 
as to call for the earnest consideration of all classes of the public. In order 
to show the magnitude of the evil, it will be sufficient to say that the disease 
in the two years 1863 and 1864 destroyed in England alone more than 60,000 
persons. In 1869 the number of victims in London amounted to 5803. In 
the quarter ending on the 30th of June, in 1870, the deaths from scarlet fever 
in London were 1076, and in England and Wales 5973; and the number 
registered in London has lately been about 200 weekly. The disease varies 
so much in character and severity, is sometimes so slight and sometimes so 
malignant, that it would be difficult to state any definite proportion between 
mortality and prevalence. If we assume this proportion to be one in twelve- 
an estimate that would probably not be very far from the truth-it follows 
that there have existed in London during a single quarter nearly 13,000 cases, 
each one of which, whether trivial or fatal, would be a new source of infection 
to the district in which it occurred. Putting the matter in another form, and 
allowing each patient a fortnight of infectious activity, we may say that 
London maintains a permanent stock of 2000 centres of contagion." 
Treatment.-Scarlet fever being evidently accompanied by many highly 
inflammatory symptoms, the practice of bleeding was adopted on the first 
breaking out of the disease, in all countries, and, according to Willan, with 
the most disastrous results. This mode of treatment was adopted by Morton ; 
and he speaks of witnessing 300 deaths from scarlatina in a week. It pre- TREATMENT of scarlet fever. 
449 
vailed down to the time of Huxham, who abandoned it, and introduced a 
treatment by bark. In this manner an entirely opposite system of treatment 
has been gradually introduced, and the records of medicine enable us to state 
the results of these opposite modes: Of cases treated at the Foundling Hos- 
pital by bleeding in 1786, and of cases treated at the London Fever Hospital 
in 1829, in the same manner, it seems proved that one in six died after bleed- 
ing, while only one in twenty-two died after a milder, if not a directly opposite, 
mode of treatment; and the conclusion which inevitably follows is, that the 
chances of recovery are diminished by the practice of bleeding, nearly in the 
ratio of four to one as compared with the chances of recovery, supposing the 
patient not to have been bled. 
It remains now to give some general directions for the treatment, and to 
point out the circumstances in which certain remedies may be most advan- 
tageously employed. 
It should be laid down as a maxim, that in scarlet fever, medical advice 
ought always to be had recourse to; for the worst cases we meet with (as those 
in which mortification of the nose, cheek, or limbs sometimes takes place) are 
those in which the disease has, from its apparently mild character, been left 
to itself. 
In the mildest form of the disease it is sufficient to confine the patient to the 
house; to enjoin strictly a milk diet; to regulate the bowels ; and, above all 
things, to avoid the nimia diligentia medicorum. Any active interference with 
the normal course of the disease is to be avoided. The sick-room ought to be 
kept at a uniform temperature, and not exceed 55° to 65° Fahr., and the 
patient must not be overladen with bed-clothes. The patient ought to be 
washed daily with tepid water, and carefully dried with soft cloths. As much 
fresh air as possible should be admitted to the room. The best drink is water, 
pure and cold, while soups of meat, Liebig's extract of meat, stewed fruit, and 
milk, ought to form the staple diet. Constipation is to be overcome by en- 
emata of tepid water and salt, avoiding purgation by medicine. In the simpler 
cases of scarlet fever such management is sufficient. 
In the cases commencing with much sickness and general disturbance, a 
gentle emetic at the outset is believed to have a happy effect in modifying the 
future course of the disease. Ipecacuanha, with or without tartar emetic, is 
the best form for administration ; and half an ounce of castor oil ought to be 
given after the action of the emetic had ceased. 
Looking to the morbid condition of the blood, and to the tendency which 
exists to the deposition of fibrin in the right cavities of the heart, small doses 
of carbonate of ammonia (three to seven grains) administered every hour, or 
every three hours, as soon as the symptoms are decided, have been recom- 
mended (Peart, Witt, Richardson). Or, the liquor ammonite acetatis may 
be used with an excess of ammonia, to the amount of from three to five drops 
of liquor ammonite added to two fluid drachms of the former in a liberal quan- 
tity of distilled water (Richardson). It is important to administer these 
medicines in small and frequently repeated doses; and, if possible, let the 
remedy be taken as a drink. 
The treatment of the milder forms of the fever, when the tonsils are con- 
siderably enlarged, is first to tranquillize the stomach and allay its perverted 
action when vomiting exists, either by small doses of the sulphate of magne- 
sia, or by the effervescing draught,-medicines which, according to the state 
of the bowels, may be given every four or every six hours. The gum resin of 
guaiacum is of great service in subduing the cynanche tonsillaris, and may be 
prescribed in the following formula: 
R. Magnes. Sulph., Jvi; solve in Aqua, oviii; adde Pulv. Guaici, 5iss-l 
Pulv. g. Tragacanth, co., 3ij; misce bene. One-sixth part of this mixture 
may be given every four hours, till the bowels are freely moved. 450 
SPECIAL PATHOLOGY SCARLET FEVER. 
As soon as this object is effected, and it is ascertained that the tonsils are 
still greatly enlarged and swollen, the practice (supposing the patient to be 
an adult} is to relieve them by the application of six to twelve leeches to the 
throat; and the bleeding may be further encouraged by the application of a 
poultice. The trifling loss of blood thus sustained does not impair the general 
strength of the patient, if it is- done sufficiently early, while it greatly reduces 
the swelling of the tonsils, and may prevent them becoming permanently en- 
larged. Another advantage is gained by the application of leeches to the 
throat-namely, that they relieve the affection of the head ; for we constantly 
observe that, in diseases depending on morbid poisons, the head symptoms are 
relieved by relieving the part specifically acted upon. 
The tonsils having been thus relieved, the fever ought to be permitted to 
run its course uninfluenced by medicine, the patient being only refreshed by 
the occasional administration of the saline draught, and ice, so grateful to his 
parched mouth and feverish state. If stimulation be adopted in these cases, 
we are apt to bring back the tumefaction of the tonsils; while, on the con- 
trary, if we take more blood, we hazard producing the more serious accidents 
incident to scarlet fever. The medicines, therefore, that have been mentioned 
should be persevered in till the disappearance of the eruption, and till the 
healthy granulations of the throat, and the decline of the fever, give evidence 
of a state of convalescence. At this point some mild tonic medicine is desira- 
ble, and prepares the patient once more for the enjoyment of health. This is 
the most successful mode of treating cases of scarlet fever in its milder angi- 
nose forms. With children, however, it is better to trust to the soothing 
effects of warm poultices round the throat, and inhalation of steam, than 
weaken the child by loss of blood. 
The severe forms are characterized by the less swollen state of the tonsils, 
and by their being more livid and gorged with blood; by the ulcers being 
deeper and more spreading; and by the slough being fouler than in the milder 
varieties. As there is a greater tendency of parts to run into mortification, 
the necessity of adopting a more stimulating plan of treatment, and one more 
calculated to support the powers of the constitution, is manifest, and experience 
has shown this view of the case to be correct. The administration of wine, 
and of the " extractum carnis Liebigii," should therefore be the basis of the 
treatment of such cases. The quantity of wine for an adult may be from four 
to six ounces in twenty-four hours, and for a child about half that quantity. 
The wine may be either port or sherry, and should be taken in small quanti- 
ties, mixed with two-thirds water; or it may be given with sago, arrowroot, 
jellies, or other demulcent food. The earlier the wine is given in the disease 
the better, and when delirium does or does not exist; regardless, also, as to 
whether the tongue is moist and white, or brown and dry ; and it should be 
continued till the patient is decidedly convalescent. Liebig's extract of flesh 
should be given like beef tea, as a drink. While pursuing this plan, it is 
necessary that the patient's bowels should be attended to. The treatment by 
wine is often extremely successful; and, as it is in general pleasant to the 
patient, whether a child or an adult, it is seldom refused. In cases more 
severe, brandy may be required, or carbonate of ammonia in liquor cinchonas, 
chlorinated soda, or creosote. 
It maybe proper, before adopting any special continuous mode of treatment, 
to follow the emetic first given by a dose of calomel, as a purgative, and this, 
especially with children, to be followed in six or seven hours by castor oil or 
magnesia; and the bowels are ever afterwards to be kept open by remedies 
suited to the state of the patient and the nature of the disease. The follow- 
ing are the principal indications which must guide the treatment: If there is 
much excitement of the system, depleting cathartics are to be given : if nausea 
and vomiting prevail, a seidlitz powder is of service. If the discharges from TREATMENT OF SCARLET FEVER. 
451 
the rectum are acrid and acid, with acidity of the stomach, magnesia is pref- 
erable; if there is abdominal pain, castor oil with opium (Wood). 
Bleeding is not successful in combating affections of the larynx; on the con- 
trary, the most beneficial mode of treatment appears to be that of moderately 
supporting the powers of the patient by wine and mild tonics. 
Again, when the synovial membranes inflame, and the joints become enlarged 
and swollen, all stimuli should be withdrawn, and a moderate action of the 
bowels should be kept up by means of the sulphate of magnesia; with camphor 
mixture, or carbonate of ammonia; and if pain be severe, some sedative should 
be added, as the tincture of hyoscyamus in a dose of fifteen minims. 
The more formidable affection in scarlet fever is dropsy; and from the great 
tendency to effusion into the head and chest, an active treatment is necessary. 
We should have imagined that in dropsy, a symptom in most cases of great 
debility, and following a disease whose characteristic is great depression, bleed- 
ing Would have been dangerous and improper; but experience has shown that 
bleeding by leeches .over the region of the kidneys is often of service; especi- 
ally if oedema appears in the face, and is accompanied by headache, some 
blood should be taken-from two to four ounces in the child, and from four 
to eight ounces in the adult. The good results of cupping are also very remark- 
able ; and even of continuously hot poultices over the lumbar regions, when 
it is not thought advisable to take blood. By these means renal congestion 
is relieved, and the urine becomes more copious and less albuminous. 
Diaphoretic doses of antimony, and moderate but not severe purging, may 
be had recourse to. The compound powder of jalap, or the bitartrate of potash 
alone in drachm doses three times a day, are among the most useful; or it 
may be given as an electuary, in which the cream of tartar is mixed with 
nearly an equal quantity of honey, treacle, or marmalade, and flavored, if 
necessary, with a few drops of peppermint oil; digitalis also is much recom- 
mended, but it does not appear to possess any specific virtue. Dr. Andrew 
Anderson recommends the use of mercury in the form of blue pill, given twice 
or thrice daily, with squill and digitalis, till the urine resumes its natural 
appearance. The patient must at the same time be well fed; and prepara- 
tions of iron may be given with advantage. The muriated tincture seems to 
have the best reputation; and the iodide of potassium in small doses is also 
useful. With this latter remedy the syrup of the iodide of iron may be com- 
bined, if it is desirable to continue the chalybeate; or syrup of the phosphate 
of iron in drachm doses. 
Gargles are unnecessary for children, for they cannot gargle; but they are 
of the greatest service, especially the deodorizing gargles or washes, when the 
patient can be taught to use them. A weak solution of chloride of lime, or 
of chlorine water, or of Condy's fluid, or of the permanganate of potash, is 
well adapted to such a purpose. But the following is recommended as the 
most effectual gargle: 
Solution of peroxide of hydrogen (containing ten volumes of oxygen), six 
ounces; tincture of myrrh, an ounce; rose water, five ounces (Richardson). 
This gargle may be used at pleasure: it is refreshing to the patient, and 
removes the offensive secretions readily. In the case of young children, who 
are unable to use a gargle, the throat may be washed out, by holding the 
little patient with the face downwards, and by pumping the solution over 
the surface of the fauces through a bit of gum catheter from a double-acting 
india-rubber bag (Richardson, Clinical Essays, p. 110). As an invariable 
routine practice, Dr. W. T. Gairdner strongly recommends that " the patient 
inhale the steam of hot water from the beginning to the end of the fever; as long 
at least as the throat is sore."* In slight affections it is sufficient to employ 
* Inhalers for the purpose may be had of most surgical instrument makers. 452 
SPECIAL PATHOLOGY SCARLET FEVER. 
infusion of linseed in water, acidulated with nitro-muriatic acid, weak solu- 
tions of alum, nitre, or common salt. When membranous diphtheritic patches 
are observed on the fauces, and the color of the mucous membrane is of a 
dark red, capsicum infusion, or powdered red pepper, is an excellent application 
(Wood); and in children who cannot gargle, it may be applied with a hair 
pencil. Solution of zinc, or nitrate of silver, is also of service. 
Ulcerations may be touched daily with a solution of nitrate of silver (one 
drachm to two ounces of water), applied by means of a hair pencil or a 
sponge probang; while a weaker solution (grains v to x to two ounces of 
water) is at the same time injected through the nostrils when there is dis- 
charge, and it gives great relief. Turpentine and glycerin in equal parts 
brushed over the ulcerated throat is also a valuable application, and the sul- 
phurous acid spray may be of service. 
In swelling of the parotid and submaxillary glands, ice in bags of oiled silk 
fastened round the neck and angle of the jaw, with lumps of ice in the mouth, 
diminish engorgement, and tend to avert suffocation. 
These details are given because the physician must decide, upon the merits 
of the individual case, the nature of the treatment he will adopt. But it 
must be remembered that cases of scarlet fever, if left to themselves, with rest 
and careful nursing, will generally get well. The mere intensity of the fever 
is no ground for active interference by way of treatment, if the pulse is full 
and of good strength. Much is to be trusted to the shortness of the fever, 
remembering that there is no disease in which the patient is more apt to be 
delirious, and in which the temperature may reach a high degree, with less 
danger, than in scarlet fever (W. T. Gairdner, Clinical Medicine, 1. c.). On 
the other hand, it must also be remembered that any continuous and exces- 
sive increase of the temperature of the body may be followed by the occur- 
rence of adynamia and threatened paralysis of the heart; and that such cases 
suddenly and urgently demand such therapeutic interference as may tend to 
reduce temperature. Treatment by the cold water douche, as originally 
advocated by Drs. Jackson and Currie, is now again recommended in the 
treatment of malignant scarlet fever, where there is no local lesion yet set up. 
Niemeyer and others bear testimony to its having a most marked beneficial 
effect. The patient may be placed in an empty tub, and have the cold water 
poured over him, or his naked body may be wrapped in wet sheets, to be 
renewed and reapplied at intervals of ten to fifteen minutes, the patient being 
put to bed in the interval. If either of the measures fail, then such powerful 
stimulants as carbonate of ammonia, camphor, 'or alcohol, may be had recourse to. 
Preventive Treatment.-Mere fumigation will not, it should be remem- 
bered, destroy the miasmata in the sick-room; and, consequently, the doctrines 
of separation, of ventilation, and of cleanliness, are as imperative in this dis- 
ease as in small-pox. The isolation of healthy persons from those affected 
with the disease, and from those who have intercourse with such patients, is 
essential, and is the only rule that promises any good results. The following 
rules (drawn up from the experience of Drs. Ballard and Budd) ought to be 
carried out in every house where conveniences can be obtained ; such conveni- 
ences ought to exist in every hospital, and in the houses of the poor they ought 
to be carried out as far as practicable: 
1. Remove from the sick apartment all superfluous woollen or textile mat- 
ters, such as carpets, curtains, and anything of that nature, which are known 
to be retentive of disease-germs. 
2. Measures of disinfection should be used as early and as thoroughly as 
possible. Carbolic acid in solution, or as carbolate of lime, is especially useful 
to sprinkle on the floor, and with which all parts of the room may be washed 
prior to cleansing and lime-whiting; and all articles to be washed ought to be 
soaked first in a solution of carbolic acid. 
3. A basin charged with chloride or carbolate of lime, or some other con- PREVENTIVE TREATMENT OF SCARLET FEVER. 
453 
venient disinfectant, is to be kept constantly on the bed for the patient to spit 
into, and which must be emptied and replaced at regular intervals. 
4. A large vessel (a tub) containing water impregnated with Condy's fluid 
or carbolic acid solution should always stand in the room (or near by) for the 
immediate reception of all bed and body linen on its removal from the person 
or contact of the patient. 
5. In place of using pocket-handkerchiefs, use small pieces of rag for wiping 
the mouth and nose, so that each piece, after being used, may be at once 
burned. 
6. Two basins, one containing Condy's fluid or carbolic acid solution, and 
another containing plain soft water with carbolic soap, and a good supply of 
towels, must always be ready and convenient, so that the hands of nurses may 
be at once washed after they may have been soiled by specific excreta. The 
dresses of nurses and attendants should be of linen, or smooth washable mate- 
rial. 
7. Glasses, cups, and other vessels used by or about the patient, are to be 
scrupulously cleaned before being used by others. 
8. The discharges from the bowels and kidneys are to be received, on their 
very issue from the body, into vessels charged with disinfectants. 
9. To prevent the minute particles of desquamation from flying off as im- 
palpable powder, their power for evil must be destroyed in situ, by anointing 
the surface of the body (the scalp included) twice a day with olive oil. It 
may be slightly impregnated with camphor, which Dr. Budd considers suffi- 
cient, or carbolic acid. The process relieves the itching of the skin, and is 
very soothing to the patient. So soon as efflorescence is observed on the skin 
of the neck and arms (as early sometimes as the fourth day), which marks the 
first liberation of the germ-carriers of the specific disease poison, the employ- 
ment of the oil is to begin, and ought to be continued until the patient is well 
enough to take a warm bath, in which the whole person (scalp included) is 
well scrubbed, carbolic acid soap (Calvert's or Macdougall's) being abundantly 
used during the process. These baths are to be repeated every second day, 
until four have been taken, when, as far as the skin is concerned, the disinfec- 
tion may be regarded as complete, although a further quarantine of a week 
may be advisable. 
10. The chamber in which the sick person has been must now be thoroughly 
washed out, using freely carbolic acid and soft or black soap (which may now 
be got combined for the purpose). (Brit. Med. Journal, 1869, Jan. 9, p. 23.) 
If a patient be from the outset thus isolated from all who are susceptible of 
contagion-if everything proceeding from him is drenched with chemical dis- 
infectants before it leaves the sick-room-if the exhalations from the skin, and 
the peeling skin itself, are mechanically imprisoned by inunction with oil until 
they can be removed by a warm bath-and if all clothing, bedding, and fur- 
niture are disinfected at the close of the illness-a case of scarlet fever will 
remain barren of results. To carry out such a process thoroughly, requires 
the command of space, of money, and of attendance; and requires also wisdom 
and self-denial on the part of relatives and friends. If it were possible to 
begin to-morrow, and to carry it out in every case, scarlet fever would have 
ceased to exist in the country at the end of two months, and it is possible, or 
even probable, that it would never return. 
" When, however, we look abroad at the actual condition of the people 
among whom the disease works its ravages, we see at once that, with regard 
to very many of them, and especially with regard to the poor in towns, isola- 
tion and disinfection are no more than idle words. In the class above the 
very poor, among small tradespeople, small employers, and the like, where 
the adoption of proper measures, although difficult, would not be impossible, 
it is rare to find the intelligence and the active conscientiousness that would 
induce them to bear restraints, to take trouble, and to incur loss, for the sake 454 
SPECIAL PATHOLOGY ROTHELN. 
of preventing injury to their neighbors. Even among the wealthy and edu- 
cated, disinfection and isolation are but imperfectly carried out. Such people 
like to do as they please, and resent dictation from medical men. If the cases 
are severe, mental anxiety and distress break down the barriers of precaution. 
If they are trivial, strict precaution would too often be thought fussy and un- 
necessary. Medical men cannot in such cases enforce what is right. They 
can only recommend it; and they recommend it subject to the remembrance 
that their business is to heal the sick, not to quarrel with the healthy. It is 
a curious weakness of human nature, that many otherwise rational creatures 
are angry at the suggestion that their loved ones can be sources of danger to 
all around them, or that their house is properly shunned by the neighbors; 
and beyond this there is the belief, not altogether unfounded, that it is useless 
to isolate and disinfect in a single case, where there is no reason to believe that 
a similar course will be generally adopted. In the case of schools and public 
institutions, it might be well to prevent dispersion by positive enactment. 
But in the other instances, if the principle were once asserted and acted upon, 
that an infectious disease must be registered, as a matter of public concern, 
public opinion would do the rest. Such provisions as we have suggested are, 
perhaps, as much as could be at present carried into effect; and their influence, 
both sanitary and educational, would be of incalculable value." 
Different prophylactic medicines have been recommended ; amongst which 
belladonna has had the greatest number of advocates; but its value has 
diminished greatly, as the weight of testimony is against its possessing any 
prophylactic virtues (Wood). Even when continued for a week, it affords no 
protection against scarlet fever (Niemeyer). [Dr. N. L. North, of Brooklyn, 
N. Y., has used the hyposulphite of soda, and he believes successfully.] 
HYBRID OF MEASLES AND SCARLET FEVER. 
Latin Eq , Rubeola (Scarlatinosa, vel Morbillosa); French Eq., ; German Eq., 
Rbtheln-Syn., Feuer maser n; Ritleln, Falschen Maseru. 
Although the following hybrid form of disease has not found a name and a place in 
the nomenclature of the Royal College of Physicians, yet, as the evidence of its occa- 
sional occurrence is so clear, I think it proper to continue the description I have 
hitherto given of it in previous editions of this Text-book. I find also that Niemeyer 
describes, under the name of " Rose rash " (Roseola Jeb riles), an eruption with red spots, 
which, on the authority of Canstatt, one is in doubt whether it should be clased with 
scarlatina or measles, from the general symptoms and affection of the mucous mem- 
branes. Moreover, the epidemic form of the disease he considers to arise from infec- 
tion, and to consist in modification or combination of scarlet fever or measles. By 
rubeola scarlatinosa is to be understood a scarlet fever where the exanthema resembles 
measles, while the high fever, the throat affection, and the dropsy which often follows, 
resemble the course of scarlet fever. By rubeola morbillosa is meant a form of measles 
where the exanthem is confluent, and resembles that of scarlet fever, while the affec- 
tion of the respiratory mucous membrane, and the escape of the pharyngeal mucous 
membrane, leave no doubt of the morbillous nature of the disease. The short descrip- 
tion of Niemeyer is sufficient to identify this hybrid disease with the following- 
Definition.-A specific eruptive disease, preceded by and accompanied with 
fever, watery discharges from the eyes and nose, sneezing, and sore throat. The 
eruption appears on the third or fourth day, and consists of crimson stigmata, 
rapidly running together into patches of an irregular shape, with obtuse angles, 
and of sizes varying from a threepenny to a crown piece, according to the severity 
of the case. The eruption continues from six to ten days, and terminates in 
desquamation by furfuraceorcs scales. 
Pathology.--Those diseases now fully considered in the previous pages- 
namely, small-pox, measles, and scarlet fever-have been termed exanthematous 
diseases by some nosologists, in consequence of their principal phenomena 
being a very marked eruption. SYMPTOMS OF ROTHELN. 
455 
The Arabians first described them, and considered them as varieties of one 
and the same disorder. Many essential differences, however, were soon ob- 
served to distinguish small-pox; but the points of resemblance between measles 
and scarlet fever were so many, that it was not until fatal accidents had oc- 
curred, from the great error of confounding them, that their differential char- 
acters were remarked, and their separate identity established. Now it is a 
generally received doctrine that measles and scarlatina, in their essence and 
in their symptoms, present two well-defined states of disease. This is, indeed, 
one of the most indisputable facts in Pathology. By Schonlein, measles has 
been classified as a peculiar exanthematic form of catarrh ; and scarlet fever 
is placed amongst the group of erysipelatous diseases; while, according to the 
experience of Dr. Kiittner, of Dresden, there are " androgynous " cases calcu- 
lated to embarrass the most experienced " diagnostiker." Measles and scarlet 
fever were especially confounded under the common name of morbilli; and 
even as late as the middle of the eighteenth century, writers of the highest 
repute supported the identity of measles and scarlet fever (the morbilli con- 
fluentes of Sir William Watson). 
All authors before Sauvages (1768) had used the term morbilli (the term 
now in use) to designate measles; but he adopted a new name, and called 
measles by the designation of " rubeola,"-an innovation which has caused 
much confusion, having been adopted by some (such as by Willan and Bate- 
man), and rejected by others. Hildebrand, following the old nomenclature, 
calls measles morbilli, and scarlet fever scarlatina; and terms the disease now 
about to be considered rubeola, as has been done by Dr. Copland. The Ger- 
man authors call it rotheln, and by this name it was first described by a dis- 
tinguished and learned Scotch physician, Dr. Robert Paterson, of Leith, in 
1840. He is the only physician in this country who has given an original 
description of the disease in the English language, his description of the disease 
being drawn from many cases of it which occurred in his practice, and some 
of which he showed me when I was his pupil in the fever wards of the hospital 
in Edinburgh. 
A difference of opinion prevails amongst authors as to whether or not this 
disease is of a distinct and specific form. Those who have most recently de- 
scribed it (Hildebrand, Paterson, and Copland) consider it to be a disease 
possessing characters common to both measles and scarlet fever, as well as 
characters peculiarly its own. In truth, it seems to be a hybrid disease, 
developed from combined poisons of the two fevers, measles and scarlet fever. 
Dr. Kiittner, of Dresden, states that he has seen occasionally in the same indi- 
vidual portions of the skin presenting the scarlatina eruption, while in other 
parts the eruption of measles was to be seen. He thus recognized not only 
examples of transition, but he recognized cases which may be termed hybridous 
(Dublin Hosp. Gazette, 15th Dec., 1858; and Ranking's Abstract, vol. xxix, 
P- 20> 
Symptoms.-The febrile stage of the disease varies, like all the diseases 
already noticed, not only in the severity of the symptoms, but also in the 
length of the attack, when compared with scarlet fever. It usually com- 
mences with rigors, not severe, but continuous. More or less cough soon makes 
its appearance--of the same clanging nature which is observed in the febrile 
stage of true measles-and is very shortly accompanied with itchiness, redness, 
and weakness of the eyes, lachrymation, frequent sneezing, and watery dis- 
charge from the nose. In persons more advanced in life, severe frontal head- 
ache is complained of, together with rheumatic pains, more especially in the 
muscles of the back and chest, nausea, and sometimes vomiting, together with 
constant drowsiness. The skin is hot and dry, with the pulse above the natu- 
ral standard. 
A greater or less number of these symptoms is always noticed; but, in ad- 
dition, sore throat is a most constant one. This, in some cases, is extremely 456 
SPECIAL PATHOLOGY - ROTHELN. 
slight, amounting only to a roughness of speech and trifling difficulty in swal- 
lowing ; but in others it goes on to severe inflammation of the tonsils, velum 
pendulum palati, and surrounding parts. This last inflammatory affection is, 
however, more severe during the eruptive stage. The sore throat is one of the 
most characteristic features of the disease, occurring in the slightest and most 
gentle cases (Robert Paterson). 
The odor given forth by patients under this disease is described by Dr. 
Heim, of Berlin, as similar to, but stronger than that which scarlet fever 
patients emit, and has been likened to the smell of a place where fish is kept- 
in short, fishy. 
When the febrile state now described has continued for three or four days, 
the appearance of an eruption is sudden and general. It breaks out all at 
once over the whole body, and consists of bright and thickly-set stigmata, 
which appear on the trunk, but are more sparingly dispersed over the face and 
extremities. It assumes different aspects and degrees of confluence, according 
to the severity of the case. Its first appearance resembles measles, but the 
stigmata rapidly run together, and soon assume an irregular shape, with 
obtuse blunt angles. These irregular patches are of an intense red color to- 
wards the centre, being gradually shaded off towards the margins, which ap- 
proach in color that of the surrounding skin. The size of the patches in 
ordinary cases seldom exceeds a sixpenny piece; but in the severe forms of 
the disease they run still further together, and are to be seen of the size of a 
crown piece. In such cases, which are usually of a malignant nature, the 
whole body may be covered over with patches, varying from the size of a six- 
penny piece to a crown piece, thickly set together, and of an intensely dark 
color towards their centres. The eruptive patches are felt to be distinctly 
elevated above the skin-some more than others, and always greatest in the 
centre of the patch. 
During the continuance of the eruption, the general symptoms already de- 
scribed are usually aggravated, and not unirequently new symptoms are 
superadded. The sore throat becomes much worse. The hoarseness becomes 
so great as frequently to cause entire loss of voice, and generally more or less 
external tumefaction of the throat takes place. In severe cases this is great, 
and is accompanied with much redness and swelling of the throat internally. 
There is a total inability to swallow even the slightest portion of fluid, which 
generally regurgitates by the nose. A large secretion of mucus of a vitiated 
nature takes place, the cough is constant, and is rendered doubly severe by 
the state of the throat. The pulse is very frequent; the skin hot and dry; 
and there is great restlessness, expressed by children tossing the head fre- 
quently from side to side, accompanied with frequent starting; and they are 
sometimes seized with convulsions. It is in this stage, in the worst forms of 
the disease, that death generally occurs, and that by coma. It may, however, 
take place either by suffocation from the large quantity of vitiated mucus, or 
by convulsions and subsequent coma. Vomiting is an occasional symptom 
during this stage, and, like convulsions, is sometimes seen in mild cases of the 
disease in children. 
The eruption in mild cases, in general, continues distinct for from four to 
five days, during which time the other symptoms are going on favorably, be- 
coming gradually milder as the period of the decline of the eruption draws 
near. In severe cases, however, the rash keeps its bright color and distinct 
form for a much longer period-e. g., six, eight, or ten days. 
The termination of the eruptive stage is, in some instances, marked by what 
is termed a distinct crisis,-such as the occurrence of copious sweating, de- 
posits from the urine, diarrhoea, and epistaxis. Most commonly, however, 
there is no such crisis, but the eruption gradually fades, and the disease 
subsides. 
As this happens, the desquamation by furfuraceous scales gradually ensues. DIAGNOSIS OF ROTHELN. 
457 
This event is indicated by the appearance of scales towards the centre of 
the patches of eruption, to the margins of which they gradually extend, and 
soon spread over the whole body. The scales are small, and not unlike those 
of measles. On the hands and feet the scales are larger, but never reach the 
size of those of scarlet fever (Robert Paterson). 
Lesions Seen in Fatal Cases.-The accounts of these are few in number. 
They vary according to the period of the disease at which death occurs. 
Death most frequently happens during the eruptive stage, from coma, or from 
the affection of the throat and lungs. No morbid appearances of a uniform 
nature can be observed connected with the mode of death by coma ; but when 
death happens from pulmonary oppression, the lungs are found much con- 
gested, the mucous membrane of the bronchia injected, with a copious mucous 
secretion. The throat presents very similar appearances to those which are 
seen in scarlet fever,-great tumefaction, and dark coloration of the mem- 
brane lining the throat, dark aphthous spots, and large quantities of vitiated 
viscid mucus. 
Diagnosis.-The accompanying febrile symptoms at once distinguish the 
disease from roseola, as also do the peculiar characters of the eruption. The 
only other affections with which it may be confounded are measles and scarlet 
fever. The following table points out the diagnostic marks more clearly by 
contrast than can otherwise be done, and shows that rubeola, rotheln, or the 
mixed disease, has every right to be considered as a distinct affection : 
TABLE SHOWING THE MOST PROMINENT DISTINGUISHING CHARACTERS OF 
SCARLET FEVER, RUBEOLA, AND MEASLES (PaterSOll). 
Scarlet Fever. 
Rubeola or Rotheln. 
Measles. 
Rigors; nausea; some- 
times vomiting, thirst, and 
heat of skin; with sore 
throat, hoarseness, and de- 
lirium, in the anginose va- 
riety of scarlatina. 
Symptoms of First Sta.ge, or Premonitory Fever. 
Shiverings; nausea ; rare- 
ly vomiting ; itching; red- 
ness and pain of the eyes, 
with increased flow of tears; 
sneezing, and watery dis- 
charge from nose; cough, 
sore throat, and hoarseness. 
Rigors; nausea, and some- 
times vomiting; frequent 
starting during sleep ; itch- 
ing; redness ; pain of eyes; 
watery discharge from eyes 
and nose ; sneezing ; harsh 
cough. 
Premonitory fever is of 
short duration; the erup- 
tion most generally making 
its appearance on the sec- 
ond day. 
Duration of Premonitory Fever 
The eruption generally 
breaks out on the third or 
fourth day, so that the pre- 
monitory fever is prolonged 
over that time. 
Eruption makes its ap- 
pearance towards the close 
of the third, or beginning 
of the fourth day. 
It first appears in innu- 
merable red dots or points, 
being at first of a pale red 
color, soon acquiring a 
deeper tint, and at last giv- 
ing the affected portion of 
skin a uniform red appear- 
ance. 
Appearance of Exanthematous Eruption. 
The rash appears in mi- 
nute dots, and rapidly as- 
sumes the appearance of 
irregular-shaped patches, 
with obtuse angles, varying 
in size from that of a three- 
penny to much larger than 
a crown piece. The red 
rash is gradually shaded off 
with the surrounding skin. 
The rash appears in mi- 
nute red points, like flea- 
bites ; several of them soon 
coalesce, and form round- 
ed masses, irregular-shaped 
crescents, or semicircular 
patches. 
There is a perceptible 
roughness in the skin af- 
fected with scarlatina. It 
is in general most evident 
on the breast and extremi- 
ties, and seems to consist 
of the enlarged papillae of 
the skin. 
Roughness or Elevation of the Affected Skin. 
In this disease, more espe- 
cially in the severer forms 
of it, the patches of erup- 
tion are distinctly and con- 
siderably elevated, and 
more especially towards the 
centre of the patch, 
The elevation of the 
patches of eruption in mea- 
sles is slight; though in 
general distinct in the worst 
cases, they are certainly 
not at all elevated as a rule, 458 
SPECIAL PATHOLOGY-ROTHELN. 
Scarlet Fever. 
Rubeola or Rotheln. 
Measles. 
The efflorescence is first 
perceptible on the face, 
neck, and chest, gradually 
passing downwards, and be- 
coming diffused over the 
whole body. 
Part of the Body First Affected. 
The efflorescence first ap- 
pears on the trunk of the 
body, the whole of which 
it at once occupies. It is 
always more sparingly seen 
on the extremities, but 
seems to break out there 
at the same time as it does 
on the trunk. 
The efflorescence first ap- 
pears on the forehead and 
among the roots of the hair ; 
and spreads slowly and 
successively over the neck, 
chest, trunk, and extremi- 
ties. 
The eruption remains 
present three days; begins 
to disappear on the fourth 
day; and is almost entirely 
gone by the termination of 
the fifth day. 
Duration of the Eruption. 
In the rotheln the dura- 
tion of the eruption seems 
to depend upon the severity 
of the disease; in mild cases 
remaining out four or five 
days, and in bad cases six 
or ten days. 
In this disease it remains 
out three days. 
The symptoms which accompany the eruption in each of the three diseases are quite 
the same as those of the premonitory fever. It is proper here, however, to remark, 
that it is only in the anginose and malignant varieties of scarlatina that we have' sore 
throat, there being little or none in the simple scarlatina, while in the mildest kind of 
rotheln this is always a prominent and troublesome symptom. 
Symptoms accompanying the Eruption. 
The cuticle in this dis- 
ease is thrown off in patches 
of considerable size, the 
largest being from the 
hands and feet. 
The desquamation of rd- 
theln consists of minute 
portions of cuticle, like 
scales of fine bran. 
The desquamation always 
begins towards the centre 
of the eruptive patch, and 
gradually extends to the 
circumference. 
Desquamation. 
The desquamation of mea- 
sles consists of minute por- 
tions of cuticle, like scales 
of fine bran. 
Anasarca is the most 
common sequela of scarlet 
fever. It is extremely 
common, and most fre- 
quently occurs after the 
mildest cases; swelling and 
suppuration of the cervical 
glands is also common. 
111 have noticed one case 
of dropsy after a mild, 
though well-marked attack 
of this disease; swellingand 
suppuration of the cervical 
glands also frequently take 
place" (Dr. Paterson). 
Sequelae. 
Affections of the lungs 
and pleura; tedious, distress- 
ing cough; chronic bron- 
chitis; pneumonia; tuber- 
cles ; gangrenous inflam- 
mation of cheeks, gums, 
lips, genital organs, &c.; 
dropsy occasionally occurs, 
but very rarely; diarrhoea is 
very common after some 
epidemics. 
Prognosis.-It requires to be as guarded as in scarlatina; for, like scarla- 
tina, rubeola is often an extremely and rapidly fatal disorder. The greater 
or less acuteness of the premonitory fever generally affords us a means of 
judging as to the probable severity of the eruptive stage; and in general it is 
a mild disease. To have a copious secretion of mucus in the back of the 
throat is always a bad symptom, or regurgitation of fluids by the nose. The 
chest ought to be examined from day to day; as sudden inflammatory action 
is apt to be established, and often it rapidly proves fatal. The condition of 
the urine requires also to be daily investigated. 
Treatment.-The treatment is similar to that of scarlet fever. The func- 
tions of the skin are if possible to be stimulated; and Dr. Paterson found that PATHOLOGY AND SYMPTOMS OF DENGUE. 
459 
the aqua acetatis ammoniac, in the proportion of two ounces to half an ounce of 
antimonial wine and four ounces of water, made into a mixture, was the most 
useful agent. The use of colchicum was also had recourse to with decided 
benefit. 
DENGUE. 
Latin Eq., Denguis; French Eq., Dengue; German Eq., Dengue; Italian Eq., 
Dengue. 
Definition.-An ephemeral continued fever or febricula, characterized by 
frontal headache, and by severe pains in the limbs and trunk, and sometimes by 
an eruption, resembling that of measles, over the body; occurring in the West 
Indies (Royal College of Physicians). 
Pathology.-This is a peculiar febrile disease which commences very sud- 
denly, and is attended with severe pains in the joints, which swell, succeeded 
by general heat of skin, intense pain in the head and eyeballs, and the appear- 
ance of a cutaneous eruption or efflorescence on the third day, commencing 
on the palms of the hands and spreading rapidly over the whole body. The 
eruption rarely continues visible beyond twenty-four hours. Remissions and 
relapses are numerous; and the disease may persist about two months, asso- 
ciated with great prostration and cachexia. The relapses are marked by 
rheumatic or neuralgic phenomena. It occurs elsewhere besides the West 
Indies. 
The disease seems to combine exanthematous eruption ushered in by fever, 
with a rheumatic or neuralgic state; and the course of the malady is so di- 
vided by intervals and remissions as to give one the idea that relapses are of 
frequent occurrence in its course. It has been chiefly prevalent in Rangoon, 
Calcutta, Berhampore, Patna, Benares, and Chunaighur, in the East Indies; 
the Island of St. Thomas in the West Indies ; the Southern States of America; 
the ports on the Gulf of Mexico; the cities of New Orleans, Savannah, 
Charleston, Philadelphia, and New York. It was epidemic in America in 
1824-28; and nothing appears to have been heard of it again till 1847 and 
1850, when it again visited the Southern States. An epidemic of dengue has 
been recently described by Lemmon as having occurred in Virginia (Amer. 
Med. Times, Feb. 16, 1861). It is not known as an epidemic disease in Great 
Britain. It has been described by Nicholson, Meilis, Kennedy, Wood, Cavell, 
Twining, Mouat, and Goodeve. Dr. Richardson, in his admirable Clinical 
Essays, notices the circumstance that we not unfrequently meet with "scarlet 
fever connected with acute rheumatic feverand he ascribes the first notice 
of this connection in this country to Dr. Golding Bird. Subsequently the 
circumstance was noticed by Dr. Kelso, of Lisburn, and by Dr. Ross. Dr. 
Andrew Anderson, in his Lectures Introductory to the Study of Fever, notices 
that rheumatic pains of the arms and legs, often very severe, connected, as he 
supposes, with the poisoned state of the blood, are not unfrequently met with. 
Lastly, Dr. Richardson himself records the cases of four children, in which 
the rheumatic state, combined with scarlatina, was distinctly expressed ( Clini- 
cal Essays, p. 85); and Dr. Wilkes has noticed similar cases. 
Symptoms.-The invasion is very sudden, and the development rapid. In 
the greater number of cases the first symptoms have been headache, with 
intolerance of light, restlessness, and more or less chilliness, debility, pains in 
the back, the limbs, and joints. The small joints swell, and there is soreness, 
with stiffness of the muscles. The skin soon becomes hot and dry, the pulse 
frequent, the face flushed, and the eyes red and watery. The tongue, though 
red, is usually clean. A rash or papular eruption sometimes appears, though 
not generally at this stage. Painful swellings in the lymphatic glands of the 
neck, axilla, and groins are common. The testicles also swell, and continue 
so till the subsidence of the other symptoms. The febrile state lasts from 460 
SPECIAL PATHOLOGY-TYPHUS FEVER. 
twelve hours to three or four days, after which it subsides, leaving tlie patient 
very feeble. This remission lasts for two, three, or four days, when a return 
of the fever and pains, with a thickly-coated tongue, nausea, and epigastric 
tenderness mark another phase of the disease. On the fifth, sixth, or seventh 
day the eruption appears in the form of a scarlet efflorescence on the palms 
of the hands, which spreads rapidly over the body, and gives relief to the 
symptoms of febrile irritation. The eruption is extremely variable in char- 
acter, being sometimes smooth, red, and continuous, as in scarlet fever; some- 
times in patches, rough, and of a dark hue, as in measles; and occasionally 
either papular, vesicular, pustular, or furunculous; often with a mixture of 
two or more of these forms. The complaint gradually subsides, and leaves 
the patient with some rheumatic stiffness or soreness for a longer or shorter 
period, with feelings of weakness and mental depression. The duration of 
the affection varies with the length of the remission; but on the average is 
about eight days. 'Decided implication of the mucous membrane of the mouth 
and throat prevailed in the last epidemic in Calcutta, with an almost entire 
absence of the articular pains. 
Diagnosis.-The peculiar eruption and characteristic phenomena of rheu- 
matic-like pains, with intercurrent remissions of febrile phenomena, distin- 
guish the disease from rheumatism on the one hand, and malarious fever on 
the other. 
Treatment.-Emetics and purgation subdue the fever; but as the disease 
runs a specific course, time is an essential element in the treatment. Calumba 
and rhubarb with soda form a useful alterative medicine. Emetics and free 
eliminative remedies, especially by purgatives, subdue the febrile heat. Bleed- 
ing is condemned by all physicians who have seen it employed in the treat- 
ment of this disease. Calomel, combined with colocynth and scammony, repeated 
every day till the evacuations are free and of a healthy color, is the treatment 
recommended by Twining. At first the stools are of a dark-green color; and 
as the greenness disappears from the stools the symptoms bedome more sub- 
dued. Calomel ought never to be given alone, or in any form likely to induce 
the specific effect of mercurialism. Emetics of tartrate of antimony and ipecac- 
uanha bring away large quantities of bile, relieving the pains of the head and 
limbs almost immediately; and the eliminative action ought afterwards to be 
maintained by sulphate of magnesia and tartar emetic. It is necessary to 
repeat the emetic till bile is discharged from the stomach. Ophthalmia is 
sometimes consequent on this disease, and is to be subdued by leeches to the 
inner membrane of the eyelids. Colchicum, sweet spirits of nitre, nitrate of 
potass, and antimony, in proportions sufficient for diaphoresis, given every two 
hours, with an additional effervescing draught, exercise a beneficial influence 
on the pains. After the acute symptoms subside, forty to sixty drops of the 
wine of colchicum, with twenty-five drops of laudanum, always insured a good 
night's rest, and thirty drops of antimonial wine may be added. 
TYPHUS* FEVER. 
Latin Eq., Febris Typhus; French Eq., Typhus; German Eq., Exanthematischer 
Typhus-Syn., Fleckfieber; Italian Eq., Tifo. 
Definition.-A continued acute specific fever with an average duration of 
twenty-one days. The disease is characterized by an eruption on the skin, of a 
* As the term typhus is very variously used, and sometimes vaguely, it is necessary 
to state precisely the meaning of the word. This cannot he more clearly, distinctly, 
and concisely expressed than in the words of Dr. Wood. 
The disease now defined is sometimes called typhus, and sometimes typhus fever. Tn 
the first instance the term is used "substantively, in the latter adjectively, just as we 
say ship fever, jail fever, &c. But a state of system, identical or closely analogous DEFINITION AND HISTORICAL NOTICE OF TYPHUS FEVER. 
461 
general dusky mottled rash, appearing generally from the third to the eighth day, 
at first slightly elevated, and disappearing on pressure, but after the second day of 
its appearance persistent, and remaining persistent for eleven or twelve days. 
Languor and weariness are prominent from the first, gradually passing into slug- 
gishness of intellect and confusion of thought, stupidity, oblivion, and complete 
prostration. In still more severe cases, somnolence, stupor, and sometimes coma, 
supervene when prostration becomes profound. 
The disease may terminate favorably from the thirteenth to the seventeenth day, 
the average duration of the attack being about twenty-one days. 
If the disease proves fatal, it is generally between the twelfth and the twentieth 
day, leaving no specific lesion in any part of the body, beyond hypercemia and blood- 
changes, softening of the heart and contractile fibre-structures, and atrophy of the 
brain. Typhus fever is eminently contagious, and occurs in strong-marked epi- 
demics. 
Historical Notice.-The first authentic accounts of typhus fever in this 
country are to be found in the early British chronicles. It is described as 
having spread in our courts of justice, giving rise to what was termed " the 
black assizes." The last black assizes happened at the sessions of the Old 
Bailey in 1756, when the lord mayor, two of the judges, and several eminent 
persons died, infected by the prisoners. This fever has had many popular 
appellations, having been known as the jail fever, hospital fever, ship fever, 
putrid fever, brain fever, bilious fever, spotted fever, petechial fever, camp fever. 
We are indebted, however, to Pringle and to Fordyce for having shown that 
these supposed different fevers are identically the same, and have no such 
essential differences as to constitute them distinct genera. 
Typhus fever is the grand scourge of armies in temperate climates, just as 
cholera and yellow fever have been destructive agents in tropical wars, 
(Parkes " On the Causes of Sickness in English Wars," Journcd of Royal United 
Service Institution, vol. vi). Wherever men are closely crowded together in 
ill-ventilated unwholesome dwellings, typhus is sure to appear. It has often 
passed from the army to the civil population, and has thus dispeopled towns, 
and even great districts of country. But its ravages in the English army 
have never been comparable to those which have occurred in foreign forces, 
as the statements of Murchison and Parkes fully demonstrate: " In the year 
1489 no fewer than 17,000 of the troops of Ferdinand, then besieging Granada, 
were destroyed by a spotted fever, to which the Spaniards applied the same 
name that they afterwards gave to typhus. In 1552 a petechial fever de- 
vastated the army of the Emperor Charles V during the siege of Metz. In 
1556 the notorious 'Morbus Hungaricus' appeared in Hungary in the army 
of Maximilian II, and thence spread over the whole of Europe" (Murchison, 
1. c. p. 21). "In 1620 the Bavarian army in a few months lost in Bohemia 
not less than 20,000 men from spotted typhus; and the disease, being carried 
into other parts of Germany, obtained the name of 'the Bohemian disease.' In 
1628 and 1632 the Swedish army under Gustavus Adolphus carried typhus into 
Northern Germany, and the population was so destroyed that, fifty or sixty years 
later, villages were left without inhabitants " (Parkes, 1. c.). In the spring 
of 1643, while the Earl of Essex was besieging the town of Reading, this dis- 
ease broke out in the army of the Parliamentary General, and in the garrison 
with that which characterizes typhus fever, is frequently met with in other febrile dis- 
eases, as a mere incidental accompaniment. To this morbid state the epithet typhous 
or typhoid is applied, the latter being preferred to the former when it is wished to im- 
ply resemblance only, and not sameness or identity. Thus we speak of a typhous or 
a typhoid condition of remittent fever, yellow fever, small-pox, measles, pneumonia, 
dysentery, or, with greater brevity, typhous pneumonia, typhous dysentery. This latter 
phraseology, however, generally implies a more thorough incorporation of the typhoid 
element with the principal affection than typhoid pneumonia or typhoid dysentery, which 
merely implies a resemblance to the typhous state occurring in these diseases." 462 
SPECIAL PATHOLOGY-TYPHUS FEVER. 
commanded by Charles I: it was communicated to the inhabitants of the sur- 
rounding country, and proved very fatal (Murchison, 1. c.). The wars of 
Louis XIV were always followed by this disease, and the losses of the French 
army were enormous (Parkes). In 1799-1800 an epidemic of typhus 
occurred at Genoa, when the garrison was besieged by the French, and half- 
famished; and the French army, during their retreat from Italy, communica- 
ted fever to the inhabitants of fifteen towns and villages where they halted on 
the route (Fodere). It was during the first fifteen years of the present cen- 
tury that the greatest ravages of typhus have been recorded, especially in the 
armies of Napoleon, and among the population of the countries which were 
the seat of war. It always became developed under circumstances of misery 
and privation, and was particularly prevalent and fatal among the inhabi- 
tants of besieged cities-as, for example, Saragossa and Torgau, Dantzic and 
Wilna, in 1803. It also told with awful severity upon the famished French 
troops during the retreat from Moscow in 1812 and 1813 (Murchison). 
When Sir John Moore's army landed from Corunna, typhus became epidemic 
in the military hospitals in the south of England (Cheyne, Dub. Hosp. Reports, 
vol. ii, p. 3). In May, 1812, the Bavarian army serving among the French 
numbered 28,000 men; in February, 1813, there were only 2250 men under 
arms. The great destroyer was typhus. In August, 1813, the first Prussian 
army consisted of 37,728 fighting men, having lost 16,000 men by the sword, 
and 10,000 men by disease, almost entirely typhus. In Mayence alone, of 
60,000 French troops composing the garrison in 1813-14, there died of typhus 
in six months 25,000 men (Murchison, p. 224). The last great ravages of 
typhus in armies which attracted public attention were those which occurred 
in the French and Russian armies in the Crimea during and after the capture 
of Sebastopol. Typhus had prevailed in the winter of 1854-55 amongst both 
the English and French troops; but in the following winter it was mainly 
confined to the French and Russian armies. In the spring of 1856 it was 
computed that more than 17,000 men of the French forces perished in less 
than three months; and the highest authority stated that the safety of the 
whole French army was endangered by the outbreak (Parkes and Mur- 
chison). 
According to Dr. Parkes, typhus fever occupies the fourth place among the 
causes which have produced disease in the British army.* 
[During the war of the rebellion there was perhaps entire immunity from 
typhus in both the United States and Confederate armies. Though 1723 
cases, and 572 deaths, are found in the returns of the Surgeon-General's office 
(U. S.), there is every reason to believe that these were not cases of true 
* These causes Dr. Parkes arranges as follows: 
1. A defective commissariat, especially as to food and fresh vegetables, causing dis- 
eases, but mainly predisposing to many more-e. y., malignant malarious fevers, 
scurvy, and bloody flux. Carthagena, 1741; Burmah, 1824 ; China, 1840. 
2. Undertaking military operations in an unhealthy site, and with an unhealthy 
season impending. Carthagena, 1741 ; San Domingo, 1796 ; Walcheren, 1747; Java, 
1811; American War, 1814 ; Bulgaria, 1853-54. 
3. Exposure to cold, with insufficient clothing and food, giving rise to catarrhs, 
slight dysentery, rheumatism, and inflammations Wars of 1742-1760; Crimea, 1854. 
4. Propagation of typhus poison; favored by bad ventilation, overcrowding, and 
filth. Examples as above detailed. 
5. Similar propagation of putrid dysentery. Indian campaigns. 
6. Propagation of typhoid fever poison and cholera, through the bad sanitary con- 
dition of camps, and the occupation of old camping-grounds. Egypt, 1801 ; Bulgaria, 
1853 ; India. 
7. The enlistment of boys as soldiers, whose bones are not yet matured, in place of 
full-grown men at least twenty-one years of age. Crimea, 1854. [See a short publi- 
cation On the Growth of the Recruit and Young Soldier, by William Aitken, M.D.] 
8. Want of cleanliness, excessive use of spirits, and debauchery. PHENOMENA AND SYMPTOMS OF TYPHUS FEVER. 
463 
typhus. Large personal observation on the part of the writer, and diligent 
inquiry amongst the medical officers of the United States army, have satisfied 
him that as an epidemic, however limited, typhus never prevailed, even at the 
depots for returned prisoners of war. It is possible that isolated cases of 
maculated fever may have occasionally happened, but positive proof of such 
is wanting. 
Professor Joseph Jones, Medical Memoirs of the United States Sanitary Com- 
mission, says: "No case of typhus fever was reported during six months in 
42,686 cases of all diseases amongst the Federal prisoners confined at Ander- 
sonville, notwithstanding that 40,000 men were crowded upon twenty-seven 
acres of land, and notwithstanding that all sanitary and hygienic laws were 
utterly neglected, and the earth was covered with abnormal human excre- 
ments and fragments of bread and saturated with urine, and the atmosphere 
was loaded with stinking effluvia. During the recent civil war I sought for 
typhus fever amongst the Confederate troops serving in the field, and amongst 
the general hospitals in various parts of the Confederate States; thousands of 
sick and wounded were examined with a view to the determination of the 
existence or non-existence of this disease amongst the Confederate armies; and 
even the prisoners confined upon Belle Isle, in the Libby Prison, and in Cas- 
tle Thunder, in Richmond, Va., were not neglected in these examinations, and 
numerous medical officers of the Confederate army were interrogated upon 
this subject personally and by letter. No case of true typhus fever came under 
my observation during the war in any army, in any field hospital, general 
hospital, or military prison" (p. 600). He further states that the cases entered 
upon the Confederate sick reports as typhus fever were, in almost every case, 
if not in all, cases of typhoid fever occurring in those whose blood was 
scorbutic.] 
Phenomena and Symptoms.-Typhus fever attacks persons of both sexes 
and of all ages, from early infancy to extreme old age, and its advent is gen- 
erally somewhat sudden, for the exact period of incubation is unknown. 
After a longer or shorter duration (generally a few days) of unpleasant sen- 
sations-in which general soreness, uneasiness, and fatigue without cause, loss 
of appetite, and disturbed sleep, are the prominent phenomena-the disease 
begins and advances gradually. From various stray observations, Dr. James 
B. Russell, physician, superintendent of the Glasgow Fever Hospital, is cer- 
tain that nine days is about the average latent period of typhus; and Dr. 
Murchison comes to the same conclusion. It is not possible in all instances 
to fix the precise time of the commencement of the attack ; but in the majority 
of cases the patient is seized with chilliness, which sometimes amounts to a 
rigor, usually followed by heat of skin, and occasionally by sweating, pains in 
the back and limbs, and frontal headache. This headache is a constant symp- 
tom, which ceases usually about the tenth day, and always before the four- 
teenth. During two or three days the chilliness and rigors occur at irregular 
intervals. The patient alternately hovers over the fire or desires to move from 
it; and although the skin at the time may be felt hot and burning, he still 
lingers near the fire-place, and yet again soon complains of the heat of the 
room; so that he feels when near the fire hot and oppressed, and when away 
from it chilly and uncomfortable. Loss of appetite, and more or less thirst, 
exist from the first; the tongue is white, large, and pale, but is afterwards 
covered with a yellow-brown fur, and is sometimes tremulous, indicating the 
early loss of muscular power and control. The bowels may be confined or 
regular ; the urine is scanty and high-colored ; and nausea with vomiting are 
often among the earliest symptoms. If sleep is obtained, it is disturbed by 
dreams, or by the occurrence every few minutes of sudden starts. It is con- 
sequently unrefreshing; and although the patient may have appeared to sleep 
for hours, yet he feels that he has not slept, and declares that he has never 
closed his eyes. This is the coma-vigil of Chomel. On the other hand, the 464 
SPECIAL PATHOLOGY-TYPHUS FEVER. 
general appearance of a typhus fever patient is characteristic. There is some- 
times a constant tendency to heaviness and drowsiness. The attention cannot 
be fixed, and the mind ceases to think. A peculiar symptom may now become 
expressed, to which Dr. Jenner has given more appropriately the name of 
coma-vigil than to that symptom which Chomel has so named. In the coma- 
vigil of Jenner, "the patient lies with his eyes open, evidently awake, but 
indifferent or insensible to all going on around him." This symptom occurred 
in one-fifth of the fatal cases observed by him. Bodily weakness becomes 
extreme, and the patient takes to bed by the second or third, and not unfre- 
quently on the first day. While there is absolute loss of muscular power and 
control, there is at the same time an amount of great exhaustion, dispropor- 
tionate by its severity to the muscular action. He lies prostrate on his back. 
The expression of his countenance betokens weariness. The eyes are dull and 
heavy, sometimes suffused and injected or bloodshot; and a dusky flush over- 
spreads the cheeks. Giddiness and noise in the ears are amongst the earliest 
and most loudly complained of symptoms. The debility increases rapidly, so 
that by the seventh day the patient can rarely leave his bed without some 
assistance. By this time also the want of control over the muscular move- 
ments becomes more decided; the legs and arms shake when raised, and the 
tongue trembles when protruded. The impairment of the mental powers mani- 
fests itself in a variety of singular ways. Memory becomes deficient,-the 
ideas of time are such that it is always supposed to be prolonged. If an event 
is impressed upon the patient's mind, he will remember it, and it alone. This 
mazy state of the intellect soon passes into delirium, which becomes manifest 
first between waking and sleeping, then by night, and finally by day and night. 
When delirium first sets in, the patient is able to correct himself; if he is 
made to think, he becomes conscious of his mental error; but this power is 
soon lost, and delirium becomes predominant. 
About the tenth day of the disease, sometimes earlier, the headache ceases 
simultaneously with the commencement of delirium ; and if it should continue 
with delirium, it suggests the probability of some commencing secondary 
lesion within the cranium, to which special attention must be immediately 
directed. 
The Eruption of Typhus Fever.-About the fifth to the seventh day of the 
disease the characteristic eruption appears on the skin in 95 per cent, of the 
cases. It consists of-(1.) Distinct spots; (2.) A subcuticular rash. 
(1.) The macxdce, measly, mxdberry, w rubeoloid rash. On the first appearance 
of this eruption it consists of very slightly elevated spots of a dusky pinkish- 
red color, somewhat like the stains of mulberry-juice. Each spot is flattened 
on the surface, irregular in outline, with no well-defined margin, and fading in- 
sensibly into the hue of the surrounding skin. The spots disappear completely 
on pressure, resuming their distinctive appearances as the pressure of the finger 
is withdrawn; and they vary in size from a point to three or four lines in di- 
ameter. The largest spots appear to be formed by the coalescence of two or 
more smaller ones; and the shape of the larger spots is more irregular than 
the smaller ones. After one, two, or three days these spots undergo a marked 
change. They no longer remain elevated above the surrounding cuticle. 
Their hue, becomes darker and more dingy than at their first appearance. 
Their margins become more defined, especially on the posterior surface of the 
body; and when the finger is firmly pressed on them, they grow paler, but do 
not entirely disappear. Thus they are said " to fade under pressurebut 
they cannot be entirely obliterated, a stain of the cuticle remaining to indi- 
cate where they are. A still further change may take place in severe cases. 
The centres of the spots may become dark purple, unaltered in appearance by 
the firmest pressure, although their circumferences may fade; or the entire 
spot may change into a true petechia, becoming of a dusky crimson or purple 
color, quite unaffected by pressure, with a well-defined margin, and level with THE ERUPTION IN TYPHUS FEVER. 
465 
the surface. The spots of such an eruption are generally very numerous, close 
together, and occasionally almost covering the skin. Sometimes, however, they 
are very few in number, and situated at some distance from each other; and 
not to be distinguished at first from the rose spot eruption. The mulberry erup- 
tion usually occupies the trunk and extremities, but is occasionally limited to 
the trunk, and may now and then be observed to extend to the face. 
When the eruption is apparent, no fresh spots appear after the first, second, 
or third day, and each spot remains visible from its first eruption till the whole 
rash vanishes-that is, till the termination of the disease. When very nu- 
merous, the eruption, viewed as a whole, has not an equal depth of color. 
Some places are much paler than others, and the spots have a dull appearance, 
as if seen through the cuticle. A mottled aspect is thus sometimes given 
to the skin, on which the darker spots are seated; and hence (2.) A subcu- 
ticular rash has been also described, which is deepest colored on the most de- 
pending parts of the body. From this circumstance the eruption sometimes 
resembles measles so closely as to be distinguished with difficulty from the erup- 
tion in that disease. When the spots on the back are of a much deeper hue 
than those on the anterior surface of the trunk, the skin is at the same time 
so much congested at the back, that slight pressure with the finger leaves a 
white mark, which slowly returns to its dusky red color. The eruption of the 
mulberry rash usually appears from the fifth to the eighth day of this disease, 
and subsides between the fourteenth and twenty-first days (Dr. Jenner). 
" As a rule, however, the eruption of typhus fever appears on the fourth or 
fifth day; it may be met with, however, as early as the third, and rarely is 
delayed as late as the seventh. It comes first on the backs of the wrists, the 
borders of the axilla, and about the epigastrium; and in many cases it covers 
the whole trunk, and frequently also the arms and legs" (Dr. George Bu- 
chanan). 
Age seems to exert a considerable influence over the eruption; and the fol- 
lowing rule has been laid down in relation to this modifying circumstance : In 
100 typhus patients under fifteen years of age the rash will be absent in 25. 
In 100 typhus patients between fifteen and twenty-two years of age the rash 
will be absent in 14. In 100 typhus patients above twenty-two years of age 
the rash will be always present. 
The spots of typhus fever continue ineffaceably persistent after death. 
At the termination of the first, or commencement of the second week, the 
tongue has a large and swollen appearance, grows dry in the centre, and at 
the same time its white fur is replaced by pale dirty-brown mucus. 
About the ninth or tenth day, or even earlier, delirium becomes decided, 
sometimes violent, and always unquiet, although the attention may still be 
fixed by a sharp question. At this time the patient is in some cases violent, 
and, unless restrained, leaves his bed to wander about the room. His expres- 
sion gradually comes to resemble that of a man unwilling to be roused from 
half-drunken slumbers. It now betokens complete stupidity, oppression, and 
decided prostration. The complexion, dull and dirty from the first, in the 
course of the second week becomes absolutely muddy, the conjunctival mem- 
branes injected, and the pupils contracted; and the danger of febrile coma, 
which may supervene, seems very much in proportion to the contraction of 
the pupil (W. T. Gairdner). The face is now often flushed-the flush being 
dingy and pretty uniform over the whole countenance; but occasionally some- 
what more marked on the cheeks than elsewhere. 
The eruption gradually becomes darker in hue, the centres of many of the 
spots, towards the termination of the second week, are unaffected by pressure, 
and here and there are to be seen some spots with well-defined outline, quite 
unalterable in appearance by the firmest pressure of the finger. These are 
true petechiae. The posterior surface of the trunk is considerably congested, 
and the spots are there much darker and less affected by pressure than on the 466 
SPECIAL PATHOLOGY-TYPHUS FEVER. 
anterior surface. Desquamation of the cuticle is never observed as a conse- 
quence of the eruption; but the skin throughout the whole course of typhus 
fever is often particularly sensitive, the slightest touch occasioning pain. 
About the tenth or eleventh clay somnolence sets in, which may gradually 
pass into stupor, or even coma, and. the expression indicates profound prostra- 
tion. The patient lies on his back, unable to turn himself in the slightest de- 
gree, and the urine is often passed involuntarily, or is retained, requiring the 
use of the catheter for its withdrawal. The tongue is thickly coated, dry, and 
dark brown, or even black, appearing as if baked, and perhaps unable to be 
protruded. The teeth are covered with sordes, the patient is unable to be 
roused for more than a minute or two, and when so roused he mutters incohe- 
rently. The conjunctivse are intensely injected, and the pupils contracted. 
The skin is cool and occasionally moist. Miliary vesicles, or sudamina, are 
sometimes observed about the end of the second week, usually in the groins, 
at the epigastrium, and under the clavicles. If such vesicles become hard at 
the summits, then black, and if then the mass drops out as a slough, leaving 
a circular ulcer, such a vesicular eruption forebodes an unfavorable result 
(Stokes). The abdomen continues flaccid and indolent throughout. The 
bowels usually act once or twice a day, the stools being somewhat relaxed. 
The pulse, from the outset of the disease, is quickened, and it increases in 
rapidity in cases which terminate fatally, ranging from 100 to even 150 in a 
minute; or, after reaching a certain point, its frequency as gradually subsides 
till health is restored. Cases in which the pulse is remarkably slow are usu- 
ally cases in which the prostration becomes extreme. In the milder and un- 
complicated cases the maximum rate of the pulse is reached before the eighth 
day, and continues for two or three days, at least, at the maximum rate-com- 
mencing to decline gradually about the tenth, eleventh, or twelfth day. In 
the more severe cases the pulse keeps up very high till the thirteenth or four- 
teenth day, when, if the disease is about to end favorably, there is a sudden 
and marked fall (say from 120 to 96, or from 100 to 84), indicating a decided 
crisis (Perry). 
Temperature in Typhus Fever.-The heat of the skin conveys a burning 
pungent sensation to the hand, the temperature ranging from 102° to 107° 
Fahr. 
Dr. Cheyne, of Dublin, has recorded 109° Fahr, as the highest temperature 
he observed, and a few days before death he observed the temperature to fall 
to 95° Fahr. Differences in the range of temperature are probably due to 
the varying types of different epidemics ; and hence the seeming inaccuracies, 
or rather discrepancies, in the records of different observers ; certain symptoms 
which accompany a high range of temperature may be more marked and fre- 
quent in some epidemics than in others. The type of typhus fever varies as 
head symptoms, heart symptoms, or symptoms of pulmonary congestion pre- 
dominate in epidemics; and as the rates of mortality in different epidemics 
also show. The highest temperature recorded by Dr. T. J. Maclagan was in a 
girl aged seventeen, with severe head symptoms ; and who, for thirty-six hours 
before death, had complete suppression of urine. Death took place by coma 
on the fourteenth day; and a few hours before death the thermometer indi- 
cated a temperature of 106.4°. In cases which terminate favorably, Dr. Mac- 
lagan never noted a temperature higher than 105.2°; and in 13.7 per cent, of 
Dr. Maclagan's cases the thermometer rose above 104.7° These were all 
severe cases. The highest range of temperature occurs in cases which prove 
fatal by acute head symptoms, and in which there is partial or complete sup- 
pression of urine. In Dr. Maclagan's experience, in the Dundee Hospital, in 
1865 and 1866, the average maximum range in typhus was 104.3° Fahr.; the 
highest temperature being 105.2° Fahr., and the lowest temperature 103° Fahr. 
The temperature gradually and steadily rises till it reaches its highest point, 
generally on the fourth or fifth evening. TYPICAL RANGE OF TEMPERATURE IN TYPHUS FEVER. 
467 
Fig. 73.-typical range of temperature in a case of typhus fever (Wunderlich and Maclagan). 468 
SPECIAL PATHOLOGY-TYPHUS FEVER. 
It shows little or no tendency to a morning fall till it reaches this point. 
It then falls somewhat, and does not again reach the same height of tempera- 
ture. On or about the sixth day the morning falls of temperature commence, 
which characterize the remaining course of uncomplicated cases of typhus 
fever. These morning falls are occasionally slight, but generally appreciable. 
If the eruption is delayed beyond its usual time, the maximum of tempera- 
ture is not reached till a later day than the fifth, and the cases are so much 
more prolonged. Thus the febrile disturbance, as measured by the thermom- 
eter, reaches its height about the time at which the rash is fully developed, 
i. e., by the fifth day. . 
From observation of fifty-eight cases which recovered, and in which no com- 
plications existed, nor disturbing influences prevailed to lower temperature 
prematurely or abnormally, the diagram (Fig. 73) on the preceding page may 
be given as typical of the cases of typhus, of that time and place, contrasted 
with the range of temperature in a severe case of typhus fever, as given by 
Wunderlich. 
The dotted lines are Wunderlich's records of a severe case. The continuous 
lines are Maclagan's typical of an ordinary case of typhus. 
Thus, in the ordinary cases of Dr. Maclagan, and in the severe cases of 
Wunderlich, the morning temperature was always lower than the evening. 
The average of morning temperature in Dr. Maclagan's typical cases was 
102.7° Fahr., and evening 103.2° Fahr., showing a daily average range of 
six-tenths of a degree between morning and evening; in Wunderlich's severe 
case the average morning temperature is 104.5° and the evening 105.7° Fahr., 
with an average daily range of one degree and one-fifth, Fahr. In both, the 
fever maintains the characteristic continuousness of typhus without interrup- 
tions till the crisis. 
If the temperature at the commencement before the fourth day does not 
exceed on any evening 103.5° Fahr., the fever may be expected to run a mild 
course; and more especially if the increase of temperature takes place moder- 
ately, and is of limited daily duration during the beginning of the second 
week. On the other hand, in severe cases the fever continues with great in- 
tensity, at least to the twelfth day, and mostly throughout the whole of the 
second week. 
Defervescence rarely takes place before the first half of the third week. 
In severe cases the temperature may rise above 104.7° Fahr., and it may reach 
106° Fahr, or more on the third or fourth evening (E. Long Fox). The 
maximum of temperature is usually attained before the ninth day (Grim- 
shaw), or on the ninth day (Warter); and according to Grimshaw the ex- 
treme height of the thermometer in typhus seldom exceeds 104°, occasionally 
reaches 104.5°, and may, in exceptional cases, rise to 105°-a conclusion 
nearly coinciding with the observations of Dr. Perry, of Glasgow. But no 
just conclusion can be drawn from Dr. Grimshaw's records as to what may be 
the maximum temperature in the simple cases of typhus terminating in recovery, 
of which he gives the history (cases 1, 9, 12, 17, 18, 19, and 21, p. 15 of his 
thermometric observations, Med. Press, 1866); because none of them were ob- 
served before the seventh day, two not till the eighth, and one not till the 
twelfth. Moreover, his observations seem to indicate only one daily observa- 
tion, which renders them valueless for scientific comparison. The same must 
be said of Dr. Compton's cases (p. 14 of his Temperature in Acute Diseases). 
That considerable diversity of experience is on record regarding the tem- 
perature in typhus, is undoubted; and, as yet, the experience of any one man 
hardly justifies him in setting down the records of another as " quite erroneous." 
According to the experience of Dr. George Buchanan, at the London Fever 
Hospital, the maximum temperature reached is rarely less than 104.9° or 105° 
Fahr., and in many cases it reaches 106.5°-107°, sometimes even a higher 
point than this. This high maximum is, as a rule, in favorable cases only at- CORRELATION OF TEMPERATURE AND PULSE. 
469 
tained once or twice throughout the fever, and generally of an evening; the 
highest morning temperature very rarely exceeds 106° Fahr. The temperature 
begins to rise at the commencement, and has been observed as high as 103.8°- 
104.9° Fahr, the first evening. It continues rising till the third day, when it 
often reaches 105°-107° Fahr. The maximum is generally attained in the 
middle of the first week, between the fourth and sixth days-generally on the 
fourth day {A System of Medicine, vol. i, p. 533). 
From these and other observations it is obvious that no just conclusion can 
be arrived at as to the maximum of temperature in typhus fever where obser- 
vations are not made at least twice daily; and where the observations do not 
commence as soon at least as to include the third day of the disease. Obser- 
vations delayed till the fifth or sixth day are obviously valueless, so far as a 
determination of maximum records are concerned. The differences between 
the morning and the evening temperatures amount, during the fastigium 
(from the middle of the first to the middle of the second week), rarely to more 
than 1° Fahr.; and from the middle of the second week to a difference of 
about 1.5° Fahr. Greater differences happen only temporarily-a character 
which distinguishes typhus from enteric or typhoid fever, so far as ranges of 
temperature are concerned. But the difference between typhus fever and 
enteric or typhoid fever is rendered still more striking by their respective 
modes of defervescence. In typhus fever the defervescence shows less fre- 
quently the gradual remissions seen in enteric or typhoid fever; on the con- 
trary, the defervescence of typhus fever is generally sudden by crisis-the 
temperature falling rapidly and continuously until it reaches the normal point, 
in from twenty-four to forty-eight hours. Sometimes the fall on the thirteenth 
day is very intense and rapid; but is followed by a rise of three degrees the 
next day, defervescence extending over a period of several days (E. Long 
Fox). This is similar to the experience of Wunderlich, as in the severe case 
given in the diagram (Fig. 73). After the great and sudden fall on the evening 
of the sixteenth, a rise of at least two degrees followed, and defervescence was 
extended over five days more (not shown in the diagram). Thus defervescence 
may sometimes be gradual, commencing from thirteenth to seventeenth day, 
and extending over ten days; but it differs from enteric fever in the absence 
of the evening exacerbations. A period of critical perturbation precedes the 
fall, the temperature rising above the highest point of the day before. The 
observations of Fox and Maclagan show that the temperature falls below the 
normal during convalescence, and especially in some cases where the previous 
range has been excessive. This is also the experience of Mr. G. Stevenson 
Smith, in the Royal Edinburgh Hospital for Sick Children. When the fall 
is great (3° to 5°) as well as sudden, critical diarrhoea may be severe and 
serious, as in some of the cases detailed by Dr. Grimshaw; and a sudden fall 
of temperature to a range much below the normal, other symptoms being 
serious, is a bad sign, and may forebode death. 
Relation of Pulse to Temperature.-The average morning pulse in Dr. 
Maclagau's case was 116; in the evening 118; and when the temperature 
showed a slight fall, about the thirteenth or fourteenth day, the pulse still 
showed a tendency to rise. He did not consider his observations showed any 
exact relationship between the pulse and temperature in typhus fever. The 
pulse may remain low all through the disease, even when the temperature is 
very high. More commonly, however, according to Dr. E. Long Fox, there 
is a tolerable relation between them, the pulse rising as the temperature rises. 
Typhus seldom shows the low pulse, with gradually increasing temperature, 
that is met with during the first week of enteric fever. 
It is quite clear that observers are not at one as to the relation between 
pulse and temperature in typhus fever. Dr. J. W. Miller's experience, as 
Physician to the Dundee Royal Infirmary, shows that the correlation between 
pulse and temperature is not constant, as shown by the following table, in 470 
SPECIAL PATHOLOGY - TYPHUS FEVER. 
which is noted the number of occasions on which each degree of temperature 
was observed in thirty cases of typhus, of eighteen years of age and upwards, 
with the average pulse, and also the maximum and minimum pulse, which, 
on different occasions, were found with each degree of temperature: 
Table showing Correlation of Temperature and Pulse in Thirty Cases 
of Typhus, of Eighteen Years of Age and Upwards. 
Temperature. 
Number of 
Observations. 
Average Pulse. 
Highest and Lowest 
Pulse. 
- 96° 
5 
82 
64- 96 
96.1°- 97° 
39 
78 
60-112 
97.1°- 98° 
77 
77 
60-120 
98.1°- 99° 
70 
94 
60-150 
99.1°-100° 
60 
99 
72-164 
100.1°-101° 
61 
104 
72-144 
101.1°-102° 
86 
106 
84-144 
102 1°-103° 
140 
114 
84-156 
103.1°-104° 
173 
115 
84-144 
104.1°-105° 
55 
120 
96-158 
105.1°-106° 
1 
96 
The average pulse here rises, though very unequally, with each degree of 
temperature, from 77 with 98° Fahr., to 120 with 105° Fahr. The range of 
pulse, however, corresponding with any one temperature, is very wide, from 
50 to 120, for example, with 98° Fahr., and from 84 to 156 with 103° Fahr. 
In some cases the disparity between the height of the temperature and the 
frequency of the pulse is very remarkable, and continues for several days, 
sometimes throughout the whole case. 
Influence of Age and Temperature.-Here, again, observers differ. Dr. 
Maclagan does not think that age has much influence in increasing the range 
of temperature. The pulse is undoubtedly more frequent in children during 
the fever as well as during health, but this difference is not apparent after 
puberty has been reached. In cases which recovered from typhus, under 
fifteen years of age, the mean temperature in the morning was 102.8°, in the 
evening 103.8°, the pulse at the same time being 116 and 117. Dr. Perry's 
experience in Glasgow shows that in severe cases, in children, it is not unusual 
for the temperature to reach 107°, or even a little higher, from the fifth to the 
ninth day. According to Dr. Grimshaw's opinion, age has a considerable 
influence in modifying the thermometric range in typhus. In the young the 
range is higher than in those advanced in life; but no observations are 
recorded by him. 
General Indications in Typhus.-The disease, if it proves fatal, generally 
terminates from the twelfth to the twentieth day; and before death the pros- 
tration increases to an extreme degree. The average duration of Jenner's 
fatal cases was fourteen days; of Reid's, thirteen days. Subsultus tendinum, 
or involuntary twitchings of the muscles of the face and arms, make their 
appearance. The face became dusky or even livid, the breathing very quick, 
and the pulse so rapid and feeble that it scarcely was to be felt. Some want 
of resonance of the most depending part of the chest may often be observed 
at this stage of the disease. The respiratory murmur at the same part be- 
comes muffled, as if heard through a covering, and there is sometimes a little 
coarse unequal crepitation. The urine, which is now secreted in large quan- 
tities-from three to four pints daily-is restrained, or passed into bed with 
the stools involuntarily. The skin is bathed in a profuse sweat, and the tem- 
perature is apt to fall below the natural standard. The patient lies on his 
back unable to move, or he sinks towards the bottom of the bed if his head 
be in the least elevated. Towards the middle or end of the second week a COMPLICATIONS OF TYPHUS FEVER. 
471 
slough may form on the lower end of the spinal region, or on the region over 
the posterior spine of the ilium. 
For a day or two before the fatal termination, the condition termed comd- 
vigil may come on. In this condition the patient never sleeps. He lies on 
his back with his eyelids widely separated, his eyes staring and fixed in va- 
cuity, his mouth partially open, his face pale and expressionless. He is totally 
incapable of being roused to give a sign of consciousness, the breathing is 
often scarcely perceptible, the pulse rapid and feeble, or unable to be felt, the 
skin cool, perhaps bathed in perspiration. Life is only known to have ceased 
by the eye losing its little lustre, and the chest ceasing to effect its slow and 
feeble movements. Dr. Jenner has never seen recovery from this condition. 
Death generally takes place without any return to consciousness, and by syn- 
cope rather than coma (Murchison). 
If the disease should terminate in recovery, the improvement in the condi- 
tion of the patient is frequently sudden. Some time between the thirteenth and 
the seventeenth day he may fall into a profound quiet sleep, lasting for several 
hours; and generally after from twelve to twenty-four, or even more hours, 
he awakes decidedly improved in all respects-indeed, quite another man. 
At first he is bewildered or confused, and wonders where he is; but he may 
recognize his attendants and friends, and is conscious for the first time of 
extreme debility. The complexion is clearer, delirium has disappeared, the 
pulse has fallen in frequency and gained in strength, the conjunctivae are no 
longer injected, the tongue is moist at the edges; there is perhaps a little 
appetite, the skin is softer and moist, and the spots of eruption are paler. 
His limbs retain their sensibility; but when he attempts to move them, they 
seem at first as if separated from the body, so great is the prostration induced 
by typhus fever (Murchison). In a few days the tongue cleans completely, 
the appetite becomes ravenous and insatiable, and the patient rapidly regains 
strength. Dr. Jenner considers the duration of the disease to be measured by 
the duration of the eruption; and the average duration of cases that recover, 
he states to be from fourteen to twenty-one days; although not unfrequently, 
in very mild cases, the fever terminates before the fourteenth day. After 
twenty-one days, local lesions sufficient to cause death were always discovered 
in fatal cases of typhus. In other words, after the twenty-first day, death 
does not then occur from the fever alone, as may be the case before the twenty- 
first day. There are two very opposite circumstances under the influence of 
which the date of the first appearance of the eruption is changed, and its 
duration shortened. These are,-(1.) A very mild attack of the specific dis- 
ease ; (2.) The development of severe local complications in the course of the 
specific disease. There are cases of typhus fever which appear to die within a 
limited period after the outset of the illness, from the direct action of the 
poison on the blood or nervous system, and with the entire absence of local 
lesion, so that even the skin is not affected with eruption. 
Occurrence of Convulsions and Cerebral Head Symptoms.-The most for- 
midable, and fortunately the most rare complication in typhus fever, is the 
occurrence of convulsions. When they do occur, the case almost invari- 
ably proves fatal, unless the convulsions occur in a patient who has suffered 
from epilepsy; and the subjects of them seldom present any morbid appear- 
ances after death sufficient to account for their occurrence. In the Edinburgh 
Monthly Journal for June, 1848, the details of six cases of typhus fever are 
given, five of which proved fatal, by convulsions, in different wards of the 
general hospital there, and all of them within a period of twenty-one days, in 
the months of January and February. The following are the days of the 
fever at which convulsions are stated to have occurred, the number of hours 
they continued to recur, and the apparent mode of death: 472 
SPECIAL PATHOLOGY-TYPHUS FEVER. 
No. of Case 
Authority. 
Day of Fever. NumberXfAOeUcurrede Mode of Death. 
1st. 
Edin. Mon. Journal, 
7th, 
• . 2 . . . 
Coma. 
2d. 
u << 
11th, 
. . 5 . . . 
Coma. 
3d. 
U U 
15th, 
. . 6 . . . 
Coma. 
4th. 
<< << 
14th, 
. . 24 . . . 
Coma. 
11th. 
Of Mary G-, re- 
lated by Dr. Jenner, 
11th to 13th, 
' ' 72 ' ' ' 
Coma. 
13th. 
Of Thomas B-, re- 
lated by Dr. Jenner, 
9th, 
' * 36 ' ' 
Coma. 
The occurrence of convulsions in such cases may be fairly referable, in the 
present state of our knowledge, to the morbid condition of the blood in typhus 
fever, and the altered condition of the nervous system which ensues. Prob- 
ably they may have a ursemic origin. With reference to the absence of any 
appreciable lesion in the brain, it may be remarked that our usual instru- 
ments of research, applied to the nervous texture, are insufficient in all in- 
stances to indicate disease, even where it does undoubtedly exist. There are, 
for instance, physical conditions of texture, which are of the utmost impor- 
tance in pathology, such as alterations in the specific gravity, and which are 
appreciable by the proper means and instruments of research, even when the 
tissue of the organ presents to our senses of sight and touch no external evi- 
dence of disease. 
The cerebral complications are generally attended with what are commonly 
called "head or nervous symptoms," and are preceded by long-continued 
high temperatures. Dr. Jenner very emphatically calls attention to the fact, 
that the continuance of the headache complained of spontaneously after the 
commencement of delirium is generally indicative of increased vascular action 
within the cranium. It may also be noticed that the headache which pre- 
cedes the delirium is often in such cases of a very severe and constant kind, 
the face being sometimes pale and sometimes red, and greatly expressive of 
the distress the patient suffers. The eye, haggard or brilliant, with its con- 
junctiva injected and its pupil contracted, is painfully sensible to the light, 
and is therefore generally closed. The least noise is insupportable, and the 
patient is troubled with noise in his ears. His temper is altered, and his 
answers short and fretful. This condition is that of increased excitement, 
but not as yet of delirium, and, supposing the membranes of the brain to be 
inflamed, denotes diffuse inflammation of those tissues. At the end of a period 
of time, varying from two to ten days, the patient becomes delirious. His 
delirium may assume every character,-joyous or melancholy, furious or tran- 
quil; and in some cases he wanders from subject to subject, while in others he 
incessantly recurs to the same theme, and even to the same few words. In 
others, though the cases are few, the disease assumes every character of in- 
sanity ; and if permitted, the patient, confined in a strait waistcoat, presents 
the extraordinary spectacle of being able, in typhus fever, notwithstanding 
prostration, to walk about the wards. The phenomena of this stage show that 
the inflammation of the membranes of the brain has extended to the sub- 
stance of the brain itself. The commencement of effusion is indicated by the 
active delirium changing into a low muttering {typhomania), by the patient 
no longer requiring restraint, by his muscles becoming spasmodically affected 
with slight twitchings, or subsultus tendinum, showing how rapidly the nervous 
power is exhausted, and how feebly supplied; also by the pupil of the eye 
becoming expanded or contracted; by the fieces being passed involuntarily; 
by the urine being retained; and by the rapid grouping of those other symp- 
toms so happily described by Shakspeare as "the stony coldness of the feet 
creeping upward and upward," "the babble of green fields," and the "fumbling 
of the bed-clothes," all indicative of approaching death. Intracranial serosity 
is generally decidedly increased; and hemorrhage into the arachnoid occurred 
in one-eighth of Jenner's fatal cases. When the patient recovers, however, from PULMONARY COMPLICATIONS IN TYPHUS FEVER. 
473 
this stage of cerebral complications, the appetite improves, the pulse becomes 
fuller and steadier, the countenance more tranquil, the mind firmer, and the 
sleep natural, till at last convalescence is fully established. 
The respiratory movements are often influenced by this cerebral condition. 
In the first week they may not exceed twenty or twenty-four in the minute ; 
but when delirium supervenes and the pulse increases in frequency, they often 
rise to thirty or more, without any pulmonary lesion. In cases of great cere- 
bral disturbance the respirations become sighing, irregular, spasmodic, or 
jerking, and then coma is apt to supervene. The "nervous respiration" of 
Dr. Corrigan, or what is sometimes also called " cerebral respiration," is de- 
noted by a blowing or hissing sound in breathing, the lips being kept closed; 
the cheeks are distended, the nostrils dilate with each expiration, and the 
breath is forced through the closed lips with a puffing, blowing noise. Such 
breathing is irregular, a long pause being followed by a deep inspiration, and 
subsequently by short respirations in rapid succession. In some cases the 
action is entirely diaphragmatic, the respiratory muscles of the trunk being 
paralyzed (Murchison). The air expired has a disagreeable odor, most 
marked in the advanced stage of severe cases. It resembles the typhus odor 
exhaled by the skin, and which has been compared to the "odor of rotten 
straw," to the "smell of mice, deer, and certain reptiles," or to the smell of 
"the leaves of rue when rubbed between the fingers." By some it is spoken 
of as "pungent, ammoniacal, and offensive;" but it must .not be confounded 
with the smell from urine passed in bed. It seems to be, however, a smell sui 
generis, as Murchison very justly observes; and nurses experienced in typhus 
fever are quite familiar with it, and are able to distinguish cases of typhus 
fever by this peculiar typhus odor alone, which is always strongest in damp 
weather, and when the ventilation is bad. It is highly probable that the 
typhus poison is contained in this odoriferous substance. The expired air of 
typhus patients contains a smaller quantity of carbonic acid and a larger 
amount of ammonia (Murchison, pp. 134-137). 
Secondary Pulmonic Complications are not uncommon in typhus fever, in 
the form of pneumonia. The congestion of the blood in the posterior parts of 
the lungs may give a tendency to this ; and its presence may be suspected from 
the livid expression of the face, the existence of cough with rusty expectora- 
tion, the diagnosis being confirmed by the usual auscultatory means. It is 
seldom that pain is complained of. The part of the lungs affected for the 
most part is that which rests against the hollow of the fourth, fifth, and sixth 
ribs, between their tubercles and angles; the position of the patient appearing 
to determine the place of consolidation. Such consolidations are not to be 
regarded as analogous to what we see in an ordinary pneumonia, occurring 
in an otherwise healthy person. The incubation of the lesion is latent, and 
the symptoms are masked, and the nature of the complication is only to be 
recognized by careful physical examination and determination of temperature, 
which suddenly rises and continues high. The full expression of the morbid 
state is often for some time undecided ; the exudation, being of a serous nature, 
is slow to solidify on the one hand, and yet the symptoms of resolution do not 
appear on the other. Dr. Hudson, of Dublin, attaches some importance to a 
certain tympanitic resonance; which becomes manifest over the diseased lung, 
as a sign of the existence of the pulmonic lesion. He describes it as "a tym- 
panitic clearness over the solidified lung, without air being present in the 
pleura." Dr. Lyons explains this abnormal clearness as the result of the in- 
creased pressure of the respiratory column of air in the permeable portions of 
the pulmonary lobules, which become expanded beyond their natural volume, 
and thus a condition of temporary emphysema is produced, which yields a clear 
sound on percussion (Dr. Stokes, in Medical Times and Gazette, May 26,1855). 
In some cases of pulmonary lesions there appears to be a combination of 
circumstances which leads to a fluid or purulent state of the diseased part, re- 474 
SPECIAL PATHOLOGY - TYPHUS FEVER. 
sembling the third stage of pneumonia as described by Laennec. The condi- 
tions which lead to this form may be stated to be,-(1.) A sudden exudation 
and abundance of fluid matter; (2.) A great amount of tissue involved; (3.) 
Diminished vascularity, and consequent (4.) Abeyance of absorption, tending 
to (5.) Increased fluidity of the diseased part; (6.) Breaking up or solution 
of the young and growing elements. A lung in this condition seems to have 
passed, as it were, at once into this state, without any well-marked hepatiza- 
tion. 
Gangrene of the Pulmonary Tissue is by far the most formidable of the 
thoracic secondary lesions of typhus fever. The hepatization of the lung is 
not, as in the last instance, obscure, but the consolidation is at once sudden, 
complete, and extensive, involving perhaps the greater part of a lung, and 
coming on without any marked physical signs different from what are to be 
heard in the simple congestion of typhus. A gangrenous cavity forms in the 
substance of the solidified mass, and is only indicated by the fetid expectora- 
tion and the accompanying physical signs of a cavity. Large eschars are apt 
to form towards the pleural surface, surrounded with well-defined lines of de- 
marcation where separation of the slough proceeds. In this gangrenous slough 
every simple element of the pulmonary tissue becomes disintegrated, almost 
perfectly liquescent; and sometimes it happens that the gangrenous cavity 
does not communicate with the bronchial tubes, and then the morbid state is 
difficult to diagnose, and its existence is often unknown till after death. With 
physical signs, the expression of the countenance of the patient is often highly 
suggestive. It suddenly becomes small, pinched, contracted, ghastly, miser- 
able, and deathlike. The eyes are sunk and void of lustre; and, along with 
languor, the patient feels nausea, and sometimes vomits. There may be sev- 
eral distinct gangrenous centres, as if the lesion had been, from the first, dis- 
seminated or lobular. 
Secondary Cardiac Lesion.-This lesion assumes the form which Dr. Stokes 
has called " typhus softening of the heart." He is inclined to consider that 
the muscles of the larynx and the circular muscles of the trachea are some- 
times similarly affected, as well as the involuntary muscles generally. This 
complication has for the most part occurred when there was a great amount 
of the secondary bronchial disease. The wasting of the involuntary muscles 
is always great in typhus. In the heart it is more obvious than in the arterial 
or systemic portion. 
The cardiac phenomena of typhus (adynamic) are chiefly indicated by a 
diminution of the impulse, and an impairment or loss of the first sound-the 
impulse diminishing progressively from the fifth or sixth day to the termina- 
tion of the disease-while the systolic sound becomes daily more feeble or quite 
inaudible, leaving the second sound clear and distinct. 
The poison, however, does not necessarily make itself manifest through all 
the series of local secondary affections already referred to. Thus, in one year 
or epidemic the lungs will be attacked in every case; in others, the bronchial 
membranes or the membranes of the brain; while in other epidemics, parotid 
swellings, symptomatic parotitis, and inflammation of the ear will prevail. At 
other times such attacks will be rare-the exception, and not the rule of the 
disease. 
Prognosis.-Cases of typhus fever are always anxious cases; and the ther- 
mometer enables us to form a definite idea of the actual state of the patient, 
adding certainty and precision to our knowledge, which, without its aid, would 
be wanting. It is, therefore, a valuable adjunct to other means of knowledge, 
in conjunction, more especially, with-(1.) General aspect of the patient, con- 
dition of the pupil, injection of the conjunctiva, and expression of the eye; 
(2.) State of the pulse; (3.) Condition of the heart; (4.) Condition of nervous 
system; (5.) Condition of respiration-character given to breathing by the 
expirations-short, hurried, or forcible breathing. The thermometer is one of SUMMARY OF PROGNOSIS IN TYPHUS. 
475 
the ordinary means of attaining a knowledge of the patient's condition, and 
one which must be taken advantage of, just as we note the state of the pupil 
and cardiac sounds. 
A knowledge of the probable course of a case, and of the mode in which 
death is threatened, is necessary to give significance to thermometric observa- 
tions in typhus as to prognosis. Coma, asthenia, or a mixture of both, are 
the usual modes of fatal termination in uncomplicated cases of typhus fever. 
Thus, death may commence at the brain, or at the heart; the former mode 
being more common in the young, the latter in older people. Pulmonary 
affections are still more apt to complicate the cases, when asphyxia will then 
have a share in producing the fatal issue. 
In severe cases, where the head affection is the source of danger, the ther- 
mometer is the earliest certain indicator of the unfavorable nature of the case, 
and the earliest indicator of any improvement. If it continues high on the 
seventh or eighth day, and with an absence of morning fall on the ninth or 
tenth day, the continued persistence of this high temperature is a most unfav- 
orable sign. 
The pulse is not so good an index of danger as temperature, because, when 
a patient is restless, excitable, and frequently endeavoring to get out of bed, 
or performing such-like muscular feats, the rapidity of pulse and respiration 
is apt to be excited. The temperature, on the contrary, is not apt to be so 
affected. With a high range of temperature from the first, and continuing 
beyond the ninth day, in typhus fever, head symptoms are generally severe. 
The urine ought to be examined for albumen, and although there may be 
nothing in the general aspect, pulse, or respirations, to suggest more than usual 
anxiety, the persistent high temperature will give the first warning note that 
the case will be severe. It will give also indications of commencing deferves- 
cence at least three days earlier than any other symptom. 
Where nervous symptoms do not predominate, but cases in which the chief 
source of danger is failure of the heart's action, in which the general symptoms 
are those of depression rather than of excitement, when the pulse may be even 
rapid, but the cardiac sounds, instead of yielding a clearly perceptible impulse 
and audible systole, give a very feeble impulse, and a first sound, faint and 
indistinct; in such cases the thermometer may not of itself be a good guide to 
prognosis, but is a reliable index of the decline of the fever. In such cases 
the temperature is often equable, and not at all high; and, therefore, it is the 
general aspect, the feeble compressible pulse, the stethoscopic examination of 
the heart, which indicates danger from another source, namely, by failure of 
cardiac action. 
The thermometer, if trusted to alone, may tend to mislead in such cases, by 
giving a false idea of the state of affairs. It may be low, even to below the 
normal standard (the result of depression), or it may never reach 100° ; yet 
the danger may be extreme. 
From the united observations of Wunderlich, Perry, Maclagan, George 
Buchanan, and E. Long Fox, a summary may be given of the combined value 
of temperature and pulse in conjunction with other symptoms. 
1. No two cases are exactly alike, and the temperature varies too much for 
being alone a safe guide to prognosis or treatment. 
2. The period at which temperature remains continuously stationary varies 
in duration in proportion to the severity of the attack. In slight cases there 
is often a temporary remission between the seventh and ninth day, which some- 
times seems to usher in a gradual subsidence of the fever, The extent and 
continued duration of fever distinguishes typhus from all other fevers; while 
its mode of defervescence distinguishes it from enteric fever. 
3. Cases are slight in which a remission takes place on the fourth day, whilst 
temperature does not rise much after this period; but in some ordinary cases 
the acm6 of temperature may not be reached till the seventh or eighth day. 476 
SPECIAL PATHOLOGY - TYPHUS FEVER. 
4. In general terms, in ordinary uncomplicated cases, the temperature 
generally attains its maximum about the time of complete development of 
the eruption; and equability of temperature is a usual characteristic of a 
mild case. 
5. In cases of great severity the evening temperature will remain at a 
maximum point until the eleventh or twelfth day, and defervescence will 
then begin with greater or less rapidity. 
6. In cases the most severe the high evening temperature, with small 
morning remissions, will persist until the thirteenth or fourteenth day, and 
even longer; and in cases the most likely from their gravity to attract 
especial notice, the temperature will seldom diminish before the thirteenth 
evening. 
7. In uncomplicated cases likely to be fatal, there is no remission of tem- 
perature between the seventh and ninth day; the temperature usually keeps 
more or less high until death, in the second or third week; and, just before 
death, it may arise to a very extreme point. Wunderlich notes a case in 
which temperature, at the time of death, rose to above 109° Fahr. 
8. If a high temperature persists into the third week, the prognosis is bad. 
On the other hand, there are cases in which death is preceded by a tempera- 
ture of collapse, as in those recorded by Dr. Grimshaw, with a temperature of 
95° Fahr., or 96° Fahr.; and it is a very bad sign if the temperature falls 
rapidly at any period of the disease, whilst all the other symptoms remain as 
they were. Such fall may be due to enfeebled cardiac action, or to pulmonary 
obstruction from deficient oxygenation of the blood, leading to extreme 
depression. 
9. A high temperature during the first week-e. g., a morning temperature 
of 104° Fahr., or an evening temperature of 105° Fahr, during the first week; 
and a morning range of 103.8° Fahr., with an evening one of 104.5° Fahr, 
after that time, continued into the second week, is the earliest indication of 
danger from head symptoms. 
10. The highest range of temperature occurs in cases which prove fatal by 
acute head symptoms, and in which there is partial or complete suppression 
of urine. 
11. Irregularities and abnormalities in range of temperature sometimes 
characterize severe cases, and are of specially unfavorable import when occur- 
ring in those cases in which a high temperature has been noted at the end of 
the first week. 
12. A rise of temperature at midnight, and a continued absence of a 
morning fall are (when the range is high) indications of dangerous nervous 
symptoms. 
13. The thermometer is of no value in estimating danger from probable 
failure of the heart's action. The state of the heart, as revealed by the stetho- 
scope, is then the best guide to the condition of the patient. 
14. When pulmonary complications exist to so great an extent as to threaten 
death by asphyxia, the records of the thermometer will not indicate the risk, 
which can only be measured by the general symptoms (as indicated at p. 473) 
and by stethoscopic examination of the chest. 
By several critics the records of Wunderlich in typhus fever, which I have 
previously taken as my authority and model, have been considered too high; 
but I believe it will be found that epidemics of typhus fever vary very much 
as to their type; and that in some epidemics cerebral symptoms run high, 
while in others their occurrence is more rare. Observations are still required 
as characterizing different epidemics in the way already indicated, before we 
are justified in setting down the records of any one observer as inaccurate or 
not trustworthy. From these statements it will appear what are the kind of 
cases in which the thermometer will be of use, and those in which it will not; 
iust as the physician knows when to use the stethoscope, and when it is of no MODES OF FATAL TERMINATION IN TYPHUS FEVER. 
477 
use. The occurrence of certain phenomena, or the presence of certain symp- 
toms, indicating the existence of complications, are the general guides as to 
danger. These may be arranged in the following summary under three heads, 
namely: 
(a.) Combinations of Symptoms and Phenomena which are of extremely 
Unfavorable Import.-(1.) A presentiment of death on the part of the patient; 
(2.) A pulse of 120, which at the same time is soft and compressible, small, flut- 
tering, irregular, intermittent, reduplicate, or imperceptible; (3.) Complete 
absence of cardiac impulse, and an audible systolic sound; (4.) An excited or 
thumping action of the heart, associated with a very feeble radial pulse; (5.) 
Hurried respiration, whether "cerebral" or due to pulmonary lesion; (6.) 
Sleeplessness, associated with delirium, both of which are persistent; (7.) Se- 
verity of cerebral symptoms, and these symptoms coming on early, with no re- 
mission of temperature, between the seventh and ninth day, the temperature 
keeping more or less high till death in the second or third week; (8.) The oc- 
currence of complete "coma-vigil;" (9.) Extreme contraction of the pupil; 
(10.) Extreme prostration occurring early; (11.) Muscular tremor, picking 
and catching at the bed-clothes, subsultus, and spasmodic twitchings of the mus- 
cles of the face; (12.) Urgent and protracted hiccough; (13.) Rigidity of the 
muscles of the limbs, and squinting; (14.) Relaxation of the sphincters before 
the tenth day; (15.) Retention of urine; (16.) Tympanitis, with extreme 
nervous prostration; (17.) A dry, brown, hard, retracted, tremulous tongue; 
(18.) The more abundant and darker the eruption the greater the danger and 
severity of the case; (19.) Great lividity of the face and extremities, and a 
dusky erythematous condition of the skin on the dependent parts of the body; 
(20.) Continuous profuse sweating, coldness of the surface, cold breath, and a 
rapid weak pulse; (21.) A sudden diminution in the amount of the excretion 
of urea; (22.) The occurrence of blood or albumen in the urine before the 
tenth day, especially when associated with casts of the uriniferous tubes; (23.) 
High temperature in the third week; (24.) Pulmonary hypostasis and bron- 
chitis, pneumonia, gangrene of the lungs, convulsions, pyaemia, erysipelas, 
parotid swellings, inflammatory swellings, bed-sores, gangrene, renal disease, 
scurvy, the gouty diathesis. 
(b.) Combinations of Symptoms or Phenomena which may be regarded 
as of Favorable Import.-(1.) A sudden fall in the frequency of the pulse; 
(2.) When a patient, after lying for days on his back, helpless and motionless, 
manages to turn himself round and sleep on his side, or if he is able to draw 
up his leg and rest it on the foot in the flexed position in the bed; (3.) Cases 
without rash, or in which the rash is scanty; (4.) When the excretion and 
elimination of urea and uric acid continue free and copious; (5.) Sudden ces- 
sation at the end of the second week of several of the unfavorable symptoms 
and phenomena; (6.) Diminution of the rapidity and increase in the strength 
of the pulse; (7.) A slight return of appetite, while the tongue becomes clean 
and moist at the edges; (8.) A diminution of the dusky tinge of the face, a 
less stupid appearance of the countenance, and a less injected state of the con- 
junctivae, with signs of returning intelligence. 
(c.) Modes of Fatal Termination.-(1.) Death during the primary fever 
may occur from syncope or from coma. In the former case the heart's action 
is enfeebled from paralysis or disease of its muscular tissue. In the mode of 
death by coma, the blood has undergone such modifications as render it inca- 
pable of supporting the changes essential to existence. Its contamination 
seems mainly due to the admixture of urea and other products of the retro- 
grade metamorphoses of tissue, and from the diminution and destruction or 
solution of its red corpuscles. (2.) Death is for the most part due to a com- 
bination of syncope and coma ; and, as a rule, the patient is quite unconscious 
for a considerable time prior to death; (3.) Death may occur from one of 478 
SPECIAL PATHOLOGY-TYPHUS FEVER. 
the many complications which happen before or after the cessation of the 
primary fever. 
Condition of the Blood.-In typhus fever the microscopical characters of the 
blood are often such as to prove a marked deviation from its normal state. 
Amorphous heaps of red discs replace the normal rouleaux, and the adhesion 
of the red discs to each other, in the imperfectly-formed rouleaux, is far less 
complete and long-continued than in healthy blood. The red discs part with 
their coloring matter more easily and dissolve more rapidly than they do in 
their normal state. This is shown by the red serosity found in almost every 
serous cavity, the deep dusky-red hue of the flesh, and of every structure in 
contact with the blood. The blood drawn during life, or found after death 
in the vessels, is loosely coagulated or absolutely fluid (Dr. Jenner). It is 
also more apt to become putrid, when taken from the body during life, than 
healthy blood, or than blood in other diseases. According to Lehmann, the 
salts are increased rather than diminished; and there is good reason for be- 
lieving that the unnaturally fluid state in typhus fever results from an abnor- 
mal amount of ammonia, possibly derived, as Dr. Murchison suggests, from 
the decomposition of urea; and there is evidence, as Drs. Richardson and 
Murchison have shown, that the blood of typhus fever contains an increased 
amount of ammonia. 
The morbid anatomy of cases of typhus fever has been carefully investi- 
gated by Gerhard and Pennock, A. P. Steward, John Reid, Thomas Peacock, 
William Jenner, Felix Jacquot, Barrallier, and Murchison. All are agreed 
that there is no constant nor characteristic lesion; and they may be summed 
up generally as follows : " A fluid condition of the blood; hyperaemia of the 
cerebral membranes and increase of intracranial fluid; bronchial catarrh 
and pulmonary hypostasis; softening of the heart, liver, spleen, and pancreas; 
hyperaemia and hypertrophy of the kidneys." (Murchison, p. 245). 
Treatment of Typhus Fever.-Before considering the treatment of typhus 
fever, it is of the greatest importance to be aware of the changes which go on 
in the system during its progress. Dr. Parkes has observed the nature of 
these changes in a most conclusive manner. His observations are of great 
scientific interest, and of important practical bearing (" Gulstonian Lectures," 
in Medical Times and Gazette for February 28, 1857). In an uncomplicated 
case of typhus fever the body loses flesh rapidly, owing not only to diminished 
ingress of food, but also to increased egress of bodily structures in the form of 
excretory products. The metamorphosis of tissue, as judged by the urine, is 
augmented. The only complete analysis of the urine in an uncomplicated and 
undoubted case of typhus fever, when no medicine whatever was given, is an 
analysis made and recorded by Dr. Parkes ( Urine in Disease, p. 258). " The 
condition of the urine," he writes, " was that of ordinary pyrexia. The water 
was lessened; the urea was increased one-fifth; the uric acid was in large 
amount, and spontaneously, or on the addition of an acid, deposited. The 
chlorides were entirely absent; there was no diarrhoea or sweating; the sul- 
phuric acid was rather high ; the phosphoric acid was not determined. The 
free acidity was very slight; and (differing from many py rexue) the pigment 
and extractive matters were throughout in small amount. The urea continued 
large, and the chloride of sodium small in amount, for some days after the 
temperature had fallen to below the normal limit. The excretion of urea was 
remarkably regular in amount from day to day; for during ten febrile days 
its range was only 15 grains (1 gramme) below the mean of the ten days, and 
20 grains (1^ gramme) above it. And this took place with great alterations 
of temperature. It then, as usual, fell during convalescence, and rose again 
to the healthy standard in three or four days. The chloride of sodium was 
clearly retained in this case, for there was constipation, and the skin was dry, 
so that none could have passed off by the intestines or surface." " It would TREATMENT OF TYPHUS FEVER. 
479 
seem also," he further observes, " that the urine in typhus is much more fre- 
quently albuminous than in typhoid fever." 
In three cases of typhus fever associated with jaundice (which is extremely 
rare in typhus cases), Dr. Murchison examined the urine, which was also 
jaundiced. There was no reaction on testing for the bile acids; but in two of 
the cases tyrosin and leucin were found. In one of these cases the urine was 
almost devoid of urea. At the autopsies of two of them there was no derange- 
ment of the biliary ducts {Path. Society, Feb. 3, 1863). 
The following inferences are drawn from the table given by Dr. Parkes: 
1. In spite of the many pints of fluid drank, a small quantity of water 
left the system by the kidneys and skin, and none at all by the bowels. This 
retention of water is not peculiar to typhus, and its cause is quite unknown. 
2. The amount of urea was greatly increased. The normal amount of urea 
excreted by active men on good diet, between twenty and forty years of age, 
weighing 145 lbs., is 491 grains in twenty-four hours. A boy ill of typhus, 
aged seventeen, weighing not more than 129 lbs., excreted not less than 532 
grains daily, although he was on fever diet, and taking scarcely any nitrogen- 
ous food. 
3. The chloride of sodium is excreted in health at the rate of 180 grains 
daily. In this case of typhus fever it was present only in traces, the amount 
being too small to be determined. Like the water, this retention is common 
to the pyrexiae. 
4. Metamorphosis of tissue was more active by one-fourth daily. 
General Indications for Treatment.-From most careful observations such 
as these, Dr. Parkes thus gives an outline of the principles upon which fevers 
are to be treated. The treatment of fever (and typhus and enteric fevers are 
not exceptions) may be summed up as being a combination of measures to 
reduce excessive heat, to insure propter excretion, and to act on the semiparalyzed 
nerves; and, as Dr. Murchison justly observes, "every remedial agent which 
shall be found to promote the elimination of urea, without increasing the de- 
structive metamorphosis of tissue, will deserve a trial in typhus" (1. c., p. 
268). 
To reduce heat and to regulate elimination are but secondary indications 
in the treatment of typhus fever, compared with the influence which must be 
exercised over the nervous system; and one of the greatest objects of thera- 
peutics at the present day is to find substances which will act on the nerves 
and the blood, and restore them in some way to their normal action. 
Special Indications for Treatment.-Our objects in the treatment of typhus 
fever should be,-(1.) To neutralize the poison and to correct the morbid state 
of the blood ; (2.) To promote elimination of the poison and the products of 
the destructive metamorphosis of tissue; (3.) To reduce the temperature; 
(4.) To sustain the vital powers, and to obviate the tendency to death; (5.) 
To relieve the distressing symptoms; and (6.) To avert and subdue local 
complications (Murchison, p. 265). 
1. In the belief that the morbid condition of the blood in typhus fever may 
be due to the presence of ammonia in some as yet unknown combination, the 
use of mineral acids has been recommended by many physicians. Murchison 
considers their beneficial effects in typhus as undoubted, and in this opinion 
he is confirmed by the experience of Huss of Stockholm, Haller of Vienna, 
and of Mackenzie, Chambers, and Richardson, in this country. Huss recom- 
mended phosphoric acid in doses of ten to fifteen drops every second hour, 
believing that the phosphorus exerts a special influence on the brain; but in 
the advanced stage, and especially if sweating, numerous petechiee, or ecchy- 
moses be present, he has recourse to sulphuric acid in doses of fifteen to 
twenty drops every hour or every second hour. Hydrochloric acid is preferred 
by Drs. Murchison, Richardson, Mackenzie, and Chambers. It may be given to 
the extent of one fluid ounce of the dilute acid, mixed in a quart of barley-water, 480 
SPECIAL PATHOLOGY - TYPHUS FEVER. 
sweetened with syrup of ginger, and flavored with lemon-peel. Dr. A. P. Steward 
has used with advantage the tinctura p er chlor idi ferri, in doses of thirty minims 
every three hours. Dr. Murchison recommends nitro-muriatic acid. He pre- 
scribes twenty minims of hydrochloric acid with ten minims of nitric acid every 
three hours, each dose being diluted with the patient's drink. But if the 
"typhoid state" is developed in a marked manner, dilute sulphuric acid, in 
doses of fifteen to twenty minims every three hours, in combination with ether, 
and small doses of quinine, are to be had recourse to as in either of the follow- 
ing formulae: 
B. Acid. Hydrochlor, dil., n^xx; Acid. Nit. dil., n^x; Spt. 2Ether. Nit., 
t^Ix; Liquor. Cinchonae, nj^xxx; Decoc. Scopar. comp., si; misce. A 
draught so composed may be administered every third hour. 
Or, B. Quiniae Sulph., gr. |; Acid. Sulph. dil., n^xx ad ngxxx; 2Ether. 
Sulph., yxxv ad rxxxx; Syrup. Aurant., rrjqlx; Decoc. Scopar. comp., §i; 
misce. A draught so composed may be administered every third or fourth 
hour. 
When the acids are cautiously administered in smaller doses, in conjunc- 
tion with a few minims of solution of muriate of morphia, if the bowels be 
irritable, sweetened with syrup of orange-peel and diluted with water, the 
draught is generally relished, and the tongue from being dry, and hard, and 
brown, becomes moist and clean (Perry). 
2. To insure proper excretion and elimination in fever is much more diffi- 
cult than to reduce temperature, of which, for obvious reasons, it is not 
always wise to attempt the reduction. 
Perhaps the best general method to insure proper excretion is to supply the 
system with abundance of alkaline salts, which are not now given in the food, 
and to maintain the action of the kidneys, the bowels, and the skin. Chloride 
of sodium, the alkaline salts of potash, and probably also those of soda, tend to 
aid the formation of urea and its elimination. In the use of nitrate of potash 
and of iodide of potassium, which are not natural constituents of the frame, 
Dr. Parkes has observed that, at the first employment of these, there is often 
a marked lessening of excretion, as if the chemical processes then going on in 
the body had been interfered with, for afterwards the elimination again in- 
creases, as if the system had accommodated itself to the remedy. 
Purgatives tend to insure a proper excretion, probably by removing from 
the blood some of the abnormal products formed in fever. The great relief 
which sometimes follows their use, as well as the fall of temperature, seems to 
show this. Where there is retention of urea, they aid its elimination, 
because we know that urea passes off sometimes by the mucous membrane of 
the stomach and bowels. The patient should be allowed to drink freely of 
water; and five grains of the nitrate of potash may be given with each dose of 
the nitro-muriatic acid already mentioned. Dr. Murchison recommends nitre 
whey, prepared by boiling Jii of nitre in a pint of milk, and straining; or a 
drink prepared by dissolving Ji to Jii of the bitartrate of potash in a pint of 
boiling water, and flavored with lemon-peel and sugar; but if the patient be 
very prostrate, or if the bowels be relaxed, nitric ether is to be substituted for 
the nitrate of potash. 
Tea and coffee have been recommended in the stupor of typhus; and it is 
probable, as Dr. Parkes has shown, that their good effects are due to their 
power of eliminating the urea already formed in the blood. The coffee may 
be given as an extract, or as a strong infusion of the powdered berry made in 
the ordinary way. Tea has been recommended as an infusion of the green 
tea leaf. As beverages or common drinks in fever, both tea and coffee have 
been found to relieve the headache, the pulse becoming fuller and stronger 
under their use. Bocker, L. Lehmann, and Hammond, all agree in showing TREATMENT OF TYPHUS FEVER. 
481 
that in health they greatly lessen the urea (Parkes On the Urine, p. 76). 
With respect to chloride of sodium, Dr. Murchison recommends that large 
quantities of this salt should be given with the beef tea. 
The action of the bowels is to be maintained by emetics and laxatives. In 
the first instance, if the patient is seen early-i. e., before the sixth day-an 
emetic of ipecacuanha (one scruple), and of antimony (one grain), or of car- 
bonate of ammonia (two scruples), in place of the antimony, is to be admin- 
istered. If the bowels remain confined after the emetic, a mild laxative of 
rhubarb and calomel, or of castor oil, is to be given; and failing these, or in 
place of them, a simple enema is to be administered (Murchison, p. 269). 
The advantages of emetics are, that they relieve the patient to some extent 
by mitigating or removing headache and general pains. They also reduce 
the temperature, abate thirst, and quiet gastric disturbance. 
Emetics, however, are contraindicated if the patients are unusually weak, 
or if the disease has advanced beyond the first week. Laxatives and enemata, 
however, ought to be repeated daily, if required, so as to secure a motion of 
the bowels once a day. In this respect the treatment is different from the 
treatment which ought to obtain in enteric fever, as already mentioned. Ex- 
crementitious matters in the intestines must be removed by gentle aperients. 
The dark offensive matters accumulated in the intestinal canal in typhus 
fever may have a secondary deleterious effect on the system if they are allowed 
to remain. Purging, however, is to be avoided, and fresh-made compound 
rhubarb pill mass, which tends to stimulate the peristaltic action of the intestines, 
is as good a medicine as can be given, followed, if necessary, or alternated, 
by a small dose of castor oil, or by a simple enema. 
Diaphoresis is not to be encouraged beyond the insensible transpiration of 
the skin; and to remove which the wholesome detergent of tepid water spong- 
ing is most beneficial. It ought to be used twice or three times daily,, and 
quantities of Condy''s fluid or of muriatic acid (JiadOj) may be mixed with the 
tepid water (Murchison). The measure is a good one in a hygienic point 
of view, and it contributes- 
3. To reduce temperature, the external application of cold water was once 
practiced to an extreme degree by Currie, as originally recommended by Dr.. 
Robert Jackson, and it has been again recently advocated. In health such 
an application as that of cold water has a great effect in reducing tempera- 
ture, and tends to increase metamorphosis of tissue (Lehman,. Sanderson). 
4. The vital powers are to be sustained by food in the first instance. For 
this purpose, nourishment ought to be given often,, and at stated intervals- 
at least once every three or four hours after the fourth day of the fever.. Even 
if the patient is asleep, or seems to be so, he must be roused at these stated, 
intervals (not often er) to take his food or his stimulants. But if, towards the 
period of the crisis, the patient appears to be in a sound sleep, he ought not 
to be disturbed. The indications for treatment just described apply to the 
earlier stages of the fever, up till about the fourteenth day. Beef tea, broths,, 
meat-juice, bread pudding, arrowroot, jellies, milk, eggs, and alcoholic fluids, 
are the foods on which the typhus fever patient must be sustained. 
Alcohol in small quantities, as well as tea, coffee, lemonade, soda water, 
water poured from standing over oatmeal, and taken cold or after boiling, 
and then cooling, and other fluids, have a directly stimulant action on the 
• nervous system and on the organs of circulation; at the same time, alcoholic 
drinks diminish the metamorphosis of the tissue-elements. Few remedies,, 
however, require more discrimination in their use; and the following guides 
for their administration are compiled from the careful observations of Dr. 
Murchison (1. c., p. 269): • 
1. Wine is not usually required during the first five or six days- of the 
illness, but most cases require some stimulants during the second, week; and,, 482 
SPECIAL PATHOLOGY-TYPHUS FEVER. 
as a rule, the physician may find it necessary to begin to administer stimulants 
about the seventh or eighth day. 
2. The indications for the administration of alcoholic stimulants are mainly 
derived from the state of the organs of circulation; and the profession is 
indebted to Dr. Stokes (1839) for pointing out the importance of cardiac and 
radial pulses as guides for the use of alcohol in fever. 
These indications are,- 
(a.) Extreme softness or extreme hardness and compressibility of the pulse. 
An irregular, intermitting, or imperceptible pulse more imperatively demands 
stimulants than a merely rapid pulse. So also an abnormally slow pulse- 
e. g., 40 to 60-is a stronger indication for stimulation than a quick pulse. 
(6.) When the cardiac impulse becomes weak, and when the first sound is 
impaired or absent, a liberal allowance of stimulants is demanded; and in 
every case where there are doubts as to the propriety of giving stimulants, 
the heart must be examined with the hand and with the stethoscope, because 
the state of the pulse alone is not sufficient to judge from. The impulse may 
be found to diminish progressively from the fifth or sixth day to the termina- 
tion of the disease; and for several days prior to death or recovery it may be 
entirely absent. The systolic sound of the heart becomes daily more feeble, 
and ultimately may be quite inaudible, leaving the second sound clear and 
distinct; and before the first sound is altogether lost, it may become so short 
that it is difficult to distinguish it from the second sound. If the action of 
the heart be rapid, its sounds may thus come to resemble closely those of the 
foetus in utero. A violently excited heart all through the disease, with cold 
surface, cold breath, and feeble pulse, demands wine from the first; but even 
with its judicious use the prognosis in such cases is extremely doubtful 
(Stokes, Graves, Murchison). 
Other indications for stimulants may be stated as follows: 
(c.) If by raising the patient to his semi-erect position a tendency to syn- 
cope is induced, or great prostration is manifest, with diminished strength and 
volume of the pulse, then stimulation must be commenced. 
(df The darker and more copious the eruption, the more is the necessity 
for stimulants, especially if petechise are numerous. 
(e.) Profuse perspiration, with no improvement in the general symptoms, 
requires an increased supply of stimulants. 
(/.) Coldness of the extremities, stupor, low delirium, tremor, subsultus, 
involuntary evacuations-symptoms generally of the "typhoid state"-are 
indications for the liberal administration of alcohol; but the propriety of 
giving stimulants in delirium depends on the state of the pulse. If, on the 
trial of stimulants, the patient becomes tranquil, they do good, and may be 
continued; if the reverse, their use must be suspended. 
(g.) A dry brown tongue is an indication for wine or brandy; and if it 
becomes clean and moist at the edges under the use of either, such stimulation 
is beneficial. 
(A.) Complications, as a rule, increase the necessity for stimulation ; and 
large quantities of stimulants are called for if pycemia, erysipelas, bronchitis, 
pulmonary hypostasis, pneumonia, inflammatory swellings, bed-sores, or local gan- 
grene should supervene. 
(id) Persons who have led intemperate lives, and old persons, require stimu- 
lants early in the fever, and in large quantities. 
The effects of alcoholic stimulation require to be most carefully watched 
throughout the whole period of their administration. Four ounces of wine 
in the twenty-four hours is enough to begin with; for if the blood be over- 
loaded with the products of'alcoholic ingestion, further alcoholic stimulation 
will lead to increased contamination, and it is rare that more than eight ounces 
of brandy in twenty-four hours are necessary. 
There are differences in the demand for stimuli in the typhus of different ALCOHOLIC STIMULANTS IN TYPHUS FEVER. 
483 
countries, and in the fever of different epidemics. Dr. Wood tells us that in 
America cases requiring wine or brandy are extremely rare.* Dr. Stokes 
says that the typhus in Ireland demands large quantities of wine. In Scotland, 
also, wine is the great mainstay in the treatment of typhus fever, requiring 
often to be administered largely. 
Port, Sherry, Marsala, Madeira, brandy, gin, or whisky, possess no peculiar 
advantages apart from the alcohol contained in each. Spirits contain from 
50 to 60 per cent, of alcohol, Sherry and Port from 17 to 24 per cent., and 
malt liquors from 6 to 8 per cent. Two fluid ounces of spirit will thus be 
equal to five or six of wine, and spirits ought to be given diluted; and if the 
prostration is great, and when the skin is cold, and covered with perspiration, 
the best stimulant is brandy or whisky punch, given as hot as it can be taken, 
in small quantities at a time, frequently repeated. In urgent cases stimulants 
ought to be given every hour; and, as a rule, a larger quantity will be re- 
quired during the night and early morning than in the daytime, for it is 
usually towards morning that temperature tends to get low, and the vital 
powers are at their lowest ebb (Murchison). At the same time it must ever 
be remembered, as Dr. Jenner justly observes, that " in no disease is the 
advantage of refraining from meddling more clearly displayed than in typhus 
fever; and in no disease is the prompt use of powerful remedies more clearly 
indicated. It is in determining when to act, and when to do nothing, that 
the skill of the physician as a curer of disease, in the case of fever, is shown. 
Interfere by depletion or by stimulation when nothing should be done, and 
the patient is lost, who, if it had not been for you, would have been safe. 
Refrain from depletion or withhold stimulants when the one or the other is 
required, and the patient sinks into that grave from which judicious treatment 
might have saved him." 
A large well-ventilated apartment, fresh air, a cool, but not a cold atmos- 
phere, quiet, abstinence from solids, and a free supply of water, milk and 
water, coffee, weak broth, beef tea, according to the discretion of the physi- 
cian, are the conditions and remedies on which a large majority of cases will 
recover. But the patient must be constantly and carefully watched ; and 
there is no disease where the attentions of a well-instructed nurse are more 
demanded; and there is no class of patients in hospital so apt to be neglected 
by the attendants, especially as to the regular administration of the remedies 
prescribed. It is not uncommon to find that the wine allotted for the day has 
been administered at a draught, when it ought to have been given in small 
quantities at regular intervals, with care and watchfulness. How often do we 
see almost hopeless cases recover under the careful nursing of an intelligent 
person, regulated by the dictates of common sense and conscientious solicitude, 
guided by the judicious directions of a physician who knows well the nature 
of the disease with which he has to deal! The nurse ought to note down the 
hours at which food, or medicine has been given, or any remarkable change 
in the symptoms. She might also, if she were instructed, take observations 
with the thermometer, for the information of the physician at each visit. 
Dr. Murchison recommends that, in urgent cases, food and alcoholic stimu- 
lants must be persisted in as long as the patient is able to swallow; and even 
when he can no longer swallow, the case is not to be given up; for he has 
seen cases where life appeared to be saved by frequent enemata -of beef tea and 
brandy after the patient had ceased to take anything by the mouth. 
Of special symptoms which call for relief, the most urgent is generally 
headache. If headache should persist after delirium sets in, with a rapid 
pulse (e. y., 120), attended with nausea, some saline effervescing mixture, with 
* [This is certainly at variance with the experience of most physicians who have 
had large opportunities in treating ship fever, or local outbreaks of typhus in this 
country.-Ed.] 484 
SPECIAL PATHOLOGY-TYPHUS FEVER. 
four drops of hydrocyanic acid, may be given every six hours. In the per- 
sistence of headache, dry cupping, such as has been recommended by Dr. 
Sieveking, might furnish an aid to guide the treatment, by determining 
whether it may not depend upon repletion or upon emptiness of the cranial 
vessels. When applied to the nape of the neck, dry cupping may afford re- 
lief, if repletion has to do with the continuance of headache. Under such 
circumstances the face is generally flushed, the 'conjunctivae red, and the-skin 
dry and hot. If the dry cupping does not relieve such symptoms, the hair 
must be shaved off the head, and the scalp covered with crushed ice inclosed 
in a bullock's bladder, or recourse may be had to the cold affusion. The 
application of cold water is best effected by bringing the patient's head over 
a basin at the edge of the bed, and having a vessel arranged so that the cold 
water (at 40° or 50° Fahr.) may drip continuously from a height of two or 
three feet upon the head (Murchison). A skein of worsted arranged in the 
water, with the ends overhanging the basin, will maintain a constant flow of 
water from the basin, and which may be directed to fall upon the scalp. Dr. 
Murchison recommends that in young subjects two or four leeches may be 
applied to the temples; and in aged or infirm persons warm fomentations to 
the head are advisable (Graves and Murchison). But if anaemia is the 
cause of the headache, as may be suspected from the state of the vascular 
system, then stimuli are called for. Four to six ounces of wine may be given 
in divided doses during the day and night of twenty-four hours. If the pulse 
continues to get weaker, the wine must be increased. 
The headache of typhus naturally abates about the eighth day; but it is 
sometimes rendered worse by sleeplessness; and if the remedies for the head- 
ache do not relieve it, nor tend to induce sleep, then opiates may be given, 
combined with antimony, if the skin be dry and hot and the pulse of good 
strength. Dr. Murchison thinks that the employment of opium in typhus is 
more dreaded than it ought to be. The dose of opium should be given about 
9 p.m., followed in two hours by half the dose if the patient does not sleep. 
The form of the opiate and dose may be ten to twenty minims of Battley's 
solution of opium, or fifteen minims of the solution of the bimeconate of mor- 
phia, or five grains of the opium pill of the British Pharmacopoeia. Dr. Murchi- 
son teaches us to distinguish two forms of delirium as a guide to the admin- 
istration of opium, combined with antimony in the one form, and with ethereal 
stimulants in the other. When the condition of the patient approaches more 
to that of delirium fer ox, the cardiac and radial pulses being of good strength, 
after trying the cold affusion, and remedies already mentioned, then opium 
combined with antimony ought to be given without delay, as in the following 
prescription: 
R. Liq. Opii Sedat. (Battley's), Rfdx; Antim. Tart., gr. i ad gr. ii; Aquae 
Camph., ^vi; misce. A large spoonful of this mixture is to be given every 
hour until sleep is induced. 
On the other hand, if the delirium approaches in its character that of delir- 
ium tremens, the radial pulse is usually quick and feeble, the cardiac impulse 
diminished, and the first sound of the heart more or less inaudible, then the 
opium must be combined with alcoholic or other stimulants, the amount being 
regulated by the state of the pulse and heart. Dr. Murchison suggests the 
following prescription: 
R. Liq. Op. Sed. (Battley's), $ss.; Spt. JEtheris, nTlx; Aquae Camph., ad 5 iii; 
misce. Commence by giving two tablespoonfuls of this mixture, and repeat 
it every hour till sleep is obtained. 
Or opium to the amount of half a grain may be combined with three 
grains of camphor in a pill, and such a pill may be repeated, if necessary, 
every two hours. TREATMENT OF HEADACHE AND DELIRIUM IN TYPHUS. 
485 
Cases requiring such treatment ought to be seen at least three or four times 
daily. If dyspnoea is urgent, and lividity of the face betoken pulmonary 
lesion, defective arterial ization of the blood, and venous congestion of the 
brain, opium in any form must be withheld, and it must likewise be discon- 
tinued if any tendency to stupor supervene, or if there be any marked con- 
traction of the pupil-e. g., " the pin-hole pupil" of Dr. Graves. This physi- 
cian proposed the use of belladonna in such cases, and he, as well as Dr. Ben- 
jamin Bell and Dr. Murchison, bear their united testimony to its usefulness. 
Dr. Graves prescribed it as follows: 
B. Ext. Belladonnse, gr. i; Ext. Hyoscyami, gr. vi; Phil. Hydrar., gr. 
xxx; misce. This mass being divided into six pills, one may be given every 
three hours; or it may be given in the form of a draught, in the following 
prescription: B. Ext. Belladonnse, gr. i; Pulv. Moschi, gr. x; Mucilaginis 
Acacise et Syrup. Aurant, aa ttj/cxx ; Aquse Campli., ^ss.; misce. A draught 
of this composition may be given every six hours. 
/ 
Tr. Murchison considers that musk and camphor are stimulants of very 
great value, which have fallen into unmerited neglect. Camphor may be 
given in emulsion in doses of five grains every two hours; or iu the form of 
an enema in doses of a scruple. Huss and Graves also bear testimony to 
the good effects of these remedies. In a case of complete sleeplessness Dr. 
Graves gave the following combination of these medicines with the best 
results: 
B. Antim. Tart., gr. ss.; Pulv. Moschi, gr. x ; Camphor, gr. v; Tinct Opii, 
Rgx; Aquae dil., ^i; misce. A similar draught may be given every two 
hours; and after 'the third dose the patient will generally fall into a quiet 
sleep. 
The lujdrate of chloral has been found by Dr. James B. Russell to be pref- 
erable, in certain circumstances, to opium in typhus fever. As a sedative and 
hyperotic, it was successful in every form of cerebral excitement; and it 
seemed to have a more immediate and permanent curative action on such cases 
of acute delirium at the acme of typhus, than in the delirium tremens of the 
second and third weeks, when the blood is loaded with the products of the 
fever. It was also of use where there was bronchitis and congestion of the 
lungs, when opium could not be given. 
With regard to the dose, 40 grains is found to be a poisonous dose in typhus, 
producing depression and irregularity of the heart's action. All the benefits 
without the dangers may be obtained with 20 grain doses for adults ; 2 grains 
for children of one to two years; 3 grains for three years; and 10 grains for 
children from nine to fourteen years. It is to be given in an ounce of water, 
sweetened with half an ounce of syrup. 
When there is danger of stupor passing into profound coma, Dr. Murchison 
has seen the best effects result from a small cupful of a strong infusion of 
coffee given every three or four hours, employing at the same time such meas- 
ures as have a derivative action on the kidneys, e. g., dry cupping; mustard 
poultices to the loins, wet compresses of thickly folded flannel, wrung out of 
hot water, passed round the loins, and covered with a piece of waterproof 
cloth, retained in its place by a bandage or a towel. These remedial agents 
are all the more necessary if the urine contain either blood or albumen. At 
the same time free evacuation from the bowels should be secured by a purga- 
tive, or by a turpentine enema. If the lethargic state supervenes early, and 
before there is great exhaustion, the douche has been found to be of great 
service as a stimulant, provided there be considerable elevation of tem- 
perature, and little irritability of the nervous system (Todd, Armitage, 
Murchison). 486 
SPECIAL PATHOLOGY-TYPHUS FEVER. 
The region of the bladder should be examined by the physician at least 
two or three times daily, by manipulation and percussion; and if thete be the 
slightest doubt as to its containing urine, the catheter must be introduced. 
Origin and Propagation of Typhus Fever.-It is yet uncertain whether 
great overcrowding and vitiation of air by the organic impurities emanating 
from the respiratory and other functions will absolutely generate typhus fever 
de novo. In all the English wars (for " typhus fever is a disease as old as the 
disputes of nations") there has always been plenty of typhus poison waiting 
for favorable conditions to assume activity. This arose from the peculiar 
system of recruiting. Commissions or commands of regiments were wont to 
be given to those who collected a certain number of men. Every low pur- 
lieu, every infamous haunt, every jail even, used to be ransacked for re- 
cruits. Wherever these men went they carried typhus, at that time the con- 
stant scourge of our towns and our jails; and complaints of the introduction 
of typhus fever from this source are frequently found in the writings of army 
surgeons of the last century. In connection with this point, Dr. Donald 
Munro, in 1764, gives the following caution: "That particular regard be 
paid to those soldiers picked up in the streets, or who have been taken out of 
the Savoy or other jails. All dirty rags from such people should be thrown 
away or burnt" (Dr. Parkes, 1. c.). There is now ample proof that typhus 
fever may be communicated by fomites adhering to apartments, articles of 
clothing, and the like; and, provided fresh air be excluded, it is known that 
such articles will retain the poison for a very long time. Herein lies a fallacy 
which pervades the argument from cases to prove the generation of the dis- 
ease de novo. The poison may be said (like that of small-pox) to be constantly 
in existence. Dr. Murchison quotes some striking instances of the propaga- 
tion of typhus fever by fomites. For example, he refers to the instance 
related by Fodere, in which the soldiers of the French army, during their 
retreat from Italy, in 1799, communicated fever to the inhabitants of towns 
and villages where they halted on their route, although the army was not 
attacked by fever, and soldiers travelling singly did not communicate the dis- 
ease. But as he omits to connect this with the fact that typhus prevailed to 
a great extent in the towns they besieged, and in some instances obtained 
possession of, the source of the fomites is not made apparent, and, therefore, 
in a previous edition (4th), I was led to misrepresent this instance given by 
Dr. Murchison, and to put it forth as an example of generation de novo. (See 
p. 87 of his work On Continued Fevers'). He quotes, however, the recent 
instance of the Egyptian vessel, the "Scheah Gehald," at Liverpool, the crew 
of which disseminated the poison of typhus by their clothes and persons, 
although, as he says, they had not the disease themselves. But this is an 
error. The careful investigation made by Dr. Parkes into the history of this 
epidemic on board the Egyptian ship clearly shows that the crew suffered from 
typhus fever (/Statistical, Sanitary, and Medical Reports of the Anny Medical 
Department for 1860, p. 359). The facts of the case have been curiously con- 
fused; but the following statement, from the above and other sources, may be 
relied on: A number of men (476, chiefly Arabs) were shipped on board the 
"Scheah Gehald" at Alexandria, to proceed to Liverpool to navigate back a 
man-of-war then in that port. The weather was cold and stormy, the hatches 
were battened down during a lengthened voyage of thirty-two days from 
Malta; and the men, unaccustomed to the rigor of a Northern winter, and 
not provided with suitable clothing, crowded below for warmth and shelter. 
Even they whose turn it was for duty had to be driven up on deck. They 
were extremely crowded on board, and the space below deck was quite insuf- 
ficient for so large a number (for the crews of two vessels were on board); 
and there was no attempt to promote ventilation. The persons and clothing 
of the men were filthy in the extreme. The space between the decks soon 
became intolerable from filth; for many of the men, being landsmen, were ORIGIN AND PROPAGATION OF TYPHUS FEVER. 
487 
sea-sick on the voyage, and they discharged the contents of their stomachs 
and bowels in all parts of the ship, which, on arriving at Liverpool, was so 
offensive that it had to be sunk in the graving dock. Moreover, the rations 
served to the men were much below the proper standard as regards quantity. 
Several deaths occurred on the voyage; and although the captain denied the 
existence of fever and the occurrence of deaths, his statements are quite un- 
trustworthy, for on arrival in Liverpool thirty-two men had to be sent to the 
Southern Hospital. Two died soon after admission, and their disease was 
returned as dysentery; but Mr. Pemberton, on whom the duty of receiving 
and treating the patients at first fell, was convinced that he had some kind of 
fever before him in the persons of these sick Arabs. He called the disease 
"febris;" and in writing to a friend expressed his belief that it was a "jail 
fever." The heat of skin, the sordes on the teeth, and the marked symptoms 
of stupor in some cases and furious delirium in others, led him to this conclu- 
sion, although he could not see the eruption on the dusky skins of the 
Egyptians; and perhaps, as he had never seen a case of typhus fever before, 
he might not have recognized the eruption, as Dr. Parkes suggests, even if 
present. This diagnosis, however, was made at once by Mr. Pemberton, and 
before the fever had been communicated to any residents in the hospital. It 
is impossible now to ascertain how many of the thirty-two Egyptians had this 
fever; but five had marked, and several others had slighter symptoms. 
Many of the patients (typhus and others) had dysentery, and several were 
frost-bitten. 
Indubitable typhus fever, with a well-marked rash, was communicated by 
these men, and by Mr. Pemberton himself (who had a well-marked rash), to 
another medical officer, and to two nurses, a porter, and some patients. The 
chaplain, also, who slept out of the hospital, but visited the sick men, was 
attacked, and died in twelve days. In all, nineteen persons contracted typhus 
in the Southern Hospital, three on board the ship after she came to Liver- 
pool, and three at the Liverpool baths. Six died of these twenty-five persons. 
"No single link of evidence," says Dr. Parkes, "is wanting here to show that 
typhus prevailed on board the ship, and that typhus patients admitted from 
the'ship into hospital communicated the disease to a number of other persons. 
The idea that the Egyptians suffered only from dysentery, and that in some 
remarkable way a specific disease like typhus arose out of this dysentery, does 
not appear to have the slightest foundation. To urge such an hypothesis, in 
the face of the simple facts above noted, is to ignore all evidence, and to 
render the progress of medical science impossible. Cases of typhus were not 
only communicated to residents in the hospital, but to persons who boarded 
the ship, and to three attendants at the public baths, to which more than 200 
of the crew were sent. Some of these men were sick, though they were not 
known to have typhus. They carried typhus, however, in some way-per- 
haps in their clothes-and communicated it to the attendants. The remain- 
ing crew (350) of the 'Scheah Gehald' were sent to Alexandria on board the 
'Voyageur de la Mer.' The people of Liverpool were probably so glad to get 
rid of them that they did not take the trouble to see that the typhus fever 
had been eradicated, and several of the men were sent at once from the 
Southern Hospital. The 'Voyageur de la Mer' lost some men on the passage, 
and landed several at Falmouth, and some, with unequivocal typhus, at 
Malta; and of thirteen Englishmen who were in her, six took the disease." 
" The case of this Egyptian vessel," continues Dr. Parkes, " afforded almost 
the best opportunity seen in this generation for the investigation of the im- 
portant question of the spontaneous generation of typhus. The opportunity 
was, however, lost. That all the circumstances which have been supposed to 
be capable of calling into existence the specific poison of typhus were present 
in this foul and filthy ship is clear ; but every one who reads all the published 
statements will at once perceive that one link of the chain of evidence is 488 
SPECIAL PATHOLOGY-TYPHUS FEVER. 
wanting, and that it has not been proved that some of the crew were not ill 
with typhus when they embarked at Alexandria, or became ill within the in- 
cubative period. On the contrary, the interpreter informed Mr. Pemberton 
that some of the men were sick when they came on board. It can never now 
be ascertained whether there were such cases or not, and the history of the 
outbreak at Liverpool affords another instance of the loss of a great oppor- 
tunity for definitely setting at rest a most important question." The case of 
the " Scheah Gehald " now assumes exactly the same aspect as many instances 
historically quoted as examples of generation de novo-namely, that however 
plausible may seem the probability, there is no proof that typhus fever arose 
de novo. Seeing that such is the state of the question as to the origin of 
typhus-that it is exactly in the same state as our knowledge regarding the 
origin of small-pox or of typhoid fever-that it has been in existence from 
the earliest periods of the world's history-that it is undoubtedly propagated 
from pre-existing foci, and by continuous succession, the immediate direction 
of investigation ought to bear especially on the following points, namely: 
How long can the typhus poison exist or be maintained in a condition fit to 
assume activity under favorable circumstances? What is the distance at 
which it is potent ? Has temperature any influence upon it ? What are the 
conditions or combination of circumstances more or less essential to the devel- 
opment and propagation of the typhus poison ? 
The fact that typhus fever is contagious is based on evidence which shows, 
(1.) That, when typhus commences in a house or district, it often spreads 
with great rapidity; (2.) That the prevalence of typhus in single houses, or 
in circumscribed districts, is in direct proportion to the degree of intercourse 
between the healthy and the sick ; (3.) That persons in comfortable circum- 
stances, and living in localities where the disease is unknown, are attacked on 
visiting infected persons at a distance; (4.) That typhus is often imported by 
infected persons into localities previously free from it; (lastly), That its con- 
tagious nature is indicated from the success attending the measures taken to 
prevent its propagation, more especially the early removal of the sick. Dr. 
Murchison fully illustrates by examples all of these statements. 
The specific poison seems capable of transmission in various ways; but many 
circumstances seem to point to the cutaneous and pulmonary exhalations of 
the sick as the media which convey the specific poison from the diseased to 
the healthy. It is thus conveyed through the air, or by fomites. That parti- 
cles of organic matter are constantly floating in the air no one can doubt who 
has seen the ingenious contrivance of M. Pouchet put in practice, and the 
substances so suspended in the atmosphere collected by drawing a current of 
air through a funnel with a very small opening. Immediately below the open- 
ing the covering glass of a microscope slide is placed, with a drop of glycerin 
spread over it. Upon this the current of air impinges, and any solid or cor- 
puscular bodies floating in the air may be in this way arrested and examined 
with the microscope. Dr. Parkes has detected by this method unequivocal 
epithelium-cells in several instances; and Eiselt was able to detect pus-cells 
floating in the air of a ward containing thirty-three children with acute puru- 
lent ophthalmia (Army Med. Dep. Sanit. Report for 1860, p. 346 ; also Comptes 
Rend., 1861; and Med. Times and Gazette, 1861). 
Such material particles, capable of conveying the specific poison of a dis- 
ease such as typhus, are thus inhaled or swallowed, and so they find admis- 
;sion into the bodies of the healthy, to exercise their morbid influence on the 
blood. A peculiar pungent odor emanates from the typhus fever patient. It 
is especially obvious from the breath, and from the skin on turning down the 
bed-clothes. 
There is no evidence to show the extent of space through which the typhus 
poison can be transmitted through the air. From some observations it would 
seem that the contagious influence of typhus is confined to a narrower sphere PROPAGATION OF TYPHUS FEVER. 
489 
than that of small-pox. Dr. Murchison concludes that, " if a patient be 
placed in a large well-ventilated apartment, the attendants incur little risk, 
and the other residents in the same house none whatever. 
" There are likewise no grounds for the popular belief that typhus may be 
propagated through the atmosphere from a fever hospital to the houses in its 
neighborhood. On the other hand, medical attendants who auscultate typhus 
patients, or who inhale their concentrated exhalations from under the bed- 
clothes, run no small danger, and the danger is always increased or diminished 
in proportion to the supply of fresh air" (Murchison, 1. c., p. 80). There are 
also good grounds for believing that typhus fever may be commmunicated, 
and even carried a great way, by fomites, or by articles of clothing strongly 
impregnated with the specific poison ; and, provided fresh air be excluded, the 
efficiency of the poison may be maintained for a long time. " Complaints of 
the introduction of typhus from this source are frequently found in the writ- 
ings of army surgeons of the last century. Typhus was several times carried to 
the West Indies, and even there prevailed apparently to some extent" (Parkes 
On the Causes of Sickness in English Wars). The poison may also adhere to the 
walls of dwellings, to beams of wood, and to articles of furniture. Dr. Murchi- 
son quotes an account by Pringle of twenty-three persons being employed in 
refitting old tents in which typhus patients had lain; and seventeen of these 
persons died of the infection. He also refers to an observation of Lind, who 
mentions several instances in which infected ships continued to impart the dis- 
ease long after the -sick had been removed. Similar cases are recorded by 
Jacquot respecting the Crimean typhus. 
Nurses and other attendants in fever hospitals are well aware of the danger 
of contracting typhus from infected clothes, and from cleaning the bedding of 
the sick; and in some instances they are in the habit of "measuring the 
amount of danger by the badness of the smell." Thus they are liable to con- 
tract typhus fever without having had any direct communication with the 
sick. With regard to the kind of clothing most apt to retain and convey the 
specific poison, woollen textures are found to be the most dangerous. Haller 
of Vienna has made experiments on this point. He observes that darZ;-colored 
materials of clothing are more apt to absorb the contagion of typhus, and to 
convey it to other individuals, than those which are light-colored. He found 
that, among troops wearing dark-colored uniforms, it more frequently happened 
that new cases of typhus entered the hospital after a convalescent patient joined 
his corps than those wearing light or white uniforms. The fact has been often 
observed, that in dissecting-rooms dark clothes acquired the cadaveric odor 
sooner, and were deprived of it less readily than light ones; and he ascertained 
by experiments that the absorption of odors is regulated by the laws which 
govern the absorption of light. Haller also found that the specific poison of 
typhus fever is lighter than atmospheric air. When the under stories of a 
hospital were filled with typhus patients, those in the upper stories were always 
observed to become infected when there was a communication between the air 
of the two stories, On the other hand, when only the upper stories contained 
cases of typhus, the patients in the under part of the house enjoyed perfect 
immunity {Edin. Med. and Surg. Journal, 1853). Dr. Murchison has observed 
that, if the poison be very concentrated, the length of the period of exposure suf- 
ficient to contract the disease is very brief-not more than a few minutes; and 
the latent period during which it remains in the body, without betraying its 
presence in any way, has been very variously estimated. Nine days is the 
result of Dr. Murchison's observations. Instances, however, are not uncommon 
in which the disease manifests itself almost instantaneously after exposure to 
the poison. In such cases these extremely susceptible persons are generally 
conscious of the peculiar and offensive pungent odor emanating from the beds 
or bodies of the sick. They are generally then immediately seized with pros- 
tration, nausea, rigors, and headache, followed by the regular development of 490 
SPECIAL PATHOLOGY - TYPHUS FEVER. 
the disease. Such persons are thus almost conscious of the moment at which 
the poison entered their system. On the other hand, the length of time be- 
tween exposure and attack may be greatly prolonged. In my own case, I was 
three months in close attendance in the fever wards of the Dundee Infirmary 
for many hours daily on cases of typhus fever, before taking the disease. 
Opinions vary as to the stage of the disease at which the typhus poison is 
most powerful. Some consider it is most powerful during the period of eruption; 
others, during the period of convalescence. . Dr. Perry was of this latter 
opinion; and Dr. Murchison's observations led him to confirm the opinion of 
Perry; but he is inclined to think that the disease is really most apt to prop- 
agate itself from the end of the first week up to convalescence, when the 
peculiar typhous smell from the skin and lungs is the strongest. 
The conditions essential to the propagation of the specific poison of typhus 
fever are mainly as follows: (1.) Overcrowding, coexisting with deficient 
ventilation; (2.) Personal squalor and filthy apparel, saturated with cutaneous 
exhalations; (3.) A deteriorated state of the constitution, such as may result 
from protracted starvation, continued underfeeding, general destitution, scurvy, 
and other debilitating causes; (4.) A moderate temperature; dry heat being 
a powerful disinfectant. 
Dr. James Russell thus writes regarding the time when a typhus fever 
convalescent may be considered to have lost the power of infecting others from 
the exhalations of his own body, that, theoretically, such would be the case 
when his various bodily functions were restored to healthy action, and when 
he has regained some measure of physical strength-not necessarily his full 
vigor, but sufficient to enable him to walk a few miles with comfort; but 
practically the question is difficult of determination. His observations are so 
much to the point that I conclude this account of typhus with an extract from 
his Report for 1870 of the "City of Glasgow Fever Hospital:" 
" It is, however, necessary to observe that infectious diseases differ one from 
another in infecting power, as in other characteristics. The virus of small-pox 
and of scarlet fever is much more tenacious of life than that of typhus or of 
enteric fever. Still, I believe that this property belongs more to the germs or 
infecting medium (whatever it may be) as conveyed during the disease to 
clothing and other material objects, than to their continued activity in the 
body of the individual. It is hardly possible that after an attack of any of 
these diseases, a thoroughly healthy person can carry about, in his tissues, the 
germs of disease. They may be in his clothing, but scarcely in the substance 
of his body in a communicable state. The practical question, therefore, in my 
opinion, becomes one of disinfecting the 'belongings' of the individual. This 
being done, and the individual being restored to health, I believe, so far as he 
is concerned, the disease is 'stamped out.' 
" The latent period of Typthus, and indeed of all such diseases, is a fact allied 
to the subject of the above remarks. It must be remembered that from the 
date a person shivers and becomes ill of typhus, you must go back for about 
a week or ten days for the date of infection. The poison has been lying 
dormant in the system during that period. Cases but rarely occur in which, 
just as if we had given a dose of poison and marked the hour and then watched 
for the appearance of the symptoms of poisoning, we can date such an event 
as sleeping one night with a fever convalescent and then note the first fever 
symptoms, and so prove a latent period. 
"I am certain, however, from various stray observations, that nine days is 
about the average latent period of typhus. Dr. Murchison comes to the same 
conclusion. Again, typhus patients are with great regularity in the eighth 
day of their disease when admitted to hospital. All save a fraction of the 
cases have gone as far as from the sixth to the eighth day. It is quite certain, 
therefore, that for the date of infection we must go back from the date of ap- PROPAGATION OF TYPHUS FEVER. 
491 
pearance of any case of fever in the books of the hospital, or of the Sanitary 
Office, at least a fortnight; and if we go back from the date of 'invasion,' oi* 
active outbreak of the disease, we will find the date of infection at least a week 
previous. On these grounds, no case of fever, arising even where convalescents 
have returned home within these periods of a fortnight from the date of ad- 
mission or a week from the date of invasion, can be ascribed to those conva- 
lescents. Of course there is also a reasonable limit in the other direction. 
"Individual susceptibility varies, but not to a very marked extent. The 
staff of a fever hospital unfortunately provides abundant material for the 
accurate determination of these questions. We have healthy persons brought, 
in exactly similar circumstances, under the influence of a poison; or, if the 
circumstances differ, the difference is known, and the result of the variation 
can be noted. In my first annual report (p. 38) I said-'It is remarkable to 
find the close agreement in the length of time different systems, under similar 
circumstances, can resist the disease. . . . They [the nurses] usually are 
attacked in between twenty and thirty days; but if they tide over that period 
they become acclimatized, so to speak, and may remain secure for two or 
three months.' This conclusion has on the whole been remarkably confirmed 
by the experience of the four following years. The data are given in Tables 
VI and VII for these years, and a similar Table for 1865-66 will be found in 
my first report. In these five years twenty-six nurses, seven scrubbers, the 
gate-keeper, under-porter, van-driver, domestic servant, and one assistant medi- 
cal officer-in all, thirty-eight persons-have been infected. The facts re- 
garding the nurses are most valuable, as their duties, diet, &c., are all so much 
alike. They fall into two very distinct classes. One class, numbering 21, 
withstood the typhus poison for periods ranging from ten days to thirty-seven 
days, and giving an average of twenty-five days. The other class, numbering 
5, withstood the typhus poison, in exactly the same circumstances as the others, 
for periods ranging from 47 to 118 days, and giving an average of eighty-four 
days. The woman who was 118 days exposed is thin, not at all robust or 
florid, but wiry, aged thirty-two, and served in the same ward as several of 
the others who gave way in from two to three weeks. The scrubbers furnish 
data scarcely so pure, as, although their duties do not lead them into close 
contact with the patients, still they are employed occasionally as substitutes, 
when they are as much exposed as the nurses: yet they very rarely live for 
sixteen hours out of the twenty-four in a fever atmosphere, as nurses do. Their 
average period of resistance is consequently much longer-forty-nine days- 
and looking at the individual periods with the knowledge of the extent to 
which each scrubber had been employed as a nurse's substitute, there is an 
evident relative approach to the nurses' shorter period. The only scrubber 
who was never, or almost never, employed in any other way did not fall ill 
for ninety-five days. The gate-keeper and assistant medical officer, who much 
resemble the nurses in the degree of exposure, resembled them also in their 
period of resistance-viz., twenty-eight days and twenty-seven days respec- 
tively. It is curious to note that the van-man carried typhus patients (about 
1500 of them) in his arms out of their houses to his van, and from thence to 
the ward, for two years before taking ill. The domestic servant went more 
or less about the wards for two years before seizure, and was then caught from 
lending friendly aid to an old nurse who required help with her patients. The 
matron, who spends some time every day in and about the wards, but without 
contact with the patients, has not been infected after five years' exposure, 
though she has never had typhus. The storekeeper has been at his post for 
five years, in daily contact with the nurses when getting their provisions, &c., 
and still retains his health. All these facts concur in proving (1) that where 
attention is paid to personal and general cleanliness typhus does not carry far, 
so to speak, through the atmosphere, and is not portable; (2) close approach 
to, and contact with, the infected individual and his dirty belongings lead 492 
SPECIAL PATHOLOGY-EPIDEMIC CEREBRO-SPINAL MENINGITIS. 
with great certainty, even in the best sanitary circumstances, and in healthy 
and well-fed people, to an attack at the end of about four weeks in the ma- 
jority of cases, but not in a few until the lapse even of some months; (3) that 
individual insusceptibility does not exist, except that which is conferred by a 
previous attack. As an interesting contrast with our experience of typhus, I 
may say that no case of enteric fever has ever arisen either among the staff or 
among the patients beside whom cases of enteric fever are treated. These 
latter have, however, in a very few cases caught typhus." 
[epidemic cerebro-spinal meningitis.* 
(Dr. Clymer ) 
Definition.-An acute specific disorder, commonly happening as an epidemic, 
general or limited, and, rarely, sporadically; caused by some unknown external 
influence; of sudden onset, rapid course, and very fatal; its chief symptoms, refer- 
able to the cerebro-spinal axis, are great prostration of the vital powers, severe pain 
in the head and along the spinal column, delirium, tetanic, and occasionally 
clonic, spasms, and cutaneous hypercesthesia, with, in some cases, stupor, coma, and 
motor paralysis; attended frequently with cutaneous hoemic spots; its morbid ana- 
tomical characters being congestion and inflammation of the membranes of the 
brain and spinal cord, although there is reason to believe that the evidence of these 
changes may be wanting, even in cases of long duration. 
History and Geographical Distribution.-Dr. Tourdes, who has shown great 
industry in the study of the history of cerebro-spinal meningitis, is of the opin- 
ion that it prevailed epidemically in Europe at different periods of the four- 
teenth, sixteenth, and seventeenth centuries. Dr. Valleix remarks, that 
owing to the descriptions being too incomplete, and the absence of post-mortem 
examinations, not much weight can be given to these researches. During the 
eighteenth century it is probable that there were outbreaks of it in France, par- 
ticularly in the French fleet at Brest (1758), Germany, Italy, England, Ireland, 
and Scotland. In the present century (1805), it is said to have prevailed at 
Geneva, Switzerland; but the recorded post-mortem examinations do not prove 
the assertion, though the symptoms of a short endemic there resembled those of 
cerebro-spinal meningitis in some respects. While occasional cases, symptomati- 
cally like the disease, had happened in the United States towards the close of 
the eighteenth century, it was first distinctly seen in the epidemic form at Med- 
field, Mass., in 1806, and from that time until 1816 it was constantly epidemic 
throughout this country, particularly in the New England States, upon which 
it seemed to fasten. It is, however, quite evident that all the epidemics de- 
scribed as cerebro-spinal meningitis during that period cannot properly be 
classed as such. From 1816 to 1860, casual endemics, with sporadic cases 
here and there, seemed to have occurred in several of the States, particularly 
the Southern and Western, the Middle and Eastern having been comparatively 
exempt. " In 1816-17 the disease appeared in various parts of South Carolina; 
from 1818 to 1822 it was seen in Mecklenburg, Lunenburg, and Brunswick, 
Va.; in some parts of the Western States during the spring of 1819, and also 
* The name cerebro-spinal meningitis is not a proper one for this affection, even with 
the prefix "epidemic," for, as Dr. Valleix remarks, it is "begotten of anatomical bias 
and an incomplete appreciation of the facts." It gives no accurate notion of the real 
nature of the disorder, and takes heed only of the local structural changes, which are, 
probably, secondary, and may be wanting. It has been also called typhoid meningitis, 
malignant meningitis; but to these names the same objections lie. Spotted fever is 
hardly distinctive enough, there being so many other essential disorders in which 
spots on the skin appear. Petechial fever, has been proposed by Dr. G. B Wood, of 
Philadelphia. Dr. W. Stokes calls it malignant purpuric fever; and Dr. K. D. Lyons, 
febris nigra. HISTORY OF EPIDEMIC CEREBRO-SPINAL MENINGITIS. 
493 
in North Carolina, and the mountainous parts of Virginia; in 1821 in Franklin 
County, Pennsylvania; in 1823 it was recognized at Saco, Maine, Berlin, Con- 
necticut, and in the Shenandoah Valley, Va. In 1823-4-5 it broke out in the 
vicinity of Middletown, Conn., and also in some parts of that State in 1826, 
and likewise at New Orleans, and Fort Adams, and in 1827, in Trumbull 
County, Ohio. In 1832, sporadic cases occurred in New London, Connecticut, 
which in many respects resembled this disease There is no mention 
made of it from that date till in 1845-46, when an epidemic prevailed in 
Clark County, Illinois, called 'black tongue,' thought by Dr. McCoy to be 
cerebro-spinal meningitis, on account of the post-mortem appearances. In the 
early part of 1847 it was seen in Mississippi, Tennessee, Missouri, and Arkan- 
sas, (?) and resembled a modified pneumonia; and in the winter of 1847-48 at 
Washington, D. C. Dr. Ames has given an account of it as it appeared aC 
Montgomery, Alabama, during the winter and spring of 1848. Dr. Sargent 
read a paper before the Massachusetts Medical Society on this disease as it 
showeditself in Millbury and Sutton during 1849; it was also noticed, the 
same year, at Mecklenburg, New York. Again a few cases happened in New 
Orleans during the last days of January, 1850, and in Central and Western 
New York during 1857. In October, 1859, there commenced an epidemic at 
Castlecraig, Virginia, which continued nearly a year" (Webber, p. 61-2). 
From 1814 to 1857 circumscribed epidemics of cerebro-spinal meningitis 
seem to have been constantly prevalent in various parts of Europe,-in the 
garrisons at Grenoble and Metz, France, in 1814 and 1815; in Ireland in 1813, 
1814, and 1815; in Italy and Germany in 1817; at the Millbank Penitentiary, 
near London, in 1823; in parts of France in 1832, and again, in a number of 
the garrisons, from 1837 to 1842. The disease was chiefly confined to the 
military, but in a few instances extended also to the civil population; notably 
at Strasburgh, in 1841 (C. Broussais). It appeared at Civiano in the Nea- 
politan Kingdom in 1837, and various districts of Naples were invaded in the 
winter and spring of 1840. In 1840, and again in 1845, it appears to have 
occurred in Algeria. From 1843 to 1849 it prevailed in more or less of the 
departments of France, but chiefly amongst the soldiers. In 1844, there was 
an outbreak of undoubted cerebro-spinal meningitis at Gibraltar. In 1846, a 
disease, called and described by Dr. Robert Mayne (Dub. Quart. Journ. of Med. 
Science, vol. ii, 1846), as "cerebro-spinal arachnitis," broke out in the work- 
houses and hospitals of Dublin, the spinal membranes suffering more than the 
cerebral. Spain was visited in 1849, and Sweden, from 1854 to 1861. In 
1863, '64, '65, it prevailed as an epidemic of wide range, and with great mor- 
tality, in West Prussia, and reaching as far as the Grand Duchy of Baden. 
About the same time, a very fatal disease devastated parts of Russia, and 
which, from Dr. Burdon Sanderson's Report, was epidemic cerebro-spinal 
meningitis. 
A severe and extensive epidemic broke out in Dublin, in March, 1866, and 
reached its height during the following year, extending to other towns in Ire- 
land, and some cases happened in England, Lincolnshire, and in London. 
The British forces in Ireland suffered much in proportion to their average 
strength. 
The rise and progress of the late epidemic of the disease in Jhis country has 
been described by Dr. Webber. It prevailed "to a considerable extent 
amongst the troops of the United States Army in camps and barracks during 
the late war" (Woodward), and also in the Confederate Army (Gaillard). 
It was first seen during the winter of 1861-2 in the Army of the Potomac, (?) 
and in Livingston County, Missouri, amongst the United States troops. "In 
the fall of 1862, it appeared among the negroes who were taken to Memphis, 
Tennessee, by the Union Army; and one or two cases were met with among 
the soldiers in the vicinity of Newbern, N. C.; during the winter of 1862-63, 
and the spring of 1863, it appeared in La Grange County and other portions 494 
SPECIAL PATHOLOGY-EPIDEMIC CEREBRO-SPINAL MENINGITIS. 
of Northern Indiana; at Newbern, N. C., during January, February, and 
March; and during these months, and also April, at Newport, Rhode Island, 
among the midshipmen of the Naval Academy; in February and March it 
was seen at Philadelphia, and during the latter part of the year at Cambridge, 
Ohio. During the two successive winters of 1862-63 and 1863-64, it was 
epidemic in Morgan County, Illinois. During the winter of 1863-64, the 
negroes at Memphis were again visited by it; and in the same winter and suc- 
ceeding spring, parts of Clark and Crawford Counties, Illinois; in the north- 
western parts of Pennsylvania, and parts of New Jersey, it was noticed during 
this year, and also in 1862 and 1863. Only a few cases' occurred around 
New York. In January it was in Brattleboro', Vermont; and in January 
and February, in Philadelphia, and at Benton Barracks, Missouri. Through 
March it was seen at Brandon, and St. Albans, Vermont, and Louisville, 
Kentucky, and during January, April, and March, there were cases in Bos- 
ton; in May, at Chicago, at Leland, and in Williamson County, Illinois. In 
the latter part of July, cases occurred at the Stanton General Hospital, Wash- 
ington, D. C. In October, Mechanicsburg was visited by it, and in November, 
Marshall, Illinois, and during the latter part of the year, St. Paul's, Indiana. 
During the winter of 1864-65, a few cases were seen at the City Hospital, 
Boston; in January, 1865, at Greenwich, and in April, at Palmer, Mass.; in 
the latter part of the month at Kewana, Ind., and early in the year at Pales- 
tine, Ind.; in May, at Nittany Hall, Pa. From September, 1864, to May, 
1865, the disease appeared amongst the troops at Gallop's Island, Boston 
harbor" (Webber, 1. c., pp. 63-4). In April, 1863, four cases occurred in 
a single regiment of the 22d North Carolina (Confederate), of which three 
died ; and eight cases and six deaths in the 3d Alabama (Confederate), Feb- 
ruary, 1863. Dr. Sandford B. Hunt saw several cases in the camp of a Mis- 
souri regiment, at Little Rock, Arkansas, during the winter of 1864-65 (San. 
Comm. Med. Mem.^. 
That cerebro-spinal meningitis may happen as an endemic, or epidemic 
limited to one place or district, or even institution, or family, there is abun- 
dant evidence. Well-marked sporadic cases, settled beyond doubt by post- 
mortem examinations, have been reported. One of the most interesting is that 
of a newly-enlisted man in the Mississippi Squadron in 1864-the only one-in 
which the meningeal lesions were well marked. Dr. Gilbert has reported two 
sporadic cases which he saw at Gettysburg, Pa., in 1844, and another in Phila- 
delphia, in 1846. Many others are upon record. In the winter of 1863-64, the 
writer saw a single case, in one of the U. S. A. General Hospitals at Beaufort, 
S. C., and several more in the spring of 1865, in the Army Hospitals at Savan- 
nah, Georgia. Dr. Samuel Wilks saw one case in each of the years, 1856,1858, 
1859, in London. Dr. Day, a fatal case at Stafford, in 1859, and another in 
1865. Dr. Geddings, of Charleston, S. C., mentioned to the writer in 1865, 
he had met with occasional cases amongst the negroes of that city, and related 
one of a negro laundress, in which the disease proved fatal within twenty-four 
hours after seizure. 
Notwithstanding its wide geographical distribution, there is no corresponding 
diffusion amongst any one population during its prevalence, it, as a rule, being 
limited during an outbreak to certain localities and to certain portions of the 
population of such localities. The distribution of the disorder seems to be by 
a series of isolated eruptions rather than by general spreading. 
Morbid Anatomy.-The morbid appearances found in the cerebro-spinal 
axis and its membranes are: when death has happened within two or three 
days after the invasion, opalescence of the upper surface of the cerebrum, seem- 
ingly in the subarachnoid fluid; an abundant vascularity of the membranes 
of the brain, chiefly of the pia mater; a large increase of serum in the subarach- 
noid space and in the ventricles, clear or turbid, and mixed with flocculi of 
lymph, and as often as otherwise, even in cases of the briefest duration, an MORBID ANATOMY OF EPIDEMIC CEREBRO-SPINAL MENINGITIS. 
495 
abundant exudation of thick, yellowish, apparently semi-organized lymph on 
the base of the brain and the medulla oblongata (Upham). The membranes 
at this stage are sometimes remarkably dry, without injection ; or they may 
be adherent to the surface of the brain, or among themselves. The cerebro- 
spinal fluid is much increased, and of a yellowish and milky hue; the spinal 
meninges congested like those of the brain; and the cord has been found soft- 
ened. Where the disease has lasted for any time, the cerebral exudation is 
soft, opaque, yellowish, two or three lines in thickness, and has been compared 
by Dr. Tourdes to a layer of butter spread over the brain; or it may be denser 
and have a pseudo-membranous look. It is found chiefly along the course of 
the vessels, and, when small in quantity, limited to, and ramifying with, them; 
or it may be in little irregular patches of variable size, scattered over the brain 
surface, or covering the pons or medulla oblongata, or cerebellum, or parts of 
the cerebrum; or, it may completely envelop the cerebrum, cerebellum, and 
the intracranial cord. Commonly superficial, it may dip down with the pia 
mater amongst the convolutions; or be found in the ventricles, " in the pos- 
terior cornua of the lateral ventricles, in its concrete form particularly, or else 
tinging and thickening, with an opaque greenish pus, the serous fluid of the 
whole cavity" (Upham). According to Dr. Tourdes this happens in about 
one-half the cases. Purulent infiltration of the choroid plexus, and super- 
ficial softening of the walls of the ventricles, have been seen. The substance 
of the brain is occasionally softened. The spinal membranes are affected in 
like manner, and the cord itself, like the substance of the brain, may be in- 
jected, or even softened. 
Dr. Burdon Sanderson found the gelatinous substance under the microscope 
to consist of cell-like bodies, either adhering to each other so closely that they 
could not be completely separated, or imbedded in a transparent interstitial 
substance, while the sero-purulent fluid which occupied the spinal subarach- 
noid space, and in some cases the ventricles, exhibited corpuscles and granules 
floating freely. The cell-like bodies, although in general resembling pus-cor- 
puscles, did not present that uniformity of size and character which are met 
with in normal pus. They were usually, but not always, of regular circular 
contour, and varied in diameter from g-d^-th to yj^^th an inch- Occasion- 
ally they exhibited the appearance of an external cell-membrane, but in most 
instances this could not be made out even in perfectly fresh exudations-cases 
that were examined as early as eight hours after death. They invariably con- 
tained numerous granules, some of which were cleared away on the addition 
of acetic acid. Those which remained were highly refractive, but did not 
assume any special form of arrangement. The interstitial substance was beset 
with granules, some of which were albuminous, and others fatty. It was most 
abundant and distinct on the surface of the spinal arachnoid, where it infil- 
trated the fine connecting tissue and minute bloodvessels of the pia mater. 
In all epidemics of this disease cases have occurred in which no appreciable 
changes have been found in the cerebro-spinal membranes. Two interesting 
instances have been reported by Dr. Levick, of Philadelphia (Am. Jour, of 
the Med. Sciences, July, 1864, and July, 1865)-one an adult female, and the 
other a child, aged eighteen months, both of whom died in twelve and fourteen 
hours after seizure in the midst of health-in which the cerebro-spinal men- 
ingeal vessels were filled with black blood, but there were no traces of inflam- 
mation, and the substance of the brain and medulla oblongata was natural in 
appearance and consistency.* The late Dr. Valleix remarks, that when there 
is more or less absence of the meningeal changes, it is among those who have 
been struck down by the disease as by a thunderbolt; and there is certainly 
much testimony to this effect; but Dr. J. J. Woodward, speaking of cerebro- 
* Dr. Parks, in quoting these cases, calls attention to the omission of stating whether 
or no there was opalescence, or unnatural dryness of the membranes (loc. cit., p. 47). 496 
SPECIAL PATHOLOGY EPIDEMIC CEREBRO-SPINAL MENINGITIS. 
spinal meningitis as observed in our armies during the civil war, in this con- 
nection writes : " There were at least two classes of cases brought under the 
observation of this, the medical, department of the army. In the first, the 
autopsy disclosed grave anatomical lesion of the cerebro-spinal axis, accumu- 
lations of serum, sero-pus, pus or tough yellow lymph, especially in the ven- 
tricles about the base of the brain and in the upper part of the spinal canal. 
In the second class of cases, no perceptible anatomical lesion in the cerebro- 
spinal axis was observable. These two groups of cases rest upon equally re- 
liable evidence, and are not to be disposed of on the supposition that the latter 
represent merely an early stage of the former, since it is to be remarked that 
both anatomical conditions appear to have been found indifferently in pro- 
tracted cases as well as those which proved suddenly fatal."* 
The blood is usually very dark-colored and fluid, even in the briefest cases; 
but in some instances firm fibrinous clots have been found in the heart after 
death (Tourdes, Stille.) The coincident lesions are: congestion and oedema 
of the lungs ; pleural, pericardial, and articular sero-purulent effusions; and, 
occasionally, enlargement of the glands of Brunner and of Peyer, without 
ulceration. 
Symptoms.-As a rule the invasion is sudden, without warning indisposition, 
except, perhaps, general weariness, or aching of the whole body, or shivering, 
which latter is often the initial symptom, and may amount to a sharp chill. 
In some cases prodromata happen. Gilchrist states that in the Gibraltar epi- 
demic, weariness and a sense of general uneasiness were frequently felt for a 
day or two before the onset of the acute symptoms. Dr. Tourdes says that 
sudden invasion was the exception, not the rule, and that it happened in at 
most one-quarter of his cases. Dr. George G. Tucker, of Westfield, Mass., in 
reporting sixteen cases, remarks : " The mode of invasion varied considerably 
in different cases. In some there were the usual symptoms of febrile disturb- 
ance ; in others there were no formative periods or premonitory symptoms, 
the patient being suddenly insensible and convulsed, with the rapid form of 
opisthotonos " (Mass. Med. Society's Report, p. 104, 1066). But the " forma- 
tive," or premonitory symptoms given by Dr. Tucker really mark the actual 
beginning, and this is nearly true of those mentioned by Dr. Tourdes as " pre- 
cursory." The onset of the disorder is almost constantly marked by severe 
headache, usually occipital, sometimes frontal; patients speak of it as acute, 
excruciating, and unbearable, and, in some instances, as if the brain were 
bound, or stretched, by a band, or by a bar of metal. Dizziness may be com- 
plained of. Excruciating pains in the nape of the neck, limbs, calves of the 
legs, and joints, particularly the knee-joint, and likened to those of rheuma- 
tism, singly or collectively, are felt at an early stage, along with stiffness of 
the jaws and neck. A sudden and acute pain in a joint, or in a finger or toe, 
compared to the stinging of a bee, has sometimes marked the access. Sting- 
ing pains in the arms and legs later in the attack have been noticed as some- 
times occurring in the late epidemic in this country. Sore throat, in some 
epidemics, has been a common initial symptom. Dr. Upham speaks of cases 
which began like a severe cold, and in such he found a tendency to palsy of 
the muscles of the tongue and face; and the same has been noticed by some 
of the German writers. There are often soreness and tenderness at the back 
of the neck and along the spine. Nausea and vomiting may happen at the 
outset. Generally there is great weakness from the beginning; the pulse is 
quick and feeble, or it may be little changed; the breathing may be natural, 
or slow and oppressed, or sighing; the surface is cool and moist, the face suf- 
fused, and eyes bloodshot. Delirium may set in soon, instances in which rav- 
* Letter to Dr. L. Parks, quoted in Report of a Committee of the Massachusetts 
Medical Society, on Spotted Fever or Cerebro-Spinal Meningitis in the State of Mas- 
sachusetts, May, 1866. Boston, 1867. SYMPTOMS OF EPIDEMIC CEREBRO-SPINAL MENINGITIS. 
497 
ing delirium has begun within half an hour of the onset, having been recorded, 
or may happen later; it is generally not violent, but wandering, or talkative, 
or muttering, with perversion and dulness of intelligence, and great apathy, 
though the patient may be readily roused to consciousness; at other times 
there may be initial stupor, or even coma. The intellect may be unimpaired 
throughout the attack. From a few hours to one or more days, the eruption 
is seen upon the neck, abdomen, back, arms, legs, and sometimes the face; it 
is luemic and distinct, made up of dark-red or purple spots of'the size of a 
pin's head to that of a dime, not raised, nor fading on pressure. In the late 
epidemic in Ireland (1866-67) the common form of the eruption was purpura. 
Sometimes there are only dark mottled spots scattered here and there over the 
skin. The eruption is not constant. In some cases the luemic spots have not 
appeared until after death. Of 98 cases admitted into the Philadelphia Hos- 
pital in 1866, 36 had petechise; 13 mixed petechiee and erythema ; 9 erythema 
and urticaria; 3 indistinct petechial mottling; and 37 no eruption at all 
(Githens). In the Lower Vistula epidemic hsemic spots were comparatively 
rare; in the Irish epidemic nearly constant. Rubeoloid patches have been 
occasionally observed. 
In some epidemics herpes first on the lips, and then extending to other parts 
of the face, and to the ears and neck, has appeared about the second, third, or 
fourth day. Dr. Phelps, of Brattleboro', Vermont, mentions having seen them 
in the late epidemic in this country, and Stille says of the Philadelphia out- 
break, "herpes labialis was noticed in a few cases." Hirsch, describing the 
eruption in the Lower Vistula epidemic (1865) calls it " A vesicular eruption 
(eczema), sometimes herpetic in character, chiefly appearing in the lips, but 
occasionally extending over the sides of the face, diffused more or less on the 
trunk, or showing itself in patches on the limbs. It has occasionally taken 
the form of shingles. When associated with purpura the vesicles may be flat- 
tened and rest upon a livid base." The tongue is moist and creamy. To these 
symptoms others are soon added: cutaneous hypersesthesia, local or general, 
is very constant, and sometimes to such a degree, that slightly touching or 
brushing the skin with the hand will bring on reflective muscular contrac- 
tions ; anaesthesia is very rare, and generally at a late stage. The muscles of 
the nape of the neck become rigid and retracted, and the head is thrown back; 
this is one of the most constant and persistent symptoms. This rigidity and 
retraction may extend to the muscles of the back, and the flexors of the fore- 
arm, and the muscles of the jaws, and have been noticed in those of the abdo- 
men, and in the flexors of the legs; they are tetanoid, and may amount to 
opisthotonos and trismus. Sanderson says that in the Prussian epidemic 
1864-65 there were many cases in which there was no stiffness or retraction of 
the muscles. Twitchings in the muscles often precede them. Epileptiform 
spasms, which may be general, or local, unilateral, or limited to a limb, have 
been occasionally noticed. The tongue may now become dry, dark-colored, 
or even black, fissured and swollen, or covered with sordes. The bowels as a 
rule are constipated, but there may be diarrhoea and constipation by turns ; 
nausea and vomiting may recur, after having disappeared, or they may not 
set in until the second or third day; the urine is scanty, and retention and 
strangury are not infrequent. The respirations are slow and labored, and 
towards the close of fatal cases hurried and irregular, or infrequent, or stertor- 
ous. The heart-beats and the pulse are often quick, feeble, and tumultuous, 
though sometimes weak and slow; and well-marked cardiac blood murmurs 
have been heard (Da Costa). In 6 adult cases, Burdon Sanderson found the 
pulse to vary from 56 to 98, the average beats being 85. In 98 cases ob- 
served by Githens, the pulse varied from the natural standard to 150 beats 
per minute. In all it was very weak, with a dicrotic tendency, sometimes 
entirely imperceptible in the radial artery, and always interrupted by slight 
pressure. There would seem to be direct correlation between the frequency 498 
SPECIAL PATHOLOGY-EPIDEMIC CEREBRO-SPINAL MENINGITIS. 
of the pulse and the body-temperature; the latter, according to the German 
observers, rarely rising above 100° Fahr. The highest temperature in dif- 
ferent cases noted by Githens varied between 100° and 105° Fahr.; while in 
two it was below 100°. The skin may be dry or moist; and profuse and 
irregular perspirations, sometimes of the head and face only, have been men- 
tioned by a few writers, and their sickly smell noted. Disorders of the organs 
of sight and hearing, though happening, are by no means constant; squint- 
ing, and some degree of deafness, and buzzing in the ears, are the most com- 
mon. The state of the pupils is very variously reported as being dilated, 
contracted, irregular. Notwithstanding the great debility, decumbency is 
most generally on the side, at least until towards the last, though there are 
usually much restlessness and tossing about. 
When the issue is happy, there is a. gradual or sudden abatement of the 
symptoms with reaction, and sometimes, the supervention of mild fever. Death 
happens by coma, or by paralysis of the heart and lungs from damage to the 
medulla oblongata, or, possibly, by asthenia. 
The chief and more constant symptoms of this disease, found on a careful 
analysis of a large number of undoubted and uncomplicated cases, have been 
grouped in the description ; but they are rarely all seen together in the same 
case, or in all epidemics of cerebro-spinal meningitis ; so various are its mani- 
festations in the same epidemic, and at one time and at another. In some 
instances, the progress is so rapid that there is no time for the development of 
many of the symptoms, the patient being struck down, and dying quickly, as 
in blasting cases of scarlet fever, diphtheria, and typhus, the fulminant form 
of recent writers. Or one or more of the common symptoms may be absent 
during a whole epidemic. There are properly no stages of this disorder; all 
the essential symptoms noticed in its course may be present at the outset, and 
with initial severity, or they may follow each other in close sequence. Abate- 
ment in the intensity of some symptoms is occasionally seen, and others dis- 
appear and return, or pass away entirely; but marked remissions, except, 
perhaps, where there is malarial complication, are not common. 
The duration of an attack is from a few hours to many weeks. Professor 
J. S. Jewell has recorded a case which ended fatally within three hours from 
the onset; Dr. Lidell another, in five and one-half hours; the German 
authorities, many within four hours ; and Dr. J. J. Levick, two in twelve and 
thirteen hours respectively. Dr. S. Gordon reports a well-marked case of 
death within five hours of seizure. More than one-half the deaths happen 
from the second to the fifth day. Rummel says that the disease runs its course 
more quickly at the beginning than at the close of an epidemic. In the 
Lower Vistula outbreak the most acute cases terminated fatally in from twelve 
to seventy-two hours. Of the cases in the Philadelphia Hospital (1866), the 
deaths were from forty-eight hours to fourteen days, while the cases which 
ended happily lasted from twenty to thirty days; the acute symptoms rarely 
continued beyond two weeks (Githens). In the late Irish epidemic, a large 
proportion of the fatal cases died in from ten to forty-eight hours; in others, 
death happened at the end of the second and during the course of the third 
week (Radcliffe). In 95 fatal cases analyzed by Parks, the duration in 66 
was five days or less, in 1 eight days, in 28 ten days or over. 
Convalescence, taking place from the fifth day to the fourth week, and often 
later, is tedious, and full health is sometimes not regained for months. Gen- 
eral weakness and lassitude are long complained of, and one or both legs may 
remain feeble for awhile; or any impairment or perversion of the senses which 
happened in the attack may last for some weeks ; and occasionally boils or ab- 
scesses appear. Relapses are not unfrequent, and often prove fatal; though in 
the Massachusetts epidemic of 1810, recovery seemed to be the rule. 
Several forms or varieties of epidemic cerebro-spinal meningitis have been 
described by writers. There is no doubt, as Dr. N. S. Davis remarks, that PROGNOSIS OF EPIDEMIC CEREBRO-SPINAL MENINGITIS. 
499 
"in regard to the disease promiscuously styled 'spotted fever' and 'cerebro- 
spinal meningitis,' as reported in our literature, no less than three or four dis- 
eases have been confounded together" {The Transactions of the American 
Medical Association, vol. xvii, 1866). The force of the aetic poison may be 
directed chiefly to the brain, or the spinal cord, or lungs, causing various 
symptomatic expressions; but in most of these cases there are certain typical 
traits which mark the real nature of the disorder. 
In blasting, fulminant, or siderant cases, the nervous symptoms are less objec- 
tive ; there is a great prostration of the vital powers from the outset; the pulse 
is small and feeble, and gets hourly weaker; the skin is cold, pale, and mot- 
tled; the face and extremities livid; the features pinched, and the expression 
anxious; the respiration hurried, sighing, or irregular; the eyes staring and 
glazed; and there is deep lethargy,with death by coma. Yet very rapid cases 
happen, in which acute symptoms persist almost to the last. The "epidemic 
influence" is seen in the occurrence of cerebro-spinal symptoms in other con- 
temporaneous disorders, as pneumonia, erysipelas, diphtheria, and typhus and 
typhoid fevers. (See vol. i, p. 355.) 
The most frequent complications are: (1.) Congestions of the lungs; (2.) 
Affections of serous membranes with sero-purulent effusions, particularly of 
the pleura and joints; (3.) Malarial toxaemia; (4.) Erysipelas; (5.) Sore 
throat; and (6.) Swelling and suppuration of the parotid gland. 
Mortality.-Most epidemics and endemics of cerebro-spinal meningitis have 
been marked by great fatality: in some instances throughout their whole 
course, in others only for awhile after the outbreak. It decimated one of the 
United States volunteer regiments in the West during the late war, one man 
in every ten dying from it. In one of the French towns, of 240 taken, 120 
died. In one Swedish epidemic, of 3051 persons attacked, 1387 died. In 
1035 cases in several towns of France, there were 592 deaths, or a mortality 
of 1 in 1.76 (C. Broussais). In the Southern States during the war, in one 
instance there were 66 deaths in 154 cases, and in another 24 deaths in 40 
cases (Jewell). The mortality from the disease in that section of the country 
during the rebellion has been estimated at from 60 to 80 per cent. (Gaillard). 
In the first winter of its visitation at Memphis, there were no recoveries. In 35 
cases reported by Dr. S. C. Young, of Grenada, Miss., not one got well; and 
Wunderlich, Stonone, and others, have given instances where every case was 
fatal. The death-rate in the several epidemics between 1838 and 1865 varied be- 
tween 75 per cent, and 20 per cent. (Hirsch). In the Massachusetts epi- 
demic (1866) there were 278 cases and 170 deaths, or a mortality of a little over 
61 per cent. In the Philadelphia Hospital (1866) there were 43 deaths and 
130 cases, or a mortality of 33 per cent. (Githens). Dr. Stille remarks that 
while ten epidemics, in various places, between 1838 and 1848, gave an aver- 
age mortality of 70 per cent., a like number during the decade from 1855 to 
1865 gave only about 30 per cent. 
Prognosis.-No case of this disorder can be regarded without anxiety by 
the attending physician, particularly during the first three or four days; for 
one-half the deaths happen before the fifth day. After the fourth or fifth day, 
if fatal symptoms are not present, the prognosis is more hopeful. But the 
patient is not safe even when convalescence has fairly set in, for there is 
always a risk of relapse, which in some epidemics has been constantly mortal. 
In blasting cases attended with collapse or coma, no recoveries have been 
reported.* The influence of age and sex upon the issue of the disease has not 
been determined. It is asserted to be more fatal between ten weeks and seven 
* Mr. J. Netten Radcliffe says, without giving, however, instances or authority, 
" Recovery from this form of epidemic cerebro-spinal meningitis is not unknown, hut 
is an exceedingly rare event" (Reynolds's System of Medicine, vol. ii, p. 680). 500 
SPECIAL PATHOLOGY EPIDEMIC CEREBRO-SPINAL MENINGITIS. 
years than at any later period of life of equal length. The favorable signs 
are, an abatement of the symptoms referable to the cerebro-spinal axis; gen- 
eral reaction, shown by the state of the heart, pulse and skin; and a more 
natural respiration. There are many instances on record in which pregnant 
females have got well. 
Diagnosis.-Though the groups of symptoms vary in different epidemics 
and in different cases of the same epidemic, and are rarely all present in any 
one case, there is generally such a combination of them, sufficiently peculiar 
and typical, that a diagnosis is readily made. The sudden onfeet and rapid 
development of the disorder, with morbid phenomena clearly referable to the 
central nervous system, overwhelming prostration, and the characteristic erup- 
tion, are all distinctive. In some cases the symptoms are imperfectly devel- 
oped, or are more or less marked by coincident disease in other organs; in such 
instances the circumstances of the access, the prevalence of epidemic cerebro- 
spinal meningitis, and exclusion, will serve to point out the real nature of the 
case. It should be remembered that sometimes the pathogenetic force seems 
to be spent at one time upon the brain, at another upon the spinal cord; and, 
setting aside all doubtful cases in which the primary disorder was probably 
pulmonary, occasionally upon the lungs. Many diseases, as erysipelas, diph- 
theria, scarlet, typhoid, and typhus fevers, especially the two latter, are, un- 
questionably, very liable to be, in some degree, influenced by the prevailing 
epidemic. When typhus or typhoid fever are accompanied with spinal symp- 
toms, the diagnosis may be embarrassing; but as a general rule, such is not 
the case. The invasion of typhoid fever is marked by more or less illness 
for several days; subsequently its symptoms are characteristic; and what- 
ever spinal epiphenomena may happen, they cannot with any care lead to a 
confusion of the two disorders, except in very exceptional cases. The differ- 
ential diagnosis of epidemic cerebro-spinal meningitis and typhus fever, will 
be considered when the nature of the disease is discussed. 
The cerebral variety of congestive malarial fever, beginning with intense 
headache, and soon followed by deep coma, may very closely resemble the 
blasting form of epidemic cerebro-spinal meningitis with early coma. The 
writer has seen several cases of this kind. When happening in a paludal dis- 
trict, or during the prevalence of an epidemic of the latter disorder, they may 
be very puzzling. Fortunately the treatment is the same, and its success or 
failure will. materially assist in clearing up any doubts. Simple acute 
cerebro-spinal meningitis, as a primary disorder, is probably a nosographic 
myth, and never a morbid entity. When it happens as a secondary, or trau- 
matic, affection, its previous clinical history and its behavior are so widely 
different from the epidemic disorder, that to confound them would seem im- 
possible. 
Etiology.-Of the host of predisposing and exciting causes of this disease 
which have been catalogued by writers, all have been named in connection 
with other disorders, endemic and epidemic, and most or all have been want- 
ing in some outbreak of cerebro-spinal meningitis, or in the several localities 
where it has prevailed, or in individual cases. In this respect nothing con- 
stant has been noticed. Dr. Jewell writes: "The disease, as regards cold, has 
often been prolonged into the hot season, and has often begun as an epidemic 
and prevailed extensively in midsummer, as many as eight times in France. 
It has prevailed in rural districts as well as civic districts, and has even 
seemed to prefer rural districts in some cases, as in our own late epidemic. 
It has appeared among both rich and poor; on the uplands as wrell as low- 
lands; among those well fed as among those poorly fed; among those who 
have enjoyed thorough ventilation, as well as those under an opposite condi- 
tion; among the civil as well as the military population; and so in relation to 
the whole of these known assumed causes, of which the malady seems to be ETIOLOGY OF EPIDEMIC CEREBRO-SPINAL MENINGITIS. 
501 
wholly independent, except that they may, in a general way, predispose to or 
intensify it; for not one of them has been observed to be constantly associated 
with the disease" (foe. cit., p. 34). 
Of one hundred and eighty-two European epidemics, twenty-four were in 
October and November, forty-six in December and January, forty-eight in 
February and March, thirty in April and May, twenty-four in June and 
July, and ten in August and September (Simon). The outbreaks in this 
country have been chiefly during the winter and early spring. In Sweden, 
of 417 local outbreaks, 311 were in winter, and 106 in summer. Of 85 epi- 
demics in Europe and the United States, noted by Hirsch, 33 prevailed in 
winter, 24 in winter and spring, 11 in spring, 1 in spring and summer, 2 in 
summer, 1 in summer and autumn, 1 in autumn, 1 in autumn and winter, 3 
in autumn, winter, and spring, and 6 throughout the whole year. 
It has been very capricious with regard to sex, in various epidemics and 
localities, sometimes males being chiefly its victims, at other times females. 
All ages have suffered, from the infant a few weeks old to the octogenarian. 
In the Belfast workhouse it was almost confined to boys between the ages of 
seven and twelve years (Mayne) ; most of the cases seen by Hirsch, Nie- 
meyer, Rummel, and others, were under fifteen years, and the same was 
remarked during the Danish and Swedish epidemics, and those at Stettin 
and Bromberg. In Berlin, the disease was almost limited to the adult popu- 
lation. Pleiffer says it prefers winter, soldiers, and children. The young 
and vigorous would seem to be more often attacked than the feeble, the 
sickly, and the aged. In 116 cases, in which the age is given, there were: 
between 1 and 15 years inclusive, 39; between 16 and 30 years inclusive, 64; 
between 31 and 46 years inclusive, 12; and 1, aged 68 years (Webber). In 
France, it is looked upon as a military disease, soldiers in garrison, and par- 
ticularly recruits, being the chief sufferers. Dr. J. J. Woodward writes : 
" Recruits have not escaped, and those have especially suffered who were 
crowded in barracks and draft rendezvous." 
Dr. John Simon writes : " Epidemics have seemed particularly apt to occur 
in establishments where masses of special population have been living in com- 
mon domicile-as in workhouses, convict prisons, schools, and (above all) 
barracks. And in several such cases the epidemic has seemed to confine 
itself to one section of the establishment-to one block of building, to one 
floor, or to one room. It is asserted that, as a general rule, the affected seg- 
ment of population has been in overcrowded and ill-ventilated quarters. 
And when the disease has spread from such centres, or has independently 
arisen among common populations, this, almost always, has been said to have 
been under similar unwholesomeness of circumstances. Where the epidemic 
has been among soldiers, officers have enjoyed almost entire immunity; and 
where common populations have been suffering, the disease has shown great, 
if not exclusive, preference for the worst lodged classes of the community. 
. . . . In some cases, according to local reports, the distribution of an epi- 
demic has very decidedly not been governed by conditions of overcrowding 
and ill-ventilation " (Eighth Report of the Med. Officer of the Privy Council, 
1865). 
The mass of testimony is against its being contagious; but Drs. Hirsch 
and Stokes have reported cases of apparent communication of the disease 
from the sick to the well; and Boudin gives instances of its appearance in 
garrisons, and among the civil population of towns, after the introduction of 
detachments of troops among whom the disorder had prevailed or was pre- 
vailing at the time. 
There is reason, therefore, to believe, that the effective cause of epidemic 
cerebro-spinal meningitis is to be sought for beyond physical and bodily con- 
ditions ; that it is outside of the degree of heat, moisture, &c., and the consti- 502 
SPECIAL PATHOLOGY-EPIDEMIC CEREBRO-SPINAL MENINGITIS. 
tutional state of the individual; and we are forced to take refuge in the 
assumption of an unknown special morbific agent as the setic factor.* 
Nature.-It has been well said by Dr. O. W. Holmes, with respect to the 
disorder as it prevailed in this country from 1810 to 1816, that "it is easier 
to say what it was not than what it wasand the same remark holds good 
of every epidemic and endemic of the disease which has since happened, both 
in Europe and the United States. Many have regarded it as a form of simple 
acute cerebro-spinal meningitis. Aside from the great infrequency of this 
affection as a primary or idiopathic affection, and the improbability of epi- 
demic or endemic outbreaks of it, it may be urged that the behavior and the 
results of treatment of the disease under consideration are not explained upon 
the supposition of its being a simple meningeal inflammation. Those patholo- 
gists who place it nosographically by the side of inflammations of serous mem- 
branes are forced to assume that " the epidemic constitution imposes upon 
these phlegmasiee a more rapid course and a greater gravity than obtains in 
sporadic inflammation of the meninges; that is the only point they appear to 
differ from the latter " (Monneret) ; which is pure hypothesis, and gives no 
rational explanation of the observed differences, but in reality concedes the 
agency of an unknown external cause. Besides, the clinical history of epi- 
demic cerebro-spinal meningitis shows that the whole system is implicated 
from the outset, and it often strikes down its victims without leaving any 
trace of local damage. Nor is there any constant relation between the se- 
verity and duration of the symptoms and the degree and extent of changes in 
the cerebro-spinal membranes; they are present or absent alike in protracted 
cases as in those which have proved suddenly fatal, writes Dr. J. J. Wood- 
ward, as the result of the observations made by the medical officers of the 
army during the late war. Granting, however, that they are always present, 
it would not prove that the disorder was a modified idiopathic meningeal 
inflammation, any more than the invariable changes of the agminate glands 
of the intestine in typhoid fever would entitle that affection to be regarded as 
a dothinenteritis. There is a great difference between a pathogenetic cause 
and an anatomical character. Those who hold to the localization of the dis- 
order, and regard the meningeal lesion as primary and essential, seem to have 
taken as hasty and limited a view of its manifold morbid phenomena, as 
Ploucquet, Marcus, and Clutterbuck did of continued fever, when they re- 
ferred it to inflammation of the brain. 
On the other hand, amongst those who believe that epidemic cerebro-spinal 
meningitis should be classed with the so-called zymotic diseases, there are 
many who consider it but a variety of typhus fever. Boudin, Murchison, 
Upham, Baltzell, and others, have ably argued this question. That there 
is a certain analogy between the two disorders, and that cases occasionally 
are met with, particularly when cerebro-spinal meningitis and typhus are co- 
incidentally prevalent, which would seem to favor this theory, must be ad- 
mitted (see Dublin Quarterly Journal of Medical Science, 1849) ; but there 
are so many striking points of difference in the history of the two affections, 
that it is difficult to understand how they have ever come to be looked 
upon as one. The identity of the two diseases has been supported by some 
of the highest authorities in the profession, who have had large means of 
* Dr. Robert Law, of Dublin, in reporting several sporadic cases of cerebro-spinal 
meningitis, observed by him in 1865, writes : " It is a fact worthy of recording, that 
at the time we were attending this lady [suffering from cerebro-spinal meningitis], 
nine rabbits out of eleven, which her son had, died all in the same way; their limbs 
seemed to fail them, they fell on their side, and then worked in convulsions, and died. 
Two hens fell lifeless from their roost." Three of the rabbits were examined ; in two 
there were congestion of the vessels of the base of the brain, and in the other vascu- 
larity of the membranes of the spinal marrow.-Dub. Jour, of Med. Science, May, 
1866. NATURE OF EPIDEMIC CEREBRO-SPINAL MENINGITIS. 
503 
clinical observation, and their views are entitled to consideration; but the 
evidence upon which they are founded cannot here be examined, or the sub- 
ject properly discussed. The suddenness of the onset in epidemic cerebro- 
spinal meningitis, its rapid course, the absence of the mulberry rash of typhus, 
the early appearance of the hsemic spots, and its non-contagiousness, whilst 
many of The characteristic symptoms of the continued fever are wanting, are 
all diacritic traits, which should, it is believed, prevent any confusion between 
the two diseases. Dr. Burdon Sanderson says, that the facts observed at 
Dantzig afforded no proof of there being anything in common between epi- 
demic cerebro-spinal meningitis and typhus, except so far as each was due to a 
specific poison (Med. Times and Gazette, May, 1865). Dr. Luther Parks writes: 
" We can conceive that on the negative side of the question of the connection 
of ' spotted fever ' with typhus, the same line of argument may be used as that 
of Dr. Holmes in speaking of the epidemic of 1806 to 1815-that a disease 
which is sometimes almost as sudden in its invasion as a stroke of lightning; 
which is rarely suspected of being contagious; which gives us a solitary case 
in a ship-of-war, a single case in a boarding-school, two cases only in an alms- 
house ; which in civil practice affects the villages and isolated farmhouses of 
the interior (where typhus ' running the ordinary course ' is unknown) as 
much, at least, as the large cities; which, in a great majority of cases, is fatal 
in a few days or even hours; the mortality of which is very variable: such a 
disease presents so many points of difference, when compared with British 
typhus, that we should hesitate before pronouncing the two identical." 
Tourdes, Levy, Lebert, Niemeyer, Hirsch, Stokes, Gordon, and other Irish 
and English authorities, clinically familiar with the disorder, protest against 
confounding, pathogenetically, typhus and epidemic cerebro-spinal meningitis. 
Hirsch says: "Apart from its very obscure pathological essence, there is 
hardly anything in its symptoms or lesions, which brings epidemic menin- 
gitis within that comprehensive and elastic term-typhus." Dr. Stille, whose 
opportunities for examining both diseases, at about the same period, were 
large, writes of Hirsch's remarks: "We fully adopt the language just quoted, 
as faithfully representing what we conceive to be the truth" (p. 116). Dr. 
J. Netten Radcliffe answers the question, Is epidemic cerebro-spinal meningitis 
a form of, or allied to, typhus ? in these words: " It differs from typhus in the 
aspect of the patient, rhythmical progress, range and course of temperature 
lower and irregularly fluctuating, form of cerebral affection, character of 
eruption, sequelae, rate of mortality, anatomical lesions, and manner of dis- 
semination. Differing in all essential particulars, doubt can only arise when 
the two diseases prevail together" (Reynolds's System of Medicine, vol. ii, p. 
699). 
It has also been regarded as a form of pernicious paludal fever, but there 
are no sufficient grounds to believe it to be of malarious origin. 
Dr. Levick believes that there is an epidemic influence which shows itself 
in its mildest form as influenza; again as typhoid pneumonia; once more as 
cerebro-spinal meningitis; whilst in some cases the blood itself appears to be 
greatly affected without presenting at once the phenomena of disease of any 
special organ (Am. Journal of the Med. Sciences, vol. xlviii, 1864). 
The pathogeny, then, of epidemic cerebro-spinal meningitis is still unset- 
tled. There is reason to say that it is not a variety of simple or idiopathic 
inflammation of the membranes of the brain and spinal cord, nor of typhus 
fever, nor of pernicious paludal fever, but a substantive disorder, consistent 
with itself in all material points, with constant symptoms produced by a con- 
stant cause, and hence entitled to be described and regarded as a distinct 
disease whose proper nosological place is amongst general diseases born of an 
external morbid poison, it must be owned that its pathogenic nature remains 
unknown. 
Treatment.-There is no antidote to the specific setic poison, nor can it be 504 
SPECIAL PATHOLOGY-EPIDEMIC CEREBRO-SPINAL MENINGITIS. 
expelled by elimination. The indications are to stay if possible the progress 
of the disorder, and sustain the vital powers. A hot bath, 102°-106J, in' 
which the patient is to remain a short time only, and to be immediately 
wrapped in blankets, often gives some relief. When the surface generally, or 
the extremities are cold, friction with turpentine and chloroform may be used, 
or sinapisms put on the arms and legs. A moderate quantity of blood may 
be drawn by cups, or leeches,- applied to the back of the neck, followed by 
counter-irritation, or a blister. Brandy, or ether, or chloroform, in small 
quantities, may be administered both as stimulants, when indicated, and to 
allay the nausea and check the vomiting. Two or three large doses of quinia 
with opium should be given, at proper intervals; or hypodermic injections of 
morphia about the seat of pain. The bowels ought to be kept free by purga- 
tive enemata, containing croton oil, turpentine, &c. Nutritious and suitable 
food must be taken, when possible, at short intervals, and through the night 
as well as the day. During convalescence fresh air, good diet, and tonics are 
required. 
Various plans of treatment have been suggested and adopted in this disease; 
some agreeing with the pathogenetic notions of their partisans, others being 
purely empirical. The results have not been very happy, though it is difficult 
to justly estimate the true value of each method, from the varying severity of 
individual cases and of different epidemics. General bleeding has had its ad- 
vocates in all countries and in every epidemic; but it is believed that an honest 
examination of the testimony, both for and against it, will show that it is 
harmful. Veratrum, aconite, and digitalis, have been tried, and proven un- 
satisfactory, though Rummel recommends digitalis in the early stage. Opium 
has been greatly extolled, and the late Dr. Valleix says that, in large doses, 
it is the only drug which has appeared to exert any real influence over the 
disease; and this good opinion of its effects is confirmed by Minor, Tully, 
Hirsch, Boudin, Forget, Levy, Boutin, C. Broussais, Lidell, W. H. Draper, 
Levick, Stille, and others. One grain of opium may be given every hour in 
very severe cases, and every two hours in less severe ones (Stille). Nie- 
meyer speaks well of subcutaneous injections of morphia. The evidence in 
behalf of quinia is very conflicting. Hirsch, Rummel, Forget, Tourdes, J. S. 
Jewell, and Upham, believe that it does no good; whilst Gassaud, who states 
that he lost but 2 cases out of 126 treated, attributes this wonderful result to 
the free and early use of quinine; and Gerhard, Wales, Ottmar, Burr, Du- 
rand, Leonard, and Levick, have found it decidedly beneficial. It is, how- 
ever, generally admitted, that when there is malarial complication, or the 
disease happens in paludal districts, it should be given. Nothing appears in 
favor of brandy, ammonia, camphor, valerian, or musk; and the same may 
be said of mercury, strychnine, and ergot. Rummel, Hirsch, aud others 
praise the iodide of potassium in the later stages, but no real proof of its 
utility has yet been brought forward. The bromide of potassium has been 
given, and it may possibly prove a valuable adjuvant in controlling some of 
the symptoms, and as it cannot do harm, merits a fair trial, but hardly to the 
exclusion of other remedies. Inhalations of ether and of chloroform have 
been found by some of the French physicians useful as sedatives. The tinc- 
ture of cantharides has, in the experience of Professor Allen, of Chicago, 
yielded good results, particularly in cases marked by great depression (Jew- 
ell) ; and from its happy stimulant effects, in cases where there is great de- 
pression of the nervous system, its employment is rational. The sulphites 
and bisulphites, and permanganate of potash, have been proposed, and used 
during the recent epidemic in this country, on account of their supposed anti- 
septic properties; but no reliance should be placed upon them as nullifiers of 
the blood poison. There is much strong testimony in behalf of counter-irrita- 
tion and blistering along the spine. The actual cautery freely applied to the 
back, has been followed by great alleviation of the pain and other symptoms TREATMENT OF EPIDEMIC CEREBRO-SPINAL MENINGITIS. 
505 
(Rollet). At the outset of an attack, stimulating embrocations to the spine 
and extremities and moist and dry heat to the limbs, have been much employed 
and praised by physicians of all countries, and are without doubt often very 
relieving. Dr. J. Burdon Sanderson recommends the application of ice-cold to 
the spine during the first day. Dr. J. Netten Radcliffe says: "The application 
of cold to the head and spine, either by means of ice or a freezing mixture, in 
Esmarch's (or Chapman's) india-rubber bags, has furnished by far the most 
satisfactory results of all direct treatment" (1. c., p. 702). If there is much 
prostration during the local use of cold, the trunk and extremities should be 
kept warm by cotton-wool, hot sand-bags, or hot-water bottles. 
When this disorder appears, either periodically or as a local outbreak, all 
the sanitary measures, commonly used in other affections of a common origin, 
should be put in force. Mr. J. Simon says : " I am strongly of opinion that 
the best sanitary precaution which, in the present state of knowledge, can be 
taken against the disease, must consist in care for the ventilation of dwell- 
ings." 
North, Elisha : Treatise on a Malignant Epidemic, commonly called Spotted Fever, 
1811. Gallup, J. A. : Sketches of Epidemic Diseases in the State of Vermont, &c., 
1815. Miner, T. and Tully, W.: Essays on Fevers and other Medical Subjects, 1823. 
Boudin, J. C.: Du Typhus Cerebro-Spinal, ou Etudes sur la Nature de la Maladie 
decrite sur le nom de Meningite Cerebro-Spinale Epidemique, et sur ses rapports 
avec la Maladie qui a regnee en 1814, dans une grande partie de 1'Europe; Archives 
Generales de Medecine, 1849. Forget, C. : Relation de 1'Epidemie de Meningite En- 
cephalo-rachidienne, observee a la Clinique Medicale de la Faculte de Strasbourg en 
1841; 1841. Levy, Michel: Histoire de la Meningite Cerebro-Spinale observee au 
Vai de Grace en 1848 et 1849; 1849. Tourdes G. : Histoire de 1'Epidemie de Stras- 
bourg, 1842. Broussais, Casimir: Histoire des Meningites C^rebro-Spinales, qui ont 
regimes epidemiquement dans differens garnisons en France depuis 1837jusq'en 1842, 
d'apres les documens recuillis, par le Conseil de Sante des Armees, 1845. Thomson, 
J. B. : Epidemic at Gibraltar; The Medical Times, London, 1845. Mayne, R.: 
Remarks on Cerebro-Spinal Arachnitis; The Dublin Quarterly Journal of Medical 
Science, August, 1846. Law, R. : Cerebro-Spinal Meningitis ; The Dublin Quarterly 
Journal of Medical Science, May, 1866. Draper, W H.: American Medical Times, 
August and September, 1864. Gerhard, W. W. ; American Journal of the Medical 
Sciences, July, 1863. Ames: New Orleans Medical and Surgical Journal, 1848. 
Valleix: Guide du Medecin Practicien, t iv, 1866. Upham J. B. : Hospital Notes 
and Memoranda, in illustration of the Congestive Fever (so-called), or Epidemic 
Cerebro-Spinal Meningitis, &c.; reprinted from the Boston Medical and Surgical 
Journal; Boston, 1863. Gaskoin, G.: On Cerebro-Spinal Meningitis in Portugal; 
Medical Times and Gazette, June, 1865. Jewell, J. S.: Cerebro-Spinal Meningitis; 
being a Report made to the Illinois State Medical Society, June, 1866; Chicago, 
1866. Webber, S. G. : Cerebro-Spinal Meningitis; The Boylston Prize Essay for 
1866; reprinted from the Boston Medical and Surgical Journal; Boston, 1866. 
Parks, L. : Report of a Committee of the Massachusetts Medical Society on Spotted 
Fever, or Cerebro-Spinal Meningitis, in the State of Massachusetts, May, 1866; Boston, 
1867. Gaillard, E S.: Richmond Medical Journal, vol. i, 1866. Levick, J. J.: 
Report in the Transactions of the American Medical Association, vol. xvii, 1866. J. 
Burdon Sanderson: A Report of the Results of an Inquiry into the Epidemics of 
Cerebro-Spinal Meningitis prevailing about the Lower Vistula, &c. Official paper, 
London, 1865. Eighth Report of the Medical Officer of the Privy Council, 1865. 
(Blue Book, 1866.) Hirsch: Die Meningitis Cerebro-Spinalis Epidemica; Berlin, 
1866. This monograph has been translated into English and published in the Trans- 
actions of the Epidemiological Society, vol. ii; London, 1867. Stille: Epidemic 
Meningitis, or Cerebro-Spinal Meningitis; Philadelphia, 1867. Githens, W. H. H. : 
Notes of 98 Cases ; American Journal of the Medical Sciences, July, 1867. J. Netten 
Radcliffe: Reynolds's System of Medicine, vol. ii; London, 1868. 
The Medical Journals of this country, published during 1864, '65, '66, and those of 
Dublin and London, during 1866-67, contain valuable articles, but too numerous to 
mention separately here.] 506 
SPECIAL PATHOLOGY ENTERIC FEVER. 
ENTERIC FEVER Syn., TYPHOID FEVER. 
Latin Eq., Febris Enterica, idem valet Febris Typhodes; French Eq., Fibvre Typhoid# 
ou Dothienente.rie; German Eq., Abdominal-typhus-Syn., Ileo-typhus; Italian 
Eq , Tifo Enterico-Syn., Febbre Tlfuide. 
Definition-J. continued fever, associated with an eruption on the skin of 
rose-colored spots, chiefly on the abdomen, appearing generally from the eighth to 
the twelfth day, occurring in crops, each spot continuing visible about three days. 
Languor and feebleness are prominent from the first, attended by headache, ab- 
dominal pains, and (early) by spontaneous diarrhoea. With the advance of the 
disease the diarrhoea increases, the discharges being for the most part liquid, 
copious, of a bright yellow color, devoid of mucus, occasionally containing altered 
blood. In reaction the discharges are alkaline, and containing a large proportion 
of 'soluble salts and some albumen. The fever may terminate favorably by a 
gradual restoration to health during the fourth week. The average duration of 
the illness is about twenty-three days. Death in the majority of fatal cases occurs 
towards the end of the third week. There are special symptoms also associated 
with the characteristic lesion of this form offerer-namely, fulness, resonance, and 
tenderness of the abdomen; more or less tympanites, with entire effacement of the 
natural lineaments of the belly; gurgling in the iliac fossae; and increased splenic 
dulness. The specific lesions are enlargement of the mesenteric glands, with 
deposit in the glands of Peyer and in the minute solitary glands of the small 
intestine. 
Pathology.-This form of fever has been described under a great variety 
of names, by various writers, such as typhus metior; nervous fever; abdominal 
typhus; common continued fever; enter o-mesenteric fever; dothienenteritis; follic- 
ular enteritis; bilious fever. The continued fevers (of which enteric fever is 
one form) were at one time embraced (without being clinically distinguished) 
under the single name of " Common Continued Fever," of which it was believed 
there were several varieties. But since about the year 1840 specific differences 
have been gradually becoming more and more obvious, so that now at least 
four distinct fevers can be recognized, allied by certain common characters, 
and not less distinctly separable by peculiar and distinctive marks. The 
plurality of continued fevers must now therefore be generally admitted. 
The four forms of Continued Fever now named respectively as follows: 
(1.) Typhus Fever; (2.) Typhoid, Enteric, or Intestinal Fever; (3.) Relapsing 
Fever; and (4.) Febricula, have been mixed up together in almost every 
epidemic, in various proportions, so that each epidemic of fever has held a 
peculiar character according to the nature of the dominant disease which was 
mainly prevalent. 
Much has been spoken and written about the identity and non-identity of 
typhus and enteric fevers; and in the first edition of this work I stated my 
belief that these two forms of continued fever were identical in their nature- 
i. e., were varieties merely of a fever which resulted from one and the same 
specific poison. I entertained this belief partly because I had been taught as 
a student so to believe, and partly because I considered that the evidence then 
existing on the subject, and with which I was acquainted, did not fully justify 
any other conclusion. This belief I recanted in the second edition. Proofs 
of numerous and remarkable differences of a specific kind between typhus and 
enteric fever have been slowly but surely accumulating since the beginning of 
the present century. The dissections, by Prost, of Parisian fever patients in 
1804, may be said to have laid the foundations of our knowledge, and to have 
turned the attention of pathologists in the direction which has led to such 
definite results. In more than 150 dissections Prost always found "inflamma- 
tion," with or without ulceration of the mucous membrane of the intestines. DIFFERENCES BETWEEN TYPHUS AND ENTERIC FEVER. 
507 
Petit, Serres, Pommer, and Bretonneau followed up the investigation; but the 
celebrated treatise of Louis, in 1829, was the first to give a complete and con- 
nected view of symptoms as well as of post-mortem lesions in the fever common 
in Paris; and although Prost asserted the connection of a certain intestinal 
lesion with a definite series of symptoms, still it was Louis who described this 
intestinal lesion in terms sufficiently precise, and. indicated with scientific ex- 
actitude the symptoms with which it is concurrent. The views of Louis were 
subsequently adopted by Chomel and Andral in France. In other parts of 
Europe, however, and especially in England, bodies of numerous fever patients 
were opened without finding any disease of Peyer's patches, although differ- 
ences in the symptoms detailed regarding the fevers of France and England 
were not then so obvious. Hence arose at once two opinions, based on a post- 
mortem distinction, namely, the "anatomical sign," described by Louis. The 
first opinion was that this "anatomical sign" was an incidental occurrence; 
or, that its occurrence was in some way connected with locality, the cases of 
fever being everywhere considered identical. A second opinion, however, soon 
began to gain ground, especially when the intestinal lesion was not found by 
the most careful observers in some cases where it was intentionally looked for 
(as in the epidemic of Toulon in 1829-30). A belief now, therefore, began to 
gain ground that there were in fact two diseases which were indifferently named 
typhus and typhoid fever-that one prevailed only at Paris, and the other in 
England, in Germany, and elsewhere, and that it was also sometimes more or 
less mixed up with the Parisian fever, as measles may be with scarlet fever. 
Louis subsequently (1841) adopted this view. 
In 1835 the "Academic de Medecine" formally proposed the question, 
" What are the analogies and the differences between the typhus and typhoid 
fevers ?" The question excited considerable interest in France, but less so in 
England, where a strong bias has always prevailed towards a belief in the 
doctrine of a single fever-a belief entertained and taught by the most emi- 
nent observers and teachers of that day. But dissenters arose. Scotch, Eng- 
lish, and American physicians, practically familiar with the fevers of their 
own countries, began to visit Paris to study fever there; and they were not 
long in learning to recognize the chief points of difference between the two 
fevers. Gerhard and Pennock, of Philadelphia, in a systematic treatise, were 
the first to indicate (1836) these differences, it having been already determined 
by Jackson and Gerhard that the fever described by Louis under the name 
of typhoid fever existed in America, and presented there the same assemblage 
and development of symptoms, and the same post-mortem lesions, as the Pa- 
risian fever.* 
In 1836 M. Lombard, of Geneva, after visiting London, Edinburgh, and 
Dublin, ultimately came to the conclusion that two different fevers had been 
confounded together ; and Drs. Staberoh, of Berlin, and Kennedy, of Dublin, 
professed the same belief through the same medium,-the Dublin Journal. 
During this year (1836), also, Dr. A. P. Stewart commenced his observations 
in the Glasgow Fever Hospital, where he continued his inquiry for two years. 
His attention was first especially directed to the study of fever by Dr. Peebles, 
who, during a long residence in Rome, had observed the maculae of typhus in 
the contagious fever of Italy, and who first showed the difference between the 
characteristic eruption of fever and the cutaneous affection to which the name 
of "petechice" is given {Edin. Med. and Surg. Journal, 1835). He pointed 
out this eruption to Dr. Perry (then Physician of the Glasgow Fever Hos- 
pital), "and who," Dr. Stewart states, "was the first to maintain the complete 
difference of the two eruptions-namely, those of typhus and typhoid fever." 
Dr. Stewart subsequently went to Paris and examined the fever there. The 
* [In February, 1835, Dr. Gerhard, of Philadelphia, and in June, 1835, Dr. Bartlett, 
indicated with perfect precision the difference between typhoid fever and typhus.] 508 
SPECIAL PATHOLOGY - ENTERIC FEVER. 
result Was a complete recognition of the existence of two fevers, and of their 
differences-an account of which he published in the Edinburgh Medical and 
Surgical Journal for 1840, p. 289. 
In 1839, Enoch Hale published an account of the fever of Massachusetts, 
and distinguished among them two perfectly different forms of fever, one of 
which agreed with the Parisian fever, while the other might be held to repre- 
sent the fever described by most English writers. 
Soon after this the characters of the prevalent fevers of England were noted 
by Shattuck (another American pupil of Louis), who published his results in 
the Boston Medical Examiner. 
The appearance of these papers, and of others about this period, gave rise 
to an elaborate discussion of the whole question (in the pages of the British 
and Foreign Medical Review, vol. xii, p. 293) ; and the conclusion the reviewer 
arrived at seemed to favor the opinion " that the French and English fevers 
were varieties, that is, different developments of a common stock, but not 
specifically distinct diseases." I understand the eminent physician who wrote 
that review now believes in the specific distinction of the two fevers. 
In America the doctrine of a specific distinction between the two fevers has 
been generally adopted, as represented in the treatises of Dr. Bartlett, in 1842 
and 1847, On Typhus and Typhoid Fevers and On the Fevers of the United 
States; [and by Dr. Meredith Clymer, Fevers: their Diagnosis, Pathology, 
and Treatment; Philadelphia: 1846, p. 234.] 
In Germany three opinions were entertained. The typhoid fever of Louis 
received from the Germans the name of "abdominal typhus"-thus regard- 
ing the disease as a variety of typhus fever, the latter being the simple and 
abdominal typhus (enteric), a complicated form and higher grade of the same 
disease. By some, however, it was regarded as a disease distinct from the 
" typhus exanthematicus." A third opinion also found followers-namely, that 
this abdominal typhus was the only form of continued fever. All these opin- 
ions were the result of a too limited and narrow field of investigation. 
Up till 1846 opinions were thus divided, crude, and, in many schools of 
Medicine, quite unformed. Relapsing Fever was distinguished by some, but 
not by all; and all other forms of continued fever were considered in this 
country as identical. Under these circumstances the inquiry was taken up in 
1846 by Dr. Jenner, then Professor of Pathological Anatomy in University 
College, and worked out by him systematically in the London Fever Hospital. 
There he patiently accumulated case after case of fever, until he had nearly 
2000 accurate reports before him. From these he separated all cases of relaps- 
ing fever, and then instituted a rigorous comparison of the remaining cases. 
He selected the fatal cases which had been examined after death, and the 
diagnosis of which had been confirmed. He found that he had 66 such cases 
and post-mortem examinations. Of these 66 cases, 23 had the intestinal and 
mesenteric lesion-the " anatomical sign " (according to Louis) of typhoid 
fever; and 43 cases were without this appearance. The following question 
then remained for solution ; namely-Did these 43 cases (in which the intes- 
tinal lesion was not present) differ so much in symptoms and post-mortem 
appearances from the other cases (in which the " anatomical sign" referred to 
was present) as to render it impossible to suppose that they were cases of the 
same disease ? Or,-contrary to the opinion of Louis,-Were the symptoms of 
the two sets of cases so similar as to lead to the belief that the presence or 
absence of the intestinal lesion (the " anatomical sign") was a matter of little 
consequence ? 
On comparing these two groups of cases, Dr. Jenner found that while the 
symptoms and post-mortem appearances of the 23 cases were exactly the same 
as those described by Louis, the symptoms, course, and post-mortem appear- 
ances of the remaining 43 cases were entirely different-so different, indeed, 
as to render their separation from the other cases a matter of absolute neces- DIFFERENCES BETWEEN TYPHUS AND ENTERIC FEVER. 
509 
sity, if accuracy was to be maintained in the description of these diseases, or 
certainty arrived at in their treatment. 
Causation, as a ground of distinction between typhus and enteric fevers, is a 
condition upon which much stress has been laid by Dr. Jenner, and subse- 
quently by Dr. Murchison. Dr. Jenner was the first to argue that the mate- 
rial media by which the two fevers are propagated are specific and different 
from each other, according as they are generated by the bodies of those 
affected with the one or the other form of fever. This argument he based 
upon the circumstance, that because certain local foci sent enteric cases to the 
hospitals, and certain other local foci sent typhus cases there, he inferred that 
different specific causes existed in each focus. Dr. Murchison has also clearly 
stated the evidence of many other observers, which goes to prove that the 
two fevers have no community of origin (Continued Fevers of Great Britain, 
p. 588). The late Professor Niemeyer has also recorded his experience that 
the contagion of enteric fever is not so intense as that of typhus fever. It 
clings more particularly to the dejections, but it is doubtful if the contagion 
is capable of transference by exhalations from the skin and lungs of enteric 
fever cases. On the other hand, exhalations from the skin and lungs are cer- 
tainly vehicles for the contagion of typhus fever. Infection of the nurses and 
physicians is rarely seen with cases of enteric fever, and when it occurs it is 
generally traceable to the influence of the dejections. At all events, using 
the bed-pans, night-stools, and privies, where the dejections of enteric fever 
patients have been emptied, appears to be more dangerous than being brought 
in contact with the patient. 
This brief history of the progress of our knowledge regarding typhus and 
typhoid fevers has been mainly condensed from an erudite and most interest- 
ing monograph on "The Diagnosis of Fevers," by Dr. Parkes, which ap- 
peared in the Medico-Chirurgical Review for July, 1851-a contribution of 
not less importance to science than the original investigations of those whose 
labors it records. Such a comprehensive Review connected the scattered ob- 
servations together, and showed at once the practical value of the discovery 
that had been so gradually made-tending, as it did, to bryig conviction to 
the minds of those not fully conversant with the literature of the subject, and 
with what had actually been achieved in different parts of the world. To 
Dr. Parkes, the clear, elaborate, and careful analysis he made was a labor of 
love-justly believing, as he does, that no subject is so important as accuracy 
of diagnosis. It is the foundation of therapeutics; and he who clearly indi- 
cates how a disease can be recognized is fellow-laborer to him who points out 
how the disease may be cured or prevented. 
This brief history also teaches how slow is the progress of discovery. The 
greatest discoveries have been rarely due to any single individual; but grad- 
ually, slowly, and surely the Light of Science dawns upon the world. It was 
so with the discovery of the Circulation of the Blood. It was so with the 
discovery of the Protective Influence of Vaccination. It was so with the dis- 
covery of the Pdwers of Steam, and the development of the steam engine to 
its present condition of perfection. 
Since 1851 proofs of differences between the typhus and enteric fever have 
been still accumulating in many different directions. They especially result 
from the observations of Dr. William Budd, of Clifton, near Bristol; 
of Dr. Murchison, of the London Fever Hospital; of Professor Wunder- 
lich, of Leipsic; and of Von W. Greisinger, of Zurich. The observations 
of these two latter physicians are especially valuable, as showing the ranges 
of temperature in the two fevers to be distinctive of two diseases. I must 
here also mention the excellent lectures given by Dr. Peacock, of St. 
Thomas's Hospital, in 1855, and published in the Medical Times of 1856, "On 
the Varieties of Continued Fevers and their Discrimination," as influential 
in forwarding these modern views; for they appeared at a time when the spe- 510 
SPECIAL PATHOLOGY-ENTERIC FEVER. 
cific distinctions between typhus and enteric fever were less generally admitted 
than at present. Thus the evidence has slowly but surely accumulated; and 
when the whole subject has been re-examined in all its relations, the conclu- 
sion irresistibly forces itself on the understanding, that a belief in the identity 
of typhus and enteric fever is no longer tenable. 
In common with many, I had, as a student, been taught to recognize the 
striking similarity between the two fevers, in outward aspect, in many re- 
spects; and therefore I was unduly biassed by the resemblances, rather than 
led to give sufficient importance to the numerous and remarkable differences 
between them which are now to be described. 
With regard to their most prominent points of resemblance and difference, 
it may be shortly stated here, that all the points in which the two fevers agree 
are common to them and many other diseases, and therefore are of no value 
as indicia of a species. The resemblance is in no respect perfect-not more 
than is seen between typhus and cases of measles which are attended with 
typhoid symptoms {typhous measles of Niemeyer). On the other hand, the 
points in which they differ are all of a very special nature. The points in 
which they agree may all be summed up in the phrase "typhoid symptoms" 
-a set of symptoms which are met with in a great variety of diseases, and 
therefore are of no specific value in the question at issue. These so-called 
typhoid symptoms occur not only during the course of typhus and enteric 
fevers, but are also found to occur and to group themselves in a similar man- 
ner in measles, scarlet fever, small-pox, pyaemia, urcemia, some forms of pneumo- 
nia, and in many cases of acute tubercle (W. Budd). 
Such so-called typhoid symptoms are made up of the following phenomena: 
A quick soft pulse; a dry brown tongue; the symptoms and physical signs 
of hypostatic congestion of the lungs; impairment of the mental faculties; 
stupor passing into coma; delirium, which at one time is acute and noisy, at 
another, low and muttering, and not unfrequently associated with muscular 
tremor; involuntary evacuations, and occasionally subsultus, carphology, or 
even general convulsions. The precise grouping of the symptoms varies in 
different cases even of the same disease (Murchison, W. Budd). 
The post-mortem appearances met with in such cases are a dark fluid con- 
dition of the blood; hypostatic congestion and oedema of the lungs; old dis- 
ease or recent congestion, with epithelial engorgement of the tubes of the 
kidneys; enlargement and softening of the spleen, and, unless the typhoid 
state has been of very short duration, an accumulation of serous fluid in the 
lateral ventricles and at the base of the brain, the veins and sinuses of which 
are usually full of dark blood (Murchison). 
This typhoid state is developed in the following diseases, namely,-in true 
typhus fever, in enteric or typhoid fever, in cases of severe pneumonia where 
symptoms of the local are masked by those of the general blood poisoning; in 
cases of acute rheumatism, acute tubercle, pyaemia, uraemia, and especially in 
those forms of disease where the kidney is contracted, granular, or "gouty," 
and where albuminuria is often absent. 
Morbid Anatomy of the Lesions in Enteric Fever, with special reference 
to the Phenomena and Progress of the Disease.-The abdominal complica- 
tions of enteric fever, as they are sometimes called, are mainly due to lesions 
of the solitary and aggregate glands of Peyer, and to enlargement of the 
mesenteric lymphatic glands. This lesion in the small intestine is especially 
recognized as the "anatomical sign" of enteric fever. It is necessary to 
remember, however, in connection with the age of enteric fever patients, that 
the solitary vesicles and the aggregate glands of Peyer are known to be most 
fully developed and most active in youth, up to the age of early manhood; 
after that time they begin to disappear, and are obviously less active in the 
adult after thirty years of age. Structure and function seem to be alike im- 
paired by age, till at length, after forty or forty-five years, traces only of the MORBID ANATOMY OF LESIONS IN ENTERIC FEVER. 
511 
existence of Peyer's glands are apparent, or they have altogether disappeared. 
The gland substance (whose structure has been so well described by Dr. Allen 
Thomson, Kbiliker, and Boehm) no longer exists; and the places where the 
patches of Peyer once were may be detected only after careful examination,- 
a mark of varied form and character being all that indicates the place of the 
patch. There is therefore a good anatomical reason why the lesions of enteric 
fever are rarely found after fifty years of age, and seldom after forty. Sir 
William Jenner records only three cases beyond fifty-namely, one at fifty- 
one and two at fifty-five. Dr. Wood has observed one case at fifty-five years 
of age. Dr. Murchison notes two cases above sixty-five, and refers to five 
other cases between sixty and seventy-five, related by MM. Lombard and 
Gendron. Dr. Wilks refers to the case of a woman aged seventy, of very 
doubtful history {Path. Society, 1861). These exceptional cases are explicable 
when it is known that the existence and functional activity of these glands 
are sometimes prolonged for an indefinite term of years beyond the usual 
period of their existence. On the other hand, it is in childhood and early 
life that Peyer's glands are most obvious, and their functional activity the 
greatest; and therefore it is extremely significant to find that " more than one- 
half of the cases of enteric fever occur between fifteen and twenty-five years 
of age; and in very early life the proportion of cases of enteric fever would 
be greater were it not that many children laboring under this disease are de- 
scribed as cases of 'Infantile Remittent Fever'" (Murchison). 
The following records with regard to the age of enteric fever patients, col- 
lected by Dr. Murchison, demonstrate these points: 
Under ten years, 6.04 
" fifteen years, .......... 20.14 
From fifteen to twenty-five years, ....... 52.08 
Twenty-five years and upwards, . . . . . . 27.76 
Thirty" " " 14.22 
Forty " " 5.19 
Fifty " " 1.46 
Sixty " " 0.5 
PERCENTAGE OF CASES OF TYPHOID FEVER AT DIFFERENT AGES. 
The average age of enteric, fever cases is 21^; and the fever is pre-eminently 
a disease of childhood and adolescence. 
Special Lesions in Enteric Fever.-Of these the most noticeable are to be 
seen in the small intestines (hence the German name of ileotyphus), and they 
may be considered in the following stages: 
I. A generally congested state of the mucous membrane of the small intestines, 
especially expressed in the vicinity of the solitary glands, which are surrounded 
by vascular rings, and clustered groups of vesicular glands which constitute 
Peyer's patches* This vascularity seems to be very general, involving more 
* The following tabular statement of the anatomical forms of the glands which com- 
pose the substance of the mucous membrane of the alimentary canal is mainly con- 
densed from a careful description of them by Dr. Allen Thomson, Professor of 
Anatomy in Glasgow, published in Goodsir's Annals of Anatomy, vol. i, p. 33, and 
from the descriptions of Kbiliker. The nomenclature is definite, and distinctive of 
the various forms of the glands; and it will be adhered to in all the future descriptions 
of lesions of the mucous membrane of the intestines. Much confusion prevails from 
the indifferent use of the terms vesicle, tubule, follicle, &c., as applied to the mucous 
glands in descriptions of the lesions in dysentery and fevers ; therefore it is considered 
necessary to explain exactly, at the outset, the nomenclature adopted in the text. 
I. Vesicular, Lenticular, or Pimple-like Glands-Usually closed. 
(a.) Solitary-e. g., in the palate, buccal membrane, oesophagus, and stomach; also 
found deeply imbedded in the great gut, and scattered more near the surface of the 
small gut. 
We know nothing about the comparative abundance of these glands in a healthy 
intestine; nor are we certain whether or not they disappear after a certain age, like 512 
SPECIAL PATHOLOGY-ENTERIC FEVER. 
or less of the abdominal viscera. Sensations of heat and abdominal distress 
are associated with this morbid state, and the lineaments of the belly are 
obliterated. 
II. Associated with this congestion, the gland-vesicles become obviously promi- 
nent. Increased growth of the gland-cells occurs, till the closed sacs of the 
glands become filled up with crude material. This condition is sometimes de- 
scribed as intumescence of the glands, and with the congestion just noticed 
constitutes the stage of " infarction," as described by the older authors. Symp- 
toms denoting intense irritation of the mucous membrane-catarrhal and gas- 
tric symptoms-prevail; and the mucous membrane of the small intestine 
generally is swollen, relaxed, and turgid, especially the villi, which are par- 
ticularly distinct, imbedded in a thick layer of dirty-yellow gelatinous mucus. 
Although these conditions seem to involve the whole of the mucous membrane 
in the first instance, yet they soon begin to be more expressed towards the 
lower end of the small gut than in any other part. The time at which thi^ 
increase of cell-growth commences in these glands is not yet well defined in 
relation to the day of the fever. It seems certain, however, that it occurs 
within the first week; but it may be later. A case is described by Dr. Sankey, 
in the first volume of the Pathological Society's Transactions, in which dissec- 
tion showed the growth in the glands as early as the fifth day. The bulging 
of Peyer's glands and the extent of intumescence vary considerably in differ- 
ent patches; and simultaneously with these conditions the mesenteric and 
bronchial glands begin to increase in size. They, too, are supplied with an 
increased quantity of blood, and the increased tissue of the gland becomes 
unusually soft and elastic, vascular and dark-colored. 
III. A subsidence of the general congestion, and of the generally turgid state 
of the mucous membrane, takes place after the gland-growth has been fully devel- 
oped, round which also the general redness and swelling concentrate. The growth 
continues actively, and progresses rapidly within the gland-structures till the 
patches of Peyer become so thick as to be elevated three or four lines above 
the surface of the surrounding mucous membrane. A beautiful vascular halo 
encircles them, stopping short at their margins; and a contracted border sur- 
rounds the margin of the patch, which gives it a sessile fungiform aspect, with 
an umbilicated-like depression on its surface. Growth is now confined within 
narrow limits, pressing on the muscular coat below and the mucous coat above. 
The patches assume various aspects as to color; and, when vascular, they have 
an appearance which has acquired for them the description of being like 
" fleshy lumpstheir tawny gray color showing through the peritoneum of 
the gut. Varicose vessels abound in the vicinity,-a fact of some importance 
in connection with the formation of thrombi, which may lead to hepatic or 
pulmonary embolism. The specific gravity of the mucous tissue of Peyer's 
patches is obviously changed by such increased growth, ranging from 1.032 
to 1.044. The size of the swollen solitary glands varies from that of a millet 
seed to a pea. Sometimes, as towards the lower end of the ileum, Peyer's 
patches and groups of solitary glands will be found to coalesce, so that the 
lesions may almost entirely cover six or seven inches of intestine. These 
the vesicles which compose Peyer's patches. Many of the so-called solitary glands 
seen in disease may be in reality new formations. At all events, they occur in much 
greater numbers in certain diseases than their known frequency of appearance in the 
healthy intestine would lead us to expect. 
(6.) Clustered in groups-e. g., Peyer's patches of glands in the ileum. 
II. Follicular Open Glands or Crypts-A transient condition of the vesicular 
glands, after rupture and discharge of their contents-e. g., great gut and stomach. 
III. Tubular Glands-Occur in the small and large intestines, as the so-called 
follicles of Lieberkuhn; and in the stomach, as the stomach tubes. 
IV. Racemose Glands-Consisting of tubes with simple sacs or vesicles, in clus- 
ters round a stalk or duct-e. g., the cardiac oesophageal glands, and the duodenal 
glands of Brunner. ANATOMY OF SPECIAL LESIONS IN ENTERIC FEVER. 
513 
changes are pathognomonic of enteric fever. Occasionally the increased 
growth (sometimes called "medullary infiltration"^ extends beyond the gland 
structures into the surrounding connective tissue of the mucous membrane- 
a cellular new growth which originates from the connective tissue corpuscles 
(Goodsir, Virchow). 
IV. Softening of the contents of the tumid gland-cells seems to be the next 
event in the series, and which would appear to be preliminary to one or other 
of the following: 
V. Conditions tender which the softened contents of the glands begin to be elimi- 
nated. This elimination seems to take place in one or other, or in each of the 
three following ways; conveying out of the body by the intestinal discharges 
abundance of morbid material, presumed, with great probability, to contain 
the specific virus of the fever: 
(1.) Elimination without ulceration-simply by the rupture of the hitherto closed 
gland-vesicles. This is the usual and natural way in which the vesicles of 
Peyer's patches become open follicles in the course of their normal physio- 
logical existence. For many reasons I am induced to believe that this is the 
natural, the most common, and the most frequent mode by which the softened 
new growth in cases of enteric fever is got rid of-namely, by the escape of 
the softened contents of the glands through the rupture of the vesicles in the 
ordinary way, and without destruction of the walls of the vesicle. The vesi- 
cles then collapse, and assume the appearance of little pits, depressions, or fol- 
licles, and so give rise to that " reticulated indistinctly pitted surface" so often 
seen after all evidence of gland-structure has disappeared. This view is also 
consistent with the observation of Wedl, when he says that "the glands in 
question not unfrequently burst; and the capsules also may collapse, in con- 
sequence simply of absorption of their contents. Owing to one or other of 
these occurrences, the Peyerian patches acquire the well-known reticulated 
aspect, since the mucous membrane surrounding the individual capsules as- 
sumes the form of a projecting border ; and entire patches present the appear- 
ance of a fine sieve" {Pathological Histology, p. 221). The description also 
agrees with the experience of Niemeyer, when he says that "not unfrequently 
the process becomes retrogressive ; without the occurrence of destruction of the 
wall of the follicle, or of the mucous membrane covering it, the swelling of 
the glands subsides, while their contents are reabsorbed after the cellular ele- 
ments have been destroyed by fatty metamorphosisand "in still other cases," 
he has written, " the individual glands composing Peyer's patches rupture and 
empty their contents outwardly, without the covering sloughing." As a result 
of this, the surface of the plaques looks as if full of holes, or has a netlike 
appearance {plaques a surface reticuleef 
The ordinary peristaltic action of the intestines may assist this mode of 
elimination by rupture of the vesicles, if the softening is complete. One case 
I dissected at Scutari led me first to the conclusion I have stated in the pre- 
ceding paragraph. In this case a process of growth and elimination seemed 
to have gone o® for at least one month previous to death ; and the elimination 
of the material from the patches took place without ulceration. The man 
died suddenly from aneurism of the aorta. A lull in the febrile symptoms 
had led to his premature discharge from hospital; and the day on which he 
suddenly died was to have witnessed his embarkation for England. Peyer's 
patches were in an extremely interesting condition. They were all greatly 
enlarged and obvious. In some parts of them the vesicles were greatly dis- 
tended with the material of new growth, in a milky-like condition; while 
other parts of the same patch were completely bare, and dotted over with 
minute points of black pigment (the probable remains of previous intense 
congestion). These parts were quite bare of all gland-structure, and had a re- 
ticulated appearance. 
In corroboration of this view, it is to be observed further, that Dr. Fried- 514 
SPECIAL PATHOLOGY ENTERIC FEVER. 
rich, of Dresden, considers the elimination of the deposit from the Peyerian 
patches in the enteric fever of children, by the formation of sloughs and 
ulceration, as extremely rare. For the most part, only single follicles [vesi- 
cles?] in the glandular assemblage are infiltrated, and these, either from re- 
sorption of the infiltrated material, or more often from rupture of the follicle 
[vesicle] within the intestinal canal, revert to a normal condition, without the 
formation of any cicatrix (Brit. and For. Med.-Chir. Review, July, 1858, p. 162). 
(2.) Elimination by ulceration of the swollen gland-vesicles occurs in groups 
of various sizes, involving more or less of surrounding tissue in ulceration, and 
tending to induce perforation of the gut or peritonitis. Considering the severe 
nature of this lesion, and taking into account the fact that a large proportion 
of cases of enteric fever recover, it seems to me that this is a mode of elimina- 
tion which occurs much less frequently than the mode already described. Of 
course, it is the state most frequently met with after death, and specimens of 
which are preserved in museums ; for ulceration of Peyer's patches is the char- 
acteristic "anatomical sign" of enteric fever. The time of commencing ulcera- 
tion of the mass appears to be about the ninth or tenth day (Murchison); 
and the softening of the new growth which precedes ulceration is associated 
with a return of the violent congestion to the small intestines, when the veins 
especially are filled with dark-colored, viscid blood. The outbreak of ulcera- 
tion is always characterized by an aggravation of the original symptoms, after 
it may have been sanguinely supposed that convalescence had decidedly taken 
place. But in such deceptive convalescence the abnormal temperature is 
maintained, showing with absolute certainty that the fever is not at an end. 
The ulceration therefore is usually denoted (a) by a reaccession of febrile 
phenomena, with or without diarrhoea; (6) by abdominal pains and ten- 
derness. 
Judging from post-mortem examinations, the ulceration seems to commence 
at the lowermost patches of Peyer in the glands nearest to the caecum, and the 
ileo-caecal valve is often implicated in the destruction. The ulcers vary in 
number and in extent; and although there is a tendency to perforation of the 
gut in fatal cases, yet actual perforation is not common, and peritonitis may 
supervene without perforation having actually taken place. Various state- 
ments have been made concerning the tendency of enteric ulcers to perforate 
the gut, and the frequent association of this lesion with peritonitis. Perfora- 
tion is said to be rare in the northern parts of Europe (Huss); but, from the 
following records of Drs. Louis, Murchison, and Bristowe, it appears to be a 
more frequent mode of fatal termination than has been commonly supposed in 
this country. Of fifty-five fatal cases, perforation occurred in eight (Louis); 
of fifteen fatal cases, perforation occurred in three (Murchison); of sixty- 
three fatal cases, perforation occurred in twelve (London Fever Hospital 
Records); of fifty-two fatal cases, perforation occurred in fifteen (Bristowe). 
From these data it appears that perforation occurs in about one in five fatal 
cases; and it generally takes place through the ileum near the valve. Post- 
mortem examination often discloses vigorous attempts on the part of neighbor- 
ing structures to limit by union and adhesion the results of perforation, obvi- 
ously indicating, in practice, the necessity of absolute rest throughout the 
disease. 
The characters which distinguish the ulcers of typhoid fever from other 
ulcers of the intestines may be stated as follows: (1.) They have their seat in 
the lower third of the small intestine, their number and size increasing towards 
the ileo-caecal valve. (2.) They vary in diameter from a line to an inch and 
a half-from the size of a hemp-seed or a pea to a crown piece; but a number 
of ulcers may unite to form a mass of ulceration several inches in extent. 
Such extensive masses of ulceration occur close to the caecum. (3.) Their 
form is elliptical, circular, or irregular-elliptical when they correspond to an 
entire Peyer's patch, circular when they correspond to a solitary gland, and ANATOMY of special lesions in enteric fever. 
515 
irregular when they correspond to a portion of a Peyer's patch, or when sev- 
eral ulcers unite to form one. (4.) Elliptical ulcers are always opposite to 
the attachment of the mesentery. (5.) The ulcers never form a zone encir- 
cling the gut, as may sometimes be seen in the case of the tuberculous ulcer, 
but their long diameter corresponds to the longitudinal axis of the intestine. 
(6.) Their margin is formed by a well-defined fringe of mucous membrane, 
detached from the submucous tissue, a line or more in width, and of a purple 
or slate-gray color-an appearance best seen when the bowel is floated in 
water. (7.) After separation of the slough there is no thickening or indura- 
tion of the edge of the ulcer, as in the case of the tuberculous ulcer. (8.) 
Their base is formed by a delicate layer of submucous connective tissue, or by 
the muscular coat, or occasionally by nothing more than peritoneum. (9.) 
There is no deposit of morbid tissue or new growth at the base of the ulcer; 
although sometimes fragments of yellow sloughs may be seen adhering to both 
the base and edges (Murchison, p. 547). The ulcers also are .known to heal. 
Their cicatrices have been seen four, five, and thirty years after known attacks 
of enteric fever (Rokitansky, Barrallier). And in cases where death 
occurs during a relapse, the cicatrices from the first attack may be found co- 
existing with the fresh growth in the vesicles, and with the recent ulcers of the 
relapse. As a rule, the reparative process does not commence till the end of 
the third week of the disease, and in one case, where the primary fever lasted 
three weeks, and where death occurred from complications about the fortieth 
day, all the ulcers in the ileum were cicatrized (Murchison). 
Cicatrization commences by the growth of a thin, delicate, shining layer of 
new growth which covers the base of the ulcer, and is also attached to the 
basement membrane of the mucous coat. The fringe of mucous membrane 
becomes adherent to this new tissue, from the circumference towards the centre, 
until the healthy mucous membrane merges insensibly into a serous-looking 
lamina. The new film of membrane cannot at first be moved upon the sub- 
jacent coat, but after a time it becomes movable, and, according to Roki- 
tansky, even becomes covered with villi (Murchison). There is no evidence 
of the vesicular gland structure ever being restored. The resulting cicatrix 
is slightly depressed, firmer, less vascular, and smoother than the surrounding 
mucous membrane. The bowel appears thinner at this part when examined 
by transmitted light. The depressed spot is never surrounded by any pucker- 
ing, nor does it ever cause any stricture or diminution in the calibre of the 
gut. 
(3.) Elimination of the typhoid growth by sphacelus of large masses of Peyer's 
patches. The whole gland-substance implicated in such cases is generally in- 
volved in the destruction. The cell-growth in the vesicles suddenly becomes 
so excessive that a condition is at last reached which is incompatible with the 
maintenance of life. The growth actually chokes itself; and the whole mass, 
or a great part of it, softens and dies. 
Such sphacelus has been known to happen as early as the twelfth day of the 
fever; but the process is generally more slow. A dirty yellow-brown slough 
forms, varying in thickness, and sometimes extending as deep into the sub- 
stance of the gut as to expose its muscular layer on separation of the mass. 
There is a tendency to bleeding on separation of the sloughs; and such hem- 
orrhage occurs in about one-third of the fatal cases. The frequent repetition 
of such hemorrhages during life has a marked influence in modifying the 
febrile phenomena. For example, in a case described by Dr. Parkes, in which 
the temperature was very carefully recorded three times daily, it was observed 
to fall beloiv the standard of health on the fourteenth and fifteenth days 
slightly, on the sixteenth day to the extent of 4° below 98°, on the seven- 
teenth day to the extent of 5°, on the twentieth day to the extent of 2°. These 
falls of temperature were all traceable to the influence of repeated hemor- 
rhages from the bowels. The occurrence of hemorrhage is always a most 516 
SPECIAL PATHOLOGY ENTERIC FEVER. 
alarming symptom, and is most frequent during the third and fourth weeks 
of the disease. It varies in amount from a mere stain to a large quantity of 
blood, sometimes discharged in clots, and generally of a red color, in conse- 
quence not only of the rapidity with which it is passed out, but also, as Dr. 
Parkes has shown, in consequence of the alkaline reaction of the contents of 
the intestine. It may cause immediate death by syncope; or, by reducing the 
temperattfre and strength of the patient, he may sink exhausted, unable to 
cope with the disease. Whenever, therefore, blood appears in a case of 
typhoid fever, it is certain that the lesions of Peyer's patches are severe. 
In addition to these three modes of elimination of the new growth from the 
intestinal glands, there are reasons for believing that it may be occasionally 
reabsorbed; unless such cases where resolution, independently of ulceration, 
commencing about the tenth day, may not be explained by the first method 
of elimination I have described. 
VI. The mucous membrane of the intestines having existed for several 
weeks in the state of irritation which has been described, and the catarrh being 
more or less excessive, an atrophic condition of the intestine at last supervenes. 
The mucous tubes become wasted, irregular in form and size, as seen on mi- 
croscopic examination, sometimes separated by an interstitial growth of a 
granular nature, and their bulbous ends disappear. The whole substance of 
the gut then becomes so thin that it resembles a portion of thin paper rather 
than intestine. 
VII. The mesenteric glands are invariably enlarged. They begin to en- 
large at the very commencement of the disease, gradually becoming soft, vas- 
cular, and dark-colored, and sometimes attain a very large size, and their 
stages of congestion, of swelling, and of subsidence, go on simultaneously with 
the similar changes in Peyer's patches. 
VIII. The spleen is usually greatly enlarged, varying from five or six to 
fourteen ounces (twice to six times its normal size), with a specific gravity 
varying from 1052 to 1059. Its Malpighian sacculi (glandular) are also in- 
tumescent; its parenchyma puffy, and of a dark violet or blackish-red color. 
Its capsule is intense; and in some cases (rare) it has ruptured, and so caused 
death by hemorrhage into the peritoneum. 
IX. Thoracic lesions occur (1) as infiltrations of the lungs, or (2) as the 
consolidation of pneumonia, or (3) as portions of lung which have become 
carnified, (4) as enlargement of bronchial glands similar to those of the mes- 
enteric, (5) bronchial catarrh, (6) laryngeal or bronchial ulceration. 
In the first-mentioned form of lesion the growth seems to commence in the 
terminal air-vesicles, ultimately assuming the form of a miliary deposit, with 
a semitransparent gelatinous appearance. It is the irritation set up by this 
sudden growth which generally gives rise to pneumonic consolidation. Soften- 
ing and friability of the pulmonary texture is thus a very constant post-mortem 
state in protracted cases of enteric fever. Such lesions usually supervene 
during the later period of the fever, and when the ulcerations of the intestines 
are extremely spread (Huss). In this respect only it differs from the consoli- 
dation of the lung described in typhus fever. This lesion has been also 
termed non-granidar consolidation, dependent for its origin and development 
on a specific cause; and it may be observed not only in the course of enteric 
fever, but in measles, scarlet fever, and small-pox. A portion of the lung in this 
condition has a mottled aspect. There are patches in it here and there, vary- 
ing in size from a single lobule to half, or more than half, of a lobe, of a deep 
bluish-chocolate, violet, or purplish-slate color, bounded by a well-defined 
-angular margin, and crossed and mapped out into smaller patches by dull, 
opaque, whitish lines. These are seen to be thickened lobular septa. Scattered 
in the midst of the larger patches one or more comparatively healthy lobules 
are frequently found, of a pale brightish-pink color, contrasting strongly with 
the hue of the surrounding tissue. The pleura which covers the part may ANATOMY OF SPECIAL LESIONS IN ENTERIC FEVER. 
517 
have a slight milky-like aspect (Sir William Jenner). It is also extremely 
probable that much of these thoracic lesions in such cases may be due to the 
direct passage of fibrinous particles from the large veins surrounding the dis- 
eased intestinal glands (in the case of enteric fever); for clots thus tend to form 
in the bloodvessels, near the site of irritation-they break up, the blood becomes 
contaminated, and the phenomena of embolism supervene. Such dangerous phe- 
nomena may be looked for from about the fourteenth to the twenty-first day. 
The tissue of the darker portions of the lungs appears tougher than in 
health, presenting nearly a uniform section; there is no appearance of granules, 
and the part sinks in water. Sir William Jenner has injected such morbid 
lungs, and found that occasionally the centre of the lobule is really the point 
at which the diseased action is first set up. The development of the new 
material appears to be very deficient; molecular granular matter and delicate 
minute cell-forms compose its structure; and the specific gravity of the part 
is greatly increased (1.040 or more). Its color is generally slate-gray or flesh- 
like ; and the lesion is commonly limited by a vascular boundary, forming 
something like a distinct line of separation between comparatively healthy 
texture and local lesion. 
Carnification of the pulmonary tissue occurs often in considerable portions 
(Walshe). The general debility of the typhoid state seems to favor the 
occurrence of pulmonary collapse-a state of atelectasis from collection of secre- 
tion or swelling of the mucous membrane of the bronchi leading to the col- 
lapsed air-vesicles, and rendering the passage impervious to air-a condition 
which must not be confounded with the hepatization of pneumonia. The 
bronchial glands are swollen and vascular, having an appearance similar 
to that of the mesenteric gland lesions. 
The tracheal glands, and those of the bronchial mucous membrane are also 
affected. 
There is generally a great tendency to ulceration of mucous membranes in 
typhoid cases,-ulceration of the pharynx occurs in about one-third of the 
cases; of the larynx and oesophagus in one out of every fifteen cases; and 
the mucous membrane of the colon becomes implicated in seven out of twenty 
cases. Louis found the colon affected (coIotyphus') by the second week in two 
out of fourteen cases, by the third week in six out of twenty-three cases, by 
the fourth week in four out of fifteen cases, and between the fifth and tenth 
week in one out of two cases. The solitary glands of the colon then undergo 
the same changes (pari passu) as those of the small intestine. Far more rarely 
the process extends to the jejunum and solitary glands of the duodenum and 
pyloris. There is also a tendency to periceecal abscess, preceded by the phenom- 
ena of the morbid state known by the name of peri-typhlitis, or inflammation 
of the areolar connective tissue surrounding the caput caecum. 
Growth of Tubercle during Enteric Fever.-There is still another pulmo- 
nary condition which frequently occurs in enteric fever, and which may either 
complicate the progress of the case, or come on subsequently to the fever. It 
is the development of tubercle. Usually when recovery takes place from 
enteric fever it is complete; but in some cases, especially where there is heredi- 
tary predisposition to scrofula, an impetus or tendency seems to be given to 
the development of tubercles in the lungs. If the physical signs of bronchitis 
continue beyond the thirtieth day, or fourth week, combined with hurried and 
difficult breathing, and with the signs and symptoms of great irritation of the 
lungs, then there are good grounds for suspecting that the deposition of tuber- 
cle has commenced in the lungs. Dr. Stokes gives two sets of cases in which 
this deposit takes place. In one set a great quantity of tuberculous matter 
seems to be formed during the existence of the fever; and although, some- 
times, such an occurrence may not have been suspected, yet the expectoration 
of pulmonary calculi, at periods of different duration after the convalescence, 
furnishes strong proofs that such a lesion had taken place. In other cases. 518 
SPECIAL PATHOLOGY ENTERIC EEVER. 
again, the cure may be effected through absorption, or by suppuration of the 
minute tuberculous points over the mucous surface of the bronchia. A doubt- 
ful convalescence, a quick pulse, and a hectic state, suggest such a state of 
things, especially when combined with persistent bronchitis. 
Erysipelas, phlebitis, parotitis, and such-like local inflammations, are not 
uncommon in cases of enteric fever. Such lesions may be excited by cold 
simply; but the absorption into the blood of putrid substances, from the 
ulcerating patches of Peyer or other diseased parts, may be usually, and 
probably correctly, considered to be the cause of most of the secondary inflam- 
mations already noticed to occur in cases of enteric fever. Dr. Parkes con- 
siders it probable, however, that deficient urinary excretion may have a share 
in their production. (Parkes On the Urine, p. 254.) 
Such are the more obvious secondary affections which may develop them- 
selves during the progress of enteric fever, and the derangements which these 
give rise to constitute new phenomena in its course. In some severe cases, 
however, the fever may destroy the patient in a few days, without leaving a 
trace of organic lesion in any part of the body. 
These secondary affections just noticed all arise after the fever has existed 
some time ; and it appears now to be pretty well established that the intestinal 
lesion at least is a special growth, which, in cases of recovery, follows first a 
progressive or developmental course, and afterwards retrogrades; just as in 
variola we first observe the development and maturation of the pustule, and 
subsequently its disappearance. The same may be said of the other local 
lesions in enteric fever, although the existence of a special growth is not yet 
so fully established in the case of the thoracic and cerebral lesions, or in the 
parenchymatous, as compared with the mucous structures of the intestine; 
still, it is believed by some that an action more or less analogous to that 
which occurs in the glands of Peyer and the minute solitary closed vesicles of the 
ileum, occurs also in all the secondary lesions of enteric fever in other parts 
(Dr. Stokes). Specific characters of the elements composing the growth 
cannot be shown to the eye even by microscopic examination. There is noth- 
ing in the new growth to distinguish it from other elementary morbid products 
which are deficient in the power of organization. Dr. Stokes gives the best 
illustration of its vital specific attributes, in the absence of any physical specific 
character. He says, if two specimens of pus be taken, one from a pustule of 
variola, the other from an ordinary ulcer, although they may appear similar, 
they have separate and different vital characters. So has the poison of enteric 
fever a specific vital attribute peculiar to itself. 
The nature of this so-called "typhoid deposit " has been the subject of much 
discussion. It is a new growth rather than a deposit or infiltration; and is, 
in the first instance, confined to the gland-elements, and seems really to con- 
sist in a directly continuous development of the pre-existing cell or germinal 
elements of the diseased glands. Eventually it pervades the submucous 
areolar tissue as a yellowish-white substance, deposited or infiltrated in a layer 
beneath the gland-tissue, and above the muscular coat. The late Professor 
John Goodsir, in his descriptions of the morbid anatomy of the cases he dis- 
sected at Anstruther, in Fifeshire, was the first to point out that the new growth 
was in the first instance confined to the interior of the closed vesicles, which 
became much distended thereby. They ultimately burst, and discharge their 
contents either into the cavity of the intestine, or into the submucous tissue, 
if the vesicles rupture at the base, as in the severe and unfavorable cases ; and 
if the vesicle is completely destroyed and falls out, or if many of them do so, 
a number of little pits are left, which correspond to the sites of the vesicles. 
The new growth has no specific structure to distinguish it from other morbid 
growths (Wedl, Virchow, and others); and although a specific "typhous 
cell" has been described and figured by Gruby, Vogel, Bennett, and others, 
its existence is not proven as microscopically characteristic. SYMPTOMS, COURSE, AND DURATION OF ENTERIC FEVER. 
519 
The development of the new growth in the glands begins like a simple 
hypertrophy (or hyperplasia rather) of the gland-cells. Nuclei and cells 
exist in great abundance, which afterwards degenerate into the abnormal dis- 
eased product which constitute the masses of new growth so pathognomonic of 
enteric fever lesion. No forms arise capable of sustained existence; but a 
directly continuous development from pre-existing cell or germinal elements 
of the glands, the follicles, and the connective tissue, furnishes the material 
of the mass (Goodsir, Virchow). An increase in the colorless corpuscles 
takes place in the blood, and deposit of pigment in the ganglia of the Sympa- 
thetic nerve-system (Virchow). When the gland-vesicles burst, the exuber- 
ance of new growth gives a fungating appearance to the part; and when the 
rose-red tumor is cut into, a milk-like turbid juice exudes: and in this juice 
many new-formed elements may be seen, consisting of cells, mostly oval or 
angular, with single eccentric nuclei-sometimes with many nuclei. The cell- 
contents are finely granular, and fat globules may conceal the nucleus. The 
growth must be examined before ulceration commences; for, as softening ad- 
vances, a viscid fluid with a bloody tinge, containing fine molecular elements, 
is all that remains, with decaying blood and blood-crystals. 
Symptoms, Course, and Duration.-Enteric fever begins gradually-often, 
indeed, so very insidiously that its commencement is not always able to be 
fixed, being preceded for days or weeks by indefinite feelings of general 
illness, mental depression, great dulness and relaxation, loss of appetite, indi- 
gestion, restless sleep, disturbed by dreams, headache, dizziness, wandering 
pains in the limbs, usually considered rheumatic, and repeated epistaxis 
(Niemeyer). 
When the commencement can be fixed, it is found that the fever proper 
may be ushered in with a distinct chill or rigors, or profuse diarrhoea. The 
chill is rarely so severe or continued as in the malarious fevers, or in pneumo- 
nia. Amongst the earlier symptoms, the most characteristic are the abdomi- 
nal pains and diarrhoea, which continue to increase. [There is early muscular 
debility, shown by the staggering walk, and, subsequently, by dorsal decubi- 
tus.] The countenance indicates anxiety, [and has a distinctive besotted ex- 
pression ;] the mind continues clear, [but intelligence soon becomes weakened, 
and questions often have to be repeated before they are understood or an- 
swered ; this partly depends on dulness of hearing, which with ringing in the 
ears, is very common ;] but delirium, when present, is generally active. The 
patients are vivacious and disposed to leave their beds. [Frontal headache 
is a constant initial symptom, and often insomnia.] The conjunctivae are 
pale, the pupils dilated, the cheeks somewhat flushed, and epistaxis not sel- 
dom occurs at repeated intervals during the first week. The belly enlarges, as 
in mesenteric disease, and is resonant on percussion. Gurgling on firm pressure 
may commonly be detected in the right iliac fossa, and there is often tender- 
ness in the same situation, [with pain on pressure around the umbilicus.] 
From the seventh to the fourteenth day the characteristic eruption appears. 
As a rule, the flushing of the face is more marked towards evening; but the 
complexion does not get muddy, as in typhus, and the flush of the cheeks is 
bright and pinkish-not dark-red-and is often circumscribed, and then 
strongly contrasts with the surrounding pale skin. 
During the third week the abdomen becomes more distended; the diarrhoea 
(which is due to catarrh and not to ulceration) increases, the stools often 
amounting to five, six, or even eight and ten, or even twenty a day. Three to four 
stools a day is about the usual amount in a favorable case. They are liquid, 
pale brownish-yellow, with flocculi of an opaque whitish-yellow color 
floating through them like coarse bran, or like badly cooked pea soup, in 
which the meal is not thoroughly cooked or mixed and sinks to the bottom ; 
and as the patient loses strength these stools are passed involuntarily. Pain 520 
SPECIAL PATHOLOGY-ENTERIC FEVER. 
is rarely complained of unless perforation of the gut occurs; and hemorrhage 
from the bowel is an occasional symptom during the third or fourth week. 
The frequency of the pulse often varies much from day to day, without any 
appreciable coincident alteration in the general or local symptoms. It is 
generally soft, sometimes feeble and slow relatively to the height of tempera- 
ture. This slowness of the circulation has no doubt to do with the tendency 
to the development of bed-sores. In such cases (which are generally pro- 
longed) the healing of the intestinal lesions are retarded, and as the patient 
becomes weaker, he slips down in bed, and bed-sores may begin to form over 
the sacrum, or trochanters, or elbows, or knees, often causing great destruction, 
and they are even produced if the patient is laid on his belly (Niemeyer). 
Emaciation in such cases becomes excessive, and the pallid skin is constantly 
bathed in perspiration. The gums and lips become pale and bloodless, and 
oedema of the limbs may supervene. 
The tongue at first is red and fissured, but ultimately becomes dry and 
covered with a pale-brown fur. At first the tongue is rarely thickly coated, 
but it is broad and moist, showing the impressions of the teeth along its edges 
(oedematous). The coating consists of a thin whitish epithelium, through 
which the papillae may project as red points. Afterwards it becomes coated 
with a rough slimy mucus. The coating generally falls off after the fifth or 
sixth day, leaving "a moist, red, smooth tongue, that looks as if covered with 
goldbeater's skin, or else is already inclined to dryness. If there be at first a 
thick, adherent coating on the tongue, it is usually detached from the point 
posteriorly, and from the sides towards the middle, so that the whitish-yellow 
coating appears inclosed in a very red border, which constantly increases in 
width. But in some cases the detachment of the coating begins centrally, so 
that in the middle of the tongue there is a red stripe, that has a peculiar ten- 
dency to become dry, and at the sides two whitish-yellow, moist, slimy stripes. 
The central stripe is often broad anteriorly, and disappears posteriorly, so 
that on the point of the tongue we see a red triangle with the apex poste- 
riorly" (Vogel, Niemeyer). 
The splenic dulness is generally increased. The enlargement of the spleen 
is generally well marked towards the end of the first week. The enlarged 
organ usually assumes the horizontal position. It rarely projects beyond the 
ribs, and is apt to be pressed upwards and backwards against the spinal 
column by the distended intestines. Hence the enlarged spleen of enteric 
fever is rarely to be reached on palpation, and even when it can be touched it 
is dangerous to attempt to define its outlines with any degree of pressure, for 
it is so soft. If the patient is laid on his right side, with the left hand over 
his head, then, on percussing the lower ribs of the left side, a dull space may 
be detected, about six inches long by four inches wide, corresponding to the 
eighth, ninth, and tenth ribs, and reaching from the spinal column posteriorly 
to the margins of the ribs anteriorly. It is the region of splenic dulness 
(Niemeyer) ; but only a small part of a very large spleen may be thus detected. 
Pulmonic complication is not uncommon. 
[The duration of convalescence is generally proportionate to the sharpness 
of the attack : when this has been severe and protracted, and the prostration 
great, strength is slowly gained, and recovery very gradual. Emaciation is 
often excessive at the beginning of convalescence. Painful oedema of the 
lower extremities, rarely extending to the arms and face, and loss of the hair 
of the head, are frequent. In many cases, the hearing remains dull for some 
time, particularly when there has been a purulent discharge from the meatus. 
Gastric disorder may suddenly arrest convalescence, digestion becoming dif- 
ficult, the skin hot, and the pulse quick; it may usually be traced to some 
imprudence of diet, and abates after a day or two. Abscesses, eschars, erysipe- 
las, and successive crops of boils on the trunk and extremities, often lengthen 
convalescence. A persistent frequency of pulse may last for some weeks. SPINAL SYMPTOMS IN TYPHOID FEVER. 
521 
Anaemic vertigo is not uncommon after a protracted attack, especially when 
proper nourishment has been deficient. Paralysis, dependent on defective in- 
nervation, both of sensation and motion, may happen. Softening of the cornea 
has been noticed.] 
In cases that recover, a remarkable fatuity remains behind long after recov- 
ery; and there appears to be some diminution of intellectual power for some 
time after convalescence is restored. Dr. Jenner has seen many cases in 
which childishness of mind remained for more than a month after apparent 
restoration to health. The patient generally wakes up as it were from the 
fever a complete imbecile. The whole man is changed. He seems to have 
renewed his youth. Childhood and infancy return, and the greatest care is 
necessary to prevent untoward events. 
[Spinal Symptoms in Typhoid Fever.-Whilst intercurrent nervous affec- 
tions in typhoid fever, referable to the brain, cerebro-spinal system, and the 
sympathetic, have been fully described by writers, those due to the spinal cord 
alone, have either had but slight recognition, or been passed by, and have gen- 
erally failed to receive any precise, or physiological interpretation. That they 
have been observed from time to time for many years is shown by looking 
over the vast bibliography of typhoid fever, and most physicians who have 
had large experience of this disorder cannot but have frequently met with 
them. To the late Dr. Fritz, of Paris, is really due the credit of having first 
studied understandingly these nervous phenomena in typhoid fever, referable 
to the spinal cord, and clearly establishing their true pathogeny. Certain 
symptoms happen occasionally in the course of typhoid fever, which show 
more or less disturbance of the functions of the spinal cord. They have been 
referred generally to spinal or cerebro-spinal meningitis. They should not 
be confounded with the consecutive cerebral disorders already mentioned. 
Their recognition and appreciation are important both as regards diagnosis 
and prognosis. Of irregular occurrence, they are much more common at one 
time than at another, being more frequent when typhoid fever is epidemic, 
and when malarial toxaemia is a complicating element; and are most often 
met with in children, women, and anaemic individuals. Of 44 patients (30 
males and 14 females) admitted into the wards of Dr. Tardieu, at the Lara- 
boisiere Hospital, Paris, from the 31st of July to the 23d of October, 1863, 
with typhoid fever, spinal symptoms were present in 26 (13 males and 13 
females). The average age in 12 females was 23 years, and in 13 males 22 
years. Of 31 observations collected by Fritz, 13 were between 5 and 13 
years, and 18 between 17 and 40 years; of whom 11 were aged 20 years or 
under, 3 were between 20 and 30 years, and 4 between 30 and 40 years. 
Spinal symptoms in typhoid fever maybe initial, or they may be developed 
in the progress of the disorder. They maybe transient or persistent. When 
prodromic, and of exceptional severity, they may be predominant and alone 
fix the attention of the patient, being the illness of which he complains, and 
for which he seeks relief. They are marked by aching pains in the lumbar, 
dorsal, or cervical regions, particularly in the back of the neck, radiating to 
the occiput, and interfering with the motions of the head and neck ; shooting 
pains in the limbs, most often the legs; with a feeling of stiffness and numb- 
ness in the muscles, especially those of the jaw; and more or less cutaneous 
and muscular hypersesthesia. These may subside on the development of the 
disease, or continue to the middle or end of the first week, and then cease; or 
they may last quite through the disorder, and even reach to convalescence. 
Again, but more rarely, they may appear during any stage of typhoid fever. 
These nervous troubles have two distinct origins: one set of phenomena is due 
to functional derangement of the spinal cord proper, and the other to that of 
the medulla oblongata. Beginning with those referable to the spinal cord 
proper, they may be arranged under two heads: (1.) Derangements of the 
sensory functions; (2.) Derangements of the motor functions. Derange- 522 
SPECIAL PATHOLOGY - ENTERIC FEVER. 
meats of the sensory functions are of three kinds: (a.) Exaltation of func- 
tion,-hypersesthesia and spontaneous pains; (6.) Perversion of function,- 
abnormal sensation of cold or heat, prickings and formillation in the extremi- 
ties and along the spine; much more rare than the first variety, and, usually, 
when present, associated with it. (c.) Diminution or abolition of func- 
tion,-the several degrees of analgesia and anaesthesia, cutaneous and mus- 
cular. 
Hyperaesthesia may be limited to the skin, or to the muscles, or both may 
be affected. Cutaneous hyperaesthesia may extend over a considerable por- 
tion of the body. Its site is often the skin of the abdomen, or of the extremi- 
ties, or conjointly, the lightest pressure, or the merest touch being intolera- 
ble ; when it is of less degree it may be provoked by gently pinching a fold of 
integument, or passing the finger over the internal face of the tibia, about the 
malleoli, or the condyles of the femur. Next in frequency we have increased 
sensibility over the spinous processes, sometimes reaching from the atlas to the 
sacrum, and soifietimes limited to a single apophysis, and induced by pressure. 
There may be severe aching pains in the muscles, generally of the lower 
limbs; .or rachialgia, radiating to different parts of the body, and increased 
by any movement; violent pains in the chest and waist; and neuralgia, which 
is commonly symmetrical. Both cutaneous and muscular hyperaesthesia may 
be chiefly complained of toward evening, when the body-temperature rises. 
Its progress is generally regularly ascending, and it disappears in inverse 
order. 
Dr. Robert Law, of Dublin, thus graphically describes the spinal symptoms 
which were observed in the Famine Fever of 1848 : " The most common and 
loudest complaints of our patients was an aggravation of what the subject of 
fever generally describes as pains in the bones, but which really means pains 
in the course of the spinal nerves. While in former fevers this complaint was 
seldom more than that of a contused or bruised feel, or of such a sense of dis- 
comfort or fidgety restlessness as the French so significantly express by the 
term malaise, here the individual in many cases seemed to suffer as intensely 
as in the severest cases of acute rheumatism. These pains were more or less 
general in different patients. In some they affected the back of the head and 
neck ; in some they only ran down the legs ; while in others they spread them- 
selves through the whole body, and embracing the sides, imparted the sensa- 
tion of painful constriction. The nape of the neck and across the loins were 
the points to which the patients most frequently referred their pain" {Dublin 
Quarterly Journal of Medical /Science, Nov., 1849). 
Derangements of the motor functions are: numbness of the extremities, 
paraplegia, partial paralysis of the respiratory muscles, retentiqn of urine, 
paralysis of the sphincters, spasm, or irregular contraction of the muscles of 
respiration or of the extremities, and muscular rigidity, particularly of the 
muscles of the neck and limbs. The special group of nervous symptoms orig- 
inating in the medulla oblongata, are: extreme breathlessness, not due to 
any morbid condition of the organs of respiration, spasm of the pharynx and 
larynx, convulsive cough, aphonia, glossoplegia, spasmodic or rhythmic con- 
traction of the sterno-cleido-mastoid and trapezius muscles, and paralysis of 
the pharynx. 
When a patient with typhoid fever has died after or during the occurrence 
of the spinal symptoms just described, no appreciable material lesion has been 
found in the cord or its membranes. In a very limited number of cases 
can these symptoms be referred with any strictness to a congestion of the cord 
(Fritz). 
When the spinal symptoms of typhoid fever have been very marked and 
severe, and especially when they have been associated with cerebral disorders, 
they have sometimes led to an error of diagnosis; and there is no doubt that 
there is a good deal of analogy between them and many of the phenomena of SYMPTOMS, COURSE, AND DURATION OF ENTERIC FEVER. 
523 
cerebro-spinal meningitis, and at times, it must be owned, a differential diag- 
nosis is difficult. As a general rule a mistake can be easily avoided by con- 
trasting the integrity of some of the functions of the cord with the great per- 
version of others; by the mobility of the symptoms and their irregular 
succession ; by the presence of the distinctive features of the idiopathic fever; 
the difference in the invasion, sudden in the one, gradual in the other; and 
the expression of face, anxious and betokening suffering in cerebro-spinal 
meningitis, besotted in typhoid fever.] 
Enteric fever is perhaps the most treacherous of all diseases, and from what 
has been written regarding its pathology and morbid anatomy, it may be 
confidently stated that no man can be considered as fit for work, or 
FOR GENERAL MILITARY SERVICE, FOR THREE OR FOUR MONTHS AFTER AN 
ATTACK OF SEVERE ENTERIC FEVER. 
With regard to the symptoms generally of enteric fever, it is of great prac- 
tical importance to be constantly alive to the fact that no necessary connec- 
tion exists between the intensity of the general symptoms of the disease and 
the extent of the intestinal mischief which may supervene, or the absolute 
danger of the case. Two cases, out of several related by Dr. Bristowe, show 
that the patients (men) carried on their daily avocations (typhus ambulato- 
rius'), so mild seemed the disease to be, up to the very moment of fatal perfo- 
ration of the gut. Indeed the most suddenly fatal cases seem to be the very 
cases in which strongly marked febrile phenomena do not occur. In a case 
related by Dr. Murchison, a man twenty-one years of age died on the twenty- 
fifth day of the fever. Up till the twenty-third day there were no symptoms 
to indicate danger. He suffered from very slight diarrhoea; the pulse seldom 
rose above 90; and the patient could get out of and into bed. About forty- 
two hours before death the pulse rose to 120, associated with sudden pain in 
the lower and right side of the abdomen. Profound collapse indicated that 
perforation had ensued, and death soon followed. The very slightness of the 
symptoms ought, therefore, to rouse suspicion, knowing, as we now do, that, 
associated with the characteristic eruption, the following four sets of phenom- 
ena may be all that precede a fatal hemorrhage or peritonitis, namely,-(1.) 
An elevation of temperature towards evening of only 1° or 2° above 98° 
Fahr.; (2.) Moderate increase towards evening in the fulness and quickness 
of the pulse; (3.) A little headache during the first six days; (4.) Scanty 
urine. 
Again, the physician must keep in view the fact that relapses of all the 
symptoms, including the eruption, not unfrequently supervene. He must not 
be betrayed into the belief that danger is past if towards the eighth or tenth 
day, the little headache that prevailed may pass away, and the other febrile 
phenomena just mentioned may subside. It is on record that events such as 
these have led to the belief that convalescence from a mere "febricula" had 
been established, leading to the discharge of the unfortunate patient from 
hospital. His vocation, if a soldier, would then compel him to undertake 
severe duties during the actual height of a severe disease, made more danger- 
ous and perhaps fatal by such a mistake. 
Another symptom, often very painful, is meteorism, or the accumulation of 
air in the large intestine. This is present in a greater or less degree in one- 
half of the cases, and when considerable it always marks a grave affection, 
and one generally fatal. On the contrary, the abdominial muscles are, in a 
few cases, tense and strongly contracted. It is, however, the experience of 
all physicians that there is no condition of enteric fever so low, and no symp- 
toms so severe, from which the patient may not recover; and, on the other 
hand, there is no case of this form of fever so slight that it is to' be considered 
free from danger. The prognosis must therefore be cautious, because perfo- 
ration of the intestine may follow the mildest case, and death from peritonitis 
ensue. 524 
SPECIAL PATHOLOGY-ENTERIC FEVER. 
The symptoms of typhoid fever cannot be said to be fully expressed till the 
characteristic eruption has appeared. 
The Eruption consists of the so-called rose spots peculiar to typhoid fever, 
the "taches rosees lenticulaires " of Louis. They begin to appear from the 
sixth or seventh to the twelfth or fourteenth day of the disease, very rarely 
later, and still more rarely at an earlier period than the sixth day. A very 
delicate scarlet tint of the whole skin, closely resembling the skin of a person 
soon after leaving a hot bath, sometimes precedes, by a day or two, the char- 
acteristic eruption of typhoid fever, and this is important to remember, 
because it may be mistaken for the rash of scarlet fever, especially if sore 
throat is present. The eruption consists of slightly elevated papulae or pim- 
ples; but, to detect their elevation, the finger must be passed very delicately 
over the surface of the skin, because, although pimples, they are not hard, 
like the first day's eruption of small-pox. Their apices are neither acumi- 
nated nor flat, but invariably lens-shaped or rounded, and the bases gradually 
pass into the level of the surrounding cuticle. No trace of vesication can be 
detected on their apices. They are circular, and of a bright-rose color, the 
color fading insensibly into the natural hue of the skin around. Their 
margin is never well defined. They disappear completely, on pressure, resuming 
their characteristic appearances as soon as the pressure is removed. These 
characters they preserve from their first appearance to their last trace. They 
leave behind no pit, scar, or stain. They vary in size, but their usual diame- 
ter is nearly 2 lines, but varying from 1 to 2|. The ordinary duration of 
each papula is about two days, but its existence varies from two to six days, 
and fresh ones generally make their appearance every day or two after tjae 
first appearance of eruption, and they continue to appear in successive crops 
till the twenty-first or twenty-eighth day of the disease. Sometimes only one 
or two are present at first, after which one or more fresh ones make their 
appearance. The eruption of such spots does not consist of a great number 
at one time-only from six to twenty. [Though the abundance and persist- 
ence of the eruption have no relation to the severity of the attack, yet when 
it reappears in successive crops, an aggravation of the general symptoms will 
be noticed with each recurrence.] The eruption occupies usually the abdo- 
men, thorax, and back ; but may be present on the extremities, and is some- 
times, though rarely, so thickly seated that scarcely an interval of normal 
cuticle is left between. This successive daily eruption of a few small, 
VERY SLIGHTLY ELEVATED, ROSE-COLORED SPOTS, DISAPPEARING ON PRES- 
SURE, EACH SPOT CONTINUING VISIBLE FOR THREE OR FOUR DAYS ONLY, IS 
PECULIAR TO AND ABSOLUTELY DIAGNOSTIC OF TYPHOID FEVER. 
[Though far from contesting the semeiological value of the papillary rose 
eruption in typhoid fever, there is no doubt that it is often wanting. In 70 
cases Chomel found it absent in 16, though carefully looking for it in every 
stage. In 70 cases observed by Flint, the eruption existed in 49, and he found 
the proportion varied in different years. In some epidemics they are common, 
in others rare, or wanting. Trousseau states that they have never been ob- 
served in any epidemic of typhoid fever in Touraine (France). Racle, Traite 
de Diagnostic Medical, Paris, 1864, believes antiphlogistic treatment at the 
outset of the disorder prevents their development, and states that, for this 
reason, they are rarely met with in the wards of Dr. Bouillaud in La Charite 
at Paris.] 
The eruption is, however, often so scanty that the physician may justly 
hesitate for a day or two to make a diagnosis. The first crop of the eruption 
is rarely quite decisive; but as soon as successive crops, even of two or three 
spots each, appear, all doubt is removed. When the eruption is scanty, it is 
advisable to surround each individual spot with an ink line, in such a way as 
to distinguish accurately the period of its appearance (W. T. Gairdner). 
It is the occurrence of this eruption which clenches the diagnosis; and which BODY-TEMPERATURE IN ENTERIC FEVER. 
525 
becomes absolute, as regards typhoid fever, when, in a febrile disease attended 
by diarrhoea, or simply looseness, unequivocal rose spots appear on the sixth 
or eighth day. If they do not appear, then the diagnosis cannot be said to 
be complete till the case has been watched for several days, and the age of 
the patient and the history of the illness have been fully and carefully studied. 
In children between one and five years of age the phenomena do not seem to 
be so easily observed as in adults. 
[A miliary eruption frequently appears in typhoid fever, from the eleventh 
to the twentieth day, consisting of groups of small, transparent, prominent 
vesicles, like congealed tears (sudaminafi, its site is the front of the neck, 
epigastrium, chest, bend of thighs, and anterior part of armpits; but it may 
extend over the trunk and extremities. It must be looked for sidewise and 
very near. Its diagnostic value is slight, as it is to be found quite as often 
in acute rheumatism, pyaemia, puerperal fever, &c. 
Occasionally we meet with clear, pale-blue, or slaty-colored oval spots 
(Piedagnel, Forget, Davost), like partially effaced ink-stains (taches om- 
brees, taches d'encre, taches bleuatres), not prominent, sometimes even appar- 
ently slightly depressed, unaccompanied with itching, and not affected by 
pressure. They form and disappear slowly, last for some time, fading one 
day and deepening the next; few in number, from four to ten ; they are found 
on the abdomen, upper part of thighs, base of thorax, and rarely on the ex- 
tremities. The time of their appearance is variable, being sometimes as early 
as the first week. They would seem to be more common in certain epidemics 
than in others. Some observers have regarded them as a species of ecchy- 
mosis, and the first stage of petechise, and connected with the blood lesion ; 
but one of many objections to this view is that when present it is constantly 
in light cases. Though, it is believed, peculiar to typhoid fever, their rarity 
takes from their diagnostic importance.] 
Typhoid Fever in Children.-It has been now clearly established that ty- 
phoid fever is by no means an unfrequent disease amongst children, and has 
been often described under the name of "Infantile remittent fever." [It occurs 
sometimes epidemically. This has been noticed at the Children's Hospital at 
Paris, and Dr. Rilliet saw an epidemic typhoid fever in a small village near 
Geneva (Switzerland), which attacked children only.] Boys seem to be more 
liable to attack than girls. [Of 121 cases recorded by Rilliet and Barthez, 
81 were boys and 31 were girls; and of 121 observed by Taupin, 86 were 
boys and 31 girls.] It is most frequent between six and eleven years of age; 
and from five to nine seems the period of greatest liability. Its occurrence is 
rare during the first years of life. Nevertheless, it is on record at the follow- 
ing very early ages : namely, between two and three months ; three months ; 
six months; seven, ten, and thirteen months (Wunderlich, Hennig, Fried- 
rich, Rilliet). The author of a very interesting Review on the enteric fever 
of children, in the British and Foreign Medico-Chirurgical Review for July, 
1858, p. 161, mentions, in his own experience, the occurrence of enteric fever 
in a girl one year and seven months old; and also in a boy two years of age. 
The chief symptoms of enteric fever in the child are-[epistaxis], splenic 
enlargement, diarrhoea, meteorism, gurgling in the course of the colon ; asso- 
ciated with pyrexia, quickened respiration, bronchial catarrh ; delirium, som- 
nolency. [The tongue, though dry, is rarely fissured or cracked; retention of 
urine is infrequent; vomiting, particularly at the outset, is common. Perito- 
neal perforation, intestinal hemorrhage, and gangrene of the intestine, seldom 
happen ; otitis often occurs.] The eruption already described, and sudamina, 
are nearly constant in children after five years of age. The rose-colored 
spots are especially frequent on the back and the extremities, so that, if the 
abdomen and chest only are examined, their presence may often not be 
apparent. 
The Temperature during Typhoid or Intestinal Fever.-Wunderlich has 526 
SPECIAL PATHOLOGY-ENTERIC FEVER. 
given a summary of results derived from the observation of 700 cases of ty- 
phoid fever, investigated thermometrically (ArcA der Heilk., vol. ii, 1861, 
p. 433; also, Edin. Med. Journal, Nov., 1862, p. 465). 
The course of the disease is typical, and the type is characteristic, distinguish- 
ing enteric fever from every other disease; and when irregular cases occur, 
irregularity may sometimes be traced to a special cause. 
The course of the disease shows two sharply bounded distinct periods, which 
correspond to the deposition and reabsorption of the new growth within the 
intestinal glands. These periods seem to agree with certain portions of time, 
and correspond to the first and last half of the disease. In mild cases the first 
period lasts about a week or a week and a half, in severe cases it extends to 
two, three, or three and a half weeks; so that the entire disease (measured by 
the records of temperature) lasts five, six, or occasionally from eight to ten 
weeks. The mode of accession is pretty nearly the same, in mild as in much 
more severe cases. Increase of temperature to the extent of two degrees in 
the evening and remissions to the extent of one degree in the morning follow 
one another for about three days, the temperature every morning and every 
evening being about 2.2° Fahr, higher than on the preceding morning and 
evening, while' the morning temperature is generally about 1.1° lower than 
that of the previous evening; or, according to the following formula: 
First day, morning, 98.5° ; evening, 100.5° ; second day, morning, 99.5° ; 
evening, 101.5° ; third day, morning, 100.5° ; evening, 102.5° ; fourth day, 
morning, 101.5° ; evening, 104° Fahr. In the second half of the week the 
evening temperature is from 103° to 104°-the morning temperature about a 
degree lower. On the third or fourth day the fastigium or height of the fever 
is attained, when the temperature in the evening amounts at least to 103.5° 
Fahr. By the end of the first week the patient becomes very weak and is 
much prostrated, with great thirst and no appetite. From this time onwards 
the fever proceeds in regular stages of weekly and half-weekly periods. 
When, therefore, the temperature on the first or second day reaches to 104°, 
or where in a child or in an adult the evening temperature, between the fourth 
and sixth days, does not rise to 103°, where, in the second half of the first 
week there is considerable abatement of the evening temperature, we have in 
such cases certainly not to do with typhoid fever. On the other hand, the dis- 
ease may always be recognized when there is in the evening hours a persistent 
elevation of temperature; and a decided increase of temperature during the 
first week is generally an unfavorable sign, while a slight increase is favorable. 
During the second half of the first week both mild and severe cases follow 
the same course, so that, for the purposes of prognosis, the- determination of 
temperature is of little consequence during the first week. In the second week 
typhoid fever may be excluded with the greatest probability, if between the 
eighth and eleventh days the temperature is below 104° and conversely, on 
the evening of the second week, scarcely any other acute disease shows repeated 
rise of the evening temperature to 104° Fahr. It is only in the maxima of 
the temperature that sometimes a difference is visible between very mild and 
very severe attacks. In the mild cases there is now and then a large decrease 
of temperature observable towards the end of the first week-namely, from 
105.8° to perhaps 102.5° Fahr. 
At the beginning of the second week, or at the latest during its second half, 
severe and mild cases diverge so unmistakably that the course at that period 
is decisive as regards what the future progress will be. A favorable course 
during the second week permits us to anticipate that the third week will be 
still milder and a favorable termination of the disease; while, on the contrary, 
a severe and unfavorable second week may lead us to expect that the subse- 
quent course of the disease will be unfavorable. In mild cases (analogous to 
those of modified small-pox), although the evening temperature may reach 
103°, and even exceed 104° Fahr., considerable abatements (1° to 2°) take BODY-TEMPERATURE IN ENTERIC FEVER. 
527 
place during the morning, which become more and more obvious towards the 
end of the second week. Such mild cases progress favorably when the exacer- 
bations do not begin before ten o'clock in the morning, so that before midnight 
an abatement takes place; when these conditions remain daily the same, or 
when a diminution of temperature shows itself, although not more than half a 
degree; and, lastly, when there is an abatement on the eleventh, twelfth, and 
fourteenth days. 
Among the favorable indications during the second week are: An evening 
temperature between 104° and 105° Fahr.; a morning temperature one or 
two degrees lower, late occurrence of exacerbation (not before 10 A.M.); early 
occurrence of the remission (before midnight); regular and daily moderate 
decrease of temperature, as compared with that of the preceding day. 
Among the unfavorable indications are: Continued elevation of the morning 
temperature; increase of the evening temperature to 105.5° Fahr., or more; 
early occurrence of the daily exacerbations; late occurrence of the daily re- 
missions; and very high temperature at any time. x 
A retardation of recovery until at least the fourth week is to be anticipated 
when in the second week the morning temperature is above 103° and the 
evening above 104.5° Fahr.; when the exacerbations occur early in the fore- 
noon and remain after midnight; and, lastly, when a fall in temperature about 
the middle of the week does not take place. 
A*permanent temperature of 104° is an unfavorable sign-so also is an 
elevation of the morning above the evening temperatures. A severe form of 
the disease is to be expected when the morning temperature at the beginning 
of the second week is above 104°, and when the evening reaches nearly 106° 
Fahr.; and when towards the end of the week a rise still takes place. The 
most unfavorable cases are those where, in addition to these unfavorable 
conditions, oscillation^ are added, even if these consist in diminution of tem- 
perature. 
In the third week the patient enters upon those highly characteristic quotidian 
vacillations of 4°, 6°, and even more degrees, Fahr., between the morning and 
the evening temperatures. In mild cases, there are well-marked great morning 
remissions, so that the morning remissions may be three to three and a half 
degrees lower than the evening temperature, and may become normal towards 
the end of the week. From the middle of the week the evening temperature 
also decreases. If the case is mild, the evening exacerbations gradually de- 
crease in intensity, and the morning temperature is regularly at first from 3° 
to 4° below the evening. The fever ceases in the course of the week, the tem- 
perature reaching its natural standard, and convalescence commences, as a 
rule, sometimes in the third week, generally in the fourth week, or at the 
latest in the fifth week. 
In severe cases on the other hand, the temperature sinks but little during 
the third week, or else it maintains the same height or even rises. In the 
latter case, we may almost positively expect a severe fourth week, and not 
look for a decided increase of the fever before the fifth week. In short, the 
characteristics mentioned as peculiar to the third week already commence in 
the second. The temperature in the mornings is high (104° Fahr., and more), 
and differs but little from that in the evening; or even that high temperature 
increases in the afternoon and evening to a still higher degree. In this it 
differs from a remission of the fever in a mild case, inasmuch as in remissions 
the heat in the mornings sinks below the average degree of temperature in 
typhoid cases-i. e., below 103.3° Fahr, to 104° Fahr. In severe cases, on 
the contrary, the temperature always remains above the average, and rises 
still higher in the evening. Real remissions in such cases are not met with 
during the whole of the second and third weeks; but when the case is favor- 
able, although severe, the temperature is about a degree lower than in the 
second week, and the remissions do not take place till the fourth week; and 528 
SPECIAL PATHOLOGY-ENTERIC FEVER. 
if the temperature remains as high, or rises higher than it was in the second 
week, the remissions do not occur till the fifth week, and irregularities in the 
ranges of temperature always render the prognosis doubtful. 
So late as the fourth week the evening temperatures are still high, and they 
decrease very gradually even in favorable cases. Towards the end of the 
fourth week, or in the fifth week, or even so late as the sixth week, the great 
and increasing remissions commence-a period at which various other phe- 
nomena occur, and when the complications and dangers are numerous. 
The complications of enteric fever generally make their appearance about 
the third week, and threaten or tend to a fatal end up to the very beginning 
of convalescence. In the mild types the growths in the intestinal glands are 
no doubt such as are eliminated by mere rupture of the vesicles, which simply 
heal without ulceration. The severe cases owe their severity partly to the 
more extensive growth of new material in the vesicles of Peyer's glands, partly 
to the mode of elimination of that material; the healing of the parts being 
accomplished under great excitement of vascular reaction, renewed hypersemia, 
sloughing, softening, and final cicatrization. 
Cases intermediate in severity between the mild and severe cases just de- 
scribed are not unfrequently met with. Many of them, although they show 
a course more or less irregular, nevertheless follow a pretty clearly defined 
type as to variations of temperature, and are capable of clinical recognition. 
There are still considerable evening exacerbations during the second week, 
yet with a tendency to abatements in the mornings. During the third week 
great vacillations between morning and evening temperature continue, and 
sometimes also between single days. During the fourth or fifth week the 
normal temperature is reached in the morning; but it is only in the fifth or 
sixth week that the temperature becomes permanently normal-the evening 
temperature showing a complete freedom from fever--4o that the beginning 
of convalescence can only be established with certainty by the use of the ther- 
mometer. 
In the majority of cases of enteric fever, severe as well as mild, a peculiar 
periodicity of weeks and half weeks cannot be mistaken. Each week shows 
a distinct character, which cannot be overlooked in a graphic representation. 
On the first and last days of each week changes generally take place which 
are either temporary changes or continue till the fever subsides. 
The approach of death may be looked for if the temperature remain for 
some time at 106° or 107° Fahr.; if it suddenly rise to 107.5° Fahr, or 108° 
Fahr., or when it suddenly falls very low (as in collapse), to, say 94° Fahr. 
There are cases so mild that towards the end of the second or beginning of 
the third week the symptoms have all disappeared. Lebert has proposed the 
designation of "abortive" for those cases; and on this point Niemeyer makes 
some very important observations. He considers the designation preferable 
to such names as "/eftncitfa," "febris typhoides," because it better expresses the 
fact that these cases are only modified, benign, brief forms of enteric fever, 
and not a peculiar variety of disease. . . . Many of the cases which former 
writers call "gastric fever," or "mucous fever," are to be regarded as abortive 
typhus. The old customary precaution of waiting till the ninth day of the dis- 
ease, before saying whether the case was "one of gastric or nervous fever," 
was and still is very justifiable. The designations, gastric and nervous fever, 
in common use, exactly correspond to what modern physicians mean by 
"abortive enteric fever," or, as the Germans call it, " abortive typhus." 
In the first week of the disease, the thermometer is the most certain means 
of distinguishing enteric fever from a genuine attack of febrile, gastric, and 
intestinal catarrh; so, in the second week, it is the most certain means of de- 
ciding whether the disease will be an abortive case of enteric fever or not; 
the other symptoms being far more deceptive, while the use of the thermometer 
is decisive. If we find that on the eighth or ninth day of the disease the tern- DURATION OF ATTACK AND THE MODE OF RECOVERY. 
529 
perature ceases to rise, but gradually falls, and especially if we find decided 
morning remissions at this time, we may be almost certain that the case is one 
of abortive enteric fever (Niemeyer). The lesions in the intestine are got rid 
of as described at p. 513, without ulceration and by natural elimination. No 
opportunity is given for post-mortem examination; and the lesions cannot be 
shown in museums; they can only be seen if the patient dies of some other 
disease, as in the case of the soldier (at p. 513) dying in the middle of an at- 
tack of enteric fever from rupture of an aneurism. 
The temperature varies much in different cases of enteric fever; and no 
series of cases, however well marked, gives an average that can be considered 
as typical of all. Among the most characteristic features are the following: 
The period of ascent is gradual-a little each day to the extent of a degree 
and a half, with a remission in the morning to the extent of one degree or 
under. This gradual and general ascent is invariable for four days at least, 
or five, and is not influenced by remedies. Such being the rule, a temperature 
of 104° Fahr, on the second day is not enteric fever; a temperature which is 
not above 102.5° Fahr, after the evening of the fourth day is not enteric fever; 
and lastly, a patient after the first day, whose temperature has been normal 
once during the first week, is not a case of enteric fever. 
A stationary period may be observed from the seventh to the twenty-third 
day, when there are no more ascents, and with slight morning remissions the 
evening temperature is variable. It may be lower by a degree or a degree 
and a half for a day or two and again rise, and if maintained at 105° Fahr, 
for two weeks or more, the case is one of great severity. 
As the descending period begins, the morning remissions are more marked, 
while the evening temperature remains the same. After three or four days 
the evening decrease begins, while morning remissions become greater. Os- 
cillations occur to the extent of 1° or 1.5° or 2° or 3° Fahr., extending over 
from seven to twenty-one days. 
The ascending and stationary periods of temperature correspond to the 
period of infarction or infiltration of the intestinal glands with the new growth 
and elimination of the products. The descending period of temperature cor- 
responds to the period of repair. 
When the course of temperature is seriously interrupted, it is evidence of 
severe complication. 
Duration of Attack and the Mode of Recovery, or the transition into the 
feverless state, is peculiar and characteristic of enteric fever. With rare ex- 
ceptions, the defervescence is a remittent one. The great vacillations of tem- 
perature between morning and evening recur for a longer or shorter interval. 
For weeks the evening temperature may amount to 104° Fahr, or more, whilst 
in the morning the patient is almost quite free from fever. At the same time 
the transition into the feverless condition may follow different courses. The 
remissions may either become longer and longer-the morning temperature 
decreasing and the evening remaining stationary; or after some time the re- 
mission may become shorter and shorter-the evening temperature, together 
with the morning temperature, gradually descending. Again, the differences 
between the morning and the evening temperatures may remain nearly the 
same, while a relative decrease takes place at both periods; or the fever shows 
a sudden transition into the remissions with low temperatures-changes which 
generally correspond with the commencement of weeks. The period of devel- 
opment of the disease occupies two weeks, or a week and a half in slight cases; 
in severe cases it may occupy two and a half to three weeks. The initial 
stage (that is, the period when the growth of material in Peyer's patches takes 
place) lasts about half a week. The removal or elimination of the growth 
may take place in a week; but the process may extend over several weeks. 
In mild cases the disease continues at its height for only a week or a week 
and a half,-rarely for two weeks; so that the whole duration of a mild case 530 
SPECIAL PATHOLOGY-ENTERIC FEVER. 
of typhoid fever e 
lescence occupies 
extends from eleven to eighteen days. The period of conva- 
s from one to two weeks. The whole disease, therefore, in 
RANGE OF TEMPERATURE IN A SEVERE AND PROLONGED CASE OF ENTERIC FEVER. THE RECORDS INDICATE 
morning (a.m.) and evening (p.m.) observations (Wunderlich). 
Fig. 74. 
mild cases, may be gone through in from three to four weeks,-rarely in two 
weeks and a half. But it is extremely difficult to fix the precise date of the RELAPSES IN ENTERIC FEVER. 
531 
commencement of enteric fever-hence it is not less difficult to fix its entire 
duration. 
In severe cases the disease continues at its height for from two weeks and 
a half to three weeks and a half. Then an undecided period of irregular 
duration succeeds, after which decided abatement is established, the deferves- 
cence occupying a week, followed by another week of convalescence. Conse- 
quently, the whole disease extends from four and a half to ten weeks, or even 
longer. Regarding the mean duration of illness in typhoid fever considerable 
differences of statement are to be found-a circumstance not to be wondered 
at when the nature and seat of the pathognomonic lesions of this form of fever 
are recognized as influencing the duration of the disease. 
Dr. Shattuck assigns the mean duration of typhoid fever to be . 22 to 24 days. 
The mean duration of the Parisian cases of 1839-40 was . . 19.6 " 
Dr. Jackson's experience in America gives . . . . . 22 " 
Dr. Jenner's experience in London leads him to give . . 21 to 30 " 
Dr. Murchison, .......... 24.6 " 
The mean of these varied statements gives nearly twenty-three days. 
It is now well known that during the progress of this form of fever there is 
a repetition of the development of new material in the individual gland-vesi- 
cles of the intestine, and consequently a succession of retrograde metamor- 
phoses ; so that, in many cases of enteric fever, it is not unusual to have the 
malady prolonged throughout a course nearly double as long as that of typhus; 
and that, undoubtedly, the influence of the secondary local lesions of enteric 
fever is great in protracting the disease. Thus it is that a very indefinite 
idea of its duration prevails; and, as Sir William Jenner has shown, it is of 
the greatest importance to know when the original fever ceases, after which 
we are to consider the subsequent symptoms as due to the effects produced by 
the local lesions. 
As long, then, as fresh eruption continues to appear, the fever cannot be 
regarded as having terminated; and, except in cases of relapse, fresh spots 
never appear after the thirtieth day (Jenner) or thirty-fifth day (Mur- 
chison). 
True relapses are occasionally observed. They occur about ten days or a 
fortnight after convalescence from the first attack, and are marked by a return 
of all the former symptoms; while the duration of the attack is usually shorter 
than that of the first; and according to the experience of Murchison, it is 
more severe. Such relapses are most common in autumn; and are indicated 
by an elevation of temperature. In the Australian Medical Journal for August, 
1867, Dr. P. H. Macgillivary records some interesting observations on enteric 
fever, and gives diagrams of temperature, one of which shows a fatal relapse, 
beginning on the 29th day, and ascending by a gradual continuous ascent of 
temperature during four days, exactly like a case originally commencing, till 
it reached 105.2° Fahr. The case terminated fatally on the 44th day. Dur- 
ing the first attack the eruption was scanty; in the relapse it was abundant. 
Diarrhoea and great prostration, with delirium, characterized the first attack. 
In the relapse diarrhoea was slight, deafness great, and no delirium. Death 
was due to bronchitis, which had scarcely existed in the first attack. 
In particular cases following a spontaneous course, and still more in cases 
treated with calomel, a considerable shortening of the whole febrile period 
will not only be observed, but some peculiar modes of defervescence will 
occur. The temperature is reduced where calomel acts beneficially; and the 
beneficial remission is persistent. 
The influence of hemorrhage from the bowels in reducing temperature has 
been also well shown in a case recorded by Dr. Parkes. It occurred in a female 
twenty-five years of age. Diarrhoea was considerable; and blood was largely 
passed in fluid stools the night before the seventeenth day of the fever. On 532 
SPECIAL PATHOLOGY ENTERIC FEVER. 
the morning of the seventeenth day the temperature was as low as 93° Fahr., 
raising in the evening to about 101° Fahr. After the eighteenth day diarrhoea 
ceased; but the differences between the morning and evening temperatures 
continued to be very great; and it was not till the twenty-sixth day that these 
differences began to grow less and less. 
Condition of the Urine in Typhoid Fever.-It is not till the third or fourth 
day of the fever that the urine assumes any special characters. It is peculiar 
in the following respects: 
I. As to normal constituents: (1.) The water is greatly diminished, generally 
about one-half or even to one-fourth or one-sixth. This lessening of the water 
is most marked during the first week; it then begins to increase gradually dur- 
ing the second and third weeks; and at the end of the fourth week, in favor- 
able cases, it has reached its normal standard. (2.) The whole amount of the 
urine does not seem to stand in any close relation to the febrile heat; but 
when the temperature begins to fall permanently, the urine increases at once, 
or very soon after. (3.) The specific gravity of the urine is high in almost all 
cases where the urine is scanty; and at convalescence the specific gravity 
diminishes, sometimes before the amount of water increases; i. e., at convales- 
cence the lessening of the solids of the urine is often prior to the increase in 
the water. (4.) The urea, as a rule, seems to be augmented, during the febrile 
period, above the physiological standard proper to the individual; and it 
sinks again below this standard during convalescence. The amount of increase 
varies: Vogel has noted 78 grammes, or 1200 grains, in 24 hours; while 
Parkes has noted 57 grammes, or 880 grains, in that time. In most of the 
cases observed by Dr. Parkes the average increase has been about one-fifth 
above the physiological standard proper to the individual; and the augmenta- 
tion is most marked in the first week, when the water and the chloride of 
sodium are at the lowest point; and if the fever be continued beyond the third 
or fourth week, the urea keeps up in amount. The relation of urea to tem- 
perature is yet uncertain. (5.) The chloride of sodium is diminished (indefi- 
nitely) ; the cause of the diminution being in part due to the lessened ingress 
of this substance on account of spare diet: or due to the elimination of large 
quantities of it with the stools or the sweat. (6.) The uric acid is uniformly 
increased in amount; and it is relatively greater than that of the urea. It is 
often doubled in amount; and the increase progresses up to the fourteenth day, 
when it is at its greatest. It then diminishes to the twenty-first or twenty-eighth 
day; and during convalescence falls below the normal amount. Spontaneous 
deposits of urates occur very frequently, and when there is no such deposit it 
may be brought about by a drop of acid; but as yet the fact has no particular 
significance. (7.) The sulphuric acid and phosphoric acids maintain their 
amounts very much the same as in health; and sometimes a little above that: 
and seeing that much of the former is derived from food, its abundance in 
typhoid fever would indicate active tissue-change, when little or no food is 
being taken. (8.) The pigment at first is sometimes enormously increased, 
measured after Vogel's method (by comparison with a scale of colors). It 
has sometimes amounted to 80 or 100 in 24 hours, the normal amount being 
3 to 6 (Vogel). This, Dr. Parkes says, is to be referred to increased disin- 
tegration of blood-cells: it is therefore much more highly colored than the 
mere concentration will account for. (9.) The acidity of the urine appears 
always great during the early period, simply from concentration; but by 
neutralization with an alkali it is found actually to be below the average by 
one-fifth, or even by one-fourth. During the third week the acidity still con- 
tinues to lessen; and ultimately the urine may even become alkaline from 
fixed alkali. It may also become alkaline from ureal decomposition, soon 
after being passed. Therefore it is necessary, in all observations on this point, 
to distinguish carefully between the alkalinity due to fixed alkali and that 
due to ammonia. DIAGNOSIS IN CASES OF ENTERIC FEVER. 
533 
II. As to abnormal constituents: (1.) Albumen occurred in 33.3 per cent, 
of the cases examined by Dr. Parkes. In 23 per cent, of these cases it was 
temporary, and entirely disappeared before the patient left the hospital. In 
the other cases it was permanent; and in one of these a very profound kidney 
lesion, which had not previously existed, was immediately excited by the 
fever. (2.) Renal epithelium, casts, and blood are sometimes seen in the 
cases with temporary albuminuria-the blood generally in microscopic quan- 
tities ; although in bad cases it may be greater in amount. Different phe- 
nomena in the course of typhoid fever variously affect the urine. The effect 
of diarrhoea is to diminish both water and solids, the chloride of sodium 
especially. Non-excretion of urea, or deficiency in its solid matters, often 
coincides with the putrid, adynamic, or profound " typhoid " state, and with 
symptoms which imply more or 'less blood poisoning from retention. Local 
lesion in the kidney may lead to this, or, from failing circulation, less blood 
may pass through the renal vessels, or there may be, as Dr. Parkes suggests, 
some special condition or combination of urea which hinders transudation. 
Such non-excretion is most apt to supervene during the third or fourth week, 
when the first stage of the disease is over, and when the growths in Peyer's 
glands, and in the mesenteric glands, are softening, when the secondary blood 
poisoning occurs, and when the heart's action tends most to fail. 
Judging from the urine alone, the febrile action appears strongest in the 
first week of enteric or intestinal fever (typhoid), although the temperature 
is highest in the second and commencement of the third week. 
Diagnosis.-Dr. Maclagan has well shown that there are two classes of 
cases in which difficulties of diagnosis are apt to be experienced, namely: 
(a.) Cases of enteric fever in which the head symptoms are so prominent 
and so early as to cause the case to resemble typhus. In these cases the range 
of temperature may not be sufficiently characteristic (from its height and 
irregularity) to be of use in the discrimination of the two diseases. In such 
cases examination of the conjunctivae may be suggestive. Cases of typhus 
with marked cerebral symptoms have the conjunctiva injected, the eyes suf- 
fused, and the pupils small. Cases of enteric fever, on the other hand, with 
severe cerebral symptoms, do not have the conjunctivae injected, but the 
sclerotics are clear and pearly, and the pupils are large. 
(6.) Cases of enteric fever in which the symptoms are so mild and equivocal, 
and of such short duration that a diagnosis is impossible. The thermometer 
gives little or no aid in such cases; but with commencing defervescence it 
supplies the only certain information that can be got regarding the true 
nature of the case. In typical cases of enteric fever, the mode of ascent of 
the temperature, and its persistence with the characteristic descending oscilla- 
tions, distinguish enteric fever from all other febrile states. In pneumonia the 
ascent is much more sudden. In ague temperature becomes normal during 
some part of the day. In gastric intestinal catarrh the height of the tempera- 
ture on the second day may be above that of enteric fever, and the remissions 
are much more considerable. In acute tubercle the oscillations of temperature 
are as irregular as in enteric fever they are regular, and there is no fixed 
point as to maximum of temperature. The morning remissions are always 
more considerable than in enteric fever; there is no stationary period, and no 
period of decline (Fox, St. George's Hosp. Reports, vol. iv). 
The leading diagnostic points, between the range of temperature of typhus 
and that of enteric fever, are briefly and clearly stated in the following table, 
by Dr. J. W. Miller, Physician to the Dundee Royal Infirmary, in a paper 
on the range of temperature in typhus and enteric fever in the British and 
Foreign Med.-Chir. Review for October, 1848. 534 
SPECIAL PATHOLOGY-ENTERIC FEVER. 
The duration of elevated temperature is 
very rarely beyond eighteen days; it is 
generally shorter by several days, and may 
be even so short as nine days. 
The evening temperature is frequently 
lower than that of the morning. 
The difference between the morning and 
evening temperature, during the height 
of the fever, or from about the third to 
the tenth or eleventh day, is compara- 
tively seldom above one degree, and al- 
though about the period of defervescence 
the difference is sometimes much greater, 
the oscillation is not continued over more 
than one or two days. 
A high temperature is, as a rule, accom- 
panied by a high pulse. 
Typhus Fever. 
The duration of elevated temperature is 
very rarely less than twenty-one days ; it 
is generally longer, and may be protracted 
to thirty-five days or even more. 
The evening temperature is almost con- 
stantly higher than that of the morning. 
The difference between the morning and 
evening temperature is generally, through- 
out the case, greater than in typhus, and 
towards the end of the fever there occurs 
the very characteristic oscillation of tem- 
perature, during which the difference is 
frequently five, six, or even seven degrees, 
and which may continue from a few days 
to a week or more. 
A high temperature is frequently ac- 
companied by a pulse but slightly acceler- 
ated, and occasionally by a pulse slower 
than normal. 
Enteric Fever. 
[Although there is no one, nor even two or three, symptoms actually pa- 
thognomonic of typhoid fever, there are certain phenomena which are met with 
so constantly, and with such greater frequency in its course than in any other 
disorder, that in most cases, when fully developed, a certain and timely diag- 
nosis can be made. When a febrile disorder of several days' duration, in a 
temperate climate, is attended with early and marked prostration of strength, 
persistent frontal headache, a puzzled and stupefied expression, epistaxis, 
diarrhoea, tympany, pain and gurgling on pressure in the right iliac region, 
an eruption of lenticular rose-coloreci papulae on the chest, belly, or back, 
sudamina, enlarged spleen, diffused bronchitis, a pungent heat of surface, with 
persistent increase of the natural temperature of the body every evening, there 
can be no doubt, with such a sum of symptoms, of the nature of the disorder. 
But many of these phenomena may be absent; for in the mild or latent forms 
of the disease the objective symptoms are few, feebly marked, and unsatisfac- 
tory ; and are but little noticed either by the physician or patient. In such 
cases the diagnosis is perplexing and difficult. Still, careful observation, and 
familiarity with the disorder, will usually enable the physician to decide posi- 
tively, even in the early stage. The duration of the attack, under such cir- 
cumstances, becomes an important element in the diagnosis. Regular daily 
increase of the body-temperature, at first at 6 p. M., and, also, at 8 A. M., being 
at 100.4° F., or 101° in the evening, and falling next morning about one 
degree, for several successive days, accompanied with muscular debility, con- 
stant headache, loss of appetite, indifference, and a somewhat besotted look, 
in a person between eighteen and forty years of age, and particularly one who 
has recently come to a large town, or during the prevalence of an epidemic 
of typhoid fever, and if, on careful examination, no local disease can be found, 
there will be good reason to suspect the presence of the disorder, even though 
the so-called distinctive symptoms are wanting. The absence of prodromic 
symptoms special to the exanthemata, should prevent its being mistaken for 
them. The visceral inflammations of old persons are often latent, and accom- 
panied with extreme debility; but a regard to the time of life, and careful 
physical exploration, will generally make the case clear. Granular meningitis 
in children, may be mistaken for typhoid fever. Besides the absence of the 
special symptoms of typhoid fever, as well as of the bronchial complication, in 
granular meningitis there are commonly constipation, frequent vomiting, re- 
traction of the abdomen instead of tympany; and active delirium is an early 
symptom, followed by deep coma. The facial expression of the two disorders 
is totally different. Acute phthisis in some respects often resembles typhoid PROGNOSIS in cases of enteric fever. 
535 
fever; but the great and increasing difficulty of respiration, the presence and 
site of the moist crepitant rhonchi, general lessened resonance of the chest, the 
peculiar hue of the surface, and, indeed, the absence of the really distinctive 
phenomena of typhoid fever, should hinder us from confounding two disorders, 
which really have but few common elements, and sufficiently distinguishing 
ones to prevent an erroneous diagnosis.] 
Prognosis in severe typhoid fever appears to be more favorable in propor- 
tion to the free excretion of urea and uric acid (Parkes). The excretion of 
these effete products is a most necessary point; for there is more danger in 
the retention than in any amount of fever and formation of them with elimina- 
tion. The greater the excretion in typhoid fever the better; and as long as 
500 to 700 grains of urea in men, or 300 to 500 in women, are being passed 
in each twenty-four hours, the progress so far is favorable. But whenever, 
while the fever continues, the urea falls much below these amounts, we may 
anticipate a low typhoid condition, or some local inflammation, as pleurisy, 
which may relieve the blood for a time from some of the effete products, but 
which at the same time may kill the patient. 
The existence of slight albuminuria or hsematuria is not of itself unfavor- 
able ; but if either be in large amount, or if there be exfoliation of epithelium 
or renal cylinders present in the urine, retention of urea and its consequences 
may be expected. 
The temperature is generally high in fatal cases. During the stationary 
period of fever-heat the lower the maximum, the slighter the case; and the 
greater the morning remissions, the more favorable the prognosis. A tem- 
perature of 105.5° Fahr, to 106° Fahr, is always serious; and a persistent 
temperature of 105° Fahr, for several consecutive evenings always indicates 
an anxious case. A temperature above 106° Fahr, is highly dangerous, and 
108° Fahr, always fatal. A sudden fall of temperature in the stationary 
period, from say 106° Fahr, or 104° Fahr, to the normal or below it, is a 
fatal sign, indicating cardiac collapse, or intestinal hemorrhage. It is also a 
bad sign if the exacerbations begin before midday, and only end after mid- 
night. It is a very serious case also if the morning temperature is highei' 
than the evening (Fox). 
The pulse has less definite relation to the temperature in enteric fever than 
in any acute disease; but the pulse of fatal intestinal hemorrhage is small 
and rapid. The coexistence of a slow pulse, or one slightly above the normal, 
with a high fever temperature, is not unusual in cases of enteric fever (J. W. 
Miller). 
When the head-symptoms are severe, and death is threatened by coma, the 
range of temperature is generally high and irregular; but the more rapid 
onset of the head-symptoms in such cases does not permit of the thermometer 
giving the same premonitory indications as in typhus fever (Maclagan). 
Such a mode of death is apt to occur when cerebral symptoms are marked 
and prominent from the first, and such cases usually terminate fatally by the 
end of the second or beginning of the third week. 
Death by asthenia may be threatened when the extent of abdominal mis- 
chief is great, as indicated by the presence of diarrhoea, hemorrhage, tender- 
ness over the caput ccecum, and small intestines. But the best indications of 
danger are to be got by a study of the thermometry of the case from the com- 
mencement. The student is referred back to what is fully given on this sub- 
ject at p. 526, et seq. 
[The younger the subject the better the chances of recovery. After forty, 
typhoid fever is a very fatal disorder. It is more fatal when it attacks robust 
than feeble persons. A sudden remission, followed by an exacerbation of 
the symptoms, is, says Dr. Chomel, invariably mortal. With respect to the 
prognostic value of particular symptoms, it may be said that parotitis is 
very unfavorable; Dr. Trousseau has never seen a patient recover with this 536 
SPECIAL PATHOLOGY ENTERIC FEVER. 
complication. Deafness, when limited to one ear, should cause a guarded 
prognosis. Early somnolence is a very unfavorable symptom, as well as the 
persistent declaration of the patient that he is quite well. Trousseau agrees 
with Graves that intestinal hemorrhage is not to be looked on as, generally, 
a very bad symptom; indeed, he seems to regard it as useful, unless abundant 
and frequent, and accompanying marked adynamic and ataxic symptoms. 
Great rapidity of pulse, with feebleness or extinction of the first sound of the 
heart, or intermittence of the beats, or a persistently quick, small, and con- 
tracted pulse, are met with in fatal cases. Early active delirium is unfavor- 
able. Few pregnant women attacked with typhoid fever, who abort in the 
course of the disease, recover. 
When the symptoms referable to the spinal cord indicate that their site is 
in the medulla oblongata, the prognosis should be guarded. Breathlessness, 
without pulmonary complications, almost always tokens a speedy fatal end- 
ing-] 
Generally speaking, the prognosis in enteric fever must always be a very 
guarded one; and there is always a risk in giving a favorable one, for reasons 
already stated at p. 523, and also on account of the variety of 
Circumstances under which Death may ensue in Cases of Typhoid Fever: 
1. By poisoning of the blood generally, as indicated by many symptoms 
which enteric fever has in common with typhus fever, cholera, small-pox, dysen- 
tery, scarlet fever, diphtheria, ichorrhcemia. The intensity of the fever (measured 
by the thermometer) is generally great in those cases, and the fatal event 
occurs either at a very early period of the fever, associated with cerebral 
congestion, or it may occur later, when it may be supposed that the danger 
is past. This is sometimes termed the secondary poisoning of the blood 
(septicsemia), and is most likely due to the ulcerated intestines, with the 
bowels perhaps 'on the verge of perforation. The pulse becomes rapid and 
small; cold, clammy sweats appear; and the body begins, even in life, to 
exhale a putrid odor. In cases where the blood is so gravely implicated, gas. 
has been observed to become developed during life, and has been detected in 
the veins at the root of the neck for some minutes before death (Closs, Frank, 
and Jeffrey Marston in Med. Times, Feb. 7, 1857). 
2. By implication of excretory organs at an early period-for example, the 
kidney, as denoted by persistent albuminuria, or by bloody urine-conditions 
which tend to aggravate the blood poisoning. 
3. By congestions of important organs-for example, the lungs and the 
brain, in consequence of poisoned blood, or its high temperature; and which 
congestions are still further brought about by the circulation, in the blood- 
vessels, of putrid juices, or of the substance of fibrinous debris of clots in a 
granular condition, having formed as plugs in the varicose veins surrounding 
the sloughs and ulcers of the intestines. 
4. By hemorrhage from the bowels during the separation of the gland- 
sloughs. 
5. By exhaustion from profuse diarrhoea in cases where the catarrh of the 
mucous membrane has been excessive. 
6. By peritonitis, with or without perforation of the intestines. There are 
two periods in the course of the fever when perforation is apt to take place. 
The first period is during the separation of the sloughs, about the end of the 
second and throughout the third week. The second period is during pro- 
tracted convalescence, with atrophy of the intestine already described, and 
when the ulcers are in a weak atonic state, the result of intense protracted 
fever and profuse catarrh. 
7. By peritonitis subsequent on suppuration of the large mesenteric glands, 
and rupture of their inclosing capsule (Jenner) ; or from the bursting of 
softened new growth from the spleen into the peritoneum (Robertson, Jen- 
ner) ; or from ulceration of the gall-bladder. The average mortality among PROPAGATION OF ENTERIC FEVER. 
537 
cases of typhoid fever appears to be about 1 in 5| to 1 in 6. It is considera- 
bly less in autumn than in spring; and is least of all in winter. It tends to 
be greater among males than females; and the average age of fatal cases 
appears to be about 23.5. The mortality increases to a small extent as life 
advances. The disease in certain places seems never to be absent, and is in- 
variably most prevalent during autumn, at the time that diarrhoea is most 
common; and it has been observed to be especially prevalent in seasons re- 
markable for their high temperature (Murchison). 
On the other hand, with regard to prognosis, it must also be remembered 
that recovery is by far the most frequent termination of enteric fever-by 
healing of the lesion, as described at p. 513. It takes place in three-fourths, 
at least, of all the cases (Niemeyer). Some epidemics, however, as is always 
the case with epidemics, are attended with a greater mortality than others; 
and the cases are of a more malignant type. 
In some cases recovery is incomplete, or sequelse remain, such as neuralgia, 
anaesthesia, mental imbecility, partial paralysis, marasmus, and anaemia. The 
tendency to the development of tubercle in the lungs in scrofulous constitu- 
tions, has been already mentioned, p. 517, ante. 
Origin and Propagation of Typhoid Fever.-It is now about thirty years 
since M. Bretonneau related to the French Academy of Medicine a series of 
cases in which the communication of this disease from person to person, and 
its modes of propagation in this way, were so evident as to admit of no reason- 
able doubt. Nevertheless, the conclusion arrived at has not been generally 
accepted by the profession, so that the communicability of typhoid fever has 
not met with general belief. " In so vital a question " (writes Dr. Budd, 
whose views, as I have attempted to put them here, seem especially deserving 
of attention), " it is, I need scarcely say, of the highest importance that the 
actual truth should be generally known." And Sir Thomas Watson, whose 
authority is undisputed, very justly remarks that, " If this fever be really 
contagious, it is not only erroneous but dangerous to hold the contrary 
opinion." 
[Though, as a general rule, the contagious principle of typhoid fever is not 
very active, it is incontestable that the disease is communicable, and, as Dr.. 
Trousseau remarks, the number of those who deny it lessens daily. Most of 
the French physicians living in the rural districts have always advocated its 
contagiousness, whilst those of Paris for a long time denied it. Dr. Nathan 
Smith, as far back as 1824, maintained that it was as contagious as small- 
pox or measles. In July, 1829, Dr. Bretonneau transmitted to the French 
Academy of Medicine a communication, in which he asserted the contagious- 
ness of dothienenterie, as it prevailed in the country (Archives Gen. des Med., 
t. xxi, p. 57). Chomel, in Leyons de Clinique Medicale, published in 1834, 
inclined to this opinion, though, as he acknowledges, it was contrary to the 
general sentiment. Gendron, of Chateau du Loirs, has given many indisput- 
able cases (Jour, des Connaissances Med.}. Louis (Fievre Typhoide, ed. 1844) 
is of the same opinion, and, in 1866, stated to the Academy of Medicine that 
he had seen in Paris four cases, about which it was impossible for him to have 
a doubt. Contagion seemed to him to be particularly manifest when the hos- 
pitals were overcrowded. The evidence of Forget, of Strasbourg, Moreau, 
Leuret, Mistier and Ruef, Jacques, Pulegnet, Patry, Lombard, Piedvache, 
and a host of others, in favor of the communicability of typhoid fever, is irre- 
sistible. In 1857, Dr. Trousseau made a report to the Academy, in which 
the importation of typhoid fever into a district hitherto exempt, by individu- 
als who had contracted it elsewhere, and its subsequent propagation from 
these centres, are satisfactorily shown. Murchison cites many instances. A 
very conclusive example is related by Prof. A. Flint. Dr. Bartholow (Sani- 
tary Commission Medical Reports} has also mentioned some striking cases.] 
" To what extent it is dangerous," continues Dr. Budd, " may be best 538 
SPECIAL PATHOLOGY-ENTERIC FEVER. 
measured by the fact, that in this country alone 20,000 persons die annually 
of this fever, and 140,000 more are laid prostrate by it." Thus, vast is the 
field for the operation of preventive measures. And when the discovery and 
success of such measures must depend in a great degree on our insight into 
the real mode of propagation, it is at once seen what importance the question 
assumes. Dr. Budd has, I think, clearly demonstrated the following facts : 
1. That typhoid fever shows a decided tendency to spread through a house- 
hold, a school, a barrack, or a village, when it has been once introduced. The 
introduction and propagation of the fever in the Clergy Orphan School at St. 
John's Wood {Lancet, 15th November, 1856) is an instance in point. The 
first case was imported, and the illness began ten days after arrival; within 
three weeks four more cases occurred ; and then nineteen cases were simulta- 
neously affected within thirty-six hours. The fever which prevailed in the 
Military School of La Fleche, in France, in 1826, is a no less instructive ex- 
ample. The outbreak commenced first with a few scattered cases, and the 
disorder spreading, the school was broken up earlier than usual, and the pupils 
sent home. But before this disruption could be carried into effect, sixty of the 
number were seized with typhoid fever. Twenty-nine others carried the seeds 
of the fever with them, and were laid up by it at their own homes. Of these 
twenty-nine, it was ascertained that as many as eight communicated the disorder 
to persons who were engaged in attendance upon them. 
In further illustration of the doctrine of communicability, Dr. Budd cites, 
with minute details, numerous examples in the village of "North Tawton," 
in which typhoid fever having once appeared in a household, it extended itself 
to one or more members of the family before it finally died away. During 
the. prevalence of the fever in this village, it also so happened that three per- 
sons left the place after they had become diseased, and each of the three per- 
sons communicated' the same disease to one or more of the persons by whom 
they were surrounded in the new neighborhood whither they went. While 
two of these men remained in the village of " North Tawton," they both lodged 
in a court having a single and a common privy in it, and next door to a house 
where typhoid fever was. In due course of time and events both took the 
disease. The third man was a friend who came to see one of the two men 
already sick. He assisted to raise his sick friend in bed, and while so em- 
ployed was quite overpowered by the smell from the sick man's body. The 
sense of this pestilent smell harassed him for days. He felt very unwell from 
'that time; and on the tenth day from the date of the event just noticed, he 
was seized with shivering, followed by the complete expression of an attack 
of typhoid fever, which was of long duration; and before he became conva- 
lescent two of his children were laid up with the same disease, as well as a 
brother, who lived at some distance, but who repeatedly visited him during 
his illness. Except in the houses of these men no fever existed in that part 
of the country. Further most interesting and conclusive examples are given 
in Dr. Budd's admirable papers published in the Lancet of 9th July, 1859, 
which prove beyond question that enteric fever is a most readily communica- 
ble disease. The facility for propagation, however, seems to be modified under 
particular circumstances of season, place, and habits of life; in other words, 
the propagation of the disease requires some special conditions, which may be 
said of the whole class of communicable diseases. 
2. The disease having once occurred, the patient is protected from a second 
attack. The specific nature of the disease is thus also established, for the 
fever not only propagates itself, but propagates no other kind of fever-one 
case following another with the same constancy of specific type that small-pox 
follows small-pox or measles succeeds to measles. 
3. There seems also to be a definite period in which the poison is latent 
after being communicated-a period of incubation, during which a definite 
interval elapses before the development of the fever begins. This period, ac- MEASURES PREVENTIVE OF ENTERIC FEVER. 
539 
cording to Dr. Budd's experience, seems to be from about a week to ten or 
fourteen days. The living human body, therefore, is the soil in which this spe- 
cific poison breeds and multiplies; and that most specific of processes which con- 
stitutes the fever itself is the process by which the mxdtiplication is effected. 
4. Like all other diseases of its kind, its origin is unknown; and the first 
case in the series of each of these outbreaks mentioned may either have been 
casual and imported, or it may have been due to a rekindling of some dor- 
mant germ left from a former similar attack. 
5. The virulent part of the specific poison by which the disease is commu- 
nicated is doubtless contained in the diarrhoeal discharges which issue from 
the diseased and exanthematous bowel. These discharges drying up, the germs 
of disease are thus preserved as effectually as the crusts of small-pox preserve 
the virus of that disease. If, therefore, through atmospheric or other agen- 
cies, these germs obtain access to the living body, diarrhoea is brought about 
in the usual course of events, and the commencement of the disease thus com- 
municated takes place. The discharges from the bowels of the person so in- 
fected, which are at once copious, numerous, and liquid, are thrown into the 
water-closet or the privy, and the drains, or systems of drains, become at once 
saturated with the specific poison of the disease in its most concentrated and 
virulent form. 
Regarding, therefore, the drain, or system of drains, as a channel directly 
continuous with the diseased intestine of the infected person, the specific virus 
of typhoid fever may be propagated amongst healthy persons in one of three 
ways, namely- 
(1.) By percolation through the soil into the wells which supply drinking- 
water to the inhabitants; (2.) By issuing through defects in the sewers into 
the air of the inhabited area; or (3.) By exhalation through the aperture of 
small, ill-trapped water-closets or privies, which are at once the receptacles 
of the discharges from the sick and the daily resort of the healthy. 
When the specific poison thus issues into the air, the atmosphere generated 
is immeasurably more likely to communicate the disease than that which imme- 
diately surrounds the fever patients. " There is reason to believe, however, 
that the duration of the period of incubation varies considerably, partly with 
the nature of the medium through which the specific poison finds admission 
to the living body, partly by reason of the conditions it meets with there, and 
still more so in virtue of the greater or less intensity of the state of change in 
which the poison itself may be at the moment of its reception." Hence the 
simultaneous seizure of a large number of persons within a definite interval 
after the occurrence of a single case points to some one or other of these modes 
of propagation. Such modes of propagation are thus the exact counterpart 
of what has been oftentimes observed (especially in schools) in the case of 
measles, scarlet fever, and, in former times, of small-pox also (Dr. W. Budd). 
Preventive Measures, or Measures for Checking the Spread of Typhoid 
Fever.-The measures about to be specified have been made public through 
the writings of Dr. William Budd on this subject; and, provided they are 
thoroughly and efficiently carried out, it is believed that the recurrence of 
typhoid fever may be entirely prevented. 
To enable us to judge of the extent of the infection to be destroyed, there 
are two elements to be taken into account,-First, The amount and duration 
of the intestinal discharge in each case; and, Second, The number of cases 
actually occurring. With regard to the first, Louis has found that the aver- 
age duration of the alvine flux in cases of typhoid fever is fifteen days in mild 
cases and twenty-six days in severe cases. With regard to the second point- 
namely, the number of cases occurring-the Reports of the Registrar-General 
show that at least 100,000 to 150,000 cases of typhoid fever occur annually in 
England alone. In other words, " every year in England more than 100,000 
human intestines, diseased in the way already described, continue each, for the 540 
SPECIAL PATHOLOGY ENTERIC FEVER. 
space of a fortnight or thereabouts, to discharge upon the ground floods of liquid 
charged with matters on which the specific poison of a communicable disease 
has set its most specific mark" (Budd). 
The measures recommended for preventing the spread of this fever are 
founded on the power of chemical agents to destroy absolutely the material 
which contains or carries the specific virus of such communicable diseases. 
Assuming it, therefore, to be certain that the intestinal discharges in typhoid 
fever are the media of propagating the disease, it is no less certain that, by 
SUBJECTING THE DISCHARGES ON THEIR ISSUE FROM THE BODY TO THE ACTION 
OF POWERFUL DECOMPOSING CHEMICAL AGENTS, THEY MAY BE ENTIRELY 
DESTROYED OR DEPRIVED OF THEIR SPECIFIC VIRUS. He Suggests the fol- 
lowing details of procedure: 
1. All discharges from the fever patient should be received on their issue 
from the body into vessels containing a concentrated solution of chloride of 
zinc. 
2. Two ounces of a caustic solution of chloride of zinc should be put in the 
night-stool on each occasion before it is used by the fever patient. 
3. All tainted bed or body linen should, immediately on its removal, be 
placed in water strongly impregnated with the same agent. 
4. The water-closet should be flooded several times a day with a strong 
solution of chloride of zinc; and some chloride of lime should be also placed 
there, to serve as a source of chlorine in the gaseous form. 
5. So long as fever lasts, the water-closet should be used exclusively as a 
receptacle for the discharges from the sick. 
The Privy Council have now made the principle of this method an integral 
part of their " general memorandum on proceedings advisable to be taken in 
places attacked or threatened by epidemic disease," and which is given in 
extenso at p. 359 of this volume. 
Vague and untenable notions have been gathering round this subject, par- 
ticularly in relation to the propagation of enteric fever; and if once a disease 
of this kind is decidedly proved to be the result of a specific poison, and to be 
propagated in the way just described, " we cannot help entertaining a doubt," 
says Sir Thomas Watson, "whether the disorder in question really ever has 
any other cause." Nevertlteless, other causes are assigned to enteric fever; 
which by some is even looked upon as a disease developed out of external 
conditions alone. In reasoning on the subject, it must be remembered at the 
outset that the dissemination of typhoid fever by a specific poison implies pre- 
cisely what it implies in small-pox; and that it is provided for in the same 
way-namely, by the multiplication of a specific poison in the living but dis- 
eased body. Each of these specific poisons (and, as we have already seen, 
they are numerous) thus multiplies in the same way, and in the same remark- 
able medium, out of the same living organisms of the human frame ; yet each 
of these several poisons sets up a series of changes which always issues in the 
reproduction of its own specific kind of disease, and no other. Small-pox 
gives rise to small-pox, scarlet fever to scarlet feveh, measles to measles, and 
so on. Herein lies their specificity. Such being the doctrine attempted to be 
maintained in these pages, the theory of the spontaneous origin of enteric 
fever, or of any other specific disease, must be in the same relative position 
as when it seeks to explain by such a principle the propagation of plants and 
animals. These-namely, plants and animals-likewise at least two diseases 
-namely,' syphilis and small-pox-are certainly now known to propagate only 
by the law of continuous succession, whatever may have been their primary 
source. But the hypothesis of spontaneous origin and indefinite propagation 
of enteric fever has assumed a definite form of expression in the doctrine 
which attempts to teach that enteric fever is often actually caused by the 
products of common putrefaction--a doctrine which has been cleverly em- 
bodied in the nomenclature of the subject by Dr. Murchison; and thus a ORIGIN OF ENTERIC FEVER. 
541 
degree of precision and permanence has been given to the opinions he has so 
ably advocated in a volume on the Continued Fevers of Great Britain,-a 
volume which is unsurpassed for its erudition and its practical importance. 
The term "pythogenetic fever," or fever "born of putrescence," is the name 
by which Dr. Murchison at once designates enteric fever, and theoretically 
implies its origin. He has thus rashly committed science to an hypothesis of 
a highly doubtful nature. Without, however, doubting the fact that animal 
and vegetable substances in some states of decomposition have the power of 
inducing ill-health; and that there is now acknowledged to be a connection 
between putrid states of the air and the prevalence of pyaemia, erysipelas, 
puerperal fever, and cholera; yet there does not seem to be sufficient evidence 
to show that any of these causes can produce a disease which is of so specific a 
nature as to be maintained and propagated by a specific poison generated in 
the body alone. Undoubtedly, the state of ill-health induced by the decom- 
posing material of night-soil and the like, does produce a state of the system 
favorable to the development, not alone of typhoid fever, but of many other 
specific diseases, such as cholera, dysentery, yellow fever, and the like. This 
predisposition to such diseases seems to be exactly analogous to the prepara- 
tion of a soil for seed. Dr. Carpenter, also, long ago showed physiologically, 
what observation has since confirmed-namely, that decaying animal material, 
especially night-soil, seems to be for some poisons (e. g., cholera and yellow 
fever) great centres or foci, where the specific germs or poisons are able to 
multiply; and for the propagation of which "foulness of medium is indispen- 
sable." An interesting question for inquiry is thus opened up as to whether 
the germs of enteric fever, cholera, and the like, could be made experimentally 
to grow or increase upon or about organic matter, just as the germs or spores 
of many fungi are induced to grow in collections of manure (Dk. Lankester). 
In such collections on the earth's surface there is reason to believe that germs 
of diseases like cholera, and enteric fever, and yellow fever, may find a rest- 
ing-place-that thus they are always extant somewhere-although it may be 
only now and then, when season and other conditions conspire, that they dis- 
play their full power as epidemic diseases. As such, they seem to occur every 
now and then as " mysterious cycles," the existence of which we admit, but do 
not understand. The experiments of Dr. Barker on cesspool air prove that 
long inhalation of an atmosphere charged with the gases evolved from decom- 
posing organic matter is capable of producing a series of symptoms of the fol- 
lowing character-namely, increased heat of skin, thirst, irregular and feeble 
muscular contractions, and diarrhoea. These symptoms continue so long as 
the person is exposed to the influence of the foul air; but when the cause is 
removed, there is no continuance of symptoms, no recurrence nor remittency, 
but a tendency to recovery. No communicable disorder is induced. The 
poison of the foul air acts for the time as chloroform might act, and so soon as 
removed, recovery progresses. 
The history of enteric fever, whose leading features have been described in 
the previous pages, is wholly inexplicable upon the " pythogenetic theory " of 
Dr. Murchison. On the contrary, it is emphatically the history of a specific 
disease generating a specific poison, and propagating itself by it: 
"Mutatis mutandis," writes Dr. Budd, "it is the history of small-pox, it is 
the history of scarlet fever, it is the history of malignant cholera. In all these 
specific contagions we meet with these same alternations of slumber and ac- 
tivity ; of widespread prevalence in one place, while other places hard by re- 
main free; and finally, with the same successive invasion of neighboring places, 
in such wise that the reigning disorder-be it small-pox, measles, scarlet fever, 
intestinal fever, or malignant cholera-often only begins to prevail in the new 
locality when it has already died out in the old. 
"It is, in fact, in a general survey of this kind that we get the clearest view 542 
SPECIAL PATHOLOGY ENTERIC FEVER. 
of the thread which really connects all these circumstances. There is plainly 
but one thing constant; that is to say, a specific morbid cause-a cause which 
is neither a permanent product of the soil, or air, or of particular seasons, but 
which is susceptible of transmission from place to place; which breeds as it 
goes, and then again dies out or becomes dormant, without leaving any sign 
to mark its track. 
"There is only one thing of which these can be the characteristics ; and that 
is the specific poison which is bred of the disease, and by which the disease 
propagates, and which, in common with the other specific poisons perpetuated 
by the same law, possesses all these properties. 
" Thus, when we come to scrutinize closely this course of the fever, even in 
these broad relations, we are again brought to recognize that which we have 
already proved by direct evidence-namely, its essentially contagious nature. 
This is the master fact in its history-the fact which governs all the rest." 
[The chief determining causes of typhoid fever in the United States army 
during the war of the rebellion, where it prevailed to a great extent (21,977 
cases and 5608 deaths in the first year), were undoubtedly, animal emanations 
and privy gases. Dr. Bartholow's personal observations have convinced him 
that the last-named cause cannot be overestimated. He writes: "The cases 
of fever occurred most numerously where the diarrhoeal discharges were most 
abundant, and were most exposed to decomposition and dissemination by the 
air and water supply. Diarrhoea was common. Badly constructed sinks 
within a few yards of the camp were the rule, and not unfrequently no sinks 
were used, but the environs of the camp were converted into a general latrine. 
Privy odor was soon developed, and the drinking-water contaminated. When 
sufficient time had elapsed, typhoid fever declared itself amongst those who 
had not completed the seasoning process, or those who had acquired a special 
susceptibility to the poison." ( United States Sanitary Commission's Memoirs of 
the War of the Rebellion, p. 200.) 
Professor Joseph Jones (U. S. Sanitary Commission Medical Memoirs, 1. c.), 
strongly argues against the validity of the theory of Dr. Budd, and Pro- 
fessors Aitkin and Parkes, respecting the chief aetic factor of typhoid fever. 
The comparative immunity of dustmen, sewer cleansers and hunters, and privy 
cleansers, and all men engaged in removing the filth and offal of large cities, 
from the various forms of continued fever, militates, he thinks, against it. He 
makes also the following interesting statement: "Notwithstanding the crowded 
and filthy condition of the Confederate Military Prison and Hospital (Ander- 
sonville, Ga.), and notwithstanding the effluvia from the immense collections 
of abnormal human excrements, only 472 cases of typhoid fever were reported 
amongst over 40,000 men, with an average monthly mean of 21,120, during a 
period of six months. The cases of typhoid fever constituted only a little 
over one per cent, of the entire number of cases of disease entered upon the 
sick reports, and of the entire number of prisoners confined during six months 
at Andersonville" (p. 601). 
Professor Jones further remarks: " If the contagious nature of typhoid fever 
be admitted, might not the relative greater proportion of persons liable to the 
disease in the country and villages, where it more seldom prevails, as well as 
the intimate relations and associations, and constant visiting amongst the en- 
tire population, and especially the collection together at stated periods in one or 
more houses of worship of a large proportion of the inhabitants, account for the 
apparent more extended action of the fever after its introduction into small 
towns and villages, without the necessity of resorting to the hypothesis of the 
propagation of the disease by the emanations of the cesspools? However, if 
the enteric lesion of typhoid fever be the characteristic manifestation of the 
disease, corresponding to the eruption of small-pox, we must admit that the 
theory of Drs. Budd, Simon, and Aitkin, has much plausibility, and even TREATMENT OF ENTERIC FEVER. 
543 
probability. According to this view the discharges from the bowels in typhoid 
fever might be regarded in the same light, as far as their contagious nature 
was concerned, as the matter formed upon the surface, and cast off in the 
form of scabs in small-pox. The admission of this theory does not at all 
overthrow the assertion that animal putrefaction does not generate under any 
circumstances a contagious fever, for in the case of the excrements voided in 
typhoid fever, the poison is the result of the actions going on in the living 
body, and is not the product of the decomposing excrements" (p. 603).] 
But whatever may be the view theoretically adopted regarding either the 
origin or the propagation of typhoid fever, it is satisfactory to know that, prac- 
tically, medical officers can employ preventive measures which (to use the 
words of Dr. Lankester) "will cover the issues of both theories." These 
measures have been minutely described; and if they are universally carried 
into effect, it is not too much to expect that this fever might perhaps soon 
become extinct. At all events, with the facts before us, it is unwarrantable 
to permit the great bulk of what escapes from the diseased intestine of typhoid 
fever patients to be let loose upon society, into the cesspool or sewer, or on 
the dung-heaps, in full possession of all their deadly power, without being first 
destroyed in the way that has been recommended. 
"The grand fact is clear," writes Dr. Parkes, "that the occurrence of 
typhoid fever points unequivocally to defective removal of excreta, and that 
it is a disease altogether and easily preventible." Typhoid fever ought there- 
fore soon to disappear from every return of disease, whether in military or in 
civil life. 
Treatment of Enteric or Typhoid Fever.-The chief indications of treat- 
ment are to reduce temperature and subdue vascular excitement, if these be 
in excess; to restrain and moderate, but not to suppress or check, the diar- 
rhoea; to stimulate the nervous system when necessary; to obtain a free action 
of the kidneys; and to influence the elimination of the morbid growth from 
the intestinal glands. 
To accomplish the first of these indications the use of digitalis has been 
especially recommended by Wunderlich. He considers that it decidedly miti- 
gates the febrile symptoms which are present in severe cases at the time when 
the ulcers begin to heal, and which often impede or prevent recovery. He 
advocates its use in the severe forms of the fever only, especially at a time 
when most danger is to be apprehended from the violence of the fever in the 
second week, when the evening temperature is at its highest (105° to 108° 
Fahr.), and when the remissions in the morning are slight; when the pulse is 
frequent, 110 to 120 or more. In mild cases it is superfluous. He finds that 
in the form of infusion it is easily absorbed by the intestines of patients suffer- 
ing from fever; and, if given in a suitable dose, has most marked effects in 
subduing the rate of pulsation, and in reducing animal heat. Large doses of 
the infusion should be given without interruption until the full effect has been 
obtained,- 
An infusion of fifteen or twenty grains of digitalis in eight or ten ounces of 
boiling distilled water may be consumed in twenty-four hours by adult 
patients. 
It acts more rapidly on animal temperature than on the heart. Foi* the 
first few days after its use the decrease of temperature is rather slight, but 
may afterwards become considerable; and after it has been much diminished 
and again rises, it never attains its former excessive height. The full effects 
of the medicine are known to be brought about if the temperature is reduced 
to 2° or 3° Fahr, in the evening; and the action of the remedy does not con- 
tinue beyond one day after its use has been discontinued. The diminution of 
the pulse is slight at first, and occurs in some cases on the second day after 544 
SPECIAL PATHOLOGY-ENTERIC FEVER. 
the remedy, but mostly on the third day, or even later; and on the fourth or 
fifth day after the medicine has been commenced, the rate of pulsation may 
be diminished by thirty to forty or fifty beats within from twelve to thirty- 
six hours. The pulse may continue to fall even below its normal velocity, 
and this reduction of pulsation may last for several weeks in succession. If 
the velocity of the pulse should decrease rapidly, the use of the digitalis must 
be discontinued at once (Arch. der Heilk., 1862, p. 116). 
[The tincture of the root of aconite (U. S. P.), in small and frequently-re- 
peated doses, alone or combined with digitalis, when vascular excitement is 
excessive, should be given.] 
Cold and tepid sponging [with vinegar and water, to which some aromatic 
spirit has been added], or the cold affusion [on the head and shoulders], are 
remedies which Dr. Murchison considers deserving of further trial for re- 
ducing the pulse and temperature. 
[The cold water treatment to reduce hyperpyrexia,-the practice of 
Wright and Cullen more than three-quarters of a century ago-has been re- 
cently revived in Germany and England. To allow a patient to continue in 
a high early temperature is often to consent to death (Allbutt). Free heat 
is to be lessened or removed. The best means is the question. Liebermeister, 
Brand, W. Fox, H. Weber, and others, contend that this can be most quickly 
and safely done by cold baths. They hold that while this treatment does not 
shorten the duration of the specific fever, it lessens the severity of an impor- 
tant symptom-pyrexia, and, at the same time, the disposition to lethargy, 
frenzy, putridity, and debility, giving support to the doctrine that the typhoid 
symptoms are due to the height and length of the pyrexia (Gee). In the 
late Franco-German war this treatment was largely, and, it is claimed, suc- 
cessfully used. The mode adopted was, if the body-heat was 104° Fahr., the 
patient was put in a bath of 59° Fahr, up to the neck for fifteen minutes'; in 
cases of much headache or delirium cold water was poured over the head, or 
cold compresses applied. A fall in the temperature of two or three degrees 
three-quarters of an hour afterwards was uniformly shown. The cold bath 
was repeated during the first week from four to six times a day. Some objec- 
tion to the bath is generally made by patients at first, shown by moans and 
cries, but if the water is undisturbed they soon become reconciled to the cold. 
After the first bath there is usually less repugnance. The contraindications 
are, very feeble action of the heart, and hemorrhages, and severe bronchitis 
(Fiehrsen). Whether larger experience of this heroic treatment will con- 
firm its present favor remains to be seen. 
It should be borne in mind that in all forms of the cold-water treatment, 
whether by wet-packing, sponging the surface, cold affusions, or cold baths, 
diaphoresis should be encouraged between the applications, and that the 
patient should not be too lightly clad, or exposed to draughts. 
Of the power of quinine to lessen the body-heat in pyrexia, there can be no 
doubt. It may be given in five-grain doses, repeated five or six times a day.] 
The oppressive headache may be greatly relieved by cold to the head 
[though often tepid or warm applications will give more relief]; and in all 
severe cases the hair should be shaved off. 
To restrain excessive diarrhoea, lime-water mixed with milk in equal parts, 
-and taken as a drink, is found to be beneficial, agreeable, refreshing, and 
nourishing. It is clear that the diarrhoea ought not to be altogether checked. 
Professor Gairdner, of Glasgow, is in favor of the French practice of giving 
saline laxatives rather than astringents; also of the diligent use of enemata to 
unload the bowels from below, where anything like abdominal distension has 
occurred. These enemata may be simply of warm water, to which a little 
aniseed is added; or the assafoetida enema may be given. On the propriety of 
restraining excessive diarrhoea there can be no question. Dr. Huss, of Stock- 
holm, is of opinion that the diarrhoea during the first stage ought not to TREATMENT OF ENTERIC FEVER. 
545 
be arrested, but abated and mitigated only if excessive. If it is suddenly 
arrested, meteorism is produced, and pains in the intestines; or vomiting may 
supervene, with cerebral symptoms, and the febrile phenomena are increased. 
The diarrhoea is too copious or excessive if the evacuations exceed four or five 
a day, being of considerable quantity, and fluid. Such evacuations weaken 
the patient rapidly, and should be mitigated by mucilaginous drinks, such as 
rice-water, infusion of linseed, decoction of althwa officinalis, or ipecacuanha 
in small and repeated doses. This latter remedy retards the peristaltic action 
of the intestines, and lessens the secretion from the mucous membrane. The 
dose must be regulated so as to avoid vomiting; and the feeling of nausea 
which is apt to follow the first dose soon disappears with continued use. 
Dr. Murchison, on the other hand, agrees with the late Dr. Todd, who 
writes as follows: "Restrain diarrhoea and hemorrhage in typhoid fever, and 
when you have fairly locked up the bowels, keep them so. Patients will go 
for four or six days, or even longer, without suffering inconvenience from this 
state of constipation." Dr. Huss and Dr. Murchison speak highly of the 
benefits to be derived from the mineral acids-hydrochloric and sulphuric* 
especially. From fifteen to thirty minims of the dilute acids may be given 
every three or four hours; and with each dose Dr. Murchison recommends 
half a grain of quinine, as in the following prescription for an adult: 
R. Acid. Sulph. dil., vel Acid. Hydrochlor, dih, npxx ad xxx. 
Quinise Sulph., gr. | ad. gr. i. 
Syrup Aurantii, $ss. 
Aquse Garni, ad ^i. 
Fiat haustus, 3a. vel 4a, hora sumendus (Murchison). 
He is of opinion that if there be more than two motions in the twenty-four 
hours, with marked prostration, that astringents should be had recourse to. 
A starch enema, containing from ten to twenty drops of laudanum, should be 
administered towards evening, and recourse may also be had to the following 
draught: 
R. Acid. Sulph. Aromat., qgxxx. 
Liq. Opii Sedativ. (Battley), njziii. 
Aq. Menth. Pip., 3i; misce. 
Fiat haustus, 4ta vel 6ta, quaque hora sumendus (Murchison). 
If the mineral acids are not tolerated by the stomach, acetate of lead is 
worthy of trial, in doses of two or three grains in solution every four or six 
hours, with or without an eighth of a grain of morphia (Murchison). 
Alum dissolved in gum, to the amount of twenty-four grains in a day, 
which may be increased to one drachm, is best given in the form of alum whey, 
prepared by adding one drachm of alum to a pint of boiling milk, and then 
straining. Two ounces may be given after each motion of the bowels 
(Fouquier, Murchison). 
A seidlitz powder may sometimes check excessive diarrhoea, by altering the 
secretions, and is especially beneficial if there be much meteorism (Trousseau, 
Murchison). 
The question, therefore, of checking excessive, or encouraging moderate 
diarrhoea is one which requires the careful study of each particular case; and 
my experience in the treatment of typhoid fever leads me to recommend 
rather the restraining of excessive diarrhoea than either encouraging the 
action of the bowels or locking them up for days. The French practice of 
giving saline laxatives is not a safe one; and if the action of the bowels is 
deemed desirable, enemata will be found sufficient. Nitrate of silver, in doses 
* [Huss recommends dilute phosphoric acid in hourly doses of ten minims.-Ed.] 546 
SPECIAL PATHOLOGY-ENTERIC FEVER. 
of one to three grains, macle into a pill, and taken every six or eight hours; 
or sulphate of copper, in doses of a quarter of a grain similarly given, are 
remedies most useful in the diarrhoea connected with atonic ulcers, after the 
fourth week of the disease (Bell, Murchison). 
[Constipation, initial or intercurrent, should be treated by small doses of 
castor oil, and tepid enemata of infusion of chamomile. They are to be pre- 
ferred to saline aperients.] 
If meteorism or tympanitis prevails, from the accumulation of air in the 
colon, it may sometimes be relieved by the passage of a long stomach-pump 
tube by the anus, as far up the colon as it can be made to go easily [or by 
enemata of water with a little tincture of rue]. 
With regard to stimulation of the nervous system, it is not decided how far 
alcohol is beneficial. The fever eventually is attended with much exhaustion, 
and is often protracted, yet typhoid fever does not seem to bear stimulation so 
well as typhus. The tendency to prostration is the only indication for its use; 
but stimulation must not be persevered in if the pulse is quickened by its use, 
the hectic flush made more manifest, the tongue made drier, or if delirium 
supervene. Food and sustenance are the real preventives of delirium, and 
the best stimulants to the nervous system when necessary. With regard to 
the maintenance of free action from the kidneys, it is to be observed that so 
long as the excretion of urea and uric acid is abundant, no diuretics are neces- 
sary ; but whenever the amount of the solids falls greatly (which can be known 
at once with sufficient accuracy by a comparison of the urine passed in twenty- 
four hours with the specific gravity), means must be taken at once to increase, 
if possible, the urinary elimination. The warm bath, with repeated small doses 
of the alkaline carbonates, or of the nitrate or bitartrate of potash, will often 
effect an increased elimination (Parkes, 1. c.). 
To accomplish the last indication-namely, to influence the elimination from 
the intestinal glands, by direct local action on the intestinal membrane- 
Wunderlich especially advocates the use of calomel, if it can be given before 
the ninth or tenth day. Dr. Parkes is also of opinion that it is extremely 
useful at this period. The late Dr. Anthony Todd Thomson used to give it; 
and, from the observation of many cases under the care of this physician, as 
well as from his own experience, Dr. Parkes considers that calomel is a medi- 
cine to be strongly recommended in typhoid fever. But it must not be given 
later than the tenth or eleventh day, and at no time in large doses. In the 
great majority of cases where it can be given during the first week and before 
the occurrence of much diarrhoea, the course of the disease is rendered milder 
and shorter. This is now the recorded experience of Wunderlich, Niemeyer, 
Parkes, and Wood. 
One or two grains twice a day is enough, although Wunderlich gives one to 
five grains twice daily; but five grains is considered by Dr. Parkes to be too 
large a dose. 
Dr. Wood, of Philadelphia, bears testimony also to the benefit to be derived 
from mercury about the seventh or ninth day of the fever. He believes "it 
tends in some degree to arrest the progress of the disease in the glands of 
Peyer, and to promote resolution of the inflamed patches. He prefers minute 
doses of the blue pill mass-a grain every two hours-till the mouth is slightly 
affected, associated with small doses of ipecacuanha, when the stomach is not 
irritable. The beneficial effect of this combination is shown by the tongue 
becoming moist, the skin relaxed, and the symptoms generally being amelior- 
ated. Dr. Wood recommends twelve grains of blue pill mass to be combined 
with two grains of ipecacuanha powder, with two grains of opium powder; and 
the whole being divided into twelve pills, one may be taken every hour, or 
every hour and a half, or every two hours (Practice of Medicine, vol. i, p. 345, 
4th edition). 
Calomel is, however, contraindicated if the diarrhoea is excessive, or if there TREATMENT OF ENTERIC FEVER. 
547 
should be excessive pains in the bowels, with early and violent meteorism. It 
is also not proper to be given if the condition of the patient is ansemic, or if 
there is a decided hemorrhagic diathesis. It is most useful as a restorative of 
the intestinal functions in cases where the tongue is dry and coated, where 
thirst is absent, and when the urine is cloudy and of low specific gravity. If 
the first dose is vomited, the administration must be repeated. Calomel has 
no direct effect On the pulsation or respiration, nor on the cerebral functions; 
but its beneficial influence is very decidedly appreciable by the modifications 
of temperature which it induces, and which have been already noticed at page 
531. 
No general rules can be laid down to guide the treatment of the intercurrent 
phenomena or accidents of the disease. Combinations of remedies must be 
adapted to correct the several functions which may be simultaneously de- 
ranged, so that treatment must be varied according to the functions mainly 
implicated or suspended, and to the degree of their affection. 
Abdominal pains and meteorism may be relieved by mustard poultices, or 
turpentine stupes may be applied, followed by simple hot-water fomentations. 
After these remedies have been used, cold-water compresses over the abdomen 
tend to lessen the tension and the gurgling in the intestines, and to diminish 
the tenderness on pressure. They counteract the inclination to meteorism, 
and lessen excessive diarrhoea. Dr. Huss believes also that the ulcerations in 
the ileum are prevented from spreading ; and that perforations of the intestine 
have been of much rarer occurrence since he commenced to use these com- 
presses. The compress, after being soaked in warm, but not hot water, is well 
wrung, and applied so as to cover the whole abdomen ; and it must be changed 
two or three times a day, according to its tendency to dry. The compress is 
composed of four to eight double folds of coarse linen, and is to be laid over 
the whole abdomen, and afterwards overlaid with a cover of oiled skin or 
india-rubber stuff, to prevent too rapid evaporation. The compress should fit 
as closely as possible, and care must be taken that it be not displaced, other- 
wise air enters between the skin and the compress, so that cold, instead of a 
moist heat, is produced. These compresses may remain untouched as long as 
they are moist and warm; and they may be employed on the chest as well as 
on the abdomen, should capillary catarrh or pneumonia supervene. 
Hemorrhage from the bowels, partly fluid and partly in clots, evacuated 
with the stools, is a symptom of grave import; and one urgent aim of treat- 
ment is to arrest the bleeding. Huss found the sugar of lead most serviceable, 
administered by the mouth, and also by clysters. By the mouth, two grains 
may be given every half hour, and even every quarter of an hour; and it is 
best given dissolved. Twenty-four grains of crystallized acetate of lead being 
dissolved in one drachm of dilute acetic acid, to which six ounces of distilled 
water is added, a tablespoonful of this solution may be given every half hour. 
At the same time a clyster may be administered, composed as follows: Ten 
to fifteen grains of acetate of lead are to be dissolved in four ounces of distilled 
water (warm), to which twenty or thirty drops of tincture of opium may be 
added; and the administration of such a clyster may be repeated in four or 
six hours if required. Pieces of ice may also be swallowed now and then; and 
even crushed ice may be applied, inclosed in a bladder, over the abdomen. 
[A combination of sulphuric acid and syrup of rhatany is praised by Trous- 
seau. Ergot has been recently recommended.] 
If bleeding from the nose is not arrested by the use of vinegar and cold 
water injected up the nostrils, nor by the use of cold water compresses applied 
to the nose, plugging by the posterior nares must be had recourse to. 
Turpentine is a most valuable remedy in hemorrhages, and in the stage of 
ulceration. It was originally recommended by Dr. Graves, and is highly 
spoken of by Drs. Huss, Wood, and Murchison. It may be given in all cases 
where the tongue is dry, and when, " instead of cleaning gradually from the 548 
SPECIAL PATHOLOGY-ENTERIC FEVER. 
edges and tip, it often parts with its fur quickly, and in large flakes-gener- 
ally, first, from the middle or back part of the surface, which is smooth and 
glossy, as if deprived of its papillae. There is also generally an increase of the 
tympanitis, and the ulceration of the ileum seems to be attended with great 
dryness of the tongue." Under these circumstances Dr. Wood gives the oil of 
turpentine in doses of five to twenty drops every hour, or every two hours. 
It is best administered in an emulsion with gum arabic, loaf sugar, water 
(Wood), or in an emulsion with the yolk of an egg and honey or mucilage 
(Huss). Amelioration of the symptoms may be observed in twenty-four or 
forty-eight hours-the tongue becoming more moist, and covered with a white 
fur-distension of the abdomen ceases to progress, and after a time diminishes. 
The use of the oil should be continued under these circumstances; but the dose 
should be gradually diminished. [The value of turpentine in typhoid fever 
is very doubtful. After a good deal of experience with the turpentine treat- 
ment, the writer has never seen any result which could be fairly attributable 
to it, except disordering the stomach. Dr. Gerhard's testimony is to the 
same point; he says: "I cannot think it of much value; ... in ordinary 
cases it is perfectly nugatory" (Pennsylvania Hospital Reports, 1868). The 
chlorate of potash, in five-grain doses, may be given in camphor-water, or 
weak bitter infusion, every two hours. Under its use the tongue often becomes 
moist and clean (Garnett, Hunt, Copland, Watson). Chlorinated soda 
is highly praised by Copland, Chomel, and Graves. Sulphurous acid-twenty 
drops every four hours-with a view to its antiseptic properties, has been 
recently recommended; and, with the same view, carbolic acid and the 
sulphites.] 
Tonics and stimulants may be absolutely essential on account of debility 
attending the advanced stage of the disease, generally about the third week. 
When the pulse is slow and feeble, the skin cool, the tongue and teeth 
incrusted with dark sordes, at an advanced period of the fever, then stimu- 
lants are obviously necessary. But even when the pulse is feeble, but yet 
frequent, and the skin hot, stimulants are even then known to be of service; 
but it is necessary to administer them with great caution, and to watch the 
effects constantly and closely. If their use is found to augment the heat of 
the skin, and to increase the frequency of the pulse, and to aggravate the 
delirium or stupor, it is then necessary to suspend their use. They are known 
to be doing good service, however, if they lessen the frequency of the pulse, 
and increase its fulness and strength; if the skin becomes cool and moist, and 
if the delirium is subdued or moderated; and especially if refreshing sleep be 
procured. Dr. Wood recommends the use of wine whey, prepared by adding 
one quart of good sherry wine to two quarts of boiling milk, and straining after 
coagulation. Of this a tablespoonful or more may be given every hour or 
every two hours. If the strength is greatly reduced, it may be necessary to 
give pure wine or brandy; or even sulphuric or chloric ether in cases of great 
prostration. [If a patient with typhoid fever is properly nourished from the 
outset of the attack, alcoholic stimulants will not be necessary in a large num- 
ber of cases. They are greatly overused. When, in spite of the early and 
regular administration of food, there is great prostration, or ataxic phenomena 
come on, stimulants should be at once prescribed; sound sherry wine is the 
best form for their administration, or, where diarrhoea is excessive, a pure 
Port, or Tarragona, wine; they are best given with milk, eggs, or broth. 
Iced champagne is often very grateful and happy in its effects, particularly 
where there is obstinate inappetency, or gastric irritability. Brandy is prefer- 
able to whisky. It has been proposed to deduce from the cardiac phenomena 
a rule to regulate the administration of stimulants in typhoid fever-the 
diminished cardiac impulse, and the feebleness, or extinction, of the first 
sound, being a direct and important indication for their use (Stokes, Pen- 
nock). May not the experiments of Claude Bernard, Marey, and de Barrel TREATMENT OF ENTERIC FEVER. 
549 
de Ponteves warrant us in regarding the therapeutic action of alcohol and its 
preparations to be more directly upon the sympathetic than upon the cerebral 
system, thus lessening the periphero-vasal tension, and increasing the cardiac 
impulsion? and is not this view more in accordance with the observed phe- 
nomena than the vague generality of a hinderer of metamorphosis, or a 
retarder of organic combustion? Dr. Warter thinks (Z. c.) that the body- 
temperature will best indicate the proper treatment of delirium. If the 
thermometer marks a low temperature, wine and food may be given with 
benefit.] Opium is also a useful stimulant. It may be given when the pulse 
is not full nor strong, and when cerebral symptoms do not exist. In the later 
stages it may be given in doses of half a grain, or a grain, every four, six, or 
eight hours. It is known to be acting beneficially when it promotes sleep, 
subdues nervous excitement, and induces gentle perspiration. [Opium is a 
valuable remedy for the nervous symptoms, but its employment is a point of 
great nicety, and requires caution and discrimination. In delicate and 
nervous patients, or such as have largely used spirituous and vinous liquors, 
or where nervous energy is prostrated, and there is little general or local 
vascular excitement, with a cool, moist skin, in such, when low delirium, rest- 
lessness, wakefulness, and twitching come on, opium will do good; it should 
be at first given in small doses, and its effects carefully watched. Sir Henry 
Holland suggests that the condition of the pupil may serve as a guide in some 
doubtful cases-where it is contracted, opium being contraindicated. Dr. 
Law, of Dublin, and afterwards, Dr. Graves, speak highly of a combination 
of laudanum and tartar emetic in controlling cerebral symptoms. Ataxic 
symptoms are, sometimes, quickly checked by camphor, and it will often bring 
on general composure and easy sleep.] Carbonate of ammonia is objection- 
able, as it may irritate the bowels and increase the diarrhoea. 
The diet is of the utmost importance to be attended to in cases of typhoid 
fever from the very commencement of the disease. [Protracted abstinence is 
not a common cause of death, but of many of the adynamic, ataxic, and 
cerebral symptoms. Autophagism, resulting from the rapid and excessive 
destructive metamorphosis of the tissues, should be hindered. If there is one 
point in the treatment of typhoid fever to be insisted on, it is to properly 
nourish the patient throughout the disease. Indifference or repugnance to 
food should not interfere with this chief means, tolerance or appetite coming 
on after a few days of persistent and graduated feeding, milk, &c.] It ought 
then to be both food and drink combined, in the form of a light nutritious 
liquid, such as meat fluid [beef tea in which some vegetable has been grated], 
soup, eggs, and milk. Barley-water, rice-water, toast and water, thickened 
more or less with solutions of tapioca, sago, arrowroot, the juice of sweet fruits, 
or the very soft pulp of fruits, or the pure jelly of ripe fruits; but fruit in its 
crude state is to be strictly withheld. It is necessary, as a rule, to give food 
at certain intervals and in certain quantities. A wineglassful should be given 
at least every two or three hours, according to the state of digestion and the 
demands upon the strength of the patient. It may be that the patient is un- 
able to swallow, from the dry and shrivelled state of his tongue. Before 
offering him food or drink, therefore, the nurse should put a teaspoonful oi 
lemon-juice and water into his mouth. She must then wait a minute or so, 
until the fur upon the tongue and mouth is softened and moist, after which 
the patient will often drink or take his food with ease. The patient ought to 
have his mouth regularly washed out with a linen rag with water in which a 
little soda has been dissolved. Milk in small quantities frequently repeated 
will be found an excellent diet; and animal broths and jellies mav ultimately 
be given. The extractum carnis, as prepared by Liebig, is a most valuable 
nutriment for typhoid fever patients. The best drink is pure spring-water, or 
soda-water, or barley-water, or water that has been mixed with oatmeal, but 
is free from any particles of oats. The patient generally desires and requires 550 
SPECIAL PATHOLOGY-RELAPSING FEVER. 
to drink freely, in order to replace the loss of fluid by perspiration and 
diarrhoea; and, 'in the advanced stages of the fever, plenty of drink should be 
given by the nurse. [The patient should be placed under the most favorable 
hygienic conditions; he should be withdrawn from all disturbing or depressing 
influences, and perfect quiet of mind and body enjoined. Free and abundant 
ventilation and strict cleanliness of the apartment are indispensable, together 
with light bedding, which should be changed daily. The excreta must be 
removed immediately, and disinfectants and deodorizers frequently employed. 
Those parts of the body that may be exposed to pressure are to be daily ex- 
amined, and if found reddened, they should be gently rubbed, and protected 
by some artificial cuticle, and a water or air-cushion used. The state of the 
bladder should be ascertained frequently, and when necessary, the water 
ought to be drawn off.] 
The utmost caution is necessary as to diet and aperients during convales- 
cence ; first, as to opening the bowels, castor oil or simple enemata are the only 
means which should be resorted to; secondly, as to diet, no flesh meat should 
be allowed till at least seven days after all the febrile phenomena have 
passed away, and the food should be as free as possible of excrementitious 
matter [and at first should be well minced]. Malt liquors should not be taken 
before food. 
[During convalescence great care and vigilance are required, and the patient 
must be closely watched. Exposure to cold, or any fatigue or mental excite- 
ment, are to be strictly avoided. The quantity of food allowed must be rigor- 
ously within the capacity of the digestive function, otherwise there will be 
risk of gastro-intestinal troubles-inappetency, nausea, vomiting, gastric pain, 
tympany, diarrhoea, and intestinal perforation; or of evening fever exacerba- 
tions ; or of a relapse. Bear constantly in mind the yet unhealed ulcers of the 
small intestine; strengthen the digestive organs; and be careful to do nothing 
that may weaken them. Most of the consecutive disorders of convalescence 
will gradually disappear as the waste of the system is healthily repaired. Paral- 
ysis, mania, dropsy, aphasia, if existing, cease by degrees as the strength 
returns. Wine and the vegetable and mineral tonics are generally necessary 
during convalescence. Obstinate wakefulness yields to opium and. wine. A 
cold infusion of the Prunus Virginiana is a valuable adjuvant when the pulse 
is persistently rapid.] 
RELAPSING FEVER. 
Latin Eq., Febris recidiva; French Eq., Figure cl rechutes; German Eq., Typhus 
recurrens; Italian Eq., Tifo recidivo. 
Definition.-A continued fever, having a very abrupt invasion and short dura- 
tion, characterized by absence of eruption and an abrupt relapse recurring after 
an interval of about a week. The fever is marked by rigors, chilliness, and severe 
headache, vomiting, and often jaundice; a white moist tongue, epigastric tender- 
ness, confined bowels, enlarged liver and spleen, high-colored urine, a frequent, 
full, and often bounding pulse, pains in the back and limbs, restlessness, and occa- 
sionally delirium. These symptoms abruptly terminate by an exceedingly copious 
perspiration between the fifth and the eighth day; and after a complete apyrectic in- 
terval (during which the patient may be so well as to get up and walk about), an 
abrupt relapse supervenes on the fourteenth day from the first commencement. 
The relapse runs a similar course to that of the primary paroxysm, and termi- 
nates between the third and the eighth day. In some cases a second, third, fourth, 
and even fifth relapse may occur. Death is apt to happen from sudden syncope, 
especially after the excessive perspiration; or from suppression of urine and coma. 
No constant eruption and no specific lesion are associated with this fever. 
Pathology.-The name by which this disease is known is derived from one PATHOLOGY OF RELAPSING FEVER. 
551 
of the most constant and striking peculiarities of the fever. It has been also 
described under the various names of "five" or "seven-day fever," "seventeen- 
day fever," "bilious remittent fever," and "bilious relapsing fever," "mild yellow 
fever," "synocha," " short fever," and "short relapsing fever." Epidemics of this 
form of fever have been recognized to prevail on different occasions since 
1739. In Dublin it prevailed at that time and in several subsequent years. 
Sometimes it has been described as a variety of a well-known form of fever, 
and at other times as a new disease. 
In Scotland in 1817-18 this fever was clinically recognized and described 
by Drs.Christison and Welsh; and when it reappeared as an epidemic in Edin- 
burgh and Leith in 1843, Dr. Christison had no difficulty in again recogniz- 
ing it. About this time it also appeared in Glasgow as an epidemic about a 
month before its outbreak in Edinburgh; and subsequently it became preva- 
lent in Dundee and other large towns in Scotland. It was observed with 
great accuracy, and its phenomena were recorded in the medical journals of 
the period, by Drs. Craigie, Alison, Arrott, Henderson, Douglas, Jackson, 
Mackenzie, Cormack, and Wardell. It formed a part of the fever epidemic 
of Ireland in 1817-18-19, described by Barker and Cheyne; and it had been 
prevalent in Ireland for many years. Epidemics of it were described by 
Rutty, in his Chronological History of the Diseases of Dublin, as early as 
1739 and 1741. In most of the periods of epidemic fever referred to, the 
commencement of the epidemic was characterized by the greater preponder- 
ance of cases of relapsing fever; and as the epidemic advanced, the number 
of cases of relapsing fever gave place to a preponderance of typhus cases 
(Steele, R. Patterson, Ormerod, Murchison). In 1847 it became again 
epidemic in Glasgow, Edinburgh, and the large manufacturing towns of Scot- 
land, as well as in London, when it was carefully described by Sir William 
Jenner, who, moreover, shows that its characters have remained constant 
since they were first described by British physicians. During the same year 
it prevailed in some parts of the Continent, and more especially in the Prussian 
province of Upper Silesia, and in some other parts of Germany. There it has 
been described by Virchow, Barensprung, Diimmler, and Suchanek. These 
observers, however, did not know or recognize the fever so well and precisely 
described by the Scotch physicians; and, indeed, Dr. Parkes was the first to 
indicate, in his admirable paper on "The Diagnosis of Fevers," already 
noticed, that the epidemics these German physicians described were mainly 
made up of the relapsing fever. This fever evidently formed the great bulk 
of the cases. Yet, although its characters are thus so striking that the most 
superficial observer could not fail to recognize them, the German systematic 
writers (except Virchow) make no allusion to relapsing fever as a separate and 
distinct disease; and even those who observed the fever in Germany failed to 
draw that obvious inference to which the Scotch physicians unanimously came, 
namely, that relapsing fever is a disease altogether distinct from typhus and 
from typhoid fever. If it is not so, " we know not," as Dr. Parkes observes, 
"that any medical evidence whatever can be relied upon." 
In the summer of 1855 it prevailed, after the hardships and privations of 
the preceding winter, among the British troops in the Crimea, where it was 
recognized and described by Dr. Lyons. It has not been observed in France, 
nor in any other part of the continent of Europe. 
The observations of Dubois, Austin Flint, and others, leave no doubt that 
relapsing fever was seen in New York, Buffalo, and other parts of North 
America, in 1847 and 1848 [see Editor's remarks below]; but Dr. Murchison 
is of opinion that all the cases are traceable to Irish immigrants, and that 
there is no good ground for believing that the disease is indigenous in America. 
It has been well described by Dr. Wood, of Pennsylvania, from the writings 
of the physicians already mentioned. In India and in all tropical countries 
it is as yet unknown. Since the epidemic of 1847 and 1848, Dr. Murchison 552 
SPECIAL PATHOLOGY-RELAPSING FEVER. 
writes that relapsing fever has been gradually disappearing; and for the seven 
or eight years previous to 1863 not one case has been observed in the hospitals 
of Edinburgh, Glasgow, ,or London. Professor W. T. Gairdner has not seen 
or heard of a single case at Edinburgh since 1855; and, according to Drs. 
Lyons and McEwen, true relapsing fever has of late years been a rare disease 
in Ireland. In 1869 and 1870 it again became epidemic in London, Edin- 
burgh, and Glasgow. 
[The history of relapsing fever in the United States may be briefly stated 
as follows: the first cases were observed and reported by the Editor of this 
work.* 
In June, 1844, a Liverpool packet with Irish immigrants arrived at Phila- 
delphia. There had been some sickness on board during the voyage, and 
fifteen of the steerage passengers were immediately sent to the Philadelphia 
Hospital, and put in the wards in my charge. They were ill with a form of 
continued fever unlike any that I was then familiar with. I thought that I 
recognized (by the descriptions I had read of it) a variety of fever which had 
prevailed in Scotland and parts of England, during that and the previous year 
(1843-44). The event proved the correctness of my conjecture. In all 
these cases the access was sudden, with severe headache, vomiting, occasional 
epistaxis, muscular and joint pains, rapid pulse, high body-heat, tongue 
coated with a thick creamy-gray or yellow fur, with red edges and tip (in some 
cases, for several days quite dry, as was the mucous membrane of the mouth), 
enlarged spleen, no special intestinal symptoms, and no eruption. In all 
there were great debility, and a peculiar bronzed hue of the face, more or less 
like that of persons suffering from chronic malarial toxsemia.f About the 
seventh day the febrile symptoms suddenly subsided, with copious sweatings ; 
the appetite became good, the expression of countenance natural, but much 
muscular weakness persisted, and the color of the face was of a dull straw 
chloro-anaemic tint. In every case about the fourteenth day a relapse hap- 
pened, which in some had all the severity of the initial paroxysm, while in 
others it was slight. So far as I know, there was no second relapse ; all were 
discharged from hospital during their second convalescence, at their own re- 
quest, though many were still quite feeble. It was perhaps for this reason that I 
saw none of the sequelse reported as so common after the disorder in Great 
Britain, as ophthalmia with amaurotic symptoms, boils, swellings of the legs 
and ankles, pain in the feet without swelling, paralysis of the deltoid and 
other muscles. The disease did not extend to the nurses or other inmates of 
the hospital, though the fever-patients were not isolated. Two sisters, how- 
ever, who had been residents of the city for several years, but whose brother 
had come out in the same ship with other fever patients, and had been taken 
ill at their house a few days after their arrival, were admitted into the ward 
with well-marked attacks. Several of the other passengers were at this time 
in the hospital, complaining of slight chills, and sweatings, headache, nausea, 
and vomiting, with loss of strength, but got well without other symptoms. 
Several cases of illness from the same ship were sent to the Pennsylvania 
Hospital, and were under the care of the late Prof. Pepper, who at first was 
disposed to regard them as cases of mild typhus, but subsequently admitted 
their resemblance to the British epidemic. 
In The Transactions of the American Medical Association, vol. i, 1847, and in 
* [Fevers: their Diagnosis, Pathology, and Treatment. By Meredith Clymer, 
M.D. Philadelphia: 1846, p. 99, and New York Medical Journal, March, 1870.] 
j- [An eminent physician of Savannah, who saw these cases in my wards, remarked 
that they had very much the physiognomy of persons with the seasoning fever of the 
South. Dr. Rose Cormack indeed suggested (Edinburgh, 1844) that there was an 
analogy, if not identity, between this fever and the malarious form of yellow fever : a 
resemblance, however, which observation and the history of the two disorders do not 
make possible.] HISTORY- OF RELAPSING FEVER. 
553 
The Annalist, June, 1848, Dr. A. Dubois, of New York, lias articles entitled 
"Ophthalmia post Febrilis; a Severe Form of Inflammation of the Eye, fol- 
lowing Typhus Fever as it appeared in the City of New York in 1847-48." 
From the ocular sequelae he infers that it might have been the same type of 
fever which prevailed in Dublin, 1826, and in Edinburgh, 1843; he does not 
say that he saw any cases of the fever, nor does he give the clinical history of 
any ; he publishes a short note from the late Dr. Swett, at the time one of the 
physicians of the New York Hospital, with a summary of the symptoms of 
the cases of fever which had been admitted into the hospital during the years 
1867-68, and certainly no one can recognize the phenomena or course of true 
relapsing fever in Dr. Swett's description. "The duration of the disease was 
from.two to three weeks," and not from five to seven days; "the condition of 
the brain and nervous system did not differ from the fever of former years 
diarrhoea was of frequent occurrence ; there were inflammatory complications, 
which varied with the season, as dysentery in the autumn, peritonitis in the 
winter, pleurisy in the spring, &c. Bronchitis was common, with occasional 
"inflammation of the fauces, tending to oedema of the glottis." In "many 
of the cases" there was "an abundant rose-colored rash on the trunk and 
limbs," which came "in patches irregular in shape and size, disappearing on 
pressure." There was no constant lesion; sometimes the glands of Peyer 
were affected, and sometimes there was ulceration of the large intestines. 
Relapses were by no means infrequent. The writer has examined the medical 
case books of the years 1847-48, and has been unable to satisfy himself of the 
identity of any of the fever cases reported therein, and those of relapsing 
fever, as described by authors, or seen by himself in Philadelphia in 1844, or 
since in New York in 1870, and subsequently. There was, however, perfect 
identity between the fever he saw in 1844 and that of New York in 1870. In 
1850-51, Professor Austin Flint made record of fifteen cases which he saw in 
the Buffalo (N. Y.) Hospital, and which, on analyzing some time afterwards, 
he was satisfied were cases of relapsing fever. The subjects were recent Irish 
immigrants. {Practice of Medicine. New York Med. Jour., March, 1870.) 
From that time to 1869-70 we have no records of relapsing fever in this coun- 
try. In the latter months of 1869 some cases of an unusual form of fever 
were reported to the New York Board of Health. It was soon recognized as 
relapsing fever, and immediately developed into an epidemic. The progress 
of the fever during twelve months is shown in the following table from the 
records of the Board of Health : 
Quarter ending April 2, 1870, .... 721 
" " " July 2, 1870, .... 873 
" " October 1, 1870, .... 394 
" " January 1, 1871, .... 133 
" " April 1" 1871, .... 60 
The epidemic reached its point of culmination in the second quarter of 
1870, and then declined rapidly. 
In Philadelphia it appeared about th® same time. Cases were also reported 
in Washington City, Havre de Grace, Md., Hackettstown, Woodbridge, and 
Keyport, N. J., Morrisania, and Jamaica, N. Y., New Canaan, Ct., and other 
places. In the six last-named towns the fever happened in isolated groups, 
amongst laborers, who all went from New York City. (See Report on Re- 
lapsing Fever, by Stephen Smith, M.D., in Annual Report of the Board of 
Health of the Health Department of the City of New York, 1870-71, p. 456. 
On Relapsing Fever: a Lecture by Prof. Austin Flint, M.D., New York 
Medical Journal, March, 1870. Notes on the History of Relapsing Fever, by 
Meredith Clymer, M.D., Ibid, and Medical Record, 1870. Lectures on Re- 
lapsing Fever, by Profs. Clark and Loomis, Medical Record, March, 1870. 
Parry, American Jour, of Med. Sc., Oct., 1870. Report of Philadelphia Board 
of Health, 1870, and other papers in the medical periodicals.)] 554 
SPECIAL PATHOLOGY-RELAPSING FEVER. 
Like other continued fevers, its specific cause is unknown; but it selects its 
victims from the poor and ill-fed, who live miserably, in crowded, filthy, ill- 
ventilated apartments, rather than from the wealthy and well-fed, who live in 
comfort and in well-aired abodes. Its poison appears to be of a specific kind, 
and the phenomena of the fever are very different from those of typhus and 
typhoid fever. Patients recovering from either typhus fever or typhoid fever 
may catch, by contagion, the relapsing fever, while patients convalescent from 
relapsing fever may also take either of the forms of continued fever already 
described. It has been supposed by some (Dr. Cormack) to be identical 
with the malarious form of yellow fever; but there is not sufficient evidence to 
establish the point. It seems more nearly to approach in its nature some 
forms of remittent fever, on account of the repetition of the rigors, often at 
regular daily periods, for two or three days. The marked periodicity of its 
relapses, which "come on like a fit of ague almost to an hour" (Dr. R. Patter- 
son), and the enlargement of the spleen to a greater extent than in any other 
form of fever (Jenner), point also to a malarious origin. On the other hand, 
epidemics of relapsing fever, as Murchison shows, appear to commence, prog- 
ress, and decline quite irrespectively of the season of the year. 
The evidence that a specific poison exists and is formed in cases of relapsing 
fever, and when so formed is communicable from the sick to the healthy, rests 
on evidence similar to that adduced in cases of typhus ; and the same objec- 
tions may be taken to the evidence which aims at establishing the spontaneous 
generation of the specific poison. There are causes, circumstances, or condi- 
tions which obviously favor the accession of relapsing fever, and no doubt, 
also, its occurrence in an epidemic form ; and chief amongst these predispos- 
ing causes must be placed destitution and want of food, while the names 
applied to the disease by different countries indicate the popular belief as to 
such predisposing causes being credited with originating the disease in the first 
instance. Thus it is spoken of as the famine fever of the British Isles, and the 
hunger pest of Germany. 
[Of the New York epidemic of 1870-71, Dr. Stephen Smith says (foe. citf: 
" The contagious nature of the fever was recognized by even the most casual 
observer. Group after group of cases were discovered to have originated by 
personal contact with the sick." Yet the contagious principle was not very 
diffusible. Those persons only caught the disease who were constantly brought 
into close and prolonged contact with the sick. Dr. Smith says: "It did not 
extend beyond the single room of a tenement house if the family remained 
isolated." The prevalence in single houses, or in limited districts, is in direct 
proportion to the degree of intercourse between the healthy and the sick]. 
The Primary Paroxysm.-The seizure is generally, indeed almost always, 
sudden. Sometimes, on waking in the morning, or when employed in busi- 
ness, severe rigors at once come on, with a sense of chilliness and frontal 
headache. These phenomena are more severe than their expression is in the 
commencement of typhus. There is slight prostration of strength from the 
first, but rarely so severe as in typhus. If premonitory symptoms exist, they 
usually manifest themselves by pains in the limbs, and lassitude, nausea, and 
perhaps vomiting, with feeling of prostration. Subsequently, and very soon, 
febrile reaction sets in, sometimes violent, expressed by intense heat of skin, 
severe headache, throbbing temples, intolerance of light and sound, suffusion 
of face, sleeplessness, remarkable anxiety of countenance and jactitation, with 
a very rapid pulse-so rapid as to range from 110, sometimes as high as 140 
beats in a minute; the tongue is coated with a white fur, and in a great ma- 
jority of cases, in some epidemics, there is uncontrollable vomiting of greenish, 
bitter fluid, with or without epigastric tenderness, and great thirst. The pains 
in the muscles and joints are sometimes so severe as to resemble rheumatism ; 
and when the pain in the back is severe, together with the rigors, the vomit- 
ing, and the headache, it may not be possible in the first instance to say that PHENOMENA OF RELAPSING FEVER. 
555 
the attack may not prove to be one of small-pox. But the pain in the back 
is not generally so severe, nor is the vomiting so incessant in cases of relapsing 
fever as in cases of small-pox. The headache is to be distinguished from what 
is commonly called a "sick headache," or "bilious headache," by the circum- 
stance that the "bilious headache" is in most cases occipital, and the heat of 
skin, combined with the quick pulse, serve to distinguish an attack of relaps- 
ing fever at its outset from one of "bilious headache." From idiopathic head 
affections the accession of relapsing fever is distinguished by the suddenness of 
the attack, the rigors, the hot skin, the pain in the joints and limbs, and the 
white tongue (Dr. Jenner). The symptoms generally of relapsing fever are 
so severe that the patient takes alarm, and takes to bed at once. He does not 
feel weak, but he feels so giddy that he is unable to remain out of bed, or off 
the horizontal position. In some cases there is pleurodynia in a severe degree, 
but without any stethoscopic indications of pleural inflammation. 
By the second or third day the pulse almost invariably exceeds 100; as a 
rule it reaches 120 ; in not a few cases it is as high as 140 or 160 ; and it is not 
rarely 140 on the second day of the disease, being at the same time full, and 
of considerable firmness-symptoms not indicative of commensurate danger- 
with anxious and oppressed breathing. There may be also sweating, profuse 
and lasting for several hours, but without relief to the headache and other 
symptoms. Almost no sleep is obtained, and the little obtained is dreamy 
and unrefreshing. The skin continues dry after the sweating ceases; or after 
the primary rigors, if sweating has not taken place. 
The heat of skin feels ardent-as much as 102° to 107° Fahr.; and these feb- 
rile phenomena are occasionally varied by short rigors oi' slight sweating. The 
thermometric phenomena differ from all other fevers. There is a rapid but 
not a sudden ascent for four or five days, and a sudden critical defervescence. 
Then the temperature remains normal for an interval extending over a variable 
number of days, after which there is a repetition, more or less intense, of the 
fever, followed by a similar subsidence. The temperature will rise to 106° or 
108° Fahr., and the highest point will generally precede the critical deferves- 
cence. In many cases the rise of temperature will be so continuous as not only 
to continue ascending from morning to evening, but from evening to morning. 
The highest point of each day is generally from four to seven o'clock p.m. 
Delirium does not generally supervene on the first attack, although, by the 
fifth or sixth day, just before the crisis, it has been in some cases of a violent 
kind. In a large proportion of cases there is decided jaundice, and in others 
the skin exhibits a bronzed hue. The jaundice is not attributable to any 
obstruction of the ductus communis choledochus, as bile passes freely, and even 
copiously with the stools, and as, after death, the gall-duct is pervious. There 
is generally tenderness over the region of the liver in such cases ; and it may 
be enlarged. Thirst is excessive ; the appetite absent or voracious, and the 
bowels constipated. The tongue, at first moist, is covered with a white or 
yellow fur, which it may retain throughout the illness; and in many cases it 
may become dry all over, or with a brown dry streak down the centre, after 
the third or fourth day. 
The Crisis.-After the patient has continued in this state for a period vary- 
ing from five to eight days, a sudden change takes place, immediately pre- 
ceded, in most cases, by an exacerbation of all the symptoms. " When every 
symptom appears hourly becoming graver-when the restlessness and general 
distress have reached their highest point-then ensues a most remarkable series 
of phenomena, followed by a remarkable intermission of all the symptoms, and 
an apparent restoration to health." This period has received the name of 
" Crisis," and supervenes generally on or about the seventh day, and its advent 
is rarely prolonged beyond the eighth. This change is ushered in by a most 
profuse perspiration, in some instances with an eruption of miliary vesicles, 
which breaks out from the whole surface of the skin, and in the course of a 556 
SPECIAL PATHOLOGY - RELAPSING FEVER. 
few hours the patient appears nearly well. More rarely the change is indi- 
cated by epistaxis as well as by perspiration, or by profuse diarrhoea, cata- 
menial discharge, or hemorrhage from the bowels; and after either or all of 
DIAGRAM OF TEMPERATURE IN A CASE OF RELAPSING FEVER (Herman). 
Fig. 75. 
these apparently critical changes have been established for a few hours, there 
is a complete and abrupt cessation of all the bad symptoms. 
So rapid is the critical change that the temperature may fall 10 or 12 
degrees in a few hours. The pulse quickly regains the natural standard, the 
tongue cleans, the appetite and sleep return, and the countenance resumes its 
tranquillity. This alteration is very often effected within a few hours, and on 
the following day the patient generally considers himself in all respects quite THE RELAPSE OR RECURRENT PAROXYSM. 
557 
well, and may so continue to improve rapidly for four or five days. During 
this period, however, there are some patients who suffer from violent muscular 
pains in the limbs. Symptoms of grave depression may also supervene, so 
that death may take place,by collapse or syncope. 
The Relapse or Recurrent Paroxysm.-About seven days after this critical 
change (which appears an interval of perfect health), or between about the 
twelfth to the twentieth day from the commencement of the illness, but gen- 
erally on tho fourteenth day, a sudden relapse occurs "in ninety-nine cases out 
of every hundred." This relapse commences suddenly, and is the character- 
istic peculiarity of the disease. Like the first seizure, it begins by rigors, 
headache, loss of appetite, vomiting of green fluid, which is quickly followed 
by a hot skin, quick pulse, and a coated white tongue, confined bowels, fol- 
lowed by delirium, so that the phenomena may be exactly represented as a 
repetition of the first attack. In the interval of convalescence between the 
first and second attacks the pulse often becomes slow to an extreme degree, 
as slow even as forty-five to sixty beats in the minute; but, suddenly on the 
relapse commencing, it again rises to 120 or more. In ordinary favorable 
cases perspiration would again occur in two, three, four, or five days, and the 
patient would be relieved as before. The chemical qualities of the sweat have 
never been determined in cases of relapsing fever; but it has a very sour and 
peculiar smell. In other cases, however, uncontrollable vomiting, great thirst, 
very rapid pulse, a hectic-looking circumscribed flush of countenance, jaun- 
dice, watchfulness, delirium, and death, may terminate the case. 
The temperature during the relapse may reach a higher point than in the 
first attack, followed by a similar sudden depression. 
The pulse generally bears a definite relation to the temperature. It rises 
with the fever heat and falls with the crisis, and is often rapid in cases other- 
wise favorable. 
The urea is diminished during the fever period, and in the interval, and is 
increased during permanent convalescence (Herman, Fox). 
In some cases the relapse is very slightly marked, and indicated merely by a 
comparative increase in the rapidity of the pulse and a greater heat of skin 
than were present on the previous day. The duration of the relapse varies 
from a few hours to several days ; the average being from three to five days, 
or less than that of the primary paroxysm. In some cases the relapse lasts 
less than twenty-four hours; and in a few it is prolonged to seven or eight days 
(Murchison). The relapse is rarely prolonged beyond these periods in un- 
complicated cases ; but Dr. Lyons observed in the Crimea that the fever of 
the relapse was occasionally protracted to twenty-one days (Lyons On Fever). 
If blood be taken from the arm, it is generally buffed, but it is not to be 
argued that therefore the lancet must be used in relapsing fever. So far as can 
be ascertained, no local inflammation attends it. 
In nearly a fourth of the cases, according to Sir William Jenner, jaundice 
is present, and is sometimes intense. If present during the first attack, it 
may disappear before the relapse, and not recur; or it may occur only on the 
relapse; and it is important to notice, that while the jaundice continues, the 
stools still retain their natural hue, and may even be darker than common, 
and at the same time the urine may be frequently loaded with bile. Epigas- 
tric tenderness is most marked in the cases where vomiting occurs. When 
pregnant women are attacked with relapsing fever they usually abort, some- 
times in the first paroxysm, but often in the relapse, and this event renders 
the prognosis more doubtful. 
There is a tendency in relapsing fever to the occurrence of sudden death. 
It may happen by syncope, immediately after the critical periods, when the 
pulse becomes so very slow.' It may also happen during the progress of the 
case, during either of the severe periods-namely, during the primary attack 
or during the relapse. It is indicated by a deep dusky hue of the face, lividity 558 
SPECIAL PATHOLOGY RELAPSING FEVER. 
of the hands and feet, and a purple marbling of the whole surface. The trunk 
feels cool, and the hands feel cold; and without suffering any severe pain, or 
without sustaining any sudden discharge of fluids, a state of collapse insidi- 
ously comes on, from which the patient is unable to be roused, and death may 
follow in a few hours, generally from twelve to twenty-four, even after it was 
supposed that danger had been escaped. But death is a rare termination to 
relapsing fever; and when it does occur, the fatal event more commonly hap- 
pens during the primary fever than during the relapse (Jenner). 
A second relapse, and a third, a fourth, and even a fifth, are reported to 
have occurred during epidemics of relapsing fever, but the cases are of rare 
occurrence. 
Duration of the Fever, and Convalescence.-Under ordinary circum- 
stances, when there are but two paroxysms-i. e., one primary paroxysm and 
one relapse-the total duration of the fever extends to about three weeks; and 
the convalescence is very slow-much slower than in typhus. The relapsing 
fever is very exhausting in its effects upon the constitution; and, dating the 
period of convalescence from the termination of the last attack, the time taken 
to recover is in most cases unusually long. To those, indeed, who suffer from 
more than one relapse, it is almost impossible to have health completely re- 
stored for a long time. They become a prey to various sequelae of fever, or 
they continue sickly for months, with pallid countenances, puffed ankles, pal- 
pitations, extreme debility, noises in the ears, dimness of vision, diarrhoea, or 
dysentery. Dysuria is a frequent complication amongst women during the 
relapse. In many instances during the epidemic of 1847 and 1848 in Ireland, 
convulsions occurred in cases which otherwise seemed to be progressing favor- 
ably, and death invariably followed them. Dr. William Robertson observed 
in Edinburgh (and the Irish physicians record a similar observation) that 
delirium of a violent character occurred during convalescence, or after the 
critical discharge had taken place. It generally came on suddenly, with in- 
cessant talking, a rapid weak pulse, followed by perfect unconsciousness, 
flushed face, and contracted pupil. 
No special anatomical lesion has been pointed out as peculiar to relapsing 
fever. The most constant lesion is enlargement of the spleen, the size attained 
by that organ being on the whole larger than in either typhus or typhoid 
fevers. Sir William Jenner has recorded the weight in one case to have been 
as much as thirty-eight ounces, and of a size in proportion. Its substance is 
generally softened, sometimes diffluent. It is usually seen at its largest size 
when death occurs during the final paroxysm; but if death occurs during 
convalescence, the spleen is of a normal size. Occasionally pale, red, fibrinous 
infarctions are found in its substance and near its surface. They are easily 
broken down, have a fine granular fracture, and are considerably firmer than 
the surrounding tissue, from which they are separated by a distinct line of 
demarcation. As a rule, there is but little congestion of the lungs, the weights 
of which contrast singularly with the weights of organs in subjects dead of 
typhus fever. 
The blood in a few cases has been found fluid throughout the body after 
death ; but generally, when drawn from the body during the febrile paroxysm, 
it is buffed; and decolorized coagula are found in the heart and large vessels 
after death more frequently than in cases of typhus. In several cases urea 
has been detected in the blood in considerable quantity. The proportion of 
white corpuscles is increased-a fact of interest in connection with enlarge- 
ment of the spleen, and the state of anaemia so commonly observed (Cormack, 
Allen Thomson, Murchison). The liver is generally large, and the gall- 
bladder filled with dark thick bile. 
Sequelae of Relapsing Fever.-One of the most common results is the 
occurrence of excessive pains in the limbs, more especially expressed about 
the knee and ankle-joints; and even the long bones appear to be the seat of TREATMENT OE RELAPSING FEVER. 
559 
these pains in some cases. Combined with those local pains, the joints may 
swell; and the kidneys are in danger of being implicated. In some respects, 
therefore, the dangers are similar to those which attend scarlatina. The lym- 
phatic glands are also liable to swell, and so is the parotid gland. Anasarca 
and furunculi may likewise supervene. 
The most important of all the sequelae, however, is a remarkable affection 
of the eyes-a form of ophthalmitis-which Dr. Mackenzie first described 
under the name of "post-febrile ophthalmitis." It may occur during the 
course of the fever, but more often during convalescence, and even some 
months after convalescence has been established. It was very common in 
Glasgow after the epidemic of 1843 ; and assumed two different forms, namely, 
(1.) An active inflammation of the shell of the eyeball and of the iris; 
(2.) An amaurotic state due to congestion of the choroid and the retina (Dr. 
Andrew Anderson). 
These two forms of disease may be associated with two characteristics of 
the fever itself-namely, " the tendencies to visceral congestions, and to rheu- 
matic-like pains;" while the constitutional character of the ophthalmia is in 
many cases proved by the unhealthy aspect of the blood, which flows dark, in 
some cases almost tarry, from the vein. Bleeding is found to be the most 
effectual-the only effectual-mode of cutting short this dangerous ophthal- 
mia ; and a very small loss of blood is found to be sufficient. This is especi- 
ally noticeable, because, during convalescence, tonics and quinine are most 
likely to be thought of (Anderson). 
Treatment.-All physicians agree that in the primary attack little medi- 
cine is required after opening the bowels by castor oil; or by five grains of 
the compound colocynth mass; or by two grains of blue-pill, and three grains 
of extract of hyoscyamus given at night, and followed in the morning by two 
drachms of the sulphate of magnesia in compound infusion of roses (Murchi- 
son). The symptoms are not readily under the control of remedies; the 
vomiting is often especially persistent. Five grains of calomel, with one grain 
of opium, has been found more efficient in subduing the severity of this symp- 
tom than counter-irritation or effervescing draughts. The violence of the 
headache in well-fed, or otherwise healthy patients, is best subdued by leeches 
or cupping; and in the poor, weakly, and ill-fed, by blisters to the nape of 
the neck, or by dry cupping there. Till the crisis comes, the symptoms may 
be mitigated, but not altogether relieved, and cases of ordinary severity are 
better left to nature, without interference on the part of the physician. Active 
purging is to be avoided; and the action of the kidneys is to be kept up by 
the frequent use of small doses of nitre (Ross, Henderson, Cormack, War- 
dell, Murchison). " By keeping up the action of the kidneys from the 
first," Dr. Murchison justly entertains the hope that we may "prevent the 
occurrence of uraemic intoxication, which is one of the main causes of death 
in uncomplicated cases." He recommends the administration of the nitre as 
follows: 
From one to two drachms of nitre are to be dissolved in two pints of barley- 
water, acidulated with a drachm of dilute nitric acid, and sweetened with a 
little syrup. This quantity is to be used up during the twenty-four hours. 
Acetate of potash and nitric ether may be used for the same purpose ; but the 
nitre has the additional advantage of keeping open the bowels. 
The surface of the body should be frequently sponged over with cold or 
tepid water. Stimulants are not usually necessary, but they may be required 
in the stage of. languor or exhaustion ensuing on the crisis, or in cases where 
great debility has preceded the attack. If any anaemia exists, or if an anaemic 
murmur can be detected, stimulants must be given early. When jaundice 
appears, Dr. Murchison recommends that nitro-hydrochloric acid should be 
given in combination with nitre, as in the following formula: 558 
SPECIAL PATHOLOGY RELAPSING FEVER. 
of the hands and feet, and a purple marbling of the whole surface. The trunk 
feels cool, and the hands feel cold; and without suffering any severe pain, or 
without sustaining any sudden discharge of fluids, a state of collapse insidi- 
ously comes on, from which the patient is unable to be roused, and death may 
follow in a few hours, generally from twelve to tzventy-four, even after it was 
supposed that danger had been escaped. But death is a rare termination to 
relapsing fever; and when it does occur, the fatal event more commonly hap- 
pens during the primary fever than during the relapse (Jenner). 
A second relapse, and a third, a fourth, and even a fifth, are reported to 
have occurred during epidemics of relapsing fever, but the cases are of rare 
occurrence. 
Duration of the Fever, and Convalescence.-Under ordinary circum- 
stances, when there are but two paroxysms-i. e., one primary paroxysm and 
one relapse-the total duration of the fever extends to about three weeks; and 
the convalescence is very slow-much slower than in typhus. The relapsing 
fever is very exhausting in its effects upon the constitution; and, dating the 
period of convalescence from the termination of the last attack, the time taken 
to recover is in most cases unusually long. To those, indeed, who suffer from 
more than one relapse, it is almost impossible to have health completely re- 
stored for a long time. They become a prey to various sequelae of fever, or 
they continue sickly for months, with pallid countenances, puffed ankles, pal- 
pitations, extreme debility, noises in the ears, dimness of vision, diarrhoea, or 
dysentery. Dysuria is a frequent complication amongst women during the 
relapse. In many instances during the epidemic of 1847 and 1848 in Ireland, 
convulsions occurred in cases which otherwise seemed to be progressing favor- 
ably, and death invariably followed them. Dr. William Robertson observed 
in Edinburgh (and the Irish physicians record a similar observation) that 
delirium of a violent character occurred during convalescence, or after the 
critical discharge had taken place. It generally came on suddenly, with in- 
cessant talking, a rapid weak pulse, followed by perfect unconsciousness, 
flushed face, and contracted pupil. 
No special anatomical lesion has been pointed out as peculiar to relapsing 
fever. The most constant lesion is enlargement of the spleen, the size attained 
by that organ being on the whole larger than in either typhus or typhoid 
fevers. Sir William Jenner has recorded the weight in one case to have been 
as much as thirty-eight ounces, and of a size in proportion. Its substance is 
generally softened, sometimes diffluent. It is usually seen at its largest size 
when death occurs during the final paroxysm; but if death occurs during 
convalescence, the spleen is of a normal size. Occasionally pale, red, fibrinous 
infarctions are found in its substance and near its surface. They are easily 
broken down, have a fine granular fracture, and are considerably firmer than 
the surrounding tissue, from which they are separated by a distinct line of 
demarcation. As a rule, there is but little congestion of the lungs, the weights 
of which contrast singularly with the weights of organs in subjects dead of 
typhus fever. 
The blood in a few cases has been found fluid throughout the body after 
death ; but generally, when drawn from the body during the febrile paroxysm, 
it is buffed; and decolorized coagula are found in the heart and large vessels 
after death more frequently than in cases of typhus. In several cases urea 
has been detected in the blood in considerable quantity. The proportion of 
white corpuscles is increased-a fact of interest in connection with enlarge- 
ment of the spleen, and the state of anaemia so commonly observed (Cormack, 
Allen Thomson, Murchison). The liver is generally large, and the gall- 
bladder filled with dark thick bile. 
Sequelae of Relapsing Fever.-One of the most common results is the 
occurrence of excessive pains in the limbs, more especially expressed about 
the knee and ankle-joints; and even the long bones appear to be the seat of treatment of relapsing fever. 
559 
these pains in some cases. Combined with those local pains, the joints may- 
swell ; and the kidneys are in danger of being implicated. In some respects, 
therefore, the dangers are similar to those which attend scarlatina. The lym- 
phatic glands are also liable to swell, and so is the parotid gland. Anasarca 
and furunculi may likewise supervene. 
The most important of all the sequelae, however, is a remarkable affection 
of the eyes-a form of ophthalmitis-which Dr. Mackenzie first described 
under the name of "post-febrile ophthalmitis." It may occur during the 
course of the fever, but more often during convalescence, and even some 
months after convalescence has been established. It was very common in 
Glasgow after the epidemic of 1843 ; and assumed two different forms, namely, 
(1.) An active inflammation of the shell of the eyeball and of the iris; 
(2.) An amaurotic state due to congestion of the choroid and the retina (Dr. 
Andrew Anderson). 
These two forms of disease may be associated with two characteristics of 
the fever itself-namely, " the tendencies to visceral congestions, and to rheu- 
matic-like pains;" while the constitutional character of the ophthalmia is in 
many cases proved by the unhealthy aspect of the blood, which flows dark, in 
some cases almost tarry, from the vein. Bleeding is found to be the most 
effectual-the only effectual-mode of cutting short this dangerous ophthal- 
mia ; and a very small loss of blood is found to be sufficient. This is especi- 
ally noticeable, because, during convalescence, tonics and quinine are most 
likely to be thought of (Anderson). 
Treatment.-All physicians agree that in the primary attack little medi- 
cine is required after opening the bowels by castor oil; or by five grains of 
the compound colocynth mass; or by two grains of blue-pill, and three grains 
of extract of hyoscyamus given at night, and followed in the morning by two 
drachms of the sulphate of magnesia in compound infusion of roses (Murchi- 
son). The symptoms are not readily under the control of remedies; the 
vomiting is often especially persistent. Five grains of calomel, with one grain 
of opium, has been found more efficient in subduing the severity of this symp- 
tom than counter-irritation or effervescing draughts. The violence of the 
headache in well-fed, or otherwise healthy patients, is best subdued by leeches 
or cupping; and in the poor, weakly, and ill-fed, by blisters to the nape of 
the neck, or by dry cupping there. Till the crisis comes, the symptoms may 
be mitigated, but not altogether relieved, and cases of ordinary severity are 
better left to nature, without interference on the part of the physician. Active 
purging is to be avoided; and the action of the kidneys is to be kept up by 
the frequent use of small doses of nitre (Ross, Henderson, Cormack, War- 
dell, Murchison). " By keeping up the action of the kidneys from the 
first," Dr. Murchison justly entertains the hope that we may " prevent the 
occurrence of uraemic intoxication, which is one of the main causes of death 
in uncomplicated cases." He recommends the administration of the nitre as 
follows: 
From one to two drachms of nitre are to be dissolved in two pints of barley- 
water, acidulated with a drachm of dilute nitric acid, and sweetened with a 
little syrup. This quantity is to be used up during the twenty-four hours. 
Acetate of potash and nitric ether may be used for the same purpose; but the 
nitre has the additional advantage of keeping open the bowels. 
The surface of the body should be frequently sponged over with cold or 
tepid water. Stimulants are not usually necessary, but they may be required 
in the stage of. languor or exhaustion ensuing on the crisis, or in cases where 
great debility has preceded the attack. If any anaemia exists, or if an anaemic 
murmur can be detected, stimulants must be given early. When jaundice 
appears, Dr. Murchison recommends that nitro-hydrochloric acid should be 
given in combination with nitre, as in the following formula : 560 
SPECIAL PATHOLOGY-SIMPLE CONTINUED FEVER. 
Twenty minims of hydrochloric acid, with ten minims of nitric acid, every 
three hours, each dose diluted with the drink of nitre and barley-water already 
prescribed. 
Contamination of the blood with urinary products is the great danger in 
cases of relapsing fever; and therefore, particular attention must be paid to 
the state of the urine, especially towards the period of the first crisis. When 
the daily amount is much reduced, or if entire suppression should ensue, and 
particularly if stupor, confusion of thought, or drowsiness should supervene, 
the bowels are to be freely moved by compound jalap powder, or by a turpen- 
tine enema. Determination to the skin should be promoted by the hot air 
bath ; and saline diuretics may be given every two or three hours (Murchi- 
son). No means hitherto discovered will prevent the occurrence of the relapse. 
SIMPLE CONTINUED FEVER. 
Latin Eq., Febris continua simplex; French Eq., Fiivre continents; German Eq , 
Fieber von unbestimmtem character; Italian Eq , Febbre continua semplice. 
Definition.- Continued fever having no specific character. 
Pathology.-It is stated in the Medico- Chirurgical Review for October, 
1869, that the College of Physicians have retained this name of a disease in 
deference to the opinion of a large body of practitioners, who find it impossi- 
ble to class all their fever cases under the more definite varieties just de- 
scribed. On the other hand, there are not a few physicians who doubt the 
occurrence of simple continued fever as distinct from the continued fevers 
already described. There can be no doubt, however, that cases of an anoma- 
lous or mixed nature do sometimes occur, concerning which a decided diag- 
nosis cannot be given from the general symptoms merely; and the term con- 
tinued fever " has become a refuge for many cases of an uncertain character." 
Thus while the distinct forms of continued fever previously described are 
capable of being recognized, there can be no doubt that cases of fever do 
sometimes occur in this country which run a continuous course, having no 
other specific characters, and which, in many respects, do not seem quite the 
same as those with which we are now familiar, and which cannot at once be 
clinically recognized. For instance, .in the very interesting investigation into 
the nature of " typhus and typhoid fever," by Dr. Murchison, recorded in the 
forty-first volume of the Medico- Chirurgical Transactions, it is related that 
about 200 cases are left out of consideration altogether because they were 
" doubtful cases," and could not be classed as either typhus or enteric cases. 
A similar class of " doubtful cases" ate seen to occur in places where yellow 
fever and remittent fevers occur, and which cannot be classed as either the one 
or the other form of fever. 
Again, in the Mediterranean latitudes, there is a " gastric remittent" fever 
described, which seems to have many characters in common with some of the 
forms of continued fever (Craigie, Marston). 
Wunderlich and Murchison both describe febrile phenomena which are of 
so anomalous a kind that they refer them to a combination of the poisons of 
typhus and typhoid fevers, so that the characters of each do not remain dis- 
tinctive. So likewise Dr. W. T. Gairdner, in stating that of late (from 1853 
till 1862) the cases of fever in the Edinburgh Royal Infirmary have not been 
more than seven or eight cases a month under his notice-including numerous 
anomalous fevers which have prevailed, and which have sometimes quite over- 
borne the numbers of genuine typhus and of enteric fever together (Clinical 
Medicine, p. 154). A fever termed "gastric" is distinctly described by Dr. 
Andrew Anderson, of Glasgow, which would also come under this head. The PATHOLOGY OF SIMPLE CONTINUED FEVER. 
561 
" bilious remittent" or "bilious typhoid," of Greisinger, of Tubingen, is another 
form of continued fever which requires investigation. He observed it at 
Damietta, in Egypt. It is probably a malarious fever of a remittent type, or 
some form of malarious yellow fever. The sudden fall of the pulse from 120 
to 75 was not attended by corresponding improvement of the patient, but was 
the forerunner of severe typhoid symptoms and jaundice. The mortality was 
equal to 19 per cent.; and quinine was found to be of signal service (Mur- 
chison). 
The works of Morehead and Sir Ranald Martin may also be referred to for 
various anomalous forms of continued fever; and in which the " ardent con- 
tinued fever" of India may be quoted as an example of a very serious disease. 
For an account of this fever the reader is referred to page 164 of Dr. More- 
head's work, and page 204 of Sir Ranald Martin's on the diseases and climate 
of India. 
It is these " doubtful or anomalous" cases especially which require careful 
and special methods of investigation. They are of the utmost importance to 
science, for more extended information regarding them will either connect 
them with forms of fever between which they seem to stand ; or these "doubt- 
ful cases" will eventually separate themselves into distinct forms, whose his- 
tory is still unknown. In such doubtful cases observations regarding the cor- 
relation of temperature, the excretions, the succession of phenomena, and 
general course of the disease, are imperatively demanded. 
The poisons of tropical fevers especially require to be carefully studied, and 
the phenomena of the febrile state which accompanies them embrace some 
medical problems of the most abstruse nature. Physiological data of an exact 
kind are now beginning to rise around us, which will give a standpoint for 
comparison in the study of the phenomena of fever in the tropics. Extremely 
important observations are being worked out by Dr. Emile Becher, of the 
Army Medical Department, regarding the influence of tropical climate on 
the excretions of the urine in relation to the body weight. At great personal 
sacrifice and denial of self, he has twice undertaken such investigations on 
his own person in voyages to India, round the Cape of Good Hope; and it is 
to be regretted these observations are not yet published. They have indeed 
been anticipated to some extent by Dr. A. Rattray, in Proceedings of Royal 
Society, June 16th, 1870. 
With all such exact information, and the improved physical aids to inves- 
tigation, it behooves the physician and pathologist to investigate medical prob- 
lems with the same logical rigor and severity as a chemical or an astronomical 
theorem demands. On this important point the opinion of one may be 
especially quoted, whose experience as a teacher of clinical medicine has 
been great, and whose philosophical investigations into the nature of fever, in 
particular, command the attention of all. On this point Dr. Parkes thus 
writes,-" The power of observation in medicine is a kind of tact, which ought 
to be cultivated with the same assiduity as the chemist practices when he 
learns how to manage his delicate manipulations, or the astronomer when he 
wields his wondrous tube. In medicine the observation and recording of phe- 
nomena has been held to be an easy and trifling task, which any tyro was 
competent to do. Hence half the error and uncertainty of Medicine. Inac- 
curate, that is, erroneous and incomplete observation, has been the cause that, 
till within these few years, the fevers of cold countries have been so abso- 
lutely uncomprehended, and that the fevers of hot countries are still shrouded 
in obscurity. The most valuable addition any one could at present make to 
our knowledge of tropical fevers would be a simple record of all the cases in 
an epidemic. These cases should be observed with the keen tact of a Chomel, 
and recorded with the fidelity of a Louis. We want no explanation or word 
of comment added to them; we want merely the cases. Then, when the 
numbers are sufficient, we should certainly begin to put order into this chaos. 562 
SPECIAL PATHOLOGY-FEBRICULA. 
And let not any one who may have the opportunities be deterred from the 
task by that fallacious and, we beg to say, most reprehensible argument, with 
which some people may favor him,-namely, that his cases will be ' tedious,' 
'heavy,' and 'unread.' Unread they will be, certainly, by some of the pro- 
fession, who consider their routine practice as great an effort as their intellect 
will bear; but read and analyzed, we will venture to say, they will be by 
those who think no labor too great if they can fix safely the foundations of 
Medicine, and for whom, if accurately reported, no cases can be too long, no 
observations too minute. Only, before the task is commenced, let the observer 
feel that his powers are equal to it; and let him bear in mind the example of 
Louis, who recorded most carefully for a long time, that he might train him- 
self to this duty, and then, throwing his probationary cases aside, as too un- 
certain for use, began to make those remarkable series of observations which 
have linked his name forever with the greatest improvements in modern Medi- 
cine-the employment of a correct method of studying his science" {Brit, and 
For. Med.-Chir. Review, Oct., 1850, p. 435). 
FEBRICULA. 
Latin Eq., Febricula; French Eq., Fiber e ephembre; German Eq., Febricula; 
Italian Eq., Febbricola-Syn., Febbre efemera. 
Definition.-A simple fever in which the expression of the febrile phenomena 
is of very short duration, lasting, as a rule, for not more than twenty-four, thirty- 
six, forty-eight, or seventy-two hours, attended with a frequent, full, and often firm 
pidse, white and coated tongue, pains in the loins and limbs, thirst, constipation, 
a scanty discharge of high-colored urine, hot and dry skin, sometimes an eruption 
of roseola or erythema about the loins or thighs, coming and disappearing with 
the fever (Morehead) ; severe headache, sometimes acute delirium, and flushed 
face. The subsidence of the fever is generally associated with copious perspira- 
tions, or herpetic eruptions. 
Pathology.-We do not know of any specific poison as the cause of such 
phenomena as those detailed in the definition; neither have we any evidence 
that febricula is a contagious or miasmatic disease. There are many different 
causes which are known to be capable of exciting expressions of febrile phe- 
nomena similar to those mentioned in the definition,-such as exposure to 
great heat or cold, surfeit, inebriety, mental or bodily fatigue or excitement; 
and specific poisons, in uncertain or otherwise mild doses, such as the typhus 
or enteric fever poisons. It is also associated with local and functional dis- 
turbances-e. g., catarrhs (bronchial, gastric, intestinal, urethral), milk fever, 
the fever of alcoholism. Such cases are especially bharacterized by the ap- 
parent severity of the febrile state, the shortness of its course, and the absence 
of any local complication or specific eruption. 
The pathology of such apparently simple fevers demands extensive investi- 
gation, and especially in the tropics, where febricula is a very common dis- 
ease. The ardent fever, the sun fever, the common continued fever of Burmah 
and India generally, are all names which indicate severe or protracted cases 
of febricula-cases of fever which "differ in degree rather than in character" 
(Morehead). They are common in those parts of India which do not ex- 
perience much of the influence of the monsoon rains. 
Cases of true febricula commence with chills, followed by reaction, and this 
by perspiration. They are characterized by a quick and comparatively sudden 
rise of temperature, as indicated by the following diagram (Fig. 76)-a rise of 
temperature in a few hours to 4°, or 5°, or 7° above the normal temperature of 
98° Fahr. They have thus a sudden beginning and a rapid arrival at a maxi- 
mum, phenomena which are only shared in by some forms of malarious fever (in- PATHOLOGY OF FEBRICULA. 
563 
termittent), variola, measles, and pneumonia. The defervescence also is charac- 
teristic. In febricula the maximum of temperature may only last for a few 
hours, or a single day, when the defervescence sets in rapidly; so that in 
twenty-four or thirty-six hours the body will have returned to its normal 
heat-an example of pure crisis. No other febrile disease gives expression to 
TYPICAL RANGE OF TEMPERATURE IN A CASE OF FEBRICULA. THE REC- 
ORDS INDICATE MORNING (m.) AND EVENING (e.) OBSERVATIONS 
(Wunderlich). 
Fig. 76. 
LINE OF NORMAL TEMPERATURE, 98° FAHR. 
similar phenomena; and the correlation of temperature to the other phenom- 
ena, especially to the excretion of urine, is also peculiar. The urine presents, 
during this disease, the very type of febrile urine. On the second or third 
TYPICAL RANGE OF TEMPERATURE IN A CASE OF PROTRACTED FEBRICULA 
(ephemera protracta). the records indicate morning (m.) and 
evening (e.) observations (Wunderlich). 
Fig. 77. 
MEMEME ME ME ME 
LINE OF NORMAL TEMPERATURE, 98° FAHR. 
clay, according to Dr. Parkes's own observations, the amount of urine is ex- 
tremely small (twelve to twenty ounces), of very high specific gravity (1035- 564 
SPECIAL PATHOLOGY-SPECIFIC YELLOW FEVER. 
1037), with the solids and sulphuric acid very much over the average, and 
the amount of urea large. When the temperature falls, the quantity of urine 
rapidly augments. The increase of urea and of the solids is not so much, 
however, as in the height of the more severe and prolonged fevers (Parkes 
On the Urine, p. 243). 
In eases of more protracted febricula, the early phenomena are similar to 
the shorter cases, and the protraction is mainly due to the slowness of the de- 
fervescence-an example of lysis. The phenomena of such defervescence, as 
indicated by the range of temperature, are shown in the foregoing diagram 
(Fig. 77). 
As a rule, these.fevers are not serious; but the degree of reaction has always 
a relation to the state of the constitution, whether sthenic or not (Morehead). 
Diagnosis.-Contrasted with the commencement of enteric fever, so far as 
temperature is concerned, it rises high more early than febricula than in enteric 
fever. On the first day it will have reached 103° Fahr., or more, while that 
point is seldom reached in enteric fever before the third or fourth evening. 
The ascent is continuous in febricula till the highest point is reached; and it 
continues high for twenty-four or forty-eight hours, with morning remissions. 
Such a fever may be induced in children by the heat of the sun alone; and 
it ought to be over within ten days (Fox). * 
Treatment of Febricula.-Such means as emetics, purgatives, tepid spong- 
ing, diaphoretics, and antiphlogistic regimen are to be employed. In plethoric 
individuals, where there is much headache and flushing of the face, a moder- 
ate general bloodletting, or leeches to the temples, may be expedient, but such 
remedies are not often necessary (Morehead). 
[specific] yelloav fever. 
Latin Eq., Febris fava; French Rq., Figure jaune; German Eq., Gelbes Fieber- 
Syn., Gelbfieber; Italian Eq , Febbre gialla. 
Definition.-A specific malignant fever of a continuous type, occurring, as a 
rule, only once during life, and propagated by contagion. It is attended by yel- 
lowness of the conjunctivae and skin, delirium, suppression of urine, interstitial 
hemorrhages and hemorrhages from the stomach, mouth, nares, and rectum (black 
vomit, black stools'), a slow and, at times, an intermittent pulse. It is limited to 
very definite geographical limits, never having been known to propagate beyond 
48° north latitude, nor without a temperature of 72° Fahr, at least. It has been 
imported into Lisbon, into St. Nazaire, in the department of the Lower Loire, 
into Plymouth and Southampton, where cases have run their course and proved 
fatal. It has been imported and become epidemic as far south as Monte Video. 
It has occurred as high as 4000 feet above the sea-level (Newcastle, in Jamaica). 
But, as a rule, it is endemic in low districts on the seacoast, and rarely occurs 
above an elevation of 2500 feet above the level of the sea. 
Pathology and Symptoms.-Yellow fever of a specific kind must now be 
regarded, from an enlightened consideration of its history, as one sui generis, 
and specifically different from the remittent and intermittent fevers (in which 
the patient may become yellow), or from any other form of malarious yellow 
fever (Cullen, Chisholm, Blane, Wood). 
The College of Physicians have given the following definition of yellow 
fever, namely,-" A malignant epidemic fever, usually continued, bid sometimes 
assuming a paroxysmal type, characterized by yellowness of the skin, and accompa- 
nied, in the severest cases, by hemorrhages from the stomach (black vomit), nares, 
and mouth." 
There is obviously mixed up in this definition a malarious form of yellow 
fever, and the true specific form, which it is desirable to separate and dis- 
tinguish. PATHOLOGY of specific yellow fever. 
565 
There are those who believe that these fevers are the same in kind, but 
various in degree; that certain atmospheric conditions, such as great heat or 
humidity, acting on a predisposed frame, will produce all the symptoms of 
the most malignant fever; that the intensest form of yellow fever is but the 
developed degree of the common bilious derangements peculiar to hot and 
rainy seasons (Tommasini, Cleghorn, Lind, Hunter, Alison, Craigie, 
Martin). It has been held also that a specific non-contagious agent pro- 
duces a fever which has been called " yellow," but which is totally different 
from the real yellow fever (Rochoux). On looking carefully into the history 
of yellow fever, on which volumes have been written, the conclusion arrived 
at seems to be,-(1.) That there is a specific yellow fever, propagated by a 
contagious virus or poison which multiplies itself by its passage through the 
human system, and which reproduces the same specific true yellow fever. 
The type of this fever is continuous. Pyrexia, delirium, suppression of urine, 
black vomit, are the leading symptoms of this fever-the hwmagastric pesti- 
lence, as it has been also called. (2.) That there are other fevers, and espe- 
cially severe marsh fevers, in certain geographical limits, which have a close 
resemblance in symptoms to the contagious and specific yellow fever. So 
also, it is said, have fevers arising simply from a high temperature acting on 
an unseasoned subject. On this point my friend and colleague, Dr. Maclean, 
Professor of Military Medicine, who has had twenty-two years' experience of 
East Indian fevers, writes me as follows : 
" I am now myself a firm convert to the doctrine that yellow fever is speci- 
fically distinct from remittent. To this opinion I have come with a full 
knowledge of the fact that some cases of remittent fever in India closely re- 
semble some of the forms of yellow fever. But of this I am now certain, that 
the yellow fever of the true yellow fever zone is unknown in India where true 
malarial fevers abound. There is in true yellow fever, for the most part, an 
absence of that periodicity which is an unfailing characteristic of true malarial 
fevers. Then there is the difference so well insisted upon by Blair in true 
malarial fevers. Men do not pass from recovery to health, as is the case in 
such a marked degree in yellow fever, after which there is no, or very little, 
evidence of the existence of any cachexy. Malarial fevers exist and are de- 
structive at a temperature at which yellow fever is at once destroyed. Albu- 
minous urine is almost invariable in yellow fever-only occasional in remit- 
tent. There is in yellow fever an unexampled range of hemorrhages; in 
remittent fever these hemorrhages are often, indeed, generally absent. Qui- 
nine has a power over malarial fevers that is beyond the reach of doubt or 
cavil; the same is not true of yellow fever. Men suffer from malarial fevers 
again and again; second attacks of yellow fever are, to say the least, rare." 
The correctness of the above view of this important question has also re- 
ceived a remarkable illustration in some observations made in Mexico by the 
Medical Staff1 of the French Army serving there. 
Yellow fever had disappeared from Vera Cruz. In the month of October, 
in the middle of a sudden augmentation of sickness, several severe cases of a 
disease like vomito appeared. The physicians dreaded a return of yellow fever 
in its epidemic form, in spite of the relative abatement of temperature and 
the almost constant prevalence of a northeast wind. These fears were aug- 
mented by the disembarkation at this time of a great many fresh troops ; also 
by the suddenness of the invasion of the disease, showing itself in a great 
many cases by hepatic symptoms, bilious vomiting, fever, prostration, articu- 
lar pains; the fever being continuous, or at least without sensible remissions, 
in. many cases. But soon many circumstances demonstrated the groundless- 
ness of the fear, ami showed that the disease was malarious. These were,- 
(1.) The quickly recognized efficacy of quinine, which in the month of May, 
when true yellow fever raged, gave only negative results at the best; (2.) 566 
SPECIAL PATHOLOGY SPECIFIC YELLOW FEVER. 
The rapid supervention of splenic enlargement, often attended with pains; 
(3.) The small relative mortality; (4.) The absence of hemorrhages, other 
than occasional epistaxis; (5.) The constant absence of albumen in the urine; 
(6.) The difference in the anatomical lesions, and chiefly in the presence of 
enormously enlarged and softened spleens; (7.) The absence of all the lesions 
characteristic of vomito, such as the yellow color of the body, with marbled 
marks, black matters in the intestines, discoloring of the liver approaching 
to yellowness ; (8.) Finally, the non-immunity of soldiers of the garrison who 
had already suffered from yellow fever (Recueil de Memoires de Medecine, de 
Chirurgie, et de Pharmacie Militaires, No. 37, Janvier, 1863). 
Considering true yellow fever, therefore, as one of the specific continued 
fevers, having a certain limited geographical range, it is necessary at the out- 
set to define what is meant by true or pestilential yellow fever, and what are 
the diagnostic symptoms which distinguish it from the diseases which resemble 
it, but which are really dissimilar. 
It may be asserted unconditionally at the outset, that the significance of 
the symptoms of yellowness of the skin and black vomit is very small indeed 
as diagnostic marks. Different shades of yellowness of the skin have been 
described as forming a prominent symptom, not only in epidemics of yellow 
fever, but by all writers on the fevers generally of hot countries. Yellow- 
ness of the skin in remittent fevers arising from malaria has been noticed in 
all climates, although it is certainly most common in those of the western 
hemisphere. Cleghorn observed it at Minorca; Irvine in Sicily, in the 
autumnal fevers ; Burnett in the Mediterranean fevers, of all depths of colors. 
In the fatal fever of the Mysore country, yellowness during some years has 
been almost universal; so also in Batavia, and in the fevers of Rangoon in 
1824-25. A fever attended with yellowness of the skin raged like a pesti- 
lence in Rohilcund from 1836 till 1840, at the same time that a fever with 
symptoms of plague was prevalent in Marwar and Meywar, and common 
remittents and intermittents prevailed between these districts. A fatal remit- 
tent fever attacked Her Majesty's 29th Regiment in 1844 at Ghazepore. In 
many cases there was "deep jaundice;" and in one case a symptom occurred 
which has been often witnessed in the West Indies-namely, sloughing of 
the penis and scrotum (Parkes "On the Contagion of Yellow Fever," in 
Brit, and For. Med.-Chir. Review, Jan., 1848). So also in some forms of 
specific yellow fever, as in the algid form, so well described by Dr. Lyons, in 
the Lisbon epidemic of 1857, yellowness was very often wanting, "many cases 
dying without having ever exhibited a trace of yellowness on any part of the 
cutaneous surface, or even the conjunctivae during life" (Lyons On Fever, p. 
338). 
Black vomit is an event which occurs in fevers of marshy origin, and in 
the so-called " seasoning fevers," as well as in gastric affections of a purely 
tropical nature, in coup de soleil, and in some injuries of the brain. In the 
remittent fevers of the African stations, black vomit is not an unusual occur- 
rence. So also in some of the yellow fevers of America, which are of marshy 
origin, black vomit is a usual symptom (Boott). 
These two events-namely, yellowness of the skin and black vomit-being 
of themselves insufficient as diagnostic marks of true or specific yellow fever, 
additional grounds of difference are found,-(1.) In the type of the fever, 
which is continuous and not remittent; (2.) In the fact that it occurs, as a 
rule, only once during life; (3.) In the fact that it is propagated by specific 
media from infected persons or places to others. But although in no one of 
those phenomena, taken singly, except in that of its communicability from 
person to person, do we find any definite characters to rely upon to prove the 
existence of a formal and specific yellow fever, yet, in the general assemblage 
and collocation of symptoms, peculiarities do present themselves which are 
easily discernible by an experienced eye. INCUBATION OF SPECIFIC YELLOW FEVER. 
567 
Though the subject of tropical fevers is too little known to warrant decided 
opinions on many points, yet the true yellow fever, or hmmagastric pestilence, 
is now so clearly stamped with characters so peculiarly its own, that it takes 
its place as a specific fever of a continuous and generally rapidly fatal type. 
Its pathology is best exemplified in the history of such isolated outbreaks of 
it as are to be found in the cases of the " Hussar" (Blane), the " Bann," the 
" Kent," the "Scout," the "Eclair," the "Hankey," the "Icarus," the Lisbon 
epidemic of 1857, and the importation of the disease from Havana, into the 
port of St. Nazaire by the "Anne Marie" in 1861; and no description of 
yellow fever can be complete which does not give an account of some of these 
remarkable instances of this disease. 
An analysis of all the circumstances connected with the "Eclair" shows 
(1.) That the immediate consequences of landing the crew at Boa Vista were 
a thorough intercourse with the inhabitants, and the communication to them 
of the same fever with which the "Eclair" was infested. For some time 
before the arrival of the "Eclair" it is certain that the island of Boa Vista 
was perfectly healthy; and this was true also of all the other islands of the 
group (Almeida, Macwilliam). So great, also, was the dread of the dis- 
ease among the inhabitants that the consul had great difficulty in procuring 
laborers; nevertheless, the crewmanaged to smuggle vast quantities of spirits, 
and, of course, it is possible that more secret intercourse went on than can be 
gathered from any official reports. Certain of the inhabitants were also 
brought more or less in contact with the crew of the " Eclair." There were 
-1st. The military guard at the fort; 2d. The laborers employed on board 
the "Eclair"-forty-one in number; 3d. The laborers employed in the 
launches, or at a coal-heap on a small island-forty-six in number; 4th. 
Washerwomen who washed the officers' clothes-seventeen in number. In 
addition to these, Captain Estcourt, the commander of the steamer, lived at 
the consul's house; the gun-room and ward-room officers and midshipmen 
occupied a house in Porto Sal Rey; and leave was given to the warrant 
officers and a few of the men, one of whom stopped in the town for two nights. 
The "Eclair" left on the 13th of September; on the 14th or 17th a corporal 
of the guard was taken ill; on the 15th or 18th, a private; and in both cases 
the symptoms were fever, wildness, and constant black vomiting. The cor- 
poral died on the 17th or 20th, and the private on the following day. Others 
of the guards were taken ill, and, being conveyed into the town, the introduc- 
tion of the fever amongst the inhabitants is attributed to them. It also 
appears (2.) That the men who were chiefly in contact with the crew and 
with the sick men, and who were in the sick men's apartments, suffered much 
more severely than any other class; (3.) That the propagation of the fever 
appears to have been strictly in proportion to the amount of intercourse; (4.) 
That within a reasonable time after the departure of the "Eclair" there were 
three persons ill with fever at Boa Vista, and two already dead-all of whom 
had been in contact with the crew of the steamer. 
The period of incubation of the fever at Boa Vista was found to vary from 
two to eight days; and the facts recorded in the history of the spread of the 
fever over the island show that certain persons living nearest and most in 
contact with the two sick soldiers were first attacked. When the disease 
appeared with great virulence in the island of Grenada in 1793, its spread 
by infection first attracted notice by the arrival of the "Hankey" from Bulam, 
on the west coast of Africa, on the 19th February, 1793, some days before 
the fever broke out on the island. In this vessel, at Bulam, the fever had 
prevailed for five months before, to a great and fatal extent (Chisholm, Sir 
William Pym). 
A most interesting and consistent account of a yellow fever outbreak has 
been given by Surgeon J. D. Macdonald, Esq., F.R.S., in the Medical Journal 
of the "Icarus" {Annals of Military and Naval Surgery, p. 126). Mr. Mac- 568 
SPECIAL PATHOLOGY-SPECIFIC YELLOW FEVER. 
donald's account is especially interesting in the following particulars: (1.) It 
tends to fix more definitely than has yet been done a period of incubation. 
(2.) It shows that in certain localities specific yellow fever is always in exist- 
ence, expressing itself by sporadic cases every now and then, especially in the 
West India Islands, as a central focus to that geographical district where the 
disease is endemic, and where it has assumed in some places an epidemic 
character. (3.) It tends to corroborate the circumstantial evidence already 
accumulating, that the disease may be propagated by fomites, much as in 
the case with typhus and scarlet fevers. (4.) As with typhus and typhoid 
fevers, so with yellow fever, "the doctrine of its spontaneous origin" can have 
no foundation to satisfy the rational mind. 
Bearing on the period of latency, Mr. Macdonald shows that yellow fever 
was rife at St. Domingo when the "Icarus" arrived there, and the profes- 
sional zeal of Dr. Maclagan, the Assistant Surgeon of that ship, led him to 
visit some half-dozen cases on shore at Port-au-Prince. He is believed to 
have visited these cases on the 10th of June, and the first appearance of the 
symptoms which ended in his much-lamented death betrayed themselves on 
the 24th of June-i. e., fourteen days after having first visited the sick, and 
after the ship had been at sea four days. Fourteen days is not uncommon as 
the period of latency for the variolous poison. Another case is cited-that 
of a boy, Lambert-which shows that the period of latency could not have 
been less than eight days. The experience of the Lisbon epidemic marks the 
time of incubation as varying from two to ten days, and in some instances 
extending to fifteen days. The importation of yellow fever by the ship "Anne 
Marie" into St. Nazaire-a town in the department of the Lower Loire, about 
47' 30" north latitude-in the summer of 1861 (Ann. d'Hygiene, Oct., 1863, p. 
416), confirms'the belief in a lengthened period of incubation; and from a 
careful analysis of the history of specific yellow fever cases, I think it will be 
found that the period of incubation tends to lengthen with the transportation 
and propagation of the disease into latitudes the most remote from the 
equator. 
The history of the importation of the disease into St. Nazaire is as follows: 
About the 13th of June the "Anne Marie," a wooden sailing vessel, laden 
with cases of sugar, left Havana, having been there a month during the prev- 
alence of a severe epidemic of yellow fever. None of the sailors suffered so 
long as she lay at Havana, except from a little depression, loss of appetite, 
and a certain tendency to vomiting. After leaving Havana for France 
there was no sickness for seventeen days. On the 1st of July two sailors were 
attacked (without precursory symptoms) with violent shivering, pallor of the 
face, injection of the eyes, congested lips, and continued delirium. One died 
in twenty-three hours, the other in one hundred and ten. On the following 
seven days other persons were attacked, making in all nine cases out of a crew 
of sixteen persons. Only two deaths occurred. The ship arrived at St. Nazaire 
on the 25th of July with seven men still sick, but all of them convalescent, 
thirteen days having elapsed from the date of attack of the case last taken ill. 
Therefore, having had no deaths and no fresh cases for ten days, the "Anne 
Marie" was not placed in quarantine at the end of her voyage on arrival at 
St. Nazaire. Near her, as she lay in that port, there were anchored two ships of 
the imperial navy-namely, "Le Chastan" and "Le Cormorant," the former 
touching her. Three other ships, "L'Orient," "Les Dardanelles," and "L'Are- 
quipa," were also near her. According to the custom of the port, the sailors 
of the "Anne Marie," being only engaged for the voyage, quitted the vessel 
on her arrival, and were dispersed throughout the town. The commander, 
who had been ill, went home, the vessel was left to the second in command, 
and the places of the men were taken by seventeen fresh men, to discharge 
the cargo of sugar. These men were strong, very robust, and completed the PROPAGATION OF SPECIFIC YELLOW FEVER. 
569 
discharge of the ship in eight days. Of these men twelve or thirteen were 
attacked with yellow fever, and many of them died. 
"Le Chastan," having been close alongside the "Anne Marie," left on the 
29th July, and sailed to Indret, on the Loire, 44 kilometres distant. Her 
crew, five in number, seemed in perfect health when they arrived at Indret; 
but on the 1st of August (i. e., three days after leaving St. Nazaire) a man 
fell sick of yellow fever; then the remaining four by the 5th of August were 
all ill; and by the 10th of August all the five men, the crew of "Le Chastan," 
were dead. These men had all been on board the "Anne Marie" for about a 
quarter of an hour. "Le Cormorant" quitted St. Nazaire on the 10th: her 
crew, six in number, were then in perfect health. On the 14th of August two 
of her men were taken ill, and died on the 26th, of decided yellow fever. 
Eight vessels in all had been near the "Anne Marie," and sick patients had 
gone on shore at St. Nazaire and its neighborhood, communicating yellow 
fever to two or three, and slighter illness of the same kind to other persons 
who were about them. Altogether, it is on record that forty-four cases of yel- 
low fever were communicated by the "Anne Marie," resulting in twenty-six 
deaths. During this period the heat was more like that of a tropical than of a 
European climate; but neither yellow fever nor anything like it had ever been 
seen in the district. It cannot now, therefore, be disputed that, by the arrival 
of the "Anne Marie," yellow fever, was imported into St. Nazaire, and by 
propagating itself occasioned an outbreak of yellow fever at that port. And 
when it is remembered that fatal cases of specific yellow fever have already 
occurred at our own doors,-in Plymouth Sound and Southampton Water,- 
there is a like possibility of the importation of yellow fever into English ports 
under climatic conditions favorable to its development, and when we might 
least expect it, through the rapid and frequent communication which we now 
enjoy with the West India Islands, the very central focus of yellow fever. 
"We have no more reason to trust in our fancied security than the people of 
Montevideo had before yellow fever made its appearance amongst them" 
(J. D. Macdonald). The Lancet, of Feb. 12, 1863, contains "An Account 
of Yellow Fever as it occurred onboard the Royal Mail Steamship 'La Plata,' 
in the month of November, 1852," from the pen of Dr. Wiblin, the medical 
superintendent of quarantine at the port of Southampton. He there shows 
that fourteen cases of yellow fever had occurred on board the " La Plata " during 
her homeward voyage to Southampton from the West Indies. On the morn- 
ing of the 18th November she arrived at Southampton, where she was kept 
for two days in quarantine. On the morning of the 28th the fourth engineer 
of the "La Plata" (Mr. Napier), who had been lodging in the town for eight 
days, was seized with symptoms of yellow fever, and, after a week's illness, 
died of the disease. No other cases occurred in the town. The " La Plata" 
was a wooden ship; and Mr. Napier had been at work on board of her during 
the time when he was lodging in Southampton. 
In connection with the extension or propagation of specific yellow fever be- 
yond its usual geographical limits of constant existence, " It is a remarkable 
fact," says Mr. Macdonald, "that the deaths from yellow fever at St. Thomas's, 
before it became a coaling depot for the Royal Mail steamers, as compared 
with the deaths afterwards, bear the proportion of 4 to 64. And in connec- 
tion with this, must also be mentioned an equally important fact, that the 
combustible and other qualities of coal, exposed to the weather as it is at that 
island, became much . deteriorated." How far this loss may prove to be a 
pabulum, to yellow fever poison is unknown, but the covering in, as well as the 
inclosure of coal in tropical climates, is worthy of the attention of that mys- 
terious assembly-the "proper authorities." 
All the cases, like the "Eclair," the "Bann," the "Imaum," the "Icarus," 
the "Anne Marie," the "La Plata," agreeing as they do in all their main fea- 
tures, it is impossible to doubt the existence of a multiplying infecting virus 570 
SPECIAL PATHOLOGY-SPECIFIC YELLOW FEVER. 
as the specific cause of yellow fever; and in cases where it was transported, 
imported, and propagated, the fever, except in certain cases, seems to have 
arisen only in persons who had been exposed to whatever deleterious influence 
was exercised by the atmosphere of ships in which cases of yellow fever 
existed. Moreover, the facts connected with the "Imaum," the "Icarus," and 
the " Barracouta," show that infected places and person are alike dangerous 
to those who are at all susceptible; and in the cases of the "Imaum" and the 
" Anne Marie," it was shown that a disease taken in a certain locality, and 
spreading from person to person, may finally affect a second locality through 
their medium. It appears also to be quite a mistake to suppose, as Mr. Mac- 
donald observes, that no individual can communicate the disease to another 
unless he himself is actually under its influence at the time ; or, secondly, to 
consider such an individual as differing in any essential particular from an 
infected locality. Indeed, a ship itself is only an individual on a grander 
scale. This is the view Mr. Macdonald takes with regard to the "Imaum" 
receiving the disease from the officers of the "Icarusand it is also the view 
which explains the events which followed the contiguity of the ships to the 
" Anne Marie " in the harbor of St. Nazaire. To some extent the disease 
spread through personal intercourse to persons who were not near the ship,- 
in one very important case, that of M. Chailion, a physician at Indret, who is 
said never to have been near the ship nor the town of St. Nazaire, but who 
contracted infection from four laborers Who came infected from the ship, and 
whom he attended medically at their houses. He contracted yellow fever, 
and died. In a second case, one of the ship laborers, who himself had yellow 
fever, is said to have carried the infection certainly to his wife, and perhaps 
to an old man in whose house he and his wife lodged. All of them were 
attacked with yellow fever-the old man fatally. Unquestionably with re- 
gard to the " Anne Marie," and doubtless also with regard to the other ships, 
the ships themselves, irrespectively of sick persons in them, were foci of yellow 
fever infection. The men, therefore, no doubt, carried infection passively, as 
they might have carried an odor from the ship, or as a student carries the 
smell of the dissecting-room on his clothes, especially felted textures. " I have 
often looked upon my own monkey-jacket with horror," writes Mr. Macdon- 
ald, "as the possible means of communicating so formidable a disease to 
others." Men thus laboring in the hold of infected ships, without themselves 
contracting yellow fever there, might carry infection to their homes, in climates 
and places where yellow fever may prevail. And it is a question how far, 
like cholera and typhoid fever excreta, the poison of yellow fever may not 
increase in places where decomposing animal material abounds. 
With regard to the Lisbon epidemic, it has been proved that the epidemy 
remained concentrated in Lisbon, and did not extend to its neighborhood, nor 
to any other part of the kingdom, although the communication by land with 
all the towns and villages continued active and uninterrupted. In many 
places there appeared cases of yellow fever, evidently brought from the capi- 
tal, but in no place was the disease transmitted or propagated in an epidemic, 
form. The official report records, that of 182 persons who left Lisbon for dif- 
ferent places in Portugal, carrying with them the germ of yellow fever, which 
broke out or developed itself in them after their arrival at those places, 86 of 
them died. In no instance was yellow fever communicated from them to any other 
person in the places whither they went. 
As to the origin of the disease in Lisbon, it appears certain that the first 
cases were amongst men employed in the custom-house, or with persons in 
close communication with them. It showed itself in the streets where these 
people lived. The disease, which commenced in July, did not become epi- 
demic till September; but it remained stationary for a while in the parishes 
where it first broke out, and then spread gradually and regularly to other 
parts. It is therefore presumed that the disease did not proceed from any PROPAGATION OF SPECIFIC YELLOW FEVER. 
571 
general cause operating on the whole mass of the population, such as would 
come from meteorological or hygienic conditions. It was not persons of 
different classes, and living in different parts of the city, who were attacked 
at the same time; on the contrary, it commenced with one distinct class, 
between the individuals of which there was much communication, and went 
from house to house, from street to street, without invading more than a cer- 
tain extent of the city. It is presumed, but not proven, that the disease was 
imported through the custom-house, where luggage and effects are opened to 
be passed. Many of the ships which arrived at Lisbon during the epidemic 
and in the previous months had cases of yellow fever and losses during the 
voyage; but the only case proved was in the "Tamar," which arrived in 
March from Brazil, the captain of which owned that he had two deaths from 
yellow fever on board during the passage. This ship arrived again in Sep- 
tember, and reported at Southampton two cases which she had had on board. 
Lisbon and Oporto have been very subject to these importations since 1849, 
when yellow fever became epidemic in Brazil. In the report it is concluded,- 
(1.) That Lisbon is not to be considered as liable to spontaneous outbreaks of 
yellow fever. (2.) But, from its latitude and local conditions (especially in- 
asmuch as it abounds in filth in some localities where population is dense and 
sewerage imperfect), it is favorable for the development and spread of specific 
yellow fever when brought to the port. (3.) It is concluded that the epidemic 
of 1857 was imported from Brazil. 
[The following facts, favorable to the doctrine of the transmissibility and 
portability of yellow fever, are mainly condensed from the valuable Report on 
Epidemic Cholera and Yellow Fever in the Army of the United States, during 
the year 1867, by Dr. J. J. Woodward, U. S. A. (^Circular No. 1, War 
Department, Surgeon-General's Office, Washington, June, 1868.) 
In June, 1862, yellow fever broke out at Key West, Florida, having been 
imported from Havana by the bark Adventure, which put into Key West in 
distress, about the 20th June. It lay in quarantine thirteen days. Sixteen 
days after leaving Havana, the first and second mates fell ill with the disease, 
and in two days these men and two others of the crew, suffering from the fever, 
were taken on shore and placed in the Marine Hospital. July 27th, a soldier 
of the 90th New York was attacked with yellow fever, which subsequently 
spread through the garrison, there being 331 cases and 71 deaths. 
The steamer Delaware, with a detachment of the 7th New Hampshire, 
arrived at Hilton Head, S. C., from Key West, early in September, 1862, 
and, after a short quarantine, lauded her passengers September 8th. Soon 
after several of these were taken ill with the fever, and eight died. On the 
9th October a quartermaster's employee, living close by the quartermaster's 
depot, in which a lot of tents brought by the Delaware had been stored, was 
attacked; subsequently, a number of officers, soldiers, and men, employed in 
the quartermaster's department, and all living around the storehouse in which 
had been put the tents brought from Key West by the Delaware, became 
affected. The hygienic conditions around this wharf were bad. The number 
of cases of the second outbreak was 30 and 17 deaths. The disease did not 
spread amongst the troops in garrison, nor did any of the physicians, attend- 
ants, or patients suffering from other diseases in the general hospital, where 
the cases of yellow fever were treated without separation, contract the disorder. 
In the same year (1862) there were outbreaks of the fever at Charleston, 
S. C., and at Wilmington, N. C.; and there is good reason to believe that it 
was introduced into both ports by blockade-runners from Nassau, N. P., 
where it prevailed. 
Early in the autumn of 1864 yellow fever appeared in Newbern, N. C., and 
continued until the end of November; 705 cases and 288 deaths were reported 
amongst the white troops, and 38 cases and 15 deaths among the colored 
troops. Evidence is wanting to show the exotic origin of the disease, and it 572 
SPECIAL PATHOLOGY-SPECIFIC YELLOW FEVER. 
is claimed that it was of domestic generation, the local hygienic conditions 
being excessively bad. Previous to the outbreak at Newbern, the fever had 
appeared at Charleston, S. C., but there is no proof of any communication 
having been had between the two towns. 
On the 10th of October, 1864, the first case of yellow fever appeared at 
Wilmington, N. C. About the last of the previous August, two blockade- 
runners, with cases of the disease on board, were at quarantine three miles 
below the town. The quarantine was subsequently removed to near the 
mouth of Cape Fear River, and here, on October 1st, there were fourteen 
blockade-runners, and on all of them the mortality from yellow fever was 
very great. At this time the fever spread from the ships to the shore, the 
first cases being in the houses nearest the quarantine, and nearly one-half of 
the inhabitants of the town died of it. Goods were known to have been 
smuggled on shore, and it is very likely some of them were carried to 
Wilmington. 
During the autumn of 1864, 191 cases and 57 deaths occurred on board 
twenty-five naval vessels lying in the Mississippi River about and below New 
Orleans. It is claimed that these cases were spontaneously generated, and 
the bad hygienic condition of the iron-clads furnished all the alleged neces- 
sary factors. But the Spanish man-of-war Pizarro, with yellow fever on 
board, had been sent on the previous 4th of July to the quarantine, the first 
cases of the disease appearing on the 12th of September. There were 12 cases 
and 3 deaths among the employees and guard at the Naval Hospital and the 
boat-landing at Erato Street; and five cases of black vomit happened among 
citizens exposed to the same cause in the vicinity of the landing. 
In the summer of 1867 there were outbreaks of yellow fever at Indianola 
and Galveston, Texas, and at New Orleans. Dr. Woodward says: "The 
more thoroughly the facts connected with the spread of yellow fever in the 
army during 1867 are known, the more strongly they appear to favor the 
theory of the exotic origin of epidemic yellow fever in the United States" 
(foe. cit., p. 18). 
The reports indicate clearly two foreign sources from which the disease 
was imported into the United States last year,-Vera Cruz and Havana. 
From Mexico it was taken to Indianola, and thence carried to other points in 
Florida. At all other stations it seems to have been carried directly or in- 
directly from Havana. The cases of Mexican origin were more fatal than 
those of Cuban origin, two out of every five cases of the former dying, and 
but two out of seven of the latter. From Indianola the pestilence was carried 
to Galveston, and from each of these points it spread towards the interior of 
the State, along the chief routes of travel. 
The fever was introduced into New Orleans from Havana. It spread from 
New Orleans to Ship Island, to Baton Rouge, and to all other places where 
it afterwards appeared in Mississippi, Alabama, and Tennessee. At Key 
West, and at Fort Jefferson, Tortugas, it was brought directly from Havana.] 
Symptoms.-Uniformity in the order and character of the symptoms of 
specific yellow fever must not be looked for. All the best writers on the sub- 
ject, whether recording their experience in the West Indies, the west coast 
of Africa, or the south coast of Spain, are unanimous to the contrary, and 
consequently, while direct and faithful descriptions may have been given of 
each epidemic, yet the results are not general nor uniform. Certain symptoms 
in certain epidemics vary in their nature and in the time of their accession, 
while others common to former visitations are wanting in those which follow. 
Sometimes the full complement of standard symptoms are present, sometimes 
they are imperfect and deficient, and sometimes displaced. At one time the 
diagnostic symptom in an epidemic is the supraorbital headache. At other 
times the tongue symptoms are alone diagnostic, or their equivalents are ex- 
pressed in the uvula and fauces. Intense surface heat, albumen early in the SYMPTOMS OF SPECIFIC YELLOW FEVER. 
573 
urine, and early black vomit, are among the later symptoms; and smoky pale 
urine, with perfect blood-corpuscles, take the place of the straw-colored or 
bilious urine, with its sediment of tube-casts and epithelial matter. 
The general appearance of the tongue in well-marked cases is redness of 
the tip and edges, with prominent papillae and a creamy surface. Subse- 
quently the fur separates from its middle surface, and lies in white wavy 
flakes; and the next series of changes consists in separation of the epithelium, 
which begins at the tip, proceeds to the edges and down the raphe, and may 
continue till the whole surface is denuded, the papillae obliterated, and the 
tongue becomes smooth and dryish, of the color and appearance of raw beef. 
Such a condition is generally associated with exudation of blood so free as to 
coat the mouth and tongue, and collect upon the teeth. The tongue is then 
usually much smaller and more pointed than in the earlier stages. 
A rare manifestation of capillary irritation in yellow fever consists in an 
efflorescence of the skin in the form of a subcutaneous rash on the chest, and 
extending over the abdomen and arms. Rose-colored spots of a somewhat 
circular shape have been noticed on fine, delicate, sensitive skins, varying 
from the size of a flea-bite to what might be covered with the point of the 
finger. They result generally from mosquito wounds, and become hemor- 
rhagic at the end of the disease, when it terminates fatally. 
Bloody furuncles appear late in the order of symptoms, and are to be re- 
garded rather as sequelae. Their most common site is on the wrist, over the 
metacarpal joints, along the front of the legs, below the scapulae, and over 
the hip, in the parotid region, and over the forehead and lip. They are gen- 
erally in close proximity to the smaller arterial branches, such as the ulnar, 
radial, anterior tibial, gluteal, intercostal, and facial arteries. They become 
tender, acuminated, and inflamed, and sometimes form large abscesses of 
purulent matter, with a pale or inflamed surface, and this chiefly when below 
the scapula or over the hip. Generally on the legs they are flat, present no 
inflamed appearance, but show a flat purplish vesication, about the size of a 
split pea or a sixpence. 
Two, three, or even four forms or types of yellow fever have been described 
by authors. These have been very clearly defined by Dr. Lyons, of Dublin, 
in the Lisbon epidemic of 1857, which he investigated with so much care and 
enthusiasm. 
The types, groups, or forms which he found capable of clinical recognition 
are,-(1.) The algid form; (2.) The sthenic form; (3.) The hemorrhagic 
form; (4.) The purpuric form; (5.) The typhous form. 
The first of these, namely, the algid form, is that which presents the most 
rapid course, and the earliest and greatest amount of prostration of the vital 
powers. These are the cases which are suddenly killed with the poison. 
"The patient, while in the enjoyment of his usual health, and in the midst of 
his usual occupation, feels suddenly the effects, as it were, of a sudden blow 
from a heavy bar on the back, falls down while walking (or if standing), and 
dies within a few hours in profound collapse, and after exhibiting more or 
less of the other svmptoms of this fever." The countenance became sunken, 
the eye dull and filmy, the surface cold, and the patient felt cold, depressed, 
and wretched. The face became of a dirty livid hue, and this appearance 
extended to the trunk and limbs, the surface then presenting innumerable 
points of minute venous congestion, and sometimes purpuric spots and patches 
of various sizes. In extreme cases the lips, the breath, and tongue were cold, 
with a temperature in the axilla not more than 96°, the pulse being small, 
feeble, and quick; and when the cardiac action became feeble the radial pulse 
would be obliterated. 
The sthenic form is a marked contrast to the algid. It is especially well 
marked in both sexes at the prime of life, and in persons with well-developed 
muscular frames. Such cases are characterized by well-marked febrile symp- 574 
SPECIAL PATHOLOGY-SPECIFIC YELLOW FEVER. 
toms, severe and persistent headache, much rachialgia at the outset, a high, 
full, and hard pulse, occasionally thrilling and resisting, with flushed face 
and throbbing temples. A remarkable elevation of temperature prevailed- 
an increase of 3°, 4°, or even 5° Fahr., and in some an increase of 7° Fahr, 
was observed. Death sometimes took place in a very unexpected manner. 
In the haemorrhagic type the cases are the most characteristic and appalling. 
In them epigastric anxiety, with or without heat, and pain on pressure in the 
epigastrium, is well marked ; but their great characteristic is a. tendency to 
profuse simultaneous effusions of blood from various parts and organs-the 
hemorrhage never being single, nor from any one source or organ only. The 
cases are fatal at an early period ; and all the connective tissue of the body is 
surcharged with blood. There is less considerable elevation of temperature 
than in the sthenic form. 
In the purpuric form the pyrexial state is well marked, with the conjunctivae 
and general surface intensely yellow. Purpuric patches commence and spread, 
sometimes with surrounding oedema. These patches are manifestly caused 
by subcutaneous effusions of the coloring matter of the blood; and all varieties 
and shades of color and tints are observable. 
In the typhus form two orders of phenomena may prevail. In one class of 
cases stupor and nervous depression exist from an early period of the fever, 
with all the other well-marked and characteristic typhoid symptoms; and to 
these are superadded the hemorrhagic phenomena. In another class of these 
cases the patient, after passing through the sthenic or the algid form, would 
insensibly glide into the typhoid state, on the cessation of the hemorrhages 
(Lyons.) 
It is of great importance to attend specially to the study of these forms or 
types; for, as Dr. Lyons justly observes, much of the discrepancy and appar- 
ent conflict of medical testimony on the subject of yellow fever is due to the 
want of discrimination of those leading characteristics and salient features 
(Lyons, 1. c., p. 375). 
When the black vomit is plentiful, or the urine free, the intelligence re- 
mains clear and unclouded, but the skin becomes cold and damp, the pulse 
small, and finally extinct at the wrist, and the patient dies of gradual exhaus- 
tion and syncope. 
According to the amount of febrile excitement, the skin is hot and dry; 
but the experience of Mr. Macdonald leads him to say that in many cases 
there is a turgid fulness of the vessels, and a tingling heat of the surface, 
which is imparted in a remarkable manner to the fingers on feeling the pulse. 
This feverish heat of skin, Mr. Macdonald thinks, is much more moderate in 
cases treated in the open air than in those treated in the wards of a hospital, 
however well ventilated. 
There is great irregularity in the temperature of the surface. Sometimes 
the forehead is the hottest part of the body; occasionally it is the chest. The 
uncovered parts, in the latter stages of the disease, are easily reduced in tem- 
perature, and thus, while the exposed chest and extremities may feel cool to 
the touch, the axilla may raise the thermometer to 102° or 103° Fahr. The 
highest temperature Dr. Blair has observed was 107° in the axilla. 
Mr. Macdonald notices that#the pulse is at first quick, and of considerable 
strength, though still compressible, and may vary in these respects within 
certain limits until it becomes feeble. In those cases which have proved 
rapidly fatal there has been a marked gradual decrease in its strength ; and 
finally, when the ferrety eye grows clear, and a pallor of countenance shows 
the mischief of blood exudation going on within, it is scarcely to be felt. 
Observations made on the urine, in yellow fever, by Dr. Blair, show that 
it is always acid in the first stage, and continues so generally till convales- 
cence, when it becomes alkaline, or until it becomes heavily charged with 
bile. During the early stage the urine is normal in color, clearness, and WHITE AND BLACK VOMIT IN YELLOW FEVER. 
575 
quantity. About the third day the color alters and becomes of a sulphur, 
primrose, straw, or light gamboge hue, perhaps slightly turbid, and with a 
little floating sediment. The color deepens till it becomes yellow or orange; 
and if the case ends in convalescence, the urine is copious, and may appear 
black. Sometimes the urine has a pale, watery, smoky appearance, with a 
layer of blood-corpuscles in the sediment, and sometimes it is very bloody. 
Albumen appears on the second or third day generally; in some cases as 
early as the first day; and in a few cases not till the day of death, and after 
black vomit has set in. Albumen appeared in every fatal case of normal 
duration. It sometimes ceased suddenly in convalescence, and always before 
the yellow suffusion of skin and eye, or bile in the urine, had disappeared. 
Between the eleventh and twentieth day of grave cases it generally disap- 
peared. Its color was never white. When the urine appeared turbid, it was 
due to the presence of mucous epithelial matter, coagulated albumen, coats of 
the urinary tubuli, or fine capillaries of the kidney or mucous membrane 
passed out with the urine. The tube-casts are generally short, thick, club- 
shaped, and opaque, attended with large organic cells and epithelial scales. 
Crystalline deposits are rare. In females the catamenia are sure to appear, 
whether due or not. No sign is so dooming as a suppression of urine, black 
vomit not excepted. The alvine evacuations may be black towards the close 
of the disease, or very dark green, and bilious ; but after the black stools have 
ceased, they are succeeded by evacuations which resemble fine, dark, sandy 
mud, and named the "caddy stool." As the disease still further advanced, 
and towards its fatal termination, the dejections again changed their char- 
acter. They became scanty and mucous, of various consistence and color. 
These mucous stools almost always appeared after black vomit, and were con- 
temporaneous with the scanty urine before described. The alvine evacuations 
in yellow fever, from the beginning to the end of the attack, are always alka- 
line, except in one instance, that of the black vomit stool; in that it is always 
acid. Its chemical quality is evidently due to the admixture of a portion of 
the black vomit, which has descended (if not found in the intestines') by peri- 
staltic motion into the intestines, and mixed with the scanty mucous stool, and 
in such quantity as not only to neutralize it, but to be in excess. The scanty 
thick mucous stool-almost a jelly-has generally a little thin serum around 
it in the bottom of the pot. The bulk of all these varieties of the scanty 
mucous stool consists of mucus, broken-up epithelial matter, and myriads of 
epithelial granules. Sometimes little wavy flakes, like morsels of cuticle, are 
also to be found. They also frequently contain the crystalline bodies of the 
caddy stool, particularly when they are rather thin and serous. By appear- 
ance, they would be taken for rectal stools, and the results of tenesmus; but 
such is not the case. A burning sensation is often complained of, but seldom 
any tenesmus, and no doubt these stools consist of that mucous matter which 
we find after death lining the intestinal canal generally. In a few cases 
where there has been total suppression of urine, these stools have become 
diarrhoeal. 
The first ejections from the stomach of a yellow fever patient are seldom 
seen by the physician. Mucus and bile soon appear, occasionally with a 
streak or speck of blood, and with violent retching. The ejections are alkaline. 
Generally after the first vomiting the stomach becomes tolerably settled, until 
the second stage sets in, on the second, third, or fourth, or as late as the fifth 
day of the disease. Then, without warning or nausea, but on any trifling 
provocative, the stomach suddenly ejects a quantity of clear, pale, limpid, or 
slightly opalescent acid fluid-the white vomit, which indicates the beginning 
of the stage of acid elimination, and is generally contemporaneous with the 
first shedding of epithelium from the tongue. Sometimes the evacuation of 
this vomit has a critical effect, equivalent to the perspiration of intermittent 576 
SPECIAL PATHOLOGY SPECIFIC YELLOW FEVER. 
fever. True white vomit consists of serum, more or less acid, which remains 
clear on the application of heat and nitric acid. 
The transition of symptoms from white to black vomit is generally gradual; 
and is attended with a "suspicious sediment" of "snuff-like specks" before it 
merges into well-defined black vomit. The stage of acid elimination continues 
to the close of the disease, and is most intensely manifested during the pro- 
duction of the black vomit. The presence of ammonia in black vomit is uni- 
versal, and may be considered as one of its tests; and its specific gravity 1.004 
to 1.006, the temperature of the air being 86°. Its sediment consists of coagu- 
lated albumen and the debris of blood-cells. Another test is acidity, and a 
third is to be observed in the phenomenon that the sediment is dissolved by 
liquor potassse, which disengages ammonia. 
Another feature in the pathological symptoms of yellow fever may be ex- 
pressed by the fact that the urea of the suppressed urine is eliminated from 
the system as a volatile salt, by metamorphosis into a carbonate of ammonia, 
which as such is frequently found in the breath, in the normal black vomit, in 
combination with an acid, almost always in the stool, and apparently pervad- 
ing all the tissues of the body. "It would seem," writes Mr. Macdonald, 
"as though the mucous membrane of the stomach were called upon to com- 
pensate for the defective secreting and eliminating power of the kidneys; and 
in those cases where little or none of the matter of black vomit was found in 
the stomach after death, the lining membrane presented a thickened appear- 
ance, with a muco-sanguineous coating" (Grant's Annals of Military and Naval 
Surgery, p. 135). 
Prognosis.-The data to judge from maybe arranged into symptoms which 
are favorable, and those which are not so. (1.) The favorable symptoms are- 
A slow pulse and moderate temperature of the body, and quiet stomach. 
Streaks of blood during the stage of black vomit, or after acid elimination 
has set in, are favorable, if the corpuscles are found entire. If the urinary 
secretion continue, and the black vomit be scanty from the first, or is after- 
wards suppressed, the patient may yet survive. Urine simply albuminous is 
a less serious sign than when it also contains tube-casts. Free, copious urine, 
no matter how dark or bilious, is the most favorable of any single sign. 
Prognostics may be derived from the effects of treatment. (2.) The unfavorable 
signs are-The more fiery crimson the tip and edge of the tongue, the more 
irritable the stomach, the severer the headache, the worse the prognosis of the 
first stage, and vice versa; but a streak of blood in the early vomit indicates 
much danger from the attack. In the second stage the earlier or more com- 
plete the suppression of urine, and the more copious the ejections of black 
vomit, the more imminent the danger. If the urine be scanty, and loaded 
with tube-casts, entangled in epithelial and coagulable matter, the light buff- 
colored curdy sediment before mentioned, indicates a complex lesion of the 
secreting structure of the kidney. It is the urine symptom in its maximum 
of severity, and is as fatal as if the suppression had already occurred. Blood- 
corpuscles in the urine are not to be looked on with apprehension. A falter- 
ing of the articulation is a bad prognostic, and a difficulty of protruding the 
tongue enhances it. The danger of the case is enhanced by inflammatory 
complications, and by hypertrophy of the heart. A recent residence in a 
temperate climate; the race or complexion of the individual; the fact of his 
previously having suffered from an attack, will enter into an estimate of his 
chances of recovery. 
Prognosis is declared by Robert Jackson to be treacherous and difficult in 
the extreme. 
Treatment.-An early attention to first symptoms among the susceptible is 
of the greatest value in saving human life. 
The diagnosis of cases in which the attack has been said to have been 
"aborted " by remedies may be questioned, and such a belief is opposed to the TREATMENT OF SPECIFIC YELLOW FEVER. 
577 
doctrines of sound pathology. Moreover, the " heroic" doses of caltfinel which 
were given in such cases; combined with quinine, cannot be too strongly dis- 
countenanced, for " they were first recommended on the strength of a crazy 
hypothesis " alone. The practice is said to have frequently proved successful 
in Jamaica; but according to Dr. Davy, it was not attended with beneficial 
results at Barbadoes, and the American physicians at New Orleans have not 
found it to answer their expectations in stopping the fever. 
The large and frequently repeated doses of quinine were often also highly 
injurious (Lawson). This discrepancy may in some measure be explained 
by what has been stated at the outset in explaining the pathology of this pe- 
culiar fever. It is in cases where the fever is of the periodic or paludal form, 
and not the continuous or true yellow fever, that quinine may be of use, if 
the system can be brought under its influence. The ill effects of quinine in 
specific yellowT fever consist in its checking secretion and deranging the circu- 
lation within the head; and Mr. Macdonald considers its employment more 
suited to the convalescent than to the patient immediately under the influence 
of the disease. 
It is an object to keep the bowels freely open, and to get the skin to act 
freely. The main object of the physician should be to moderate excessive 
action in any organ, and to endeavor to bring about as complete a crisis as 
possible about the fifth day, which seems to be the natural period of resolu- 
tion of the disease. For this purpose nothing is of more importance than to 
re-establish the secreting function of the colon, and to obtain feculent evacua- 
tions-not mere bilious discharges, but proper dark-brown feculent stools 
(Lawson). Gentle excitement of an extensive portion of the lining mem- 
brane of the colon, with frequent copious enemata of a pint and a half of 
warm water, in which a tablespoonful of common salt has been dissolved, and 
to which has been added a tablespoonful of olive oil, or more stimulating 
enemata, such as of turpentine, deserve a full and careful trial. All the dep- 
urative functions must be kept in activity. Turpentine is recommended by 
Dr. Copland, by Dr. Archibald Smith, and Mr. Laird, of H. M. S. "Medea" 
-one drachm doses by the mouth, or half-ounce doses as a lavement, several 
times daily, using it also as an epithem on the abdomen. 
"When the mucous surfaces," writes Dr. Blair, "as indicated by the tongue, 
were denuded of epithelium, the use of gum-water was decidedly beneficial. 
It lubricated, defended, and soothed the raw surfaces. The strength was gen- 
erally three drachms of the purest powdered gum arabic, dissolved in six 
ounces of cold water, and a tablespoonful of this given every one or two 
hours. The patient at last gets tired of it; but for thirty-six or forty-eight 
hours of the most critical period of the disease it is used without dissatisfac- 
tion, and then can be substituted by, or alternated with, smoothly and thin- 
made arrowroot. When the heat of surface was ardent, a wet sheet or blanket 
was used for the reduction of temperature by evaporation, with frequently 
very good effect (and if ice could be obtained, its internal use is well worthy 
of a trial). But in the later stages of the disease, when the skin was cool or 
cold, the pa*tient seemed to have an instinctive craving for its reapplication, 
and frequently asked to be put into it. There would appear to be two causes 
for this feeling. We find it to exist in cases in which black vomit has been 
copious, and the associating thirst distressing; also in cases where there has 
been no black vomit of any consequence, and the breath is highly ammoni- 
acal. In the former class of cases the stomach ceases to be an absorbing viscus 
in anything like the proportion of its secretions and transudations. I he skin 
is therefore employed in reducing the crisis of the blood by the absorption of 
water, as shipwrecked mariners are said to quench their thirst. But not only 
does the skin afford an inlet for the imbibition of diluting fluids, but the soft- 
enino- of the cuticle would seem to afford an additional outlet for the noxious 
elements of the circulation; and it is probably in this direction we must in 578 
SPECIAL PATHOLOGY SPECIFIC YELLOW FEVER. 
future look for auxiliary means of relieving the blood of its poisonous, meta- 
morphosed, and effete constituents, the onus of which is now thrown on such 
vital organs as the stomach and lungs. At one time the heat of the surface 
was so ardent and persistent that the wet sheet failed to reduce it effectually." 
The most distressing symptom in yellow fever, both to the patient and the 
medical attendant, is irritability of the stomach; it is so constantly present, 
and so often uncontrollable, that the knowledge of every available means of 
checking it is of the utmost importance. 
The /ood during the course of yellow fever should be of the blandest de- 
scription-chicken tea, arrowroot, sago, and barley-water constituting the 
chief articles ; and these should be taken in minute quantities at a time when 
the stomach is at all irritable. This rule applies to drinks of all kinds. The 
patient is greedy for a large draught of fluids; but by sucking them through 
a glass tube, or a straw, or a hollow reed of small bore, or by the tea or table- 
spoonful, they are much more likely to be retained. A cold infusion of oat- 
meal was found an agreeable drink for Scotch seamen, of which they did not 
seem to tire. A dislike of sweets was observed among the patients; and 
when lemonade was asked for, the usual quantity of sugar was objected to, 
probably from its rendering the liquid too dense for ready absorption by the 
stomach, and therefore less quenching. Tea was found so uniformly to disagree 
with the patients, and cause vomiting, particularly in the advanced stages, 
that at length it had to be expunged from the yellow fever dietary. Dilute 
alcoholic drinks were given freely, and with good effect. Where brandy 
could be obtained pure (tolerably free from acidity and fusel oil), and was 
well diluted with water, that spirit answered every indication. Sometimes 
the effervescing wines were relished and retained, but they are very liable to 
the objections of containing foreign matters and the products of mismanaged 
fermentation (Blair). 
Mr. John Denis Macdonald has several times proved that four or five 
minims of chloroform prepares the stomach for the reception and retention of 
food, by lessening its irritability; and the dose should be repeated a short 
time before food is again taken, as the effect of the chloroform is transitory. 
On the same principle the administration of chlorodyne* may be advocated. 
Lime-water has been also found to have a most beneficial effect in allaying 
vomiting, and thus enabling the patient to partake of food ; and the essence 
of beef is well adapted for such cases. 
During the course of the disease, auxiliary treatment may be required to meet 
contingent symptoms. This is embraced chiefly in the use of sinapisms and 
stimulating liniments. Tenderness over the liver may be benefited by them. 
Dr. Blair writes that when the primary reaction was violent, and the face 
was turgid, and the head symptoms severe, arteriotomy was performed, and 
with benefit. In a few such cases, and when the patient was young, strong, 
* The composition of chlorodyne is variously stated by chemists, but the following 
formula may be given as a very useful one: 
R. Chloroform, fglv; JEth. Sulph., f^ii; Theriacae, f^i; Mucilag Acaciae, f^i; 
Morph. Muriat., gr. viii; Acid Hydrocyanic dil. (2 per cent ), fgii; Ol. Menth. pip., 
n^iv ad vi; misce bene. 
Syrup or water may be added to the mucilage of gum, and tincture of cannabis in- 
dica (5 to 20 minims), or other anodynes, may be added at the time of prescribing, if 
deemed desirable. The difficulty in compounding chlorodyne is in getting the chloro- 
form to mix with the treacle. It will not do so alone, but the use of a little thin gum, 
or even water, effects their mixture almost at once. The morphia ought first to be 
dissolved in the chloroform ; then mix with the treacle the gum or water, first using 
about the same bulk of chloroform and treacle, afterwards adding the rest of the chlo- 
roform by degrees, constantly shaking briskly the bottle in which it is made up; and 
then add gradually the other ingredients. The dose is from 5 to 10 minims, repeated 
as often as its sedative effects subside (compare Mr. Squire's Companion to the Pharma- 
copoeia, p. 58, and Mr. Ashburner, in Lancet for 11th June, 1864, p 688). PREVENTION OF YELLOW FEVER. 
579 
and full-blooded, and where the dynamic congestions were so violent that the 
vessels yielded to the turgescence and impulse, aud blood-corpuscles without 
tube-casts, or even but a haze of albumen, was present in the urine, a vein in 
the arm was opened, and free bleeding relieved the tension of the vascular 
system. In such cases convalescence was slow and unsatisfactory, but the 
immediate results were beneficial. The severe pain in the loins, which is a 
constant symptom in yellow fever, is generally associated with renal conges- 
tion ; and sinapisms or stimulating liniments afford great relief to the lumbar 
pain (Macdonald). 
With regard to the administration of opium in any form, the rule is, not to 
give it when there is suppression, or tendency to suppression, of urine. Restless- 
ness and sleeplessness are best met by chlorodyne, remembering that the effect 
of yellow fever on the system is to make it sensitive to narcotics. 
The congestion of the kidneys, about the fourth or fifth day, requires watch- 
ing, so as to diminish the chances of suppression, by reducing congestion and 
preventing the closure of uriniferous tubes by accumulated epithelium. For 
this purpose Dr. Lawson recommends cupping, either dry or with the abstrac- 
tion of blood, and the use of frictions, with stimulating liniments over the 
loins. These, with warm baths or hot-air baths, deserve a full trial; and 
small doses of acetate of ammonia, with potash or soda, or their salts in common 
use, with diaphoretics (so as to act gently on both kidneys and skin), may 
prove beneficial. 
[Prevention of Yellow Fever.-Although the profession is not at one re- 
specting the indigenous or the exotic origin of yellow fever epidemics in our 
Southern States, experience during the late war conclusively shows that both 
the domestic and foreign factors of the disease may be controlled, and the 
spread of an outbreak from supposed local causes prevented, or all risk from 
importation avoided. These questions were fairly tried and decided at and 
about New Orleans, in the seasons of 1862-63-64-65. Dr. Elisha Harris, in 
a paper On Yellow Fever on the Atlantic Coast and at the South during the War 
( U. S. Sanitary Commission Memoirs, 1868), observes: " All the physical con- 
ditions that are supposed to promote the prevalence of yellow fever-except- 
ing only such as are immediately controllable by a sanitary police-prevailed 
continually and in unusual force in the delta of the Mississippi during this 
period of immunity from that disease " (p. 253). Previous to the wai' the an- 
nual average of yellow fever victims in New Orleans was about 1000. The 
average annual death-rate, from all causes, from 1829 to 1861, was six and a 
half per cent. There were years when the death-rate exceeded ten per cent. 
During the aforementioned years, the town was full of unacclimated persons. 
" One hundred thousand Northern men annually arrived in or passed through, 
without a single individual being smitten with yellow fe^ver " (Harris, 1. c., 
p. 256). These summers passed without a sign of yellow fever epidemic. Be- 
sides the observance of a rigid quarantine, the strictest sanitary regulations 
were enforced by the military government, and to them is to be ascribed the 
exemption. The thorough cleansing of the towns of Savannah and Charleston, 
after their occupation by the U. S. troops, and the rigorous sanitary regula- 
tions maintained, together with a military quarantine, have kept them, it is 
believed, from any outbreak of yellow fever since 1864. 
In the Army Report, already quoted from, Dr. Woodward holds this lan- 
guage : " The experience of the army throws no satisfactory light on the treat- 
ment of the disease, but it must be admitted that it is most instructive with 
regard to measures of prevention. Besides those general hygienic precautions 
which are so important in the prevention or mitigation of all epidemic dis- 
eases, two simple and effective measures would appear to be specially indicated 
by the experience of the army during the war and subsequently. The first is 
quarantine, as a means of preventing the introduction of the disease; the sec- 
ond is the prompt movement of the command to some rural site on the appear- 580 
SPECIAL PATHOLOGY - PLAGUE. 
ance of the fever among the citizens of the town at which it is stationed, or 
even after the disease has appeared among the men of the command itself. 
" The minimum period of an effective quarantine against yellow fever may 
then be set down at about twenty days. Twenty-five or thirty days would be 
better if attainable. 
" Should the disease be introduced through neglect to provide an efficient 
quarantine, it becomes the duty of the medical officer to recommend the im- 
mediate removal of the command to some healthy rural site. At the only 
places at which any large number of cases occurred during 1867-at Galves- 
ton, at Houston, at Hempstead, at New Orleans, at Fort Jefferson-the troops 
faced the pestilence, and at each the greater portion of those exposed were at- 
tacked. On the other hand, the troops moved on the approach of the disease 
to camp in the country, escaped almost wholly at New Iberia, Baton Rouge, 
Alexandria, Shreveport, &c.; while at Indianola, Mobile, Pass Christian, &c., 
the command being moved after the disease had appeared among the men, 
almost all those thus removed escaped. The Newbern epidemic afforded a 
similar experience. After the disease had fairly broken out among the troops, 
the greater part of them were moved away from the town, and nearly all thus 
moved escaped. When a command is thus moved, it should be encamped on 
a dry and elevated site, not previously used for camping purposes; the men 
should be sheltered by tents, should not be crowded, and should be surrounded 
by the best hygienic conditions attainable.''] 
PLAGUE. 
Latin Eq., Pestilentia; French Eq., Peste; G-erman Eq., Pest; Italian Eq., Peste. 
Definition-A specific malignant fever which has prevailed at different times 
and places epidemically; attended with bubo or swellings of the inguinal or other 
lymphatic glands, and occasionally with carbuncles, pustules, spots, and petechice 
of various colors, and distributed in different parts of the body. 
Pathology and History.-Modern medicine restricts the term " plague" to 
a disease of dreadful severity, and of a peculiar character, which appears to 
have been first recognized in Egypt and in the neighboring countries. It is 
impossible to determine the time when the plague first appeared in Egypt. 
The remotest period to which we can distinctly trace it is when spreading into 
other countries, as the plague of Constantinople, which broke out in 544, when 
Justinian was emperor. This is the first time that the disease, from its course 
and symptoms, can with certainty be recognized as the plague of more modern 
times. The symptoms were shivering and fever, at first so slight as to alarm 
neither the physician nor the patient; but the same day, the next day, or the 
day after, there appeared swellings of the parotid, axillary, or inguinal glands, 
with carbuncles, and sometimes gangrene; and from the more usually diseased 
state of the glands it was called "pestis inguinaria." 
The disease from that period has prevailed at short intervals in various parts 
of Europe as late as the seventeenth century. Sir Gilbert Blane has calculated 
there were no less than forty-five epidemics of plague in the seventeenth cen- 
tury. Fourteen of these occurred in Holland, imported, it is supposed, by 
the Dutch engaged in the Levant trade, about the year 1612 ; and twelve in 
England, imported, as has been supposed, from Holland. The last epidemic 
of plague which prevailed in both of these countries was in 1665, the year 
before the memorable fire of London. This epidemic was termed the " Great 
Plague," and spread "with such intolerable infection" that 7165 persons are 
said to have died in one week, while in one year no less than 68,526 died in 
the city of London and its suburbs alone-an immense mortality, considering 
the then comparatively small amount of population. PATHOLOGY AND HISTORY OF PLAGUE. 
581 
The plague is still occasionally epidemic in Egypt, and sometimes prevails on 
the Barbary, Arabian, and Syrian coasts, and also at Constantinople ; but it 
has been rarely seen out of the Turkish dominions since the seventeenth cen- 
tury. Nevertheless, it broke out at Copenhagen in 1712, at Marseilles in 
1720, and at Moscow in 1771. In the present century it has appeared at 
some of the Russian ports in the Black Sea. In 1813 it broke out at Malta 
and at Gozo, when the number of victims was estimated at between 4000 and 
-5000 (Burrell). It subsequently broke out at Noja, in Calabria, in 1816 ; 
at Corfu in 1818 ; it appeared at Gussemberg, in Silesia, in 1819 ; and, lastly, 
in 1828-29, it devastated the ranks of the Russian army in Bulgaria; and 
there is reason to believe that at Odessa, towards the end of the recent Russian 
war, there were cases of a malignant fever, with buboes and swellings in the 
glands of the groin and axilla, which policy prevented calling plague. 
It is believed that in this disease, as in others of this order, a specific poison, 
after a given period of latency, produces certain specific actions, which are 
either preceded, accompanied, or followed by fever. The more specific actions 
of the poison are the induction of a state very similar to that of typhus fever, 
as seen in this country; also a singular enlargement of the heart, the liver, 
or the spleen. But the most constant action of the poison is on the lymphatic 
system generally, as in typhus fever-the cervical, inguinal, axillary, and 
mesenteric glands being for the most part found enlarged or otherwise in- 
flamed, and thus giving rise to the characteristic bubo. The areolar tissue 
appears to be often the seat of a specific action of the poison, in the form of 
carbuncles: every organ and tissue of the body is likewise covered with petechiae, 
and may be the seat of hemorrhagic effusion. 
The extreme danger believed to attend posthumous examinations, and the 
prejudices of the Mohammedans, long prevented our acquiring any satisfactory 
data respecting the pathological phenomena of the plague; but a commission 
appointed by Mohammed Ali in 1834-35, and consisting of Clot Bey, Gaetani 
Bey, Lachesi, and subsequently of Bulard, examined the bodies of sixty-eight 
persons who died of the plague, and the following is a summary of their re- 
sults : 
On removing the cranium the sinuses were found filled with black blood, 
the arachnoid veins greatly injected, and the arachnoid cavity often infiltrated 
with serum, and occasionally with a trifling effusion of black blood. The 
substance of the brain was generally less consistent than in health, and sprin- 
kled with more bloody spots than usual. The bronchial membrane appeared 
sensibly inflamed, although during life the patient had presented no catarrhal 
symptoms. The pericardium frequently contained a reddish serosity. The 
serous membrane covering the heart and pericardium was often extensively 
affected with petechiae. The heart, distended with blood, was almost always 
enlarged from a third to a half greater than its natural size, its tissues being 
often pale and sometimes softened. 
In acute cases the stomach and small intestines were softened, and presented 
similar petechial appearances. 
The liver was almost always larger than natural, and loaded with blood, 
while petechial spots were often seen at its surface. The gall-bladder was the 
seat of petechiae, and in two cases blood was effused into the submucous areolar 
tissue. 
The spleen was always twice its natural size, or even more, but was rarely 
the seat of hemorrhagic effusion. It was softened, and deep in color. . 
The kidneys were often found immersed in a hemorrhagic effusion into the 
surrounding tissue. They were loaded with blood, and the pelvis filled with 
clots. The ureters occasionally contained blood, and sometimes the lumbar 
glands were so enlarged as to press upon them, and to account for the sup- 
pression of urine. The bladder occasionally presented petechiae, and occasion- 
ally the urine was mixed with blood. 582 
SPECIAL PATHOLOGY PLAGUE. 
Every dissection showed that buboes, wherever seated, always resulted from 
enlarged lymphatic ganglia, varying in size from an almond to a goose's egg. 
The least altered were hard and injected. In a more advanced stage some 
of these glands were without any change of color, and others again as richly 
colored as lees of wine, and either wholly or partially softened or putrescent. 
Sometimes these glands became agglomerated, forming masses which weighed 
two pounds or more, and around these agglomerations a hemorrhagic effusion 
extended into the areolar tissue. The cervical glands often became so enlarged 
as to form a sort of chaplet, united with those of the axilla and of the medias- 
tinum. The axillary glands, again, communicated with the cervical, and 
with those which surrounded the bronchi. Those in the groin connected them- 
selves in the same manner with those of the abdomen, and these might be 
traced without interruption through the crural arch into the pelvis and along 
the vertebral column. It was especially among these latter that sanguineous 
effusion was found in the subperitoneal tissue. The mesenteric glands were 
often so numerous that the whole of the mesentery seemed covered with them, 
but they seldom exceeded an almond in size. 
In the Mediterranean cities, where plague epidemics have prevailed, it is of 
importance pathologically to remember that epidemics of "anthrax," "car- 
buncle," "phlegmon," "boil," or "pustule," are not uncommon. The disease 
usually shows itself in the form of tumors at the lower part of the neck, be- 
tween the shoulders, or in the loins. These vary in size from that of a pigeon's 
egg to a circumference of eight inches. They are preceded by shivering, 
headache, prostration, sickness, occasional vomiting, and sleeplessness, suc- 
ceeded by fever, the appearance of the carbuncle, and typhoid symptoms. In 
some years the disease is severe, and yields a high mortality. The subjects of 
such disease are generally persons of sickly appearance, of gross habits of life, 
and who live in damp, filthy localities, where the plague formerly committed 
its ravages. It is extremely probable that these diseases are cognate to the 
true plague-that, having been born together, the source of the true plague is 
always in existence where these diseases prevail, requiring only the requisite 
unfavorable sanitary conditions to call forth the epidemic pestilence (see .Re- 
port on the Sanitary Condition of Mediterranean Stations, by Capt. Galton and 
Dr. Sutherland, pp. 88, 89). 
Symptoms.-The poison of the plague produces those disordered functions 
of the great nervous centres which constitute the phenomena of fever, either 
of a low or of an active character, and sometimes so severe as to destroy the 
patient within one or two days, and before any secondary lesions are set up. 
"At Aleppo," Dr. Russel says, "in the most destructive forms of the plague 
the vital principle seems to be suddenly as it were extinguished, or enfeebled 
to a degree capable only for a short time of resisting the violence of the dis- 
ease; and the form of the plague beyond all others most destructive exists 
without its characteristic eruptions, or other external marks considered pesti- 
lential. These cases perished sometimes within twenty-four hours." 
The manner in which the disease commences varies, but generally it is pre- 
ceded fqr a greater or less length of time by " lassitude, loss of strength, 
general uneasiness, and mental anxiety, to which shivering, headache, vertigo, 
and vomiting soon succeed; then appear the general and local phenomena, 
and among them the characteristic bubo, carbuncles, and petechise, preceded 
or followed by delirium or coma, too often terminating in death." 
The buboes of plague seldom maturate till the fever is on the decline, which 
rarely happens till the eighth or ninth day; nor are they generally ripe for 
opening till between the fifteenth and twenty-seventh day. In general, sup- 
puration has not been so frequent as resolution, and never were the buboes 
seen to be gangrenous. Aubert considers the bubo as of good augury for the 
patient, and its suppuration as the sign of his recovery. 
The carbuncle is by no means of constant occurrence, Dr. Russel having DIAGNOSIS AND CAUSE OF PLAGUE. 
583 
found it only in 490 cases out of 2700. It appears more commonly in the 
middle or towards the decline of the disease. Hardly any external part is 
free from them, not even the penis; and in one instance a carbuncle formed 
in the throat, which was fatal. They occur more particularly on the limbs, 
and more especially on the legs. In some cases they form on the cheek or 
lips, and, by the tumefaction they cause, give to the face a hideous aspect; in 
others the whole of one side of the jaw has been laid bare; while in others 
they have formed on the eyebrow and on the eyelid, and partly destroyed the 
eye. Clot Bey, however, observed they never formed on the scalp, the palms 
of the hands, or on the soles of the feet. 
There are three different varieties of carbuncle, and all commence in the 
same way, or by a small red pimple, which increases, and in the centre of 
which a vesicle forms, containing first a yellow and afterwards a blackish 
serum. In the most benign the vesicle bursts, and dries up in three or four 
days from its first formation, the epidermis alone having been infected. The 
second variety involves the whole thickness of the skin, as well as portions of 
the cellular tissue, which is moderately tumefied, and surrounded by a dark- 
red areola. The gangrene in this form is circumscribed, and there results an 
eschar from one to two inches in diameter, which is detached by suppuration, 
leaving an ulcer with a sharp perpendicular edge. In the severe forms the 
redness and tumefaction cover a large space, and the gangrene rapidly involves 
the skin, the cellular tissue, and sometimes even the bones. It has been ob- 
served that the malignity of the carbuncle is in the direct ratio of the severity 
of the disease, but the mere existence of carbuncle is not of unfavorable 
augury. Their number is very various, sometimes only one, at others ten or 
twelve. When there are several, they often form in succession. These tumors 
are often very painful; and Aubert mentions one, seated on the back of an 
Arab soldier, four inches in diameter. 
Petechiae are observed in some seasons and not in others. They present 
different shades of color, according to the intensity of the disease-rose color, 
violet color, or black. Aubert considered their appearance an almost certain 
sign of death. The duration of the disease is from a few hours to fifteen, 
twenty, thirty, or even more days. 
Diagnosis.-Clot Bey says the diseases which most resemble the plague are 
typhus fever, severe forms of paludal fever, apoplexy, dysentery, parotitis, 
and scrofulous or syphilitic affections associated with febrile symptoms of a 
typhoid type. 
Cause.-The plague, and the specific poison which it generates, seem to 
have a very limited geographical range. Clot Bey, indeed, considers it to be 
endemic along the whole of the eastern and southern coasts of the Mediter- 
ranean, the principal centres of propagation being Egypt, Syria, and Con- 
stantinople. But most authors are agreed that Egypt is the great focus of 
the plague, whence it may be propagated under circumstances of overcrowd- 
ing, filth, dampness, and organic decomposition. It seems determined also 
that the disease is often circumscribed within a very small space of country. 
Volney states that in Egypt the plague never commences in the interior, but 
always appears first on the coast at Alexandria, passes from Alexandria to 
Rosetta, and from Rosetta to Cairo. 
All that we can safely affirm of the poison of the plague is, that it is at all 
times endemic in Egypt, along with the cognate diseases of "carbuncle," 
" anthrax," or " boil," already referred to, and every five or six years it be- 
comes epidemic. It also appears to be, to a certain extent, influenced by 
season, not spreading in any very sensible degree till December, and attaining 
its greatest height in June, when it rapidly declines. 
The period of the year, however, at which the plague prevails differs in 
some degree in different countries; but the total duration of the disease in 
any country to which it is not native appears to be inconsiderable, unless kept 584 
SPECIAL PATHOLOGY-PLAGUE. 
up by a fresh importation. At Aleppo it lasted from 1760 to 1762, a period 
of three years. But in Malta, Marseilles, and in the western parts of Europe, 
it has generally subsided in about twelve months. 
In selecting its victims, this poison follows the law of most other morbid 
poisons, attacking the poor rather than the rich,-women rather than men,- 
patients laboring under disease rather than healthy individuals,-persons con- 
stitutionally feeble rather than the robust, and those addicted to intemperance, 
or other excesses, rather than those who more strictly observe the precepts of 
Mohammed. As to races-the Arab suffers more than the Negro, the Negro 
than the Turk, and, in Egypt, the Turk more than the European. 
Modes of Propagation.-The belief that the plague is capable of being 
communicated is so general that it still continues to be the terror of Europe, 
and the ports of every nation are closed against a vessel supposed to have the 
plague on board. The facts by which this precaution is warranted are ex- 
tremely striking; for every time the plague has appeared in Christian Europe, 
the arrival of a ship has been an invariable antecedent, on board of which 
one or more persons have died of the plague. The disease also invariably 
broke out at the port or town at which such vessel arrived ; and if proper 
precautions were not taken, it spread into the interior of the country. 
It is known that the antecedent arrival of a vessel having the plague on 
board, at each of the three ports of Marseilles, Messina, and Malta, and the 
breaking out of the disease in all those places shortly afterwards, is so remarka- 
ble that it can be only explained by admitting, in these instances, the connec- 
tion of cause and effect. Moreover, the fact of the plague having originated 
in the preceding instances from imported cases of the disease, and not from 
any local influence, is demonstrated by the exemption of large bodies of per- 
sons "shut up" in the very heart of the pestilence. Thus, in the plague at 
Marseilles, the large nunnery of Les Dames de la Visitation Sainte Marie 
"shut up;" and although there was an infirmary on one side for those ill of 
the disease, and a burying-ground on the other for those who died of it, yet 
all the inmates of the nunnery escaped. The Hospital de la Charite of the 
same city, a sort of poor-house, making up about 300 beds, "shut up," and 
escaped with complete impunity; but being converted into an infirmary 
for the plague patients, 200 of the poor, left in attendance, all died of the 
malady. 
Another class of facts demonstrative of the communicable nature of the 
plague is the great number of persons attending on, or in communication with, 
the sick who die from this disease. The French army, on first taking pos- 
session of Egypt, lost no less than eighty medical officers by the plague-an 
immense proportion compared with the loss of the army generally. In the 
English army only one in forty-eight of the military died of the plague, while 
one-half of the medical officers died. Some few persons also have ventured 
voluntarily to inoculate themselves with plague-matter, and these have, with 
hardly an exception, fallen victims to their rash experiments. 
Dr. Russel states that at Aleppo he met with twenty-eight cases of reinfec- 
tion, or 1 in 157; and Clot Bey states that he and his colleagues saw many 
individuals perish of plague in 1834-35 who had formerly survived an attack 
of the disease. 
Treatment.-In the treatment of the plague neither the practice of the 
French nor English medical officers serving in Egypt has led to any happy 
result; and it is to be regretted that recent experience has not in any degree 
advanced the successful treatment of the plague. " In the beginning of the 
epidemy," says Clot Bey, "when the morbid cause acts with a rapidity so 
great that some hours are sufficient to compromise the life of the patient, every 
treatment, even the most energetic, is powerless to arrest the course of the dis- 
ease. When, however, the intensity of the disease abates, we may hope for 
the recovery of the patient." Looking, however, to the pathology of the dis- DEFINITION AND SYMPTOMS OF AGUE. 
585 
ease, and regarding it as a form of malignant typhus fever, the principles of 
general treatment ought to be similar to those laid down in the account of 
that disease. 
We have no sufficient evidence toprove that plague may be carried beyond 
those geographical limits where it or the cognate diseases already noticed are 
epidemic. Quarantine establishments to prevent the transmission of such 
epidemic diseases are now therefore unwarrantable nuisances, and vexatious 
interruptions to mercantile enterprise. I am informed by a medical friend 
who visited Malta in 1861, that a curious instance of the wavering nature of 
opinion regarding the efficacy of quarantine was afforded during the last Beng- 
hazi plague. The Maltese-the most sensitive people formerly on the sub- 
ject-absolutely declined to put any quarantine on arrivals from Benghazi, 
and trade went on as usual until the Austrians intimated that, unless Malta 
put Benghazi in quarantine, Trieste would put Malta in quarantine ; and the 
poor merchants were obliged to submit. There is little risk of plague now, 
because of the great improvements which have taken place; and it is to be 
hoped that as sanitary measures are developed the barbarism of quarantine 
will entirely disappear; except, perhaps, where the intelligence of the people 
does not go beyond that of the Governor of Eupatoria, who requested that the 
allied armies of France and England might go into quarantine when they 
landed in the Crimea in 1854! (Kinglake). 
AGUE-Syn., INTERMITTENT FEVER.* 
Latin Eq., Febris iniermittens; French Eq., Fihxre intermittent; German Eq., 
Kaltes Fieber-Syn., Iniermittens; Italian Eq , Febbre intermittente. 
Definition.-Febrile phenomena occurring in paroxysms, and observing a cer- 
tain regular succession, characterized by unnatural coolness, unnatural heat, and 
unnatural cutaneous discharge, which prove a temporary crisis, and usher in a 
remission. T hese phenomena are developed in an uninterrupted series or suc- 
cession, more or less regular, which pass into each other by insensible steps. 
Symptoms.-The disease may be sudden in its attack, and without previous 
illness ; but more commonly it is preceded by general indisposition, headache, 
weariness, pain in the limbs, thirst, loss of appetite, white tongue and frequent 
pulse, high-colored urine and dark-colored discharge from the bowels. These 
prodromes are accompanied with well-marked exacerbations and remissions of 
fever, displaying a periodic tendency. After this feverish state has lasted 
from four days to a fortnight, the patient is seized with severe rigor, and the 
ague is manifested. The phenomena of an attack or " fit of the ague" are the 
following: 
The paroxysm, like the disease, may be of sudden invasion, and the patient 
may be in good health up to the time of attack; or it may be preceded by 
languor, debility, frequent yawnings, and great unwillingness to make the 
least exertion. In whichever way the cold stage begins, the patient experi- 
ences first a sensation of coldness of the extremities, then of the back, and 
lastly, of the whole body; at the same time the nails turn blue and the fea- 
tures shrink, becoming pale and sharp. If the case be severe, the whole body 
shrivels up, turns purple, and the surface of the skin assumes that rough con- 
dition popular!v named "goose-skinned." The coldness increasing, the motor 
nerves of the fifth pair are affected, and the teeth begin to chatter; and this 
tremor extends to every muscle, till the whole body shakes with rigor. Cough, 
dyspnoea, and oppression of the prsecordia now occur, with a painful sensation 
* [It would appear from the statistics of the Surgeon-General's office (Circular, No. 
6. 1865), that during the first two years of the civil war, 262,807 cases of intermittent 
fever, with 1780 deaths, occurred. A large proportion of the fatal cases were from the 
congestive or pernicious forms.] 586 
SPECIAL PATHOLOGY INTERMITTENT FEVER. 
round the temples and down the back. The patient often, suffers from nausea 
and vomiting, and the latter symptom is speedily followed by the hot stage. 
[The chill is sometimes so slight as to amount to only a feeling of chilliness 
along the spine, or over the extremities, or it may be limited to a single limb. 
The cold stage may be manifested merely by severe pain in the supraorbitar 
nerve, or there may be simply a drowsiness with excessive yawning or a leth- 
argic state, preceded or accompanied with nausea and vomiting. Dr. Flint 
has known a state of intense nervousness take the place of the cold stage.] 
When the cold stage has lasted a period varying perhaps from half an hour 
to two hours and a half, a reaction takes place, accompanied by partial 
warmth, or flushings. These extend, and at length the whole body acquires 
a heat greater than natural, or from 105° to 107°. As the heat returns, so 
also does the color, and the body, especially the face, becomes preternaturally 
swollen and red. The hot stage being formed, the heart and arteries beat 
with unusual violence, and headache, with a frequent full pulse, and all the 
distressing symptoms of continued fever, are present. The mean duration 
of this stage is from three to eight hours. At its close a gentle moisture breaks 
out, first on the forehead, and thence extends till the patient lies in a general 
sweat, sometimes so profuse as to soak the bed and linen as completely as if they 
had been dipped in water. After the sweat has continued to flow for some 
time, the fever gradually abates, a state of apyrexia ensues, the paroxysm is 
terminated, and (a sense of exhaustion excepted) the patient feels restored to 
health. Sometimes, however, he continues pale, debilitated, and incapable of 
all exertion, till, on the recurrence of the paroxysm, the symptoms just de- 
scribed are repeated. 
Upon the approach of the attack the pulse is slow and feeble, but as the 
sense of coldness increases it becomes small, rapid, and irregular. When the 
hot stage forms, the pulse becomes full and strong, and on the sweat break- 
ing out it again becomes soft, less rapid, and at length natural. 
The tongue, in mild forms of the disease, is clean in the cold stage, white 
in the hot stage, and again cleans after the swreat has flowed. In severe 
cases the tongue is white during all the stages, and also during the apyrexia, 
while in the worst cases the tongue is brown in all the stages. Excepting 
some unusual instances, attended throughout with diarrhoea, the patient 
seldom passes a stool till towards the close of the paroxysm, when it is gen- 
erally a loose one. It frequently also happens during the cold stage that 
tumors subside, or ulcers dry up, but the tumor generally reappears, and the 
ulcers discharge as soon as the sweating stage is formed. 
The paroxysm of intermittent fever, of whatever description, is conven- 
tionally considered to terminate in twenty-four hours. The duration, how- 
ever, varies in different types. These types or varieties have been named- 
quotidian, tertian, and quartan; and of these there are subvarieties-namely, 
double tertian and double quartan. The mean length of a quotidian paroxysm 
is about sixteen hours, that of a tertian ten hours, and that of a quartan six 
hours. 
The febrile paroxysm, or fit of intermittent fever, has three stages,-a cold 
stage, a hot stage, and a sweating stage. These three stages are not neces- 
sarily of an equal duration, but vary greatly in different cases. The duration 
of the cold stage is from a few minutes to five or six hours, and in general, if 
the case be severe, the shorter the cold stage, the longer the hot stage. The 
hot stage may last from half an hour to any period less than twenty-four 
hours. The sweating stage is generally shorter than either of the former, and 
sometimes does not exist at all. The rule, however, is, that the quotidian has 
the shortest cold stage and the longest hot stage; the tertian a longer cold 
stage and a shorter hot stage than the quotidian; while the quartan has the 
longest cold stage and the shortest hot stage of all the varieties. An " irregular " 
variety is also recognized, which takes the form of "Brow ague." SYMPTOMS OF AGUE. 
587 
The varieties of intermittent fever are distinguished from each other by the 
interval of time which elapses between each paroxysm. For instance, when 
the paroxysm returns every twenty-four hours it is termed a quotidian, when 
every forty-eight hours a tertian, and when every seventy-two hours a quartan; 
and these primary types have been extended by early writers to every period 
comprised within a mensual or bimensual period. [Varieties in the types are 
occasionally met with. The anticipating quotidian is where the paroxysm, 
instead of recurring at the usual time, sets in two hours before. The counter- 
part is the retarding quotidian, the paroxysms being put off for two hours 
(Fordyce). In the double quotidian there are two daily paroxysms. The 
double tertian is where there are two paroxysms and two intermissions in the 
forty-eight hours-the alternate paroxysms being similar, while those imme- 
diately following one another are not so. In the triple tertian there are two 
paroxysms on the odd, and one on the succeeding days. The true paroxysm 
in the double quartan takes place on one day, a slighter one on the second, 
while the third is a day of intermission, and there is another paroxysm on 
the fourth day resembling that of the first, and so on, in succession. In the 
triple quartan there is a daily paroxysm, but it varies on the first, second, and 
third days,-the paroxysms happening on the first and fourth, on the second 
and fifth, on the third and sixth, and so on successively, being respectively 
similar. In the duplicated quartan two paroxysms occur on the first day, 
while there is an intermission during the second and third.] 
Of these primary types it is believed that in Europe the tertian is by far the 
most common type, then the quartan, and lastly the quotidian (Watson, 
Copland, Christison). But this law is by no means general; for M. Maillot 
treated 2354 cases of intermittent fever occurring in the French army in 
occupation of a portion of the northern shores of Africa, and he found of that 
number 1582 were quotidian, 730 tertian, and 26 quartan. In the Peninsular 
war the quotidian was likewise the prevailing type, and at one time they were 
in the proportion of'16 to 1 of any other type. In the West Indies the tertian 
and the quartan are only about one-twelfth of the whole number of intermit- 
tents treated, the rest being quotidians. At Prome, in Burmah, 298 cases from 
the 2d Bengal European Regiment were admitted into hospital for intermittent 
fever in 1853, of which 249, or 83.5 per cent., were quotidian, and 49, or 1.6 per 
cent., were tertian (Murchison). The results given concerning the Madras 
Medical Service are very similar (Waring). [It would appear from the official 
reports, that of the several forms of intermittent fever, which prevailed in the 
armies of the United States and Confederate armies, that the quotidian was 
somewhat the most frequent form, and next the tertian. The quartan was rare.] 
Most authors who have written on intermittent fever have stated that the 
accession of the quotidian paroxysm occurs early in 'the morning, that of the 
tertian about noon, and that of the quartan in the afternoon, between three 
and five o'clock. But to this law there are many exceptions. According to 
Maillot, of 1582 quotidians, 1089 occurred from midnight to midday, and 
493 from midday to midnight. This result is corroborated by Dr. Murchi- 
son's observations at Prome, in Burmah. In 86 out of 113 cases-i. e., in 76 
per cent.-the paroxysm commenced between midnight and noon; and in 27 
cases, or 24 per cent., between noon and midnight. The most frequent hours 
of attack were 9, 10, and 11 a.m.; and in 65 per cent, of the cases the parox- 
ysms commenced between 8 a.m. and noon. 
Of 730 tertians, 550 occurred from midnight to midday, and 180 from mid- 
day to midnight; out of 26 quartans, 13 were seized from midday to midnight, 
and 13 from midnight to midday. As the most general conclusion, the parox- 
ysm returned in a great majority of the quotidian cases from ten to twelve 
o'clock, and in the tertian from nine to twelve o'clock. 
[Congestive Form.-A severe and dangerous variety of intermittent fever 
is the congestive, pernicious, or malignant intermittent, more frequently met 588 
SPECIAL PATHOLOGY INTERMITTENT FEVER. 
with in the Southern and AVestern States, and occasionally in those parts of 
the Northern States where paludal fevers are endemic. During the first two 
years of the late war, there were reported in our armies 6081 cases of conges- 
tive fever, and 1381 deaths, whilst in 156,726 cases of all other varieties of 
intermittent fever there were only 407 deaths. There are two forms, the 
comatose and algid. In the comatose the head-symptoms may vary from 
lethargy to deep coma; the pulse is large, soft, and generally slow; the respi- 
ration is laborious, noisy, and infrequent; the patient lies on his back, uncon- 
scious, and cannot be roused; the limbs seem paralyzed; the jaws are locked; 
deglutition is difficult; there are, sometimes, epileptiform spasms, or active 
delirium. After the continuance of these symptoms for a variable time, 
sweating comes on, and there is gradual awakening, with an astonished look, 
and the senses are regained one by one. The algid variety is marked by an 
icy coldness of the surface, like marble or the collapsed stage of cholera. The 
extremities, face, and trunk, become cold in succession, the skin of the abdo- 
men remaining warm longest; the tongue is pale, shrunken and cold; the 
breath is chilled, and the lips livid. The action of the heart is feeble, and 
the pulse rapid, small, and almost extinct. The respiration is quickened, 
broken, and embarrassed. The mind is often undisturbed, and a sensation of 
repose is felt. The eyes are hollow, glassy, and surrounded with a bluish 
circle; the face is pinched, and all expression gone. If death does not happen 
in the fit, the pulse is slowly developed, and the heat of the surface gradually 
comes back, beginning at the abdomen and extending to the extremities. 
The congestive variety of intermittent fever is very insidious, and may come 
on in the second or third paroxysm of a quotidian, or tertian; or it maybe initial, 
though generally preceded by prodromic phenomena, as drowsiness, headache, 
languor, and gastric derangement. The accession of the algid form is some- 
times sudden, the patient becoming rapidly cold, lying down, and dying in a 
few hours. If there should be more than one fit, each succeeding one is more 
severe. The patient may die in from two to twelve hours.] 
The Temperature in Cases of Intermittent Fever.-The paroxysm of 
(1.) TYPICAL RANGE OF TEMPERATURE IN A CASE OF INTERMITTENT FEVER 
OF QUOTIDIAN TYPE. THE RECORDS INDICATE THE HIGHEST AND 
LOWEST TEMPERATURES DAILY (Wunderlich). 
Fig. 78. BODILY TEMPERATURE IN AGUE. 
589 
fever, notwithstanding the subjective sensation of chilliness, is invariably indi- 
cated by a decided, sudden, and rapid rise of temperature. In this respect it 
resembles the accession of febricula; but while the latter requires only from 
eighteen to twenty-four hours from the commencement of the rise of tempera- 
ture to the end of the defervescence, in perfectly normal cases of intermittent 
fever there is a whole day free of fever between every two days of the paroxysm. 
All the types of the fever present this characteristic peculiarity of a sudden 
and speedy rise of temperature to a high degree (mostly up to 105° or 106.3° 
Fahr.); and of an equally rapid and complete defervescence, till the period 
of another fever paroxysm comes about. This comportment as to tempera- 
ture secures correctness of diagnosis in cases which may be obscure or am- 
biguous. 
The annexed diagrams represent variations of temperature in cases of mala- 
rious fever. 
(2.) RANGE OF TEMPERATURE IN A CASE OF INTERMITTENT FEVER OF TERTIAN TYPE. THE 
RECORDS INDICATE THE HIGHEST AND LOWEST TEMPERATURES EACH DAY (Wunderlich). 
Fig. 79. 
In a paroxysm of intermittent fever much may be learned as to the rela- 
tions of the excretions to temperature, and especially those of the urine, by 590 
SPECIAL PATHOLOGY-INTERMITTENT FEVER. 
observing the changes of temperature in very short spaces of time; for exam- 
ple, every fifteen, or even every five minutes (Michael, Jones, Ringer). 
The rise of temperature is found to begin with, or even to precede, the sensa- 
tion of chilliness. It takes place at first slowly; and gradually, by about 
the middle of the period of chilliness, the rise becomes greatly accelerated, 
lasts through the period of the sensation of great heat, and may even extend 
into the sweating stage. At the commencement of the sweating stage, small 
vacillations occur, and continue for a short time; and when the sweating has 
fairly set in, the decrease of temperature begins, and progresses steadily, 
without any temporary rise, and with great regularity, decreasing at the rate 
of .2° Fahr, (or more) every five to fifteen minutes, till it has arrived, after 
several hours, at the normal heat. 
Condition of the Urine.-The observations made on the condition- of the 
urine are divisible into two series, as arranged by Dr. Parkes (1. c., p. 235). 
(1.) The condition of the urine during the fit, as compared with the urine of 
a non-febrile period; (2.) The condition of the urine of twenty-four hours 
during a fever day, as compared with the twenty-four hours urine of a non- 
fever day. 
During the fit and the apyrectic period the water of the urine is increased 
in amount during the cold and hot stages: it is most abundant at the termina- 
tion of the cold or commencement of the hot stage. It decreases during the 
latter part of the hot stage slowly, and rapidly during the sweating stage. The 
amount of increase is variable, and stands in no relation to the quantity of 
fluid drank, and may be great when this is small (Ringer). The amount of 
urea excreted by a person with ague, not actually suffering from a fit, is less 
than in health; but directly the fit commences-that is, at the very first 
moment of elevation of temperature-or even for some time before this, the 
urea suddenly increases-an increase which lasts during the cold and hot stages, 
and then sinks, sometimes gradually, sometimes suddenly, through the sweating 
stage, or into the commencement of the intermission. It then falls below the 
healthy average. The amount of increase is very variable, and the type of the 
fever has no influence upon it; but there seems to be a very close connection 
between the temperature and the amount of urea. The amount corresponding 
to a degree of Fahrenheit was greater at a high than a low temperature; and 
in the fit of each day the same amount was excreted for each degree of tempera- 
ture {Med.-Chir. Trans., 1859). This increase in the urea must be regarded, 
in some measure at least, as an indication of increased metamorphosis; and the 
close relation to the febrile heat certainly implies that it owns only this source, 
and is not caused by elimination following previous retention (Parkes). 
•The uric acid is greatly increased during the fit; and after the fit there 
are often deposits of urates, either spontaneously or on the addition of a drop 
of acid, and it seems probable that the increase in the excretion of uric acid 
continues for some time after the paroxysm; and the enlargement of the 
spleen in connection with this great increase of uric acid is probably not 
fortuitous (Ranke). The influence of quinine in diminishing the amount of 
uric acid in health is of interest in connection with its effect upon malaria, 
and with the condition of the spleen in malarious fever (Ranke, Bosse). 
The chloride of sodium is increased during the cold and hot stages to a great 
degree (Traube, Ringer),-to five times the normal amount; and phos- 
phoric acid is diminished to one-eighth (Nicholson). 
The results are contradictory regarding the urine of a fever day, compared 
with the urine of a fever-free day. This may be explained to some extent by 
the relative duration of the fit, compared with the fever-free period ; and 
great differences may arise from the comparative length of the apyrectic 
period on the fever days ; also from the severity or the reverse of the fit, and 
from the amount of food and drink able to be taken. With respect to abnor- 
mal constituents, albumen is found during the fit in a considerable number THE URINE IN INTERMITTENT FEVER. 
591 
of cases. Blood in some quantity, and renal cylinders, are seen about as fre- 
quently as albumen; and occasionally chronic Bright's disease is a conse- 
quence of ague (Parkes, 1. c.). 
Treatment.-The treatment of agues varies in a great degree with the com- 
plications of the disease; such as with the splenic and hepatic congestions, 
and the inflammatory affections of these and other organs, which are apt to 
be established during the existence of an intermittent fever. Daring each 
paroxysm, and subsequent to it, the condition of the two important organs 
referred to ought to be carefully observed; and it ought to be observed, also, 
whether any symptoms exist of congestion or actual exudation into the cranial 
or abdominal organs. When the type of the fever is malignant, or of a se- 
vere and complex kind, or when the. complications are locally severe, it is 
difficult to cure an ague, which otherwise is a very manageable disease. Dur- 
ing the cold stage, especially if it is of long duration, the liver, and especially 
the spleen, become turgid, the symptoms of which generally disappear with 
the sweating stage of the fever. It is when the endemic influences are severe, 
or when the attacks are prolonged over months and years, that these organs 
begin to suffer permanently from organic disease. 
It is useless to attempt, the cure of intermittent fever if the sufferer is per- 
mitted to remain within the sphere of malarial influences, or even in those 
geographical latitudes which are said to be peculiarly malarial. It is now 
an established fact that none can become acclimated so as to withstand the 
influence of malaria. When organic complications exist, they must, if pos- 
sible, be remedied, because they maintain the morbid sensibility during the 
intermission, and prevent the cure of the ague. 
In the warmer latitudes, the following account of the treatment of inter- 
mittent fever is that laid down by Sir Ranald Martin. During the cold 
stage of the fever, while emetics seem to be indicated, they are not in repute. 
Warm drinks, ammonia, ether, camphor, and other diffusible stimuli, with 
the application of external warmth, seem to be preferred by most practi- 
tioners. During the hot stage a full dose of calomel, with James's powder, 
should be given at once, and in three hours this should be followed by a brisk 
cathartic, diluent drinks being freely used meanwhile, along with some cool- 
ing diuretic. The tartarized antimony, with nitrate of potash, is recom- 
mended, as it answers the double purpose of exciting to action the functions 
of the skin and the kidneys. On the following morning, the intermission 
being completely established, the sulphate of quinine is to be administered. 
The influence of this medicine on a person in health, as observed by Dr. 
Ranke, is to diminish the quantity of uric acid in the urine (Med. Times, 
May 30, 1857)-an observation which has been recently confirmed by Bosse, 
of Dorpat, and is of interest in relation to its influence upon the spleen. It 
is to be given at intervals of three hours during the day, the patient being 
kept in bed, and supplied with farinaceous food only. In the simple cases, 
when removed from the sphere of malarial influence, it may not be necessary 
to give mercurials more than once or twice, but active purgatives are always 
beneficial in relieving the full and congested state of the abdomen generally, 
during the continuance of intermittent fever. There are cases of intermittent 
fever,"however, complicated with hepatic and other engorgements, and which 
continue to recur despite of all means, until a few doses of calomel, followed 
by purgatives, are administered; then the quinine, which before failed, will 
speedily cure the disease. The compound jalap powder, combined with calo- 
mel, is found very beneficial for this purpose. It appears that certain morbid 
conditions both of liver and spleen may produce and maintain the tendency 
to recurrences of ague. Ramazini relates the case of a patient harassed by 
an obstinate ague, and who was cured by mercurial frictions administered 
for syphilis. The influence of splenic disease in keeping up the morbid train 
of actions of the original fever, and in producing relapses, has been recorded 592 
SPECIAL PATHOLOGY INTERMITTENT FEVER. 
by M. Piorry. In more than 500 cases of ague in which he observed the 
state of the spleen, he conies to the following conclusions : namely, that the 
organ is invariably enlarged during the progress of the fever, and that by the 
use of quinine the spleen diminishes in size ; that its reduction in size bears 
some relation to the quantity of quinine taken ; that the effect it produces 
upon the fever is in proportion to the reduction of the spleen ; that the dis- 
ease is cured simultaneously with the subsidence of the splenic enlargement; 
and that the fever is apt to recur so long as the spleen exceeds its normal 
size. 
When the fever is severe, accompanied with prsecordial oppression, pain, 
fulness of the spleen or liver, or both, or where there is severe headache, or 
headache with giddiness, or an oppressive fulness of the chest, a general or a 
local bloodletting, or both combined, is imperatively demanded, as a means 
of promoting cure and preventing future evils. The antiperiodic power of 
bark, quinine, or arsenic, then becomes more easily developed. According to 
Dr. Copeland, such depletion is almost an indispensable preliminary to the 
administration of quinine or bark, especially in the complicated and conges- 
tive forms of the disease. Without such depletion the medicine will either 
not be retained, or, if retained, it will convert congestions or slight forms of 
inflammatory irritation into active inflammation or serious structural changes. 
It is chiefly to a neglect of such a mode of practice that unfavorable conse- 
quences have so often followed the use of bark, quinine, or arsenic; for their 
influence is at first to interrupt secretion, or to over-excite, and subsequently 
to inflame organs already loaded, obstructed, and congested. But if blood is 
to be drawn at all, it should be drawn at the very onset of the hot stage, or 
that of reaction; and it should be regulated by the constitution, the age, and 
the habit of the patient, as already explained. 
When, on the contrary, the fever assumes a low adynamic form, or when 
the patient is amemic, mercurials must be carefully avoided in the treatment 
under all circumstances, and reliance placed on change of air, quinine, and 
chalybeates, and improved diet. With regard to liver complication in such 
cases, the nitro-muriatic acid is to be used internally, in doses of ten drops, 
three, four, or five times a day, and externally in the form of baths. 
With regard to the doses of quinine, some give very large quantities, such 
as twenty or thirty grains before the expected paroxysm (Maillot) ; others 
begin to administer the quinine on the subsiding of the paroxysm, and during 
the sweating stage. According to the experience of Sir Ranald Martin 
(which has been great in tropical climates), the most rational plan is to give 
the quinine every three or four hours during the interval of freedom from 
fever, and in such doses as the urgency of the symptoms may demand. It is 
to be administered in solution, dissolved by a small quantity of dilute sul- 
phuric acid. He also recommends antimony to be conjoined with the quinine 
in plethoric subjects; and, on the contrary, if the patient is feeble, irritable, 
or exhausted, he adds a few drops of tincture of opium to the antiperiodic. 
When arsenic is given in large doses, and its use prolonged, it permanently 
injures the circulating system and the mucous membranes of the stomach and 
bowels. It should be given in small doses, and not persevered in for more 
than eight or ten days. From six to eight drops of the solution of the College 
formula may be given every three hours during the interval of freedom from 
fever. Dr. Murchison's ■ experience in Burmah goes to prove that the prac- 
tice most effectual in at once checking the paroxysms of intermittent fever is 
that of administering one large dose of quinine during the third or sweating 
stage. The usual dose given was twenty grains in a draught, with a few drops 
of sulphuric acid to dissolve the quinine. In no case did he observe any un- 
pleasant symptoms from the physiological action of the drug, although many 
of the patients complained of slight buzzing in the ears-some amount of 
which is deemed necessary by Dr. Murchison for the success of the remedy; TREATMENT of intermittent fever. 
593 
and when it occurs, "it is a sign that there is no use of pushing the medicine 
farther." Christison also recommends the administration of large doses of 
quinine for the cure of tropical intermittent fevers, as deduced from the ex- 
perience of the medical officers of the Madras army (Madras Med. Reports, 
1831; Edin. Med. and Surg. Journal, Jan. and April, 1855); and Superin- 
tending Surgeon Corbyn has long been convinced of the efficacy of this mode 
of giving quinine (Indian Annals of Medical Science, Oct., 1853). Repeated 
small doses, on the contrary, have been recommended in this country, by 
many eminent physicians, to be given during the intermissions (Home, 
Brown, Barker, Watson); but the evidence of Dr. Murchison is so clear 
and decided, that one large dose, given as he recommends, seems more effica- 
cious and more economical than repeated small doses. 
When the intermittent fever has become chronic, or when there is organic 
disease of the liver or spleen as a secondary affection, change of climate be- 
comes a measure of necessity, and should never be neglected. Sir Ranald 
Martin's personal experience does not allow of his writing in favorable terms 
of the practice of bleeding in the cold stage of ague. After quoting many emi- 
nent authorities both for and against the practice, he remarks, "that in 
Europe, at least, the treatment of intermittent fevers by bloodletting in the 
cold stage, whilst it has the show of being prompt and energetic, proves, in 
effect haphazard, systemless, operose, and tedious; and from all that I have 
seen and heard in the East, the result there has not been more favorable." 
The rule of practice laid down by Pringle and Cleghorn has received little or 
no addition in more recent times. Where general bloodletting is had re- 
course to in the treatment of intermittent fevers, whether simple or compli- 
cated, it should, as in the case of all other fevers, be performed at the very 
outset of the stage of reaction. 
[In simple intermittent fever, particularly when there is evidence of de- 
rangement of the digestive organs, an emetic of ipecacuanha, or ipecacuanha 
and sulphate of zinc, should be administered at the outset, followed by a 
warm infusion of chamomile, and a mild non-mercurial purgative. Fifteen 
to twenty grains of the sulphate of quinia should be given in solution, either 
in a single dose, or in two or three doses at intervals of two or three hours, 
according to the type and urgency of the case, so that the whole amount shall 
have been taken two hours before the expected paroxysm. When, from gas- 
tric irritability or other causes, quinia cannot be taken by the mouth, it may 
be administered in an enema, or hypodermically; in the latter case dissolved 
with tartaric, instead of sulphuric, acid, as less locally irritating. Five grains 
of quinia should be ordered daily, in divided doses, for from fifteen to twenty 
days, particularly if the disease has lasted any time. It may or may not be 
combined with iron or arsenic. Where there is intolerance of quinia, arseni- 
ous acid, in doses of from one-twentieth to one-thirtieth of a grain, four or 
five times a day, will be found quite certain. In very young children, arsenic 
is especially reliable. Numerous substitutes for quinia have been proposed, 
and have had more or less repute. Amongst these are piperin, tela araneae 
(Robert Jackson, Condie), beeberin (Logan, Watt, Nicholson), fer- 
rocyanuret of iron (Stokes, Flint), chloride of sodium (J. C. Hutchinson), 
muriate of ammonia, nitric acid (E. S. Bailey, W. A. Hammond), cornus 
florida, &c. Of these the cornus florida is the most valuable. 
The congestive variety of intermittent fever requires prompt and vigorous 
treatment. To save life minutes must be counted. The chief reliance should 
be on the immediate administration of large doses of quinia-twenty grains, 
repeated every half hour, or hour, till there is reaction. If the patient can- 
not swallow, or there is vomiting, it is to be given in an enema, in larger 
dose. Chloroform alone, or with sulphuric or chloric ether and camphor and 
capsicum, is a useful adjuvant. Sinapisms should be applied over the chest, 
abdomen, and to the extremities, or along the spine; or flannels, steeped in 594 
SPECIAL PATHOLOGY-REMITTENT FEVER. 
hot water to which mustard has been added, and well wrung; or friction with 
the hands or a woollen cloth. In the comatose form dry cups may be applied 
to the nucha, and along the spine. But the sheet-anchor is quinia; it is the 
only antidote to the virulent and quickly-killing poison. After the paroxysm 
is over, if there are no symptoms of cinchonism-and there usually are not- 
quinia should be given at intervals, in five or ten-grain doses, and the patient 
carefully watched, and kept in bed, until the period of recurrence has fully 
passed. If about the time of the expected paroxysm the nails should become 
blue and the finger tips shrivelled, or gaping or drowsiness come on, active 
means must be at once taken.] 
REMITTENT FEVER. 
Latin Eq., Febris remittens-Idem valet, Febres pestiferce singularum regionum; 
French Eq , Fiivre remittents, Syn., Figures pernicieuses; German Eq., Bbsarti- 
ges endmisches Fieber, Syn., Bosartiges locales Fieber; Italian Eq., Febbre remit- 
tente; Febbri perniciose de' climi caldi. 
Definition.-Febrile phenomena with exacerbations and remissions, the remis- 
sions being less distinct in proportion to the intensity of the fever. The fever is 
malarious, characterized by irregular repeated exacerbations, the remissions being 
less distinct in proportion to the intensity of the fever. There is great intensity 
of headache, the pain darting with a sense of tension across the forehead. It is 
accompanied by functional disturbance of the liver, and frequently by yellowness 
of the skin. The malignant local fevers of warm climates are usually of this class. 
Symptoms.-There are so many grades of intensity in remittent fever 
(varying as it does from a severe intermittent to malarious yellow fever), and 
so many different modifications are impressed on it, from the great variety of 
country by which the poison is generated, that it is extremely difficult to 
generalize the phenomena. 
The severer forms of remittent fever may be preceded by certain premonitory 
symptoms, such as languor, listlessness, restlessness, or chilliness ; or there may 
be a want of appetite, anxiety, lassitude, pain at the epigastrium, pains in the 
loins and limbs, headache; slow, small, and irregular pulse ; coldness of the 
skin, and chilliness for one or several days before the commencement of the at- 
tack ; these arc symptoms which usher in a short cold stage. But in other cases 
the attack is sudden, and the patient, for instance, immediately after a hearty 
dinner, may be seized most unexpectedly with faintness, vertigo, nausea, con- 
fusion of thought; and these almost without a rigor, or a very short one, not 
exceeding half an hour: a hot stage follows, usually of much greater intensity 
than that which accompanies the worst forms of intermittent fever. 
The hot stage, or period of exacerbation, generally commences in the fore- 
noon of the clay, or early in the afternoon, subsiding towards evening, or in 
the early part of the night, the remissions being generally most complete early 
in the morning. Sometimes, however, the exacerbations come on towards 
evening, and last all night, the remissions being then most complete in the 
forenoon; while, in a few cases, there may be two exacerbations in the 
twenty-four hours; and these cases are generally the most severe. The exac- 
erbation is usually marked by much cerebral affection, as severe headache, a 
painfully acute state of every sense, an injected state of the conjunctiva, and 
great action of the carotid arteries. The pulse, varying from 90 to 120, is 
generally at first full, but is sometimes from the first small, and generally soft 
and easily compressible. The tongue is dry, with a white and sometimes 
yellowish fur, and a bad taste in the mouth. There is generally unquench- 
able thirst, parched lips, tenderness at the epigastrium, and sometimes pain, 
with increased dulness on percussion, in the region of the liver. These symp- 
toms are frequently accompanied by delirium, sometimes of a violent character. SYMPTOMS OF REMITTENT FEVER. 
595 
When giddiness is distressing, and proceeds to delirium at an early period, 
and runs high, a severe form of fever may be expected. In other cases the 
patient is oppressed with great drowsiness, lethargy, or coma. The stomach 
also is often the seat of great pain and uneasiness, followed by vomiting, and 
the matters vomited are either colorless, bilious, or bloody. The duration 
of this paroxysm varies considerably, and when the disease is mild it may 
terminate in six or seven hours; but if severe it may last fifteen, twenty-four, 
thirty-six, or even forty-eight hours; and Dr. John Hunter once saw a case 
in which there was no remission for seventy-two hours. Inability to sleep is 
almost constant. The urine is scanty, high-colored, and of high specific 
gravity (1024 to 1030), acid, not coagulable'by heat (Murchison). Albu- 
men was tested for by Dr. Murchison in numerous instances, but never de- 
tected ; and according to Jones's experience in America, it is very rarely 
present,-a point of difference, if verified, of great importance as a distinction 
between severe remittents and specific yellow fever (Parkes). In severe 
remittent fever Jones found the urea increased, and the uric acid lessened till 
convalescence, when it again increased, and the pigment was also lessened 
(Parkes, 1. c., p. 242). The fever, however, at length remits, sometimes with 
sweating, but at other times without any sensible increase of perspiration. 
The first exacerbation is generally the longest, lasting, in some cases, for 
twenty or twenty-eight hours; but generally after twelve or sixteen hours the 
symptoms remit. 
The duration of the remission which follows is as various as that of the hot 
stage. Sometimes it does not last longer than two or three hours ; more com- 
monly it extends to six, eight, ten, fifteen, thirty, or even thirty-six hours. 
The fever then returns, and in some cases assumes a quotidian type, and has 
an exacerbation every day, and perhaps nearly at the same time, yet more 
frequently there is no regularity in the times either of its accession or 
remission. 
The second paroxysm is always more severe than the first, if the progress 
of the fever has not been checked during the remission, and usually neither 
any cold stage, rigor, nor even chilliness precedes it. On the other hand, all 
the febrile symptoms run much higher, the skin is hotter, the pulse more fre- 
quent, the headache greater, the senses more confused, and the delirium or 
coma, when that exists, more violent in degree and more sudden in its acces- 
sion. Delirium, with more or less loss of consciousness, may not supervene 
till the third or fourth paroxysm; and is of a low wandering character in the 
asthenic form of the fever. The tongue becomes dry, hard, and brown, or 
almost black; the teeth covered with brownish scales; and the pulse becomes 
small and weak. The symptoms sometimes persevere, with or without the black 
vomit, till they terminate perhaps in coma more or less profound, great prostra- 
tion, subsultus tendinum, fetid breath, resembling the odor of a dead body, con- 
vulsions, and at length in death. The severe forms of the fever are sometimes 
accompanied with a yellowish hue of the skin and white of the eyes. The 
yellowness is said to be less where there is a copious bilious diarrhoea, and where 
the urine is of a dark yellow-brown color. When the disease does not terminate 
fatally, amendment is generally observed after the fifth exacerbation, which 
may subside in very copious perspiration, with the following symptoms of pro- 
gressive amendment: the tongue begins to clean and grow moist at the edges, 
the sordes disappear from the teeth, the thirst diminishes, and the appetite 
gradually returns. The pulse remains slow ahd soft, but begins to acquire 
strength; and the skin continues cool and moist, sleep returns, and the 
strength is gradually but very slowly recovered. Headache may continue for 
some days, till relieved by epistaxis. Young and robust men, particularly 
recruits, who recently arrive in India from Europe, suffer a considerable 
amount of vascular excitement, with marked symptoms of determination of 
blood, either to the head or to the abdominal viscera, at a very early stage of 596 
SPECIAL PATHOLOGY REMITTENT FEVER. 
the fever. In such cases the pulse is at first full, and of tolerable strength, 
the skin burning, and the delirium raging and acute. Again, in other men 
more advanced in years, or those debilitated by long service in India, by pre- 
vious disease, or by habits of intemperance, there is very little vascular ex- 
citement, even during the exacerbations; and the pulse, though quick, is 
small and weak. There is no great heat in such cases-there is even coldness 
of the skin, with a yellow tinge, often severe hiccough and vomiting, with 
great prostration of all the vital powers. In such cases the chief indications 
of the exacerbations are increased restlessness, vomiting, headache, or wan- 
dering delirium. In these cases the remissions are not well marked, even 
from the commencement of the attack (Murchison, 1. c.). 
There are great varieties in the degree of severity and type of this fever, 
more especially as they occur in England, France, Holland, and Germany, 
compared with those which occur in Spain, Italy, the Mediterranean Islands 
-or still more so in Africa and the East and West Indies; and accordingly 
some authors (Craigie) distinguish three varieties,-e. g. (1.) The autumnal 
remittents of temperate countries, as England, France, Germany, Holland, 
Hungary.- (2.) The summer and autumn remittents of warm countries, as 
Spain, Italy, Greece, the Mediterranean coasts and Islands generally, the 
Levant, the north of Africa and Asia, and the United States. (3.) The 
endemic remittents of hot and tropical climates, as in the south of Asia, Cen- 
tral and Western Africa, Equinoctial America, and the West India Islands. 
Accordingly, remittent fever has received different names from the localities 
where it prevails. Thus we have the gall-sickness of the Netherlands, the 
Walcheren fever, fever of the Levant (Irvine), Mediterranean fever (Bur- 
nett), Hungarian sickness, puka fever of the East Indies, jungle fever, hill 
fever of the East Indies, bilious remittent of the West Indies and Mediterranean, 
Bulam fever, Sierra Leone fever, fever of Fernando Po and Bight of Benin, 
African fever, and Bengal fever. Prevailing on the borders of inland lakes, 
as in America, it is sometimes called the lake fever. (See page 241 on such 
nomenclature.) 
[Remittent fever is, after intermittent, the most prevalent type of fever in 
the Middle, Southern, and Western regions of the United States. It is their 
summer and autumnal epidemic, and unacclimated strangers are very liable to 
be attacked with it when visiting those sections. From its annual presence and 
severity in so large a portion of the country, its study is of interest and im- 
portance to the American physician. It begins very much like a paroxysm 
of intermitent fever, with a varying period of lassitude, yawning, and pain in 
the head, back, and limbs, particularly the calves of the legs; an indescribable 
uneasiness about the stomach sometimes precedes all the other symptoms; the 
tongue is coated, and there is a bitter taste in the mouth ; the pulse is small, 
and the action of the heart labored, with increased impulse, and intensity of 
the sounds. The initial chill may be severe, or moderate, or, what is more 
frequent, there is a general sensation of cold, lasting from fifteen minutes to 
a couple of hours, during which there is great thirst, with nausea and vomiting 
before its termination, particularly if a meal has been recently eaten. The 
hot stage comes on, with increase of the throbbing headache, which is usually 
frontal, but occasionally occipital. Violent pain in the back is often com- 
plained of. In some cases there is wandering delirium, most frequently asso- 
ciated with a drowsy stupor, shown when the patient is half awake, and pass- 
ing off when he is quite roused. The pulse is quick, rising in the first paroxysm 
to 120 or 125, and may be small or full, but rarely hard; the tongue is coated 
with yellowish fur, and dry, though it may remain moist and almost natural 
in color; the respiration is hurried and sighing; the thirst is excessive; the 
urine scanty and muddy. The paroxysm lasts from five to ten hours, when 
a remission takes place. The first may be decided, and last several hours. 
In the subsequent exacerbations there is an aggravation of all the symptoms SYMPTOMS OF REMITTENT FEVER. 
597 
of the first paroxysm, except the chill, which is rarely well marked, though 
slight shivering, or a sensation of coldness, often precedes the second or third 
exacerbations. When there is a recurrence of the chill, it is most commonly 
at the tertian period (Stewardson). Dr. Boling says: " Where the fever is 
of the double tertian type, the first and third, perhaps the fifth, exacerbations 
may be ushered in by tolerably distinct agues, while the second and fourth 
may be preceded but by the very slightest sensation of coldness, if any. The 
pulse in each succeeding paroxysm becomes more frequent, and there is a 
gradual diminution in fulness. In the subsequent remissions a corresponding 
increase in frequency will be noticed; and though relatively to the preceding 
exacerbation the pulse shall have fallen, it will still be quicker than during 
the preceding remission. In the second exacerbation the moisture about the 
tongue is slight, though the tongue is not very dry. In the third and fourth 
it is apt to become dry, at least on the dorsum, the edges yet moist. Still 
later, it is parched, rough, and cracked. In each succeeding exacerbation it 
becomes drier, of darker color, contracted, and sharp-pointed, with intensely 
red edges and tip. During the remissions the dryness and other morbid char- 
acters somewhat abate ; and in the early remissions it often becomes moist, 
and otherwise nearly natural. In each remission the tongue assumes a more 
natural look; but in each succeeding one this is less than in the immediately 
preceding one-so that in any given remission, though its appearance will 
have improved from its state during the preceding exacerbation, it will be 
worse than during any former remission." The salivary secretion, diminished 
or even suspended during the exacerbations, becomes free during the remis- 
sions, but less so with each succeeding one. There is great disgust for food, 
and craving for cold and sour drinks. Distressing and constant irritability 
of stomach is constantly present, increasing with each paroxysm. The matter 
vomited is bitter, and of a yellowish or greenish color; or, later, dark grass 
green, and small in quantity. In many cases the vomit is, besides what may 
have been lately swallowed, a tough, glairy fluid, which holds suspended small, 
dark-green flocculi, which fall to the bottom of the vessel; or there-is a green- 
ish-brown, dirty-looking sediment. The bowels are costive, and the evacua- 
tions, provoked by purgatives, serous, containing but little fecal matter, and 
yellow or greenish. Delirium, when it happens in the later exacerbations, is 
rarely violent, and commonly abates or ceases during the remissions. The 
mind seems occupied with the ordinary avocations and thoughts. Perspiration 
during the remissions is less and less marked as the disease advances; and the 
skin gets a yellowish tint, first noticed in the conjunctivae, or there may be 
jaundice. Sudamina are met with in protracted cases ; and herpetic vesicles, 
singly or in groups, seated usually on the edges of the lips, or about the alae 
nasi, are common (J. F. Meigs). There is no true eruption. The sense of 
debility is extreme, and is often as much complained of in the first or second 
exacerbation as later in the disease, when the actual debility is greater. At 
whatever time of the day the first exacerbation may happen, the tendency in 
the subsequent ones is to come on the after part of the day-some time between 
noon and six o'clock in the evening-and to continue during the night, the 
pulse rising to 112 or 116; while in the morning it will fall to 100 or 96. In 
remittent fever of the double tertian type, however, it will, in most cases, be 
found to occur alternately in the fore and after part of the day. In protracted 
cases, say from the eighth to the twelfth day, the remissions become less and 
less marked, not more so than in continued fever; the distinctive type-period- 
icity in the exacerbations and remissions-is lost; and ataxic and adynamic 
symptoms supervene. Bronchitis is a common complication. 
A favorable change is earlier indicated by the secretions of the mouth and 
tongue than by any other sign. Even when the tongue is quite dry in the 
exacerbation, some moisture is apt to appear upon the edges and lower surface 
during the remissions; and diminished intensity in the coming exacerbations- 598 
SPECIAL PATHOLOGY REMITTENT FEVER. 
may be inferred from the slightest increase of this moisture during a remis- 
sion, upon what it was in a previous one. 
The diagnosis between remittent and typhoid fever is, in general, very easy, 
even when the intermissions are not well marked, and it has run into the contin- 
ued type. The absence of many of the chief distinctive traits of typhoid fever 
will enable us to avoid an error. In remittent fever there is no true eruption, 
no constant tenderness, with gurgling on pressure, in the right iliac region; 
the intelligence is nearly always good in the beginning, and may continue so 
throughout; and the peculiar besotted expression of the face in typhoid is 
wanting. The access is much more sudden. There is usually an initial chill. 
Malignant Congestive or Pernicious Remittent Fever-(African fever, 
Country fever, Lake fever), styled by Dr. Dickson "a hideous and pestilential 
modification," prevails in our Southern, Western, and Northwestern States. 
It begins often as a simple intermittent, and the first paroxysm attracts but 
little notice. The next chill is more severe; there is extreme coldness of the 
surface, which is shrivelled, and of a livid hue, and the body is bathed in a 
clammy sweat, sometimes limited to the face and neck. There is violent gas- 
tro-intestinal irritation, with incessant purging and vomiting, the discharges 
being often mixed with blood, and rarely with bile; the intestinal evacuations 
have been described as having the appearance of water in which a piece of 
recently-killed beef has been washed (Parry). The abdominal tenderness 
is slight, but a sense of weight and burning heat in the stomach is com- 
plained of. The thirst is intense and unquenchable. The respiration is diffi- 
cult and peculiar-a deep-drawn double inspiration, or double sigh, and one 
expiration. The pulse is small, thready, and frequent-120 to 140 beats in 
a minute; but, according to Dr. Boling, the action of the heart continues 
strong, as shown by the loudness of its sounds and the force of its impulse. 
There is excessive restlessness, the patient tossing about, and wanting to get 
out of bed. The intelligence may remain good during the attack, though 
there is sometimes delirium, and coma'may come on after the second parox- 
ysm. Severe headache is very constantly present. If the termination is 
happy, the restlessness abates, the skin dries, the temperature of the body 
slowly rises, and the pulse becomes slower and fuller. 
A comatose variety is met with in the Southern States, which resembles very 
much the same form of intermittent fever already described. Stupor comes 
on in the first paroxysm after the cold fit, with dilated pupils and stertorous 
breathing. As it declines, the stupor passes off, and there is no alarming 
symptom during the remission. In the exacerbation, the lethargic state re- 
turns more marked, and may at once deepen into coma; and this is repeated 
until recovery or death. The remissions are sometimes very imperfect, and 
marked only by a temporary and slight abatement in the force, and a dimin- 
ution of a few beats in the frequency, of the pulse, and cessation of stertor, 
with yawning and stretching. Dr. Boling relates a case where the patient 
lay eight days comatose, waking up during the hour of remission on the ninth 
morning. 
The anatomical character of remittent fever is a peculiar alteration in the 
color of the liver, which is more or less uniformly bronze, or a mixture of 
bronze and olive, or some shades of lead color, the natural reddish-brown 
being lost, or only faintly to be seen (Stewardson, Swett, Howard, Pow- 
ers, Anderson, Frick, Stille). This essential hue is caused by the deposit 
within the liver-cells of hematoidin, and described by Frerichs as pigment- 
liver (A. Clark, J. F. Meigs). Prof. Alonzo Clark found, in two persons 
who had had remittent fever several years before their death from other dis- 
eases, the same color of the liver, less intense than in recent cases, but yet 
well marked, and the microscope showed the coloring matter unchanged, 
except, perhaps, in quantity. The liver is often softened, and the gall-bladder 
distended with thick grumous bile, resembling molasses. The glands of Brun- TREATMENT OF REMITTENT FEVER. 
599 
ner are enlarged (Stewardson, Frick, Anderson, Stille). The glands of 
Peyer are often slightly prominent, and their mucous membrane injected and 
softened. The spleen is enlarged and softened, and the heart flabby.] 
Treatment.-With fever so various in its degrees of severity, it is not possi- 
ble to do more than indicate the nature of the treatment which may be fol- 
lowed, as every special case must be prescribed for and treated by its own 
special indications, and with a due regard to the nature of the prevailing 
epidemic. 
The extent to which bloodletting may be carried, as recommended by Drs. 
Irving and Cartan and Mr. Goodison, will depend on the constitution of the 
patient, the type of the fever, the season, the climate, its immediate effect, and 
whether the prevailing epidemic is of such a kind as to he benefited by blood- 
letting. From the testimony of Dr. Hennen as to Corfu, Mr. Muir as to 
Cephalonia, Mr. Goodison as to Zante, and Mr. Boyle as to Sierra Leone, 
those who have long resided in these places do not bear bloodletting so well 
as strangers from colder and more temperate regions. When bloodletting is 
beneficial, its effect is in general to abate remarkably the pain, throbbing, and 
constriction of the head, and the pain of the orbits, to relieve epigastric oppres- 
sion and tenderness, to render the pulse slower, less tense and oppressed, and 
to render the motion of the blood more free and less embarrassed. In some 
instances in which delirium is urgent, leeches applied to the occipital region 
are of the greatest benefit. 
Local depletion over the epigastric region is often of great service, and 
enables the stomach to retain fluids and medicine. Purgatives are indicated 
to unload the alimentary canal, and to relieve the congestion of the visceral 
bloodvessels. The form most useful is the compound powder of jalap, with 
calomel, given in a bolus, and followed by three or four ounces of infusion of 
senna. Sometimes ordinary doses of purgatives have little effect till the local 
depletion has been effected over the region of the stomach; and it is also a 
good plan to change the purgative from time to time. 
In every form and variety of the fever one of the most important guides in 
the treatment is to be derived from the nature of the prevailing disease, whether 
endemic or epidemic. Too much attention cannot be given to every means 
of knowing the type of the epidemic fever^ whether sthenic or asthenic, and to 
study each individual case in relation to the prevailing type. First, the 
duration of the stage of the fever must be ascertained,-i. e., whether it be of 
some hours' or of some days' duration, and whether, when the practitioner 
sees the patient for the first time, the actually existing paroxysm is at its 
accession or its decline. It is known by experience that the means of treat- 
ment which would be salutary during the first few days cannot be used later 
to the same effect and in the same amount. There is less tolerance of reme- 
dies, and their effects are less therapeutic. Again, it is also known that the 
means which would arrest fever and save life, if applied at the accession of 
the paroxysm, would induce a dangerous collapse, or even destroy life, if 
applied at the stage of its decline, or towards its termination. 
The various therapeutic agents which have been employed with various 
degrees of success in the treatment of remittent fevers are-emetics, the warm 
bath, tepid and cold affusions, cold drinks, bloodletting, purgatives, diaphoretics, 
mercury, quinine or bark, arsenic, wine, and opium. A review of the prominent 
modes of treatment of remittent fever, by the most eminent of British army 
surgeons, has led Sir Ranald Martin to make the following general remark, 
namely, that a disease so varying in its nature, so general and complicated in 
its influence on the system, is not to be justly treated by one remedy. Bark 
and calomel, each a remedy of great power, will nevertheless not succeed in 
the cure of fever if used exclusively; and so it is with the most powerful of 
all means, bloodletting. Each remedy must therefore have its proper place 
in the treatment. 600 
SPECIAL PATHOLOGY-REMITTENT FEVER. 
The first and most immediate object of treatment is to reduce the force and fre- 
quency of arterial action during the paroxysm. If the patient be seen in the 
forenoon of the first, second, or third paroxysm of an ordinary remittent fever, 
of sthenic type, and if he is of a sound constitution, and not beyond middle life, 
bloodletting from the arm, while the patient is in the recumbent posture, should 
be practiced to the extent of relieving the sufferer from prsecordial oppression, 
from visceral fulness and congestion, or from the intensity of the headache, 
whichever may predominate. The quantity of blood to be taken is to be 
regulated by the effects produced, and not by any arbitrary measure in ounces. 
Evidence of the relief from visceral congestion is obtained from the following 
indications: namely, reduced force and frequency of the pulse, reduction of 
morbid temperature, and gentle relaxation of the skin. This relaxation of 
the skin ought not to proceed to sweating, with further symptoms of depres- 
sion of the vital powers. If it should do so from untoward circumstances, from 
half a grain to a grain of opium, or from fifteen to twenty drops of laudanum, 
with as many of chloric ether, should be administered, the object of the ad- 
ministration of either of these medicines being to influence and soothe the 
heart's action, and to allay gastric or intestinal irritation; and it is only in 
cases of depression that opium is to be administered thus early in the treat- 
ment of the fever. 
One general bloodletting will generally be found sufficient to relieve the 
patient from abdominal or cerebral oppression; and it will further have the 
effect of simplifying and rendering more efficient all the subsequent means of 
cure.* Within an hour after the bleeding, a dose of calomel, with compound 
extract of colocynth and James's powder, should be given, followed in two hours 
by a powerful cathartic, such as infusion of senna, with sulphate of magnesia; 
[or from ten to twenty grains of a pilular mass of resin of jalap, rhubarb, eight 
parts each, and calomel and quinine, four parts each.] After the free action 
of these remedies, some degree of remission will be obtained in the afternoon, 
and the patient should be directed to take at bedtime from three to five or six 
grains of calomel, with four of James's powder, if the skin be dry; and during 
the past eight or ten hours he may have the free use of cooling drinks. On 
the early morning visit of the following day the remission will probably be 
more complete, when the sulphate of quinia alone, or in combination with the 
purging mixture, should be freely and repeatedly administered. Sir Ranald 
Martin recommends that it be given with the purgative mixture. By the 
forenoon the paroxysm may again recur in a milder degree, though to such 
an extent as to demand the application of leeches to the epigastric region, if 
any oppression or uneasiness exist there, or behind the ears if headache per- 
sists. A mixture composed of antimonial wine, with the acetate or nitrate of 
potash, should be given every two hours, so as to soften the skin and deter- 
mine increased action of the kidneys. By these measures the daily decline of 
the disease is seen, and consequently there is a daily diminishing occasion for 
the use of active measures of cure, till, towards the fifth, sixth, or ninth day, 
convalescence is established. 
If, however, remittent fever has existed unrestrained for several days, and 
the patient has not been seen till the accession of the third or fourth paroxysm, 
or even later, a general bloodletting is still the principal means of saving life, 
provided the general powers of the constitution remain uninjured; and it is to be 
followed by calomel, purgatives, and quinine, in the manner already indicated. 
If the paroxysms have become indistinct, running into each other, with brief 
or ill-defined intervals, while abdominal or cerebral complications arise, as in- 
dicated by epigastric fulness, or by approaching stupor or delirium, blood- 
letting may even now constitute the principal means to save life; but the blood 
must be still more gradually abstracted than before, whether generally or locally. 
* [In this country, general bloodletting is unnecessary, and often harmful.-Editor.] TREATMENT OF REMITTENT FEVER. 
601 
Generally speaking, it is to be done by leeches, at the accession of the paroxysm. 
Antimonials are also to be used; cold must be applied to the shaved head; and 
while sinapisms and blisters must also be applied, on the influence of calomel 
chief reliance is to be placed, and the very first dawn of remission is to be 
seized upon to give quinine. We are not, in such cases, to wait for a clean 
tongue, the absence of heat of skin, or local complication. It must be given 
every three or four hours, with an occasional mild aperient in the intervals, 
until the dangerous symptoms shall have yielded-a result often observed to 
be coincident with the manifestations of the mercurial influence. Dangerous 
symptoms, such as those just noticed, will sometimes rise suddenly, without 
any loss of time on the pare of the medical attendant, or neglect in treatment. 
If such symptoms are associated with yellowness of the skin, in persons broken 
in health, or of feeble constitution, or of dissipated habits of life, or who may 
have undergone much mental distress, the chances of a fatal termination are 
imminent. 
When the spleen is enlarged, mercury is not to be used in the treatment of 
the fever; and bloodletting, either general or local, is not borne well. The 
blood is changed in such cases; it is more or less dissolved, and a general 
cachexia prevails. 
The period of convalescence demands no less careful attention on the part 
of the medical attendant, especially as to diet and a timely removal from all 
malarious influences, by a voyage to sea or a change of climate. It is to the 
mismanagement of convalescence, and a too early discharge from hospital 
principally, that we must refer the numerous and fatal relapses in the fevers 
and dysenteries of our seamen and soldiers (Martin). 
Regarding the method of treatment just described, my friend and colleague, 
Professor Maclean, writes in the following terms: 
"I have been led to take a view of the treatment of malarial fevers generally, 
and remittent fever in particular, differing from that laid down by many 
authors. It appears to me that the so-called antiphlogistic treatment, so much 
insisted on by many writers, is based on the belief that the phenomena ob- 
served in a case of remittent fever are consequent on a process of inflammation. 
It is only on such a belief that antiphlogistic treatment can be justified. 
" During the exacerbation of a remittent fever there is violent disturbance 
both of the vascular and nervous systems. Almost every organ, almost every 
function suffers,-the gastric intestinal membrane is affected, the liver and 
spleen suffer, the brain is involved, for rending headache and delirium are 
often present. Is it rational to suppose that an inflammatory process can be 
going on at one and the same time in all these various organs? Do the ap- 
pearances observed in post mortem give any support to such a doctrine? If 
not, on what principle can spoliative treatment be justified? Is it not rather 
the case that this terrible disturbance of so many organs is due to the presence 
in the blood of a subtle poison acting on them all? If so, surely the guiding 
principle of the physician in his treatment should be to counteract this poison, 
to neutralize it, or to expel it from the system, and so to prevent a recurrence 
of the exacerbation. This is the principle on which I have long acted, and I 
am satisfied that it is at once a safe and successful one. In quinine we have 
such an antidote-a therapeutic agent of unrivalled efficacy, which, if skil- 
fully used, will rarely disappoint the expectations of the practitioner. 
" It is always, of course, advisable to have the bowels thoroughly evacua- 
ted ; and if the patient is seen when his stomach is loaded, it is well to evacuate 
its contents by an emetic. In ardent remittents, however, there is generally 
little call for this, as obstinate vomiting is almost always a troublesome symp- 
tom. This done, the period of remission must be watched for, and, the mo- 
ment it arrives, quinine in a full dose should be given-not less than fifteen 
grains in the case of an adult. If the irritability of stomach be so urgent that 602 
SPECIAL PATHOLOGY-REMITTENT FEVER. 
the remedy is rejected, while measures must be adopted to allay it-such, for 
example, as alkaline remedies iu combination with hydrocyanic acid, turpen- 
tine stupes, or even a blister to the epigastrium-time-precious time-should 
not be lost. Quinine should be given by the rectum in a full and efficient dose. 
By mouth or by rectum, or by both, quinine, in quantity sufficient to induce 
some of the symptoms of saturation (cinchonism), should be given before the 
time of expected exacerbation. According to my judgment and experience, 
it is bad practice to withhold quinine until an impression has been made on 
the force and frequency of the heart's action, from fear of increasing headache, 
causing congestion of organs, or the like. An impression on the force and fre- 
quency of the heart's action is best attained by arresting the paroxysm ; and 
this is done most quickly, simply, and effectively by the early administration 
of quinine. I have over and over again had patients brought to me from the 
malarial quarters of the city of Hyderabad, in whom it was impossible to dis- 
tinguish any period of remission-the tongue black and dry, sordes on the 
teeth, the skin hot and parched, the pulse enormously quick, the intelligence 
feeble or gone-all pointing to a system so charged with malarial poison, as to 
be well-nigh overwhelmed. In such cases quinine, with concentrated beef tea 
and brandy, are urgently called for, and should be administered freely; and 
it is astonishing how men, by such measures, are often snatched from impend- 
ing death. I have seen in a few hours consciousness return, a striking reduc- 
tion in temperature, in the frequency of the pulse, with a remarkable acces- 
sion of force and volume, follow the treatment indicated above. I do not 
advise, and never used quinine in the heroic doses advised by some. I have 
never exceeded twenty grains; but within such reasonable limits I have never 
seen it aggravate headache. On the contrary, I believe that in remittent 
fever-in fact, in all forms of malarial fever with which I am acquainted-I 
believe quinine to be a powerful remedy in quieting the tumultuous action of 
the circulation disturbed by the presence of this terrestrial poison. For some 
years past Warburgh's tincture has been much used in the treatment of mala- 
rial fevers in Southern India. It is a secret remedy, and therefore open to the 
objections very properly urged against all such remedies. It is understood 
that quinine enters largely into this remedy, and I do not doubt it. Be this 
as it may, I have given this ' tincture ' a fair trial in some of the gravest forms 
of malarial fever, and it has also been extensively used by some of the most 
experienced officers of the Madras army; and I do not hesitate to say that I 
think it a valuable remedy. I have known it arrest at once some of the 
severest cases of remittent fever, no exacerbation appearing after the second 
dose. It almost invariably acts as a powerful diaphoretic-the most power- 
ful with which I am acquainted. I have seen patients, under the influence of 
this remedy, saturate not only the bed-clothes but the very mattress, the pa- 
tient's room, and his person for days after giving out a strong odor of the medi- 
cine. For this reason it requires to be used with extreme caution, if at all, 
in the adynamic form of the disease. In urgent cases I follow the practice of 
the American physicians. I do not wait for a remission, but give quinine at 
once; and in all I am conservative of the patient's strength. I have seen 
violent delirium follow free leeching of the temples, and over and over again 
seen extreme and dangerous prostration follow depletive treatment, and that 
in cases where the violence of the disturbance indicated power; but these 
signs of power in the system are often most delusive, and, if combated by 
depressing measures we must be prepared for sudden signs of collapse. Against 
the system of treating this fever by saturating the system with mercury I enter 
my strenuous protest. I know nothing more deplorable than the condition 
of a patient whose constitution, already depressed by the presence of malaria, 
is further saturated by another poison which acts as a powerful ally of the 
first." MORBID ANATOMY OF MALARIAL TOXEMIA. 
603 
In the asthenic form of remittent fever, such as that so well described by 
Dr. Murchison as prevailing in Burmah, it is necessary to exercise great cau- 
tion in depletion. All the cases he relates which had been freely bled exhib- 
ited the most aggravated typhoid symptoms, and most of them died. Even in 
the instance of young and robust recruits, low adynamic typhoid symptoms 
were sure to supervene in a short time after bloodletting; and, even although 
it gave temporary relief, it was certain to aggravate, if not to induce, the sub- 
sequent typhoid condition. If the headache is very severe, and the pulse full, 
a few leeches may be applied to the temples at the commencement of the 
attack; but if the hair be cut short, or shaved off the scalp, cold lotions 
applied to the head, or the cold douche kept up for ten minutes at a time, 
gives great relief, and is the preferable remedy (Murchison). As soon as pos- 
sible after the commencement of the paroxysm the bowels should be cleaned 
out with a purgative of calomel and compound jalap powder; or by colo- 
cynth, antimonial powder, and calomel. If typhoid symptoms betray them- 
selves, stimulants, such as wine and brandy, must be given; but, as in inter- 
mittent fever, " quinine is undoubtedly the sheet-anchor," and it is best given, 
as in the former fever, in one large dose of twenty grains at the very com- 
mencement of a remission. Carbo-azotic or picric acid has been lately intro- 
duced as an active remedy in the treatment of malarious fever. Prepared by 
Calvert, of Manchester, it is of a light yellow color; and in doses of two 
grains, cautiously repeated, it is to be pushed till the patient gets yellow- 
skinned. 
[CHRONIC MALARIAL T0X2EMIA. 
(Dr. Clymer.) 
Chronic Malarial Toxaemia was very common amongst the United States 
troops in the late war, who were exposed to the influence of paludal poison. 
The manifestations of the poison upon the system are slow but characteristic. 
As observed in the army they have been thus described : The man is evi- 
dently out of health, and unfit for duty. He is said to be laboring under 
"general debility." There is a gradual loss of power, and fatigue comes on 
from slight exertion, with breathlessness and palpitation ; the senses are dull 
and perverted ; there are moroseness, despondency, and irritability; head- 
ache,.and neuralgic pains in the course of the fifth pair of nerves ; lameness 
of the muscles of the back and legs is often complained of after little exer- 
tion ; occasionally, there is more or less diminution of sensibility or motion 
of the lower extremities, which become enlarged, and the integument is shin- 
ing, smooth, and pits upon pressure; the appetite is capricious and lessened, 
and there is constipation, alternating with diarrhoea ; the urine, at first copi- 
ous, soon diminishes, with an increase of the urates and phosphates, and fre- 
quently of the oxalate of lime, and is loaded with epithelium ; the bladder is 
irritable, with frequent micturition ; the skin is harsh, dry, of a greenish-yel- 
low hue and bronzed in portions; and the hair has a dead look and feel. 
Persons in this condition are very liable to acute disorders, particularly pneu- 
monia, and which constantly are fatal. 
Morbid Anatomy of Malarial Toxaemia.-The integument is bronzed, 
especially, in the regions of the face, neck, sub-axilla, arm, forearm, and outer 
side of thigh. This change consists in a pigmentary deposit resembling that 
of Addison's disease, and is to be distinguished from icterus, or the icteroid 
hue, which is probably from altered hsematin. Leanness does not amount 
to emaciation ; the fat has largely disappeared, but the muscles retain their 
fulness. The muscular tissue is generally of reddish-brown color, tears more 
easily than in its healthy state, but its specific gravity is not lowered. The 
blood is fluid, but fibrinous coagula full of white corpuscles are found in the 604 
SPECIAL PATHOLOGY CHRONIC MALARIAL TOXEMIA. 
cavities of the heart and in the great vessels. The chief and most character- 
istic changes are, however, to be found in the liver, spleen, kidneys, the 
lymphatic glands, and the intestinal glandular apparatus. The liver is large, 
of a pale reddish-slate or fawn-color, and its relative and absolute gravity are 
increased. It is firm to the touch and divides firmly; the faces of the divided 
parts are smooth and the edges sharp; the acini are small and indistinct, and 
the interlobular substance is increased in thickness and development. This 
increase of the interlobular substance is either by development of its own sub- 
stance, or, as is more probable, by the addition of new material, albuminous 
in character. This encroaches upon the vessels, or deposits take place in the 
walls of the vessels, lessening their calibre and diminishing the supply of 
blood to the lobules; hence the hepatic cells become pale and shrink, and 
fatty transformation finally occurs. This fatty metamorphosis I observed 
but in a single instance; the liver was small and very flaccid. The secretion 
of bile does not cease; the gall-bladder is well distended, but the character 
of the bile is changed; it is usually dark brown and tarry in consistence. 
Corresponding changes occur in the kidneys. They are enlarged, their rela- 
tive and absolute gravity being increased. They divide firmly. The cortical 
substance is whitish or fawn, and the cones of Malpighi are congested, pur- 
plish, and the papillae red. The tubules are seen to be crowded with epithe- 
lial cells, and their walls are thickened. From the papillae may be expressed 
a milky urine, which is loaded with the debris of cells. The change appears 
to consist primarily in the interstitial deposit of molecular albumen (albu- 
minoid degeneration). Changes, not very definite nor uniform, occur in the 
suprarenal capsules ; the most constant alteration seemed to consist in the 
relative increase of the cortical substance ; but frequently they were not at 
all changed. The spleen is also somewhat enlarged; its trabeculse more dis- 
tinct and tougher ; the splenic pulp brick-red, firm and fleshy; the Mal- 
pighian bodies, much enlarged, are plainly seen in great numbers throughout 
the pulp. Very characteristic alterations are found in the intestinal canal. 
They vary in degree with the stage at which they are examined, but they are 
always capable of being demonstrated. At the earliest period the intestines 
are pale and transparent; the solitary glands are slightly enlarged, elevated 
and filled with a granular matter, albuminous and fatty; the follicles of 
Lieberkuhn come into view by reason of a deposit of pigment in their epithe- 
lium, and are thickly strewn at the sites of the oval patches of Peyer ; the 
villi are pale, their cells shrunken, and the basement-membrane transparent 
(waxy). In the large intestines,41 pigment deposit, greenish in color, takes 
place about the orifices of the tubular glands ; the flask-shaped solitary glands 
enlarge, and their contents accumulate. Pari passu with these changes, the 
veins of the submucous coat become more prominent. The changes in the 
lymphatic system are found in greatest perfection in the mesentery. Its color 
is yellowish or fawn, and the glands are enlarged and prominent. Exteriorly 
the individual glands are red or purplish ; interiorly they contain a central 
whitish, fawn-colored, or yellowish spot of variable size, sometimes solid and 
resisting, but frequently granular and cheesy. The alterations in the nervous 
centres are not easily followed. The brain is generally firm, pale, and resists 
decomposition remarkably. (Bartholow, U. S. Sanitary Com. Med. Me- 
moirs, 1867.) 
The morphological changes of the blood in malarial fever have been studied 
by Frerichs, and, lately, more thoroughly by Dr. J. Forsyth Meigs, of Phila- 
delphia (Pennsylvania Hospital Reports, vol. i, 1868), to whose interesting 
paper the reader is referred. Pigment matter has been largely found in the 
blood, brain, spinal cord, spleen, liver, kidneys, &c. "This adventitious mat- 
ter occurs in the form of granules, mere molecular dots, very numerous, iso- 
lated, loosely aggregated, or connected together in groups (flakes and scales) 
by a pale substance soluble in acetic acid and in caustic alkalies." The MORBID ANATOMY OF MALARIAL T0X2EMIA. 
605 
capillaries of the nerve-centres usually contain it in this form (the larger 
particles not readily passing so far), and the granules often appear as though 
imbedded in the vascular walls. Then again we find these granules con- 
tained in cells, not otherwise distinguishable from white blood, or splenic 
corpuscles in their ordinary condition.* Sometimes these cells have an ob- 
long, or even spindle-shaped outline.^ They occur most abundantly in the 
spleen and portal vein, but appear also, in aggravated cases, throughout the 
organism. In the liver the molecules are seen adherent to or contained 
within the hepatic cells; i. e, within their " formed material." Still other, 
and not less frequent, forms, are those of the grain and larger mass ; which 
are distributed in an analogous manner, and are found even in the brain in 
an extravascular position. Some of these, upon pressure, look like " frag- 
ments broken off from yet larger masses." Their size varies indefinitely from 
a mere dot up to grains many times as large as red blood-globules. Frerichs 
states that some of the masses are of a line in breadth and of a line 
in length ; and these he regards as probable casts of the smaller vessels. My 
own measurements correspond closely with these. I have not recorded any 
isolated grains of more than t^-qo °f an inch breadth, but have frequently 
observed aggregations of granules and "larger masses" which measured gy0 
to of an inch; yf° itots °f an bich was an approximate average size 
of the separate grains. Now when we bear in mind that the common width 
of red blood-corpuscles is in man about of a line, and of the white cor- 
puscles °f a line, we see that many pigment grains would be necessarily 
arrested where these could pass. And in different structures of the body the 
capillaries range only from to of a line in diameter.); In shape these 
pigment-grains are very irregular, rounded, or sharp, with an angular, brittle- 
looking outline. Indeed the sharpness of their angles, which, however, are 
in no degree definite or uniform, "has suggested the term crystalloid as appli- 
cable to them (Lebert), or rather to the pigment-material common in the 
lungs."§ Arnd I may here allude to their close resemblance to the black 
matter so frequently seen in old coagula ; in patches of chronic inflammation 
and ulcers of the intestines ; and in the fluids vomited in cases of gastric 
cancer with a bleeding surface. Some writers go so far as to claim an iden- 
tity, || but this is certainly premature. We cannot safely assert more than 
their common origin in some blood metamorphosis. In color the pigment 
varies almost as much as in size and shape. Usually it is deep black, quite 
opaque, and with abrupt, non-translucent margins. Then, again, we find a 
brown rim through which some light passes. Frequently the color is reddish- 
brown, or even reddish-yellow, as seen by transmitted light, and the granular 
scales are seldom opaque. In the splenic pulp I satisfied myself of the exist- 
ence of red blood-globules in different stages, not only of disintegration, but 
also of advancing metamorphosis toward black pigment, and am therefore 
prepared to agree with Frerichs, " that these different colors represent the 
various stages in the transformation of the red pigment of the blood into 
melanotic matter." I have occasionally seen tinged gelatinous particles, as 
though there was a union between the coloring matter and some protein ele- 
ment. But of their intimate chemical nature we are ignorant. All agree, 
however, that while the pure black forms resist the action of even the strong- 
est acids and alkalies, the paler products lose their color with greater or less 
rapidity under the influence of these reagents. (Meigs, 1. c., p. 106.) 
* Pre-existent nucleated cells (of various forms) take up hsematin, which as the 
contents of the cells becomes molecular pigment. Rokitansky, op. cit., vol. i, p. 210. 
t Cell. Pathology. Virchow, p. 257. Frerichs, op. cit., vol. i, p. 320. 
t Human Anatomy, Leidy, Philadelphia, 1861, pp. 337, 339. 
g Clark, op. cit, p 611. 
|| It is the pseudo-melanose or elements hematiques of Lebert; when crystalline, the 
hoematoidin of Virchow.-Clark. 606 
SPECIAL PATHOLOGY-CHRONIC MALARIAL TOXEMIA. 
That the pigment-granules and masses are not foreign bodies, but have their 
origin in some abnormal action within the organism, and are the product of 
certain changes of the blood-elements, is probably certain. Whether strictly 
pathognomonic or not of malarial toxaemia, there is abundant evidence to 
show their constant connection with that condition, whether acute or chronic. 
In 90 cases of malarial fever, examined by Dr. Meigs, in 1865, in one only 
did he fail to discover, in the blood taken from the body during life, pigment- 
granules. Dr. Meigs gives the following conclusions : 
1. That in examining blood during life with a view to determine the pres- 
ence or absence of pigment-matter, great care is necessary to exclude all for- 
eign particles from the epiderm or elsewhere. 2. That pigment may exist 
abundantly in the visceral capillaries, and in the contents of the portal vein 
and other large vessels, when blood obtained from the derm and subcutaneous 
tissue does not exhibit it. 3. That only in cases of excessive pigment-devel- 
opment will granules and pigment-cells be visible in such blood. 4. That in 
the acute stages of malarial fever, the red blood-corpuscles are darker than 
natural, appear soft, are sometimes crenated, readily yield their coloring ma- 
terial when mingled with water, and are disposed to mass irregularly rather 
than to form distinct rouleaux. 5. That as the disease progresses they are 
rapidly and very greatly diminished in number, become pale, lose their ten- 
dency to aggregation, and either remain isolated or arrange themselves in im- 
perfect columns. 6. That in the early stage of the disease, the number of 
white corpuscles is not perceptibly increased, and that later their increase, 
though very irregular, is always observable; from six to thirty-five appearing 
in the same microscopic field which presents in normal blood only two or 
three. 7. That excessive ansemia, with a large increase in the number of white 
corpuscles, may exist in malarial cases without marked enlargement of the 
spleen. 8. That no other morphological alterations are to be detected except, 
as also in some cases of severe anaemia from other causes, certain colorless, 
highly refracting granules, free or in membranous-looking fragments, appear- 
ing like white corpuscles broken up, and giving to portions of the field a filmy, 
clouded aspect. Thus we see that our diagnosis, except in the most aggra- 
vated cases, cannot safely rest upon an examination of blood from the periph- 
eral vessels (1. c., p. 109). 
Treatment.-Chronic malarial toxsemia is best treated by a combination of 
the tincture of the chloride of iron, quinine, and arsenic; mild saline cathar- 
tics ; a nourishing mixed diet, including milk, meat, vegetables, and fruit, 
with the digestive capacity of the stomach ; exercise short of fatigue; and 
change of climate. Great attention should be paid to the skin ; tepid baths, 
or daily sponging of the surface followed by gentle and long-continued hand- 
rubbing over the whole body, will be found of great use. In many cases the 
Turkish bath, or wet packing, may be recommended. If there is derange- 
ment of the chylopoietic viscera muriate of ammonia alone, or combined with 
colchicum, leptandrin, hydrastin, podophyllin, or taraxacum, is to be given 
for some time. No preparation of mercury must be given. When there is 
much depression of the nervous system, phosphoric acid, or the hypophos- 
phites, along with arsenic, should be administered. 
In the treatment of malarial toxsemia it is of the first importance to keep 
the sluices of the system-the kidneys and intestinal canal-open, unless there 
are contraindications, and this is best done by the frequent use of mild saline 
cathartics. A course of Kissingen, Piillna, or Friederichshall, bitter waters, 
natural or artificial, serve an excellent purpose. There is great alteration of 
the blood by the morbid poison-excess of some of its constituents, and di- 
minished quantity of others; it is imperfect, degenerate, and devitalized; its 
formative power is weakened, and, as a consequence, the ability of the build- 
ing and excreting viscera, as'well as the functional force of the nerve centres, 
are lessened. The nutritive fluid must, in a measure, be remade, and elimi- HISTORY AND SYMPTOMS OF TYPHO-MALARIAL FEVER. 
607 
nation through the renal and intestinal organs aid in this by increasing the 
power and quickening the action of the renewing remedies.* 
Chronic enlargement of the spleen frequently subsides as the toxic symp- 
toms abate, and with the general improvement in health. The special treat- 
ment is by bromide of sodium or potassium, and iodine-paint locally. Pro- 
fessor Maclean, of the Netley Hospital, speaks highly of the officinal ointment 
of the biniodide of mercury, a piece the size of a nutmeg to be rubbed in over 
the region of the spleen with a spatula. The patient then sits before a fire 
until there is a good deal of smarting. About half the quantity is again ap- 
plied over the tender surface. Some blistering follows, which is to be dressed 
simply. The process is repeated in a fortnight or three weeks, according to 
circumstances. Two or three applications suffice. In no case, he states, has 
this treatment failed, and its effect has often been very striking, reducing rap- 
idly the enlarged organ, and that in very unpromising cases {Statistical, Sani- 
tary, and Medical lieports {British) Army Medical Department, vol. v, 1865).] 
[TYPHO-MALARIAL FEVER-CHICK AHOMINY FEVER, AMERICAN CAMP FEVER. 
Definition.-An idiopathic fever of mixed type, caused by a combination of 
paludal and pythogenetic influences, with marked remissions and exacerbations 
at the beginning, and, after a variable period, becoming continuous; attended 
with early prostration, diarrhoea, and subsequently extreme adynamia: the char- 
acteristic lesion is enlargement and ulceration of the solitary intestinal glands. 
History.-This form of fever attracted attention first in 1862, as the Chicka- 
hominy fever, from its prevalence in the Army of the Potomac at that time, 
but has since been common whenever our armies operated in malarious regions, 
amongst men saturated with paludal poison, exhausted by over-exertion and 
insufficient rest, imperfectly nourished, exposed to the action of animal effluvia 
from the decaying bodies of both men and brutes, and drinking water impreg- 
nated with the products of common putrefaction. These coincident causes, 
tending to lower the vital forces and corrupt the blood, produce a compound 
disorder, in which the combined action of paludal, pythogenetic, and scorbutic 
influences are evident, and which varies in type, as one or other of the deter- 
mining conditions is predominant. The name typho-malarial was proposed 
and first used by Dr. J. J. Woodward, U.S.A. {Outlines of the Chief Camp 
Diseases of the United States Armies, 1863). 
Symptoms.-The attack is generally sudden, beginning with a chill; there 
are headache, anorexia, thirst, diarrhoea, and sometimes epistaxis. The tongue 
soon becomes coated with a thick, dry, brown fur. For some days there are 
distinct remissions and exacerbations; in the early part of the second week 
they become less marked, though they may persist throughout the attack. 
Regular remissions very commonly again take place on the approach of con- 
valescence. Diarrhoea is apt to be troublesome and persistent, as the continued 
type is developed; the mouth is coated with sordes; an herpetic eruption may 
(Dr. Clymer.) 
* The following will be found good reconstructive remedies: 
R. Leptandrin ; Ext. Aloes, aa gr. xxx ; Ext. Colchici Rad., aa gr. xv ; Ext. Nucis 
Vom. Alcohol., gr. viij ; Resinae Podophylli, gr. iv; Ext. Ipecac fl., n^v; Ext. Hy- 
oscyam , gr. xxx. M. Divide in pil. xxx. Sig. One to be taken every night, or every 
other night. 
R. Pulv. Ferri Sulphat., ; Acidi Nitrici (C. P.), f^j; Quinine Sulph , ^ij ; Potass. 
Citrat., giij ; Aquae Cinnam., ad f^viij. 
Rub the iron and acid well together in a mortar; add first the quinine gradually, 
until dissolved, and then the potash, first dissolved in water. Mix well, filter, and 
keep in a dark-colored bottle. 
Dose. One or two teaspoonfuls three times daily (Gadberry).-Editor. 608 
SPECIAL PATHOLOGY MALARIOUS YELLOW FEVER. 
appear about the lips and nose; wakefulness is constant, with low muttering 
delirium; tympany, rare in the first week or ten days, occurs; and purpuric 
blotches, or petechial spots, with hemorrhage from the bowels, gums, mouth, 
and nostrils ; and all the phenomena of a low form of fever now set in. Matter 
resembling coffee-grounds is sometimes vomited towards the last. If the dis- 
ease is to terminate favorably, regular remissions again happen, generally in 
the forenoon, with evening exacerbations. Congestive pneumonia, bronchitis, 
and parotitis are the intercurrent affections, particularly bronchitis. An at- 
tack lasts from three to five weeks; and convalescence is very lengthened. 
Anatomical Characters.-The characteristic lesion is enlargement of the 
solitary follicles of the small intestines. There may be universal congestion 
of the mucous membrane of the small intestines, more marked in their lower 
part, or there may be only congestive patches of variable size in the ileum, 
the solitary follicles being enlarged from the size of a pin's head to that of a 
pea, and black with pigment deposit; they sometimes look like yellow mustard- 
seed sprinkled on a red ground ; their apexes are sometimes ulcerated. The 
mucous membrane of the colon may be of a slate color, with patches of con- 
gestion and spots of ecchymosis, or it may be streaked of ash and dark red. 
Small ulcers are occasionally found in the follicles of the colon, csecum, and 
appendix vermiformis. The patches of Peyer are generally unaltered, though 
they may be congested, of a dark-red hue and slightly prominent, and the 
individual follicles forming the agminate patch may be the seat of a pigment 
deposit giving the " shaven-beard " look, or bluish-black tattooing, the adjacent 
membrane being uncongested. The spleen is usually enlarged, and most fre- 
quently softened, though its texture may be firm. The lower lobes of the 
lungs and bronchial mucous membrane are congested (Woodward). 
Treatment.-Quinia should be given by the mouth, in enema, or hypoder- 
mically, according to circumstances. It will not, no matter how promptly 
given and in what dose, cut the disease short, in a very large majority of 
cases, if it ever does; but in moderate, and fractional, doses-10 to 15 grains 
in the course of the day-it decidedly modifies and controls the disorder by 
its antidotal property. When, later in the attack, marked remissions reap- 
pear, it may be administered in larger doses with advantage. The treatment 
generally should be that already directed for typhoid fever.] 
MALARIOUS YELLOW FEVER-Syn., FEBRIS ICTERODES REMITTENS. 
Definition.-Febrile phenomena due to malaria, in which the exacerbation and 
remission are so connected that the fever resembles a continued fever, and is char- 
acterized by great intensity of headache and yellowness of the skin (Copland, 
Dickenson, Boott) ; but in which the urine is not suppressed, and continues 
free from blood or albumen. 
Pathology.-It immediately results from the history of yellow fever, that 
in its malarious form it is the product of the coasts of the West India Islands, 
the American equinoctial continents, several districts in Spain, and the West 
Coast of Africa. All over the Caribbean Sea the disease takes place sporad- 
ically, or in insulated cases every season, more or less numerous according to 
the subjects and the number of new visitors, and there never is a season in 
which a few cases do not occur. At Vera Cruz, Havana, and other towns on 
the Spanish Main, malarious yellow fever invariably attacks Europeans or 
Canadians who may land there between the months of May or June and Oc- 
tober or November; but so long as such cases continue few, isolated, and spo- 
radic, they attract no attention, and the disease is not heard of in ordinary 
years. It seems to prevail, for the most part, in towns situated on the sea or 
river coasts of alluvial countries in warm climates; and that, while the banks 
of these rivers or seas are liable to occasional alternate periods of inundation PATHOLOGY OF MALARIOUS YELLOW FEVER. 
609 
and drying up, the fluctuations of the tides, co-operating with these, contribute 
powerfully, under intense solar heat and a windless atmosphere, to render the 
towns along the shores of such districts the seat of malarious yellow fever. 
"While ague is the offspring of the marsh or its margins, and remittent is the 
effect of a more concentrated form of the same exhalation from some moist 
surface in the process of solar desiccation, the malarious form of yellow fever 
appears to be the product of that state of the atmosphere which takes place after 
a long continuance of solar heat, with little or no wind, in those points chiefly 
where the atmosphere of the sea and that of the land are in constant commu- 
nication and interchange. It is, indeed, a remarkable fact that the intense 
form of remittent fever which has been distinguished as malarious yellow 
fever, and sometimes as 'bilious remittent of malignant type,' is rather rare 
in the interior of countries, and is seldom found in towns, situated on rivers, 
higher than the influx of the tide. The fevers which appear in these situa- 
tions are more of the usual remittent character; and in the interior of the 
American continent there is little doubt that the lake fever represents the ma- 
larious yellow fever of the coasts. Even in Europe, while the towns on the 
seacoast and on riyers were laboring under the malarious yellow fever, the 
sickliness in the interior approached more to that of the remittent or remit- 
tent continuous type" (Craigie). For this reason the term littoral, as well as 
paludal, is used to designate this class of fevers. 
The endemic conditions under which the malaria gives rise to this form of 
yellow fever might be referred,-(1.) To thermometric temperature of the air; 
(2.) To the state of the atmosphere as to currents of winds and electricity; 
(3.) Local peculiarities of surface already referred to; (4.) Constitutional 
susceptibility, and crowding together of masses of people. 
That intense solar heat contributes greatly to the development of the yellow 
form of malarious fever is shown by the situations of those parts where it is 
peculiarly endemic, in relation to the prevailing temperature. Thus, it is 
found to prevail chiefly in places situated in the eastern regions, between 10° 
of south latitude and 42° of north latitude. On the continent of Europe it 
has generally prevailed in places situated between 36° and 38° north lati- 
tude, and has never gone farther north than Barcelona on land, or in latitude 
48° north on the sea. That it has gone farther north, it has been alleged, 
but the authenticity of the statement is doubted. In these northern latitudes 
it is also observed that the malaria of yellow fever cannot pass over a thousand 
yards of water without being deprived of its power. 
The following observation was made by Sir John Pringle on the fevers of 
Walcheren and South Beveland in 1747: 
" These epidemic fevers, by reason of the great heats of the season, not only 
began more early than usual, but were fully as fatal to the natives as to us. 
But Commodore Mitchell's squadron, which lay all this time at anchor in the 
channel between South Beveland and Walcheren, in both of which places the 
distempers raged, was neither afflicted with fever or flux, but amid all that 
sickness enjoyed perfect health-a proof," he says, "that the moist and putrid 
air of the marshes was dissipated or corrected before it could reach them" 
(Diseases of the Army, p. 58). 
The very same observation was made at the very same spot, fifty-two years 
afterward, by Sir Gilbert Blane: 
"I had, in the course of this service (at Walcheren, in 1809), an oppor- 
tunity of observing the extent to which the noxious exhalations extended, 
which was found to be less than I believe is generally known. Not only the 
crews of the ships in the road of Flushing were entirely free from this endemic, 
but also the guard-ships stationed in the narrow channel between this island 
and South Beveland. The width of this channel is about six thousand feet; 610 
SPECIAL PATHOLOGY-MALARIOUS YELLOW FEVER. 
and although some of the ships lay much nearer to the one shore than the 
other, there was no instance of any of their officers or crew being taken ill 
with the same disorder as that with which the troops on shore were affected" 
(^Med.-Chir. Trans., vol. iii, p. 27). 
It is now also generally believed that the malarious form of yellow fever 
cannot exist except in places where the average range of temperature is high 
throughout a considerable part of the year; and for this reason it is believed 
that it will not become a disease of this country. Sir Gilbert Blane asserted 
that it never appeared either in tropical climates or in the temperate latitudes, 
unless when the atmospheric heat has been for some time steadily at or above 
80° Fahr., 21° of Reaumur, or 26.67° Cent.; according to Humboldt, 75° of 
Fahr., or 24° Cent.; and according to Matthei, 72° Fahr., or more. The dis- 
ease is also found not to prevail in mountainous situations. According to 
Humboldt, it has never ascended to 3044 feet above the level of the sea, and 
according to Sir Ranald Martin, never above 2500 feet; and below the former 
limit the Mexican oaks do not flourish, showing that the constant average 
temperature below this is of a tropical character. In Jamaica, according to 
Dr. Craigie, it rarely ascends 1600 feet above the level of the sea (Dr. Law- 
son's instance of the outbreak at Newcastle being considered an instance of 
"specific yellow fever"). In Jamaica the medium temperature of Spanish 
Town in the hottest months is about 85° Fahr., or between 83° and 85°; and 
in Kingston it is much the same, ranging from 85° to 90°, and rarely falling 
below 80° from May to the end of September. At the more elevated parts, 
however, the temperature diminishes, being only about 70° at Stony Hill, 
elevated about 1300 feet; at Cold Spring, 4200 feet above the level of the sea, 
only 60°; and at the summit of the Blue Mountains, which are estimated to 
be 7200 feet above the level of the sea, the thermometer is found to range in 
August from 47° at sunrise to 58° (Hunter) at noon: or at an average of 
60° (Moseley). 
At Stony Hill, the first of these places, yellow fever has sometimes, though 
not very often, displayed its epidemic virulence in a very bad form. 
In the Island of Trinidad, however, the ridge behind Port of Spain, which 
is a limestone rock elevated 1500 feet above the level of the sea, has been 
highly productive of yellow fever, and has cost the lives of many men in 
attempting its clearing and fortification. 
The composition of the soil has been believed to exercise some considerable 
influence on the production of malarious yellow fever. On this subject, how- 
ever, the facts are discordant. Alluvial soils are those where malarious yellow 
fevers have mostly prevailed, as at Grenada, St. Domingo, New Orleans, 
Philadelphia, New York, Boston; or calcareous, as in Jamaica. It has also 
been observed that a beach, bank, quay, or wharf is the place where the dis- 
ease first makes its appearance, when such beach, bank, quay, or wharf is 
alternately immersed in sea-water and exposed to the drying effects of great 
solar heat. The drying effects of great solar heat have also been supposed to 
extricate some deleterious material from the green wood of new ships (Wil- 
son), and also from forests of mangroves (Ingram, Humboldt, Wilson). 
In all those localities where the disease is endemic it seems to manifest a 
decided preference for the natives of the colder regions. Thus the British, 
Germans, Swedes, Danes, are more liable to suffer than Italians, French, or 
Spaniards ; and in ordinary years the natives, and especially the colored popu- 
lation, are rarely attacked. 
The diagnosis between the specific contagious yellow fever and the malari- 
ous form of yellow fever is at all times difficult; and severe marsh fevers in 
certain geographical limits have a close resemblance to contagious yellow 
fever. But they are not contagious, and urinary and blood symptoms do not 
occur in them. It must also be remembered, in accounting for its origin in DEFINITION AND PATHOLOGY OF MALIGNANT CHOLERA. 
611 
any case, that marsh fevers have become developed weeks, and even months, 
after exposure to the exciting cause. 
With regard to the further history of the phenomena and treatment of this 
form of fever, the reader is referred again to what is said under remittent 
fever, and simply stating that when an observer has seen only the milder 
form of marsh remittent fever, and is then suddenly called upon to witness an 
attack of malarious yellow fever, he may well believe that the affections are 
entirely distinct. But after a time, when the intermediate forms have been 
more closely scrutinized, it is found that at no point can any valid line of de- 
marcation be drawn between the several forms of these malarious fevers, so 
numerous are the connecting links which bind them to each other (Alison, 
Parkes). 
MALIGNANT CHOLERA Syn., SEROUS CHOLERA ; SPASMODIC CHOLERA; 
ASIATIC CHOLERA. 
Latin Eq., Cholera Pestifera-Idem valent, Cholera serosa, Cholera spastica, Cholera 
Asiatica; French Eq , Cholera Asiatique; German Eq., Cholera Asiatische; 
Italian Eq., Colira Asiatico. 
Definition.-A disease essentially specific, existing at all seasons of the year 
among human beings inhabiting certain parts of India (perennial endemic area), 
and capable of being propagated or disseminated over the surface of the earth, 
and also through the atmosphere, or in other ways, and chiefly by means of human 
intercourse between the healthy and the sick. 
The seizure is characterized in many (but not in all) cases by premonitory 
diarrhoea, sudden muscular debility, tremors, vertigo, occasional nausea, and 
spasmodic griping pains in the bou'els, depression of the functions of respiration 
and circulation, and a sense of faintness and oppression in the proecordial region. 
A copious purging of serous fluid, alkaline when passed, and in appearance re- 
sembling water in which rice has been washed, and sometimes containing blood, 
is succeeded or accompanied by vomiting and burning heat at the stomach, cold- 
ness and dampness of the whole surface of the body, coldness and lividness of the 
lips and tongue, cold breath, a craving thirst, a feeble rapid pulse, difficult and 
oppressed respiration, with extreme restlessness (a state expressed in physiological 
language by the term " anxietas "), suppressed urinary secretion, blueness of the 
entire surface of the body, a sunken and appalling countenance, a peculiarly sup- 
pressed voice, a peculiar odor from the body, partial heats, of the prcecordia and 
forehead-fatal collapse, or reaction and secondary fever. Under conditions 
favorable to its development Malignant Cholera often becomes epidemic. 
Pathology.-During recent years volumes have been written on the nature 
and causes of cholera; and the description of it which I here give is chiefly 
drawn from the writings of men who have seen much of the disease, alike in 
India and in this country. 
The College of Physicians have simply defined cholera as "an epidemic dis- 
ease, characterized by vomiting and purging, with evacuations like rice-water, ac- 
companied by cramps, and resulting in suppression of urine and collapse." 
The remote cause of cholera is unquestionably a specific poison; and that 
it should spread over countries which, in respect to climate, soil, geological 
formation, and also as to the moral and physical habits of the papulation, are 
the most opposite to those where it first originated, is only explicable by the 
hypothesis of its propagation as a specific disease-poison. 
The subject is so extensive and yet so full of undecided points, that it may 
be well to begin by simply stating the theories by which the occurrence of 
Asiatic cholera, in this country especially, has been explained. They are as 
follows: 612 
SPECIAL PATHOLOGY-MALIGNANT CHOLERA. 
(1.) One doctrine has been very extensively and very generally accepted 
regarding the pathology of cholera-namely, that it is a miasmatic poison 
which has been absorbed, and infects the blood; that, after a longer or shorter 
time, it produces a primary disease of the blood; that it undergoes enormous 
multiplication in the living body of the cholera patient, as a result of the 
morbid process so established; and that changes are induced in the function 
of respiration directly consequent upon this alteration of the blood by the 
poison: 
" Whose effect 
Holds such an enmity with blood of man, 
That, swift as quicksilver, it courses through 
The natural gates and alleys of the body; 
And, with a sudden vigor, it doth posset 
And curd, like eager droppings into milk, 
The thin and wholesome blood."-Hamlet, Act I, Scene V, line 64. 
Sowrote our greatest English poet three hundred years ago; and by such 
characters it has been ably shown by Dr. Wm. Budcl, of Bristol, Sir Thomas 
Watson, and others, that cholera identifies itself with that group of contagious 
disease-poisons which give rise to acute general diseases. It is this multipli- 
cation, and the disturbance to the vital functions, which in each case consti- 
tutes the disease and destroys life. In small-pox the work of reproduction is 
seen in results directly appreciable to the eye. An impalpable speck of small- 
pox virus inserted into the skin may produce a disease which, in the course of 
a few days, issues in the development of a new stock of the same virus, suffi- 
cient in amount to inoculate myriads of other persons with small-pox; and 
although the fact may not yet be opened to evidence so precise, yet the cir- 
cumstantial evidence is conclusive which shows that, in any case of Asiatic 
cholera, its specific poison is multiplied in a ratio at least as great. 
The facts on which Dr. George Johnson tests his belief that a morbid poison 
in the blood is the essential cause of cholera, may be stated as follows: 
(a.) There is as much circumstantial evidence to show that the poispn may 
be inhaled as well as swallowed, and that being so inhaled, it must enter the 
blood before it can reach the alimentary canal. In this respect there is some 
analogy between the action of a poison producing malignant cholera and the 
action of poisons producing some forms of ordinary diarrhoea. It is a notori- 
ous fact, that when diarrhoea has been excited by the inhalation of fetid gases 
or emanations, which are inhaled, and perhaps also swallowed at the same 
time, the stools have the same peculiar fetor as the foul air which has excited 
the disease. I have frequently experienced this result from foul post-mortem 
examinations, and also when at daily work, foi' many years in the dissecting- 
room. 
(6.) "In many instances of malignant cholera, and perhaps in all, there are 
^symptoms of general constitutional disturbance prior to the occurrence of 
diarrhoea." These symptoms, Dr. Johnson believes, correspond with the 
initiatory fever of small-pox and other acute exanthemata-an initiatory 
fever as regards cholera, which the thermometer will one day be found to 
indicate. 
(c.) In most cases of cholera the urine is albuminous; so it is in diphtheria 
and in scarlet fever, as a rule-facts pointing to the existence of a blood- 
poison. 
(dA) The foetus in utero has been killed by cholera, the characteristic dis- 
icharges being found in the alimentary canal of the foetus. 
Thus Dr. Johnson's treatment of cholera rests on the belief that cholera 
depends upon a poison which enters the blood, and thereby produces the 
symptoms of the disease. 
'"The belief," writes Mr. Simon, in his Report on Public Health for 1866, 
" that the proximate cause of cholera is a ' poison first acting in the blood ' is PATHOLOGY OF MALIGNANT CHOLERA. 
613 
common to Dr. Parkes and Dr. Johnson, as well as to many other writers; 
and Dr. Johnson builds on that belief his advocacy of a particular principle 
of treating cholera-the principle, namely, of 'assisting nature,' by emetics 
and purgatives, in what he deems to be her'salutary and curative efforts' 
of vomiting and purging: but Dr. Parkes's doctrine of the state of the circula- 
tory system in collapse, and Dr. Johnson's doctrine of the dependence of that 
state on spasmodic closure of the minute pulmonary arteries, are doctrines, 
which do not necessarily involve an acceptance of the ' eliminative treatment' of 
cholera, nor presuppose any belief that cholera begins as a blood-disease. It is 
important that the different questions should not be jumbled together as one; 
particularly important now since the notion of a primary blood-poison in 
cholera seems to be a question still at issue. 
" First, as regards the state of the circulation in collapse. Personally know- 
ing Dr. Parkes's great accuracy of statement, I attach (says Mr. Simon) the 
utmost importance to the descriptions contained in his work. And their de- 
tails do certainly in great part justify the generalization which he makes of 
them.* But whether the morbid phenomena which he describes are rightly 
accounted for by the doctrine of arterial obstruction in the lungs (either such 
as he supposes, or such as Dr. Johnson supposes) is matter of much more 
doubt: for feebleness of heart-contraction appears to be an invariable fact in 
choleraic asphyxia; and so far as this affects (or at least predominantly affects) 
the right side of the heart, so far it tends to produce much such a disturb- 
ance of circulation as would result from the supposed arterial obstruction. 
Present opinion seems, I think, generally to be that, in the main, it is the 
dynamical affection of the heart (not the supposed obstruction of pulmo- 
nary arteries) which gives the true explanation of Dr. Parkes's facts; but 
this would not of necessity imply, either for the pulmonary or for the aortic 
circulation, that all the arterial resistances are normal. Whatever etiological 
view be taken of the connection of the symptoms of collapse, it cannot be 
deemed unlikely that a much diminished volume and impaired fluency of the 
blood, when they have arisen,- should excite certain phenomena of their own 
in the sphere of arterial contractility, as well as have their own physical con- 
sequences ; nor, again, that certain changes of arterial tone should go with 
certain changes of cardiac action. Be this as it may, some of the phenomena 
presented in the aortic system in collapse are such as arterial contractility 
would seem very plausibly to explain. Such are some of the inequalities of 
temperature and circulation in the diseased body, not only as between internal 
and external parts, but as between different parts (external or internal) in 
the aortic circulation. Specially, for instance, I cannot conceive from what 
* "Yet it deserves notice," says Mr. Simon, "that even among Dr. Parkes's own 
cases of death in collapse the post-mortem evidence of interrupted pulmonary circula- 
tion was not universal; and I may add, though without attaching equal importance to 
the fact, that a citation of miscellaneous authorities on the state of the heart and lungs 
in death by collapse (such a citation as was given in 1833 by Prof. Phoebus in chapters 
v and vi of his classical Leichenbefund bei der Orientalischen Cholera') would show still 
less uniformity of evidence in that respect. Also, in my opinion, the assertion made 
by Prof. Griesinger (in § 483 of the admirable essay on cholera which forms part of 
his Infections Krankheiten in the Handbuch der Pathologic und Therapie) deserves much, 
weight-viz., 1 that the distension of the right cavities of the heart appears not to be 
present during life, as percussion gives (invariably?) a small area of cardiac dulness.' 
Supposing the general accuracy of Dr. Parkes's descriptions to be conceded, judgment 
must, I think, be reserved on the meaning of the alleged exceptions. For, whatever 
question there may be as to the interdependence of the symptoms of cholera, it is cer- 
tain that the disease, in proportion to its flux, tends to reduce more or less rapidly both 
the volume and the fluency of the blood ; and till we know exactly what would be the 
ultimate anatomical expression of those changed physical states of the blood, taken by 
themselves, it is impossible to affix a right value to the cases of cholera where post- 
mortem appearances, or facts observed during life, have not answered to Dr. Parkes's 
general description of the anatomy of death in collapse." 614 
SPECIAL PATHOLOGY-MALIGNANT CHOLERA. 
other basis to explain the tendency to equalization of temperature between 
external and internal parts which is apt to show itself in the fatal ending of 
collapse, and even to continue after death, as though a final relaxation of 
arterial rigidity permitted the blood at last to find way through its normal 
channels. And if the cold and cyanosed state of external parts in cholera be 
not to some extent under control of arterial contractility, I cannot conceive 
through what mechanism to explain that exceptional state of mammary cir- 
culation which permits the continued secretion of milk by nursing women who 
are in collapse. 
" Secondly, the belief that a primary ' blood-poison' is the proximate cause 
of cholera, the direct source equally of its intestinal and of its asphyxial mani- 
festations is, so far as I know, mere hypothesis. It has been much accepted 
as the only possible explanation of c'ertain supposed, but very questionable 
facts in the natural history of the disease; especially in explanation of the 
supposed fact, that the utmost collapse of cholera may concur with little or no 
affection of the intestinal canal. It is of supreme pathological importance to 
be right in the matter of these premises. Is it, or is it not, true that choleraic 
asphyxia can arise otherwise than in consequence of the bowel disease ? This 
question has been much perplexed, partly through the vast number of vague 
assertions which are current on the subject, and partly through an assumption 
which has often been prematurely, and perhaps wrongly, made, that the sig- 
nificance of the bowel disease in cholera is to be measured by the quantity of 
the fluid secretion from the bowel. Properly to discuss the main question, 
that assumption must be disallowed, and the points be separately considered. 
" a. That the large, often enormous, fluid discharges which generally char- 
acterize cholera represent corresponding de-aquation and de-salination of blood 
and textures in the patient's body, and that such changes must, at least for a 
time, interfere to some considerable extent with all or most of the chemical 
processes of the body, cannot, I suppose, be disputed. And on the hypothesis 
that cholera begins in the bowels, it might seem probable that all, or nearly 
all, the facts of collapse and secondary fever would admit of being referred, 
directly or indirectly, to that generally enormous flux. Especially it would 
seem plausible to refer to the altered blood either a power of mechanical 
obstruction or a power of provoking resistant muscular constriction, in the 
vessels through which it has to pass. At present, however, very strong argu- 
ments against any such doctrine of collapse are adduced. Dr. Goldbaum's 
conclusion, in his recent report (published in Virch. Arch., Feb., 1867) of the 
experience of the Berlin Cholera Hospital, No. Ill, in the epidemic of 1866, 
supported by many illustrative cases, is strongly against the doctrine that 
inspissation of the blood is the cause of the asphyctic state. He (like many 
previous observers-notably the chief Anglo-Indian authorities, and in Europe, 
Romberg, Parkes, and others) insists that the relation of flux to asphyxia is 
rather an inverse than a direct proportion, and that the cases of worst augury 
are cases which have fallen into collapse after but little or no vomiting and 
purging. He, moreover, expressly guards against undue importance being 
attached in such cases to the quantities of fluid (half or two-thirds of a gallon 
at the utmost) which may be retained within the patient's intestinal canal; 
pointing out that the contrast is with cases where, perhaps, as much as seven 
gallons are discharged by vomiting and purging, and that consequently no 
allowance made foi' intestinal contents can affect the truth of his proposition. 
In this context, too, it seems convenient to refer to the comparison which many 
experienced observers of both sorts of disease have drawn between the phe- 
nomena of cholera collapse, on the one hand, and those of the cold stage of 
malarious disease on the other. Dr. Goodeve, for instance, in his article on 
eholera, in Reynolds's System of Medicine, arguing that 'symptoms similar to 
collapse may be produced by poisons without any purging,' observes, that he 
has 'seen people under the influence of malarious poison in Calcutta lie for PATHOLOGY OF MALIGNANT CHOLERA. 
615 
hours as cold and pulseless, and as embarrassed in the breathing, as in cholera.' 
No doubt both sorts of collapse have very much in common as regards their 
spheres of manifestation, and much also as regards the phenomena themselves; 
but of course the likeness between them does not exclude the possibility that 
they may be induced by very different causes. 
" b. As regards the other point, materials for judgment are less definite ; but 
certainly, in the present state of information on the subject, the proposition 
is by no means established that cholera collapse ever occurs without bowel 
disease enough probably to account for it. Abstraction of fluid, I need hardly 
observe, is not the only way by which abdominal lesions can affect the circu- 
lation of the blood. There are channels for nervous as well as for humoral 
sympathy; and the heart's action can be lowered to the utmost (whether with 
consensual changes of arterial tone, I know not) by abdominal lesions in 
which little or no fluid is expended. Physiologists will remember those admi- 
rable researches of Goltz* and Bernstein,f which elucidate the exact course 
and mechanism of such sympathies ; and every practitioner of medicine or 
surgery can recall instances where he has seen mortal collapse (substantially, 
so far as I know, not different from the collapse of cholera) produced by the 
very onset of traumatic and other abdominal inflammations, sometimes of no 
great apparent magnitude. In comparison with some of such instances, the 
least amount of bowel disease which (so far as I know) has ever yet been 
found in the bodies of persons dead with the cholera collapse, must, I believe, 
be deemed very considerable. Doubtless there are cases on record where men 
stricken with cholera collapse are said to have suddenly fallen, even numbers 
of them together, in the streets or elsewhere in their ordinary pursuits, ' tum- 
bling over each other lifeless,' or as if 'knocked down dead by lightning,' or 
' as if they had drunk the concentrated poison of the upas tree.' It may well 
be that some of these pictures are unintentionally overdrawn; representing 
less the real objective occurrences than they represent that utter dismay, that 
sense of mysterious death too swift for remedy, which severe epidemics of 
cholera are singularly apt to produce. But, taking them at what they are 
worth, what reason is there to believe that the sufferers who were so stricken 
down had not bowel seizure as the ground of their collapse? No doubt the 
opinion has been current that cholera, acting in some mysterious way on the 
total organism, may ' kill and leave no sign;' but in proportion as exact morbid 
anatomy has been cultivated, that opinion has, I think, more and more seemed 
to rest on a mythical basis ; and the doctrine of primary collapse ought at 
least, without hesitation, to be rejected for cases where post-mortem examina- 
tion of the bowels has not been made. In illustration of these remarks, I 
would refer very particularly to the important case given by Dr. Sutton, in 
his report On the Clinical Characters of Cholera, 1866. It was a typical case 
of cholera sicca. It was a case of cholera death so swift that probably none of 
the reported 'upas poisonings'were swifter. But fortunately the body was 
anatomized. The whole length of the small intestine was found containing 
choleraic effusion ; and to assume, in the face of that fact, that the cholera 
collapse was primary, would, in the present state of knowledge be, to say the 
least of it, a simple petitio principii. 
"In the present state of knowledge, then, I do not find it proven, nor do I 
see any theoretical convenience in taking for granted that cholera begins as 
an active blood-change capable of producing primary collapse. The facts, so 
far as I know them, can all be reconciled with the belief that cholera begins 
as bowel disease, producible by direct contagion, without even a passive inter- 
vention of the blood, and that all asphyctic phenomena of the disease are 
supervenient sympathetic phenomena. That, so far as they are facts of car- 
diac paralysis and arterial contraction, they may be attributed to nervous 
* Virch. Arch , vol. xxvi. f Reichert and Du Bois Reymond's Archiv., 1864. 616 
SPECIAL PATHOLOGY-MALIGNANT CHOLERA. 
sympathy between bowels and circulatory system, without reference to the 
greater or less humoral effect of the coincident flux from the bowels, is at 
present a tenable view. At the same time, I hesitate to accept as proven that 
cholera collapse is independent of humoral sympathy. That it may often be 
apparently so is, no doubt, well shown by the statements I have quoted from 
Dr. Goldbaum and others. But it must be remembered that in those com- 
parative statements two most important variables are not .taken into account. 
First, there is the varied rapidity of the local morbid process-a very consid- 
erable range of difference; and it is imaginable that the power of the intes- 
tinal flux to produce collapse may vary with the rapidity, rather than with 
the mere degree, in which it tends to inspissate the blood. Secondly, there is 
the varying susceptibility of the individual patient; and that this has range 
enough to account for very considerable differences of manifestation in the 
functions concerned in collapse will be evident to any one who has attentively 
studied the very kindred subject of febrile rigors. Indeed, the power of both 
the variables in question may be illustrated from that analogy; for all ob- 
servers know how essentially the rapidity of the thermal rise is the determin- 
ing condition for the rigor; and all equally know how one patient suffers 
rigor to the very verge of death from influences which would not appreciably 
disturb another one. 
"In questioning the fact of a primary blood-poisoning in cholera, I, of 
course, do not intend to deny that the blood during cholera is poisoned. From 
our earliest knowledge of the disease it has been on record that, when preg- 
nant women have cholera, the intrauterine offspring almost invariably dies ; 
and more recently, in proportion as the anatomy of the disease has got to be 
better studied, cases have accumulated, giving detailed evidence in support of 
an opinion which had from the first been entertained, that the infant in such 
cases dies of true choleraic infection. Waiving particular reference to earlier 
cases of this sort (for which see, for instance, Phoebus, 1833, op. cit. § 51,* and 
Buhl, 1856, in the famous Bavarian report), I may quote some statements 
made by Dr. Goldbaum in the report to which I have already referred. In 
the three last epidemics, he says he has carefully anatomized twenty-two such 
infants, and never failed to find appearances which, collectively, he deems 
characteristic of cholera. 'In the stomach and upper part of the small in- 
testines always there was a fluid like rice-water, sometimes a thick mass, con- 
sisting of exfoliated bowel epithelium ; the heart was always ecchymosed ; at 
the back of the tongue there were swollen papillse, as there are in greater de- 
gree in adult cholera corpses; and in the kidney the yellowish cortex con- 
trasted strongly with the more blood-holding medullary substance.' It may, 
I think, be assumed for certain that the death of the foetus is death by cholera, 
and that the foetus is infected through its blood. And since its blood is a mere 
derivative of the mother's blood, the fact seems to be beyond dispute that the 
mother's blood had cholera contagium in it. In relation to our main argu- 
ment, however, the question is virtually unchanged. Is there any reason to 
suppose that the cholera contagium in the mother's blood was not a secondary 
product of disease-was not let into her circulation from the ferment-seething 
interior of her bowels ? In this point of view the case may be usefully illus- 
trated by another and closely kindred fact. Dr. Thudichum (see p. 477, Ninth 
Report on Public Health, 1867) has made the important observation, that some- 
times in cholera the blood, like the rice-water of the intestinal canal, contains 
butyric acid. He does not believe that this poisonous product of fermentation 
is primarily formed in the blood; he believes that it is only to be found there 
when, after collapse, absorption from the bowels has recommenced, and when 
* " Among the cases given in Phoebus's work is one where the infant was not 
actually born dead, but died an hour afterwards with all symptoms of the epidemic 
disease." PATHOLOGY OF MALIGNANT CHOLERA. 
617 
evidently the presence of that and other like matters in the blood can be in- 
terpreted as a fact of secondary infection from the bowel." 
There is thus evidence, both chemical and physiological, to show that the 
organic infecting matter of cholera is absorbed into the patient's blood, at all 
events to some extent, during the deep collapse of cholera. 
(2.) From observations made during the epidemic of 1848-49, Dr. J. Snow 
promulgated his belief that the poison of cholera is swallowed, and acts 
directly on the mucous membrane of the intestines, and is at the same time 
reproduced in the alimentary canal, and passes out, much increased in quan- 
tity, with the discharges; and that these discharges afterwards, in various 
ways, but chiefly by becoming mixed with the drinking-waters in rivers and 
wells, reach the alimentary canals of other persons, and produce the like dis- 
ease in them. 
(3.) In 1849, Dr. W. Budd, of Bristol, expressed a somewhat similar belief 
-namely, that the disease depends on a living organism-a distinct species 
of fungus, which, being swallowed, becomes infinitely multiplied in the intes- 
tinal canal, and the action thus excited causes the flux of cholera. These 
organisms Dr. Budd believes to be disseminated by contact with food, but 
principally through drinking-water of infected places. 
But the idea of cholera depending upon the presence of a fungus growth 
affecting the epithelium of the intestinal canal had previously originated with 
Boehm in 1838, who described and gave drawings of forms of cryptogamic 
growth amid the debris of the epithelium in choleraic dejecta. He remarks 
that after death from cholera, the matters found in the intestines "teem with 
vegetations of micro-fungi, and that innumerable round, oval or elongated 
corpuscles are to be found in all the vomits and dejections, as well as in the 
intestinal canal; sometimes single, sometimes two, three, four, or more joined, 
end to end, as links of a chain." 
In 1849, Dr. Swayne also published drawnings of "cholera cells" in the 
Lancet for October 13th, 1849; and these were subsequently shown by Mr. 
Busk to be the spores of a species of uredo, and other extraneous matters 
introduced into the intestinal canal with the food. (This so-called "fungus 
theory" of cholera will be considered more fully afterwards.) 
(4.) Dr. W. Farr, reporting on the epidemic in 1852, states his belief that 
Asiatic cholera is induced in man by a certain specific matter-the zymotic 
principle of cholera, which he proposes to call cholerine. "A. variety of that 
matter was produced in India in certain unfavorable circumstances; it had 
the property of propagating and multiplying itself in air, or water, or food, 
and of destroying men by producing in successive attacks a series of phe- 
nomena which constitute Asiatic cholera. . . . That cholerine is an or- 
ganic matter cannot be doubted by those who have studied the whole of its 
phenomena and the general laws of zymotic disease." The great questions 
remain,-Is cholerine produced in the human organization alone, and propa- 
gated by excreted matter ? Is it produced and propagated in dead animal 
or vegetable matter, or mixed infusions of excreta and other matters out of 
the body ? Is it propagated through water, through air, through contact, or 
through all those channels ? 
(5.) The London College of Physicians, in 1854, gave forth their opinion 
" that it is not probable that in the case of cholera the influence of water 
will ever be shown to consist in its serving as a vehicle for the poison gene- 
rated in the bodies of those who had suffered from the disease; " that " the 
theory that the cause of the disease is a general state of the atmosphere," a 
general "atmospheric influence," or epidemic constitution, has been found 
untenable; and believe "that human intercourse has at least a share in the 
propagation of the disease; and that, under some circumstances, it is the most 
important, if not the sole means of effecting its diffusion, the poison attaching 
itself to the surface of bodies, to the walls of rooms, and to furniture. It will 618 
SPECIAL PATHOLOGY-MALIGNANT CHOLERA. 
also be collected by the clothes of persons living in infected dwellings; will 
be carried by them from place to place, and, wherever it meets with condi- 
tions favorable to its increase and action, will produce fresh outbreaks of the 
epidemic. But it by no means follows that cholera is always propagated in 
this way. It may spread independently of communication between the sick 
and the healthy; the agent then most likely to have conveyed the poison 
from one spot to another is the wind. 
(6.) A committee was appointed by the Board of Health, composed of the 
following eminent men, Drs. N. Arnott, W. Farr, W. Baly, and Messrs. 
Owen and J. Simon, to conduct a scientific inquiry into the circumstances of 
the epidemic of 1854. They extended their investigations into the meteoro- 
logical phenomena of the two seasons of 1853-54, and arrived at the follow- 
ing conclusions: " 1st, That 1854 and other years, when cholera prevailed, 
had their marked meteorological characters, the general tendency of which 
was to render the season defective in those atmospheric changes which renew the 
purity of the air; and, 2d, That these characters, apparently so definite in their 
meaning, are in their kind such as to prevail with greatly increased development 
in those low levels of London where all visitations of cholera have most cruelly 
pressed; for high barometric pressure, excessive night temperature, and hazy air, 
with absence of wind, of ozone, and of electricity, would all appear in their most 
marked degrees throughout those alluvial districts." The committee also 
came to the conclusion that "the undiscovered power or exciting cause of the 
epidemic manifestation of cholera, in its wanderings, acts after the manner of 
a ferment, and that it therefore takes effect only amid congenial circumstances, 
and'that the stuff out of which it bears poison must be air or water abounding 
with organic impurity. Either in air or water it seems probable that the 
infection can grow; but, on the whole evidence, it seems impossible to doubt 
that the influences which determine in mass the geographical distribution of 
cholera in London belong less to the water than to the air. Exemption from 
the mortality has followed more nearly the degree of elevation of the soil than 
it has been proportionate to any other general influence; and on the supposi- 
tion (which this result greatly confirms) that the choleraic infection multiplies 
rather in air than water, meteorology explains how the balance of healthful- 
ness is weighed in favor of the higher levels, by their less participation in the 
high night temperature of the metropolis, by their comparative clearness from 
mist, and, above all, by the curative resources of more free ventilation." 
Here the zymotic theories of Drs. Farr and Baly are interwoven with the 
theory of the College of Physicians. 
(7.) In 1855, Professor Pettenkofer, of Munich, attributed the propagation 
of cholera to the rice-water stools of patients in a state of fermentation (a re- 
vival of the doctrine of Bayer in 1832), but that this ferment can only act 
where it meets with suitable local conditions {localizing conditions'). Thus 
a special leaven sets up a zymosis or series of decompositions in the impure 
soil itself, and the special poison of cholera is a miasm generated out of this 
earth-fermentation. While, therefore, Pettenkofer considers the presence of 
special ferment as essential to the production of cholera epidemic, he also 
insists upon the coexistence of certain local peculiarities; namely, a damp sub- 
soil, sufficiently porous to be penetrable by the decomposition products of 
human and animal excrements. It is only on such a soil, thoroughly impreg- 
nated with this peculiar organic matter, that the specific cholera poison is 
generated. Hence the susceptibility or otherwise of towns, for a cholera epi- 
demic is in exact proportion to their soil relations (Greenhow) ; and the fer- 
ment necessary to setup the peculiar decomposition of which cholera poison 
forms one of the products is the matter of the dejections of cholera patients. 
A cholera miasm is the result which becomes diffused through the atmosphere 
of dwellings in common with other exhalations; and thus, although formed 
in the ground, the air is the vehicle for its transmission to the patient; and he PATHOLOGY OF MALIGNANT CHOLERA. 
619 
believes farther, that the dejecta of persons suffering from diarrhoea or cholerine, 
is equally capable with the cholera dejections of producing the pestilence. 
(8.) Dr. Macnamara maintains a theory which is a modification of that pro- 
pounded by Dr. Snow, in conjunction with the views of Drs. W. Farr and 
Pacini, that Asiatic cholera depends upon a specific organic matter, derived 
from the faeces of a person suffering from the disease. This organic matter, 
when in a certain stage of decomposition, is capable of imparting its specific 
action to the epithelium lining the walls of the intestinal canal of a person 
swallowing it. If swallowed in this stage (which is a vibrionic stage of decom- 
position), it excites, by conversion of force, changes in the epithelium of the 
intestinal canal similar to those which it is itself undergoing. The epithelium 
being thus destroyed, the serum of the blood is allowed to drain away from the 
capillary arteries of the intestine, and at the same time venous absorption is 
prevented from taking place through the mucous membrane. The characteris- 
tic rice-water stools of cholera are thus produced, which consist of serum of 
blood and the altered epithelium and mucus, together with gland cells, from 
the walls of the intestinal canal. The result of these changes is a further out- 
pouring of serum from the denuded walls of the intestines, while at the same 
time absorption of fluid through the mucous membrane is stopped. In pro- 
portion to the rapidity of this drain of fluid from the intestines the patient's 
blood becomes viscid; and not being able to circulate freely through the 
lungs, the blood becomes imperfectly aerated, its corpuscles are incapable of 
carrying oxygen, and the vis afronte of the capillaries is in consequence sus- 
pended. At the same time, the circulation is further impaired by the hydro- 
static pressure of the blood on the walls of the vessels being suddenly with- 
drawn, which tends to destroy the contractile power of the muscular fibre of 
the heart and other parts of the body; and the patient is speedily killed, un- 
less the outpouring of fluid from the intestines is suspended, by the vessels of 
the part becoming occluded with the viscid blood they contain; in which case 
the water remaining in the tissues of the body flows into the dehydrated blood 
in the vessels, rendering it sufficiently fluid to circulate through the system 
until absorption can take place by means of the newly-formed intestinal 
epithelium. Dr. Macnamara believes that this organic matter is the sole 
cause of cholera; and, with the exception of this specific cholera-infecting mat- 
ter, he entirely ignores all other causes, or combination of causes, as capable 
of producing this disease. It may be preserved in a dry state for years; and 
that whether fresh or old, it undergoes rapid changes in water. 
The first change is what he terms the " vibrionic stage of decomposition, last- 
ing from two to five days in water slightly contaminated with cholera matter, 
and exposed to a high temperature; the organic substance therein becomes 
oxidized, and is no longer injurious. Furthermore, the acids of the healthy 
stomach, and in fact all acids, are capable of destroying the action going on 
in the cholera matter, and so render it harmless. Certain degrees of tempera- 
ture, both high and low, have a similar effect." 
(9.) Dr. Bryden, the most recent reporter on cholera, does not directly state 
a theory, but he adopts the conclusions of Dr. Beasley, of Midnapore {Report 
on Cholera of 1866-68, p. 57), who writes, that " The cholera germs lie hidden 
in the ground. Occasionally they are extricated in sufficient quantity to de- 
velop a few cases of cholera; but when the atmospheric condition, which is air 
and water, to the cholera seed, presents itself, their vitality is roused into full 
play. This atmospheric condition progresses through the air, and it is at- 
tracted to, and is resuscitated by, swampy lands and localities that revel in sani- 
tary defects." He considers there are sufficient grounds for ascribing much 
of the advance of an epidemic to currents of wind. He thus fully acknowl- 
edges the influence of meteorology, of bad sanitary conditions and localities in 
augmenting, and of personal communication in propagating, the disease. He 
believes that there is a movement of epidemic bodies of cholera in India which, 620 
SPECIAL PATHOLOGY-MALIGNANT CHOLERA. 
springing up among its teeming population, overflows its endemic boundary 
from time to time, and commences a destructive march, invading other regions 
of Asia, Africa, and Europe. Much cholera within the endemic area of 
cholera in India forebodes danger to the districts beyond it; and, conversely, 
little cholera is unfavorable to its epidemic advance. 
The ultimate cause or materies of cholera Dr. Bryden does not define; but, 
whatever it may be, its behavior is more like an organized vitalized body than 
anything else. It has a period of growth, existence, decay, revitalization, and 
death-all of which are under the influence of time, place, and atmospheric 
conditions. 
The direction which any epidemic may take depends on the point at which 
cholera overflows the epidemic boundary; and, once started on its epidemic 
course, its life-period as such for Northern India appears to be four years. 
The force which moves an epidemic of cholera, Dr. Byson believes to be the 
wind. 
All the theories now given agree in assigning an Eastern origin to the 
poison of cholera, which is believed to have reached this country either by 
means of direct human intercourse, as by fomites or individual contagion ; 
or the poison itself is assumed to be migratory, and to have come hither by a 
kind of wave-like extension from India.* All of the theories (with the ex- 
ception of the second and the eighth, propounded originally by Dr. Snow) con- 
sider the existence of certain local conditions, or of a predisposition in the 
inhabitants of infected districts, as usually necessary to give strength and 
vitality to the poison. 
It is also to be observed that, while each of the theories just noticed is ap- 
parently supported by a large amount of evidence, direct and circumstantial, 
each is also opposed, to some extent, by a " considerable number of obstinate 
facts," which the particular theory does not explain. In opposition to the 
view that a specific fungus is the cause of cholera, there seems now to be posi- 
tive evidence to show that there is no special cholera fungus in India. In 
opposition to the theory that cholera springs from some special condition of 
ground water, there is evidence that cholera has assumed great intensity where 
there is no ground water; and that Pettenkofer's theory does not find con- 
firmatory evidence in India. In opposition to the view that cholera excreta 
are the special foci of cholera, the disease has spread where the excreta have 
been carefully dealt with in conformity with the indications of this theory, 
and ceasing to spread in the hospitals of Calcutta, where the excreta had not 
been so dealt with. In opposition to the belief that cholera spreads by its 
specific poison getting into water, it has been known to spread where no such 
occurrence could possibly have taken place. 
On looking into the distractingly confusing history of this disease, it will 
be found that there are quite as many false facts (so-called facts, which are 
not facts) as there are false theories; and although it may be wrong to expend 
public money, and so wraste it simply on developing a theory, yet it surely is 
wise to spend public money in determining whether so-called facts regarding 
cholera, are, or are not, true, more especially if the determination of their 
truth affects public interests, and is of vital importance to the welfare of the 
community, more especially when the means for the determination of the truth 
are beyond the resources of private persons. 
All the theories I have stated, however, agree in two main points-or at 
least they are not at variance with them-namely, that cholera is induced by 
* Our early knowledge of the progress of cholera in Great Britain was originally 
contained in an official report presented by the Commissioners to His Majesty King 
William IV, of which only one copy existed. This was rescued from oblivion by the 
late Sir James Clark, aided by the Royal Librarian, who found it in a drawer, buried 
among a heterogeneous mass of papers. It is now appended to Dr. Graves's Report 
on the Progress of Cholera. PATHOLOGY OF MALIGNANT CHOLERA. 
621 
a special poison, and that this poison is of foreign extraction, not indigenous 
to this country. It comes into existence among the hot moist vapors of the 
wet, undrained, uncultivated deltas of the large rivers passing through the 
plains of Central India. These are the perennial endemic sources of cholera, 
capable of spreading everywhere, from those endemic centres which are the 
breeding-grounds of the disease. 
There are also good grounds for believing that cholera has not in the present 
century for the first time appeared in this country, and extended itself over 
the greater portion of the habitable globe. The " cholera morbus " of Syden- 
ham, prevalent in his time, and the " griping in the guts," or "plague in the 
guts," as recorded in the mortality bills of 1665, and described by Willis, and 
subsequently by Dr. W. Heberden, Jr., do not seem to differ in their essen- 
tial phenomena from the disease imported now so frequently into this country 
from the East; although some believe that these descriptions of disease refer 
to dysentery, and not to cholera. 
There are also abundant facts which seem to show that, under a different 
name, cholera was one of the most fatal epidemics by which the population of 
London was formerly afflicted. And there is no doubt that cholera, like every 
other epidemic disease, varies in its type, as it does in severity; for if it is 
conceded that the diarrhoea so prevalent during an epidemic of cholera arises 
from the same cause, and is, in fact, the same disease in a different degree of 
intensity, as Orton showed in 1832, " there is as much variety in the aspect 
and symptoms of cholera as of scarlet fever; between the malignant cases of 
which and the extremely mild ones there is so vast a difference." 
The principal differences shown by Mr. Radcliffe between the recent epi- 
demic (1866) of cholera in Europe and those of former years are,- 
(1.) For the first time in the history of the disease, Europe was invaded 
from the south. In 1829-32 and 1845-48 the disease spread from Persia to 
Russia, and thence along the Danube into Central Europe; and in Britain the 
towns first attacked on all previous occasions were seaports on the east coast. 
(2.) A remarkable feature in the epidemic of 1866 was its rapid and great 
extension along the coast line as compared with its slight and sluggish pene- 
tration inland. The central districts of Europe escaped altogether during 
1865, except that there was an isolated outbreak in Saxony. 
(3.) The progress of the disease was much more rapid than in former epi- 
demics. In 1829 cholera took fifteen months from the time of its entrance 
into Europe to reach Great Britain; two years, less one month, to arrive on 
the North American coast. In 1848 its diffusion occupied nearly the same 
period of time. In 1866 the disease had in less than five months spread from 
Alexandria to the coasts of the Euxine, and even to the Western hemisphere. 
A strong point in favor of the view that in 1866 cholera was introduced from 
the Mediterranean by ships coming thence is furnished by the fact that South- 
ampton was the only port at which ships arrived having had cholera deaths 
on board shortly before reaching England. Moreover, it had been predicted 
that the disease would enter the country by Southampton, and not, as before, 
by towns on the east coast; and the fulfilment of the prophecy will seem to 
many, as Dr. Parkes observes, sufficient evidence that the outbreak at South- 
ampton arose in this way (Sydenham Society Biennial Retrospect, 1867, p. 494). 
(4.) This swift propagation of the epidemic does not appear to have been 
dependent on any peculiar virulence of the disease. 
The evidences of importation or transmission of the disease in this country 
in 1866, by human intercourse, were sufficiently abundant, and as demonstra- 
tive as possible consistent with the nature of such evidence; and there can be 
no doubt, as Mr. Simon concludes, that if a quarantine could be conducted 
with the extreme rigor and precision of a chemical experiment, cholera could 
be kept out of any part of Europe wherever such extremely difficult condi- 
tions could be absolutely fulfilled. Experience has proven, however, that 622 
SPECIAL PATHOLOGY-MALIGNANT CHOLERA. 
they can never be fulfilled, that quarantine has always been a " futile ex- 
pedient for arresting an epidemic" (Bryden), that all such quarantine 
arrangements are beset with insurmountable difficulties, and that ineffective 
quarantine is worse than useless (Townsend). 
England seems to have been infected in 1866 at many different points of 
invasion, and from many different directions, almost at the same time, as the 
following details by Mr. Simon will show: 
"On 28th April a first case was reported from Bristol-that of a trader 
who had arrived there sick from Rotterdam. 
"On 15th May telegrams from Liverpool and Birkenhead reported that 
the disease was prevailing on board certain vessels in the Mersey, among 
German and Dutch emigrants, who, with a view to crossing the Atlantic for 
New York, had come in flocks, travelling rapidly from the Continent, often 
from infected parts of it, by way of Hull, Grimsby, and other of our north- 
eastern ports, and had now fallen ill at their port of embarkation. Much 
alarm was occasioned by this outbreak; the more as new arrivals of the same 
sort were occurring from day to day. The outbreak, so far as England was 
concerned, soon came to an end; but the subsequent progress of the emigrants 
was unfortunately not unattended by cholera. Indeed, in several cases, ves- 
sels such as the above, leaving in apparent health, suffered during their 
voyage cholera'deaths among their passengers and crew, and were of course 
very dangerous arrivals for their port of destination. 
"Within the next few days after the 15th, my Lords of the Privy Council 
were apprised of the first two cases of what afterwards became a serious epi- 
demic at Swansea; and single cases in various other parts of the country were 
also notified to them. Anxiety became general in the country; and there 
was much correspondence with local authorities, often on precautions to be 
taken against the disease, or provisions to be made for treating it, and often 
on questions of jurisdiction and responsibility. 
"On 15th June the Peninsular and Oriental Company's steamship 'Poonah' 
arrived at Southampton with a case of cholera on board, and several other 
cases had appeared in the town. On the 29th two deaths were reported by 
telegram to have happened at Goole, whither clearly the disease had been 
imported from Antwerp. On the 30th three deaths were reported to have 
occurred at Northwich, in Cheshire, and on the same day a case of cholera 
occurred at Shields, on board the 'Clio,' from Hamburg. On 3d July a case 
was reported to have happened at Harwich, on board the 'Redstart,' from 
Brussels; and on the same day, from Brixham, the death of the captain of a 
coasting vessel was reported. 
"A serious extension of the disease was imminent. Reports of new centres 
of infection became more and more frequent; and on 14th July, the time had 
come for putting the Diseases Prevention Act in force throughout the whole 
of England and Wales, by which ample powers of medical relief (not re- 
stricted to paupers) were exercisable by local authorities throughout the 
country. 
"On 18th July, from Poplar, the first cholera death in the metropolis was 
reported. Two days afterwards there was already an alarming proportion of 
cholera cases in parts of East London; and on the 21st the Secretary of the 
London Hospital reported that the resources of that most useful institution 
were being overtasked by such claims for admission as attested a very terrible 
epidemic of cholera." 
At the same time diarrhoea of so severe a form as to be called " choleraic " 
preceded the epidemic outbreak in 1865 and 1866; and if it is found impossi- 
ble to disentangle, at the beginning of an outbreak, cases of a quasi epidemic 
character from those of a true epidemic character, and to shut out absolutely PATHOLOGY OF MALIGNANT CHOLERA. 
623 
a theory of the development of epidemic cholera by gradation out of quasi 
epidemic or severe diarrhoea, it is equally impossible to set aside the fact of 
exposure of the metropolis (and busy ports of embarkation and debarkation, 
like Southampton, and Hull and Liverpool) to continuous transmission of the 
epidemic malady from the early autumn of 1865 to the early summer of 1866 
(Radcliffe). 
The apparently distinct outbreaks in several towns and localities, however 
isolated, must all be regarded as forming parts of one general epidemic; and 
the histories of them, so ably set forth in the various reports collected together 
by Mr. Simon, Dr. Parkes, and others, compel the conclusion that the chief 
agents in the dissemination of the epidemic of 1866 have been the sick from 
the malady in its slighter, as well as more marked and characteristic forms- 
a conclusion which has been adopted absolutely of epidemic cholera by the 
International Sanitary Conference which met at Constantinople to consider 
the question of the preservation of Europe from this pestilence. The history 
of the epidemic in its entirety in this country points to the transmission of the 
disease to the metropolis and other ports from localities previously visited by 
it in Western Europe. Mr. Simon's dictum, that "contagious currents on the 
continent of Europe must be deemed virtually current in England," is to be ac- 
cepted as an axiom in State Medicine, notwithstanding that links of trans- 
mission may fail to be discovered {Ninth Report, p. 288). The testimony of 
Dr. Macpherson also is to the effect that, whatever cholera we have had in 
Europe in.former times, since 1817 at least, it has been always carried out of 
India, or Persia, or Arabia, to other places. 
"The outbreak of cholera in the metropolis in 1866 cannot well be con- 
sidered apart from the wide diffusion of the disease on the continent of 
Europe during 1865 and 1866. It is inextricably linked, both chronologi- 
cally and etiologically, with that rapid dissemination of the malady which, 
in May of 1865, commencing at the most sacred city of Mohammedanism, 
Mecca, extended to Egypt, and thence, before the close of the summer, to 
many places on the eastern and southern coasts of Europe, and in the basin 
of the Mediterranean. During the autumn the epidemic spread largely in 
the south of France and in Spain, appeared at Altenburg in Saxony (where 
it was introduced from Odessa),* and extending to several neighboring towns, 
broke out with severity in Paris, and infected slightly our own coast at 
Southampton. From the 24th September to the 4th November, thirty-five 
individuals succumbed to the disease in the last-named seaport town; and 
from the 28th September to the 31st October, nine deaths occurred from 
cholera (an offshoot of the Southampton outbreak) at Theydon Bois, in Essex, 
a hamlet lying about eleven miles in a direct line N.N.E. from Bow bridge. 
As the winter of 1865-66 advanced, the epidemic extended to Northwestern 
France, chiefly affecting the departments of Finisterre, Morbihan, and Cotes 
du Nord; and throughout the cold season it manifested more or less activity 
along the opposite coast of the Channel. In the Northeast, the department 
of the Vosges received the infection. With the increasing spring the disease 
became more rapidly disseminated. In several localities of Belgium and 
Holland it early showed itself. As the summer grew, and its mid-season ap- 
proached, the diffusiveness of the epidemic augmented largely. The malady 
reappeared in several cities and towns of Eastern, Southern, and Western 
Europe which had suffered from it the previous year; it spread generally 
throughout the provinces of Belgium and Holland; and extended widely in 
Prussia, Central Europe, and European Russia. 
"The epidemic broke out in Rotterdam prior to the 21st April; in the port 
of Antwerp on the 19th May; in Stettin before the 2d June; in St. Petersburg 
* Die indische Cholera in Sachsen, 1865; Dr. Rudolf Gunther, p. 9. 624 
SPECIAL PATHOLOGY-MALIGNANT CHOLERA. 
on the 26th June, or somewhat earlier; in Memel before the 10th July; and 
in Dantzic before the 12th of the same month" (NinthReport to Privy Council, 
by Mr. Simon). 
But other and occasional circumstances give energy to the spread of the 
poison of cholera, although they may not be able to generate or reproduce the 
disease independent of the existence of the specific poison. These may be 
described under the two heads of "meteorological conditions" and "localizing 
causes." 
(1.) Meteorological Conditions.-Of the first of these, temperature appears 
to have some marked influence. The average temperature of 1846, in which 
the mortality occasioned by diarrhoea, cholera, and dysentery, was very large, 
was 4° higher than that of 1845, and 3° above the average of the six preced- 
ing years, and the fall of average temperature was accompanied by a corres- 
ponding fall of mortality from the choleraic and flux diseases. Dr. Barton, 
of New Orleans, states that cholera always coexists there with an east or south- 
east wind. A temperature above 70° Fahr, increased as the disease attained 
its maximum, a dew-point of from 60° to 70°, and a barometric elevation of 
over 30°. The maximum barometer occurred on November 18, 1853, and 
was 30.46° (a very unusual height), soon after which cholera broke out. 
During December the wind continued from the east, north, and northeast; 
the maximum barometer was 30.48° on the 2d, when the cholera was at its 
height, and declined to its minimum, 29.57°, on the 30th. The cholera ceased 
soon after the middle of the month. 
Dr. Macnamara states generally that the disease is most active when the 
thermometer stands at from 70° Fahr, to 80° Fahr., or even 94° Fahr, in 
India, rising in the sun to 120° Fahr, and upwards. 
The first epidemic of cholera in this country, during the present century, 
began in the north of England, in October and November, 1831. The pre- 
ceding summer was unusually fine, the nights being warmer, in proportion, 
than the days. In November, December, and January, the atmosphere was 
observed by many independent observers, both on land and sea, to be singu- 
larly stagnant, unusually still, close, and hot, so that it was impossible to venti- 
late even large houses, in which no change of air "seemed to take place for 
almost a week together." According to the delicate and accurate observations 
of Mr. Glaisher, the meteorological phenomena of the three visitations of 1832, 
1848, and 1854, appear to have been remarkably similar (excepting as to tem- 
perature). Indian medical officers, and those of the Black Sea fleet, give 
similar accounts as'to the meteorological phenomena which attended the out- 
breaks of cholera, in their experience. 
The chief meteorological phenomena of the epidemic period of 1865-66 have 
been summed up by Mr. Glaisher,* and a comparison instituted between them 
and those occurring during the previous cholera outbreaks. The contrast is 
remarkable. The visitations of 1832, 1848, and 1854 were coincident with 
great atmospheric pressure, high temperature (except in 1832),f small diurnal 
range (owing mostly to high night temperature), deficiency of rain, very little 
wind (and comparative stagnation of atmosphere and prevalent mist), a de- 
ficiency of electricity (indicated by the few electrical disturbances), and in 1854 
"the presence of a remarkable blue mist," which prevailed night and day, 
and total absence of ozone. But on this point Dr. Macnamara writes as fol- 
lows: 
" With regard to the supposed influence of certain states of the atmosphere, 
having reference to the amount of electricity and ozone it may contain, in the 
* Quarterly Return of the Registrar-General, July-September, 1866, p. 18. 
f Appendix to Report of Committee for Scientific Inquiries-Cholera Epidemic, 
1854, p. 114. PATHOLOGY OF MALIGNANT CHOLERA. 
625 
generation of cholera in the human body, all such ideas are purely hypo- 
thetical. 
"We have no evidence at all in favor of such views; and reason points out 
to us the extreme improbability of any such agencies affecting the production 
of cholera, because we find the inhabitants of the Andaman Islands and the 
Rajmahal Hills almost free from cholera, although living under the same at- 
mospherical conditions as the people around them, who are constantly subject 
to cholera. The same train of reasoning applies to the case of Australia and 
other countries as yet free from cholera, in contrast with Europe and America, 
which have so often been affected by it." 
During the three months of principal prevalence of the outbreak of 1866 in 
the metropolis (July, August, and September), the atmospheric pressure was 
remarkably low. From the 26th of July to the end of the quarter the barom- 
eter, reading at the height of 160 feet, never reached the point of 30 inches- 
"a most rare occurrence," as Mr. Glaisher writes. 
The temperature of the air was low night and day, except in September, when 
the nights were warm. The daily range of temperature was small "chiefly 
owing to low day temperature, particularly in August, and to a somewhat less 
degree in September; but the range in September was still further lessened by 
the high temperature of its nights." There was an abundance of rain, and 
the air was in almost constant motion, " frequently blowing a much heavier 
gale than-usual at this, season of the year." "Nearly all the circumstances," 
Mr. Glaisher observes, "are directly opposite to those mentioned above as 
being present at the previous visitations of cholera, and have probably aided 
in checking its wider extension." He adds, " One of the most remarkable 
atmospheric phenomena during the past quarter has been the prevalence of 
a peculiar blue mist, first seen by myself on 30th July, but which had been 
remarked by other observers in the preceding week. This blue mist since 
that time has been generally present. On some days no trace of the mist has 
been visible, and on other days it has been seen for parts of a day only. It 
has extended from Aberdeen to the Isle of Wight, and of the same tint of 
blue everywhere. This mist increased in intensity when viewed through a 
telescope; usually no mist can be seen when thus viewed: it increased in den- 
sity during the fall of rain; usually mist rises after the fall of rain. Its density 
did not decrease when the wind was blowing moderately strong, but did de- 
crease when a gale was blowing, but increased again on its subsidence. I do 
not know the nature of this blue influence; but the fact of its presence not 
having been noticed since the cholera period of 1854 till now, points out a 
possible connection; but independently of this, it is of high meteorological 
interest." 
Mr. Glaisher's observations are restricted to the September quarter; but 
Mr. Radcliffe extended his observations over the whole period of the outbreak 
in London, and especially calls attention to two points. The first of these is 
the probable effects of certain excessive variations in the temperature of the 
air upon the early, sudden, and large development of the outbreak; the second, 
the relationship of the fluctuations of the outbreak during its decline to varia- 
tions of temperature; also to the deficiency of ozone during the four weeks in 
which cholera became active and the outbreak attained its greatest develop- 
ment. 
The initial activity and rapid development of the outbreak in London of 
1866 was preceded and accompanied by an excessive range of temperature. 
The mean temperature of the weekending the 30th June, in which the earliest 
cases of cholera occurred, was 4.8° above the mean of the same week on an 
average of 50 years. During the next week the mean temperature fell 5.1° 
below this average; but in the following week the mean was in excess 6.3°^ 626 
SPECIAL PATHOLOGY MALIGNANT CHOLERA. 
In the first third of these weeks the range of temperature was 24.0°; and in 
the second, 17.5°. 
It is not improbable that the great range of temperature in the last week 
of June and the second week of July was influential to some extent in causing 
the sudden development of the epidemic in other districts than the East of 
London during the third and fourth weeks of July and first week of August. 
The relationship here suggested between the temperature and the develop- 
ment of the epidemic, in the districts referred to, is supported by the corres- 
pondence between the lagging of the epidemic during its decline and certain 
sudden elevations of the temperature above the mean. The rate of decline of 
the outbreak was much slower after the third week of fall than in previous 
epidemics. The epidemic lagged, in fact, and this lagging first followed and 
partly accompanied a three-weeks elevation of the mean temperature slightly 
above the average, after a four-weeks persistent fall beneath it. And it may 
be here observed that of the four weeks during which the mortality of the out- 
break was greatest, and in each of which the temperature fell below the 
average, two of the weeks were weeks of rapid decline of the disease. 
An augmentation of the outbreak in the last week of September and first 
and second weeks of August, during which the mortality in the metropolis, 
exclusive of the East Districts, reached its maximum, occurred contempora- 
neously with a three-weeks elevation of the temperature above the average; 
and the subsequent fall of the epidemic, near the commencement of winter, 
contemporaneously with a temperature maintained above the average, was 
sluggish. Among the facts about cholera in India, none are more clearly 
made out than its prevalence in different places at particular seasons. It 
is very plainly influenced most by the combination of influences known as 
"season" (Macpherson). 
Such meteorological conditions have a marked tendency to favor the chemical 
decomposition of organic substances, and to render the season defective in those 
atmospheric changes which by decomposing and dispersing into space the products 
of decomposition, reneic the purity of the air. "The effect of temperature upon 
the Thames water is very remarkable in tainting the surrounding air, and is 
exhibited in the well-known fact that diarrhoea and summer cholera become 
prevalent among the inhabitants along the banks of the Thames after the 
temperature of the river has attained to 60°; and as the water declines from 
this temperature, so do these diseases in its vicinity." In Europe all the 
great epidemics have occurred in times of prolonged drought; and the dissemi- 
nation or dispersion of the disease is very closely related to rainfall, as Dr. W. 
Budd, of Bristol, has shown. By diluting the poison, and by giving rise to 
floods which rapidly sweep it beyond the inhabited area, rain seems to have a 
powerful influence in checking the disease. But to have this effect the rain- 
fall must be heavy and continuous-while, on the contrary, light and inter- 
mittent rains favor its spread. 
"But, with regard to rainfall, it is hardly possible," writes Macnamara, "to 
appreciate its influence on cholera in England. Moreover, what the rain does 
in India towards spreading the disease, water companies and rivers, from time 
to time, accomplish in England. In the one case the rivers, tanks, and wells 
of India are contaminated by the dejecta of cholera patients, which, according 
to the custom of the country, are broadcast over the soil, or thrown into open 
drains, to be washed into the tanks and other sources of drinking-water by 
heavy showers of rain. In England, water companies appear occasionally to 
distribute contaminated water through their pipes; or, the leaking under- 
ground drains and cesspools allow their contents to flow into the rivers, wells, 
and other sources whence drinking-water is obtained." 
In India cholera is endemic after down-pours of rain followed by intensely 
hot weather; and, in districts absolutely free from moisture, cholera can only PATHOLOGY OF MALIGNANT CHOLERA. 
627 
be generated to a very limited extent. No widespread epidemic has ever 
occurred in India unless during or immediately after rain (Macnamara). 
The general result of all such observations is, " that whilst cholera may 
prevail within a considerable range of temperature, a moderately elevated one 
is most suitable for its development and propagation; and this, accompanied 
by a still, stagnant, and peculiarly oppressive condition of *the atmosphere 
(more oppressive than the elevation of the thermometer can account for), 
and a moderate amount of moisture." With regard to the apparent anomaly 
as to temperature in the case of its outbreak in Moscow, and in the northern 
countries of Europe, such as in Sweden and Norway, it must be remembered 
that the internal atmosphere of the Russian, Swedish, and Norwegian houses 
is maintained at a high elevation during the winter months by means of 
stoves. It must be remembered, too, that the water used by the Russians in 
winter is often got from the melting of snow in the vicinity of the houses, and 
which snow is generally exposed to the reception of various excreta from the 
houses, just as the surface of the soil would be exposed. Hence the facilities 
for its spread in Russian hamlets. 
Although meteorological statements appear to be a mass of confusion, from 
which we can scarcely deduce a single general principle; yet we know that 
organic germs, and seeds of various kinds, are capable of preservation under 
the most different and variable meteorological conditions; and also that par- 
ticles or germs most microscopically minute are capable of actual demonstra- 
tion in the air we breathe, as already stated at page 488. (See also a most 
interesting and very suggestive paper on Germinal Matter and the Contact 
Theory, by James Morris, M.D., Fellow of University College, London, 2d 
edition, November, 1867.) 
(2.) Local Causes.-But, in order to give character and energy to the 
development of cholera, there are other conditions required besides those 
meteorological phenomena just noticed. These other conditions are described 
by Dr. Barton as the "terrene element," and correspond with what have been 
termed the " localizing causes " of cholera, especially also as developed in the 
theory of Pettenkofer. 
That some local circumstances play a very important part in the evolution 
of cholera is evident from the following facts: 
1. An analysis of the history of cholera epidemics shows that they are 
most frequently made up of a succession of partial local outbreaks, not only 
in different districts, but even in the same place. 
2. The pestilence has also been observed to linger in some few favorite 
haunts throughout the entire course of an epidemic ; and that, now and then, 
after visiting a place at the commencement of an epidemic, it has returned to 
it again, after an interval of complete immunity, before its close. 
3. That some places escape an epidemic visitation at the very period when 
others in the immediate vicinity are suffering severely from its presence, the 
meteorological influences being the same. Even in the same town, whilst the 
inhabitants of some streets or courts are being decimated, those dwellings in 
others not far distant altogether escape, or, as frequently happens, the inmates 
of certain houses suffer severely, whilst their neighbors are entirely spared. 
4. That the limits of a tainted district are sometimes clearly marked out. 
In illustration of this, my amiable teacher, the late Dr. W. P. Alison, Pro- 
fessor of Medicine of Edinburgh University, quoted a most striking example 
in his paper on " The Exciting Causes of Epidemics," in The Medico- Chirur- 
gical Review for 1854. He wrote (on the authority of Ashton Bostock, Esq., 
Surgeon of the Guards), that one wing of a cavalry regiment, just arrived 
from England, and in high health, ascended the Ganges from Calcutta in 
boats, there being no cholera at the time in Calcutta. At a certain period of 
the voyage the troops arrived at a part of the country where cholera prevailed 628 
SPECIAL PATHOLOGY-MALIGNANT CHOLERA. 
in the villages on the banks of the river, but with which they did not communi- 
cate. Here cases of cholera occurred in the boats; the men were advised to 
push on rapidly, and after a few days, when they had passed the limits of the 
existence of the disease on the banks, it ceased to show itself in the boats. 
What makes the case peculiarly conclusive is, that the other wing of the 
regiment, followed afterwards by the same mode of conveyance, became 
" affected with the disease at the same point, and lost it again at the same point." 
Although very great differences of opinion prevail as to the part which ob- 
vious local causes of insalubrity bear in the production of cholera, yet it is 
almost universally considered that they are necessary for the development and 
propagation of this disease in its epidemic forms. M. Bayer, in 1832, and 
followed by Drs. Barton, Carpenter, Pettenkofer, and Snow, all agree in this 
general proposition. Pettenkofer, of Munich, maintains,-(1.) That a cer- 
tain condition of soil is necessary to the local development of epidemic cholera. 
The soil must be a stratum of earth, inhabited by men, pervious and perme- 
able to water and air. (2.) It must possess a particular degree of humectation, 
depending upon the position of the subsoil water to the surface ; but a consid- 
erable fluctuation, temporarily, in the degree of humidity of this stratum is 
necessary; which fluctuation shows itself in the simplest and surest manner 
by the difference in the level of the subterranean waters, the most dangerous 
moment being when the level of the water sinks after having attained a con- 
siderable height. (3.) It must be charged with organic, especially excremen- 
titious, matter. These he believes are essential conditions, as to soil, for the 
development of epidemic cholera. But (4.) The nidus, or cholera poison, or 
cholera ejecta, once finding admission to such a soil, undergoes those devel- 
opmental changes which is characteristic of its rapid dissemination as an epi- 
demic. Such a condition of soil fosters the multiplication of the cholera 
poison. It does not generate the poison de novo, but by means of the evacu- 
ations of those sick of the disease, or even the evacuations of men who are 
healthy, but who came from infected places, may produce the same result,- 
the fermenting contents of choleraic intestines find their way into such soils. 
Thus Pettenkofer believes that two elements are indispensable for the produc- 
tion of cholera,-(1.) The importation of the choleraic germ into the locality; 
but the nature of this germ he does not define or characterize in any way. 
(2.) A peculiar constitution of the soil. Neither the first nor the second is 
sufficient of itself; but the simultaneous action of both is necessary to pro- 
duce certain emanations which give rise to choleraic infection. 
But apart from the local conditions as to soil insisted on by Pettenkofer, 
there is very strong evidence to show that the decomposing choleraic dis- 
charges (already in a state of active fermenting change in the intestine of the 
cholera patient) will alone produce the disease-which will go on changing 
and multiplying a virus capable of spreading through the air as well as 
through the medium of water. In the outbreak at Southampton in 1866, 
there were instances both of transmission by water and by air (Parkes, in 
Mr. Simon's Ninth Report on Public Health, p. 253). The discharges need 
not pass into the ground to decompose or ferment there. They can decompose 
equally well in sewers, and, of course, can propagate their specific fermentation 
to the contents of such sewers, and such contents may find their way as gases, 
or more material elements, in the air or in the water. 
Impure water, lorvness of sites, and the emanations arising from the decompo- 
sition of animal refuse, or of excreta, are the local causes now satisfactorily de- 
termined to have a more or less constant connection with the development 
and propagation of cholera. 
That impure water has a powerful influence over the intensity of cholera 
outbreaks is now unquestionably established by the observations of Drs. Ac- 
land, Sutherland, William Budd, Parkes, and the late Dr. Snow, and the PATHOLOGY OF MALIGNANT CHOLERA. 
629 
specific inquiries of the Registrar-General and Mr. Simon. Yet still it is 
found that impure water is not a necessary element in the generation of the 
cholera poison, as shown in the report of Dr. Baly (pp. 201-205), Budd as to 
Bristol, Pettenkofer as to Munich, and Gunther as to Saxony. From their 
evidence, " cholera can do its very worst where the drinking-water can play 
no possible part in its dissemination " (Brit. Med. Jour., April 13,1867, p. 416), 
The localized attacks at Theydon Bois in 1865, in the East of London and 
in Southampton in 1866, all point unequivocally to impure water. With the 
general outbreak at Southampton, however, impure water had nothing to do. 
It had only to do with the production of the disease on board the steamship 
" Poonah," just before her arrival from Gibraltar, where she took in a tankful 
of very foul water, which, from its peculiar smell, evidently contained sewage 
(Parkes). 
As regards London, it has been shown by Dr. Farr that the elevation of the 
soil has a more constant relation to the mortality from cholera than any other 
known element, the mortality from cholera being in the inverse ratio of the 
elevation. Yet, like the condition of the water, the elevation of the soil has 
not been always found to be a necessary localizing condition; and there is 
now only left to be noticed the influence of an atmosphere contaminated, by the 
effluvia arising from decaying animal matter and excreta. Dr. Cullen long ago 
remarked, and every industrious dissector knows, that the effluvia from very 
putrid animal substances readily produces diarrhoea. Yet it appears that the 
nature of the decomposing matter, and of the transforming process it under- 
goes, have some influence in modifying the effects on the human constitution. 
Districts in which the most putrid odors tainted the air have sometimes almost 
entirely escaped, whilst others contiguous to them have suffered severely. 
Dr. Chisholm (quoted by Dr. Alison in his paper already referred to) gives 
numerous pointed illustrations of this, in the cases of " bone manufactories," 
"manufactories for the conversion of dead animal matter into a substance 
resembling spermaceti;" "of places where blood is putrefying, waiting to be 
used by sugar refinersand " of leather-dressing establishments." In dis- 
secting-rooms, where the process of animal putrefaction goes on to a great ex- 
tent, diarrhoea is comparatively rare, if the rooms are kept clean. During 
my experience as Demonstrator of Anatomy in the University of Glasgow, 
for a period of six years (including the severe epidemic of cholera there in 
1848-49, and during which time almost all the subjects for dissection had 
died of cholera), not a single student suffered from cholera; and when the 
proper agents are used, such as the injection of arsenical solutions into the dead 
body, which have the effect of arresting and modifying the putrefactive 
changes, I believe the production of diarrhoea is an exception, and may be 
found to have as significant a cause in errors of diet or of drink as in too close 
an attendance in the dissecting-room. That the poison of cholera does not 
attach itself to the dead body (in a certain state of decomposition at least) is 
a fact confirmed by the experience of those connected with the dissecting-rooms 
in Edinburgh. It is certain that these were supplied during the greater part 
of 1848-49, as they were in 1832, almost exclusively by cholera subjects, and 
in neither year was there a single case of the disease among the numerous 
students attending these rooms (Dr. Alison). 
Much pains have been taken by Dr. E. H. Greenhow to investigate the pre- 
cise conditions which, from their more uniform coexistence with cholera, might 
be supposed to produce or to aggravate epidemics of it. The result of his 
observations tends to confirm what Mr. Orton (London Med. Gazette, vol. x, 
p. 222, 1832) was the first of English writers to show-namely, that " an at- 
mosphere impregnated with the products of fermenting excrement is at once the, 
most obvious and most constant concomitant of cholera (the privy or fecal 
contamination theory}. Such exhalations were often found, even in a concen- 
trated form, in houses where the existence of any palpable cause of insalubrity 630 
SPECIAL PATHOLOGY MALIGNANT CHOLERA. 
would scarcely be suspected, and thus the fact is in some measure explicable, 
that the pestilence, sometimes passing over slums and rookeries, knocked at 
the door of the comfortable annuitant or the wealthy tradesman. It was found 
that persons appeared to suffer in proportion to the contamination of the air 
they breathed with the 'privy odor,' and that immunity from this appeared to 
secure immunity from cholera." The observations of Mr. Orton and of Dr. 
Greenhow are confirmed by the investigations of Dr. Pettenkofer at Munich 
and at the village of Gaimersheim. Dr. Barton, of New Orleans, Dr. Milroy 
in his report on the epidemic at Kingston, Dr. Buckler in his account of the 
outbreak in the Baltimore Almshouses, and Dr. Parkes at Southampton, give 
similar evidence confirmatory of the influence of the fermentive decomposition 
of animal excrement as favorable to the spread of cholera. 
The outbreaks of cholera in some of the camps in Bulgaria and the Crimea, 
especially at Aladyn and Alma during the war, also furnish sufficient illustra- 
tions ; and I believe the outbreak of cholera at Scutari, in November, 1855, 
which suddenly commenced in the camp of the Osmanli Horse Artillery, was 
similarly influenced as to its spread. 
Propagation'of Cholera by Human Intercourse.-When cholera appeared in 
its epidemic form in this country in 18-31, the majority of European practi- 
tioners were decided contagionists. Subsequently to that period a reaction 
of opinion occurred, and the question was discussed for many years without 
any definite result. In 1848, when the disease again became epidemic, many 
of the higher authorities coincided with " the solemn declaration of the Board 
of Health, that the malady was not in any way contagious, and that no dan- 
ger was incurred by attendance on the sick." " A large body of evidence, 
however, now renders it certain that human intercourse has at least a share 
in the propagation of the disease, and under some circumstances it is the most 
important, if not the sole, means of effecting its diffusion " (Dr. Baly). Very 
positive evidence has now accumulated in abundance to prove the transmis- 
sion of the disease by human intercourse. Healthy men carry the disease 
with them by their clothes, by their ships, and by their caravans. That such 
is the case, we have now ample evidence in the Bengal Report, of 1824, by 
Dr. Jameson ; in cases related by Mr. Orton, in 1832, and by Dr. J. Y. Simp- 
son, in 1838 ; in The Edinburgh Monthly Journal for 1849, by the late Dr. 
Cruickshank, at Dalmellington, in Ayrshire ; by Dr. William Robertson, 
detailed in The Edinburgh Monthly Journal for August of that year; and 
more recently the account of the outbreak at Arbroath, in Scotland, in 1853, 
by Dr. T. Trail; and cases by Dr. Alison, in 1854, in the paper already no- 
ticed ; in the report of Dr. Berg, of Stockholm, in 1848; in the Norwegian 
Reports of 1850-53 ; in the Report of the College, of Physicians of London, 
in 1854, and the several reports of 1865 and 1866. See especially the more 
recent works of Macnamara and Bryden, and the reports of the various In- 
dian Sanitary Commissioners during the past three years, for evidence of a 
similar kind. 
These records afford undoubted instances which show that human inter- 
course is occasionally influential, in some way, in transmitting cholera into 
detached localities, where it may seize upon two or more individuals, and then 
cease. 
But it is no less certain that its general extension over the world cannot 
be accounted for by human intercourse alone, to the exclusion of aerial con- 
tamination. It is curious that in India, the birthplace and headquarters of 
the disease, the doctrine of contagion is almost universally disbelieved in by 
our professional brethren. The opinion generally entertained in India is in- 
deed opposed to the doctrine of contagion (Morehead, Indian Annals of Med. 
Science, vol. i, p. 456). Such difference of opinion may admit of explanation, 
in the fact that in India all the causes of cholera in its original home are in 
constant operation, and more especially prolonged heat, decomposing organic PROPAGATION OF CHOLERA BY HUMAN INTERCOURSE. 
631 
matters, a more or less debilitated state of the European constitution ; and 
hence, no sooner is the specific poison of cholera imported than the disease 
spreads with such rapidity as to resemble an epidemic invasion. Cases, how- 
ever, of undoubted contagion are not wanting in India. Mr. Barry, .of the 
Bengal service, records an outbreak of cholera at Gowalparrah, in Upper 
Assam, in 1853. In this instance cholera was evidently imported into a. 
healthy place by a body of sepoys coming from an infected locality. Every 
case of the disease could be traced to communication with the sick : a large 
number of attendants on the sick were seized, but those who separated them- 
selves escaped in every instance. (Ind. Annals, vol. i, p. 448. See also the 
instance of Dominica, twenty-two miles from Guadaloupe, referred to by Mr. 
Simon in the Ninth Report of Public Health, pp. 25 and 26. Also those re- 
ferred to in the Army Medical Departmental Report for 1865, p. 349, given by 
Dr. Parkes, from Dr. Gunther's work on the Cholera in Saxony.) 
According to the accurate observations of C. T. Kierulf in the vicinity of 
Bergen, it appears that, when the disease is propagated by human inter- 
course, from one to four days elapsed from the supposed period of infection 
to the outbreak of the disease. Most frequently the disease appeared on the 
second day after exposure to the infection ; and he found that the diarrhoea, 
so frequent during the invasion of cholera, is a part of the disease, and itself 
capable of infecting others with true cholera. This, Mr. Orton also showed, 
was the case in 1832 (1. c.). The extreme shortness of the period of incuba- 
tion is an important element to be remembered in all investigations regard- 
ing the course of events in cholera epidemics. According to Dr. Budd's 
observations it seldom exceeds three days ; and where the disease is virulent, 
there is evidence to show that it may not exceed six hours. 
The inoculation experiments of Namias with needles loaded with the evac- 
uations from cholera, and the experiments by tasting the vomited fluids by 
M. Foy and his coadjutors, have given entirely negative results. So also the 
influence of exhalations from the blood and evacuations of patients with 
cholera, as designedly experimented on by inoculation, has been of a nega- 
tive kind. On the other hand, Lauder Lindsay, Marshall, Thiersch, and 
Meyer, have succeeded in communicating cholera to dogs and cats and mice, 
chiefly through the rice-water evacuations from cholera patients being swal- 
lowed by these animals. 
Dr. Wm. Budd, of* Bristol, maintains, with most cogent reasoning and evi- 
dence, that the poison is cast off by the intestine of the cholera patient in the 
characteristic rice-water discharges, and that it may be transmitted to other 
and uninfected persons in the following principal ways : 
1. By the soiled hands of attendants on the sick: a mode of communica- 
tion probably very common within the limits of the family circle. 
2. By means of bed and body linen, and other articles tainted with the 
rice-water discharges. 
3. Through the medium of the soil. The discharges being liquid, the 
great bulk of them find their way to the ground, from which the poison may 
be propagated in three ways,-(a.) By rising into the air as a product of' 
evaporation ; (6.) By percolating into the drinking-water; (c.) By atmos- 
pheric dispersion in the form of impalpable dust, after it has passed into the 
dried state. It is, of course, difficult to establish these modes of propagation 
by direct proof; but circumstantial evidence, and evidence by analogy, is so 
cogent and weighty, that no reasonable doubts can now be entertained regard- 
ing these modes of propagation. By experiment the enthetically contagious 
poisons (e. g., vaccine variola, woorara, &c.) are known to retain their prop- 
erties in a dormant state for indefinite periods of time after having been dried 
up, and to recover these properties again when moistened. Evidence almost 
as certain as experiment demonstrates the same regarding the poison of scarlet 
fever, malignant pustule, glanders, and syphilis. Therefore, it is probably true 632 
SPECIAL PATHOLOGY - MALIGNANT CHOLERA. 
of cholera, and the more so that the numerous and well-authenticated instances 
of the propagation of the disease through articles of dress shows that the poison 
during its transit must necessarily have been in a dried condition-a condi- 
tion which entirely protects organic bodies from certain molecular changes ; 
so that, so long as the material holding poison remained in this dry state, no 
definite limit could be stated as to how long the morbific agent might retain 
its specific powers. From this point of view a single case may give rise to a 
widespread infection ; and as cases multiply, it becomes more and more im- 
possible to trace their lineal succession. 
The relative share which the modes of propagation (here indicated by Dr. 
Budd) take in the propagation of cholera must vary with season and climate, 
with temperature, with the habits of the people, with the nature of the soil, 
with the water supply, with the prevailing wind, and with general sanitary 
arrangements. 
The experience of 1865 and of 1866 confirms all previous experience as to 
the propagation of cholera, so well summed up by Mr. Simon in his official 
memorandum of July, 1866. In it he assured the public that cholera is so 
little contagious, in the sense in which small-pox and typhus fever are com- 
monly called contagious, that, if proper precautions are taken where it is 
present, there is scarcely any risk that the disease will spread to persons who 
nurse and otherwise closely attend upon the sick. But he admits it is not less 
true, that all matters which the patient discharges from his stomach and 
bowels are infective; that the patient's power of infecting other persons is due 
entirely, or almost entirely, to these discharges; that these, however, are com- 
paratively non-effective when first discharged, but afterwards, while under- 
going decomposition, acquire their maximum of infective power; that, if cast 
away without previous disinfection, they impart their own infective quality to 
other excremental matters; that if they get access, even in the smallest quan- 
tity, to wells or other sources of drinking-water, they may infect very large 
volumes of water; that the infective influence of choleraic discharges attaches 
to whatever bedding, clothing, towels, and like things have been imbued with 
them; and that thus even a single case of cholera may exert a terrible power 
over large masses of population, if local circumstances co-operate. 
The rapidity with which the rice-water discharges must pass into a dry 
state under the burning rays of a tropical sun, renders it highly probable, as 
Dr. Budd suggests, that in India "dust," bearing the poison of cholera, in a 
dry state ("cholera dust"), has a large share in the mode of propagation; 
and when the disease has prevailed, the poison may be left behind in a dor- 
mant state, from being simply dry, so that seeds of a new outbreak may exist 
in the soil coextensive with the first. Hence the imprudence of encamping 
on old encamping-grounds (to which I have so often referred); and, in short, 
these views of Dr. Budd appear to explain, in the most natural way, almost 
all the leading facts which characterize the diffusion of the pestilence. They 
explain especially the relation of cholera to filthy habits and defective drain- 
age-its predominance in low levels-its striking tendency to follow the 
natural line of water-shed-its communication to persons who not only have 
never been in the presence of the sick, but who are stationed at a distance 
from them-contamination of those only who visited one particular or single 
privy, into which the rice-water evacuations had been discharged from the 
first casual case-and the operation of tainted privies in propagating the dis- 
■ease in work-houses, barracks, prisons, and places of public resort (Dr. Budd's 
Letters addressed to the Association Med. Journal in 1854-55; Dr. L. Lind- 
say's able papers; and Dr. Alison's paper "On the Communication of Cholera 
by Dejections," in Edin. Med. Journal, 1855; also Mr. Simon's Ninth Report, 
for 1866). Under circumstances, therefore, of great concentration, or other- 
wise, some unknown poison is communicated, probably by fomites, through 
human intercourse; and as emanations, of some kind or other, passing through CHOLERA IN THE UNITED STATES ARMY. 
633 
the air, they act as poisons on the gastro-pulmonary mucous membrane of 
susceptible persons. Dr. Parkes has shown, in his Indian experience of 
cholera, that it may pass with extreme slowness even against the wind (and 
even the trade or monsoon wind), which only retards its course, but that a 
favorable wind promotes its transmission; and that it sometimes travels in 
this way, and not by the shortest route of human intercourse, or even by the 
route of greatest intercourse between places. 
The communication of cholera by the so-called premonitory diarrhoea (t. e., 
the early stage of cholera) is now beyond dispute. "An instance in point oc- 
curred at Southampton in 1866, where no cholera prevailed at the time. A 
man in the diarrhoeal stage of the disease landed at Southampton, and went 
to his house, a clean airy place, where his wife and young child lived. He 
was laboring under great diarrhoea when he landed on Monday. On Wed- 
nesday following his child was attacked with cholera, and died on Thursday; 
and on Thursday the man became worse, and died of cholera on Friday." 
Here the observations of Parkes confirm the observations of C. T. Kierulf, 
near Bergen, and of Mr. Orton in 1832, already referred to. 
[Cholera prevailed extensively in the United States army during the year 
1866. There were 2813 cases, and 1269 deaths. It appears from Dr. J. J. 
Woodward's report to the Surgeon-General (^Circular No. 5, War Department, 
S. G. 0., 1867), that it spread over the country during that year, extending 
as far westward as Forts Leavenworth, Riley, and Gibson, and in the south- 
west to Texas. In its progress it followed the lines of travel rather than any 
general westward course, and, in the case of the army, it especially followed 
the movements of bodies of recruits. The epidemic, so far as the army is con- 
cerned, evidently radiated from two chief centres,-New York city, and New- 
port Barracks, Kentucky. The first reported case in the army, in 1866, was 
at Fort Columbus, Governor's Island, New York Harbor, in a recruit from the 
rendezvous at Minneapolis, Minnesota, of whose previous history and exposure 
nothing was known ; he had been but three days at the post. In about an hour 
after his admission into the hospital another case occurred, also a recruit with 
previous history unknown. Cholera was at the time prevailing in New York 
city. The fort too was in the immediate neighborhood of a quarter of the 
town chiefly infected, through which recruits passed with more or less delay. 
There was besides frequent daily communication between the fort and the 
town. Recruits from Governor's Island carried cholera to Hart's Island, 
another recruiting depot on the East River. The infection spread by readily 
traceable steps to Georgia; to Louisiana, byway of New Orleans; to Texas, 
by way of Galveston ; to Louisville, Kentucky; to Richmond, Virginia; and 
to La Virgin, Nicaragua Bay. From Richmond it was carried to Norfolk, 
Virginia; from Louisville to Bowling Green, Kentucky. The probabilities 
appear to be that the disease was carried from New Orleans up the Missis- 
sippi River to various points on that stream, and west of it; and though the 
whole chain of evidence is not complete, yet there is a sufficient number of 
known cases of the transfer of the epidemic from one post to another in this 
region, to put this view of the whole movement beyond reasonable doubt. 
The other principal centre appears to have been Newport Barracks, Ken- 
tucky, where the disease was plainly introduced from the infected city of 
Cincinnati, on the opposite side of the Ohio River. Although it did not pre- 
vail to any great extent at this post, yet it is in evidence that it was car- 
ried thence to Augusta and Atlanta, Georgia, and to Nashville and Memphis, 
Tennessee (Woodavard, 1. c.). 
The following instances of the portability of the disease are cited from the 
official report. 
1. On the 14th of July the steamship San Salvador left New York with 634 
SPECIAL PATHOLOGY MALIGNANT CHOLERA. 
seventy or eighty cabin passengers, and sixty in the crew and steerage. She 
touched at Governor's Island and took on board 476 recruits for the Seventh 
United States infantry. The men were lodged between decks, and were greatly 
overcrowded. On the second day out cholera appeared among the recruits, 
and when the vessel arrived at quarantine, near Savannah, Georgia, three 
deaths had occurred, and there were twenty-five ill of the disease. The troops 
were landed on Tybee Island. Cholera continued to prevail on the island 
during July and the first few days of August. Altogether there were 202 
cases, and 116 deaths. The cabin passengers and crew of the San Salvador 
appear to have escaped, but of the ten white citizens residing on Tybee Island, 
nine were seized with cholera shortly after the arrival of the infected ship, and 
five died. The tenth fled from the island, and is reported to have died of 
cholera somewhere in the interior of Georgia. No cases of cholera occurred 
among the troops stationed in Savannah. 
2. The steamship Texas, with recruits from Hart's Island, left New Or- 
leans, July 19th, and arrived at Galveston, Texas, on the 22d. The day after 
arrival one of the recruits was attacked with cholera, and died in thirty-six 
hours. In the outbreak which followed, 44 cases and 24 deaths are reported 
among the white troops at Galveston, and one fatal case of a colored soldier 
in the post hospital during August. 
The portability of cholera was again amply shown in the army experience 
of 1867, by the movement of infected troops and trains. By these means the 
disease was carried, in July, from the Mississippi Valley, where it prevailed, 
across the Plains to every post on the Arkansas River, and the Smoky Hill 
Ford. Three other notable instances of transplantation happened : one on the 
route between Forts Gibson and Arbuckle, one in the case of the posts in New 
York Harbor, and the third in that of certain recruits distributed from New 
York, by way of New Orleans, through Texas. 
The importation of cholera into the posts of New York Harbor, in the sum- 
mer of 1867, by an infected person, and the communicability of the disease, are 
clearly made out. The first case at Fort Columbus was on the 21st August, 
in the recruit Vassar, who had arrived at the post on the previous evening 
with a detachment of recruits ftom St. Louis, Mo., where cholera was prevail- 
ing. One man had died on the way with cholera symptoms, and Vassar had 
nursed him. On the 24th August, 144 recruits were sent from Governor's 
Island to Bedloe's Island, amongst them a man named Harden, who, with 
Vassar, had nursed the recruit who had died in transitu. Harden was at- 
tacked with cholera on the 25th August, and died. Subsequently during 
August and September there were 35 cases and 18 deaths at Fort Columbus, 
and 10 cases and 4 deaths at Fort Wood {Circular No. 1, War Department, 
A G. 0., June, 1868). 
Among the many striking and incontrovertible instances that cholera poi- 
son may be carried from one place to another by individuals, or by their lug- 
gage, is the outbreak of the Marseilles epidemic in the autumn of 1865. 
Dr. Woodward, U. S. A., the author of the admirable and instructive Army 
Reports referred to and quoted from, remarks: "In a general way it may be 
said that the experience of the army in 1867 confirms the views in favor of 
quarantine formed during 1866, and especially confirms the opinions formed 
with regard to the danger of distributing recruits or other bodies of troops 
from an infected point to other garrisons (1. c., p. vi). Early in 1867 the 
Surgeon-General had instructed medical officers, to endeavor, as far as possi- 
ble, to protect any threatened command by a proper quarantine. The meas- 
ures thus adopted, in conjunction with the hygienic precautions directed, un- 
doubtedly saved many lives in the army, for the total number of deaths from 
cholera during 1867 was 230, and it cannot be claimed that the disease in 
itself was less virulent during 1867, for the proportion of deaths to the total USUAL MODES OF DISSEMINATION OF CHOLERA. 
635 
number of cases was 1 death to 2.19 cases, while during 1866 it was 1 to 2.22" 
(Woodward, 1. c.).* 
Those who argue against the availability of quarantine as positively pro- 
tective against the dissemination of cholera, assert that it has never succeeded, 
and never can. The difficulty lies in making the means absolute. In pro- 
portion to its strictness is the risk from infected sources lessened. It is rela- 
tively, if not positively protective, and this view is fast gaining ground, as 
the result of a large body of facts. If efficient, it stops one mode of diffusion, 
and that a pretty potent one. 
But admitting all that is claimed and probable of the dissemination of 
malignant cholera by human intercourse-body emanations, gastro-intestinal 
discharges, infected clothing-it is equally certain that, to account satisfacto- 
rily for its spread at times, we are obliged to own the agency of the atmosphere 
as a carrier, or an epidemic constitution, as well as the influence of localized 
conditions determining outbreaks and intensity. During the first two months 
after the French army landed in the Crimea, it lost more men by deaths and 
invaliding from cholera, than from gunshot wounds, from the battle of the 
Alma to the fall of Sebastopol; yet it brought no cholera with it, nor was 
there any at the time of disembarkation. The outbreak seemed to be due 
solely to atmospheric causes and insanitary conditions. 
The organic theory as a cause of epidemics, first broached by Kircher, 
sanctioned by Linnaeus, and ably advocated in late years by Sir Henry Hol- 
land, Henle, Dr. J. C. Nott, and others, was applied to cholera in Great 
Britain in 1849 and 1854, but, unsupported by observation, made but little 
headway. Recently there seems to be a tendency to a reconsideration of this 
hypothesis, which is certainly a very attractive one, and which would, if 
demonstrated by physical evidence, offer an easy and satisfactory solution of 
many of the mooted points surrounding the dissemination of cholera. " Many 
of the phenomena observed during the march of cholera epidemics," writes 
Mr. Goodeve, " might be explained much more satisfactorily upon the suppo- 
sition of the exciting cause being masses of organisms moving in obedience to 
atmospheric impulses and currents, than by most other theories. They might 
multiply wherever they found a fitting nidus, which might be in privy atmos- 
pheres, or in air abounding in emanations from decaying and putrefying matter, 
or in crowded rooms, and, indeed, in all vitiated atmospheres. They might 
appear to impart an infecting character to the choleraic discharges by multi- 
plying enormously in them" (Reynolds's System of Medicine, vol. i, p. 147). 
Dr. Henry Hartshorne ( Cholera, &c., 1866) is a decided advocate of the or- 
ganic theory, and he believes that the cause of cholera is a (yet undiscovered) 
protozoon, or primal organism, of extreme individual minuteness, which, on 
entering the human body, affects it as an organic poison; and that the condi- 
tions which favor and maintain in life multiplication and migration, this 
ens primalis, are afforded by animal matter in a state of rapid and foul decom- 
position, along with moderately high temperature and ordinary moisture. 
Dr. Lionel S. Beale, for some time engaged in the study of the poison of 
contagious diseases, has, as the result of minute microscopical inquiry, reached 
* [''At several points, as, for example, Augusta and Atlanta, Georgia, the epidemic 
did not extend beyond the infected recruits by whom it was imported. In many cases, 
however, it involved the rest of the command, and it is highly probable that this 
would have been the case far more generally but for the stringent hygienic precau- 
tions adopted. 
" As a particular example of the value of such precautions, attention may be appro- 
priately drawn to the appended extracts from the reports of Brevet Major E. McClel- 
lan, Assistant Surgeon United States Army, from which it appears that cholera broke 
out at various points in the vicinity of Fort Delaware, in fact, encircling the post, but 
did not invade the garrison, although one case, which recovered, occurred in the family 
of an officer on the island" (Circular No. 5, 1867).] 636 
SPECIAL PATHOLOGY MALIGNANT CHOLERA. 
these conclusions: (1.) The contagious or infecting principle consists neither 
of insects, of animalcula, nor any kind of vegetable organism. (2.) But of 
living matter formed in the organism of man or animals-the particles being 
exceedingly minute and capable of retaining their vitality for a long time, 
and under various conditions, although separated from the body. (3.) That 
these living particles bear somewhat the same relation to the germinal matter 
of normal cells that pus-corpuscles or cancer-cells do. (4.) And that the living 
contagious particle is not, therefore, of the species of a parasite, nor can it be 
regarded zoologically as a species, nor has it originated in the external world, 
and grafted itself upon man ; but it has originated in his organism, and is 
degraded living matter, descended from what was once normal living matter 
of the body itself. 
Direct observation is yet lacking to the support of the organic theory, and 
however inviting and satisfying it may be, positive proof of the existence of 
the organisms will be required before its advocates can ask for its final accept- 
ance. Future microscopical investigations of air, after the manner of Pasteur, 
may possibly settle the question. 
In treating of the causation of cholera, Mr. Goodeve pertinently asks, 
whether it be not "more in accordance with facts to suppose that neither a 
miasm from without nor a miasm from within exclusively contains the specific 
poison ? Might it not be that two factors are needed, the one some air-borne 
material or some dynamic modification of atmospheric elements coming from 
without, the other some local element, neither being potent unless united?" 
(foe. cii.).] 
Endemic Area and Epidemic Spread of Cholera.-Cholera is and has been 
endemic or common to the inhabitants of a certain part of the world only. It 
is a native disease within a certain area of India,-the endemic area of 
cholera. It is not endemic either in Arabia, or Persia, or the Straits' settle- 
ments, nor in China, nor in any part of Europe, Africa, nor America. 
The chronological and geographical history of cholera has commonly been 
considered as affording prima facie evidence that, as regards this country, it 
is originally an exotic disease, the product of another climate, which yet has 
met with conditions favorable for its development and propagation in this 
country. It is now quite clear (as Dr. Macpherson has shown) that exactly 
the same disease as Indian cholera was known in India when the Portuguese 
went there first, about the year 1500. The disease in India has had periods 
of increase and of decrease; but it was never diffused in that country so 
widely as it has been since 1817; nor had it ever wandered so extensively 
from India before. Whatever cholera we may have had in Europe in former 
times, few doubt that, since 1817, it has always been carried out of India to 
other places. 
It is endemic in Calcutta, Madras, and Bombay, and probably in all large 
towns along the seaboard of British India, including Chittagong, and parts 
of the Pegu division. It frequently makes its appearance in the ceded dis- 
tricts of Madras, of which Bellary is the capital, and which includes the 
table-land between the Eastern and Western Ghauts, having an elevation of 
some 1600 feet'above the level of the sea. It breaks out year after year 
during the annual festival at Humpi. From these districts, passing north- 
ward to Saugur and Nagode, in the Gangetic basin, it appears there, to a 
greater or less extent, twice a year; and to identify the cholera endemic area 
within a general but definite boundary, Dr. Macnamara draws "an imaginary 
line to the northeast, through Saugur, Allahabad, and Gorruckpore, to the 
foot of the Himalayas. Throughout the whole of the plains to the east of this 
line cholera is endemic, the intensity of the disease increasing as we approach 
the seaboard of the bay of Bengal, the cities of Dacca and Calcutta being pre- 
eminently the stronghold of this terrible malady." "Cholera is less fre- ENDEMIC AREA OF MALIGNANT CHOLERA. 
637 
quently met with as we advance to the northwest and west from the line I 
have above indicated, until the disease may with certainty be said not to be 
endemic in the Punjaub, Rajpootana, and Sind. But along the valley of the 
Nerbudda and Tafty Rivers, and throughout a very considerable part of the 
Bombay Presidency, cholera is endemic." 
The geological feature of the soil characteristic of this endemic area is allu- 
vial, consisting chiefly of soft incoherent beds of fine sand and silt, of enor- 
mous extent and thickness, as regards Calcutta and the district near the 
mouth of the Ganges. But large plains of laterite also crop up, as in the 
Orissa, Midnapore, and Beerboom districts; or the soil consists of beds of clay, 
of a yellow color, strongly coherent, and abounding in runkur, on which 
Patna, Dinapore, Benares, and Mirzapore are built. 
Dr. Bryden's endemic area is somewhat different from this. He roughly 
describes it as the region bounded on the east by the 91° or 92° of east longi- 
tude ; on the west, by about the 85°, passing a little to the west of Patna ; on 
the north, by the 27th parallel of latitude; and on the south, by the coast of 
the bay of Bengal, including the deltas of the Ganges and of the Mahanuddy 
rivers, or from about Chittagong round to Porree. It forms a great basin, 
having the hill country east of the Bramahpootra River for its margin in that 
direction, and the Rajmahal and Cuttack hills for its western margin; while 
its northern limit is the Terai of the Himalayas, from Lower Assam, on the 
east, to the Terai of the Purneah district on the west. Its rainfall is double 
that of any other province in the Bengal Presidency; and the ground moist- 
ure is always within a few feet of the surface. 
But although there may be differences of statement as to the exact bounda- 
ries of the district of India where cholera is endemic, this much seems now to 
be accepted, namely : "That cholera comes into existence among the hot, moist 
vapors of the wet, undrained, uncultivated deltas of the Ganges and Bramah- 
pootra. That it intensifies itself. That at first it scarcely attracts attention. 
That after a time it covers more ground, and becomes more fatal. That then 
it overflows its accustomed limits, and spares neither race, class, age, or sex. 
That it becomes the deadly connecting link between the filthy inhabitants of 
the lowest classes in Bengal and the highest civilization of the Western Na- 
tions" (Florence Nightingale). Here, therefore, in the endemic area of 
cholera must the army of Sanitary Reformers find their work in doing away 
with those conditions of unhealthiness which abound in India. Land drain- 
age and cultivation must go hand in hand with the improvement of Indian 
villages, whose unhealthy conditions exist in the greatest intensity, as de- 
scribed by Drs. Macnamara, Smith, De Renzy, and Townsend. To the 
Health Officers of India, and to the Local Sanitary Commissioners we must 
now look for the "breeding-ground" of cholera being rendered a soil less 
productive of that disease. The education of the people, the cleansing out of 
their villages, the cultivation of the soil, the abundant and systematic supply 
of pure water, are the main directions for sanitary improvement. 
The details of the geographical distribution of cholera, with reference to the 
routes it has followed in its progress from its endemic area in India over the 
face of the earth, are of extreme interest; and it is of the greatest practical 
advantage to be familiar with them. "It is one of the most important sub- 
jects that can be studied in connection with cholera; for, by defining accu- 
rately the various outlets from India which have from time to time been 
taken advantage of by this insidious enemy of mankind, we may hope to bar 
its exit from its breeding-ground on future occasions." But beyond stating 
general results, the topic is much too long for a text-book; and therefore the 
student is referred to the most interesting account given by Drs. Macnamara 
and Bryden in their great works on cholera. From such works they will 
learn to form a sound judgment as to the true nature and habits of cholera. 
" One of the first things that strikes us in the ' interesting history given by 638 
SPECIAL PATHOLOGY-MALIGNANT CHOLERA. 
Dr. Macnamara' is, that in every instance in which cholera has extended be- 
yond the confines of its endemic area, it has originated in an outburst of the 
disease in Lower Bengal or in Madras, as in 1833-34." Excluding this 
latter epidemic, it may be stated as a general rule, "that cholera has two well- 
defined routes from Bengal,-the one its westward course, along the basin of 
the Ganges into Nagode and Saugur, and from thence into the Bombay Pres- 
idency. The other, its northwestern route from Cawnpore (or up the Jumna) 
to Agra and Muttra, to Delhi, and so over the northwestern provinces, into 
the Punjaub." 
Cholera appeared in Central India, and from thence extended to Bombay 
in 1818, 1834, 1845, 1850, and 1864; and in 1820, 1835, 1846, 1850, and 
1865, it had burst out either in the south of Persia, or along the seaboard of 
Arabia and the Red Sea, usually in both localities at the same time. 
From Mecca cholera travelled with the returning pilgrims into Egypt, and 
thence over Europe, in 1831, 1848, and 1865; and in connection with out- 
breaks of cholera in Europe, Dr. Macnamara has traced the disease up the 
Persian Gulf, and the rivers Tigris and Euphrates, in 1823, 1846, 1852, and 
1865. "It appears very certain, therefore," he concludes, "that the course 
usually followed by cholera in its advance westward into Europe from India 
has been either along the Red Sea (notably from Mecca) into Egypt, or else 
along the shores of the Persian Gulf, and up the Tigris or Euphrates into the 
north of Persia, or into Turkey in Asia, passing into Europe via Astrachan, 
or else gaining Orfa and Aleppo, and so reaching the Turkish dominions in 
Europe. Its passage in this direction is impeded on account of the difficulty 
presented in the navigation of the Tigris and Euphrates, the country to the 
west of the former river being protected by the desert separating Bagdad from 
Syria. 
" It is evident, also, that cholera has on several occasions travelled from the 
Punjaub into Cabul, appearing at Herat, and from thence extending to Mushed, 
Teheran, and Tabreez, or along the shores of the Caspian Sea. It followed 
this course in 1829, 1845 (from Cabul), and in 1853. Each of these years 
was followed by an outburst of cholera over the north of Persia, and its ex- 
tension into Europe over the Caucasus Mountains, or more commonly by the 
sea-route from Reshd to Astrachan." All the routes thus indicated by Dr. 
Macnamara are those by which the natives of these various countries travel. 
He mentions especially the natives, because it is quite certain that cholera has 
never yet reached Suez by means of the Peninsular and Oriental Company's 
steamers, although it has, without doubt, been imported by pilgrims passing 
up the Red Sea from Mecca in several instances. Mecca and Kerbella are 
extensively resorted to every year by pilgrims from India; besides this, there 
is a very considerable trade kept up between the various parts of India and 
Muscat, Makalla, Mocha, and Jeddah, and still more extensive commercial 
relations between India and the various ports (particularly Bassora) on the 
Persian Gulf. 
And so, again, in the passage of cholera from the west and northwest of 
India, it evidently travels with human beings through Peshawar and the 
Kyber Pass, or else from Dera Ismael Khan to the Kattawaz Plain, south of 
Ghazni-this being the great caravan route from the Indus valley to the 
Candahar Steppes. It may also pass from Sind via the Bolan Pass into 
Afghanistan. From this latter country the disease has on several occasions 
travelled via Herat into Persia ; and this is the only possible route it can take 
westward by land into Persia, the deserts of Rajpootana, and those again of 
Beloochistan, protecting Persia (as deserts always do) from the disease, except 
by way of Herat, or by sea from Bombay and the Persian Gulf (Macnamara). 
But the history of cholera within the endemic area requires more careful 
study. There the disease must be prevented by drainage, and sanitary meas- 
ures, and cultivation, and especially by a clean, abundant, and sytematic water CHARACTERISTICS OF MALIGNANT CHOLERA. 
639 
supply. More detailed information has been requested by the Sanitary Com- 
missioners with the Government of India (No. 109, dated Allahabad, June 
21st, 1870), under the following heads, namely : Names of cities or Pergunnah 
towns of the district (1.) In which cholera prevails epidemically; (2.) In which 
isolated cases of cholera occasionally occur; (3.) In which cholera never breaks 
out. 
According to Dr. Gavin Milroy, the only countries which, up to the present 
time, have remained free from cholera, are Australia, New Zealand, and the 
other islands of the Pacific; the Cape of Good Hope and its adjoining settle- 
ments, the West Coast of Africa from the Cape as far northward as Gambia, 
including the islands of St. Helena and Ascension; the Azores, Bermuda, Ice- 
land, the Faroe, and also the Orkney and Shetland islands; and lastly, the 
Western Coast of South America. The characteristic features of the countries 
exempt from cholera are, that they are at a great distance from India, sepa- 
rated from her by a wide expanse of ocean, and having very slight intercom- 
munication with India. The exemption of these countries is strong presump- 
tive evidence against the spontaneous generation of the disease. 
It is stated also by Macnamara that a desert is a district in which cholera 
is unable to establish itself. It never spreads beyond three stages into a 
desert. The deserts of Arabia and Syria have been the most effectual 
barriers to the propagation of cholera, by companies of pilgrims coming there. 
A great desert is the best of all obstacles to the propagation of cholera (Con- 
stantinople Cholera Conference). So, also, the suppression of the usual rains 
is known to have brought the progress of cholera to a standstill. 
Dr. Macnamara's Characteristics of Cholera.-There are several character- 
istic features of Asiatic cholera, especially considered at length by Dr. Mac- 
namara, and which require to be enumerated here-the student being again 
referred to this excellent work for more extended information. These features 
are as follows: 
1. The unequal and very partial distribution of cholera out of its endemic area. 
In this respect it is more nearly allied to influenza than to any other known 
form of disease. The history of cholera in Indian jails is an example. Pris- 
oners may be free from the disease while it is raging outside the walls of the 
prison. This characteristic is an argument against any general atmospherical 
or epidemical influences being a cause. The "localizing action must be asso- 
ciated in our minds with some more tangible and specific cause than an im- 
aginary something floating about in the air, or carried by the winds from 
place to place." 
2. The inhabitants of certain districts being specially liable to be visited by 
cholera, these localities have features in common with one another, differing from 
other places which have usually escaped its influence. It has been most destruc- 
tive in large seaport towns built on low-lying alluvial soils, at the mouths of 
rivers; and, as Dr. Farr has shown, there is an inverse ratio between the mor- 
tality and the elevation of the dwellings above high water mark. The lower 
the land the greater the mortality from cholera. 
3. It by no means, even in the majority of instances, attacks the inhabitants of 
the most insalubrious localities even in our large towns. While many habitual 
seats of fever in such towns are visited by cholera, many of the worst fever- 
nests in the whole metropolis are unaffected by it. 
4. No amount of overcrowding, no special conditions of the soil, nor any cir- 
cumstance ivith which we are acquainted, has ever been known to originate Asiatic 
cholera de novo among men removed from its endemic influence, or unless the dis- 
ease has been epidemic at the time, beyond the confines of India. On this charac- 
teristic Dr. Macnamara writes with a strong conviction of its truth. The dis- 
ease, he remarks, has been traced to the Mauritius on several occasions, but 
always after the arrival of vessels from India with persons on board who had 
been among those suffering from cholera. The same thing has occurred in 640 
SPECIAL PATHOLOGY-MALIGNANT CHOLERA. 
America, Gaudaloupe, the islands of the Grand Canary group, and so on. A 
direct chain of cases always connects cholera in British India with an out- 
break of the disease in this country. But it is not always possible to trace 
cholera immediately from man to man in its progress over the world, and this 
for two reasons, namely, (1.) Because our evidence must frequently be want- 
ing in precise data; (2.) Because articles of clothing, or goods soiled with the 
dejecta of cholera patients, are capable of propagating the disease. 
5. The intensity of cholera varies during its continuance in a county or a large 
town, so that it has periods of little and great activity-in fact, usually well-marked 
periods of increase, culmination, and decline. As a general rule, the first out- 
burst of the disease is the most malignant; so much so that ninety-six out of 
ninety-eight may die. It declines more gradually than it commences, and 
often exhibits periods of renewed activity. These becoming fewer and less 
virulent in the course of time, the malady finally disappears from the infected 
locality. 
6. After having been a certain time epidemic in a locality, it entirely disap- 
pears, unless in its endemic area. Passing out of India, it reaches Europe or 
America within the usual period of time; and after exercising its'baneful in- 
fluence for two or three years, it gradually dies out and disappears, until 
again rekindled by a fresh importation of the disease from India. It is capable, 
however, of a long-continued existence if fostered by a suitable climate. It 
may live and bear fruit even in the cold of a European winter, if fostered in 
carefully warmed conservatories, such as the over-heated houses of the Rus- 
sians. The imported disease is terribly prolific and fatal in its first year's 
growth on a new soil; but from that time it deteriorates in its power of destroy- 
ing life, and gradually declines. The counterpart of this characteristic is 
seen in the case of newcomers into a locality under the influence of cholera: 
here the virgin soil is brought to the seed. 
7. Every outbreak of cholera, beyond the confines of British India, may be traced 
back to Hindustan, through a continuous chain of human beings affected with the 
disease, or through articles stained with their dejecta. 
"In this characteristic, cholera has been seen invariably to follow the routes 
by which man travels; and if it has thus spread from country to country by 
his agency, then we may fairly assume that it has extended continuously from 
man to man. Cholera has never been known to extend from one place to 
another faster than man can travel. Whatever the specific poison is, it never 
appears to spring up in a new locality, unless introduced by men or articles 
of clothing from an infected place." 
This is the first elementary fact to be accepted and inculcated in the pathol- 
ogy of Asiatic cholera. 
8. The more explicit the examination the clearer the fact appears, that the dis- 
ease, in the majority of cases, spreads from one human being to another by means 
of the cholera faces finding its way into drinking-water, and thus into the intes- 
tines of other people. 
"So surely as water contaminated with cholera dejecta is capable of repro- 
ducing the disease when consumed during the vibrionic stage of decomposi- 
tion, so certainly it may be drunk with impunity after this stage is over, and 
when various forms of ciliated infusoria have replaced the vibriones." Not 
that the vibriones have any influence in inducing cholera in the human body, 
but they indicate that the organic matter "in the water is passing through 
a certain stage of decomposition, during which process it seems capable of im- 
parting a similar action to the epithelium of the intestinal canal." Positive 
evidence is given by Dr. Macnamara of water contaminated with cholera 
evacuations, being a medium of the communication of cholera from one person 
to many others, during the epidemic of 1861, in the Punjaub. The most 
positive evidence exists in this case as to the fact of fresh cholera dejecta 
having found their way into a vessel of drinking-water, the mixture being MORBID ANATOMY IN CASES OF MALIGNANT CHOLERA. 
641 
exposed to the heat of the sun during the day. Early the following morn- 
ing, a small quantity of this water was swallowed by nineteen persons (when 
partaken of, the liquid attracted no attention, either by its appearance, taste, 
or smell). They all remained perfectly well during the day-ate, drank, 
went to bed, and slept as usual. One of them, on waking next morning, was 
seized with cholera; the remainder of the party passed through the second day 
perfectly well, but two more of them were attacked with cholera the next 
morning; all the others continued in good health till sunrise of the third day, 
when two more cases of cholera occurred. This was the last of the disease: 
the other fourteen men escaped absolutely free from cholera, diarrhoea, or the 
slightest malaise. Cholera was not prevalent in the place. It had not visited 
the locality for several years, nor has it appeared there since. Examined 
microscopically, the surface of the fluid was found covered with numerous 
large vibriones, and showed that the organic matter in the water was in the 
vibrionic stage of decomposition. 
Morbid Anatomy.-After death, during collapse, the following lesions have 
been noticed: 
External Appearances.-The face is often distorted. Eye sunk deep in the 
orbits, and surrounded by wide cyanotic or dusky rings. The eyelids only 
partially closed; exposing portions of the eyeballs dry as parchment. The 
deeply-sunken cheeks gave undue prominence to the nose, which is itself 
shrunken at the point. The lips are livid, or even deep blue; and many 
parts of the body are cyanotic, especially the terminal phalanges of the 
fingers and toes, the skin of which may be shrivelled and wrinkled like that 
of a washerwoman from constant immersion in soapy water. Where the skin 
is cut through, the hardness and dryness of the subcutaneous connective tissue 
is remarkable, and also the dark-red color of the muscles. The follicular 
structure of the intestinal canal has been found to be swollen as large as hemp- 
seeds, and the intestine filled more or less with a turbid, inodorous, semi- 
diaphanous fluid, usually compared to a thin starch or rice-water, the remains 
of that immense secretion which has taken place during life, and which, 
being tested, has been found always alkaline. It is found in its most unmixed 
condition in the small intestines. It consists of a thicker and thinner por- 
tion, and it appears to be the latter which chiefly constitutes the "rice-water" 
stools, which may be passed off without admixture of the thicker substance. 
A layer of grayish mucus has also been found coating the whole of the mucous 
membrane of the alimentary canal, but without a trace of bile, although the 
gall-bladder is usually filled with that fluid. If the first stage has been pro- 
longed, the mucous membrane of the alimentary canal is of a livid color, and 
in some instances has presented a mammillated appearance, caused by an en- 
largement of the tubular glands, from which a white opaque fluid can be 
squeezed out, and the mammillated appearance effaced. The mucous mem- 
brane of the whole canal is in a state of uniform arborescent injection, especi- 
ally near the ileo-colic valve; or, venous congestion may exist in patches, 
leaving other parts pale and bloodless; and spots of ecchymosis are common 
in these congested patches. The small intestine is relaxed and baggy, hav- 
ing a peculiar rosy appearance before it is opened into. The tissue is swollen 
from oedematous infiltration. From these appearances, seen after death, Nie- 
meyer concludes that, " It is a condition of extensive catarrh of the intestines, 
accompanied by detachment of its epithelium and copious transudation, great 
thickening of the blood, and excessive venous hypersemia of the kidney." 
The mesenteric glands are always found hyperaemic, and infiltrated with a 
whitish granular exudation, like the milt of a herring. The liver, the spleen, 
and the kidneys have in general been found gorged with blood as to their 
veins, and the veins of the kidneys are quite as visible as from " contracted 
mitral-valve " disease (Sutton). This engorgement extends even to the bones, 
which, Louis says, appear as if the animal had been fed on madder. The 642 
SPECIAL PATHOLOGY-MALIGNANT CHOLERA. 
capillary vessels are empty. Professor W. T. Gairdner considers this state 
the natural appearance in persons dying of such very acute diseases as do not 
remove the coloring matter from the blood (Edin. Med. Journal, July, 1849). 
The gall-bladder is almost always distended with thin brown or green bile. 
The urinary bladder is contracted and empty; but the mucous membrane 
of the urinary passages is coated with white mucous epithelial accumulation. 
The membranes of the brain and cord are in general congested, and the 
substance of the brain dotted with more puncta cruenta than usual. Venous 
congestion, and serous effusion beneath the membranes, are the prominent 
pathological changes found in the cranium. 
The most common appearances in the lungs are the presence of blood, col- 
lected chiefly in the ramifications of the pulmonary arteries; the collapse and 
the deficient crepitation-arising from the more or less complete absence of 
air in the air-cells, which readily makes its exit through the dry bronchi when 
the cavity is opened; and blood in the minuter capillaries, and from the ap- 
proximation of the molecular parts of the pulmonary substance. The ulti- 
mate tissues of the lungs are pale and bloodless-remarkably dry, and free 
from hypostasis and oedema. In other cases-about one-half of the whole- 
there is more blood in the minute structure, congestion throughout, a corres- 
ponding dark color of the lung, and a variable amount of frothy serum. In 
Dr. Macnamara's dissection of the lungs, in thirty-six cases out of sixty-four, 
after death in collapse, the lungs were congested; such also is Dr. Chucker- 
buty's experience. 
The right side of the heart and the pulmonary arteries were generally filled, 
and, in some cases, distended with blood ; the left side and aorta are generally 
empty, or contain only a very small quantity of dark blood ; the left side evi- 
dently had received little or no blood, but had continued to contract, in some 
cases even violently, on the last drop of blood which had entered it (so-called 
" concentrical hypertrophy"). 
The icy coldness of the body in the stage of collapse passes away after death, 
when the temperature is said to have risen sometimes to 102° or 104° Fahr. 
Rigor mortis is very difficult to overcome; and I have often noticed in the 
dissecting room that cases of death from cholera would frequently have the 
muscles ruptured, especially the rectus abdominalis, within its sheath. 
Dr. Johnson gives the following diagramatic representation of the state of 
Fig. 80. 
Explanation of the Figure (after Dr. Johnson).-The venee eavse, the right cavities of the heart, and 
the pulmonary artery with its branches, are seen to be distended ; while the pulmonary capillaries, the 
pulmonary veins, the left cavities of the heart, and the aorta with its branches, are comparatively empty: 
(d. c.d.) vena cava descendens; (v. c. a.) vena cava ascendens; (r. a.') right auricle; (r. u) right ventricle; 
(p. a.) pulmonary artery; (p. c.) pulmonary capillaries; (p. v. p. v.) pulmonary veins ; (Z. a.) left auricle; 
(I. v.) left ventricle; (a.) aorta; {t.) trachea; (&.) bronchus. MORBID ANATOMY IN CASES OF MALIGNANT CHOLERA. 
643 
the heart, lungs, and large vessels, when death has occurred during the stage of 
collapse in cholera, from an original drawing by Mr. John Wood. The lungs 
weighed very much less than usual, often not half'their usual weight; and 
on section they appear dry. The blood they contain is all in the branches of 
the pulmonary arteries: it is black-looking blood-thicker than usual, but 
still fluid ; so that on puncturing a vein, such as the jugular, it escapes in 
such quantities that the right side of the heart is emptied in a few minutes 
(Sutton). The anterior portions of the lungs were of a gray color-very 
much paler than normal; the posterior portions and the bases of the lungs 
were much darker in color, soft in consistence, and easily broken down. A 
section of the lung-substance rapidly became of a bright scarlet color on ex- 
posure to the air. 
Such are the appearances which the body has presented when the patient 
has died in the first, the asphyxiated, pulseless, or collapse stage. The en- 
largement of the solitary follicles of the intestines is believed to be peculiar 
to those cases in which diarrhoea, or other disorder of the alimentary canal, 
had for some time preceded the fatal attack. This enlargement bears no re- 
lation to the intensity of the disease, being often most conspicuous in the least 
severe cases; and it is an appearance considered of secondary importance. 
In the experience of Dr. W. T. Gairdner it has been found in about two-thirds 
of the cases. 
When the patient has survived until reaction has taken place, and the 
second or febrile stage has been formed, the body no longei' presents that 
shrunk, worn, and livid appearance it did on death taking place in the first 
stage; but, on the contrary, rather a full and plump appearance. The in- 
jection of all the large organs disappears, the blood being recalled to the sur- 
face of the body. The alimentary canal is no longer distended with the turbid 
secretion peculiar to cholera, but contains a thin yellowish puree of fecal 
matter, having the usual odor. The mucous membrane of the alimentary 
canal has now, however, been found more or less diffusely inflamed, some- 
times in all its divisions, but more especially in the pyloric portion of the 
stomach, and also in the duodenum. The glands of Peyer, as well as the 
solitary glands, though occasionally found enlarged, were seldom found ul- 
cerated ; but when that was the case the corresponding mesenteric glands 
were also enlarged, being sometimes pale or purple, and when cut into, gave 
issue to a dark liquid blood. 
The post-mortem appearances, and the order of the symptoms tend to show 
that the blood has a difficulty in passing through the lungs, mainly on ac- 
count of its viscid and thick condition ; and that the loss of animal heat, 
embarrassment of the respiration, and gradual arrest of circulation, are pro- 
duced by some aberration of the proper respiratory changes, 01* impediment 
to them. But as the mechanical part of respiration remains perfect, and as 
there is no impairment in the voluntary command of the respiratory muscles, 
and as the heart evidently beats in many cases till stopped by the want of 
blood on the left side, and by its accumulation on the right side, " we are 
compelled to look," says Dr. Parkes, " for the cause of such arrest of the cir- 
culation in the only remaining element of respiration-namely, in the blood 
itself" {Researches into the Pathology and Treatment of Asiatic or Algid 
Cholera, p. 107). 
The most important researches on the chemistry of the blood in cholera 
have been made by Dr. Parkes and Dr. Garrod, of London, and Schmidt, of 
Dorpat. The latter observer has attempted to trace out the exact chemical 
steps which attend the period of transudation from the blood into the intesti- 
nal canal. The most prominent phenomena of cholera, during this period of 
transudation, consist in " separation of the water and of the salts of the inter- 
cellular fluid (of the blood) through the mucous membrane of the intestinal 644 
SPECIAL PATHOLOGY MALIGNANT CHOLERA. 
canal, and the retention in the blood of an important excess of albumen, and 
of blood-cells, with apparently less, but in reality with great diminution of 
the salts and fibrin." The period during which this transudation takes place 
is generally one of definite duration (about thirty-six hours), and in it the 
serum and fibrin (intercellular fluid of the blood) are first affected. Water, 
salts, and a small portion of albumen, pass off, and form the well-known 
liquid stools. The order in which the constituents of the serum are affected 
is thus stated by Schmidt: The water transudes before the solids of the serum; 
the inorganic before the organic solids ; the chlorides before the phosphates ; 
the salts of soda before the salts of potash; and the order is very much the 
same as takes place during the action of purgative medicines, such as ela- 
terium. Very soon after this transudation commences, an important change 
occurs in the blood : the normal diffusion currents between its fluid part and 
the fluid in the blood-cells alter; and the constituents of the blood-cells trans- 
ude into the serum, in the same order as the constituents of the serum trans- 
ude into the alimentary canal; that is to say, the water diffuses more readily 
than the solids; the inorganic solids more readily than the organic; the chlo- 
rides (and of these the soda salts) more readily than the phosphates. The 
result of all these changes in the fluid of the blood, and in the blood-cells, is, 
that at the height of the transudation-period the constitution of the blood is 
profoundly altered. The inorganic constituents, if compared to the water, 
are during the first four hours increased, because at this time the water is 
passing off with great rapidity; afterwards, as the salts pass off, the dispro- 
portion is lessened, and after eighteen hours or so the proportion of salts is 
greatly diminished, and, if compared with the organic constituents, the dim- 
inution is enormous. With respect to the individual salts there is in the 
blood a relative preponderance of phosphates over chlorides, and of potash 
salts over soda salts. By the end of eighteen hours or so, the blood-corpuscles 
are left in a most abnormal condition. The great loss of water and of salts, 
especially of the chloride of potassium (a most important constituent of the 
blood-cells), at once leads to the conclusion that their functions must have 
been greatly impaired. Schmidt accordingly found that the amount of oxy- 
gen contained in them was lessened by one-half. 
According to the observations and analyses made by Dr. William Robert- 
son, of Edinburgh, the fibrin of the blood is usually in large amount, and 
coagulable with great firmness. On the other hand, defective or imperfect 
coagulation of the blood in cholera was observed by Dr. Parkes as occurring 
in little less than a quarter of the whole number of cases observed by him. 
The presence of fibrin in the blood was not indicated by any coagulation 
either in or out of the body; and, whether coagulated or not, the blood has 
usually a dark color ; but it generally acquired an arterial tint when brought 
into contact with the air in thin layers. Dr. Robertson's observations were 
made on the cases occurring in the Edinburgh epidemic of 1848 and 1849; 
while Dr. Parkes's observations were made on two severe epidemics of cholera 
in India in 1843 and 1845. He also made the interesting observation, that 
a few drops of the thick substance taken from the intestines had sometimes 
the effect of restoring the vivid arterial color of the blood, a result which the 
transudation of salts just described may in some measure explain. During 
the transudation into the intestinal canal, it appears that the diffusion cur- 
rents from the blood into various structures are diminished; while, on account 
of the density of the blood, the inverse currents from these structures to the 
blood are augmented in rapidity. In this way fluids are drawn from the 
muscles, the viscera, and, in fact, most of the tissues ; and it is probable that 
these fluids are charged with substances (such as sugar, &c.) which, under 
ordinary conditions, are taken very much more slowly into the blood, and 
are soon decomposed when they get there. The extent to which the blood MORBID ANATOMY IN CASES OF MALIGNANT CHOLERA. 
645 
is contaminated and injured by this admixture, and also by the retention of 
urinary constituents, is not yet accurately known. " When we remember," 
says Dr. Parkes, " the great share taken by the blood-globules in the respi- 
ratory and heat-furnishing processes, it is scarcely possible to avoid conclud- 
ing that their loss of salts is connected with the characteristic cyanosis and 
lowered temperature in cholera. In most cases there is vomiting and purging 
before there is loss of heat, though this very soon follows in a slight degree, 
and then gradually augments. In other words, the diarrhcea coincides with 
the first or early chemical changes in the blood-the transudation of some of 
the constituents of the serum. The lowered temperature follows afterwards, 
at the time when we know that diffusion from the blood-cells into the serum 
must be taking place, and augments gradually as the diffusion increases." In 
all the cases examined by Dr. Marcus at Moscow, in 1832, the clot and serum 
evinced acid qualities on the application of litmus, except in four cases, where 
the discharges were watery and the reaction alkaline. The phenomena of 
the disease may thus be traced from the transudation of serum constituents 
as the starting-point. All the other. chemical changes in the blood, and the 
most marked symptoms (such as the abnormal respiratory process), follow as 
a matter of course. 
But the question may be also put in another form, as it has been already 
so well put by the able reviewer of Dr. Johnson's book in the Saturday Review: 
" Why has the circulating blood stopped here (in the pulmonary arteries), 
and by what means has it been brought to a stand ? Were the arrest of motion 
due to gradual thickening in consequence of the continued abstraction of its 
liquid portion, it would be found stagnating in the capillaries, as well as in 
the arteries. It must be borne in mind that one characteristic symptom of 
cholera-that symptom which, irrespectively of the fatality of the disease, 
renders it truly a disease to be dreaded-consists in very painful cramps of 
the larger muscles of the body. These contractions, it may be assumed, are 
produced by the choleraic poison, just as we know they are producible by the 
poison of strychnine. Dr. Johnson supposes that a similar spasm or cramped 
state of the muscular fibres which embrace, and by their natural contractions 
regulate the size of, the minute pulmonary arteries, is caused by the same 
choleraic poison, and bars these slender channels against the advancing blood. 
The thickening of the blood is a consequence, and not a cause, of the collapse. 
Precisely in the same way does a similar condition of the muscular fibres of 
the smaller air-tubes of the lungs constitute a fit of spasmodic asthma. . . . 
Thus the emptiness of the systemic arteries accounts for the extinction of 
the pulse at the wrist, for the cadaverous sinking in of the eyeballs and falling 
of the features, for the blueness and coldness of the skin, and for the absence 
of syncope. The circulation stops, not from debility of the heart, as in ex- 
haustion, but in consequence of a direct mechanical impediment to the onward 
course of the blood. We can understand the impotence of brandy against 
this condition; and how, on the other hand, bleeding may heip, both by re- 
laxing the spasm and by unloading the distended right heart, to restore the 
circulation. Into this explanation Dr. Johnson presses, plausibly enough, 
the singular effect of the injection of fluids into the veins of these patients. 
It appears that, to be influential at all, the fluids must be hot; and he con- 
cludes that they act chiefly by relaxing, through their warmth, the spasm of 
the smaller arteries. The blood then flows on again, and the symptoms of 
collapse are fol' a time removed. Again, the husky whispering voice is owing, 
not to muscular weakness, but to the small volume of tidal air in the respira- 
tory currents. As but little venous blood reaches the lung-tissue proper, there 
is but little demand for air to meet and decarbonize it. The respiration 
accordingly becomes shallow, and the vocal pipe, feebly blown through, re- 
fuses to speak. Under the temporary impulse of the warm injections, the 646 
SPECIAL PATHOLOGY-MALIGNANT CHOLERA. 
voice regains its usual tone and note. Once more, there are chemical and 
less obvious changes already noticed which receive their explanation from 
this theory." 
The contraction of certain muscles after death is a phenomenon very com- 
mon in cholera, by which the extremities, especially the fingers and toes, are 
moved after death, so as to change their position from that which they held 
immediately before death. This no doubt has given rise to the belief that 
many supposed to be dead were yet alive; and to the still more painful belief, 
that so they may have been prematurely buried. 
Such is the nature of cholera, according to the observation of Drs. Parkes, 
William Robertson, Schmidt, Niemeyer, Johnson, and Sir Thomas Watson; 
and thus " an early theory of the nature of this disease has received the sup- 
port of the best physicians and chemists of the day-namely, that the blood, 
if not the primary seat of the disease, becomes eventually contaminated by 
the action of a specific poison." 
The microscopy of the body in cholera, and especially of the stomach and 
intestines, has led to the rediscovery in Germany (by Drs. Thome and Klob) 
of microscopical bodies like fungi, innumerable and vehemently multiplying, 
whereof swarms are shed with prolific and infective power in each character- 
istic evacuation of the sick. At the International Medical Conference on 
cholera, which met at Easter of 1867, at Weimar, and which Mr. Simon 
attended, Professors Hallier, of Jena, and De Bary, of Halle (two of the lead- 
ing mycologists of Germany), were associated with Drs. Thome and Klob to 
make, in common with them, a statement and appreciation of the facts which 
had been observed, and which are in substance that-" Both observers find in 
cholera evacuations and in the intestinal mucus of the dead body definite 
organic structures, consisting of excessively fine granules, clustered more or 
less densely in the interspaces of a jelly which surrounds them. The granules 
divide and subdivide themselves, to form beaded threads, which interlace in 
immense numbers, into felted masses in the mucus. The further development 
of these organisms has been determined by Thome and Hallier. By sowing 
or cultivating them, these observers have got, after some time, larger round 
cell-like bodies, which rapidly multiplied, and also abundant filamentous fungi 
(cylindrotcenium) on which grew cylindrical spores, capable of developing 
again to filaments" (Ninth lieport of Mr. Simon, p. 31). 
In 1849 the question of fungi in cholera stools was repeatedly discussed on 
the repeated observation of several independent observers; but the objects 
then described do not seem capable of precise identification, or as being ex- 
actly the same as those now described. It would appear that Boehm in 1838 
described " the whole extent of the intestine as teeming with a vegetation of 
microfungi; that innumerable round and oval, or more elongated corpuscles, 
are to be found in all the vomit and dejections, as well as in the canal, some- 
times single, sometimes two, three, four, or more, joined end to end, as links 
of a chain, and these chainlets sometimes branching; that such forms are held 
together in mucous floccules, and come best to light when liquor potassce is 
used; that within the small intestine they are often so numerous that not the 
smallest specimen will fail to show numbers of roundish fungi forms amid the 
debris of epithelium" (Uber das vorkommen der Gdhrungokeime (FUze) im 
Nahrunga-Kenal der Cholera-Kranken, quoted by Mr. Simon, Ninth Report, 
p. 518). 
In the microscopic examinations of the "rice-water stools" of cholera in 
1848, made by Dr. Parkes (whose observations were at the time confirmed by 
Drs. Sharpey and Jenner, and by Bowman, Hillman, Ellis, and Quekett), 
"peculiar corpuscles" were observed and were variously named as such, or as 
"dark-yellow granules," or as "organic corpuscles (about the size of the pale 
corpuscles of the blood), finely granular on the surface, and containing from QUESTION OF SPECIFIC FUNGI IN CHOLERA EXCRETA. 
647 
six to twelve dark-yellow or black granules." Without being able to state 
what these "peculiar corpuscles" are, Dr. Parkes goes on to show that they 
are not mucous, but that their existence and development are confined to the 
deep algid period-that they are not seen in the premonitory diarrhoea, nor 
after the algid stage, and disappear when the pulse and the warmth of the 
surface are returning. They coexist in their greatest perfection with the 
purest type of the cholera fluid (London Journal of Medicine, 1849, p. 144, 
et seq.f Thus Dr. Parkes, and those observers who aided him, recognized 
certain "peculiar corpuscles or granules" in the rice-water stools of cholera; 
but neither of them suspected the peculiar corpuscles or granules to be of 
vegetable or fungoid origin. They appeared then to Dr. Parkes to be "but 
modifications of the same substance-namely, fibrin." He, however, recog- 
nized "vibriones in great numbers, and two or three oval transparent bodies 
placed end to end. When the stool was kept, these fungi increased in num- 
bers" (Ob. 6). In the descriptions and plates of Klob, Thome, and Hallier, 
the corpuscles and granular bodies which they figure were recognized by Dr. 
Parkes as similar-to those which so attracted his attention in 1849. He again 
noticed these bodies in 1865 and 1866, when they vividly recalled the pre- 
vious observations to his mind. Dr. Parkes concludes from these and his 
own observations, that this fungus development really exists, and invariably 
in cholera dejections. He found them in every stool which he examined in 
1849 and in 1854; and he again saw them in 1865 and 1866. He is familiar 
with all the forms described by Klob and Thome; and believes them univer- 
sal in cholera stools; and they form the major part of the white flocculi of 
the true "rice-water stools" (Report on Progress of Hygiene in Army Med. 
Dep. Reports for 1865). In 1854, Dr. Lauder Lindsay also recognized large 
bodies which he named "gonidic," from their resemblance to the gonidia of 
the lichens. They appear quite globular, usually larger than pus-corpuscles; 
have a distinct wall, colorless and transparent; frequently a distinct central 
nucleus, also colorless, round which are aggregated a number of rounded 
granules of a bright greenish-yellow or orange color, resembling the chloro- 
phylle grains in the cells of plants. These bodies have occurred in greater or 
less abundance in the evacuations of all the cholera patients under Dr. Lind- 
say's charge; and they pass through the digestive apparatus both of man and 
the dog apparently without change (Edin. Med. and Surg. Jour., 1854). 
Professor E. Hallier, of Jena, whose reputation as a fungologist is not sur- 
passed, has made numerous experiments by the cultivation of these spores; 
and from an able summary of his paper by Dr. Buchanan (Ninth Report to 
Privy Council, p. 512), it appears that his observations were made on the stools 
of a person ill with cholera at Berlin in 1866, and on the stools and vomita 
of a cholera patient at Eberfeld in 1867. The characteristic vegetable ele- 
ments consisted of a fine fungiform matter which floated, and of more highly 
developed spore-cysts which sank to the bottom (Figs. 1 to 4 of engraved plate). 
These spore-cysts were yellow or brownish bodies, consisting of a pale mem- 
brane inclosing highly refracting colored spores. The cyst-wall undergoes a 
series of changes, ending in its rupture or solution, when the spores become 
free. The spores then, by progressive (tomiparous) partition (a process which 
may begin before they leave the cyst), resolve into very small cells, grouped 
into balls and heaps, which Hallier calls "colonies of micrococcus." The 
small cells constitute the fungiform matter seen in the evacuations, and they 
attach themselves to any bodies there may be in the stool-to remnants of 
animal or vegetable food, to epithelium cells, or to oil-globules, when these 
and all nitrogenous matters to which these fungi cells fix themselves become 
of a dirty aspect and lose their structure. 
Besides these two elements (the spores and minute cells), torula-like bodies 
(Fig. 3, c) were found in smaller number, and were shown by cultivation to 648 
SPECIAL PATHOLOGY-MALIGNANT CHOLERA. 
develop from the micrococcus cells. The formation of these cells (which 
occur singly or in rows) marks a step towards a higher development of the 
micrococcus-towards the production of oidium* forms of fungi. 
In the stool and vomit from Eberfeld, the cysts and colonies of fungi were 
found in smaller proportion, and the free micrococcus cells more abundantly, 
and epithelium was seen in which the process of invasion by the micrococcus 
could be watched. The little cells fastened themselves upon the epithelium, 
and increased in size as the epithelial elements wasted. The parasitic cells of 
fungi always grow at the expense of any nitrogenous organic substance which 
they attack. 
To learn the development and ultimate form, so as to identify the fungus, 
Hallier had recourse to the artificial cultivation of the spores, on several sub- 
stances on which fungi are known to increase, multiply, and grow, such as in 
sugar, starch, paste, flesh, and the like (Figs. 5 to 8 of engraved plate), in the 
same way that our distinguished fungologist, the Rev. M. J. Berkeley, made 
out the nature of Mycetoma. Conducting the growth at a temperature of 68°- 
88° Fahr, in sugar, Hallier succeeded in growing from the spore-elements a 
long pale filament containing granular plasma, and divided by septa; from 
this elongated processes branched off, and the whole formed a structure greatly 
resembling the oidium lactis. This oidium plant bore at the ends of its branches 
bulbs (macroconidia, Fig. 7, m), either single or in shorter or longer series: if 
single, generally larger, and apt to develop mucor forms; but if in series, more 
apt to develop penicillium forms. On the ninth day of the experiment some 
of the branches bore a cyst containing spores, pale and weakly. Only once 
did a well-developed colored spore-containing cyst make its appearance; and 
Hallier's experience led him to connect the absence of such cysts with the ab- 
sence of nitrogenous matter from the soil in which the fungus was growing. 
A variation of the experiment, by providing the fungus with starch paste, 
produced scarcely different forms; but a more interesting result came of the 
addition of a small quantity of tartrate of ammonia to the paste. For the first 
few days of this experiment nothing but micrococcus cells, and chains of similar 
elements resembling leptothrix,f were seen; but about the fifth day there ap- 
peared a small brown speck in the paste at some little distance from the sur- 
face, at a spot where the reaction was alkaline. This brown spot gave to the 
microscope colored forms, filaments bearing macroconidia, single and in series 
(Fig. 7), and some of them also bearing bunches of spores, or well-developed 
cysts containing spores, and greatly resembling the cysts found in the original 
stools. Upon the occurrence of an acid reaction in the paste the growth of 
these bodies ceased. 
The spores of the fungi were further grown upon muscular tissue immersed 
in sugar solution. The micrococcus cells were seen enlarging and budding, 
and developed the usual oidium plant with conidia at the ends of its branches. 
Shortly after numerous cysts appeared, which went through the same 
changes as the cysts in the original stool. The muscular fibres were invaded 
* The oidium fungi belong to the order mucedines-the " blue moulds "-having 
flocci very short, producing a monoliform string of spores by tomiparous division. In 
temperate climates they grow on damp paper, dead wood, decayed fruit (grapes, 
oranges), on porrigo lupinosa, on honeycomb, on nettles, ground ivy, and on plants in- 
fested with ergot. They belong to the family Hyphomycetes, or "thready fungi," the 
characteristics of which are filamentous, with fertile naked threads, for the most part 
free, and bearing the spores at their apices. (See Berkeley's Outlines of British 
Fungology, pages 337 and 350.) 
f These belong to the family Coniomycetes, or " dust-like fungi," of which the spores 
are the prominent feature, and not the threads (as in Hyphomycetes}, the spores being 
either solitary or concatenated, produced on the tips of generally short threads, which 
are either naked or contained in a perithecium, or compacted into a gelatinous mass. 
Rust and mildew are examples of this family. Leptolhrix consists of the mycelial fila- 
ments of mildew fungi, abounding in foul water in flocculent masses. FUNGI, AND THEIR DEVELOPMENT BY CULTIVATION, 
PROM THE "RICE-WATER-LIKE-STOOLS" OF MALIGNANT CHOLERA 
(AFTER D^ ERNST HALLIER.) QUESTION OF SPECIFIC FUNGI IN CHOLERA EXCRETA. 
649 
and decomposed by the micrococcus, just as the intestinal epithelium had been 
in the stool.* 
A subsequent observation made with cholera fungi grown in Hallier's isola- 
tion apparatus, upon paste which had been boiled with tartrate of ammonia, 
gave highly developed cyst formations with the contained spores in a state of 
actual germination, and pushing their processes through the cyst-wall. This 
is the exact counterpart of a form known as Urocystis occulta, found in the 
tissues of cereals; and a very similar form, Urocystis intestinalis, is found in 
diphtheritic diseases of the intestine. The observation of cysts apart from 
filamentous growth, as they were in this experiment, is particularly instructive, 
as it is under somewhat similar conditions that the development of the cysts, 
also apart from filamentous growth, takes place in the intestine of cholera pa- 
tients. (Fig. 9, a, commencement of proliferation.) 
Twenty-two such experiments were made with the cholera stools, and results 
consistent with those above described were obtained. Hallier's experience 
thus enabled him positively to prevent, and to know that he had prevented, 
the accidental entrance of any atmospheric fungus into his cultivation experi- 
ments. He proved the "peculiar corpuscles" to be spores of a fungus, and to 
belong to a species which comprises forms of Penicillium\ crustaceum, Mucor^ 
ramosus, Tilletia,§ and Achlya,\\ which are four different forms or developments 
of the Macroconidia in the same oidium-like fungus. But in the actual rice- 
water stool it is none of these four developments, but a fifth, which systematists 
would place under the group of Urocystis.9^ Hallier has obtained in the course 
* Explanation of the Engkaved Plate in Illustration of Professor Sal- 
lier's Experiments on the Fungus found in the "Rice-water" Stools 
of Cholera (p. 617 to 620 of text). 
Figs. 1 to 4-Vegetable Growths of Nature of Fungi, seen in the Cholera Rice-water 
Stools: Berlin, 1866. 
1. Groups of swollen gelatinous spores in the act of forming micrococcus by re- 
peated divisions of the nucleus. The spores are surrounded by micrococcus cells. 
2. Gelatinous cysts swollen and breaking up. (c) Small cyst with clear spores; 
(1} gelatinous cyst; (A) wall of cyst subsequent to discharge of the spores. 
3. Yeast formations, (m) A large colony of micrococcus corresponding with a 
spore; (&) a large colony of micrococcus about to break up; (k) a group of colonies 
originating from the spores of a cyst; (c) torulaAike cells grown from swollen and 
enlarged micrococcus. 
4. (n) Several cysts connected ; (o) a large globular cyst discharging its spores ; 
(a) semi-divided spore, showing the commencing formation of micrococcus; (&) 
spore quartered ; (c) groups of spores from a small cyst. 
Figs. 5 to 8.-Products of " Cultivation," No. 1: Berlin Rice-water Stool of 1866, 
with Sugar Solution. 
5. Micrococcus and torula formations. 
6. Germination of toruia cells. 
7. Filamentous termination of a healthy germ, (m) Macroconidice; (c) cysts; 
(d, c) degenerated cysts. 
8. Completely formed cyst with spores, one of which is just about to germinate, (k). 
Fig. 9.-(a ) Commencement of proliferation. 
f Penicillium.-Hyphomycetous fungi, the commonest constituent of green and blue 
mould, a form which grows in all kinds of decaying substances, but especially in semi- 
fluid matters. 
| Mucor.-Physomycetous fungi, hearing vesicles containing indefinite sporidia, the 
common mould of paste and of decaying fruit. 
| Tilletia.-Conomycetous fungi, the "bunt" of various corn grains, especially the 
Dhoora corn of the tropics and the maize of temperate regions. 
I| Achlya.-An aquatic form of mucorinous fungi-parasitic on the bodies of dead 
flies in water, fish, frogs, and decaying plants. It appears as colorless filamentous 
tufts enveloped in a gelatinous cloud. 
<[ Urocystis, of Eastern habit, seem to belong to the forms of Ustilago of temperate 
regions, of the order Puccinioei and family Coniomycetes. The spores of this order are 
simple, springing from delicate threads, or produced in the forms of closely packed 
cells, which ultimately break up into a powdery mass. The spores produce in germi- 
nation secondary spores, and the plant is parasitic on living plants, and is deeply 
seated. Ustilago yields the " smuts" on corns and grasses of this country. 650 
SPECIAL PATHOLOGY-MALIGNANT CHOLERA. 
of his mycological studies oidium plants exhibiting the other forms of growth, 
but he has never produced by artificial cultivation cysts of Urocystis on them, 
except from these cholera stools. Thus, in the course of innumerable obser- 
vations on milk oidium, where penicillium and mucor were met with, nothing 
resembling the cyst forms was ever seen. From this and other considerations, 
Hallier infers that this form is not indigenous to Germany, and that it has 
travelled with cholera from India. In the next place, he cannot think that 
the original habitat of the fungu^ should be the human intestine, which is 
under much the same conditions in India as in Europe; but he sees in the high 
temperature of the intestine a condition capable of maintaining this fungus in 
activity, once it is introduced (as it may be by direct intercourse with India). 
A similar high temperature, as provided by the mean climate of India, and 
by the extreme summer climate of Europe, also furnishes the condition requi- 
site for the development of the fungus outside the body. Thus in summer, 
and in summer only, in European latitudes, could the fungus find in earth 
and night-soil the necessary temperature for its. increase. The conditions for 
the production of Urocystis appear by the experiments to be, not high tem- 
perature only, but also a copious supply of nitrogenous with some hydrocar- 
bonous nutriment, and a high degree of moisture. But besides these conditions 
the reaction of the fluid was found to be important, and this again to be de- 
pendent on the nitrogenous elements of it. 
Hallier points out that the home of all penicillium-bearing fungi is Asia. 
The tilletia-bearing form occurs only on wheat, which is a plant imported from 
Asia. Hence he infers a further probability that the cholera fungus, which 
appears to be another development of the same species, is also originally 
Asiatic. 
Further observations as to the precise effects of temperature confirmed the 
foregoing deductions. Fungus, while developing Penicillium only at ordinary 
temperatures, was grown upon appropriate nitrogenous soils at a temperature 
of 88° to 110° Fahr., and (when other circumstances were favorable) a devel- 
opment of cyst forms took place from the budding of the Penicillium, pre- 
cisely like the forms met with in the stool. A piece of intestine exposed to 
the action of the cholera fungus at this temperature got its epithelial elements 
rapidly destroyed by micrococcus. Converse experiments with low tempera- 
tures showed that the characteristic cyst forms of cholera stools were not pro- 
duced upon materials that were kept below 54° Fahr. The inference is there- 
fore confidently drawn, that if the fungus be indeed the contagious material 
of cholera, cholera cannot maintain itself permanently in our latitudes. Other 
conditions under which the fungus did not grow were,-(1.) A temperature 
over 144° Fahr.; (2.) Sulphate of iron in concentrated solution ; (3.) Carbolic 
acid (not the most potent agent of its kind in these experiments); (4.) Per- 
manganate of potash; (5.) Wine (from its acidity, probably) and strong 
alcohol. Quinine had some influence, opium none, in preventing the destruc- 
tion of animal tissue by the micrococcus. Of all experiments made to deter- 
mine the power of chemical agents upon the fungus, chief success was obtained 
by the free acidification of the fluid. This is confirmatory of Pettenkofer's 
views upon the disinfection by acids of substances infected by cholera poison. 
Whenever the fungus grew in acid solutions it showed no cysts and no micro- 
coccus, only penicillium and cognate forms. For fungus destruction on the 
large scale Hallier would give preference to sulphate of iron. But he insists 
particularly on the destruction of each individual stool before mixing it with 
other night-soil, and of course urges the systematic removal of all such matters 
to the field. 
Professor Hallier's inquiry is next concerned with the circumstances under 
which the so-called cholera fungus, indigenous to Asia, and only travelling 
into northern latitudes in the bowels of cholera patients, grows in its native 
soil of India. He recalls the fact that other forms of the fungus under con- SPECIAL INQUIRY AS TO THE FUNGI OF CHOLERA. 
651 
sideration are peculiar to cereal plants, and that the Urocystis, with its char- 
acteristic cysts, inhabits the delicate and highly nitrogenized tissues of grasses; 
and he asks whether the cholera cysts may not also in their native soil be 
parasites to some graminaceous plant, just as the form Tilletia, which can 
exist in a European climate, is a parasite upon the imported cereal, wheat, 
which acclimatizes itself in these latitudes. 
Herein he considers the circumstance assumes a peculiar importance, inas- 
much as at their first acquaintance with cholera English physicians in India 
named it "rice-disease" [Morbus oryzeus, Tytler), and connected it with a dis- 
eased condition of the rice plant. Examination into the existence of a similar 
fungus attacking rice in India must of course be undertaken by inquirers in 
that country; and on the best authority (that of the Rev. M. J. Berkeley) we 
know nothing of the microscopic fungi of India ; but Hajlier makes a notable 
contribution to this aspect of the question by his experiments. He planted 
rice under conditions of heat and moisture as nearly as could be obtained like 
those of Asiatic rice-fields, and he watered these plants with the stools and 
vomita whose investigation had occupied the earlier parts of his paper. He 
obtained in every one of these experiments positive results. Carefully taking 
out his little rice plants in an early stage of their growth, he made longitudinal 
sections of them, and found fungus threads in great numbers perforating the 
epidermis of the plant in several places above the junction of the rootlets. 
The cells, as well as the intercellular spaces of the tissue, were invaded, and 
the delicate plasma of the cells was shrivelled and coarsely granular; and by 
the aid of glycerin a multitude of cryptococcus cells were seen, and had the 
same characters as when known Urocystis grows within cereal plants. Here 
his investigation ended, without proof having yet been obtained of the identity 
of the parasitic fungus with the cyst-bearing plant, but with the important 
result that a form of the same type, at any rate, could be produced in rice 
during its growth, when watered with the cholera evacuations (Buchanan, 
1. c.). 
With reference to such positive assertions by the most eminent botanists in 
Germany, that there are fungi of a special character in cholera discharges, 
and that many physicians adopted the belief that cholera spread by the growth 
of such plants, the Professors of the Army Medical School at Netley consid- 
ered this special subject relative to cholera as one which ought to be thor- 
oughly examined by men specially trained for the inquiry. The examination 
of microscopic fungi is one of extreme difficulty and delicacy, as has been 
shown at p. 220 et seq.; and their pathological bearings require a competent 
knowledge alike of botanical and of medical science. 
In the event, therefore, of any continued and exhaustive inquiry into the 
origin and spread of cholera in India, the Professors recommended to the 
Senate of the Army Medical School, at their meeting on 6th of June, 1868, 
that two of the medical candidates then at Netley, who were considered spe- 
cially qualified for this particular training, should receive special instruction 
on the point, with a view to their employment in India in this particular in- 
quiry ; and that after leaving Netley they should visit Germany, spending 
some months there in learning practically the modes of investigating fungi 
employed by Professors De Bary and Hallier. 
The reason for recommending that these gentlemen should be sent to Ger- 
many was not only that the assertions on the cholera fungus had been chiefly 
made there, but also because the means of investigating the growth and char- 
acters of fungi could at that time be more completely taught there than in 
England. With respect to the investigation itself, it was considered quite a 
reproach to this country that it had not been hitherto made. 
The following scheme was submitted to the Director-General of the Army 
Medical Department, in the hope that he might sanction its being laid before 
the Secretaries of State for War and for India, for their joint consideration 652 
SPECIAL PATHOLOGY-MALIGNANT CHOLERA. 
1. That two gentlemen now studying at Netley, and who are first in the 
respective lists for the British and Indian services, shall be sent to Germany 
for the purpose of receiving particular instruction and directions from those 
German professors who have described the so-called cholera fungus. 
2. That arrangements shall be made to give these gentlemen leave of ab- 
sence and payment of expenses during the time that they are so employed. 
3. That they shall subsequently be sent to Bengal, and be placed under the 
orders of the officer appointed to carry out the investigation on cholera, with 
directions that they are to be solely employed in the investigation of the ex- 
istence, nature, and relations of the so-called cholera fungus, with a view to 
settling this disputed point completely. 
In accordance with the above recommendation, the visit of Drs. D. Cun- 
ningham and Lewis to Germany was sanctioned by the Government. Special 
instructions were drawn up for them; and they went on the 1st of October, 
1868, and remained till the 18th November, visiting Professor De Bary at 
Halle, Professor Hallier at Jena, and Professor Pettenkofer at Munich ; and, 
after their return, they saw the Rev. M. J. Berkeley, Mr. Huxley, and Mr. 
Thompson at Kew, on the subject of their special inquiries. 
They afterwards sailed for India on the 12th December, 1868, the Senate 
of the Army Medical School having made a recommendation as to the con- 
duct of inquiries for the approval of the Secretary of State for India in the 
following terms: 
" With regard to the course of inquiry, it is believed that details will be 
best settled in India after conference between the two gentlemen and the Sani- 
tary Authorities in Bengal. The Senate believe, if it is clearly understood 
that the investigation has for its object the examination of the causes of 
cholera, no difficulty will be felt in framing a correct course of inquiry. Of 
course, all the evidence at the disposal of the Bengal Government will be 
placed before these gentlemen, and the first five or six months should be occu- 
pied in Calcutta with an examination of this evidence, with learning the 
native language (an essential point), and in preparing the chemical and mi- 
croscopical arrangements for the subsequent inquiry. 
" Without desiring to lay down any fixed arrangement, the Senate consider 
that the investigation should take two directions: 
" 1. Personal visits of greater or less duration to places notorious for cholera 
outbreaks, or noted for decided exemption, and regular study of all the con- 
ditions of soil, water, and air, which may throw light on the cause of the 
prevalence or exemption, should be made. The part which fungi play in the 
production of cholera will perhaps be first settled ; and if this part of the in- 
vestigation is found to be fruitless, the inquiry, so far from being given up, 
should be continued in all possible directions. 
" 2. The two gentlemen, besides making these personal inquiries, may desire 
to have investigations carried on in places which they are not personally ex- 
amining. When they see their way to effectively instituting such inquiries by 
deputy, it is very desirable that assistance should be given to them, and that 
they should extend their investigation by making use of native, or, possibly, 
European aid. It may be possible for them to train natives, and observe va- 
rious points connected with drinking-water, the level of ground-water, the 
presence of fungi on plants, &c., and thus to get information from a wider area. 
" The Senate understand that a systematical inquiry into cholera is about 
to be instituted by the Government at the suggestion of the Director-General 
of the Army Medical Department and of the Army Sanitary Commission.* 
* That the Commission, after analysis of papers and consideration of results relative 
to cholera in the Northwest Provinces of India in 1867, arrived at the conclusion 
that the only lesson of practical importance conveyed by the papers is, that it is most 
desirable a special inquiry into the whole subject of epidemic cholera in the East should 
be undertaken-; and, accordingly, the Commission issued a memorandum, of date CONCLUSIONS REGARDING THE SO-CALLED CHOLERA FUNGI. 
653 
They would suggest that the work of these two gentlemen should form part 
of that larger inquiry, which would of course embrace questions not only of 
origin and transmission, but also of treatment and morbid anatomy, &c., 
which it is not intended that Drs. Cunningham and Lewis should enter into. 
The Senate is satisfied that this intricate question will not be solved unless 
the undivided and earnest attention of scientific observers, such as these gen- 
tlemen, can be given to it." 
With careful appliances these men went out to India, where they received 
every attention from the authorities ; and a Report has since been published 
by Dr. Lewis, after a long and elaborate investigation of the fungoid forms 
referred to by Hallier and others, in which he arrives at the following con- 
clusions : 
The results of the investigation referred to in the Sixth Annual Report of 
the Sanitary Commissioner with the Government of India for 1869, p. 164 
(Calcutta, 1870), may be thus summarized : 
" (1.) That no ' cysts ' exist in choleraic discharges which are not found 
under other conditions; (2.) That cysts or ' sporangia ' of fungi are but very 
rarely found under any circumstances in alvine discharges; (3.) That no 
special fungus has been developed in cholera stools, the fungus described by 
Hallier being certainly not confined to such stools; (4.) That the still and 
active conditions of the observed animalcules are not peculiar to this disease, 
but may be developed in nitrogenous material even outside the body; (5.) 
That the flakes and corpuscles in rice-water stools do not consist of epithelium, 
nor of its debris, but that their formation appears to depend upon the effusion 
of blood-plasma; and that the ' peculiar bodies ' of Parkes found therewith 
correspond very closely in their microscopic and chemical characters, as well 
as in their manifestations of vitality, to the corpuscles which are known to 
form in such fluid ; these are generally to a greater or less degree associated 
with blood-cells, even when the presence of such is not suspected, especially 
as the disease tends towards a fatal termination, when the latter have been 
frequently seen to replace the former altogether; and (6.) That no sufficient 
evidence exists for considering that vibriones, and such-like organisms, prevail 
to a greater extent in the discharges from persons affected with cholera than 
in the discharges of other persons diseased or healthy; but that the vibriones 
bacteria and monads (micrococcus) may not be 1 peculiar in their nature,' for 
these ' do ' vary, may not be the product of a peculiar combination of circum- 
stances, and able to give origin to peculiar phenomena in predisposed persons, 
is not proven." 
Dr. Macnamara also asserts his conviction, after a long and attentive study 
of the subject, that fungi peculiar to cholera dejecta have not yet been dis- 
covered ; that no doubt fungoid growths appear in this as in other nitrogenous 
matters undergoing decomposition-notably the oidium lactis and mucor 
ramosus; but neither are peculiar to decomposing cholera dejecta. Moreover, 
he desires particularly to affirm, that neither these nor any other fungoid 
growths can be discovered in fresh cholera stools. The more recent the speci- 
men the clearer this fact appears. Dr. Macnamara has examined the contents 
of the intestinal canal for the appearance of mycelial threads or sporangia, 
and even after protracted collapse, has absolutely failed in numerous instances 
in detecting any characteristic elements of the kind, and he states that he is 
reluctantly compelled to abandon his faith in the existence of any such growth. 
So far, therefore, as fungi are concerned in the spread of cholera, I am 
satisfied that we have no grounds for such a belief. 
April 12th, 1869, giving detailed instructions concerning points on which information 
is necessary. The Sanitary Commission, with the Government of India, are now car- 
rying out these special investigations as far as practicable, and accounts of their pro- 
ceedings are published monthly. 654 
SPECIAL PATHOLOGY-MALIGNANT CHOLERA. 
Chemical Changes undergone by the Body in the Progress of Cholera.-. 
Dr. J. L. W. Thudichum, at the instance of Mr. Simon, made important ob- 
servations during the epidemic of 1866, which are published in Mr. Simon's 
report of that year. The following is a summary of his results: 
The blood after death, during collapse, contains urea in variable abundance. 
The rice-water-like evacuations contain butyric acid, and yield nitrogen and 
carbonic acid, but no urea. In bodies deaci, at an early period, there was nd 
urea; and more seemed to accumulate after a protracted algid stage, and 
much more after three to six days' torpid condition. The greatest amount of 
urea was found after a long algid stage, with rise of temperature at the end. 
The secretion of bile is completely arrested; and in extreme cases a clear 
white fluid percolates through the hepatic ducts, free from bile, coloring mat- 
ter, and albumen. It seems to be simply water, with a trace of alkali and a 
vestige of mucus. In some instances the fluid is colored, but contains no bile 
acids. The bile-ducts shed their epithelium. 
This can only be determined after death, when all ducts shed epithelium in 
all diseases or modes of death that I have examined (W. A.). 
The blood loses ivater, albumen, and salts, and is incapable of passing the 
capillaries with the usual freedom. It retains most of its coloring matter in 
its normal chemical composition ; and Dr. Thudichum's observation led to the 
conclusion that any fermentation of the blood in the manner in which the 
intestinal contents are fermented was very improbable. The blood absorbs 
water from the tissues; and there is no chemical evidence of any special cholera 
poison in the blood. The epithelium of the inner surface of the bloodvessels 
becomes detached and mixes with the blood, and the blood adheres to the 
bloodvessels with great pertinacity. 
The Epithelium.-Death and desquamation of the epithelia pervade the 
entire surface where epithelium exists. 
In all of this description post-mortem results are unfortunately mixed up 
with vital phenomena; and it is to be regretted that evidence is so contradic- 
tory on a matter of .fact so definite as the shedding of epithelium during life 
in cholera patients. So long as the patient lives and passes the characteristic 
rice-water evacuations, I have never seen them containing shed epithelium in 
any notable quantity. 
In August and September, 1849, I examined numerous stools from patients 
dying in the collapse of cholera immediately after they were passed; and on 
reference now (1871) to my notes and drawings, I conclude that it is only 
in the post-mortem contents of the bowel (small intestine) that cylindrical 
epithelium is to be found-the result, no doubt, of maceration, and the usual 
desquamation that follows death. If they were shed so abundantly during 
life, as some say they are, how do they come to be so abundant in the con- 
tents of the intestine after death-a statement which is not denied ? Epithe- 
lium after death is alike found in the stomach, urinary, and gall-bladder. 
Denudation of the intestinal villi, or desquamation of the epithelium, is no 
essential lesion of cholera. Boehm's statement seems to have been adopted 
as one of authority, without further question; and while competent observers 
have agreed with him (e. g., Beale) on the one hand, no less competent ob- 
.servers have not been able to confirm it on the other (e. g., Parkes, Gairdner, 
Lauder Lindsay). The observations at the London Hospital (Report, vol. iii) 
and those of Dr. Bruberger, of Berlin, who examined the stools of 540 cases, 
confirm the statements of Parkes, Gairdner, and Lindsay ( Virch. Arch., 1847, 
p. 361, quoted by Parkes in Army Med. Report for 1865). It may be, how- 
ever, that a distinctive change in the epithelium, described by Dr. Mac- 
namara, may be so complete as to prevent its recognition as such. He thus 
describes a rice-water stool: "They are always alkaline, consisting of a watery 
gruel or cream-like fluid, composed of thinner and thicker portions. Its con- 
sistence varies according to the varying quantity of its component parts. The QUESTION AS TO EPITHELIUM IN THE STOOLS. 
655 
thicker portions are flaky, stringy, curdy, or clotted. When first passed, the 
rice-water evacuation soon separates into two portions, the flocculent curdy 
matter sinking to the bottom of the glass or vessel in which it is contained, 
leaving a whitish fluid above. This separation of the material into two parts 
takes place rapidly in many instances, say in from one to three hours, and is 
evidence of the severity of the disease ; for if the more solid matter of the de- 
jecta collects in the lower part of the fluid very speedily, it indicates the com- 
plete death and disintegration of the organic matter. On the othei' hand, if 
the separation of the fluid and more solid components of the rice-water prod- 
uct takes place slowly, it is on account of the evacuation containing a con- 
siderable quantity of comparatively healthy mucus, and the case so far allows 
of a more favorable prognosis. The flocculent matter of the stools is com- 
posed of epithelial cells, and the mucus lining of the intestinal canal in 
various stages of decomposition; but the perfectly fresh dejecta in the active 
stages of the disease contain no vibriones. Towards the encl of collapse, when 
the evacuations are passed less frequently, probably remaining in the intes- 
tine for some hours, vibriones may be seen in the fluid immediately after it is 
passed." 
" The epithelial cells are often shed in large quantities during the early 
stages of cholera. For instance, in the case of a little boy-three years of 
age-whom I was called to see, and who had gone to bed apparently in perfect 
health, and slept soundly through the night; on rising next morning he had 
a call to stool, and the mother noticed something peculiar in his appearance; 
on examining the pot, she discovered it to be full of a dirty brown-looking 
fluid. The child lay down, and seemed much exhausted. I was sent for, and 
within half an hour arrived at my patient's house, to find him almost pulse- 
less, and passing fast into a state of collapse. The first stool had been kept 
for my inspection. I secured a specimen of it, and had it under the micro- 
scope within two hours of the time it was passed. It contained a vast num- 
ber of columnar epithelial cells ; all of them were more or less under the in- 
fluence of the molecular change I have so frequently referred to. The stools 
passed by this poor child at ten p.m. contained comparatively few cells that 
could be identified as such, though I am not prepared to say that much of the 
flocculent matter was not composed of disintegrated epithelial gland-cells and 
mucus, doubtless combined with albumen and other organic matters in a state 
of decomposition." Again, he states, that "the changes in epithelium occur 
during the life of the patient, and are evidence of the rapid destruction of 
these cells taking place before death." The cells under a quarter-inch ob- 
ject-glass contain a vast number of minute dark specks, precisely similar to 
those seen in a pus-corpuscle. The majority of the epithelial cells are invaded 
by this molecular matter. In a few hours this increases, so that the outlines 
of the cells become altered, their margins jagged, and ultimately their shape 
is completely destroyed, the molecular matter increasing at their expense. The 
result at the end of a few hours is an irregular mass of molecular matter- 
granular, diphtheritic, or amorphous deposit, as it has been variously called by 
authors. It is an aggregation of these molecular masses which constitutes 
the bulk of the flocculent substance noticed in the rice-water stools of cholera 
patients. 
I have underlined certain portions of this description to draw attention to 
its bearing on the varied descriptions given as to the presence of epithelium 
shed, and seen as such. As form is one of the chief modes by which objects 
are recognized under the microscope, and as ultimately the shape of the epithe- 
lium is completely destroyed, and the result is an amorphous deposit, it must 
be very difficult to identify this result as having been originally epithelium. 
The simple question of fact regarding the shed epithelium has yet to be de- 
cided by observation, just as the question of fungi has been. 
After death, Niemeyer states that the most important appearance in the intes- 656 
SPECIAL PATHOLOGY - MALIGNANT CHOLERA. 
tines is the great loss of epithelium. The intestinal villi are stripped of their 
protecting covering, or it is elevated by a serous effusion, and still loosely 
adherent to the villi; or it lies on the intestinal wall as shreds of mucus. So 
also Niemeyer, on the authority of Bruberger, states that the white flocculi 
floating in the serum rarely consists of perfect cylindrical epithelium, but gen- 
erally of its remains, in the shape of fine loose nuclei, with coarse or fine granu- 
lar masses imbedded in a mucous basement-substance, and of round, nucleated, 
coarse or finely-granulated cells. 
The tissues generally are doughy to the feel, from want of water. The mus- 
cles become dry and are affected with cramps; the spasms, beginning at the 
most distant parts, rise gradually to the centres; and the cramped muscles 
show deposits; urea accumulates in them, and nuclei of their sarcolemma 
multiply. 
Intestinal Contents and Rice-water Evacuations.-The contents of the colon 
half an hour after their removal were observed to evolve gas, and to lift off 
the heavy glass stopper of the bottle in which they were contained. Their 
smell was putrid, but not fecal. The flocculent deposit which formed on 
standing filled one-half of the bulk of the fluid. It consisted of intestinal 
epithelium in patches, single cells, and cells in all conditions of disintegra- 
tion, and great numbers of vibriones. The fluid filtered but very slowly, and 
the filtrate was not clear. Its reaction was strongly alkaline. On dialysis 
of the alkaline rice-water, the dialyate gave an acid reaction, from which, on 
being neutralized by baryta water, and the fluid evaporated, several matters 
could be obtained, namely: (1.) A body crystalline like leucin, and combin- 
ing with nitric acid; (2.) An oily substance, which was soluble in water, and 
with nitric acid gave a peculiar pink reaction ; (3.) Butyric acid, combined 
with the added barium; (4.) Inorganic salts in considerable quantity; (5.) 
No urea could be discovered in the rice-water stools. 
Volatile acids, butyric and acetic, were obtained also from the rice-water 
stools and intestinal contents, the latter apparently prevailing in quantity. 
They were combined with ammonia in the original fluid. The rice-water evac- 
uations, therefore, contain the following ingredients: Vibriones, cells from the 
surface of the intestine, granular debris of cells, mucin, modified hsemochrome, 
albumen, albuminous body giving rose-pink reaction, butyric acid, acetic acid, 
ammonia, leucin, inorganic salts. Nearly the same results were obtained by 
Dr. Lauder Lindsay in 1853. The evacuations are in an active state of decom- 
position, and evolve gas, which at first is composed almost entirely of nitro- 
gen ; soon, however, carbonic acid prevails, and ultimately nothing but car- 
bonic acid is evolved. At one period some hydrogen is developed. In 1848 
Dr. Parkes examined many cholera stools, and his observations coincided with 
those of O'Shaughnessy, Vogel, Wittstock, and Andrew Buchanan (of Glas- 
gow). The thin fluid was always alkaline, and contained an abundance of 
alkaline chlorides, phosphates, and sulphates, and a certain proportion of albu- 
men. The odor was always peculiar. 
Dr. Thudichum cannot discover any specificity in the above ingredients; 
but many of them are analogous to the products of ordinary processes of putre- 
faction. If it is admitted that the cholera evacuations acquire infective pow- 
ers only after a period of fermentation, it is also easy to understand that the 
specific infecting power may belong to albumen or mucin at a particular stage 
of disintegration or chemical cleavage. The nextknowdedgewhich.it is nec- 
essary to acquire is evidently this-namely, the exact period at which the 
rice-water stools acquire infective properties, and their chemical composition 
at that period. The most dangerous period of the choleraic stools is believed 
to be when they become very ammoniacal. This occurs usually immediately 
they are passed, but not to any extent for some time ; and anything which 
makes and keeps them acid prevents the ammoniacal change (Parkes). 
Symptoms and Various Forms of Cholera.- Cholera Indica has many de- COMPOSITION OF CHOLERA EVACUATIONS. 
657 
grees of severity, and hence many pathologists have divided it into Cholera 
Indica mitior, and into Cholera Indica gravior. The French have termed the 
slighter forms of the disease Cholerine, and this name has been also recently 
used by Dr. Farr to designate the specific poison or zymotic matter of 
cholera. 
Malignant Cholera, is divided into two stages,-the cold, pulseless, or 
asphyxiated stage, and the febrile stage, when the patient outlives the first. 
This latter stage, however, is not essential to the disease, and has been observed 
in India in a small proportion of the cases only. In Europe, however, the 
febrile paroxysm has followed in the majority of instances. The duration of 
the cold stage varies from a few minutes to twelve, twenty-four, forty-eight, or 
even more hours; while the febrile stage lasts from four to eight or more 
days,-making the total duration to vary from a few hours to two, three, 
or even four weeks. 
The attack of this fatal disease is most commonly sudden, the patient at the 
time of his sickness being apparently in his best health; yet not uufrequently 
slight diarrhoea or other general indisposition has preceded it. In India, in 
some cases, the premonitory symptoms are vertigo, noise in the ears, the latter 
sometimes so loud as to have been compared to the humming of a swarm 
of bees, to the beating of drums in the camp, or to the roaring of the surf on 
the Coromandel coast. 
A period of incubation has been variously fixed at from one to fourteen 
days. Niemeyer fixes it at not less than thirty-six hours, and not more than 
three days. 
A classification may be made of the disease into three principal varieties, 
which coincide in their phenomena with many of the changes known to take 
place in the blood (Parkes). 
1. The slighter forms commence with much watery purging and vomiting, 
and pass into the second and third varieties in varying times. There may be 
from ten to fifty copious watery stools, but losing neither their odor nor color, 
and frequent copious vomiting, before there is any great loss of heat and fail- 
ure of circulation. When purging commences twenty-four hours, or two or 
three or four days, before the violent symptoms, such as vomiting, purging, or 
cramps, such patients are said to have "premonitory diarrhoea." But there 
is always some degree of loss of heat and failure of circulation even in the 
slightest cases, else the case would be mere watery diarrhoea, attended only by 
exhaustion, and not by the symptoms peculiar to cholera. Cramps are sel- 
dom present till the stools put on the true choleraic character-viz., of copious 
white flocculi suspended in a watery fluid. The algid symptoms come on 
gradually, and are less intense than in the following forms; recovery is also 
more common. In the recent epidemic in London (1866), Dr. Sutton gives 
forty-one examples in which there was undoubted premonitory diarrhoea, the 
duration of the diarrhoea being as follows: In three cases, 12 hours; in one 
case, 18 hours ; in one case, 19 hours. In seven cases, 1 day ; in one case, 1 day 
and 9 hours; in twelve cases, 2 days ; in six cases, 3 days ; in two cases, 4 days; 
in two cases, 5 days; in one case, 6 days ; in one case, 7 days. In two cases, 2 
weeks; in one case, 5 weeks; and in one case, 8 weeks. In more than half the 
number of cases the diarrhoea preceded the marked symptoms by one, two, or 
three days; and of the forty-one cases, the diarrhoea in twenty-six was limited 
to the first three days. 
During an epidemic of cholera, all such cases of severe diarrhoea ought to 
be regarded practically as cases of cholera, with reference to sanitary meas- 
ures; seeing that the transportation of cholera is now known to have been 
effected by persons suffering from these diarrhoeas, which sometimes pass on 
into the severest forms of cholera. 
2. If the poison acts with greater intensity, we have the second variety, in 
which there is less physical alteration in the fibrin, and the circulation is 658 
SPECIAL PATHOLOGY MALIGNANT CHOLERA. 
carried on for a longer time. Consequently, the characteristic change is not 
evidenced solely or chiefly in the interior of the vessels, but it is partly 
transferred to the exterior of the vascular system. The albuminoid constit- 
uents, fibrin, and perhaps albumen, are effused in large quantities, and in all 
parts of the body, though chiefly on the free surfaces of the skin, alimentary 
mucous membrane, and more rarely the bronchial mucous membrane. The 
general nature of this effusion forms two characteristic distinctions between 
cholera and diarrhoea; for diarrhoea is a disease confined, in the first instance, 
to the eliminating part-viz., the large or small intestines, as the case may be 
-and is unattended, as a general rule, by the effusion of albumen and fibrin. 
The worst forms of this variety are seen in those cases in which, after two or 
three choleraic stools, severe and long-continued cramps come on, accompanied 
and followed by intense algid symptoms: after death the small intestines are 
generally found distended with the thick, white, flaky substance. Other cases 
of this variety present infinite modifications in severity, according as watery 
elimination is added to effusion of the fibrin; in other words, according as they 
tend towards the slighter forms. 
3. Thus, if the final change at once occur, and there is a complete and rapid 
arrest of the circulation, either from the intensity of the cause or from consti- 
tutional predisposition, the worst variety is produced, in which "a mortal 
coldness comes on from the beginning." As the circulation is soon almost 
entirely arrested by physical alterations in the blood-presumably, changes 
in the fibrin-there can be little purging and comparatively little sweating; 
there is always some effusion of the thick white substance into the intestines, 
but often little of the watery part of the blood. The symptoms might be in- 
ferred from a statement of this condition; we might have presupposed a very 
rapid loss of animal heat, loss of voice, deafness, and vertigo, total arrest of 
all secretions, defective aeration of the blood, consequent dark color of the 
surface, and early and deep coma. 
The more usual course of the disease in this country, when limited to the 
cold stage, is as follows: 
After the patient has been troubled for a few days with diarrhoea (the more 
insidious and dangerous because it is painless), but more commonly while he 
is yet in perfect health, and has retired to rest, and has slept soundly till the 
middle of the night, or even till early morning, he is suddenly seized with an 
unaccountable sickness and vomiting, together with a most profuse discharge 
from the bowels. More persons were seized from twelve o'clock at midnight 
to three o'clock in the morning than at any other time (Dr. Sutton, Health 
Report, p. 371, for 1866). These profuse evacuations are attended with severe 
pains down the thighs, and more especially by an indescribable and subduing 
sense of exhaustion, the patient often fainting in the water-closet. In an 
instant the physical powers of the body are not only exhausted, but its 
temperature sinks rapidly below the natural standard. An icy coldness 
benumbs it; while the skin is sometimes rendered so insensible that it has 
been known to resist even the action of boiling water or other powerful chem- 
ical agents. The breath, as it issues from the mouth, communicates a glacial 
sensation to the back of the hand; still, notwithstanding this great loss, of 
temperature, the patient complavas of being oppressed, and is incessantly 
throwing off the bed-clothes; while cold water, copiously and eagerly drank, 
is grateful to him; and, although it does not seem to afford relief to his in- 
satiable thirst, it ought not to be withheld, but given in small quantities, or 
as ice to melt in the mouth, for the symptom is a most torturing one. 
The extreme coldness of the first stage is further accompanied by a blue, 
livid, or purple discoloration of the hands and feet, extending not only a con- 
siderable way up the arms and legs, but sometimes over a great part of the 
body. These parts often become, in a few minutes after the seizure, not 
merely shrunken, but singularly wrinkled, like the hands of a washerwoman TERMINATION OF CASES OF MALIGNANT CHOLERA. 
659 
after a day's hard labor. These symptoms are rendered still more distressing 
by the shrieks and groans of the poor sufferer, often tortured by spasms which 
affect the fingers, the toes, the arms, and the legs-spasms which clench the 
jaw, fix the walls of the abdomen in contact with the spine, or draw the trunk 
into singularly contorted forms. The patient thinks he obtains some relief by 
the use of friction, and his cries to his attendants are incessant to "rub hard." 
The calves of the legs are especially liable to these cramps, and I have often 
seen the gastrocnemii ruptured after death from cholera, as well as the rectus 
abdominalis muscles. 
As the disease proceeds, the countenance assumes a character peculiar to 
this great struggle, the "facies choleritica," the eye being deeply sunken, red, 
and injected; while the aqueous humor, transuding its coats,leaves the cornea 
flat and depressed, as in the dead body; a broad and livid band encircles the 
lower portion of the orbit; every feature, moreover, is sharp and pinched, as 
after a long wasting disease; the complexion thick and muddy; the lips and 
tongue purple. All these great changes have been known to take place in a 
few minutes. 
In addition to this sad state, the vomiting is constant, the purging most 
incessant, and the pulse, though often natural, sometimes rapid, yet in some 
cases is not to be felt, even after the first hour of the attack, either in the 
large superficial arteries or at the wrist. The voice is strangely altered; its 
firm and manly tone changes to a low, feeble, and unnatural sound. The 
urinary secretion is likewise entirely suppressed, while no bile flows into the 
intestines. The only organ which seems to preserve its powers is the brain; 
and the patient often to the last moment of his life retains the power of 
thinking, and of expressing his thoughts distinctly, sometimes full of hope, 
while at other times he seems indifferent to the fate which too often inevitably 
awaits him. Most patients are apathetic. Reflex excitability is also dimin- 
ished, irritating vapors will not produce coughing nor sneezing; the eyelids 
refuse to wink if the finger is approached to the conjunctivse, and patients do 
not wince if water is suddenly dashed on the naked skin. 
The symptoms characteristic of the collapse stage during the late epidemic 
(1866), according to Dr. Sutton, in the Cholera Hospital and in the London 
Hospital, corresponded with those witnessed in other epidemics. " The pulse 
was only just perceptible-that was with great care-or the patients were 
pulseless ; the extremities were cold ; the tongue was very cold, sodden, coated 
with thin white fur; marked lividity, especially in adults; old people and 
infants were, as a rule, less livid; the voice was reduced almost to a whisper ; 
the eyes were sunken, pupils dilated, conjunctiva white and glassy; hands 
sodden and shrivelled ; the patient restless, turning from side to side, with the 
eyes for the most part wide open, or closed only for a few moments at a time; 
very wakeful; excessive thirst, to such a degree that little children would get 
out of their beds and go and place their mouths under the water tap ; cramps 
in the calves of the legs, extending up to the thighs and walls of the abdomen, 
in exceptional cases into the upper extremities. The patients manifested a 
great indifference as to their condition. When the patients were in extreme 
collapse the purging often ceased, and that in some cases for some hours. 
" In the worst cases of cholera the vomiting and purging began suddenly 
and violently, went on rapidly, the algid symptoms set in very early, and 
there was very little and often not any purging during collapse" {Ninth Re- 
port on Public Health, p. 381). 
On the accession of the spasms, the vomiting, and the purging, the disorder 
is fully developed, and the crisis is at hand, which in a few hours must decide 
the fate of the patient. The termination may be favorable or unfavorable: 
if unfavorable, he may die with all the symptoms just narrated strongly 
marked; or, should it be favorable, they may abate, and a happier prognosis 
be formed. Unfortunately, however, it too often happens that, although the 660 
SPECIAL PATHOLOGY - MALIGNANT CHOLERA. 
stomach retains what is taken, and the purging appears checked, and the 
patient falls into a sleep, yet the weakness, the entire cessation of the pulse, 
the coldness and lividity of the surface, and the ghastly expression of the 
countenance, show that a few hours must close the scene, often with so little 
struggle that death is only marked by the phenomena of cadaveric contrac- 
tion, which sometimes continues active in the muscles for some hours after 
death. The largest number of deaths take place betwixt the hours of 7 and 
11 A.M., and between 7 and 11 p.m., both with respect to males and females 
(Sutton, 1. c.). These might be considered as the critical hours; and a true 
knowledge of such times would be of the utmost importance in the treatment, 
and especially the expectant treatment of the disease. The aim of expectant 
medicine is not simply to stand by and do nothing, but it is to watch the dis- 
ease-to see if it is running its " natural " course-to judge whether the patient 
tends to do well; and if not, to ascertain how he tends to die, and to strive to 
counteract such tendency, and thus to gain time. It is very important, there- 
fore, to know the hours when the vital powers are likely to be very feeble, and 
the vital functions almost brought to a stop : we may then assist the struggling 
patient at these particular times. " In any future registration of such facts," 
writes Mr. Simon, " it would be desirable to make separate enumeration of 
deaths in collapse, as distinguished from deaths in reaction and fever. Of 
course, too, in discussing the subject of the hour of death, regard must be had 
to the hour of so-called ' attack '-i, e., the hour of manifestation of severe 
symptoms; and if this should seem to be governed, at least locally, by some 
general law, the determining influence of local modes of life would need con- 
sideration." 
If the patient should happily survive the cold stage, the disease may termi- 
nate by a rapid recovery, or it may pass into the second or febrile stage. The 
former is the more usual course in India, the latter in Europe. The first 
symptom of returning health is shown by the patient falling into a sleep of 
unusual soundness, during which the respiration becomes light and easy, the 
pulse freer, while a gentle, warm perspiration bedews the whole body. This 
grateful pause in the disease appears to be the result of the returning powers 
of life uninfluenced by medicine, for it often occurs where none has been given. 
After this balmy slumber the patient awakes refreshed, and often recovers so 
rapidly that, in the natives of India, it almost resembles a restoration after 
syncope. In all the Presidencies, indeed, and especially in Bengal, the re- 
covery of the European has, in general, been followed by a stage of reaction, 
usually slight, but in some cases assuming the form of the bilious remittent 
fever of the country, and which has occasionally terminated fatally. 
In Europe, restoration after the cold stage, and without febrile reaction, is 
by no means so frequent or so rapid as in India. Sometimes the reaction is 
trifling, and sleep may indeed have ensued, fecal evacuations containing bile 
may have passed, the urine may again have flowed, the purging, vomiting, 
and spasms may have subsided, the pulse may have risen, the blueness may 
have disappeared, and the temperature of the body may have increased, yet 
in many instances this amelioration of the symptoms has been only tempo- 
rary ;-the patients relapsed and died. 
In most cases, however, the reaction was more considerable, and the patient, 
in a few hours after the subsidence of the cold stage, labored under a severe 
form of fever, in no degree dissimilar to, and not less fatal than, typhoid fever. 
These typhoid symptoms, common in Europe and America, are said to be un- 
known, or nearly so, in India, where, if a secondary fever ensues, it assumes 
the form of the remittent fever of that country. But remittence is character- 
istic of typhoid fever; and this character may only be more expressed in India 
than in Europe. For the first few hours after the febrile reaction commences 
the tongue is white, but it quickly becomes brown and dry, while black sordes 
incrust the teeth and lips. The eye becomes deeply injected and red, the THE BLOOD AND URINE IN MALIGNANT CHOLERA. 
661 
cheek pale or flushed, the pulse rapid, and the temperature of the body a little 
above the natural standard. The patient, either delirious or comatose, then 
lies in a state resembling the last stage of the severest typhoid fever of this 
country. This struggle usually lasts from four to eight days, when the symp- 
toms either gradually yield or death ensues. In a few mild cases the fever 
assumes an intermittent type, or sometimes a quotidian, sometimes a tertian 
form: all these cases usually recover. Such is a general outline of the symp- 
toms of this formidable disease. 
The blood in cholera varies according to the state of the disease. In the 
cold stage it is usually of an unnaturally dark color and thick consistency, so 
that it flows with difficulty from the veins, and very imperfectly separates into 
clot and serum. Blood taken from the temporal artery has been found equally 
black and thick. After the secondary fever is formed, the quantity of serum 
increases, till at length it is much more abundant in the blood than natural; 
and it is singular that this takes place notwithstanding that the secretion of 
urine is re-established. 
The phenomena resulting from the changes in the blood in cholera are the 
proper and distinctive symptoms of the disease; and the term "algid," first 
used by the French pathologists, very properly designates one of its most re- 
markable and constant symptoms-namely, the diminution of animal heat. 
The sensation of cold communicated to the observer has been compared to 
that experienced on touching a moist bladder or the skin of a frog. It is 
" reptile-like." The ,algid symptoms, therefore, essentially constitute the 
characteristic phenomena of this disease. In proportion to them is the malig- 
nity and rapidity of the case. They afford the only measure of its severity, 
and from them only can a correct prognosis be formed. The vomiting, purg- 
ing, and cramps are considered as non-essential phenomena; for authentic 
cases of cholera are on record entirely divested of these symptoms; and the 
suddenness with which the disease sometimes extinguishes life is extremely 
remarkable. Instances of death taking place in two, three, four, or six hours 
are by no means uncommon. When the disease broke out at Teheran, in 
May, 1846, Dr. Milroy states that those who were attacked dropped suddenly 
down in a state of lethargy, and at the end of two or three hours expired, 
without any convulsions or vomitings, but from a complete stagnation of the 
blood. Tn Bulgaria, during the outbreak of cholera in the allied armies, in 
the summer of 1854, the rapidly fatal character of the early cases was noto- 
rious. 
Urine in Cholera Reaction.-.As the complete suppression of the urinary se- 
cretion in collapse, lasting for hours or days, is one of the most striking and 
peculiar features of cholera, so its reappearance is amongst the earliest and 
most auspicious signs of beginning recovery. The first secretion mostly con- 
tains the evidence of the mechanical obstruction of the minute channels of the 
kidneys, and of the general death of the epithelia of the urinary passages. It 
also contains the sign of continued resistance to the blood current through the 
kidneys, in the form of transuded albumen of the blood. And in many cases 
it carries small quantities of peculiar abnormal ingredients, which may per- 
haps be products or remnants of processes engendered by the choleraic pro- 
cess in the blood. The quantity is at first very small-urea much diminished. 
The Temperature in Cholera, as determined by Dr. Thudichum, falls 
steadily from normal to 5.4° Fahr, or 7.2° Fahr, below7 it, and in most cases 
very rapidly. 
The lowest temperature is quickly reached in deepest collapse; and the 
minimum temperature of all cases observed in the algid stage is below the 
lower limits of the fluctuation of health. The maximum temperature of the 
majority of cases observed is below the upper limits of the fluctuation of 
health. 
The lower the temperature, and the longer the duration of the algid stage,. 662 
SPECIAL PATHOLOGY MALIGNANT CHOLERA. 
the higher and the longer continued is, on the whole, the temperature of the 
tepid stage, which does not exceed the upper normal, unless the temperature 
of the algid stage had previously sunk below 95° Fahr. But the tempera- 
ture may for a short time reach 95° Fahr., or less, and yet the temperature of 
the tepid stage not rise above the upper normal. 
When the maximum temperature of a case of cholera remains throughout 
below the normal average, the case will probably be fatal. Among the thirty- 
nine cases observed, all such eases, seven in number, proved fatal. 
On the basis of the thermometric observations alone, cholera may be divided 
into two stages,-the first or algid stage, from the beginning of symptoms to 
that period where temperature reaches again the normal limits or average; 
and the second or tepid stage, in which temperature either remains within the 
normal limits or rises more or less above them, in some cases even to febrile 
height, afterwards descending again to normal limits. 
Only observations taken in the rectum or vagina are of service as a standard 
of the temperature in cholera. Great differences between the axillary and 
rectal temperature are decidedly unfavorable; for, as soon as there are any 
indications of asphyxia, the temperatures become more divergent, and the 
axillary temperature lower than normal. In death, during the algid stage, 
the temperature in the vagina and rectum has been as high as 108.32° Fahr.; 
and any considerable rise of temperature, or any considerable fall (especially 
with quickened respiration), indicates great danger. As temperature rises, 
the alvine discharges tend to diminish ; but if the rise is high, rapid coma is 
likely to occur. The less the temperature fluctuates the greater is the chance 
of recovery (Wunderlich). 
But on the basis of all the pathological phenomena and clinical data, the 
following seven stages of cholera may be distinguished (Thudichum) : (1.) 
Fecal diarrhoea; (2.) Choleraic diarrhoea and vomiting, quick sinking of tem- 
perature ; leading to (3.) Asphyxia or collapse, in which lowest temperature is 
reached; (4.) Reaction, which may be defined as the cessation of collapse and 
the beginning of the re-establishment of the suppressed functions ; (5.) Torpid 
stage, or secondary period of algid stage, in which, reaction notwithstanding, 
temperature remains below the lower normal limits, and then gradually or 
suddenly rises to the normal average; (6.) Tepid stage, in which, during con- 
tinued reaction, temperature rises to normal or its upper limits, more rarely 
somewhat above; (7.) The febrile stage, only reached in cases where the entire 
algid stage has been very long, or where there are complications, or secondary 
lesions arising out of the choleraic process. Reaction does not always termi- 
nate the algid stage. For although, from the moment of the beginning of 
reaction, temperature rises somewhat in most cases, in exquisite cases it does 
not reach the lower limits of normal fluctuation. The algid stage is evidently 
continued into the state of reaction, and the tepid stage is the result only 
of continued reaction. Reaction begins mostly with absorption from the in- 
testinal canal within thirty-six hours from collapse, possibly also with some 
actual secretions. 
The influence of the temperature of the external air upon the temperature 
of the choleraic process was imperceptible during the observations recorded 
by Dr. Thudichum, as its range was very equable during the time of observa- 
tion, the wards being mostly at 66.2° to 68° Fahr. 
The lowest temperature observed in any case which recovered was 92.8° 
Fahr. It is at present uncertain whether there is a minimum temperature 
below which the body (axilla) cannot be cooled down without fatal results. 
If there is such a temperature it will probably be about 92.3° Fahr. A loiv 
minimum temperature is at present of less significance than a low maximum. 
All cases of cholera, the temperature of which ranges persistently below the 
lower healthy limits, even if no very low minimum temperature was reached, 
.seem to have a fatal prognosis. BODY-TEMPERATURE IN MALIGNANT CHOLERA. 
663 
" It is all-important to remember," observes Mr. Simon, " that the ther- 
mometric observations recorded in this instructive section of Dr. Thudi- 
chum's report are exclusively of external temperature. In order to a com- 
plete understanding of the thermal phenomena of cholera, observations of 
this kind require to be supplemented by observations of internal temperature." 
And Mr. Simon therefore refers to some such, which have been elsewhere 
recorded. 
In forty cases of collapse treated in the London Hospital in the late epi- 
demic, temperatures were measured, simultaneously in the rectum or vagina 
and in the axilla, by Mr. F. M. Mackenzie, assistant resident medical officer 
of the hospital.* Another important set of double observations has been 
published in Germany by Dr. Giiterbock. From these observations Mr. 
Simon concludes that " the choleraic affections of the bowels is a heat-making 
or inflammatory " process, on which the development of inflammatory fever, 
by circulation of blood from the inflamed parts, would as a matter of course 
attend, were it not that circumstances special to the disease (but accidental) 
suppress or circumscribe the manifestation. In a typical case of collapse the 
axillary thermometer shows a temperature perhaps a little above 90° Fahr., 
while a thermometer in the rectum or vagina is marking a temperature high 
above the normal. With the superficial pulselessness of collapse before one, 
the suspicion cannot fail to arise that this vast difference of temperature 
between external and internal parts denotes mainly the failing blood supply 
of the former ; a state which, in so far as it does not equally affect all parts 
in the aortic circulation, may not improbably " be deemed to depend on the 
muscular contractility, of peripheral arteries." It is not yet determined 
whether the general temperature of the blood is not febrile. 
As regards temperature, the following conclusions were arrived at by Sur- 
geon A. Leith Adams and Assistant-Surgeon F. H. Welch during the epi- 
demic at Malta, of which they have given so admirable a report {Army Med. 
Dep. Report, vol. vi, 1864, p. 341): 
" 1. That a strongly marked, rapid downfall from the average normal 
temperature, 97°, takes place soon after the setting in of the cholera symp- 
toms, and the extent in proportion to the dose of the poison ; the downfall 
being characterized in the healthy young, and up to middle age, by elevations 
and depressions, each succeeding one of the latter reaching a lower point than 
the preceding one; in the aged, weak, or debauched constitution by an unin- 
terrupted sinking of the thermometer. The average fall from normal tem- 
perature into collapse was 11°, the extremes 7° and 15° Fahr. 
" 2. That the highest temperature at which the general symptoms of col- 
lapse became apparent was 90°, the lowest 82°, the average 86° Fahr. 
" 3. That during the period of collapse the temperature underwent but slight 
variations in the aged, weak, or debauched; while in the young, and up to 
middle age, it was characterized by undulations. 
" 4. That the stage of complete collapse is not marked by any character- 
istic unvarying point of temperature. It would seem that an excessive dose 
of the poison is accompanied by a corresponding loss of heat; but when the 
vital stamina is deteriorated by drunken habits or delicacy of constitution, 
either the general symptoms of collapse are present when the thermometer 
makes no great fall, or an excessive lowness is reached with no corresponding 
general indications-e.g., Cases 1, 2, 6, and 13 [in their Report]; while, on 
the other hand, a hardy well-used constitution does not betray signs of failing 
* Mr. Mackenzie's notes of these observations are published in the third volume 
of the London Hospital Reports. Besides his observations, others, also made in the 
East London epidemic, are mentioned more or less fully in the same volume-viz., a 
few made in the London Hospital by Messrs. McCarthy and Dove, and some made in 
the Wapping Cholera Hospital by Dr. Woodman and Mr. Heckford. 664 
SPECIAL PATHOLOGY-MALIGNANT CHOLERA. 
until the respiratory function is much interfered with. The lowest point 
reached during life was 73°. 
" 5. That a general brightening up of the patient, unaccompanied by any 
change of temperature, often preceded the final downfall, and was exceedingly 
deceptive until appreciated rightly. 
" 6. That the general signs of reaction were preceded by a marked eleva- 
tion of the temperature ; and when convalescence ensued, this reaction was 
characterized by fluctuations tending towards reinstation of normal tempera- 
ture. The average rise from complete collapse into full reaction was 6°, the 
extremes 8° and 4°. 
" 7. That when death ensued, whether preceded by reaction or not, the fall 
of the thermometer wTas most marked and rapid. 
" 8. That after death a rise of temperature ensued in the cases of great 
severity and quickness of course ; but when the disease was prolonged, the 
patient falling into that senseless condition well expressed as ' death in life,' 
the contrary was the rule. 
" 9. The readings of the hands and epigastrium followed the breath's varia- 
tions, though not always in the same ratio. As will be seen, the epigastrium 
specially showed a great tardiness in assimilating itself to the others, and was 
very tenacious of its heat. 
" Thus, the thermometer indicated that in the aged and delicate the vital 
powers gave in to the poison, step by step, commensurate with the dose; 
collapse reached, a comparative quietness ensued, followed by the system 
asserting its superiority, or succumbing rapidly. The course from the onset 
to the termination was gradual, with no marked deviations. Not so, how- 
ever, with the young and healthy. Although the system was compelled to 
give way to the attacks of the virus, it was not without a struggle ; the col- 
lapse was marked by constant attempts at reaction, and this having once set 
in, the vital powers seemed to overreach themselves in their eagerness to re- 
sume their normal condition. 
" As helps to prognosis, it may be said that a rapid and marked fall at the 
onset, a temperature below 86°, a further loss of heat during collapse, a setting 
in of general symptoms of reaction not preceded by rise of temperature of 
breath and hands, each and individually indicated badly; but it must be 
borne in mind that the previous habits of life were great influencing causes, 
and this more especially when drunkenness was the deteriorating agent. 
This vice, per se, appeared to predispose to the disease ; but no words can 
express its baneful effects as demonstrated by the manner in which its devo- 
tees succumbed to the poison, even when in a minor state of intensity." 
Duration of the Disease.-It is of importance to determine whether the 
cholera process is limited in its duration. Dr. Sutton has attempted the ob- 
servation ; and finds that while the " cold stage " is always present more or 
less, the " hot stage " may be absent, and is no essential part of the disease. 
It varies very much when present. In mild cases it is very short and scarcely 
appreciable. In severe cases it is long and protracted, at least in this country. 
The phenomena of collapse appear not to be limited to any definite time. 
Some patients became collapsed very early; others not until vomiting and 
purging had continued several hours, and was then often not protracted. In 
the milder cases the algid symptoms were scarcely, or even not at all, marked; 
and all experience has shown that the collapse of cholera is not always present. 
Dr. Sutton then endeavored to ascertain what period elapsed from the time 
when a patient was seized with the characteristic symptoms of the cold stage- 
the violent symptoms-to the time of his entering reaction. He finds there 
are good reasons for believing that the cholera process runs a definite course of 
from twenty to thirty hours. 
Relation of Vomiting and Purging to Algid Symptoms.-When patients EVIDENCES OF REACTION. 
665 
went into collapse the vomiting and purging very greatly diminished, and in 
some cases entirely ceased ; and some of the worst cases-cases which seemed 
almost sure to prove fatal-had very little, and often not any, purging. Thus 
cases characterized by the most continued purging and vomiting were not by 
any means the worst class of cases-for the most part the very opposite. It 
was the exception for such cases to pass into collapse; and if so, the algid 
symptoms came on slowly. 
It by no means follows, because a patient is very much purged, and vomits 
violently and very frequently, that he is in a worse condition than another 
patient who vomits and is purged much less. Dr. Sutton brings forward evi- 
dence which clearly shows that the algid symptoms were not in regulated 
proportion to the frequency of the vomiting and purging. He shows that a 
patient may be purged hour after hour, may almost continually vomit, yet 
may not pass into collapse ; whereas another patient is purged and has vomit- 
ing for two or three or five hours, and passes into deep collapse. If the col- 
lapse be dependent solely on the loss of fluid, it is difficult to understand why 
in the very class in which there is the protracted purging there is the least 
collapse; and even on the assumption that one patient passes in two or three 
evacuations more water than another does in double the number, and admit- 
ting that it is so in some cases, we are yet called upon to explain how it is 
that a patient who is not purged at all-that is, has had no discharge from 
his bowels-dies very suddenly; that another who has only been purged four 
times passes into collapse and dies; while others are purged twenty or thirty 
times without ever showing any well-markeH symptoms of collapse. It is dif- 
ficult to conclude that one patient passes more fluid in one evacuation than 
another does in twenty; and any explanation of this difficulty, to be satisfac- 
tory, must take into consideration not only the quantity of fluid withdrawn 
from the blood, but the rapidity with which it is withdrawn. 
In the worst forms of cholera a considerable quantity of water and other 
constituents of the blood are withdrawn very suddenly from the system ; and 
there seems to be a decided relation between the severity of the collapse and 
the rapidity and violence with which the cholera process sets in and. is car- 
ried on. 
Evidences of Reaction.-When a patient dies in advanced reaction, or was 
in complete reaction at the time of death, the different organs of the body 
regain their weight, sometimes even weighing heavier than usual. This is 
especially the case with the lungs. In collapse the lungs and spleen weigh 
much lighter than normal. 
In favorable cases of reaction the wakefulness characteristic of true collapse 
gives way gradually to sleep. The color returns, the pulse becomes distinct 
and more perceptible, and in some cases the patient may sleep quietly for 
some time. 
The thermometer, in the experience of Dr. Sutton, is of all single guides the 
best, but cannot be absolutely relied on, unless the temperature in the axilla 
be very low indeed, and in the rectum very high-e. g., if the temperature in 
the axilla be 92° Fahr., and in the rectum 102° Fahr., the patient is still in 
collapse; but if the temperature in the axilla were 95° or 96°, imperfect re- 
action may be commencing. Some parts of the body appear to pass into re- 
action before others; and imperfect reaction is sometimes associated with 
bloody evacuations; and if a patient is pulseless, but with a natural color 
and a greasy perspiring skin and a coated tongue, he will in all probability 
pass bloody evacuations, and then will certainly die. Dr. Sutton thus recog- 
nizes a class of cases having the following symptoms: The patient is seen 
lying on his back, eyes open, looking very wakeful, mind collected, voice weaker* 
than natural, at times the typical choleraic voice, color natural, lips natural, 
complexion greasy, tongue sometimes cold, livid, of gray color and covered 
with white fur; at other times the tongue is warm and coated with yellow 666 
SPECIAL PATHOLOGY MALIGNANT CHOLERA. 
fur. The hands are of a livid red color, cold, and shrivelled. The tempera- 
ture in the axilla is generally lower than usual. Respiration is labored, and 
generally accelerated-often 25, sometimes 40, a minute. The pulse at the 
wrist may be only just perceptible, and very often such patients are pulseless; 
there may be no purging for hours together, and very little vomiting. There 
may be profuse perspiration, the face and hair wet with it. The patient may 
lie for hours like this, and even one or two days. Such bloody evacuations 
appear on an average about twenty-eight hours after the violent symptoms of 
cholera set in. 
When the algid symptoms are most severe the reaction is greatest and 
most protracted. The longest reaction was seventeen days, the shortest sixty 
hours, in Dr. Sutton's experience. In the mild cases the longest reaction was 
seven days, and the shortest twelve hours. The duration of suppression of 
urine is also in proportion to the severity of the algid symptoms. In one 
case no urine was passed and none discovered in the bladder for six days and 
ten hours; in two cases none for five days, and in two none for four days. 
In the milder class of cases three days was the longest period of suppression, 
and the shortest ten hours. 
Circumstances Predisposing to Cholera, or Presenting Resistance to the 
Attack.-The influence of these is chiefly apparent in the age and sex, food, 
fatigue, housing, ventilation, filth, misery, and intemperance of the people. 
Both sexes, and all ages, including new-born children, are liable to the 
disease. Dr. Farr's results show that males suffered more than females at all 
ages under twenty-five years, but between twenty-five and forty-five the 
femaleg suffered more than the males. The deaths from cholera in Paris were 
estimated at 18,402 in 1832; and it was remarked that the mortality was 
least from six to twenty, greater from thirty to forty, and greatest of all in 
old age. The influence of sex in predisposing to cholera can hardly be said 
to be determined; for in Calcutta, of the native inhabitants attacked with 
cholera, the males were to the females as four to one, while in Bombay the 
proportion was as seven to twenty-five. In Canada, the soldiers' wives were 
observed to suffer nearly in an equal proportion with their husbands; and 
this was the case among the civil inhabitants of Gibraltar. 
In all countries the lower classes have always suffered in a much greater 
proportion than the upper classes. In Calcutta, the disease ran a wide career 
of destruction in the native town, while the "City of Palaces," inhabited by 
the'English, was much less affected in proportion to their numbers; and the 
same disproportion has been observed in Bombay. In general, it has been 
observed, among the native inhabitants of India, that the Brahmin and 
Banian merchant suffered less than the Ryot or farmer, while the poor out- 
cast Pariah suffered the most of all. In every town in Europe it has been 
observed that the lower classes, and especially those resident on the banks of 
rivers, have suffered infinitely more than the upper classes. 
In military life it has been believed that the Sepoy suffered more than the 
European soldier living in India. This, perhaps, is true in some instances; 
but the returns of the Madras army show this not to have been the fact in 
that Presidency. There the European soldiers attacked appear to have been 
as one to three, while of the Sepoy force it was only one in four and a half. 
The influence of cholera on different races attacked at the same stations in 
India, and at the same dates, is stated by Dr. Bryden in the following gen- 
eral results: 
European troops were attacked in the proportion of 89.20 per thousand, 
while Native troops were attacked in the proportion of 9.56 only. 
Of these attacks there died per thousand, of Europeans, 53.68 ; of Natives, 
4.11 only. 
Again, out of every 100 cases there died, of Europeans, 60.19; and of 
Natives, 43.02. PROGNOSIS OF MALIGNANT CHOLERA. 
667 
The Goorkhas suffer even more than Europeans from cholera. 
In the Indian army, also, it appears to have been universally observed that 
the officer suffered in a less proportion than the soldier, the cavalry than the 
infantry, and the infantry less than the hard-laboring ill-fed camp follower.* 
The troops on march likewise universally suffered more than the troops in 
quarters; and this influence of long marches appears to indicate something 
more powerful than mere fatigue in bringing about the disease. Dr. Balfour 
has proved that of the native soldiers of the Madras army thirty-two died of 
cholera in cantonment, and eighty-six when marching, to an average of 
10,000 strength; the number attacked being respectively 85 and 200 in 
10,000. Dr. Lorimer's reports show that the men were more frequently at- 
tacked on long than on short marches, the men (as Dr. Farr observes) being 
longer exposed to the causes of disease. These causes are those which are 
incidental to the life of a soldier on the march, such as lying by the banks of 
rivers, on low marshes, jungly grounds, sleeping on the ground, and encamp- 
ing amongst the filth of encampments recently occupied, but abandoned-of 
which indiscretion there were many melancholy examples during the war 
with Russia in 1854; for example, the occupation of the evacuated camping- 
ground at Aladyn, in.Bulgaria, and that on the heights above Alma, pre- 
viously occupied by the Russians, the consequences of which were so fatal to 
the first and fourth divisions of our army. 
The effects of a poor diet in predisposing to cholera will perhaps be better 
understood by stating that the European suffers less than the Mohammedan, 
and the Mohammedan, who is better fed and better clothed, than the Hindoo, 
except during their rigid fasts, when the Mohammedans suffer in a much 
larger ratio. During the epidemics of 1848 and 1849, in Edinburgh, Dr. 
William Robertson, of that city, found that anaemic persons were those most 
predisposed to cholera. 
Prognosis.-The mortality from cholera in all countries is very great. 
Taking the whole number attacked, it is said that the number of deaths in 
Astrachan were as one to three; in that of Mishni Novogorod as one to two; 
in Moscow and Kasan as three to five; and in Penza, in the country of the 
Don Cossacks, as two to three. In the summer of 1831 the mortality at Riga, 
St. Petersburg, Mittau, Limburg, and Brody, according to the Berlin Gazette, 
was about one-half, while at Dantzig, Elbing, and Posen it was about two- 
thirds of the whole number attacked. The period of the epidemic, however, 
greatly influenced the mortality; for, on the first onset, nine-tenths of all 
those attacked perished, then seven-eighths; and the proportion of deaths 
forms a gradually decreasing series of five-sixths, three-fourths, one-half, one- 
third, till, towards the close, a large proportion of those attacked recovered. 
The uniformity of this law in every country affected with cholera, whether 
Europe, America, India, or China, is extremely remarkable. 
The chances of recovery are much diminished in young children and in the 
aged; the age of greatest number of recoveries being from fifteen to twenty. 
The feeble in constitution, the ansemic, the sick, and the convalescent, were 
* The Madras Sepoy, of whom alone Dr. Balfour wrote, invariably carries his 
family with him. At the end of a long march he puts off his accoutrements, and 
hastens back, without tasting food, to assist his family out of the difficulties incident 
to a country in which the roads are often mere tracks. He thus often performs nearly 
double the route march, and finally encamps on ground which for years has been used 
for the purpose, and is saturated with the excretion of former sufferers from the dis- 
ease. Moreover, for a long time the authorities in Southern India were most reckless 
in sending regiment after regiment in one another's footsteps, through districts known 
to be infected; and as they all occupied the same encamping-ground, the last regi- 
ments pitched in places saturated with cholera evacuations, and surrounded by the 
half-buried remains of the dead. These facts to some extent explain the effects of 
marching on Sepoys (W. C. Maclean). 668 
SPECIAL PATHOLOGY-MALIGNANT CHOLERA. 
in all cases the surest victims of cholera. But, whatever the age of the pa- 
tient, Gendrin states he lost every case which became pulseless. 
Treatment.-There are few diseases for the cure of which so many different- 
remedies and modes of treatment have been employed as in cholera, and un- 
fortunately without our discovering any antidote to the poison. In Moscow, 
it is said that the mortality was not greater among those destitute of medical 
aid than among those who had every care and attention shown them. It may 
be fairly inferred, therefore, that in the severer forms of the disease the action 
of this poison is so potent as to render the constitution insensible to the influ- 
ence of our most powerful remedial agents. When, however, the disease is 
mild, or on the decline, much may be done, by obviating symptoms, to pro- 
mote the recovery of the patient. 
In considering the treatment of cholera there are three periods to be • pro- 
vided for,-(1.) The period of diarrhoea which so frequently precedes cholera. 
This indication of intestinal lesion must be distinctly recognized as the start- 
ing-point of all other symptoms, and the true source of danger. (2.) The 
algid period, or collapse; and (3.) Period of reaction. 
(1.) The Period of Diarrhoea.-To check or arrest the diarrhoea is the prac- 
tical result aimed at by a variety of formulae. Those in which opium is the 
main remedy have acquired the most amount of confidence. 
The management of a case embraces the following conditions: (1.) That 
the horizontal position of the body be maintained ; (2.) That the administra- 
tion of opium, with or without cordial stimulants, be at once commenced; 
(3.) That the induction of perspiration be brought about. 
The necessity for the horizontal posture of the patient is, that it aids the 
efforts of the circulative powers, which tend to weakness. 
With regard to opium, its dose must be regulated by (1.) The extent of the 
nervous prostration ; (2.) The rapidity of the dejections ; (3.) The extent of 
vascular depletion. In the cases which present these phenomena in the ex- 
treme a much larger dose of opium is required to be given at the outset at 
one time than in the cases less urgent. 
The following formula for pills, each containing a grain of opium, with 
stimulants, is well known as an antispasmodic pill in the early stage of bowel 
relaxation: 
B. Pulv. Opii, gr. xii; Camphor, gr. xxx; Pulv. Capsici, gr. ix; Spt. vin. 
rect., q. s.; Conserv. Rosar, q. s.; Misce et divide in pil. xii. 
Moderate doses of opium or morphine, either alone or combined with stimu- 
lants, as the pulvis cretce aromaticus cum opio, are sometimes sufficient to check 
diarrhoea. The following cholera mixture (as it was called) was proposed by 
the Board of Health during the prevalence of cholera, and was no doubt 
useful in many cases of diarrhoea: 
B. Pulveris aromat., Jiii; Tinct. Catechu, fjx; Tinct. Cardam. Comp, fjvi; 
Tinct. Opii, Ji; Mist. Cretm, preparat. ad f^xx. Of this mixture the dose is 
one ounce. 
[The prodromic diarrhoea is said to be promptly arrested by the lavement 
Gaillard, composed of 19 parts of the sulphate of soda, and one part of com- 
mon salt in a suitable quantity of water. Sulphurous acid has proved efficient. 
Equal parts of paregoric and aromatic spirits of ammonia, to which a small 
quantity of camphor is added, is an excellent remedy.] 
Bulky doses of remedies are, however, very obviously objectionable; and 
the usual remedies known as " astringents " (compared with each other, or 
with opium) have no decided influence for good. " Astringents," as such, 
have merely a negative effect. 
The extensive experience of my friend, Dr. Fergus, of Glasgow, in whose TREATMENT OF MALIGNANT CHOLERA. 
669 
practice I was privileged to assist during the epidemic of 1849, led him to 
the conclusion, which I believe to be true, that "there is a first stage at which 
cholera is curable and preventible"-namely, laxity of the bowels previous 
to vomiting, spasms, or uneasiness of any kind. The relaxation of the bowels 
may not even amount to diarrhoea, and may be to the extent of only two or 
three stools a day, where one only was usual. Such relaxation was generally 
thought of no moment, being attended with no pain; on the contrary, the 
evacuations often gave a feeling of relief. This is the only stage at which 
opium is to be given, and that in a full dose. At this stage, in combination, 
with a stimulant, it is often of the highest value. It is only to be given " if 
the evacuations are still bilious, the pulse fair, and the skin warm." When vom- 
iting, "rice-water" purging, and cramps set in, it is generally then too late 
for opium. Drs. Macpherson and Macnamara also record, as the result of 
their extensive experience in India, that if administered at the proper stage, 
no remedy is nearly so effectual as opium, and the drug may be safely trusted 
to cure the premonitory diarrhoea of cholera. A dread has arisen of using 
the remedy, for fear of secondary effects ; but the same writers justly observe, 
that if it has a curative effect, we must not shrink from its use, for the dread 
of ulterior consequences. "The vast majority of practitioners have found 
opium extremely useful in the early stages of the disease. Men like Twining 
and Parkes, who by no means considered the disease to consist merely in vom- 
iting and purging, are agreed that opium is the medicine to be given in the 
commencement of the great majority of cases." It calms the brain, relieves 
the excessive feeling of constriction at the epigastrium, tends to counteract 
oversecretion from the mucous membrane, favors cutaneous transpiration, and 
assists the action of such other remedies as stimulants, astringents, carmina- 
tives, or absorbents (Gubler). 
When medical men have charge of large numbers of people, as in the army, 
navy, prisons, workhouses, asylums, hospitals, and the like, it is incumbent on 
them to make frequent inspections of those under their care, and to seek out 
any cases of incipient diarrhoea. Responsible officers should be made to take 
notice of those who go more than once a day to the water-closets at times when 
a cholera epidemic influence prevails. " In military practice," as Dr. Maclean 
justly observes (MS. notes to the author), "frequent inspection of the men is 
of cardinal importance. Every man in a regiment should be seen at least 
three times a day by some medical officer, who should also visit the various 
guards. By walking down the ranks at roll-call, and picking out the men 
who show the earliest symptoms, cases are thus caught in the stage of pre- 
monitory diarrhoea and saved." 
The following rules were drawn up by Dr. Fergus for the management of 
large numbers of men, in the factories and offices of Glasgow, over which he 
had charge when cholera was epidemic: 
"1. Do not be afraid of cholera, or make it the topic of conversation. 
Fear and all the depressing passions are injurious. 
"2. .Do not take brandy; it is not a preventive; and it does harm by 
disordering the action of the stomach and bowels. 
"3. Do not make any change in your usual diet, if it is simple and of easy 
digestion; take it moderately, and at regular intervals, as long fasting is 
injurious; and carefully avoid excess in any intoxicating beverage. 
" 4. Take no excessive fatigue; if overheated, beware of any sudden chill, 
and see that the skin is kept comfortably warm. If the disease appears in 
winter, much benefit may be derived from wearing a flannel belt around the 
body, covering the stomach and bowels. 
"5. As soon as cholera appears in a town, a bottle of solution of morphia 
or laudanum (and a graduated measure) should be kept in every house, place 
of business, factory, or wherever, in fact, there are a number of people gath- 670 
SPECIAL PATHOLOGY MALIGNANT CHOLERA. 
ered together. Persons travelling should always have it with them, or easy 
of access. During the existence of the epidemic, one person in each factory, 
&c., should take the charge of the health of the inmates, and should act as 
'house physician,' warning all under his or her care to attend to the slightest 
relaxation of the bowels. He should remind them that the less pain the 
more danger, and therefore the more need of immediate and energetic action. 
" 6. Should the slightest diarrhoea occur, the individual so attacked should 
at once receive forty minims of solution of morphia or laudanum.* If from 
home or at business, the patient should be at once conveyed home in a cab, 
put to bed, and kept warm. If chilled, warm water bottles may be put to 
the feet. If the first dose has not checked the looseness, the patient should 
take a second, and then have a flannel cloth thoroughly dipped in turpentine, 
placed all over the stomach and bowels for from forty minutes to an hour, or 
a large, soft, warm poultice of linseed meal and mustard for one or two hours. 
If the second dose has not effectually checked the diarrhoea, and medical 
assistance has not arrived, a third dose may be taken. 
" 7. The patient must remain in bed two or three days after the diarrhoea 
is checked. I insist strongly on this, for the patient often feels so well that it 
is difficult to get him to attend to it. 
" 8. To relieve the thirst, a piece of ice may be given, or a mouthful of 
iced water, or soda water; but in no case must more fluid be taken at a time, 
and all food should be abstained from till from fifteen to eighteen hours after 
the opiate has been administered. Then, and for two or three days, the diet 
should consist of such food as rice, sago, arrowroot, Indian corn flour, tea and 
toast, &c.; about the third day beef tea or chicken-soup might be taken. 
"9. These rules are for the first stage, and for it only-i. e., the diarrhoea. 
If a person has neglected the first warning, and is in the second stage-i. e., 
has cramps, vomiting, and stools like rice-water, without smell-you should, 
till medical assistance arrives, place the patient in bed surrounded with bottles 
of hot water, and give him a little ice, and mouthfuls of soda and water. If 
the cramps are severe, you must rub the limbs with turpentine, or chloroform 
and oil" (Glasgow Med. Journal, 1866). 
Of the various preparations of opium, Dr. Macnamara gives preference to 
the tincture. Thirty drops of laudanum in water should be administered as 
soon as possible after the first watery motion has been voided, and this must be 
repeated if the purging does not stop after the first dose has been given. 
Supposing thirty drops of laudanum to have been administered, and that 
within half an hour the patient is again purged, Dr. Macnamara does not 
hesitate to repeat the dose at once. It is not advisable to wait until two or 
three motions have been passed. Watery painless purging should be at once 
stopped by such means. When the disease is endemic, and still more so when 
it is epidemic, every family should have a bottle of laudanum in the house, 
to be resorted to at once after the first watery motion; and if it is accompa- 
nied by a feeling of exhaustion, and a faintish sensation at the praecordial 
region, the dose of laudanum should be followed by "a stiff glass of brandy 
and water." "No more erroneous practice can possibly exist," in India or 
any other place where cholera exists, says Macnamara, " than that of allow- 
ing diarrhoea to go on, upon the supposition that the attack is a bilious one, 
and that the purging is a salutary or a harmless process. More deaths from 
cholera have been occasioned from this than from any other mistaken notion 
* If a measure is not athand,a small teaspoonful. Of course this dose is for adults. 
Below that age the doses should be a drop for each year till twelve or fifteen, and 
after fifteen a drop and a half for each year, up to forty minims, or a small teaspoon- 
ful. More portable than laudanum, and of equal efficacy, would be pills composed of 
a grain and a half of opium and a grain of cayenne pepper in each pill, three of which 
may be taken with safety, till medical assistance arrives. treatment of malignant cholera. 
671 
on this subject. The issue is simply this: Supposing the attack to be a bil- 
ious one, we stop it with opium, and may subsequently have to administer a 
dose or two of blue pills and rhubarb; or, perhaps, a little judicious starving 
may answer the same purpose. But, if under the impression that the diar- 
rhoea is bilious, we allow it to run on, it may become, in the course of a few 
hours, the second stage of cholera, and our opium may then be of little or no 
use." 
In the case of children the dose of laudanum must be regulated by the age 
of the child. 
A pill composed of one grain of opium and two grains of the acetate of lead, 
to be taken every hour till the purging stops, is a useful formula, and more 
easily distributed than laudanum. 
But there are certain cases in which, although the diarrhoea may be alto- 
gether checked by such remedies, yet the disease is not cured. Symptoms 
characteristic of the algid stage and collapse supervene. These are the cases 
which give support to that method of treatment which has for its object elimi- 
nation by the promotion of purging and of vomiting-excretion of the poison 
by the alimentary canal. In support also of this method of treatment, its 
advocates lay stress upon the fact that those are the worst cases in which the 
diarrhoea is the least; and that those cases are the most hopeful in which 
diarrhoea and vomiting are the most severe. 
Dr. Johnson's treatment by castor oil has for its object the elimination of 
the specific poison; and it may be said of it, at the outset, that it is neither 
more nor less successful than other remedies of its class. It, as well as purely 
astringent mixtures, excites such loathing in most cases that they cannot be 
persisted in. 
Dr. G. Johnson agrees with the rule that " diarrhoea during an epidemic 
season ought not to be neglected even for an hour." He regards such diar- 
rhoea as an indication of the presence of offending material in the alimentary 
canal-e. g. (1.) Unwholesome, undigested food; or (2.) A large and un- 
natural accumulation of the feculent contents of the bowel ; or (3.) Noxious 
secretions poured from the blood into the bowels, in consequence of the action 
of a specific blood-poison : to this latter Dr. Johnson believes choleraic diarrhoea 
to belong. 
Therefore he lays down the following rule : "Not to attempt by opiates, or 
by other directly repressive means, to arrest a diarrhoea while there is reason 
to believe that the bowel contains a considerable amount of morbid and offen- 
sive material; for such must come forth before diarrhoea can permanently 
cease." Purging he considers the natural way of getting rid of the irritant 
cause; and the safest purgative he believes to be castor oil. So far as meeting 
the conditions of examples (1) and (2) as above, the treatment cannot be 
improved upon; but that it is the best possible treatment to meet the prelimi- 
nary diarrhoea or relaxation of the bowels in cholera cannot be regarded as 
established, nor warranted by what we know of the pathology of the disease 
as set forth in the text. 
Assuming it to be proven that malignant cholera is a specific disease in 
which there is poisoning of the blood; and believing, as I do, that such is the 
pathology of the disease ; and, seeing that the College of Physicians entertain 
a similar belief-for malignant cholera has been classed by the College in 
section A of the general diseases, concerning which it is written, that " it 
comprehends those disorders which appear to involve a morbid condition of the blood, 
and which present the following characters: they run a definite course, are attended 
with fever, and frequently with eruptions on the skin, and are more or less commu- 
nicable from person to person:" Assuming the pathology of malignant cholera 
to be as here represented, I cannot admit that the best indications for the 
treatment of the disease are those which suggest an attempt to eliminate the 
poison. I do not believe we can, by any remedy, nor by the over-stimulation 672 
SPECIAL PATHOLOGY-MALIGNANT CHOLERA. 
of any eliminative function, ever get rid of any such poisons as those of small- 
pox, measles, scarlet fever, typhus fever, enteric fever, or any othei* general and 
specific disease-poisons comprehended in section A. No method of treatment, 
based on the so-called principle of eliminating a poison, has ever effected a 
cure of any one of these diseases ; and I do not see any likelihood of the prin- 
ciple being more successful in cases of malignant cholera than with other dis- 
eases of the class. We have never yet been able to " cut short" any of these 
diseases by emetics, purgatives, or diaphoretics. Neither emetics nor purgatives 
have ever cut short small-pox, although, if we are to follow indications of treat- 
ment eliminative of poison, we ought to encourage such vomiting and purging 
which mark the initiative stage of most of the exanthemata. The early attempts 
also to cure small-pox, scarlet fever, and measles, by promoting copious eruption 
on the skin, in the belief that the poison was so eliminated, proved a signal 
failure. . The popular belief that "better out than in" was not found to be a 
safe principle of treatment in the management of those diseases. 
We have no eliminative method of treatment which will rid the blood of 
such specific disease-poisons; just as we have no antidote which will destroy 
or counteract the influence of snake-venom when once it has got accidentally 
or artificially into the blood. We do our best when we try only to guide the 
patient through those specific diseases, by moderating the violence of the ex- 
pressions of the malignant phenomena, not by increasing them. We cannot 
cure them. The most successful results in the treatment of all those diseases 
have been got by those agencies which have led to modified and less malig- 
nant forms of the disease by sanitary improvements generally, and by agencies 
such as vaccination, in regard to small-pox, in particular. We do not think 
of, and dare not attempt to promote, diarrhoea or specific lesion in the intes- 
tines during enteric fever. Why should we be induced to promote diarrhoea 
in malignant cholera in the belief that we are thereby to free the blood from 
the specific poison of the disease ? The blood discharges may be, and un- 
doubtedly are, means (but not necessarily the only means) of propagating the 
disease; but it does not follow that promoting their discharge frees the blood 
from poison either in enteric fever or in cholera. By moderating the catarrhal 
flow in enteric fever, it is not found that we aggravate the disease and lock up 
specific poison in the system ; certainly by moderating, curtailing, or restrain- 
ing the diarrhoea of cholera, the only chance is left us of guiding the patient 
through that disease. 
Opium is the remedy which, by actual experience, alike in India and in 
this country, seems most worthy of reliance; but only at the commencement of 
laxity, or relaxation of the bowels, in seasons when cholera is epidemic. 
Treatment based upon conflicting theories (which are but theories after all) 
as to the nature of the disease, is greatly to be deprecated; and on this point 
Dr. Fergus makes the following pertinent remarks: 
" The influence of the theories of Dr. Johnson and others is to be seen in 
the instructions recently issued by the Board of Supervision in Scotland- 
very excellent as to the sanitary part, but in the medical portion (like most 
things issued by a committee) an evident compromise. It is a compromise, I 
believe, between the facts and a theory We are told, under the fourth 
section, to take castor oil or rhubarb and soda for looseness of the bowels, and 
afterwards the astringent mixture or pills-the former being intended as 
eliminators to promote the diarrhoea, the latter to check it. If this advice is 
followed during an epidemic of cholera, the consequences may be very serious. 
It is well known that during an epidemic, there is a general tendency to re- 
laxation of the bowels, and that they become very susceptible of the smallest 
dose of even the mildest medicine. Any one who has had much to do with 
cholera must have frequently met with cases which appeared to be the direct 
consequence or result of a slight dose of medicine. The risk is that the castor TREATMENT OF MALIGNANT CHOLERA. 
673 
oil and rhubarb would drive most of the cases into the second stage of cholera, 
and then the use of astringents and opiates at that stage would increase the 
danger immensely. 
"As to the remedies ordered, the quantity of laudanum (viz., five drops per 
dose) is too small, and there is no necessity for the chalk and catechu. Be- 
fore the opiate could produce much effect, the stomach would be overloaded 
with the chalk and catechu, to the extent of inducing vomiting. The pills 
should be ordered after each discharge from the bowels; but people will find 
it easier to provide themselves with laudanum than to use complicated mix- 
tures or pills." 
"With regard to castor oil," writes Dr. Macnamara, "I was acting as house 
physician to King's College Hospital, in 1854, when Dr. G. Johnson was 
treating his cholera patients on eliminative principles. I caught some of his 
enthusiasm on the subject, and came out to India the same year full of con- 
fidence and hope in castor oil. These ideas were destined soon to pass through 
a severe ordeal; for in the following year I was left at Bhangulpore in charge 
of a field hospital. I was the only medical man in the place, when cholera 
burst out among the Europeans and natives under my care. I went boldly 
to work with castor oil, but it absolutely and completely failed; the mortality 
from the disease was fearful. I have since, on several occasions, tried castor 
oil in cholera, but I have now finally abandoned it, having never seen any 
benefit arise from its use." 
In the second or algid stage the object is to promote reaction and to keep 
it in moderation. If the patient is not seen till profuse discharges-rice-water- 
like-have taken place, the time for all active treatment has passed, and efforts 
must be directed solely to restoration and repair, and, if possible, to rendering 
the stools acid, by the following draught every half hour for four hours, and 
then to continue every hour (Macnamara). 
B. Dilute sulphuric acid, and dilute acetic acid, of each TTgxv; carbolic add, 
half a drop; water, an ounce and a half; and opium may be added to the first 
and second doses, as existing circumstances may indicate. 
To promote reaction in cholera and diarrhoea, the following formula has 
met with most universal approval in this country and in India. So highly is 
it valued, indeed, that it is ordered to be always in store, and in readiness in 
the " Medical Field Companion " of the army when on the march: 
R. 01. Anisi, 01. Cajeput, 01. Juniper, aa $ss. ;* JEther., ^ss.; Liquor 
Acid. Halleri, Jss. ;f Tinct. Cinnam., ^ii; misce. The dose of this mixture is 
ten drops every quarter of an hour in a tablespoonful of water. An opiate may 
be given with the first and second dose, but should not be continued, for reasons 
already given. 
Some physicians think calomel should be given in moderate doses, for the 
purpose of producing a flow of bile into the intestines, as well as of restoring 
the other suppressed secretions.^ The indications, however, more generally 
followed are to treat the case as we should a similar state in typhoid fever 
(and calomel in small doses has been shown to be of service in connection 
with the affection of Peyer's glands in that disease-see pages 531 and 546), 
* A memorandum from Savory and Moore, of date 7tb June, 1866, shows that the 
quantities of the essential oils in the mixture now issued are increased to giss. 
f The Liquor or Elixir Halleri consists of one part of concentrated Sulphuric Acid 
to three parts of Rectified Spirit. It is commonly employed in Germany in the treat- 
ment of typhus and allied diseases, in doses of five to twenty drops in solution (Mur- 
chison, 1. c., p. 266). 
J [There is much evidence in favor of the administration of calomel in large doses- 
(20 grains), frequently repeated, to control the vomiting and purging.-Editor.} 674 
SPECIAL PATHOLOGY - MALIGNANT CHOLERA. 
and to moderate the affection of the bowels by mild opiates, by enemata, and 
by sinapisms to the abdomen ; also, to relieve the head by leeches and cold 
lotions, and subsequently, as the tongue becomes brown, to support the patient 
with wine, sago, strong broths, and a generally cordial treatment. 
During the reaction stage Dr. Andrew Clark, of the London Hospital, em- 
ployed with great success a powder composed as follows: 
Hyd. c. Creta, gr. ii; Pulv. Ipecac., gr. ss.; Pulv. Doveri, gr. iiss.; night 
and morning. 
The cases most benefited by this remedy were those in which the tongue 
had become dry and hard,-saline, lemonade, and chlorate of potash drinks 
being freely given. Mustard plasters or blisters to the nape of the neck were 
believed to be of use by inducing the return of the urinary secretion. 
[Dr. Leclerc, of Tours, France, and Dr. A. Rodrigues Barraut, of Mauritius, 
claim to have had large success with the following treatment. The extract 
of belladonna is given every half hour in quarter-grain doses, and continued 
until its physiological effects are produced, then increase the intervals to every 
1st, 2d, 3d, and 4th hour, giving the remedy until the urinary secretion re- 
appears. Atropia, used hypodermically, was found to relieve the cramps. 
White of eggs well diluted with water was freely given as a drink. Dr. 
Hodgen, of St. Louis, who has adopted the theory, and followed the treatment 
of Dr. Leclerc and Barraut, speaks well of the results. It has also been tried 
by Dr. J. W. Brewer, U.S.A., and he records a favorable experience.] 
The sick-room should be supplied with fresh air. Liquids should be assidu- 
ously applied to every surface capable of absorbing them, and the patient 
should be suffered to remain as free from officious treatment as possible. Heat 
applied in the dry form is to be avoided, but cloths moistened with hot water 
may be applied; or the patient may be wrapped up in warm, moist blankets, 
and hot bottles or bags of heated sand placeci around his cold and benumbed 
body. 
After the temperature is restored, the surface should still be kept moist, by 
sponging from time to time, or by the use of the wet sheet, to moderate the 
reaction. 
Urgent thirst is one of the most distressing symptoms in cholera. There is 
incessant craving for cold water-doubtless instinctive, to correct the inspissated 
condition of the blood, due to the rapid escape of the liquor sanguinis. It was 
formerly the practice to withhold water-a practice as cruel as it is mischiev- 
ous. Water in abundance, pure and cold, should be given to the patient, and 
he should be encouraged to drink it, even should a large portion of it be re- 
jected by the stomach ; and when the purging has ceased, some may, with 
much advantage, be thrown into the bowel from time to time (Maclean). 
Niemeyer recommends cold compresses to be frequently laid over the abdo- 
men. They are said to be very grateful to the feelings of the patient, whose 
sense of heat is great, although he may be cold to the bystander. The practice 
also is consistent with the lesions, especially the intensely pink vascularity 
existing in the intestines; and with the compress treatment he recommends 
also a grain of calomel every hour. 
Dr. Andrew Buchanan, of Glasgow, recommends the following as a drink 
generally relished and retained upon the stomach: "A raw egg beat up with 
half a pint of milk, and then mingling them with about a pint and a half of 
water, adding as much salt as will give the whole an agreeable taste." Or 
whey, milk and water, weak chicken soup, or any similar decoction, may be 
drunk ad libitum. Enemata of warm milk, repeated as often as expelled, are 
of the highest importance, by supplying an absorbable fluid, by mitigating 
abdominal pains, and diluting acid secretions. 
[It is important to r&store and maintain the action of the kidneys, uraemic TREATMENT OF MALIGNANT CHOLERA. 
675 
poisoning being one of the chief difficulties met with after the stage of col- 
lapse.] The secretion of urine may be promoted by dry cupping over the loins, 
by the use of solutions of chlorate of potash, and the like. But suppression of this 
secretion is most to be dreaded where opium has been too freely used in the 
treatment. In men of intemperate habits we often see, during the stage of 
reaction, obstinate vomiting of thick, tenacious, green paint-looking matter, 
probably bile-pigment, acted on by some acid in the stomach or alimentary 
canal. It is a symptom of evil omen, and often goes on uncontrolled until 
the patient dies exhausted, and this although all other symptoms may promise 
a favorable issue. It may last for a week, resisting all remedies, and proving 
fatal when the urinary secretion has been restored, and all cerebral symp- 
toms have subsided. Alkalies in the effervescing form, free stimulation of the 
surface, and chloroform in small doses, offer the best hope of relief for such 
cases. The patient should be nourished more by the bowel than the stomach 
when vomiting is present. 
Ice should be given ad libitum, where it can be obtained, not only to dis- 
solve in the mouth, but to swallow in pieces of convenient size (Maclean). 
A plan, peculiar perhaps to this country, and which was practiced to bring 
about reaction when the inefficiency of medicine was generally admitted, was 
an injection into the veins of the suffering patient of a solution of half an 
ounce of muriate of soda, and of four scruples of sesquicarbonate of soda, in ten 
pints of water, of a temperature varying from 105° to 120° Fahr. This solu- 
tion was injected slowly, half an hour being spent in the gradual introduction 
of the ten pints, and the immediate effects of this treatment were very strik- 
ing. The good effects were rapid in proportion to the heat of the solution, 
but a higher temperature than what is stated could not be borne. After the 
introduction of a few ounces, the pulse, which had ceased to be felt at the 
wrist, became perceptible, and the heat of the body returned. By the time 
three or four pints had been injected, the pulse was good, the cramps had 
ceased, the body, that could not be heated, had become warm, and instead of 
a cold exudation on the surface, there was a general moisture; the voice, be- 
fore hoarse and almost extinct, was now natural; the hollowness of the eye, 
the shrunken state of the features, the leaden hue of the face and body, had 
disappeared; the expression had become animated, the mind cheerful, the 
restlessness and uneasy feelings had vanished; the vertigo and noises of the 
ear, the sense of oppression at the prcecordia, had given way to comfortable 
feelings; the thirst, however urgent before the operation, was assuaged, and 
the secretion of urine restored, though by no means constantly so. But these 
promising appearances were not lasting ; the vomiting continued, the evacua- 
tions became even more profuse, showing that the remedy did not touch the 
root of the evil. The patient soon relapsed into his former state, from which 
he might again be roused by a repetition of the injection ; but the amendment 
was transient, and the fatal period not long deferred. Of 156 patients thus 
treated at Drummond Street Hospital, Edinburgh, under the direction of Dr. 
Mackintosh, only twenty-five recovered,-a lamentably small proportion, and, 
small as it is, it seems doubtful if the recoveries were final or complete (Mack- 
intosh, Principles of Pathology, p. 365). Nevertheless, injection of fluid by 
the veins ought still to be persevered in as a remedy in the right direction, and 
as a means of prolonging life. 
Stimulants tend to inflame the stomach, and are of no use in exciting 
the heart to any salutary action. Employed as in typhus, they are worse than 
useless. 
All violent remedies in this disease, as in others, are greatly to be depre- 
cated. Strychnia, prussic acid, tobacco, galvanism, boiling water, the actual 
cautery, or firing the spine, or bags of ice to the spine, or injections of spirits, 
are proven by trials to be of no use; nor can their recommendation be sup- 
ported except upon baseless theories, having no rational relation to the 676 
SPECIAL PATHOLOGY - MALIGNANT CHOLERA. 
pathology of the disease. Large doses of calomel or of lead are alike detri- 
mental. Nature effects a cure by slowly restoring the normal constitution of 
the liquids of the body. 
To generalize on the subject of remedies in cholera, the broadest conclusion 
seems to be, that remedies with an acid rather than an alkaline or neutral 
reaction have been most beneficial. 
Prevention of Cholera.-The following summary, by the highest authority 
on this subject, Dr. Parkes, will best conclude this account of cholera. The 
importance of the topics noticed, and the uncertainty that yet enshrouds many 
of them, may justify, it is hoped, the large amount of space which the subject 
has taken up: 
" For the first time in the history of cholera a new system of prevention 
has been brought largely into play in Europe-viz., the addition to the dis- 
charges of a presumed disinfecting substance. This plan, of course, is based 
on the belief that the principal (perhaps the only) mode of spread is by means 
of the putrefying evacuations; and the results obtained by it give certainly 
some strong evidence in favor of this opinion. 
"In this country the difficulty has been to make the public (and, in some 
cases, even the medical men) sensible of the importance of this plan, and of 
the necessity of giving it a complete trial. In some cases in which it has 
really been fairly tested, it appears to have arrested the spread of the disease, 
as at Bristol; and Dr. Budd's paper in the British Medical Journal, April 13, 
1867, gives good evidence on this point. In Southampton also, I believe, the 
spread was limited in this way, though it was not arrested so perfectly as at 
Bristol. In London, and several provincial towns, the method was also tried 
more or less fully. 
" In Germany, owing to the influence of Pettenkofer, the disinfecting plan 
was also brought into play, and the system followed has been described by 
that chemist.* 
" Without analyzing all the evidence, I proceed to give the most important 
practical rules. 
"The dangerous period of the choleraic stools is supposed to be when they 
become very ammoniacal. This occurs sometimes immediately they are 
passed, but usually not to any extent for some time. It is thought (but of 
course exact scientific proof is not readily attainable) that anything which 
makes and keeps them acid prevents the changes which cause the poison. 
"The three principal means of doing this are the use of carbolic acid, and 
sulphate of iron (with or without permanganate of potassium}, and the salts of 
zinc. Each has its advantages, and all may be used. The carbolic acid, from 
its liquid form and from its volatility, is excellently adapted to purify air, and 
to be used when surfaces are to be washed. It is also useful for sewers and 
closets. The sulphate of iron in substance and strong solution is better adapted 
for being put in the utensils in a room, as it has no smell, but it may be equally 
used for sewers and for watering streets. The sulphate of zinc (for the chloride 
is too dear) is better adapted for being put on linen or on floors, as it does not 
iron-mould the linen like the sulphate of iron. 
" The carbolic acid has not been used much in Germany, as it is still too 
dear; but Pettenkofer makes an observation of importance-viz., that when 
added to sulphate of iron the mixture seems to have more power of preventing 
ammoniacal development than either substance separately. If so, it might 
be desirable, as a matter of practice, to use the two together as much as pos- 
sible. The salts of zinc {sulphate or chloride} may be also used, but are per- 
haps not so good, and in some forms are dearer than the iron salts. Chloride 
* Cholera Regulativ, von H. Griesinger, M. Pettenkofer, and C. A. Wunderlich 
Zeitsehrift fiir Biologie, Band II, p. 435. USE OF DISINFECTING AGENTS. 
677 
of lime does not prevent the ammoniacal change, and appears altogether less 
useful. 
"The quantity in which these substances must be used is as follows: For 
each healthy person, daily, about three-quarters of an ounce of sulphate of iron, 
or one drachm of strong (but impure) carbolic acid, are sufficient. This amount 
will entirely prevent any decomposition of the feces for several days. In a 
town, therefore, where sewers are used, the above amount of sulphate of iron, 
or carbolic acid, multiplied by the number of persons, should go into the sewers 
daily, and, if possible, should be passed in from the houses, so as to act on the 
house drains as well as on the main sewers. If the place is not sewered, then 
the disinfectants should be added to the cesspools, middens, latrines, or what- 
ever plans may be in use. If both sulphate of iron and carbolic acid are used, 
which is to be recommended, half the quantity of each should be employed. 
The iron should be dissolved in a good deal of water. 
"Dr. Kiihne, who has made a great number of experiments on the action 
of various agents on fermenting substances, does not reckon the value of the 
sulphate of iron or of carbolic acid so highly as other observers. He states that 
neither arrest the various fermentations. Such an arrest is, however, attained 
with strong alkalies and strong acids; with chlorine, chloride of lime, bromine, 
permanganate of potassium and sodium, and permanganic acid. On the hypoth- 
esis, therefore (for it is nothing more), that the dangerous condition of the 
cholera discharges is one of 'fermentation,' he recommends any one of these 
substances rather than carbolic acid, and for common use prefers permanganate 
of sodium, to which (as a concession to Pettenkofer) he mixes some sulphate of 
iron. The proportions are two parts of permanganate of sodium (solution ?), 
forty-five parts of acid sulphate of iron, and fifty-three parts of water in one 
hundred parts. 
"It must be remembered, however, that such points as these must be de- 
cided by actual experience, and that arguments derived from the action of 
these substances on common ferments are not very satisfactory as regards the 
prevention of cholera. 
"In Southampton, in 1866, carbolic acid was chiefly used ; and the average 
amount was about twenty gallons daily for a town of 50,000 people; it cer- 
tainly appeared useful. 
"If an aerial disinfection is needed, sulphurous acid (obtained by burning 
sulphur) is perhaps the best. Nitrous acid fumes are certainly very powerful; 
and one or other of these substances should be used for half an hour daily in 
all privies or latrines. 
"For washing clothes the iron salts are not applicable, as they stain linen. 
Carbolic acid gives a disagreeable smell. Either a watery solution of sulphur- 
ous acid or a solution of zinc salts should therefore be used. Baking the 
clothes, at a temperature of 250°, or boiling, should be used. 
"In hospital wards, dead-houses, &c., it is a good plan to sprinkle sawdust 
on the floors, and to moisten it with weak carbolic acid (one part of crude acid 
in sixty or eighty of water). 
"These measures should be commenced when cholera is apprehended. 
Every privy and sewer should have twice daily the mixed carbolic acid and 
sulphate of iron solution. If cholera is introduced, the amount should be 
doubled in the privies of all the adjacent houses, while the closet of the 
affected house should never act without a portion of the disinfecting liquid 
being placed in it. If the disease breaks out, a plan recommended by Dr. 
Budd is worthy of imitation-viz., to place a layer of carbolic acid powder 
(carbolic acid and lime) in the bed, under the breech of the patient. 
"The disinfection in this way of the closets and privies of hotels, railways, 
and workshops, should be commenced very early. 
"As a precaution against cholera, quarantines have only answered when 
they are absolute; and an absolute quarantine is not possible for a commer- 678 
SPECIAL PATHOLOGY CHOLERA MORBUS. 
cial people. The reason of the failure of partial quarantines is the fact that 
the diarrhoeal stools will propagate the disease, and that the period of in- 
cubation, though usually short, may be prolonged even to twenty or twenty- 
five days. Restriction on movement must therefore be used or not, according 
to circumstances; but in all cases persons coming from infected districts ought 
to take measures for disinfecting their evacuations in the above manner." 
A new saline antiseptic "chloralum" has been recently much commended. 
[More experience has proved it of no value.] 
The inquiries made through the Epidemiological Society show that special 
hospitals, or special wards in hospitals, ought to be devoted (with a separate 
and special staff of attendants for day and night duty, or more frequent periods 
of relief) entirely to the management of cholera patients. 
For further details, see management of epidemics generally, page 359 ante. 
Much may still be expected from a thorough improvement of the sanitary 
condition of India; and especially of the filthy towns and bustees, or native 
villages, constructed without any plan or arrangement, without roads, with- 
out drains, ill-ventilated, and never cleaned-the abodes of misery, vice, and 
filth,-the nurseries of sickness and disease. These are the localities within 
the endemic area of cholera which require special attention and improvement 
in the first instance; and which are now receiving the attention of the Indian 
authorities through their special sanitary administration. 
[CHOLERA MORBUS-SPORADIC CHOLERA, SIMPLE CHOLERA, CHOLERA 
BILIOSA. 
Definition.-A disorder of hot climates and hot seasons, characterized by sud- 
den, incessant, violent vomiting and purging of acrid, sometimes bilious matters; 
attended with spasms of the muscles of the abdomen and extremities, cold surface, 
feeble and rapid pulse, and prostration which may pass into collapse; the direct 
exciting cause being generally some undigested article of diet. 
History.-The term cholera has been in use since Hippocrates (Epidem,., 
lib. v). Celsus derives it from %Ay, bile, and I flow,-a bile-flux; others 
from intestine, and pdu-intestinal flux; whilst Trallian and Ruysch 
give as its derivation yokypa, the rain-gutter of a house. Galen gives its true 
pathogeny. Celsus accurately describes it (lib. iv, cap. 2), and mentions, as 
an occasional symptom, watery and white discharges; he speaks of it as a 
dangerous disorder, and one that may quickly cause death. Aretseus (lib. ii, 
cap. 5) is minute in his account of the gastro-intestinal evacuations. Of mod- 
ern writers Sydenham has given a most graphic delineation in his narration 
of the disorder as it prevailed in England in 1669. 
Nature and Pathogeny.-Cholera morbus is a disorder of hot climates, and 
the hot seasons of temperate climates. Sydenham says, " It seems partial to 
a particular part of the year. It sets in at the end of the summer and begin- 
ning of autumn, as truly as the swallow comes in spring, or the cuckoo sings 
in summer."* It is most common in that part of the hot season in temperate 
countries when the temperature during the day is high and falls at night-time; 
or after those sudden weather-changes so frequent in our summers. Whatever 
part climate and temperature may have in its causation, it is only collateral 
and predisposing, the immediate cause in most cases met with in practice being 
the presence in the stomach and upper bowel of some article of diet, imper- 
fectly digested, which sets up a fermentative and putrefactive process, making 
the matters acid and acrid, and causing great irritation of the gastro-duodenal 
(Dr. Clymer.) 
* Med. Obser., ch ii. Works of T. Sydenham. Syd. Soc. ed., vol. i, p. 163. SYMPTOMS AND DIAGNOSIS OF CHOLERA MORBUS. 
679 
lining membrane, which brings on vomiting and purging.* The irritation 
extends to the liver, inciting, in some cases, the biliary secretion, for a while- 
to the spinal cord, causing cramps in the muscles of the abdomen and legs, 
-to the sympathetic, producing, through the periphero-vasal system, coldness 
of the skin and capillary torpor. The most common offending articles of diet 
are shell-fish, salted or tainted meat, and decaying vegetables. From the 
peculiar state of the digestive organs, sound food may not be acted on by the. 
gastric juices, and, undergoing the putrefactive process in the stomach, be- 
comes an exciting cause. Drinking largely of iced water, when the body is 
overheated, is an occasional cause. Emanations from cesspools and sewers, 
and putrilage, have produced a train of symptoms identical with those of 
cholera morbus. 
Cholera morbus is a disorder essentially distinct in its nature and setic gene- 
sis from Asiatic cholera. The one is caused by a material toxic agent directly 
in contact with the gastro-intestinal membrane, rendered specially susceptible 
to its action from the influence of season and temperature; the other owns 
for its cause a specific poison, infecting through the atmosphere and the evacu- 
ations of those suffering from it. The discharges of cholera morbus are acrid, 
dark-colored, and, often, during some time in an attack, bilious; while in 
Asiatic cholera, there is no evidence of the presence of bile in the evacuations, 
and they are light colored, and turbid from whitish particles-the epithelial 
cells of the mucous membrane of the stomach and bowels. 
Symptoms.-An attack of cholera morbus is most often sudden-though 
it may be preceded by nausea, colicky pains, and rumbling in the belly-be- 
ginning with incessant, uncontrollable simultaneous vomiting and purging: 
first of' the usual contents of the stomach and bowels, and then of highly 
acrid, acid, and often bitter matters, varying in color from a light brown to a 
dark green. The discharges both from the mouth and anus are suddenly and 
violently projected, rocket-like, or squirted out without effort. The stools are 
very fetid. At the outset there may be tympany, which soon disappears, the 
belly becoming contracted. Painful and quick recurrent cramps in the abdo- 
men, legs, and, sometimes, upper extremities, come on, the muscles contracting 
into hard knots. The thirst is excessive, and there is a keen craving for 
drink; the tongue is covered with a whitish or yellowish fur. The pulse, de- 
pressed at first, becomes quick, compressible, and gradually feebler; the skin 
very soon gets cold, and is bathed with moisture; the voice is weak, and its 
tone peculiar; the breathing is oppressed and sighing; the urine is high-col- 
ored and scanty; and debility is complained of. If the disorder is not checked 
these symptoms worsen, the features become shrunken, the eyes have a hollow 
look and are surrounded by bluish circles; the skin is shrivelled, algid, blue, 
and covered with a clammy sweat; the pulse is fluttering, and finally imper- 
ceptible ; the respiration labored ; the secretion of urine stops ; the discharges 
and spasms cease, though there may be retching and a desire to go to stool; 
hiccough is troublesome; the prostration is great and growing; collapse is per- 
fect ; and finally death happens from asthenia. The mind is usually through- 
out unaffected both in mild and in severe attacks. A favorable issue, the 
ordinary one in this country, is shown by diminished violence of, and longer 
intervals between, the spells of vomiting and purging, a more natural look, and 
gradual reaction. 
The duration of an attack varies from a few hours to twenty-four ; it rarely 
lasts several days. Recovery is usually rapid, though symptoms of gastro- 
intestinal irritation may remain for some days, and there is not unfrequently 
much emaciation and haggardness even after a short sharp attack. 
Diagnosis.-The diacritic features of cholera morbus and epidemic cholera 
* Galen attributes cholera morbus to the presence of acrid humors generated by the 
corruption of the food. 680 
SPECIAL PATHOLOGY-CHOLERA INFANTUM. 
have already been dwelt on. There is much more likeness between, the symp- 
toms of cholera morbus and those produced by irritant poisons, but a differ- 
ential diagnosis is generally easy ; the history of the case, when it can be got, 
and an examination of the vomit and the state of the mouth and fauces, where 
the poison is a caustic, should prevent a mistake. 
Cholera Morbus. 
After vomiting and purging, sometimes 
scald of the mouth and fauces com- 
plained of. 
Vomiting and purging often simultane- 
ous. 
None, or slight pain in epigastrium. 
Cramps in abdomen and legs. 
Never. 
Poisoning from Irritant Substances. 
Burning heat in mouth, pharynx, and 
oesophagus usually precedes vomiting, 
and is more intense. 
Vomiting generally precedes purging, and 
is not simultaneous with it; and mat- 
ters are ejected with less force. 
Constant severe pain in epigastrium. 
None. 
Alvine evacuations often bloody. 
Treatment.-Opium and its preparations must be our chief trust in the 
treatment. They are to be given both by the mouth and rectum, in liquid 
form, and in full doses, to be repeated at once if thrown off, and if kept, at 
such intervals as to hinder narcotism. There is great tolerance of opium in 
this disorder. Morphia may be used hypodermically.* A chief point is to 
withhold all drink, but small pieces of ice may be held in the mouth, the 
water being spit out. Dry rubbing with the hand, or with woollen cloths, 
should be made over the body, and particularly over the abdomen and lower 
extremities, to relieve the cramps, and revive the capillary circulation. Sina- 
pisms may be applied to the calves of the legs, inside of the thighs, and along 
the spine, in severer cases; or the upper and lower extremities, belly, chest, 
and spine, be covered with woollen cloths, well wrung out of hot water, to 
which mustard flour has been added, and the patient then wrapped in a dry 
warm blanket. If prostration is very great with a tendency to collapse, a 
mixture of chloroform, camphor, ether, and capsicum, will prove an excellent 
stimulant, and has sometimes quickly checked all the symptoms. Iced brandy 
and iced champagne are favorite stimulants in an advanced stage of the dis- 
order. On the abatement of the acute symptoms, the tongue remaining furred, 
a mild mercurial, followed by a small dose of castor oil, may be administered 
without risk of bringing on a relapse.] 
[CHOLERA INFANTUM-SUMMER COMPLAINT-INFANTILE CHOLERA. 
(Dr. Clymer.) 
Definition.-A perilous disorder of early infancy, most common in the first 
year of life, the chief symptoms being stubborn purging of variously colored serous 
fluid, and vomiting; occurring under the combined influence of high atmospheric 
temperahire, great humidity, and malnutrition. The solitary follicles of the intes- 
tines are more or less diseased. 
History.-Cholera infantum has been thought by many writers to be a dis- 
order peculiar to the United States, but, as Dr. Trousseau remarks, it has 
always been observed, and shows itself in all countries under the same circum- 
stances of season, age, and bodily state, and he describes it as cholera infantile 
or mal d'ete.f Sydenham says, " There is a sort of cholera morbus exceed- 
ingly fatal to infants."^ It is probably more generally prevalent in the 
* From a limited experience with the sulphites in cholera morbus, the writer is dis- 
posed to think that, in small doses, at the outset of an attack, they may prove benefi- 
cial 
t Clinique Medicale, 2d ed., t. 3, p 1'28. Paris, 1865. 
+ Works of Thomas Sydenham, M.D.: Processus Integri, ch. xxiv, vol. ii, p. 267 ; 
-Syd. Soc. ed., London, 1850. SYMPTOMS OF CHOLERA INFANTUM. 
681 
Middle and Western States than in Europe, recurring with uniform seasonal 
regularity, and being the chief cause of the great loss of life amongst infants 
in the large towns of those states during the summer months. There is no 
doubt that in the death-records distinct pathogenetic affections are ignorantly 
reported under the same general head of cholera infantum,-as the diarrhoea 
of dentition, cholera morbus, enterorrhoea, enteritis, and typhoid fever; yet 
we must admit the existence of a disorder of early infancy, of a special 
nature, characterized by typical symptoms, bred by the operation of the same 
causal factors, and whose true pathogeny and precise phenomena have yet to 
be accurately studied and described. 
Symptoms.-One form of cholera infantum resembles very much the 
cholera morbus of adults; is sudden in its invasion; and has for its chief 
symptoms incessant and violent purging and vomiting of serous fluid, of a 
greenish or yellowish hue; great thirst; sharp and incessant cries, betokening 
pain; cold surface; quick pulse; and early collapse. Such cases may end 
fatally within twenty-four hours. The more chronic and common form of the 
disorder begins with looseness of the bowels, soon followed by steady vomit- 
ing. The intestinal evacuations are at first fecal, very liquid, sour and offen- 
sive, but soon become serous, of a light-yellow color-like water to which a 
little yolk of egg has been added, or the urine-which changes often to a 
greenish hue, from the presence of shreds or flocculi, like finely-chopped 
spinach or sorrel. Occasionally the stools may be for a while pasty and 
frothy, with a more or less yellow or green tinge. Vomiting is rarely an 
initial symptom, but soon sets in, and is incessant; everything swallowed is 
thrown up at once; if milk has been taken it is rejected in cheesy lumps; the 
odor of the ejected matter is sour, and often quite acrid. In the early stage 
the temperature of the body is natural, or very slightly raised at times during 
the day; the rate of the pulse is quickened; the tongue is moist, and its base 
is coated with a light-brown fur; the belly is slightly tympanitic; the child is 
restless, irritable, and cryful. As the phases of the disorder deepen, there is 
rapid and, frequently, excessive emaciation; the surface is dry and of a dusky 
hue, with heat-exacerbations; the skin of the body and extremities is flabby 
and inelastic, a fold of it pinched up between the fingers remaining for some 
time; the pulse is wiry, sharp, small, and frequent; purging and vomiting 
continue. There is little change in the character of the stools, except the 
predominance of the greenish hue, owing to the presence of broken-up blood- 
discs, and dark granular coloring matter; sometimes they are pinkish, like 
water in which fresh meat has been washed; there is rarely any trace of bile 
in them after the first day or two; they are acid, and have a cadaveric smell. 
Vomiting,- or the effort to vomit, is obstinate and distressing, and, on placing 
the hand over the abdomen, a spasmodic or rolling motion of the muscles will 
be felt, simultaneously with the action of the stomach, though sometimes pre- 
ceding it. There is pain in the abdomen, which is retracted and hot, shown 
by a pinched and distressed expression of the face, by a fold in the commis- 
sure of the lips outside of the orbicularis muscle, and by a line extending 
from the labial angle to the inside of the ala nasi, and sometimes surrounding 
the orbicularis (Stewart). Thirst is ardent, and when any liquid is offered 
it is swallowed with avidity, the vessel being seized, or if the child is lying 
down, it will quickly raise its head, no matter how weak or indifferent it may 
be. The eyes are hollow, with a blue circle; the face is wan; on awakening 
there is knitting of the eyebrows followed by a loud and frequent cry; and 
the tone of the voice is changed. There is much debility from the outset, 
and it gradually increases and becomes excessive. At this stage of the dis- 
order there may be collapse and speedy death, or cerebral epiphenomena may 
happen, as convulsions or coma. Not infrequently there is more or less stupor, 
the eyes drawn up beneath the upper lid, with injected conjunctivae, rolling 
of the head, hydrencephalic shriek, taches cerebrales, which end in deep coma, 682 
SPECIAL PATHOLOGY-CHOLERA INFANTUM. 
or convulsions, particularly if there is dental irritation. Or, sooner or later, 
and this is probably the most common termination, typhous symptoms, the 
necessary result of prolonged innutrition, set in, and soon carry off the little 
patient. 
Causes and Nature.-It would seem necessary that certain conditions 
should come together for the production of cholera infantum ; it is the sure 
sequence of given antecedents. The effective causes may be said to be age, 
high temperature, humidity, and malnutrition. The influence of age is positive, 
it being a disorder limited to the first eighteen months of life. Stewart 
asserted that the true disease never appeared but during the period of teeth- 
ing.* Of 278 reported deaths from cholera infantum during the week ending 
July 21, 1866, 199 were under one year. It is a disorder of the hot months. 
In the city of New York, during a period of eleven years, out of 1245 deaths 
from cholera infantum, 1061 were in the months of July, August, and Septem- 
ber. During the first twenty-eight days of July, 1866-a month of unusually 
great heat-there were reported 687 deaths from cholera infantum, in a total 
mortality from all diseases of 3452. In the preceding trimester, in a total 
mortality of 5597, the deaths from cholera infantum were 76. The influence 
of high temperature is more striking, if the weekly mortality of the month of 
July, 1866, from cholera infantum, is examined. For the week ending July 
7, mean temperature 81^° Fahr.: total deaths, 493; deaths from cholera in- 
fantum, 61. For the week ending July 14, mean temperature 82y° Fahr.: 
total deaths, 827; deaths from cholera infantum, 172. For the week ending 
July 21, mean temperature, 82Fahr.: total deaths, 1362; deaths from 
cholera infantum, 278. For the week ending July 28, mean temperature, 
73$° Fahr.: total deaths, 770; deaths from cholera infantum, 176. 
The late Dr. James Stewart instituted a series of observations to ascertain 
the relation of atmospheric humidity to cholera infantum, and came to the 
conclusion that ordinary climatic humidity had but little influence in its de- 
velopment ; but, directing his attention to the occasional state of the dew- 
point, as it occurred in localities where the disorder was most rife-the popu- 
lation living in overcrowded underground cellars and tenement-houses-he 
" discovered a great difference within doors between it and the general dew- 
point of the external air, continuing often for a long time." His observations 
showed-(1.) That the moisture was always greater nearer the surface of the 
earth, the difference at times being 4° ; (2.) That in very hot weather, in 
crowded rooms at night, " when all were within, the dew-point is very nearly 
the temperature of the air, thus saturating it with moisture." With a tem- 
perature of 90° to 95°, and a dew-point in a crowded room almost equal to 
the temperature, a feeling of suffocation is experienced, which is easily ac- 
counted for when it is known that the dew-point of the breath, as it is expelled 
from the lungs, is 94°, and that the mean dew-point of the atmosphere is 38° ; 
and also, that in the hottest weather it rarely exceeds 70°. j" 
Malnutrition is due to several sources. The depressing and exhausting 
effects of great heat and moisture are exerted on a body imperfectly nour- 
ished. The mother, suffering from the devitalizing and septic influences 
which surround her, secretes a milk imperfectly elaborated and unfitted for 
food ; or, when in itself wholesome, the digestive organs of the infant are so 
disordered, that there is a lack of the changes it should undergo ; a chemical 
act of decomposition happens, directly the opposite of the vital act of diges- 
tion, and cheesy clots of the coagulated casein are rejected in the vomit, or 
pass unaltered or corrupt through the bowels. Infants brought up by hand, 
as well as those just weaned, are very liable to cholera infantum. Here a 
* Prize Essay on Cholera Infantum. By James Stewart, M.D. The Transactions 
of the New York Academy of Medicine, vol. i, part vi, 1856. 
f Loc. cit., p. 290. treatment of cholera infantum. 
683 
deleterious and inadequate diet-often exclusively farinaceous or gelatinous, 
or of milk.from diseased animals, or so dilute as to be unfit for food-plays a 
chief part. The direct influence of animal poison must not be passed over. 
The chief haunts of cholera infantum are the fever-nests and cholera-fields 
of large towns. Diphtheria, scarlet fever, putrid sore-throat, typhus, and 
Asiatic cholera, herd together, and fester in the slums, where the wretched 
and squalid dwellers are stowed away in ill-ventilated, ill-drained under- 
ground cellars and tenement-houses, in the midst of every possible insanitary 
condition ; breathing a septic atmosphere, poisoned without, by the putrilage 
of slaughter-houses, soap and glue factories, cesspools and sewers, and within 
by emanations from the human body, filthy clothing and bedding, and often 
the excrements of man and beast. 
The necroscopic characters are-congestive, and, sometimes softened, patches 
of the mucous membrane of the small intestines, sometimes extending to the 
large, which is covered with mucous or membranous exudations ; the solitary 
follicles are invariably enlarged, often resembling the sprinkling of white 
sand over its surface, and frequently ulcerated (J. Jackson, Horner, Bax- 
ter, Lindsley, Hallowell, Stewart). Many observers state the liver 
to be congested, enlarged, or altered in color or texture, it being lighter than 
when healthy, or variegated and firmer. In 37 cases, carefully examined 
after death by Dr. J. Lewis Smith, there was no evidence that the liver was 
affected, either as to size, or in any way involving any modification of func- 
tion. Microscopic examination showed a variable amount of fat-sometimes 
in excess, sometimes deficient, and sometimes greater in one part of the organ 
than another. The green stools, so long referred to the liver, are due to 
causes operating within the intestines, the green color not appearing until the 
lower part of the jejunum or upper part of the ileum is reached. The green 
matter under the microscope is found to be in small shreds or masses {Ameri- 
can Medical Times, vol. v, 1862). Where coma and convulsions have hap- 
pened, there are softening and hypersemia of the cerebral substance (Hallo- 
well}. 
The conditions under which cholera infantum is produced, the constant 
intestinal lesion, and the symptoms of the more chronic and common form of 
the disorder, bring it in close relation to chronic camp diarrhoea, and would 
place it, in its developed stage at least, amongst autophagic diseases. All the 
deleterious causes which act as factors in the one case are equally potent in 
the other. The greater the insanitary conditions of any given locality, the 
higher the death-rate from cholera infantum. The digestive organs, disor- 
dered by the circumfusa, are unable to perform their office; for days and 
w7eeks, at a time of life when the tissue-changes are active, the constant waste 
of the body is unrenewed ; there is, besides, another and great destructive 
force at work in the large and frequent drain by the intestinal discharges ; 
there are extraordinary demands and no supply. As a consequence, all the 
phenomena of innutrition occur,-rapid and excessive emaciation, wan and 
shrunken face, harsh, dry, and dusky skin, and general typhous symptoms, 
including the cerebral epiphenomena, when these are not directly due to the 
irritation of dentition. - 
Treatment.-The indications for the treatment of cholera infantum are 
clear and positive. The conditions which seem to be the likely cause of the 
disorder must be got rid of. The instant threatening symptoms are the purg- 
ing and vomiting, showing the state of the stomach and bowels. These must 
be stopped. That there is an excess of acid in the stomach and bowels, at 
least in the early stages of the disorder, cannot be doubted. Fermentation, 
and not chymification, is going on in the stomach and duodenum, and is, 
without question, one of the causes of the vomiting and purging. Various 
remedies have been suggested and used to check these symptoms, as calomel 
in fractional doses, mercury with chalk, creasote, the alkalies, &c. Small 684 
SPECIAL PATHOLOGY-CHOLERA INFANTUM. 
doses of the bisulphites of soda or potassa, with limed whey, will often act 
very happily, whilst the effect of poisonous drugs is always doubtful, and 
generally positively harmful. Mercury cannot have any curative power; it 
is at best negative. If not contraindicated by cerebral epiphenomena, and 
the effects carefully watched, opium and its preparations will be found a 
valuable remedy. Sydenham speaks strongly in its favor, and the preju- 
dice against its use, is not, within certain restrictions, warranted. Flannel, 
wrung out of hot water, and on which laudanum is poured, applied to the 
spine, will be found useful in checking vomiting. The skin, in common with 
all the excreting organs, is inactive; the effect of great and prolonged heat 
is always to increase its function ; there is for awhile local hyperaemia, with 
swelling of the papillae, giving rise to the eruption familiarly known as 
prickly-heat; finally there is loss of tone and sluggishness, especially when 
exposed to currents of air. The indication is to restore its functions, and this 
may be done by gentle friction by woollen cloths, or a warm alkaline bath, 
in which the little patient should not remain longer than three minutes, and 
then be quickly dried, and wrapped in flannel. So soon as the stomach and 
bowels will tolerate food, it should be given of fitting quality, and in proper 
quantity. Farinaceous food-the usual diet in all diarrhoeal disorders-is 
entirely inappropriate. The starches are unaltered by the peptic solvent, 
and turn acid in a mass ; very often in the mouth, from the action of the 
saliva, so abundant in infants, before they reach the stomach. In infants 
so fed they will be found in the bowels almost unchanged. The natural 
food of the infant is entirely dissimilar from these amylaceous articles, which 
not being digested and assimilated, are consequently not only innutritive, 
but act as direct irritants to the alimentary mucous membrane. Limed 
milk, to which a little gelatine has been added, or rennet whey, may be 
given ; but in protracted cases, where the prostration is great, and emacia- 
tion rapid, beef essence, freshly prepared and well salted, will often be 
well borne and quickly appropriated. The avidity with which the little 
patient takes animal food*-seizing on meat, salt fish, &c., when it*can- 
shows an instinctive craving for proper nourishment, too constantly withheld 
from false notions of the nature of the disorder. Some twenty-five years 
since, Dr. Weisse, a Russian physician, used raw meat in a case of infantile 
chronic diarrhoea, and with success. It is a popular remedy in some parts 
of Europe in chronic and wasting affections. His example was followed by 
others, especially by Dr. Trousseau, of Paris.f Lean beef or mutton is first 
finely hashed, pounded in a mortar to a pulp, and then passed through a fine 
sieve: a thick concentrated juice--puree de viande-is thus obtained, nutri- 
tious and digestible, and often, when salted or otherwise flavored, quite ac- 
ceptable. Give a half to three-quarters of an ounce, in fractional doses, the 
first day; and if well borne by the stomach, increase the quantity day by 
day, until a quarter or half a pound is taken in the course of the twenty-four 
hours. Dr. Trousseau mentions a case in his own family, where he continued 
it for more than one year ; the child, about two years of age, finally taking 
a pound of raw meat daily. For the first day or two much of it may pass 
hardly changed in the stools, but this alone should not prevent it being per- 
severed in. From the observations of Weisse, Braun, Van Siebold, and 
Trousseau, this diet, if long continued, is liable to generate taenia. White of 
eggs, thinned with natural or artificial Selters, or Vichy, or weak lime, water, 
is an excellent drink ; or a few grains of bicarbonate of soda, may be added 
* " I have seen many children recover," said the late Dr. Rush, in reference to the 
treatment of cholera infantum, "from being gratified in an inclination to eat salted 
fish and meat. In some instances they evince an appetite for butter, and the richest 
gravies of roasted meat, and eat them with obvious relief to all their symptoms."- 
Medical Inquiries and Observations, 2d ed. 
f Clinique Medicale, par A. Trousseau, t. iii®, 2® ed., Paris, 1865. DEFINITION AND HISTORICAL NOTICE OF DIPHTHERIA. 
685 
to the albuminate. Tonics and stimulants are very frequently required in 
the course of the disorder. Of the former, minute doses of arsenic (tlie liquor 
potassse arsenitis), alone or combined with quinine, or the chloride of iron, or 
the pernitrate of iron, or the tincture of nux vomica, may be given. Wine- 
whey, or brandy and water, to which a few drops of the aromatic spirits of 
ammonia have been added, are the best stimulants. The gums should be 
often looked to, and freely lanced if hot and swollen. But all treatment is 
too often unavailing, unless the child is removed from the insanitary condi- 
tions by which it is surrounded. The effect of change of climate is generally 
immediate and lasting, and where it can be done, the little patient should be 
sent without delay to a cool and mountainous region.] 
DIPHTHERIA. 
Latin Eq , Diphtheria; French Eq., Diphtherite; German Eq , Diphtherische Ent- 
zundung der Rachenschleimhaut-Syn., Diphtheritis ; Italian Eq., Difterite. 
Definition.-A specific disease with membranous exudation on a mucous sur- 
face (generally of the mouth, fauces, and air-passages), or occasionally on a 
wound. 
The disease is attended with great prostration of the vital powers; by a very 
early appearance of albumen in the urine, which may continue for a very short 
time only, or may become persistent. In some cases a remarkable series of ner- 
vous phenomena are apt to supervene, characterized by progressive paralysis, and 
sometimes by fatal syncope. The disease is contagious, and apt to be epidemic. 
Historical Notice.-Diphtheria is by no means new to England; and the 
writings of the older physicians prove that from time to time it has been epi- 
demic, or at least very common in many parts of England. The historical 
accounts of the disease show that it has preserved its essential character and 
nature from age to age. Ever since the end of the "sixteenth century, 
diphtheria has been observed in every region of the Old and New World." 
At first it continued for a time in Spain; and during nearly forty years 
was noticed in different parts of the Peninsula. Rather later, all Italy 
was successively afflicted by it. Towards the middle of the last century 
especially, epidemics of the disease have occurred, less general and less pro- 
longed, but more multiplied, in England, in France, in Sweden, and in 
America, and particularly at New York and Philadelphia. It terminated 
the life of Washington, and of the Empress Josephine. The outbreaks have 
usually been limited in extent, sometimes not spreading beyond a single 
dwelling, building, village, or quarter of a large town. It prevailed as an 
epidemic in the north of France and south of England in 1859, to a consid- 
erable extent; and since that time many excellent monographs have been 
written on the subject in our own country, generally recognizing the disease 
as distinctly specific, infectious, and sometimes epidemic, among which those 
of Hunter, Semple, Chatto, Wade, Ernest Hart, Greenhow, Sanderson, and 
Jenner are conspicuous. It was M. Bretonneau's investigations and writings 
which gave to diphtheria the characteristics of a substantive affection; and 
the literature of the various forms of sore throat will show how the disease 
has been confounded with croup on the one hand, and malignant scarlet fever 
on the other. Recognizing the existence of diphtheria expressing itself first 
by a lesion in the larynx, and so constituting croupal diphtheria, or diphtheria 
with the local symptoms of croup; or, to put it in another form, that there is a 
form of croup due to diphtheria, there is yet abundant evidence to show that 
true croup is a different disease, and one quite sui generis. A disease different 
from diphtheria is so named by the College of Physicians, and will be de- 686 
SPECIAL PATHOLOGY-DIPHTHERIA. 
scribed in its proper place, together with laryngeal catarrh and acute laryngitis, 
each of which diseases has also been confounded with croup. 
Of the historical accounts of diphtheria, the best is that given by William 
Squire, L.R.C.P., London, in Reynolds's System of Medicine; and Mr. John 
Chatto's valuable account of the bibliography of diphtheria since Breton- 
neau's first essay will show the confusion of ideas entertained and expressed 
upon diphtheritic croup, and sore throat. One source of confusion is to be 
traced to the different uses of the term croup, a term which the French have 
always used in the sense of diphtheria. 
Pathology and Morbid Anatomy.-In this disease, as in many others of 
the miasmatic kind, the general or the local symptoms may predominate, 
giving special features to each case; and the patient may die from the 
severity of the general disease-the specific fever-or from the severity of 
some one of the local lesions. 
The mucous membrane covering a tonsil may be the primary seat of the 
characteristic local exudation, or the arches of the palate, or the posterior 
surface of the soft palate, the uvula, the nares, the pharynx, or the larynx 
maybe the primary seat. "It may extend continuously from the nares to 
the bronchi-may be moulded on to any anfractuosity of the nasal passages; 
it may line the whole pharyngeal cavity, adhere to both surfaces of the epi- 
glottis, cover the interior of the larynx, form a cylindrical cast of the trachea, 
and may thus be removable from even the smaller bronchi. More rarely it 
is found to extend in this manner throughout the oesophagus" (Squire). The 
membrane has been found even in the gall-bladder. Thus the disease may 
prove fatal very early simply by reason of the vital importance of the parts 
affected. < 
At first there is redness and swelling; and the normal mucous secretion is 
so altered in its physical properties that it adheres by its own increased 
viscidity to the mucous membrane. A white or gray patch now forms on the 
membrane, which indicates the presence of a layer of lymph on the reddened 
surface. The layer of lymph may thus spread from one or from several 
centres over the reddened surface; and this redness may involve the whole 
mucous membrane within reach of the eye. The lymph which grows upon 
this reddened surface may descend into the larynx, the trachea, and the 
bronchi. Dr. Stokes has recorded a fatal case, in which the tongue, tonsils, 
pharynx, epiglottis, larynx, trachea, and right bronchus were more or less • 
thickly coated with the deposit, even as far as the fourth or fifth bronchial 
ramification, while the left bronchus remained quite free from it. The right 
lung was cedematous and consolidated, the left comparatively healthy {Dub. 
Jour. Med., Feb., 186$). Sir William Jenner has known the diphtheritic 
exudation to extend into the oesophagus and stomach {Diphtheria: its Symp- 
toms and Treatment, by Sir William Jenner, p. 4). If the lymph be torn 
from the mucous membrane, a raw, bleeding surface is exposed, which in a 
few hours is again covered by a new layer of lymph. The lymph of diph- 
theria has a variety of appearances. Sometimes it is granular, with very 
little consistence or. tenacity. Sometimes the partis covered with a pulpy 
substance of a white or gray color; but this pellicle is constant in some form 
or other, and is possessed of the power of reproducing itself. It is this exuda- 
tion, together with the specific constitutional symptoms of general infection, 
which establishes the disease as one sui generis, and to which Bretonneau gave 
the name of " Diphtheritis," and which has been subsequently modified to 
"Diphtheria." The latter term has the advantage of being the shorter word, 
and is that adopted by the Registrar-General and by the College of Physicians. 
Etymologically, the terms are derived from SupOipa vel dapOepis, signifying the 
prepared skin of an animal; while' d'.cpOsplry'; vel StcpOeplyz signifies that which 
is covered with a fur, or with a leathern coat. 
In microscopical characters it does not appear that this "fur," "pellicle," MORBID ANATOMY OF DIPHTHERIA. 
687 
or "false membrane" of diphtheria can be distinguished from the concrete 
exudation or blistered surfaces, or that which forms in the angina of scarla- 
tina (Empis). The commencement of the formation of the pellicle is in 
reality an act of coagulation. The mucous membrane exudes, in the first 
instance, a fluid in which theyi6rm or mucin coagulates; and such coagulated 
material forms the tube-casts which line the surface of the larynx and trachea, 
but from the mucous surface of which they come to be separated by a consid- 
erable interval; and generally it may be stated that there is the greatest pos- 
sible variation as to the extent, the consistence, the color, and adherence of 
the pellicle. The changes begin in close contact with bloodvessels in the 
mucous membrane beneath the epithelium, the submucous layer of which is 
transformed or replaced by the exudation. The exudation which thus forms 
the diphtheritic membrane (a false membrane) cannot be detached without 
leaving a bleeding surface; and if detached the exposed surface is very quickly 
re-covered with another layer of exudation. So long as this exudation con- 
tinues and exists, the surface will not cicatrize, neither will the membrane 
become organized. Unhealthy secretion is discharged, resulting from the 
interstitial death of tissue invaded by the exudation, and so there is some- 
times a superficial ulceration, but without gangrene or mortification. Decom- 
position, however, takes place rapidly in the exudative membrane itself; and 
hence the very fetid effluvia proceeding from the mouth of the diphtheritic 
patient. The integrity of the mucous membrane beneath the exudation is 
thus not always maintained, and it is rare not to find some evidence of loss of 
substance-the surface "being bare and granular, without defined ulceration; 
at other times a defined ulcer exists, exposing the muscular fibres. The uvula 
and part of the soft palate have been lost by ulceration " (Squire). Some- 
times the particles of the lymphy exudation are so thin, soft, and separated 
from each other, that the term membrane can scarcely be correctly applied 
to it. At other times it is tough, elastic, and as much as an eighth of an 
inch in thickness. In the one case the lymph resemblse cream in consistence; 
in the other it resembles wash-leather; and between the two extremes we meet 
with all intermediate conditions as regards consistence and tenacity. Pus, 
granular corpuscles, oleo-protein granules, and epithelium constitute the bulk 
of the softer forms of the so-called lymph; while such fibres as we see in the 
huffy coat of blood-coagula constitute the bulk of the toughest variety of the 
lymphy pellicle (Jenner). In reaction it is alkaline, swelling up and becom- 
ing transparent in strong acetic acid. It is disintegrated and dissolved by 
caustic alkalies. It has all the characters of pure fibrin, with no albumen 
and no gelatine. Vegetable growths, as the oidium of muguet (Vogel), occur 
in the pellicle of diphtheria from time to time, and have been reported by 
some as a constant occurrence. It is, however, by no means so; and the acci- 
dental existence of such vegetable growths is no evidence that epiphytes have 
any essential connection with cases of diphtheria (Sir William Jenner). 
The lymphatic glands to which the lymphatics of the pharynx lead are 
found in cases of diphtheria to be larger, redder, and moister than natural; 
and if the disease has continued long, they become brittle, pale, and of a 
brightish red color on section-characteristic of inflammation of their sub- 
stance. These enlarged glands may be felt during life behind the angle of 
the lower jaw on either side, as well as down the neck by the sides of the 
larynx, when that organ is implicated. Such enlargement of the glands is 
just in proportion to the severity and depth of the local, nasal, pharyngeal, 
laryngeal, and tracheal disease: and when the discharges from the pharynx 
are fetid and the mucous membrane ulcerating, not only are the glands behind 
the angles of the jaw enlarged, but the connective tissue in which they are 
placed is the seat of the effusion of serum, and even the exudation of lymph, so 
that very great general swelling of the parts is the result. But suppuration 
rarely occurs in the cervical glands. 688 
SPECIAL PATHOLOGY DIPHTHERIA. 
Condition of the Urine in Diphtheria.-Albumen is found in many cases; 
50 per cent. (Lee), 66 per cent. (Bouchut, Empis), in the majority (Mangin), 
and in all the cases examined by Sanderson. Its quantity appears to be some- 
times enormous, so that the urine becomes quite solid from heat and nitric acid 
(Parkes, 1. c.). 
Although it is not established that albuminuria is an essential element in 
the disease, yet it is a most important symptom, both as connected with the 
pathology of the disease and with its prognosis. The first discovery of the 
relation of albuminuria to diphtheria was made by Dr. Wade, of Birming- 
ham, and was communicated to the Queen's College Medico-Chirurgical 
Society in December, 1857. During the following year Bouchut and Empis 
made a similar discovery in Paris. These observers attach very great impor- 
tance to the renal complication, as affording an anatomical explanation of the 
fact that, in many cases of diphtheria in which death occurs neither by suffo- 
cation nor by septic poisoning, it cannot be due to local lesion. Bouchut con- 
siders it a sign of the commencement of purulent infection of diphtheria, and 
coincides with very great gravity of the disease. The blood then assumes the 
tinge of bistre; and numerous masses of pulmonary apoplexy may be found 
after death, resembling those which precede the development of metastatic 
abscesses in the lungs. Dr. Wade expresses himself as follows, in a letter to 
me of date January 12, 1868: 
" When my attention was first turned to diphtheria, the doctrine of Bre- 
tonneau was paramount that diphtheria is a local disease, and for the most 
part always remains so, infecting the system, if at all, only by absorption of 
putrescent matters from the throat, and, consequently, all treatment was to 
be local. I was struck early by the fact that many slight cases die; and I 
resolved to make a full dissection as soon as opportunity should offer, without 
any preconception as to what I should find. In the first case I found (after 
about seven days' illness) a pair of white kidneys, such as one finds after scar- 
latinal dropsy. The spleen was occupied by a similar deposit. After this I 
turned my attention to the kidneys during life, and found not infrequently 
albuminuria. I have never said (because I never believed) that albuminuria 
and urcemia were convertible terms; but I do say that I have seen many 
cases of diphtheria which presented distinct symptoms of uraemia-comatose 
or comatoid phenomena-coincidently with an obvious diminution of the 
urinary secretion, and relieved (and that very suddenly) by restoration of the 
secretion. I looked upon the discovery of renal complication as important, 
for two reasons,-Firstly, because it showed that diphtheria does not spread 
solely (as Bretonneau taught) by continuity of surface. Secondly, as account- 
ing for death in certain cases previously inexplicable. 
"From considerations, flowing mainly from the discovery that the'con- 
tinuity of surface' theory was erroneous, I revived the doctrine that diphtheria 
was an essential fever, and hence the inutility of local treatment, at that time 
universally carried out, under the influence, and as a corollary to, the theory 
of its being a local disease. 
" In Dr. Sanderson's essay, he seems to suggest that I had overlooked the 
fact of there being hyperoxidation in diphtheria. So far from ignoring it, it 
formed the basis of my views. 
" Dr. Sanderson relates a case in which there was, with albuminuria, abnor- 
mal amount of renal excretion, and says that this case proves that my views 
are incorrect, and that in no case does insufficient elimination exist. I suggest 
that, in the first place (admitting all the facts of this case to be as he has stated), 
to draw the inference that in no case can there be insufficient elimination, is 
to commit the logical error of reasoning from a particular to a universal. In 
the second place, admitting that the renal elimination going on during the 
height of the pyrexia was vastly greater than that of a period of health or ALBUMEN IN THE URINE OF DIPHTHERIA. 
689 
convalescence when the ingesta were greater, proves nothing at all as to the 
adequacy of the elimination during the former period. The real question is 
this-' Was the elimination adequate to remove from the system the abnormally 
excessive quantity of effete material produced by the pyrexia f To this Dr. San- 
derson's comparative experiments give no answer. There are no scientific 
data in existence which can answer it. I admit that it is eminently desirable 
that these should be procured. But this is to be done, not by comparing the 
total daily excreta during convalescence with those of a part of the pyrexial 
period, but by comparing the excreta of the £j>re-renal' pyrexial period with 
those of the 'pos^-renal.' In the meantime, the answer I offer to the question 
is based upon clinical experience. I find a certain amount of urine, of a certain 
specific gravity, without certain general symptoms one day, and the next day 
I find urine of less specific gravity, probably less in total quantity, with certain 
general symptoms. These symptoms resembling some of those found in cases 
of pure kidney disease (and commonly reputed to depend upon that disease), 
I infer that, in these cases also, the symptoms depend upon insufficient elimi- 
nation. I do not say that we find these symptoms in all cases of diphtheria. 
I do not say even that we find them in all cases of diphtheria with albumi- 
nuria. 
" As regards treatment, I recommend the adoption of the Cullenian doctrine 
here, as in other specific pyrexia-namely, ' to avoid the tendency to death.' 
One tendency is to death by insufficient elimination of effete material. I try 
to avoid this principally by copious supplies of aqueous liquids. I do not 
object to meet other tendencies by appropriate remedies, whether of a stimu- 
lant, tonic, or any other suitable character. 
" I also strongly condemn the indiscriminate employment of topical appli- 
cations, as being most painful and distressing to the patient, and commonly 
inoperative. On the other hand, some of the most striking recoveries I have 
seen have been unquestionably due to the timely use of local means suitable to 
the exigencies of the particular case." 
Dr. Sanderson is of opinion that neither of these doctrines regarding the 
pathology of albuminuria in diphtheria is the true one. In several of the cases 
related by him the cessation of albuminuria was coincident with amelioration 
of the patient's condition and the disappearance of the most alarming symp- 
toms. The early period of the disease at which the albumen appears, and the 
short time during which it lasts, are facts of great importance. Dr. Sanderson 
is of opinion that either (1) the kidneys must be the seat of the primary mor- 
bid process, or (2) the albuminuria must depend on an original change in 
the blood. That it is not due to the former of these is evident from the fact 
that the renal disease is only coincident with disease elsewhere (e. g., in the 
fauces), so that the special morbid condition of the blood induced by the diph- 
theria miasm must be regarded not only as the primary cause of albuminuria, 
but of all the other symptoms. This Dr. Sanderson illustrates by comparing 
the poison of diphtheria to that of the poison of cantharides, which, from the 
moment it enters the circulation, manifests its presence by albuminuria, and 
produces a series of anatomical changes in the kidney, which are identical 
with those described by Mr. Simon and Dr. Bristowe in diphtheria. Dr. San- 
derson's observations still further show that, at the acme of the disease, when 
the urine was intensely albuminous-when there was complete anorexia, and 
the ingesta reduced to a minimum-that then the quantity of urea excreted 
in twenty-four hours was about twice as great as that excreted during a similar 
period when convalescence was established-when the patient was eating, with 
an appetite, the ordinary hospital diet, with extras. Thus it is shown that 
diphtheria agrees with the other pyrexiee in being attended with a marked 
increase in the excretion of urea, and that the existence in the kidney of the 
condition implied by albumen and fibrinous casts in the urine does not nec- 690 
SPECIAL PATHOLOGY DIPHTHERIA. 
essarily interfere with increase in the elimination of nitrogenous material. 
There is, therefore, no reason to apprehend the occurrence of uraemia as a con- 
sequence of the renal complication in diphtheria, this complication not being 
the cause of the blood-poisoning, but merely the index of its existence {Brit, 
and For. Med.-Chir. Review, Jan., 1860, p. 196). The kidneys are rarely 
found healthy under microscopic examination after death. There is a special 
change in the in^ra-tubular structure. With conspicuous congestion of the 
Malpighian tufts, there is great opacity of the tubules from engorgement of 
their interior with finely granular epithelial cells, in which oil-globules are 
sometimes abundant, and occasionally blood. 
Phenomena and Symptoms.-The prodromata which forebode an attack of 
diphtheria may be set down as general malaise, anorexia, slight fever, dys- 
phagia, and glandular swelling. Some general constitutional symptoms super- 
vene very gradually and insidiously; such as feelings of depression, prostration, 
and muscular debility, attended by headache, nausea, diarrhoea, and chilliness. 
There is a sense of stiffness about the neck and throat, and the drowsiness 
which often attends the accession of an attack of diphtheria may lead the 
patient to fancy he has caught a slight cold in the throat while indulging in a 
short sleep. 
Sir William Jenner has grouped his cases of diphtheria into six varieties, as 
follows: (1.) The mild form of diphtheria; (2.) The inflammatory form; (3.) 
The insidious form; (4.) The nasal form; (5.) The primary laryngeal form; 
(6.) The asthenic form. 
In the mild form of diphtheria the general symptoms and the local lesions 
are trifling, and no sequelse follow. Febrile disturbance prevails to a slight 
degree; and there may be the least possible soreness of the throat on swallow- 
ing. No albumen occurs in the urine, and no nervous symptoms follow. Dr. 
Jenner is pf opinion that many inflamed throats, when diphtheria is epidemic, 
have their origin in the diphtheria miasm (whatever that may be), just as many 
cases of diarrhoea, when cholera is epidemic, originate in the cholera miasm; and 
it is as difficult to say in some cases that an inflamed pharynx is not due to 
mild diphtheria as it is to say that a serious diarrhoea is not cholera. 
In the inflammatory form of diphtheria, symptoms of severe cynanche pharyngea 
precede the exudation of lymph. There is redness, of a vivid or dusky hue, 
and swelling of the mucous membrane, covering the arches of the palate, the 
uvula, and the tonsils. The swelling is often considerable, from the effusion 
of serum into the submucous tissue, which becomes of a jelly-like transparency 
and aspect. The pain in the act of swallowing is great, so that deglutition 
becomes impossible. The febrile disturbances may be extreme or moderate; 
and although the pulse is frequent, it soon becomes weak, and there is the 
sense of considerable prostration. In from twelve to forty-eight hours after 
the first symptoms of the throat affection supervene, a 'layer, more or less ex- 
tensive, of tough lymph coats the inflamed surface, and death may follow 
from extension of the exudative process into the larynx or trachea. The 
urine may contain albumen, and sometimes the joints are swollen, hot, and 
tender. 
The insidious forms of diphtheria are dangerous, because they seem sudden 
and unexpected. The general symptoms are not severe. There is no marked 
soreness of the throat, no notable swelling of the lymphatic glands; but sud- 
denly laryngeal symptoms supervene, and death rapidly follows from suffoca- 
tion; and the disease may be confounded with primary croup, if the pharynx 
has not been examined. 
In the nasal form of diphtheria a sanious discharge from the nose attracts at- 
tention, after some febrile disturbance of a low type. The glands about the 
angle of the jaw begin to swell, the arches of the palate and tonsils become 
red and swollen, muco-purulent fluid bubbles in quantity from the narrowing 
isthmus of the fauces, and is apt to prevent the physician from seeing clearly DIAGNOSIS IN CASES OF DIPHTHERIA. 
691 
the state of the pharyngeal mucous membrane. After a few days the disease 
may subside so completely as to leave its nature doubtful; but it may, on the 
other hand, spread to the larynx or the pharynx, when laryngeal or pharyn- 
geal symptoms prevail, and the diagnosis is easy. 
In primary laryngeal diphtheria the disease begins with painful deglutition, 
and is attended by redness and swelling of the mucous membrane of the 
pharynx, arches of the palate, uvula, and soft palate. Laryngeal symptoms 
rapidly supervene: and lymph may be seen on the arches of the palate, the 
exudation being more abundant at the base of the arch than above it, looking 
as if it spread from the larynx. Death threatens from apnoea. 
In the asthenic form of diphtheria the patient dies from the constitutional 
effects of the general disease, which may begin with general and local symp- 
toms of very moderate severity. The pulse, however, soon becomes rapid and 
feeble; the sense of weakness and of illness becomes extreme; the skin has a 
feverish pungency of heat to the touch; the complexion assumes a dirty-look- 
ing, pallid, and opaque aspect; and from an early period of the disease the 
tongue is brown, with sordes on the teeth. More or less lymph may be seen 
on the pharyngeal mucous membrane; and this lymph is of a granular, pulpy, 
or soft form. The patient may also swallow with perfect facility, and the 
throat symptoms may appear to be trivial in degree, even when the pharyngeal 
mucous membrane is covered with lymph. In some cases, however, the pain 
on swallowing is extreme. The exudative process may extend to the larynx, 
and this extension is indicated by a little huskiness and want of power in the 
voice, and imperfect laryngeal breathing. As asthenia progresses, so do the 
local exudations increase. Death tends to supervene by asthenia about the 
tenth or twelfth day of the disease, preceded or not by delirium, which may 
commence at an early period of the disease. 
There is no sharp line of distinction, however, between these several varieties 
of diphtheria. 
The duration of cases of diphtheria varies from forty-eight hours to fourteen 
days; but local lesions may prolong the illness to weeks or months; and when 
the disease is fatal within a week, it is so by extension of the exudative pro- 
cess to the larynx. The disease may be presumed to exist so long as there is 
elevation of temperature, with excess in the excretion of urea, and of urates 
and albumen in the urine. Laryngeal symptoms .rarely commence after the 
expiration of the first week of the disease, although they have been known to 
occur as late as the fourteenth day; and in more than half the fatal cases of 
diphtheria death results directly from disease of the larynx. When death 
occurs from asthenia the fatal result usually takes place about the second week 
of the disease. In the cases that are not fatal the specific disease terminates 
between the eighth and fourteenth day of the illness (Jenner). 
There is great liability of other mucous membranes and of the skin when 
denuded of epithelium, as the surface of ulcers and wounds, to become covered 
with the specific diphtheritic exudation. Hence the duration of the disease 
may be greatly extended by the occurrence of such events as when the lips, 
eyelids, ears, cheeks, vulva and the like may be affected. 
Diagnosis.- Croup and scarlet fever are the two diseases most likely to be 
mistaken for diphtheria ; and, as already noticed, there is a form of diphtheria 
commencing in the larynx (laryngeal diphtheria'), which has been described as 
a form of croup, but which is diphtheria, and not croup-a disease quite sui 
generis; and which, beyond the site of the local lesion, being the san^e, has 
little else in common with diphtheria. The anatomical characters of the 
lesion in diphtheria are generally obvious on the fauces somewhere, over the 
uvula, tonsils, or pharynx; and, in connection with constitutional symptoms, 
are generally conclusive as to the nature of the disease. 
Diphtheria is attended with less febrile disturbance than scarlet fever; but 
records of temperature have not yielded results of practical value. 692 
SPECIAL PATHOLOGY-DIPHTHERIA. 
The white patches of ordinary sore throat are generally due to inspissated 
secretion of the mucous follicles, or patches of aphtha, or small spots of ulcera- 
tion ; and so long as no constitutional symptoms of a specific febrile kind exist, 
the existence of diphtheria may be negatived. 
Prognosis.-However mild a case of diphtheria may appear to be, no case 
is unattended with danger. The great danger during the first week, and 
towards its end, is from extension of the exudative process to the larynx; and 
the least laryngeal quality in the respiration heard at the bedside is suggestive 
of danger. Much exudation in the nares and nasal passages is also unfavora- 
ble. Subsequently to the first week death is to be apprehended from exhaus- 
tion and loss of nervous energy. An extremely rapid and feeble pulse is of 
grave import; and a very infrequent pulse is of fatal significance. Vomiting 
and purging are also unfavorable symptoms, especially if they should recur 
many days in succession. Hemorrhages and albumen in the urine indicate 
blood change of great severity ; but the mere abundance of the albumen is 
not serious so long as the urine is normal in amount, without blood corpus- 
cles or casts of tubes, and its specific gravity continues to be high (Squire). 
All the cases in which Sir William Jenner has known delirium to occur have 
ended fatally. 
A sudden rise in the temperature of the body is also unfavorable-103° 
or 104° Fahr.-indicating a probable complication with some intercurrent 
lesion. 
To recognize the disease early, and its specific nature, and to manage it judi- 
ciously, are important elements towards a favorable prognosis. 
The danger in diphtheria seems to be in proportion to the youth of the 
patient. In the child, death is generally due to extension of the disease to 
the larynx;-after puberty it more often occurs from the general affection. 
Sequelae.-Long after the termination of the disease, symptoms of a very 
peculiar and characteristic kind are apt to supervene. The phenomena are 
referable to deranged innervation ; and although their frequency and intensity 
are by no means invariably proportional to the severity of the primary disease, 
yet the more severe the case is, the more likely is nervous disorder to occur, 
and the more intense is it likely to prove. These consecutive phenomena do 
not appear at once. There is usually a period of convalescence between the 
disappearance of the primary and the appearance of the secondary phenomena 
of diphtheria. This period of temporary convalescence varies from a few 
days to a few weeks. The most alarming symptoms are referable to the heart. 
The frequency of its beats per minute begins to diminish, and a sense of lan- 
guor supervenes, with tendency to vomiting. The heart's beats are found to 
be feeble, infrequent, and slow, and death may supervene from cessation of 
the heart's action (Jenner); or suddenly, from the deposition of fibrin within 
the heart, or in one of the great vessels (Tanner). 
In other cases the paralysis is more widely spread, and the nervous symp- 
toms are more striking; although the nerve affections do not at once attain 
their maximum of intensity, but are progressive; and the progress of the 
paralysis, even in the same set of muscles, is seldom quite uniform. It is be- 
lieved that the paralysis is due to a primary peripheral alteration of the 
nerves, which is propagated from the originally affected part to the spinal 
centre, much in the same way as in tetanus the irritation is transmitted from 
the wound (Weber). If several sets of muscles are attacked, the faucial or 
pharyngeal are usually the first set to suffer ; and the impairment of function 
is very early betrayed by the condition of the voice, and by the act of swallow- 
ing, with loss of sensibility of the velum pendxdum palati ( Trousseau). The 
sight is subsequently apt to become impaired; then the muscles of the tongue, 
the lips, and those of the upper and lower extremity, become affected in the 
order named. In Dr. Greenhow's experience anaesthesia has coexisted with 
the paralytic affection of the fauces in all the cases. The mucous membrane PROPAGATION OF DIPHTHERIA. 
693 
over that region, naturally so sensitive, becomes altogether insensible and cal- 
lous, even to repeated and forcible pricks with the nib of a pen; and in rare 
cases speech becomes so inarticulate as to be almost unintelligible. It has 
also been observed that the paralysis and anaesthesia are sometimes more com- 
plete on that side of the fauces which was most severely affected in the early 
stage of the disease. When the pharyngeal muscles are paralyzed, and anaes- 
thesia prevails, there is alarming difficulty in swallowing. The impairment 
of vision is probably due to paralysis of the ciliary muscle. It generally comes 
on suddenly, and is preceded for a day or twTo by dilatation and sluggish 
action, or actual paralysis of the iris. The tongue, lips, and cheeks may also 
become affected, both as regards motion and sensation. The parts then become 
numb or cold, or they experience a sense of formication or of scalding, and 
taste may be lost. The upper extremities are either first affected, or simulta- 
neously with the lower. The power over the movements of the limbs becomes 
impaired, and anaesthesia is also more or less complete; or there may be ten- 
derness with abnormal sensations, such as formication, and a perception of 
constriction or of tightness in the fleshy parts; or there maybe convulsive 
movements of the limbs, resembling chorea. The earliest indications of these 
phenomena connected with the functions of the limbs are peripheral. Tin- 
gling is experienced at the tips of the fingers, accompanied with numbness, ren- 
dering the patient unable to pick up small objects. These phenomena then 
extend gradually to the wrist, and upwards to the elbows, and even to the 
shoulders; but the tingling and numbness are especially felt on the palmar 
surface of the hands. The limbs when so affected, feel heavy, feeble, and cold. 
If the paralysis continues, the muscles concerned become flabby and ema- 
ciated, and strength becomes so much impaired that patients, who can move 
the affected limbs freely in bed, often walk with much difficulty, or are unable 
to stand unless supported. Increased sensibility of particular parts of the 
affected limbs accompanies the loss of power and general numbness, causing 
great distress, such as tenderness of the soles of the feet, the calves of the legs, 
or fleshy parts of the arms. There is also pain on pressure along the course of 
the principal nerves, such as the median nerve of the arm and the sciatic nerve 
of the leg {Edin. Med. Journal, August, 1863). The duration of the paraly- 
sis varies greatly, but generally the cases eventually terminate favorably; the 
paralysis being only dangerous when it affects the respiratory muscles, and 
aggravates thereby an intercurrent pneumonia. 
These phenomena of impaired nervous power generally betray themselves 
within three weeks from the date of convalescence; and the longest period at 
which Sir William Jenner has known death to occur after the first symptoms 
of diphtheria has been about two months. 
Propagation of Diphtheria.-The disease seems to be contagious or infec- 
tious ; and family constitution favors its development and determines its prog- 
ress (Jenner, Greenhow, Sanderson). The exact mode in which the 
specific miasm operates is not known. Like all other specific diseases of its 
class, the earlier period of an epidemic outbreak is generally attended with 
the largest proportion of fatal cases. 
Direct contagion by inoculation is only probable; and there is no reason 
to suppose that greater power of propagation attaches to the fibrinous exuda- 
tion, than to the general secretion and exhalations from the sick. The pres- 
ence of one sick person in a house is sufficient for communication of the dis- 
ease to the susceptible, however carefully kept apart. Therefore, to some 
extent, the material of infection must be diffusible in the air, so that by some 
the danger of infection is greater from this source than from direct contagion 
(Squire). Like scarlet fever and erysipelas, the specific miasm of diphtheria 
clings, with great tenacity, to particular houses or apartments. A period of 
incubation of thirty hours, or even less, is said to be sufficient. 694 
SPECIAL PATHOLOGY DIPHTHERIA. 
Convalescents from diphtheria also retain the power, for an indefinite (un- 
known) period-the power of disseminating the disease (Squire, Jenner). 
Treatment.-So long as there is firmness of pulse the physician ought to 
abstain from alcoholic stimulants, and rest contented by giving such saline 
medicines as exert »a slight action on the skin and on the kidneys, or on both. 
But a rapid pulse indicates the necessity of alcoholic stimulants, which ought 
to be freely given on the development of the earliest general symptoms. The 
bowels should be opened freely by a dose of calomel and jalap; or by calomel 
and colocynth pill, followed, in the inflammatory or sthenic forms of the disease, 
by a saline aperient-e. g., sulphate of magnesia in the infusion of roses. 
We have no specific treatment which can cure the disease nor eliminate the 
poison. 
The throat affection should be treated with warm fomentations externally, 
and by the inhalation of water vapor with acetic acid. A wineglassful of 
vinegar to a pint of water is a good proportion (Jenner), and an inhaler 
should be used, as mentioned under scarlet fever. Dr. Jenner recommends 
Squire's inhaler as the best. A lead gargle may be of service, composed of 
one fluid drachm of the solution of diacetate of lead in eight ounces of rose- 
water ; but gargles must not be persisted in if pain is caused by their use. 
The temperature of the room .in which the patient is confined to bed ought to 
be kept at 68° Fahr., and its atmosphere made moist by the steam from a 
kettle with a long spout constantly boiling on the fire. If the patient can be 
enveloped in a warm moist atmosphere, so much the better; and this may be 
done by making a tent with blankets over the bed, and, by the aid of a spirit- 
lamp, a tin kettle of boiling water may be maintained at the boiling-point, 
and its steam thus made to envelop the patient. 
If feebleness of pulse supervene, if the redness of the throat assume a dusky 
hue, if the sense of general weakness become extreme, wine in large doses 
frequently repeated is required. Six or eight ounces of port or sherry during 
the day for an adult may be given from the first, with as good a diet as the 
stomach can digest. During the course of the disease, much larger quantities 
of wine and even brandy may be necessary; but the quantity of stimulants 
must be regulated by the habits and age of the patients. A child of three 
years of age may take with advantage one or two drachms of brandy every 
hour-i. e., from three to five ounces of brandy during the twenty-four hours 
(Jenner). Under all circumstances efficient daily action of the bowels must 
be secured, and the urinary and intestinal secretions should be examined daily. 
If blood or albumen appear in the urine, diuretics are contraindicated. 
Mustard poultices, warm linseed-meal poultices, or the warm wet sheet, as 
recommended by Dr. Huss in typhoid fever, may be applied to the loins under 
these circumstances. The hot air bath applied to the body, without removal 
from the bed, is also of great service. , 
Tincture of the perchloride of iron has been recommended by Dr. Hislop, of 
Birmingham, as well as by Druitt, Hamilton Bell, and others; so that it is 
now fully recognized as having a beneficial local as well as general influence 
on the disease; and it may be advantageously combined with quinine in the 
following formula (Tanner) : 
R. Quime Sulphatis, gr. ii; Acidi Hydrochloric! diluti, rrj7x; Tincturse 
Ferri Perchloridi, nj^xv; Infusi Calumbse, ^i; misce. Fiat haustus, omnibus 
sextis horis sumendus. 
As soon as nourishment can be retained by the stomach, five to ten grains of 
the perchloride of iron, equivalent to twenty or forty mimims of the tincture, 
combined with half a drachm of glycerin and half an ounce of water, should be 
given, and repeated every three or four hours (Squire). It should be com- 
menced on the first day of the illness, or as soon as the nature of the disease TREATMENT OF DIPHTHERIA. 
695 
is recognized. Evidence of its good effects is shown by a diminution of the 
secretions from the fauces and throat, and improvement in .general symptoms. 
Syringing the throat and nares with the perchloride of iron in solution is 
also very beneficial. The solution ought to consist of tincture of perchloride 
of iron, and of glycerin, each half a drachm, with two or three drachms of 
water. A stronger solution-the strength of the tincture-may be applied 
with a large camel's-hair brush to a patch of exudation, and the adjacent 
surface of the mucous membrane; or a preparation, twice the strength of the 
tincture, may be made by mixing equal parts of the liquor ferri perchloridi 
and of glycerin, and may be used to brush over the patches if the exudation 
is very thick. But such an application, as it is powerfully styptic, should be 
confined to the surface of the exudation only. It readily penetrates it, and 
exerts its beneficial influence on the vessels below (Squire). 
In short, the application of this remedy to the whole of the pharynx, with 
food, or separately as a lotion, to be applied as a gargle, or a medicine to be 
swallowed, affords relief. 
Copaiva and cubebs are also highly spoken of by Frideau and by Trous- 
seau. 
Saline remedies are contraindicated; and ammonia in continued doses is 
injurious (Squire). 
With regard to topical applications, Dr. Jenner is of opinion that repeated 
applications to the throat of caustic, solutions are injurious. He recom- 
mends one single but efficient application of a strong solution of nitrate of 
silver Qi to Ji of water), as a remedy which may stay the spread of the 
exudative inflammation; but that, on the whole, hydrochloric acid and water 
in equal parts will more frequently attain the object. It is especially the 
surface round the exudation, as well as the exudation itself, that should be 
painted well over with the solution, the brush being passed over the surface 
two or three times in quick succession. The white discoloration which results 
must not be confounded with the spread of the diphtheritic exudation. The 
discoloration from the acid passes away in about thirty-six hours, and that 
from the nitrate of silver somewhat quicker. Medicinal carbolic acid (as pre- 
pared by Calvert, of Manchester) is valuable as a gargle, in the proportion of 
1 of acid to 200 parts of water. 
There are considerable differences of opinion regarding the usefulness of 
topical applications, and the best means of applying them. The tincture of 
the perchloride of iron is recommended by some to be gently painted over the 
fauces, as already directed. The local application of lime-water by frequent 
gargling or gentle brushing, with the internal administration of nitrate and car- 
bonate of soda, prove speedily curative in the milder cases, and alleviate the 
more severe. Ice kept dissolving in the mouth is often also a great comfort, and 
its use should never be omitted where it can be had. Dr. Greenhow remon- 
strates against the application of the more severe topical remedies. The pel- 
licle or false membrane ought never to be torn off. In the consecutive paral- 
ysis tonics and local galvanism are the most important remedies, and the 
bowels should be kept open by a pill, taken morning and evening, containing 
from a quarter to half a grain of the extract of nux vomica, with a like quantity 
of sulphate of iron, combined with tzvo or three grains of compound rhubarb pill 
mass. These may be varied with the administration of pills containing y^th 
of a grain of strychnia, the strychnia being triturated with sugar of milk, and 
made into pills with a sufficient quantity of extract of gentian. Syrup of the 
phosphate of iron in fluid drachm doses may be given twice a day, and stimu- 
lants in the form of malt liquors, especially stout (if free of cocculus indicus'), 
are beneficial if taken with or after meals, and the doses of iron may be taken 
at the same time. The syrup of the phosphate of iron, quinine, and strych- 
nia combined, I have also found of great use. 
Tracheotomy undoubtedly saves a small proportion of cases. It ought to' 696 
SPECIAL PATHOLOGY-HOOPING-COUGH. 
be had recourse to if the exudative inflammation extends to the larynx and 
advances in severity. The degree and increase of the recession of the soft 
parts of the parietes of the chest during inspiration is the guide to its neces- 
sity. In the adult, laryngotomy is to be preferred to tracheotomy. Sir Wil- 
liam Jenner is of opinion that the opening should be made even through the 
seat of disease, and not below it; for, in opening through a healthy part, a 
new centre of irritation and inflammation is established. The mere admis- 
sion of air will sometimes dispel exudation, just as it will the growth of fungi. 
The sole object contemplated by an opening in the windpipe is the preven- 
tion of death by suffocation. The operation will not cure the disease. In 
this respect it differs greatly from croup; and it is chiefly in cases of croup, as 
distinguished from diphtheria, that tracheotomy is attended with such favorable 
results.-(See, under Croup, vol. ii.) 
Feeding is all-important in the treatment of diphtheria. The night should 
never be passed without either nourishment or stimulant being given; and the 
quantity of liquid nourishment and of stimulant given in the twenty-four 
hours must be equal to the estimated requirement of the patient (Squire). 
A young child (one to two years) may require a teaspoonful of brandy every 
two hours; a child of three years, two teaspoonsfuls, diluted and given in 
small portions at a time. By so averting death, time is gained for the general 
disease to run its course (Jenner). 
Bleeding, mercurial action, and antimony, are especially prejudicial and 
pernicious. 
HOOPING-COUGH. 
Latin Eq., Pertussis; French Eq., Coqueluche; German Eq., Keuchhusten-Syn., 
Stickhusten; Italian Eq., Tosse convulsa-Syn., T. canina. 
Definition.-An infectious and (sometimes epidemic) specific disease, preceded 
and accompanied by fever of variable intensity: attended in the first instance 
by catarrh, and subsequently by paroxysmal fits of convulsive coughing, which 
occur in numerous short, rapid, spasmodic movements of forcible expiration, sud- 
denly followed by a prolonged and deep inspiration, marked by a characteristic 
sound of a loud, sonorous kind, and variously named the "kink," "hoop", or 
"whoop." These paroxysms of expiratory and respiratory convulsive movements 
alternately recur several times, till the fit ends by a quantity of mucus being 
brought up from the lungs, or till the contents of the stomach are evacuated. 
Pathology and Morbid Anatomy.-The theory of this disease is that a 
specific morbid poison produces slight primary fever, which for the most part 
subsides on specific or secondary actions being established. These are catarrh, 
followed by a peculiar cough and vomiting, ascribed to irritation of the vagus 
nerve by the specific poison. The disease is a "specific pulmonary catarrh 
but very different opinions have at various periods been entertained as to its 
nature. Its origin appears to have been comparatively of no very distant 
date, Sprengel not having been able to trace it beyond 1510, when it was en- 
demic in Paris; but its epidemic character was not determined till 1580. 
Like other diseases of this class, it appears, as a rule, but once during life, 
and attacks chiefly infants and children. Dr. Watson gives an instance of a 
child born with hooping-cough. There are instances, however, of its occurring 
not only late in life, but also a second time (Heberden). Blache gives a re- 
markable instance of a grandfather and grandmother catching hooping-cough 
a second time from their grandchild, all of them laboring under the disease 
together. Some consider the disease to be a specific affection of the nervous 
system ; others, that it is a specific catarrh ; but both these pathological con- 
ditions coexist in hooping-cough. Inflammation does not necessarily accom- SYMPTOMS OF HOOPING-COUGH. 
697 
pany the disease, although a state of the mucous membrane exists by which it 
is morbidly irritable, or susceptible to impressions. 
Pathologists have also ascribed the complaint to a morbid condition of the 
pneumogastric nerve-an explanation supposed by some to be confirmed by 
the circumstance that that pair of nerves is sometimes found red, with the 
medullary matter altered in color, dense in texture, and of cartilaginous firm- 
ness (Kilian, Autenrieth). Others believe that a specific poison acts on 
some part of this nerve "(Todd). 
The results of nineteen post-mortem observations made by Dr. Graily Hewitt 
during a recent epidemic of this disease (1855), in children varying from one 
month old to four years, showed the chief lesion to be collapse of the lung- 
substance-a condition also known under the various names of foetal condition, 
Gamification, and atelectasis. The experimental test to detect the presence of 
this morbid collapse is that suggested by MM. Bailly and Legendre, and con- 
sists in inflating the lung, the effect of which is to produce uniform distension 
in a simply collapsed lung; but the force necessary to distend the carnified 
parts is more considerable, and some portions are not capable of inflation by 
any force. The air-cells most distant from the roots of the lungs were most 
liable to this change, and the margins of the lungs were chiefly affected; and 
there was generally emphysematous distension of the air-vesicles adjoining the 
collapsed portions of these organs. 
Other pathologists have ascribed the disease to cerebral irritation (Web- 
ster, in Medical Gazette). But facts tend to show that the cerebral symp- 
toms are effects, rather than the cause of the disease. In short, the formation 
and development of hooping-cough seem to follow as the result of a specific 
poison of an unknown kind, but which is communicated through the atmos- 
phere, and seems to affect directly the nervous system and the pulmonary 
mucous membrane, like influenza and measles, and, like them, the disease 
sometimes becomes epidemic. 
Symptoms.-It is observed that, in the majority of cases, hooping-cough 
commences like a simple catarrh, alike in children and adults; afterwards, 
however, the specific nervous element of the disease predominates and is com- 
bined with the catarrhal element. In the first instance high fever, and the 
secretion of a viscid mucus from the bronchial mucous membrane, with re- 
peated paroxysms of coughing-several times in a minute-and continuing for 
many days, or from one to two weeks, are sufficient to indicate a specific 
catarrh, as distinguished from an ordinary cold. In some cases, again, the 
nervous element of the disease is mostly developed; so that from the very 
commencement a kind of hiccough exists, or "spasms in the throat," from the 
efforts to inspire, causing a whistling through the larynx. The paroxysms of 
coughing are thus more frequent, obstinate, and severe in hooping-cough than 
is usually the case in a common cold ; and the patient has also a more trouble- 
some sensation of tickling in the throat and inside the trachea-the commence- 
ment of the nervous element of the disease-which eventually becomes so 
characteristic. The catarrhal symptoms may last for several days-three to 
fourteen-or even for several weeks-one to four (Willan, Trousseau); six 
to eight (Lombard)-before the specific convulsive cough supervenes; and 
in some instances, where all the other symptoms are present, the convulsive 
cough may be absent. The fever of invasion is also characteristic of hooping- 
cough. It is of greater intensity and of longer duration than the fever of an 
ordinary catarrh. It may last from seven to fourteen days; while the fever 
of a simple catarrh is rarely prolonged beyond two or three days. In the first 
stage of the disease it is the incessant repetition of the cough which is most 
characteristic; in the succeeding stage, when the cough becomes convulsive, 
the incessant repetition subsides, the cough recurs less frequently, and is more 
convulsive. A sensation of tickling or prickling in the larynx and trachea is 
the indication of a convulsive cough coming on; and no doubt this is the 698 
SPECIAL PATHOLOGY -HOOPING-COUGH. 
warning which young children recognize and dread as the harbinger of a par- 
oxysm, which suggests to them the necessity of seizing something for support 
during the fit of coughing, which almost immediately commences. The irri- 
tation is attempted to be got rid of by coughing; and in the expiratory efforts 
the air is expelled with great violence, and so repeatedly and irresistibly that 
the lungs are ultimately almost emptied of air. At the conclusion of these 
expiratory efforts the condition of the lungs resembles that produced by as- 
phyxia. A sudden inspiration now necessarily and suddenly follows, the air 
being drawn through the glottis by the gasping patient, with a force and velocity 
which gives rise to a shrill, sonorous sound, not unlike the crowing of a cock, 
and which has been variously named a kink, a hoop, or whoop; and the disease 
has accordingly received various names, such as kink-host, hooping-cough, 
whooping-cough, chincough. The anxious and distressing inspirations are 
scarcely completed when the convulsive expirations of the cough are again 
renewed, and again followed by the gasping and crowing inspirations, till a 
quantity of mucus is brought up from the lungs, or till the contents of the 
stomach are rejected by vomiting. Such are the phenomena of the fit or par- 
oxysm of hooping-cough. After it is over, the patient in ordinary cases ap- 
pears to be but little affected, and returns immediately to play, or to any other 
occupation which takes the attention at the time. 
When these phenomena are prolonged, secondary effects are produced, 
whose morbid appearances have been noticed. The immediate consequence 
of the violent fits of coughing is to interrupt the free transmission of blood 
through the lungs, and the return of blood from the vessels of the head. This 
causes not only the turgidity, swellings, redness, and lividity of the face and 
eyelids which attend the fits, but also the discharges, even of blood, from the 
mucous surfaces of the nose, ears, or eyes. The little sufferer may shed tears 
of blood. 
Hooping-cough varies greatly in intensity, and most authors divide the 
group of symptoms into three stages. The first stage comprehends the period 
from the first symptoms of illness until the "whoop" confirms the convulsive 
nature of the cough. This is the period of development or evolution. The 
second stage commences as soon as the nature of the cough is determined, 
and lasts till the violence of the cough and the danger of secondary compli- 
cations are past. This is the period of spasmodic paroxysms characteristic of 
the disease. The third stage comprehends the convalescence of the patient, 
until the final and happy termination of the disease; or the occurrence of any 
event which may destroy the sufferer. 
When the convulsive stage of the disease is fully formed, and the series of 
fits or paroxysms of severe coughing occur at uncertain periods, during the 
interval the patient generally enjoys his usual health, recovers all his gayety, 
returns to his play, and relishes his food with a good appetite. 
A paroxysm or fit of hooping-cough comprehends the following phenomena: 
The approach of the fit is notified to the patient by an unpleasant titilla- 
tion of the glottis, by a sharp pain in the chest, or by a spasmodic contraction 
of the diaphragm. As soon as the child is thus warned, he instinctively 
ceases from play-his spirits suddenly droop, and he runs to his nurse, and 
either grasps her arms, or lays hold of her chair or her dress, to support him- 
self during the paroxysm, which in a few minutes or seconds is about tp 
follow. In severe cases the cough is quite convulsive, and so rapid is the 
action of the diaphragm, that the air is almost instantly expelled from the 
lungs, and the patient, half suffocated, turns black in the face, and frequently 
passes urine. At length the crisis approaches, the diaphragm relaxes, and a 
violent inspiration follows, accompanied by the characteristic whoop. This 
sound perhaps remits, but after a few seconds returns; and thus convulsive 
inspirations and expirations continue, till the patient is at length relieved by 
a copious expectoration, or by vomiting. The matters expectorated from the SYMPTOMS OF HOOPING-COUGH. 
699 
lungs are frequently thick, ropy, and viscid; or a colorless liquid. When 
vomited from the stomach, the patient throws up a glairy fluid of much 
tenacity, semitransparent, and frequently amounting to the greater part of a 
pint; and should he have recently eaten, the food returns with it. It fre- 
quently happens, however, that the stomach retains the food and rejects the 
offending matter. If the fit be violent, the fluid rushes not only from the 
mouth, but also from the nostrils; and in some instances is mixed with blood, 
for blood occasionally bursts forth in considerable quantities from the con- 
gested vessels of the mouth, the nostrils, the ears, the eyes, and in some in- 
stances from the rectum. Such cases are most severe. 
If the stethoscope be applied to the chest previous to the fit, the mucous 
rhonchus common to catarrh may exist, yet in most cases the respiration is 
natural. During the act of coughing the respiration appears completely sus- 
pended, and is not sensible to the ear in any part of the chest. On the 
"wAoop," however, taking place, the air is heard to rush with remarkable 
violence into the trachea; but at this point it stops for one or more seconds 
till the bronchial tubes relax, and the air is then admitted into the lungs. 
The fit having subsided, the eyes, which seemed to have started from their 
orbits, resume their natural position, but are inundated with tears, or the con- 
junctiva is more or less gorged with blood; the natural expression and ap- 
pearance of the countenance returns, and in a few minutes, in favorable cases, 
the good spirits of the little patient are renewed, and he eats with appetite. 
On the contrary, in severe or unfavorable cases, long-continued exhaustion, 
headache, and some fever, are the preludes to convulsions, inflammation, or 
the other more severe complications of the disease. 
The paroxysm varies greatly in frequency and severity, but, in general, its 
frequency is as its severity. In ordinary cases it returns every two hours; 
but in severer cases, and especially during the second and third week, it re- 
turns every half or every quarter of an hour, or even oftener. This disease 
commonly reaches its acme at the end of the third, fourth, or fifth week; after 
which the paroxysms diminish in frequency, the intervals are prolonged, and 
the patient is to a certain degree convalescent. The duration of this second 
stage is from two to six or eight weeks. 
The third stage commences with the convalescence of the patient, when the 
paroxysms become milder, the intervals longer, the expectoration thicker and 
more opaque, greenish, or pus-like, and more like ordinary catarrh. The 
vomiting ceases, and the general health of the patient begins to improve 
greatly. The duration of this stage, however, is often long and variable, and 
the cough may still harass the patient for many weeks, or even many months. 
It is to this stage that the term chronic is usually applied. 
The disease lasts from six to eight weeks; but there are exceptional cases, 
which on the one hand get well in a week, and on the other hand may con- 
tinue several months, or even a year. "The general duration of the disease 
is directly proportionate to the duration of the prodromata;" and the more 
quickly the convulsive cough makes its appearance, the more quickly does 
the disease subside (Trousseau). 
Many accidents may arise to complicate the symptoms of hooping-cough, 
and to increase the danger, as inflammation of some of the tissues of the lungs, 
of the mucous membrane of the stomach or intestines, or of the serous mem- 
branes of the brain. 
Inflammation of the minute bronchia is the most usual complication of this 
disease-capillary bronchitis, or peripneumonia catarrh. The form of inflam- 
mation may be that in which the secretions are in defect, so that the mucus is 
not only greatly diminished in quantity, but is thick and viscid, teasing the 
patient with fruitless efforts to free it from the air-tubes, and thus causing a 
frequent recurrence of the paroxysm. In other cases it may assume the form 
of purulent inflammation, the pus secreted being formed into sputa, and mod- 700 
SPECIAL PATHOLOGY-HOOPING-COUGH. 
erate in quantity ; or it may be thrown up pure, as from an abscess, and so 
enormous in quantity as to amount to one or two pints in the twenty-four 
hours. The inflammation of the bronchial membrane may spread to the sub- 
stance of the lungs, when the danger, as well as the symptoms, of some of the 
various forms of pneumonia will be added to the disease; but the most for- 
midable accident is when the pleura is inflamed, for then the patient's suffer- 
ings during the paroxysm are fearfully increased, from the agonizing pain 
inflicted during the paroxysm of the cough. These lesions are the most fre- 
quent causes of death in cases of hooping-cough. 
The mucous membrane of the stomach and intestines is often the seat of 
inflammation; and this is denoted by pain in the epigastrium, and by the 
suppression of the glairy fluid thrown up by vomiting, so that on the termina- 
tion of the fit the patient often lies in a state of complete exhaustion, unable 
to discharge anything either from the stomach or lungs, or even to " whoop 
and he is then said, in popular language, to labor under the " dumb kink." 
In mild cases the bowels are little affected in this disease, except that the 
patient sometimes passes fseces during the paroxysm. In severe forms the 
stools are often either black and offensive, or they consist of a colorless mucus, 
the latter evidently depending on an inflamed state of the mucous follicles. 
Headache is a symptom which usually attends the catarrhal stage, but gen- 
erally ceases when the fever subsides. In some instances it continues through- 
out the disease, and is not unfrequently the forerunner of fatal convulsions, or 
epilepsy, or of inflammation of the membranes of the brain, terminating in 
delirium, coma, hydrocephalus, and death. 
Diagnosis.-It is impossible to determine whether the febricula of the first 
stage is the result of simple catarrh, or will, on its subsiding, prove to be 
hooping-cough. The earliest recognition of hooping-cough is by the obstinate 
coughing. A cold giving rise to paroxsyms of coughing recurring fifteen, 
twenty, or thirty times in a minute; and which continues in this manner for 
four to ten days in succession, attended with high fever, is certainly a specific 
catarrh; and after a period varying from one to two weeks later hooping- 
cough will manifest itself with its well-marked characteristics (Trousseau). 
As soon, however, as the cough has been followed for two or three paroxysms 
by the " whoop," the diagnosis is perfect, no other disease being accompanied 
by this symptom. 
Cause and Modes of Propagation.-That hooping-cough is induced by a 
specific poison there is little doubt; but in what manner this agent is gen- 
erated is not determined. The disease is always sporadic, sometimes epidemic, 
and the " epidemic influence " is the most common cause and mode of propa- 
gation. 
The predisposition to the disease is so strong that few persons pass the 
period of childhood without suffering from it; but it may occur at any subse- 
quent age. The early age at which the large majority of patients pass through 
the disease is, however, a sufficient reason for our very slight acquaintance 
with the predisposing causes. 
When hooping-cough is once excited, the patient evolves a poison which is 
both infectious and highly contagious, communicable from one human being 
to another-a fact which necessarily implies the idea of "specificity." The 
general public are so unanimously of opinion that this disease is infectious, 
that no parent will permit his yet unaffected child to mingle with such as may 
be laboring under it. The profession are, with a few exceptions, of a similar 
opinion ; and it is probably most contagious at the period of its highest de- 
velopment. 
The infecting distance of the poison must be considerable, from the utter 
impossibility of isolating the patient at home, or of preventing the spread of 
the disease in schools. 
Rosen conceives that, without being aware of it, he has often carried the TREATMENT OF HOOPING-COUGH. 
701 
disease from house to house. Frank also says that it is often propagated 
from patient to patient, from house to house, and from village to village. In 
Geneva, Lombard has often traced the first cases occurring in that city to a 
neighboring town, or to a sick child from the country. Hooping-cough was 
some years ago introduced into St. Helena, where it proved very fatal: the 
captain of a ship, having some children laboring under the disease on board, 
allowed their dirty linen to be sent on shore to be washed, and so introduced 
the disease among the inhabitants. 
The poison of this disease may coexist with many other poisons, and in this 
case they often greatly influence each other's actions. Small-pox and hooping- 
cough have often coexisted; and a very common and fatal combination is 
measles and hooping-cough. Hooping-cough and cow-pox are not unfrequently 
combined. Indeed, the lower classes erroneously look upon vaccination as in 
many instances a cure for hooping-cough. 
Period of Latency.-The disease has a stage or period of incubation, but 
our knowledge of the extent of this period is at present extremely imperfect. 
The disease never shows itself immediately after exposure to contagion, but a 
certain number of days (five or six) elapses before the symptoms of catarrh 
are to be observed. 
Prognosis.-The proportionate number of deaths to recoveries in hooping- 
cough is not determined, but greatly varies in different years; for in one year 
hardly a death will occur from the disease in a large city, while in another 
year many children will die. In general, however, the milder forms of the 
disease are rarely fatal, while the more severe and protracted cases very com- 
monly are so. Lombard thinks station in society greatly affects the mortality; 
for he says that of ten fatal cases nine belong to the poorer classes. The re- 
ports of the Registrar-General show that the mortality is greater from this 
disease in towns than in the country, being in the metropolis, in 1838, .111 per 
cent., while in England and Wales it was .061. In the year 1839, also, it was 
for the metropolis .061 per cent., while for England and Wales it was .053. 
Lombard gives the ages of forty fatal cases as follows : 
Ages. 
Cases 
From birth to 6 months, . 
... 6 
" 6 to 12 months, . 
... 7 
" 1 to 2 years, 
... 10 
" 2 to Byears, 
... 6 
" 3 to 4 years, 
. . . 7 
Ages. 
Cases. 
From 4 to 5 years, 
.... 2 
" 5 to 6 years, . . 
.... 2 
Above 6 years, . . . . 
. . . . 0 
Total, . . 
.... 40 
Danger from bronchial inflammation is to be dreaded rather towards the 
end than the beginning of the disease. Convulsions are apt to occur if denti- 
tion is going on at the time ; and if they arise from the congestion or effusion 
within the cranium, the case is generally fatal. The number of paroxysms 
which a child may have in twenty-four hours is the best basis of prognosis. 
Twenty fits in twenty-four hours denote a very mild case ; when more violent, 
forty to fifty paroxysms may occur in that period ; and when the number of 
paroxysms exceeds forty, the case is a serious one, and prognosis grave. 
If a predisposition to tubercle exists, hooping-cough may determine the de- 
velopment of phthisis. 
Treatment.-On the invasion of the disease, beyond putting the patient on 
a low or very moderate diet, and attending to the daily action of the bowels, 
there is little occasion for medicine. 
The " whoop " having confirmed the nature of the affection, and the second 
stage being established, the disease will run its course, and one of two indi- 
cations of treatment may be followed. The first is to prevent, if possible, 
convulsions, or any attack of inflammation, either of the lungs, the stomach, 
or of the membranes of the brain. The second indication, after the period of 
danger is past, is to prescribe such medicines as may diminish the frequency 702 
SPECIAL PATHOLOGY -HOOPING-COUGH. 
of the paroxysms. Indeed, the best mode of obviating the danger of cerebral 
irritation, or of inflammation of any of the organs that have been mentioned, 
is to mitigate and control, as far as possible, the frequency of the paroxysms, 
to check those secretions which are in excess, and to excite those which are 
in defect, and these objects are best obtained by mild sedatives, combined 
with gentle purgatives or laxatives. 
The choice of the sedative has been considered a matter of much impor- 
tance. The Continental physicians have bestowed much praise on belladonna, 
others on hemlock, others on henbane, while some have contented themselves 
with opium. It must be admitted, however, that none of these narcotics pos- 
sess any specific property in controlling this disease, so that the selection of 
the particular one must be left to the discretion of the practitioner. But 
supposing the patient to be a child, as the head is especially the organ to be 
protected in such cases, the mildest sedatives, such as hyoscyamus, or the syrup 
of poppies, are the safest and best. Should, however, belladonna be selected 
(as it seems to be the most efficient sedative), if the child be under four years 
of age, the dose ought not to exceed one-eighth or one-tenth of a grain of the 
extract, with the same quantity of the powder of the leaves in a pill, the pill 
being dissolved in syrup at the time when it is to be administered (Trous- 
seau). The dose should be given in the morning; and only once daily, 
commencing with one pill, and increasing to two or more. Or if hyoscyamus 
is chosen, half a grain to a grain every six or eight hours; while, if it be the 
syrup of poppies, this medicine should be given in such fractional doses of a 
drachm as are suited to the age. Powdered belladonna root has been recently 
recommended by Vollaut. The dose is one-fifth of a grain, given at first once, 
then twice, then/ow times a day, and so on until the paroxysms begin to sub- 
side, when it is to be given at much longer intervals. Thus, he says, the 
spasmodic period may be positively arrested in three or four days. The pow- 
der of the leaves he considers to have little efficacy (Syden. Society Year-Book, 
1862). Infusion of wild thyme, slightly sweetened and mixed with gum, is 
also said to effect great improvement in cases of spasmodic cough (Joset, 1. c.). 
Cochineal is an anodyne which sometimes affords relief. It is usually pre- 
scribed in the form of a mixture, consisting of cochineal, 10 grains; subcar- 
bonate of potash, 20 grains; sugar, £ oz.; water, 4 oz.; rub together and strain 
(Squire's Companion to the Pharmacopoeia, p. 62). Of this mixture, a quarter 
of a teaspoonful four times a day is sufficient for a child one year old ; half 
a teaspoonful for a child of two years ; and a teaspoonful for a child of four 
years. [Or the bromide of potassium, or of sodium, or of ammonium, may be 
given.] Boiled apples in milk should be given for food. 
An opiate, in the early stage of the disease, ought not to be administered 
alone, and some purgative or laxative ought, as a general rule in all cases, 
to be combined with it. The selection of the particular laxative is perhaps 
unimportant, and any saline or vegetable purgative may answer equally well, 
as the confectio sennce, rhubarb, castor oil, or manna. The neutral salts, how- 
ever, sit easiest on the stomach, and (as the medicine must be continued) they 
are the most agreeable to the patient. Opium is a dangerous remedy alone, 
and is liable to the objection of being apt to check the mucous secretion. 
If at the outset or afterwards the cough is very suffocative, an emetic is 
useful. Five to nine grains of sulphate of copper dissolved in three ounces 
of distilled water, and a dessertspoonful every ten minutes is the most efficient 
(Trousseau). 
Nitric acid, in the following formula, has been found of service : 
Acid. Nitrici diluti fjxii; Tinct. Cardam. comp., fjiii; Syrup, f^iiiss.; 
Aquse, f^i; misce. Of this mixture, one or two small teaspoonfuls may be 
given every two hours (Gibb). 
Towards the close of the second stage the symptoms may become unfavor- TREATMENT OF HOOPING-COUGH. 
703 
able, and cerebral irritation, with convulsions, or inflammation of the mem- 
branes of the brain, of its substance, or of the tissues of the lung, or of the 
alimentary canal, may complicate the disease, and then the treatment of the 
case is always exceedingly difficult, and frequently unsuccessful. 
If convulsions should come on suddenly, and without headache or other 
symptom of inflammatory action, small doses of any opiate, and mustard 
poultices to the feet, may relieve the patient; but should convulsions still con- 
tinue, an asafoetida injection may be administered. It often happens that con- 
vulsions are combined with a suppression of the vomiting, and of the usual 
glairy discharge; and in these cases leeches, followed by a large linseed poul- 
tice, should be applied to the epigastrium. If the unfavorable symptoms 
should advance, and headache or other symptoms show an affection of the 
membranes of the brain, leeches should be applied to the temples and cold to 
the head. 
When the poison excites inflammation of the tissues or substance of the 
lungs, bleeding to a limited amount by leeches may be required; but we should 
be satisfied with such mitigation of the symptoms as may obviate immediate 
danger, and even that is not always obtained, since the affection is not to be 
subdued by bleeding, as in simple inflammation; for, being dependent on the 
action of a morbid poison, it will run a definite course. Blache bled in nine 
cases, either with the lancet, by leeches, or by cupping, and in one case no 
less than five times; yet, he adds, with a desolating want of success, and eight 
out of the nine cases terminated fatally. This result makes him add an axiom, 
in which every practitioner will agree, that there is in severe hooping-cough, 
as in typhus, cholera, and many other affections, an unknown element which 
modifies and gives a specific character to all these intercurrent inflammations. 
If the intestinal canal be affected, some purgative, combined perhaps with 
calomel, may be necessary to act on the bowels and free them from their con- 
tents ; and if the stools he white and muciform, and the patient not relieved, 
an enlarged state of the follicles may be suspected, and consequently a linseed 
pozdtice should cover the abdomen for some hours, preceded, perhaps, by an 
enema of syrup of poppies and barley-water, and which should be administered 
night and morning. Many other modes of treatment have been recommended 
for the cure of hooping-cough, and more especially by emetics repeated every 
second day. For obvious reasons such a method is not to be recommended. 
The disease having passed into the third stage, and the inflammation or 
other threatening symptom, if any has existed, having subsided, it is desirable 
to attempt to abridge the duration of the cough, which often extends to a most 
distressing leiigth; and for this purpose tonics, antispasmodics, counter-irritants, 
and other remedies, either externally or internally, have been recommended. 
The more stimulant antispasmodics, as asafoetida, musk, castor, oil of amber, 
cantharides, and camphor, are the remedies which have obtained the most suf- 
frages in the cure of this stage of hooping-cough. The first two are in most 
esteem ; and some persons even considered asafoetida to be a specific, not only 
in this, but in every other stage of the disease. It should be given in emulsion, 
in the dose of one or two grains to a child two years old, repeated three or four 
times a day, or even as often as every two or three hours. Cullen, however, 
preferred cinchona to asafoetida, and considered it " the most certain means of 
curing the disease." Many other remedies have been mentioned, as alum, 
hydrocyanic acid, oxide of zinc, arsenic, and many preparations of iron, and all 
of these remedies have been found to a certain extent useful as tonics; but in 
estimating the results of remedies, we should be careful not to mistake tem- 
porary recovery for cure; and the fact of so very many remedies being highly 
spoken of suggests doubt as to the value of either. 
When internal remedies have failed to make any impression, the cure is 
often attempted by means of local treatment, or by derivatives. The early 
physicians applied the actual cautery to the nape of the neck ; the modern ones, 704 
SPECIAL PATHOLOGY-MUMPS. 
blisters to the spine, or directed the back to be rubbed with the unguentum 
antimonii cum potassio tartarizati, or with some liniment or embrocation, as 
the liniment of camphor or of ammonia, or with asafoetida, oil of amber, oil of 
turpentine, or the tincture of cantharides. The general opinion, however, is,' 
that these do little good unless they contain some opiate, whose absorption 
they facilitate, and this is attended with danger. Foot baths and the warm 
bath have also been used, and often with much efficacy. 
When ordinary remedies have failed, a change of air is a resource of great 
value, and was first mentioned by Dr. Forbes, in his thesis De Tussi Convulsivi, 
in 1754; and since that period it has been recommended in dangerous cases 
by most physicians with that praise it so eminently deserves. While it is 
determined that a change from the bad air of a town to the purer air of the 
country is at all times a great benefit, Lombard contends that he has found a 
change from the country to the town to be not less beneficial, and that the 
patient is benefited even by the removal to so short a distance as half a mile. 
Indeed, it is impossible to witness more striking instances of the advantages 
of treatment than we occasionally observe in patients when removed from 
large towns to their environs, for even in a few hours they have been known 
to recover from an apparently hopeless state. A sail across a river is also 
beneficial, although the distance may be short. 
Dietetic and General Treatment.-The patient should not be allowed ani- 
mal food from the commencement almost to the termination of the disease in 
its acute form. It is desirable also that the temperature of his apartment 
should be regulated, and that he should not be exposed to any considerable 
or sudden change from heat to cold. In mild weather also, if no local symp- 
tom forbids, he should be permitted to take exercise in the open air. He 
should likewise wear flannel. 
There are no known means of prevention, except an entire removal from 
every source of contagion. 
MUMPS. 
Latin Eq., Parotides; French Eq., Oreillon; German Eq., Ziegenpeter- 
Syn., Mumps; Italian Eq., Parotitide-Syn., Orecchioni. 
Definition.-A specific idiopathic inflammation of the parotid and salivary 
glands, contagious and sometimes epidemic. 
Pathology.-This disease is most common in male children ; less frequent 
after puberty; and second attacks are rare. It is sometimes epidemic, and 
in certain localities it prevails rather than in others ; so that local causes may 
have to do with its propagation and maintenance. 
A symptomatic parotitis often occurs also in the course of severe fevers 
(typhus and enteric); and it has been noticed in cases of cholera. In some 
epidemics of typhus it follows almost every case, and is sometimes a fatal com- 
plication, from the tendency to purulent infiltration of the gland, with suppu- 
ration of the interstitial tissue,-all of which, rapidly extending, assume the 
fatal characters of diffuse phlegmonous inflammation. It is a result also of 
ptyalism from iodine or from mercury. 
The idiopathic parotitis of mumps is quite different, and rarely proceeds to 
suppuration. The disease is spread by contagion, and of direct propagation 
from person to person. Dr. John Harley gives the following example: "A 
medical student had mumps in London, at a time when his mother was stay- 
ing with him. They remained in town till the swelling disappeared, and then 
went-a hundred miles into the country-home. There was no mumps in that 
neighborhood; but a fortnight after their arrival one of the children was taken 
with the disease, and it afterwards successively affected, at regular intervals DEFINITION OF INFLUENZA. 
705 
of a fortnight, each member of a large family" (Hooper's Physician's Vade 
Mecum, 7th edition, p. 558). 
Epidemics of mumps usually occur in spring and autumn, when the weather 
is cold and damp. It is rare in the dry warm weather of summer. 
The disease commences as a catarrhal affection of the gland ducts of the 
parotid (Virchow). The swelling that ensues is a soft swelling; and as it 
disappears rapidly when improvement takes place, the swelling is probably in 
great part composed of serous infiltration among the connective tissue of the 
ducts; and it extends far beyond the borders of the gland. In other casespain 
in the region of the ovaries, increased by pressure, shows that the ovaries in 
women inflame similar to the testicles in men. 
When suppuration does take place, as it may in patients of unhealthy con- 
stitution, the swelling, in place of beginning to subside about the fifth or sixth 
day, continues painful and hard; and when abscesses form, they either open 
on the cutaneous surface or into the external auditory meatus. If suppuration 
does not take place, still there often remains a circumscribed, hard, painless, 
swelling in the region of the parotid, which exists for some time. 
Symptoms.-Febrile phenomena generally precede the local symptoms, but 
sometimes they are associated with pain and uneasiness in the region of the 
parotid. The pain on moving the jaw soon becomes so great that masti- 
cation becomes impossible in severe cases. Considerable fulness and soreness 
prevail at the angle of the jaw over the malar region and region of the parotid, 
on both sides generally. Beneath one or both ears redness prevails, with pain 
on pressure; and the pain becomes so great as to prevent sleep at night*in 
severe cases; and in such cases the swelling generally extends to the submax- 
illary glands, and to the tonsils, and neighboring parts of the pharynx, so that 
swallowing becomes very difficult and painful. The region of the swollen 
glands becomes tense and glossy; sometimes of dusky livid hue; and when 
both sides are affected at the same time, the face is of an enormous size; and 
continues so for four or five days, after which it gradually subsides, and reso- 
lution ensues, the fever and pain gradually subsiding, and the swelling rapidly 
diminishing. The fever ceases about the fifth or sixth day; and after eight or 
ten days the face has generally assumed its natural dimensions. Occasionally 
during the course of the disease, but generally towards its subsidence, the tes- 
ticles swell, or the mammae in the female; and in some cases the cerebral 
membranes become implicated, as also the gastro-enteric mucous membrane. 
Treatment.-Constant hot fomentations (after leeching in severe cases) 
should be applied to the swollen parts. The maintenance of a constant but 
gentle action on the bowels, by saline cathartics, must be attended to. Abso- 
lute rest ought to be enforced, a farinaceous diet enjoined, and no irritating 
applications ought to be applied to the swollen glands. The disease runs a 
definite course, and is not likely to terminate unfavorably. 
INFLUENZA. 
Latin Eq., Catarrhus epidemicus ; French Eq., Grippe; German Eq., Grippe- 
Syn., Influetzza; Italian Eq., Influenza. 
Definition.-A specific catarrhal inflammation of the mucous membrane of the 
air-passages, with severe constitutional disturbance. The disease is invariable in 
its essential characteristics, frequently prevailing as an epidemic, attended with 
lassitude and prostration to an extreme degree, with special and early implication 
of the naso-laryngo-bronch ial mucous membrane. Chills occur, and great sensibility 
to cold exists over the surface of the skin; the eyes become injected and tend to fill 
with tears, the nostrils discharging an acrid fluid, attended with fixed and intense 
pain in the head, mostly frontal over the eyes, sometimes also attended with giddi- 706 
SPECIAL PATHOLOGY-INFLUENZA. 
ness. The nights are sleepless, with delirium or lethargy; cough prevails, with 
yellow expectoration, most troublesome at night, and tending greatly to increase the 
headache. Fever attends the disorder, sometimes slight and sometimes severe, and 
of a type varying in different epidemics and localities. The duration of the fever 
is definite, of from four to eight days (Parkes). The sense of taste is generally 
greatly disordered, and there is great anxiety and depression over the region of the 
heart. 
Historical Notice.-We have no credible accounts of the existence of in- 
fluenza previous to the tenth century. In 1311 it was very fatal throughout 
France. In 1403 the courts of law in Paris were closed on account of the 
deaths. Towards the close of the twelfth and thirteenth centuries it was ob- 
served that catarrh was not only endemic in particular districts, but that it 
occasionally spread over large portions of country, while .still later, in the 
year 1557, it was found to prevail epidemically, not only over the whole of 
Europe, but even over the whole of the northern hemisphere, begining in Asia 
and proceeding westward till it terminated in America. In the eighteenth 
century, having advanced westward till it reached the Elbe, it passed over the 
intermediate countries and reached England, where the stream broke into two 
branches, the one crossing the Atlantic to America, while the other retrograded 
southeast through France, Spain, and Italy, till it was lost in the Mediterra- 
nean-a course similar to that described by cholera. 
Influenza has occasionally originated as far eastward as India, but more 
commonly it has broken out in the north of Europe, as Moscow, Warsaw, or 
ifresden. It seems probable that, like the poison of Cholera Indica, its 
spread may be limited to a small number of primary foci; for we find in every 
volume of the Calcutta Transactions accounts of some catarrhal fever spread- 
ing for a season along the banks of some principal river, and then subsiding; 
so that it is evidently only occasionally and at long intervals erratic, as in 
1729, 1743, 1775, 1782, 1831, 1833, and 1837. The influenza, therefore, is 
both endemic and epidemic; and, in the latter case, we find it, at least in 
Europe, spreading from east to west, prevailing in the depths of winter as well 
as the heights of summer, lasting nearly the same space of time in the dif- 
ferent towns and cities it attacks, or from four to six weeks, affecting contig- 
uous places in different degrees and at different times. 
On looking to the habits of this poison, it is probable that its actions are 
not limited to man; for in most years, when influenza has been epidemic, a 
similar disease has been epizootic, especially among horses and dogs, as in the 
years 1728, 1732, and 1775. It is a disease of extraordinary rapidity of prog- 
ress ; and as its diffusibility is great, so are its periods of recurrence frequent- 
those cycles of its visitation which are as yet beyond our comprehension to 
explain. 
Pathology.-A specific poison is believed to be absorbed, and to infect the 
blood, when, after a period of incubation varying from one to two or three 
days, or even to two or three weeks, it produces disordered functions of the 
great nervous centres, causing great general depression, extreme debility, 
together with slight or severe remittent fever. The specific actions of this 
poison are on the mucous membrane of the eyes, of the nose, and of the 
bronchi; in a smaller number of cases on the mucous membrane of the fauces, 
causing sore throat; and in a still smaller ratio on the substance of the lungs 
and on the pleura, causing inflammation of those organs. In most instances 
the disorder terminates in diarrhoea. These different pathological phenomena 
vary in frequency and complexity in different seasons and places. 
In most cases, when the poison is of sufficient intensity to produce fever,-the 
type is remittent in this country, with exacerbations in the evening. Its usual 
duration is two, three, or four days, when it terminates in an abundant sweat, 
and which not unfrequently leaves great debility behind it. In Germany the 
fever is sometimes intermittent. At the same time, however, or, it may be, COMPLICATIONS OF INFLUENZA. 
707 
preceding or succeeding the fever, the patient has in general been seized with 
a slight inflammation of the ocular and nasal membranes, followed by coryza, 
or the serous discharge of a common cold or catarrh; and this inflammation 
generally extends to the larynx and trachea, or to the lungs. 
The pneumonia occupied most commonly the middle and lower lobes, and 
only rarely the summits of the lungs. Out of forty cases observed by M. Lan- 
dau, the inflammation occupied twenty-one times both lungs, eleven times the 
right lung, and eight times the left. The forms of pneumonia are principally 
serous inflammation and red hepatization, the latter occasionally interspersed 
with a few points of pus. Gluge states that in the fatal cases of pneumonia 
connected with influenza he has found exudations in the bronchia, which he 
can only compare to the false membrane of croup. Such exudations were 
seen in the hepatized portions of the lung as white, elastic, firm cylinders fill- 
ing the bronchia, from the fourth or fifth divisions of these tubes, into such 
as are not more than a quarter of a line in diameter. The inner membrane 
of the bronchia in such cases was extremely reddened, but not softened. 
Symptoms, Course, and Complications.-The symptoms of influenza as- 
sume a variety of different forms. Thus, catarrh often exists without the 
fever, and, in a smaller number of cases, the fever without the catarrh. Severe 
nervous depression, prostration, anxiety, and prsecordial oppression, were fre- 
quently the most prominent symptoms, while in other instances the bronchial 
affection alone harassed the patient. 
The disease usually begins suddenly with chilliness and shivering, rapidly 
succeeded by an immediate and evident impression upon the mucous mem- 
branes of the nose, mouth, frontal sinuses, trachea, and bronchial tubes, to a 
greater or less extent. General soreness accompanies these symptoms, with 
severe, darting, neuralgic headaches, aching of the limbs, listlessness, great 
mental depression, complete anorexia, and an extraordinary weakness, which, 
in the experience of Dr. Parkes, bore a close ratio to the extent of the pulmo- 
nary affection, and consequently to the severity of the disease. These symp- 
toms were accompanied by fever, slightly increased towards evening. Patients 
were usually seen about the third or fourth day, and then they were found com- 
plaining of cough, tightness of the chest, of pain in the epigastrium, and also 
of dyspnoea. The face was flushed, and sometimes swollen, the ake of the 
nose red, the lip vesiculated, the eyes streaming with coryza, and the voice 
altered as in a common cold. The tongue was moist, or coated with a yellow 
mucus, and taste was vitiated, the skin soft and without morbid heat, the 
pulse little augmented in frequency. But although each of the particular 
symptoms might be mild, there was a languor, debility, and dejection of 
spirits far beyond what might have been expected, and almost exceeding that 
of common continued fever. These symptoms were in many instances long in 
subsiding. The average duration of the cases in the epidemic of 1847 (so 
admirably described by Dr. Peacock) was from three to five days in the mild 
forms, and from seven to ten in the more severe. 
In mild cases such phenomena constituted the whole disease, and the 
patients recovered about the eighth or tenth day, after suffering for a few 
hours from sharp diarrhoea or profuse perspiration. In many instances, how- 
ever, the patient, in addition, suffered from mild or severe sore throat; or 
cough came on, and continued for many weeks. In a few cases the symptoms 
were of a more aggravated character, the fever being more marked, the pulse 
accelerated, the skin hotter, and the cough more troublesome ; and these con- 
ditions have often been followed by inflammation of the lungs. 
The pulmonary complications maybe arranged into four forms,-(1.) Capil- 
lary bronchitis; (2.) Bronchitis supervening on tuberculous disease of the lungs; 
(3.) Bronchitis with disease of the heart or aorta; (4.) Pneumonia. 
The accession of capillary bronchitis is indicated by the chest symptoms 
becoming more severe and the cough paroxysmal, and the dyspnoea at first 708 
SPECIAL PATHOLOGY-INFLUENZA. 
quite disproportionate to the cough and to the physical signs. The expectora- 
tion is scanty, and consists of small yellowish pellets, forming tenacious masses 
of a peculiarly nodulated form. The pulse becomes rapid (120-140), the 
tongue covered with a white-brown fur, and prostration is extreme. The only 
auscultatory signs are roughness of the inspiratory murmur, with occasional 
sibilus, and slight crepitation at the back. There is soreness and contraction 
of the chest, but no acute pain. Crepitation, unattended by dulness on per- 
cussion, soon extends over a greater or less extent of both lungs; and the 
dyspnoea speedily becomes so intense as to prevent the patient from lying 
down, the lividity of the lips and face increases, and the eyes become promi- 
nent. The cough is now very frequent, the sputa very viscid, of a greenish- 
yellow, without air-bubbles, and often streaked with blood. The respirations 
are quickened; but there does not appear to be any uniform connection between 
the extent of the disease and the disturbed ratio of the pulse and respiration 
movements. The general rule is, that the respirations are relatively more 
quickened than the pulse (Peacock, Parkes). The physical signs soon 
become modified by rapidly developed emphysema of the lungs. Generally, 
it may be said that the capillary bronchitis of influenza is distinguished from 
pneumonia by the greater severity of the general symptoms; by the tendency 
of the fine crepitation of the early stage to pass into subcrepitant and mucous 
rales, rather than to g'ive place to evidences of condensation, and by the pecu- 
liar characters of the cough, which is paroxysmal, and not attended by pain; 
and lastly, by the character of the expectoration, which consists of whitish 
viscid pellets, cohering into irregular masses, and destitute of the glairy adhe- 
sive character, russet color, and small air-bubbles of pneumonia expectoration 
(Peacock). 
Inflammation of the substance of the lungs seldom occurs till the second or 
third day, and more commonly not till the fifth or sixth; and, although gen- 
erally, is not always preceded by shivering, or even bronchitis. The pneu- 
monia in some years has been characterized by well-marked symptoms, as pain 
in the side, dyspnoea, and by purulent or sanguineous expectoration, so that 
nobody could mistake it; but in general the pneumonia has been adynamic in 
character, and presented a striking contrast to the usual symptoms, there 
being scarcely any local pain, the pulse ordinarily so large and full, has been 
slow and small, and though sometimes counted between eighty and ninety, 
has ranged more commonly from sixty to seventy. The face also, instead of 
being full and red, has been sharp and pale, the lips blue, and the extremities 
cold. The patients also, who generally preserve a good deal of power in the 
ordinary forms of pneumonia, were now so weak that they were obliged to be 
supported while auscultated. Even this mode of exploring the chest did not 
afford the usual indications, for crepitation was rare, the respiratory murmur 
was heard, except in a few points, all over the chest, and there was little or 
no bronchophony. The ascultatory signs are in general those simply of bron- 
chitis, dry rhonchus in some parts, and harsh vesicular murmur in others. 
The expectoration likewise had not the characters observed in simple pneu- 
monia ; for, instead of being purulent and mixed with blood, it was thin, 
transparent, and viscid, and, if fever prevailed, it was usually of an adynamic 
character, marked by a brown tongue, an accelerated pulse, and occasionally 
by delirium. Throughout the progress of this disease the symptoms of nervous 
derangement are much more prominent than in ordinary catarrh, and the 
muscular debility is great, which is the most distinguishing feature of the dis- 
ease. So great is this prostration, that in some instances the patient has 
fainted merely by attempting to sit up. The extreme debility often continues 
after all other symptoms have passed away. The disease generally terminates 
favorably by perspiration, or by a copious secretion of mucus from the bron- 
chia, or a copious discharge of urine, which deposits a sediment on cooling. TREATMENT OF INFLUENZA. 
709 
Towards the termination of the complaint, rheumatic affections, especially of 
the face and head, assume an intermittent type. 
Causes and Modes of Propagation.-Influenza is for the most part so uni- 
versal a disease that large portions of the population of every country in which 
it has prevailed, without respect to age, sex, or condition, have been commonly 
infected. The air seems to be the main medium of propagation, rather than 
food or drink; and the special agent of propagation seems to be one incapable 
of indefinite increase, continual reproduction to a greater or less extent in 
different places (Parkes). In general, women, from being less exposed to 
the weather, have suffered in a smaller proportion than men, and children 
less than either. In all epidemics the aged suffer greatly. According to Dr. 
Blakiston's results, the ages from ten to sixty furnish the most patients. The 
ages from thirty to forty furnish most male patients, and from twenty to 
thirty most female patients. In the epidemic of 1847 the mortality was greatest 
amongst the adults and aged. In childhood the average mortality was raised 
83 per cent.; in manhood, 104 per cent.; and in old age, 247 per cent. 
It has been remarked in several epidemics that the lower parts of towns 
have been more generally and more severely affected than the higher and 
more healthy districts. The epidemic of 1847 was much more fatal in the 
insalubrious parts of London than in those less unhealthy; and according to 
Dr. Peacock's experience, the mortality of influenza was owing more to the 
condition in which the disease found the patient, than to any inherent power 
of the poison itself,-a result conformable to general experience and the returns 
of the Registrar-General (Parkes). 
The nature of the "epidemic influence" which gives rise to influenza is quite 
unknown. Sudden changes of temperature appear to assist the development 
of the influenza poison; and exposure to cold predisposes the individual to the 
disease-which seems to be a disease especially of the higher latitudes. 
Susceptibility Exhausted.-Few persons suffer more than one attack of 
influenza in the same epidemic, although many relapse; and one attack of 
this disease in no degree protects the constitution from a second attack in an- 
other epidemic. 
Prognosis.-Children and persons under forty die in a very small propor- 
tion, unless in a previous state of ill-health. The mortality, however, among 
the aged has in every country been great from this disease. It has been re- 
marked, also, that the disease, if not fatal in itself, left the patient, of what- 
ever age, often greatly debilitated in body and depressed in spirits, and that 
those with tender lungs who suffered from it frequently fell into phthisis, or 
continued to cough for several months afterwards, so that a complete recovery 
was often long and tedious. 
Treatment.-As a general rule, the great majority of cases in epidemics of 
influenza have scarcely required any medical treatment. In that of 1782 it 
was observed that " many, indeed, were so slightly indisposed as to require 
little or no medicine; nothing more was wanted to their cure than to abstain 
for two or three days from animal food and fermented liquors, and to use 
some soft, diluted, tepid drink." A lenient purgative at the beginning of the 
disease was useful in moderating the fever; and nature seemed to point out 
the repetition of it afterwards when there was pain in the stomach and bowels, 
and a tendency to diarrhoea. The same was observed in 1762. Nothing, 
likewise, was observed so successful in mitigating the cough as a gentle purge 
to open the bowels, anol afterwards giving a gentle opiate at night. In the 
year 1837 it was also remarked that, as long as the symptoms were limited to 
cough, hoarseness, headache, or other pains moderate in degree, the patients 
all recovered by putting them on a low diet, by attending to their bowels, and 
confining them for a few days to the house; and, if more was attempted, it 
was quickly found that the disease ran a course scarcely influenced by medi- 710 
SPECIAL PATHOLOGY-INFLUENZA. 
cine. A smaller number, however, required medical attendance, either from 
the severity of the bronchitis, the occurrence of pneumonia, of angina, or of 
severe dyspnoea, of the disordered state of the bowels, or more frequently from 
the debility induced by the disorder. 
Bloodletting is always hurtful. It does not relieve the fever, and increases 
the nervous depression. In general, when pleurisy, bronchitis, or pneumonia 
may supervene, leeches to the chest, or cupping, may relieve symptoms. A 
mild purgative dose of calomel (one to three grains) should be given once at 
first, followed by a saline purgative. Dark-colored motions are brought away, 
the spirits improve, and the fever abates. But mercury must not be given 
beyond an occasional purge. 
Emetics are also to be avoided. They increase depression, and are apt to 
produce irritability of the stomach difficult to subdue. 
In the epidemic of 1847, Dr. Peacock found bloodletting of little use, ex- 
cept in the very early stage. It increased prostration, without benefiting in 
any commensurate degree the pulmonary disease. Leeches, however, were 
sometimes useful, and counter-irritation of various kinds. During convales- 
cence sulphate of zinc was found to be a useful tonic when the expectoration 
was thin and spumous, and alkalies more useful when it was viscid and glairy 
(Peacock). Nitrate of potash, highly diluted and mixed with lemon-juice 
and sugar, is a most useful drink. From 60 to 120 grains in twenty-four 
hours may be taken. 
In pneumonia it has been found that although a few persons bore the loss 
of a considerable amount of blood, yet, in general, blood taken beyond a very 
limited quantity either did not relieve the complaint, or the practice was ac- 
tually prejudicial. It is in this form of pneumonia that large doses of the 
tartrate of antimony have been found so advantageous. Indeed, it seems dis- 
tinctly proved that this form of pneumonia will not bear that powerful anti- 
phlogistic treatment which is necessary when it arises from general causes, and 
is of a more sthenic character. 
When the patient was affected with angina, it yielded readily to small local 
bleedings when the tonsils were swollen, and to small quantities of wine when 
the tonsils presented little or no increase of size. The derangement of the 
bowels also readily yielded to purgative medicines when constipated, and when 
affected by diarrhoea, and accompanied by pain, to mild purgatives and opiates, 
or to the compound powder of chalk with opium. 
But opium must be used with great caution in severe pulmonary complica- 
tions. Its use ought to be put off till the later stages, otherwise it may in- 
crease the tightness of the chest and the dyspnoea. It must not be given till 
all danger of lung congestion is passed. When the fever and other imme- 
diately alarming symptoms of the influenza had ceased, there frequently re- 
mained a teasing cough, and the convalescents in general complained of lan- 
guor, want of appetite, and that their sleep was broken and unrefreshing. 
For removing these complaints, change of air and riding on horseback were 
most effectual. To some they were absolutely necessary; and, in addition to 
these, mild tonics, or the natural chalybeate waters drank at the spas, were 
of singular service. In slight cases it was sufficient to limit the patient to 
white fish and puddings, and in the more severe forms to slops and light pud- 
dings. The night air was universally prejudicial. It does not appear that 
any precautionary treatment was of service in preventing the spread of this 
disease among the attendants on the sick. PATHOLOGY OF GLANDERS. 
711 
GLANDERS. 
Latin Eq., Equinia; French Eq., Morve; German Eq,, Rotz; Italian Eq., 
Gimurro. 
Definition.-A specific catarrhal inflammation of the nasal mucous membrane, 
produced by the contagion of matter from a glandered horse. 
It is a febrile disease of a malignant type, characterized by vascular injection 
of the nasal mucous membrane, from which an aqueous, viscid, glutinous, or puru- 
lent discharge proceeds, on which chancre-like sores are formed, extending to the 
frontal sinus and neighboring mucous surfaces. The lymphatic glands enlarge 
in the vicinity of these mucous membranes. 
Pathology.-The horse, the ass, and the mule, animals possessing an undi- 
vided hoof, are liable to a specific disease termed glanders. Under the com- 
mon name of Farcinoma, veterinists have considered glanders, farcy, and grease 
of the horse as one and the same disease; but the influence of the animal 
poison in man has been considered by the Royal College of Physicians to give 
rise to three distinct diseases in him-namely, glanders, farcy, and equinia 
mitis. The weight of evidence, however, is in favor of the view that glanders 
and farcy are varied expressions of the same disease, according to the locality 
in which the specific lesions induced by the virus develop themselves. 
There are several grades or varieties of glanders diseases. Thus, if glanders 
be defined to be a fever with a running of matter from the nose, farriers dis- 
tinguish three kinds: one consists of swelling, ecchymosis, and gangrene of 
the mucous membrane, with a discharge principally from the pituitary, 
tracheal, or bronchial membrane ; another, of a pustular eruption of the same 
parts, followed by ulceration; while a third consists in a combination of these 
two forms of disease. 
It may be shortly stated, that in glanders the nasal passages especially 
suffer; while in farcy it is the lymphatic system which is affected. 
A number of severe accidents occurring to persons employed about glan- 
dered horses has shown that the poison producing glanders is capable of being 
transmitted from the horse to the human subject, and again from the human 
subject to the horse and to the ass; and there is reason also to believe that it 
is capable of being transmitted from one human being to another (Zimmer- 
man, in Virch. Arch., vol. xxiii, p. 209, Year-Book of New Syden. Society, 1862). 
The attention of the profession was first called to this subject by Mr. Muscroft, 
in The Edinburgh Medical and Surgical Journal, in the year 1821, where he 
relates the case of the whipper-in of the Bradworth hunt, who wounded himself 
in cutting up a glandered horse for the kennel, and died, at the end of a week, 
of confirmed glanders; and two similar cases appeared in the same work about 
two years afterwards. Simultaneously with Mr. Muscroft, Dr. Copland, in 
the course of a discussion at the Medico-Chirurgical Society of London, stated 
that the fact of the disease having been thus communicated had been proved 
by cases that had occurred in Germany, and which were published in Bust's 
Magazine for 1821. The cases excited but little notice till Mr. Travers pub- 
lished his valuable work on Constitutional Irritation, in 1828, containing a 
letter from Professor Coleman on the transmission of glanders from the horse 
to man, and from man to the ass, together with some other cases which had 
fallen under his own observation. The subject was now followed up by Dr.. 
Elliotson, in two papers in the Transactions of the Medico- Chirurgical Society, 
narrating three cases which had occurred in his own, Dr. Roots's, and Dr. 
Williams's practice. At length all the then known facts were collected in an 
elaborate paper by Rayer, in the sixth volume of the Memoires de I'Academic 
Royale de Medecine. 
In the cases collected by Rayer, the nose and nasal fossae had only been 712 
SPECIAL PATHOLOGY-GLANDERS. 
examined in four cases out of fifteen, and in these there was found either 
ecchymosis, ulceration, or gangrene of the mucous membrane of the sep- 
tum nasi, or of the sinuses. The mucous membrane of the larynx, or 
trachea, has likewise been found studded either with the peculiar eruption, or 
diffusely inflamed or ulcerated, so much so that in one case the epiglottis was 
in part destroyed. The lungs have likewise been found either gorged with 
blood, or the seat of lobular pneumonia, or of vomicse, with typhoid symp- 
toms-broncho-pneumo-typhus, as it is called in Germany. In Dr. Roots's case 
there was an encysted abscess of the lung, which contained about two ounces 
of pus. Besides these affections of the more vital organs, a number of small 
farcy tumors have been found in different parts of the trunk and extremities, 
and perfectly remote from the point originally punctured. These tumors 
were in different states of inflammation, some being white and indurated, 
others soft and injected, and others in a state of suppuration. In Dr. Roots's 
case an abscess on the back of the hand communicated with the articulation 
of the metacarpal bones; and in another case an abscess had opened into the 
knee-joint. The absorbent vessels have likewise been found inflamed along 
the arm from the point of puncture, or site of primary inoculation, and the 
glands to which they lead have been found enlarged and indurated, or in a 
state of suppuration. 
The result of all these observations shows that in cases of glanders a 
specific poison is implanted which infects the blood, and after a given period 
of latency, produces, in slight cases, an abscess at the point of puncture, fol- 
lowed by some tumors in the course of the absorbents connected with the 
punctured part. In severe cases fever is previously set up, and after this has 
continued for some days, there follows either a diffuse or an eruptive inflam- 
mation of the mucous membrane of the nostrils and of the trachea, termin- 
ating in suppuration, ulceration, or gangrene; also some inflammatory 
affection of the lung, together with the usual farcy button or bud tumors in 
different parts of the body. Transmission of the virus from one animal to 
another, or from one individual to another, is the most frequent, and probably 
the only manner in which the malady is propagated. It is a specific disease, 
which is purely contagious; and the specific virus is contained alike in the 
discharges of the "farcy buttons," the flow from the nostrils, the blood, and 
in the excretions, saliva, urine, and sweat. It is known also that the disease 
has been transmitted at a distance of ten or twelve paces from the original 
source of infection, probably by particles of nasal secretion cast off by the 
horse-the snorting of the animal to get rid of the stuff in his nostrils carry- 
ing the secretion into the air, and so dispersing it about. 
Morbid Anatomy.-The specific lesion of glanders consists in the growth 
of peculiar nodules in the mucous membrane of the nose, the lymphatic 
glands, the skin, the muscles, the lungs, and other organs. At first these 
nodules are hard, but afterwards they soften, disintegrate, and pass into 
abscesses and ulcers. In substance they consist of a proliferation of cells, 
young, small, and delicate, with numerous free nuclei. In the older nodules 
the cells are large, distinctly nucleated, lying closely together and forming 
and making up almost the entire mass of the tumor. As they progress, the 
older cells degenerate, and become partially filled with fat-globules. They 
lose their sharply defined contour and break down, so that the nodule finally 
contains only a mass of detritus, with a few isolated elements. In the horse, 
ass, and similar brutes, these nodules are of the size of a hemp-seed or a pea; 
and the resulting ulcers are at first solitary or in groups ; but as they coalesce 
they give a peculiar worm-eaten appearance to the surface. The ulcerative 
distinction continues to extend by the development and breaking down of 
new nodules upon the edges of the ulcers, as well as on the base and sur- 
rounding parts, and by gangrenous disintegration of large portions of surface. 
The ulceration penetrates to a great depth, laying bare portions of cartilage SYMPTOMS OF GLANDERS. 
713 
and bone, which die and are discharged. The catarrh is very intense around 
the ulcers, and the discharge is at first thin and transparent, which subse- 
quently becomes thick, transparent, and purulent, discolored by blood, acrid 
and fetid, containing the debris of dead tissue (Virchow, Niemeyer). 
Symptoms.-Glanders may be either acute or chronic. Acute glanders is 
expressed by primary fever, followed by local inflammation; chronic glanders, 
when the local inflammations exist per se. 
The acute disease is ushered in by an attack of primary fever, with or with- 
out rigors, and followed by pains in the joints and limbs so severe as often to 
be mistaken for an attack of acute rheumatism. In some cases the rigors are 
repeated several times. "The skin grows hot, thirst increases, the pulse 
quickens, and the patient feels depressed and languid, complains of pain in 
the head, sleeps badly, has no appetite-in short, exhibits a series of symp- 
toms such as accompany other infectious diseases" (Niemeyer). Violent 
pains in the joints, especially of the greater articulations, and the muscles, 
are constant and characteristic phenomena. The pains in the joints are aug- 
mented by motion and pressure, and sometimes the joint is swollen. Hence 
the disease may be mistaken for rheumatism. 
This stage of the disease may continue for three or four weeks or more, 
during which the symptoms either increase steadily or gradually grow milder, 
and subside into the second or eruptive stage. The pained parts become the 
seat of phlegmonous tumors, accompanied with much pain, redness, and ten- 
derness ; these more commonly terminate in abscess, sometimes discharging a 
laudable pus, but more usually a bloody sanies, and rapidly become gan- 
grenous. Towards the close of the disease, in almost all cases there has been 
a discharge of matter more or less purulent, viscid, and mixed with blood, 
from the nostrils. This lesion begins by an erysipelatous inflammation upon 
the exterior of the nose and its vicinity. The nose, the eyelids, and the fore- 
head swell, assuming a dusky redness. The skin becomes covered with blebs, 
which are the precursors of gangrene (Niemeyer). The patient cannot 
breathe through his nostrils, and there flows from them a fluid which is at 
first scanty, thin, and mingled with streaks of blood, afterwards the discharge 
is foul and sanious. The period at which this symptom appears is not con- 
stant. It has been seen as early as the fourth, and as late as the sixteenth 
day. In the course of the disease the eyelids are generally tumefied, and dis- 
charge a thick viscid matter, like that from the nose. Enlargement of the 
submaxillary glands occurs. 
If the patient lies on his back, the discharge from the frontal sinuses and 
nose flows back through the posterior nares into the pharynx, and causes 
much distress, with erosion of the soft palate and tonsils. The mucous mem- 
brane is then of a deep red hue, and is soon covered with ulcers and sloughs. 
One of the most remarkable symptoms of acute glanders in man is an erup- 
tion on the face, trunk, limbs, and genital organs. This eruption has been 
compared to varicellce, to small-pox, and to ecthyma; but in fact it is an erup- 
tion sui generis, and cannot be compared to any other. It has been observed 
to occur about the twelfth day, and to be preceded and accompanied by pro- 
fuse fetid sweats. This eruption has been described as pustular; but Virchow 
has shown that in glanders there is no elevation of the epidermis by any exu- 
dation, but the skin beneath circumscribed spots of the cuticle becomes dis- 
integrated. The affected portions of the skin are at first intensely red, at a 
small point, resembling a flea-bite. A papule then forms, which afterwards 
appears like a pustule, from the thick yellow liquid which is found to fill up 
the hole or loss of substance from the disintegrated corium. The contents 
of this glander-pustule sometimes grow bloody, and dry up into small black- 
ish-brown crusts. Besides this eruption, a number of black bullse have been 
observed on the nose, forehead, below the ears, on the fingers, toes, and geni- 714 
SPECIAL PATHOLOGY-GLANDERS. 
tai organs, and these have been followed by gangrene more or less extensive 
and deep. 
The pulse is full and quick in the early stages, but towards the close it be- 
comes rapid, small, irregular, and even intermittent. The tongue varies as 
in typhus, being first white and coated, and subsequently brown or black. 
Diarrhoea and meteorism often complicate the disease, and blood has been 
observed in the stools. Cerebral disturbance has come on as early as the 
second day, but more commonly not till towards the tenth; sometimes marked 
by a singular want of intelligence, at others by a sinister presentiment, fol- 
lowed by stupor and death. 
Acute glanders is rapid in its course, and two-thirds of the cases have ter- 
minated before the seventeenth day; some have died on the twenty-first day, 
a few on the twenty-eighth day, and only one has survived till the fifty-ninth 
day. 
Chronic glanders, or farcy, differs from acute glanders in the circumstance 
of the local lesion preceding the general febrile derangement, the introduc- 
tion of the poison being followed in a few hours by inflammation of the lym- 
phatics proceeding from the wounded part, and extending sometimes to the 
elbow or axilla, and involving the axillary glands. These effects are fol- 
lowed by inflammation and extensive abscesses in the subcutaneous cellular 
tissue, often involving the whole limb. From this state the patient may re- 
cover ; but should these abscesses be multiplied over various parts of the 
body, and be accompanied either by the pustular or gangrenous vesicular 
eruptions, or by both, the result is generally fatal; hectic symptoms super- 
vene, and hasten the final catastrophe. 
The disease has terminated within a fortnight, but more commonly it has 
not proved fatal till the end of a month ; and, in cases still more chronic, a 
twelvemonth has been known to elapse before the patient finally recovered 
or died. Such are the general phenomena of acute and chronic glanders, as 
they have been observed in the human subject. 
Cause.-The cause of glanders in the horse is but little understood. It is 
probably due to a specific miasmatic poison, having a peculiar affinity for the 
horse and animals of his class. Glanders, however, when it affects the human 
subject, has in all instances been distinctly traced to the glandered horse as 
the cause. No instance is known of the disease occurring primarily in man. 
In the horse certain predisposing causes greatly favor, and are perhaps 
necessary to, the spread of glanders, such as dirty, close, ill-ventilated stables, 
especially if the situation be low and damp. Horses when crowded on board 
transports are greatly liable to this affection. The Arab, in transporting his 
horses from Arabia to India, always chooses that part of the year when the 
passage is shortest, lest the accidents incident to a long voyage, and, especially, 
want of ventilation, might promote the development of glanders. Bad food 
is a powerful predisposing cause in the horse, especially when these animals 
are picketed on military service, and thus exposed to the inclemency of the 
weather. At the close of a campaign the cavalry are often decimated by this 
disease; and towards the termination of the Peninsular war the losses from 
this cause are said to have been enormous. The cases occurring in the human 
subject are too few to allow of any inference being drawn as to the influence 
of the predisposing causes in the production of glanders; but the disease gen- 
erally occurs in young men; and probably a close investigation would have 
shown that the habits of the patient were such as to fall within those laws 
which favor the production of the disease in the horse. 
The majority of veterinary surgeons, of stable-keepers, and coach proprie- 
tors, believe that the disease is contagious among horses, and if a glandered 
horse has been introduced into stables, the stock in these stables have become 
diseased. There are few districts in which some farmer, by the loss of a con- 
siderable part of his team, has not had sufficient proof of the communicable PERIOD OF LATENCY IN GLANDERS. 
715 
nature of glanders. In this country the law is severe against offering for sale, 
or even working, a glandered horse; which shows that the opinion of our an- 
cestors, time out of mind, has been that glanders is a contagious and a fatal 
disease. In Germany the belief of contagion is so general that it is said the 
law directs any horse that has been in contact with a glandered animal to be 
immediately killed. Again, Professor Coleman has produced glanders by 
direct inoculation from horse to horse; so also have Professors Peal and 
Renault; while Leblanc assures us that he has repeated these experiments till 
he has demonstrated that not only is glanders contagious, but that farcy and 
glanders are mere varieties of the same disease,-the farcy matter producing 
glanders, and the matter of glanders producing farcy. 
Cases of the transmission of glanders from the horse to man are now nu- 
merous ; and that the disease is actually glanders has been shown by Professor 
Coleman, who directed two asses to be inoculated with matter taken from the 
arm of a person then laboring under this disease, consequent on a puncture 
received in dissecting a glandered animal, and both animals died of glanders. 
These experiments have been repeated with similar results by Gerard, Hering, 
of Stuttgardt, and more recently by Leblanc, with matter taken from a 
patient that died glandered under the care of Rayer, so that no doubt can 
exist of the fact. It seems proved, therefore, that glanders is transmissible 
from the horse to man, and again from man to the ass. It has been con- 
tended, also, that if glanders is transmissible from man to animals, the dis- 
ease must be capable of being communicated from one human subject to 
another; and a case of this description appears actually to have occurred in 
St. Bartholomew's Hospital about twenty years ago, when the nurse, a healthy 
woman, contracted the disease from a patient in the ward, and, after a short 
illness, died with every symptom of glanders. 
The fact of repeated inoculation with glandered virus distinctly shows that 
fomites may be so infected as to produce the disease. The spread of the 
malady has been attributed to healthy horses having drunk out of the same 
pail or trough with a glandered horse, or to licking the neighboring rack or 
partitions of the stalls in which a glandered horse had been placed. Mr. 
White attributes the occurrence of glanders in a mare and two foals to some 
hay left by a team of glandered horses being blown into their paddock. 
The specific poison of glanders has been introduced into the system both by 
the cutaneous and mucous tissues. The disease has been produced by insert- 
ing the virus under the cutis with a lancet, and by rubbing it on the greasy 
heel of a horse; it has also been produced by inoculating the mucous mem- 
brane of the nose of the horse, or by smearing that membrane with farcied 
matter. Farcied matter has also been made up into balls, and introduced 
into the stomach of the horse, and glanders has resulted. There can be no 
doubt, therefore, that the poison is absorbed both by the cutaneous and 
mucous tissues, and that, being absorbed, it infects the blood. This latter 
fact has been distinctly proved by Professor Coleman. "I have," says this 
gentleman, " produced the disease by first removing the healthy blood from 
an ass, until the animal was nearly exhausted, and then transferring from a 
glandered horse blood from the carotid artery into the jugular vein of the ass. 
The disease in the ass was rapid and violent in degree; and from this animal, 
by inoculation, I afterwards produced both glanders and farcy. In acute 
glanders, therefore, the blood is undoubtedly affected." 
Period of Latency.-The poison of glanders has its period of latency, like 
all other morbid poisons, and that period is in general short. Two asses were 
inoculated by Mr. Turner, the one about a year and the other a year and a 
half old, and in the first the maxillary glands became tender on the second 
day, and the discharge from the nostrils was established on the third. In the 
other the maxillary gland enlarged on the third day, but the discharge from 
the nostrils did not take place till the sixth day. Sometimes, however, the 716 
SPECIAL PATHOLOGY-GLANDERS. 
incubation is much longer. In the Proces-verbal de VEcole de Lyon a case is 
given of a horse which was inoculated with farcy matter, but the disease did 
not appear till the end of three months, and then precisely at the points of 
puncture. M. Gerard, an ex-veterinary surgeon of the French "artillerie de 
la garde," states that he introduced the matter of the discharge every day 
into the nostrils of certain horses, by means of a brush, and that the disease 
appeared in one on the seventh day, but in two others not till the thirty- 
second day. 
In the human subject the poison has in general been latent from two to 
eight days after the accident of inoculation. 
Where the virus has been implanted through a wound, the first symptoms 
generally appear within three or four days; but when there has been no 
breach of surface (as when the virus is inhaled), the malady may not break 
out for months. The course and magnitude of the disease also differ in the 
two cases. When the poison acts on an abrasion, or is inoculated, the earliest 
symptoms are usually local. The wound inflames at the site of injury ; the 
lymphatics proceeding from the part form knotted chains, and their glands 
form painful swellings. The cutaneous inflammation assumes an erysipela- 
tous character, and is attended by intense oedema. Blebs form and pustules 
full of discolored ichorous contents, and sometimes real gangrenous bullse, 
arise upon the skin. Abscesses may also form, and diffuse destructive phleg- 
monous inflammation occur in parts about the inflamed lymphatics (Nie- 
meyer). Sometimes the disease remains thus a local One, so far as the lesions 
are concerned; but there is always fever of an intensity which is the measure 
of the severity of the case. The febrile signs of general implication of the 
system generally usher in the expression of the lesion. 
Prognosis.-Of fifteen cases of acute glanders collected by Rayer only one 
recovered. Of fifteen cases of acute farcy only five recovered. Of seven 
cases of chronic farcy only one died. Of the three cases of chronic glanders 
two died. A favorable prognosis, consequently, is only warranted in the 
chronic form of the disease. 
Diagnosis.-"Acute glanders," says Rayer, " cannot be confounded with 
poisoning from puncture in dissecting or opening dead bodies; for," he adds, 
" out of fifty such cases reported by various authors, no mention is made in 
them of a discharge from the nostrils, or of a nasal or laryngeal eruption 
being found after death, or of the peculiar cutaneous eruption." Leblanc 
also states that he has inoculated the horse with a great number of other 
morbid secretions from the human subject, but has in no instance produced 
any disease similar to glanders. It may for a short time be mistaken for 
rheumatism, but the occurrence of the secondary actions quickly dispels this 
error. 
Treatment.-All the remedies hitherto tried in acute glanders have failed. 
The coming on of typhoid symptoms has led to the administration of quinta, 
valerian, serpentaria, ammonia, and other stimulating medicines; but all of 
them have failed. Vomiting and purging have likewise been had recourse 
to; but these measures have been equally unsuccessful. It is probable, there- 
fore, that the cure of this disease depends on the discovery of a specific 
remedy; and experiments in treatment may be warranted as the only chance 
of subduing a malady which has so constantly proved fatal. In the more 
chronic forms of the disease the recovery of the patient has appeared to be 
owing to the excellence of his constitution, during the natural elimination 
of the poison, to good ventilation, and to generous diet, rather than to any 
powerful effect produced either by general or local treatment. 
Preventive Treatment.-The prophylactic treatment is the same as that 
of all other contagious diseases-namely, being careful to avoid all contact 
with the morbid poison, and especially when a finger or other part of the 
hand is abraded; and if by accident the veterinary surgeon should inoculate DEFINITION AND PATHOLOGY OF FARCY. 
717 
himself, he ought instantly to destroy the part with potassafusa. It has been 
recommended, after the disease has set up, to extirpate the enlarged glands; 
but, according to the doctrines set forth in the text, this practice is as unwar- 
rantable as hopeless. 
FARCY. 
Latin Eq., Farcinimum; French Eq., Farcin; German Eq., Wurm; Italian Eq., 
Farcino. 
Definition.-An inflammatory affection of the skin and of the absorbent system 
produced by the contagion of matter from a horse having farcy. 
Pathology.-By many this affection is regarded as a form of glanders, 
and there is evidence to show that the poison of glanders will produce the 
anatomical lesions of farcy, and of farcy glanders. While glanders is ex- 
pressed especially by lesions of the mucous membranes, farcy is expressed 
mainly by a tubercular and pustular lesion appearing upon the skin, followed 
by suppurating, bloody, or gangrenous ulceration in various parts. A general 
inflammation of the lymphatics and of the glands may occur, giving rise to 
the small tumors known as "farcy buds" or "farcy buttons." These gradually 
suppurate, and the secretion from the open sores contain the specific virus of 
farcy. 
The b ud farcy and the button farcy are regarded as different forms of the 
same disease. 
The " bud farcy" consists in the formation of a number of tumors on dif- 
ferent parts of the body, as on the head, neck, and extremities, and particu- 
larly on the hinder ones of the horse. These tumors are formed not only by 
enlargement and inflammation of the glands, but of the areolar tissue; and 
at the end of four or five days the tumor softens and ulcerates. Similar bud- 
like tumors form in the substance of the pituitary membrane, and these follow 
a similar course of softening and ulceration. 
The form known as " button farcy" is an inflammation limited to the 
lymphatic glands and vessels, without involving, to any considerable extent, 
the neighboring connective tissue. It usually commences in the hinder ex- 
tremities of the horse, causing lameness and enlargement of the limb; and 
when the valves of the lymphatic vessels become thickened, it forms the 
peculiar tumor called "farcy bud;" and when the lymphatics only are swollen, 
and show this peculiar enlargement throughout their course, the lesion is 
known as " farcy pipe." • 
The tubercles, buds, or tumors of farcy are larger than the tubercles of 
glanders. They contain also a greater quantity of case'ous matter, and they 
may be isolated or aggregated in clusters, chains, or wreaths, according as 
different parts of the lymphatics are specially involved. The open sores left, 
after softening and ulceration, are round, with elevated and everted edges, a 
foul, irregular, sloughy base, which discharges profusely an ichorous fluid, 
gluing the surrounding hairs together, and drying up with them into a hard 
crust. The clusters of "farcy buttons" lie deeper in the skin than the pecu- 
liar cutaneous eruption of glanders. They are in the form of large, flat, 
hard, red tumors, from which the cuticle is finally separated by an effusion 
of blood, so as to form livid or bluish bullse. The upper portion of the 
cuticle covering these clusters is also infiltrated by a hemorrhagic exudation, 
.and the whole afterwards breaks down into a pulpy detritus (Virchow). The 
"farcy buttons" of the subcutaneous tissue and muscles arise either with 
diffuse inflammatory infiltration of the adjacent parts, and all the symptoms 
of a severe phlegmon; or small, circumscribed, hard, boggy tumors form, 
which are so painless that they may develop unobserved. The ulceration of 
these may extend even to the bones. 718 
SPECIAL PATHOLOGY-MALIGNANT PUSTULE. 
Farcy is more common in man than glanders ; and the peculiar eruptions 
on the skin of the farcy tubercles are larger and more numerous than those 
in brutes; and their contents, as well as those of the tubercles in the muscles 
and lungs, are purulent rather than caseous. The lymphatics and glands are 
similarly implicated in man as in brutes; and the skin becomes involved in 
a malignant erysipelas tending to its great destruction by gangrene. 
EQUINIA MITIS. 
Latin Eq., Equinia Mitis; French Eq., Grease; German Eq., Equinia Mitis- 
Syn., Gutargiger Wurm, Druse; Italian Eq , Equinia Mite. 
Definition.-A pustular eruption, produced by the contagion of matter from 
a horse affected icith the grease. 
Pathology.-Grease in horses is a specific inflammation of the sebaceous 
glands of the skin in or about the heels. There is at first a catarrh from these 
glands, the secretion which flows being greatly vitiated in quality, giving forth 
a very loathsome smell. The catarrhal inflammation of the glands passes into 
ulcers, which present the appearance of unhealthy sores, the discharge from 
which is very offensive. The ulceration assumes the form of deep, raw, and 
excessively tender cracks or fissures, from which exuberant granulations may 
arise, to which the name of "grapes" has been given. These may increase to 
an enormous size, accompanied with much general swelling of the leg. 
It is this earlier catarrhal discharge, which is at first a very thin acrid exu- 
dation, that is the most virulent; and when it escapes on to the hands of those 
who attend upon horses, dressing their heels when affected with the grease, 
gives rise to the specific pustular affection of equima mitis. The term equinia 
was proposed for the disease known as glanders by Dr. Elliotson, and was in- 
tended to express its derivation from the horse, just as the term vaccina or 
vaccinia was before given to cow-pox; subsequently, Dr. Shedel adopted the 
name of equinia mitis to the more mild affection derived from the grease of 
horses, now being described. The eruption is pustular, and the pustules are 
large, very similar to those of ecthyma, elevated above the skin, and with a 
red, purple tumid base. If there are abrasions, or much unsoundness of the 
skin of the hands, the eruption may be extensive in proportion, and very severe. 
Symptoms.-The eruption is preceded and attended with febrile symptoms, 
and, in some cases I have seen, with very marked depression and tremor or 
shivering. The eruption takes about ei^t days to become pustular; but the 
pus seems watery and abnormal; and inten or twelve days the lesions begin 
to die away, scabs form, which fall off, leaving well-defined scars. 
There is generally considerable constitutional disturbance and much foul- 
ness of tongue; rapid pulse, with alternate heats and chills. 
Treatment.-The greatest relief to the constitutional disturbance is obtained 
by frequent purgation with aloes combined with ammonia, and such moist 
local applications as may relieve pain. 
MALIGNANT PUSTULE (VESICLE?). 
Latin Eq., Pustula maligna; French Eq., Pustule maligne; German Eq., Milzbrand 
-Syn., Pustula maligna, Karbunkel-krankheit; Italian Eq., Pustula maligna. 
Definition.-A spreading gangrenous inflammation, commencing as a vesicle 
on exposed skin, attended with peculiar hardness and fetor, and derived from 
cattle similarly diseased. It is thus the result of a specific poison implanted on 
some uncovered part, which produces, in the first instance, a redness like the bite 
of a gnat, and afterwards a minute vesicle. The lesion rapidly spreads from the PATHOLOGY OF MALIGNANT PUSTULE. 
719 
point first affected to the neighboring tissues. Hardening and blackening of this 
part is so extreme, and death of tissue is so entire, that the part creaks when cut 
with a knife-no pain attends the incisions, crops of secondary vesicles form round 
an erysipelatous-like areola, chains of lymphatics become inflamed, the breath is 
fetid, and death follows amid all the indications of septic poisoning (Budd). 
Pathology and Historical Notice.-This disease has been long familiarly 
known and described by French, German, Russian, Swedish, Lapland, and 
Italian medical men; and it proves fatal every year to a large number of 
persons in various parts of Europe. British medical men are not generally 
familiar with the disease; and its occurrence in this country escaped general 
recognition till the admirable papers of Dr. William Budd on the subject 
(read at the meeting of the Medical Association in London, and published in 
the British Medical Journal of 1863) gave a full account of the literature of the 
subject, and showed that malignant pustule has been long known in this 
country as an epizootic, causing every year a large mortality among English 
live stock. The "joint murrain," " black quarter," or " quarter evil," and the 
"blood" (the name by which the malady is known in the sheep), are the same 
diseases as the "charbon," "quartier," and "sang" of the French, and the 
" milzbrand " of the Germans. From the writings of Dr. Budd on this subject 
the following account of this remarkable and terrible disease is taken. The 
disease has prevailed from time immemorial, in various continental countries, 
in oxen, sheep, horses, and other animals ; and, concurrently with the cases of 
malignant pustule, which are the result of direct inoculation from the morbid 
material of those animals, other cases occur in which the exact vehicle of the 
poison cannot be identified; but these cases have all the significant peculiarity, 
that the disease is always seated on some part of the person which is habitually 
uncovered. 
In animals, and especially in oxen, the action of the specific poison seems 
to be even more virulent than it is in man. Death is more speedy ; there is 
a more rapid spread of gangrene; and while the animal is yet living, the ex- 
trication of fetid gases from the tissues of the parts affected goes on to a great 
extent. The contagious property of the poison is possessed in the highest 
degree by the lymph contained in the characteristic vesicles, and, next to 
this, by that peculiar exudation which occurs in the areolar tissue of the 
affected part, and in that of various parenchymatous organs, and sometimes 
in the serous cavities of the chest and abdomen. The identity of the malig- 
nant pustule of man with the "charbon" of cattle has been satisfactorily proved 
by the fact that the disease, when contracted by man, has been communicated 
back to the animal by inoculation from man. [Inoculation .of man with matter 
from a braxy sheep will produce malignant pustule, and the inoculation of 
the matter of malignant pustule of man in a sheep will produce braxy (Re- 
nault).] 
It is only at the onset that the disease is a local one; but very soon general 
poisoning ensues, which is due to the after-diffusion of the morbid changes 
and products engendered in the part first affected. This is a very important 
point in the pathology of the disease, and with a view to successful treatment; 
for the early destruction of the diseased part by caustic not only prevents the 
development of the constitutional disorder, but in many cases issues in a per- 
fect and speedy cure. 
Propagation.-The disease may be communicated to man in the following 
ways : (1.) By direct inoculation, as in the case of butchers, farmers, skinners, 
herdsmen, drovers, and others, in whom accidental inoculation with it appears 
to be an event of no uncommon occurrence in countries where " charbon" is 
most rife. (2.) By means of the skin, or simply by the hair of diseased beasts. 
Trousseau, for example, relates that in two factories for working up horse 
hair, imported from Buenos Ayres, and in which only six or eight hands were 
employed, twenty persons died in the course of ten years from malignant pus- 720 
SPECIAL PATHOLOGY-MALIGNANT PUSTULE. 
tule. There are many other cases related by Dr. Budd, and some which 
clearly show that the virus of malignant pustule, like other contagious poisons, 
when once in the dried state, may retain its powers for an indefinite period of 
time. The disease may thus be propagated through contact with bones, hoofs, 
horns, and the fat and tallow of animals dead of the " charbon." (3.) The 
disease may be communicated by eating the flesh of animals killed while 
affected with it, as also by using the milk and butter of affected cows.* (4.) 
Insects which have been in contact with the bodies or carcases of diseased 
cattle may communicate the disease to man. Most commonly it is the insects 
with piercing probosces, such as gad-flies, after having sucked the putrid juices 
of dead or sick animals, and then settled on the persons of men, which effect 
the inoculation ; but flies which make no wound may also implant the poison 
on the skin by their soiled wings and feet (Virchow, Bourgeois). The latter 
observer says " he has seen the disease produced by the puncture of a gad-fly 
which came out of a fleece of wool" (Budd). 
[Although, in nearly every instance, malignant pustule in man is commu- 
nicated directly by the virus of an infected animal, still there are a few excep- 
tional cases where, it would seem probable, it was of spontaneous origin, under 
certain special conditions (Recueil de Mem. de Med. et de Cliir. Mil., t. 1859; 
Manoury, Fournier, Bayle, Maret, Swygenhoven).] 
Phenomena and Symptoms.-A considerable degree of pruritus in the part 
is succeeded by the appearance of a red spot like a flea-bite. A vesicle, in 
the course of twelve or fifteen hours afterwards, may be observed, at first 
about the size of a millet-seed, but very soon it acquires larger dimensions, 
and, if not ruptured by the patient, bursts spontaneously, and dries up in 
about thirty-six hours, leaving the exposed cutis vera dry, and of a livid color. 
Twenty-four or thirty-six hours after the attack (itching having now ceased), 
a small, hard, and circumscribed nucleus-the "parent nucleus" of Virchow, 
the " maltka" of the Russians-having the form and size of a lentil, is percep- 
tible under and around the seat of the vesicle. In the circumference of this 
a soft but still resisting swelling, of a reddish or livid color, forms an inflamed 
areola, and becomes covered eventually with secondary sero-sanguinolent 
vesicles, similar to the vesicle which first appeared. These are at first isolated, 
but speedily they become confluent. The central spot may contain at first a 
transparent, bright yellow fluid, which very early becomes reddish or bluish ; 
then of a brownish hue, when the spot becomes extremely hard, very insensi- 
* [There is much diversity of opinion and discrepancy of evidence with regard to the 
risk of eating the flesh of animals affected with malignant pustule. Ramazzini, Lan- 
cisi, Caillot, Enaux, Chaussier, Fodere, Gamgee, Rendle, and others, give many 
instances where the disease has been developed in such as ate of the meat of cattle suf- 
fering from carbunculous fever. Dr. Livingstone (Travels in Southern Africa), says, 
that those who eat the flesh of animals who die from pleuro-pneumonia, are attacked 
with carbuncles. Menschel (quoted by Parkes, Manual of Practical Hygiene, 2d ed., 
p. 173), states that twenty-four persons were attacked with malignant pustule, the 
majority after eating the flesh of beasts suffering from the disease, the others from 
direct inoculation; five died. Dr. Samuel R. Percy (New York Medical Journal, 
August, 1866), mentions, that on the third day after eating sparingly twice of a piece 
of beef which had "a peculiar swilly odor and taste," he was taken suddenly sick 
while in the street, with severe pain in his left shin. On his return home, he found 
" an inflamed spot, about three inches in diameter, and in the centre of this, two pus- 
tular elevations, each about the color and size of a split pea. The next day the inflamed 
surface had become a vesicle ; eventually the whole skin peeled off, and the two pustular 
spots were deep-seated ulcers ; six weeks elapsed before they were perfectly healed." 
On the other hand, Parent Duchatelet,' Levy, Pappenheim, Morand, Duhamel, Thom- 
assin, and Neffel, relate cases where the flesh of animals with malignant pustule has 
been eaten with impunity, and that too in several instances where the disorder had 
been communicated by inoculation; and Thudichum (Brit. Med. Jour., April 28, 
1866), maintains that there is no satisfactory evidence to warrant the belief that man 
can be infected by eating the meat of animals so diseased.] ANATOMICAL CHARACTERS OF MALIGNANT PUSTULE. 
721 
ble, and rapidly becomes gangrenous. The inflammation extends to a con- 
siderable distance, both in depth and circumference; the neigboring skin is 
red and shining ; the subcutaneous areolar tissue is puffy and emphysematous- 
like ; the excoriated surface readily dries up, and becomes, as it were, mum- 
mified ; and in its neighborhood new vesicles spring up, which run the same 
course as the former. The part soon loses its vitality, so that it may be pierced 
with needles without the patient becoming aware of the experiment. It is 
also a remarkable feature of malignant pustule, that severe pain is generally 
absent. If the disease ceases to advance, an inflamed circle of vivid redness 
now surrounds the gangrenous portion, the tumefaction diminishes, and the 
patient experiences something like an agreeable warmth, accompanied by a 
pulsatory motion of the affected part. The pulse, which before was irritable 
and feeble, begins to revive, strength increases, a gentle perspiration indicates 
the crisis of the febrile state, and nausea ceases. . Separation commences be- 
tween the living and the dead parts, and is attended by copious suppuration. 
If the disease should not tend to a favorable issue, suppuration does not take 
place; the gangrene spreads rapidly; the pulse becomes smaller and more 
contracted ; the patient suffers from extreme lassitude and inability to sleep ; 
and, finally, with a tendency to syncope, he becomes passive as to the result. 
The tongue is dry and brown, the features shrink, the skin is parched, the eyes 
are glassy ; and cardialgia and low delirium indicate the approach of the fatal 
termination (Budd, Rajer, Virchow, Bell, Craigie). 
The face (often in the lip, or immediate neighborhood of the mouth), the 
neck, the hands, the arms, and the legs, are almost the only parts on which 
it appears; and if by chance it becomes developed on other parts, we may be 
sure the poison has been carried there directly by the fingers, or other agents 
impregnated with the virus. The phenomena, therefore, which such cases 
exhibit in man are identical in every particular with those which have been 
seen in farriers and others, in continental countries, who have the charge of 
cattle, and who in numberless instances are known to have become diseased 
from the accidental but direct inoculation of the " charbon" virus. 
[Malignant (Edema of the Eyelids would seem to be identical in its nature 
and origin with malignant pustule (Debrou,* Bourgeois,! Raimbert|). 
It begins with itching, quickly followed by great swelling, so that very soon 
after the onset the lids cannot be forcibly separated, owing to the degree 
of serous infiltration. The skin is tense and smooth, and without change of 
color. No excoriation, vesicle, pimple, or areola, no "parent nucleus," can 
be seen. The swelling soon extends to the temple, forehead, and cheek of the 
affected side, subsequently invading the lips, nose, chin, and neck. It is hard, 
pale, and indolent. There is neither headache nor nausea, and the pulse is 
regular. If the part has been early cauterized, there is a continuous weeping 
of a yellowish serosity. Unless the disease is arrested within the first day or 
twro, .constitutional infection is announced by a chill, or a sensation of general 
coldness; the pulse becomes quick and feeble, with excessive prostration; the 
respiration is embarrassed; there are nausea, vomiting, jactitation, delirium, 
and cold extremities, ending, in from two days to a week from the initial 
symptom, in death. 
Anatomical Characters.-An examination under the microscope, by M. 
Robin, of a malignant pustule excised by M. Manoury, showed nothing pecu- 
liar in its structure. There was a granular appearance, analogous to what is 
seen in all gangrenous tissues. The meshes of the subcutaneous connective 
tissue are enlarged, and its fibres are of a brownish color, due to serous infil- 
* [L'CEdeme Malin ou Charbonneux des Paupieres. Par le Dr. Debrou. Gazette 
des Hopitaux, No. 133, 1860. Arch. Gen. de M4d., Oct., 1865. 
f Traitede la Pustule Maligne. Par Bourgeois (d'Etampes). 
j Traite des Maladies Charbonneuses. Par L. A. Raimbert. Paris, 1859.] 722 
special pathology - PHAGEDENA. 
tration (Goujot). The absence of the inflammatory process in the oedematous 
tumor is an important and essential character of malignant pustule, which seems 
to oppose the formation of pus, so long as the infecting virus is present (Bour- 
geois, Salmon, Manoury). The blood is fluid, fetid, and gaseous; the cor- 
puscles broken down, and vibrios are found in it, which, according to Duvaine, 
are bacteria (Leuret, Hamont, Brauell). The heart is softened; and the 
spleen reduced to a pulp, and contains bacteria. In the stomach and small 
intestines there are a number of round, elevated patches, resembling, when 
scraped off, Indian ink, or the vomit in cancer of the stomach. A vertical 
section show's them to be limited to the mucous membrane-which is sound 
immediately around them-and composed of a homogeneous, almost black 
substance which examined microscopically is found to be altered blood, with 
a large number of amorphous granules of hematbidin (Davaine). Hence 
they are not, as stated by some writers, internal malignant pustules, or gan- 
grenous eschars. 
As far back as 1850 Davaine found in the blood of braxy sheep certain 
vibrios, which resembled bacteria in all respects except being without move- 
ment. To these he gave the name of bacteridia. Since 1863 he has made a 
number of experiments, with the view of elucidating the question, and ascer- 
taining what actual relation there was between the presence of these bodies 
and charbon virus, and with the following results: (a.) Bacteridia are found 
in every disease of this nature (dans toute maladie charbonneuse), whatever its 
form, and in every animal affected with the disease, (b.) The presence of 
these vibrios in the spleen, liver, and blood, precedes the development of the 
morbid phenomena, (c.) The blood ceases to be infecting when bacteridia 
can no longer be found in it (Archives Generales de Medecine, t. i, 1868).] 
Treatment.--The affection only admits of cure when its aspect is trivial; 
and it can only be cured by a process which leaves a mark. 
The progress of the disease is only certainly to be averted by the use of 
caustics; and of the various caustics in use the evidence appears to prepon- 
derate in favor of potassafusa; although Chaussier and others prefer nitric acid 
or the chloride of antimony. [The pustule may be excised, and the wound 
covered with corrosive sublimate (Manoury). MM. Mauvezins cut out the 
" parent nucleus " or the entire vesicle, and then apply the actual cautery at 
a red heat. Most of the French surgeons rely on the actual cautery. When 
constitutional symptoms set in, alcoholic stimulants and carbonate of ammonia 
must be largely given, together with concentrated food.] But everything 
hangs on the recognition of the disease in its first stage (Budd). 
PHAGEDENA. 
Latin Eq., Phagedena; French Eq., Affection Phagi^nique; German Eq., Phageda- 
enischer Zustand; Italian Eq., Fagedena. 
Definition.-A condition of wounds or ulcers in which they spread with a 
sloughy surface. 
Pathology.-The medical interest of this condition (otherwise within the 
province of the surgeon rather than the physician) consists in the ill health 
which attends it, and which betokens a general disease. There is general con- 
stitutional irritation, usually attended with debility; and the loaded tongue 
and fetid breath show that the functions of the alimentary canal are abnormal. 
Endemic causes, such as deficient ventilation and of sunlight combined with 
want or improper food and drink, together with'exposure to cold and wet, will so 
affect the general health as readily to induce qohagedena in the slightest sore. 
The lesion is regarded as a special form of mortification or gangrene. The 
destruction of tissue advances by molecular death, and not by masses, as in DEFINITION AND PATHOLOGY OF HOSPITAL GANGRENE. 
723 
sloughing. The margins are abrupt and ragged, and the surrounding integu- 
ment red and swollen. The base is brownish or of an ash-gray color, devoid 
of granulations, sometimes with a viscid and bloody discharge. The base and 
the edges present the appearance of having been gnawed or eaten out by the 
fine teeth of a small animal. Hence the name, from to eat. The destruc- 
tive process is "much more rapid, considerable, and unequivocal, than in simple 
ulceration." 
Treatment.-Improvement of the general health by the removal of the 
unsanitary surroundings of the patient, or the removal of the patient from 
them, and the administration of wholesome food, are the means to be adopted 
in the first instance. Concentrated essence of beef, highly nutritious soups, 
are to be given as often as the stomach will receive small quantities of them. 
But alcoholics are generally called for, and wrell borne. They are best given 
with food, such as rum with milk, or Curasao; or brandy with milk, or with 
soup, or with eggs and spices. The stimulants are called for to counteract 
the general depression which marks the general disease; and large quantities 
are often required. Of medicinal restoratives the best is opium. It allays 
local pain, subdues the nervous irritability, and secures rest at night. The 
bowels require to be especially set right, and the fluid solutions of aloes, com- 
bined with quinine and ammonia, are most useful. 
The local treatment of phagedenic sores is laid down in all the best text- 
books of surgery, and within the reach of all students. 
SLOUGHING PHAGEDENA. 
Latin Eq., Phagedena putris; French Eq., Gangrene phag&d&nique; German Eq., 
Phagedaenischer Brand; Italian Eq., Fagedena gangrenosa. 
Definition.-A severe form of phagedena, in which the slough extends deeper 
than the surface. 
Pathology.-In some cases the constitutional symptoms of general disease, 
in the form of irritation, fever, and asthenia, precede the gangrenous change 
in the character of the sore (Thomson, Hennen). In other cases, the altera- 
tion in the character of the sore is seen to precede the expression of constitu- 
tional symptoms (Rollo, Blackadder, Erichsen). The severest form of 
the disease is to be seen in the next topic for consideration, namely: 
HOSPITAL GANGRENE. 
Latin Eq., Gangrcena nosocomiorum; French Eq., Gangrene d'Mpital; German Eq., 
Hospitalbrand; Italian Eq , Gangrena di spidale. 
Definition.-Sloughing phagedcena occurring endemically in hospitals. 
Pathology.-The influence of foul air, by inducing decomposition of dis- 
charges from the surface of a wound or a sore, together with the liberation of 
absorbable gases and other fluids, influence the blood passing the part, and 
tend to bring about not only coagulation in living vessels, but also poisoning 
of the blood itself, as in hospital gangrene. 
There are certain cases more than others prone to Hospital Gangrene.-The 
disease shows a preference for those cases where cancellous bone-structure has 
been injured, as in compound fracture, or in the surgical procedures of ampu- 
tation and resection; and all the more, perhaps, in proportion as the injured 
bone is large. The other cases in which it is apt to occur are those in which 
large vein trunks have been involved in traumatic inflammation (as in gun- 
shot wounds). Although the exact local changes are not well understood, 
yet very often they seem part and parcel of a process not simply suppurative, 724 
SPECIAL PATHOLOGY - ERYSIPELAS. 
but involving also much foulness of wound, putrefactive softening of fibrin and 
bloodclot, with the evolution of such products as have been already noticed, 
which, entering the circulation, establish the general constitutional state of 
irritative fever, and therewith usually more or less of putrid infectioii of the 
blood. Many phagedenic and gangrenous materials are inoculable from patient 
to patient (Thomson's Lectures on Inflammation, 1813, p. 484), and are so far 
specific diseases. All the forms of disease which come under the term metastatical 
dyscrasite having thus, in common, an intimate affinity with ordinary putrefac- 
tive processes, they are provisionally regarded as general diseases, of the class 
A, the respective contagia of which may arise in some specific putrefaction of 
wound-products; and when such diseases as hospital gangrene, erysipelas, or 
pyannia break out in an hospital, it shows that the ventilation is inadequate to 
remove the traumatic or other organic impurities generated in the wards. Thus 
there prevails an atmosphere which contains much decaying animal matter of 
the kind which wound-surfaces contain ; and any specific change arising in this 
atmosphere, or on any wound-surface which exhales its excreta into the atmos- 
phere, has peculiar chemical facilities for infecting other wound-surfaces within 
the range of atmospheric influence (see Simon's Sixth Report on Public Health, 
pp. 61, 62). Therefore, in ill-kept hospitals, wounds go on badly. They 
undergo certain characteristic morbid changes. Erysipelas frequently attacks 
them. They become to a large extent phagedenic, tending to putrefactions of 
effused or otherwise stagnant blood, to the reopening of half-healed arteries 
and veins, to septic and suppurative infections of the system generalized under 
the term traumatic infection, all of which are comprehended amongst the 
phenomena of metastatical dyscrasice. 
For further details regarding such cases and their treatment, the student is 
referred to text-books on Surgery. 
ERYSIPELAS. 
Latin Eq., Erysipelas; French Eq , Ery sip^le; German Eq., Erysipelas-Syn., 
Rothlauf; Italian Eq., Risipola. 
Definition.-Inflammation of the integument tending to spread indefinitely and 
which may involve the areolar tissue beneath the skin. 
Pathology.-As in other diseases of this section, it is believed that in 
erysipelas a specific poison is absorbed and infects the blood, and that after a 
given period of latency it produces fever. The specific action of the poison, 
however, is mainly made manifest by a peculiar inflammation of the skin, 
characterized especially by " diffuseness." It may also extend to the subcu- 
taneous areolar tissue, and is especially apt to become complicated with visceral 
inflammations of membranous structures, such as of the brain, the lungs, and 
bronchi, or the gastro-intestinal mucous surface. 
The inflammation and the fever are of a peculiar nature, not yet clearly 
understood. It diffuses itself rapidly, and mginly by continuity of surface; 
but it no less frequently tends to change its seat, and does not tend to be 
limited by any adhesive action. The lesion is not one simply limited to the 
skin; but it may affect any surface, external or internal, such as the mucous or 
serous membranes, the connective tissue, the orbit, the scalp, the lining mem- 
brane of arteries, the veins and lymphatics; but the essential morbid condition 
is the constitutional or general disease, often marked by much gastro-intestinal 
irritation (Ericksen). There may, indeed, be no local or cutaneous evidence 
of lesion, but the general febrile symptoms, with irritation of the stomach and 
bowels. Mr. Erichsen has seen such a form of disease prevail amongst patients 
in a ward where erysipelas prevailed amongst other patients, in the ordinary 
cutaneous form. 
The lymphatic vessels and glands are invariably implicated in the lesions of PATHOLOGY OF ERYSIPELAS. 
725 
erysipelas. Niemeyer considers it proved that some forms of the inflammation 
of erysipelas proceed from the walls of inflamed lymphatics into the surround- 
ing tissue. Mr. Busk also believes that the actual primary seat of the local 
inflammation of erysipelas is in the absorbent system (quoted by Campbell De 
Morgan). 
In Scotland the disease is known by the name of the Rose; in England it is 
sometimes called St. Anthony's fire. 
Idiopathic erysipelas is very constantly preceded by fever-eighteen times 
out of twenty; and although it may be supposed that the fever is consecutive 
to the inflammation of the skin, yet, before the redness of the skin is seen, the 
temperature, if measured by a thermometer, will be found above 98.6° or 99° 
Fahr., and attended with general malaise. The affection of the areolar tissue 
may be trifling, but it is seldom altogether wanting. 
The pathological phenomena which result from the action of the poison on 
the skin are, first, that the cutis is diffusely inflamed, the affected part being 
either of a bright scarlet or a rose-colored tint, evanescent on pressure, but 
returning on that pressure being removed. This inflammation is usually of 
great extent, occupying very commonly the whole face, head, and neck, or a 
considerable portion of the trunk, or one or both lower or upper extremities. 
It runs a course which may be characterized as "tolerably regular and 
definite." 
It may terminate by resolution, by vesication, or by gangrene. When it 
terminates by resolution, the rose tint gradually changes to a deeper and more 
venous hue, and at length fades away, leaving the skin of its natural color, 
but with the texture so impaired that desquamation follows. If the inflam- 
mation terminates in vesication, the cuticle is raised into a number of vesicles 
of greater or less size, and sometimes into large bullse or bladders containing 
a yellowish transparent serum. The cuticle at length ruptures, the fluid is 
discharged, and a crust sometimes forms, which on falling off, leaves the skin 
underneath either sound or superficially ulcerated. Should the termination 
be by gangrene, the skin becomes livid or black, its whole texture more or less 
disorganized, while the bullee or phlyctense which often form in these cases are 
filled with a bloody serum. The cutis, when examined after death, whatever 
may have been the form of the disease, is always found greatly thickened and 
infiltrated, but the redness, except in cases of gangrene, has entirely disappeared. 
It is seldom that erysipelas is limited to a simple affection of tbe skin. 
More commonly, at some period of the disease, the areolar tissue beneath the 
affected skin becomes the seat of a serous exudation; and it may suppurate, 
or proceed to gangrene. When the termination is by effusion of serum, the 
quantity of fluid effused is generally so considerable that the head, face, or 
limb, is greatly, and sometimes even hideously swollen; and if the part be 
now incised, the vessels are seen enlarged and numerous, and the connective 
tissue loaded with serum, sometimes turbid and flaky. The tissue is more 
easily torn than usual. This inflammation may terminate by absorption of 
the serum ; but in a few cases ulceration follows, and sometimes gangrene. 
Adhesive inflammation does not take place in erysipelas. It is indeed 
opposed or antagonistic to that result of inflammation. Any inflammation 
that may be already existing, erysipelas causes to spread still farther; and 
when erysipelas attacks a wound already partially united by the adhesive 
process, such lymphy adhesions as may have formed are rapidly broken up, 
the wound opens afresh, and suppuration is established from its erysipelatous 
surface (Ericksen). 
Suppurative inflammation of erysipelas is preceded by serous effusion, and 
the result is generally that pus is infiltrated through the areolar tissue. The 
parts more usually the seat of phlegmonous circumscribed abscess are the 
eyelids and the integuments covering the cheek-bones, and the pus in these 
cases is usually of a laudable and healthy character. In all other parts of 726 
SPECIAL PATHOLOGY-ERYSIPELAS. 
the body the pus is generally diffused, and, the inflammation being of a low 
type, the pus is poor, and often little more than a fetid sanies. Should the 
parts slough, the purulent fluid becomes loaded with a dirty broken-down 
areolar tissue, generally mixed with some loose lymph. In some instances 
the suppurative process extends between the muscles, causing extensive and 
often irreparable mischief. In the event of this inflammation terminating by 
gangrene, the integuments of an entire limb are sometimes detached, laying 
bare the muscles, a large artery, or a bone, involving the aponeurosis and 
tendons, and sometimes destroying the interior of a joint. Gangrene, how- 
ever, does not equally take place in all parts, for it is seldom seen on the 
scalp, the face, or the trunk. It is the extremities, then, and more especially 
the leg and thigh, and also the labia and scrotum, that are apt to suffer from 
erysipelas. 
Morbid Anatomy.-The appearances found after death from erysipelas are 
similar in many respects to those found in cases of typhus fever. The visceral 
organs do not present any special characters beyond congestion of the spleen, 
kidneys, and liver, and mucous surface of the stomach and intestines. As in 
typhus fever, so in erysipelas-the bood is obviously altered. It has no dis- 
position to separate into its fluid part and coagulum ; and any coagulum that 
may form is loose and thin. The blood may be very fluid and thin, or pitchy 
and dark, staining by decomposition of its coloring matter the inner surface 
of the large bloodvessels; and showing the veins distinctly through the skin 
by transudation of the colored fluid through their coats. It is also mentioned 
by Mr. Busk, that in all the fatal cases he has examined, the lungs were 
highly congested ; and that, on close inspection, the smaller pulmonary ves- 
sels were always found to contain pus. In fact, a minor degree of pyaemia 
was always present; and, when the head was the seat of erysipelas, pus was 
similarly found in the small veins of the head (Campbell De Morgan). 
Symptoms.-The symptoms of erysipelas arise out of the fever and local 
affection, and appear of various degrees of intensity. 
In acute sthenic cases the erysipelatous inflammation is preceded and ac- 
companied by fever; and the attack may be sudden, or ushered in by rigors, 
irregular flushings, muscular pains, accelerated pulse, white tongue, nausea, 
vomiting, and deranged bowels. Sore throat is an early and constant accom- 
paniment. These symptoms, when they do exist, last for some hours-per- 
haps till the end of the second night or beginning of the third day-when 
the fever becomes continued, the tongue brown and dry, and shortly after- 
wards the cutaneous inflammation appears, but without any remission of the 
fever. 
The inflammation generally appears at the seat of any injury to the skin, 
such as a wound, and is most intense there. By some, indeed (Trousseau, 
for example), it is held that erysipelas always originates from some external 
injury or irritation, which may be very slight. But this character erysipelas 
has only in common with other eruptive diseases, as Mr. Paget has described 
in his admirable Address on Surgery, delivered to the British Medical Asso- 
ciation at their meeting in London, in August, 1862. He noticed that, 
" having cut a boy for stone, the boy became very ill three days afterwards, 
and seemed in danger of his life ; but soon a vivid red eruption appeared at 
and about the wound. This was measles, earliest and most intense at the 
seat of injury, just as erysipelas might have been. Thence it extended, and 
ran its ordinary course, and did no harm." Mr. Paget states that he has 
seen similar events with scarlet fever, the eruption commencing in an injured 
and inflamed knee. Dr. William Budd records similar events in a case of 
small-pox, in which the eruption first appeared and was most intense over a 
bruise on the nates. The argument from such facts is, " that the local deter- 
mination of erysipelas, and of other allied diseases, after operations, is no 
proof of their local origin or local natfire." BODY-TEMPERATURE IN CASES OF ERYSIPELAS. 
727 
Diagnosis.-The diagnosis of erysipelas is in general easy. For a few 
hours, perhaps, if a joint be attacked, it may be mistaken for acute rheuma- 
tism ; or if a surface be attacked, it may be confounded for a short time with 
erythema, but the intumescence and spread of the disease quickly enable us 
to rectify the error. 
Frank has pointed out a symptom which he considers diagnostic-namely, 
that whenever a patient has exhibited, for twenty-four or forty-eight hours, 
an intense febrile movement, attended with pain, swelling and tenderness of 
the lymphatic glands of the neck, he does not hesitate to announce the approach- 
ing development of erysipelas; and in no case has the diagnosis been invali- 
dated by the result. Chomel expresses a similar belief; and Mr. Campbell 
De Morgan's experience confirms the statement that the neighboring lym- 
phatic glands are generally, if not always, tender before erysipelas of a part 
sets in ; and Mr. Busk concurs with this statement of Mr. De Morgan's ex- 
perience. These records go far to confirm the view that the specific inflam- 
mation of erysipelas commences in the lymphatics. 
The course of the fever in erysipelas is very similar to that of measles, and 
the maximum temperature may be higher than measles ; but the advance of 
the fever to its height continues longer-seven to eight days-and the epoch 
TYPICAL RANGE OF TEMPERATURE IN A CASE OF ERYSIPELAS AFFECTING THE 
FACE. THE RECORDS INDICATE MORNING (A.M.) AND EVENING (P.M.) OB- 
SERVATIONS (C. L. Fox'). 
Fig. 81. 
for the commencement of the defervescence vacillates between the fourth and 
the eighth days. Temperature rises rapidly, and may reach 104° oi' 105° 728 
SPECIAL PATHOLOGY-ERYSIPELAS. 
Fahr, on the first evening of cutaneous inflammation. It may so remain 
for a variable number of days, with slight but decided morning remissions. 
The temperature may continue rising to 106° Fahr., or 108° Fahr., as long as 
inflammation of the skin continues; every extension of the inflammation 
being indicated by a rise of temperature. Thus high evening exacerbations 
may be maintained for from one to two weeks or more. In this respect it 
differs greatly from measles. 
The defervescence, as a rule, is rapid, the normal heat being attained, or 
nearly so, in from twelve to thirty-six hours. Frequently, however, the case 
is not terminated therewith. New relapses may take place, and the course of 
the disease may be prolonged through two or even three weeks. These re- 
lapses are severally of short duration; but they come on again and again, 
and are ushered in by a smaller or larger increase of heat, connected with a 
renewed spread of the cutaneous affection. It is only after the eruption has 
ceased that complete and definite defervescence ensues. In favorable cases 
the temperature generally falls to the normal standard on the sixth or seventh 
day of the eruption. Very sudden changes of temperature are characteristic 
-4° or 5° Fahr, in twenty-four hours, or a fall of 7° or 8°, commencing im- 
mediately on the appearance of the characteristic redness (Compton). This 
erratic and protracted form of erysipelas is most frequently met with in the 
aged, associated with gouty or rheumatic states of the system, as well as with 
albuminuria or renal disease. 
The local symptoms vary according to the part affected, the mode of termi- 
nation of the inflammation, and also according to the character and duration 
of the fever. 
When erysipelatous inflammation affects the face, it may begin either in 
the skin or in the subjacent areolar tissue. If the areolar tissue be primarily 
affected, the face at the inflamed part becomes swollen, but the skin suffers no 
discoloration for some hours, so that it is impossible to distinguish it from an 
ordinary attack of swelled face. At length, however, the skin inflames, and 
the part is now red, hot, and painful, as well as swollen, and the disease is 
fully formed. At the commencement of erysipelas of the face the attack is 
usually partial, and perhaps limited to the bridge of the nose, to one ear, to 
the lower eyelids, or to one cheek; but in severe cases it gradually extends, 
often involving the whole of the integuments of the face, head, and neck; so 
that at the end of three or four days those parts present a strangely swollen, 
disfigured, and even, in some instances, hideous appearance, scarcely a feature 
being discernible. The nostril, moreover, is imperforate from internal swell- 
ing, so that the patient is obliged to breathe with his mouth open, while the 
inflammation may extend to the auditory passages, and render him completely 
deaf. Extension of the inflammation to the membranes of the brain some- 
times takes place, while the external inflammation continues. This untoward 
event is followed by delirium and coma. But delirium frequently supervenes 
in the course of erysipelatous attacks, independently of any metastasis or ex- 
tension of the disease to the membranes of the brain. It commences with 
wandering of the mind at night, similar to that which is observed in fever. 
Utterance is given for the most part to low, muttering, and rambling expres- 
sions, which rarely assume a noisy character, but which in fatal cases terminate 
by coma. When the patient has been of dissipated habits, or is otherwise of 
a dilapidated constitution, then the delirium resembles that of delirium tremens, 
not due to inflammation of the brain, but in consequence of an altered con- 
dition of the blood and of the nervous system (Barclay). 
On the fourth, sixth, eighth, or some later day, the bright red color of the 
skin changes to a deeppr hue; the serum effused is absorbed, desquamation 
takes place, and the skin gradually returns to its natural color. It is not 
unusual, however, for abscesses to form, particularly on the eyelids or cheeks, 
and which, being opened quickly, heal, and hardly retard the convalescence PHLEGMONOUS AND GANGRENOUS ERYSIPELAS. 
729 
of the patient. In some cases the disease becomes erratic, and extends over 
the chest or down the back, and desquamation is seen going on in one part 
while the erysipelas is spreading in another. This is characteristic of cases 
associated with gouty or rheumatic constitutions. 
The extremities are more commonly the seat of erysipelatous inflammation 
than the trunk, and the lower extremities are more frequently affected than 
the upper. When these parts are affected, the fever is less severe than 'in 
erysipelas of the head ; but the local symptoms are generally more formidable, 
for the degree of heat is greater, and the pain so severe that the weight of a 
sheet can hardly be borne. The inflammation likewise may obviously involve 
the lymphatic vessels, when they can be traced by white or red lines for many 
inches, as from the knee or elbow to the inguinal or axillary glands; and 
these sometimes enlarge and suppurate. If the erysipelatous inflammation 
ends in suppuration, the pus is always diffused, and the swollen limb gives a 
peculiar sensation to the hand. The sensation has been compared to what a 
person feels with his feet on passing over a quagmire. The dark, black, dis- 
colored appearances of gangrene are too obvious to render any description of 
the parts so affected necessary. 
Numerous varieties of erysipelas are referred to in practical works, especially 
surgical, most of which are modifications of the disease as above described. 
Besides the erratic form just noticed, there is the- 
Phlegmonous Erysipelas {Erysipelas Phlegmonodes) and diffuse inflammation 
of the cellular or connective tissue, in which the inflammation extends deeply 
into the subcutaneous textures, and tends to spread indefinitely. It is at- 
tended with greater pain and swelling than the more superficial variety, and 
usually the general symptoms are more severe. Diffuse suppuration, slough- 
ing, and gangrene of the areolar tissue are the usual results; and if the dis- 
ease penetrates beneath the fascia, the sufferings of the patient are greatly 
aggravated by the compression of the inflamed parts, and much organic mis- 
chief may result from the confinement of pus and the various products of the 
gangrenous state. 
Gangrenous Erysipelas {Erysipelas Gangrenosum').-As the name implies, 
this form is accompanied with death of parts, and the tendency to death of 
tissue may be due either to the inherent depressing nature of the disease, or 
the depraved state of the system, as of the blood, the co-operating influences 
of an epidemic constitution, debility, confined and impure air, as in crowded 
hospitals, unwholesome or scanty food, or simply the excessive violence of the 
inflammations. The peculiar hot and burning pain, with the purple or livid 
hue of the redness, indicate the tendency to gangrene ; and its near approach 
is shown by the slowness with which the blood returns after removal by pres- 
sure, and by the formation of vesicles (phlyctense) filled with turbid reddish 
serum. These vesicles are to be distinguished from those which are to be seen 
on the skin in severe contusions on fractured limbs. The fluid in the vesicles 
of gangrene can be pressed from under one part of the cuticle to another, 
which is not the case in the vesicles on a fractured limb or a severe bruise. 
Patients with typhoid fever, infants soon after their birth, and young children, 
are most frequently the subjects of gangrenous erysipelas; and it is not un- 
common in hospitals, during the prevalence especially of malignant epidemics 
of erysipelas. 
Besides these external forms of erysipelas, the disease also expresses itself 
by internal lesions, such as diffuse inflammation, spreading over mucous or 
serous surfaces, the lining membrane of arteries, veins, and lymphatics. 
Of mucous surfaces the most liable are the fauces, the pharynx, and larynx. 
These parts are liable to be affected by the continuous spreading of the in- 
flammation from the scalp or skin of the face. 
This form of the disease in the throat is eminently contagious. When the 
larynx is implicated, the danger is extreme from the oedematous infiltration of 730 
SPECIAL PATHOLOGY-ERYSIPELAS. 
sero-plastic fluid, which 'occupies the rima glottidis, and extending into the in- 
terior of the larynx, obliterates its cavity by the extent of the swelling. Such 
swelling, however, never spreads below the true vocal chords (Erichsen). 
Erysipelas of serous membranes is chiefly seen in the arachnoid and peritoneum 
after surgical operations, or, as regards the arachnoid, after injuries of the 
head or erysipelas of the scalp. As regards the peritoneum it is met with after 
operations for hernia, or as the result of disease or injury of the pelvic or ab- 
dominal organs, or of puerperal fever. 
Cause.-The mystery which hangs over the origin of disease-poisons does 
so, in a remarkable degree, over erysipelas: for this disease is often epidemic, 
and appears to be very constantly present in communities, and especially in 
large towns. 
The predisposing conditions are age, mechanical or chemical injuries, as 
blows, punctured wounds, and incised wounds generally, bites of insects, or 
burns; also certain articles of diet, as mussels or periwinkles; and many dis- 
eases likewise, as dropsy with renal disease, typhus fever, and others of a de- 
bilitating kind. The effects of age in predisposing to this disease are consid- 
erable. New-born children, for instance, are occasionally subject to it, but 
from that period to adult age it is seldom witnessed. The period of life most 
subject to acute attacks is from twenty to forty; and to frequent asthenic at- 
tacks from forty to old age. Both sexes suffer in nearly equal proportions. 
Propagation of the Disease.-The spread of erysipelas has been so fre- 
quently observed, both in the sick-room and in the wards of hospitals, that no 
doubt can exist of this disease being communicable by impalpable emanations. 
It is thus eminently contagious. In the year 1760 erysipelas spread so exten- 
sively through the wards of St. Thomas's Hospital, in London, that it was be- 
lieved the plague was in the hospital. Dr. Baillie described it as spreading 
also in St. George's Hospital, London; and Dr. Cullen, in the Hospital at 
Edinburgh. It has been found to spread extensively on board ship; and Drs. 
Wells, Watson, and others, have given several remarkable instances of its 
spreading in families. Dr. Steele writes, in his excellent Annual Report on 
Guy's Hospital for 1863, that "for some years past it has been customary to 
place patients suffering from erysipelatous wounds in these (the medical) 
wards, in order to diminish as much as possible the risk of extending infection 
in surgical wards, as well as to promote recovery in the patients themselves. 
It happened, however, that in one of the wards of the new hospital into which 
a patient suffering from erysipelas was placed in the course of the past year, 
five persons suffering from other complaints were attacked with the disease; 
and although none of the cases was attended with fatal consequences, the oc- 
currence is sufficient to point out the danger which must be occasionally ap- 
prehended." Mr. Erichsen gives a remarkable proof of the contagious nature 
of erysipelas occurring in the winter of 1851 in one of his wards in University 
College Hospital. "The hospital," he states, "had been free from any cases 
of the kind for a considerable time, when, on the 15th of January, at about 
noon, a man was admitted under my care and placed in Brundrett Ward. On 
my visit, two hours after his admission, I ordered him to be removed to a 
separate room, and directed the chlorides to be freely used in the ward from 
which he had been taken. Notwithstanding these precautions, however, two 
days after this a patient, from whom a necrosed portion of ileum had been re- 
moved a few weeks previously, and who was lying in the adjoining bed to that 
in which the patient with the erysipelas had been temporarily placed, was 
seized with erysipelas, of which he speedily died. The disease then spread to 
almost every case in the ward, and proved fatal to several patients who had 
recently been operated upon" {Science and Art of Surgery, vol. i, p. 495). 
Another striking instance is given by Mr. De Morgan, which came under the 
observation of Dr. Rogers, of Dean Street. "A medical student went into the 
country, and was requested by his brother, a medical man, to visit an erysipel- PROPAGATION OF ERYSIPELAS. 
731 
atous patient. Whilst leaning over her he became conscious of a nauseous 
odor, which almost caused him to be sick. A few days after he was suddenly 
seized with shivering, followed by fever. Erysipelas shortly came on in the 
head and face, and he died after a week's illness." Such cases are too numerous 
and too striking to admit of any reasonable interpretation save that of the pres- 
ence of a specific poison, miasm, or virus, capable, by contagion or infection, 
of inducing the specific disease. 
That it is communicable by some palpable virus was also long ago demon- 
strated by Dr. Willan, who says, that if a person be inoculated with the fluid 
contained in the phlyctense or vesicles of a genuine erysipelas, a red, painful, 
diffused swelling and inflammation analogous to erysipelas is produced. The 
danger, however, attending this experiment has not allowed it to be re- 
peated. 
Erysipelas also spreads by fomites. In hospitals wards are occasionally 
obliged to be cleared out to stop the continued spread of this disease. In 
the navy the spread by fomites is so well understood that it is debated whether 
swabbing the decks or dry rubbing them is the best mode of disinfecting a 
ship, and preventing the spread of the disease. It has spread extensively, 
and for long periods, in the Birmingham, Edinburgh, Glasgow, and London 
hospitals, and is only got rid of by emptying and whitewashing the wards. 
It is said, however, that dry rubbing is preferable to washing, moisture 
appearing to promote the extension of the disease. The old "Dreadnought" 
hospital ship in the Thames was so impregnated with the fomites of erysipelas 
that she had ultimately to be broken up, and a new vessel substituted. 
A patient having passed through an attack of erysipelas has no security 
against future attacks of the disease; and many persons suffer repeatedly 
from erysipelas-some periodically. There appears to be a constitutional 
predisposition to the disease in some people, and especially in those who have 
periodic attacks. Some women have attacks every month. Intemperance, 
and all influences which tend to depress the system, predispose to the disease, 
and hence partly the prevalence of the disease in hospitals. But there are 
unquestionably some unknown conditions of the atmosphere which seem to 
favor the dissemination of the disease. It has been observed that this pre- 
disposition to erysipelas exists in the ordinary wards of hospitals at the same 
time that puerperal fever prevails, and it was formerly not an unfrequent 
accompaniment of small-pox. 
Indeed some forms of puerperal fever seem to be identical with erysipelas. 
Each may coexist or seem so interchangeable that either seems capable of 
exciting the other by contagion. It is also within the experience of surgeons 
that patients will perish a few days after operations when erysipelas prevails 
in an hospital without any external sign of even erythema. They die of an 
internal form of erysipelas (Warren, Campbell De Morgan). It is also 
within the experience of physicians that malignant forms of pneumonia will 
result from communication with erysipelatous cases, and that such forms of 
pneumonia may convey erysipelas to others having open sores or wounds 
(Gibson, Campbell De Morgan). 
Period of Latency.-Erysipelas has occasionally followed a few hours after 
exposure to the infection. Dr. Elliotson thinks five days elapsed in his own 
case, and Dr. Watson has given three cases in which the interval was a week. 
It has been observed in hospitals that a fortnight has elapsed after its sub- 
siding in one case and appearing in another in the same ward. It is probable,, 
therefore, that the period varies from two to fourteen days. 
Destructive epidemics of erysipelas have now and then occurred in Europe, 
and several parts of America have of late years been the scene of similar 
ravages, especially in the New England States, the Southwestern States, and 
the interior of Pennsylvania (Dr. Wood). 
Prognosis.-The most experienced physicians consider erysipelas, at all 732 
SPECIAL PATHOLOGY-ERYSIPELAS. 
periods of life, "a dangerous and deceitful disease;" and when it fixes on the 
face or scalp, it is one of the most serious diseases to which an aged person 
especially is liable; for when all appears to be going on well, the membranes 
of the brain may become involved, or the powers of life may give way, the 
patient sinking suddenly under the depressing influence of the poison. The 
disease may extend to the fauces or the glottis, and the patient then dies 
suddenly from the oedema of the glottis which supervenes. The disease is 
peculiarly fatal to drunkards and to patients of broken-down habits, and fre- 
quently recurring attacks show such a bad state of health as indicates a speedy 
break-up of the constitution (Maclachlan). It is five times more fatal to 
people above sixty than to people between fifteen and sixty years of age 
{Registrar- General's Fifth Report, p. 456). 
Treatment.-Broussais states that when he served with the French armies 
in Italy, he has seen erysipelas allowed to run its natural course, and the 
result was, that it made immensely rapid progress, and ended either in sup- 
puration, in gangrene, or in fatal visceral inflammation. 
Long experience has now shown that erysipelas, in common with all other 
specific diseases of this class, will not bear bloodletting; a tonic and restorative 
mode of treatment is much more uniformly successful. 
There are very few physicians, from the days of Hippocrates to the present 
time, who have not bled patients in erysipelas, and consequently the experi- 
ment has been made on a large scale; still, many of the warmest advocates 
of bleeding admit that the operation is occasionally followed by unpleasant 
consequences. The treatment by bleeding has been so often followed by 
many unfavorable results, that many physicians, the most intelligent of the 
profession, affirm that, according to their experience, the practice is not only 
unfavorable but highly injurious. Andral is reported to have said, "In ery- 
sipelas with delirum, bleeding pales the skin, but the disease continues; the 
cellular tissue remains gorged, and death follows. We open the body, but 
find nothing." Cruveilhier says, "des erysipeles rentres" is a consequence of 
unusual or too abundant bleeding; and he considers the question of bleeding 
in this disease to have been " depuis longtemps jugee." Blache and Chomel 
likewise say that "experience has proved that general bleeding has no other 
effect than to blanch the eruption, without notably abridging its duration." 
In this country, Drs. Fordyce, Wells, Pearson, Heberden, and Willan, all 
give their testimony to the frequent ill effects of bleeding in this disease; and 
in consequence, for the most part, they recommend a tonic treatment. 
It is therefore to be recollected that bleeding will not cure the specific ery- 
sipelatous inflammation, in the way that it produces a salutary effect on a 
simple idiopathic inflammation of the lungs, occurring in an otherwise healthy 
person. It is also to be borne in mind that, as a rule, bleeding is not borne 
well by persons suffering from erysipelas; and it is necessary to be ever mind- 
ful of the fact that people of a certain class in populous towns cannot bear 
bleeding so well as those who pass their life in the country. For instance, a 
brewer's drayman in London, accustomed to a large allowance of the beverage 
which he delivers to his customers, would sink suddenly under the influence 
of a bleeding; when if double or even treble the amount of blood were ab- 
stracted from a countryman suffering from erysipelas of a sthenic form, but 
heretofore in good health, it would produce but little effect, and that prob- 
ably for good. Bleeding, as a rule, is only indicated in the young, the 
healthy, and the vigorous; and it must equally be avoided entirely in the 
aged, and in broken-down cachectic patients. , 
Rest, saline laxatives, cooling drinks, and low diet, are the elements of 
treatment in mild and simple cases. An emetic is useful at the commence- 
ment; and I have seen, in the practice of an eminent surgeon, that frequent 
resolution of an erysipelatous attack has followed an antacid laxative, such as 
of rhubarb powders and bicarbonate of soda (forty grains of rhubarb to sixty TREATMENT OE ERYSIPELAS. 
733 
of bicarbonate of soda, divided into twelve powders, one to be taken every six 
hours), together with the counter-irritation of a mustard poultice over the 
stomach. Laxative and cathartic remedies are to be selected and apportioned 
according to the violence of the attack and its nature, as tending to the un- 
favorable results of the specific inflammation already noticed. Calomel is a 
most valuable purgative, as a sedative in febrile disturbance, especially when 
followed by castor oil, or the common black draught. The indications to the 
use of certain remedies, as given in the treatment of scarlet fever, are equally 
applicable here. 
If the febrile state- is not subdued, antimonials are of great service, for so 
far as they are diaphoretic in their action they tend to subdue the vascular 
excitement. If symptoms of nervous depression ensue, opium, or opium and 
ipecacuanha are indicated, also wine and quinine, ammonia and camphor, in 
asthenic cases with a tendency to a typhoid state. The tincture of the perchlo- 
ride of iron, in doses of ten to thirty minims, three, four, or five times a day, in 
water, infusion of quassia, or calumba, is now also a remedy much in use, and 
it may be alternated with the syrup of the phosphate of iron, in doses of a tea- 
spoonful three or four times a day. In cases where the system is obviously 
gouty or rheumatic, and where the joints are affected, colchicum with saline 
diaphoretics are the most efficient remedial agents. 
Local applications are potent for good or evil, and must therefore be used 
with great caution. The effects seen on the skin do not constitute the whole 
disease; and if the development of these processes on the cutaneous tissue is 
imprudently interfered with, there is imminent danger to internal organs. 
To check the advance and prevent the encroachment upon new territory, 
rather than to subdue it, if already in possession, ought to be the sole aim of 
local treatment, and to mitigate the local pain and uneasiness. Bland muci- 
lage, such as that of viscid linseed tea, from which light muslin cloths have 
been steeped and spread over the inflamed surface, sometimes affords relief. 
Dry flour, or rye-meal, frequently dusted from a dredge-box over the erysipel- 
atous patches, are soothing applications. A thick layer of cotton-wool dusted 
with powder is also a soothing application to the part. A lotion of nitrate of 
silver painted daily over the affected parts sometimes gives great relief (one 
scruple of the nitrate to an ounce of water, to which ten drops of dilute nitric 
acid are added). Dilute nitric acid should, at the same time, be given inter- 
nally, if typhoid symptoms predominate, as in the following formula: 
B. Acid. Nitrici dil., Ji; Syrup. Zingib., ^ss.; Aquie, ^vss.; misce. A 
tablespoonful every four hours. 
To arrest the spread of the process over sound skin, nitrate of silver in very- 
strong solution, or tincture of iodine, have been considered efficient agents. A 
line of circumvallation is to be painted round the erysipelatous part, so as 
completely to inclose it. The nitrate of silver should either be employed in the 
solid stick, or as proposed by Higginbottom, in solution of eight scruples of 
the nitrate with twelve drops of nitric acid in a fluid ounce of water. Dr. 
Wood has practiced with success, and recommends the use of tincture of 
iodine. But in this country the boundary line of nitrate of silver has not been 
attended with success; and our best surgeons are now discontinuing the prac- 
tice as a useless source of irritation (Ericksen; Campbell De Morgan). 
Sulphite of Soda, in solution of ten grains to one ounce of water, is recom- 
mended by Dr. Addinell Hewson, of Philadelphia. He has never seen it fail 
to arrest the progress of the disease, if it has not advanced to the deeper parts 
below the skin. Lint soaked in the solution is to be applied to the affected 
part, and over a considerable distance beyond any visible appearance of red- 
ness ; and the lint is to be covered with oil-silk, to prevent evaporation. 
The application of sulphate of iron as a lotion or ointment tends to shorten 734 
SPECIAL PATHOLOGY PYAEMIA. 
the disease. In lotion, one drachm of the salt to a pint of water; in ointment, 
a scruple to an ounce of lard (Velpeau, Luke, De Morgan). It has the 
inconvenience, however, of soiling linen with which it comes in contact. None 
of these lotions should be applied cold, but tepid or warm. Collodion and 
iodized collodion are also worthy of commendation. 
Long and deep incisions into the inflamed textures are sometimes demanded. 
This is more especially the case if there be tension of fibrous tissue, such as 
the subcutaneous fasciie; and erysipelas of the head is frequently greatly alle- 
viated by repeated innumerable minute punctures, made by the point of a 
lancet all over the parts of the face and scalp which are affected. 
PYAEMIA. 
Latin Eq., Pycemia; French Eq., Pyohtmie; German Eq., Pyaemie; Italian Eq., 
Piemia-Syn., Piemasia. 
Definition.-A febrile affection generally sequent on wounds, suppurative in- 
flammation of bone, the puerperal state, or surgical operations, resulting in the 
formation of secondary abscesses in the internal visceral organs (most frequently 
in the lungs, the liver, kidneys, spleen, and brain), and also in the joints and 
connective tissue-sometimes, but not necessarily, associated with phlebitis or em- 
bolism. 
Pathology.-The multiplicity of views and great uncertainty which still 
pertain to many points regarding the pathology of the phenomena compre- 
hended under the name of pyaemia, make it necessary to write with doubt and 
some hesitation; more especially as the details into which the topics may be 
carried, which are embraced under this head, are daily becoming more and 
more extensive. The aim of this account, therefore, is to put the student in 
possession of the more important bearings of the subject, in relation especially 
to such pathological conditions as are constant and characteristic of the dis- 
ease. One constant character is the tendency to suppuration ; and hence it 
has been considered that "suppurative fever" would be a more suitable term 
than pyaemia (Braidwood), because this latter name implies a theoretical 
origin of the disease, now considered to be incorrect. 
There are febrile conditions in which the blood is materially disturbed in 
various ways, which tend to complex forms of lesions in many parts, and 
especially to multiple centres of inflammation, with a great tendency to sup- 
puration in them. A number of morbid processes, having many elements in 
common, of great practical importance, of frequent occurrence, and dangerous 
to life, have been described of late under the various names of-(1.) Pyogenic 
fever (Sir William Jenner); (2.) Acute purulent diathesis (Tessier); (3.) 
Purulent infection (Sedillot); (4.) Septic or putrid infection of the blood 
(Panum); (5.) Septicaemia (Vogel) ; (6.) Systemic infection (the ichorsemia 
of Virchow); (7.) Putrid fever; (8.) Pyaemia (Pyohemie of Piorry); (9.) 
Phlebitis; (10.) Surgical fever (Sir J. Y. Simpson); (11.) Purulent absorption 
(Solly); (12.) Multiple abscesses (Larrey, Pott). 
The first two-namely, the pyogenic fever of Jenner, and the purulent dia- 
thesis of Tessier-are characterized by the occurrence of mxdtiple abscesses. 
The remaining five of the morbid states which have been enumerated have 
been recently classed by Virchow, Bilroth, and others, under the common 
name of "metastatical dyscrasise." In them there is evidence of the occurrence 
of secondary or metastatical inflammation, which seem like the translations 
of matter from one part of the body to another-a tendency to multiple cen- 
tres of inflammation, to "multiple abscesses," and to suppuration in various 
parts of the body. Associated also with these lesions is the occasional forma- 
tion of clots, thrombi, plugs, or embolia, the occurrence of thrombosis, or of em- DIFFERENCES OF PYOGENIC FEVER FROM PYAEMIA. 
735 
holism, or of phlebitis, softening of the minute tissue of visceral organs, such as 
the brain, the lungs, the heart, the liver, or the kidney, or of gangrene of the 
extremities. 
I believe, on careful analysis of this subject, and from what I have seen of 
patients during life in the course of pyaemia, and after their death, that two 
classes of cases may be distinguished-namely, (1.) Cases which came on very 
soon after injury, or operation, or the puerperal state, and in which the fever 
temperature is extremely high from the first, and who die leaving little or 
no evidence of secondary lesion. (2.) Cases which are prolonged and essen- 
tially chronic, in which fever does not reach a high degree of temperature, but 
in which the suppurative tendency is necessarily expressed in many organs, 
and in different parts of the same organ. 
There is in reality a septicaemia, or blood-poisoning, from the action of a 
specific poison proving fatal, as other specific fevers do; and another class of 
cases in which there is superadded to the septicaemia the suppurative tendency 
which expresses itself in multiple abscesses-true pyaemia. 
Pyogenic Fever.-In the Gulstonian lectures delivered at the Royal College 
of Physicians in London, for 1853, Dr. (now Sir William) Jenner directed 
particular attention to some lesions which are apt to follow immediately after 
the termination of acute specific diseases, such as scarlet fever and the like. 
The simplest form of these lesions consists in the formation of several (or mul- 
tiple) abscesses of small size in the subcutaneous connective tissue, especially 
of the scalp, chest, loins, legs, or arms, accompanied by more or less febrile 
disturbance. Such multiple abscesses are (on circumstantial evidence only) 
presumed to owe their origin to a diseased condition of the blood-to repre- 
sent what is popularly known as "the dregs of the fever"-as the media by 
which something unwholesome is ultimately evacuated-or as a crisis in which 
the specific affection terminates. Sometimes, on the other hand, these abscesses 
are accompanied by severe constitutional disturbance, and instead of being 
superficial, are deeply seated, either in the connective tissue or into the cavi- 
ties of the joints, and in rare cases even into the serous cavities of the cranium, 
abdomen, or thorax. Cases of all these varying degrees of severity are ob- 
served, which seem to differ only in the more or less wide diffusion of the local 
affections. Such cases are found to be in close alliance with those diseases in 
which purulent discharges issue at the same time from the mucous passages, 
and to that chronic cachexia in which the least scratch or abrasion of the skin 
tends to "fester" and not to heal. This condition of the blood and system 
was first recognized and described by Tessier, in 1838, under the name of the 
"purulent diathesis," or "a tendency to suppuration in the solids and coagu- 
lable fluids." 
In the cases which are recognizable as of this nature, the febrile disturbance 
se^ms to be established before any local lesion is set up ; and the morbid con- 
dition of the blood thus came to be looked upon as " a primary substantive 
affection," because it seemed to lead to a "fever" followed by these lesions. 
Cases of this morbid condition are related by Sir William Jenner in the 
Medical Times and Gazette for May 7, 1853 ; and they may be compared with 
a case of multiple abscesses in and about the joints, associated with rheuma- 
tism, and described by Dr. Bennett in his valuable Principles and Practice of 
Medicine, p. 803, under the name of ichorcemia, or so-called pyaemia. 
The subcutaneous tissue and the joints are the most frequent seats of these 
abscesses; much less frequently the lungs or other viscera, which in the follow- 
ing class of cases are the most frequent seat of the multiple abscesses. Here 
we have an important distinguishing character between the two classes of dis- 
eases-namely, that the abscesses of pyogenic fever seem to be developed out 
of a constitutional state of general ill-health, whereas those which are about to 
be considered may be regarded from the beginning as due to a blood-poison, 
or other causes of irritation set up from external sources. In the former case 736 
SPECIAL PATHOLOGY-PYAEMIA. 
the cause of the disease seems to be constitutional; in the latter, specific. Hence 
the College of Physicians places pyaemia among the general diseases, Class A. 
Again, the class of lesions associated with pyogenic fevers is still further dis- 
tinguished as of one kind, by the following characters: (1.) The abscesses are 
not consequent upon the pre-existence of any abscess, ulcer, or clot, or plug in 
the bloodvessels ; (2.) There is no evidence of the formation of pus or of fibrin- 
ous debris in the veins, nor of the passage of that fluid into the blood, and the 
establishment of pyaemia in the literal sense of the term; (3.) The symptoms, 
and still more the situation, of the disseminated abscesses differ in cases of 
pyogenic fever from those which occur in cases of true pyaemia or phlebitis. 
It is with typhus or typhoid fever only that pyogenic fever is apt to be con- 
founded ; but from this fever it is distinguished by the activity of the febrile 
symptoms at the outset, the early delirium, the absence of eruption, and the 
rapid formation of the numerous centres of suppurative action. The closest 
alliance, pathologically, of pyogenic fever seems to be with phlegmonous ery- 
sipelas, but from true pyaemia, either in the form simply of septicaemia, or in 
that combined with the tendency to multiple abscesses, I think it ought to be 
distinguished. 
Metastatical Dyscrasise, under the generic name of pyaemia, have attracted 
considerable notice from two points of view: 
(1.) In connection with various conditions of the veins, to which the name 
of " phlebitis " has been given; (2.) In connection with various changes in 
the blood itself, such as septic or ichorous infection, and more especially of 
late years, as described by Virchow and Bennett, under the name of " leuco- 
cytosis." 
Several scientific questions associated with each of these views are still the 
source of controversy. 
Pyaemia literally means a condition in which-(1.) There are pus-cells in 
the blood; but the expression has now come to imply-(2.) That the blood 
is altered throughout the whole system; it becomes morbidly coagulable by 
the poisonous action of putrid animal substances. These substances may act 
in the form of gases, fluids, or solid particles, which so disturb its relations 
with the living tissues as to induce coagulation of the fibrin of the blood in 
some part, during life, within the bloodvessels. These changes are associated 
with fever, and the formation of local abscesses in one or more of the viscera 
and other parts, and usually accompanied by phlebitis. These secondary 
lesions appear first as minute spots of congestion; serum or lymph is then 
found, and subsequently pus. 
This latter signification of pyaemia has been in some measure forced upon 
us, because it is found impracticable to say when any given specimen of blood 
is full of white blood-discs, or of pus-corpuscles. It was once supposed that 
pus could be absorbed as pus, and be conveyed away in substance; and that 
two results might follow such an event: either (1.) That the pus would be 
passed off by the urine or the faeces as an excretion, but still in the form of 
the original pus; or (2.) That the phenomena of pyaemia would be the other 
alternative. 
Now we know that neither of these results ever takes place. Pus, as pus, 
is never taken up or absorbed into the system. Its fluid part only may be 
absorbed by veins or lymphatics; but the solid portion remains as a thick, 
inspissated, or concrete mass; and thus the absorption or disappearance of an 
abscess sometimes gives rise to such " cheesy " products as are described by 
the name of " tubercleand which may subsequently induce ulceration, as a 
foreign body would. Again, pus may be completely absorbed ; but cnily after 
the cells have been reduced to a state of milkiness by fatty degeneration, and 
become converted into an emulsive mass-a kind of milk, composed of water, 
albuminous matter, fat, mucus, cholesterin, sulphates, lactates, and the like, 
and in which also sugar may be present. RESULTS OF THE DECOMPOSITION OF PUS. 
737 
The composition of pus varies considerably ; and the conditions under which 
it varies have not yet received the attention which its importance demands. 
It seems to vary with the locality whence it comes, and with the circumstances 
under which it is formed. The pus of a pulmonary vomica differs from that of 
a psoas abscess, and that again from the pus of a mammary or hepatic abscess; 
and so also the pus of syphilis differs from that of small-pox. The very large 
and variable amount of organic elements which pus contains renders it also 
extremely liable to change ; and the products of decomposition of the elements 
of which pus is composed are extremely various and diffusible-e. g., ammonia, 
gas products, and salts, leucin and tyrosin; the acids also of the butyric 
group, as well as formic acid. Another fact to bear in mind is the " sponta- 
neity" which they (and especially albumen) undergo the process of putrefac- 
tion, without any apparent co-operation of other matters, and solely by the 
influence of atmospheric agents. As constant products of such putrefaction 
there are always to be found carbonate and butyrate, and valerianate of ammo- 
nia, sulphide of ammonium, leucin, and tyrosin. 
By putrefaction, and under the influence of impure air especially, pus may 
thus undergo an acid or an alkaline fermentation. The former is rare ; but 
when it does occur, there are developed volatile and fixed fatty acids, such as 
butyric acid and margaric acid. 
Unhealthy pus more commonly tends to become alkaline without becoming 
acid. It evolves ammonia and hydrosulphate of ammonia. The large com- 
pound granular corpuscles, which attend inflammatory lesions, soften and run 
together, nuclei disappear, and the whole becomes a mass of granules, which 
are probably capable of reabsorption. This is the condition in hospital gan- 
grene. 
Pus essentially consisting, as it does, of cells in a pus-serum, varying in 
size from ^^th to -j-go-th an inch, has only one mode in which its cells 
can find their way into the blood-namely, by the perforation of a bloodvessel 
by an ulcer or a puncture. An abscess close to a vessel may open into it; but 
the result is harmless if the pus is fresh and healthy. The passage of pus into 
lymphatic vessels is still more easy when such vessels run into open abscesses. 
But then lymphatics do not empty their lymph into bloodvessels (with one 
exception) till they have elaborated such lymph in the lymphatic glands ; and 
from the nature of gland-structures it is known that no pus-corpuscle, as 
such, can pass a lymph-gland. Such glands not only filter mechanically, but 
are living absorbents of some constituents only with which they come in con- 
tact, and amongst others, no doubt, the constituents of the pus-fluid without 
the actual pus-corpuscles, whose debris would simply be retained within the 
glands. Irritation of these glands lead to proliferation of the gland-cells, 
and subsequently to the passage into the blood, by the left jugular vein, of 
cells which cannot be distinguished from pus-the colorless blood-cells. Under 
such circumstances nothing is easier than to demonstrate what seems to be 
pus. The presence of white or pus-like cells in the blood, by what we know 
of blood-formation, can be explained. We know that the blood gets these 
blood-cells-(1.) After every meal we take; (2.) By irritation of lymphatic 
and other glands from cachexia; (3.) With the advance of pregnancy and 
splenic enlargement. In scrofula, typhoid malaria, and cancer, they also 
abound. 
The existence of pus in the blood cannot therefore be demonstrated as the 
term "pyaemia" has hitherto been understood to mean; and now, therefore, 
when the term is used, it is meant to imply that an unknown matter, derived 
apparently from the spontaneous decomposition of some kinds of purulent 
or albuminoid substances, has mingled with the blood-has poisoned that cir- 
culating fluid, or has so altered it that it tends to coagulate in the vessels 
during life, and has given rise to various secondary phenomena about to be 
noticed. 738 
SPECIAL PATHOLOGY-PYAEMIA. 
" Pyaemia," as a specific original entity-the result of absorption of pus, as 
such-is not now believed in ; and any evidence of such an event daily becomes 
less and less obvious. Pycemia is now rather to be regarded as a collective 
name for many very different disease processes, just as the essential phenom- 
ena of Bright's disease are brought about by several different morbid condi- 
tions of the kidney. It is especially necessary to distinguish between the 
following phenomena-namely, (1.) Leucocythaemia; (2.) Embolism, with 
resolution of clots, putrid decomposition, or gangrene; (3.) Absorption of 
putrid fluid, without embolism; (4.) Septic endosmosis of gases, independent 
of embolism. 
To these phenomena (excluding those connected with leucocythaemia) Vir- 
chow has given the general term of "metastatical dyscrasiae;" and amongst 
them phlebitis and hospital gangrene are too often fatal, as the result of opera- 
tions under certain unhygienic conditions. 
The phenomena presented by individual cases, capable of being classed 
under the head of metastatical dyscrasite, are sometimes so extremely varied 
that names have been given to diseases as well as to lesions which do not 
always have the same anatomical limit or range of significance. 
Suppurative fever caused by embolism may occur (according to Virchow) 
when a considerable fragment of a clot or thrombus becomes arrested at a cer- 
tain point in the course of the circulation. It may then crumble down and 
be carried away by the pressure onwards of the blood, the minute particles 
being conveyed into still smaller vessels, and so limited deposits occur which 
may break down or suppurate. Thus far certain local lesions having the 
appearance of multiple abscesses may be accounted for, but the specific sup- 
purative fever is not always present in such cases. Neither phlebitis nor 
thrombosis, with the phenomena of embolism, are constant in relation to pyae- 
mia (Savory). 
["Careful examination of the secondary foci has failed to show," says Dr. 
J. J. Woodward, U. S. A. (Trans. Am. Med. Association, vol. xvii, 1866), "em- 
boli impacted in the arterial twig by which the region of the focus is sup- 
plied. On the contrary, the vessel continues generally quite patulous even 
after it is involved in the substance of the morbid nodule. This I have ob- 
served in a case of foci in the lungs consecutive to syphilitic suppuration of 
the tibia, as well as in a number of similar cases due to wounds and amputa- 
tions. I have investigated the branches of the portal vein leading into simi- 
lar foci in the liver in cases of ulcerative dysentery, and with like results. 
On the other hand, it has frequently occurred to me to see the most diverse 
coagula in the veins leading from an amputated limb, where death has hap- 
pened from other causes, without any pyaemic symptoms, and where the most 
critical examination of the body has failed to discern any secondary foci. As 
far as my own personal observations have gone, pysemic phenomena have been 
invariably connected with the primary occurrence of local septic processes. 
In cases of wounds, the local conditions brought under my notice were, chiefly, 
sloughing of the edges of the wound, and the peculiar gangrene of the marrow 
which has so generally been miscalled osteomyelitis The first 
phenomena noted are the peculiar coagiflation of the blood in the bloodves- 
sels, and the granular aspect of the tissues under the microscope, which show 
that the part is already dead and that decomposition has begun. The subse- 
quent changes are purely chemical, and the normal elements become less and 
less recognizable amidst the host of actively moving molecules set free by the 
putrefactive alteration In cases which prove fatal by inducing 
pyaemia, no line of demarcation, no barrier of inflammation limits the gan- 
grenous portion; and the veins leading from the affected bone are usually 
full of coagula, which have entered into a form of putrefaction quite similar 
to that going on in the marrow. The ultimate result of this change is a yel- 
lowish or greenish-yellow fetid fluid, in which the microscope recognizes PHENOMENA OF EMBOLISM. 
739 
nothing but actively moving molecules with bright centres and dark borders. 
I have once or twice seen the veins leading from the flaps of a sloughing 
stump in a similar condition ; but, in most of the cases to which my attention 
was drawn, the veins affected proceeded from the diseased bone itself. The 
putrefactive change going on in the marrow is transmitted through the coagu- 
lated blood-mass in the veins by actual continuity. 
" The femoral vein, the saphena, and their branches, were sometimes stuffed 
with thrombi throughout a part of their extent, but in all the cases I found 
the veins from the bone, filled with their fetid contents, were clearly traceable 
to the point where the trunk with which they were connected discharged into 
the femoral, or one of the larger branches, with no thrombi intervening on the 
cardiac side. The granular yellowish fluid could sometimes be traced some 
little distance towards the heart. In short, there was clear anatomical proof 
of the introduction into the torrent of the circulation of the putrefying debris 
of the coagula which had formed in the veins leading from the affected bone. 
As for the detaching of larger fragments which should deserve the name of 
emboli, I found no actual anatomical proof, though abundant possibility for 
such an occurrence existed. What was to be seen discharging into the femo- 
ral vein, was simply the putrefying liquid described, a liquid more viscid than 
blood, which could not be expected to circulate as readily as blood, and which 
might readily, I admit, although I saw nothing of the sort, carry with it more 
coherent fragments of the involved coagulum, but which, in any case, might 
be expected to be arrested in the capillaries of the lungs, and if so arrested, 
to set up there, by actual contact, a similar form of change. It is also easier 
to conceive how a part of such a viscid, putrid fluid, which had passed 
through the capillaries of the lungs, might subsequently be arrested in the 
systemic capillaries, than it is to account for the frequent occurrence of foci 
in the liver and kidneys after amputations of the thigh, on the supposition of 
solid emboli. 
" I do not offer this summary of my own observations as a solution of the 
question of pyaemia ; but rather as a statement of facts, difficult to account 
for on the supposition of emboli, impossible to account for on the supposition 
of suppurative phlebitis, which must yet be fully embraced by any satisfac- 
tory explanation of the disease. The general series of the phenomena here 
sketched, as observed in connection with wounds, perfectly accords with what 
I have been able to observe in puerperal pyaemia, and in the pyaemia con- 
nected with dysentery. In the inflamed womb of the first group of cases, 
and the colon ulcers of the second, all the autopsies I have witnessed or made, 
demonstrated the existence of gangrenous or phagedenic, that is, septic, pro- 
cesses in connection with the local lesion. Without insisting upon any exclu- 
siveness for the opinions which must necessarily spring from such cases, it is 
difficult to avoid the conclusion that local septic processes have a significant 
connection with the genesis of pyaemia, and that viscid septic liquids, derived 
from the degenerating primary coagulum, may at times play the part which 
Virchow ascribes only to solid emboli. These considerations assume still 
more importance when an attempt is made to arrive at some definite notion 
with regard to the causes of pyaemia."] 
From experience, and by analogy, there are grounds for belief that a specific 
poison is the cause of pyaemia. The individual poison (as with other disease- 
poisons) has not yet been isolated; but by analogy its existence is inferred, 
because measles and other diseases have been communicated by means of inoc- 
ulating the blood taken from persons affected with them; although the 
specific poison of measles has not itself been isolated. So the suppurative 
fever of pyaemia has been communicated, and is developed from a specific 
cause. Professor Panum, and, after him, Dr. Richardson, have analyzed the 
blood of patients dying from pyaemia. After boiling and subsequent evapo- 
ration to dryness, there remains a fixed and non-volatile substance, soluble in 740 
SPECIAL PATHOLOGY - PYEMIA. 
water and insoluble in alcohol, which can be compared in the intensity of its 
action to such poisons only as that of serpents, curare, and the vegetable alka- 
loids. Dr. Richardson has named the substance "septine," and with it he 
has caused the death of animals by inoculation or injection into veins. 
It seems clear that the poison forms in the body in connection with the wound 
or injury; that it is frequently reproduced or multiplied during the progress 
of the disease; and that it passes afterwards into the blood; and that the 
blood and the juices of the patient can communicate by inoculation, a similar 
disease, which operates with variable degrees of virulence in different instances. 
The results of post-mortem examinations of such cases have too often pain- 
fully demonstrated the virulence of the poison. In the examination of patients 
dying after ovariotomy, I have found the fluid in the cavity of the perito- 
neum so acrid or poisonous as to irritate, to a painful extent, the skin of the 
hands. 
The evil effects also which follow the use of sponges in hospital practice, 
and the readiness with which the poison is thus carried from patient to patient, 
is a strong argument in favor of the local absorption of some poisonous mate- 
rial (Erichsen). 
Morbid Anatomy.-The remains of the secondary or metastatic abscesses, 
as they have been called, are some of the most remarkable characteristics of 
pycemia,. They differ from ordinary purulent collections: 
(1.) In the peculiar character of the pus they contain, which is usually a 
thin oily-looking pus, containing an immense number of granular cells, while 
"conspicuous by its absence" is the true nucleated pus-corpuscle. The fluid 
also sometimes forms a fine fibrinous coagulum after removal from the abscess. 
These collections form with great rapidity; and a few days commonly suffices 
for their attaining a large size. 
Decomposition of the body sets in very rapidly after death, and is indicated 
by the livid mottling of the skin, the change of color, or dark red lines along 
the course of superficial veins or lymphatics, and the green hue of the lower 
part of the abdominal region. 
The purulent deposits are generally isolated in the lungs and liver, but 
diffuse when they occur in the connective tissue. They generally show evi- 
dences of congestion of capillaries in a limited portion of tissue as in a lobule 
of the liver or the lung. 
The chief seat of these secondary abscesses is in the thoracic viscera. 
The pleurce are generally inflamed-sometimes adherent by deposit of recent 
loose yellow lymph, while serum, mixed with pus, or a deeply colored turbid 
fluid, exists in the cavity. 
The lungs are generally much congested at the base, posteriorly, and the 
tissue is generally friable in the congested parts. Sometimes they are com- 
pletely consolidated in their lower halves, and emphysematous or cedematous 
in the remainder of their extent. The secondary abscesses may be seen studded 
over their surface, or they may only be seen on section imbedded in their 
substance. They vary in size from that of a pin's head or hemp-seed to that 
of a hen's egg. They are generally surrounded by a zone of condensed 
lung-tissue, with hemorrhagic infarction; and when the abscess is of consider- 
able size, it may present a distinct lining membrane. The contents are gen- 
erally pus-corpuscles more or less changed, fatty granules, disintegrated 
globules, and amorphous debris. In the smaller lesions the central part gen- 
erally consists of a gray slough, and sometimes a grumous semifluid matter; 
and where hemorrhages have existed, they may present the usual characters 
of lung apoplexy, appearing on section like a slice through damson cheese, or 
of a tawny yellow color, from absorption of coloring matter. These deposits 
are most frequently found on the posterior surface of the lower lobe, or in the 
interlobular fissures. 
In the liver the abscesses are generally of a larger size than those in the BODY-TEMPERATURE in cases of pyaemia. 
741 
lungs; but they have the same general characters as to form and position, 
with a zone of hemorrhage and congestion similar to those in the lungs. But 
even in severe cases, where the lungs suffer most markedly, there may be no 
abscesses in the liver; and occasionally abscesses are met with in the liver 
when none exist in the lungs. When such is the case they are regarded as 
primary abscesses, and sometimes appear as a simple collection of pus, having 
a more or less branched arrangement. 
The cortical substance of the kidneys stands next in order of frequency as the 
site of secondary abscesses in pyeemia, and the abscesses present similar varie- 
ties to those in the lungs and liver. 
In the spleen, owing to its pulpy and diffluent condition in pyaemia, abscesses 
are not so readily recognized after death; and they are not so common as in 
other parts. 
Secondary abscesses of pyaemia are also frequent in the connective tissue, 
and also in muscles. There they have no well-defined zone of congestion or 
limitation of fibrin, and hence the pus tends to infiltrate the limbs and trunk, 
forming immense diffuse collections of thin serous fluid, mixed with shreds of 
lymph and of dead areolar tissue. These collections are most common in the 
axillae, the loins, the back, the iliac fossae, the thigh, and the calf of the leg. 
The joints, especially the knee and shoulder joints, are also sometimes the site 
of thin, yellow, purulent-like liquid. 
Phlebitis may exist, and so may embolia; but as they are not now considered 
essential features in the pathology of pyaemia, these lesions will be considered 
in their proper place among local diseases. 
Symptoms.-The suppurative fever of pyaemia supervenes most frequently 
after injuries or operations in which bones are involved, or in which veins are 
especially implicated. The thin-walled veins in bones, the large distended intra- 
cranial sinuses in close proximity to the eyes and ear, the large hsemorrhoidal 
and prostatic vein plexuses, the open state of the uterine veins after delivery, 
are all favorable local conditions for promoting the development of pyaemia 
fever poison, while suppuration affects those parts. The specific fever of 
pyaemia generally commences suddenly with rigors and pyrexia, from the 
third to the fifth day after injury or operation. This is the acute form. But 
it may be chronic, and its syptoms may not commence for weeks after such 
diseases as typhus, enteric fever, scarlet fever, rheumatism, or dysentery. 
When pyaemia commences, the expression of the countenance is anxious, 
and the face pallid or flushed alternately; mental depression prevails to the 
extent of expecting or foreboding a fatal issue. The eyes lose their lustre, 
the features become pinched and careworn. The conjunctivae and skin assume 
a "dusky," "sallow," "leaden," "icteric," or "yellowish" tinge, but much 
less bright than the golden hue of true jaundice. It is like yellow mixed with 
a dull leaden or ash-gray color. A peculiar odor has been noticed as exhaled 
from the body during the progress of pyaemia (Savory), and the breath gives 
forth a peculiar, "sweetish," "heavy," "purulent," hay-like odor (Berard). 
Respirations become more frequent-40, 50, or more in the minute (Bris- 
towe). Bronchitis or pneumonia generally supervene. In this character it 
resembles measles, small-pox, and typhus fever. 
The nervous phenomena are essentially "typhoid" or adynamic; sleepless- 
ness and restlessness night and day prevail; rigors, with depression succeed 
each other; and muttering delirium marks the severity of the attack. The 
pulse is generally always above 90; and if it rise high at the commencement, 
it so continues to the end-140, 160, and even 200 in the minute (Bristowe). 
Profuse perspirations occur, and generally mark the commencement of secon- 
dary abscesses. No period similar to a crisis can be defined, and no incuba- 
tive stage can be fixed. The commencement is generally dated from the 
occurrence of the first rigor, or increased temperature of skin, thirst, and per- 
spiration. A close observation of temperature after operations is all-important. 742 
SPECIAL PATHOLOGY-PYEMIA. 
A nurse experienced in the use of the thermometer can very early detect the 
accession of pyaemia. 
Death generally ensues, in cases of pyaemia with multiple abscesses, from 
exhaustion; and when the multiple centres are in process of evolution, the 
febrile phenomena are always increased-a distinct attack, with rigor, being 
excited and associated with each centre of development. Thermometrically, 
the commencement of pycemia is very sharply defined, either by a sudden fall 
of temperature or a sudden and rapid rise-the first effect of the virulence of 
the poison. The elevation of temperature is, as a rule, rapid-complete in a 
few hours, or in half a day (4.5° or 6.3° Fahr.), or in the course of a day, and 
seldom lasting more than a day and a half. The temperature always rises 
above 104° Fahr., and generally exceeds 105.8° Fahr., and commonly reaches 
107.6° Fahr. 
The mode of rising of temperature is as follows: During the first twelve or 
fifteen hours, from morning till near midnight, the temperature rises about 
1.8° to 2.7° Fahr.; but after midnight a more rapid rise takes place, so that 
in the morning the temperature is considerably increased ; and if in the course 
of a febrile state already existing, the fever of pysemia is at least 2.7° Fahr, 
to 4.5° Fahr, higher than that febrile state would warrant, or than the daily 
maximum of the days which preceded the commencement of pyaemia. A 
further rise may persist on subsequent days; and generally rigors occur during 
the ascent of the temperature (Wunderlich). Dr. Ringer believes that the 
rise of temperature precedes the occurrence of the rigors ; so that he has been 
able to predict the approach of rigor by noticing a commencing rise in the 
thermometer. Le Gros Clark also records that the temperature rises always 
shortly before the commencement of the rigor, and remains high for a varying 
length of time-generally about half an hour after the termination of the 
shivering {Diagnosis of Visceral Lesions, p. 74). As the rigors subside, the 
profuse sweating commences, and so they repeat themselves at intervals of 
every eight or twelve hours. 
On reference to the diagram, it will be seen that the first sudden paroxysm 
of fever, as Wunderlich shows, takes an acuminated form ; and after the tem- 
perature has reached the highest summit or maximum, it begins immediately, 
and just as rapidly (or even more rapidly than it rose), to fall again, so much 
so that in a few hours it may sink from 3.6° to 7.2° Fahr. Thus the tempera- 
ture comes to be lower after the first paroxysm of fever in pyaemia than it was 
before, even in cases where fever existed before pyaemia set in. After the first 
paroxysm, the temperature seldom falls quite to normal, although, indeed, it 
comes very close to it. It generally falls as low as 100.4° or 101.3° Fahr. 
The low temperature which immediately succeeds the first rise rarely lasts 
longer, or scarcely so long as half a day. It begins to rise again immediately, 
and this fresh rise, whether a rigor is associated with it or not, is generally 
just about as rapid as the first, but may not reach to so great a height. The 
temperature in pyaemia reaches a greater height in a shorter time than it does 
in any other disease; and the first pyaemic paroxysm maybe distinguished 
from all forms of continued fever by the temperature quickly turning back 
and falling rapidly as soon as it has reached its maximum (Ringer, Wun- 
derlich). 
" Brusque," sudden rises of temperature, with corresponding falls, repeat 
themselves more or less frequently (twice or thrice daily) without any regular 
rhythm. This is well shown in Dr. Ringer's diagram. Rapidity of move- 
ment downwards after the summit is reached is characteristic. Evening ex- 
acerbations of fever are distinctly marked, so that the ranges of temperature 
during the course of the disease are similar to those of extensive suppuration 
attended with fever. The temperature, however, in some of these cases is not 
very high ; but in both forms of pyaemia-namely, those with multiple ab- 
scesses and those without-the type of the fever is intermittent during the day SYMPTOMS OF PYAEMIA. 
743 
(Ringer, Bilroth)-i. e., the temperature between the hours of greatest eleva- 
tion varies considerably, and may even become normal, or below; and Pro- 
fessor S. Ringer writes that he has never met with any disease in which this 
occurs except pyaemia. It is no doubt due to this circumstance being hitherto 
overlooked that such varied statements are current regarding the heat of the 
skin in pyaemia. In some cases, indeed, the temperature is never very high, 
nor the intermittent elevations very numerous, yet these are the kind of cases 
in which the internal organs are apt to be studded with secondary abscesses. 
The secondary abscess formation is among the most characteristic phenomena 
of the suppurative fever of pyaemia. When fully developed, these abscesses 
are surrounded by a zone of congested bloodvessels. They occur most fre- 
quently in the lungs-oftener in both than in either separately. Their next 
most frequent seat (stated in order of frequency) is the liver, kidneys, spleen, 
joints, areolar tissue, muscles, brain, heart, bloodvessels, bladder, intestines, and 
organs of special sense. 
In the class of cases of pyaemia in which intense febrile phenomena occur, 
or of multiple abscesses, the temperature is very high, the intermittent eleva- 
tions are numerous, and frequently there are no multiple centres of inflamma- 
tion in visceral parts (Ringer). Though the exact chemical change in the 
composition of the blood has not been made out, yet, as lesions have been pro- 
DIAGRAM OF TEMPERATURE IN A CASE OF PYAEMIA (Ringer). 
Fig. 82. 
duced experimentally by the injection of filtered putrid fluids into the veins 
or intestinal canal, it may be fairly concluded that such cases are due to the 
absorption of putrid poisons in a gaseous or other fluid form especially result- 
ing from the decomposition of tissues. Tissue-change or metamorphoses in the 
febrile state may also establish sources of blood-poisoning (e. g., " Rheuma- 
tism"). Dr. Parkes states how the amount of urea in a case of pyaemia, after 744 
SPECIAL PATHOLOGY-PYJEMIA. 
amputation, rose from 3.1 for every lb. of body-weight to 4.26 grains. The 
weight of the body was 131 lbs. It fell to 110 lbs. in eleven days, and the 
temperature rose from 101° Fahr, to 105.6° {On the Urine, p. 178). Rapid 
wasting of the body is characteristic of the fever of pyaemia. 
In surgical cases the phenomena commence to be expressed between the 
second and fourth day after an operation or injury. The tissue round the 
source of the mischief becomes red and oedematous towards the third day; 
and ichor may exude from the injured part, mixed with bubbles of gas. 
Disintegration spreads with great rapidity from the seat of injury; and where 
the part is to-day simply oedematous, to-morrow it will be an ichorous infiltra- 
tion ; and so it proceeds till death occurs. In some cases it may be looked 
upon as a progressive gangrene of areolar tissue (the acute purulent oedema 
of Perigoff). If thrombi form in the veins, and the phenomena of embolism 
occur, the danger is increased, and the case is more complex; but the septic 
phenomena, in the first instance, are quite independent of embolism. A very 
high temperature and a more continued fever are characteristic of septicaemia. 
The pulse rises (generally above 120), and the intense burning heat commu- 
nicated by the skin of the patient is well known to the hand of the experienced 
surgeon. On the evening of the fourth day after an injury, Bilroth records 
the temperature at 37.3° C. = 99.5° Fahr. In the night the oedematous in- 
filtration commenced, and on the ensuing morning the temperature was 40.1° 
C. = 105.8° Fahr. On the eighth day the patient died, up to which time the 
temperature remained high, its lowest point being 39° C. = 102.2° Fahr. 
A rapid and considerable increase of temperature on the third or fourth day 
after a wound or operation, with delirium and a somnolent state, with an ich- 
orous appearance of a wound, and oedematous infiltration around it, are cer- 
tain signs of septicaemia. Albumen occurs in the urine in some cases, and 
sweats are common (Bilroth) ; the skin acquires a faint yellow color; and 
the breath a hay-like smell. The highest temperature recorded by Prof. S. 
Ringer is 107.4° Fahr. {MS. Notes'). 
Diagnosis.-It is necessary to distinguish the suppurative fever of pyaemia 
from the following diseases, namely : meningitis, bronchitis, pneumonia, typhus, 
icterus, intermittent fever, gonorrhoeal or urethral rheumatism, hectic fever. It is 
the combination of symptoms presented by the suppurative fever of pyaemia 
which must distinguish it and prevent error. There are the occurrence of 
fever four or five days after operation or delivery; the dusky and icteric hue 
of the conjunctivae and skin; the " heavy," "sweet," "purulent," " hay-like" 
odor of the breath ; the inflammation, with effusion into and suppuration of 
joints; the formation of secondary abscesses in various parts of the body- 
following each other in natural sequence with great prostration. At the same 
time these symptoms are often so mixed up with those of the condition out of 
which pyaemia may arise, that the specific suppurative fever of pyaemia may 
be recognized with difficulty (Bristowe). 
It is to be distinguished from erysipelas by the fact that erysipelas is an 
eight-day fever, the poison of which acts most virulently on the skin and 
serous membranes ; whereas the suppurative fever of pyaemia alters the blood, 
inducing secondary changes in the vascular pulp of many viscera, without 
affecting their serous coverings (Braidwood). 
Prognosis.-The disease is one of the most fatal; and the premonitory 
symptoms are therefore the ground for the gravest alarm; because recovery 
from a fully developed and unmistakable attack of pyaemia is almost quite 
hopeless (Bristowe). 
Some cases, however, undoubtedly get well, although a very large proportion 
die; and the chances of getting well are greater in proportion to the freedom 
from embolism, and from intense febrile disturbance, as indicated by tempera- 
ture, and from the formation of secondary abscesses. On the other hand the 
prognosis is unfavorable in proportion to the rapidity with which the effects CHRONIC PYEMIA. 
745 
of the disease are developed. In acute and well-marked pyaemia we can 
hardly venture to admit a ray of hope; but, as a general rule, the longer the 
patient can struggle against the mischief, the more chance is there of his being 
ultimately rescued from the perils through which he has to pass (Savory). 
Youth is favorable to recovery ; and as the fever varies in degree, just as other 
fevers do, the prognosis must not be always hopeless. As in cholera, so in 
pyaemia, " as long as there is life there is hope,'* if the patient's strength can 
be supported. One or two pycemic rigors may be recovered from; but it is 
the repetition of the rigors, followed by profuse sweating, and attended by 
such extreme exhaustion, that is so fatal. The danger and rapidity of fatal 
termination in any given case, will, coeteris paribus, depend on the rapidity of 
the recurrence of the rigors and their severity (Ericksen). 
Dr. Gillespie, and Mr. Spence, Professor of Surgery in the University of 
Edinburgh, have recorded undoubted instances of recovery from cases of 
this kind; and Mr. Prescott Hewett recounts ten recoveries within his ex- 
perience. 
Treatment.-The indications are-(1.) To remove all those conditions 
which favor the degeneration, metamorphoses, or putrefaction of blood-clots 
or tissue. (2.) To subdue the force of the circulating current, so as to pre- 
vent excitement during the long and slow metamorphosis of a clot when it 
has formed. (3.) To sustain the strength and allay the nervous irritability. 
Wine, brandy, rum, milk, strong animal soups, and nourishing diet should 
be freely given, from time to time, in small quantities. Opium should be 
given freely. [Conclusions are adverse to the therapeutic value of the sul- 
phites.] 
Exposure of the patients to currents of fresh air-treatment in the open 
air, in fact-has been shown by Mr. Paget to be the most promising of success 
in cases of pyaemia. 
The use of disinfectants and attention to ventilation give support to the 
belief that the poison is one generated among cases of accumulated severe 
wounds and open sores. The patient ought to be isolated. Candy's fluid, 
carbolic acid wash, and the new substance, chloralium, are each useful disin- 
fectants. Preparations of iron are the most suitable tonics. 
[CHRONIC PY2EMIA. 
(Dr. Clvmer.) 
It is not uncommon to meet with cases, more frequently happening in the 
course of diseases than following surgical injuries, which present all the essen- 
tial characters of pysemia, as ordinarily described, but are much slower in 
progress, and less severe and perilous. To these cases Mr. James Paget pro- 
poses to give the name of chronic or relapsing pyaemia. He has called the 
attention of the profession to the subject in a paper published in the first 
volume of St. Bartholomew's Hospital Reports.* Chronic pyaemia is not 
referred to in any of the Systems of medicine or surgery, yet it resembles the 
typical pyaemia in the formation of widely dispersed, shapeless collections of 
pus, in the probability that these formations are due to some infection of the 
blood by the entrance of diseased or septic products, and often in the occur- 
rence of rigors, profuse sweatings, phlebitis, and inflammations of joints. It 
differs from the acute type in that its course extends, continuously or with 
relapses, over many weeks or months, and is often free, at least, in its later 
stages, from all severe general disturbance of the health, and from nearly all 
risk of life. 
* Cases of Chronic Pyemia. By James Paget, F.R.S., St. Bartholomew's Hospital 
Reports, vol. i, London, I860. 746 
SPECIAL PATHOLOGY-PUERPERAL FEVER. 
Mr. Paget believes that the difference between groups of cases of acute and 
of chronic pyaemia is not greater than those between cases of acute and chronic 
tuberculosis. Sameness of designation is, he thinks, in both cases alike justi- 
fied by the rule, that differences in degree do not constitute or prove difference 
in kind. 
The local evidences of chronic are more often than those of acute pyaemia, 
seated exclusively or chiefly in different parts of the same tissues; they are 
more frequent in the trunk and limbs than in internal organs, and when 
seated in the veins are most frequently found towards the close of the dis- 
ease. 
The nearest affinities of chronic pyaemia are with rheumatism, through 
gonorrhoeal or urethral rheumatism (p. 774), with simple or single abscess- 
formation after fever, and with hectic fever. Yet with very rare exceptions 
the diagnosis from all these is in practice clear. 
The Prognosis is usually favorable, especially when there are long inter- 
vals between the successive local manifestations of disease, and no evidence 
of serious pulmonary disorder. The more natural the pulse and breathing, 
and the less the sweatings, the greater, as a rule, are the probabilities of 
getting well. 
The Treatment is good food, careful nursing, abundance of fresh air, and 
a moderate use of stimulants and tonics. Mr. Paget thinks that the influence 
of the liquor potassse is worthy of consideration.] 
PUERPERAL FEVER. 
Latin Eq., Febris puerperarum; French Eq., Fibwe puerp&rale; German Eq., 
Puerperatfieber-Syn., Kindbettfieber; Italian Eq., Febbre puerperale. 
Definition.-"A continued fever, communicable by contagion, occurring in 
connection with childbirth, and often associated with extensive local lesions, espe- 
cially of the uterine system." 
Pathology.-As a contimied fever this disease seems to be classed, by the 
College of Physicians, with typhus, enteric, and other continued fevers, and 
certain important local lesions are specified as attending or following this 
form of continued fever-namely, peritonitis, effusions into serous and synovial 
cavities, phlebitis, diffuse suppuration, as well as exudations, congestions, puru- 
lent secretions, and other changes of structure of the mucous lining of the 
alimentary canal and respiratory organs. Many theories have been pro- 
pounded relative to the pathology of puerperal fever-some setting forth 
that it is an essential or specific disease, sui generis; another, that it is simply 
a local inflammation of a sthenic type; a third, that it is a phlegmasia of an 
asthenic type, of the nature of typhoid fever. Some maintain that it is in 
close alliance with hospital gangrene; others, that it is of the nature of ery- 
sipelas, or of uterine phlebitis. 
True epidemic puerperal fever is characterized by great depression of the 
powers of life, so great as to resemble the depression of enteric fever, and the 
various lesions found after death are results of the constitutional disturbance, 
which of itself may induce death, and leave no sign, as Fergusson, Tessier, 
Tardieu, Depaul, and others have shown. The weight of evidence as to the 
pathology of puerperal fever is in favor of the opinion originally expressed 
by Dr. Fergusson, when he wrote: "The phenomena of puerperal fever 
originate in a vitiation of the fluids, and the various forms of puerperal 
fever depend on this one cause of vitiated blood, and are readily deducible 
from it." But we know no more of the real essence of this specific poison 
than we do of the other disease-poisons whose existence is recognized by ORIGIN OF CASES OF PUERPERAL FEVER. 
747 
their effects-which are so varied, and yet so constant and characteristic of 
each. 
The most intimate alliance seems to be between puerperal fever and ery- 
sipelas. The diseases seem to be mutually interchangeable, so that if erysip- 
elas prevail in a district, a third party may communicate from a patient 
affected with erysipelas puerperal fever to a woman recently delivered. There 
are also instances on record where husbands, and nurses in attendance on 
women dead of puerperal fever, have been themselves attacked with erysip- 
elas, and during an epidemic in the "General Lying-in Hospital," London, 
the child born of every female in whom puerperal fever proved fatal, died of 
erysipelas in a few hours (Rigby's Midwifery, p. 392). The disease was long 
ago (1750) known as "epidemic erysipelas of the peritoneum" (Plouteau). 
A most valuable contribution to our knowledge of puerperal diseases has 
been recently (1871) made by Dr. J. Braxton Hicks, F.R.S., Physician Ac- 
coucheur and Lecturer on Midwifery, at Guy's Hospital. He concludes that 
there are " states of the system engendered in some way or other in the puerperal 
woman by poisons {disease-poisons') which, in other conditions or states of the 
system, manifest their presence in a different mode." Trousseau expressed some- 
thing similar when he wrote: "The lying-in female exhibits a peculiar morbid 
opportunity, and presents a remarkable pathological aptitude, for the malady." 
Evidence is also brought forward which shows that while puerperal fever 
exists in the mother, her children were affected with scarlet fever, either before 
or immediately after. One case is quoted where erysipelas succeeded in the 
nurse and infant, at least a week after the occurrence of puerperal fever in 
the mother, and another where the husband and nurse were severely attacked 
by sore throats a day or two after the puerperal woman was attacked by 
fatal puerperal fever. Such cases give support to the belief, that a woman 
having puerperal fever derived from scarlet fever, or from erysipelas, can 
give to a non-puerperal person the original disease. But the difficulty exists, 
that a common origin may explain them all. Certain diseases, in entering 
the puerperal woman, may act upon her system in such a manner as to give 
evidence of its presence in a mode widely different from that which it presents 
ordinarily in the non-puerperal state. 
Dr. Hicks then shows : 
1. That, of those who are severely afflicted after delivery, in private prac- 
tice, a large number owe their troubles to the poison of scarlet fever. 
2. That half of this number have most of the usual symptoms of ordinary 
scarlet fever-namely, the rash and sore throat. 
3. That, with this ordinary appearance, secondary troubles are frequent, 
both local and general,-e.g., metritis, cellulitis, peritonitis, pyaemia. 
4. That the sore throat is slight in all cases, and the rash appears more si- 
multaneously over the body than in ordinary cases of scarlet fever. 
5. That the influence of scarlet fever is shown in the puerperal female with- 
out necessarily the rash or sore throat, the patient having symptoms of blood- 
poisoning in a greater or less degree, producing, if the patient survive a suffi- 
cient time, secondary local and general lesions, such as are to be observed when 
the ordinary symptoms are present. 
6. That the disease almost always commences from the third to the fifth 
day after delivery. 
7. That though the woman may be exposed continuously for months before 
labor, still the disease does not generally manifest itself till the third to the 
fifth day after. 
The temperature in such cases has been noted at about 105.6° Fahr. 
In private practice erysipelas causes fewer cases of puerperal fever than in 
hospital practice, where it is a most frequent cause of puerperal disturbance- 
so frequent that some pathologists regard puerperal fever as erysipelas of the 
peritoneum. By some also, scarlet fever and erysipelas have been considered as 748 
SPECIAL PATHOLOGY-PUERPERAL FEVER. 
slight modifications of the same poison, and apparently interchangeable, and 
that certainly they have much affinity. 
Another class of puerperal fever cases seems to be caused by diphtheria, 
and are often due to typhus and enteric fever poisons. 
A fifth class of puerperal fever cases seems to have arisen in connection 
with an offensive state of the lochia and vaginal discharges. Medical men 
are not all equally alive to the greatness of this danger. The decomposition of 
an intrauterine clot or portion of placenta is a frequent source of much mis- 
chief, particularly if there are any abrasions of the parturient passages. Local 
metritis, cellulitis, peritonitis of the worst type tend to aggravate the general 
infection of the system, caused by the absorption of the decomposing material. 
There is undoubtedly an intimate connection between the specific disease- 
poisons of the general diseases comprehended in this section (A), and forms 
of puerperal fever; and hence it is easy to understand, as Dr. Hicks points 
out, how imperfect drainage, close rooms, and bad dwellings are sufficient, by 
continued action, to induce such a state of the constitution as tend to effusions, 
suppurations, pyaemia, and peritonitis. Dr. Hicks has also noticed that the 
forms of puerperal fever are more frequent in newly built than in older houses; 
and the inmates of such houses are also more liable to attacks of scarlet fever, 
enteric fever, and diphtheria, probably from the drains of new houses being 
more liable to be deficient. Hence the broad conclusion must be drawn, that 
while the special poison of puerperal fever may originate in the person of the 
parturient woman, and be conveyed into her blood through the absorption of 
putrid coagula, portions of placenta, and decomposition of discharges, there 
are other modes, especially by the specific disease-poisons, through which the 
fever may be induced. Thus, also, the fever may be propagated through the 
intervention of a third party; or by the hand of the accoucheur carrying a 
putrid poison into the system during vaginal explorations. That it has thus 
resulted from poisonous material carried from the dissection of the dead body 
was abundantly and disastrously proven in the midwifery clinic of Vienna in 
1847 and 1848. Any fluid matter in a state of putrefaction, communicated by 
linen, by a catheter, by a sponge, by small particles of placenta, or even by 
the ambient atmosphere impregnated with foul substances, may produce puer- 
peral fever (see Braithwaite's Retrospect, Part 23, p. 492). 
Morbid Anatomy.-In the lesions which follow puerperal fever, nothing 
can be set down as constant. Evidence of peritoneal inflammation is perhaps 
the most frequent; and hence sometimes the fever is described under the name 
of 11 puerperal peritonitis." In such cases the inflammation is general over 
the peritoneum, and there is more or less sero-purulent effusion in the perito- 
neal sac, and any lymph is soft and bloody. There is no tendency to plastic 
forms of lymph. Uterine phlebitis is another frequent lesion. In such cases 
multiple abscesses are apt to be formed in the lungs; so that such cases may 
be regarded rather as cases of pyaemia than of puerperal fever. Such cases 
have generally thrombi or clots in the pelvic vessels ; and such cases are to be 
distinguished from cases of puerperal fever, where the uterus is softened as to its 
tissue, as well as the ovaries, and where the lymphatics only are inflamed. In 
such cases there are no multiple abscesses and no pyaemia. 
Symptoms.-Increase of body-temperature, followed by rigors from the 
third to the fifth day after delivery, are the earliest indications. Consequent 
upon these phenomena there is generally tenderness over the whole surface of 
the abdomen, or limited to the lower half. The pulse at the same time in- 
creases in rapidity, ranging from 120 to 160, or more. Respiration is rapid 
and short. Thirst is distressing ; and not unfrequently nausea and vomiting 
occur. As a rule, the lochial discharge is suppressed or altered as to its char- 
acter, and sometimes also the flow of milk ceases. 
Symptoms of great prostration are constant, and the countenance expresses 
great anguish, with sunken features and circumscribed lividness round the TREATMENT OF PUERPERAL FEVER. 
749 
eyes. Diarrhoea is apt to occur, and the abdomen becomes distended. The 
patient lies on the back with the knees drawn up, instinctively to relieve the 
abdomen from muscular pressure and weight of the bed-clothes. 
Treatment.-Having regard to the varied sources whence puerperal fever 
may take its origin, prophylactic treatment ought to be the first consideration. 
Preventive measures are of vital importance, for such measures have been 
proven sufficient to arrest the development of the disease. If scarlet fever can 
be prevented, the number of puerperal fever cases would be diminished one- 
half (Hicks); and every possible step ought to be taken to remove the preg- 
nant female alike from the influence of scarlet fever and from erysipelas. Dr. 
Hicks observes, also, " with regard to the medical attendant, although I have 
found some fully aware of the risk of carrying scarlet fever and erysipelas to 
the woman in labor, yet I have met with not a few who either have not taken 
care, or have not been fully alive to the danger in which they are placing their 
patients." He considers it well to keep three suits of clothes in use when 
attending such cases, keeping those out of use before a very warm fire, or hung 
out in the open air; the hands to be frequently washed and the nails short; 
and a good walk in the air should be taken before going to any other patient. 
Where there are partners, it is advisable for one to attend contagious cases, 
leaving the other to manage the midwifery; and too much care cannot be 
taken to prevent the lying-in woman being exposed to the chance of contagion. 
With regard to the nurse, the tendency of women's dress to retain the fomites 
of contagion must suggest their frequent purification by disinfectants, and the 
use of material capable of being boiled in the process of washing, and of other- 
wise being subjected to the action of disinfectants. 
With regard to the prevalence of the disease in hospitals, the wards ought 
to be closed entirely against the admission of patients, at regular intervals, 
during which the process of purification should go on. The ward to be puri- 
fied should then be filled with chlorine gas, in a very condensed form, for forty- 
eight hours at least; the windows, doors, and fire-places being kept shut. The 
floors and woodwork should be covered with chloride of lime, mixed with 
water, to the consistence of cream. The woodwork should then be painted, 
and the walls and ceilings washed with fresh lime; the blankets and sheets 
should also be washed and heated in a stove to a temperature of 120° to 130° 
Fahr. The hospital beds should be stuffed with straw; and as soon as the 
case is concluded, the straw ought to be burned, and the covering of the bed 
washed and heated like the blankets and sheets (Collins's Midwifery, p. 388). 
Patients threatened with puerperal fever ought to be isolated. 
With regard to medical treatment, pure air, mitriment, and stimulants are 
the agents best able to obviate the great depression which marks the com- 
mencement of puerperal fever. Quinine in large doses has also been found 
useful after the bowels have been fully evacuated. It ought to be given till 
the physiological action of the drug is manifest, from the deafness and vertigo 
it produces. A form of quinine is now made soluble in warm water, and which 
may be injected hypodermically. 
Opium is of great value. It has been given, to a very large amount in the 
twenty-four hours, by Drs. Graves, Stokes, and others, since its great value 
became known. It must be given until incipient narcotism is produced ; and 
the best evidence of its good effects is seen when the respirations become sen- 
sibly diminished from the great frequency they attain in puerperal fever. If 
they can be reduced to fourteen or twelve, with a pulse below 100, a subsi- 
dence of tenderness, and of tympanitis, the amount of opium may be gradu- 
ally lessened, and finally discontinued (Clark). 750 
SPECIAL PATHOLOGY-NATURE OF GENERAL DISEASES. 
PUERPERAL EPHEMERA OR WEED. 
Latin Eq., Ephemera puerperarum; French Eq., EphemFre puerperale; German Eq., 
Puerperale Ephemera; Italian Eq., Febbre efemera puerperale. 
Definition.-A fever, consisting of one or more paroxysms, occurring a few 
days after delivery, generally attended by diminution of the milk and lochia, and 
unaccompanied by local lesions. 
Pathology.-This fever approaches in character the type of intermittent 
malarious fever rather than any other. One great characteristic is its short 
duration, and hence the name "ephemeral." The term weed or weid is a 
Scotch generic term applied to "any feverish cold taken by women during 
their lying-in." It rarely comes on before the seventh day after delivery, 
and sometimes it may occur later. A humid, malarious atmosphere is favor- 
able to its occurrence; and cold alone will bring about the phenomena of 
chilliness, which mark the accession of puerperal ephemera. It prevails in 
low, marshy, thinly populated districts, or where stagnant ditches intersect 
houses, or where dwellings have been erected over rubbish thrown into shallow 
pools (Ramsbotham). 
Symptoms.-Increase of temperature with rigors and perspiration are the 
earliest phenomena of this affection. The rigors are usually of great severity 
and long continuance, accompanied with more or less pain in the head, the 
back, and the extremities. There is great depression. The features shrink, 
and the eyes sink back in their sockets. The fingers present a blue or livid 
shrivelled aspect, as in the chill of ague. The pulse is feeble and slightly 
accelerated. The secretions of milk, of urine, and of lochia are suppressed 
for a time. Despondency, with depression of spirits and hysterical phenom- 
ena, are apt to prevail, and as they tend to increase, delirium may even super- 
vene. Profuse perspiration then eventually succeeds, and the patient begins 
to improve. The secretions of milk, urine, and lochia return; the patient 
falls into a sleep; the disease departs and rarely returns. 
The pulse never acquires the rapidity of puerperal fever. 
Treatment.-The indications are to restore reaction with warm drinks and 
external warmth till the stage of rigors has passed away, very much as in ague. 
CHAPTER X. 
PATHOLOGICAL SUMMARY REGARDING THE NATURE OF THE GENERAL 
DISEASES DESCRIBED UNDER SECTION A. 
Grouping these diseases together, according to more or less natural alliances, 
they may assume the following arrangement: 
I. Exanthemata-namely, small-pox, cow-pox, chicken-pox, measles, scarlet 
fever-five in number. 
II. Continued Fevers, defined as such by the College of Physicians,- 
namely, dengue, typhus fever, enteric fever, relapsing fever, simple continued fever 
(specific), puerperal fevei-seven in number. 
III. Malarious or Paroxysmal-namely, yellow fever (paroxysmal), ague 
in its various forms, remittent fever, puerperal ephemera or weed. 
IV. Epidemic and Malignant, but paroxysmal rather than continued- 
namely, cerebro-spinal fever and pyaemia, and specific yellow fever. 
V. Specific, Epidemic, and Contagious, but not otherwise characterized 
-namely, plague, cholera, diphtheria, hooping-cough, mumps, influenza. NATURE OF CONTAGION AND INFECTION. 
751 
VI. Disease-poisons connected with diseases of animals, with unhealthy 
states of wounds or sores, or with epidemic exanthemata-namely, glan- 
ders, farcy, equinia mitis, malignant pustule, phagedena, sloughing phagedena, 
hospital gangrene, erysipelas. 
Our knowledge regarding the specific poisons by which each of these diseases 
is produced and propagated is inferential. We know that the respective poisons 
are specific organic existences, from the mode in which the diseases are capa- 
ble of propagation by inoculation, contagion, or infection. 
When a disease is communicated by inoculation or contagion, a poison of 
material substance is transported from one person to another. Observation 
and experiments by Drs. Chauveau and Sanderson, on vaccine lymph, small- 
pox, variola ovina, and glanders, have recently shown that the agents, specific 
poisons or material of contagia, of these diseases are solid particles, and not 
merely vapors or exhalations. They are of the same specific gravity as the 
liquid with which they are surrounded, and have the same color and trans- 
parency. - Although these particles cannot be uniformly diffused in fluids or 
in gases, yet experiments have been made by diluting the fluid containing the 
particles, with this result, that the success of inoculating the particular dis- 
ease-poison depends on the chance of inserting one of the poison-carrying par- 
ticles ; and that the greater the dilution of the fluid, the less is the chance of 
inoculation ; but that the intensity of the resulting disease when produced is 
in no way modified by the extent of the dilution. 
As to the nature of these poison-carrying particles, Sanderson considers 
them albuminous and capable of increase by continuous development when 
they find suitable nutriment for growth. In this respect they seem allied to 
the micrococci of Hallier, and the germinal matter of Beale. 
An appreciable substance, capable of growth and development, is thus con- 
veyed when diseases are produced by inoculation or contagion, and that the 
poison and disease is each specific is shown by the constancy of the sequence 
of phenomena in each ; and that one disease does not give rise to another (see 
pages 328, 329, ante). 
At page 66 I have already expressed the hope that the day may come 
when we shall be able to demonstrate the material poison of each specific dis- 
ease, just as the chemist is able to show the active principle of substances like 
opium, cinchona, and the like. 
It has been usual to limit the application of the term contagion to matter 
palpable and appreciable, like the fluid of the small-pox or cow-pox vesicle; 
but when the substances could not be seen in any form, but were believed to 
exist, as emanations not apparent to the senses, such disease-producing matter 
has been known as "miasms." Such impalpable emanations or "miasms" 
were understood to act by infection. Considerable confusion has always per- 
tained to the use of these terms, contagion and infection; but when observa- 
tions like those of Drs. Chauveau and Burdon Sanderson can demonstrate 
that the essential poison-carrying substance is a germ or granule of minute 
microscopic size, capable of indefinite growth and multiplication, when it 
comes in contact with suitable soil, the contagiousness of infecting miasms 
becomes quite intelligible, and the one word becomes synonymous with the 
other. It is a great step gained to be able to individualize the particle which 
is the poison-carrier or disease-producer; although we may be unable to show 
what is the nature of the peculiar vital property it possesses, which is capable 
of producing effects so specific as the disease its inoculation brings about. We 
know only that it may be implanted, that it grows, multiplies, and is repro- 
duced a thousand fold. We know also that time for inoculatioh and time for 
development and maturation are important elements in the course, duration, 
and final termination of all of these diseases. We have no antidote for any 
of them. We cannot cure any of them; we can but guide the patient with 752 
SPECIAL PATHOLOGY - ACUTE RHEUMATISM. 
the best of our knowledge and experience through such dangerous periods of 
life as some of these diseases imply. 
A distinction ought to be made, however, between the poisons that are re- 
produced during the processes of disease, as of the exanthemata and continued 
fevers, contrasted with those poisons which do not appear to be reproduced in 
the system, as in the case of malarious and paroxysmal fevers, and which are 
not believed to be propagated by contagion or intercourse with the sick. 
CHAPTER XI. 
DETAILED DESCRIPTION OF THE GENERAL DISEASES COMPREHENDED IN 
SECTION B. 
The Diseases belonging to this section comprise, " for the most part, disorders 
which are apt to invade different parts of the same body simultaneously or in suc- 
cession." They are sometimes spoken of as constitutional diseases, and they 
often manifest a tendency to transmission by inheritance. They are typically 
represented by rheumatism and gout, also by those affections in which an altera- 
tion in the proportions or qualities of the elements of the blood is the obvious 
and prominent fact, such as anaemia, chlorosis, general dropsy, and, lastly, by 
those diseased states of the constitution which manifest themselves by such 
diseases as syphilis, cancer, lupus, scrofula, rickets, cretinism, purpura, scurvy 
and beriberi (see p. 373, ante). 
With reference to the term "diathesis" (a word which has been often used 
in connection with descriptions of these diseases), it is to be explained that 
there are certain states of the human body which physicians have called 
"morbid dispositions" {diathesis morbosa). The term diathesis, however, has 
been used extensively, and sometimes vaguely. By it pathologists have meant 
to designate an unknown, impalpable, undefined state of the human constitu- 
tion, the existence of which is sometimes assumed, or is sometimes legitimately 
inferred by inductive reasoning, and which then is made to explain the char- 
acteristic tendency of some morbid constitutional state, which betrays itself 
by repeated local manifestations of morbid action (Craigie). A rheumatic 
diathesis, a gouty diathesis, a cancerous diathesis, a lithic acid diathesis, are all 
thus spoken of. It is now generally understood to imply-(1.) The existence 
of latent conditions in the constitution of the body itself, necessary for the de- 
velopment of peculiar diseases; (2.) A tendency to the development of special 
and peculiar diseases during the course of the nutrition and other morpho- 
logical changes between the solids and fluids of the body, and which are only 
influenced by the operations of agents from without, acting as stimuli or ex- 
citants to the morbid development. 
ACUTE RHEUMATISM-Syn., RHEUMATIC FEVER. 
Latin Eq., Rheumatismus acutus-Idem valet, Febris rheum,atica; French Eq,, 
Rhumatisme articulaire aigu; German Eq., Acuter Gelenk-rheumatismus-Syn., 
Rheumatisch.es Fieber; Italian Eq., Reumapira-Syn., Febbre reumatica. 
Definition -A specific febrile disorder, probably due to a morbid state of the 
■system by constitutional development, and expressed by inflammation of a peculiar 
and non-suppurative kind in the fibrous tissues about or surrounding the joints, 
■especially in the white fibrous tissues-such, for instance, as the sheaths of the 
muscles and muscular fibres, tendons, aponeuroses, bursae, capsular ligaments,peri- PATHOLOGY OF ACUTE RHEUMATISM. 
753 
osteum, and pericardium. Many joints may be affected at the same time or in 
succession. The various local phenomena of the disease have a tendency to shift 
from part to part, the most remote from each other; and the febrile state is accom- 
panied by profuse acid excretions from the skin, by the separation, in some cases, 
of large quantities of uric and sulphuric acid through the kidneys, and by a 
highly fibrinous condition of the blood. 
Pathology.-Various opinions have been entertained from time to time re- 
garding the nature of rheumatism. It was believed to be of miasmatic origin; 
but the most recent inquirers into the nature of rheumatism (Basham, Gar- 
rod, Fuller) show that it acknowledges no general external source, and it is 
not even yet demonstrated that any definite offending matter or poison per- 
vades the system. It is presumed, however, by inductive reasoning, that some 
morbid material is generated by and within the bodies of those in whom rheu- 
matism is fully developed, or is not eliminated by them in the ordinary func- 
tions of life, and that the poison is not absorbed from without. 
Evidence of the abnormal state of the blood exists in-(1.) The symmetri- 
cal development of the local symptoms-a phenomenon which obtains in all 
disorders connected with a vitiated condition of the circulating fluid (Budd) ; 
(2.) The constancy of premonitory fever, or of fever associated with the pro- 
gressive development of the disease, with a large number of local symptoms, 
and lesions of internal organs, occurring simultaneously; (3.) A series of ob- 
servations by Chomel (Legons de Clinique Medicale} tend to show that the 
internal inflammations in rheumatism, like those of small-pox, typhus, scarla- 
tina, and the like, are referable to an alteration of the animal fluids, and more 
especially of the blood ; (4.) The phenomena of metastasis, when it does occur, 
points to a morbid matter in the blood itself as an explanation of the occur- 
rence (Holland, Fuller). The most constant morbid condition of the 
blood in rheumatism is the abnormal relative proportions which become de- 
veloped between the fibrin and the saline elements; the mean of the fibrin to 
the saline elements being in the relative proportion of 7.163 to 8.478 in 1000. 
In normal blood the fibrin rarely exceeds 3 in 1000. 
The following circumstances point to the constitutional origin of rheuma- 
tism-(1.) Its victims are apt to experience symptoms clearly denoting at an 
early period of life certain functional derangement which leads to impairment 
of general health (Fuller, Todd, and Chomel). (2.) Rheumatic patients 
are sensitive to atmospheric vicissitudes, prone to perspire, and their perspira- 
tion has a sour, disagreeable odor. Their urine, also, though usually clear 
when passed, not unfrequently deposits, on cooling, a red, brick-dust sediment 
oflithates and lactates. By such constitutional signs the "rheumatic diathe- 
sis" is indicated. (3.) The heart of such persons is irritable, prone to take 
on inflammatory action, and its nutrition is apt to become perverted. (4.) 
A change of the mode of living has been observed to induce the rheumatic 
diathesis. (5.) The long continuance and frequent recurrence of symptoms, 
or paroxysms of severe disease, also point to a constitutional origin of the ma- 
teries morbi of rheumatism. 
It was first suggested by Dr. Prout that all the phenomena of rheumatism 
are referable to the presence of lactic acid developed too freely or abundantly 
in the system-a suggestion adopted by Drs. Furnivall and Todd, and subse- 
quently by Drs. Headland, Fuller, and Mr. Spencer Wells. Before the starch 
of the food can be applied to the maintenance of animal heat, it has to be con- 
verted into lactic acid, which then combines with oxygen to form carbonic 
acid and water; and whatever tends to interfere with this normal series of 
changes from taking place may lead to the accumulation of lactic acid, or other 
allied acids, in the system. 
Dr. Fuller believes the poison of rheumatism to be identical with some 
natural excretion of the skin, and he grounds his belief chiefly on the follow- 
ing circumstances : (1.) That when the skin's action is interfered with, espe- 754 
SPECIAL PATHOLOGY - ACUTE RHEUMATISM. 
cially in old people, pains or stiffness of a rheumatic character are generally 
the consequences; (2.) That the perfect development of the means which na- 
ture adopts to relieve these symptoms suggests a relationship between rheuma- 
tism and cutaneous excretion. "No sooner is a person attacked by the 
disease," writes Dr. Fuller, "than excessive perspiration is set up, as if with 
the view of getting rid of some peccant matter, and the secretion is most pro- 
fuse at the very part where local inflammation is taking place." Neverthe- 
less, although rheumatism is undoubtedly stamped with a peculiar and 
specific character, yet the material morbific matter is as yet undiscovered. The 
exact conditions of the system under which the disease becomes developed are 
hitherto undetermined. Both Dr. Craigie and Sir Thomas Watson hold that 
rheumatism implies inflammation of a peculiar and specific kind ; and the 
latter goes a step farther, and writes that " Rheumatism is a blood disease,- 
that the circulating fluid carries with it a poisonous material which, by virtue 
of some mutual or elective affinity, falls upon the fibrous tissues in particular, 
visiting and quitting them with a variableness that resembles caprice, but is 
ruled, no doubt, by definite laws to us as yet unknown." 
Dr. W. B. Richardson made some important experiments to try whether 
the theory admits of any direct demonstration which maintains that super- 
abundance of lactic acid in the system induces pathological phenomena of the 
rheumatic type. He injected into the peritoneum of a healthy cat seven 
drachms of a solution of lactic acid, with two ounces of distilled, water. Two 
hours after the operation the action of the heart became irregular. The ani- 
mal was left for the night about six hours after the operation, and in the 
morning was found dead. The post-mortem inspection showed no peritoneal 
mischief, but the most marked endocarditis of the left cavities of the heart. 
The mitral valve, thickened and inflamed, was coated on its free borders with 
firm fibrinous deposit. The whole endocardial surface of the ventricle was 
intensely vascular. The experiment was afterwards repeated on two healthy 
dogs. The first dog died on the second day after the experiment, and the in- 
spection revealed the most striking pathological signs of endocarditis. The 
tricuspid valve was inflamed, and swollen to twice its ordinary size. The 
aortic valve, swollen and inflamed, was coated on its free border with fibrinous 
beads. The endocardial surface was generally red from vascularity. The 
pericardium was dry and injected. As before, the peritoneum escaped injury. 
The joints were not affected, but there was distinct sclerotitis in the left eye. 
These experiments demonstrate that endocarditis may be physiologically pro- 
duced by the injection into a serous cavity of lactic acid (Medical Times and 
Gazette, July 18, 1857). Similar experiments, with similar results, are re- 
ported by the late Dr. Brinton to have been made about eleven years pre- 
viously by Mr. Simon, of St. Thomas's Hospital (Transactions of Med. Soc. of 
London, Jan. 23, 1858, and reported in various Journals). 
Whatever, therefore, the abnormal condition of the juices or fluids of the 
body may be which induces the rheumatic state, it is one which appears to be 
generated within the system as the result of faulty metamorphosis; and that 
many agencies may conduce to the formation of a poison, and to its retention 
within the system. Whatever the poison may be, if it be a poison, it does 
not seem to be absorbed from without. It is inbred, and not derived from 
extrinsic sources. The researches of Dr. Parkes lead to the belief that it may 
be some substance rich in sulphur. 
The parts affected in acute rheumatism are for the most part the ligaments, 
fasciae, aponeurosis, periosteum, perichondrium, tendons, bursae, and serous mem- 
branes of the heart and brain; but the joints and surrounding structures are 
the parts most frequently affected. The heart, the kidneys, and the arteries all 
subsequently sometimes suffer. A red and injected state of the vessels of 
some of these structures is often the only evidence after death of the existence 
of any approach to inflammatory action, especially in the synovial mem- HEART AFFECTION IN ACUTE RHEUMATISM. 
755 
branes, the pericardium, and the membranes of the brain. This diffuse red- 
ness and injection of the vessels may terminate by resolution, or serum may 
be effused. Serous inflammation is extremely common, and is evinced by the 
swollen state of the bursas and parts external to a joint, often by an evident 
fluctuation within the cavity of a joint; and should the patient die, the cavi- 
ties of the arachnoid and of the pericardium may be found loaded with serum, 
the latter often to the extent of many ounces. 
One of the most frequent results of acute rheumatism is the tendency to 
thicken parts, and to cause opposing surfaces to adhere. The connective 
tissue surrounding the diseased articulation is often not only found thickened, 
but infiltrated with a loose coagulable lymph. The tendinous sheaths and 
capsular ligaments sometimes exhibit the same alterations. After a time the 
new material becomes consolidated, and in this manner parts are bound down, 
and the motion of joints greatly and sometimes permanently impaired: The 
alterations of the synovial membrane are not the least curious of the changes 
which occur in rheumatic joints from the adhesive process. The tissue is not 
only often thickened, but villous processes, like the papillae of the tongue of 
herbivorous animals (only soft and red), and dipping into the depressions 
around the neck of the bone, are occasionally formed, which are intractable 
even to long treatment, and often lead to destruction of the joint. The 
strongest evidence of the tendency to thickening, consolidation, and adhesion 
of parts may be seen in the immense effusions of lymph which take place in 
rheumatic pericarditis, sometimes covering the whole surface of the heart and 
pericardium with a layer of lymph half an inch in thickness, and whose 
irregular surface has been compared to a honeycomb, a calf's stomach, or to 
the external aspect of a pine-apple. 
It is rare that the exudative process in acute rheumatism advances to sup- 
puration. It has been observed, however, sometimes in the muscles, but 
more commonly within the capsules of the joint (Stohl, Chomel, Moreau, 
Piorry, Cruveilhier, Bouillaud, Macleod). 
Ulceration of texture is by no means unusual in cases of rheumatism, some- 
times perforating capsular membranes or destroying ligaments, but more 
frequently eroding cartilages and the ends of bones. A remarkable change 
also sometimes takes place in the bones of rheumatic joints when the carti- 
lages have been lost. They becoine enlarged, and almost eburnified from in- 
creased ossific deposit, causing not only a change of form in the articular 
extremity, but presenting a mechanical obstacle to the motion of the joint. 
When the hip-joint is affected, the acetabulum becomes deeper and wider 
than natural, and the head of the femur, flattened and expanded, assumes 
something of the shape of a turnip. 
The parts most commonly affected in acute rheumatism are the joints, and 
such textures as are composed principally of the white fibrous tissue. Ac- 
cordingly, the valvular apparatus of the heart, its fibro-serous covering, the 
strong white glistening sac of the pericardium, are parts which most frequently 
suffer. Some joints are more prone than others to be attacked, such joints 
also being the most exposed, as the knees, the feet, the ankles, the wrist, and 
the hands, are the parts most commonly implicated; next in order, perhaps, 
follow the elbows, and then the shoulders and the hips. The larger joints 
suffer more frequently than the smaller, and the small joints, of the hands and 
fingers more commonly than those of the feet. Joints which have been in- 
jured, such 'as those which have been sprained, are more apt to suffer than 
others; so also those parts which are exercised violently, when that exercise 
is long continued. There is also a tendency to the symmetrical implication 
of joints. 
The constitutional expression of the disease may persist without the impli- 
cation of any external organ; but not unfrequently the investing or lining 
membrane of the heart becomes inflamed, and so do the lungs or pleurse- 756 
SPECIAL PATHOLOGY ACUTE RHEUMATISM. 
complications whose existence had been long unnoticed, or at least uncon- 
nected with the state of rheumatism. 
The heart affections embrace both the immediate and the subsequent 
dangers in an attack of rheumatism. The occurrence of the heart affection 
was at one time considered as due to a retrocession of the disease from external 
parts, and its consequent transfer to the membranes of the heart But endo- 
cardial or exocardial inflammation may occur as the first, and be for some 
time the only local symptom of the disease (Watson, Hope, Hache, Graves, 
Taylor, Fuller, and others). Acute rheumatism and pericarditis may also 
coexist without any articular affection (Hache, Graves, Taylor) ; and the 
cardiac complication sometimes even precedes by several days the access of 
articular redness and swelling; and even in cases where cardiac affection does 
not take place until after inflammation of the joints has been set up, it is 
rarely'preceded or accompanied by subsidence of the previously existing artic- 
ular inflammation. In other words, in the great majority of cases it has been 
shown that no connection can be traced between the two sets of actions, 
beyond their origin in one common source of mischief-in one poison which 
excites inflammation now at one spot and now at another. At one time the 
disease attacks several joints simultaneously, or in succession, and then the 
investing or lining membrane of the heart; at another time reversing the 
order of attack, it excites inflammation first of the heart and then of the 
articular structures. Hence, although rheumatic inflammation of the heart 
may possibly be connected in some rare instances with the sudden subsidence 
of articular inflammation and the transfer of irritation from the external 
parts, it must be regarded in most instances as a mere coincidence, and as an 
extension of the local manifestations of the disease (Fuller). 
As a general rule, like the severe cases of articular rheumatism, the occur- 
rence of cardiac complication may be expected in cases remarkable for the 
severity of their general symptoms. But from the nature of this disease all 
cases are liable; and the cardiac symptoms may for a time be the only ones. 
Hence has arisen the apparent difference of opinion as to which are the cases 
peculiarly prone to heart disease. Dr. Latham and Dr. Watson state that 
"pericarditis is not more to be looked'for when the disease is severe than 
when it is mild; " but, according to the experience of Dr. Fuller, it is incon- 
sistent to believe that it often occurs in case's which are not characterized by 
active symptoms of disease. "Whenever I have met it," he writes, "even 
though the articular inflammation may have been slight or evanescent, the 
febrile disturbance has always been severe, and accompanied by profuse and 
sour-smelling perspiration." His experience expressed numerically stands as 
follows: "That whereas pericarditis occurs once in about every 6.3 patients 
suffering from acute rheumatism, it does not accompany above one in every 
66.5 cases of the subacute form;" and his experience in this respect is con- 
sistent with that of M. Bouillaud, Drs. Macleod, William Budd, and Copland. 
In many instances the heart remains unaffected throughout the attack ; and 
though it does sometimes suffer even in the milder cases, it is most commonly 
damaged in those instances which are marked by unusual severity of their gene- 
ral symptoms, by the number and intensity of the articular inflammations, and 
by the rapidity and frequency of their migration. It is found in youth, in women 
rather than in men, in those persons who have been weakened by illness, or 
by large and repeated bleedings, and in those peculiar states of the system 
marked by a deficiency of red globules in the blood, when the heart's irrita- 
bility is much increased, and palpitation is readily induced. These are the 
cases in which cardiac inflammation is most liable to arise during an attack of 
rheumatism (Fuller). 
The lesions from which the heart is apt to suffer in cases of rheumatism are 
-(1.) Inflammation of the pericardium or endocardium; (2.) Inflammation 
of the substance of the heart itself; (3.) Fibrinous vegetations on the valves COMPLEX LESIONS IN ACUTE RHEUMATISM. 
757 
and on the lining membrane of the heart, independent of endocardial inflam- 
mation. 
These vegetations, like other exudations, are doubtless common in endocar- 
ditis, but they are not necessarily dependent on endocardial inflammation, 
and may take place without its occurrence (Kirkes, Ormerod, Fuller). 
These fibrinous deposits seem to be more immediately connected with the 
abnormal condition of the circulating fluid, or alterations on the surface of 
the lining membrane of the vessels; for they are almost entirely confined to 
cases accompanied by acute and widespreading inflammation, and by condi- 
tions productive of unusual quantities of fibrin in the blood, and which tend 
to impair its solubility. The statistics of Dr. Barclay, in the Med.-Chir. 
Trans., vol. xxxi, confirm these observations. 
But although endocardial inflammation may fail in the first instance to pro- 
duce the fibrinous deposits on the valves, yet such endocardial attacks leave 
behind them a tendency to endocardial degeneration. The most common 
lesion which thus results is the fibroid degeneration of the valves-a rheu- 
matic lesion which may occur without any articular symptoms. It slowly 
advances from year to year, with a gradual but constant and more undoubted 
expression of symptoms; and ultimately the implication of important viscera 
(e. g., fibroid degeneration of the kidneys, with oedema, and anasarca) ensues. 
Rheumatism is often protracted and rendered complex by other lesions 
besides those of the heart. The different muscles of the body, their fascia, or 
tendons (in addition to the joints, or independent of them), are often the seat 
of rheumatism, and there are few structures of this kind which entirely 
escape. The scalp, for instance, is often affected. The muscles of the eye are 
occasionally so : Stohl quotes one case in which the patient squinted while 
the disease lasted. Rheumatism of the face is by no means unfrequent, and 
the muscles of the larynx are occasionally affected, causing aphonia. Every- 
body is familiar with the rheumatic affection termed " crick in the neck," 
" stiff neck," and which at the same time may affect the articulations of the 
clavicle and the intercostal muscles. Rheumatism of the abdominal muscles 
is by no means rare, the principal pajn being at their insertions into the crista 
of the ilium. Lumbago is well known as a rheumatic affection of the sheaths 
of the fleshy mass of the lumbar muscles, on one or on both sides of the loins, 
extending often to the ligaments of the sacrum. The pain is increased by 
every movement of the back, or pressure on the muscles implicated. The 
insertion of the tendo Achillis into the os calcis is another frequent seat of 
rheumatism ; but no parts are more often or more painfully affected than the 
tendinous structure of the soles of the feet. When the neurilemma of the 
sciatic nerve is affected, such rheumatism is one form of sciatica. Pleurodyne 
designates the rheumatism of the intercostal muscles, or the fibrous fascia 
which incloses them. These .forms of muscular rheumatism are seldom ac- 
companied by any swelling or other external symptom. 
When catarrhal affections are prevalent, inflammation of the lungs or 
their investing membranes may be expected. Acute inflammation of the 
sclerotic coat of the eye is not uncommon, and appears to be most of all 
liable to occur in cases where the tendency to gout prevails as well as the 
rheumatic condition. Inflammation of the brain or of the investing mem- 
branes is one of the most frightful but happily rare complications. Cases of 
active maniacal delirium, sympathetic and symptomatic, of cardiac or pul- 
monary disease, or of the general vitiated condition of the circulating fluid,, 
have also been recorded. 
"It is worthy of note," writes Dr. Fuller, in conjectures regarding the 
reason why constant lesions of particular textures occur in rheumatism, "that 
the textures most commonly implicated are all examples of the albuminous 
and gelatinous tissues, from the decomposition of which, in the wear and tear 
of the body, are formed those secondary organic compounds, the lithic and 758 
SPECIAL PATHOLOGY-ACUTE RHEUMATISM. 
lactic acids, with which gout and rheumatism are intimately connected 
and probably also, he might have added, the increase of fibrin, as John Simon 
has conclusively indicated. It may be for this cause, therefore, that the 
rheumatic poison has a special affinity for the fibrous and fibro-serous textures 
throughout the body, and fixes more especially upon those which are in any 
way subject to irritation. According to the intensity of the febrile disturb- 
ance, as measured by the thermometer, so, coeteris paribus, would appear to be 
the liability to inflammation, whether of the joints, the heart, or any other 
part of the body; and the increase of temperature above 98.4° Fahr, will 
give a tolerably accurate measure of the amount of the poison present in the 
system, and of the patient's susceptibility to its influence. The number and 
intensity of the articular inflammations, and the proneness they exhibit to 
shift their quarters, serve also as guides to the probability of heart or other 
internal affections ; and the extreme liability to cardiac inflammation, engen- 
dered by the repression or rapid subsidence of the articular inflammation, is 
explicable by the greater quantity of the poison which is thus suddenly thrown 
into the blood's current (Fuller). 
Rheumatism may be acute or chronic ; but the proportion of cases of the 
latter is infinitely greater than of the former. 
The varieties of rheumatism are as follow: (1.) Acute Rheumatism; (2.) 
Subacute Rheumatism-a disorder analogous to the acute, but " of moderate in- 
tensity, with little or no febrile disturbance;" (3.) Gonorrhoeal Rheumatism-an 
analogous affection associated with gonorrhoea, and no doubt influenced more or 
less by the characters imparted by the virus transmitted through the specific gon- 
orrhoeal matter. (4.) Synovial Rheumatism-a rheumatic affection in which 
an accumulation of non-pumdent fluid occurs in the synovial sacs, and especially 
in those of the knee-joints; (5.) Muscular Rheumatism-pain in the muscular 
structures, increased by motion. The local varieties are-(a.) Lumbago, (b.} 
"stiff neck," (c.) Chronic Rheumatism-chronic pain, stiffness and swelling of 
various joints. 
Morbid Anatomy.-The synovial capsule of joints which has been the seat 
of pain and swelling is generally more or less congested, with' bloodvessels 
visibly ramifying over the synovial tufts. The inflammation, as judged of 
by the lesions, never attains a very high grade ; and the exudation into the 
joint is usually neither copious nor fibrinous-nor does it contain many pus- 
cells. The swelling of the joints is generally accounted for by the inflamma- 
tory oedema of the connective tissue about the joint. The synovia of the joint 
varies in its morbid condition from slight turbidity to absolute purulent or 
fibrinous exudation. Lesions in connection with the complications have beep 
already noticed. 
Symptoms.-Acute rheumatism expresses itself by a severe inflammation 
of the feet, of the hands, or of the larger joints,- as the wrist, ankle, knee, hip, 
elbow, and shoulder-joint, or of one or more of these parts, and this is usually 
accompanied by severe inflammatory fever. Affection of a single joint may 
constitute the whole disease ; but in some cases, eith'er with or without the 
subsidence of the articular inflammation, the heart or pericardium, or the 
membranes of the brain, may become the seat of rheumatic inflammation. 
The proportion of persons whose heart is thus affected probably varies ac- 
cording to the treatment, and other circumstances noticed in the former 
section. Bouillaud estimates the number at more than one-half, or as 64 in 
114 cases, and Dr. Macleod at one-fifth. The affection of the membranes 
of the brain is much more rare, but the proportionate number is not deter- 
mined. 
In an attack of acute rheumatism the fever often precedes by twenty-four 
or forty-eight hours the inflammation of the joints ; but this is not constant, 
for in some instances the local and general symptoms are contemporaneous, SYMPTOMS OF ACUTE RHEUMATISM. 
759 
while in others the inflammation of the joints is established before the acces- 
sion of the fever. 
The fever which attends acute rheumatism is well marked and striking, 
and symptoms of functional derangement present themselves long before its 
full development. Before actual fever is established, the patient feels " out 
of sorts," and unusually sensitive to atmospheric vicissitudes ; he looks pale, 
with a sallow, unhealthy complexion, and a dull eye with yellowish conjunc- 
tivae. The chilliness or shivering with which, in common with other acute 
fevers, rheumatism is ushered in, speedily passes away, and is followed by 
great heat of the skin, by copious but partial perspiration, almost invariably 
acid, reddening litmus paper, and of a disagreeable sour odor. It is a mis- 
take to suppose that much perspiration is useless. It is Nature's cure for the 
disease. It may be "wasting and enfeebling," as excessive perspiration always 
is, but it is highly sanative. If it does not occur, the pains are always more 
excessive, and if perspiration should unexpectedly cease, the constitutional 
symptoms become more severe. The materies morbi is obviously got rid of, 
to some extent, by the sweating, and the natural cure of the disease is mainly 
effected by these profuse sour-smelling perspirations, which are only useless 
when they are not of this characteristic sour description. They are then em- 
phatically " useless, wasting, and enfeebling," and ought to be arrested. 
The urine in acute rheumatism presents the strongest type of the so-called 
febrile urine (Parkes, 1. c., p. 286). It is scanty, of high specific gravity, 
deeply pigmented, and deposits, on cooling, deep-colored sediments of urates. 
It very much resembles pea-soup. The water is lessened; the total solids 
augmented (chiefly by increase in urea and pigment); and the urea in most 
cases is very considerably augmented. Dr. Parkes has observed an excess of 
one-fourth or one-fifth over the physiological amount; and the amount is greater 
in equal periods during the day than during the night; and when the very 
spare diet of rheumatic patients is considered, the great disintegration of nitro- 
genous tissue is obvious-represented as it is by a daily excess of from ten to 
twenty grammes of urea. The uric acid at the same time is somewhat increased; 
and there is usually a great quantity of water passed during the height of the 
disease, and at the commencement of improvement, or some days afterwards. 
The chlorides are often diminished, and sometimes disappear. Dr. Parkes 
has found a very great increase in the elimination of sulphuric acid, being 
sometimes double that passed during convalescence. The analyses of others 
have shown no increase. The pigment and extractives are always greatly 
increased. Albumen appears in some cases, generally small in amount, and 
very transient; the kidneys suffer much less frequently and much less pro- 
foundly than in many other diseases where the system generally is so much 
out of order. The pulse rises to 90, 100, and 110, and is large, full, and 
strong; and if the temperature rises above 104° Fahr., the chances of danger 
increase, and the case is a severe one. The tongue has usually a creamy-like 
covering, and is greatly loaded with a white or yellowish-white mucus; the 
bowels sluggish; the evacuations dark and offensive. There are many remark- 
able differences between the fever of rheumatism and the phenomena of con- 
tinued fevers; for it runs no given course, is not marked by changes of the 
tongue, nor by any great depressing action; while delirium and headache are 
of rare occurrence. 
Dr. Sydney Ringer, the Professor of Materia Medica in University College, 
has made some very accurate and extremely interesting observations on the 
range of temperature in three cases of acute rheumatism, and he has kindly 
permitted me to make use of his MS. notes. 
The concurrent phenomena in one of his cases (a man twenty-three years of 
age) may be shortly stated as follows: 
On the evening of the third day, two days after rigors, the temperature in 
the axilla indicated 102.6° Fahr.; at ten o'clock at night of the Same day it 760 
SPECIAL PATHOLOGY-ACUTE RHEUMATISM. 
had fallen to 101.4°. The face was flushed, the eyes bright, the lips rather 
dry, the skin very hot to the feel, and dry, the tongue very red and rather 
dry; and thirst was greatly complained of. The bowels, hitherto confined, 
had been opened by medicine. Pulse, 150; respiration, 36. Some dulness 
underneath the right clavicle. Enlargement of the liver. 
On the morning of the fourth day (at nine a.m.) the temperature had fallen 
to 100° Fahr.; by noon of the same day it again rose to 103° ; in the after- 
noon it fell to 102.6°; and by ten o'clock at night of the same day it had 
again risen to 103.4°. 
He had passed a quiet night, without delirium, sweated much, looked better 
in the morning, was less flushed, and had a moist skin. Much pain and ten- 
derness in both shoulders for the first time yesterday. Seized with pain in 
the left knee during the night, which was very severe. Left knee is greatly 
swollen ; the swelling is tense, pushing the patella before it, rising some dis- 
tance above and round that bone. No local redness, but some heat; has had 
frontal headache for several days ; tongue red and rather dry at the tip; thirst 
less; bowels opened several times during the night; edge of liver rather 
rounded, can be felt as low as the umbilicus; heart appears displaced some- 
what towards the middle line-sounds normal-no friction; pulse, 120, weak; 
respiration not hurried ; no action of nares ; urine contains a large quantity of 
lithates and a small amount of albumen. No casts nor blood seen on micro- 
scopic examination. 
On the morning of the fifth day (at nine a.m.) the temperature had fallen 
to 103°, where it remained till three o'clock p.m. At seven in the evening it 
had fallen to 102°, after which it began to rise, and continued to rise till ten 
o'clock at night, when the thermometer indicated 104.6° Fahr. 
Pie had slept badly during the night, and perspired freely. His complexion 
has acquired a sallow appearance, and the conjunctivae are jaundiced. Sordes 
exist about the teeth and gums. Pain in both shoulders, in elbows, and in 
left knee; no pain in other joints, nor in the head. Tongue red and dry; 
much thirst; bowels open twice ; heart healthy. About ten o'clock at night 
he complained of great pain over the lower part of the sternum ; and friction 
is heard with the systole at the base of the heart; and there is pain in the 
chest, which is rather increased by breathing. 
On the morning of the sixth day (at nine a.m.) the temperature had fallen 
to 101°, and by noon had only risen T%ths of a degree; but by four p.m. the 
thermometer indicated 104.8°, after which it continued to fall till 9.30 p.m., 
when it indicated 100° Fahr. 
He had passed a very restless night, and was delirious. The features appear 
shrunken and very sallow; the conjunctivae yellow. Sordes exist on the gums 
and teeth ; sudamina on the chest; sweated freely ; pain in the right shoulder 
and elbow, none in the left. No redness, no swelling, and no tenderness save 
only on movement; but the pain and swelling still continue in the left knee; 
pulse, 106, weak; friction at the base of the heart, the same as the previous 
night; bowels moved once daily, the motions being liquid, and of a pale yel- 
low color. 
On the morning of the seventh day (at nine a.m.) the temperature was 104° ; 
at noon of the same day it had fallen to 102°; in the evening (six o'clock) it 
registered 101.6°, after which the temperature continued to rise slightly till 
nine at night, when the thermometer indicated 102.2°. 
He had been delirious during the night. Sordes exist on the teeth and lips; 
face and chest distinctly but not intensely yellow; perspired much during the 
night. No pain when at rest, but on movement there is pain in the right 
shoulder and elbow, also in both knees. Right knee is now tender, but not 
swollen; tongue dry and red; motions pale; much thirst; heat as before; slight 
cloud of albumen in the urine. 
On the morning of the eighth day (at nine a.m.) the thermometer indicated BODY-TEMPERATURE IN ACUTE RHEUMATISM. 
761 
a temperature as high as 104.2° Fahr.; in the afternoon (two p.m.) it had 
fallen to 103°, and rose again slightly in the afternoon. 
Emaciation has advanced rapidly; he lies in an apathetic state, with the 
eyes partially open, and mucus begins to cover the cornea. Conjunctivae finely 
injected. Delirium during the night, but replies to questions reasonably in 
the morning; yellowness increased; right knee much more swollen, the left 
less so; tongue very dry; no increase of dulness over the heart; slight friction- 
sound still heard at the base; no endocardial murmur; urine high-colored, no 
albumen. 
On the morning of the ninth day the thermometer indicated 103° Fahr. 
By noon of the same day it fell to 101.4°. It rose slightly in the after- 
noon, and remained at 102° Fahr.; at nine p.m. is getting worse and losing 
flesh rapidly. He lies with his eyes almost closed, noticing nothing, but 
answering questions correctly; yellowness more marked in the conjunctiva; 
right knee swollen; swelling of right ankle; liver much less enlarged-a dis- 
tance of four fingers' breadth between its margin, as now felt, compared with 
the line to which it formerly reached; motions liquid and dark-colored; 
heart's boundaries as before; no friction-sound. 
On the morning of the tenth day (at nine A.M.) the temperature had risen to 
103°, but fell towards noon to 102°. In the afternoon it had again risen to 
103.2°, after which it again began to fall. 
On the morning of the eleventh day (nine A.M.) the thermometer indicated 
102.8°, and by noon it had fallen to 102°. During the afternoon it rose 
again steadily, and by ten at night it registered 104°. 
On the morning of the twelfth day (at nine A.M.) it had fallen to 101°, but 
by noon it had risen to 103.3°, after which it fell in the afternoon to 102.2°, 
but rose in a short time again to 103.4°, falling in an equally short time to 
102°, where it remained at eight o'clock at night. 
On the morning of the thirteenth day (nine A.M.) the thermometer had risen 
to 105.4° Fahr., when he was moribund; and it remained at that high tem- 
perature till death in the afternoon. 
At the post-mortem examination an abscess was found in the right sterno- 
clavicular articulation, and much clear tenacious fluid .of a yellow color was 
found in many of the joints. 
Universal pericarditis surrounded the heart, but no fluid effusion existed 
to any extent. 
The liver weighed eighty ounces, the left lobe being enormously enlarged, 
and the right diminished. Its substance was deeply notched, giving a lobu- 
lated appearance to the organ. On section it is very firm and rather pale. 
The lobules are very much enlarged, and distinct from each other. An excess 
of fibrous tissue is seen by the microscope to surround the lobules, the cells 
of which look pale and free from granules. The spleen was much enlarged, 
but normal. The kidneys were much enlarged and congested; and the pyra- 
mids were marked by opaque streaks of fat. 
This case and others indicate remarkable vacillations of temperature, occur- 
ring irregularly during the day; and they show a very high temperature, met 
with occasionally before death-in some cases as high as 109.6° and 110°. 
This is an extreme and severe case; and although the fever appears to show 
remarkable and extreme differences in different cases, so much so that no 
range of temperature can be represented as common to every case; yet, when 
a great number of cases of acute rheumatism are compared, certain typical 
ranges of temperature are more commonly met with than others (Wunder- 
lich). In a large number of cases the temperature rises gradually during 
the commencement, and reaches its maximum height at the end of the first 
week, or at the beginning of the second. It then remains for a few days with, 
if any, very slight fluctuations; and afterwards, with care and good nursing, 
continues to descend with moderate morning remissions. Nothing like weekly 762 
SPECIAL PATHOLOGY - ACUTE RHEUMATISM. 
cycles is to be noticed; and the thermometric indications seem not able to aid 
the diagnosis of inflammation of the internal organs, such as the heart. 
RANGE OF TEMPERATURE IN A CASE OF ACUTE RHEUMATISM AFFECTING MANY JOINTS (Wunderlich). 
Fig. 83. SYMPTOMS OF HEART COMPLICATION IN RHEUMATISM. 
763 
The fever never commences in the sudden manner of pneumonia, but with 
an insidiousness like that of enteric fever. Exceptional cases have been noted 
as high as 104° Fahr., or more, as early as the second to the fourth day; but 
by the middle or end of the first week of illness, the temperature may be 
moderate and continue so. The maximum reached in the evening hours may 
be 104° Fahr., and occurs generally between the fifth and ninth day, and it 
may remain high for from two to three days, ranging, as a daily maximum, 
from 101.48° Fahr., to 103.1° Fahr. The character of the fever up till now 
may be continuous, exacerbating or remittent. The defervescence may be by 
lysis; and it is exceptional to meet with a rapid downfall, such as would war- 
rant the name of crisis; ten to twenty or more days may be taken in this pro- 
cess, the daily decrease being so trifling in amount. Repeated attacks and 
hereditary tendency protract convalescence. 
Pericarditis or endocarditis may occur without elevating the temperature 
even one-tenth of a degree. Aortic valve insufficiency, however, generally 
causes greater disturbance than mitral. But, on the other hand, a marked 
increase of temperature for more than one day ought to rouse suspicion, and 
suggest inquiry into the condition of the heart and lungs. The supervention 
of pneumonia is certain to raise the temperature. 
Cases of a malignant rheumatic character reveal themselves by rigors, with 
intense fever, severe nervous symptoms, jaundice, hemorrhages, diarrhoea, and 
enlargement of the spleen ; and death occurs with enormous elevation of tem- 
perature-109.4° Fahr, to 111.2° Fahr. Wunderlich considers that such cases 
ought to rank with cases of spontaneous pycemia or acute yellow atrophy of the 
liver. Death often occurs when the temperature of rheumatism reaches 105° 
Fahr. (Ringer, E. L. Fox, Woodman). 
A persistent temperature above 102° for ten or twelve days will generally 
be followed by protracted convalescence. 
High temperatures usually correspond with a high pulse; but an evening 
temperature of 103° Fahr, may go with a pulse of 84 or 90, so that there is 
often a disproportion between the temperature and frequency of the pulse 
(Woodman's Translation of Wunderlich, p. 394, et seq.f 
These phenomena are associated with acutely painfid, hot, and swollen 
joints; thus the local symptoms which accompany the inflammation of the 
articulations are pain, heat, redness, and tumefaction. The pain is generally 
active and severe, although in a few cases it is latent-that is, the patient is 
at ease, unless the joint or limb be moved. At first the pains may wander 
capriciously from limb to limb, and produce more or less temporary stiffness. 
It has many degrees of intensity, being in a few instances trifling, but more 
commonly atrocious and agonizing; and, though generally constant, it is 
sometimes intermittent. It is always greatly augmented by pressure, so that 
the slightest touch-even the weight of the bed-clothes-is insupportable; it 
usually somewhat remits during the day, and is aggravated at night. The 
heat of the inflamed joint is constantly increased, the thermometer indicating 
a temperature of 100° to 105° Fahr., or even more. Redness, though not 
universally present, is nevertheless the rule, and the affected joint is sur- 
rounded by a rose-colored blush, evanescent on the slightest pressure, yet re- 
turning on its removal. The tumefaction of the part is generally so consider- 
able that the shape of the hand, the ankle, or other joint, is completely 
destroyed. In affections of the knee the patella is often more or less displaced 
by effusion into the cavity of the joint; and this, together with the swelling of 
the external parts, obliterating all the markings of its healthy state, renders 
the knee misshapen and rounded. "The surrounding skin becomes dry, tense, 
and shining-so much so, indeed, that experience alone enables us to predict 
that suppuration will not take place." 
One of the most remarkable and suggestive facts in regard to rheumatism 
is, that "the fever and constitutional distress are not always commensurate 764 
SPECIAL PATHOLOGY ACUTE RHEUMATISM. 
with the extent and intensity of the local symptoms." The rheumatic inflam- 
mation of the joints is very frequentlypreceded by febrile disturbance; and 
sometimes the fever runs so high before any local symptoms have been estab- 
lished, that even cautious and intelligent practitioners may mistake the nature 
of the impending attack. Moreover, when febrile symptoms do thus precede 
the establishment of local inflammation, they are not only not increased by 
its occurrence, but they are very generally relieved, the pulse becoming calmer, 
the countenance1 less anxious, and the patient altogether easier (Sydenham, 
Fuller). 
Such are the general and local expressions of a diseased state of the system 
in acute rheumatism ; and at the height of the disorder it is difficult to con- 
ceive a more complete picture of helplessness and suffering than that to which 
the patient is reduced. A strong and powerful man, generally unused to ill- 
ness, lies on his back motionless, unable to raise his hand to wipe the drops 
which flow fast from his brow in the paroxysms of pain, or the mucus which 
irritates his nostrils. Indeed, he is so helpless that he is not only obliged to 
be fed, but to be assisted at every operation of nature. The sweat in which 
he lies drenched seems to bring him no relief; his position admits of no change; 
if he sleeps, his sleep is short, and he wakes up with an exacerbation of suf- 
fering which renders him fretful, impatient, and discontented with all around 
him. 
The duration of acute rheumatism is various; in some cases both the fever 
and local pains are gone in three or four days, but in the majority of instances 
they continue till about the tenth to the fourteenth day, when the fever dis- 
appears and the pains begin to subside. Towards the close of the third week 
or the beginning of the fourth, the patient is recovered, and generally without 
injury to the joints affected. In almost all cases, however, the pain continues 
till after the fever is gone, and sometimes for a very long period afterwards. 
Dr. Fuller's observations lead him to believe that under ordinary methods 
of treatment acute rheumatism continues from four to five weeks, and patients 
are generally able to leave an hospital about the end of the sixth week. But 
the average duration of an uncomplicated attack may be reduced by judicious 
treatment from a month or five weeks to ten days or a fortnight. The patient, 
though recovered, is liable to relapse, and often suffers from it. 
The symptoms which indicate cardiac mischief are pains or soreness all 
over the chest, increased on pressing between the intercostal spaces, and also 
on taking a deep breath. The patient is restless, his countenance anxious, 
and occasionally he coughs. On applying the stethoscope to the chest a mur- 
mur may be heard, loud and permanent, and evidently arising from some 
irregular contraction about the orifices of the heart or from some affection of 
the valves. Many physicians believe that the exact pathological state of the 
pericardium can always be determined. Thus, if the inflammation be diffuse, 
we shall have a crackling sound like that of new leather, the parts being dry; 
or if serum be effused, we shall find the heart moving in a larger space than 
usual. Again, if lymph be poured out, we shall have a rubbing sound ; and, 
lastly, if pus be poured out, it will be determined not only by the greater 
space in which the heart moves, but by the sudden collapse and rapid sinking 
of the patient. (See " Pericarditis," &c.) 
If acute rheumatism be severe and neglected, the patient may die in three 
or four days of this secondary cardiac affection; but under proper treatment 
the complication seldom continues beyond a week. If this attack be alto- 
gether neglected, and the patient survive, the pericardial surfaces either be- 
come adherent or the valves of the heart become permanently diseased. The 
ulterior effects of these lesions are dropsies, asthma, or affections of the lungs, 
which baffle all the resources of our art, and ultimately they are to be classed 
among the most fatal maladies incident to humanity. 
The pain in chronic rheumatism is often latent, unless the part be moved, PROGNOSIS IN ACUTE RHEUMATISM. 
765 
and then the agony is severe. In many cases it is quiescent during the day, 
but it is extremely acute during the night. This pain has a great tendency 
to shift from joint to joint, often subsiding and again recurring. Redness is 
rarely present in chronic rheumatism; and, indeed, pain is the character by 
which it is most commonly indicated; so that the term "pains" is not unfre- 
quently understood to mean " chronic rheumatism." In military medical 
practice much caution and circumspection are necessary in assigning to "pains " 
alone their proper significance. 
It is often impossible at first sight to state positively, from the appearance of 
a soldier, whether a man who complains of " pains" is or is not suffering from 
chronic rheumatism, expressing itself by " pains" amongst the extensive white 
fibrous tissues which constitute the sheaths of the muscles, the covering of the 
bones, and the ligaments of the joints. The man may really suffer excru- 
ciating pains in the muscles of a limb, or in the fibrous tissues round a joint, 
and may be quite incapable of using his limbs in anyway, or at all events of 
performing the active duties of a soldier; and yet there may be no apprecia- 
ble heat or local swelling-no material disturbance of the system at the time 
-no altered state of the tongue or disturbed condition of the pulse, to indi- 
cate what he really suffers. Such cases must have the benefit of the doubt, 
with due caution to prevent " pains " becoming epidemic amongst the men. 
The military medical officer must therefore be prepared to meet with two 
classes of cases, namely,-(1.) Old soldiers who have previously suffered from 
rheumatism, or who are predisposed to the disease, and, it may be, " worn 
out" by previous disease and mode of life, and who suffer from chronic rheu- 
matism, expressed by "pains" diffused over all the joints and general fibrous 
tissues of the body. The continued exercise of military duties induces so 
much fatigue that the digestive functions become impaired, and "pains" are 
induced. Such men must not be regarded as schemers. (2.) Another class 
of men present themselves with " pains," who have resolved, by all and every 
means in their power, to escape as much duty as possible, and endeavor to 
make the hospital a house of refuge. "Pains" are complained of in the 
knees, hips, shoulders, or loins ; yet the men may be in good health. Such 
men, in the first instance, must also have the benefit of the doubt till, by care 
and patient investigation of all the phenomena of life in those men, the nature 
of the case is fully made out (Gordon, in Indian Annals, 1860). Records of 
temperature taken regularly and continuously will be found especially useful 
in coming to a conclusion regarding such cases.. 
The lesions of motion vary from mere stiffness to an entire binding down 
of the joint. In this manner the hip and shoulder may be so firmly fixed 
that the arm cannot be extended nor the leg raised. The knee and elbow- 
joints are generally semi-fixed and cannot be straightened, while the fingers, 
if straightened, cannot be bent, or, if bent, cannot be straightened. When 
the joint is fixed, the muscles of the limb often become atrophied, sometimes 
partially so. Chronic rheumatism sometimes disappears in a few hours or in 
a few days; but, on the other hand, it may last many weeks, or months, or 
even years. 
Diagnosis.-The only diseases with which acute rheumatism, when attended 
with swelling and redness, can be confounded, are erysipelas, gout, and 
trichinous disease (see page 153, ante). Acute rheumatism is also often of 
difficult diagnosis when it attacks the intercostal spaces or diaphragm. It is 
apt to be confounded with pleuritic pains, or with other affections of the chest. 
It may also be confounded with many neuralgic affections, as well as with 
pleuritic diseases. 
Prognosis.-The number of deaths from acute rheumatism hardly exceeds 
one out of every thousand deaths from all causes; whence it is manifest that 
rheumatism is seldom fatal, although one of the most common, painful, and 
severe diseases of this country, and perhaps the number of unsuccessful cases 766 
SPECIAL PATHOLOGY-ACUTE RHEUMATISM. 
hardly exceeds one or two per cent. But although this disease is rarely im- 
mediately fatal, yet a considerable number of persons ultimately die from 
diseases of the heart, apparently resulting from the action of the rheumatic 
poison. The tendency to heart complication is greater in proportion to the 
number of joints affected (Bambeger). 
Prognosis requires to be guarded as to the results of acute rheumatism, 
besides cardiac complication and its consequences. Delirium, coma, or symp- 
toms, of extreme nervous depression are unfavorable signs, especially when 
at the same time the temperature rises high. Meningeal symptoms in acute 
articular rheumatism may eventually lead to chronic cerebral disturbances, 
which may last for months, or more-appearing as a form of insanity with- 
out fever, characterized by depression, or as a pronounced melancholy, 
with more or less stupor. It may be followed or alternate with states of 
excitement, and sometimes with choreic convulsions. The prognosis even 
in such cases is favorable, and recovery seems to result more rapidly and 
certainly if the joints become again attacked by acute rheumatism (Gries- 
inger). 
Chronic rheumatism may also be a more or less permanent result of the 
acute attack. 
A ground of prognosis has been also based upon indications derived from 
the condition of the urinary excreta: 
(1.) When the excretion of solid materials is large, other things being 
equal, the patient makes a rapid recovery; on the other hand, in lingering 
cases the excretion of solids is usually small. 
(2.) The urine being invariably scanty (12 to 14 ounces in the twenty- 
four hours), but generally from this cause only of high density, a guide to 
prognosis may be found by diluting the urine to the normal amount in ounces, 
and then determining its specific gravity, and according as that is high or 
low will the probable course of the disease be favorable or unfavorable (Dr. 
Stevenson, in Guy's Hospital Reports, 1866). 
The state of other excreta by the urine has been already noted at p. 759, 
ante, and in proportion as these excreta are free, so will the case progress 
favorably. 
Very few deaths occur from chronic rheumatism, so that the numbers that 
die bear but a very small proportion to those that more or less constantly 
suffer. The constitutional state associated with rheumatism is one in which 
attacks of bad health culminate at last in more or less severe paroxysms, 
after which the person for a time appears to have improved in health, and 
been better for his illness. 
Causes.-If we look to the course and antecedent phenomena of rheuma- 
tism, the disease may be observed to differ from all ordinary inflammations 
in the tendency it has to subside in one part and to appear in another- 
phenomena explicable by the laws of morbid poisons of constitutional origin, 
but which are opposed to all we know of the laws of ordinary inflammation 
occurring in a joint of a healthy person. An attack of acute rheumatism is 
a series of febrile paroxysms, during which, while one joint gets well, another 
becomes affected; and this is especially likely to be the case in anaemic con- 
stitutions, or in those who are enfeebled from any cause. Supposing this view 
of the case should ultimately prove correct, it will follow that cold and wet, 
by lowering the vitality of parts, greatly assist or promote the action of the 
poison, but are not the sole agents in the production of this disease. Any 
more express investigation into the remote or predisposing causes of rheuma- 
tism is extremely unsatisfactory. They are generally supposed to be identical 
with those causes which produce catarrh. Those, however, who refer catarrh 
to the vicissitudes of temperature only also attribute rheumatism to this 
cause alone; but the returns of rheumatism occurring in the different com- 
mands of our army effectually blast such an hypothesis. It is not in the TREATMENT OF ACUTE RHEUMATISM. 
767 
coldest climates that rheumatism is most prevalent, but at those seasons and 
in those climates remarkable for damp and variable weather. "Thus," says 
Sir A. Tulloch, "we find in the mild and equable climate of the Mediter- 
ranean or the Mauritius the proportion of rheumatic affections even greater 
than in the inclement regions of Nova Scotia and Canada; and though 
some of the provinces of the Cape of Good Hope have occasionally been 
without rain for several years, yet rheumatism is more frequent in that com- 
mand than in the West Indies, where the condition of the atmosphere is as 
remarkably the reverse. Exposure to wet, however, would appear to have 
much influence in causing that impairment of health which induces rheuma- 
tism, for we find the returns of the navy show a considerably larger pro- 
portionate number of attacks than in the army; the number per thousand 
annual mean strength attacked in the Mediterranean fleet being 63.9; in the 
West India and North American station, 69; and in the South American 
station, 72.3. A predisposing cause of rheumatism lies not so much in the 
abstract degree of cold as in the range of atmospheric vicissitudes; and 
Dr. Haygarth has estimated that the number of persons attacked with 
rheumatism in summer is to those attacked in winter in the ratio of five to 
seven." 
A very small number of children suffer from rheumatism. Out of 73 cases 
given by Chomel, 2 only were attacked under fifteen years-35 for the first 
time between fifteen and thirty-22 from thirty to forty-7 cases from forty- 
five to sixty-and 7 cases after sixty. At whatever age, however, rheumatism 
occurs, one attack, while it indicates the existing diathesis, does not establish 
a predisposition to another; and although many are always martyrs to the affec- 
tion, yet a well-developed rheumatic paroxysm and a complete recovery tend to 
establish (under attention to diet and the prevention of exposure to cold and 
wet) a greater' or less protection for a time. But anything which exercises a 
prolonged depressing influence upon the system, especially if there is at the 
same time an hereditary tendency to the disease, may induce the development 
of a severe rheumatic affection. The disease is distinctly hereditary. Dr. Ful- 
ler has traced the hereditary taint in nearly 29 per cent, of the cases admitted 
into St. George's Hospital. Men are believed to be more liable than women 
to rheumatism, but women, after menstruation has ceased, become more liable 
to rheumatism than males about the same age. 
Treatment.-It seldom if ever happens that the cure of rheumatism can be 
safely intrusted to any single remedy. The nature of the disease, as already 
indicated, points to various methods and combinations of treatment as most 
likely to lead to a successful issue. 
Venesection, calomel combined with purgatives, and opium, are the three reme- 
dies which have been most generally made use of in the treatment of rheuma- 
tism ; but many other remedies have also been employed, and are still advo- 
cated exclusively by not a few. These are especially vapor and hot-air baths, 
antimony, cinchona, colchicum, guaiacum, sulphur, nitre, lemon-juice, alkalies, 
'and their salts. Veratria has recently been added to the list. 
But as the disease, when uncomplicated, tends to terminate sooner or later 
in recovery, and may sometimes subside with marvellous rapidity under 
every variety of remedy, it is obvious that no sound inference can be drawn as 
to the success of any particular method of treatment, unless such treatment has 
been largely adopted in cases of similar severity-as estimated by the correla- 
tion of pulse, respiration, and temperature (measured by thermometer)-and 
been attended with tolerably uniform results. Each and every plan of treat- 
ment which has therefore been hitherto proposed is regarded by the profession 
as unsatisfactory. (See account of a discussion upon a paper read by Mr. 
Dickinson to the Royal Med.-Chir. Society of London, and reported in the 
Medical papers of 21st June, 1862.) If in one person's hands any particular 
remedial course has proved efficient, it has signally failed in those of another. 768 
SPECIAL PATHOLOGY ACUTE RHEUMATISM. 
If at one time a remedy has proved efficacious, it has been found inert or in- 
jurious at another, under different circumstances of age, sex, constitution, and 
the like. These facts ought not to appear strange to those who consider the true 
nature of the disorder, and the variety of circumstances under which the phy- 
sician may be called upon to minister to his patient's relief. Bleeding, which 
in the young, plethoric, and robust, may be necessary to allay excessive vas- 
cular action and cause free secretion, may in the weakly induce irritability of 
the heart and a consequent attack of cardiac inflammation. Opium, which 
in one person may prove of the greatest service in promoting free perspiration 
and in allaying the general irritability of the system, may in another check 
the biliary, "lock up" other secretions, and thus prevent the elimination of 
effete or deleterious matter from the system. The continued use of calomel, 
and constant purging by its means, which may be beneficial to one patient, 
by removing large quantities of unhealthy secretions, may unnecessarily ex- 
haust the strength of another, and tend very greatly to impede recovery. 
And so in regard to every remedy which has been proposed : what is useful at 
one time may prove useless, or positively injurious, at another. 
To learn how to adapt our present remedies to the exigencies of each par- 
ticular case is what is now most of all required. Acute rheumatism is mani- 
festly a highly inflammatory disease, but of a peculiar constitutional origin, as 
has been fully illustrated. The blood drawn presents a more copious layer 
of "buff" than it does in most other diseases. The proportion of fibrin being 
greatly increased, we can hardly feel surprised that bleeding has been largely 
had recourse to. But although bleeding has been extensively adopted, the 
profession has hitherto been much divided as to the advantage derived from the 
practice. A careful analysis of conflicting evidence leads to the conclusion 
that general bloodletting is not to be recommended, and on pathological 
grounds it is not justifiable. No advantage is gained as to time; the loss of 
a large quantity of blood is worse than the disease, for it would be felt by most 
persons all their lives ; but temporary, if any abatement of sufferings follows 
its use; lastly, this mode of treatment appears to have caused in the practice 
of Bouillaud an unusually large number of cases of myocarditis-a larger 
number, indeed, than has been witnessed by any other person in the profes- 
sion. A predisposition to cardiac inflammation is doubtless engendered by 
copious and repeated bloodletting: one-half the cases of acute rheumatism be- 
came so complicated after treatment by bleeding (Dickinson). It undoubt- 
edly increases the irritability of the heart, and consequently favors the pro- 
duction of cardiac complication. Repeated observation has led Dr. Fuller 
and others to believe that general bloodletting is only beneficial in first attacks 
occurring in young, robust, and otherwise healthy persons, particularly in 
those cases which are marked by unusual severity of their symptoms, or are 
unaccompanied by free perspiration. It ought at all times to be cautiously 
employed, and carried to a small extent only-viz., from eight to twelve ounces, 
according to the age and strength of the patient, the object being to favor the 
action of other remedies, and to promote free secretion by its use, rather than to 
arrest or cut short the disease (Latham, Fuller). If, therefore, perspira- 
tion is free, and remedies are absorbed, bloodletting is not to be thought of. 
In mild cases it is unnecessary; in the delicate, and those of weakly constitu- 
tion, it is inadmissible; and in the well-expressed rheumatic diathesis, or when 
the disease is distinctly ascertained to be hereditary, it utterly fails in modify- 
ing the morbid action, is ill-borne by the system, and therefore should only 
be practiced under the extremely urgent and specific conditions just men- 
tioned (Willan, Fordyce, Alison, Todd, Watson, Fuller, Dickinson). 
If circumstances, therefore, ever warrant its employment, it ought neces- 
sarily to take the lead of all other measures, and may be used in the young, 
plethoric, and robust, in whom secretion is insufficient, whose pulse is full and 
bounding, and whose skin is dry, and hot, and burning. A single bleeding is TREATMENT OF ACUTE RHEUMATISM. 
769 
sufficient to relieve the excessive congestion, on which the want of secretion in 
a great measure depends, and which forms an obstacle to the action of those 
remedies on which we rely for effecting a cure. Active purgation is also to 
be avoided. It is injurious for three reasons,-First, Because it is not neces- 
sary to the cure of the patient, and, like bleeding, tends greatly to reduce his 
strength and protract recovery. Second, Because, from the nature of the com- 
plaint, the patient is quite incapable of moving, and his sufferings are aggra- 
vated, his irritability is increased, and his heart's action accelerated, by the 
repeated shifting of his position, which is rendered necessary by the calls of 
nature. And, Third, Because it necessarily gives rise to more or less exposure, 
which must be prejudicial to a person bathed in perspiration (Fuller). 
After having obtained one full dejection by the following searching combi- 
nation, namely- 
R. Calomelanos, gr. v; Pulv. Jalap Co., 9ij-$i; Pulv. Zingiberis, gr. iii 
-gr. v; misce-to be taken in a little milk (which will secure an abundant 
secretion from the glandular follicles of the intestinal mucous membrane),- 
the subsequent aim of purgation in rheumatism should be to obtain merely a 
single free evacuation every morning. 
Such a daily evacuation of the bowels is then to be maintained by mild 
saline purgatives, such as the potassio tartrate of soda, sulphate and carbonate 
of magnesia, taken as a draught in the morning; and preceded every second 
night by a Plummer's pill at bedtime, combined or not, according to circum- 
stances, with a full dose of opium; or, a grain of the watery extract of Barba- 
does aloes may be found sufficient on alternate days. Opium may be given 
with the greatest advantage in the early and most painful stage of the disease 
occurring in adults, to the extent of six or eight grains of the powder in twenty- 
four hours, or two grains of the extract of opium may be given every night: 
to children, half-grain doses of the powder, or less, according to age, may be 
given every three or four hours. The bowels require to be kept open during 
its use; and its influence requires to be closely watched. If the urine increases 
in quantity, if the motions become more healthy in appearance, and the coated 
tongue cleaner and less red, the influence of the opium is beneficial. It en- 
courages sweating. 
Colchicum administered alone is a dangerous agent; but its virtue as a remedy 
may be obtained in small doses in combination with other medicines. It may 
be given with small doses of ipecacuanha, alkalies, and opium. It promotes 
evacuation by the kidneys, and appears to exercise some unknown influence 
over the process of assimilation, whereby the formation of the rheumatic poison 
is checked. It is only in some cases, however, that it appears to be of 
service. It is far less efficacious in the weak and nervous than in the more 
robust and less easily depressed, and of less value in purely fibrous rheumatism 
than in cases where the synovial inflammation predominates. In the hands of 
Dr. Fidler it has proved less advantageous in proportion as the fever has ex- 
ceeded the articular swelling and as the urine has been less highly charged 
with lithates. The operation of this remedy must under all circumstances be 
most carefully watched; and a daily evacuation from the bowels must be secured 
during its use. If the lithates disappear from the urine, if the pulse becomes 
weak, if faintness, nausea, or purging supervene, the colchicum must be at once 
discontinued; but till some one of these symptoms occurs, a grain or a grain 
and a half of the acetous extract or the inspissated juice, or from fifteen to twenty 
minims of the wine of colchicum, may be safely and with advantage admin- 
istered two or three times a day. 
Veratria is to be used in small doses. The ordinary formula recommended is: 
Veratria and extract of opium, one grain each, to be divided into ten pills, 
of which two pills are to be given the first day, three the second, four the 770 
SPECIAL PATHOLOGY-ACUTE RHEUMATISM. 
third, five the fourth, and so on, increasing one pill each day, until the con- 
dition of the pulse or the irritation of the mucous membrane compels a dimi- 
nution. 
The beneficial effects of guaiacum are obtained in those cases which are un- 
accompanied by perspiration, and in which the excretory organs are gently 
excited by the action of the remedy; but when the patient is perspiring freely, 
and when it neither purges nor causes diuresis, very little benefit is obtained 
from its use. Combined with bitartrate of potass, sulphur, and rhubarb, it con- 
stitutes the chief ingredient in a celebrated empirical formula, well known to 
army medical officers under the name of " Chelsea Pensioner," which has ob- 
tained a high reputation amongst old soldiers as a remedy for the " pains," or 
chronic rheumatism. 
In some large hospitals, both civil and military, this remedy is in common 
use in the treatment of old chronic cases. Its composition is as follows: 
B. Pulv. Guaiaci, Ji; Pulv. Rhei, Jii; Bitartr. Potasses, Sulphur. Sublim., 
aa Ji; Pulveris Nucis Moschatce, Jii; Mel. Tbi; misce bene. Of this compound 
two large spoonfuls may be taken night and morning. 
Another formula is the following: 
B. Pulv. Sinapis; Sulph. Sublim., aajiii; Pulv. Guaiac., Jiss.; Pulv. Rhei, 
Potas. Nitratis, aa gr. xlv; misce bene. Honey, treacle, or glycerin, sufficient 
to make the dose into an electuary, is the most convenient form for use, of 
which a teaspoonful every alternate evening is useful; or a teaspoonful of the 
powder may be mixed with milk, and so taken at bedtime. 
The general treatment originally recommended by Brocklesby (1764), and 
followed successfully by Macbride (1772), Basham, Fuller, Furnival, Garrod, 
and now by many other physicians, is that by alkalies and the neutral salts, with 
colchicum, a little antimony being sometimes added, with the occasional aid of 
calomel, used only as a purgative, to promote evacuation from the glands of 
the intestinal mucous membrane. Baths are never to be employed if the skin 
is acting freely; but if it is hot, dry, and burning, its action may be success- 
fully stimulated by means of the vapor or hot-air bath. 
If the bowels act once a day, a laxative dose of calomel and opium may 
now and again be prescribed, if necessary, with the view of modifying the 
character of the intestinal secretions. Dark-colored and offensive stools indi- 
cate the necessity for the dose, followed by a draught of infusion of senna, 
together with half an ounce of the potassio tartrate of soda and twenty minims 
of the vinum colchici, and these should be repeated every evening and morn- 
ing till healthier evacuations are obtained-i. e., till the motions are light- 
colored, more bilious, and less offensive. 
Mercury has been recommended with the view of warding off cardiac symp- 
toms ; but when it is given so as to affect the constitution before the com- 
mencement of cardiac inflammation, it not only has no influence in preventing 
the disease, but, by the irritability and general depression which it occasions, 
appears to modify the course of the disease in a manner by no means condu- 
cive to recovery. It destroys the red blood-corpuscles, and adds to the anae- 
mia. About one in four cases treated with mercury are liable to cardiac 
complication (Dickinson). 
Alkalies, or the neutral salts, may be given in combination with colchicum, 
full doses of opium, and a little antimony. They aid the disintegration, and 
increase the elimination of sulphuric acid, by augmenting the alkaline condi- 
tion of the blood (Parkes). The alkalies ought to be given largely. The 
patients lose their pains under their influence, and proceed rapidly to conva- 
lescence. The pulse is generally tranquillized within forty-eight hours from 
the commencement of treatment; and if in twenty-four hours the pain is lulled treatment of acute rheumatism. 
771 
and the local inflammation greatly subdued, the constitution is evidently com- 
ing under the influence of the remedy. 
The form in which the remedy is to be given is that of a simple saline or 
nitre draught, to which from two to three drachms of the potassio tartrate of 
soda may be added, with ten to fifteen minims of the vinum colchici, from fif- 
teen to twenty minims of the vinum antimonii, and from ten to fifteen minims 
of the tincture of opium, or of Battley's sedative solution, to prevent the salt 
running off by the bowels. This draught is to be repeated for the first twelve 
or twenty-four hours, at intervals of three or four hours, according to the 
strength of the patient and the severity of the attack ; and if pain is excessive, 
a pill containing half a grain to a grain and a half of opium, or an equivalent 
dose of Dover's powder, may be given once or twice daily. In the use of 
these remedies, constipation and narcotism are to be avoided on the one hand, 
and diarrhoea to be guarded against on the other (Fuller). If the saline 
treatment is to be used alone, then a solution of nitrate, acetate, and bicarbonate 
of potash should be given in such doses that ten or twelve drachms of the two 
latter salts together are taken in the twenty-four hours. Half a drachm of 
the acetate, with a drachm or a drachm and a half of the bicarbonate, and ten 
grains of nitre, dissolved in an ounce and a half of water and sugar, or lem- 
onade, and given every two hours, night and day, until the joint affection and 
pains have begun to yield in severity, are sufficient for this purpose. Or the 
following : Nitrate of potash, one drachm ; acetate of potash, three drachms ; 
water, eight ounces;-of this mixture one ounce for a dose ought to be repeated 
every two, three, or four hours, according to the urgency of the symptoms; 
or from twenty to sixty grains of the bicarbonate of soda, or of potash, may be 
given every three or four hours in half a bottle of soda or seltzer water; or in 
an effervescent citrate of ammonia, or potash draught (Tanner). This is the 
treatment which most of all seems efficient in warding off the cardiac compli- 
cations ; and Dr. J. J. Furnival wras the first (after Prout) to direct the atten- 
tion of the profession to the use of alkaline remedies (carbonas potassce) in the 
treatment of Rheumatism, and especially as a preventive of the cardiac com- 
plication {Lancet, 1841, p. 305). The good effects of such treatment as a 
preventive of the cardiac affections have been since fully demonstrated by 
Fuller, Garrod, Basham, Goodfellow, and others. To be effective, the remedy 
must be carried out with energy and perseverance, till the articular and febrile 
disturbance are lessened, and till an alkaline condition of the urine is estab- 
lished as soon as possible. Liquor potassce in $ss. doses may also be given to 
the extent of Jiii to Jvi in twenty-four hours (Parkes). Brocklesby is the 
earliest authority for the use of large doses of nitre in the treatment of acute 
rheumatism. He enjoined, for a diluting drink, water-gruel boiled smooth, 
in each quart of which he dissolved two drachms of nitre, with or without 
sugar. He often thus prevailed on soldiers to take ten drachms or more of 
nitre in twenty-four hours. Dr. Garrod speaks well of the combination of quinine 
with the alkaline treatment, after ten years' trial. It is simply following out 
the treatment by bark (unpractical, from the large doses required) recom- 
mended by Fothergill, Morton-, and Hay garth. Five to ten grains of sulphate 
of quinine are to be given two or three times a day. 
The alkaline treatment of rheumatism as the basis of operations seems by far 
the most rational; for it has now been abundantly demonstrated that in cases 
of acute rheumatism there is an absolute deficiency of the saline ingredients 
of the blood; and while there is also a liability to fibrinous exudation, the 
tendency of saline remedies is to suspend the separation of fibrin (Stevens). 
The treatment which has saline remedies for its basis thus contributes to restore 
the balance of the saline ingredients in the blood, and controls the tendency 
to fibrinous deposition. The progress of inflammatory action being thus re- 
tarded, time is gained for other remedies to effect the diminution of the excess 
of fibrin present in the blood, as well as the destruction of the rheumatic ele- 772 
SPECIAL PATHOLOGY - ACUTE RHEUMATISM. 
ment, whatever that may be. One, two, or even three ounces of nitre may be 
taken in the twenty-four hours ; but it must be very freely diluted in lem- 
onade or in gruel. The urine passed under its influence acquires a high specific 
gravity, 1.026,1.040. 
In the experience of Dr. Chambers the nitre treatment is not so preservative 
against cardiac complications as the treatment with bicarbonate of potash; but 
his observations are not conclusive, because those treated with the latter remedy 
were also enveloped in blankets and flannel, so that no linen was allowed to 
touch the skin-a most important curative management of rheumatic cases, 
which cannot be overvalued. "Bedding in blankets reduces by a good three- 
fourths the risk of inflammation of the heart run by patients in rheumatic fever, 
diminishes the intensity of the inflammation when it does occur, and diminishes 
still further the danger of death by that or any other lesion; and at the same time 
it does not protract the convalescence" (Chambers's Lectures, chiefly Clinical, p. 
147). The patient, either naked or covered by a muslin shirt or shift, ought 
to be carefully wrapped up in blankets of the newest and fluffiest kind that 
can be got, which are to be so arranged as to shut off all accidental drafts of 
air from the head. On no account are the bedclothes to be thrown off, how- 
ever warm the surroundings may become; for an evenly high temperature to 
the skin, combined with absolute rest, are of the greatest value in rheumatic 
fever. Dr. Chambers considers thesatwo conditions worth all other means of 
relief put together. 
There is some difficulty in fixing exactly the date at which the disease may 
be said to have yielded, or to have disappeared. Cessation from pain has 
sometimes been taken as the sole indication. But a morbid state of the.sys- 
tem in rheumatism may exist after the joints are free from active pain, and 
even without the presence of any cardiac affection, which requires but the 
smallest exciting cause to bring back the articular or heart affection in all its 
pristine intensity. Patients in such a state, though free from pain at the 
time, cannot be considered rid of the disease. Dr. Garrod looks upon the 
following conditions, therefore, as indicating real freedom from the disease: 
(1.) Absence of pain and any acute tenderness of the joints; (2.) Freedom 
from any active cardiac affection; (3.) Absence of marked thirst, with re- 
turning appetite; (4.) No unusual rapidity or hardness of the pulse; and I 
would add, a normal temperature. 
External topical applications are also efficient aids in treatment. Warm 
fomentations are always employed with advantage; and of all applications a 
mixed alkaline and opiate solution, applied as a fomentation, is the most 
powerful in allaying the pain of rheumatic inflammation. The solution so 
highly recommended by Dr. Fuller for this purpose is composed of an ounce 
of the carbonate of potash dissolved in a pint of the decotion of poppies or of 
rose-water, to which six drachms of Battley's solution is added, or common 
tincture of opium, which is less expensive and equally efficient as an external 
application. The efficiency of salines as a local application is probably due to 
their influence in correcting the disordered state of the blood at the part, by 
preventing or destroying the aggregation of the corpuscles, and consequently 
their tendency to separate from the fibrin and to accumulate in the minute 
vessels. On this principle the application was theoretically indicated many 
years ago by Mr. Gulliver as useful in inflammation. Spongio-piline is ad- 
mirably adapted for the purpose of applying locally the saline remedies. Dr. 
Basham recommends its application in the following manner: "If the hands, 
elbows, knees, or feet are the seat of inflammation, gloves or caps are made 
of the spongio-piline to fit these parts; if a greater extent of surface be in- 
volved, a portion of the spongiogoiline is cut large enough to envelope the 
entire surface. The spongy surface of this epithem is first moistened freely 
with water, and any superabundant fluid squeezed from it, so that the linen 
or bed of the patient may not be unnecessarily wetted. Nitrate of potash, or TREATMENT OF ACUTE RHEUMATISM. 
773 
the salt to be employed, in powder, is then freely and plentifully sprinkled 
over the moistened surface, or rubbed in, to secure its solution and the 
thorough impregnation of the epithem; it is then applied to the inflamed part, 
and lightly secured by a roller. Nothing further is required than once in 
about six hours to remoisten the spongy surface; fresh addition of nitre is 
never required, if sufficient quantity has been used in the first instance. The 
salt in powder is hence better than a saturated solution, which nurses seldom 
succeed in making" (Basham, Med.-Chir. Trans., vol. xxxii, p. 10). 
Alkaline baths are recommended by Dr. Austin Flint. Two pounds of the 
bicarbonate of potass and one pound of the nitrate of potass are to be dissolved 
in water, at a temperature of 100° or 99° Fahr., and the patient ought to go 
into the bath at a temperature of 98° or 98.5° Fahr., and remain for not 
longer than ten minutes. 
In contradistinction to the principle of cure now laid down, and which has 
been called the method of neutralization, Dr. Herbert Davies, physician to 
the London Hospital, has recently advocated a method, by elimination, origi- 
nally recommended by Dr. Dechilly of Vancouleurs, in France, in a Memoir 
to the Academy of Medicine, in 1850 {Bui. de I'Acad, de Med. t. xv), as a 
safe and rapid mode of combating rheumatic fever. For this purpose his 
treatment is absolutely and entirely local, and consists of free blistering only. 
Believing that the virus localizes itself for a time in the inflamed joints, and 
that the intensity of the local inflammation is a measure of the amount of 
virus collected, he orders blisters varying in width, but of considerable size, 
according to the locality, to be applied round each limb, and in close prox- 
imity to the parts inflamed. Thus he affords, through the serous discharge 
from the blistered surface, a ready means of exit for the virus. The blisters 
are to be applied near to, but not upon every joint inflamed, at the very height 
of the inflammatory stage, even when the local pains are the most severe, and 
the constitutional disturbance the greatest. Dr. Dechilly enveloped the whole 
joint in a large blister, followed by others, according as joints became affected. 
Dr. Jeffreason, of St. Batholomew's, and Dr. Greenalgh, of the Middlesex 
Hospital, report favorably as to the results of Dr. Davies's method of treat- 
ment of acute articular rheumatism. It has been tried in France also, and 
reported on favorably by Dr. Laseque, of the Necker Hospital in Paris {Arch. 
Gen. de Med., Nov., 1865). 
The success of the plan is said to depend entirely upon the blisters being 
applied and allowed to remain until they have thoroughly acted. Linseed- 
meal poultices subsequently applied will be found highly serviceable in pro- 
moting a sufficient flow of serum. The blisters should be put entirely round 
the affected limb; and when the knees are the joints which suffer, the blisters 
should be cut at least three inches wide. 
If this method of treatment be adopted, no medicine ought to be given be- 
yond an occasional purge, and no advantage results from combining the alka- 
line or neutralization system of treatment with that by blisters, or the method 
by local elimination. If the two methods are combined, the period of conva- 
lescence is protracted. That the poison is really thrown out by the blister 
method of treatment is deduced as well from the rapid and permanent relief 
resulting from the local treatment as from the neutral and even alkaline condi- 
tion of the urine, which is a usual and early result of the treatment, as well as 
a rapid diminution in the force and frequency of the pulse {London Hospital 
Clinical Reports). 
The diet of the patient, in acute rheumatism, should be strictly limited to 
slops, such as arrowroot, beef tea (Liebig's Extract of Flesh), milk and lime- 
water, or milk made warm, to which a little carbonate of soda, nitrate of potash, 
or bicarbonate of potash is added, light puddings, to which sherry or brandy 
may be added, if depression exist; and even in many chronic cases it is de- 
sirable to limit the diet to puddings and white fish. 774 
SPECIAL PATHOLOGY-GONORRHCEAL RHEUMATISM. 
To obviate the great drain upon the system, it is necessary, however, that 
the rheumatic patient be better fed than in cases of idiopathic inflammation. 
Beef tea and jellies may be given, and strong coffee might also be administered 
frequently, on the same principle that it has been given in typhus fever by 
Dr. Parkes, following up the indications obtained from the physiological action 
of that beverage as expounded by Lehmann. 
The nature and treatment of the local complication, such as pericarditis, 
will be considered subsequently; but in addition to the alkaline remedies, 
which have an undoubted influence in shortening the duration of the illness, 
the bedding in blankets, referred to at p. 772, is a most important measure for 
preventing the cardiac affection. 
In the forms of muscular rheumatism the local appliances which secure 
rest and warmth are those which afford most relief. In lumbago nothing is 
so instantaneously beneficial as strapping the back from the level of the "seat" 
upwards, in imbricated layers, by straps of adhesive sticking-plaster, or warm- 
plaster (Tufnell). 
[In chronic rheumatism, sciatica, and lumbago, the means which give the 
readiest and most relief is the constant galvanic current.] 
GONORRHOEAL RHEUMATISM. 
Latin Eq., Rheumatismus Gonorrhdicus; French Eq., Rhumatisme Blennorrhagique; 
German Eq., Gonorrhoischer Rheumatismus - Syn., Tripper Rheumatismus; 
Italian Eq., Reumatismo da Gonorrea. 
Definition.-An affection analogous to acute rheumatism, associated with gon- 
orrhoea. 
Pathology.-It is only since the commencement of the present century that 
rheumatism, as a distinct complication of gonorrhoea, has been recognized. It 
was first recognized by Swediaur, who described it under the name of "Arthro- 
cele, Gonocele, or Blennorrhagic Swelling of the Knee." It has since been de- 
scribed by Sir Astley Cooper, Sir Benjamin Brodie, Ricard, Rollet, and many 
others, more recently in this country, especially by Barwell, Chambers, and 
Berkeley Hill. 
Numerous theories have been advanced as to the nature of gonorrhoeal 
rheumatism. 
(1.) The rheumatic diathesis, conjoined with urethritis, is held to explain 
the connection; but, as a rule, patients who are liable to gonorrhoeal rheuma- 
tism are generally those exempt from acute rheumatism, or anything like the 
rheumatic diathesis. 
(2.) It is maintained that gonorrhoeal rheumatism is not rheumatism, but 
the phenomena are considered the result of some reflex influence of the gon- 
orrhoea exerted through the inflamed urethra (Grisolle, Fournier). 
(3.) That the gonorrhoeal matter acts like a disease-poison, and infects the 
system like the poison of scarlet fever; and that the discharge of pus and ure- 
thral suppuration correspond to the cuticular eruption of scarlet fever 
(Texier). In this respect such a theory would bring the nature of the dis- 
ease in correspondence with the view taken by Barwell, who regards it, 
(4.) As a "slower form of purulent infection, produced by inflammation of 
the prostatic veinsand Dr. T. King Chambers considers that the " disease 
ought to be classed with pyaemia." If such is the correct interpretation of 
gonorrhoeal rheumatism, the pyaemia must be of that chronic kind described 
by Mr. James Paget, which is much slower in its progress, and less severe and 
dangerous in its course, than the pyaemia described at page 734, ante. The 
form Mr. Paget describes under this name has a close alliance with rheuma- 
tism (St. Bartholomew's Hospital Reports, vol. i, 1865). SYMPTOMS OF GONORRHCEAL RHEUMATISM. 
775 
That the rheumatic phenomena of such a complication are due to the gon- 
orrhoea may be inferred from the fact-namely, that it attacks patients who 
never suffer from rheumatism, except when they contract gonorrhoea; and 
that it sometimes recurs in the same patient with every gonorrhoea he' con- 
tracts. The disease presents certain characteristic features sufficient to indi- 
cate its origin. 
This special form of rheumatism commences either when the gonorrhoeal 
discharge continues in a profuse degree, or when it has been more or less 
speedily suppressed, or after it has quite disappeared. The parts affected are 
generally the knee-joints, or the knee, ankle, and toe of one side. Sometimes 
these affections are accompanied, preceded, or followed by severe rheumatic 
ophthalmia, in the form of a "sclerotitis." But the sclerotic and the iris are 
less frequently attacked than the joints. The knee-joint is affected, however, 
far more frequently than any other joint; next the ankle; then the hips, and 
fingers and toes in about an equal ratio; then the shoulder and wrists. The 
bursae connected with the muscular tendons, especially the tendo-achillis, and 
sometimes the sheaths of the muscles, are affected, and fasciae of the plantar 
region. Generally two or three joints at the most are affected in each case; 
and it is not usual for the affection to change about from joint to joint, as in 
ordinary acute articular rheumatism. In about one-third of the cases only 
one joint suffers (Rollet). It also differs from acute rheumatism in another 
respect-namely, that when it extends to more joints than one, the first af- 
fected joint does not recover its normal condition, but continues after the 
affection has seated itself in other joints. It is extremely rare for the heart 
to suffer. The sheaths of the great sciatic nerve sometimes suffer, when the 
pain along the course of the sciatic nerve is exceedingly obstinate (gonorrhoeal 
sciatica^. 
The tissues of the eye affected in gonorrhoeal rheumatism are-the lining 
membrane of the anterior chamber, causing cloudiness and misty vision; the 
iris, and the sclerotic; the affection sometimes passing from one eye to another. 
The influence of sex is also remarkable in the pathology of gonorrhoeal 
rheumatism. Women rarely suffer. All the undoubted cases of the disease 
have occurred in men ; but as men contract gonorrhoea from women, a ques- 
tion arises of great pathological importance, but very difficult to collect 
evidence upon-namely, suppose a woman inheriting or suffering by habit or 
diathesis from rheumatism, and at the same time from gonorrhoea, may she 
not convey to man the rheumatic condition with the gonorrhoea ? Knowing 
as we do that persons subject to rheumatism are particularly prone to con- 
tract gonorrhoea, may not the cases of gonorrhoeal rheumatism be those con- 
tracted from rheumatic women suffering from gonorrhoea ? 
Symptoms.-The rheumatic affections usually appear before the urethral 
discharges have ceased. It has been known to occur so early as the first or 
second week of the gonorrhoeal discharge; but in the majority of cases it is at 
later periods, either when the discharge has been suddenly arrested or sup- 
pressed, or when it has passed its climax and is gradually passing into a gleet. 
It is then generally observed that the running becomes more copious for a 
day or two preceding the rheumatic phenomena; and this occurs with each 
exacerbation of the rheumatism and each joint affected. The affection ex- 
presses itself by stiffness and severe aching in one, generally the knee-joint, 
and usually more severe on one side than on the other. Sometimes a chill 
and wandering pains are experienced before any particular joint becomes 
implicated; but the general symptoms are at no period comparable in violence 
to those of acute rheumatism. When a joint becomes affected the pain soon 
becomes acute and burning, and increases in severity. Effusion rapidly takes 
place, distending the synovial sacs of joints or bursae of tendons; but the 
integument over the affected part generally retains its normal color-the blush 
of inflammation being rare. This collection of fluid greatly interferes with 776 
SPECIAL PATHOLOGY-SYNOVIAL RHEUMATISM. 
the movement of the limb; and pain is also felt on the slightest movement or 
on pressure. The more decidedly inflammatory the symptoms, the more likely 
will the case be to recover soon; and the more passive the effusion into the 
synovial sac, the more obstinate is it likely to prove. In any case recovery is 
rare under six weeks, and is often delayed for months, or even years, especially 
if the gonorrhoea continues, which it is apt to do, as a scanty gleety fluid from 
the urethra. The subacute and chronic stages are the most obstinate. Re- 
lapses are apt to take place, generally in a chronic form; the urethral dis- 
charge generally returning with renewed violence, immediately before each 
relapse. The tongue is generally loaded and the bowels confined. Perspira- 
tion is often copious, and generally offensive. 
Treatment.-The condition of the digestive organs generally requires atten- 
tion and correction. Fomentation, with leeches,generally affords relief to the 
pains of the joints, with Dover's powder at intervals; and after the more acute 
symptoms have been subdued, the greatest benefit is obtained from blisters, 
repeated several times, when effusion within the capsule of the joint is a prom- 
inent symptom. Vapor baths and Turkish baths are both of great service. 
The gonorrhoea must be cured. 
The preparations of iron, iodine, quinine, combined with ammonia, potass 
or soda, in bitter vegetable infusions, according to the nature of the urinary 
symptoms, are the best tonic remedies, together with fresh air and good diet. 
Iodide of potassium ought to be used in the chronic form of the disease. 
Pressure over the joint by strips of adhesive plaster, aided with bandaging 
from the toes upwards, is often of great service in subduing the swelling which 
remains, after all other symptoms have subsided. Passive motion must after- 
wards be used. 
SYNOVIAL RHEUMATISM. 
Latin Eq., Rheumatismus synovialis; French Eq., Hydarthrose rhumatismale; Ger- 
man Eq., Synovialer Gelenk-rheumatlsmus; Italian Eq , Reumatismo sinoviall. 
Definition.-A rheumatic affection, in which an accumulation of non-purulent 
fluid occurs 'in the synovial sacs, and especially in those of the knee-joints. 
Pathology.-In this form one joint generally is alone affected. The fluid 
effusion is not merely increased in quantity, but the synovia is more or less 
altered from its normal condition. Considerable irritation exists, and is kept 
up in the surrounding tissues. The disease thus continues with great obsti- 
nacy; and the structural changes in the capsule of the joint are in the end 
apt to be serious, involving the cartilages, and eventually the joint-ends of the 
bones. Such lesions are especially apt to be of grave importance in scrofu- 
lous, cachectic, and otherwise impaired stages of the constitution. In the 
mildest forms of the disease the capsule is generally thickened and greatly 
congested. 
Treatment.-Leeches are of service in recent attacks. Fecal accumula- 
tions require removal. The secretions are, as a rule, greatly disordered. Four 
or five grains of calomel, with one or two grains of Ipecacuanha, and one grain 
of opium and one of capsicum, should be given at bedtime. Iodide of potas- 
sium, in the decoction of cinchona and liquor potassi, ought then to be com- 
menced and continued for some time. 
After leeches, small-sized blisters, repeatedly applied on each side of the 
joint, are of great service. Iron tonics are also beneficial. Copland writes in 
praise of oil of turpentine in such cases, and prescribes it in the following 
formula: 
B. Olei Terebinthince, Ji; Sodce vel Potassce Bicarbon, 9i; Tinct.' Cinchonce 
comp., Jiss.; Tinct. Capsid, REv; Aquse menthse piperitse, ^iss.; misce. To 
be taken two or three times a day. PATHOLOGY AND TREATMENT OF MUSCULAR RHEUMATISM. 
777 
MUSCULAR RHEUMATISM. 
Latin Eq., Rheumatismus musculorum; French Eq., Rhumatisme musculaire; Ger- 
man Eq., Muskel-rheumatismus; Italian Eq., Reumatismo muscolare. 
Definition,-Pain in the muscular structures, increased by motion. 
Pathology.-The aponeurosis and fibrous tissues of the loins, as well as 
the muscles of the back and the neck, are the parts usually affected. Hence 
two local varieties are especially noticed-namely, (a.) Lumbago; (6.) Stiff 
neck. 
Lumbago affects the sheaths of the fleshy mass of the lumbar muscles, on 
one or on both sides of the loins, extending often to the ligaments of the sacrum. 
It is characterized by the severity of the pain, and frequently its very sudden 
occurrence. A patient who, a few minutes before could move with perfect 
ease, suddenly finds himself unable to rise from his seat, or to move from the 
position he is in when thus seized with pain, if movement is attempted in any 
direction. At last he finds some peculiar attitude favorable to the pained 
parts, which enables him to move to a very limited extent. The pain is in- 
creased by every movement of the lower part of the spinal column, or on 
pressure upon the muscles implicated. Hence the patient walks bending for- 
ward, or leaning on a stick, and he dare not attempt to raise himself erect. 
Lumbago is apt to be confounded with phenomena due to congestion of the 
venous sinuses of the lumbar vertebrae, and of the kidneys. These forms of 
congestion generally cause marked disorder of the urinary excretions, pains, 
numbness, cramps, or pricking or lancinating pains in one or both limbs. 
Stiff neck or crick in the neck, cervical rheumatism, generally follows upon 
exposure to currents of cold air on the neck. The pain is either in the back 
of the neck, or affects only one side. It complicates many cases of sore throat. 
Sometimes the articulations of the clavicle are also affected. 
Other forms of muscular rheumatism affect especially the intercostal muscles 
and pectorales, as pleurodynia rheumatica. Coughing, sneezing, and bending 
of the body or arm, influencing those muscles, increase the pain, and causes 
the affection to resemble pleurisy. The frontal, occipital, and temporal muscles, 
as well as the aponeurosis or periosteum of the skull, are sometimes affected, 
and may be confounded with neuralgia, or with syphilitic periostitis. Diag- 
nosis requires that the pain be traced to muscular tissue or its connections. 
The changes induced in the tissues by muscular rheumatism are sometimes 
in the form of rheumatic callosities, produced by proliferation of connective 
tissue, which replaces muscles ; but this is only in chronic forms of the dis- 
ease. 
Treatment.-In muscular rheumatism, the local appliances which insure 
rest and warmth afford most relief. In lumbago nothing is so instantaneously 
beneficial as strapping the back from the level of the "seat" upwards, in im- 
bricated layers of straps of adhesive sticking-plaster spread upon chamois 
leather, or the common warm-plaster of the Pharmacopoeia may be used (Tuf- 
nell). The patient ought to sit with his bare back before a large fire during 
the process. Calomel purgation is generally indicated, combined with rhubarb 
and soda, as the excretions are generally greatly at fault. 
CHRONIC RHEUMATISM. 
Latin Eq., Rheumatismus longus; French Eq., Rhumatisme chronique; German Eq., 
Chronischer Rheumatismus; Italian Eq, Reumatismo cronico. 
Definition.- Chronic pain, stiffness, and swelling of various joints. 
Pathology and Symptoms.-This is one of the most common forms of 778 
SPECIAL PATHOLOGY - CHRONIC RHEUMATISM. 
rheumatic disease. The knee, ankle, hip, elbow, or shoulder-joint are those 
which usually suffer. The soreness, stiffness, and pain generally extend 
from the joint along the fibrous structures to a greater or less extent, the 
limb thus becoming the seat of severe pain. Commencing generally in the 
aponeurotic expansions of these large joints, the affection is apt to pass to the 
periosteum, and to induce there and in the interior of the joints such a chronic 
morbid action as in some cases occasions the removal of the synovial mem- 
brane and cartilages, while a porcelain-like substance comes to supply the 
place of the cartilage, having a polished surface, and without any of the elas- 
ticity of cartilage, and destitute of secreting power, from being destitute of 
synovial structures. The affection of the joints, however, even when most 
severe, rarely causes immediate destruction of the cartilages. But if forcible 
or passive motion is prematurely resorted to, the joint may become the seat 
of inflammation and suppuration in the usual form. When chronic rheuma- 
tism is primary, it most frequently attacks those joints or places which had 
previously been the seats of dislocation, contusion, or other severe injury. 
The immediate effects are expressed first upon the ligamentous structures of 
the joint, passing thence to the periosteum covering the articular ends of the 
bones, and to the tendinous attachments of the muscles in connection with 
the bone and its periosteum. These textures all become finally thickened ; 
they lose their flexibility, becoming impaired in tone and in vital cohesion 
(Todd, Copland). When effusion of lymph occurs in the synovial con- 
nective tissue, the synovial membranes also become thickened and opaque, 
and effusion of fluid may take place into a joint. The pain is then generally 
aggravated by pressure, and still more by motion. If the effusion is moderate, 
the pain may be relieved by the swelling and separation of surfaces it causes; 
but if the effusion is considerable, or very great, pain is increased by the dis- 
tension, but is still less than it was before - effusion took place. These phe- 
nomena are most expressed in the knee-joints, and in their greatest severity 
are the result of frequently repeated attacks and long continuance of the 
rheumatic diathesis. 
The nature of the " pains " in chronic rheumatism has been already de- 
scribed at p. 765. 
Prolonged and repeated attacks of chronic rheumatism chiefly affect the 
hip-joint, and generally all the large joints. It is most common after thirty 
years of age ; and is especially frequent among the laboring poor, and among 
soldiers and sailors, who are exposed to the changes of season and weather- 
to cold and wet. The symptoms are always aggravated at night, and by 
vicissitudes of weather, especially the prevalence of east winds, humid and 
cold states of the atmosphere, and is mostly associated with derangement of 
the digestive organs. 
The joints of the hands are often also liable to be affected; when those of 
the fingers are generally most deformed, the joints being liable, in extreme 
cases, to dislocation, when the fingers are drawn more or less out of their nor- 
mal position. 
The Treatment of chronic rheumatism does not differ in its general details 
from that of acute rheumatism. Decoction of cinchona, preparations of guai- 
acum, with alkalies and colchicum, are the best remedies after the action of 
such searching evacuants as calomel and jalap have removed morbid accu- 
mulations, and improved intestinal secretions. The various forms of the so- 
called " Chelsea Pensioner," comprising guaiacum and sulphur, the composition 
of which is given at page 770, ante, are of great service. 
Iodide of potassium is also of great benefit in the arthritic forms of chronic 
rheumatism, combined or not with preparations of aconite and colchicum. 
Warmth of flannel and the warmth of bed, with free perspiration, generally 
tends to mitigate and shorten the severity of the paroxysms of chronic rheu- 
matism. 779 
DEFINITION AND PATHOLOGY OF ACUTE GOUT. 
ACUTE GOUT. 
Latin Eq., Podagra acuta; French Eq , Goutte aigue; German Eq., Acute Gicht; 
Italian Eq., Gotta o Podagra acuta. 
Definition.-A specific febrile disorder, characterized by non-suppurative in- 
flammation, with considerable redness of certain joints-chiefly of the hands and 
feet, and, especially in the first attack, of the great toe, and attended by excess of 
uric acid in the blood, and probably also of phosphoric acid. The constitutional 
affection tends to culminate in a paroxysm, or "fit of the gout," at longer or 
shorter intervals, when various joints, textures, or parts of the body are apt to 
become affected. 
Pathology.-The constitutional origin of gout may be explained in a similar 
manner to that of rheumatism; but the nature of the gouty poison appears to 
have been more definitely ascertained. About 1787-1793, Mr. Murray Forbes, 
remarking the close connection between gout and gravel, and the tendency 
of the disease to form concretions, ascribed gout to the presence of Lithisiac, 
or what has since been named uric or lithic acid in the blood. These concre- 
tions are liable to periodical deposition, through the medium of inflammation, 
in organs whose vessels are of the smallest order-for example, tendons and 
ligaments (Treatise on Gravel and Gout, pp. 78-80). About the same time, 
Berthollet had advanced an opinion not dissimilar with regard to the presence 
of phosphoric acid. From numerous observations, this chemist concluded that 
phosphoric acid is more sparing in the urine of the gouty and the rheumatic 
than in that of healthy persons, and that during a paroxysm it became more 
abundant, and equalled the proportion found in the urine of the most healthy 
persons. He therefore ascribed gout to the retention and accumulation of 
this acid, and its diffusion through the system (Journal de Medecine, Juin, 
1786, p. 476). The reverse of this doctrine was afterwards maintained by 
Richerand, who observes that, on the approach of gouty fits, the phosphoric 
ingredients of the urine diminish, and seem to be conveyed to the joints, to 
produce the arthritic concretions ( Craigie). 
In 1848, Dr. Garrod, of London, published a paper in The Med.-Chir. 
Transactions (and he has since that time constantly directed his attention to 
the subject), in which he proves experimentally the statements of Forbes, and 
shows that the blood, in cases of gout, contains lithic acid in the form of lithate 
of soda, and that in cases of chronic gout with chalky deposits round the joints, 
lithic acid is always present in the blood and deficient in the urine, both abso- 
lutely and relatively to the other organic matters. He believes that the acid 
is always in excess in the system during gout, and constitutes a very important 
and almost a pathognomonic sign of gouty disease with affections of the joints. 
The uric acid is found to exist not only in the blood-serum, but also in the 
fluid effused by blisters, and in the abdominal and pericardial fluids. The 
abstraction of a very small amount of blood is required to discover the uric 
acid if it is present in quantity. From one to ten fluid drachms of the serum 
being taken, it is to be put into a broad and flat glass dish (not watch-glasses), 
about three inches in diameter, and about a third of an inch deep. Add acetic 
acid, of the strength of the London Pharmacopceia, in the proportion of about 
six minims to each fluid drachm of the serum ; a few bubbles of gas are gene- 
rally evolved at first. When the fluids are well mixed, a very fine thread is 
introduced, consisting of from one to three ultimate fibres, from a piece of un- 
washed linen fabric, about an inch in length, which should be depressed by 
means of a glass rod. After resting for from eighteen to forty-eight hours, 
depending on the warmth (temperature at or below 70°) and dryness of the 
atmosphere, the uric acid will crystallize upon the thread. To observe this, 
a microscope must be used with a linear magnifying power not below 60. 780 
SPECIAL PATHOLOGY-ACUTE GOUT. 
When gout has become fully developed, and has assumed its specific inflam- 
matory character, it produces all the forms of articular inflammation which 
have been described in rheumatism, and these inflammations attack nearly 
the same parts, as the bones, cartilages, synovial membranes, bursae, ligaments, 
muscles, tendons, and aponeuroses. These inflammations have little to dis- 
tinguish them from rheumatism, except the singular pathological phenomenon 
of a tendency to the deposition of the urate of soda-a discovery we owe to 
the late Dr. Wollaston. 
' Occasionally the urate of soda appears to be nearly the sole secretion from 
the affected part, nothing being seen on the poultice or fomentation cloth ap- 
plied to the part but this salt in a more or less fluid state. It is secreted from 
the joints of the toes or fingers, and probably from all their different tissues. 
Portal gives a case in which the articulations of both hands presented deposits 
of urate of soda, both within the capsules of the joints and externally among 
the ligaments, while the tendons of the extensor muscles of the fingers were 
almost destroyed. In the Hunterian Museum of Glasgow there is a finger 
from a gouty hand, with a joint opened and bent upon itself, showing not only 
a deposition of the salt, but an erosion of the cartilages; also another, in 
which the joint is full of this peculiar secretion, and a third in which the joint 
is everywhere invested with it. In the Museum of St. Thomas's Hospital 
there is a specimen in which the femoral cartilage of the knee-joint is coated 
with it, as if smeared over with plaster of Paris; and another in which it is 
deposited on the ligaments of the extensors of the hand- Guibert gives a case 
in which the metatarsal articulation of the great toe was surrounded by urate 
of soda of a rose tint, and on the inside of the foot, in the cellular tissue, was 
an abscess containing urate of soda making its way to the surface. On open- 
ing the joint the same substance was found, and on cutting through the ten- 
dons, pieces of urate of soda were distinctly seen between the fibres. Simon 
gives an account of a gouty skeleton, of which the bones were completely 
anchylosed. In the preparations of diseased joints in the Museum of the 
Army Medical School at Netley (and described by Mr. Gulliver in The Edin. 
Med. and Surgical Journal, vol. xlviii), the material is said to be deposited 
outside the joint in the cellular tissue, exterior to the periosteum and articula- 
tion capsules. Similar dissections are described by Watson, Moore, and Parry. 
The bones affected in cases of gout have been found swollen, and sometimes 
so soft as to have been easily cut by the scalpel. 
The urate of soda is deposited first in a white fluid state, like a mixture of 
chalk and water; after a time this fluid portion becomes absorbed, leaving 
concretions consisting of little more than bundles of crystals of urate of soda, 
and often in such quantities that a poultice, though applied several times a 
day, has been covered with them, and that for several days together. The 
concretions afterwards harden, and form what, from their color and appear- 
ance, have been termed chalk-stones, tophi, or tophaceous deposits, often super- 
ficial and of considerable size, so that, when the skin has ulcerated, a patient 
has been said in one instance to have scored his game of cribbage with his 
knuckle, and in another to have written on the table with the chalk penetrat- 
ing through the ulcerated tips of his fingers. Not unfrequently, after a time, 
deposits of phosphate and carbonate of lime ensue in and around these semi- 
fluid concretions; but it is not believed that such deposits ever replace the 
urate of soda in gouty subjects. 
Although these specific exudations and morbid elements in the blood are 
but indications of the gouty condition, they nevertheless confirm the belief 
again gaining ground, which teaches the ancient humoral doctrine, that the 
phenomena of gout are induced by some peccant matter (probably uric acid) 
which, through malassimilation of food, or of food and drinks of particular kinds, 
combined sometimes with excessive labor of body as well as of mind, becomes 
inbred in the constitution, and which it is the business of the paroxysm of PATHOLOGY OF ACUTE GOUT. 
781 
gout to eliminate. The fact seems now to be established by several indepen- 
dent observers, that the blood in gout is charged with uric acid to an extent 
considerably beyond its normal amount. There are three theories, however, 
put forth to account for its abnormal excess in the blood: 
(1.) That it depends upon imperfect oxidation of the blood, together with im- 
paired nervous energy, as the cause of imperfect oxidation (Duncan in Dublin 
Quarterly Journal of Medicine, May, 1865). 
(2.) Urea and uric acid already existing in the blood in the form in which 
they are to be eliminated; the kidney is regarded as the organ of their excre- 
tion by elective elimination, such that the power of secreting the one may be 
maintained in full energy, while the power of eliminating the other may be 
diminished or averted. 
The elimination of uric acid is thus impaired in gout, just as the elimina- 
tion of urea is impaired in Bright's disease. Thus each of these products accu- 
mulates in the blood in each of these diseases respectively; and acting as a 
poison, the accumulation of uric acid ultimately gives rise to a paroxysm of 
gout, which "would thus appear partly to depend on loss of power (temporary 
or permanent) of the acid excreting function of the kidneys, the premonitory 
symptoms, and those also which constitute the paroxysm, arising from an 
excess of this acid in the blood, and from the effort to expel the materies morbi 
from the system. Any undue formation of this compound would favor the 
occurrence of the disease; and hence the connection between gout, uric acid, 
gravel, and calculi; and also the influence of high living, wine, porter, and 
want of exercise in inducing it" (Garrod). 
Thus Dr. Duncan's theory tends rather to account for the abnormal and 
excessive formation of uric acid; while Dr. Garrod's rather tends to explain 
its non-elimination. But the experiments of Hoppe-Seyler, and Zalesky, show 
that urea and uric acid are both produced in the kidneys; and when found in the 
blood, their existence there is due to reabsorption. They tied the ureter in 
geese and chickens, and, in a few days after the operation they found almost 
all the viscera, including the stomach, heart, and lungs, covered with crystals 
of the urates, and the joints incrusted with them in a manner very strongly 
suggestive of gout. From such experiments the following theory regarding 
gout is the most probable: "The gouty diathesis depends on an anomaly of 
nutrition, in which far more uric acid is produced than in healthy persons, 
although not to the same extent as in birds and serpents. As long as the 
excess of uric acid is regularly excreted by the kidneys, the affected person 
gets along tolerably well, or with no trouble at all. But the case is different 
when the uriniferous tubules are plugged up by deposits of the urates, and the 
excretion of the urine is impeded; for then, just as in the animals above 
mentioned, there is a collection of urates in the blood, whence they are 
deposited in the joints and other organs, when we have an attack of gout. If 
the deposit of urates in the uriniferous tubules be soon washed away, and the 
red sandy sediments form in the urine, which are sometimes found even on 
the diaper of infants, the attack of gout passes over; if this do not take place 
and the kidneys atrophy, the acute attack becomes chronic gout" (Nie- 
meyer). 
(3.) Dr. Bence Jones holds views somewhat similar to Dr. Duncan, so far 
as a process of oxygenation has to do with the attack: 
"The gouty diathesis," he writes, "consists in an excess of urate of soda, not 
only in the serum of the blood, but in the fluid that diffuses from it into all 
the vascular and non-vascular textures of the body. An attack of gout is a 
chemical process of oxidation set up in the parts where the urates are most 
able or liable to accumulate. By the oxidizing action the urates are wholly 
or partly changed into urea and carbonates, which can more readily pass from 
the textures into the blood, and be excreted by the kidneys, skin, and lungs. 782 
SPECIAL PATHOLOGY-ACUTE GOUT. 
The oxidation even in the bloodless textures causes increased flow of blood 
and mechanical pressure in the vessels nearest to the inflamed part, and hence 
pain and redness, and then swelling and oedema, proceed. Though the gouty 
diathesis is a disease of the textures as well as of the blood, yet in its origin 
and situation an attack of gout is even more a disease of the tissues than a 
disease of the blood. The urate of soda bears the same relation to gout that 
sugar does to diabetes; and as the want of oxidation of sugar is the cause of 
the diabetic diathesis, so the want of oxidation of the urates, and their conse- 
quent accumulation in the textures and blood, is the cause of the gouty diathesis. 
There are at least two ways in which an excess of uric acid may occur in the 
blood and textures: 1st, from an excess of animal or vegetable albuminous 
food entering the system-i. e., from excessive production; and 2d, from an 
arrest of oxidation-i. e., from want of destruction." (Lectures on Some of the 
Applications of Chemistry and Mechanics to Pathology and Therapeutics.') 
The natural history of the disease shows-(1.) That there is a disposition 
or tendency in the morphological relations between the solids and fluids of 
the whole system to develop some specific constitutional poison, which betrays 
itself by certain constant effects at periodical intervals, although these may 
be irregular. (2.) That these local effects are prone to develop themselves 
in the joints of the extremities, or to express themselves by symptoms of a 
particular kind in the internal organs, and in various textures of the body. 
Dr. Graves has given the most interesting illustration of these propositions 
in his clinical lectures, and especially of the development of peculiar local 
affections in connection with gout. For example, the occurrence of-(1.) 
" Fugitive pains," or twitches which suddenly attack persons of gouty habit. 
The pain is, no doubt, due to congestion. Sometimes the congestion is more 
lasting, as in the lobes and cartilages of the ear, and where, as Dr. Garrod 
shows, concretions sometimes occur. (2.) A singular affection of the teeth, 
which consists in an insuperable desire to grind them, is noticed by Graves. 
(3.) The occurrence of tic douloureux of the several branches of the fifth 
pair. (4.) Daily paroxysms of intense heat of the nose, which continues for 
three or four hours, the part becoming first of a bright and then of a purplish- 
red color, spreading over the upper portion of the cheek. (5.) The occur- 
rence of gouty sciatica, in which the specific inflammation affects the trunk of 
the sciatic nerve, and which, extending by the neurilemma of the nerve, may 
in process of time extend to the spinal marrow and its investments, and give 
rise to derangements of the latter, terminating in ramollissement and struc- 
tural degeneration. This complication of gout was first decidedly pointed 
out by Dr. Graves. These affections are always greatest when the stomach is 
most deranged. 
It is now generally believed that gout is hereditary, and in many instances 
it is so, whether the intemperate habits of ancestors are followed out, or 
whether the mode of living be abstemious. In some families it attacks only 
alternate generations, following what has been called " the law of atavism." 
The power of hereditary transmission to induce gout has been illustrated in a 
most interesting way by Mr. Spencer Wells in his treatise on this disease. 
He shows that the children of a patient born prior to the development of 
gout in their parents were free from this affection in after-life, but that those 
children born subsequently to the development of gout in the same parents 
became afterwards gouty. The potent influence of hereditary predisposition 
in regard to gout is now known to betray itself even amongst some of the 
laboring classes, and in the upper classes in a still greater proportion. Dr. 
Garrod instances the case of a gouty gentleman who is able to trace the disease 
in his family for four hundred years, and in which the eldest son has invari- 
ably inherited, with the estates, gout of the worst form, and developed at an 
early age. On the other hand again, it is certain, and consistent with the CAUSES OF ACUTE GOUT. 
783 
constitutional origin of this disease, that an unusually large proportion of 
non-hereditary cases are met with among the indolent and luxurious inhabit- 
ants of large metropolitan towns. 
A flattering hallucination has been transmitted traditionally, hereditarily, 
and historically, which connects the gouty diathesis with high mental develop- 
ment. But the conditions for the constitutional development of this disease 
must either be more common, or physicians must be getting more acute, for 
eminent and observant men are now inclined to discard the doctrine which 
teaches the noble origin of gout, and its necessary association with high mental 
development. The disease is now' certainly common and plebeian, as well as 
aristocratic. It may have been, in the days of Sydenham, that the gouty 
patients of a physician were to be found amongst "magni reges, dynastce exer- 
cituum, classiumque duces, philosphi, aliique his similes." Nowadays it is no 
less certain that the physician, in London at least, must pay his visits and 
prescribe for gout amongst " the London labor," as well as among " the 
London poor," and his list will number " coal-heavers, bakers, brewers, dray- 
men, house painters, butchers, innkeepers, publicans, butlers, coachmen, and 
porters in wealthy families especially" (Copland, Budd, Garrod, Todd). 
A gouty conformation of the body has been accurately described by Syden- 
ham, Frank, Scudamore, and others, and one of the constant characters of 
such a confirmation is former or existing corpulence. It is now also known 
as consistent with the constitutional origin of this disease that the disposition 
to develop gout may be brought about by abnormal habits of existence, and 
if the hereditary predisposition is present, the conditions for developing the 
latent diathesis are more easily made efficient. All are agreed as to the in- 
fluence of full living, with the free and habitual use of wine, and especially 
now as to the influence of what may be called gross living, great and indis- 
criminate consumption of animal and vegetable food, with indulgence in beer 
and malt liquors generally (Budd and Todd); and it appears, both from 
the observations of Sydenham, Craigie, Wm. Budd, Todd, and Wood, that 
it is not so much the particular variety of alcoholic drink used, as the mode 
and extent of the use, which tends to develop the gouty state; but it is be- 
lieved that, of all wines in common use, those of the Rhine vintages are the 
least productive of gout. They are said to contain less alcohol than any of 
the Southern wines, and less than those of Portugal, Spain, Sicily, Cyprus, 
and Madeira. The influence of malt liquors is ,especially obvious in those 
examples of gout which occur in the lower classes. " There is a body of 
men," writes Dr. Wm. Budd, "employed on the Thames, whose occupation is 
to raise ballast from the bottom of the river. As this can be done only when 
the tide is ebbing, their hours of labor are regulated by that circumstance, 
and vary through every period of the night and day. They work under great 
exposure to inclemencies of the weather; their occupation requires great 
bodily exertion, occasioning profuse sweating and much exhaustion. Each 
man drinks from two to three gallons of porter daily, and generally a consider- 
able quantity of spirits besides. Gout is remarkably frequent among them." 
Such an instance contrasts strongly with the prophylactic influence of cor- 
poral labor displayed amongst other classes of the people who do not labor 
under the influence of gallons of malt liquor; and it is interesting to notice 
that in the non-beer-drinking countries the lower classes escape. Gout is 
rarely seen in Scotland. 
Generally, it may be stated that (1.) Hereditary tendency is the most im- 
portant factor in causing gout in any individual case. It can be traced to this 
source in about one-half the cases. (2.) The supply of more nourishment (and 
especially of nitrogenous elements) than is used or required by the wants of the 
system, to replace what has been used up in the body, is another most impor- 
tant factor in the development of gout. 
A belief in the prophylactic virtue of labor and moderate living probably 784 
SPECIAL PATHOLOGY - ACUTE GOUT. 
instigated the abrupt reply of Abernethy to the question, "What is the cure 
for gout?" when he said, "Live on sixpence a day, and earn it." The disease 
very rarely occurs before puberty, but is seen in both sexes under twenty. 
Many cases occur between twenty and thirty, but the period of greatest lia- 
bility is perhaps from thirty to fifty. After this the chances of exemption 
increase with age, probably from the more temperate habits of advanced life. 
But at whatever age gout may appear, every attack establishes a greater dis- 
position to another. Women often suffer greatly from gout, but hot in an 
equal degree with men. Gout is never developed without being associated 
with indigestion, or as a sequence of impaired digestion from some error in 
diet or drink. The foul breath, the loaded tongue, the nausea and sense of 
weight in the stomach, and the flatulence that most gouty patients are subject 
to, all tend to show that much more work is thrown upon the organs of diges- 
tion, by the quantity and quality of the food and drink, than they are capa- 
ble of using. Of all wines, Port wines and Burgundy are most apt to induce 
such kind of indigestion as accompanies or precedes an attack of gout. 
The immediately exciting causes of this disease are very much similar to 
those of rheumatism. In thus describing the pathology of gout, the direct 
causes and constitutional source of the disease have been sufficiently indicated. 
The varieties of gout, in addition to the acute form, are: (2.) Chronic Gout 
-a persistent constitutional affection, characterized by stiffness and swelling of 
various joints, with deposits of lithate of soda; (3.) Gouty Synovitis. 
Morbid Anatomy.-Genuine gout is characterized by the incrustation of 
the articular surfaces of the affected joints by chalk- 
like masses, composed of urates generally of soda. 
The first joint of the great toe may be the only one 
showing such a lesion; but in severe and old cases 
numerous other joints may be so affected. In such 
cases a thick layer of urates covers the surfaces of 
the joints; the cartilages are rough; and the liga- 
ments, periosteum, and bursae near the diseased joints 
are covered with thick deposits of these salts. Thus 
the joints are often greatly deformed, and the chalky 
masses may sometimes be seen and may actually protrude through the integ- 
uments covering the joints. Such concretions may exist in the eyelids and 
cartilages of the ear, forming concretions like white pearls, surrounded by vari- 
cose veins-a certain sign of gout. These appearances are well represented 
in Plate I, facing page 64 of Dr. Garrod's classic work on Gout. In the pyra- 
mids of the kidneys, there are usually white striae, composed of urates running 
in the direction of the tubuli recti. (See page 231 ante.') 
Symptoms.-These vary according as the disease attacks the joints, the 
stomach, or the intestinal canal; but the proportionate frequency with which 
these different parts are attacked is not yet ascertained. It may be acute or 
chronic; and when the viscera are affected, it has been termed irregular, re- 
trocedent, or misplaced gout. Sydenham was himself a great sufferer from 
this affection, and labored under it for more than thirty-four years. He thus 
describes an acute attack or fit: 
"It comes on a sudden towards the close of January or beginning of Feb- 
ruary, giving scarce any sign of its approach, except that the patient has been 
afflicted for some weeks before with a bad digestion, crudities of the stomach, 
and much flatulency and heaviness, which gradually increase till at length the 
fit begins. The patient goes to bed, and sleeps quietly till about two in the 
morning, when he is awakened by a pain, which usually seizes the great toe, 
but sometimes the heel, the calf of the leg, or the ankle. The pain resembles 
that of a dislocated bone, and is attended with a sensation as if water just 
warm were poured upon the member; and these symptoms are immediately 
succeeded by a chilliness, shivering, and slight fever. The chilliness and 
Fig. 84. 
Urate of Sodsein stelliform 
crystals, from Wedl. SYMPTOMS OF ACUTE GOUT. 
785 
shivering abate in proportion as the pain increases, which is mild in the begin- 
ning, but gradually becomes more violent every hour, and comes to its height 
towards evening, adapting itself to the numerous bones of the tarsus and meta- 
tarsus, the ligaments whereof it affects so as sometimes to resemble a tension 
or laceration of those ligaments, sometimes the gnawing of a dog, and some- 
times a weight and coarctation or contraction of the membranes of the parts 
affected, which become so exquisitely painful as not to endure the weight of 
the clothes, nor the shaking of the room from a person walking quickly 
therein; and hence the night is not only passed in pain, but likewise with a 
restless removal of the part affected from one place to another, and a contin- 
ual change of its posture. Nor does the perpetual restlessness of the whole 
body, which always accompanies the fit, especially in the beginning, fall short 
of the agitation of the gouty limb. Hence numberless fruitless endeavors are 
used to ease the pain by continually changing the situation of the body and 
the part affected, which notwithstanding abates not till two or three in the 
morning-that is, till after twenty-four hours from the first approach of the 
fit. Being now in a sweat, he falls asleep, and upon waking finds the pain 
much abated, and the part affected to be swelled; whereas before only a re- 
markable swelling of the veins thereof appeared, as is usual in all gouty fits. 
" The next day, or perhaps two or three days afterwards, the part affected 
will be somewhat pained, and the pain increases towards the evening, and 
remits towards break of day; and what we call a fit of the gout is made up 
of a number of these small fits. At length the patient recovers, which, in 
strong constitutions, and such as seldom have the gout, often happens in four- 
teen days; and in the aged, and in those who have frequent returns of the dis- 
ease, in two months; but in such as are more debilitated, either with age or 
the long duration of the distemper, it does not go off till summer advances." 
In aggravated cases it attacks both feet, the hands, wrists, elbows, knees, 
and other parts; sometimes bending the fingers crooked and motionless, and 
at length " forms stony concretions in the ligaments of the joints, which, de- 
stroying both the scarf skin and the skin of the joints, stones not unlike chalk 
of crabs' eyes come in sight, and may be picked out with a needle. Some- 
times the morbific matter is thrown upon the elbows, and occasions a whitish 
swelling almost as big as an egg." 
During the first fourteen days the urine is high-colored, and aftei' separation 
lets fall a kind of red gravelly sediment, and not above a third part of the 
fluids taken is voided by urine during the febrile paroxysm, the bowels also 
being generally constipated during this time. The fit is accompanied through- 
out with loss of appetite and chilliness of the whole body towards the evening. 
The urea is probably not below the normal standard, its elimination not 
appearing to be interfered with during the paroxysm (Garrod, Parkes). 
The elimination of uric acid by the urine is impeded during the paroxysm ; 
but it exists in large amount in the blood. It has also been suggested, as a 
hint for further inquiry, that the substances which, in a healthy state, would 
furnish urea, are converted into uric acid in gout (Gairdner). The phos- 
phoric acid is also greatly lessened, and its retention is probably as common 
as that of the uric acid. Albumen is not uncommon in small quantities, but 
its occurrence is generally temporary; and if it is persistent, there is reason 
to suspect the chronic disease of the kidney which is produced by gout (Todd) ; 
and casts without albumen may be found in the urine sediments. After the 
paroxysm the water is usually copious ; and the uric acid increases as the fit is 
passing off. Before the paroxysm of gout the urine is found to be very deficient 
in solids, especially in urea, uric acid, extractives, and phosphate of lime; 
there is, in fact, a diminution of all the chief ingredients. During the parox- 
ysm there is insufficient elimination of uric and phosphoric acids, while the 
urea and sulphuric acid are in sufficient amount; and after the paroxysm the 
elimination again increases (Parkes, 1. c.). 786 
SPECIAL PATHOLOGY-ACUTE GOUT. 
When the fit is going off*, a violent itching seizes the foot, especially between 
the toes, and the skin peels off. 
The functions of digestion, and especially the hepatic and urinary secre- 
tion, are much deranged in all cases of gouty paroxysms. Besides loss of 
appetite, flatulence, heartburn, stomach-ache or colicky pains prevail, the 
tongue is loaded, the bowels are bound, and air, with impacted faeces, distends 
the intestines, especially in the epigastric and umbilical regions. The hypo- 
chondriac regions, especially the right, are the seat of painful tension and 
uneasiness. The first alvine dejections are generally solid and dark-colored, 
not unfrequently very fetid ; and in some instances large quantities of dark- 
colored excrement are brought away. 
The urine, when scanty and of a deep red color, is voided with pain and 
scalding along the urethra. The sediment already mentioned, and soluble in 
water, is rose-colored or lateritious, and is deposited during the whole course 
of the attack, and its appearance is not confined to the close or subsidence of 
the febrile symptoms, though at that time it is more abundant. It consists 
of urate of soda, the phosphoric salts, and urea mixed in various proportions. 
When dyspeptic symptoms are associated with feebleness, a whitish magnesia- 
like powder, consisting chiefly of the phosphates, is deposited, or alternates 
with the other deposits. 
When the paroxysm of gout has taken place, and terminated in the man- 
ner described, the patient appears to enjoy better health than formerly. The 
appetite is good, the mind more cheerful and active, the body more agile, and 
the patient is delivered from many feelings of languor and oppression with 
which he had previously been afflicted. In this state he may remain for two 
or three seasons without being conscious of any complaint or symptom which 
would indicate a return of the disorder. In the course of time, however, gen- 
erally about the same season of the year, he begins to be sensible of the pres- 
ence of some of his former feelings, and at length a fit takes place much in 
the same manner as it did on the first occasion. This second paroxysm is, in 
some instances, shorter and less violent; in others it is accompanied with va- 
rious circumstances which show some deviation from the first attack. But 
whatever be the mode or duration of its attack, anotjier succeeds after a less 
lengthened interval; in some cases, the same year in the autumn-in others, 
next year in the spring or summer. In general the intervals are shorter the 
younger the patient. The most common, perhaps, is the biennial or triennial 
attack for the space of eight or ten years; then the attacks are annual, then 
twice in the year; and in some severe cases the attacks are so frequent that 
the patient can scarcely be said to be free from gout the whole year round. 
Much in all this depends on the habits and constitution of the individual. 
The disease tends to acquire a chronic character, and rarely quits the patient 
till it destroys him, either by complete lameness, helplessness, and debility, 
or by attacking the heart or the brain (Craigie). 
Diagnosis.-The diagnosis between gout and rheumatism is often exceed- 
ingly difficult, so much so that nosologists have1 described a hybrid disease, 
and named it "rheumatic gout." Mr. Hunter warmly opposed this com- 
pound appellation, as many have since done; and, for reasons afterwards 
stated, the College of Physicians have excluded the name from the nomencla- 
ture. Hunter's opinion was founded on the belief that no two distinct dis- 
eases, or even distinct diatheses, can coexist in the same constitution-a belief 
which must now be admitted to be incorrect. Such a hybrid disease has been 
■described by Craigie, Wood, Spencer Wells, and Fuller, depending on the in- 
fluence of the combined cachexia of gout and rheumatism. 
Cases of chronic pain, with stiffness and swelling of various joints, are thus 
far cases of chronic rheumatism; but when they are attended with deposits of 
lithate of soda, such cases are directed by the College of Physicians to be 
returned as cases of "chronic gout;" and those in which there is marked dis- PROGNOSIS AND TREATMENT OF ACUTE GOUT. 
787 
tortion, as cases of "chronic osteoarthritis"-a disease which may be defined 
as follows: "An affection characterized by pain, stiffness, and deformity of one 
or more of the joints, associated with deposition of new bone around them." The 
disease is also named "chronic rheumatic arthritis," and is described in its 
place in this volume. 
Prognosis.-Every Assurance Office objects to a gouty person as liable to 
a disease which tends to shorten life from the deterioration of the constitution 
it occasions. The objection is unquestionably well founded; for although a 
few persons may reach advanced age notwithstanding repeated attacks of 
gout, yet many die prematurely from this affection, or from asthma, disease 
of the heart, apoplexy, or from the accidents to which helplessness and 
debility render the patient liable. 
Treatment.-Seeing that the disease is clearly of constitutional origin, its 
treatment resolves itself into-(1.) The selection and administration of those 
remedies which shall tend to subdue, control, or eradicate the latent disposi- 
tion, constitutional tendency, or gouty diathesis; (2.) The adoption of such 
means as may be safely used to modify the severity of, or shorten, the 
paroxysms. The paroxysm must be interfered with cautiously. It is the 
means which nature takes to rid the constitution of the materies morbi, and 
which it undoubtedly relieves for a time, if allowed to run its course. But 
the removal of the paroxysm, or its subsidence, does not necessarily remove 
the constitutional diathesis. That must be modified by promotiong the trans- 
formation of the tissues of the body as much as possible. 
As to any local treatment during the fit, Sydenham writes, "If outward 
applications be required to ease the pain of the gout, I know of none, though 
I have tried abundance both on myself and others, and I have laid aside the 
use of topical remedies for many years." It is generally admitted that cold 
is dangerous, while warmth is productive of little relief. In some instances 
the urate of soda is deposited in such quantity that the skin ulcerates, and 
the salt is discharged in considerable abundance in a fluid state. It might 
appear the right practice to apply a poultice and encourage the discharge, in 
order that, by its entire removal, the joint might be saved. This, however, is 
by some considered dangerous practice, for the discharge is so debilitating 
that patients are said to have sunk under this mode of treatment. It is much 
safer to wait till the chalk-stone becomes concrete, and then operate, by the 
smallest possible incision, for its removal. With respect to the use of cold 
water, the practice is as old as Harvey, and subsequently it has been adopted 
and abandoned by many practitioners. Dr. Parry had at one time two 
patients who attempted to cut short the fit by plunging their feet in cold 
water. The relief was instant, but in a few hours both were dead of apoplexy. 
The fatal result of this remedy in Sir Francis Burdett's case is another in- 
stance in point. 
"A gentleman," writes Dr. Wood, "contrary to the advice of his physician, 
and anxious for speedy relief, ordered a bucket of water to be taken into his 
chamber at bedtime, with the view of employing it in this way. In the morn- 
ing he was found dead in bed." 
A few leeches have been recommended to be applied to the part with great 
caution, if the inflammation is unsually violent; but Dr. Garrod is of opinion 
that in no case are they likely to prove efficacious, and their use may be at- 
tended with injurious consequences. Antiphlogistics neither alleviate the 
pain of gouty inflammation nor shorten the attack; while their untimely use, 
especially general and local bleeding and active saline purges, favors the 
passage of acute into chronic gout. 
Warm anodyne lotions or fomentations may be used, and the part after- 
wards lightly covered or incased in flannel or fine wool, while the limb is at 
the same time kept elevated. 788 
SPECIAL PATHOLOGY - ACUTE GOUT. 
The "bootikins" of Horace Walpole, so strongly recommended and given 
away by him to all his gouty friends, seem to have been merely a fine band- 
age of flannel, applied moist and firmly over the limb, and then a roller of 
oiled silk over it, giving moist warmth like a poultice. Writing to Horace 
Mann, he says: "You must put them on at night, and tie them as tight as 
you can bear-the flannel next to your flesh, the oil-skin over. In the morn- 
ing, before you rise, you must dry your feet with a hot napkin, and put on a 
pair of warm stockings freshly aired." Over the bootikins at night draw a 
pair of thread stockings (Life and Letters, vol. vii, p. 224). 
Dr. Wood uses a warm mixture of tincture of camphor with milk, applied 
by means of linen compresses, and frequently renewed. 
Tincture of aconite may be similarly applied (f^iss. to f^iv of milk). 
The hypodermic injection of a fourth to a third of a grain of muriate or 
bimeconate of morphia, in any convenient part of the body, often relieves the 
local pain. 
Blisters have been recommended, and are of most advantage in asthenic 
chronic cases, when the inflammation has a tendency to linger in the articu- 
lations, and to cause liquid effusion. In the early fits of sthenic gout they are 
unnecessary; and are contraindicated in advanced gout, when the kidneys 
have become impaired, and alsofin cases of extreme gouty deposits (Garrod). 
As a general rule, however, the less that is done to the local affection the 
better. When the pain is very intense, relief may be given by the applica- 
tion of a solution of atropine, made by dissolving from two to three grains of the 
alkaloid in a weak mixture of spirits and water, and applying it to the inflamed 
joint by means of compresses of lint, preventing evaporation by a covering of 
oil-silk (Garrod). 
In the general treatment of gout, bleeding is now generally restricted to 
two methods, namely-(1.) By leeches to the part where the inflammation 
rises so high, or is so chronic as to threaten the patient with the permanent 
loss of the use of some joint, and to cases of metastasis of the disease to the 
stomach or other internal organ, when leeches are absolutely necessary. (2.) 
By general bloodletting. 
The following rules are laid down by Dr. Garrod as to the use of bleeding 
in gouty cases: (1.) Never bleed with the idea of directly subduing gouty 
inflammation. (2.) Never bleed in advanced gout, or when the constitution 
is much weakened. (3.) If bleeding be required in order to relieve general 
or local plethora, abstract only as much as will effect that object, remembering 
that further depletion tends greatly to aggravate the disease and prolong its 
duration. Bloodletting produces a decided sedative action on the heart and 
other parts of the circulating system, and it has a most powerful influence 
upon the progress of gouty inflammation-an influence not merely limited to 
the removal of gout when it attacks the joints, but also of great efficacy in 
its marked and irregular forms, in the ophthalmia of gouty habits, in gouty 
bronchitis, and in headaches connected with the gouty diathesis (Sir H. 
Holland, Garrod). 
Sydenham, who was as great an enemy to purging as he was to bleeding, 
says: " I am abundantly convinced, from much experience, that purging, 
either with mild or strong cathartics, whether used during the fit or in its 
declension, or in a perfect intermission or healthy state," . . . " endangers 
the life of the patient by hurrying on the disease to the viscera, which were 
quite safe before." The objection taken by Sydenham to purgatives was quite 
valid against those in use in his day, which were of the most drastic kind; 
but it may be laid down as a rule, that neutral salts are not only safe but 
efficient in relieving gout, though perhaps not to be depended on alone for its 
cure. The theory on which they are prescribed is, that the alkaline base of 
the neutral salt is absorbed, and combines with the insoluble urates deposited 
in the joints, forming a soluble suburate, which can readily be absorbed; and TREATMENT OF ACUTE GOUT. 
789 
again more alkali being sent to the kidney, that organ is enabled to remove 
more uric acid in a soluble state from the system than under ordinary circum- 
stances. The salts most in use are the sulphates of magnesia or of soda, and 
especially the former; and half a drachm to a drachm should be given every 
eight, six, or four hours, according to the state of the bowels and the acute- 
ness of the symptoms. It is also necessary to afford some relief to the patient 
from his excessive suffering. With that view an anodyne should be added, 
such as the tincture of hyoscyamus, syrup of poppies, or some preparation of 
opium. This method of treatment relieves the patient and shortens the 
paroxysm; but when the relief is complete, it should be abandoned, for some- 
times a paroxysm of gout will return even under its use. 
Colchicum or meadow-saffron was long ago introduced as a specific in gout, 
of which the once popular " eau medicinale" was supposed to be a preparation. 
Colchicum is still, however, used, and is valuable for its purgative qualities, 
and in some cases it seems to be almost specific in its effects, and may be given 
as an extract or tincture, or as a wine, combined with some form of saline 
draught. Its mode of action is unknown. It very generally promotes secre- 
tion from the skin and kidneys; but it is useful even when it does not exercise 
any such physiological action. The quantity of uric acid and urea in the 
urine is said by some to be increased during its use (Chelius). Dr. Graves 
makes an opposite statement; and Dr. Garrod proves conclusively that col- 
chicum does not increase the amount of uric acid. Dr. Laycock suggests that 
it may have a sedative effect on the vital actions going on in the tissues them- 
selves, and so may arrest the formation of the gout poison. 
The wine of the root of colchicum is generally the form preferred, fifteen to 
thirty minims being given every four, six, or eight hours, and this remedy ought 
to be continued for some time in reduced doses, after all symptoms of gout 
have disappeared (Budd). The bowels ought to have been freely moved 
before colchicum is given; and a full dose having been given at first, much 
smaller doses may be continued, as from ten to twenty minims two or three 
times a day, in Seltzer or Vichy water, or in other alkaline solutions, and 
combined with Iodide of Pfiassium, carefully watching its effects on the pulse, 
and never allowing sickness or depression to ensue. 
Scudamore's mixture of colchumm, magnesia, and sulphate of magnesia, is 
said to be an excellent purgative in gout, when a purgative is required. Al- 
though Dr. Garrod has shown that purging is not necessary to the action of 
colchicum, yet as there are many who believe that the action of colchicum is 
promoted by its combination with laxative remedies, Dr. Wood is in the habit 
of using it in the following formula in a draught: 
B. Magnesise, §ss.; Magnes. Sulphat., §ss.; Vin. Colchici rad., qExx; 
Aquse Fluv., vel Aq. Acid. Carbon., f^iss. 
Mercury in the form of "blue pill," or in the form of the "compound 
calomel pill" (Pil. Plummeri), followed by the draught just written, is useful 
where it is desired to act upon the intestinal secretions. But mercury in any 
form must not be given if the urine contains albumen. If mere constipation 
is to be got rid of, rhubarb pill, colocynth and scammony pill, or podophyllin, 
may be advantageously used. The iodide of potassium has been much recom- 
mended by Mr. Spencer Wells. Alkaline remedies are of much value in the 
treatment of the paroxysms of the joint affection, and may be prescribed in 
the form of the bicarbonate or of the citrate or acetate of potash. Dr. Garrod 
prefers the bicarbonate, and Dr. Parkes has shown that it increases the elimi- 
nation of uric acid and organic solids by the urine (Parkes On the Urine, p. 
298). Much benefit is also derived from the continuous administration of 
salines in small doses, repeated two or three times a day, in a very dilute form 790 
SPECIAL PATHOLOGY-CHRONIC GOUT. 
and always on an empty or nearly empty stomach, and some little while before 
food (Garrod). 
If acute gout should have " retroceded," as it is called, and the stomach or 
intestinal canal be inflamed, leeches should be applied to the abdomen or epi- 
gastrium, followed by a poultice, while the neutral salts, with the tincture of 
hyoscydmus, should be given at least every four or six hours. It is very rare 
that more active medicines are necessary. 
For farther indications regarding the management of gout, see treatment of 
the next subject-namely, chronic gout. 
CHRONIC GOUT. 
Latin Eq., Podagra tonga; French Eq., Goutte chronique; German Eq., Chronische 
gicht; Italian Eq., Podagra cronica. 
Definition.-J. persistent constitutional affection, characterized by stiffness and 
swelling of various joints, with deposits of urate of soda. 
Pathology and Symptoms.-The nature of chronic gout does not differ 
from acute gout, except as regards its chronicity. This chronicity is shown 
by the frequency of the attacks of gout, and by other persistent and perma- 
nent signs of the gouty constitution. The dyspepsia is especially persistent; 
and although distinct paroxysms are accompanied by less pain and fever than 
in acute gout, they last for weeks or months, and several joints are affected 
at once or in rapid succession. The chalky deposits described as a character- 
istic lesion, and in and about the joints, are most common in cases of chronic 
gout. The swelling and redness of parts develop very slowly. The redness 
is generally less intense and the swelling more diffuse and cedamatous than 
in acute gout, and it does not subside with the desquamation of the cuticle. 
It continues, feeling at first soft and doughy, but latterly it contains firm 
nodules of variable size, and at last a hard mass of concretion is left, which 
is small in comparison with the swelling, the remains of which it represents. 
After repeated attacks, however, it grows by new7 deposits, and may eventu- 
ally attain a considerable size ; and the continued irritation of these deposits 
causes pain, difficulty of motion, and great deformity of the parts implicated. 
Phlegmonous inflammation is common ; abscesses sometimes occur about the 
joint, and the pus contains masses like soft mortar, from the breaking up of 
these chalky concretions. 
Observations on body-temperature are wanting alike in gout and in chronic 
gout. The febrile phenomena may be characteristic. Chronic gout may per- 
sist at intervals for fifty years ; but in some cases the paroxysms become fre- 
quent and irregular, so that instead of occurring annually or half-yearly, only 
a month or two may elapse between the attacks. These attacks are generally 
more prolonged than in acute gout, and a fresh paroxysm may ensue before 
the subsidence of the preceding one, so that the patient is scarcely ever free 
except in a few of the summer months (Garrod). 
Sydenham thus describes an attack of chronic, or, as he terms it, " inveterate 
gout"After yawning, especially in the morning, the ligaments of the bones 
of the metatarsus are violently stretched, and seem to be squeezed with great 
force, as if with a strong hand. And sometimes, though no yawning has pre- 
ceded, when the patient has disposed himself to sleep he feels a blow on a 
sudden, as if the metatarsus were breaking in pieces, by a large stick, so that 
he wakes crying out with pain. The tendons of the muscles of the tibiae are 
sometimes seized with so sharp and violent a convulsion or cramp, that if the 
pain it occasions were to last only a short time it could not be borne with 
patience." 
The succeeding paroxysms, after many racking pains, become less painful, NATURE AND COURSE OF RETROCEDENT GOUT. 
791 
when, " instead of the usual external pain, a certain sickness, a pain in the 
belly, a spontaneous lassitude, and sometimes a tendency to diarrhoea suc- 
ceeds." Besides the pain and sickness, the patient becomes lame, and almost 
incapable of motion, and is perhaps obliged to be wheeled or carried from 
room to room ; and he is not only reduced to this helpless condition, but, to 
complete his misery, his mind sympathizes with his body. "For every par- 
oxysm may be justly termed a fit of anger, the rational faculties being so 
enervated by the weakness of the body as to be disordered on every trifling 
occasion, whence the patient becomes as troublesome to others as he is to 
himself." 
Another form of chronic gout is known as atonic gout, when the joints en- 
large, and the tissues and ligaments become thickened, and the seat of various 
effusions, so as often to distend and even to dislocate the bones; and yet, if 
the patient be kept quiet, he suffers no pain. The debilitated organism is 
believed to be in a condition too feeble to develop a normal sthenic or acute 
attack of gout. The general symptoms, however, are most distressing. The 
permanent constitutional diathesis is generally apparent, by the excessive 
general hyperaesthesia, muscular weakness and dyspepsia, increased perspira- 
tion and thick cloudy urine. The patient suffers from loss of appetite, indi- 
gestion, sickness, nausea, flatulence, acid eructations, pains of the stomach, 
cramps in the legs and in various parts of the body; also great dejection of 
spirits, vertigo, palpitation, fainting, asthma, and also, perhaps, from stone or 
gravel. The most insignificant causes, such as errors of diet, excitement, ex- 
posure to cold, changes of weather and the like, will bring about these general 
constitutional symptoms, accompanied sometimes with pains in one or more 
joints, resembling commencing attacks of gout. These affections, in some 
form or other, continue with occasional intervals during the remaining life of 
the patient, who believes that he has the gout flying about him, and that he 
should be well if he had a regular fit. 
In the course of this disease there may be a metastasis to the stomach or 
other part, and the affection is then termed " retrocedent gout," the pain in 
the joints being trifling, or having entirely subsided. This form is the arthritis 
metastatica retrograda of the older authors, whose belief in this form of gout 
is not only supported now by such experiments as those of Hoppe-Seyler and 
Zalesky, already referred to, but by clinical observation also. The term is 
"applied to cases of gout in. which some internal organ becomes affected on the 
disappearance of the disease from the joints, and is referable either to acute or 
chronic gout." The organs most frequently affected are the stomach, brain, 
and heart. When the metastasis is to the stomach or intestines, gout in 
the stomach may be either of a spasmodic or inflammatory character. The 
spasmodic is the most frequent. The patient is seized with violent pains in 
the stomach (cardialgiaj, with faintness, coldness of the extremities, and a 
quick, small, and scarcely perceptible pulse, accompanied with much flatu- 
lence, acidity, or vomiting. If, on the contrary, the attack be of an inflam- 
matory character, the pain is perhaps equally great, but is increased on pres- 
sure, and there is more reaction, some fever, a fuller pulse, with vomiting, and 
sometimes with hoematemesis, and perhaps obstinate constipation. 
Gout affecting the encephalon may sometimes present the phenomena of an 
apoplectic seizure, or be indicated by severe circumscribed headache, giddi- 
ness, and vomiting. 
Gout affecting the heart may induce irregular and feeble action of that organ, 
associated with disturbed circulation, dyspnoea, and fainting. 
Gout affecting the spinal canal may induce sudden paraplegia. 
The duration of these attacks is short, as the patient must be quickly re- 
lieved or quickly perish. Besides metastasis to the stomach and intestines, 
this retrocedence may take place to other parts-as to the testicle, bladder, 
or rectum. The transition of the gouty virus is often marked by a pain shoot- 792 
SPECIAL PATHOLOGY-CHRONIC GOUT. 
ing along the nerve, as sudden and as rapid as a galvanic shock, and so violent 
as to have been compared to stabbing with a knife. 
It is only when gout runs its course with unusual symptoms, when the 
patient suffering from gouty inflammation of the joints suddenly is attacked 
in some of these inward parts, especially when the gouty affection of the joint 
is subsiding or developing, or terminating by copious excretions of urates by 
the kidneys, that we are warranted in considering such attacks as " retroce- 
dent gout." 
Besides being thus a migratory disease from part to part, gout often alter- 
nates with other chronic diseases, such as ' asthma and rheumatism, and may 
coexist with them. 
Treatment.-In chronic gout the treatment is the same as in acute gout; 
but as, next to hereditary predisposition, a disproportion, between the amount 
of food and drink taken and the necessity for it, is a great cause of the disease, 
means ought to be taken to regulate the diet and promote metamorphosis of 
tissue during intervals of freedom from gouty paroxysms. The habits of the 
patient ought to be regulated by written rules for him to abide by, if he would 
be free from gout. The form, the quantity, and the quality of the food ought 
to be precisely prescribed. Vegetables, with soups and meat, must be allowed 
only once a day-not oftener. Beer, wine, and alcoholic fluids generally are 
injurious, and must be forbidden to gouty patients, as they retard the meta- 
morphosis of tissue. The same is true of tea and coffee. Water, pure water 
only, taken in quantities as large as possible, promotes the metamorphosis of 
tissue to a greater extent than any remedies we know of. Its use does not 
lessen appetite for food-as is the case with beer, wine, spirits, tea, and coffee. 
It promotes the flow of fluid by the kidneys, and increases the excretion of 
urea. Combined with muscular exercise, the use of pure water hastens, to 
the greatest possible extent, the transformation of tissue; and, combined with 
the use of certain mineral waters and baths, " a connecting link," as Niemeyer 
writes, is established between the dietetic and medicinal treatment of gout. 
The mineral springs which exercise the most favorable influence on the 
gouty constitution are those of Aix in Savoy, Bath, and Buxton, Ems, Gastien, 
Homburg, Karlsbad, Kissengen, Marienbad, Neuenahr, Pfaffers, Pyrmont, 
Schwalbach, Spa, Toplitz, Wiesbaden, Wildbad, and Vichy. Dr. Garrod 
lays down the following general rules as a guide to the use of them: 
1. Their use should be prohibited when there is much structural disease in 
any important organ, especially in the heart or kidneys; and even when or- 
ganic mischief is slight, the greatest caution in their use is necessary. 
2. They are to be avoided when an acute attack is either present or threat- 
ening. 
3. The particular mineral water must be selected according to the nature 
of the individual case: for the robust, and those of full habit, the alkaline 
saline springs should be chosen ; when torpidity of the bowels predominates, 
the purgative waters should be used ; when the skin is inactive, the sulphur 
springs may be used; and when much debility prevails, or an atonic state 
exists, then the more simple thermal springs may be prescribed. 
They contain either alkaline, carbonates, chlorides, or sulphates. Some are 
impregnated with sulphurated hydrogen, and others contain iron ; many, like 
Wiesbaden, Karlsbad, and some of the Vichy springs-Wildbad and Neue- 
nahr-are of an elevated temperature. 
The beneficial influence of these natural mineral waters is especially per- 
ceptible in the reduction of plethora, on the part of the alkaline springs, and 
in the regulation of the functions of the bowels and skin. 
The springs of Vichy are all rich in carbonate or bicarbonate of soda-about 
forty grains to the pint. Some have a temperature of 101° Fahr. In mod- 
erate doses they cause the urine to become alkaline or neutral; and used as 
baths, they have a similar effect. They influence especially the functions of TREATMENT OF CHRONIC GOUT. 
793 
the liver and the skin, and are more adapted for the robust and persons of 
full habit of body; but if the system is enfeebled by frequent attacks of gout, 
or if there is a tendency to the formation of chalk concretions, the waters of 
Vichy are not to be recommended. 
The waters of Wiesbaden contain a large amount of chloride of sodium, 
and are as high in temperature as 160° Fahr. They are more highly stimu- 
lating and more generally debilitating than those of Vichy, and are of service 
in those cases where the circulation is slow and the secretions deficient. 
The springs of Neuenahr range in temperature from 90.5° Fahr, to 104° 
Fahr., and contain nearly 50 per cent, by volume of free carbonic acid, with a 
considerable quantity of soda salts, chiefly as carbonates. They stimulate the 
circulation, augment the excretions from the kidneys and the skin, increase the 
appetite, and diminish stomachal acidity. 
They are unsuitable for plethoric habits and where the liver is enlarged; 
but where the constitution is impaired or enfeebled, they are of great service. 
The waters of Wildbad, in the Black Forest, have also a high temperature 
-92° Fahr.-with much free carbonic acid, holding salts of soda, and mag- 
nesia, and iron in solution. They are alkaline, and their influence is similar 
to the springs of Neuenahr. 
The waters of Aix are slightly saline, and of a temperature as high as 135° 
Fahr., containing chloride, carbonate, and sulphide of sodium, with free sul- 
phurated hydrogen. They stimulate the liver, kidneys, and skin, and are in- 
dicated where there may be sluggish action of these functions, and where the 
joints are stiff. 
The Karlsbad waters are rich in sulphate of soda, with carbonate of soda and 
common salt. Their temperature is about 167° Fahr. They are purgative, 
diuretic, and diaphoretic, and are beneficial where there is constipation, with 
congestion of the liver; and are unsuited for feeble patients. 
The waters of Baden-Baden contain common salt combined with iron, and 
are also rich in lithia. 
Toplitz, Gastien, Buxton, and Bath waters are also all somewhat elevated 
in temperature, and are peculiarly adapted for the treatment of gout in the 
infirm, feeble and old patients. 
The chalybeate waters of Spa and Pyrmont are most suitable for anaemic 
patients and in the asthenic forms of chronic gout. 
The salts of lithia, so abundant in the waters of Baden-Baden, were originally 
proposed by Dr. Garrod as a remedy for gout. They have since been exten- 
sively used, and found generally beneficial. They abound also in the Karlsbad, 
Aix, Marienbad, and some of the Vichy waters. 
The salts of lithia are actively diuretic, powerful solvents of uric acid, and 
generally they tend to render the urine neutral. Taken for a length of time 
in a dilute form, they tend to prevent paroxysms of gout in chronic cases, and 
cause solution and absorption of chalky matter. They certainly lessen the 
deposit of water and uric acid in the urine; and are of service both in the acute 
and chronic forms of gout. The dose is from^w to ten grains of the carbonate 
of lithia, dissolved in aerated water, three or four times a day; of the citrate, 
eight, ten, or more grains may be given (Garrod, Flint, Clymer). 
Iodide of potassium is a remedy of very great value, especially in cases where 
"the pains are increased at night;" but in the experience of Dr. Clymer, in 
which I agree, the bromide of potassium is still more useful. It seems more 
highly anodyne and soothing. 
Of the iodide of potassium Dr. Garrod writes, that it is useful in removing 
the recent thickening in the tissues round joints; and of gouty inflammation, 
wdien fluid is effused into the cavities of joints, and is slow of absorption. 
Of guaiacum, he considers it especially useful in the asthenic gout of old 
subjects, and to younger patients also it is beneficial. 
Dr. Clymer has found a combination of quinine, iron, and arsenic of special 794 
SPECIAL PATHOLOGY-CHRONIC GOUT. 
service, in very minute doses, in the fornj of chlorides. Dr. Garrod considers 
it advantageous to unite small doses of colchicum with the quinine. 
The pills of Becquerel are recommended by Trousseau. They consist of: 
R. Quinice sidphatis, gr. xx; Ext. Digitalis, gr. iii; Ext. sem. colchici, gr. x. 
Divide into ten pills, of which two or three may be taken daily for three or 
four days. 
Laville's Anti-gout Liquid and Pills are French preparations, and are so 
popularly known and so much esteemed by many sufferers, who have used 
them with excellent effect, that they challenge attention, although they are 
open to the objection of being secret as to their composition like chlorodyne, 
James's powder, and Warburg's drops. According to Dr. Tanner, "From an 
analysis, the liquid contains the active principle of colocynth, quinine, and 
cinchonine, with unimportant salts of lime. It is used at any period of the 
attack; a teaspoonful being taken in sweetened water or tea, and repeated in 
six hours, if the pain continue and the bowels be not moved. Twenty-four 
hours are to elapse before the next dose, when half the quantity is to be taken 
daily, two or three times, unless the bowels are irritable. The pills consist of 
physalin mixed up with silicate of soda and powdered chamcedrys." One is 
taken just before a meal, for several weeks. 
In the chronic forms of the disorder, where there is no organic disease of 
the brain, heart, or lungs, wet-packing, and the Turkish bath, cautiously and 
occasionally used, but not during a paroxysm, under the immediate supervi- 
sion of the attending physician, would sometimes seem to be of service, in less- 
ening stiffness of the joints and restoring or improving the action of the skin 
(Clymer). Trousseau speaks well of the wet-packing. Hot salt-water baths 
are beneficial. In chronic gout, Dr. Goolden has seen the inhalation of 
oxygen followed by clear urine, and great relief, and in some cases cures have 
resulted. 
In atonic gout some light tonic medicine may be given, as five to ten grains 
of the citrate of iron. A large number of chronic cases, however, though the 
general health is improved by this treatment, are often altogether unrelieved 
as to the local symptoms, and are often quite unable to assist themselves. In 
these instances the terebinthine remedies appear to be beneficial, as spruce beer, 
and Canadian balsam; or, one drachm of the oil of turpentine may be taken in 
an effervescing draught once or twice a day. Sydenham's method of treat- 
ment by manna may also be used. 
Sydenham recommends, from experience in his own case, large doses of 
manna in all cases of what he terms "bloody urine." 
If the chronic or atonic gout should become retrocedent, and the stomach 
and intestinal canal be the seat of the spasmodic form of the disease, Syden- 
ham strongly recommends that laudanum should be given; but perhaps the 
following draught is more efficacious, namely- 
R. Aquce Camphorce,^; Sp. xEtheris Sxdphuricffp-, Sidphatis Magnesice, Jss. 
It will remove from the stomach any undigested matter which may remain 
as an irritating cause. This should be given every hour till the patient is re- 
lieved ; and while it is being prepared, hot brandy and water should be freely 
administered, or the spiritus ammonice aromaticus, in doses of sixty minims, and 
hot cloths applied to the abdomen, as well as hot bottles to the feet. 
As indiscriminate feeding appears to have a great influence in the produc- 
tion of gout, so we expect the regulation of diet should have great influence 
in its removal. During the fit the diet should consist of slops and light pud- 
dings, and afterwards white fish, till the paroxysm has terminated. 
This disease is so distressing that many persons are inclined to diet them- TREATMENT OF CHRONIC GOUT. 
795 
selves with great strictness during the interval. Sydenham says that a milk 
diet, or drinking milk as it comes from the cow, or boiled, without adding any- 
thing to it, except perhaps a piece of bread, once a day, had been much used 
for twenty years past in his time, and had done much service to gouty pa- 
tients. But on quitting it, and returning to the mildest and tenderest diet of 
other persons, gout has immediately revived; and he adds, that many cannot 
bear this regimen. An entirely water regimen he considers hurtful. The 
most digestible meats, such as mutton, well-kept beef and poultry, with the 
white kinds of fish, as codfish, sole, and whiting, may be eaten; but salmon, 
veal, and pork are to be avoided, as well as cheese, salads, highly seasoned 
dishes, and rich sauces, or other " elaborate preparations on the part of the 
cook." If alcohol in any form is required, it may be taken in the form of a 
little weak brandy, gin, or whisky and water, or pure sherry, like Amontillado 
or Manzanilla. Port, Burgundy, and sweet wines must be avoided; but wines 
of the Rhine vintages may be taken, if they do not contain a large percent- 
age of alcohol. All of these spirits ought to be taken much diluted with Selt- 
zer or soda-water. His recommendations are, that we should be early to bed, 
keep the mind free from all disquietude, live with the greatest moderation, 
clothe ourselves warmly, and ride on horseback. When exercise cannot be 
taken, friction over the surface of the body is exceedingly useful. The patient 
should be rubbed down with a flesh-brush once or twice a day, just as a horse 
is groomed. Turkish baths taken regularly once a week, or as often as may 
be indicated to the medical attendant, are most beneficial. 
Much harm may be done, however, by excessive limitation of the supply of 
nourishment' as well as by the sudden and complete abstraction of spirituous 
fluids that had been used for years; as well as by other debilitating courses 
of treatment set about too hastily and pursued too vigorously. If the patient 
is cachectic, debilitating treatment will make him worse. 
" There should be a due admixture of animal and vegetable food; it is an 
error to suppose that an animal diet tends more to the formation of uric acid 
than a vegetable one. The tortoise, feeding on a simple lettuce, excretes a 
large quantity of urate of ammonia, far more in proportion to the weight of 
the animal than is excreted by the dog exclusively nourished with meat. 
Vegetables, as potatoes, greens, and the like,maybe partaken of with advan- 
tage ; the soluble salts they contain are of value in keeping up the activity 
of the secreting organs. The same remarks hold good with regard to soft 
fruits, when eaten in moderation, as strawberries, grapes, and oranges; also 
other fruits when stewed or baked, as apples and. pears; but these latter, as 
likewise plums, and stone-fruit in general, should be avoided in a raw state. 
Extreme moderation should be exercised when saccharine fruits are eaten, as 
sugar is liable in many subjects to lead to the production of acidity. The same 
precaution is necessary in reference to the addition of sugar to other articles 
of diet" (Dr. Garrod). 
One other point with regard to the treatment of the patient during the fit 
is, that if it be necessary to move him, either on account of his restlessness or 
other cause, this should be done with great care and tenderness by the atten- 
dants ; for although the pain may be latent while the parts are quiet, yet the 
least shock often causes the most excruciating agony. 
The irritable state of mind of the patient during the paroxysm has been 
mentioned; and it is well known that slight moral causes will often produce 
a fit, while powerful emotions have sometimes cured one. It is quite essential, 
therefore, that the minds of gouty patients should be kept as tranquil as pos- 
sible, both for their own sakes as well as for the comfort of others. 796 
SPECIAL PATHOLOGY-GOUTY SYNOVITIS. 
GOUTY SYNOVITIS. 
Latin Eq., Inflammatio synovialis podagrica; French Eq., Arthrite. goutteuse; Ger- 
man Eq., Gichtische Synovialhautentzilndung; Italian Eq., Sinovitide gottosa. 
Definition.-Inflammation of the synovial membranes of a joint, in a person 
who suffers from chronic gout. 
Pathology.-In chronic forms of gout the local affection of a joint may pre- 
dominate over the constitutional disease, and then, as a rule, it comes under 
the care of the surgeon, rather than the physician. When repeated attacks 
of gout affect a joint, during the course of which the inflammation is invaria- 
bly accompanied by the deposition of the salts peculiar to gout, the joint at 
last loses its capacity for movement. In place of the normal products of in- 
flammation in the synovial structures of a healthy subject, the synovial fluid 
is thickened by the chalky-like material, and the synovial membrane is stud- 
ded with the small white masses of urate of soda. Thus the synovial mem- 
brane becomes thickened and vascular; the ligaments and areolar tissue be- 
come condensed, and serious lesion of the joint is apt to be the final result. It 
is permanently injured, either by becoming so rigid that its functions are prac- 
tically destroyed, or from the formation of the chalk concretions or tophi, 
which destroy the joint-structures. It is the existence of these chalky deposits 
-the special characteristic of the gouty affection-which distinguishes gouty 
synovitis from the chronic osteo-arthritis about to be described. 
Treatment.-The principles of management do not differ from those already 
laid down under the topic of chronic gout. The diet must be carefully regu- 
lated, and the dyspepsia relieved. The secretions, urinary and intestinal, must 
be regulated. Small doses of colchicum, combined with salines and alkalies, 
in small doses, frequently repeated, and much diluted, taken on an empty 
stomach before food, are the agents likely to be of most service. The mineral 
waters taken at the various spas are the best media for saline remedies. 
Where debility is great, the chalybeate springs of Schwalbach or of Pyr- 
mout are often of advantage. 
CHRONIC OSTEO-ARTHRITIS-Syn., CHRONIC RHEUMATIC ARTHRITIS. 
Latin Eq., Osteo-arthritis Longa-Idem valet, Arthritis rheumatica Longa; French 
Eq., Arthrite rhumatismaLe chronique; German Eq., Chronische depormirende 
gelenkentzundung; Italian Eq., Osteo-artritide cronica. 
Definition.-An affection characterized by pain, stiffness, and deformity of one 
or more of the joints, associated with the deposition of new bone round them. 
Pathology and Symptoms.-By some this affection has been regarded as a 
form of chronic articidar rheumatism; others regard it as essentially different; 
and although the College of Physicians have retained a synonym to indicate 
the connection of the disease with rheumatism, they have placed the affection 
after gout, and not after rheumatism. It seems also to have been one of the 
numerous affections comprehended under the name of rheumatic gout-a term 
which has been advantageously omitted in the nomenclature of the College 
of Physicians. "It is regarded by the most competent observers as one con- 
veying altogether an erroneous impression of disease; and it has not been 
mentioned as a synonym, because it was found that any two members of the 
committee were not in the habit of hearing it applied to the same form of 
affection" (Med.-Chir. Review, 1869, p. 365). 
The disease may attack any joint indiscriminately, when it becomes so 
swollen and misshapen that the term "arthritis deformans" has also been PATHOLOGY OF CHRONIC OSTEO-ARTHRITIS. 
797 
given to the disease. The articular inflammation generally commences with 
the synovial membrane (Cruveilhier, Adams, Brodie). It not only affects 
the synovial capsule and ligaments, but the cartilages and ends of the bones 
become involved in lesions which are characteristic of the disease. The artic- 
ular cartilages and surface of the bone eventually disappear, an induration of 
the central parts of the joint succeeds, followed by an extensive proliferation 
of new bone (osteophytes), which grows round the peripheral portion of the 
joint ends of the bones, giving them a very ragged appearance. The^nds of 
the bones are in immediate contact by smooth articular surfaces, without any 
intervening cartilage. 
Table Exhibiting the Differential Diagnosis of Gout, Rheumatism, and 
Chronic Osteo-arthritis (Dr. Garrod). 
Garrod) 
Gout. 
Rheumatism. 
Chronic Osteo-arthritis. 
Strongly hereditary. 
Less so than gout. 
Less so than gout, if at all. 
Much more frequent in 
males. 
As frequent in females. 
More frequent in females. 
Seldom occurs before pu- 
berty, generally much 
later. 
More frequent in the young, 
and before middle age. 
Occurs both in young and 
old. 
Induced by high living, 
wine and malt liquors. 
Occurs in the weak, and 
not caused by wine, &c., 
excited by cold and damp 
Often induced by depress- 
ing causes, and some- 
times excited by cold. 
One or more of the smaller 
joints particularly affect- 
ed in early attacks, and 
especially great toe. 
Large joints more affected 
than small, usually seve- 
ral in number. 
Large and small joints 
about equally affected. 
Great pain, oedema, and 
desquamation of cuticle. 
Pain less intense; seldom 
oedema. 
Less pain ; much swelling, 
and often some oedema. 
Does not induce acute in- 
flammation of the struc- 
tures of the heart. 
Often causes acute pericar- 
ditis and endocarditis. 
No tendency to cause heart 
disease. 
Febrile disturbance moder- 
ate. 
Febrile disturbance great; 
more than from local in- 
flammation. 
Little febrile disturbance. 
Paroxysms periodic in early 
attacks. 
Attacks not periodic. 
No periodicity. 
Early attack lasting but a 
week or ten days. 
Attacks generally much 
longer. 
Duration of attacks indefi- 
nite. 
Blood rich in uric acid. 
No uric acid in blood. 
No uric acid in blood. 
Constant deposit of urate 
of soda in inflamed car- 
tilages and ligaments. 
No deposit of urate of soda. 
No deposit of urate of soda; 
ulceration of cartilages. 
Often leads to kidney dis- 
ease. 
No tendency to cause kid- 
ney disease. 
No tendency to induce kid- 
ney disease. 
Often produces chalk-stones 
externally. 
Never causes chalk-stones. 
No chalk-stones produced, 
but swelling of joints. 798 
SPECIAL PATHOLOGY-CHRONIC OSTEO-ARTHRITIS. 
The disease develops very slowly-most commonly between the twentieth 
and fortieth years of life; but it may begin late in life, and even in advanced 
age. It is said that affections of the smaller joints are more common in women 
than in men (Haygarth), but that men more frequently suffer in the larger 
joints, especially the hip, and the disease is much more common among poor 
people than among the well-to-do classes. 
At the commencement of the disease there is considerable pain in the joint, 
sometimes so severe as to prevent sleep at night. The pain is also increased 
on pressure and on movement of the joint; and if the hand be laid on the 
joint when it is moved, a crackling or crepitation may be felt, the joint being 
almost dry, or containing a very small amount of synovia. The disease gen- 
erally begins in both hands, and passes to the feet, and great deformity takes 
place, from subluxation of joints, enlargement of the epiphysal ends of the 
bones, and destruction of the articular cartilages. The fingers ultimately are 
flexed on the metacarpal bones, and drawn over seriatim to the ulnar side of 
the palm, so that the fingers lie over each other. These characteristic enlarge- 
ments of the joints acquired for the disease originally the name of nodosity of 
the joints (Haygarth), affecting chiefly the hands and feet; and more 
recently this is the form and site of disease to which the term rheumatic gout 
has been most commonly applied. When the larger joints were implicated 
in a similar morbid process, the disease was then generally considered to be 
chronic rheumatism; and when seated in the hip-joint, as is usually the case in 
old people, the disease was described under the name of "morbus coxce senilis." 
Now, the name placed at the head of this subject is the official name, which 
is meant to comprehend all these forms of the disease. 
Chronic osteo-arthritis sometimes succeeds chronic rheumatism, when, as a 
rule, many joints are affected, and the disease is no doubt influenced by the 
constitutional diathesis of rheumatism. 
There is generally a great resemblance to rheumatism in the phenomena of 
this disease; but the table on the preceding page, drawn up by Dr. Garrod, 
and published at page 544 of his valuable work on gout, will show the char- 
acteristic differences between gout, rheumatism, and chronic osteo-arthritis, which 
last name I have substituted for rheumatic gout and rheumatic arthritis in Dr. 
Garrod's table. 
Treatment.- Chronic osteo-arthritis must not be treated either as gout or as 
rheumatism. Colchicum is considered by Dr. Garrod to be generally injuri- 
ous, and so also is alkaline treatment. 
The course of management may be shortly indicated as follows: Gregory's 
powder at bedtime and more active aperients at regular intervals, are required 
as a necessity. The action of the skin ought to be encouraged by hot-air baths, 
the frequent use of the Turkish bath, and Dover's powder at bedtime. Warm 
bathing is generally attended with relief, and recourse should be had to the 
mineral springs of high temperature, already mentioned at page 792. Schwal- 
bach, Spa, Wildbad, Neuenahr, and Tunbridge Wells, are the best. Guaiacum, 
if borne by the stomach-combined or not with sulphur-is of great assistance 
(Garrod); and the free use of dilute phosphoric acid is recommended by Mr. 
William Adams. Iodide of potassium is also well spoken of. Whichever of 
these remedies may be considered suitable for any particular case, it ought to 
be steadily persevered in for several weeks. 
Warm clothing and residence in a warm climate during the winter months 
are necessary elements for increasing the comfort of the patient. 
If much emaciation has resulted, cod-liver oil and fats must be prescribed, 
combined with the usual tonic remedies, according to the nature of the case. 
The local remedies must be regulated by the surgeon. 799 
PATHOLOGY OF SYPHILIS. 
SYPHILIS. 
Latin Eq., Syphilis; French Eq., Syphilis; German Eq., Syphilis; Italian Eq., 
Sifilide, 
Definition.-The result of a specific poison, produced solely by contagion or 
implantation on some part of the body, generally through an abrasion or sore con- 
sequent on sexual intercourse with an infected person. Three weeks or a month 
after absorption of the poison a peculiar series of phenomena supervene, which 
mark the general infection of the system. The principal anatomical signs of gen- 
eral infection consist of induration (specific) round the spot where the virus has 
been implanted, induration of the lymphatic system of glands, the formation of 
nodes or gummatous nodular tumors in the connective tissue generally, and espe- 
cially in that of the true skin, bones, mucous membranes, and solid visceral organs 
-e. g., liver, brain, lungs, and heart. A cachectic condition of the system follows, 
and accompanies the phenomena of infection; and indurations may remain in the 
form of hardened fibrous tissue in various parts of the body for an indefinite period 
of time. 
Pathology and. Morbid Anatomy.-Advances in pathology of late years 
have not been more marked in any direction than in demonstrating the very 
remote effects which the poison of syphilis exercises upon the organs and the 
constitution of man. These advances are due to clinical, experimental, and 
post-mortem observations. They have shown that a considerable number of 
doubtful cases of ill-health are in reality due to the specific poison of syphilis, 
whose morbid effects are not fully developed till many days, months, and even 
years after inoculation. Hitherto surgeons have claimed the subject of syphilis 
as their peculiar field; but after the surgeon had healed the sore, the morbid 
influence of the poison in many cases still remained, and internal lesions, im- 
paired health, and degenerate constitution, eventually brought the patient to 
consult the physician as well as the surgeon. 
The pure surgeon and the pure physician must, therefore, condescend to 
forget their purity, if they would comprehend the pathology of this disease: 
for the relations of syphilis are so vast and complicated that both the physi- 
cian and the surgeon must combine their knowledge and their skill, before 
the many interesting points in the pathology of syphilis can be fully cleared 
up. To heal the original sore and obtain a cicatrix is but the beginning of 
the end. 
It is partly to the unscientific division of the field of medical practice, into 
Medicine and Surgery, that the phases of opinion regarding the pathology of 
syphilis have been so remarkably diversified. The surgeon alone saw the pri- 
mary sore or inoculation, and only by chance he might see the development 
of the future lesions, now so important in pathology. The physician, on the 
other hand, rarely saw the primary sore; and when at last he sees the victim 
of secondary and tertiary syphilis, the case is often extremely complicated, 
"mixed up with and overlaid by other constitutional and local diseases," which 
in their turn are made more serious by the existence of syphilis. 
Venereal sores, commonly known as chancres and gonorrhoea, were described 
in Chinese systems of medicine 4500 years ago; also in Hindoo, Arabic, Greek, 
and Latin literature (Berkeley Hill). 
Towards the close of the fifteenth century a great epidemic, believed to be 
syphilis, pervaded Europe; and the historians of the disease described a form 
of neuralgia as one of the remote results of the venereal poison. It was known 
as the " Great Pox," was known to be contagious, and communicated most 
readily during sexual intercourse. 
In the sixteenth century syphilis was clearly recognized as the result of a 
specific poison or virus. It was believed to be capable of combining with all 800 
SPECIAL PATHOLOGY-SYPHILIS. 
other diseases, and so to modify them, and to give them new forms. Even at 
that early period in medical history, syphilis was recognized as producing 
phthisis, diarrhoea, dropsy, skin diseases profoundly affecting the constitution, 
and demonstrating the presence of a poison in the system by remote general 
symptoms of ill health (Paracelsus). Towards the close of the seventeenth 
century the ulterior results of venereal disease were fully recognized; but they 
were believed to be due to bad treatment. Van Swietan taught that no organ 
escapes the influence of the venereal poison. He recognizes it as the source 
of gummy tumors, exostosis, deep-seated pains, apoplexy, epilepsy, blindness, 
deafness, paralysis. 
In the present century Benjamin Bell is the first writer on syphilis who 
puts forth clinical facts in support of his belief that "the venereal disease in- 
duces blindness, amaurosis, deafness, phthisis, rheumatism, epilepsy, mania;" 
and he demonstrated that Gonorrhoea was distinct from Syphilis; and the most 
recent researches show that syphilis and local chancres of venereal origin are 
quite distinct diseases. 
After a period, indeed, of skepticism and doubt, we are now confirming, by 
actual observations (aided by all the advanced knowledge and appliances of the 
day), the crude surmises of the physicians of four hundred years ago regarding 
the pathology of syphilis. 
The quality of the poison of syphilis and soft chancre is now established 
upon the same evidence as naturalists determine the identity of species in the 
animal and vegetable kingdom-namely, by the immutability of certain 
characters which the diseases exhibit through successive generations. " Im- 
mutability of species " lies at the foundation of all classification in natural 
history and specific diseases. It is the groundwork on which the whole super- 
structure of the pathology of specific diseases rests. Into this consideration 
the mere external appearance of venereal sores or ulcers does not enter as an 
element. Even if we could not recognize the one sore from another, by any 
outward sign, the fact of two different diseases would be established sufficiently 
by the fact, that the action of one poison was always local, and of the other 
poison as certainly always general. 
But the chancre of syphilis and the soft chancre do present in most cases 
differences recognizable by the sight and touch; which must be regarded as 
only additional, and not essential, evidence of the distinct nature of the two 
diseases. 
The distinguishing local characters which are " conspicuous by their ab- 
sence" in some instances, and especially in cases where syphilis has already 
existed, does not invalidate this view of the pathology of syphilis. 
There is no disease which more imperatively demands the careful study of 
the profession at this time, and especially of the army medical officer-for he 
has the best and most certain means for determining many points in the 
pathology of syphilis. The specific distinctions between the " infecting" and 
the "non-infecting" poison, and the characteristic phenomena they induce, 
are now recognized at most of the schools of medicine in this and other coun- 
tries. They are distinctions which are of great value in practice, and likely 
to become more valuable as our knowledge becomes more defined. By watch- 
ing a primary sore we are able to predict, with absolute certainty, at an early 
period of its development, whether the patient will or will not be the subject 
of secondary symptoms. 
A history of syphilis in soldiers is too often the starting-point of a fatal 
disease. The impairment of the health takes its origin from the date of the 
infecting syphilitic sore. Early implication of the lymphatic glands leads to 
impoverishment of the blood as an immediate result, and then to degeneration 
or wasting of tissues, which attends the general cachexia, and which may 
eventually terminate in death, with complicated and varied lesions, especially 
implicating the internal viscera. REDUCTION OF VENEREAL DISEASES IN THE ARMY. 
801 
No statistics can give any adequate idea of the number of men lost to the 
public service from syphilis. Venereal diseases compose the greatest number 
of admissions to Army Hospitals. The loss of strength from venereal diseases 
alone in the British service, in 1860, was computed by Dr. Balfour as equal 
to the loss of more than eight days annually of every soldier in the service. 
Dr. Balfour relates, in his most excellent and interesting Medical, Sanitary, 
and Statistical Report of the Army Medical Department for 1860, that "more 
than one-third of all the admissions into hospital have been on account of 
venereal diseases (369 per 1000) ; and the average number constantly in hos- 
pital is equal to 23.73 (reduced to 14.87 in 1869) per 1000 of strength (2315 
men), each remaining in hospital on an average 23| days. Thus the ineffi- 
ciency was then constantly equal to about 2| regiments." Dr. Balfour also 
observed the individual history of 1126 men of the Grenadier Guards for three 
years and five months; 536 of these men gave rise to 1250 admissions; 212 
were admitted once; 146 twice; 70 three times; 55 four times; 24 five times; 
19 six times; 6 seven times; 2 eight times; 1 ten times; and 1 fourteen times. 
These figures have great practical significance. They do not tell us how 
many of these men became constitutionally contaminated by syphilis, or 
finally suffered from syphilitic lesions of internal organs. In the Ninth Re- 
port of the Department (that for 1867), it is shown that although the admis- 
sions to hospital for venereal diseases were greater than in 1866, at all the 
large stations (except Warley, Chatham, and Sheerness), the ratio of admis- 
sions in 1867 was 49 per 1000 of strength lower than in 1866. The increase 
was most marked at Manchester, Preston, Dover, Isle of Wight, Edinburgh, 
and Limerick. 
Now, it is satisfactory to know that, compared with 1860 and still more 
with 1866, venereal diseases in the army in this country show a very consider- 
able reduction in their prevalence up to 1869. 
The proportion constantly in hospital for venereal diseases, per 1000 of 
mean strength in the United Kingdom in each year, as estimated by Dr. Bal- 
four, from 1860 to 1869 inclusive, was as follows: 
1860-23.73 per 1000 of Mean Strength. 
1861-24.70 " " 
1862-22.32 " " 
1863-20.31 " " 
1864-19.21 " ' " 
1865-18 14 per 1000 of Mean Strength. 
1866-16.00 " " 
1867-17.95 " " 
1868-17 82 " " 
1869-14.87 " " 
In 1866 the Contagious Diseases Act came into operation, with the follow- 
ing results for the three years, 1867-8 and 9: 
In 1867 the ratio of admissions per 1000 of strength for primary venereal 
sores, at stations under the Act, was 86; at stations not under the Act, 106. 
In 1868 the ratio of admissions was 70, as against 108; and in 1869 the ratio 
of admissions was 61, as against 113, at stations not under the Act. 
A progressive decrease in the admissions, a progressive decrease in venereal 
sores at stations under the Act, and an increase in the proportion of admissions 
at stations not under the Act, are the final effects. 
During the last thirty years venereal diseases have always formed a class 
by themselves in the Army Medical Returns, at first under that title, and 
latterly as "Enthetic Diseases;" but the College of Physicians did not deem 
it necessary to retain a separate class for these affections. From a military 
point of view, however, they form so important a class, especially with refer- 
ence to the amount of inefficiency they cause, and of invaliding to which they 
gave rise, that the Director-General of the Army Medical Department has 
decided to call for a special return of them annually from every corps; and 
the following instructions for its preparation have been issued: 
" In this Return, under the head of Primary Syphilis, are to be included 
all those cases in which the venereal sore is one of the indications of a con- 
t came into operation, with the foliow- 
and 9: 
1000 of strength for primary venereal 802 
SPECIAL PATHOLOGY-SYPHILIS. 
stitutional infection, usually attended with more or less hardness of the sore 
and induration of the inguinal glands, and followed by general constitutional 
manifestations. 
"Under Local Venereal Ulcer are to be included all cases of sores arising 
from impure sexual intercourse, which are not attended or followed by any 
constitutional affection. These cases are frequently attended with inflamma- 
tion and suppuration of the inguinal glands, which must be considered as a 
complication, and not as a separate disease. 
" Care must be taken not to include in the Return cases of inflammation 
or suppuration of the inguinal glands arising from causes other than venereal 
affections: all such cases should be entered in the Periodical Returns in 
Class II, Order 6, of the nomenclature. Cases of inflammation of the tes- 
ticle, when the result of gonorrhoea (formerly returned as hernia humoralis 
and gonorrhoeal orchitis) should be entered as gonorrhoeal epididymitis, 
Class II, Order 10; when arising from other causes, they should be entered 
in the Periodical Returns as orchitis, Class II, Order 11, and carefully 
excluded from this Return. (See Part II of this text-book, pages 310 to 
325.) 
" Blank lines are left for the entry of any cases which may appear so ex- 
ceptional as not to justify their being included in any of the groups; but such 
cases must be specially noticed, and the grounds on which they have been 
deemed exceptional must invariably be appended to the Return. 
" Medical Officers are requested to take particular care that all cases of 
venereal diseases are included in this Return; that they are grouped in 
accordance with these instructions; and that none but venereal cases are 
included." 
From these returns the department will be able to give all the necessary 
information respecting the prevalence of this important class of diseases in 
the military service of the country, so as to show eventually how many men 
have become constitutionally contaminated by syphilis, and how many have 
merely had sores (simple or suppurating soft chancres), with or without glan- 
dular complication, and how many gonorrhoea. 
The following classification and definitions of the forms of syphilis have 
been given by the College of Physicians: 
A. Primary Syphilis. Definition-Syphilis while limited to the part inocu- 
lated, and the lymphatic glands connected with it. The varieties are hard chancre, 
with its indurated bubo; soft chancre, with its suppurating bubo; phagedenic 
sore and sloughing sore. 
B. Secondary Syphilis. Definition-Syphilis when it affects parts not directly 
inoculated. 
Tertiary syphilis is a term sometimes applied to the later symptoms, when 
separated by an interval of health from the ordinary secondary syphilis. 
C. Hereditary Syphilis. Definition- Constitutional syphilis of the child, de- 
rived during foetal life from one of the parents. 
Nomenclature.-Syphilis, comprehending primary and successive constitu- 
tional symptoms of contamination, ought now to be distinguished from simple 
venereal ulceration not followed by specific gland complication nor contami- 
nation of the system. 
The etymology of the term "syphilis" is unknown; but as now used the 
term comprises-(1.) The primary sore, and the changes it undergoes. (2.) 
The successive constitutional symptoms or phenomena which denote the con- 
tamination of the system. A man or a woman may have had a soft chancre 
or suppurating sore on the genitals, and a suppurating bubo, and yet remain 
free from any taint. Such a case should not be set down as a case of syphilis, 
but simply as a case of "venereal ulceration" with glandular complication. In 
such a case the gland complication is consequent on the irritation of the sore, 
and is not specific. NOMENCLATURE OF SYPHILIS. 
803 
There can be no doubt that there are several distinct diseases which, from 
their most common origin in sexual intercourse, have been conveniently 
grouped under the name of "Venereal diseases," namely-(1.) Gonorrhoea. 
(2.) Contagious ulcers of the genitals, chancroid or soft chancres, with suppu- 
rating buboes. (3.) Syphilitic ulcer or hard chancre, with indurated non- 
suppurating glands. 
But the time has certainly come when syphilitic ulcers ought to be dis- 
tinguished from soft chancres or simple contagious ulceration, not followed 
by contamination of the system. 
Syphilis should now be reserved to designate the more serious affection, in 
which the constitution is implicated, and in which the infecting phenomena 
occur; and if the term "chancre" is used, it should be stated* whether it is 
* The following very excellent directions have been drawn up by my colleague, 
Mr. Longmore, the Professor of Military Surgery in the Army Medical School, to be 
attended to in recording cases of primary venereal lesions (exclusive of gonorrhoea), 
and their consequences, among patients in the wards of the Royal Victoria Hospital 
at Netley. These directions are in accordance with our present knowledge of the 
Pathology of Syphilis. 
"1st. The term 'syphilis,' or 'syphilitic,' when used in the case-book, is to be 
applied only to such cases as are believed to be of a specific infecting kind. Non- 
syphilitic venereal lesions are to be named according to their local and physical char- 
acters, as 'superficial abrasion,' 'ulcus,' and the like. 
"2d. The following five points are to be noted in entering the history of each 
venereal case in the case-book : 
"I. Physical characters and exact site of the lesion. II. Period of incubation. 
III. Character of attendant inflammation. IV. Effects on neighboring glands. V. 
Prognosis. 
" 3d. Under I, 1 Physical characters and exact site of lesion,' state whether, 
" (a.) The lesion has the appearance of a papule, fissure, an abrasion, of a dry or 
moist open sore; whether, if a sore exists, it is superficial, not appearing to 
penetrate the whole thickness of the integument, or deeper, with a smooth 
surface, scanty, chiefly serous secretion, grayish in the centre; whether the 
texture around the lesion is indurated, and, if so, what is the character of this 
induration, especially whether it is circumscribed, cartilaginous-like, and ap- 
pears to be distinct from the subjacent and surrounding tissues; or whether, 
"(b.) An excavated sore exists with abrupt defined edges, involving the whole 
thickness of the integument, with an uneven surface, covered all over with 
copious secretion, and without circumscribed induration. 
" Mem.: The induration which exists from simple inflammation excited by the 
rubbing of clothes (the probability of which the site of the sore will perhaps indicate, 
or by the use of irritating applications, such as nitrate of silver, &c , and which dis- 
appears gradually in the surrounding tissues) must be carefully distinguished from 
the circumscribed hardness characteristic of the true syphilitic sore. 
" If more than one sore exist, it must be noted whether the several sores appeared 
together from the first, or appeared in succession. 
" If some time has elapsed since the patient was first taken under treatment, the 
original form and appearance of the sore should be traced as far as possible, and noted 
whether it began as a pimple, abrasion, fissure, or otherwise. 
'"4th. Under II, ' Period of Incubation ' should be ascertained, and stated whether, 
" (a.) The lesion first appeared after a lapse of one week, or from that time to a 
month, after exposure to contagion ; or whether, 
" (b.) There was no period of incubation, the sore appearing within a week after 
exposure. 
" Mem.; The importance to the patient of the questions at issue should be frankly 
explained to him, and his confidence secured, so that he may be induced to state as 
exactly as he can the number of times he has been exposed to contagion within a 
period of four or five weeks prior to his discovering the existence of the lesion. A 
patient usually himself dates the origin of the lesion from the time when he was last 
in the way of contracting disease. He may, however, have been in the way of con- 
tracting disease many times after the particular occasion on which he really con- 
tracted it. 
"5th. Under III, 1 Character of attendant inflammation,'state whether, 
" (a.) The inflammation appears to be of the adhesive; or whether, 
" (b.) Of the suppurative or phagedenic kind. 804 
SPECIAL PATHOLOGY-SYPHILIS. 
a "soft," "non-infecting chancre," or an "infecting" one; otherwise diagnosis 
is incomplete. Men or women may have primary sores on the genitals, with 
suppurating bubo, and yet remain free from any taint. Such cases cannot 
be regarded as " syphilitic," or even general diseases. They are simply cases 
of " local venereal ulceration," with glandular complication, only consequent 
on irritation from the sore, and not contaminating the system. Such are the 
so-called soft chancres. 
A comparison of the three poisons whose lesions are expressed by the names 
of (1.) Gonorrhoea, (2.) Soft chancre, (3.) Syphilis, leads to the following con- 
clusions : 
1. That the only property common to them all is their communication, for 
the most part, by contact of the genital organs; hence venereal lesions-a term 
now far too indefinite. 
2. That the poisons of gonorrhoea and of the soft chancre are alike in this- 
(a.) That their action is limited, and never extends to the general system. 
(6.) That one attack does not afford the slightest protection against a 
second. 
They differ, however, in this, that gonorrhoea may arise from different 
sources of infection-purulent discharges of different kinds, in the female ; 
while the soft chancre does not arise except by inoculation from an ulcer of its 
own kind. In gonorrhoea ulceration is rare, it affects the surface only of the 
mucous membrane; and its complications mainly attack parts continuously 
connected by'mucous surface with the original site of disease, as the prostate, 
bladder, testicle. 
The soft chancre, on the other hand, is an ulcer involving the whole thick- 
ness of the integument or mucous membrane; and its complications are limited 
to the adjoining absorbent vessels and glands. 
Pus also is the vehicle of communication of the poison of gonorrhoea and of 
soft chancre. It is said (Rollet) that if the discharges of gonorrhoeal oph- 
thalmia be deprived of its pus-globules by filtration, the remaining fluid is 
innocuous; and so also of soft chancre. Pus-globules, as such, are incapable 
of absorption ; and neither the pus of gonorrhoea nor of chancres ever reaches 
the general circulation. The pus never passes the first chain of lymphatic 
ganglia. It is arrested, like the granules, in the process of tattooing. 
The syphilitic poison is alone capable of infecting the system at large, and 
also of affording protection by its presence against subsequent attacks. 
Unlike the poisons of gonorrhoea and soft chancre, the poison of syphilis is 
not only conveyed by pus, but it exists in the blood, in the fluid serum of 
secondary lesions, in the serum of the blood itself, and probably in other 
secretions. 
The secretion of a superficial hard syphilitic chancre, as shown by micro- 
" 6th. Under IV,' ' Effects on neighboring glands,' state whether, 
" (A.) The superficial inguinal glands are, on one or both sides, generally and sepa- 
rately indurated, the inflammation with which they are affected being of an 
indolent character and without pain ; or whether, 
" (b ) The glands are free from enlargement; or whether one or more of the glands 
are enlarged, and exhibit a tendency to suppurative action. 
" 7th. Under V, ' Prognosis,' state whether you consider the case to be one of (a) 
syphilis, or (&) of local venereal sore, or (c) of a doubtful nature. 
" If the circumstances described under (a) exist, the conclusion will be that the 
lesions are indicative of the constitution being affected by syphilis; if those described 
under (b) exist, the conclusion will be that the lesions are local. 
" If your prognosis is doubtful, state the considerations which cause it to be so. 
"If the prognosis that the patient is afflicted with syphilis be correct, then the 
specific sore will not be capable of repetition on the same person by inoculation; if 
the prognosis be correct that the sore is a simple one, then the sore will be capable of 
indefinite repetition on the subject of it by inoculation. 
"•If your prognosis is doubtful, regard the disease as local, until further observation 
establishes a contrary opinion." NATURE OF THE SYPHILITIC POISON. 
805 
scopic examination, is often entirely destitute of pus. Indeed, unless irritated, 
the secretion is not purulent. The presence of the poison of syphilis in sec- 
ondary lesions is proved by the power which the serum or discharge from 
these lesions possesses of communicating the disease; and in semen by the 
occurrence of hereditary syphilis in the offspring, when the father is alone 
infected. 
On the other hand, the coexistence of the three poisons is not incompatible. 
They may all coexist in the same person, who may at the same time have 
gonorrhoea, soft chancre, and syphilis. Hence there are also " mixed" chancres 
or venereal sores. 
Thus the vaccine virus may also carry syphilis. 
With a view to the accurate investigation of venereal diseases and record- 
ing results, the following points require special notice: 
1. The nature of the contagious principle of the syphilitic poison, as expressed 
in the opinions of the most trustworthy observers in this and other countries. 
2. The characters and the phenomena which distinguish a sore that will 
contaminate or infect the system, and one which will not. 
3. The vehicles or media by which the specific or " infecting " virus maybe 
inoculated. 
4. The secondary lesions and local growths in the internal viscera, which 
are now so uniformly found to be associated with a history of syphilis, and 
which are the remote effects of a specific venereal poison. 
1. Nature of the Syphilitic Poison.-The disease develops itself after the 
introduction of a specific virus; and the source of the poison is more distinctly 
traceable than that of the diseases known to be inoculable in the previous sec- 
tion, such as small-pox or measles. The actual substance or matter which con- 
tains the virus can be obtained, and can be inoculated. Yet the active principle 
of the poison has not been isolated by any chemical process; and in this respect 
it is in exactly the same position as the poison of other inoculable diseases. 
The poison of syphilis undergoes a process of multiple elaboration or develop- 
ment in the system before its full effects are completed ; and the lesions it 
induces demonstrate some of the most interesting points in the pathology of 
the multiplication or reproduction of morbid poisons. It is this multiplica- 
tion which ultimately destroys life, through a degeneration of the tissues and 
the establishment of a cachexia, already referred to ; or by the induction of 
grave lesions in important visceral parts, such as the brain, the lungs, the 
liver, or the kidney. 
The earliest effects of the syphilitic poison, after the period of incubation 
has passed, become established upon the system during the occurrence of a 
" hardening process" or induration of the tissue which ultimately surrounds an 
infecting venereal sore-the local papule and its subsequent ulcer or sore. 
This hardening process is peculiar; and although not constant as to the local 
sore, it is constant as regards the glands or lymphatics, which proceed from 
the vicinity of the part inoculated. It occurs in one or other of the three 
following conditions: (1.) Hardening or induration of sore and glands; (2.) 
Hardening and induration of the cicatrix and glands; (3.) Hardening and 
induration of lymphatic glands only-the original local lesion never having 
become hard (Sigmund). The induration is best developed in the skin, and 
less so in the mucous membranes. It may continue, and generally continues, 
from three to nine months. 
Anatomy of the Induration.-Its elementary constitution is constant. It 
always presents the same anatomical composition. It resembles the develop- 
ment of fibro-plastic tissue in the substance of the true skin (dermis). It is 
an exuberance of growth (a proliferation) of the elements of tissue; and similar 
to the gummy tumors or nodes that afterwards appear in the solid viscera, 
such as in the liver and testicles. 
There is thickening of the epidermis over the induration or surrounding the 806 
SPECIAL PATHOLOGY SYPHILIS. 
ulcer, after an ulcer has been established; and in the dermis small hemor- 
rhagic foci are to be seen in the papillary layer. 
The papillae of the true skin are thus augmented in volume; and they 
become infiltrated by a large quantity of new growth, in which they seem 
imbedded-the embryonic elements of the growing connective tissue. These 
are round or oval nuclei-like, or small uniform bodies, not much larger than 
a blood disc, interspersed with bundles of fibre-like elements-also of new 
growth. 
Irritation of the neighboring sudoriparous glands also adds to the indura- 
tion, and augments the volume of the parts. 
This induration and hypertrophy does not live long. It soon commences to 
degenerate-to undergo a change into granules of fat; and to this molecular 
death is due the formation of the dry ulcer, so characteristic of the true syph- 
ilis sore. 
This degeneration of the new elements of growth is characteristic of all the 
subsequent lesions of syphilis, whether they be called secondary or tertiary- 
whether they occur in the true skin, the bones, the liver, the heart, the arte- 
ries, or any other part. 
But although the elements are thus far definite, they are not definite enough 
to be characteristic of syphilitic lesion, without a complete account of the 
specific physiognomy of the case. And thus the symptoms and progress of 
the original sore must be seen and described from the beginning to the end of 
its existence. 
From these specific and characteristic local conditions, as from a focus, the 
system eventually becomes contaminated. The steps or sequence of phenom- 
ena associated with this contamination are not yet clearly understood ; but as 
the contamination is expressed by very constant and specific characters, it is 
obvious that the original virus has become intensified in its action (as is also 
the case with the virus of hydrophobia), its pernicious influence more active 
and obvious, while its specific secondary and tertiary effects become more fully 
and extensively developed. Some of these secondary lesions of syphilis are 
even now known to be inoculable. 
2. Characters of Venereal Sores, and especially of the "Infecting Sore." 
-There are several independent affections to which the common name "Ve- 
nereal" has been applied, each capable of transmission from person to person 
within certain definite periods. From time to time it has been a subject of 
discussion, " Whether these several affections are due to one and the same virus, 
whose action is modified by admixture with secretions, or by peculiarities of 
constitution on the part of the recipient ?" or " Whether a separate specific 
poison exists for each form of venereal disease?" This latter alternative is 
now proven to be true: and the following are the classes of venereal affections 
which are specifically distinct: (a.) Gonorrhoea; (6.) "Simple" "non-infect- 
ing" chancres, ulcers, or sores; (c.) "Infecting" chancres, papules, ulcers, or 
sores ; (dff Mixed chancres-the combined result of the virus of (6) and (c) ; 
(e.) Subsequent lesions retaining specific powers of contagion (some local forms 
of secondary syphilitic lesions). 
The history of the identification of the separate poisons which give rise to 
the several venereal affections arranges itself into three periods as to time, and 
is comprehended in the medical records of the past century. 
I. The Period and Doctrine of Hunter-The Hunterian Chancre.-Hunter 
taught the doctrine (now known to be an error), "That the various forms of 
syphilis and gonorrhoea depend upon one and the same poison-that the matter 
or virus produced in both is of the same kind, and has the same properties." 
He believed that he had established, by experiment and observation, that the 
discharge from a gonorrhoea will produce either a gonorrhoea, or a chancre, or 
the constitutional affections of syphilis-and that the matter from a chancre 
will indifferently give rise to either of these venereal affections. Hunter rested SEVERAL VENEREAL AFFECTIONS. 
807 
his belief and his doctrine mainly on an experiment on himself. He dipped 
a lancet in the venereal matter from a gonorrhoea. He made two punctures in 
the tissue of his own penis with the lancet so charged. One inoculation he 
made on the glans-the other on the prepuce. Two distinct results followed, 
each of them marked by a distinct and specific period of incubation. The lu )cu- 
lation on the prepuce was followed by itching from the third to the fifth day. 
On the fifth day the site of the puncture was red, thickened, and swollen. A 
speck became visible; and in a week this speck had commenced to suppurate; 
the urethra at the same time indicating the commencement of a discharge. 
The inoculation on the glans was followed by itching fourteen days after the 
puncture was made: three days later a speck appeared where the puncture had 
been made. The speck became a papule, then a pimple, and ultimately dis- 
charged yellow matter. The sore on the prepuce broke out several times after 
it healed up; but the sore on the glans never broke out again after it healed. 
The secondary lesions of syphilis followed this experiment, demonstrating the 
"infecting" nature of a virus with which he had been inoculated. Ulceration 
of the throat commenced in due time, and copper-colored blotches on the skin 
followed in the usual sequence. The time the experiment took, from the 
first infection to the complete cure and elimination of the poison was three 
years. 
With the knowledge of syphilis which we now possess, can we say from 
which of these sores the constitutional disease arose? The answer will evolve 
itself in the sequel. Hunter believed he had inoculated the discharge of a 
specific gonorrhoea only and alone; but two important questions now suggest 
themselves, concerning which Hunter does not enlighten us, namely: Had the 
person a concealed infecting chancre from whom Hunter took the virus? 
Was the patient suffering from constitutional syphilis at the time he had a 
gonorrhoea. 
Besides Hunter, Carmichael in this country taught the same doctrine of a 
single virus; and Cazenave in France. 
II. The Period and Doctrine of Ricord.-Ricord established, by numerous 
experiments repeated in various ways,-(1.) That the inoculation of gonor- 
rhoeal discharge by the skin is followed by no specific result; (2.) That at least 
two, if not three, distinct poisons exist-namely, one virus which would produce 
a gonorrhoea-another virus which would give rise to a specific ulceration, 
called a chancre. The ulceration of a chancre he observed to follow a very 
definite course. It commenced as a rule, within twenty-four hours after the 
inoculation of the poison. A pustule formed, which breaking, a soft or sup- 
purating chancre was the result. Ricord, however, eventually recognized two 
classes of chancres-the soft and the hard.; but he described them as originat- 
ing in the same way-by contagion from a similar primary sore. His experi- 
ments were of one or other of two kinds. Either they were made on persons 
who had been already affected by syphilis (involving a most vital fallacy in 
drawing conclusions regarding the nature of syphilis) or on persons concern- 
ing whom it was not ascertained whether they had been infected with syphilis 
before or not. 
Hunter showed that the secretion from one kind of syphilitic sore is not 
capable of being inoculated on the same body that produced it; and now we 
know that the discharge from the "infecting" sore cannot be inoculated on the 
already infected person. Ricord has further shown that the plastic lymph, the 
increased growth of tissue round a true chancre-the specific sclerosis or indura- 
tion-does not take place a second time on the same subject; while Sigmund 
£nd many other observers are now agreed that the "infecting" disease does 
not repeat itself. This fact is analogous to the freedom from farther attacks 
of scarlet fever, measles, small-pox, enjoyed by persons who have once suffered 
from these diseases. This brings us to- 
HI. The Present Period in the History of Syphilis.-Its commencement is of 808 
SPECIAL PATHOLOGY-SYPHILIS. 
very recent date-since 1856; and is characterized by a belief in the duality 
of the venereal virus exclusive of gonorrhoea. 
The surgeons of Lyons-Rollet, Diday, and Viennois-Mr. Henry Lee, of 
the Lock Hospital, and Mr. Henry Thompson, of University College Hospital 
in London, Hubbenet, of the Syphilitic Clinique at Leipsic, Sigmund, of 
Vienna, and Von Barensprung, of Berlin, are those who, by experiment and 
careful observation, have thrown most light on this remarkable disease. In 
addition to the specific virus of gonorrhoea (which may now be eliminated as 
distinct from those about to be noticed), these observers recognize two forms 
of venereal disease, distinct in their origin,propagation, and development. They 
recognize specific differences in the mode of development, and in the sequence 
of phenomena which distinguish an "infecting" and a "non-infecting" sore. 
They have shown that the sore which eventually contaminates the system com- 
mences differently from the sore which does not infect the system. The "in- 
fecting" sore (the one which contaminates) commences as a dry papule, pimple, 
abrasion, fissure, or crack, around which, after a period of incubation of three 
or four weeks-average twenty-four days, a specific growth of tissue takes 
place-a sclerosis or induration, forming a lump or protuberance more or less 
voluminous. A pustule is no essential part of the process, nor is suppuration. 
They are accidental phenomena, the result of irritation, pressure, or laceration, 
which produces a sore or ulceration-a result always very easily established 
and maintained in connection with infecting sores, as compared with other 
sores. There is then established an erosion, as a second form of primary lesion 
often seen; and lastly, the indurated chancre (syphilis) as the third form of 
primary lesion. 
In women, compared with men, the open sore is said to be still more rare 
as the form of " infecting " sore. A hard chancre or sore in them is excep- 
tional ; and when it does occur, it remains small, is ill-developed, and is 
readily overlooked, even when searched for with great care, aided by a vagi- 
nal examination with the speculum. In them the primary lesion which infects 
the system is always a papule (Sigmund, Clerk). Another peculiarity con- 
nected with the " infecting " sore in women is, that such papules are apt to 
form along the course of the superficial lymphatics ; and Ricord admits that 
induration is generally absent or ill-developed in primary sores in the vagina. 
Forms of Syphilitic or Infecting Sore.-1. The dry papule is the rarest 
form seen by the surgeon; for usually that stage has passed before advice 
is sought. It is a papular protuberance, varying in size from a pin's head 
to that of a sixpence, at the point of contamination, of a dark-brown, red, or 
purplish color, round or oval, firm and elastic, sometimes covered with white 
scales of epithelium or scurf-hence, sometimes called a desquamating papule. 
The induration and the papule sometimes both disappear by resolution or 
absorption, without ulceration, just as the gummy tumors or nodes disappear 
in the same way. The induration loses its resistance and elasticity, diminishes 
in extent and volume, becomes gelatinous, finally subsides, and leaves behind 
a slight violet, copper, or black depression. These are the most insidious 
cases; and when secondary phenomena appear, the existence of a primary 
sore is generally denied, as never having been considered of sufficient impor- 
tance to attract attention. It may, in fact, never have been seen or noticed 
in any way. 
. 2. The syphilitic or hard chancre erosion.-This is the most frequent form 
in which primary syphilis presents itself. Patchy excoriation, or superficial 
ulcer of primary syphilis, or parchment-like chancre (Ricord's chancre par- 
chemine) are other names by which this form has been described. It com- 
mences as a copper-red spot, scarcely raised, papular, and dry. It is covered 
with a crust or thin scales, which desquamate, and finally the spot becomes 
eroded or slightly ulcerated on the surface. 
The ulceration is circumscribed within the induration, and presents a flat FORMS OF SYPHILITIC SORES. 
809 
rose-colored surface, projecting on a level with the summit of the swollen 
part; and is prominent in proportion to the amount of increased volume and 
induration. If it is pinched up between the finger and thumb, it imparts a 
feeling as if a bit of parchment had been inserted beneath the surface < ' the 
ulcer. 
It discharges a small quantity of serous fluid from a diffused base, which is 
indurated on its surface, rather than deeply. This sore is often so slight, the 
discharge so little abundant, cicatrization so rapid, that, in the absence of 
induration of the sore, prognosis must be doubtful, till some secondary result 
demonstrates contamination of the system. 
This lesion lasts about two months, terminates by resolution and cicatriza- 
tion, and generally leaves a slight induration, with the corresponding ganglia 
hard and indolent. 
When the papule opens and becomes a sore, the fluid discharged from its 
open surface has been shown by Hubbenet, Lee, and Rollet to furnish a diag- 
nostic test of the kind of disease, and of the sore from which it proceeds. 
Sigmund does not go so far as this. He does not consider the sores or chan- 
cres so different in form or character as to be at once distinguishable the one 
from the other. He waits to see the virus produce part of its effect upon the 
system beyond the site of inoculation before he decides as to the nature of the 
sore. He waits to see the lymphatics indurate. He believes that then, and 
not till then, the distinction can be absolutely drawn between a sore which 
will infect the system and one which will not. He believes-(1.) That if 
induration of the lymphatics does not take place within six or eight weeks, 
and (2.) That if repeated successful auto-inoculations can be made on the 
bearer of the chancre during this period, then it is certain that the sore will 
not infect the system. If, on the contrary, the lymphatics indurate, and 
auto-inoculations cannot be then effected, the sore is assuredly an " infecting " 
chancre. 
The addition to our means of diagnosis from the nature of the discharge- 
pus from the one, not from the other-is one of great value when it can be 
made, because the diagnosis as to the probability of subsequent infection may 
in some cases be made earlier. The distinction, however, is considered by 
Dr. Berkeley Hill to be untrustworthy, for the following reasons : First, the 
syphilitic virus may be present in a patient suffering with local ulcers also, 
and the pus of those ulcers might be inoculable, notwithstanding the pres- 
ence of general syphilis. Secondly, the thin discharge of the ulcerated papule 
of syphilis is not inoculable on its bearer ; nevertheless, if the papule is made 
to suppurate by any kind of irritation, the pus from it sometimes becomes 
freely inoculable. The test is therefore considered useless as a guide in 
diagnosis. 
3. The indurated sore of syphilis - non-suppurating chancre - Hunterian 
chancre (ulcus vallatum).-Induration is the primary lesion, first as a papule, 
over which a crust may form, and underneath this crust a cup-shaped ulcer 
of greater or less depth rapidly develops itself. It is indolent in its progress, 
and having the appearance of being scooped out; it presents raised and 
rounded edges, a glossy iridescent surface, a base generally grayish or larda- 
ceous-like, bathed with a serous or watery-like secretion, not reinoculable, and 
not pus. 
This is the most characteristic lesion of commencing syphilis. The indura- 
tion, which forms the bed of the lesion and base of the ulcer, extends beyond 
its circumference, and has been compared to the half of a dried pea for hard- 
ness. It is elastic, resistent, and cartilage-like, quite different from cicatricial 
hardness or oedema. 
This condition of ulcer lasts about three to six weeks, when the edges of the 
chancre begin to empty themselves and collapse. The granular particles which 
covered its base become eliminated or absorbed. At any rate the false mem- 810 
SPECIAL PATHOLOGY-SYPHILIS. 
brane-like surface disappears, granulations form, and cicatrization commences 
from circumference to centre. The resulting cicatrix is round and slightly 
depressed, and is the seat of induration, sometimes persistent. For a long time 
it is of a dark-brown or bronze color, and finally all color disappears, and an 
unnatural whiteness takes its place. 
Soft chancre develops itself in a short time, generally at the end of two or 
three days. In the first twenty-four hours the point of inoculation becomes 
red, and surrounded by a small circle of inflammation, tumefaction super- 
venes, a vesicular pustule appears, and finally a pustule-like ecthyma. To 
this succeeds an ulcer, more or less deep, round in shape, with a tendency to 
have its edges cleanly cut, and sometimes everted. A magnifying glass shows 
small indentations on the edges, each surrounded by a red inflamed circle. 
The floor of the ulcer is uneven, covered with a yellow gray matter, which is 
a dirty thick pus, virulent and contagious in the highest degree. The base is 
as supple as the neighboring tissue. 
This chancre is always inoculable on the same individual; and if the chan- 
cre is at first single, it may multiply to any extent. 
The glands are not affected; and if affected, usually only a single gland is 
painful from the first, and tends to suppuration. 
The peculiar clinical characteristics of the syphilitic sore may be arranged 
in the following order: 
1. Not auto-inoculable unless the discharge is purulent. 
2. Absence of suppuration and long duration of the ulcer. 
3. Induration accompanied by multiple firm and movable gland lesions. 
The last two characteristics are especially important; for, with induration 
of local lesion and multiple affections of the glands, the conjunction is demon- 
strative of syphilis, with as much certainty as any question in pathology. 
True Syphilis. 
{Infecting Chancre.) 
1. Incubation of a mean duration of 
twenty-four days. 
2. Lesion mostly single, not reinocu- 
lable on the subject of it. 
3. Consisting in a papule of greater or 
less size, which erodes or ulcerates, but 
always forms a superficial ulcer, without 
detachment of the edges and without sup- 
puration, unless it be in the period of cica- 
trization. 
4 Almost always accompanied by firm, 
indolent multiple, non-suppurating en- 
largements of glands. 
5 Influenced by iodide of mercury and 
iodide of potassium. 
Pseudo Syphilis. 
{Soft Chancre.) 
1. Incubation none (commences within 
twelve hours). 
2. Lesion generally multiple, indefi- 
nitely reinoculable on the subject of it. 
3. Showing itself as a vesico-pustule, 
which terminates in a deep ulcer, with 
detached perpendicular edges,- and fur- 
nishing an abundant purulent secretion. 
4. Accompanied in some cases only by 
enlargements of the glands, which furnish 
inoculable pus. 
5. Aggravated by mercury. 
Period of Incubation.-The time of the commencement of a sore or lesion, 
after inoculation or contagion, is of great importance to be noticed. A defi- 
nite period of incubation exists for the "infecting" syphilitic sore, fixed by 
experiment upon persons free from the disease, and who never have had 
syphilis, as well as by casual observation. . From the eighteenth to the thirty- 
fifth day (counting from the time at which inoculation was performed), the 
first symptom indicative of the general infection appears; and a mean of 
twenty-four to twenty-seven days may be considered as the usual period of 
incubation. The most common periods, according to Berkeley Hill's observa- 
tions, have been twenty-five and twenty-eight days-the extremes ten and THE FEVER OF SYPHILIS. 
811 
forty-six days. Sometimes it may be longer, but it is never beyond six weeks 
or forty-two days. Longer periods are quite exceptional, and must be regarded 
as doubtful. 
Contamination of the System and General Course of Syphilis.-Th "in- 
fecting" sore of syphilis does not remain merely a local disease. It contami- 
nates the system, giving rise, by a multiplication like that of small-pox poison, 
to one of the most malignant, most lasting, and most destructive forms of a 
disease-poison that affects the human frame. How is this brought about? 
The only constant index of such contamination or secondary disease com- 
mencing, seems to be the occurrence of multiple enlargement of related lym- 
phatics and lymphatic glands, which begins about ten or twelve days after 
the indurated papule has made its appearance; or from four, five, or six weeks 
after contagion, implantation, or inoculation by sexual intercourse, or otherwise. 
Such glands do not suppurate. They are merely congested, and become hyper- 
trophied. They enlarge slowly, and without pain, in the immediate vicinity 
of the sore; and can be felt as a group of enlarged glands beneath the skin. 
Eventually those in the axilla become similarly affected, and ultimately 
enlargement of the chain of glands, extending up towards the occiput, behind 
the sterno-mastoid muscle, is apparent. 
A general morbid condition of the whole system is the necessary result of 
this extensive disease of the lymphatic glands. Nutrition becomes defective. 
The blood is changed; it becomes anaemic. Emaciation is then often rapid. 
The digestive organs are impaired in function. The muscles lose their hard- 
ness, elasticity, and energy; and the lesions peculiar to syphilis set in. 
State of the Blood.-It is the seat of considerable modifications. These 
occur mainly in the earlier stages of syphilis, and consist in a diminution 
of the blood capsules-to the extent of one-seventh or one-half of the usual 
number. An increase of the albumen also takes place, and an increase of 
white globules; but unless the chronic ill-health of syphilis-syphilitic cachexia 
-supervene, the blood begins to improve again. 
Fever of Syphilis.-In cases of syphilis, during the early period, the differ- 
ential diagnosis amongst febrile phenomena lies between "intermittent fever, 
rheumatic fever, typhoid fever, gastric derangement, and the cephalalgia of 
Bright's disease." The severity of the general symptoms are apt to divert 
attention from the investigation of the original and primary syphilitic lesion, 
even if it were known to exist. 
Syphilitic fever requires special study. Its relation to the severity of the 
future lesions is quite undetermined as yet. It is ushered in by symptoms like 
those which precede eruptive fevers. It usually precedes, by eight or ten days, 
an early secondary eruption; but the fever continues after the eruption appears. 
The fever is attended by general derangement of the functions, nausea, flying 
pains, frontal headache, and depression of spirits. The bodily temperature rises 
to 100° or 1023 Fahr., at night, falling in the morning to 98° or 99° Fahr. This 
alternation may continue for days or even weeks, so long as fresh cutaneous erup- 
tions continue (Smith). Dr. Berkeley Hill has observed the course of syphil- 
itic fever in six cases. At the outbreak of the eruption he found the tempera- 
ture rise in the evening to 100°-101.4° Fahr., 100° Fahr., and 102° Fahr. In 
two cases where the eruption was scanty, it did not reach 100° Fahr. In the 
morning the temperature of all the cases was 98° to 98.6° Fahr. 
Another important character of the secondary affections of syphilis is uni- 
versality. The lesions occupy several parts of the body at the same time. 
The skin, the muscles, the globe of the eye, the bones, the joints, may all be 
affected at the same time. The symptoms simulate most closely acute arth- 
ritic rheumatism; and the morbid state is expressed by successive bursts or 
relapses, preceded and accompanied by the febrile disturbance, named " syphil- 
itic fever." 
Periodicity of the febrile exacerbations is a frequent phenomenon-a chill, 812 
SPECIAL PATHOLOGY-SYPHILIS. 
followed by a hot stage and sweating, occurring with great regularity at a 
certain hour of the day, generally towards evening (Zambaco, Yvaren, 
Boyer). The ague-like fits are repeated for some time-a week-then the 
fever becomes continuous, and so persists, in spite of quinine. The influence 
of mercury alone subdues the febrile exacerbations. Hence syphilitic fever 
may be mistaken for " intermittent fever." Epistaxis and palpitations are 
also not unfrequent concomitants. 
Order of Evolution of Syphilitic Lesions.-There is an order in the evolu- 
tion of syphilitic lesions and symptoms; and hence the classification into 
primary, secondary, and tertiary. The primary symptoms are those developed 
at the site of contagion. The so-called secondary symptoms are those lesions 
which are generally superficial as to cutaneous and mucous surfaces; while 
the so-called tertiary affections are considered to be those which attack the 
visceral organsand deeper structures. But, in point of time, such a classifica- 
tion rarely exists in fact, as it is a very common occurrence for a patient to have 
the phenomena of all the three periods present at one and the same time; and 
at all stages of the disease the histological elements of the lesions are the 
same. It has been attempted by some to maintain that the elements of syphilis 
are peculiar as to form, and microscopically characteristic; the same has been 
maintained of cancer, enteric and tubercular lesions; but the distinctions are 
not able to be maintained. It is in their vital properties afid development, 
and not in their form, that they are characteristic. The lesions of syphilis 
have no specific microscopic characters to distinguish them. 
The primary symptoms include the original sore of syphilis and induration 
of contiguous lymphatic ganglia. 
The secondary and tertiary symptoms ought to be regarded as " general " 
(or constitutional signs of syphilis), because they are developed at various 
points distant from the original sore, having no direct anatomical relation 
to it. 
Of these general symptoms, their arrangement into "primary" and "secon- 
dary" was based upon Hunter's division of the "tissues affected in syphilis" 
into "parts first in order," and "parts second in order" of being affected. The 
secondary he reckoned to begin from the third week to the sixth month ; the 
tertiary, not before the sixth month, and in many not till after several years. 
This was an artificial and no real distinction. 
A division, based on the anatomical characters of the lesion, seems to be 
more satisfactory than any arbitrary arrangement into stages of a supposed 
primary, secondary, or tertiary order (Haldane). 
1. In the so-called primary and secondary affections we have mainly to do 
with congestions, inflammations, and ulcers. 
2. In the tertiary lesions and advanced stages of syphilis there is-(a.) 
A "constitutional cachexia," with certain definite anatomical characters; and 
(6.) A tendency to the growth of a peculiar material, chiefly in the form of 
gummatous tumors or nodules, of which the node is the common and familiar 
type, but which are found not only in the bones, but in the areolar tissue, the 
liver, the lungs, the heart, the brain, the muscles, the testicles, the eye. (c.) 
There is likewise to be observed a tendency to various interstitial inflamma- 
tions; and (d.) The occurrence of cicatrix-like losses of substance visible on 
the surface of solid organs. 
With regard to the "constitutional cachexia," it is necessary, if possible, to 
distinguish the degenerate nutrition brought about by "inherited" syphilis, as 
contrasted with that brought about by acquired syphilis. 
The constitution of the person also materially influences the phenomena 
which supervene during syphilis-e. g., gout, rheumatism, tuberculosis, and 
cancer modify the syphilitic lesions and degenerations; while constitutional 
syphilis in its turn modifies the character of ordinary diseases. 
Persons with a tendency to rheumatism are apt to have the same tissues SUCCESSION OF PHENOMENA IN SYPHILIS. 
813 
involved in syphilitic lesions, as if they suffered from rheumatic inflamma- 
tion. Hence syphilis is often set down as a cause of rheumatism. The serous, 
fibro-serous, white connective tissues are the sites of the lesion in the forms of 
periostitis, iritis, corneitis, and affections of the true skin. 
In tuberculous patients those tissues are apt to be involved in the syphilitic 
lesions which are most prone to ulcerate, and to have tubercles grow in them. 
Hence syphilis is often set down as a cause of phthisis. The mucous mem- 
branes are most prone to suffer in such cases. Hence syphilitic growths 
develop themselves in the lungs, the glands and brain, pharynx, larynx, ton- 
sils, tongue, and testicles. 
In the gouty or vascular subjects the arterial or vascular structures and 
joints are apt to suffer most from the syphilitic virus, and the lesions are 
chiefly in the form of degenerations. Hence syphilis may be set down as a 
cause of disease in the great bloodvessels, leading to thoracic and abdominal 
aneurisms at an early period of life; and of the smaller bloodvessels, leading 
to lardaceous disease of the liver, kidney, spleen, and intestines. 
The ultimate lesions in syphilis eventually assume a variety of anatomical 
forms; but in the first instance they are to be recognized in the typical forms 
of nodes, gummata, tubercles, or knots, as periostitis and inflammations of fibrous 
tissues, tending to caries, necrosis, or abscess, or to hypertrophy, as in exostosis, 
and ultimately to cicatrices in various organs. Secondly, in substantive lesions, 
such as lardaceous disease (see page 129, ante). 
Anatomically, the secondary symptoms embrace skin affections in the form 
of eruptions; lesions of the mucous membrane, in the form of-(1.) Mucous 
patches; (2.) Condylomata; (3.) Superficial ulcerations; (4.) Affections of 
the eyes (iritis); (5.) Alopecia, onyxia; (6.) Affections of lymphatic ganglia- 
engorgement of the glands generally (the back of the neck most obvious). 
Anatomically, the tertiary affections are more deeply seated. They consist 
of changes in subcutaneous or submucous connective tissue; in the form of 
gummy tumors in the testicles, as orchitis; in the fibrous and osseous tissues; 
in the form of periostitis, nodes, ostitis, caries; and in the visceral organs, as 
gummata. 
The general lesions (i. e., secondary and tertiary symptoms) make their ap- 
pearance, with a very marked degree of order and regularity, especially those 
immediately consequent on the original sore of syphilis. 
If the sore of syphilis goes without treatment (as many do) it may be pre- 
dicted that, within three months, there will occur the following category of 
symptoms: 
First,-General lassitude, headache, fleeting pains in various parts of the 
body, resembling rheumatism, evidently seated in the periosteum, chiefly the 
cranium and joints; alopecia, eruption of blotches or papulae upon the skin; 
pustules upon the hairy scalp; engorgement of post-cervical ganglia; while 
patches on the mucous membrane of the mouth, anus, vulva, occur, which 
may ulcerate. 
After this, the order of evolution is not so constant and uniform in every 
case. Certain symptoms absent in one case may be present in another. 
The cases of tertiary lesions may be arranged into two classes: 
1st Class. Those in which the lesions follow immediately, as to time, upon 
the earliest general symptoms, and are identical in character with them. 
2d Class. Those which occur after a considerable interval of time. 
The regular succession may be very much modified by treatment. 
It is therefore natural for syphilis to show itself, not in a continuous, but 
rather in an interrupted, succession of phenomena; and the reappearance of 
many syphilitic lesions (such as the lesion of skin and mucous membranes)- 
erythema, alopecia-the alopecia differing in the early and late periods. In 
the early period, one of the earliest general symptoms is shedding of hair, 
which may grow again, because the hair-bulbs are not seriously damaged; in 814 
SPECIAL PATHOLOGY-SYPHILIS. 
the late periods, the bulbs are damaged, and the scalp becomes permanently 
bald. So also two forms of iritis and ecthyma are distinguishable. 
These are not to be regarded as relapses of the disease, but as phenomena 
in the natural course of its development. 
The first lesion is " induration of the sore itself." The hardness of the in- 
duration is peculiar. It arises without inflammatory action, and must be dis- 
tinguished from the hardness caused by irritation or friction, as of clothes 
rubbing on the sore. A sore after a few weeks may heal up, but it leaves a 
"lump"-that "lump" is specific induration, and denotes contamination of 
the system. The original sore is very often overlooked or forgotten, never 
having been seen or observed in any way. 
The following are the characteristics of specific induration, as contrasted 
with inflammatory engorgement ; । 
Specific Induration. 
Boundary clearly defined, terminates ab- 
ruptly. 
Freely movable. 
Firm, hard, resistent, like a mass of car- 
tilage or a split pea. 
Continues persistent. 
Inflammatory Engorgement. 
Boundary unlimited, shades gradually 
into normal suppleness of parts. 
Adherent to parts below. 
Soft, dough-like, and tough. 
Subsides in a few days. 
Both conditions of hardening may coexist. But when the inflammation 
subsides, the specific induration is laid bare, which was previously buried or 
masked underneath the inflammatory products. 
The induration is very insidious in its appearance; hence cases of syphilis, 
without chancre or sore, are recorded simply because the original lesion has 
never been noticed. The testimony of venereal patients may be influenced 
by a want of honesty; but quite as often they are influenced by ignorance, 
want of experience, and absence of medical knowledge as to the nature of 
their disease. Many vulgar errors prevail on the subject. The surgeon and 
physician must each judge for himself. Some believe patients implicitly; 
some, as a rule, always disbelieve them; but the distinction requires, in most 
cases, to be drawn between honesty and ignorance. 
Reinoculation or auto-inoculation is of no value in the practical diagnosis 
of chancres, for reasons already stated. 
Induration of Glands, with induration of the original sore, is pathogno- 
monic of syphilis. The induration of glands is constant. It commences 
usually during the first week of the existence of the ulcer ; always within the 
third or fourth, and from ten to twenty days after induration of the sore. 
The phenomena are: 
I. All superficial ganglia of both groins attain the size of a filbert or almond, 
and are generally more developed than the others. There is no inflammation, 
the enlargement is slow and insidious. They are freely movable upon each 
other and over the tissues. They may be slightly tender on pressure, and the 
pain is peculiar, but not severe. They never suppurate, except when injured 
by violence, or if the patient be scrofulous, or unless a soft chancroid or sup- 
purative urethritis coexist. 
The enlarged ganglia may even point to the original site of chancre. Thus, 
the inguinal ganglia, enlarged and indurated, point to the genital organs, 
urethra, or hypogastric region; the group of glands near the anterior and 
superior spine of the ilium point to the anal region ; the submaxillary group to 
the lip, mouth, tongue; the axillary group to the elbow, hand, arm, or fingers, 
as the original sites of the sore. 
The following table exhibits a scheme of the order of evolution or periods 
of appearance of the phenomena after inoculation or contagion from an in- 
fecting sore, estimated from the first appearance of the papule or sore (based 
on the experince of Bassereau, Sigmund, Fournier). SECOND ATTACKS OF SYPHILIS. 
815 
After contamination of the system, the specific lesions peculiar to syphilis 
begin to appear somewhat in the following order of events: 
Lesions or Symptoms. 
Date of usual 
Development. 
Date of earliest 
Development. 
Date ot 'atest 
Development. 
Roseola, 
45th day. 
25th day. 
12th month. 
Papular Eruption, 
65th " 
28th' " 
12th " 
Mucous Patches, 
70th " 
30th " 
18th " 
Secondary Affections of Fauces, . 
70th " 
50th " 
18th " 
Vesicular Eruptions, 
90th " 
55 th " 
6th " 
Pustular Eruptions, 
80 th " 
45th " 
4 years. 
Rupia, 
2d year. 
7th month. 
4th year. 
Iritis, 
6th month. 
60th day. 
13th month. 
Sarcocele, 
12th " 
6th " 
34th " 
Periostitis, 
6 th " 
4 th " 
2 years. 
Tubercular Eruption, 
3 to 5 years. 
3 years. 
20 " 
Serpiginorts Eruption, 
3 " 5 " 
3 " 
20 11 
Gummy Tumors, 
4 " 6 " 
4 " 
15 " 
Onychia, 
4 " 6 " 
3 " 
22 " 
Exostosis, 
4 " 6 " 
2 " 
20 " 
Ostitis-Changes in Bone and Car- 
tilages, . 
3 " 4 " 
2 " 
41 " 
Perforation of Palate, 
3 " 4 " 
2 " 
20 " 
Cutaneous Affections.-Besides the general involvement of the lymphatic 
glands, the condition of the skin may further demonstrate the contamination 
of the system. In the more insidious form of contamination its color gener- 
ally is altered. It becomes pale, white, fawn, yellow, or brown; and is 
wrinkled, dry, harsh, rough, and hard, and no longer soft and elastic. 
The first general eruption of the skin takes place about ten weeks after 
contagion, or about seven weeks after commencing induration of the original 
sore, and between five or six weeks after enlargement of the lymphatic glands. 
The eruptions are papular, pustular, or scaly-the papular being the com- 
monest, and the type or basis of all syphilitic eruptions. But they are often 
also associated together; and they are peculiar in their symmetry of distribu- 
tion and in the c.urvilinear character of their grouping. They leave behind 
them stains of color, pale cicatrices, or persistent ulcerations of the true skin. 
The local distribution of the syphilitic eruptions is also peculiar (Devergie). 
Their seats of election in the order of frequency are,-(1.) The parts round 
the alse of the nose and the angles of the mouth; (2.) The roots of the hair 
at the forehead and back of the neck; (3.) The inner angle of the eyes; (4.) 
The centre of the breast; (5.) The inner side of the limbs, the neighborhood 
of the axilla, and the groins. 
The Early Affections of the Fauces are often not more than a peculiar 
color of the mucous membrane, persistent, however, like the staining of the 
skin (Gairdner), and eventually leading to disorganization. In women the 
process may cease with a slight follicular swelling of the mucous membrane 
of the fauces, tonsils, and soft palate (Sigmund). If the process does not 
cease, then superficial erosions or deep ulcers of the soft palate supervene. 
Or still more diffused forms of ulceration may set in, involving great destruc- 
tion of parts, and spreading in all directions-encroaching on the nasal fossae 
and pharynx, eating away the epiglottis, extending down the air-passages, 
and even causing necrosis and exfoliation of the cartilages of the larynx. 
Second Attacks of Syphilis.-The general infection is of such a kind as to 
render the system, as a rule, proof against a second invasion of the specific 
" infecting " virus. The disease never repeats itself, except, it may be, after a 
long interval. Sigmund has seen such a case. But they are rare, and are 
often mere relapses of the original disease. In this respect it resembles other 816 
SPECIAL PATHOLOGY-SYPHILIS. , 
virulent diseases, acknowledging a specific virus as their orign; and in them 
the immunity is usually, but not invariably, complete-e. g., small-pox, cow- 
pox, scarlet fever, and the like. 
After the system is once infected, the specific sore cannot be transplanted 
by contagion or inoculation to any other part of the body. The "infecting" 
sore is not auto-inoculable; and a person suffering from a chancre affecting his 
system will not be affected by a further inoculation of the same specific virus. 
There is, however, a slight qualification to be made here. Mr. Henry Lee 
has shown that (1.) There is a stage in the existence of an "infecting" sore 
when it is auto-inoczdable. That period or stage is a very early one in the ex- 
istence of the sore-namely, before any specific systemic action has begun to 
develop. If at this period the poison of another "infecting" chancre from 
another person, or from the chancre already existing on the same person, be 
inoculated, then a second "infecting" chancre, accurately representing the 
original, will result. The period when this event can happen is before the 
gland induration. (2.) Mr. Lee has shown that there is a certain condition of 
the chancre in which, at any stage, on being inoculated or transplanted, it 
will produce a sore. It then appears to be auto-inoculable. But this is only 
in appearance, and not in reality. The condition of the chancre that does 
this is one of irritation. Blister a chancre, or irritate it by an irritating oint- 
ment, or by any other means, so as to cause pus to flow-free pus-corpuscles 
being generated-and then we may have what has been recently termed a 
"mixed chancre," of much more frequent occurrence than has generally been 
supposed (Sigmund). Sigmund has produced such chancres by inoculation. 
The utmost caution, therefore, is necessary before pronouncing a sore to be 
non-syphilitic-i. e., "non-infecting." Sigmund inoculated the pus of a soft, 
contagious, or suppurating sore upon the infiltration or sclerosis of a hard 
papule on which the skin had remained unbroken. Between twenty-four and 
forty-eight hours after, a suppurating ulcer was established, which afterwards 
assumed Hunterian characters. Inoculation of two poisons may thus be in 
some cases simultaneous or successive. Hence "mixed chancres" present 
two aspects: on the surface is the soft, contagious, pus-producing ulcer; while 
deeper down is the specific syphilitic infiltration of the true "infecting " virus. 
Local plugging and enlargement of the superficial absorbents take place from 
such "mixed chancres," followed by similar infiltration of the group of 
lymphatic glands nearest to the sore, spreading gradually to distant and more 
distant groups. This is the constant series of phenomena after syphilitic "in- 
fection,"-a regular series of connected events, giving rise to such symptoms 
as are associated with no other disease-poison except that due to syphilis. 
On the other hand, the sore which does not infect, and which does not con- 
taminate, is the "soft," suppurating sore-the "chancroid ulcer," as it has 
been called-or "the simple contagious ulcer of the genitals." The virus 
begins to act from the very moment of its application, and, after the forma- 
tion of a pustule, ulceration is generally established by the sixth or eighth 
day from the time of infection. It is purely a local disease, and is generally 
very soon accompanied by an enlargement of the lymphatic glands, which goes 
on to suppuration, and ends there. This sore may be transferred or transplanted 
at will, by contagion or inoculation, from one part of the body of the patient to 
another, or from one person to another. It is thus auto-inoculable, and is 
always so, the period of incubation being short-about twenty-four hours only. 
Its virus is particularly irritating. Hence numerous sores of this nature may 
exist on a person at one and the same time; but successive infecting sores do 
not as a rule ever exist on the same person. The multiple character of the 
simple sore is now generally recognized, and likewise the solitary character of 
the infecting one. The soft chancre is altogether a local sore, and so remains; 
while thousands of them may be multiplied at will successively over the same 
person's body, especially during its stage of suppuration and ulceration. The MODES OF SYPHILITIC CONTAMINATION. 
817 
ordinary site of the soft chancre is on the prepuce, and in the sulcus behind 
the corona glandis. The parts most susceptible of laceration are the parts 
most exposed to the inoculation, and where the virus is most likely to nestle 
and to be overlooked (Miller). 
As far back as 1856, Mr. Lee showed, and Mr. Rollet since then has also 
shown, that not only is the infecting sore not capable of being transmitted 
from one part of the body to another, but it is not inoculable upon a person 
who has been already contaminated by syphilis, more particularly so long as 
lesions continue to develop themselves. It is, therefore, as necessary now to 
distinguish " infecting" and "non-infecting" sores as it is necessary to distin- 
guish the various forms of continued fevers. 
In future experiments and observations as to the effects of primary syphilis, 
it must be remembered that the subject cannot be studied or experimented 
with, to any extent, upon the patient himself. For this reason many of the 
early observations of Hunter and Ricord are limited and fallacious: one 
might as well attempt to study the vaccine disease byreinoculation of it on the 
same person a second time, immediately after it has produced its specific 
effects.* 
3. Vehicles or Media by which the Specific " Infecting " Virus maybe 
Inoculated.-Besides the discharge (non-purulent or mixed with pus) from 
an infecting sore, there are other sources of infection, namely,-(1.) The con- 
tagion of secondary syphilitic sores-e. g.,-the syphilitic secondary ulcera- 
tion of the female nipple inoculating the mouth of the healthy infant born of 
healthy parents. (2.) It is now also established that secondary syphilitic in- 
oculation (e. g., the thin fluid discharge from the softening and ulceration of 
gummatous tumors, mucous tubercles, condylomata, papules, and the like) gives 
rise to a sore which exactly resembles a primary infecting chancre (Lee, Rol- 
let, Viennois). But it is said to differ in the following particulars, namely, 
-(ad) The period of incubation is said to be somewhat longer; (bd) Ulcera- 
tion is superficial; (cd) The sore heals in a shorter time; (dd) Induration is 
less marked ; (ed) The constitutional infection is longer in developing itself; 
and (/.) The lesions which result are said to be not again contagious. Thus 
* Another kind of sore very frequently seen about the prepuce or glans penis of inen, 
or the vulva of women, is mentioned here to guard against its being confounded with 
soft venereal sores, or with chancres-I mean the sore which forms after the eruption 
of Herpes preputialis. The eruption of Herpes preputialis commences by itching, which 
is felt at the base of the glans, at the internal surface of prepuce, or at the junction 
of the prepuce and the glans. This itching is often so slight as not to attract notice, 
and it is not of the same kind, nor does it occupy the same site, as the itching of gon- 
orrhoea. The surface of the glans or of the prepuce may be red ; and although noth- 
ing may be at first visible with the naked eye, yet, by means of a hand lens, small cir- 
cular elevations of cuticle are to be seen, raised by limpid serum. Several groups of 
these small vesicles generally occur, separated from each other by the space of a few 
lines. These eventually burst, and in their place small circular ulcerations, perfectly 
distinct, are to be seen, with a red bottom, and measuring scarcely a quarter of a line 
in diameter. The site of these herpetic ulcers is highly sensitive, and secretes pus and 
fluid, usually of an offensive and peculiar odor. 
When the groups of vesicles are situated on the cutaneous surface of the prepuce, 
they are but slightly inflamed, compared with those situated on its internal or raucous 
surface. Frequently the fluid contained in the vesicles on the cutaneous surface is reab- 
sorbed, when slight desquamation ensues over the lesion. If the fluid is not absorbed, 
it becomes opaque after a few days, and small scaly incrustations take the place of the 
group of vesicles. The disease may thus terminate in about seven or eight days. 
When the groups of vesicles form on the internal aspect of the prepuce, they increase 
in size rapidly, and the inflammation is much more active. The walls of the vesicles 
are so extremely thin and transparent that the red color of the inflamed tissue may be 
seen through them. But the fluid soon becomes opaque and sero-purulent, small moist 
crusts or scabs form, which, being detached naturally or accidentally, expose excoriated 
spots ; and it is important to distinguish these from soft venereal chancres. The ve- 
nereal sores never commence as vesicles. 818 
SPECIAL PATHOLOGY-SYPHILIS. 
it is supposed the great epidemic of the fifteenth century gradually abated. 
Hence also, perhaps, the modern belief in the modifying influence of syphili- 
zation may to some extent be explained-an operation which is not warranted 
by the present scientific knowledge we possess. (3.) The blood of those suf- 
fering from acute secondary syphilis, in the form of general eruptions, inocu- 
lates. It is probable that the blood is virulent only during the febrile period, 
or up to and including the period of cutaneous eruption-as it is not found to 
be so during the tertiary phenomena. 
Experiments at Florence, at the Clinique for venereal diseases, show that 
healthy persons may be inoculated with the blood of syphilitic patients. It 
is related that, on January 23d, 1860, two young doctors were inoculated 
with the blood of a syphilitic patient, but no result followed ; on Feb- 
ruary 6th, 1862, three other doctors (perfectly free from syphilis) were 
inoculated by venous blood taken from a female suffering from the acute 
lesions of secondary syphilitic disease. Charpie soaked in the blood was 
applied to an abrasion in the arm of each. On March 3 (twenty-five 
days after the operation) a slight itching and elevation was perceptible, a pap- 
ule formed, which, eight days afterwards, became covered with a crust. This 
crust increased in thickness day by day, and twelve days after the appearance 
of the papule two glands in the axilla became enlarged, and the sensibility 
of the papule increased. Nineteen days after its appearance the crust fell off, 
leaving a funnel-shaped chancre, with elastic resistant borders. On the 
twenty-third day the chancre had increased in size and induration. On the 
fortieth day eruption on the skin and glandular swellings in the neck super- 
vened. The erythema lasted eight days, and pursued a regular course. 
On the forty-eighth day the glands had increased in size and hardness, the 
chancre maintaining its specific condition, showing no tendency to heal. On 
the fiftieth day the color of the erythema became decidedly coppery, and 
treatment by mercury was then begun. In these experiments the blood com- 
municated disease to one out of five who submitted to the experiment. 
The recognition of this fact explains many occasional cases of syphilitic 
affection, hitherto obscure-e. g., syphilis from vaccination, contamination of 
a healthy nurse from the sore mouth of an infected infant, and the like. One 
of the most remarkable and lamentable instances of the inoculation of syphilis 
through vaccination is that which is now well known as the epidemic at 
Rivalta. At that place no fewer than forty-six children became affected with 
syphilis, the disease being communicated to each of them through the operation 
for vaccination (Pachiolli, Sperino, New Syden. Society Year-Book 1861-62). 
(4.) A female, otherwise free of syphilis, may become contaminated during 
the gestation of a foetus begotten of a male who, at the time of the fruitful 
connection, was himself alone suffering from contamination of the system by 
syphilis, in some form of active secondary phenomena (Hay, Harvey, Diday, 
Maclean). In such cases no syphilitic sores existed on the genital organs of 
either party at the period of sexual intercourse; but the begetting of a syph- 
ilitic child within the body of the mother contaminates the mother, "through 
the foetus-itself begotten of the father, from him inheriting the virus, and 
having in utero the disease resulting from it in such manner and degree as to 
impart it to its mother through the medium of the placenta " (Robert Har- 
vey). Several years ago Professor Harvey, of Aberdeen, directed attention 
to the power of the foetus to inoculate the maternal with the anatomical and 
physiological peculiarities of the paternal organism; and that he then sug- 
gested the probability of secondary syphilis being imparted in this way (Ed. 
Mon. Journal of Med. Sc., Oct., 1849, and Oct. and Nov., 1850). 
4. Morbid Anatomy of the Secondary Lesions and Local Growths in the 
Internal Viscera.-These are now so uniformly found associated with a his- 
tory of syphilis, that they are rightly regarded as the remote effects of the 
specific venereal or syphilitic virus. Sp varied and multiform are the effects GUMMATA. 
819 
of syphilis that a complete account of syphilis and its lesions has yet to be 
written; but it may be useful to illustrate some of the points of view from 
which the subject in its pathological bearings is now being examined, pre- 
mising that it is necessary to examine the subject carefully from year to year, 
as opportunity offers and as fresh facts add to our knowledge, being ever 
alive to the fallacies which inevitably surround the most patient investiga- 
tions. 
From any one of the sources of infection already noticed, the later stages of 
syphilis are characterized by lesions which are distinguished from the earlier 
specific affections, both by their situation and by their morbid anatomical 
peculiarities. The earliest lesions are expressed chiefly in the superficial 
structures of the skin and of the mucous membranes in the vicinity of the 
natural orifices; but deeper seated lesions soon also appear, as in the bones 
and certain visceral organs. 
The anatomical form which the lesion assumes at the commencement bears 
a stamp altogether peculiar. 
Gummata are the basis of the characteristic lesions of syphilis. They form 
growths which lead to the development of elastic tumors, composed of a well- 
defined tissue, but with elements extremely minute. The gummatous tumor 
takes origin from the elements of connective tissue, or the analogues of such 
tissue, and hence the universality of the site of these lesions. They are like 
pus or an abscess in this respect. 
When they first attract attention (as a node on the skin, or on the shinbone) 
they are small, solid, pale swellings, like a hard kernel, varying in size from 
that of a pea to the size of a haricot bean. They may be generally first seen 
in true skin, or subcutaneous or submucous tissue; and where the tissue is lax 
they grow to a considerable size, and give a sensation to the hand as if filled 
with gum {tubercula syphilitica, nodular syphiloma'). Repeated examinations 
of this growth show that in the gelatinous condition it arises from a prolifera- 
tion of nuclei in the cells of the connective tissue-like the formation of granu- 
lations in a wound {granulation tumors of Virchow). The component cells 
appear as round, oval, or oat-shaped particles, imbedded in a matrix of fine 
connective tissue, of a granular character, tending to fibrillation. The cells 
are a little larger than blood-globules, and contain granules in their interior 
when mature. In the young condition they are contained, and are seen to 
grow in groups, within the connective tissue corpuscles. In some respects 
they resemble tubercle, but differ thus in the mode of growth. It is the de- 
velopment and degeneration of such neoplasms which cause most of the 
lesions of syphilis. How, then, do we recognize the nature of such growths ? 
First, taking the history of the case as a guide, we are led to conclude en- 
tirely from the anatomical character of the growth; and when such lesions 
are seen in a case with a distinct history of syphilis, several questions suggest 
themselves for consideration. Is the growth the result of inflammation ? Is 
it cancer or tubercle ? Is it a syphilitic lesion ? Are there traces of other 
similar lesions in the body ? 
As a rule, inflammation leads to abscesses or hypertrophies of tissue or fibroid 
degeneration, and round all the syphilitic nodes we have such hypertrophy 
and degeneration, just as we have round tubercle nodules. Abscesses are 
easily recognized by the pus; and which, being altered by age, may still be 
anatomically recognized. Cancerous masses are recognized by the juice ex- 
pressed from them. Here we have no juice; and the cell-elements seen in 
cancer are characterized by the diversity of their form and growth. Here 
the elements are uniform in appearance and size, and form growths less 
highly organized than cancers, which tend to infiltrate and involve neighbor- 
ing textures; whereas the gummy syphilitic node remains isolated, and is 
usually surrounded by a dense but clear, semitransparent, grayish, vascular, 
fibrous tissue, and very resistant to the finger. Thus these nodes appear some- 820 
SPECIAL PATHOLOGY-SYPHILIS. 
times as if inclosed in a kind of cyst, from which they may sometimes be 
enucleated. 
By way of elimination or exclusion, therefore, we may thus come to recog- 
nize such growths as syphilitic-even without a history of syphilis (Hal- 
dane). They have been recognized now and described in all the solid 
viscera of the body. The microscope has enabled us to study them with 
minuteness ; but it is only their history, position, mode of appearance, struc- 
tural elements, cause, and results, which enable us to recognize their true 
character. 
Development and Course of the Syphilitic Node, or Gummy Tumor.-(1.) 
Proliferation goes on, and a glue-like mucous fluid forms, constituting the 
inter-cell material. Recent nodules are soft, of a grayish-red color, and infil- 
trated with a scanty juice. The tumor, if near the surface, melts, opens, and 
ulcerates, thereby giving evidence of active or acute constitutional disease. 
(2.) The tumor continues gelatinous and coherent (if in dense parts, deeply 
seated), as in gummata of the periosteum, scalp, brain, liver, lungs, and heart; 
thus giving evidence of constitutional disease, latent or inactive. (3.) Having 
arrived at a more or less complete degree of development, they may undergo 
a retrograde or fatty degeneration, which may eventually lead to its absorption; 
and this is a natural or spontaneous process of cure ; but traces of the exist- 
ence of such nodes may be left in the form of cystoid membranes, as in the 
brain ; or of fibrous bands, or cicatrix-like loss of substance, as in the liver. 
In some instances the nodes undergo calcareous degeneration. The most fre- 
quent seat of syphilitic cutaneous gummy tumor is upon the face, especially 
upon the forehead (corona veneris), next between, or on the shoulder-blades, 
and posterior aspect of the legs and arms. 
In the Skin there are two groups of syphilitic lesions to be recognized 
(syphilides, syphilitic exanthemata)-(1.) Local growths, which generally as- 
sume the form of eruptions ; (2.) Cicatrices. The local growths occur in the 
superficial layer of the cor ion (Virchow, Barensprung) ; and ultimately 
tend to grow deeper, and to affect more permanently the derma and subcu- 
taneous tissue (A. T. Thomson). 
When such growths soften (as they tend to do when superficial), great de- 
struction of tissue is the result. The cicatrices which follow are permanent 
and unseemly, and may ensue without any abrasion of surface. This is especi- 
ally the case in papular and tubercular forms of syphilitic skin diseases. The 
growth is generally associated with effusion of fluid, which causes the hard- 
ness ; absorption taking place, atrophy of tissue follows ; there is a falling in 
of textures, accompanied by obliteration of bloodvessels, and resulting in an 
unseemly white scar. 
The diagnosis of syphilitic eruptions may in general be arrived at,-(1.) 
From the history of the case. A chancre commencing at least three weeks after 
exposure to contagion, becoming indurated, and followed within six or eight 
weeks by induration of the lymphatic glands. (2.) From the symptoms accom- 
panying the eruption. A dusky tint of the skin, rheumatic pains in the head 
and joints, alopecia, ulceration of the throat, iritis, nodes, gummata, disease of 
the testicle. (3.) From the eruption appearing in several forms at one time on 
the body-e. g., Condylomatous, roseolous, lichenous. (4.) From the general 
coppery tint of the eruption. Strumous inflammations have a dusky red or 
vinous tint, simple inflammations in a healthy person have a bright red tint, 
but syphilitic eruptions in the chronic stage have a characteristic coppery 
color. (5.) As a rule, there is an absence of itching in syphilitic eruptions. 
(6.) Syphilitic eruptions tend to assume a more or less circular form. (7.) When 
the eruptions of syphilis ulcerate, the ulcers are generally round, with perpen- 
dicular edges and unhealthy bases. More than one of these characters must 
guide the diagnosis, and not one only. Ulceration is not a usual character- 
istic. The syphilitic lesions of the skin arrange themselves in two classes. SYPHILITIC LESION OF MUCOUS MEMBRANE. 
821 
(a.) Early, superficially disseminated exanthematous eruptions. (6.) Late 
eruptions, which are deep and circumscribed. 
The early exanthematous eruptions are confined to the most superficial 
layers, are disseminated over the skin, and appear in successive crops. They 
consist especially in a hypersemia, which runs a chronic course, and may 
secrete products inoculable upon persons unaffected with syphilis. They are 
not itchy, of a red or copper color, the capillaries are dilated, and allow 
transudation of the coloring matter of blood. 
The lesions may take the form of-(a.) Erythema ; (Z>.) Papular erup- 
tions ; (c.) Pustular eruptions ; (d.) Vesicular eruptions ; (e.) Squamous and 
pigmatous eruptions. But a syphilitic characteristic is peculiar, namely, that 
many of these forms coexist, and spots of roseola may be covered with scales 
of epidermis. The crusts and scales of syphilitic eruptions are generally also 
much thicker than in non-syphilitic cases. The most common form is roseola, 
often preceded by febrile disturbance {syphilitic fever), and appearing on the 
belly, sides of chest, and flanks. This eruption is one of the earliest symp- 
toms of constitutional infection. Treated by mercury, it usually subsides in 
about a month ; but if neglected, it may proceed to the papulous, squamous, 
or pustular form of syphilitic lesion. 
The papular eruption consists of coppery-red miliary papules, varying in 
size from that of a millet-seed to a pea or bean. Their most common site is 
at the junction of the hairy scalp with the skin of the forehead. Scaly syph- 
ilitic eruptions commence generally as roseola, or as lichen, and the spots are 
numerous, but rarely large, and the scales are very thin and fine. 
Pustular eruptions, in the form of impetigo or ecthyma, appear on the face, 
scalp, body, or extremities, at later periods of the disease. The pustules dry 
up into scabs ; underneath which ulcers often form, which destroy the tex- 
tures deeply into the true skin. It is a serious, because it is a persistent, 
lesion, and often quite intractable, and sometimes outlasting all the other 
symptoms of syphilis (Niemeyer). 
Syphilitic Lesions of the Mucous Membranes are analogous to those of 
the skin ; and, next to the skin, are the most common lesions. Erythema of 
the mouth and pharynx; patches on the palate, velum, pharynx, inner surface 
of lips and cheeks, with sharp pains and dryness of throat, usher in the usual 
and mildest form of lesion, as syphilitic catarrh. 
Gastro-intestinal derangement leads us to believe that the intestinal tract 
is also affected by the syphilitic poison at the same time as the throat; and 
bronchitis also is a result of the disease. 
Ulcerative affections have their seat in the nostrils, tongue, anterior pillars 
of the velum palati, the tonsils, internal surface of the pharynx. The larynx is 
subsequently affected. The post-mortem appearance of the ulcers shows much 
thickening and induration, with adventitious lymph. 
Mucous patches and papules are lesions altogether peculiar to syphilis. 
They consist in elevations of the skin or mucous membrane. The borders 
of the patches are distinctly circumscribed, and the surface more or less moist 
or whitish. They assume the form of a large papule, or of a flattened, circu- 
lar, ovoid or ellipsoid tubercle. A layer of thickened epithelium covers the 
tubercle at first. The secretion is a dirty fetid fluid, extremely irritating to 
the neighboring parts, and apt to develop vegetations or warts. In consist- 
ence they are soft, and rarely painful or itchy. 
They commence as a red spot (congestion), which gradually spreads in a 
circle; and the epidermis covering it is raised by serous fluid very slightly, 
and at last is separated, exposing a bright red surface surrounded by a white 
ring. This surface soon becomes covered with a grayish, white, moist skin. 
Sometimes the original chancre is converted into such a moist papule, 
tubercle, or mucous patch. 
The seat of mucous patches is mostly about the genito-anal region, and 822 
SPECIAL PATHOLOGY-SYPHILIS. 
next to the vulva or anus; they are met with most frequently on the inner 
and upper part of the thighs, on the tonsils, in the mouth, upon the lips, in 
the interdigital spaces, about the nipples (women especially), in the groins 
and about the ears, on the scrotum, inguinal folds, and between the toes. 
Fissures (rhagades) occupy by preference the cutaneous folds, especially in 
the neighborhood of the anus. The most common seats of election are-(1.) 
In men, round the anus, and within the mouth. (2.) In women, upon the 
vulva (Ricord, Iconographie, Pl. xvii, also xx). 
The color is peculiar in different places. Within the mouth it is grayish- 
white, like the result of the application of nitrate of silver-hence named 
" opaline patches "-described on the internal surface of lip or cheek, side and 
dorsum of tongue, the gums, tonsils, and soft palate. 
The Laryngoscope will show them on the epiglottis, larynx, and pharynx. 
Affections of the Nails occur in two forms, namely-(1.) As onychia; and 
(2.) As a dark-red eruption on the nail, due to congestion of the vascular 
layer beneath, with numbness and tingling beneath the surface. The nail 
atrophies, desquamation from its surface commences, and continues with split- 
ting up of the substance, and pitting. Lastly, the nail crumbles down from 
the edges and free margin, point, or tip. It is irregular, and thickened from 
the under part (Psoriasis of the nail), analogous to the "Seedy toe" of horses. 
(Compare Richardson's very interesting paper in Clinical Essays, vol. i.) 
Syphilitic Condylomata are lesions which rarely fail to appear as a frequent 
symptom of general infection of the system. Their appearance is generally 
the first symptom which succeeds the primary infection and enlargement of 
the lymphatics. They consist of broad elevations of tissue above the level of 
the skin or mucous membranes; covered in the skin by a thin coating of epi- 
dermis, usually in a state of superficial ulceration, and bathed in a slimy, 
bad-smelling secretion. The most frequent seat of soft condylomata is between 
the nates-in women between the labia, and in men upon the scrotum and 
outer surface of the penis. Sometimes they spread over the inner surface of 
the thighs. They may appear also at the angles of the mouth ; more rarely 
at the commissures of the eyelids, and between the toes. They often become 
fissured, especially when they have coalesced to form extensive growths; and 
in this way painful and often obstinate ulcers, fissures, and cracks form, at- 
tended by severe pain, and which heal slowly. 
The Syphilitic Lesions of the Testicles (syphilitic sarcocele) have been mi- 
nutely examined by Virchow and Wilks. Where the general substance of 
the testicle is affected the deposit is interstitial, and the free portion of testicle 
is first attacked; then the tunica albuginea thickens, and the inflammation 
extends along the tubes. The disease generally begins in the tunica albuginea, 
and induces a proliferation of new connective tissue and young cells upon the 
interior of the tunic and between the seminal tubes. 
The middle cones of the testicle are most frequently affected, and they in- 
crease in size from this proliferation of tissue-elements. The interstitial tissue 
softens and is red, the tubes thicken, fatty epithelium becomes developed, and 
atrophy results. 
Solitary nodules may sometimes form, varying in size from a millet-seed to 
a cherry. They look like yellow tubercle, and are analogous to the gummata 
observed in the scrotum and in the substance of the tongue, which are hard 
and elastic, about the size of a pea, and easily overlooked. These tumors in 
the testicles and tongue are peculiar, in not growing from a centre, like other 
tumors, but rather as infiltrations of tissue (Wilks). Thus they are not per- 
fectly circumscribed, but are found mixed up with the adjacent tissues 
(gummy orchitis'). 
In the Substance of the Heart Virchow describes the syphilitic growth, 
and refers to cases of a similar kind recorded by Ricord and Lebert. Ricord, 
in his Atlas, gives illustrations of them, and calls them " Syphilitic muscular SYPHILITIC LESIONS OF BONES. 
823 
nodes in the substance of the heart " ( Clinique Iconographiquef Firm, yellow, 
cheese-like masses were found in the substance of the ventricles. There was 
a history of old chancres and ulcerated tubercles of the skin. 
In LebeTt's case these gummata were seen at a comparatively early stage 
of development, and were found in the wall of the right ventricle. There 
were tubercles of the skin, of the subcutaneous tissue, genital organs, and 
bones of the skull (Anat. Pathologiquef In Virchow's case there were syph- 
ilitic gummata in the testicles. 
Dr. Haldane records a case of a similar kind, and gives excellent drawings 
in Edin. Monthly Med. Journal for Nov., 1862. 
In the Museum of the Army Medical Department at Netley there are two 
preparations which show such gummata in the substance of the heart. One 
occurred in the case of a soldier, twenty-four years of age, under treatment 
for venereal ulcers of nine months' duration, on various parts of the body. 
He had lost his palate, and eventually sunk from exhaustion, with symptoms1 
of phthisis. Sections of the muscular substance of the heart showed several 
isolated deposits in its substance and beneath its serous covering; and isolated 
portions of the lungs were converted into a substance of the consistence of 
cheese. 
The lesion often assumes the form of interstitial myocarditis. White fibrous 
tissue abounds in the left ventricular layers of muscle, and the heart is usu- 
ally larger. Round nuclei abound in the sarcolemma or connective tissue. 
Vascularity increases, yellow deposits follow the result of fatty degeneration 
of the new growth; and this lesion passes ultimately to the muscular fibres of 
the heart. 
The lesion is to be distinguished from the myocarditis of rheumatism, and 
from that of alcoholic myocarditis. In rheumatism the lesion is usually that of 
orifices and valves. In alcoholism the adipose tissue is in excess at the base of 
the .heart, is of a yellow color, and fatty degeneration extends from this between 
the fibres of the heart. Lesions in the muscles generally also occur in two 
forms,-namely, interstitial myositis and circumscribed gummy node. The 
interstitial myositis shows itself most frequently in the flexor muscles of the 
fore-arm. The gummy nodes appear most often in the gluteus maximus, tra- 
pezius, sterno-mastoid, and vastus externus. 
Site of each, the sheaths in the first instance, and secondary atrophy of 
muscle follows. 
In the Bones syphilitic lesions arrange themselves in three groups or forms: 
1. The primary characteristic growths, or various states of gummata or 
nodes, which advance to the formation of ulcers; and the death of parts in 
little necrotic sloughs or cores of dead bone, imprisoned within circles of bone. 
There are usually several points of attack, where swellings form, accompanied 
by great pain, especially at night. Such gummata or nodes are most apt to 
appear upon the skull, the shins, sternum, and clavicle; and generally upon 
such bones as are covered by skin only. 
2. The virus of syphilis seems to have the power of fostering the growth of 
simple interstitial inflammatory products, and thus leading to hyperostosis, 
exostosis, and hard nodes. Caries and necrosis of the bone follow the eating 
ulcers of soft parts, such as the roof of the palate, the nasal septum, the 
laryngeal cartilages; or caries and necrosis may follow periostitis of the long 
bones. Internal caries and necrosis may also occur, beginning in the marrow 
of the bone, giving rise to suppurating osteo-myelitis. Most of these forms of' 
syphilitic lesions are to be seen in the skull bones, especially in the forehead 
and anterior parts of the skull. They may be seen as superficial or deep 
exfoliations of the outer laminae. The deeper portions become dead in small 
circles, inclosed by new bone; or existing like the core of a carbuncle, they 
cannot be removed without enlarging the aperture through which they make 
known their existence. 824 
SPECIAL PATHOLOGY-SYPHILIS. 
3. The dry caries of bone, or cicatricial form of lesion in bone, with consid- 
erable loss of substance, is recognized by numerous holes or pores with fur- 
rows converging to a centre, where the lesion first began, giving rise to the 
stellate depressions so characteristic of this cicatricial-like loss of substance. 
The cicatrices which result after absorption or elimination of gummata in 
bone have a characteristic appearance, especially denoted by the want of 
growth in the centre, and activity of growth at the edges, after loss of sub- 
stance. 
The inflammatory form commences as an osteo-periostitis, and forms a 
swelling of a rounded form, and merging insensibly into neighboring tissue. 
The bony canals become dilated, and contain a substance like soft callus, 
into which small bloodvessels pass, so that the whole area of lesion becomes 
very red, congested, and vascular. Microscopically, the elements of the new 
growth are embryonic forms of connective tissue. 
These elements are very liable to the granulo-fatty metamorphosis, so that 
finally such lesions assume a cheesy, yellow, tubercular appearance, and so 
become almost entirely absorbed. If the new material does not become ab- 
sorbed, but continues, then the thickness of the bones (such as the cranium) 
is considerably increased, and the tissue becomes dense and heavy. The 
periosteum may remain unchanged, except that it is increased in thickness; 
but generally nodes form upon it, with circumscribed spots of inflammation, 
disappearing in a week or two, to be followed by others in the vicinity. These 
nodes tend to suppuration, and to caries of the bone beneath, in small por- 
tions. The ulcer generally cicatrizes without spreading, leaving the surface 
of bone uneven below; and the cicatrix adheres to the bony tissue. 
Thickening of the cranial vault is one of the most common lesions in 
syphilis. The tibia, the clavicle, the elbow, the bones of the cranium, nose, 
and all superficial bones, are the seats of selection of syphilitic inflammation. 
Gummy tumors occupy either the periosteum or the bone itself. 
In the bone they usually start from the medullary substance. In the long 
bones it is usually the medullary canal where they grow. 
When in flat bones, usually those of the cranium, the medullary gummy 
growth appears in the diploe, separating the laminae of the compact sub- 
stance, and finally causing caries or necrosis of small portions of bone. Ab- 
sorption, suppuration, caries, necrosis, are the various modes of termination. 
In the necrosis of gummy lesions of bone the dead portion has a worm- 
eaten appearance, with large holes over a plain surface; and it becomes sepa- 
rated from the living bone by a line of demarcation proceeding from within 
outwards. The edges of this line become more and more dense from new 
bone, and so project and inclose the dead portion. The neighboring bone is 
generally eburnated and heavy. 
Atrophic forms of bone lesions-dry caries, bony cicatrices-are usually 
seen on the cranial bones, associated with gummy tumors of the periosteum. 
The lesion is very slow and insidious in its origin and progress, and is never 
observed till it has existed for a considerable time. 
It exists, simultaneously, at several points or foci, characterized at the 
centre by a process of thinning, and at the circumference by a process of 
hypertrophy. The thinning is due to dilatation of the vascular canals, with 
absorption of bone tissue; large orifices, pores, and furrows converge to the 
affected point; and the depression has a cracked, fissured appearance, like 
some of the cicatrices of the skin and mucous membrane. These stellated 
•depressions increase in circumference and depth, and sometimes the bone is 
slowly perforated. Osteophytes surround the lesion. This form is believed to 
be the last stage of gummy deposits which has been absorbed. 
Mammillated protuberances on the cranium, and gummy tumors are known 
by their evolution. Tubercles occupy, by preference, the joints. Necrosis has 
a peculiar sequestrum. Dry caries is slow, and confined to the cranium. SYPHILITIC LESIONS OF THE NERVOUS SYSTEM. 
825 
In the Brain such gummatous tumors have been especially described by 
Bonet, Ricord, Cullerier, aud Lallemand. Ricord describes them under the 
name of the syphilitic tubercle of the brain. Dr. Steenberg (physician for 
the insane *at Schleswig) believes that a great proportion of the syphilitic 
affections of the brain are subsequent to lesions of the arteries ; and the organs 
of circulation generally he observes to be the frequent seat of syphilitic locali- 
zations. Hence softening of the cerebral substance, and various lesions of the 
nervous system, are by no means rare in cases of prolonged syphilis; and 
Virchow has frequently noticed lesions of the great vessels in those who die 
from syphilis with lesions in the brain. The tendency to aneurismal dilata- 
tions and cicatricial-like loss of substance in the lining membrane of the great 
vessels, in young subjects who are severely affected with syphilis, is a subject 
in morbid anatomy which requires yet to be investigated. 
In the cases where cerebral symptoms have long coexisted with syphilis, 
" a quantity of tough, yellow, fibrous tissue unites together the surface of the 
brain with the adjacent membrane, and this again is adherent to the bone. 
The cortical substance of the brain at the affected spot is often partly de- 
stroyed, and the adventitious material occupies its place. The question has 
still to be solved as to what structure is primarily affected. Many have given 
the authority of their name to the opinion that the disease commences first in 
the bone, but simply for the reason that the osseous system is that which has 
so long been recognized as liable to be affected. But since we now know that 
other structures may be similarly attacked, we are prepared to look for its 
commencement in other parts, and even in the brain-structure itself. . . . The 
cases which are so frequently met with are those where the deposit involves 
both sides of the dura mater, and includes in it the bone on one side and the 
brain on the other. The probabilities are in favor of its occurring in the dura 
mater first, as it arises in the periosteum on the exterior of the cranium " 
(Wilks in Med. Times and Gazette, Oct. 25, 1862). 
But the lesion also occurs in isolated gummatous nodules in the great ner- 
vous centres, such as the thalami optici or corpora striata. I saw on the 29th 
May, 1863, a most interesting dissection of such a case in the Middlesex Hos- 
pital, which had been under the care of Dr. Goodfellow. There had been a 
history of syphilis, and some of the children of the man had died of inherited 
secondary syphilitic lesions. A gummatous tumor occupied the left optic 
thalamus. Numerous cases of syphilitic tumor of the nerves and nervous cen- 
tres are to be found collected together in the pages of the Medical Times and 
Gazette, and two may be referred to of the intracranial nerves, related in the 
17th vol., for 1858, p. 419, in each of which paralysis was due to such syphil- 
itic neuromata. Dr. Thomas Reade, of Belfast, has also just published (1871) 
a most interesting monograph on syphilitic affections of the nervous system. 
The lesions of encephalic syphilis are ushered in by obscure phenomena; 
but the following may be especially noticed: Insomnia manifests itself at the 
commencement; and headache is characterized by-(1.) Violence; (2.) Pro- 
longed duration; (3.) Nocturnal recurrence or exacerbation. The general 
nervous symptoms are especially obvious in alteration of intelligence, of sensi- 
bility, and of motion. These, combined with such obvious local lesions as 
caries, or necrosis of the facial bones or of the cranium; or tumors on the 
external surface of the cranium, such as gummata, periostitis, or exostosis, at 
once point to cerebral syphilitic lesions; which are sometimes expressed by 
persistent epilepsy. Any form of syphilitic infection may be followed by 
nervous affections, from a year old up to old age. Syphilitic brain-disease 
generally leads to softening of the cerebral substance surrounding the nodule ; 
and this softening cannot be distinguished from the softening induced by any 
other cause. The duration of syphilitic nervous affections averages about one 
year; and their natural courseis characterized by intermissions; and at the 
outset the intermissions are very distinctly expressed. 826 
SPECIAL PATHOLOGY-SYPHILIS. 
A point in the pathology of syphilis at present assuming considerable impor- 
tance, is the influence which an open suppurating sore of a secondary or ter- 
tiary kind has in removing the tendency to the localizations of lesions else- 
where, and especially in internal parts. Dr. Steenberg says, with reference 
to cerebral lesions, that he has seen the existence of an ulcer of a tertiary 
kind act as a natural issue in subduing the irritation of cerebral lesions, an 
entire remission of the nervous symptoms occurring while the ulcer remained 
open. Hence the great benefit which often follows the use of a seton in syphil- 
itic epilepsy. Mr. Henry Lee also writes that " fresh inoculations from suppu- 
rating sores during the time of their development check the activity of other 
lesions of the skin and, no doubt, of lesions elsewhere. Hence the reputed 
good effects of the filthy process of syphilization may in some degree be ex- 
plained by these facts, as in cases where syphilization has been continued 
during several or many months. 
The syphilitic lesions capable of affecting, directly or indirectly, the sense 
of sight are numerous and varied. These involve either the optic nerve itself 
or the constituent parts of the eye-e. g., choroiditis; diffuse exudation through- 
out the retina; atrophy of the optic nerve and its papilla, with diminution in 
the calibre of the central vessel; circumscribed abscesses, or partial softenings 
developed in the course of the optic nerve (Von Graefe). 
Syphilitic Lesions in the Lungs have been long ago described by Morton, 
Sauvage, Portal, Morgagni, and more recently by Graves, Stokes, Walshe, 
Wilks, Virchow, Ricord, and Munk. 
Two forms of syphilitic lesions of the lungs are recognizable,-(1.) Bron- 
chitis, or bronchial irritation at least, with fever, in many cases precedes the 
skin lesions, and disappears wholly or partially when this is established: and 
if the syphilitic eruption suddenly disappears, bronchitis may again ensue 
(Walshe). The patient may thus have all the symptoms of phthisis, yet no 
tubercle existing in the lung. The tendency of syphilis is thus to induce 
phthisis in those especially constitutionally predisposed, and where much 
mercury has been taken. Periostitic thickening of the clavicle and the upper 
ribs is apt to lead to the belief that tubercle is present, on account of the con- 
solidation. Care is necessary in the case of young soldiers, who, having been 
just discharged from hospital, after the cure of an infecting chancre, may be 
exposed to cold and wet on guard, and so have an attack of syphilitic bron- 
chitis induced-the probable commencement of a growth of tubercles in the 
lungs, or of solitary syphilitic gummata {Annual Report of Army Med. De- 
part. for 1861). (2.) Deposit in the pulmonary substance, in the form of 
gummata, of the same histological constitution as the well-known subcuta- 
neous product, which has been described by M. Ricord and McCarthy as 
forming in the lungs, especially towards their periphery and bases. Towards 
the periphery they are like nodules of lobular pneumonia. They soften, and 
are eliminated very much like tubercle, and have at first a consistence like 
scirrhus. They are non-vascular (Walshe). 
Syphilitic Lesions of the Liver.-Dittrich and Gubbler were the first to 
give an accurate description of these syphilitic deposits in the liver. Virchow 
has also described a perihepatic lesion and a simple gummy interstitial hep- 
atitis. The former never occurs alone, but is generally associated with the 
latter. The hepatic substance atrophies, and the deposit contracting is eventu- 
ually absorbed, causing a cicatrix-like mark. The liver lesions are usually 
among the later symptoms of syphilis, and are well described by Wedl, Vir- 
chow, Wilks, and Frerichs. 
Interstitial hepatitis or syphilitic cirrhosis requires to be distinguished from 
alcoholic cirrhosis. The syphilitic cirrhosis sometimes involves a part only, and 
sometimes the whole of the liver. It is associated with-(1.) Vascular injec- 
tion ; (2.) In the fibrous capsule and main septa there grow at various points 
the new tissue, which thickens the web, and leads to enlargement; (3.) Con- SYPHILITIC ULCERS. 
827 
traction ensues as a result of the retraction of the new tissue. Hence furrows, 
more or less deep, cause the characteristic appearances which stamp the lesions 
as syphilitic; (4.) Perihepatitis is invariable; hence adhesions are common to 
the diaphragm and other parts. Alcoholic cirrhosis progresses always along 
the course of the portal veins, and the liver is never ploughed up into large 
furrows, so characteristic of syphilis. 
When gummy tumors exist, the liver generally adheres to the diaphragm or 
other parts in the neighborhood of the superficial growths. The surface of the 
organ is generally traversed by cicatricial furrows and deep depressions. The 
nodes are usually multiple and deep-seated, and sometimes superficial, when 
they appear immediately beneath the capsule. They vary in size from a pea 
to a walnut or pigeon's egg. On section, they are white, gray, or yellow, firm 
or a little soft, having a dry and elastic surface. Generally they are sur- 
rounded and circumscribed by a thickened retractile zone, less prominent on 
section than the node itself, on account of this retraction. 
Syphilitic depressions and cicatrices are due to absorption of gummy nodes, 
or to partial hepatitis. 
Lesions of the Tongue of a syphilitic nature are to be seen in many cases. 
They are mostly expressed by ulcerations at the base, often in such positions 
that the laryngoscope only can disclose them to view. Sometimes they appear 
as a raw, indolent, abraded-like surface, in circumscribed patches, on the 
dorsum or edge of the tongue-the aphthous exfoliation and syphilitic tuber- 
cles of Erasmus Wilson. (See Plate 3, Fig. e, of his work, On Syphilis.} 
Hints for the Investigation and Description of Syphilitic Ulcers.-1. 
Ascertain as near as possible the date of contagion, keeping in view the media 
or vehicles of contagion, in addition to virus from a true primary chancre- 
namely, from ulcers in acute secondary syphilis; from the blood of patients 
suffering from acute secondary syphilis; from sexual intercourse, followed by 
conception, with a man who is at the time suffering from syphilis in some of 
its active secondary forms; from mixed chancres carrying the virus; from 
sloughing sores carrying the virus. 
2. Examine the patient, keeping in view- 
(a.) That the soft, "non-infecting" sore commences almost immediately 
(i. e., twenty-four hours to within three days after connection). It commences 
as a red spot, or a point, passing very soon into a pustule and a soft suppur- 
ating sore. 
(6.) That the "infecting" sore does not commence before the end of the 
second or beginning of the third week (eighteen to twenty-four days); and if 
the disease has been contracted from a secondary ulceration, not before the 
expiration of the third or fourth week (Rinecker). A specific sore results 
in the form of a papule, abrasion, fissure, or crack; the formation of pus, or 
an ulcer discharging pus, being an accidental occurrence. 
3. Examine microscopically the discharge from all syphilitic sores, keeping 
in view-(1.) That a "soft, non-infecting" sore discharges pus-cells ; (2.) That 
the fluid discharged from an "infecting" sore is not pus, but a molecular 
debris. 
4. The irritation of an "infecting" sore may cause it to discharge pus along 
with the "infecting fluid." Hence "mixed chancres." 
5. The soft, purulent, non-infecting sore may be transplanted at will, and 
at any time, on the patient's body. The true "infecting" sore cannot be mul- 
tiplied after glandular enlargement and general infection becomes developed. 
It remains a solitary sore. 
6. Look every day for cutaneous eruptions during the existence of a pri- 
mary sore. 
7. Examine the lymphatic glands-not only in the vicinity of the chancre, 
but also those in the axilla, and the neck up to the occiput. Note as to the 828 
SPECIAL PATHOLOGY-SYPHILIS. 
slowness or rapidity of the enlargement-hardness or softness-tendency to 
suppuration, and whether painful or not. 
8. From the account of syphilis and venereal sores which has been given in 
the preceding pages, it must appear clear that definite nomenclature must be 
adhered to in describing venereal or syphilitic sores. 
Syphilization.-By this name an operation is now known which has for its 
object the eradication of syphilis from the system by repeated inoculations 
of the virus. Dr. Boeck, of Christiana, is the most persistent advocate of 
this mode of dealing with syphilitic cases as a remedy against constitutional 
affections. 
It may be useful to explain here in detail the origin and doctrine of Syph- 
ilization, previous to considering the rational treatment of the disease. 
In 1844 a young French physician-Auzias Turenne-commenced a series 
of experiments with the view of testing John Hunter's doctrines regarding the 
non-communicability of syphilis to the lower animals. He succeeded at length 
in producing, on monkeys inoculated with chancre matter, a disease which had 
all the characters of a chancre. A disease was communicated to them capa- 
ble of being transferred to rabbits, cats, and horses. It appears, also that 
syphilis was established in these animals; and the chancres produced by 
inoculation became less and less in each animal, until at length a period ar- 
rived at which the virus seemed to lose all its power. No sores of any kind 
occurred. When a sore was established, however, in these animals, the virus 
was preserved, and was capable of transmission, and of retransmission back 
to man. It was inoculated from a cat upon Dr. De Welz, a German physi- 
cian and Professor in the University of Wurtzburg. On him it gave rise to a 
hard chancre, then to constitutional syphilis, demonstrating that the virus lost 
none of its virulence by the transference front man to animals, and from ani- 
mals back to man. Nevertheless, Turenne believed that by prolonged inocu- 
lation the system became protected. 
Sperino, of Turin, next took up the question. He inoculated persons suf- 
fering from syphilis by virus from a chancre, and repeated the inoculations 
once or twice a week till the virus ceased to produce any effect; and when 
this point was reached, all other sores had healed. This naturally gave rise 
to the belief that, like vaccination, the system became protected ; and to this 
process the name of Syphilization has been given. 
When we consider the suffering, the long confinement, the filthy sores, and 
the innumerable cicatrices left, as well as the doubtful results, the uncertain 
state of our knowledge regarding the virus of syphilis, and the media of its 
conveyance, it cannot be conceded that we are warranted in sanctioning the 
method of treatment by syphilization. At Copenhagen, at Florence, at 
Turin, and other places where large hospitals exist, extensive experiments 
have been carried out in public; and although time and additional evidence 
are both wanted to learn ulterior results, nevertheless I think the facts are 
capable of a totally different explanation from that which has been given 
them, and to which I have adverted. But, let me go more into detail. 
Sperino's cases and Lee's experience show that during the active existence 
of phagedenic suppurations and continuous suppurating sores, in a patient suf- 
fering from syphilis, the phenomena of secondary infection do not advance, 
but the symptoms of contamination gradually wear out. Moreover, suppura- 
tions are easily established on the syphilitic. The action set up in them by 
repeated inoculations-the so-called syphilization-is merely a continuous 
suppurative action : indurated sores are not produced. The system is already 
contaminated ; and the infecting virus will not produce any additional specific 
effect. Lastly, syphilis, in course of time, tends to wear itself out of the con- 
stitution. Hence the modus ojjerandi of so-called syphilization may be ex- 
plained, conjointly-(1.) By lapse of time ; (2.) By continuous suppurations 
affording a drain or source of depuration to the system; (3.) From simple TREATMENT OF SYPHILIS. 
829 
non-specific ulceration being sufficient to accomplish this result, as shown by 
the fact that the experiments on syphilization have been effected from all 
forms of venereal sores, discharge having been taken indiscriminately from 
soft as well as true infecting chancres. Moreover, the experiments recently 
made by Dr. Lindwurm, of Munich, clearly prove that any curative influence 
which the so-called process of syphilization may possess is due to the excretory 
action of numerous and prolonged simple ulcerations. He submitted four- 
teen syphilitic patients to friction with tartar-emetic ointment, without any 
other treatment. When the pustules from one inunction had dried up, a fresh 
crop was produced by a second inunction in another place; and this was re- 
peated. The results were, in some instances, surprisingly favorable, in others 
less good, and in others negative. He therefore justly considers that syphili- 
zation and tartar-emetic-ointment frictions produce like results (New Syden. 
Society Year-Book, 1860, p. 325). 
The process to which the name of Syphilization has been given consists of 
the following details: 
(1.) Matter is taken from a sore-an indurated one by preference. (2.) A 
patient suffering with secondary syphilis is inoculated with it. (3.) From the 
pustules (which form in about three days') fresh inoculations are made, (4.) 
Every third or fourth day continue so to inoculate, always taking matter 
from the last pustule as long as it continues to give any result. (5.) When 
it ceases to give any result, new matter is to be sought for from another pri- 
mary indurated ulcer, and continuous inoculation to be made as before on the 
sides of the person's body. (6.) When this ceases to take effect, new matter 
is again to be sought for and inoculated on the arms, and so on till no further 
inoculations will succeed. (7.) The operator is to go on inoculating so long 
as any new matter will product a pustule. (8.) When no sores can be pro- 
duced, the cure is considered complete; and all the symptoms of contamina- 
tion from syphilis will then be found to have vanished. (9.) During this pro- 
cess the diet must be good and generous, no wines or spirits being allowed. 
The artificial ulcers are to be covered with wet cloths, and the utmost clean- 
liness is necessary. (10.) The mean time required to complete the cure is 
said to be four mouths (some say six months). The very length of time im- 
plies a fallacy, for by lapse of time alone the disease, in some constitutions, is 
known to wear itself out (Gatrdner) ; but the belief in the virtue of syphili- 
zation appears to be based on a total misconception of the nature of the results 
obtained by the process, and on an erroneous interpretation of the facts which 
suggested the process. It is therefore of importance to note that the value of 
syphilization as a remedy may be expressed in the following summary: 
1. In the experiments on syphilization all forms of the venereal poisons 
have been indiscriminately used. 
2. The action set up by the operation is merely a continuous suppurative 
action. It is not alleged that the repeated inoculations produce indurated 
sores. Indeed, it is proved that, once the system is contaminated, the infect- 
ing virus will not produce any specific effect so long as symptoms of syphilitic 
contamination continue. 
3. Lee's cases, and such experiments as those of Dr. Lindwurm, show that 
if continuous suppuration is maintained, the phenomena of secondary infec- 
tion do not advance, but tend to wear themselves out; and that suppurations 
are easily set up in those contaminated by syphilis. 
4. The modus operandi of syphilization is therefore explained-(a.) By lapse 
of time; (b.) By continuous suppuration (simple), affording a drain or source 
of depuration to the system. 
Treatment of Syphilis.-As in the case of other specific diseases that are 
implanted by inoculation, the effect of the virus begins at once at the point 
of inoculation, and may not be destroyed as to its contaminating powers by 
any agency we know of. Experience shows that we must not conclude that, 830 
SPECIAL PATHOLOGY-SYPHILIS. 
even by an early destruction of the sore, the occurrence of constitutional in- 
fection will be prevented ; and the application of caustics to abraded surfaces 
after their exposure to contagion is quite useless to prevent infection. The 
poison is absorbed in a very short time-within a few hours (Berkeley 
Hill). The exact nature of a sore cannot yet be recognized at a sufficiently 
early date (apart from all other means of diagnosis) as to whether it will or 
will not prove a sore carrying a virus which will affect the system. In cases 
where the sore is a suppurating one, occurring soon after exposure to infection, 
such a sore may be of a mixed nature, and therefore is of doubtful character, 
and always suspicious; for induration may set in later, at the usual period, 
showing its syphilitic character. 
The local progress of such sores may be arrested with escharotics, if they 
are applied at an early period of their existence, and before contamination of 
the system is evinced by induration of the base of the sores. Ricord and 
Sigmund have found that sores destroyed by the more powerful caustics, within 
from three to five days, have not been followed by syphilitic symptoms. But 
these may have been cases of soft chancre, which would not infect. The only 
efficient caustics for this purpose are-(1.) The strong nitric acid; or (2.) The 
potassa cum calce (most conveniently used in the form of small sticks). Nitrate 
of silver is useless, from its limited action and deficiency of penetration. Dr. 
Berkeley Hill has clearly shown that no escharotic applications to the origi- 
nal syphilitic sore will prevent contamination of the system. 
If the sore threatens to slough, the parts should be wiped dry, and nitric 
acid applied, and afterwards a lotion of the potassio-tartrate of iron, while the 
same drug is given internally. Chloride of zinc paste (Fell's) is a useful es- 
charotic to excite a healthy action round the periphery of a sore. If great 
pain attends the local progress of the chancre, morphia in liquor ammonia ace- 
tatis is highly beneficial. 
Mercury, administered during a primary sore, seems to be one of those 
agents which are able to break the regular order of the manifestation of symp- 
toms, as it does to several other diseases; although it may not seem to possess 
any certain prophylactic power. 
There are remarkable variations in opinion as to its influence in curing 
syphilis. At one time discussion ran high regarding its use; and, of course, 
extreme statements were made on both sides, while the facts adduced never 
warranted the extreme conclusions. 
Consequently, at one time mercury has been regarded as capable of abso- 
lutely preventing the constitutional affection; at another time it has been 
accused of giving to the syphilitic virus the impulse which sets up the consti- 
tutional affection. It is now quite certain, however, that mercury adminis- 
tered continuously to the extent of salivation, or approaching it, exerts a poi- 
sonous influence, and produces constitutional effects of a very dangerous 
kind (Graves) ; and Hunter himself says " new diseases arise from mercury 
alonewhile it cannot be doubted that in cases in which mercury has been 
freely given, we are never certain that secondary symptoms may not supervene. 
Barensprung, of Berlin, during his most extensive experience, came to the 
conclusion that syphilis not only can be cured without mercury, but, under 
its use, he believed the disease is often rendered latent for months and years, 
and its complete cure delayed. Starvation and Zitman's weaker decoction 
were the means he employed for cure (Ann. de Berlin Charite, ix, 1, 1860; 
Syden. Society Year-Book, 1861). Herman came to similar conclusions, from 
his experience in the syphilitic wards of the Vienna Infirmary. The experi- 
ence of Diday is not less decided. He states that mercury cannot now be 
said to cure syphilis radically, so as to render all relapse impossible. 
He does not, however, as is the case with the others, practically withhold 
mercury in every case. If the primary lesion becomes an indurated, woody 
chancre, mercury is given. If the chancre is a doubtful one, he recommends QUESTION OF MERCURY IN SYPHILIS. 
831 
waiting till some of the early constitutional phenomena render the nature of 
the case evident, and indicate the probable gravity of the syphilis with which 
he has to deal. He employs iodine, iron, and quinine, on the appearance of 
slight relapses, with a tonic and supporting regimen. He recommends iodides, 
to combat the chloro-anoemia, and to relieve the pain of tertiary ulcerations. 
The cumulative evidence regarding the action of mercury renders it neces- 
sary for me to modify considerably the statements in previous editions. 
Numerous examples may be seen in museums, which are placed there to 
show that the poisonous effects of mercury produce worse lesions than those 
of syphilis ; and, when combined with the syphilitic virus in a strumous person, 
the worst lesions of all. In the extreme of syphilitic infection, it ought never 
to be forgotten that a specific chlorosis results from syphilis, amounting to 
anaemia; and that mercury will bring about a similar anaemia. But while 
numerous instances are quoted by authors, of the poisonous effects of mercury 
inducing lesions similar to those of syphilis, the investigations of Kussmaul, 
Professor of Medicine at Erlangen, show that mercurial poison produces no 
single affection or symptom that is identical with, or not easily distinguishable 
from, those of syphilis. His experience was among the manufacturers of 
mirrors using mercury in the town of Furth; and he shows that mercury has 
but one influence over syphilis-that is, the power of controlling many of its 
symptoms. 
Both kinds of treatment (mercurial and non-mercurial) have been exten- 
sively tried since 1816, and formal experiments have been organized on the 
subject, namely,-First, In 1822, in Sweden, by Royal command, when reports 
were annually furnished from civil and military hospitals as to trials of the 
two methods; Second, Dr. Fricke experimented in the Hamburg General 
Hospital, and published his results in 1828; Third, In 1833 the French 
Council of Health published a report on the subject. 
Long before any of these reports were initiated, however, the surgeons of 
the British Army had the boldness to declare themselves against the system 
of treatment with mercury, as it was then carried out, and, running into the 
opposite extreme, introduced measures of non-mercurial treatment altogether. 
This change was mainly due-(1.) To Mr. Fergusson, who practiced it 
during the Peninsular wars (Med.-Chir. Trans., vol. iv); (2.) To Mr. Rose, 
of the Coldstream Guards, at the same time, but independently of Mr. Fer- 
gusson; (3.) To Dr. John Thomson, the first Professor of Military Surgery; 
who by lectures in the University and College of Surgeons in Edinburgh, 
and by his published writings, was mainly influential in convincing Scotch 
medical men of the evil effects of mercury in venereal diseases. 
The inquiry begun in 1816 by these military surgeons, requires to be reinves- 
tigated with all the present advanced knowledge of the nature of the disease 
which we now possess, and with a better prospect of detecting the fallacies 
which surround the investigations. Under the simple treatment of those 
eminent men, there can be no doubt that mixed cases of soft, as well as of 
indurated chancres, and specific or syphilitic sores, were allowed spontane- 
ously, as it were, to develop their distinctive characters. No confidence can 
now be placed in the results thus published, as derived from clinical observa- 
tion, because the cure of soft, suppurating, and mixed sores, gonorrhoea, vegeta- 
tions, suppurating buboes, are all indiscriminately given as evidence of the cure 
of syphilis. Moreover, cases cannot be accepted as cured at the time they 
are simply discharged from present treatment, because they may seem to 
be progressing to a favorable termination, but not absolutely cured, as is 
the case with the records of Fricke's experiments. 
The great benefit obtained by the experiments, observations, and discussions 
regarding mercury in syphilis, carried on during the first quarter of the 
present century, as Dr. Berkeley Hill justly observes, has been to show-(1.) 
That all venereal ulcers can be healed without mercury; (2.) That this drug 832 
SPECIAL PATHOLOGY - SYPHILIS. 
is not the cause of the relapses so frequent in syphilis; and (3.) That very 
much less mercury is required to control syphilis than had been previously 
supposed necessary. 
The present position of opinion with regard to mercury in the cure of vene- 
real sores seems to be this, namely,-That it is a very valuable and essential 
remedy in cases of syphilis, but not in cases of soft chancre; and the diffi- 
culty is to express always the nature of the cases for which it is most suitable. 
Even those who believe most fully in its virtues acknowledge that in primary 
affections, as when given in the treatment of the local sore, its administration 
will not always prevent the occurrence of constitutional symptoms; nevertheless, 
the value of mercury in the cure of the induration of the true infecting 
chancre is now fully recognized. The local lesion, if it appears after the 
usual prolonged period of incubation, is as much a manifestation that the 
constitution is already affected as is the developed vesicle of variola vaccina a 
manifestation that the constitution is affected with variolous poison. Looking, 
also, to the nature of the virus of syphilis, as expounded in the text (espe- 
cially at page 805, et seqf, the excision of the primary lump or sore-the specific 
induration-as practiced by Dr. Veale (Edin. Monthly Journal, July, 1864), 
and by Dr. Humphry, of Cambridge (British Medical Journal, August 13, 
1864), is a justifiable operation; for the original sore, when it has become-a 
"lump" (as in its state of "woody-like" induration), is an undoubted main- 
tainer of infection, and of contamination of the system. If, therefore, it can 
be easily and completely insulated, as when on the prepuce, the cure of the 
constitutional symptoms may be facilitated and shortened. 
There are also certain forms of secondary syphilis for which the adminis- 
tration of mercury is unsuitable. These are the pustular eruptions, or ecthym- 
atous states in rupia and in syphilitic anaemia. For the cure of other secon- 
dary symptoms mercury is certainly of service. If given to the extent to 
which I have limited its use in the text, I believe that secondary symptoms 
disappear more rapidly under its regulated use than by any other plan of 
treatment. All our treatment of syphilis rests on that evidence which must 
always guide the hand of the physician, namely-practical experience. That 
has certainly taught us that the mercurialism of John Hunter's time was an 
error; and that its regulated administration in cases of syphilis is undoubtedly 
beneficial, and especially during the evolution of the specific symptoms of 
infection. Dr. Jeffrey Marston, late of the Royal Artillery, has given an 
admirable summary (British Medical Journal of Feb. 21, 1863) of the means 
and indications of treatment by mercury which he has found most useful. 
His experience shows that the system ought to be affected as slowly as possi- 
ble ; and there ought to be a remission of the remedy for a time as soon as 
that effect has been attained. As soon as the symptoms for which the mercury 
was given have disappeared, steel and other remedies ought to be given; and 
in three cases where the general health seemed to have suffered, podophyllin in 
small doses (one-sixth of a grain), with extract of belladonna, was given with 
marked benefit. If the system is too early brought under the influence of 
mercury, and the symptoms are not benefited, chlorate of potash in compound 
tincture of cinchona may be given with advantage; and in strumous subjects the 
bichloride of mercury, dissolved in ether and added to cod-liver oil, is found 
to be most useful. Some of the more intractable forms of syphilitic squama 
are best treated by a combination of liquor arsenicalis, solution of bichloride of 
mercury in very small doses, and tincture of sesquichloride of iron; while the 
use of soap in ablution ought to be avoided (Startin). 
In the administration of mercury for the cure of syphilis, salivation, or 
anything approaching to that condition, should never be induced. Tender- 
ness of the gums should be the utmost physiological effect, very gradually 
and gently brought about. As soon as the evolution of constitutional symp- 
toms has commenced, such as the specific induration of the sore or glands, TREATMENT OF SYPHILIS. 
833 
cutaneous, scaly, tubercular, condylomatous affection, or iritis, the sooner 
mercurial treatment (to the extent indicated) is commenced the greater will 
be the benefit. 
The good effects of mercury are known by the following results : " Given 
early, it promotes the dispersion of the induration at the point of contagion 
or inoculation, and the enlargement of the glands; it delays and lessens the 
severity of the cutaneous eruptions, and of all the symptoms which accompany 
the early skin eruptions " (Berkeley Hill). 
When induration is apparent, mercury ought to be at once administered; 
and all the useful effects of the remedy are generally obtained when the 
slightest possible sign of its influence is betrayed by the gums and breath. In 
some few instances it may be necessary to push the remedy to more decided 
physiological evidence of its effects. The most convenient form of adminis- 
tration is either a pill or fluid solution of corrosive sublimate (perchloridef 
The dose should always be small, and combined so as not to irritate the 
bowels. Gray powder or blue pill may be compounded in the following 
forms, namely : Two grains of gray powder, with two grains of compound ipe- 
cacuanha powder made into a pill with glycerin, two of which are to be taken 
daily; or two or three grains of blue pill combined with a quarter of a grain of 
opium powder, with sufficient glycerin to make a pill, and taken every night 
at bedtime. Either of these forms is sufficient for women and young men. 
In adult men three grains of blue pill or gray powder twice or thrice a day; 
or one grain of calomel every night and morning, with a third of a grain of 
opium, are most suitable. When the mercury is obviously producing its phys- 
iological results, it may be omitted for a day, and then again carried on in 
smaller or less often repeated doses. 
Dr. Berkeley Hill recommends that the perchloride of mercury be mixed 
with iodide of potass, so that a freshly formed biniodide of mercury is kept 
suspended in a solution of iodide of potass, in the following formula : 
R. Perchloride of Mercury, grs. 3; Iodide of Potass., grs. 96; Compound 
Tincture of Bark, 4 ounces; Sesquicarbonate of Ammonia, grs. 60. Water suf- 
ficient to make up 8 ounces. 
The dose of this compound ought to be two teaspoonfuls, half an hour be- 
fore meals, three times a day. 
Two-thirds of a grain of perchloride of mercury may be taken daily; but 
except in such a solution as the above its action is uncertain. 
[The antidotal, curative, or specific property of mercury in syphilis may, 
perhaps, be not proved ; but no medical man of large opportunity, free from 
partisanship, and who has fairly tried both the mercurial and non-mercurial 
practice in true syphilis, will deny that, when properly administered, mercury 
hastens the healing of the primary sore, abates the induration, lessens the 
liability to the happening of constitutional phenomena, removes these, for 
awhile at least, when they appear, and in many of the syphilitic sequelae, 
when the dyscrasy is fairly established, with tissue contamination, often pro- 
duces marvellous results, after other remedies have failed. Hebra and Zeissl, 
after giving a fair trial to all the different plans of treatment-extractum 
graminis, subcutaneous injections of cold water (expectant), iodine and its 
preparations, syphilization-have come back to mercury. Mr. Hutchinson 
states that during two years of his practice in the Metropolitan Free Hospital, 
he abstained systematically from adopting any treatment in cases of indurated 
chancre and its consequences; the chancre and the rash were allowed to 
develop themselves and to disappear spontaneously; in each the duration was 
evidently longer than when mercury was given (Reynolds's System of Medi- 
cine, vol. i, 1866). 
The Venereal Commission reported unanimously in favor of mercury, as 834 
SPECIAL PATHOLOGY-SYPHILIS. 
the most efficient agent yet known in the treatment of syphilis. They say, 
mercury cannot be deemed a specific in the ordinary acceptance of that term, 
as it exercises no direct influence on the poison itself, but only on its effects. 
In the celebrated discussion upon syphilis, which during 1867 occupied so 
many sittings of the Societe de Chirurgie, Dr. Verneuil said: "Till some 
remedy is discovered, mercury is, and will remain the most powerful agent 
against syphilitic accidents. If it cannot be quite admitted that its action 
against the disease is proved, it cannot be denied that it modifies the mani- 
festations of the disease." 
The notion that mercury is capable of producing conditions of the system 
similar to those following syphilitic poisoning, rests on no evidence. Necrosis 
of the bones has been charged upon mercury, and yet repeated experiments 
made on animals by accurate observers, show that this metal does not affect 
the bones. Mercurialism in the human subject never implicates the bones. 
Dr. Wilks states that he has seen several cases of this disease in artificers in 
quicksilver, where the nervous system was greatly implicated, the power of 
locomotion lost, the mind gone, " and the whole body undergoing decay, and 
yet the bones had escaped" (Guy's Hospital Reports, 3d ser., vol. ix, 1863). 
So far from mercury producing effects resembling those of syphilis, the re- 
verse is the case, and that it is antagonistic of the characteristic condition 
existing in the disease. The tendency in syphilis is from the onset of the 
primary sore towards the production of plastic albuminoid material in the 
tissues, while the action of mercury is to retard its deposition, and promote 
its absorption. In syphilis there is a formative action; in mercury a de- 
structive one. Where a cachexy has been established and tissue degenera- 
tion is going on, the action of mercury, being in harmony with the morbid 
process, is hurtful.] 
In Germany, Zitmann's decoction is much used. It is of two kinds-the 
stronger and the weaker. The former is compounded as follows : 
R. Rad. Sarsaparillse, ^xii; Aquae, tbxxiv; Coque per horas duas et adde 
Aluminis, ^iss.; Hydrarg. Chloridi, mitis (calomel), ,?ss.; Antimonii Oxy. 
Sulphureti, Ji; misce. Coque ad i, et adde Fol. Sennae, ^iii; Rad. Glycyr- 
rhizae, ^iss.; Sem. Anisi, Jss. Infunde per horam et cola. The dose of this 
decoction is half a pint to a pint morning and evening. 
The weaker decoction is compounded as follows : 
Capiat residuum decocti fortioris et adde Radicis Sarsaparillse, ^ii; Aquse, 
tbxxiv; Coque per horas duas et adde Cort. Canellse, Cort. Limonum, Sem. 
Cardamomi, aa Jiii. Infunde per horam et cola. The dose of this decoction 
is one pint at intervals during the day. 
Another mode of preparing it with somewhat different proportions of in- 
gredients is given by Dr. Berkeley Hill, as follows : 
R. Sarsaparilla, Jxii; Water, three gallons. Macerate twenty-four hours, 
and put in a linen bag; White Sugar, Jvi; Alum, Jvi; Calomel, Jiv; pre- 
pared Cinnabar, Ji. 
Hang the linen bag in the liquor and boil down, while adding four gallons 
more water, till the liquor is reduced to two gallons ; remove the bag and 
add to the decoction* the following ingredients, namely: Anise seeds, Jiv; 
Fennel seeds, Jiv ; Senna leaves, ^li ; Liquorice root, ^iss. Press and strain. 
About half a pint to a pint is the daily quantity to be consumed of the 
compound. While the amount of mercury it contains is rarely enough to 
produce any unpleasant effects, it is enough to control the disease. A weaker 
decoction of the woods is free from mercury, but is of no value beyond a diet 
drink. TREATMENT OF SYPHILIS. 
835 
Iodide of potassium, in doses adjusted to the individual case, appears to act 
with rapid benefit in some of the syphilitic diseases of the interior of the cra- 
nium giving rise to extreme pain. Its administration often causes intense 
suffering in patients who have been treated by mercurials. Two distinct 
effects are produced: First, the compounds of mercury fixed in the body are 
rendered soluble and active ; and, secondly, a form is given to them which 
allows of their elimination, with more or less rapidity, in a state of combina- 
tion with one of the elements of the iodide; and thus the patient is subjected 
anew to a mercurial treatment by the compounds of mercury already present 
in his body (Meisens, in Brit, and For. Med.-Chir. Review, 1853). The dose 
of iodide of potassium should at first be small-not more than fifteen grains 
in the twenty-four hours-increasing the dose, if the patient bears it well 
(Melsens, Guillot). Its action is aided by a blister over some portion of 
the shaven scalp, and by having the blistered surface dressed with mercurial 
ointment; and, generally, it may be said that local treatment gives very 
valuable aid. For example, cutaneous or mucous raised papules remaining 
persistent, an ointment composed of oxide of zinc, calomel, and simple cerate, 
hastens their absorption. Eruptions of lichen, acne, and herpes are similarly 
benefited by the application of oxide of zinc lotion or ointment; and if prurigo 
and urticaria be also present, diacetate of lead lotion will expedite the cure. 
Vesiculo-crustaceous spots will cease to reappear if the affected parts are 
painted for a few days with a solution of nitrate of silver (gr. x-xx to §i), and 
oxide of zinc lotion applied afterwards. 
In the more advanced stages of the suppurative affections, the use of pyo- 
genic counter-irritants ought not to be neglected, such as tartar emetic oint- 
ment. They tend to keep up just so much of a discharge as maybe consistent 
with the strength of the patient; and are worthy of a trial on the principle 
explained under syphilization. 
In the dry forms of syphilitic cutaneous diseases, and in chronic eczema of 
the extremities, tar ointment, or an alcoholic solution of tar, is an excellent 
application ; and the disappearance of indolent glandular swellings is greatly 
aided by the use of strong solutions of iodine. Superficial forms of ulceration 
attending the pustules of ecthyma are benefited by the use of solutions of 
nitrate of silver or sulphate of copper, and generally by caustics and local stimu- 
lants. If a sloughing condition threaten ulcerating sores, lotions of the potassio- 
tartrate of iron will generally improve their aspect. In psoriasis palmaris, and 
similarly fissured conditions of the skin, glycerin lotions are most useful. But 
all these local remedies, it must be remembered, are only aids to the constitu- 
tional treatment, whether by mercury or iodide of potassium, or simply by a 
well-regulated hygiene. The patient, during the whole of the treatment, 
should be warmly clad-should be fed upon a good but plain diet-should 
take plenty of exercise in the open air-should use occasionally (once or twice 
a week) warm baths-and avoid stimulants, unless specially indicated and 
prescribed. 
The administration of mercury, to affect the system rapidly, is best effected 
through the agency of the mercurial vapor bath. It is a mode of administra- 
tion not liable to affect the digestion, and it permits other remedies to be given 
by the mouth at the same time, if they be considered necessary. It is also 
mild, slow, and equable in its action-so that it is safer than many other 
plans. The mercurial vapor bath is to be managed in either of the following 
ways. The first method is best adapted for the practice of a large institution ; 
the method recommended by Mr. Lee is better suited for private practice: 
" The patient is seated on a chair, and covered with an oil-cloth lined with 
flannel, which is supported by a proper framework. Under the chair are 
placed a copper bath, containing water, and a metallic plate, on which is 
placed from one to three drachms of the bisulphuret of mercury, or the same 836 
SPECIAL PATHOLOGY - SYPHILIS. 
quantity of the gray oxide, or the binoxide of this metal. From five to thirty 
grains of the iodide of mercury may be employed, or a scruple of the iodide, 
with a drachm and a half of the bisulphuret. Under the bath and plate 
spirit-lamps are lighted. The patient is thus exposed to the influence of three 
agents,-heated air, steam, and the vapor of mercury. At the end of five to 
ten minutes perspiration commences, which becomes excessive in ten or fifteen 
minutes longer. The lamps are now to be extinguished ; and when the patient 
has become moderately cool, he is to be rubbed dry. He should then drink 
a cup of warm decoction of guaiacum or sarsaparilla, and repose for a short 
time" (Langston Parker). 
Mr. Henry Lee's mode of proceeding is more simple : " A special and con- 
venient apparatus is used (made by Savigny & Co.), which consists of a kind 
of tin case, containing a spirit-lamp. In the centre, over the flame, is a small 
tin plate, upon which from fifteen to thirty grains of calomel is placed, while 
around this is a sort of saucer, filled with boiling water. The lamp having 
been lighted, the apparatus is placed under a common cane-bottomed chair, 
upon which the patient sits. He is then enveloped, chair and all, in one or 
more double blankets, and so he remains well covered up, for about twenty 
minutes, when the water and mercury will be found to have disappeared." 
With regard to sarsaparilla as a remedy, Sigmund, Syme, and many other 
acute observers, have come to the conclusion, after long and careful trials of 
the best sarsaparilla, that it does not, per se, exercise the slightest perceptible 
influence on the course and termination of syphilitic diseases. It is usually 
given in combination with some mercurial preparation, as in the decoction of 
Zitmann, already mentioned at page 834. 
As to the original local sore of syphilis, it may be dressed simply with lint 
soaked in warm or cold water, and renewed every three or four hours. The 
indurated glands, if they are painful, may be fomented, and the horizontal 
posture maintained. Moderate exercise may be taken if all local irritation is 
subdued; and then slightly stimulating lotions may be used to the sore, such 
as sulphate of zinc, in the proportion of one or two grains to the ounce; or the 
liq. plumb, diacet. dil. of the Pharmacopoeia; or the black or yellow wash if the 
surface is indolent. 
Preventive Treatment.-From what has been written, it must appear clear 
that the only chance of preventing infection, alike on the part of the male 
and the female, is personal cleanliness after sexual intercourse. Much of the 
good that has resulted from inspection of females, to the females themselves, 
as in Paris, Brussels, and other places, has been, I believe mainly attributable 
to the greater attention to personal cleanliness which such inspections have 
brought about. At the same time the working of the Contagious Diseases 
Act of 1866, as carried out in this country, has been shown to have effected a 
marked diminution of venereal sores in the army (see page 801, ante) ; and 
no doubt also has been the means of curing and relieving many women. The 
most convincing results of prevention were also shown in the Ionian Islands 
and Malta, under the able administration of Sir Henry Storks, alike to the 
soldiers and to the women, in checking venereal disease. 
If a man will have sexual intercourse with a strange woman, let him wash 
the penis immediately after the act, taking care to cleanse thoroughly the 
folds of the prepuce, especially near the fraenum, and in the sulcus of the 
corona glandis. If a woman will have sexual intercourse with a strange man, 
let her use a syringe with hot water, to wash out the vaginal passage, taking 
care to cleanse thoroughly the folds of the mucous membrane at the orifice of 
the canal and of the labia pudenda. Medical inspections tend, undoubtedly, to 
greater personal cleanliness, and may be the means of detecting soft chancres, 
and so may prevent their being communicated ; but the infecting sore, the true HEREDITARY SYPHILIS. 
837 
syphilitic one, can rarely be detected in a female. The real preventive remedy 
is the most ancient, the most simple, and the most efficient,-wash, and be 
clean. 
[hereditary syphilis. 
(Dr. Clymer.) 
Paracelsus was the first who asserted that syphilis was transmissible from 
the parent to the child (1536): "Est morbus fcedus . . . magis hereditarius 
quam lepra;" and after him, it was admitted by most of the writers of the 16th 
century. Ambrose Pare says (De la grosse verole qui survient aux petits en- 
fans): "Souvent on voit sortir les petits enfans du sein de leur mere, ayant 
cette maladie, et tot apres avoir plusieurs pustules sur leur corps." Since then 
most syphiliographers have treated of hereditary syphilis, though Hunter 
always denied it, whilst he reported two cases which were undoubtedly of in- 
herited origin. It is, however, only within a short period that it has been 
understandingly studied, and its several expressions at different ages satisfac- 
torily made out, particularly the morbid changes which happen in the viscera. 
For the precision and extension of our knowledge on this subject, we are main- 
ly indebted to Trousseau and Lasegue, Cullerier, Gubler, Nat. Guillot, Desru- 
elles, Diday, Barensprung, Forster, Henri Roger, Hutchinson, and others. 
In all stages of constitutional syphilis the taint may be transmitted to the 
child. The degree of severity of the inherited taint is probably in proportion 
to the shortness of the period which has elapsed since the presence of active 
symptoms. A child may inherit syphilis in a serious form from but one 
parent-from its father alone, or from its mother alone. When both parents 
are the subject of syphilis, the child is more certain to suffer severely than 
when only one is so. There are as yet no sufficient data to form an opinion as to 
whether a child is more likely to be gravely affected when its father is the 
source of contamination, than when it derives the disease from its mother, or 
the reverse. In a large proportion of the cases met with in practice, the taint 
is derived from the father only (Hutchinson). Though infection of the 
offspring by the father is still contested by some authors, the numerous 
and positive cases collected by Von Barensprung, E. Vidal, and others, put 
beyond doubt that constitutional syphilis of the father is transmissible to the 
child; but when he is suffering from the sequelae of syphilis, the so-called 
tertiary stage, it rarely or never is. During the period of latency, often a 
protracted one, when there is no apparent manifestation of the disorder, he is 
capable of tainting his offspring. Von Barensprung reports fourteen cases 
where it happened, and Diday cites several observations in support of this view. 
Mr. Hutchinson gives several facts in his paper published in the London Hos- 
pital Reports, vol. ii, p. 184, and remarks (Reynolds's System of Medicine, vol. 
i, p. 299): "It is very common for a man who does not himself display a 
single symptom of any kind, and who appears to be in perfect health, to beget 
a syphilitic child, the symptoms displayed by the child being usually those of 
the secondary class. There is no doubt that the nearer the occurrence of the 
primary symptoms in the parent is to the birth of the offspring, the more 
certain is the latter to show symptoms of a severe character, and typically 
secondary in stage. Instances, however, are met in which infants, born ten 
years after the original disease in the parent, still display first a secondary 
rash, with the characteristic snuffles, &c. In several instances I have known 
a whole family of children, born during a period of from five to ten years, dis- 
play each one the characteristic and transitory rash soon after birth." If the 
father alone is affected at the time of procreation, it is clear that the spermatic 
fluid must be the vehicle of transmission; but when the mother alone is dis- 
eased, the mode of infection of the child becomes a question. Is it through 838 
SPECIAL PATHOLOGY HEREDITARY SYPHILIS. 
the blood, or by the ovum? Though it is contended by many that the sole 
agent is the blood, others believe the toxic matter to exist in the ovum, and to 
be subsequently developed along with it. Neither theory is supported by di- 
rect proof; analogy would favor the ovular theory, for, as Lancereaux remarks: 
" In view of the difficulty of the inoculation of the blood, and from the great 
likeness of the properties and the characters of the secretion of the testicles and 
that of the ovaries, there is more reason to believe in the influence of the ovum 
than of the blood. The hereditary transmission of syphilis we believe to be 
accomplished by a modified and vitiated germ; which germ is, in fact, but an 
anatomical element, a cell, which like all the cells of the tainted body, has 
undergone impregnation by the virus" (p. 657). 
Syphilis may affect the foetus at an early period, is a frequent cause of its 
death, and of the consequent miscarriage of the mother. According to Potton, 
abortion happens in one-tenth of the cases where the foetus is syphilis-tainted. 
Forster reports 3 deaths in 26 cases; and Whitehead found 117 miscarriages 
in 256 women suffering from syphilis. In these cases, appreciable lesions of 
the skin, viscera, and serous cavities exist in the foetus. Though the influence 
of the syphilitic poison may destroy the foetus, this, as Mr. Hutchinson re- 
marks, " unfortunately is far from being its constant effect. In the great 
majority of such conceptions, the tainted foetus is carried to its full period;" 
and sometimes comes into the world with evidences of the disorder, in the 
shape of coryza and skin disease; but this is exceptional, for, in most cases it 
is apparently in good health, and it is not until after an interval of days, 
weeks, and sometimes months, that the disease shows itself. Usually from 
a fortnight to two months, the characteristic snuffling and eruption happen 
in a tainted child. Taking 14 observations of Henri Roger, 158 of Diday, 28 
by Meric, and 49 by Mayer, a total of 249 cases, in which the appearance of 
the first symptoms was accurately noted, we find that they appeared during 
the first month in 118, or nearly one-half; and before the end of the third 
month, in 217, or seven-eighths; this limit being exceeded in only 32. They 
may, however, occur at any time before the end of the first year, though very 
rarely after the seventh month. There is, then, a stage of latency, extending 
to the period of the second dentition, puberty, or even later. 
The earliest and most striking symptom of inherited syphilis, is usually the 
coryza, which gives the popular name of "the snuffles" to the disease. It 
is probably due to erythema and mucous patches of the Schneiderian mem- 
brane, which is swollen, and, stopping the nostrils hinders breathing and suck- 
ing, and may become threatening to life. The nasal passages may be ob- 
structed, too, by crusts and plugs of half-dried secretions. The skin and lining 
membrane, at the entrance of the nostrils, are cracked and ulcerated. The 
mouth is hot, and its mucous membrane and the gums swollen. The skin is 
either simultaneously or very soon affected. The exanthems differ but little 
from those seen in the acquired form of the disorder, generally showing the 
same coppery tint, and crescentic outline. Mucous patches are very common 
about the lips, nostrils, external palpebral commissures, anus, and genital 
organs of both sexes; they are moist, often fissured, soon have a whitish hue, 
and, when situated at the mouth or anus, give a puckered look to these orifices 
(Trousseau). When their site is the mucous membrane, they will be found 
as whitish patches upon the fauces, uvula, tonsils, and more rarely, the tongue 
and buccal membrane. Deep-seated pustular eruptions may appear at a later 
period, ordinarily upon the face; occasionally upon the neck, ears, and fold of 
the groin. Ecthyma and pemphigus are occasionally seen in connection with 
hereditary syphilis, but whether directly due to the virus, or the result of the 
general cachexy, is doubtful. The viscera may be affected in the same way 
as in the inherited disorder. A syphilitic infant has commonly a wizened and 
shrunken countenance, with the skin of a dirty greenish-yellow hue; there is 
extreme anaemia; it is puny and often stunted, and presents the aspect of old 
age on the threshold of life. " The face," says Trousseau, " is of a peculiar bistre HEREDITARY SYPHILIS. 
839 
tint, as if it had been washed with coffee-grounds, or a weak infusion of soot; it is 
not the pallor; nor yet the icteric or strawy hue, of the other each exite; it hardly 
extends to the rest of the body. The eyelashes are not developed, or have 
fallen out; the eyelids are often everted, and at the external angle are fissured. 
In the place of the missing eyebrows, there are yellowish scaly stains, which 
are sometimes found about the chin and mouth" ( Clin. Med., &c., vol. iii, 1865). 
The child is generally fretful and cryful; sleeps but little; is troubled with 
vomiting and diarrhoea; and very liable to serous inflammations, as pleuritis 
and arachnitis, which are frequent causes of death. Erysipelas and pneumonia 
are common intercurrent disorders, and are generally fatal. The child some- 
times dies in a state of extreme marasmus. 
When the syphilitic symptoms are present to any extent at the time of 
birth, it is rare for the infant to live beyond a few months. 
In those cases of hereditary syphilis which survive the first year, all traces 
of the disease disappear about that time, except perhaps unusual paleness, 
and an expanded nasal bridge, caused by long-continued swelling of the parts 
within. During the period of latency there is usually excellent health, though 
Mr. Hutchinson asserts condylomata sometimes reappear; but there is scarcely 
ever a return of the cutaneous rash. The third epoch may begin at any time 
after the fifth year, but it is commonly delayed until at or near the period of 
puberty. It is characterized by the lesions known as the tertiary stage in the 
acquired disorder. The diagnosis of inherited syphilis, at or after the age of 
puberty, may sometimes be made with much certainty, or it may be surrounded 
with great difficulties. "Our most valuable aids," says Mr. Hutchinson, "are 
the evidences of past disease, more especially of the inflammations which may 
have occurred in infancy. A sunken bridge of nose, caused by the long-con- 
tinued swelling of the nasal mucous membrane when the bones were soft, a 
skin marked by little pits and linear scars, especially near the angles of the 
mouth, the relics of an ulcerating eruption, and a protuberant forehead, con- 
sequent upon infantile arachnitis, are amongst the points which go to make 
up what we recognize as an heredito-syphilitic physiognomy." In a certain 
number of cases a characteristic dwarfed, notched, dental malformation, will 
give valuable aid. It is only in the permanent set that any peculiarity is 
noticed; the milk teeth are liable to decay, but are not pegged, or notched. 
It is the upper central incisors which are the test-teeth. Even in grown-up 
persons, whose incisors are so much worn that the notch is obliterated, the 
tooth has still a diagnostic form, which Mr. Dixon likens to that of a screw- 
driver, being wide at the neck, and narrow at its cutting edge; its lateral 
edges are also bluntly rounded off. The complexion is usually pale, or of 
Fig. 85. 
leaden hue; and though the taint may dwarf the body, in most cases the 
general growth is not hindered. Mr. Hutchinson has met with several in- 
stances of an arrest of sexual development, and Lancereaux with one. A 
form of phagedenic lupus has been observed; and deafness and amaurosis 
from nerve or cerebral disease are both far more common in the inherited form 
of the disease than in that which is acquired, and are usually symmetrical. 
" As a rule all syphilitic symptoms in the inherited disease are symmetrical " 
(Hutchinson). Lagneau believes that epilepsy may be one of the results, 
and Critchett idiocy. All the visceral deposits, met with in the later stages 
of the acquired disorder, may be developed in the hereditary. Lancereaux 
has seen chronic pneumonia developed under its influence/ Nodes on the 840 
SPECIAL PATHOLOGY HEREDITARY SYPHILIS. 
long bones, hyperostosis and caries occasionally are present; and the bones 
of the nose and palate may be destroyed. 
Several affections of the eye are of great interest in the history of hereditary 
syphilis, and we owe much to the intelligent observations of Mr. Hutchinson 
for an accurate understanding of them. It was he who first showed, that cer- 
tain morbid appearances which would have been chosen as typical specimens 
of strumous ophthalmia, were really due, not to scrofula, but to inherited 
syphilis. He named the affection Chronic Interstitial Keratitis; but it is now 
called Syphilitic Keratitis. It never happens in acquired syphilis. The sub- 
jects of this form of corneal disease are generally from five to eighteen years 
of age. The phenomena of syphilitic keratitis in the acute stage are peculiar, 
and easily recognized. Both eyes are usually affected about the same time; 
though several weeks may elapse. A diffused haziness, like that of ground 
glass, is first noticed in the centre of the cornea; white dots appear in the 
midst of the haze in the substance of the tissue, and, generally, soon run to- 
gether. For awhile, the vascularity of the conjunctiva and sclerotica is but 
little increased, but as the corneal opacity becomes marked, these tissues be- 
come reddened, and a fine plexus of vessels spreads on to the cornea itself, 
gradually occupying the opaque portion, and giving to the ground glass tint 
a red salmon hue; and its site is commonly the upper and central part of the 
disk, in preference to the lower part. A zone of ciliary congestion is usually 
well marked. There is no tendency to ulceration. The intolerance of light 
is great, and the patient is often for several months, when the disorder is at 
its height, practically blind. The vascularity of the cornea is wholly unlike 
that which attends granular lids, and other chronic forms of keratitis. In the 
latter the vessels are large and superficial, whilst in syphilitic keratitis they 
penetrate the cornea so deeply, and are so fine, and so closely set together, 
that it gives the look of tissue infiltrated with blood (Dixon). After the 
inflammation has passed away the cornea most often clears in a remarkable 
manner, but rarely regains such perfect transparency that the traces are not 
left, which may be detected by the experienced observer. These traces con- 
sist in a somewhat dusky aud thin sclerotic in the ciliary region, and in the 
presence of slight clouds here and there in the corneal substance, there being 
no scars in its surface. The difference between these clouds and ordinary leu- 
comata is easily recognized (Hutchinson). Mr. Hutchinson has rarely seen 
the subjects of this affection with enlarged cervical glands, or showing other 
evidences of scrofula, while in thirty-one out of sixty-four cases he has recorded, 
he got a clear history of the occurrence of syphilitic symptoms during infancy. 
Most frequently it is an eldest child which suffers; and females seem to be 
more liable to it than males. 
While Law'rence {Lectures on Surgery, 1863) speaks of iritis as a common 
symptom in infantile syphilis, Holmes {System of Surgery, vol. iv, p. 831,1864) 
says it never occurs, and Diday does not mention it as one of the affections of 
inherited syphilis. It is no doubt of rare occurrence, but it does happen, and 
the careful researches of Mr. Hutchinson have shown that it is not quite so 
rare as has been supposed. Dixon in ten years saw but five or six cases out 
of many thousand patients treated by him in the Moorfields Ophthalmic Hos- 
pital. Mr. Hutchinson thinks it often escapes notice, from the absence of the 
sclerotic zone, the small amount of local symptoms it causes, coupled with the 
fact that infants usually keep their eyes shut. In twenty-three cases collected 
by him, the mean age of the infant was nine months and a half; the oldest 
was sixteen months, and the youngest six weeks ; five were males, and sixteen 
females, and in two the sex is not given. In eleven cases both eyes were 
affected. The red sclerotic zone, unfailing in adult iritis, is either wanting or 
scarcely traceable in the syphilitic form in the infant. The lymph is some- 
times scattered over the iris in small isolated granules, but more frequently 
flows down to the bottom of the anterior chamber, either presenting the appear- DEFINITION AND PATHOLOGY OF CANCER. 
841 
ance known as hypopyon, or massed together in a more solid nodular form. 
The iris becomes dusky, the pupil irregular, and sometimes clouded by the 
turbidity of the aqueous humor. 
The choroid is occasionally implicated in hereditary syphilis at about the 
same period of life as the cornea. The ophthalmoscope shows in'such cases 
the presence of whitish spots on its surface, slightly raised, and covered by the 
retinal vessels; or the appearance of cicatrices, apparently due to the absorp- 
tion of these deposits. The retina is congested, and obscured by inflammation 
of the membrane of the vitreous body. In the first stage, that of exudation, 
there is lessened vision ; in the second the sight improves, the spots becoming 
defined ; the third is that of absorption. In 14 cases reported by Hutchinson, 
in 10 there was choroiditis (?), in 2 retinal deposits, in 1 inflammatory opacity 
in the vitreous body, and in 5 opacities in the crystalline lens. In 6 out of 
10, the children were the eldest born living.] 
CANCER-Syn., MALIGNANT DISEASE. 
Latin Eq., Carcinoma-Idem valet, Morbus malignus; French Eq , Cancer; Ger- 
man Eq., Krebs-Syn., Cancer; Italian Eq., Cancro. 
Definition.-A deposit or growth that tends to spread indefinitely into the sur- 
rounding structures and in the course of the lymphatics of the part affected, and 
to reproduce itself in remote parts of the body. 
Pathology.-The morbid condition of the body, the ill-health, or cachexia, 
which is associated with cancers, cannot be referred to the blood alone. In- 
deed, we have no direct proofs that the blood is peculiarly affected. We can- 
not find in it anything distinctive or peculiar to the cancerous diathesis, either 
by microscopic or chemical investigation. But while none can doubt the ex- 
istence of a cancerous cachexia, ,we have no positive knowledge concerning 
the state of the blood in cancerous states of the body. It is rather inferred, 
from various considerations, that a peculiar material is separated from the 
blood, and is constantly being renewed in the formation of cancers. There 
are no germs in the blood previous to the development of a cancer-tumor 
which can be recognized as a cancer-structure. It is evident, however, that a 
specific state of the system exists in the cachexia associated with cancer,-(1.) 
Because all parts of the body are liable to be infiltrated with the peculiar 
and specific growths which constitute the "cancers or malignant tumors," and 
that without any direct communication with the place where the first growth 
took place; (2.) Because the removal of the locally diseased part does not 
arrest the progress of the constitutional disease; (3.) Because the cancer- 
growths tend naturally towards destruction of life, not necessarily from their 
local position, but through a peculiar marasmus which their existence estab- 
lishes, and which some think due to the demands which these new growths 
make upon the system for increase and nutrition. They tend also to destruc- 
tion of tissue around them, and to suppuration. A continual hectic febrile 
state is established, and increasing emaciation follows the intense bodily suf- 
fering and mental anxiety they induce. The countenance becomes pale and 
anxious, with a slight leaden hue, the features become pinched, and the lips 
and nostrils slightly livid. The pulse is frequent and the pains are severe. 
At length there is generally nausea and weakness of digestion, and a tickling 
cough frequently supervenes. Severe stitches strike through the local morbid 
parts, the pulse becomes rapid and faltering, the surface cadaverous, the 
breathing anxious, and death alone brings relief. 
" Cancerous disease," says Mr. Paget, "or a tendency to it, is prone to pass 
by inheritance from parent to offspring, and to occur (probably by inheritance 
of common properties) in many members of the same family and generation; " 842 
SPECIAL PATHOLOGY-CANCER. 
but whilb there appears to be a tendency to the hereditary transmission both 
of cancerous and uon-cancerous growths, there is a much greater probability 
of the hereditary transmission of cancerous than of non-cancerous growths, and 
that in the proportional probability of 22.4 for the cancerous and 8.2 for the 
non-cancerous {Med. Tinies and Gazette, Aug. 22, 1857). 
The general disease is thus inherited by birth, or otherwise inbred. Its pres- 
ence and complete development are indicated by the occurrence of peculiar 
growths in different parts of the body, to which the names of cancers or ma- 
lignant growths have been applied. The malignant character of cancers is 
indicated by one or more of the following conditions : Constant progress of the 
growths, their continuing to return after extirpation, not only in the original 
seat, but in the distant and internal parts of the body; destroying and caus- 
ing absorption of the invaded textures; infiltrating the tissues to an indefinite 
extent; and tending to suppurate, and to affect the glands to which the lym- 
phatics lead from the-seat of local lesion. The increase and nutrition of these 
growths produce a peculiar marasmus, which tends to terminate in death. 
The anatomical constitution of the new growths is heterologous. 
There is abundant circumstantial evidence to show that malignant tumors 
are of constitutional origin-that they are local manifestations of a constitu- 
tional disease-that there is something specific, probably elaborated from the 
blood, which accumulates in their elements of structure. This specific mate- 
rial which composes cancers is different from all the natural constituents of the 
body ; is different from all the materials formed in other processes of disease; 
and is associated in the malignant tumor with structural elements which 
must be regarded as specific and peculiar, both in form and in mode of life. 
The main grounds for this belief are-(1.) The evidences, not always abso- 
lutely demonstrable, of a pre-existing unhealthy state of the constitution; (2.) 
The prolonged duration of the constitutional state which precedes the local 
expression of the cancerous tumors-the long-continued elaboration, often ex- 
tending through several generations-thus showing sometimes a tendency to 
alternation in the inheritance of the inborn state of ill-health ; (3.) The sec- 
ondary pyrexia, which is the result of irritation or of elimination of a morbid 
material, the reabsorption of which may tend secondarily to affect the blood. 
[Whether the cancerous cachexy is primary or secondary; whether, under 
any circumstances, a true blood-cause exists, and what is the state of the blood 
in the cancerous constitution, are questions which at this day, with all the 
lights of modern pathology, and the investigations of Bennett, Lebert, Han- 
nover, Paget, Rokitansky, Virchow, and others, are as much involved in 
obscurity as they were a century ago. Virchow, in his recent work on 
Tumors {Die Krankhaften Geschwulste, 1863-67), inclines to the opinion that 
the dyscrasia or diathesis theory is pure hypothesis, and will disappear in a 
more advanced state of knowledge of the subject; and that, in the vast 
majority of cases, the change in the blood is to be regarded as a secondary 
phenomenon, due to the absorption of matter from an existing primary focus, 
the malignant growth being due to a local irritant. Mr. C. R. Moore, of the 
Middlesex Hospital, London, in a recent memoir on "The Antecedents of 
Cancer," after stating the grounds on which cancer is held to be originally of 
constitutional nature, viz., a. Its final universal effusion throughout the body; 
b. Its occasional commencement in many primary tumors simultaneously; c. 
Its capacity to grow in various textures; d. Its local recurrence after an ope- 
ration on the primary tumor; e. Its appearance in internal organs, notwith- 
standing the extirpation of the primary tumor; f. Its repetition in families; 
g. Its relation to tubercle-is of opinion that it arises as a local disorder, 
independently of a constitutional cause, assigning as evidences: 1. Its invaria- 
ble origin as a single tumor; 2. The manifest dependence of the later tumors 
upon the first. (This view is supported by the observed similarity of the 
morbid substance, in whatever organ or texture it may grow; by the order PATHOLOGY OF CANCER. 
843 
regulating its dissemination; by the interruption of the progress and disper- 
sion of the disease, if the primary tumor be removed; and by the possibility 
of extirpating that tumor by an early and adequately extensive operation.) 
3. Because of the remarkable manner it is inherited as a local, and not as a 
constitutional, peculiarity-a disease of a corresponding organ of the plural 
members of one family; whilst at the same time any inheritance of the dis- 
ease is uncommon, and that by infants extremely rare; 4. And because of its 
preference of the healthiest persons. He writes: "The general conclusion to 
which I am led by the foregoing considerations is, that cancer has no depend- 
ence on any malady anterior to the appearance of the first tumor, but that 
it originates in persons otherwise healthy and strong. If this conclusion is 
inconsistent with prevailing opinions as to the cause and nature of the dis- 
ease, the collision of the facts proves the need for more satisfactory evidence 
on behalf of these opinions than is at present in our possession. The existence 
of an antecedent general malady is, as far as I can perceive, pure conjecture, 
being entirely destitute of proof, or even of reasonable support. The idea 
sprang up in error; and it has been perpetuated mainly by the erroneous 
conclusions drawn from repeated want of success in surgical operations." 
Virchow {loc. cit.} shows that those organs which have a soft surface, and are 
most often in contact with irritant foreign substances, are more liable to be 
primarily the seat of cancer, than those organs which are inclosed and have 
no communication with external objects. He quotes, in support of this opin- 
ion, from large statistics, collected by Tanchou, Marc d'Espine, and himself, 
to show that 80, 87, and 78 per cent, (according to these observers) of all 
cases of cancer occur in the alimentary canal, the uterus, and the breast, the 
large preponderance being of those in the alimentary canal. Virchow re- 
marks, and with justness, that "the more marked a really demonstrable con- 
tamination of the blood with certain matters is, the more manifest is the 
relatively acute course of the process I shall have to examine this 
question more closely when I come to consider the theory of the propagation 
of malignant tumors, in the case of which recourse'is so often had to the sup- 
position that the malignancy has its root in the blood which gives rise to the 
local affections. And yet it is precisely in the course of these processes that 
it is comparatively most easy to show the mode of propagation, both in the 
immediate neighborhood of the diseased part and in remote organs; and it is 
in them we find that there is one circumstance which especially favors the 
extension of such processes, namely, the abundance of parenchymatous juices 
in the pathological formation" {Cellular Pathology, Am. ed., p. 250-1). Nor 
should be forgotten, among the arguments for the local origin of malignant 
tumors, the fact of the rapid and great improvement of the general health 
after the extirpation of a cancerous growth, and which again begins to fail on 
its recurrence (from some of the germ-matter having been left behind), with, 
sometimes, a repetition of the same phenomena, after a second operation; to 
account for which, Mr. Paget is obliged to bring forward what he styles "the 
secondary cancerous cachexia." This great pathologist is a decided partisan 
of the hypothesis that cancer is the local manifestation of a disease which 
already, in its specific material, exists in the blood. "The existence of the 
morbid material in the blood, whether in the rudimental or effective state, 
constitutes the general predisposition to cancer. . . . The morbid material is 
the essential constituent of the 'cancerous diathesis or constitution;' and 
when its existence produces some manifest impairment of the general health, 
independently of the cancerous growth, it makes the primary cancerous 
cachexia" {Leet, on Surg. Pathology, 3d Am. ed., p. 669); and yet, as a prac- 
tical surgeon, he admits, in his description of the disease, that the cancerous 
cachexia "may at first have been absent" (p. 553). Most unsatisfactory, if 
not unphilosophical, too, is his conclusion that "the reconciliation, not only 
of the two conflicting opinions, but of the seemingly conflicting facts upon 844 
SPECIAL PATHOLOGY-CANCER. 
which they chiefly rest, is to be found in this, that the complete manifestation 
of cancer, the formation of a cancerous growth, is suspended till such a time 
as finds both the constitutional and the local conditions coexistent-till the 
blood and the part are at once appropriate" (p. 669); words ■without practi- 
cal meaning.] 
It has not been proved that the inoculation of cancerous matter is followed 
by even the growth of cancers, far less by the development of cancerous ca- 
chexia ; and there is every reason to believe that this loathsome disease cannot 
be communicated by the secretions from a cancerous ulcer. Alibert has made 
dogs swallow the ichorous serosity collected from such a source, but the health 
of those animals was not impaired. Duputryen has likewise introduced por- 
tions of cancerous parts into the stomachs of many animals-has injected the 
pus into their veins, and into their different serous cavities, but without pro- 
ducing results different from what any other irritating matter would have 
caused. Women, also, having the neck of the uterus destroyed by carcinoma, 
have conceived and borne children, and yet neither the husband nor child have 
appeared to suffer in consequence. Alibert and others have likewise inocula- 
ted themselves with cancerous matter, and yet no contagious effect has followed. 
Neither has this disease at any time been known to result from accidents in- 
cident to the examination either of the living or the dead person so affected. 
The more recent experiments of Harley and Lawrence upon dogs have simi- 
larly failed to inoculate cancer. There are several cases known, however, in 
which inoculation of cancers having failed at the time, yet, nevertheless, the 
subjects of inoculation have died of cancer at an advanced period of life; but 
the value of the observation does not as yet extend beyond a mere coincidence. 
Women appear to be more liable to this disease than men, and the increase 
is chiefly due to cancers of the breast and uterus; while in man it is chiefly 
the skin, the bones, and the digestive organs which suffer. 
The mortality from the disease goes on steadily increasing with each suc- 
cessive decade until the eightieth year (Walshe). 
Age has also much influence in determining the forms of cancer and the 
part affected. Hard cancers are rarely observed till after forty, and from 
that period the liability increases with age. Its most usual seats are also those 
on which age and functional activity have left their marks upon the organs. 
Thus it seldom occurs in the mamnue, uterus, or in the ovaries, till after the 
cessation of menstruation, nor in the organs of generation of the male till 
towards old age, nor in the different portions of the alimentary canal till after 
forty. 
Soft cancers are most common in the earlier periods of life; but then also 
they are observed to involve textures whose functional activity has been ever 
active, such as the glandular parts-for example, the lymphatic and lachry- 
mal glands. 
The cancerous cachexia seems to be particularly influenced by physical cli- 
mate, mental distress, and anxiety; and according to Dr. Walshe the maxi- 
mum amount of cancerous disease is found to occur in Europe, and is rare 
amongst the hospitals of Hobart Town and Calcutta, and the natives of Egypt, 
Algiers, Senegal, Arabia, and the tropical parts of America. 
We know very little, however, as to the conditions which give rise to can- 
cers. In the words of Mr. Paget,-" The richest and the poorest alike seem 
to be subject to it; so do the worst and the best fed; those that are living in 
the best conditions of atmosphere and those that are immured in the worst; 
those that are cleanly and those that are foul; those of all temperaments and 
of all occupations; those that appear healthy and those that are diseased. We 
can hardly lay our hand upon any one of the various circumstances of life, 
in the various orders of society in this country, to which we can refer as ren- 
dering one more or less liable than another to the acquirement of the cancer- 
ous constitution." PATHOLOGY OF CANCER. 
845 
The history of the development of cancers makes up some of the dark pages 
of Pathology; and in many respects the origin of such tumors is confessedly 
mysterious. Their first beginnings are generally hidden, being deeply buried 
in the tissues, so that when a swelling manifests the possible existence of a 
tumor, it is regarded with doubt in the first instance, and then by astonish- 
ment as well as dismay at the rapidity of its growth. In such doubt, aston- 
ishment, and dismay, we must recognize and acknowledge our ignorance. 
The normal course of cancerous tumors we now know to be that of steady 
increase-a steady and certain progress towards death. No radical cure for 
cancer is yet known. The hand of death is most unmistakably stamped upon 
those who are the subjects of cancerous growths; and we seek, in all humility, 
to learn something from an examination of the history of such a disease. But, 
to learn anything from pathological growths, they require to be studied and 
examined in stages, from time to time, in the course of their development. 
There are certain stages in pathological as in physiological growths, at which 
periods alone the actual mode of origin and development can be traced. A 
large cancerous mass does not look very promising; and we might as well ex- 
pect to be able to discover, by an examination of the mature fcetus, the differ- 
ent steps by which its organs and parts had been formed, as hope to be able 
to determine in what way a tumor which at first was scarcely visible had been 
converted into a mass of obviously malignant growth. Thanks to Walshe, 
Bennett, Paget, Wedl, Rokitansky, Virchow, and others, we are able to ex- 
plain many of the phenomena of growth of such tumors, while there is much 
that is still dark and mysterious in their history. 
It is during the time of active increase that tumors ought to be studied, 
having regard to their origin, development, growth, and maintenance as inde- 
pendent parts. 
The idea that local cancers were due to entozoa, originally advanced by 
Adams and older writers, has never met with any proof, although it is yet en- 
tertained as probable by some; and there are many facts in the history of 
malignant tumors which indicate that their existence is attended with conse- 
quences very analogous to those of the existence of parasites. For-(1.) Every 
new formation which contributes to the body no serviceable structure must be 
regarded as a parasitical element in that body, alike foreign and injurious to 
it. (2.) The elements of malignant growths withdraw nutrition from the body, 
and in some instances elaborate specific secretions, to be stored up in their own 
structures. (3.) The malignant growth, whatever it may be, in the body or 
constitution, is the result of long-continued elaboration, and passes through 
a life of continual change before it attains its highest degree of malignant in- 
fluence on the constitution. The alternate generation of the malignant growths 
are also exemplified in the frequent hereditary transmission of the cancerous 
'constitution. (4.) In active growth and partially independent existence we 
have another remarkable analogy to parasites. Malignant tumors grow and 
thrive while the normal tissues far and near them are only able to maintain 
existence. 
The local exudations which constitute the tumors or cancers consist in general 
of two parts, namely,-(1.) The material peculiar to cancer, consisting of very 
varied forms of nuclei, nucleated cells, and juice, all of peculiar natures, dis- 
tributed through an intercellular medium; (2.) Areolar tissue, which consti- 
tutes the stroma or skeleton part of the new growth. The first part is the 
essential and heterologous part of cancer. The relative quantity of these 
crude materials gives the most marked and obvious ground-that of consist- 
ence-on which cancers have been classified-namely, into hard and soft can- 
cers ; but the grounds of classification are by no means fixed. The nature 
of the substance affords a ground of classification. When the fibrous stroma 
is predominant, the new growth is hard, and has received the name of scirrhus. 846 
SPECIAL PATHOLOGY-CANCER. 
When the cellular elements predominate, the new growths are soft, and have 
received the name of encephaloid or medullary tumors. Sometimes the sup- 
posed nature of the substance is a ground for classification,-e. g., meliceris, 
atheromata, steatomata. Many names given to cancers are only stop-gaps, 
tending to retard inquiry,-e. g., colloid, alveolar, and the like. 
The true nature, rather than form, ought to be the ground of classification. 
Cancers again, are subdivided into a considerable number of varieties. For 
instance, the stroma takes various forms, like net or trellis-work, with large in- 
terspaces, or it grows papillary or villous in ramifications or vegetations. Some- 
times it undergoes ossification, and then the skeleton of the cancer is formed 
of a network of true bony texture. This stroma part of the cancer is to 
be distinguished from the common binding tissue of the organ or texture into 
which the new growth is infiltrated. It is really and truly a part of the 
cancer-exudations, and forms their basis. In the soft cancers it is more defi- 
cient, and then the cellular element predominates; and in the cells, rather 
than in the stroma, has the more distinctive elements of cancer-exudation 
been said to exist. The questions are, indeed, often asked, What are the 
characters of the true cancer-cell ? Has the microscope discovered any struc- 
ture which is decisive per se of cancer growths wherever found? It may be 
said that it is significant of cancers that the forms of the elements of the 
tumors are after the pattern of those elements whose office is to separate 
whatever is refuse or abnormal from the blood-i. e., the glands. Cancer- 
cells are formed on the types of the excretory gland-cells; and although they 
have no special anatomical characters, it is highly probable that malignant 
tumors eliminate something specific-something peculiar to each of them- 
which may yet be discovered. Much importance has therefore been assigned, 
and with justice, to the character of the cell-elements, as affording a specific 
distinction between malignant and benign forms of growth. Viewed, how- 
ever, with reference to single isolated cells, it is now agreed that they offer 
in themselves nothing anatomically characteristic. It is the grouping of 
cells and their varied forms which characterize cancers; and therefore I will 
select the best representations of the different cancers and combine them in 
woodcuts, from Paget, Wedl, and Rokitansky. 
The practical questions to solve when a growth is first apparent are-(1.) 
Is it a mere hypertrophy-a growth from a spot, of the same nature as the 
structure of the spot, or is it different? (2.) Will it produce a fluid, or 
germinate elements which will spread and contaminate neighboring parts ? 
In other words-Is it simple and innocent? or, Is it complex and malignant? 
To judge of these things it is necessary to remember that all tumors are com- 
posed of a conglomerate mass, made up of numerous little lobules. The first 
development takes place at a definite point or points. Round the original 
rudiments of the tumor (that is to be), and which are produced by the prolif- 
eration of a limited group of cells, little new foci are formed, which, increas- 
ing in size, group themselves around the first, and thus gradually give rise to 
a continuously progressing enlargement of the original tuber. At the periph- 
eral portions of tumors, therefore, the most recently formed portions of the 
new growth are to be found; while in the centre of these tumors the elements 
are disintegrating. Thus the last zone of new growth may extend a con- 
siderable distance beyond any line of degeneration or alteration of struc- 
ture visible to the naked eye; and hence in some tumors there may exist 
sources of local recurrence after extirpation. The more free the anastomosis 
and the greater the facilities for the passage of juices, the more readily do the 
surrounding parts become diseased. Cartilage is slow to become cancerous 
by contiguity, so also are white and elastic fibrous tissues. Hence joints are 
often unaffected in the midst of cancerous tumors. The more readily the 
morbid juices are transferred from the original seat of disease, the anastomos- characters of the cancer-cell. 
847 
ing elements will be found more numerous. Thus nerves are often the best 
conductors for the spread of cancers, not because they are nerves, but because 
they are parts with soft interstitial tissue. Diffusion also takes place readily 
by means of vessels. 
While simple tumors are overgrowths, in addition to being outgrowths ox' 
new growths, they imply a continuous reproduction of one or of several tissues 
taking place to an excessive extent in any limited territory, ultimately giving 
rise to a tumor by coalescence and growth. But to cancers or malignant 
tumors there is something more specific superadded. Their intimate structure 
is not like that of any fully developed natural parts of the body, nor like that 
found in a natural process of repair or of degeneration. 
Malignant tumors are indicated by the following characters: 
1. Elements of structure and mode of growth of malignant tumors. (1.) 
Continuous development of simple cells, largely supplied with very fine blood- 
vessels, so that the tumor is very succulent. (2.) The growth is mainly a 
growth of cell-elements, to the exclusion of connective or fibrous tissue. (3.) 
In the first instance the cell-elements resemble the cells which compose the 
blastodermic membrane of embryos. (4.) If a new growth is composed 
mainly of cells, each containing growing matter within it, in the form of 
another cell, or cells, or granules, it must be regarded as of malignant ten- 
dency if it is supplied with bloodvessels. (5.) Generally a constant or con- 
tinuous repetition of the same structural element is evidence of malignancy. 
(6.) A tumor consisting entirely of nuclei or of minute cells abundantly sup- 
plied with fine ramifying bloodvessels is perhaps the most malignant type of 
all. 
2. The grouping of the elements which distinguishes cancer. (1.) The elements 
are heaped together disorderly, with seldom any lobular oi' laminar arrange- 
ment. (2.) Multiplicity of elementary forms are sometimes seen in the mass, 
due to (a) development, or overgrowth, nodulatiou being an important fea- 
ture in such tumors. (6.) Degeneration, calcareous, yellow, oi' fatty, (c.) 
Proliferation of cells. 
3. Infiltration by juice through parts abounding in anastomosing tissue. Nerve- 
sheaths and sheaths generally are proven to give facilities for the extension 
of cancers-an important point for the surgeon to recognize. 
4. A peculiar tendency to ulcerate, preceded by softening, with no disposition 
to heal, but a constant tendency to spread. 
A peculiar softness of texture precedes ulceration, which simulates the slow 
fluctuation of a thick pulp, and appears to be more liquid in some places than 
in others. The softening is a continuous process of secretion of fluid in many 
respects peculiar, and is a physiological property of their structure. 
5. Malignant tumors constantly grow and progress to a fatal end, and at the 
same time tend to multiply or propagate themselves. 
6. There is scarcely a tissue they will not invade. 
It is in the comparative appearance of the multitude of cells, and especially 
in their relative size, that most distinguishing features may be observed. 
While the cellular cancer-mass often shows merely small pus-like or large 
lymph-like cells of an oval form with many nuclei, yet when all kinds of cancer 
are compared, "typical canter cell-elements" in quantity may be described by 
the following general characters: 
While the external cell-wall presents the greatest multiformity of shape, the 
dimensions of the cell are comparatively fixed to a mean of about j-j^th to 
ToWth °f an inch in diameter. Its nuclei, however, are more constant in ap- 
pearance and more characteristic than the cells (Lebert, Bennet, Paget, 
Lawrence). They are always voluminous in themselves, as well as in rela- 
tion to the area of the cell in which they are inclosed; of a more regular form, 
being generally oval, or nearly rounded, cleax* and well defined, with a distinct 848 
SPECIAL PATHOLOGY-CANCER. 
single nucleus, and rarely two. Their average mean long diameter is from 
^'ooth to 200th °f an inch. 
While Lebert attached too exclusive an importance to "a specific cancer- 
cell," he fully admitted the possibility that the most active and baneful cancers 
may vegetate through the system without exhibiting any of the cells now de- 
scribed, corroborating in this respect the general statement previously made by 
Dr. Walshe, "that a tumor may present to the naked eye the characters of 
encephaloid, and be the seat of interstitial hemorrhage, affecting the commu- 
nicating lymphatic glands, run in all respects the course of cancer, and never- 
theless contain no cells but such as are undistinguishable from common exu- 
dation-cells." Muller, Bennet, Paget, and Lawrence have also since stated 
the impossibility of distinguishing the cell-element of cancer, as now described, 
in all cases, from the cells in certain other abnormal and even normal tissues, 
so that no single element can be considered as characteristic of cancer. 
The general microscopic characters of cancer-tumors, so far as they can be 
determined, may thus be summed up as follows: 
I. The Structure which characterizes Cancerous Growths: 
1. Nucleated cells-free and not imbedded in any formed interstitial sub- 
stance. 
2. The arrangement of the elements of structure in no defined order-dis- 
order and confusion of elements being the rule. * 
II. Microscopic Distinctions of Cancer-Elements: 
1. Cells of the following characters either compose the tumors alone or are 
associated with other elements: 
(a.) Cells in which the nucleus is very distinct and very large in proportion 
to the cell. 
In size the cells range from ygVoth to Tg^th of an inch in diameter, with a 
mean of about y^gth of an inch; the cells of the smaller dimensions being 
usually found in cancers of the quickest growth. 
In structure the cell-wall is peculiarly thin and delicate, so as to give the 
appearance of cell-shaped masses of a soft but tenacious substance inclosing 
nuclei. 
The nuclei are constant as to size and presence. They are large, regularly 
oval, or nearly round, clear, and well defined. Are not easily altered by de- 
composition or any usual reagent. In size about sooth of an inch. Two 
nuclei are frequent-more than two are rare. 
Inform the cells are very various-the outline being linear, angular, or ex- 
tended in processes. 
There is thus great diversity in the elements which compose cancers. The 
diversity exists alike in the corpuscles, the basis-substance, or inter-cell material. 
The cells are often loosely held together in an abundant, soft, almost liquid 
substance, as in medullary cancers. 
(6.) Free round or oval nuclei alone sometimes compose a medullary cancer. 
They are bright, clear, perfectly defined, largely and often doubly nucleolated. 
(c.) Nuclei mixed with elongated, narrow, strip-like, caudate, or pyriform 
cells. 
(d.) Elongated caudate cells. 
(e.) Moniliform growths, or jointed and branching cells. 
The basis-substances proper to cancers are: 
(a.) Liquid alone; amongst which the cells are suspended, and either infil- 
trated amongst the tissue or contained in small cavities (e. g., in cancers of EXTENSION OF CANCER-GROWTHS. 
849 
rapid growth). This is " cancer-juice," and may be thick, creamy, yellow, or 
pink, or of a glairy consistence like synovia or oil. 
(6.) A framework of granular tissue, extremely delicate, sometimes hyaline, 
and containing oblong nuclei. 
It is important to notice, however, that the " modes of life," development, and 
growth, rather than structure, should determine whether a tumor is malignant 
or not. There are cancers not formed of such structures as those mentioned, 
namely,- 
(1.) Some fibrous tumors, the clinical history of which is undoubtedly can- 
cerous; also (2) some osteoid tumors. 
The multiplicity of structures composing a tumor is often due to the min- 
gling of cells in various stages of growth, development, or degeneration; or it 
may be due to disorderly overgrowth and proliferation of cells. When the 
diversity is due to development, overgrowth, or proliferation, nuclei, brood-cells, 
and caudate cells are characteristic; when due to degeneration, granule-masses 
predominate, or withered corpuscles, with fatty and calcareous masses in yellow 
parts. 
What is supposed to be the blastema or mother-fluid amongst which the 
cells and stroma of cancers grow, consists of an albuminous synovial-like, color- 
less, or pale yellowish fluid. It gives rise to the materials which compose the 
cancer-juice, and to the essential cancer-mass now described-namely, the 
stroma and the cellular elements. The development of cancer, therefore, pro- 
ceeds pari passu with this fluid as amongst the interstices of textures or on the 
free surfaces of the membranes; and lastly, even by endosmosis of the specific 
fluid into the natural cells of parts (such as into cartilage or bone-cartilage 
cells), the characteristic cancer-mass may commence to grow by endogenous 
growth within such cells, hitherto healthy. Dr. Bennett, of Edinburgh, and 
Dr. Van der Kolk, of Utrecht, have made most interesting observations on 
the extension of cancers by means of the parenchymatous fluid; and from all 
that has been observed on this subject, the latter author draws the following 
conclusions: 
"1. Through an interchange of material, taking place between cancer-cells 
and intercellular fluid, the latter acquires the property of forming new nuclei 
and cells of a similar nature. 
"2. This intercellular fluid passes, along with the parenchymatous fluid 
pervading the sound parts, into the textures adjoining the tumor. The paren- 
chymatous fluid thus acquires the same constituents and tendency to form 
similar cells, which now become developed among the healthy surrounding 
tissue, in the course of the areolar membrane. 
" 3. On account of the minuteness and small number of the last-mentioned 
cells, their presence cannot be detected with the naked eye; so that the sur- 
rounding parts may appear to be perfectly sound, notwithstanding that they 
contain the germs of the advancing formation of cancer. 
"4. It is, therefore, of importance, in removing cancer by operation, not 
only to take away at the same time a large quantity of the adjacent sound 
parts, but also to examine the innermost sectional edges under the microscope, 
in order to ascertain whether any trace of cancer-cells in process of formation 
is to be discovered in them. 
" 5. The existence of burning or shooting pains in carcinoma may be taken 
as a proof that the cancer-cells have reached the neighboring nerves, and the 
disease can then scarcely be looked upon as a local one, in which an operation 
might be permanently successful. 
"6. By the absorption of the infected parenchymatous fluid through the 
lymphatics and veins, the whole body seems to become more or less tainted, 850 
SPECIAL PATHOLOGY CANCER. 
so that secondary cancer ensues in distant situations, when, as is self-evident, 
operation can no longer be thought of. 
"7. This altered parenchymatous fluid penetrates the organic tissues which 
are washed by it, the sarcolemma of the muscular fibres, the tubes of the 
nerves, and the like. These membranes, too (both the sarcolemma and the 
walls of the nervous tubes), appear to take up the altered nutritive fluid; the 
consequence of which is, that both within the sarcolemma and the nervous 
tubes similar nuclei and cells arise, accompanied with an absorption of the 
muscular fibre and of the contents of the nerve, and attended with the deposi- 
tion of fat, by which these parts waste and are destroyed, while the surround- 
ing membranes (sarcolemma and walls of the nervous tubes) remain" (Brit, 
and For. Med.-Chir. Review, April, 1855). 
The cancer-juice is a most important element of the new growth. To the 
naked eye it appears as a viscid, whitish, creamy, yellowish fluid, which may 
be squeezed or scraped in considerable abundance from the surface of a sec- 
tion. 
It is from the performance of the vital functions by all these elements that 
we are to draw our conclusions regarding the innocency or malignancy of the 
new growths in which they form a part, rather than from their anatomical 
forms. If we find adjacent textures are being infiltrated, poisoning the lym- 
phatic current which passes from them, inducing new growths of a like nature 
in the lymphatic glands through which these currents pass, affecting the gen- 
eral system with a peculiar cachexia, marked by languor, debility, emaciation, 
and a peculiar sallow, leaden-like color of the skin ; and if after removal such 
growths return, then there is no doubt that the cachexia of cancer is made 
manifest by such local lesions. These present so many elements in common, 
that all these new growths are but manifestations of one disease, which has 
been named "cancer," and attributable to the constitutional cachexia already 
described. The varieties of this disease also run into one another by charac- 
ters which are so insensible that definite lines cannot be drawn between them, 
and thus many species of cancers are described under various synonyms, as 
shown in the following nomenclature: 
I. 
Walshe ^nd Bennett 
(1846-49). 
Scirrhus, or hard cancer. 
Encephaloma, or soft 
cancer. 
Colloid, or jelly-like can- 
cer. 
All other forms of can- 
cerous new growths are 
described by Bennett un- 
der the name of cancroid 
growths. 
II. 
Paget (1853). 
Scirrhus, or hard cancer. 
Medullary, or soft can- 
cer. 
Epithelial. 
Colloid. 
Osteoid. 
Melanotic. 
Villous. 
Haematoid. 
III. 
Rokitansky (1855). 
1. Fibrous carcinoma. 
2. Medullary. 
(a.) Villous cancer. 
(6.) Cancer mela- 
nodes. 
3. Epithelial cancer. 
4. Gelatinous cancer. 
5. Carcinoma fascicula- 
turn. 
6. Cystic carcinoma. 
IV. 
College of Physicians 
(1869). 
(a.) Scirrhus. 
(&.) Medullary cancer. 
(c.) Epithelial cancer. 
(d.) Melanotic cancer. 
(e.) Osteoid cancer. 
Of the$e particular kinds of cancer some tend to affect certain organs rather 
than others,-for instance, alveolar cancer is more frequently found in the stom- 
ach or intestines ; epithelial cancer, in the skin and mucous membranes. 
The primary cancer-growth commences in the textures of some organs rather 
than others,-for instance, in the uterus and female breasts, in the stomach, 
the colon, the liver, the bones, and the brain. Secondary cancers, on the other 
hand, are most frequently developed in the lungs, the spleen, the salivary and 
lymphatic glands, in the small intestines, and in the serous membranes. But 
the local aptitude for cancer-growths is a subject unknown. We have no 
knowledge why one part rather than another should be the seat of cancer; 
but certain organs seem more liable than others at certain periods of life. For 
example, before thirty years of age the eye and the orbit are the parts first CONSTITUENTS OF SCIRRHUS OR HARD CANCER. 
851 
most liable to be affected, next the bones, testicles, and areolar tissue of limbs 
and trunk. Between thirty and fifty years of age the penis, uterus, external 
sexual parts, and breasts. After fifty years of age the integuments and diges- 
tive organs are more apt to suffer. 
Simple tumors may also become the seat of cancers, just as any part of the 
body may be the seat of a cancer, although the event is rare. About one-fifth 
of cancers are ascribed to the effects of injury; and although in many cases 
the statement may be fallacious, yet the consequences of injury are sometimes 
too obvious to admit of doubt. 
(a.) Scirrhus, or Hard Cancer, has two stages-a hard stage and a stage of 
softening. It is a "cancer characterized by hardness of the primary tumor, and 
by a tendency to draw to itself the neighboring soft structures. When ulcerated, 
the sore is commonly deep, uneven, and bounded by a thick everted edge." 
The local hard or scirrhous state constitutes the first stage. It may grow 
in masses, or may be infiltrated into the tissues of the organ or part affected- 
the latter being by far the most common form. When in masses, they are 
generally lobulated, dense, and often contained in a cyst; again, when these 
masses are cut into, we find them to consist of two substances-the one is the 
cancerous growth, and the other is areolar tissue; so that the appearance of 
the divided surface in general is that of a hard, white, semi-cartilaginous sub- 
stance, streaked by fibres radiating from what appears to be the centres of 
connection to the circumference. They are of considerable density and firm- 
ness, and in hardness of texture vary from hard-boiled white of egg to carti- 
lage-the knife making a grating noise as it cuts through them. The specific 
weight of these tumors is extremely great; and although in those parts which 
are external and more or less pendulous, as in the mamma, this fact is, by 
some distinguished surgeons, an element in diagnosis, our exact information 
relative to the specific gravity of cancerous growths is still very limited- 
1.040 to 1.160 is the very wide range which I have observed such tumors to 
indicate. 
The cancerous growth, however, is much more frequently infiltrated among 
the areolar tissue of the different organs or tissues it affects. Mr. Paget here 
shows how the cancer cells of new growths are in- 
filtrated amongst the connective tissue areolae (Fig. 
86). The affected tissue becomes gradually in- 
creased in thickness and in density by a slow 
growth of the morbid matter, so that the part, if 
divided, presents the same hard, semitransparent 
character as in the mass, but it is more interspersed 
with areolar tissue, the diseased portion being 
gradually shaded off into the healthy structures. 
In the mucous tissues, as those of the stomach or 
uterus, the infiltrated growth has often a consid- 
erable thickness, measuring from a quarter of an 
inch to an inch, or perhaps even more. On the 
contrary, when infiltrated into the cutaneous tissue, 
the layer is often so attenuated as to be scarcely 
appreciable, and the disease commences with little 
other appearance than a small hard pimple, or a 
small erysipelatous tumor, or even by a slight 
fissure or crack in the skin. 
The minute elementary structures of scirrhus 
are chiefly two: (1.) Certain cells and corpuscles; 
(2.) A nearly homogeneous intercellular substance, in which they lie imbed- 
ded. As to the cells, multiformity of shape is their chief malignant charac- 
teristic (Fig. 87, showing the combined experience of Paget and Wedl). 
Fig. 86. 
Cancer cells of scirrhus, filling 
interstices among bundles of con- 
nective tissue, in the skin of the 
breast-magnified about 200 times. 
(After Paget, Fig. 99, p. 615, 3d 
ed., 1870.) 852 
SPECIAL PATHOLOGY-CANCER. 
After a certain but indefinite period, which varies from a few months to a 
few years, the scirrhous stage of hard cancer ter- 
minates, and the second stage, or that of softening, 
begins. In mucous membranes this softening 
usually takes place at the surface, or superficially, 
-as at the mucous surface of the neck of the 
uterus, or at the mucous surface of the stomach. 
An ulcer is the consequence of this softened state, 
and is at first superficial, presenting many re- 
markable varieties, such as an inverted or everted 
edge, and an irregular form, while its base may 
be granulating at one part and sloughing at 
another. Its course is burrowing, often penetra- 
ting between the cancerous lobules, and ultimately 
may perforate the limiting serous covering, such 
as the peritoneum. The pus secreted by this sore 
is fetid; often a mere ichor, or pus mixed with 
blood, and so acrid as to inflame the parts over 
which it flows. In a few instances the large ves- 
sels participating in the disease ulcerate, and the 
patient dies of hemorrhage. 
The duration of the scirrhous or hard stage of 
a cancerous tumor is very uncertain, and may 
terminate in a few months, or may last several 
years. A cancerous mammary gland, for instance, 
has been known to remain indolent for fourteen 
years, and has at the end of that time been re- 
moved by an operation. This indolent character 
of cancer is limited, however, to the hard stage; 
for, after it has commenced to soften, its course is 
rapid, and a few weeks or a few months generally 
terminate the patient's life, the part affected in 
no instance cicatrizing, or being again restored to 
a healthy condition. 
(6.) Medullary Cancer} or Sofi Cancer, affects 
more especially the solid visceral organs. It is a " cancer characterized by a 
smoothly lobed surface, soft, irregular consistence, great vascularity, and usually 
rapid growth and reproduction. When ulcerated, it protrudes in large masses, 
which bleed copiously." Its cell-products are most profuse, and its course much 
shorter than hard cancers, the disease generally terminating in a few months. 
While hard cancer for the most part affects persons in the decline of life, soft 
cancer is most common in its earlier period, or adult age, from twenty-five to 
forty. 
Although generally found in masses, it may be infiltrated; the former is 
the more common form, the latter the more rare. In whichever form it 
grows, however, it has two stages-namely, one of induration and one of soft- 
ening. If we examine a soft cancer-tumor in the first stage, we find it com- 
posed, as in hard cancer, of very delicate stroma tissue and a peculiar morbid 
growth. The areolar stroma is of various densities, often extremely fine, and 
then again of considerable consistency and tenacity, and in either case radia- 
ting through the tumor and dividing it into lobules. The morbid substance 
or growth is of many degrees of hardness, varying from lard to cartilage, but 
is generally softer than in hard cancer: it is of a bluish semitransparent 
whiteness. The duration of this hard stage is from a few weeks to two, three, 
or four months, and only in a few instances does it exceed that latter period. 
"Hard encephaloid is a designation sometimes applied to medullary cancers 
of unusually firm consistence." 
Fig. 87. 
Elementary cells of scirrhous can- 
cer from the rib. (a.) Rounded cells 
with single nuc leus ; (6.) Cells with 
two nuclei and fibre-cells (Wedl, 
Fig. 161, p. 5731; (c and d.) Cells and 
free nuclei of scirrhous cancer from 
cancerous breasts-magnified about 
500 times. (After Paget, Fig. 100, 
3d ed., 1870.) X ELEMENTS OF MEDULLARY CANCER. 
853 
The woodcut (Fig. 88) brings together representations of the experience of 
Paget and Wedl, as to the varied microscopic forms which the new growth of 
medullary cancer assumes. 
Fig. 88. 
(a.) Nuclei of Soft Medullary Cancer imbedded in a molecular basis stroma, and without multiform 
cells-magnified 500 diameters. (After Paget, Fig. 105, p. 668, 3d ed., 1870.) 
(6.) Dotted nuclei of Medullary Cancer, containing several shining granules (Paget, loo. cit.). 
(c.) Developed nuclei of Medullary Cancer (Paget, 1. c.). 
(d.) Caudate and elongated cells of Firm Medullary Cancer-magnified 450 times (Paget, 1. c.). 
(e.) Medullary Cancer Cells of multiform shape, with nucleus and prominent nucleoli-Cancer of 
Breast. (After Wedl, Fig. 166, p. 592.) 
(/.) Medullary Cancer Cells with two to eight nuclei (Wedl). 
(g.) Medullary Cancer Cells with large vesicular nuclei and granular nucleoli (Wedl). 
The firmness of cancers seems to be in proportion to the abundance and 
fineness of the elongated cells figured in c and d. The soft cancers are 
mainly made up of cells and stroma, as in a and b, more or less mixed with c 
in the figure. 854 
SPECIAL PATHOLOGY-CANCER. 
The first stage passed, the process of softening, or of ramollissement, takes 
place. This is evident on cutting into the tumor, and passing the handle of 
the scalpel over the divided surface, a milky-white substance being expressed. 
As the disease proceeds, the parenchymatous substance of the new growth is 
changed into the consistence of soft cerebral matter, or of thickened pus ; it is 
consequently opaque, and varies in color from white to red, and even black. 
These variations of color appear to be owing to the different quantities of 
blood or of melanic matter which are effused, and with which the cancerous 
matter is commixed. When bloodless and white, the product is so peculiar 
that it has been termed cerebriform, and when mixed with blood, medullary 
sarcoma, fungus hoematodes, and many other terms, according to the different 
quantities of that fluid effused, which is often so abundant that the cyst or 
cavity at length contains little else than fibrin. "Fungus hoematodes is a 
term applied to some cases of medullary cancer which are more than usually 
■vascular." 
The process of softening seems to commence indifferently in any part of the 
medullary tumor, at its centre, or towards its circumference; and if the tumor 
communicates externally, the quantity of softened matter discharged often 
amounts to many ounces in the course of the day. This profuseness of dis- 
charge appears to be owing to the great vascularity of the growth ; for although 
in the hard stage only a few bloodvessels, with coats of great tenuity and 
delicacy, can be traced between the lobules, yet, in the softened state, a 
successful injection shows the growth to be made up almost entirely of blood- 
vessels. 
The duration of the second stage is generally a few weeks, and very rarely 
extends to months. It appears, however, that anything which greatly irri- 
tates the part accelerates the process of softening. Thus, if a cancerous limb 
or tumor be amputated, the cancerous matter primarily in a hardened state 
appears to grow in new sites, subsequent to the operation, in a softened condi- 
tion, no previous hard stage occurring. 
The minute organic structure of this form of disease, in its hard state, is 
probably not dissimilar to that of hard cancer; and of the vital organic 
characters there can be no doubt of their similarity. 
There is scarcely any organ or tissue in which soft cancer has not been 
found; and by some pathologists the frequency of its occurrence in certain 
parts is believed to be in the following order: the liver, epiploica, the mesen- 
tery, the lymphatic glands, the brain and nerves, the spleen, the testicles, the 
uterus and ovaries, the eye, the bones, the heart, and lastly the bloodvessels. 
It has been stated that soft cancerous matter far more frequently grows in 
masses than infiltrates into these parts. In general there is only one tumor; 
but there may be, as is often seen in the liver, three or four, and in some 
cases they are extremely numerous. Dupuytren has met with a carcinoma- 
tous heart which contained more than 600. In size they commonly vary from 
a millet-seed to a large egg; but when they form in loose cellular tissue, as 
between the folds of the mesentery or of the epiploica, or in the substance of 
the lungs or testicle, they have been known to weigh, in extreme cases, 20, 
30, 40, and even more pounds. These tumors may also be encysted or non- 
encysted. 
One of the most constant features of this disease, and which distinguishes 
it from hard cancer, is, that it often appears in many organs or tissues at the 
same time in the same patient. Thus, it has been met with in the coats of 
the bladder, in the liver, and in the lungs of the same individual. It has 
also a greater tendency to be reproduced after an operation for its extirpation 
than any other kind of cancer. This reproduction may take place either at 
the part operated on, or in some organ or tissue distant from the primary seat 
of the disease. CHARACTERS OF EPITHELIAL CANCER. 
855 
(c.) Epithelial Cancer, or Cancroid Epithelioma.-Of late years, under these 
names, or that of Cancroid, Lebert, Bennet, Hannover, and Paget have de- 
scribed a form of tumor which has all the vital and malignant qualities of 
cancer already described, but its minute elements consist of cells resembling 
those of epithelium or epidermis. It is therefore defined as " cancer character- 
ized by its occurrence chiefly in parts naturally supplied with epithelium, and by 
the resemblance of its cells to those of the epithelium." It occurs almost solely 
on the skin or mucous membranes, being frequently seen on the lips or cheeks. 
Rokitansky has observed it in the liver; Bennett has described it as com- 
mencing primarily in the lymphatic glands; and in two cases of what has 
been termed acute hypertrophy of the mamma, both of which proved fatal 
with secondary lesions in internal organs, which I examined after death, I 
believe that this form of cancer was the primary local lesion in the gland 
{Med. Times and Gazette for 1857). It only seems to occur where there is 
pavement, or spheroidal epithelium. Lebert has seen it on the serous layer 
of the arachnoid, and Robin has described it on the interior of a vein in a 
horse. 
The principal sites are in the vicinity of the great orifices of the body; but 
the lips, and more particularly the upper lip, are most liable to the develop- 
ment of epithelial cancer. The cancer commences first as a small indura- 
tion, afterwards a pustule or excoriation forms, and subsequently the deeper 
parts participate, and determine the form of the growth, which may be 
mulberry-shaped, villous, cauliflower-like, or nodulated. The surface is apt 
to become ulcerated at an early period, and an actual loss of substance takes 
place from the central parts. The resulting open sore has an irregular, 
gray, and often a bloody base; or it is covered with crusts, from below the 
edges of which a fetid and ichorous discharge may be caused to exude by 
pressure. 
When the tumor is cut into at an early stage, the section presents a well- 
defined border of epidermis, sometimes several lines thick, while the rete be- 
tween the surface-layers and the chorion is much hypertrophied. The sub- 
stance is friable, and is easily separated from the surface of the chorion. The 
tumor soon tends to take deep root in the substance of the chorion, presenting 
a white and gray speckled surface, with a basement substance, in which a 
variable quantity of whitish bodies may be seen, varying in size from a visi- 
ble point to the size of a millet-seed. The fluid which exudes is milky and 
granular, and does not mix with water, so as to form such an opalescent, 
semitransparent emulsion as the mixture of other cancer-juices with water. 
It mixes as if it contained fat. 
The tumor tends to infect secondarily the neighboring lymphatic glands; 
and the fatal termination is generally by exhaustion or by putrid infection, 
when the progress of ulceration is not arrested. 
The mean duration of cases of epithelial cancer is about six and a half 
years; and the duration seems to vary with the part as follows: Nearly three 
and a half years for the lower lip; three and two-third years for the penis; 
nearly nine years for the neck and limbs; and nine and a half foi' the vulva 
and face (Lebert, Hannover). 
Not a few pathologists doubt the propriety of classifying epitheliomata with 
cancers. Mr. Collis and others do not consider that the affinities of epithe- 
lioma with cancers are sufficiently strong to warrant their being included in 
the cancroid group of new growths. 
Epitheliomata originate in the deeper layers of the epidermis or epithelium 
of mucous membranes, where their development and growth may be recog- 
nized in three stages: 
(1.) Simple cellular hypertrophy. 
(2.) Hypertrophy with ulceration, in which the number of cells has so in- 856 
SPECIAL PATHOLOGY CANCER. 
creased as to press clown on the papillse, and cause ulcerative absorption of 
them by pressure. 
(3.) Hypertrophy with infiltration, in which enlarged papillae overtop the 
masses of cells, which not only press on and ulcerate the papillae beside them, 
but also push the new-formed cells downward between the papillae. 
It is this continuous cell formation which accounts for the widespread de- 
struction of parts induced by epitheliomata. The growth gradually presses 
on before it, and destroys whatever tissue it meets with. Great irritation is 
also given to the bloodvessels by the proliferation of the cells, and the push- 
ings of them along between the separated papillae, producing an interstitial 
effusion of plastic lymph. In this lymph the epithelial cells develop fresh 
nuclei and cells like themselves, and thus become a fresh centre of irritation, 
the disease advancing by fresh development of cells in the interstitial effusion. 
" Its superficial origin, its slow progress, its indisposition to infiltrate the 
deeper structures, or to contaminate the glands, the certainty of cure which 
follows its timely removal, and the different appearance when occupying 
similar localities, are of sufficient importance to outweigh the points of resem- 
blance which it undoubtedly bears to cancer in its advanced and secondary 
stages. In its early stage it is strictly an hypertrophy, and in this condition 
it may remain for an indefinite period. Its second stage is one of hypertrophy 
and ulceration combined. This stage also, as far as external or cutaneous 
epithelioma is concerned, is slow to advance into the third or destructive 
stage-that of infiltration and secondary deposit " (Collis). " It remains 
for a very long time local, so that the nearest lymphatic glands often do not 
become affected until after the lapse of years ; and then again the process is 
for a long time confined to the disease of the lymphatic glands, so that a gen- 
eral outbreak in all parts of the body does not take place until late, and only 
in rare instances" (Virchow). 
But admitting all these points in the descriptions of Collis and Virchow, 
neither of them, individually, nor are they collectively, incompatible with 
constitutional or physiological malignancy. For, whether the growth takes 
its origin from connective tissue, as Virchow, Forster, and Webber hold, or 
from epidermis or epithelium, as Collis, Hannover, and Thirsh maintain, 
and grow as they are described to do, the vital properties of the growth are 
really those of malignancy. The anatomical form is no essential part of that 
specific character. 
The essentially characteristic anatomical elements of epithelial cancers are 
-(1.) Cells which bear a close resemblance to flat, pavemented, scaly, or 
tessellated epithelium ; (2.) The insertion or infiltration of these into the 
proper structures of the skin or other textures (Paget). Partaking of these 
characters, the mass of new growth becomes so condensed by the presssure 
of rapid growth, often within limited space, that peculiar whorls of growing 
matter constitute the forms seen, on section of microscopic specimens. The 
explanation of this is to be learned by the combined representations of Paget 
and Rokitansky, as shown in the following woodcut (Fig. 89). 
(d.) Melanotic Cancer, or Melanosis, is a "cancer characterized by the pres- 
ence of pigment," and which may be found distributed very generally in every 
organ and every structure of one and the same body-often becoming first 
manifest in the soles of the feet or in the axillae. The lymphatic glands sub- 
sequently become affected. Such growths are also found in the ovaries, in 
the mucous membrane of the bladder and intestines, in the kidneys, supra- 
renal capsules, heart, and brain. 
The "fungus hcematodes " have generally been considered related to melan- 
otic cancer; and the relationship is more than ever established in the connec- 
tion which subsists between pigments and the changes which take place in 
extravasated blood. Frequent hemorrhages are common in melanotic growths EPITHELIAL CANCER CELLS. 
857 
Fig. 89. 
Various typical epithelial cancer cells, a to p (after Paget and Rokitansky). Old, dry, and filmy,. 
b ; wrinkled-like fibres, c; very elongated, d (Paget). 
e, f, g, h-Epithelial cancer cells, with endogenous development of nuclei-brood cells-magnified 350 
diameters (Paget). 
i, k, l, m, n-Laminated epithelial capsules, requiring maceration and separation by liquor potassoe, to 
separate and distinguish them (Paget). 
o, p-Epithelial cancer of the calf of the leg progressing into the fibula: o, Single cells, vexed vesicle, 
with concentric laminae; P, Alveolus, containing fresh breeding-cells, one or more of which growing with 
rapid growth; the others become compressed about it, within the capsule or alveolus, so producing appear- 
ances, as shown in I, k, l, m, and n (Rokitansky). 858 
SPECIAL PATHOLOGY CANCER. 
of a cancerous nature, due to extreme dilatation and thinning of the walls 
of the bloodvessels, and the red color of such 
tumors must be referred to such kind of vas- 
cularity. Pigmentation of such tumors is 
therefore to be considered as of secondary 
formation; and in the majority of instances 
melanotic cancer consists of encephaloid or 
soft cancer, with the addition of black or 
brownish pigment. The pigment-deposit, 
per se, is not necessarily malignant. The 
pigment of cancers is readily decomposed by 
nitric and other acids, while the spurious 
melanosis or carbon is not. The true melanic 
deposit exists with the soft cancer-cells either 
as an infiltration into them or in the form of 
isolated granules or small corpuscles. The 
pigmentation may be seen on microscopic 
sections to take place along the course of di- 
lated bloodvessels. In an early stage the 
pigment is first contained in cells, whilst later 
it is found in free granular masses, through 
the dissolution and disappearance of the cells 
which contained it, and a gradual transition 
may in general be traced from the affected 
part into the normal structure of tissue, where 
it will ultimately become developed, and 
which is freely traversed by bloodvessels. Cells of various forms are to be 
seen in such tumors, which have first a yellow appearance and then a black, 
according to the amount of pigment deposited in them. The cell-walls sub- 
sequently disintegrate, leaving the pigment free. 
The cells composing them-the greater part of the structures-are such as 
might belong to uncolored medullary cancer, so that a small proportion of 
pigment seems to blacken the whole lump. The pigment is generally in 
granules or molecules. 
Osteoid Cancer is a "tumor usually commencing in the bones, consisting almost 
entirely of bone, and followed by similar growths in the glands and viscera." 
Villous Cancer is a name given to "cancer in mucous membrane, when covered 
by a villous groicth." 
Causes of Cancer.-The theories or hypotheses regarding the cause of can- 
cer may be reduced to three: 
(1.) That it is originally of constitutional origin, with a true blood-cause 
and primary cancerous cachexia, is mainly based on the following grounds: 
(a.) Its final universal diffusion throughout the body. 
(fbf Its occasional commencement in several primary tumors simultaneously, 
(c.) Its capacity to grow in various textures. 
(d.) Its local recurrence after operation or on removal of the primary 
tumor. 
(e.) Its appearance in internal organs, notwithstanding the complete ex- 
tirpation of the primary tumors. 
(/.) Its repetition in families. 
(gf Its relation to tubercle. 
(2.) That the change of the blood in cancer is not primary, but secondary, 
and due to the absorption of matter from an existing primary focus, the 
original malignant growth being due to a local irritant (Virchow). 
(3.) That it arises as a local disorder, independently of a constitutional 
cause, is the belief of Mr. C. R. Moore, of the Middlesex Hospital, London, 
based on the following grounds: 
Fig. 90. 
Melanotic cancer from the orbit: (a.) 
Two deeply pigmented cells; (6,6.) Five 
cells containing larger and smaller pig- 
ment molecules; (c, c ) Four pigmented 
fibre-cells; (d, d.} Multinuclear pigmented 
cells; (e.) Pigmented fibre-cell, with a dis- 
integrated nucleus-350 diameters. (After 
Wedl, Fig. 170, p. 602.) TREATMENT OF CANCER. 
859 
(a.) Its invariable origin as a single tumor. 
(6.) The manifest dependence of later tumors upon the first, especially 
confirmed-by the observed similarity of the morbid substance in the later 
growths to that in the first; by the order in which subsequent growths are 
disseminated ; by the interruption to subsequent growth and dispersion of the 
disease, if the first and primary tumor be effectually removed. 
(c.) Its inheritance as a local and not as a constitutional peculiarity. 
(</.) Its preference for healthy-like persons. 
Mr. Moore concludes from these data, which he believes to be correct, 
" that cancer has no dependence on any malady anterior to the appearance 
of the first tumor, but that it originates in persons otherwise healthy and 
strong. If this conclusion is inconsistent with prevailing opinions as to the 
cause and nature of the disease, the collision of the facts proves the need for 
more satisfactory evidence on behalf of these opinions than is at present in 
our possession. The existence of an antecedent general malady is, as far as I 
can perceive, pure conjecture, being entirely destitute of proof, or even of 
reasonable support. The idea sprang up in error; and it has been perpetuated 
mainly by the erroneous conclusions drawn from repeated want of success in 
surgical operations" (The Antecedents of Cancer, by C. R. Moore). 
Notwithstanding the strong statements contained in the last quoted passage, 
each of the hypotheses has plausible grounds to rest upon ; and there can be 
no doubt of the hereditary and therefore constitutional origin of many cancers. 
On the other hand, in other instances, and these not few, cancer seems to be 
strictly local in its origin. 
Diagnosis.-Cancerous affections of internal parts may be simulated by 
many nervous disorders, and also by chronic inflammation of the respective 
parts, scrofulous enlargements of glands, with deposit of tubercle (tyroma) ; 
but the long continuance of the symptoms, their gradual augmentation, the 
severe pain, which admits of no permanent relief, together with the loss.of 
health and slow emaciation of the patient, at last give a moral conviction that 
it must be cancerous growth in some organ from which the patient suffers. 
Prognosis.-Cancer, though long latent, and its course slow, pursues its 
destructive progress unimpeded; and in rare instances does amendment or 
a return to health await the patient, who ultimately falls an inevitable victim 
to the disease. 
Treatment.-No remedy has yet been found which can in any degree be con- 
sidered curative of the constitutional state associated with cancer, and the 
efforts of the practitioner are consequently limited to relieving symptoms, and 
to the adoption of such palliative measures as may prolong life. It has gen- 
erally been believed that to remove a cancerous growth where it is practicable 
must, on theoretical grounds merely, be attended with as much benefit to the 
constitutional disease as would attend the removal of a leg for acute rheuma- 
tism chiefly expressed in the knee-joint. The statistics of cancer show, so far 
as they go, and as Dr. Walshe long ago showed, that " excision of a cancerous 
tumor seems to awaken a dormant force. Cancers spring up in all directions, 
and enlarge with a power of vegetation almost incredible." Nevertheless, 
there are good reasons for removing cancers in some cases, especially mam- 
mary cancers, and others accessible to the knife. The greatest measure of 
good may be done, as Mr. Paget has clearly shown, " by making a careful 
selection of cases fit for operation, and rejecting all the rest as unsuited for 
operation" (Med. Tinies and Gazette, September 27, 1862, p. 319). 
With regard to excision of the breast for cancer, the main objection in the 
first instance is, that even of cases selected with some care, 10 per cent. 
(Paget) to 16 per cent (Lebert) die of pyaemia, or erysipelas, or tetanus, 
or secondary hemorrhage, or some calamity subsequent to the operation. On 
the whole, however, taking the results of some hundreds of cases, it is certain 
that the average duration of life of those operated on is not less than those in 860 
SPECIAL PATHOLOGY-CANCER. 
whom the disease runs its course. In well-selected cases it will be found 
always greater. A recent tabulation of hospital and private cases by Mr. 
Paget showed that 85 cases operated on lived an average of 55.6 months; and 
62 cases not operated on lived an average of three months. It has also been 
said that the recurrent disease is more painful than the primary one ; but in 
very many cases Mr. Paget has found that the recurrent disease was much less 
severe than the continued disease. Considering, therefore, the danger of the 
operation, and the fact that in every case a recurrence of the disease'may be 
expected, is it reasonable to submit a patient to the risk of dying from the pri- 
mary operation for the sake of that interval of health between the operation 
and the recurrence of the disease, for the probability of adding a year to 
life, and for the chance of having a less severe disease? The average length 
of the interval before recurrence is little more than thirteen months; more 
than half return within twelve months; and two-fifths return within six 
months. The extremes between which the average is drawn are very wide. 
In some cases the return may be within three, months ; in others not for ten, 
twelve, or more years. 
It is of great importance to determine in what cases the risk of life is 
greater, and in what the probability of a speedy return of the disease is greater 
than the average. 
The old after 60 ; the very large breasted in cases of mammary cancer; the 
fat and plethoric; the cachectic; the overfed on animal food; the drunk- 
ards; the gouty; the habitually bronchitic; the albuminurious; the very 
dejected-not timid merely; in short, those with any organic disease of the 
internal organs-all such cases are "doubly hazardous" to interfere with by 
operation (Paget). 
The probability of rapid recurrence is great in acute cancers-i. e., all those 
that are rapid in their progress-and in those which are observed to in- 
crease very quickly before the operation. Great pain, however, is often saved 
by performing the operation even under such circumstances. In illustration, 
Mr. Paget records the case of a lady "whose breast he removed when she was 
five months advanced in pregnancy. She recovered well from the operation, 
and the benefit procured by its performance was very great. She went to her 
full term, bore her child, and was able to suckle it for a year before she died, 
with her most anxious wish fulfilled in comparative comfort." 
Another condition unfavorable to operation is a brawny skin, with firm 
oedema and wide-open hair-follicles, or wide adhesion of skin, or in which the 
skin is cancerous, or where there are scattered tubercles of cancer in the glands 
and skin; or where there is considerable affection of the lymph-glands in the 
vicinity, and especially numerous diseased glands. A moderate amount of 
lymphatic disease Mr. Paget does not consider a serious obstacle to an opera- 
tion. In very chronic cases the operation is needless-where the breast is 
small, shrivelled, knotty, and sunk down on the pectoral muscle. By thus 
selecting with care, on the one hand, cases fit for operation, and refusing 
to interfere in those cases in which the operation would be attended with 
more than a proper share of danger, Mr. Paget believes that the life of a 
large number of those who suffer from cancer may be considerably prolonged. 
In whatever part the disease may be situated, one great rule is to endeavor 
to restore the healthy functions of that part, and to alleviate by opiates, chlo- 
roform, or chlorodyne internally, the distressing pains the patient endures. 
These remedies are for a time successful, but make no impression on the dis- 
ease, which silently proceeds, and the patient finally limits himself altogether 
to opiates. The quantity of opium or other narcotic known to have been 
taken in such cases is something enormous-five, ten, fifteen, or twenty grains 
of opium at a dose, or a proportionate quantity of hyoscyamus or of conium, 
three, four, or more times in the twenty-four hours. But although these 
large doses have occasionally been given, yet it may be questioned whether DEFINITION AND PATHOLOGY OF COLLOID GROWTHS. 
861 
they are not more hurtful than beneficial; for usually they produce headache, 
delirium, loss of appetite, and narcotism, so that the patient is only the more 
rapidly exhausted. In general, therefore, the patient does better under mod- 
erate doses of opiates, as one or two grains, or its equivalent of morphine or 
other narcotic, every four, six, or eight hours, than when more excessive doses 
are given-a larger dose producing headache and much cerebral disturbance, 
without in any sensible degree mitigating the sufferings. 
When the disease is seated in the colon or intestine, the tumor is in general 
difficult to make out. One loop of intestine may open into another; and 
death by hemorrhage may terminate the case. The symptoms vary greatly 
according to the position of the cancer and the part of the intestinal canal 
affected. Great sickness and vomiting generally attend cancer in the duode- 
num. 
When the stomach is so irritable that it rejects everything, it is our duty to 
support the patient by nutritive injections, as of strong broth, egg-flip, sago, 
or other fluid substances. It has been attempted to impart strength to the 
patient by means of milk baths, or baths of strong broths; but the skin has 
not generally sufficient power of absorption, and it has been found that the 
heat of the bath has exhausted the patient in a far greater ratio that its nutri- 
ment supported him. 
As a general principle, diet has little or no influence over the course of the 
disease, when once established, except it may be that total abstinence from 
nitrogenous food may starve out the growth, and most likely also the patient; 
so that whatever agrees with the patient's digestion may be safely indulged in. 
Preventive treatment must be directed to the infant life of those who are 
hereditarily predisposed. 
colloid-Syn., colloid cancer, alveolar cancer. 
Definition.-A new growth, a great part of ivhich is formed of transparent or 
gelatinous substance. 
Pathology.- Colloid, Colloid Cancer, or Alveolar Cancer, is sometimes also 
called gelatinous or gum-cancer. In this form of disease the meshes of the 
new growth are filled up by a glue-like or gelatinous substance, like half-dis- 
solved gum-arabic. It is ''a new growth, a great part of which is formed of 
transparent or gelatinous substance." The fibrous stroma are arranged in the 
form of alveolar spaces, the fibroid tissue being extremely delicate and trans- 
parent, and the spaces are occupied by the glue-like matter in greater or less 
quantity. These growths are not now regarded (and their position in the 
nomenclature as a substantive disease would also indicate that they are not 
to be regarded) as cancers. They are limited growths, and not infiltrations; 
but they expand or grow to a very great extent, as in a case related by Dr. 
Ballard, where the greater part of the parietal, and much of the visceral per- 
itoneum, were involved in colloid cysts. Six quarts of colloid matter were 
removed from the peritoneal cavity after death; and Mr. Paget remembers a 
case where the colloid matter was still greater. 
Mr. Paget acknowledges that "it seems difficult to believe that such a 
structure [colloid] can have any close affinity with the cancers already 
described; but he considers it has, as to its clinical history, all the other dis- 
tinctive features of cancer: (1.) Its seats of election are those where medul- 
lary cancers are apt to occur; (2.) Sometimes it infiltrates, replaces, and 
supersedes the natural tissues of the part; (3.) It is prone to extend and 
repeat itself in lymphatic glands; (4.) It is often associated with other forms 
of cancer in the same mass, or in different tumors in the same person; (5.) It 
recurs after removal; (6.) It is derived hereditarily from a parent having 862 
SPECIAL PATHOLOGY LUPUS. 
scirrhous cancer, and a parent having colloid may have children with medul- 
lary cancer (Paget). 
Mr. Collis regards colloid as structurally and clinically removed from can- 
cer. In structure they are aggregations of the smallest lymph-cells, or of 
mucous tissue like the umbilical cord, and held together by the finest connec- 
tive material, and never of large cells like cancer. Nevertheless, such tumors 
sometimes recur after removal, and, in other respects, manifest the worst fea- 
tures of malignancy. 
[There is a form of colloid which belongs to the true cancer group anatom- 
ically and clinically. Such are the cases described by Lebert (Virchow's 
Archiv, Bd. iv) and by Forster. The latter writer states that both scirrhous 
and medullary cancer may undergo transformation into colloid. Paget Hoc. 
cit., p. 663) has suggested, as a reasonable hypothesis, that the peculiarities of 
colloid cancer may be ascribed to cystic degeneration in elemental cancer 
structures, while the elements are in a rudimentary state. Forster has traced 
the colloid metamorphosis in cells, and describes their advancing in three 
different ways. First, the cell contents themselves become transformed into a 
colloid mass, which gradually increases in size and is set free. Secondly, the 
colloid change begins in the form of a zone round the nucleus of the cell; 
another zone is laid on this, and then another, until the well-known large 
laminated colloid body, so like in appearance to the laminated capsule of 
epithelial cancer, is formed; the central nucleus at the same time undergoes 
partition and multiplication, and a group of nuclei fill up the centre of the 
laminated body. Thirdly, the nucleus is itself the seat of metamorphosis, 
and swells up so as to be converted into a great colloid bladder. The differ- 
ent consistence and appearance of colloid tumors generally seem to depend 
on the different ways in which the colloid substance is distributed; for there 
maybe colloid cells in pure fibrous stroma; or cells with ordinary albumi- 
nous contents in a colloid stroma; or colloid cells in colloid stroma (Wurzb. 
Med. Zeit., Bd. iv, Hft.5 and 6; Brit, and For. Med. Chir. Rev., April, 1867).] 
The reader is referred to Mr. Paget's classic work for an account of the 
various combinations of colloid cysts with cancers of all kinds. 
It generally corresponds with the history of scirrhus and medullary cancers; 
and there can be no doubt that the clinical course of the disease often resem- 
bles that of cancer. The characteristics of its structure consist of a very 
delicate translucent membranous stroma, out of the spaces of which there 
conies a glue-like substance. Its growth is rapid, and it may reach an enor- 
mous bulk. The spaces or alveolar loculi vary from a very minute size to 
that of a pea. The contained substance is of a yellowish or greenish-yellow 
color, but yields no gelatine on boiling. It is "a clear, flickering, or viscid 
substance, like soft gelatine." The most common places where colloid cancers 
form are the stomach, the ovaries, the bones, the kidneys, the intestinal canal, 
uterus, mammary gland, peritoneum (Paget), and spleen, and they may be 
combined with the hard or soft cancers. 
LUPUS. 
Latin Eq., Lupus; French Eq., Lupus; German Eq., Lupus-Syn., Fressende flechte; 
Italian Eq., Lupus. 
Definition.-A spreading tuberculous inflammation of the skin, usually of the 
face, tending to destructive ulceration. 
Pathology.-The disease is prone to extend itself quite irrespective of 
tissue; and in this respect lupus has been considered as allied to malignant 
disease; but its most evident affinities are with scrofula. It depends upon a 
neoplasm-upon a development of new growth in the tissue of the dermis, SYMPTOMS AND TREATMENT OF LUPUS. 
863 
classed by Virchow among "granulation growths,"-the elements of which 
have been already described, under the head of gummata, in syphilis. But it 
is not here implied that lupus has necessarily any connection with syphilis. 
The nodules of lupus, which indicate its existence, are either isolated or they 
are diffused, causing considerable thickening of the skin; and the new growth 
advances from the superficial layers to the deeper parts, even to the cartilages 
and bones. Crusts of epidermis next form over the lesions, under which the 
new growth begins to soften and ulcerate. But sometimes the new growth sub- 
sides, the cell elements undergo fatty degeneration, followed by absorption-' 
when a deep cicatricial-like loss of substance remains. 
Two varieties of the disease have been distinguished by the College of Phy- 
sicians, namely: 
(a.) Chronic lupus. 
(6.) Lupus exedens, defined as a variety, " characterized by the rapidity, depth, 
and extent of the ulceration, and by appearing in rare cases on other parts than 
on the face." 
The disease is rare before the tenth year of life, and still more rare after 
the fortieth ; being most common between the ages of ten and twenty. It is 
less frequent among the rich than among the poorer classes (Niemeyer). 
Symptoms.-The most frequent seat of lupus is upon the face, especially 
the nose; but in the exedens variety it may attack other regions, such as the 
neck, shoidders, chest, and extremities, especially over the joints. The disease 
first appears as small, painless, brownish-red specks ; and although they feel 
quite hard nodules, they are very easily made to bleed, and are very easily 
penetrated. In this form of lesion the disease may remain for years, making 
no advance. When the disease is about to progress, the nodules multiply and 
grow larger, their surface becomes tense, shining, and covered with exfoliated 
scales of epidermis CUPUS exfoliations of Hebra). As hardness subsides, the 
lesion also subsides beneath the level of the skin, and the place is converted 
into a white, hard, shining cicatrix, without any ulceration having occurred. 
But in other cases, where new nodules continue forming, the surrounding 
skin becomes hyperaemic, red, and shining; a superficial erosion forms under 
a scab, which becomes thicker and broader from the accretion of fresh matter 
at the base. The most destructive form begins at the tip of the nose and alee 
nasi. Thus, either ulceration or interstitial absorption (the cuticle remaining 
intact) is invariably present in lupus, and constitutes the most marked feature 
of the complaint (Parkes). 
The second variety is sometimes known as lupus hypertrophicus, and attacks 
other parts of the body besides the face. 
Diagnosis.-Lupus maybe confounded with syphilitic tubercles, true leprosy, 
or elephantiasis, some forms of acne, of cancer of the skin, and impetigo. It is 
to be distinguished from syphilis by the history, by the absence of induration, 
and of coppery hue before ulceration ; and the absence of syphilitic characters 
after ulceration. Lupus is never pustular. 
The Prognosis is always unfavorable to the extent of local destruction ; 
and there is continual tendency to relapse and renewal of new growth, especi- 
ally if the cicatrices remain soft, bluish, and surrounded by soft tumors, which 
yield to the fingers, and if the tumors do not disappear after cicatrization 
(Biett). 
Treatment.-The new formation must be removed or destroyed ; but opin- 
ions differ so much as to how this is best effected, that the reader is referred 
to the best surgical works. 
The medical treatment has in view the prevention of the formation of more 
similar deposits in the substance of the skin, by improving the general health.. 
Cod-liver oil, iodide of potassium, quinine, and bitter vegetable tonics, are all 
useful in this respect. 
Dr. A. T. Thomson placed great reliance on three medicines-namely, iron, 864 
SPECIAL PATHOLOGY-LUPUS. 
iodine, and arsenic, which were generally used at the same time. Mercury, in 
the form of biniodide, was also often given. 
" When a patient first came under treatment," writes Dr. Parkes, in record- 
ing the practice of his relative, "if the general health had been at all lowered, 
and if there were any anaemic symptoms, cod-liver oil and iron, especially the 
iodide, were given for ten or fourteen days; the diet being nutritious, and 
other usual means adopted to improve the tone of the system. Afterwards 
the alteratives were commenced. The biniodide of arsenic was given in doses 
of from yj to |, or even of a grain. In such large doses, however, it often 
produces gastrodynia; and when this has once occurred, the stomach is ex- 
tremely intolerant afterwards of the smallest dose. Therefore, as the utility 
of the medicine can only be looked for after some considerable period, Dr. 
Thomson considered it safest to keep to the smaller doses, and to continue 
them regularly for a long time. If any gastrodynia came on, the medicine 
was at once left off, and opium and hydrocyanic acid administered. The cod- 
liver oil and the iron were sometimes continued, with the biniodide. Conium 
was found useful, if there were pains in the tubercles; and even if not, ap- 
peared sometimes to have a good effect; so that it was frequently combined 
with the biniodide in the form of pill. If the biniodide could not be borne 
in any form, the liquor arsenicalis of the London Pharmacopoeia, in small 
doses, of from four to eight minims, was given, and iodine rubbed in over the 
healthy skin with a view to absorption.* 
" Local caustic applications were very little used by Dr. Thomson. He 
sometimes employed the strong nitric acid to the edges of the ulcer, or nitrate 
of silver in strong solution (viz., from J ij to 5iij of the nitrate to 5j of water), 
over the tubercles, and subsequently acetate of lead wash, to lessen the tem- 
porary heat and swelling which followed. In children, the solution of the 
nitrate should be much weaker. When ulceration had occurred, he used 
simple dressings; solution of nitrate of silvei' or chlorinated soda being occa- 
sionally used. If unhealthy, pale, fungous granulations rose, an ointment 
of iodide of sulphur, or a very weak ointment of the biniodide of arsenic, or 
of either of the iodides of mercury was employed. The quantity of the binio- 
dide should not be above half a grain, or one grain to of lard. There is, 
however, always a great risk of erysipelas after the employment of powerful 
local applications. 
" Caustics and corrosives are recommended by many writers; but it may 
be questioned whether their use is productive of such marked benefit as has 
been stated. Lupus is but the local manifestation of a general disease, and 
local applications can never touch the real seat of the evil. Cazenave recom- 
mends chloride of zinc, arsenical paste, or the powder of ' Come,' Vienna 
paste (equal parts of chalk and quicklime), and other powerful applications 
of the like kind. Hebra also recommends cauterization, and employs usually 
strong nitric acid over the unulcerated, and nitrate of silver over the ulcer- 
ated surface. 
"It is a remarkable fact in the history of Lupus, affirmed by Hebra, that 
the Lupus disappears during acute febrile diseases, and especially during 
typhus. It seems to recur with convalescence." (See Dr. A. T. Thomson 
on Diseases of the Skin, edited by Dr. Parkes, where numerous interesting 
cases are detailed, p. 310.) 
* Donovan's solution (a mixture of arsenious acid, peroxide of mercury, and hydri- 
odic acid) was very useful. The dose-if the solution be made according to Donovan's 
formula-is from 10 to 40 drops. PATHOLOGY OF TRUE LEPROSY. 
865 
RODENT ULCER. 
Latin Eq., Ulcus erodens; French Eq., Ulcere rongeant; German Eq., Fressendes 
Geschwiir; Italian Eq., Ulcer a rodente. 
Definition.-A destructive ulcer, characterized by the extent and depth to which 
it spreads in the adjoining structures, and by the absence of preceding hardness 
and of constitutional affection. 
Pathology.-They are sometimes called lupoid or cancroid ulcers, and seem 
to have some affinities with lupus and cancer, rather than with scrofula. They 
occur in the later half of life rather than in the earlier periods, and in this 
respect differ from lupus. For a detailed description of this disease, the reader 
is referred to text-books on surgery. 
TRUE LEPROSY-Syn., ELEPHANTIASIS GRAECORUM. 
Latin Eq , Leprce verce-Syn , Elephantiasis Grcecorum; French Eq., Lipre vraie- 
Syn., Elephantiasis des Grecs; German Eq., Aussatz-Syn., Elephantia.si Graico- 
rum; Italian Eq., Lepra-Syn., Elefantiasi deis Greci. 
Definition.-A constitutional, non-contagious, hereditary affection, essentially 
chronic in its nature, expressing itself mainly by shining tubercles of different 
sizes, of a dusky red or livid color, on the face, the ears {and often the extremities); 
the skin being thickened, wrinkled, rough, unctuous, divested of hair, and the per- 
spiration highly offensive; in which there is loss of feeling, or other disorder of 
innervation, and a tendency to ulceration or death of the affected parts. The eyes, 
in extreme cases, are fierce and staring, and the voice is hoarse and nasal. 
Pathology.-The position which this disease now holds in the nomenclature 
of the College of Physicians implies that it is of constitutional development- 
a theory which is now more generally accepted than the belief in the propa- 
gation of the disease by contagion. To a very great extent the disease is 
hereditary, and springs usually from some specific taint transmitted from 
parents to children. Out of 213 cases recorded by Danielssen and Boeck, 
185 were derived from families in which one or more persons had suffered 
from the disease. In 28 cases only, no hereditary history could be made out. 
In Iceland, in 1837, Hjaltelin, among 125 diseased persons, hardly found one 
who did not belong to a diseased family. 
As with other diseases of hereditary development, it sometimes passes over 
one or two generations, to appear in the third and fourth ; and it has been 
found to manifest itself more in the second and fourth generation, and with 
much greater intensity, than in the first or third generations, and the heredi- 
tary influence is most marked on the maternal side, and more in a collateral 
than in a direct line. 
Happily, in Great Britain, the disease is now unknown; but it prevailed to 
a great extent during the middle ages, as shown by the records of those insti- 
tutions, well known as Lazar-houses, or Leper Hospitals, which were instituted 
for the reception and seclusion of the infected, as well as to restrain the rav- 
ages of a disease believed to be "most powerful in dragging men to death, dis- 
gusting to the sight, and in all respects terrible, like the beast of the same 
name" (Aret^eus). 
The history of leprosy is as ancient as the records of man in the countries 
where it seems to have been indigenous. More than 3360 years ago (B. C., 
1490), Moses described leprosy (Leviticus, chapter xiii). More than 1800 
years ago it was described by Aretseus in clear and unmistakable language; 
and, from the earliest records to the present day, the distinctive characters of 866 
SPECIAL PATHOLOGY TRUE LEPROSY. 
the disease have continued, and have been transmitted unchanged from gener- 
ation to generation. 
In the middle ages it prevailed almost epidemically upon the continent of 
Europe; and various minute descriptions of leprosy are left us in the writings 
of different European physicians and surgeons of those days, who had oppor- 
tunities of studying the disease during its actual prevalence. The details 
given by these observers (as shown by the late Sir James Simpson, in a series of 
admirable papers in the fifty-seventh volume of the Edin. Med. and Surg. Jour- 
nal} are similar in all essential parts; and the symptoms and cause of the dis- 
ease described by them are the same as those described by Aretseus. The 
leprosy of Europe, during the middle ages, was undoubtedly the Elephantiasis 
of the Greeks. It is one of those diseases which history has shown to change 
its geographical stations to such an extent as to have made inroads upon whole 
districts and regions of the world, where it was formerly unknown, leavingmow 
untouched the localities which, in olden times, suffered most severely from the 
disease. It is now almost entirely unknown as a native endemic disease on any 
part of the continent of Europe, except in some provinces of a few countries; 
and yet, from the tenth to the sixteenth century it prevailed in nearly every 
district of this great continent. 
In the Scandinavian peninsula it still lingers. In a portion of Norway 
it appears to be as rife as it has ever been; whereas the conterminous coun- 
try of Sweden is comparatively exempt. In 1858 the number of known 
lepers in Norway was 2087 (Report of International Congress of 1862). Sev- 
eral districts in the south of Europe-in Spain, Portugal, and Italy-are still 
affected with leprosy to a considerable extent. These exceptions, to it^ almost 
complete departure from Europe, have some importance in pointing to the 
probable causes that favor the continued development and persistence of the 
disease. 
The most clear and distinct accounts of the disease in modern times have 
been given by Dr. Bateman, of London, and Dr. Schedel, in Paris. Sir James 
Simpson has adduced the clearest proof that the leprosy of England and Scot- 
land was of the same specific nature as the leprosy of the Greeks, and in one 
instance, that of the Leper Hospital of Shirbon, one of the largest in England, 
founded in 1181 by Hugh Pudsay, "the jollie Bishop of Durham," the inmates 
are directly designated "Elephantuosi," instead of being termed " Leprosi" 
(Simpson). 
Long after the disease had left the more southern parts of the British Islands, 
it continued to prevail in the Shetlands down to 1742, when the infected were 
kept in the Island of Papa (contracted for Papastown), as shown by a document 
drawn .up for Sir John Pringle, and bequeathed by him in MS. to the College 
of Physicians of Edinburgh. Afterwards as late as 1778, and lastly as late 
as 1798, patients with leprosy were sent from the Shetlands to the Edinburgh 
Infirmary for the cure of their disease. These cases all presented the same 
unequivocal signs of ancient leprosy; and in the last, if not the very last, 
Scotch leper, in a member of a Shetland family, the disease was a family in- 
heritance, and decidedly marked by the true and genuine characteristics of 
the Elephantiasis of the Greeks. 
No change has taken place in the characteristic features of leprosy, as still 
seen among the hideous victims of the disease, "on the plains of Egypt and 
Palestine, in the summer climates of Madeira and the Crimea, on the cold 
hills and valleys of Iceland and Norway, among the cities of British Hindostan, 
and the villages of Central Africa. Its existence may still be traced over 
these vast regions of Europe and Asia, inhabited by the Mongolian tribes, 
and the wandering life of the northern nomadic Tartars does not escape its 
ravages. It is common also among the Malays of Java, and the Dyaks of 
Sumatra and the Indian Archipelago. It is frequent in China; and the 
traveller in Burmah may see, in the neighborhood of Ava, one of these un- GEOGRAPHICAL DISTRIBUTION OF TRUE LEPROSY. 
867 
clean villages of lepers which the Burman turns from his path to avoid, lest 
its very air should blow upon him" (Parkes). 
The geographical distribution of true Leprosy is as follows: 
1. British North America', in a small part of the province of New Brunswick, 
and of comparatively recent date-since 1815. 
2. In all British India Colonies to a greater or less extent. In Jamaica 
it has been long known; and also in Barbadoes, where it is very common. 
3. In South America, especially in British Guiana, it is very common, and 
has excited much attention for several years. It is met with throughout the 
whole extent of Guiana-Dutch, French, and British-while in Dutch Guiana 
it is said to have increased. 
4. Africa.-Amongst the Hottentots and half castes, it has been long preva- 
lent at the Cape of Good Hope. It is met with at Sierra Leone. 
5. In Palestine and Syria, it mostly prevails at Jerusalem, where it is con- 
fined entirely to the Mohammedans. It is known in the consular district of 
Damascus, chiefly among' the mountain classes of the poorer peasantry-both 
Moslems and Christians. The districts most subject to it are the Highlands 
and the Tablelands, and very rarely on the seacoast. It is occasionally also 
met with in the villages adjacent to Aleppo, but not in the city itself. 
6. Islands in the Archipelago.-In Rhodes the disease is chiefly confined to 
the Greek population. It has been rare in Smyrna for twenty years previous 
to 1868; but has been known in Scio from time immemorial. It is endemic in 
Mitylene, and prevails extensively in Samos. In Crete it has existed for cen- 
turies; and in 1866 or '67 there were no fewer than 1000 lepers out of an island 
population of 250,000. 
Leprosy has long existed in the Ionian Islands; and it appears principally 
in the villages'of the mountainous parts of Corfu; rarely in the towns and 
plains. 
7. Turkey in Europe.-On the seacoast of the district of Salonica and the 
adjacent provinces of Thessaly and Macedonia leprosy is endemic. 
8. Persia.-It exists certainly in the northwest provinces, and probably in 
other districts. 
9. China.-Leprosy prevails extensively throughout the Chinese empire, 
especially in the southern provinces. It is very common in and around Can- 
ton and Shanghai; and a large number of lepers flock from the mainland to 
the island of Macao, to be under the kind treatment of the Portuguese au- 
thorities. 
10. Japan.-The disease is believed to e?dst in this country, but nothing 
certain is known. 
11. Australia.-In and round Ballarat, Castlemaine, and Beechworth, cases 
of tubercular leprosy have been met with among the Chinese emigrants to the 
gold diggings. 
12. New Zealand.-The disease described by the late Dr. Thomson of the 
58th Regiment, styled by the natives Ngerengere, is a form of leprosy, dying 
out as civilization advances. 
13. Mauritius.-In this island the disease is very common, and occurs among 
all classes. It is also remarkably prevalent in the chain of islands lying 
between the Cape of Good Hope and Ceylon, including Madagascar and the 
adjacent islands of St. Marie, the French colony of Bourbon or Reunion, and 
the group of Seychelles, where there is a leper establishment. 
14. India has been for all ages, and continues to be, the greatest seat of 
leprosy in the world. No province of the empire, from Point de Galle to 
Peshawar, or from the Indus to the Straits of Malacca, seems exempt. 
Ceylon.-Among the lower orders of the natives it is not uncommon, and it 
has occasionally been seen among the Europeans and the better classes. It is 
said to be on the increase during the fifteen years previous to 1868, chiefly 
from the influx of Malabars. 868 
SPECIAL PATHOLOGY TRUE LEPROSY. 
In the Bombay Presidency, inchiding Aden, leprosy is well known, particu- 
larly in the concan, south and east of Bombay. In some villages lepers are in 
the proportion of 1 to 80 or 100 of the inhabitants. 
In the Madras Presidency leprosy is of frequent occurrence more especially 
in the larger towns, on the eastern and western coasts, particularly the latter. 
In the Bengal Presidency, and generally throughout India, especially in the 
lower provinces and districts bordering on the sea, leprosy prevails, and is 
held in great dread by Europeans and natives. 
One of the most recent accounts of this disease has been given by Dr. Parkes 
in Dr. Thomson's treatise on Diseases of the Skin, on the authority of Schilling, 
Robinson, Kinnis, Gibert, Simpson, Biett, Cazenave, Pruner, Danielssen, and 
Boeck, the most recent authorities up to 1848 on this disease. Since then (in 
1867), an exhaustive report has been published by the College of Physicians 
of London, at the request of the Secretary of State for the Colonies, and the 
account of leprosy here given is almost a transcript of this valuable record, 
supplemented from the account by Dr. Parkes. 
The great extent to which leprosy prevails in many distant dependencies of 
the British empire, as well as a report that in some the disease was increasing, 
and the inevitable destitution and mendicancy that attend its existence among 
a population, rendered a thorough investigation a matter of special duty on 
the part of the Government of this country. 
In many regions of India the lepers may be counted by thousands; and in 
several of the West India Colonies their number is very large. The disease 
is known to be present also in the colonial dependencies of many European 
countries, more especially those of France, Spain, Portugal, and Holland. A 
few rare cases of indigenous origin have been met with in the British Islands 
during the present century. Reference is made to the case of a youth from 
one of the Hebrides, admitted to the Edinburgh Infirmary (Edin. Med. Jour., 
July, 1855); to a case in Guy's Hospital, described by Dr. Gull, in the Hos- 
pital Reports for 1859, vol. v, p. 147 ; and to a case by Mr. Norise, of Brigh- 
ton, in Medical Times and Gazette, Sept. 2, 1865; and in 1866 a case of the 
mixed form of the disease was received into Guy's Hospital, under the care 
of Dr. Owen Rees. But the majority of cases recently recognized in this 
country have occurred in persons who have either been born in one of our 
tropical possessions, or who had been long resident there. Such cases are 
more frequent than is generally believed, and some anomalous forms of in- 
tractable skin-disease are pronounced to be vestiges or obscure expressions of 
a partially leprous diathesis. / 
The course of the disease has been described as acute and as chronic; and 
two varieties have been distinguished, namely, the tuberculous and the anaes- 
thetic. 
Heberden witnessed the acute and rapid course of the disease in Madeira, 
and Danielssen and Boeck in Norway. It is there accompanied by fever, 
and commences suddenly by violent delirium, sleeplessness, a dry, reddish 
skin, a quick full pulse (120 to 130), dry and red tongue, constipation, scanty 
and pale urine. In from twelve to fifteen days there suddenly appears patches 
all over the body, which become elevated, and pass into large tubercles; and 
the general constitutional symptoms subside as the tubercles rise up. Thus, 
in a few weeks, the disease has arrived at a stage which it usually takes years 
to attain, and its course afterwards is usually chronic. 
The disease is one sui generis, characterized by certain kinds of cutaneous 
eruption and discoloration, associated with a tendency to ulceration or to the 
death of the affected parts, and with disorders of innervation, such as hyper- 
cesthesia, but more particularly by impairment or loss of sensibility (anaes- 
thesia f 
Two forms of the disease, the "tuberculous" and the " anaesthetic," have been 
described; but as the term tubercular or tuberculous is suggestive of some alii- MORBID ANATOMY OF TRUE LEPROSY. 
869 
ance with tuberculosis -which leprosy does not possess-the College of Physi- 
cians propose to designate the form in question by the term " tuberculated 
leprosyand inasmuch as the loss of sensibility is not confined to the " anaes- 
thetic" form of the disease, the term "non-tuberculated" might designate the 
other form. But as those two forms, which have often been described as dis- 
tinct, are not unfrequently known to coexist, or to succeed one another, in the 
same patient, they are now regarded as modifications of one morbid condition. 
There are also cases included under the varieties of non-tuberculated leprosy 
characterized by white spots or blotches on the skin, and which are also more 
or less anaesthetic. They are sometimes named leucopathic. Non-tuberculated 
leprosy also comprehends those cases in which the cutaneous eruption consists 
of circular or annular spots, not unlike lepra vulgaris, but in which the centre 
of the spot is anaesthetic, and having other distinctive characters of leprosy. 
These two varieties seem to be of frequent occurrence in the East Indies. 
The development of leprosy is not restricted to any period of life. It occurs 
most frequently about puberty, and onwards to maturity; but it has been 
observed from infancy or early childhood up to fifty years of age, or upwards. 
Occasionally signs of the tuberculated form of leprosy have been seen in the 
offspring of lepers at or soon after birth. According to the observations of 
Danielsseu and Boeck, the tubercular form of leprosy begins to manifest itself 
generally at some period between ten and forty years of age, most frequently 
between the twentieth and the thirtieth year of life. The non-tuberculated 
form between the tenth and the thirtieth year. Scarcely any period of life is 
exempt. Young children have been seen afflicted with the tubercles of lep- 
rosy, and their parents stated that these children had at birth bluish spots on 
the skin, which subsequently became tuberculated. At eight years of age the 
anaesthetic form has been met with in Norway; and in those cases there had 
been bullae on the extremities at a very early period of life. 
Morbid Anatomy.-The principal morbid changes have been carefully 
investigated by Drs. Danielsseu and Boeck; and they have been especially 
confirmed by Dr. Carter, of Bombay (Journal of Med. and Phys. Soc., vol. 
viii, N. S.). 
The anatomical signs of the disease are derived from the infiltrating of a 
peculiar exudation into the skin, the mucous membranes, the glands, the 
serous membranes, and the parenchyma of some organs. In the developed 
stage of the tuberculated form, the chorion or cutis vera of the affected parts is 
tumefied and thickened. On squeezing it between the fingers, a yellowish- 
white, viscid, or gruelly fluid exudes, and a gelatinous or lardaceous effusion 
infiltrates the areolar tissue underneath the skin, to which it firmly adheres. 
The subcutaneous veins and nerves are also thickened and enlarged from this 
effused material on their surface. 
In the more advanced stages of the disease, the deep-seated parts, as well 
as the superficial nerves, especially lying near to ulcerations, are very much 
thickened and enlarged, in consequence of the results of inflammation of 
their sheaths. 
The mucous membrane of the nares, fauces, and larynx is swollen, occupied 
with tubercles or nodules, soft, and of a yellowish color, and often ulcerated. 
The opening of the larynx is frequently the seat of morbid deposit, so as 
nearly to close up the rima glottidis. Similar nodules are occasionally found 
in the mucous lining of the trachea and larger bronchi. The cervical glands 
are occasionally much enlarged. 
The substance of the lungs is seldom altered; but the pleurae are often 
much thickened, in consequence of the exudation into its tissue, and the for- 
mation of an infinite crowd of tubercles, which sometimes run together. 
The subperitoneal connective tissue may also be similarly infiltrated. The 
mesenteric glands are generally more or less enlarged. Isolated rounded 870 
SPECIAL PATHOLOGY-TRUE LEPROSY. 
ulcers are occasionally found on the inner surface of the intestines. The liver 
is sometimes the seat of the deposit of nodules. 
In the advanced stages of the disease the kidneys are usually affected with 
a form of albuminous nephritis. 
In the non-tuberculated form, when anaesthesia is the characteristic feature, 
and where paralysis of muscles as well as of the skin exists, the skin is often 
very much attenuated, and the muscles atrophied. All fat has disappeared. 
The connective tissue in the parts surrounding the seat of ulceration or ne- 
crosis is infiltrated with a serous or lardaceous deposit; and the nerves are ex- 
cessively swollen, their sheaths being filled with a fine albuminous matter, in 
which the ultimate nerve filaments are imbedded. The axillary and inguinal 
glands are often much enlarged. The central organs of the nervous system 
are usually the seat of notable morbid changes, chiefly congestion of the pos- 
terior or dorsal veins of the spinal marrow, effusion of an albuminous serum 
within the arachnoid membrane, and between it and the dura mater, adhesion 
of the arachnoid membrane to the dura mater, and consolidation or hardening 
of the substance of the spinal cord at the part affected. The cord is generally 
somewhat contracted in size, and sometimes so atrophied as not to be much 
larger than a quill in its dimensions. The cineritious substance has generally 
acquired a dirty yellow color, so as to resemble the medullary substance. The 
roots of the nerves within the vertebral canal are invested with albuminous 
exudation. The axillary and ischiatic plexuses, and the principal nerves 
issuing from them, may be visibly atrophied. 
The cervical and lumbar regions of the cord are always most conspicuously 
affected. 
Within the cranial cavity the lesions are sometimes similar to those in the 
vertebral canal, but less decided and advanced. In well-marked amesthesia 
of the face, the Gasserian ganglion is always the seat of lesion; usually it is 
imbedded in a sero-albuminous exudation, so considerable that the part bulges 
out, and the nerve filaments are glued together by the exudation. 
The blood contains albumen and fibrin in excess, even before spots appear 
on the skin. Local congestions and hypersemia then ensue. 
Danielssen and Boeck have made several analyses of the blood after the 
method employed by Simon; and their results have been condensed by Dr. 
Parkes in the following tables: 
A.-Analyses oe Venous Blood in Norwegian Tuberculous Elephantiasis, 
by Danielssen and Boeck. 
Sp. gr. 
of 
whole 
blood. 
In 1000 parts. 
6 
Sex. 
Age. 
Period of Disease. 
Fib. 
Fat. 
Album. 
Globu- 
lin. 
Hiema- 
tin. 
Saltsand 
Extract. 
Water. 
1 
M. 
24 J 
Early precursory 
symptoms. 
1.046 
3.201 
2.531 
100.609 
65.831 
3.273 
11.244 
813.311 
2 
M. 
26 
Advanced. 
1.049 
4.539 
3.421 
73 139 
96.186 
5.465 
10.930 
807.521 
3 
M. 
38 
do. (12 years.) 
1.051 
4.265 
4.240 
116.971 
39 672 
6.135 
17.382 
811.335 
4 
M. 
36 
do. (8 years.) 
1.042 
4.722 
2.806 
93.092 
46.719 
4.153 
6.921 
851.687 
5 
M. 
29 
do. (6 years.) 
1.048 
4.878 
5.309 
93.913 
74.504 
2.713 
15.86] 
802.822 
6 
M. 
22 
do. (10 years.) 
1.053 
3.592 
4.623 
128.785 
65.336 
2.830 
15.332 
779.522 
7 
F. 
34 
do. (between 3 
and 4 years.) 
1.048 
3.111 
2.336 
106.926 
66.774 
3.547 
13.532 
803.771 
8 
F. 
43 
do. 6 years, 
complicated 
with Anaes- 
thetic Ele- 
phantiasis. 
1.052 
4. 
6.1 
113.6 
68. 
4.1 
1.4!? 
802.8 
Healthy blood analyzed by the same method. 
1 
1 
|F. 
20 
Healthy. 
1.051 
2.205 
2.129 
79.353 
94.437 
3.299 
11.339 
807.228 SYMPTOMS OF TRUE LEPROSY. 
871 
B.-Analyses of Venous Blood in Anesthetic Elephantiasis, by 
Danielssen. 
8pir 
whole 
blood. 
In 1000 parts. 
6 
Sex. 
Age. 
Period of Disease 
Fib. 
Fat. 
Album. 
Globu- 
lin. 
Haema- 
tin. 
Saltsand 
Extract. 
Water. 
1 
F. 
48 
Advanced (17 
years.) 
1.052 
2.578 
2.457 
100.500 
84.420 
4.020' 
10.497 
205.524 
2 
M. 
29 
do. (13 years.) 
1.046 
2 409 
4.854 
135.975 
80.850 
4.900 
17.150 
247.184 
3 
M. 
41 
do. (9 years.) 
1.045 
6.027 
3.440 
104.649 
62.189 
7.077 
14.582 
199.010 
Same. Second analysis, Albu- 
min u ria 
(lOj years.) 
1.042 
4.361 
3.567 
66.733 
72.209 
4.449 
6.844 
159.205 
4 
M. 
29 
do. (12 years 1 
1.058 
3 092 
2.777 
52.221 
139.404 
5.089 
8.851 
212 492 
5 
F. 
40 
do. (24 years.) 
1.052 
2.967 
4.662 
60.150 
121.652 
6.757 
9.011 
199.251 
The minute anatomy shows that the material of infiltration into the skin 
composing the tubercles, and into the sheaths of nerves and spinal cord, has 
the same microscopic and chemical composition. When newly formed it con- 
sists of a delicate fibrous network or stroma, in the meshes of which lie a 
great number of adherent whitish granules, which cannot easily be separated 
by washing. Acetic acid renders the fibrillae transparent, but increases the 
opacity of the granules. At a later period the fibrous network and granules 
disappear, and a great number of cells can be seen, rather larger than the 
so-called exudation-corpuscles, oblong in shape, and inclosing a large nucleus, 
which leaves only a small space between itself and the cell-wall. This space 
resembles a shining ring. The nucleus is of a gray color, and less transparent 
than the ring. It incloses from seven to eight well-marked brownish gran- 
ules ; and which probably accounts for the general brown color which the old 
nodules of leprosy acquire. The outer cell-wall is rendered transparent by 
acetic acid ; but the nucleus is not much changed. The texture of the cuta- 
neous vessels and nerves is all destroyed; the sudoriferous glands have dis- 
appeared, and only a homogeneous mass is left. The hair-follicles are in part 
destroyed ; but the sebaceous follicles are enlarged. 
In the Museum of Oxford, in 1865, I saw some very good specimens pre- 
served and prepared by Van der Kolk. The material exuded in the spinal 
sheath was yellow, diaphanous, and interspersed with numerous bright points, 
perhaps fatty. 
Chemical analysis of the exudation in the anaesthetic form, by Danielssen, 
gave the following results: 
Water, 80.45. 
Albumen, 17.38. 
Fibrin, traces only. 
Salts, 2.10. 
Before softening, in the tuberculated form, no effect was produced on test- 
paper; after softening the reaction was alkaline. The firm mass contained 
fibrin, albumen in large quantity, fat, and salts. After softening there was 
less fibrin. 
Symptoms.-Before any visible or external mark of leprosy is seen, there 
are usually premonitory symptoms expressed, which continue for a longer or 
shorter period. A feeling of general malaise is obscurely'marked and ill- 
defined, having no uniform or regular course. It is usually indicated by 
recurrent ague-like chills, or by formication and itching in the limbs, by 
numbness in a hand or foot, or in one or more of the fingers or toes, and by 
general weakness and depression alike of mind and body. 
In certain cases of the non-tuberculated form there is sometimes in the 872 
SPECIAL PATHOLOGY- TRUE LEPROSY. 
early stage of the disease an intense burning sensation, and a painful tingling 
along the course of one or more of the nerves of a limb, increased by pinching 
or tapping the skin over the affected part. This sensation is sometimes ac- 
companied by a dry fissured state of the skin, falling off of the hair, and 
shrivelling of the nails. 
Before the eruption of the elevated, discolored, and shining spots charac- 
teristic of the tuberculated form of leprosy, an erythematous redness of the 
parts about to be affected takes place-generally the face-attended with a 
feeling of heat or burning, a puffiness of the features, and increased sensibility 
of the skin. The duration of these premonitory symptoms varies much in 
different cases before the appearance of the characteristic eruptions of the 
cutaneous tubera or nodules of leprosy. 
Hypenesthesia, or increased sensibility, is invariably replaced, in course of 
time, by anaesthesia of the affected parts. Drs. Danielssen and Boeck have 
noticed that an excessive sensibility in some spots is sometimes accompanied 
by periodic rigors. This hyperaesthesia is sometimes limited to patches of the 
skin, at other times it affects extensive surfaces, as entire limbs, and a great 
part of the face. It may gradually increase to such a degree that, on the 
slightest touch, the patient experiences a sensation almost like an electrical 
shock. Every movement causes violent pains, as if the patient were pricked 
with a thousand pin points. Such extreme sensitiveness may continue for 
several years; but eventually it diminishes till it ceases altogether. It is 
gradually succeeded by anaesthesia of the affected parts, which becomes more 
and more complete. 
The same observers record that in the tuberculated form several successive 
outbreaks and disappearances of the discolored spots of the skin occur, after 
intervals of several weeks or months, or even of a few years, before they re- 
main and become persistent. Such external symptoms were generally pre- 
ceded by constitutional malaise, accompanied sometimes with a slight febrile 
disturbance of longer or shorter duration. In a few rare instances the dis- 
ease has set in with sharp paroxysms of fever, enduring for a week or two, 
and followed by the eruption of bluish spots on the surface. The case then 
either lapsed into the ordinary chronic form of the disease, or the patient was 
carried off by an attack of pleurisy, pneumonia, or meningitis. 
The formation of bullae in the anaesthetic varieties is usually among the 
earliest symptoms, and they supervene upon a state of general weakness, lassi- 
tude, and depression. The seat of these bullae is very often the palm of the 
hand or sole of the foot. They burst, and form superficial ulcers, which heal 
after a time. Although these bullae may go on recurring at short intervals 
for a length of time without the general health being much impaired, yet 
their occurrence is an almost certain premonition of the anaesthesia which 
will follow. The appearance of white spots or blotches on the skin is also a 
frequent but not a constant precursor of anaesthesia. 
The following summary may express in a short form the symptoms of the 
two forms of leprosy: 
1. Tubercular Leprosij presents the following characters: 
(a.) Tumefaction or tubercular thickening of the skin-principally of the 
face and extremities, less marked over the trunk. 
(6.) The affected skin is discolored, dark-brown, bronzed or shining, with 
the sensibility much diminished or entirely lost. 
(c.) The mucous membrane of the mouth and fauces ultimately becomes 
affected, and the voice altered. 
(d.) Contraction of the fingers and toes is a frequent symptom, and the 
phalanges may drop off from ulcerated fissures forming over the articulations, 
or from sphacelus supervening on ulceration. The entire hand or foot may 
thus be lost. CAUSES OF TRUE LEPROSY. 
873 
(e.) The constitutional disturbance is much greater in this than in the other 
form. 
2. Non-tuberculous Leprosy.-The anaesthetic form is the most frequent in 
India. It presents the fbllowiug characters: 
(a.) Anaesthesia of the skin of the face, ears, and extremities, followed in 
the latter case by atrophy, interstitial absorption, and occasionally ulceration 
of the benumbed parts, notably of the fingers and toes, with little or no con- 
stitutional disturbance. 
(6.) Large circular superficial ulcers may form on the lower extremities. 
(c.) The affected fingers and toes become contracted, the joints enlarged, 
the ends of the fingers broad, flat, or clubbed {Edin. Med. Jour., Dec., 1868, 
p. 546). 
Duration of the Disease.-No definite duration can be assigned to leprosy. 
According to Danielssen and Boeck, the average duration of the tuberculated 
form among patients in the Bergen Hospital, from 1840 to 1847, was between 
nine and ten years; and of the anoesthetic form, from eighteen to nineteen 
years. The shortest period was three years, and the longest twenty-two years 
of the tuberculated cases. The shortest period of the anaesthetic cases was 
five years, and the longest thirty-one years. 
Much seems to depend-(1.) On the age at which the disease appears; 
(2.) Upon the constitution of the patient; and (3.) The circumstances in 
which he is placed. 
The tuberculated form is the most rapidly fatal; but in all forms the disease 
may remain stationary for many years. Death is generally the result of some 
intercurrent affection, such as diarrhoea, dysentery, or inflammation of the lungs 
and air-passages; and if lepers are attacked with the malarious fevers of the 
country they usually die. Disease of the kidney, with albuminuria, is not 
unfrequent; and death in some cases is from marasmus and atrophy. Destitu- 
tion and neglect greatly aggravate the liability to such intercurrent diseases. 
Causes.-Leprosy is generally believed to be decidedly more frequent in 
males than in females; but females afflicted with leprosy usually live much 
more secluded than men, and are less willing to expose themselves when 
afflicted; so that the real truth may be that the disease is quite as frequent 
in women as in men. 
The proclivities of particular races of men to the disease are not known 
with any certainty; but the great majority of cases of leprous disease in all 
countries occur among the lowest and poorest of the people. In some coun- 
tries, however, it is believed that the better-conditioned classes are quite as 
frequently affected as the poor. It appears to be most frequently met with in 
low and malarial districts, especially on or near the seashore; but it is also 
common in inland and hilly districts, as among the Hottentots, the mountain 
inhabitants of Lebanon, and of the Highlands in the North of Persia and 
Hindostan. 
The dwellings of the leprous poor are generally as miserable and unwhole- 
some as they can be; and personal uncleanliness of the sufferers is on a par 
with the filthiness of their abodes. Ablution of the body is seldom or ever 
thought of, so that the skin is often incrusted with the impurities of years. 
Their clothing is not less foul, being seldom taken off by night or by day, but 
kept on the person as long as it will hold together. 
The food of the leprous poor is almost always described as poor, deficient in 
nourishment, generally unwholesome, and often insufficient in quantity. The 
frequent or constant use of fish, much salted and often tainted or semi-putrid, 
is more frequently referred to than any other article of food as a cause of the 
disease, especially in the West Indies, the Cape of Good Hope, Egypt, Crete, 
Corfu, Calcutta, and Ceylon. Deficiency of fresh meat and vegetables in the 
diet is also frequently noticed. Rancid oil is also believed to be an exciting 
cause of the disease when consumed in large quantities. In India the eating 874 
SPECIAL PATHOLOGY TRUE LEPROSY 
of unsound pulse is also believed to favor the development of the disease. 
In Norway most of the cases of leprosy occur among the very poorest of the 
people living round the shores of the deep bays or fiords on the west coast. 
Their food consists almost entirely of fish-fresh, or very much salted-meal, 
potatoes, and badly-made cheese. Fresh meat is rare. The lepers themselves 
generally ascribe their disease to constant exposure in the cold, damp, and 
wet weather of the climate, frequent at all seasons, and especially in the long 
severe winters. They often get thoroughly wet to the skin and chilled, with- 
out the means or opportunity of drying their clothes, or obtaining any warm 
nutriment. 
The opinion is almost unanimous as to the hereditary transmission of lep- 
rosy ; and the conviction is now not less unanimous amongst the most experi- 
enced observers, in all parts of the world, that the disease is not contagious 
nor communicable by proximity or contact with the diseased. 
At a very early period of the inquiry carried out by the College of Physi- 
cians, the nature of the replies received enabled the College to assure the Sec- 
retary of State for the Colonies that " there was no evidence which, in their 
opinion, justified any recourse for the compulsory segregation of lepers." 
After receiving this decided opinion, the Duke of Newcastle forthwith issued 
a circular to the Governors of the Colonies, expressing his opinion, " that any 
laws affecting the personal liberty of lepers ought to be repealed; and that, 
in the meantime, if they shall not be repealed, any action of the Executive 
Government in enforcement of them, which is merely authorized and not en- 
joined by law, ought to cease." 
There appears no more need (or just about the same) for restricting the 
liberty of lepers as for restricting the liberty of those afflicted with gout. 
Diagnosis is between syphilis and venereal tuberculated affections; and 
more especially it is difficult, if the two morbid states coexist. 
Yaws is another disease with which it may be confounded, as it is a disease 
met with in many countries where leprosy is common. It was formerly very 
common in several of the West India islands. The disease may also be con- 
founded with scrofula, with which some consider it is at least closely allied. 
The elephantoid enlargements of the scrotum and lower extremities have 
also been considered in many places as allied to leprosy; and the circumstance 
of the two diseases bearing the same generic name {Elephantiasis Arabum, 
the "Barbadoes" or "Cochin leg"), has doubtless contributed to the belief. 
They have no real affinity with each other, although both are sometimes en- 
demic in the same countries, and may coexist in the same patient. 
Prognosis.-The more the disease is developed, the more unfavorable must 
be the prognosis. Nevertheless, Drs. Danielssen and Boeck will not say that 
it is incurable, even in its advanced stage. Nature seems to have brought 
about a cure in several instances where the patients were grievously affected. 
Dr. Fiddes relates a case of spontaneous cure of leprosy, after an attack of 
erysipelas {Edin. Med. Journal, June, 1857), 
Treatment.-The only hope of exterminating leprosy lies in the adoption 
of hygienic measures, tending to improve the general conditions, physical and 
moral, of the leprous poor. Medicinal treatment is of no avail, unless com- 
bined with the regular use of a nutritive unstimulating diet, suitable clothing, 
protection against the vicissitudes of the weather, personal cleanliness, and 
exercise in the open air. 
The medicines which have been found of most service are tonics and altera- 
tives, especially preparations of iron and iodine. 
Mercury is extremely injurious. 
Arsenic has for centuries been held in high esteem in India as a remedy in 
true leprosy. It is given in the following combination : 105 grains of arsenious 
acid are triturated with five or six times the quantity of black pepper. Thus 
made into a mass, it constitutes the material of the well-known "Tanjore pill," DEFINITION AND PATHOLOGY OF SCROFULA. 
875 
of which one the size of a " tare " is to be taken night and morning (Waring's 
Therapeutics, p. 110). 
The systematic use of baths, simple, saline, or sulphurated, is decidedly 
beneficial. 
Cupping-glasses or moxas, along the line of the spinal column, has been of 
marked advantage in relieving the lesions of innervation, whether of increased 
or diminished sensibility. 
SCROFULA. 
Latin Eq., Struma; French Eq., Scrofule; German Eq., Scrophidose; Italian Eq., 
Scrofola. 
Definition.-A constitutional disease, resulting either in the deposit of tubercle, 
or in specific forms of inflammation or ulceration. 
Pathology.-The diseases with which the name of scrofula is associated are 
manifested by a remarkable tendency to certain forms of nutritive disorder, 
and hence they are strikingly wasting in their effects upon the body. They 
comprehend the following specific forms, namely ; (a.) Scrofula, with tubercle; 
(b.) Scrofula, without tubercle, and certain local scrofulous affections, such as 
tubercular meningitis, hydrocephalus, scrofulous ophthalmia, tubercular pericar- 
ditis, scrofulous diseases of glands, phthisis pulmonalis or pulmonary consump- 
tion, acute miliary tuberculosis, or tabes mesenterica, tubercular peritonitis- 
each of which will be considered in its proper place, under the local diseases 
of the organs affected. 
Many of these are characterized by the growth of a peculiar substance in 
the tissue of some organs rather than in others, to which the name of tubercle 
has been given. These growths occur in the tissue of the alimentary canal; 
in the peritoneum, arachnoid, or pleura; in the lungs, liver, spleen, or kid- 
ney ; in the tissue of the lymphatic glands, especially the cervical, inguinal, 
and mesenteric glands; and sometimes in the pancreas and the tonsils. 
These lesions owe their existence to constitutional conditions. There can 
be no doubt that, in the condition of scrofula with tubercle-the tubercular or 
wasting diseases-as well as in those in which scrofula is expressed without tuber- 
cle, there is a latent condition existing before the tubercles are apparent in the 
one case, and a scrofulous diathesis in the other. 
The relation of the nutritive and other morphological changes between the 
solids and the fluids of the body has everything to do with the development 
of the scrofulous state. In cases where the tendency to the growth of tubercles 
is hereditary, the operation of agents from without act as stimuli or excitants 
to the growth of them. 
Previous to 1829, when the late Sir James Clark published his classic 
work On Climate, the tendency of pathological researches into the nature of 
the diseases just mentioned was to keep up the idea that these diseases, and 
especially pulmonary consumption, were merely local, and referable to a local 
cause. 
The terms phthisis, consumption, or wasting, were originally used vaguely to 
designate a variety of chronic diseases, described entirely by local symptoms 
and physical signs, and therefore having few characters in common, except 
the marked emaciation which attends them. When researches in morbid 
anatomy became more frequent and efficient, the local lesion most commonly 
connected with the wasting of the body was discovered to be a peculiar mor- 
bid condition of the lungs, and to this the name of "consumption" was applied, 
and afterwards more definitely, "pulmonary consumption." From the fre- 
quency of this local lesion the pulmonary state of necessity attracted far 
greater attention than any other form of scrofula in which wasting was a 876 
SPECIAL PATHOLOGY SCROFULA. 
marked feature ; and when lesions in other organs were found associated with 
"pulmonary consumption," they were regarded as complications rather than 
as local manifestations of one and the same general constitutional state, and 
were looked upon as the primary cause of the emaciation. In 1819 Laennec 
first showed, by his accurate post-mortem observations on the state of the 
lungs, that growths to which the name of "tubercles" were applied formed 
almost the sole cause of consumption, and consequently he restricted the term 
phthisis to "the disease produced by tubercles in the lungs." Louis and Andral 
confirmed the observations of Laennec; and thus the view of this morbid 
state, based as it was on morbid anatomy alone, led to the enunciation of 
limited and erroneous doctrines regarding the real nature of the disease which 
the existence of tubercles indicates, either in the lungs or in any other part of 
the body. 
The relations subsisting between pulmonary phthisis, consumption, or wasting, 
and the occurrence of " tubercle," must now be even still more modified under 
the combined researches of morbid anatomy and progressive knowledge in 
pathology. Consumption, or wasting, in the common acceptation of the term, 
is not now found due always to tubercle (Addison, Gairdner, Reinhardt, 
Virchow, Jenner, and Maclachlan), so that the terms phthisis and tubercle 
cannot now be considered always as synonymous. Ulceration of the lungs 
and partial destruction of pulmonary tissue are found to arise from other 
causes than the existence of tubercles, which become equally efficient causes 
of phthisical mischief (Bayle, Armstrong, Graves, Stokes, and Mac- 
lachlan). Nay, we know also that many states of the body to which the 
name scrofula or struma is applied are not necessarily attended with " tuber- 
cles" at all; yet, when the local lesions of a tubercular nature are observed 
to be connected with marked constitutional states under various circumstances, 
the connection between scrofula with and without tubercle is seen to be of the 
closest description, and their pathological history is now generally believed 
to be identical. 
The extensive observations of morbid anatomists since the time of Laennec, 
elucidated by the most learned pathologists of the age, now tend to establish on 
a very broad foundation the doctrine first so strenuously and ably advocated 
by Sir James Clark, that the morbid conditions now mentioned are due to 
what he termed a "tuberculous cachexia;" and accordingly it is proposed to 
consider the constitutional disease, of which the occurrence and growth of 
"tubercles" is but a local expression, under the general title of Scrofula, of 
which the varieties are (a.) Scrofula with tubercle; and (b.) Scrofula without 
tubercle; while the local scrofulous affections are those named at the com- 
mencement of this topic. 
Clinical and pathological research tend more and more to confirm the be- 
lief in the constitutional origin of scrofula. There is undoubtedly a predis- 
position to scrofulous growths, either hereditary or acquired ; and that there 
is a bad habit of body-a cachexia-which precedes the development of tu- 
bercle, is now almost a general belief. 
The development of tubercles, wherever found, is undoubtedly a local lesion 
which indicates a constitutional disease. It has been hitherto, however, the 
custom to name the local lesions as the disease, rather than to describe the 
constitutional state. Thus, when the lesions have been most marked in the 
bones and glands, the name of scrofula has been given to the condition ; when 
the lungs are the site of the deposits, phthisis or consumption is the name by 
which the condition is familiar; and when in the glands of the mesentery, it 
has been called " tabes mesenterica;" and in the meninges of the brain it has 
been named " hydrocephalus," or " water in the head." The constitutional 
disease under which all these affections are now comprehended is named 
" scrofula," and is shortly defined as " a constitutional disease resulting either 
in the deposit of tubercle or in specific forms of inflammation and ulceration." PATHOLOGY OF SCROFULA. 
877 
The changes in the general system by which the scrofulous cachexia is 
brought about are apparent in the physical condition of the patient, and in 
the exercise of some of the vital functions especially connected with nutrition. 
To the late Dr. Tweedy Todd, Sir James Clark, and Professor Bennett, the 
profession is principally indebted for the clear and earnest elucidation of 
scrofula or tuberculosis considered as a constitutional affection : and on our 
knowledge of it as such rests our only hope of success in the prevention and 
treatment of this most formidable scourge of civilized society. 
Many observations have been made and statements recorded with the view 
to connect scrofula with morbid states of the blood, but hitherto no constant 
morbid condition of the circulating fluid can be said to be peculiar to the 
disease. As Dr. Bennett observes, we must look to something beyond-we 
must look to the pabulum which ministers to the nutrition of the body itself 
through the blood ; for with an impoverished state of that fluid there is doubt- 
less an impoverished state of the tissues. But there are some curious and de- 
tached observations which, when connected together in certain pathological 
relations, appear to throw more light on the nature of the constitutional state 
which leads to the development of scrofula than any single observation of in- 
dividual authors. These I would thus shortly enumerate: 
1. There is to be noticed the albuminous character of the fluid material 
which infiltrates the tissues of an organ previous to the process of tuberculiza- 
tion, by which this infiltration is in part changed by coagulation into gray 
tubercles, each of which may block up from three to twenty air-vesicles in the 
lung. 
2. There is in some cases, as shown by Drs. Alison, Williams, Bennett, and 
Rokitansky, an obvious affinity between the lymph of the blood and tubercle. 
3. There is an albuminosity or venous state of the blood which is consid- 
ered by some as peculiar to the scrofulous state of the constitution. 
4. There is the peculiar state of the blood, amounting to an appearance of 
leucaemia, which immediately succeeds digestion in healthy persons, as ob- 
served and described by Dr. Andrew Buchanan, of Glasgow, in The Trans- 
actions of the Philosophical Society (vol. ii) of that city, resembling the mo- 
lecular and corpuscular elements of chyle or lymph, and consisting of fat 
emulsionized with albumen. To this substance he gave the name of pabulin, 
and which is still further elaborated in the blood, in the glands, and in the 
lungs, before it takes part in the general morphological changes connected 
with nutrition. 
5. The observations of Dr. Acherson, of Berlin, and of Dr. Bennett, rela- 
tive to how nutrition may be impeded by diminishing the molecular state of 
the nutritive elements, and improved by increasing them. 
6. The observations of Panum and Parkes relative to the precipitation of 
albumen by acids and neutral salts, in which Dr. Parkes especially shows that 
the albumen as it exists in the serum of the blood is usually in that condition 
in which it is most easily precipitated by acids and chloride of sodium (Med. 
Times and Gazette, July, 1850 and 1852). 
7. The excess of intestinal acidity in the alimentary canal of phthisical 
patients, as shown by Dr. Bennett, by which, under some conditions, the albu- 
minous constituents of the food are rendered easily soluble, whilst the alkaline 
secretions of the saliva and the pancreatic juice are more than neutralized, 
and so rendered incapable of transforming the carbonaceous constituents of 
food into oil, or of so preparing fatty matters introduced into the system as 
will render them easily assimilable. Hence an increased amount of albumen 
enters the blood compared with fatty elements. 
According to the observations of Mr. Jonathan Hutchinson, acid eructa- 
tions were present in 62 per cent, of the cases of dyspepsia which preceded 
the deposition of tubercle, and were a prominent symptom in 46 per cent, of 878 
SPECIAL PATHOLOGY-SCROFULA. 
cases reported on by him in an admirable paper on the forms of dyspepsia 
preceding and attending phthisis (Med. Times and Gazette, vol. x, 1855). 
Any one of these statements considered by itself does not seem of much 
importance; but considered as a whole, in their relation to nutrition and their 
influence upon morphological changes between the solids and the fluids of the 
body, they leave very little room for doubt that the bad habit of body in 
scrofulous affections associated with the growth of tubercle-matter must be 
established in the first instance through the digestive processes, as first de- 
scribed by the late Dr. Tweedy Todd under the name of strumous dyspepsia, 
and which has been since so fully described by the late Sir James Clark, Ben- 
nett, Hutchinson, and others. 
The more closely these links of circumstantial evidence can be bound 
together, the more intimate a pathological relationship will be found to exist 
between the albuminous constituents of the food, the blood, and tubercle, and 
the saline constituents of the circulating fluid, the malassimilation of food, 
and the waste of the tissues, as connected with the development of the bad 
habit of body associated with scrofula. 
Although it must be confessed that we do not fully understand the living 
processes by which all the molecular changes take place to which I have just 
adverted, yet there can be no doubt that in the seven statements enumerated 
we obtain some glimpses of a rational pathology which may yet tend to ex- 
plain the very complex constitutional morbid state which precedes and is asso- 
ciated with the growth of tubercle in scrofulous affections, or with the specific 
inflammations and ulcerations of scrofula. ■ 
The diathesis which expresses the latent existence of scrofula has been 
variously described by the terms tuberculous, scrofulous or strumous diathesis. 
There is perhaps no subject in the whole range of medical science which the 
student ought to study more carefully than the cachexia, or special form of 
ill health, associated with the occurrence of tubercle and scrofulous affections. 
As a practitioner he will find that he becomes often painfully concerned in 
the deepest interests of families and society, through the threatened or actual 
ravages of scrofulous diseases. The extensive prevalence of the scrofulous 
cachexia-the great and almost inevitable mortality of the scrofulous diseases 
themselves, when completely developed, stamp the morbid state associated 
with them as a topic which at the outset of the student's career ought to engage 
a large share of study. Most assuredly the physician will have to turn his 
knowledge of the pathology of scrofula to account in every phase of his pro- 
fessional life; nay, further, when he knows, what experience has now ade- 
quately demonstrated, that the scrofulous cachexia springs from causes over 
which the public, rather than the medical profession, have control, he must 
be at once impressed with the belief, and encouraged with the hope, that when 
he acquires the confidence of the public in the practice of his profession, he 
may exercise a powerful influence for good in teaching how much the public 
may control the ravages of consumption by prudent marriages, sanitary atten- 
tion to offspring, and the necessity of free ventilation and of fresh air in places 
inhabited by man. 
There are several circumstances which show the great influence of public 
sanitary measures in controlling the development of scrofula, when these 
measures are scientifically directed to the preservation of the general health, 
and especially when men are associated together in great communities-an 
influence much greater than the best directed efforts of the medical profession 
can establish through their materia medica. It is by the mode of life as citi- 
zens of the world, in the social relations of husbands and wives, parents and 
children, and in the public relation of masters and workmen, that the extent 
and ravages of consumption and scrofula are to be controlled. It is by a strict 
attention to the rearing of offspring, and in the subsequent regulation of food, 
clothing, cleanliness, occupation, the choice of a profession, and by many other MORBID ANATOMY OF TUBERCLE. 
879 
circumstances which have an obvious influence (perhaps at first sight inap- 
preciable) on the maintenance of the general health, that our hopes of success 
as practitioners of medicine must rest in the prevention of that bad habit 
of body which develops and propagates the scrofulous diseases in civilized 
society. 
When the late Sir James Clark, in 1835, published his treatise on pulmonary 
consumption, he expressed some doubts as to tuberculous diseases being com- 
paratively more prevalent at the time he wrote than they were some fifty or a 
hundred years before. He was also of opinion that while many circumstances 
favored the probability of a diminution of tuberculous diseases, there were 
circumstances which might materially counteract such an influence; and 
while he was convinced that tuberculous diseases had increased, in the middle 
and upper ranks of life at least, he believed that, as a rule, the constitutions 
of the three past generations had deteriorated progressively from father to son. 
The annual returns of our Registrar-General up to 1846 show a progressive 
increase in the mortality from consumption. In 1854, however, we find it re- 
corded "that phthisis is twice as fatal as any other disease in England, but 
that within the last eight ears it appears to have declined to,some extent." 
The inquiries of Dr. H. Greenhow show that this diminution is in a great 
degree due to those hygienic measures which have contributed to diminish the 
causes of miasmatic diseases in general; and which have especially lessened 
the prevalence of those febrile exanthematous diseases which, by weakening the 
constitution, tend to bring about those conditions under which that bad habit 
of body is established which leads to the growth of tubercles and the develop- 
ment of scrofulous affections. To no kind of sanitary measure are we more 
indebted for this result than to the influence of vaccination in diminishing 
small-pox-a disease which, of all others, seems to have tended to the develop- 
ment of the scrofulous cachexia as a sequel to its existence. Accordingly we 
find it recorded by Dr. Greenhow that " during the middle of last century, 
before vaccination was known, the scrofulous death-rate was more than five 
times as great as our present one; and the pulmonary death-rate of'the present 
time is 7 per cent, lower than the pulmonary death-rate of 1746-55." 
While, therefore, such statements and careful observations, extended through 
long periods of time, show how much may be done by general sanitary meas- 
ures in preventing the extension of scrofulous diseases, there is still great 
necessity for a careful study of the nature of these diseases; for we find them 
in reality decimating the civilized part of the world, cutting off in some in- 
stances as many as 35 per cent, of our metropolitan populations, and a much 
larger percentage of the army. 
Morbid Anatomy of Tubercle.-The peculiar growth (erroneously called a 
deposit) which sometimes attends the diseases now under consideration is named 
tubercle from its external form, occurring as it does in small nodules', isolated 
or grouped together, or as large irregular masses, dispersed through the tex- 
tures of an organ. One essential character of tubercle is its incapacity to 
development beyond the state in which it first becomes visible, and in which 
state it may remain latent. It generally, however, exhibits a tendency to 
degenerate in various ways, involving in such degeneration the destruction of 
the tissue with which it is surrounded. It contains no trace of fibrous develop- 
ment (Rokitansky). 
The term tubercle is always understood to refer to adventitious masses of 
this nature, the type of which is found in the lungs, as the essential anatomi- 
cal constituent of pulmonary consumption. But the same material which- 
composes tubercles in the lungs is also found in many different forms in other 
organs; and wherever it occurs it is described as tubercle or tuberculous mat- 
ter; and tuberculous disease, or tuberculosis, is the usual designation of the 
specific malady of which the essential feature is the production of this peculiar 
matter (Paget). A review of the opinions of recent writers, by Dr. Jenner, 880 
SPECIAL PATHOLOGY SCROFULA. 
as to the nature of tubercle, in The British and Foreign Medico- Chirurgical 
Review for January, 1853, shows that the most eminent pathologists of the 
day are not at one as to the nature of this morbid product. "The opinions 
entertained regarding the nature of tubercle," writes Sir William Jenner, 
" may be divided broadly into two classes." One class of pathologists holds 
that tubercle is an exudation essentially morbid in character (Rokitansky, 
Bennett, Ancell, Lebert). Another class holds that tubercle is merely a 
retrograde metamorphosis of pre-existing structures, tissue-elements, or mor- 
bid products (Williams, Reinhardt, Henle, Gulliver, Addison). 
Virchow may be said to hold a doctrine combining both views. For, while 
he holds that tubercles are essentially composed of dead tissue-elements, 
whether these are physiological or morbid products, he also holds that a local 
process in all cases leads to an exudation of a material which is poured out dur- 
ing what he terms "a tuberculous inflammation," and which becomes organized 
to a certain extent, and then dies, breaks up, shrivels, and so leaves a knot, to 
which the name of tubercle is given. This process Virchow calls tuberculosis; 
and scrofulosis is the general constitutional state in which this tuberculizing 
process occurs, and which commonly leads to tuberculosis; or, in the words of 
Paget, "the relation between the two (terms) is, that the scrofulous constitu- 
tion implies a peculiar liability to the tuberculous diseases." According to 
Virchow, tuberculosis is the local process in scrofulous affections in which 
there occurs an exudation of a material, nutritive or pathological, which de- 
velops into cells, and that these cells tuberculize, or undergo the tuberculous 
metamorphosis. Tuberculization is therefore the local process by which the 
metamorphosis of the elements of a part into tubercle is effected by endoge- 
nous development, atrophy, shrivelling, and desiccation of its textural element. 
A form of tubercle thus results out of the detritus of the metamorphosed 
and atrophied cells, with the remains of the vessels and other structures of 
the part in which they were seated (Jenner). 
Whatever may be the view entertained regarding the exact nature of 
tubercle, this morbid product appears to us under two conditions, in forms 
more or less spherical, the contour of the masses being influenced-(1.) By 
the nature and movements of the surrounding tissue; and (2.) By the form 
of the part in which it first accumulates. The more recent and accurate 
microscopic observations which have been made into the nature and seat of 
the tuberculous deposit serve but to establish and confirm the more crude but 
scientific generalization made by the late Sir Robert Carswell, when he wrote 
that "the free surfaces of mucous membranes form the chief seat of tubercu- 
lous deposit." It is necessary, however, to extend the significance of the 
term free surface, and make it now apply to the ultimate and miscroscopic cul 
de sac terminations of mucous tubes. 
Gray and yellow tubercle-masses are the names by which such deposits are 
described, and they are first visible in the form of roundish granulations 
about the size of millet-seeds, and isolated or in groups of nodular masses of 
more or less irregular form. 
The gray tubercle is tough, soft, and compressible, of a pearly-gray color, 
and semitransparent. Microscopically, it is seen to be composed of irregular- 
shaped bodies, approaching a round, oval, or triangular form, and varying in 
size from ^^th t0 -zoVcJh of an inch. These sometimes appear to be im- 
bedded in a hyaline adhesive basis-substance, infiltrated with granules and 
molecules varying from a point scarcely measurable in size to the 
part of an inch in diameter. The most characteristic semitransparent gray 
granulations appear to contain more of the hyaline basis or connecting sub- 
stance than of formed elements, the whole field of view being more transpar- 
ent, and the elements less well expressed or defined. Acetic acid (weak, one 
part to four or six of water) dissolves many of the granules, and renders all MORBID ANATOMY OF TUBERCLE. 
881 
the corpuscles more transparent, while a similarly weak solution of potash 
completely dissolves them. 
Various opinions are entertained as to whether or not tubercle-masses ever 
consist of tubercle-cells with nuclei. Rokitansky holds that there are cells 
present containing one or more nuclei, and which indicate an endogenous de- 
velopment and growth of the elements just noticed. Gulliver and Vogel 
believe in the existence of such nucleated cells; Bennett, on the other hand, 
has never been able to discover nuclei in the corpuscles of tubercle. By many 
these cell-like elements are described and believed to be nuclei (Bennett, 
Schroeder Van der Kolk, Rokitansky, Paget, and Sieveking); and 
the view now related as entertained by Virchow, how existing tissue-elements 
may tuberculize, renders it highly probable that they,may be the nuclei of 
epithelial cells, as suggested by Van der Kolk, or of other cell-elements, nor- 
mal or pathological, as believed by Virchow; or they may be cell-particles, 
like nuclei, of slow formation and without any tendency to reproduction, but 
tending to disintegrate or break down into molecules, as described by Ben- 
nett. Paget enumerates the elements of tubercle as follows: 
"1. Molecules, granules, and oil-particles, usually of small size and ex- 
tremely predominant in yellow tubercles. 2. Nuclei of cytoblasts, of various 
shapes and structure, but all degenerate or defective; some glittering, hard- 
edged, wrinkled, and withered; others granular; and few or none with dis- 
tinct nucleoli. 3. Nucleated cells, similarly misshapen, withered, or granu- 
lar. 4. Certain compound cells, as described by Van der Kolk, and consisting 
of epithelium charged with the nuclei which become the common tubercle- 
corpuscles." 
When the masses of gray tubercle exist in the substance of the lungs, their 
resemblance to millet-seeds has sometimes procured for the deposit the name 
of miliary tubercles; and when the lung is cut through, the elastic nature of 
its texture causes it to contract upon itself, so that the parenchyma recedes 
from the tubercle-deposits visible on the surface of the section, and the de- 
posits appear slightly raised from the cut surface, and the finger may feel them 
as little resisting bodies set in the lung (Paget). When examined with a 
moderately magnifying hand lens, the borders of these masses are seen to be 
irregular, with short projecting processes. The contraction of the lung and 
the consequent squeezing of the tuber cle-ruwss, probably render these appear- 
ances mere secondary forms assumed by the gray granulations. 
Yellow tubercle is of various shades of color, and occurs in masses of vari- 
able size, generally larger than the gray deposits. These masses are opaque, 
friable, and of a cheesy, lardaceous consistence. The masses of yellow tubercle 
are more commonly grouped so close together that the movements of the lungs 
cause them to become fused in uniform tubercle-masses half an inch or more 
in diameter. 
Microscopically, yellow tubercle contains a much greater abundance of fine 
molecules than the gray tubercle, and there are also present in it elements 
similar to those in gray tubercles, which are shrivelled, indented, and wrinkled. 
There are thus no positive or characteristic morphological elements in tubercle, 
and the pathologist is therefore obliged to make the microscopic diagnosis of' 
tubercle by a process of exclusion or elimination. For example, if he finds 
that the substance he is examining consists of the elements just enumerated,, 
and that there are no bloodvessels nor blood-spaces in its interior, and that there 
is nowhere in it any fibrous matrix inclosing cells, he is surely dealing with a 
tubercular formation. But, on the other hand, if he finds, besides these ele- 
ments, a fine vascular provision for its nutrition and growth, with cells of a 
fully developed kind, and others degenerating, with blood-spaces, and having 
an areolar matrix-tissue, then he is most probably dealing with a malignant 882 
SPECIAL PATHOLOGY-SCROFULA. 
infiltrating growth, or a pneumonia in the lung, between the gradual invasion 
of which and tubercle there are points of analogy as well as of difference. 
The walls of the pulmonary artery are thickened in both; also the lining 
membrane of the bronchial tubes. In pneumonia, also, as well as where 
tubercle is being developed, the air-cells are increased in capillary action, fol- 
lowed by obstruction and breaking up of tissue. 
The developmental origin of tubercle is to be sought for, in the first in- 
stance, as a growth from the elements of the surrounding tissue, nourished by 
the adjoining capillaries; and if an exudation of a fluid kind is present, its 
infiltration assumes the granular form of albuminoid elements, and is incapable 
of further growth, but capable of receiving a deposit of earthy salts in its sub- 
stance, or of otherwise- degenerating. 
The fatty degeneration of tubercle seems to be a subsequent process, associ- 
ated with a softer state of the mass in which the organic cell-elements still re- 
main. To this oily or fatty degeneration is due the yellow color of tubercle; 
and hence, also, this yellow form is regarded as a secondary form to the gray 
granulation. It is in reality a degeneration or retrograde change. And this 
oily degeneration is not so favorable a local change as that by which the 
tubercle already formed wastes and dries up, while its further development 
ceases, and the mass assumes a cartilaginous-like consistence. At the same 
time calcareous salts are deposited in the mass, which then hardens or 
cretifies. 
In the gray tubercle this salutary change is uniform throughout the mass; in 
the yellow tubercle the calcareous salts are usually fouud in larger amount 
round the peripheric portion of the tubercle, closing in a pultaceous friable 
substance, composed of free fat-granules, aggregated globules of fat, brown or 
black pigment-masses, and plates of cholesterin. 
Vogel, Wedl, Virchow, and several other first-rate observers, are agreed that 
"an organized new formation constitutes the basis of the pathological structure 
known as tubercle." 
To verify this, the study of tubercle as a morbid growth ought to be com- 
menced with the development and growth of the new structure in the serous 
membranes, as in the arachnoid or pleura. In these textures we are not so 
apt to regard half-destroyed tissues as new products-a risk we always run in 
the examination of pulmonary tubercle. 
When thus examined in its early state, tubercle takes the form of a granule 
or a knot, as Virchow has demonstrated (Fig. 91) from examination of tuber- 
Fig. 91. 
Development of tubercle from connective tissue in the pleura. The whole succession of transitions is 
seen from the simple connective-tissue corpuscles, the division of the nuclei and cells, up to the produc- 
tion of the tubercle-granule, the cells of which in the middle are disintegrating into fatty granular 
■debris. 300 diameters. (After Virchow.) 
■cle, commencing in serous membranes like the pleura and arachnoid. The 
knot constitutes a new formation of cellular development, having its first be- 
ginnings in the connective tissue, and appearing, ab initio, in the shape of a 
granule. The special anatomical characteristic of the new growth is its ex- MORBID ANATOMY OF TUBERCLE. 
883 
treme richness in nuclei. By isolating the constituents of the youug tubercle- 
knot, either very small cells with one nucleus are obtained-so small that the 
membrane closely invests the nucleus-or larger cells with multiple division 
of the nuclei, so that 12, 24, or 30 are contained in one cell. The nuclei are 
always small, and have a homogeneous glistening appearance. The elements 
of scrofulous tubercle are relatively the smallest of any histological formation. 
It is only at its commencement it is pervaded by bloodvessels. When it en- 
larges, the little cells are so closely pressed together, that the bloodvessels are 
gradually obliterated, and only such large ones remain as traverse the tubercle 
altogether. Fatty degeneration very soon sets in at the centre of the growth, 
where the oldest cells exist; and when all trace of fluid disappears, the cells 
of the new growth begin to shrivel, the centre of the tubercle becomes yellow 
and opaque, and a yellow spot is seen in the midst of the gray translucent 
granule, knob, or tubercle. This is the commencement of the so-called cheesy 
metamorphosis. This change advances from without, outwardly progressing 
from cell to cell, till the whole tubercle-granule is gradually involved in the 
change. The elements of tubercle at last lie so closely together that the 
growth destroys itself; inducing, by pressure, the disappearance of the blood- 
vessels which supply its nutrition. The tubercle then begins to die away, 
and nothing remains but debris, in the form of the shrunken cells, and cheesy 
matter,-a condition common alike to pus, cancer, and sarcoma. The nature 
of tubercle cannot be learned after it has reached this stage. It is only at the 
early period, when engaged in proliferation, that its anatomical nature and 
structure can be determined. The histological elements of tubercle resemble 
those of the lymphatic, glands more closely than they do any other normal 
element of the body ( Cellular Pathology, Lecture xx). 
Few objects of morbid anatomy have been submitted to more minute research 
than "tubercle;" and there is scarcely any organ where the growth may not 
occur. Considerable differences of opinion have been entertained respecting the 
relation of the two varieties of tubercle which have been described. Laennec 
taught, and it has been the general belief since his time, that the gray tubercle 
is the earliest stage of the deposit, which subsequently becomes converted into 
yellow. Dr. Walshe has also investigated this point, and has taught a similar 
doctrine. Rokitansky, in the first edition of his great work on morbid anat- 
omy, regarded the yellow and the gray as essentially distinct forms, and con- 
sidered it an error to believe that the one is converted into the other. He 
now affirms that gray tubercle is sooner or later converted into yellow tubercle, 
as Laennec first taught, and which is now the common belief. When the 
gray tubercle does not pass into the yellow, it withers away. It loses its 
lustre, and becomes dry, dense, and hard, and shrivels into an indistinct shape- 
less fibrous-like mass. Sometimes such a change is associated with a calca- 
reous degeneration, the surrounding tissue in which it is imbedded becoming 
dark with the deposit of pigment. 
It is now believed and taught by Rokitansky, Virchow, and others, that cer- 
tain abnormal products, not apparently at first tubercular, afterwards tubercu- 
lize, and assume the appearance of yellow tubercles. To this change Virchow 
proposes to restrict the term " cheesy metamorphosis." The metamorphosis of 
gray to yellow tubercle generally commences in the centre of the growth, and 
subsequently the yellow tubercle undergoes most important secondary changes 
in a sanative point of view. These changes consist-(1) in softening; (2) in 
cretification or calcification; but it is not to be understood that the first of 
these two changes always passes into the second. 
The descriptions already given, and the metamorphosis about to be noticed, 
illustrate the distinctive and peculiar characters of tuberculous growth- 
namely, its early degeneration and abortiveness. It seems to be a substance 
which acquires a certain stage of organic development, when it is arrested in 
its course, recedes, and degenerates. Such characters may be read from the 884 
SPECIAL PATHOLOGY-SCROFULA. 
shrivelled or granular state of the so-called free nuclei and the barren cells. 
The changes about to be noticed show a still more retrograde decay (Paget). 
When tubercle softens, its substance breaks down into a tolerably uniform 
creamy pus-like fluid, in which are to be seen an immense number of fine 
granular points or molecules. The basis-substance appears to soften first; 
but in some kinds of softening much of the corpuscular forms are retained in 
a thin, whey-like, flocculent fluid, approaching in character to what is known 
as scrofulous pus, both microscopically and to the naked eye. The softening 
appears, on the whole, due to the breaking up of the corpuscular elements, as, 
well as of the basis-substance. When softening begins in the centre of the 
yellow crude masses, it leads one to believe that fluid may transude from the 
surrounding effusion or hypenemic state, and penetrate to the centre of the 
whole mass, where it may accumulate and increase the softening, without 
becoming developed into the visible cell-elements of tubercle. As each tuber- 
cle or group of tubercles undergoes this softening process, the softened mass 
occupies a cavity, which thus becomes an abscess, though not a purulent one, 
and the tissue involved by the growth of the tubercle is destroyed. It dies 
with the increased growth and softening of the mass. During this process of 
softening, tuberculous matter continues to grow in other portions of the organ, 
and when it occurs in the lung, generally from above downwards, so that 
excavations or cavities are found at the apex of the lung, while lower down 
yellow tubercle-masses, beginning to soften, exist; and still lower down the 
yellow tubercle is found in a crude state, as if newly changed, or in the process 
of being changed, from the gray granulations which are disseminated through 
the base of the lung. 
Pathologists are now agreed that the production of tubercle is quite inde- 
pendent of inflammation, in the ordinary acceptation of that term, implying 
thereby the presence of pain, heat, swelling, redness, lymph, or pus; but that 
in the great majority of cases inflammation is set up round the tubercle- 
masses, and plays an important part in promoting further growth of tubercle, 
which proceeds in a rapid course to softening and destruction of tissue. The 
phenomena of the growth of tubercle are also associated with the existence 
and supply of material which forms the fibrous thickenings and capsules 
around tubercular cavities or ulcerations. These phenomena also bring about 
the separation of the tubercle-mass from the surrounding parts, and if it is 
eliminated in any way, a cavity or an ulceration remains. When thus in- 
closed by fibrous thickenings or capsules, the softened tubercle may undergo 
the process of cretification or calcification; in other words, it becomes converted 
into a greasy, fatty, chalky mass, which gradually becomes hardened into a 
brittle substance. There appears to be either a deposit or a liberation of cal- 
careous particles in the mass, for the elements become mixed up with gritty 
particles of earthy salts; and at the same time there is absorption of the 
animal part, so that the original size of the tubercle growth is diminished. 
When tubercle is thus completely calcified, a thin section presents a granular 
appearance, but with no definite forms, combined with more or less pigment. 
Tubercle has been analyzed by many chemists. The analysis by the late 
Dr. R. M. Glover, of Newcastle, appears to be the most accurate and exten- 
sive.* His conclusions are as follows: 
"1. That tubercle consists of an animal matter mixed with certain earthy 
salts. 
" 2. That the relative proportion of these varies in different specimens of 
tubercle. That animal matter is most abundant in recent, and earthy salts in 
chronic tubercle. 
* This analysis, to be satisfactory, should be made on tubercles at different periods 
of life. The tubercle of the young strumous subject is believed to differ greatly from 
the tubercle-growth found in advanced life, especially in a gouty habit. MORBID ANATOMY OF TUBERCLE. 
885 
"3. That the animal matter certainly contains a large amount of albumen, 
while fibrin and fat exist in small but variable proportions. 
"4. The earthy salts are principally composed of the insoluble phosphate 
and carbonate of lime, with a small proportion of the soluble salts of soda. 
"5. That very little difference in ultimate composition has yet been detected 
between recent tubercle and the other so-called compounds of protein." 
Thus much is known regarding the histology of tuberculous growths and is 
here stated minutely, because we have the testimony of most experienced 
morbid anatomists, such as Bennett, Paget, and many others, that the micro- 
scope alone can decide as to the nature of those growths which closely resem- 
ble tubercle when examined by the naked eye. Indeed, such are the vague 
definitions given of tubercle, that, in the words of Bennett, "every morbid an- 
atomist must frequently have experienced much difficulty in endeavoring to 
determine by the naked sight whether a certain morbid product be or be not 
tubercle." 
The term "tubercular deposit" can scarcely be regarded as correct, although 
in common use. The expression ought rather to be " scrofulous or tuberculous 
inflammation;" just as we have been accustomed to use " tubercular meningitis" 
as synonymous with " scrofulous or tuberculous inflammation of the meninges." 
In the peritoneum the seat of scrofulous inflammation is immediately beneath 
the serous coat, where sanguineous congestions and minute extravasations first 
take place during the rapid formation of the tubercular granulations. 
In the mucous membrane of the alimentary canal the seat of scrofulous in- 
flammation is principally in the lower part of the small intestine. The tuber- 
cle grows originally in the submucous tissue, and elevates the mucous mem- 
brane stretched over the granulations. They project in the form of nodules 
assembled together in several groups. New7 granulations spring up between 
the older ones; and as these growths degenerate and soften rapidly in the in- 
testines, a fusion of the whole very soon takes place. The circulation in this 
part of the intestine is impeded, and its vitality is gradually destroyed; its 
mucous membrane is lost, and ulcerations form, whose shapes are decided by 
the form of the original growth. Thus: A single tubercle-nodule gives a 
crater-like ulcer. A number produces extensive ulceration, with irregularly 
excavated borders, the growth of the tubercle-masses being continued at the 
margins of the ulcers; and hence the thick border, with particles of yellow 
crude tubercle imbedded in it, so characteristic of these ulcers. Similar 
material may also be seen on the floor of the ulcers, the softening of which 
leads to perforation of the peritoneum. 
A considerable portion of the scrofulous exudation may transude in a fluid 
state, in the first instance, through the capillaries, and collect in those places 
outside the vessels that offer least resistance (Bennett). While, therefore, 
infiltration more or less extensive, as described by Baillie, is the first condition 
in which the exudation can be observed to exist, tubercle may be observed to 
accumulate on the free surfaces of mucous and serous membranes, or on the 
outer surface of minute bloodvessels. While, therefore, scrofulous material 
does not differ in its seat from the simple or cancerous exudations, when these 
form minute growths in the lungs or other parts, yet there is an important 
difference in regard to their relation with the bloodvessels, which requires to 
be specially noticed. It was first pointed outby Dr. William Stark that when 
attempts are made to inject a tuberculated lung, the finest injection will not 
reach, far less penetrate, the tubercle-masses. Bloodvessels which are of a con- 
siderable size at a little distance from tubercle-masses speedily become con- 
tracted, so that a large vessel, which at its origin measured nearly half an 
inch in circumference, could not be cut open, further than one inch ; and when 
cut open such vessels presented a very small canal, filled by a coagulated sub- 
stance. Schroeder Van der Kolk made similar experiments. He sometimes 886 
SPECIAL PATHOLOGY-SCROFULA. 
found that large vessels remained pervious which crossed a tuberculous cavity 
in a lung, but that all the small or capillary branches which adhered and were 
given off from the larger trunks were obstructed and impervious. These obser- 
vations lead to the conclusion that obliterat ion commences in the smaller vessels 
and proceeds to the larger trunks, and are of some importance with reference to 
haemoptysis and to the process of softening, and other changes which are ob- 
served to take place in this non-vascular growth. The process of softening is not 
so uniform in its progress as the notice already given might lead one to suppose. 
Cancerous growths, on the other hand, are highly organized, containing 
large, voluminous, and generally multiform elements. 
It appears difficult in every instance to ascertain at what part softening 
commences, so that it is incorrect to give a general description of this change 
as always commencing in one place. In one case it may begin in the centre 
and proceed to the circumference of the growth; in another it may begin at 
the circumference and go round the whole mass, detaching it from the sur- 
rounding textures; in a third case it may begin at once in the centre and at 
the margins; and in other instances it has been observed to commence at the 
same time in several parts of the substance of the tubercular mass ; and this is 
especially the case where the masses are large (Craigie, Bennett). The 
portion or spot about to soften loses its firmness and becomes friable, the cells 
swell and break up, adding thus by their solution to the diffluency of the mass. 
Inspected with a common hand lens, the mass seems as if perforated here and 
there with holes, and this softening extends by degrees throughout the whole 
growth. The air-vesicles necessarily are destroyed by this process, and the 
terminal extremities of the bronchi are amongst the first structures to suffer. 
The mucous membrane which covers them is red and villous in the vicinity of the 
softened part, and as tuberculosis proceeds, the whole of the pulmonary mucous 
membrane presents the anatomical characters of chronic bronchitis. The 
softening of the growth and the inflammation of the textures seem to act and 
react upon each other; liquefaction seems to extend more rapidly when local 
inflammation is set up, and the softenings on the other hand, appear to aug- 
ment the local reaction. 
Healing of Local Lesions in Scrofula.-It is of the greatest importance to 
study how some of the most unmanageable and hopeless diseases will some- 
times spontaneously become cured, and how the local lesions will heal. That 
scrofula sometimes tends to these results we have abundant testimony daily 
afforded in almost every post-mortem examination of those who die of phthisis 
pulmonalis. Laennec, Carswell, Clark, and Bennett have recorded their tes- 
timony on this interesting point; and the practical result of their observa- 
tions shows that if the further growth of tubercle can be arrested, the 
masses already existing may silently retrograde, become absorbed, or dimin- 
ish in size, and the part cicatrize, or it will remain latent as a cretaceous mass 
in the lung. 
Symptoms of Scrofula, or of the Cachexia which Precedes and Accom- 
panies the Growth of Tubercle.-Ever since scrofula has become more 
studied as a constitutional affection, it has been rendered more apparent that 
impairment of the digestive organs is the primary disorder of. function 
which ushers in the cachexia, and that a certain form of dyspepsia is not 
only present in the hereditary strumous constitution, "but is capable of gen- 
erating the bad habit of body, and of leading ultimately to the deposition of 
tubercle." 
It was first observed by Dr. Wilson Philip " that there wrere some forms of 
indigestion which ended in phthisis;" and it was subsequently distinctly 
stated by Lepelletier that the causes of scrofulous disease were referable- 
(1.) To those agents which impair the assimilative action; (2.) To the ele- 
ments of nutrition being insufficient, by the influence of bad diet, impure air, SYMPTOMS OF SCROFULA. 
887 
deficient exercise of the general functions, and obstruction of the functions 
of excretion. 
It was reserved, however, for the late Dr. Tweedy Todd, as already noticed, 
to show that in cases in which the strumous cachexia was present a particular 
form of dyspepsia prevailed, to which he gave the name of "strumous dys- 
pepsia." Subsequently the views of Dr. T. Todd were more or less fully ac- 
cepted and developed by Sir James Clark, Bennett, Ancell, and others in this 
country ; but the most precise and most recent exponent of them has been 
Mr. Jonathan Hutchinson, in two valuable papers in The Medical Times and 
Gazette, vol. x, 1855. Mr. Hutchinson, from statistical evidence, shows that 
the tuberculous cachexia is preceded by a peculiar form of dyspepsia; in other 
words, that there is a peculiar form of dyspepsia which has a natural ten- 
dency to end in phthisis; and that it is a form of dyspepsia not common to 
other conditions of the system-different, for instance, from that which pre- 
cedes and attends gout, chlorosis, or cancer, although accurate observation is 
wanting on the exact symptoms of dyspepsia which are associated with these 
diseases. 
The conclusions which have been arrived at by Mr. Hutchinson are as 
follows: 
1. In a very large majority of cases of established phthisis a condition of 
well-marked dyspepsia is present as a complication. Out of fifty-six cases it 
was absent in four, present mildly in twenty-one, moderately in twenty-two, 
and severely in nine. 
2. Of the form of dyspepsia most common in established phthisis, the 
prominent symptoms relate to difficulty in the assimilation of fatty matters. 
The patient acquires a remarkable distaste for all fats, which occasionally ex- 
tends itself to sugar and even to alcohol; he suffers much from "biliousness," 
heartburn, flatulence, and, above all, from acid eructations after taking food; 
everything he takes "rises acid," to use a common expression of such patients, 
but more particularly everything containing fat, oil, or sugar (butyric fermen- 
tation). 
The dislike for fat was present in 71 per cent, of the cases of confirmed 
phthisis, and had existed through life in 48 per cent. It invariably produced 
what is commonly called "biliousness," and "rose acid" from the stomach. 
The fat of fresh meat was generally the first to disagree, then salted meats, 
such as bacon, and lastly butter; but many could enjoy butter who could not 
touch any other kind of animal fat. Such an intense dislike to an important 
element of a mixed diet indicates a deficiency on the part of a patient to digest 
it. Coincident with the development of such symptoms emaciation usually be- 
comes apparent, the adipose tissue of the body already existing being reab- 
sorbed by the blood to supply the respiratory element deficient in that fluid. 
The fat disappears from the subcutaneous tissue, hollows of the cheeks, orbits, 
and mammary glands, and other parts where it generally abounds in quantity, 
just as it disappears from the body of an animal during hibernation. The 
patient now gradually loses weight and becomes thinner. Other tissues of 
the body, such as the muscles, skin, and areolar tissue, subsequently begin 
to be used up for a similar purpose, till the patient is wasted to a living 
skeleton. 
The acid eructations were present in 62 per cent, of the cases, and were a 
prominent symptom in 46 per cent., small quantities of an extremely acid fluid 
being repeatedly brought up into the pharynx at various periods after taking 
food, and in bad cases these eructations were persistent throughout most of 
the clay, and almost always attended by heartburn. Sick headaches and bilious- 
ness were very commonly present. 
Dr. Pollock's experience shows that acidity of digestion has only a constant 
relation to the acute form of the disease. Of that form it is a distinctive 888 
SPECIAL PATHOLOGY-SCROFULA. 
character. Laennec, Louis, and Pollock all record diseased states of the 
stomach in post-mortem examination of phthisical patients. 
3. The majority of cases of phthisis pulmonalis, whether hereditary or other- 
wise, are preceded by a well-marked stage of dyspeptic symptoms. By this 
it is meant that symptoms referable to the digestive organs have preceded 
those connected with the lungs. Out of the fifty-two cases in which, as has 
been shown, dyspepsia was present, it had followed pectoral symptoms in nine, 
was developed nearly coincidently with them in ten, and preceded them in 
thirty-three. 
4. The symptoms of the dyspepsia premonitory of phthisis are the same in 
character with those which complicate it when developed. The very earliest 
are alterations in the tastes, and the most constant of all is a disrelish for fat. 
5. The subjects of phthisis have in a large number of cases had peculiarities 
of likes and dislikes for different articles of food even from very early life, and 
whilst seemingly in perfect health. Amongst those peculiarities the dislike 
of fat, often amounting to extreme aversion, ranks first. Thus it might be 
predicated of a family in which one child distinguishes itself from its brothers 
and sisters by constant refusal to eat fat, that such a child will, cceteris paribus, 
be more prone to become the subject of tuberculous disease in after-life than 
any of the others. 
Besides the indications afforded by the functions of digestion, there is a 
peculiar modification of the whole organization, as regards structure, form, 
and the exercise of functions generally, which impresses distinctive characters 
on the scrofulous cachexia when it is of hereditary origin. Miller gives the 
following concise description of this organization: 
" The complexion is fair, and frequently beautiful, as well as the features. 
The form, though delicate, is often graceful. The skin is thin, of fine texture; 
and subcutaneous blue veins are numerous, shining very distinctly through 
the otherwise pearly-white integument. The pupils are usually spacious; and 
the eyeballs are not only large but prominent, the sclerotic showing a lustrous 
whiteness. The eyelashes are long and graceful-unless ophthalmia tarsi exist, 
as not unfrequently is the case; then the eyelashes are wanting, and their 
place is occupied by the swollen, red, unseemly margin of the lid. 
" In the phlegmatic form the complexion is dark, the features disagreeable, 
the countenance and aspect altogether forbidding, the joints large, the general 
frame stinted in growth, or otherwise deformed from its fair proportions. The 
skin is thick and sallow; the eyes are dull, though usually both large and 
prominent; the general expression is heavy and listless; yet not unfrequently 
the intellectual powers are remarkably acute, as well as capable of much and 
sustained exertion. The upper lip is usually tumid, so are the columna and 
alee of the nose, and the general character of the face is flabby; the belly in- 
clines to protuberance; and the extremities of the fingers are flatly clubbed, 
instead of presenting the ordinary tapering form " {Principles of Surgery, 
P- , . 
Canstatt has given the following description: "An unusually large head, 
coarse features, a thick chin, swollen abdomen, enlarged cervical glands, and 
flabby, spongy flesh. The skin is of remarkable whiteness, with a tendency to 
redden easily, and through which the rose-pink or bluish subcutaneous veins are 
visible; a deep redness of the cheeks and lips, blueness of the thin and trans- 
parent sclerotic, which imparts a swimming and languishing look to the eyes. 
The muscles of such persons are thin and soft, and their weight is light in 
proportion to their stature, indicating a slightness of their bones. The teeth 
are handsome and of a bluish lustre, though long and narrow; and the hair 
is soft." 
The growth of the body is generally unsteady in its progress; very often it 
is slowly and imperfectly developed; in other cases it is unusually rapid, par- 
ticularly towards puberty. The physical powers are generally feebly devel- CAUSES OF SCROFULA. 
889 
oped, and incapable of sustained exercise. The muscles of the limbs, though 
full, are soft, flabby, and weak, and have neither the form nor the firmness of 
health. The general circulation is feeble, the weak pulse and cold extremities 
indicating the debility. Digestion is feebly and imperfectly performed, the 
bowels being irregular, and more frequently slow in their action than the 
reverse. 
The mucous membranes generally are very susceptible to disordered action. 
Discharges from the nose, ears, or eyes are not uncommon; the tonsils enlarge, 
and the air-passages inflame from the slightest causes. The insensible perspi- 
ration is defective, and is said to be unduly acid, and loaded with sebaceous 
matter; while, on the other hand, copious partial perspirations are common, 
particularly on the feet, where the odor is often fetid. 
In children, the impaired functions of the digestive organs are indicated by 
increased redness of the tongue, especially toward the extremity and along 
the margins. The anterior part is thickly spotted with small red points of a 
still brighter color, the central portion being more or less furred, of a white 
or of a brown color, in the morning. Thirst prevails; the appetite is variable, 
more frequently craving than deficient, seldom natural; and the breath is 
fetid. The bowels are occasionally loose, and the evacuations are always 
unnatural, generally of a pale-grayish color, of the consistence and appearance 
of moist clay; and they are often mixed with mucus and partially digested 
food. While the urine is often turbid, and sometimes high-colored, it is also 
often abundant and pale. The skin is generally harsh and dry, or subject to 
cold perspirations, particularly the hands and feet, which are habitually cold; 
and copious partial night-sweats are common. The sleep is seldom sound; 
the child is restless, talks in his sleep, or grinds his teeth (T. Todd, Clark). 
Subsequently, when the disordered state has continued for some time, the 
internal fauces become full and red, and inflammatory sore throats are com- 
mon, the tonsils often becoming permanently enlarged. The nostrils are gene- 
rally dry, or thick mucus may be discharged in large quantity. Epistaxis 
occasionally occurs. 
The nervous sensibility is sometimes greatly increased, and the intellectual 
functions are often performed with a preternatural degree of activity. So 
frequently is this observed, that it has become a popular belief and saying 
regarding such a child, " that it may be too wise to live long." 
Inflammation in any tissue in a scrofulous subject generally assumes a slow 
chronic type, accompanied with little pain or heat; and suppurating parts 
heal very slowly. 
When the scrofulous cachexia becomes fully developed into phthisis pul- 
monalis the duration of the disease ranges from about nine months to two 
years ; but in what are called " acute " cases of consumption, it may termi- 
nate fatally in three or even in two months, and occasionally in as short a 
period as three weeks, or even less. 
The most reliable results of the duration of phthisis are those given by Dr. 
Pollock. His experience shows that it lasts much longer than has been gen- 
erally believed. Early invasion, subsequent subsidence of symptoms, and 
long tolerance of the deposit obtain in many cases, and thus show an un- 
doubted tendency to extreme chronicity. Since greater accuracy in diagnosis 
has prevailed, consumption has been known to last much longer,-the aver- 
age duration, out of 3566 cases observed by Dr. Pollock, being two years, six 
months, and three-fifths nearly, including cases of the most acute form. 
Causes.-In describing the pathology and the symptoms of the scrofulous 
cachexia, the cause of the constitutional disorder has already been in some 
measure indicated. 
The tendency to the formation of tubercle in scrofula is not equally great 
at all periods of life, nor in all parts of the body. Tubercle in the bronchial 
glands, the lungs, the cervical glands, the mesenteric glands, the spleen, the 890 
SPECIAL PATHOLOGY -SCROFULA. 
pleura, the liver, the small intestines, and the brain, is most common in in- 
fancy, childhood, and early adolescence. But the occurrence of tubercle, 
which forms so large a portion of the lesion in all scrofulous affections, al- 
though it has been found in the foetus, and at every period of life up to eighty, 
yet it will be observed that tubercle, after the age of fifteen, is more frequently 
met with in the intestines, the mesenteric, cervical, and lumbar glands. Scrof- 
ulous disease is frequently developed during infancy ; and " I have met with 
several cases of infants," writes Sir James Clark, " dying of consumption 
within the first year of life, in whom the lungs were not only extensively 
tuberculous, but contained large caverns, with all the characters of those 
found in the lungs of adults." After the second year of life, pathologists 
agree as to the universal prevalence of scrofulous disease. Age exercises a 
paramount influence on the generation of scrofula. It is peculiarly a disor- 
der of childhood and youth (Gueesent, Lombard, Papavoine, Alison, 
Clark, Bennett). Dr. Alison demonstrated that the mortality from scrofu- 
lous diseases in the children of the lower orders in Edinburgh and other large 
towns was .so great that they died in the enormous proportion of forty-five 
or fifty to five and even three, as compared -with the agricultural aud upper 
classes. Tubercles prevail most through the third, fourth, fifth, and sixth 
years, when the annual growth does not exceed one-tenth of the child's weight, 
and the mortality declines to nearly one in a hundred. More than a fourth 
of those who die in the interval from birth to puberty are affected with scrofu- 
lous disease ; yet the disease itself causes death in about one-sixth only of 
the cases (Clark). The greatest number of deaths occur between the ages 
of twenty and thirty; the next in proportion between thirty and forty; the 
next between forty and fifty. The mortality is at its maximum about thirty, 
and from that age declines. 
The broadest fact established regarding the exciting cause of scrofula is, 
that the domesticated animal is more liable to scrofulous disease than the 
same animal in a wild state. The stabled cow, the penned sheep, the tame 
rabbit, the monkey, the caged lion, tiger, or elephant, are almost invariably 
cut off by scrofulous affections-no doubt due to deficient ventilation and the 
abeyance of normal exercise of the pulmonary function. 
On this point Dr. Clymer has drawn up the following appropriate results : 
" There appears to be little doubt that persons who breathe continuously 
air vitiated by respiration furnish a large percentage of phthisical cases. 
This cause is potently aided by the coincident conditions of deficient exercise, 
poor feeding, and, often, excessive work. Baudelocque, years ago, asserted 
that impure air was the chief cause of phthisis. Carmichael, in his work on 
Scrofula (1810), gives a number of examples of the influence of foul air and 
want of exercise in the production of the disorder. Lepelletier, Neill Arnott, 
Toynbee, Guy, Greeuhow Baly, and others, have collected a good deal of evi- 
dence in support of this cause of tuberculosis. Of 104 compositors who worked 
in rooms of less than 500 cubic feet for each person, 12.50 per cent, had had 
haemoptysis; of 115 in rooms having from 500 to 600 cubic feet, 4.35 per 
cent, had had haemoptysis ; and in 101, in rooms of more than 600 cubic feet, 
1.98 had had haemoptysis (Guy). In the prison of Leopoldstadt, at Vienna, 
very badly ventilated, in the years 1834-1847, 51.4 per 1000 died from phthis- 
is, there being 42 cases of acute tuberculosis ; while in the well-ventilated 
House of Correction, in the same city, the deaths from phthisis were only 7.9 
per 1000. The great prevalence of phthisis in the Indian jails is ascribed to 
bad air and bad food (Parkes, loc. cit., p. 96, 2d ed.). Dr. Henry MacCormac 
is, perhaps, the most enthusiastic advocate of the doctrine of the effects of re- 
breathed air in the etiology of tuberculosis; so far does he carry his doctrine 
that he makes it almost an exclusive cause of phthisis. 'Wherever the air, 
habitually respired, has been respired in whole or in part before, there tuber- DEFICIENT VENTILATION A CAUSE OF SCROFULA 
891 
cular deposits are found.'* The greater relative frequency of phthisis in 
females Dr. Lawson attributes to their indoor occupations and sedentary 
habits.^ The chief cause of the extraordinary frequency of phthisis in the 
European armies, to be presently spoken of, Dr. Parkes says, ' can scarcely 
be accounted for in any other way than by supposing the vitiated atmosphere 
of the barrack-room to be in fault. This is the conclusion which the Sanitary 
Commissioners for the British Army came to in their Report, after assigning 
all probable influence to exposure on duty, intemperance, syphilis, and faulty 
diet. The disease is found to prevail in the most varied stations of the army, 
and in the best climates, but where there was always the one common condi- 
tion,-the impure air of the barrack system. And, as if to clench the argu- 
ment, there has been of late years a most decided decline in phthisical cases 
in these stations (Gibraltar, Malta, Ionia, Jamaica, &c.); while the only cir- 
cumstance which has notably changed in the time has been the condition of 
the air. So also the extraordinary amount of consumption which prevails 
among the men of the Royal and Merchant Navies, and which, in some men- 
of-war, has amounted to a veritable epidemic, is in all probability attributable 
to the faulty ventilation ' (Parkes). The statistics of the Hospital for Con- 
sumption and Diseases of the Chest, London, show that among 3214 men, who 
composed all the cases of decided phthisis which were registered as in-patients 
in ten years, more than one-half-1812-had followed indoor occupations ; 
and of the 2413 females nearly all had. 
Table Showing the Occupations of 5627 Persons of Both Sexes affected 
by Phthisis.| 
Males. 
Bakers, ..... 64 
Bookbinders, .... 17 
Bricklayers, .... 109 
Butchers, ..... 3 
Carpenters, .... 295 
Clerks and Shopmen, . . 394 
Coachmen, .... 211 
Gardeners, . . . .82 
Laborers, ..... 539 
Smiths, ..... 89 
Teachers, ..... 42 
Tailors, ..... 145 
Weavers, ..... 11 
At Home, ..... 63 
Males. 
Various, ..... 49 
Mechanics, .... 176 
Painters, . . . . .105 
Printers, ..... 103 
Publicans,. . . . . 46 
Railway, . . . 38 
Sailors and Watermen, . . 74 
Servants, ..... 285 
Shoemakers, . . . .171 
Soldiers and Police, . . . 103 
Other Trades, . . .150 
At Home, ..... 278 
Total, 3642 
Females. 
Servants, 984 
Domestics, .... 447 
Milliners, ..... 397 
Laundresses, .... 77 
Females. 
Governesses, &c., . . . 80 
Total, 1985 
"Dr. Pollock, one of the physicians, states that the occupation of out- 
patients would give the same result. It must then be admitted, from over- 
whelming testimony, 'that deficient ventilation and crowded apartments are 
eminently productive of tubercular disease.' Those trades which require a 
stooping posture-as tailors, boot-makers, weavers-which by mechanical 
hindrance to the free entry of air into the lungs, restrict the expansion of the 
* Consumption, as Engendered by Rebreathed Air, &c., 2d ed London, 1865. 
f A Practical Treatise on Phthisis Pulmonalis. Cincinnati, 1861. 
j Second Medical Report of the Hospital for Consumption and Diseases of the 
Chest, 1863. 892 
SPECIAL PATHOLOGY-SCROFULA. 
chest-walls, and result in imperfect performance of the respiratory function, 
and consequent interference with the proper nutrition of the pulmonary 
tissues, and general lessened vitality of the system, furnish, no doubt, a large 
proportion of cases of tuberculosis. The influence of lessened breath-mo- 
tion as an exciting cause of phthisis, has been particularly insisted on by 
Dr. Edward Smith, in his excellent work on Consumption, its Early and Re- 
mediable Stages." 
Hirsh also has collected a large number of facts, proving that in foundling 
hospitals, orphan asylums, boarding schools, factories, and similar institutions, 
the continual abode in a badly ventilated atmosphere, saturated with steam, 
and poisoned by animal effluvia, and the products of putrefaction, is in the 
highest degree favorable to the development of scrofula; and that, according 
to the experience of these institutions, where there is no lack of cleanliness, 
good food, and warm clothing, the above pernicious agents alone suffice to 
induce the disease (quoted by Niemeyer). 
Bowditch, in America, ascribes the most efficient development of scrofula 
to moisture and damp. 
The disease springs most frequently, however, from the combined effects of 
all these different anti-hygienic influences, the chief of which is bad nourish- 
ment and want of fresh air. 
Parents whose digestive organs are habitually disordered, who suffer from 
gout, the injurious influence of metallic and other poisons, such as mercury, 
malaria, syphilis, chlorosis, or paludal anaemia, the debility of advanced age, so 
that a cachectic state is induced, entail upon offspring begotten during such 
morbid states of the parent, to an extent still undetermined, but obvious and 
appreciable, a tendency to the scrofulous constitution, not necessarily to be 
expressed by the growth of tubercle in the lungs, but certainly and surely 
by various forms of dyspepsia, and a precarious state of health. 
There are many circumstances in the state of the parents' health, pre- 
sumed, with justice, to influence the health of the children born under them. 
Among these may be mentioned a disordered state of the health of the mother, 
interfering with the state of the foetus in utero, depressing passions, and gener- 
ally an unhealthy mode of life. " In the present state of our knowledge," 
writes Sir James Clark, " it is not possible to determine the various circum- 
stances in the health of the parent which may give rise to scrofulous growth 
in the child, much less to explain the development of scrofula. I rather 
allude to them as subjects deserving the investigation of the general pathol- 
ogist and practical physician. There may be differences of opinion as to the 
particular condition of the parent which induces the tuberculous constitution 
in the offspring, and also as to the degree in which this constitution may exist 
in the child at birth." 
Let the topics suggested in this quotation be diligently inquired into by 
those who have the opportunity; and let the initiative be followed up, so ably 
set forth by Dr. Walshe in the model paper from which the previous state- 
ments have been quoted. 
In the experience of Dr. Pollock, the disease was hereditary in 362 or 
30.16 per cent, of all the cases. Of the remote causes of tuberculosis, he 
writes: 
"Of all of these, doubtless the, most important is hereditary predisposition; 
for, in its absence, how many struggle through influences and errors which 
destroy others in early life, and attain a considerable longevity? Not all the 
predisposing causes united could, in a given instance, induce consumption 
with certainty, without some subtle agent to precipitate, concentrate, and 
shape those elements of disease into tubercle. ... In the absence of more 
accurate knowledge than science yet possesses, we are inclined to refer the hereditary transmission of scrofula. 
893 
actual precipitation of the disease which we call tubercle to the influence of 
hereditary predisposition acting in conjunction with, or occasionally even in 
the absence of, all or any of the other remote agents which give rise to 
phthisis. ... If to any or all of these conditions that of inherited tendency 
to phthisis be superadded, very few indeed escape the disease. . . . Finally, 
the forms of disease, those modifications on which depend its rapidity, devel- 
opment, and duration, are most distinctly reflected in families. How often 
do we witness child after child carried off at the same age by the same variety 
of tubercular disease. Tuberculosis, though not present in the parents, may 
have an ancestral origin generations back." 
The concurrent opinions of the entire profession now fully establish the 
fact that the tuberculous predisposition is capable of transmission from parent 
to offspring. 
The scrofulous constitution has been observed to manifest itself in the 
child under the following circumstances: 
1. At birth tubercles may exist in one or more organs (Chaussier, Oehler, 
Husson, Billiard). 
2. The scrofulous cachexia, already defined and described, may rapidly 
show itself. 
3. By the rapid occurrence of tubercles commencing very soon after birth, 
subsequent to the gradual appearance of symptoms of the scrofulous ca- 
chexia. 
4. By a disposition to the various forms of dyspepsia, whose characters 
have been already noticed (page 887, ante). 
Race has an influence in the production of phthisis. In this country the 
tendency of the Creole and Negro to phthisis is notorious. But it is noto- 
rious also that the Creole and the Negro, when removed beyond certain 
limits of the land of their nativity, become tuberculous in other lands besides 
Great Britain. In the West Indies some of the black races -arc by no means 
exempt from this disease, and the Creoles die of phthisis in large numbers in 
Martinique (Rufz, Nott, Morton). This is the more unlooked for, because 
as children they live almost in the open air, bathe daily, or still more fre- 
quently, and are singularly cleanly in their persons. 
"Among the predisposing causes of phthisis," writes Laennec, "I know of 
none more certain than the depressing passions, especially when they are pro- 
found and long indulged; and this perhaps is the cause of the greater preva- 
lence of this disease in larger towns, where bad habits and bad conduct are 
more common, and often the cause of those bitter regrets which neither time 
nor consolation can assuage." He adds, " I had under my own eyes for ten 
years a most striking example of the influence of melancholy in the produc- 
tion of phthisis. There existed in Paris for that space of time a nunnery of 
a new foundation, and which had not been able to obtain from the ecclesias- 
tical authorities anything but a temporary tolerance, on account of the 
severity of its rules. The alimentary regimen of the nuns, although ex- 
tremely severe, was still not beyond the bounds of nature; but the spirit of 
the rules of the nunnery, directing the mind to the inost terrible rather than 
to the consoling truths of religion, as well as compelling the inmates to resign 
themselves in everything to the will of the abbess, produced effects as sad as 
unexpected. These effects were the same in all. At the end of two months' 
sojourn in this house the menses became suppressed, and in a month or two 
afterwards symptoms of phthisis appeared. As the nuns had not been 
allowed to take the usual vows, I entreated that they would leave the house, 
and all who followed this advice recovered. But during the ten years I was 
physician to this establishment the members were renewed twice or thrice, 
with the exception of the superior, the tour lire, the sisters who had the care 
of the garden, of the kitchen, and of the infirmary, or of such as had more 894 
SPECIAL PATHOLOGY-SCROFULA. 
frequent intercourse with the city, and consequently greater distraction. The 
rest died of phthisis." 
These circumstances now noticed-namely, hereditary predisposition, or 
the influence of parental cachexia generally, of various sources, especially 
syphilis, the influence of race, and of depressing passions-all co-operate, 
where they exist, in establishing the scrofulous cachexia ; but the efficient 
cause seems to be " the impoverished nutrition resulting from impure air, and 
an improper quantity, quality, or assimilation of food; and so long as misery 
and poverty exist on the one hand, or dissipation and enervating luxuries on 
the other, so long will the causes be in operation which induced this terrible 
disease" (Bennett). 
It is, therefore, the constitutional state previous to the actual occurrence of 
local scrofulous affections like tubercle which it is of the utmost importance, 
if possible, to recognize; and the question has been proposed, "Whether or 
not a predisposition to scrofula can be anatomically or otherwise demon- 
strable ?" There can be no doubt that an assemblage of phenomena, more 
or less well expressed and obvious, are characteristic of the scrofulous con- 
stitution. These phenomena are mainly due to impaired nutrition of the 
fundamental parts of the frame, and are associated with imperfect growth, 
especially of the skeleton, the nervous system, and the intestinal tract-im- 
perfections capable of hereditary transmission to a remarkable extent. Of 
the structural characteristics of scrofulous persons, none are so significant as 
the weakness of cell-growth apparent in imperfections of the areolar tissue, 
as seen in the smooth, soft, delicate, blanched, and transparent skin. The 
nails are generally defective, elongated, and remarkably incurved. The 
mucous membranes are thin, pale, delicate, attenuated, and easily expanded. 
The debility of their function has been already fully noticed. The vascular 
system is thin, the vessels are transparent, more distensible, and less contrac- 
tile than in the robust and healthy, and the visible tenuity of the vascular 
coats is sometimes rendered apparent in the tendency to hemorrhages from 
slight causes. The veins are conspicuous, and appear to be more numerous 
under the skin. The bones are imperfectly grown, and there is often a greater 
want of symmetry than usual in the skeleton. 
The weight of the man is light compared with his size and his age, and on 
these points in healthy men there ought to be a due concurrence. So impor- 
tant is the information capable of being derived from accurate observations in 
this direction that the following tables are given for the purposes of com- 
parison. (See pages 895 and 896.) 
Growth, expressed by stature and weight, is thus most marked between the 
ages of fourteen and sixteen years (p. 896). Its rate is as much as three inches 
in height during that time, and about ten inches from the age of eleven to 
eighteen, and it goes on to be marked between eighteen and twenty-five years 
of age to the extent of about two inches. 
There are also ample physiological reasons of the most cogent kind, which 
clearly show that great care is necessary in the physical training of young 
persons.* The main reasons are to be found in the correlations which obtain 
amongst the following elements, and which ought to be maintained at the 
healthiest standard, namely-(l.)Age; (2.) Weight; (3.) Stature; (4.) De- 
* I. Compare the average height of full-grown men at twenty-five years of age, as 
given by the following observers: 
Quetelet, . . 5 feet 5.27 inches = 65.27 inches. 1 
Danson, . . . 5 " 6.30 " -66.30 " I . q 
Boyd, . 5 " 7 " =67 " Average, 66.8. 
Liharzik, . 5 " 8.89 " =68.8 " J 
II. The average height of the growing lad at eighteen years of age : 
Boyd, . . . 5 feet 0.5 inches = 60.5 inches.'] 
Liharzik, . . 5 " 4.17 " =64.17 " ( Average, 63.003. 
Danson,. . . 5 " 4.34 " =64.34 " J 895 
WEIGHT AND HEIGHT OF HUMAN BODY. 
Growth of the Human Body from Eighteen to Thirty Years of Age, indicated by Weight and Height: Averages taken from 
100 Observations and upwards at each Age. Records taken from Observations upon 4800 Criminals at all Ages. {Statistical 
Society's Journal, March, 1862, by J. W. Danson ) 
18 
19 
20 
21 
22 
23 
24 
25 
26 
' 27 
28 
29 
30 
Age. 
Weight. 
8 10.79 
9 4.11 
9 5.58 
9 5.02 
9 12.41 
10 2 95 
10 2. 
10 5.65 
10 1.06 
10 4.75 
10 2.62 
10 5.53 
10 1 55 
Stones. 
Pounds. 
Average. 
10 13 
12 8 
12 8 
12 0 
13 2 
12 12 
12 12 
13 8 
13 8 
13 10 
13 2 
13 12 
14 1 
Stones. 
Pounds. 
Maximum. 
6 6 
7 4 
7 13 
7 3 
7 0 
7 12 
7 12 
8 2 
6 12 
7 12 
7 7 
8 4 
8 1 
Stones. 
Pounds. 
Minimum. 
2 2.2 
3 3.89 
3 2 42 
2 9. 
3 2.59 
2 9.05 
2 10. 
3 2.35 
3 6.94 
3 5.25 
2 13.2 
3 6.47 
3 13.45 
Stones. 
Pounds. 
Maximum 
over 
Average. 
2 4 79 
2 0.11 
1 6.58 
2 2. 
2 12.41 
2 4.95 
2 4 
2 3.65 
3 3 06 
2 6.75 
2 9.62 
2 1.53 
2 0.55 
Stones. 
Pounds. 
Maximum 
under 
Average. 
4 7 
5 4 
4 9 
4 11 
6 1 
5 0 
5 0 
5 6 
6 10 
5 12 
5 9 
5 8 
6 0 
Stones. 
Pounds. 
Maximum 
over 
Minimum. 
5 4.34 
5 4.94 
5 5.11 
5 5.57 
5 6 17 
5 6.17 
5 5.94 
5 6.30 
5 6.28 
5 6.38 
5 6.65 
5 7.02 
5 6.36 
Feet. 
Inches. 
Average. 
Height. 
5 11 4 10$ 
5 11$ 4 11 
5 11 5 1 
5 11J 5 0$ 
6 1 5 0} 
6 1 4 11 
6 1 4 9 
60 : 4 11 
6 If , 4 9 
5 Ilf ' 5 1 
6 15 1 
6 0$ 5 1} 
6 1 5 Of 
Feet. 
Inches. 
Feet. 
Inches. 
Maximum. Minimum. 
6 66 
6.56 
5 89 
5.68 
6.83 
6.83 
7 06 
5.77 
7 07 
5.37 
6.35 
5.48 
6.64 
Inches. 
Maximum 
over 
Average. 
5.84 
5.94 
4.11 
5 07 
5.92 
7.17 
8 94 
7.30 
8 78 
5.38 
5.65 
5.52 
5.51 
Inches. 
Minimum 
under 
Average. 
12$ 
12$ 
10 
10f 
12} 
14 
16 
13 
16} 
lot 
12 
Hi 
12} 
Inches. 
Maximum 
over 
Minimum. 896 
SPECIAL PATHOLOGY-SCROFULA. 
Analysis of air. Maclaren's Annual Measurements of 168 Boys at the 
Gymnasia of the Magdalen College School and the St. Peter's Col- 
lege, Badley, Oxford, in 1862 and 1863. 
Number 
of obser- 
vations. 
Year of 
Age. 
Stature. 
Weight. 
Increase of 
Stature 
during the 
Year. 
Increase 
of Weight 
during the 
Year. 
Shortest. 
Tallest. 
Lightest. 
Heaviest. 
Average. 
Average. 
Ft. In. 
Ft. In. 
St. lbs. 
St. Ibs. 
Inches. 
Ibs. 
5 
9-10 
4 0 
4 lOJ- 
3 11 
4 7 
.5 
4 
7 
10-11 
4 3^ 
4 7 
4 6 
5 11 
.8 
3.7 
14 
11-12 
4 3| 
4 Ilf 
4 2 
6 5 
1 1 
5 
28 
12-13 
4 4f 
5 
4 8 
7 11 
1 6 
5.9 
28 
13-14 
4 5f 
5 7f 
4 9 
9 10 
2.2 
7 9 
23 
*14-15 
4 5f 
5 7j 
4 5 
9 6 
2.5* 
8.1 
33 
fl5-16 
5 0^ 
6 0 
5 8 
10 4 
2.2 
10.6f 
19 
16-17 
4 8j 
5 10| 
5 10 
10 10 
1.3 
8.3 
7 
17-18 
5 
6 Of 
7 13 
11 8 
.6 
5.5 
4 
18-19 
5 
5 6| 
8 8 
9 10 
.5 
5 
Height, and Circumference of Chest, ©f 1270 Young Persons, recorded by 
Dr. Harrison, of Preston (Edin. Med. and Surg. Journal, 1835, p. 425). 
Age. 
Number 
Examined. 
Height. 
Circumference. 
Average. 
Tallest. 
Lowest. 
Average. 
Great. 
Small. 
11-12 
210 
Ft. In. 
4 2f 
Ft. In. 
4 11 
Ft. In. 
3 10$ 
Inches. 
25^ 
Inches. 
30 
Inches. 
22 
12-13 
203 
4 5 
5 0 
3 11 
26 
29 
21 
13-14 
192 
4 6| 
5 3 
4 0 
26 
32 
23 
14-15 
197 
4 7 
5 3 
4 0 
26J 
32 
21 
15-16 
186 
4 10 
5 6 
4 1 
27J 
32 
23 
16-17 
131 
5 0| 
5 7 
4 4 
28 
34 
24 
17-18 
151 
5 Of 
5 7 
4 3 
27| 
34 
23 
velopment and growth of the skeleton ; (5.) The vital capacity of the chest; 
(6.) The growth of the muscles in relation to the bones, and the progressive 
increase of muscular force with advance of years. 
There are individual peculiarities connected with the skeleton which at 
once ought to excite suspicion and suggest careful training. These are,-(1.) 
Narrowness of the thorax, especially at the expansion of the false ribs-a con- 
dition, when combined with functional incapacity or inefficiency in the acts of 
respiration of most characteristic significance. The vital capacity of the lungs, 
as determined by (Hutchinson's) spirometer, compared with age, weight, and 
height, ought to be observed and recorded in all physical examinations. 
Hutchinson's observations show that men from five to six feet high have a 
vital capacity of lung ranging from 174 to 262 cubic inches, in an ascending 
scale according to height and age; and whenever the quantity of air is 16 
per cent, deficient, there is reason to suspect some local affection of the chest. 
Dr. Graham Balfour has subsequently followed up these investigations with 
the spirometer. He has especially examined how far a capacity under the 
average may be taken as an indication either of a tendency to pulmonary 
disease or of a feeble constitution, rendering the man liable to a higher rate 
of mortality than that to which men of or above the average are subject. He 
found that the loss to the service by consumption was much greater among 
the men having a " vital capacity" under the average than amongst men of 
* Year of greatest increase in stature. f Year of greatest increase in weight. RELATION OF ANASMIA TO SCROFULA. 
897 
average capacity or above it; and although the proportion of deaths did not 
differ materially amongst those three classes, yet the invaliding was four times 
as high among men under the average as among the others. A " vital capacity " 
below the average may therefore be considered as indicating a generally feeble 
organization, less capable of resisting the deteriorating influences to which a 
soldier is exposed ("Contributions to the Study of Spirometry," Med.-Chir. 
Transactions, vol. xliii). 
Such functional incapacity is further indicated by the " breathing being 
shorter," with less " breath-motion." The Aspiration is quick and forcible; 
and there is a minimum quantity of air taken in by ordinary /respiration. 
Such lessened respiration tends of itself to induce accumulation of mucus in 
the air-cells, and thereby to set up inflammation. Everything which tends to 
impede or to interrupt or obstruct the regular, complete, and continous per- 
formance of the respiratory acts has a most prejudicial effect upon the lungs 
(especially of " growing lads "), favoring the accumulation of growing mate- 
rial in the air-cells, which may eventually degenerate and form a cheesy mass 
in all respects resembling tubercle. Life not only depends on breathing, but 
the energy and the vigor of life are in a great measure ruled by the capacity 
and the free play of the breathing organs (Sibson, 1844). 
Dr. Walshe has very justly directed attention to the prevalence of anaemia 
amongst female servants in London, who are obliged to go up numerous and 
long flights of stairs very often in their daily labors; and is of opinion that 
the suspended inspiratory acts have much to do with the peculiar state of the 
blood that ensues (" Clinical Lectures," Lancet, 1849). Dr. Pollock, on the 
other hand, however, protests against anaemia being considered a frequent 
antecedent or manifestation of phthisis. He considers it a condition least fre- 
quently associated with phthisis. In none of 125 cases of anaemia was there 
any sign of tubercle; and although the girl with extreme anaemia is always 
supposed to be consumptive, the diagnostic points -are: (1.) The build of the 
anaemic patient is generally antiphthisical, and, in spite of her color and deli- 
cate appearance, there is neither loss of flesh to any great extent nor fever. 
(2.) Mobility, percussion, and tone of respiratory sounds are normal, even 
when cough, dyspnoea, and haemoptysis may have existed for months. 
The blood-changes characteristic of anaemia Dr. Pollock considers antago- 
nistic to tubercle ; and cases of anaemia very rarely proceed to tubercle of the 
lung. Anaemia wastes those organs and tissues dependent on an abundant 
supply of red blood ; phthisis wastes all tissues by furnishing them with im- 
pure blood. The phenomena of anaemia are insufficiency ; the phenomena 
of phthisis are impurity of blood (Pollock). 
It is very important to remember, in regard to training animals and young 
persons, that they have much more extent and range of lung than are required 
in the quiet every-day pursuits of life. Less lung is used when the animal 
lies down or sleeps, or is depressed; and, on the contrary, walking, running, 
wrestling, the force of the passions, each or all of them bring the greatest 
amount of lung into action or use. In short, the amount of lung in use is an 
ever-varying quantity; and just as much lung may come to be used as A habit 
as the listlessness or vigor of the moment requires. There is every range, 
every variety, till the top of the wind, the top of the speed (the full vital 
capacity) is attained (Sibson). 
Practically, therefore, the more fully the lungs are judiciously used, the 
more is their capacity nursed; and conversely, the less they are used and ex- 
panded, the more useless they are likely to become, if not absolutely diseased. 
Under a judicious system of training, an undeveloped man, even although he 
may be feeble, narrow-chested, and sickly, may yet become active, full-chested, 
and healthy. We have numerous examples of this among the boys in our 
training ships for seamen. The over-fed, short-winded pugilist, rower, or 
cricketer, may in a few weeks be changed, by training alone, to the firm- 898 
SPECIAL PATHOLOGY-SCROFULA. 
fleshed, clear-skinned, long-winded winner of the boxing fight, the foot race, 
or the rowing-match. 
It is this want of use that probably renders the apices of the lungs more 
liable to the growth of tubercle in them than in any other part of their sub- 
stance. It is a portion of the lungs which has less play or expansion than 
any other portion, and is apt to be bound down by the surrounding parts. 
The apices are, therefore, the parts most likely to remain in a quiescent state 
of non-expansion, especially when acts of respiration are inadequately per- 
formed, either owing to the constrained position of the body in certain trades, 
or from habitual stooping of the body from listlessness of habit or want of 
vigor in the system. This quiescent state of the air-cells is favorable to the 
growth of tubercle; and thus the apices of the lungs are the most common 
seat of tuberculous growths (Reviewer in Medical Mirror, vol. i, p. 638). The 
effects of want of exercise and of impure air are thus most potent agencies in 
causing phthisis. " The much greater prevalence of phthisis in most of the 
European armies (French, Prussian, Russian, Belgian, and English) can 
scarcely be accounted for in any other way than by supposing the vitiated 
atmosphere of the barrack-room to be in fault." In all the places where 
phthisis has prevailed, in the most varied stations of the army, and in the 
most beautiful climates, the only common condition was the vitiated atmos- 
phere which our barrack system everywhere produced ; " and, as if to clench 
the argument, there has been of late years a most decided decline in phthisical 
cases in these stations, while the only circumstance which has notably changed 
in the time has been the condition of the air" (Parkes, 1. c., p. 91). Indeed, 
the air is rendered so impure by respiration, that while an atmosphere so 
vitiated has a most injurious effect upon the health, contamination of the air 
has been so great, where lung diseases abound, as to give rise to the idea that 
phthisis appeared to be propagated by contagion (Bryson, Parkes). 
It is therefore within the power of the medical officer to direct the physical 
training of young persons so that the apparently sickly and the short-winded 
may in time be developed into the wiry and active young man, long in wind, 
sound in body, and lithe of limb-a result which, however, can only be at- 
tained by judicious feeding, careful exercise throughout the development of 
the body, and by the gradual nursing of the breathing powers. The opposite 
of this is seen in the breaking down of recruits at a very early period of ser- 
vice in the army-within the third year-a result likely to be greatly obviated 
by the gymnasia, which are now being introduced by Government for the physi- 
cal training of recruits before and after they are instructed in drill. 
The Austrian runners are another class who furnish instances of breaking 
down by over-exertion in running at ages unsuited for their strength. They 
seldom live above three or four years, and gradually die of consumption (Re- 
mains of Mrs. Trench, p. 72). 
In all physical training the condition of the heart must be considered not 
less than the lungs, seeing that its movements respond to the movements of 
the chest and the lungs. They are members of one great system; and in 
nursing one we nurse the other; for by giving tone and health to one we must 
give tone and strength to the other (Sibson). If, on the contrary, the devel- 
opment and gradual training of the lungs are not successful, the lesions which 
become developed are of a peculiar character, and are apt to be thought very 
lightly of; because, in the first instance, they are so little capable of appre- 
ciation by a single observation; and, secondly, because the lesions are insidi- 
ous, and take some time before they reach a stage to be apparent. Frequent 
observations, extended over a considerable interval of time, are necessary to 
appreciate the wasting of delicate tissues which sets in, and which progresses 
so insidiously, and creeps on almost imperceptibly, but with a result so sure 
" that day by day and grain by grain the mortal part wastes and dies away." 
It is this progressive atrophy which it is so important to detect. Time is GENERAL TREATMENT OF SCROFULA. 
899 
necessary to do this, and some certain mode of detecting the gradual decay. 
For this reason it is absolutely necessary to have the means of weighing men, 
and so to determine the ratio of the weight of the person to his age, to his 
height, and to his respiratory and other functions. These data are absolutely 
necessary to be known and recognized before any conclusions can be arrived 
at as to those healthy or normal physiological states with which weight has to 
do. It may, indeed, be stated generally that every organ and function has a 
physiological relation to weight and age; and, as a general rule, weight in- 
creases with the height and age, and there are physiological limits beyond 
which the range may not extend.* 
Loss of body weight is therefore exceedingly significant, if progressive, as 
indicating a persistent atrophy-the grain by grain decay which is frequently 
the earliest appreciable sign of disease. The first manifestation results from 
absorption of the fat and wasting of the muscles of the body. The appetite 
may be good and the secretions regular, yet emaciation below the lowest aver- 
age normal to the individual steadily goes on-a condition more marked and 
more perilous in those who have been previously stout than in others. The 
loss of weight is regularly progressive, and necessary to be distinguished from 
transient loss of weight. In senile phthisis a long period of emaciation com- 
monly precedes positive evidence from physical signs. Sudden and great loss 
of weight is always serious. It indicates, in the early stages, rapid pulmonary 
lesions; and generally the most rapid reduction of weight is in males (Pol- 
lock). 
The most rapid loss of weight observed by Dr. Pollock was a loss of 56 lbs. 
in three months; and in twenty-eight cases the following table shows the pro- 
gressive reduction in weight: 
Period. 
Number of Cases. 
1 stone. 
1% stone 
2 stone. 
2% stone. 
3 stone. 
4 stone. 
Iii 5 weeks, 
1 had lost 
- 
1 
" 2 months 
4 " (respectively), 
- 
1 
2 
- 
■ 1 
- 
" 3 " 
7 u ii 
1 
2 
1 
- 
1 
1 
"4 " 
3 " " 
- 
- 
2 
- 
1 
- 
" 6 " 
3 " " 
- 
1 
1 
1 
- 
- 
" 8 " 
I IC IC 
- 
- 
- 
- 
1 
- 
" 9 " 
1 cc cc 
1 
- 
- 
- 
- 
" 10 " 
3 " " 
- 
1 
1 
1 
- 
- 
" 12 " 
5 11 " 
1 
- 
1 
- 
2 
1 
Total cases, 
28 
The lowest weight in health of one of these persons was 10 st.; he lost in 
five weeks 1J st. The rest in health averaged 12 st.; and one was 14 st. 10 lbs., 
and he lost 3 st. in eight months. Another, whose weight in health had been 
13 st., was reduced to 10 st. in three months; 20 out of 28 observed, were 
between twenty-five and thirty-five years of age ; 6 were in the first stage; 10 
in the second; and 12 in the third of phthisis when examined, showing that 
the period of deposit was exceedingly short, and the softening and destructive 
processes accelerated. 
General Treatment of the Scrofulous Cachexia.-From what has been 
already stated in illustration of the pathology of this malady, it is to be ob- 
served that the general treatment now in most repute is founded on the doc- 
trines-(1.) That scrofulous local lesions will heal of themselves if the nutri- 
tion of the system can be maintained and the continuous growth of tubercle 
* Henry Pooley & Co , 89 Fleet Street, E. C., supply suitable weighing machines 
at a cost of £3 15s., and upwards. 900 
SPECIAL PATHOLOGY-SCROFULA. 
arrested; (2.) That the periods of frequent temporary arrest of all the gen- 
eral and local symptoms of disease ought to be diligently taken advantage of 
to improve and preserve health by hygienic means; (3.) That the efforts of 
the practitioner should be directed to the digestive rather than to the pulmo- 
nary system; (4.) That the kind of morbid nutrition in the body generally, 
and altered morphological change in the tissues of the organ where the de- 
posit takes place, appear to be chiefly due to excess of albuminous and defi- 
ciency of fatty elements in the chyle. 
The treatment, therefore, to be pursued must be essentially reparative of 
the waste of tissue generally; corrective of what has been unfit in the indi- 
vidual diet and mode of life; and, lastly, supplementary of the elements of 
nutrition which have been deficient. 
During the past thirty years in Germany, and twenty-three years in this 
country, the treatment of scrofulous affections has gradually but steadily 
become more and more firmly based on those pathological doctrines which 
Dr. Bennett, of Edinburgh, was mainly instrumental in first elucidating, and 
in earnestly recommending to the notice of the profession generally in this 
country. The view here taken regarding the nature of scrofula leads to the 
belief that-(1.) The blood is impoverized through the preliminary dyspepsia 
which precedes the growth of tubercle; (2.) That in pulmonary phthisis the 
growth of tubercle results from the exudation of lymph and of new growth 
which is consolidated primarily in the air-vesicles; (3.) That the successive 
formation and softening of these tubercles lead to ulcerations of the pulmon- 
ary and other tissues, and promotes wasting of the body generally. 
It has been now fully shown, especially by the observations of Dr. Bennett, 
in the first instance, confirmed by the extensive experience of the physicians 
at the Brompton Hospital for Consumption, in London, that such treatment 
as is directed to remove the malassimilation of food frequently checks the 
tendency to the repeated occurrence of tubercles, while those which previously 
existed remain harmless; that general symptoms and physical signs may dis- 
appear completely; and that even extensive excavations in the pulmonary 
tissue may heal up and cicatrize. According to the testimony of Dr. Wood, 
of Pennsylvania, the fatal results have not only been postponed, but the death- 
rate from phthisis has diminished in the principal cities of the United States 
since such principles of treatment have been adopted. 
The indications of general treatment are therefore- 
First, To improve the faulty nutrition, which is the cause of the scrofulous 
cachexia, and of the exudations assuming the characters of tubercle. 
Second, To subdue the fever which attends the growth and changes going 
on in the tubercle-nodules, and to favor the absorption either of the entire 
exudation, or of such portions of it, that what remains may undergo such 
changes as are consistent with its future harmless existence in the organs or 
other parts where it may have grown. 
Third, To prevent the recurrence of fresh exudation by careful attention 
to hygienic regulations, especially during the intervals of apparent return to 
health. 
To fulfil the first of these indications it is of all things important that 
fatty matter be assimilated in large quantities, and it appears that such are 
most readily absorbed and assimilated when in the fluid condition. The sub- 
stance of all others found most beneficial has been cod-liver oil. At the 
Brompton Hospital more than 600 gallons of this oil are used annually. 
There, on a great scale, its merits have been tested and compared with the 
effect of treatment conducted on general principles, and irrespective of its use. 
The result has been to confirm, in the estimation of the medical profession, 
the great value of the remedy in the treatment of phthisis, when appropri- 
ately administered, and combined with the use of such other measures as any 
special circumstances in the individual patient may require (Thompson). TREATMENT OF SCROFULA. 
901 
The general opinion of the profession with regard to cod-liver oil may be 
summed up in the statement originally made by Dr. Bennett,-namely, that 
"it rapidly restores the exhausted powers of the patient, improves the nutri- 
tive functions generally, and stops or diminishes the emaciation. The night 
perspirations subside, the cough is quieted, and the expectoration is dimin- 
ished after the oil has been used for a few weeks." A very constant and well- 
marked favorable change under its use is to be noticed in the diminution of 
the pulse, which gradually but steadily has been observed to come down at 
the rate of five or six beats weekly; and during the same period the weight 
of the body has been known steadily to increase at the rate of half a pound 
to a pound. In females it is a significant and highly favorable symptom when 
the catamenia return after the oil has been used for some time. The usual 
dose adopted by the late Dr. Thompson, at the Brompton Hospital, is one or 
two teaspoonfuls twice a day at first, and gradually increasing the quantity to 
half an ounce three times a day. Dr. Bennett recommends somewhat larger 
doses-namely, for an adult, a tablespoonful three times a day, which may 
often be increased to four or even six with advantage. When the stomach is 
irritable, however, a tea or a dessertspoonful is enough to commence with. It 
appears from the observations of Dr. Thompson that no additional advantage 
is obtained by pushing the oil beyond the limits of the doses adopted by him 
at the Brompton Hospital, from the fact that where its use has most obvi- 
ously increased the weight of the body, to the extent in one instance of a 
pound per week for twenty-one weeks, only three pints had been taken during 
that time. The kind of oil used, as far as coarseness or fineness is concerned, 
seems not to affect the beneficial result in any material degree. Some patients 
even prefer the coarse to the fine oil. The experience of some is, moreover, 
favorable to combining the oil with liquor potasses as an emulsion; and as 
it appears that undue acidity prevails as well in the stomach as in the intes- 
tinal canal, the addition of the alkali ought, on theoretical grounds, to be 
advantageous. 
It seems also that, when cod-liver oil was first used as a medicine, more 
than fifty years ago, in the treatment of rheumatism, it was then ordinarily 
combined with an alkali. It may be taken, however, unmixed, or it may be 
floated on milk, or nitro-muriatic acid, mixtures, or on lemonade, soda-water, 
lemon-juice, or on a saline draught during effervescence, when such combina- 
tions are suited to the patient. Creasote has been recommended to be added, 
as it is said to render the stomach more tolerant of the remedy. The follow- 
ing formula, quoted from Dr. Thompson's Clinical Lectures on Pulmonary 
Consumption, yields a palatable mixture, which ought to be combined as an 
emulsion: 
"An ounce and a half of cod-liver oil, four drops of creasote, two drachms 
of compound tragacanth powder, and four ounces and a half of aniseed water. 
Of this mixture an ounce may be taken thrice daily." 
The more direct and immediate action of cod-liver oil upon the blood has 
been attempted to be ascertained by Simon, Snow, and Thompson. They re- 
cord an increase of blood-corpuscles and a diminution of fibrin under its use; 
and from the researches that have been made in animal chemistry regarding 
the blood in phthisis, a deficient proportion of blood-corpuscles is observed to 
be a most constant peculiarity. But phthisis is not the only disease in which 
this occurs, as shown by the following table (Simon) : 
Average Proportion op some Constituents of the Blood. 
Albumen. 
Corpuscles. 
In Health, . . 
. . 76 
130 
In Pneumonia, . 
. . 80 
122 
In Phthisis, . . 
. . 100 
78 
In Rheumatism, 
. . 100 
74 
Albumen. Corpuscles. 
In Diabetes, . . . 
. 105 80 
Tn Bright's Disease, 
. 103 50 
In Chlorosis, . 
. 72 56 
In Carcinoma, . . 
. 45 55 902 
SPECIAL PATHOLOGY-SCROFULA. 
Rheumatism and diabetes present the greatest similarity in these states of 
the blood to phthisis; and they are diseases for which cod-liver oil has been 
used with advantage. 
Cod-liver oil, therefore, is indicated, where it can be taken, in all those dis- 
eases in which the blood-corpuscles are deficient, where nutrition is impaired, 
and where fat is not readily assimilated. 
Besides cod-liver oil, other animal fats and oils, where they can be taken 
and assimilated, are sure to be followed with benefit. Hence milk rich in 
fatty matter, such as asses' milk, and milk drawn from cows at a short inter- 
val after the greater part of their milk has been withdrawn, and which is 
known in Scotland as the "afterings," are found to be followed by improve- 
ment where they are persevered in and are assimilated. So also has it been 
with cream and butter. Dr. Bennett instances the partial success occasion- 
ally of caviare, bacon, pork, mutton chops, and the marrow of the bones of 
oxen ; while Dr. Thompson instances the good effects he has obtained from 
the use of oil obtained from the foot of the young heifer (neat's-foot oil). The 
administration of any of these remedies is quite consistent with doctrines now 
taught regarding the pathology of tuberculosis, and it is useful to know their 
individual value, in order that in particular cases one may fall back upon 
their use where a change may be desirable. 
It has been considered that some of the good effects of cod-liver oil may be 
due to the biliary elements with which it has been incorporated. This view is 
not supported by the experiment of adding ox-gall to other animal oils not 
derived from livers, as no beneficial resultshave been observed to follow. But 
as the active principle of the gastric juice has been now successfully isolated 
by chemistry, and has been successfully used to aid the digestion of food 
in the stomach, might not some principle be obtained from the liver which 
might aid the assimilation of fatty substances when mixed with the intestinal 
juices? 
In fulfilment of the second indication mentioned (p. 900), the propriety of 
abstracting blood has been much discussed. 
It has been already seen that febrile symptoms of a very severe kind some- 
times attend the exudation and consolidation of tubercle. It is also a more 
or less frequent clinical observation that pneumonia, bronchitis, and pleur- 
itis, in acute or chronic forms, are intercurrent attendants on the deposit and 
future changes of tubercles in the lungs. " Hence," as Dr. Bennett justly ob- 
serves, "there are all kinds of intermediate changes between the simple and tu- 
bercular exudations constantly going on in the progress of a case of pulmonary 
tuberculosis. The phenomena of phthisis, pneumonia, pleurisy, and bron- 
chitis, in their acute or chronic forms, may appear together, and be inextrica- 
bly mingled, or they may succeed each other at intervals." Thus tuberculo- 
sis, both as a constitutional and as a local disease, is scarcely ever free from 
exacerbations, the various local and constitutional states acting and reacting 
on each other. While, therefore, on the one hand, the system requires an in- 
creased and well-directed supply of nutritive materials, on the other hand, 
there are constitutional states of excitement, depending on local irritation, 
which require to be subdued, and even demand antiphlogistic treatment. 
Whatever theoretical view may be taken as to how the exudation may most 
readily be absorbed, all physicians are now at one as to the propriety of pre- 
serving the general strength, of effecting elimination of effete material, and of 
meeting antiphlogistic indications rather by diaphoretics, diuretics, emetics, 
and purgatives, than by abstracting any considerable-amount of blood, either 
at once or at repeated intervals. In fact, it is now observed that the admin- 
istration of appropriate diet, and abstinence from lowering remedies, with cod- 
liver oil, while they correct the general nutrition, may be so regulated as to 
subdue the constitutional irritation by a perseverance in their use for a period 
of not less than four or six weeks. Moderate general bleedings in acute TONIC TREATMENT OF SCROFULA. 
903 
phthisis, as well as local bleedings during the excerbations of chronic phthisis, 
undoubtedly confer a temporary relief in the diminution of local pain and 
general febrile reaction, and allow a more free respiration to be performed, if 
respiration should be impeded by congestion of the lungs. Dr. Bennett, how- 
ever, is opposed to bleeding. His object is simply to favor excretion by means 
of antimonials; and, on subduing the reaction by their means, he again pro- 
ceeds with the nutritive mode of treatment to fulfil the first indication. Nev- 
ertheless, it cannot be doubted that the condition of some cases demands blood- 
letting; but, as Sir James Clark observes, "The employment of general 
bloodletting in consumption requires great judgment and circumspection. 
The more general error is the abstraction of too great a quantity of blood at 
a time-treating the disease as if it were a purely inflammatory one, and for- 
getting that the inflammatory symptoms are merely consecutive upon tuber- 
cles, and that the constitution of the consumptive patient is little capable of 
replacing the blood, too lavishly drawn." Simply to remove or diminish con- 
gestion, the condition of the patient and nature of his constitution being con- 
sidered, "blood maybe abstracted," he continues, "with advantage at any 
stage of consumption when the symptoms require it." The experience of 
Dr. Wood leads him to teach similar doctrines. Topical counter-irritants fur- 
nish the best means of subduing constitutional irritation in chronic forms of 
the disease. These may be in the form of setons, issues, succession of blisters, 
tartar emetic ointment, or croton oil rubbed on the chest in any of its regions. 
Amongst these the frequent use of dry cupping ought not to be omitted. 
In fulfilling the third indication, the real power of the science of medicine 
may be demonstrated. It is by well-directed hygienic measures, successfully 
and efficiently carried out, that the real strength of the physician may be put 
forth to prevent the recurrence of fresh exudation ; and his hygienic exer- 
tions towards the patient are to be redoubled during the temporary intervals 
of apparent return to health. It is now almost an axiomatic truth, that of 
all things which deteriorate the constitution on the one hand, and influence 
pulmonary congestion on the other, none are so detrimental as impure and 
deficient air, together with frequent variations of temperature, and changes 
from sudden heat to chilling cold. These latter vicissitudes may be considered 
characteristic of the physical climate of Great Britain and Ireland. " The 
conditions of preventive treatment which have seemed most useful are nutri- 
tious food and proportionate great exercise in the free and open air. So im- 
portant has this last condition proved to be, that it would appear that even 
considerable exposure to the weather is better than keeping phthisical patients 
in close rooms, provided there be no bronchitis or tendency to pneumonia or 
pleurisy " (Parkes, 1. c., p. 445). 
Tonic treatment consists essentially in the adoption of those means which 
promote or stimulate the healthy nutrition of the body. Its elements exist 
in fresh air, abundant exercise, sufficient repose, and judicious diet. A hygi- 
enic code applicable to the tuberculous cachexia has been recently laid down 
by Dr. Richardson, in the second volume of the Sanitary Review, and very 
recently in a special work On the Hygienic Treatment of Pulmonary Consump- 
tion. It is derived from these elements of tonic treatment; and as it puts 
well-known truths, too little appreciated, in a formal and more important 
aspect than is wont, its precepts are here quoted. 
I. A supply of pure and fresh air for respiration is constantly required by the 
tuberculous patient. 
As it is known that if one per cent, of carbonic acid exists in a room, the 
air is unfit for a healthy person, it is therefore much more so for a consump- 
tive one. The temperature of a room ought to be equally maintained at from 
55° to 56° Fahr., ventilation and heating being effected by open fireplaces. 
A single room ought not to perform the two offices of a bedroom and a sitting- 
room. The sleeping-room ought not to afford less than 1000 feet of space ; 904 
SPECIAL PATHOLOGY-SCROFULA. 
and if larger, so much the more healthful will it be. In connection with 
these statements, while it is objected, for obvious reasons, with much justice, 
to the treatment of tuberculous patients in special hospitals, there is much 
on the other hand that might be improved in all our hospitals, with refer- 
ence to the arrangement of the patients, to secure to them fresher air than 
they generally obtain. " Constant though imperceptible movement of the 
air is the point to be attended to "-i. e., thorough ventilation. All who 
are able to be out of bed ought to have their meals in a common room, which 
is not used for any other purpose, and is apart from the wards or dormitories. 
II. Active exercise in the open air is imperatively demanded by the tuberculous 
patient. 
In the words of Dr. Jackson, " He must be made to feel that the risk is in 
staying in the house, and not in going out of it." But the skin must be per- 
fectly protected ; and while a chill, or inclement weather is to be avoided, 
the patient must go out in all seasons, without being too fastidious about the 
weather, walking exercise being persevered in as much as possible. " The 
best climates for phthisis are perhaps not necessarily the equable ones, but 
those which permit the greatest number of hours to be passed out of the 
house " (Parkes). Next to diet exercise in the open air is, of all things, 
the most important: it should be carried as far as the vigor of the patient 
will permit. It should not be done rashly, but boldly ; and, if possible, the 
patient ought to have faith in it; for without this he is not likely to pursue 
it so far as he can, and then he will not derive from it all the benefit which 
it can afford (Jackson). 
III. It is important to secure for the patient a uniform, sheltered, temperate, 
and mild climate to live in, 'with a temperature about 60° and a range of not 
more than 10° or 15° ; ivhere also the soil is dry, and the drinking-water pure 
and not hard. 
The classic work of reference on this topic is that by the late Sir James 
Clark. If it is possible to give a practical abstract of his extensive and valu- 
able experience, it may be done somewhat as follows : 
1. After the functions of the digestive organs and skin have been re-estab- 
lished in improved action, the patient who labors under a tuberculous ca- 
chexia may derive benefit by a residence in a mild or temperate climate 
(such as has been defined), conforming to all the hygienic and medicinal 
treatment already mentioned. 
2. When symptoms, however slight, indicate that tuberculous deposit has 
located itself in the lung, removal to a mild climate, especially if effected by 
a sea voyage, under favorable circumstances, may still be useful as a means 
of improving general health, of lessening the chance of intercurrent inflam- 
matory affections of the pulmonary organs, and even of arresting the further 
progress of the disease. The nausea, squeamishness, or even sickness, which 
with some are always more or less associated with a sea voyage, are beneficial 
to cases of incipient tuberculosis. The effects of such nausea tend to increase 
the natural secretion and elimination from the pulmonary mucous membrane; 
so that minute portions of tubercular exudation, commencing to consolidate 
in the air-vesicles, are effectually, gradually, and gently passed out with the 
motion of the pulmonary mucus in the expectoration. The sensation of nausea 
tends to subdue any local vascular irritation ; and the unceasing motion of a 
sailing vessel tends to keep up a constant exercise which is advantageous to 
the patient. 
3. When extensive tuberculous disease exist in the lungs, little benefit is to 
be expected from a change of climate; and a long journey will most certainly 
increase the sufferings of the patient, and hurry on a fatal termination. 
4. There are cases, however, of chronic consumption which .may derive 
benefit from residence in a mild climate,-namely, cases in which the deposit 
is limited to a small portion of the lungs, and little systemic irritation prevails; DEFINITION AND PATHOLOGY OF RICKETS. 
905 
or in cases in which the disease has ceased to extend in the lungs, but where a 
long time is required to complete repair. 
IV. The dress of the scrofulous patient ought to be of such a kind as to equalize 
and retain the temperature of the body. 
Under this topic waterproof coats, boots, and shoes are to be condemned. 
Flannel ought invariably to be worn next the skin in all seasons; and in 
winter a chamois leather vest may be required over the flannel. 
V. The hours of rest should extend from sunset to sunrise. 
VI. Indoor or sedentary occupation must be suspended; bid outdoor employ- 
ment in the fresh air, even in the midst of snow, has been and may be advantageous. 
VII. Cleanliness of body is a special point to be attended to in the hygienic 
treatment of tuberculosis. 
VIII. Marriage of consumptive females, for the sake of arresting the disease by 
pregnancy, is morally wrong and physically mischievous. 
IX. The medicinal treatment must be adapted to the site of the local deposits 
and the general nature of the particular case. Iron and iodine in various forms 
are the most useful remedies; but medicine is utterly powerless and useless un- 
less the hygienic means now insisted upon are carried out to the uttermost. 
RICKETS. 
Latin Eq., Rachitis; French Eq., Rachitisme; German Eq , Rhachitis-Syn., En- 
glische Krankheit; Italian Eq , Rachitide. 
Definition.-A constitutional disease of early childhood, characterized by an 
unhealthy state of the system, which precedes for several weeks or months a peculiar 
lesion of the bones, manifested by curvature of the shafts of long bones and enlarge- 
ment of their cancellous extremities. Some of the solid visceral organs exhibit also 
peculiar lesions. The growth of the bones is characterized by irregularity, by non- 
solidification of their growing layers, and by the progressive formation of medullary 
cavities in the old bone, thus rendering the bony laminae thin and brittle (Vir- 
chow). In the solid visceral organs, such as the spleen and liver, there is generally 
lardaceous disease. 
Pathology.-From the great vascularity and infiltration of the affected bones, 
some have regarded the disease as expressing some form of inflammation ; more 
especially as pain accompanies the lesions from the first. But the course and 
the constant results of the disease do not favor this view. Another theory 
(based on the fact that the urine of rachitic children is often extremely rich 
in lactic acid, and contains as much as from four to six times of phosphate of 
lime as normal urine contains) holds that the calcareous salts taken up by the 
food cannot be deposited in the terminal and peripheral layers of bone, being 
held in solution by the lactic acid in the blood and excreted by the kidneys. 
But the actual changes in the bones do not support this view; these consist- 
ing of-(1.) Proliferation of the cartilages and epiphyses, and of the periosteum 
-the sources of the normal growth in length and thickness of the bones. 
(2.) The cartilaginous and fibrous tissues ossify more densely, and at a later 
period than in the normal growth of bone. The tissues remain abnormally 
soft for a length of time, after which they become abnormally hard (Niemeyer). 
Virchow considers the retarded ossification due to a diminished supply of 
chalky salts. The most probable hypothesis regarding the cause of rickets is 
that which refers to inflammation of the epiphysal cartilages and periosteum, 
and local disturbance of circulation hindering the deposit of calcareous salts 
(Niemeyer). 
Active decomposition also goes on in the stomach and intestines of rachitic 
children. 
Symptoms.-The earliest recognition of the cachexia associated with rickets 906 
SPECIAL PATHOLOGY-RICKETS. 
is rarely apparent before the fourth month of infant life; and usually between 
the fourth and twelfth months. It does not in general declare itself until the 
child first begins his attempts to walk, or until he shows suffering during the 
first dentition ; and at first the progress of the disease is so very slow as almost 
to be imperceptible. The number of cases happening in the first or second 
years of life very greatly exceeds that of other periods ; and there is a period 
of at least six months during which a marked series of deranged actions succeed 
each other, and which eventually culminate in the condition known as rickets. 
Many of the phenomena of these deranged actions are common to other dis- 
eases; but some are characteristic, and when they occur in sequence are suf- 
ficient indications of the specific characters of rickets. 
The symptoms may be arranged into four classes: (1.) Those which are 
common to many diseases-symptoms which might arise from deranged diges- 
tion, from improper food, or from scrofula, and which are often referred to the 
" irritation of teething," or to the so-called " infantile remittent fever." These 
phenomena always denote the precursory or incubative stage of rickets; (2.) 
Those which at once mark the nature of the disease, render its diagnosis easy, 
and which enable us to predict that the bone affection will show itself; (3.) 
The stage of characteristic deformity; (4.) Phenomena of favorable or of un- 
favorable import, inasmuch as they may characterize a period of restoration 
to health, of irremediable atrophy of the body, or of approaching dissolution. 
During the precursory or incubative period, the most ordinary symptoms of 
impaired general health are those which indicate gastro-intestinal irritation. 
The bowels are irregular in their action; sometimes confined, but more com- 
monly there is diarrhoea (intestinal catarrh), with tumidity or enlargement of 
the abdomen. The stools may be of a dirty brown or leaden color, and of a 
most offensive odor. There is great proneness to decomposition of the contents 
of the intestines. In some respects the odor therefrom is peculiar in its resem- 
blance to rotten or half-decayed meat. Appetite is feeble, or entirely lost, and 
digestion is difficult. The child becomes dull and languid, sad or peevish; 
febrile irritation prevails ; the skin is hot; and the temper irritable. Although 
drowsy, it sleeps but little. It is thirsty, and will drink large quantities of 
water. If it has begun to walk, it is " taken off its legs." It lies about, and 
is unwilling to play or to be amused, or to indulge in any kind of action. 
It prefers to sit or to lie; and it appears to be feeble or indolent, and is un- 
able to use exertion of any kind. The transition from health to these phenom- 
ena is always gradual and slow; but there are at least three sets of phenom- 
ena which, according to Sir William Jenner, being superadded to these, are 
characteristic of the approach of rickets. These symptoms, therefore, stand 
by themselves in the second class as pathognomonic of this affection. 
{a.) The most remarkable is profuse perspiration of the head, or of the head 
and neck, and upper part of the chest. It arrests the mother's attention, and 
she seeks medical aid. She will tell the physician that the perspiration 
stands in large drops on the child's forehead-that it runs in streams down 
the face; and it is especially when the child sleeps that such copious perspi- 
rations of the head occur; but they are not unfrequent when the child is at 
the breast, or even when only resting its head on the mother's arms. A little 
increased exertion, or a little increased temperature, may induce such ex- 
cessive perspiration. Such perspirations are extremely weakening and col- 
liquative during sleep; and when they occur the superficial veins of the scalp 
are generally large and full; the jugular veins are much dilated, and some- 
times the carotid arteries may be felt strong and pulsating (Copland, 
Jenner). 
(6.) Another characteristic feature of the disease is seen in the desire and 
in the efforts of the little patient to be cool, particularly at night. The child 
kicks the bed-clothes off, or throws its naked legs on to the counterpane; and 
this even in cold weather. TREATMENT OF RICKETS. 
907 
(c.) There is also, thirdly, general tenderness. The child cannot be moved 
without its uttering a cry; pressure on any part of its body is followed by 
evidence of suffering. It ceases to play and to move, but lies with out- 
stretched limbs as quietly as possible, for all movement produces pain; and 
it will cry at the approach of any one who has been accustomed to move it 
in play. 
As the disease progresses the child becomes staid and steady in appear- 
ance. It assumes a pensive, aged, and languid aspect. Its face grows broad 
and square; and when placed on the mother's arms, it sits (as she says) "all 
of a heap." The spine bends, and the muscles are too weak to keep the spine 
erect. Its head thus seems to sink between its shoulders, and its face appears 
turned a little upwards. Before the general cachexia has lasted long, the 
bone deformity begins to attract attention, and usually the lesion of the bones 
is out of all proportion in severity to the enlargement of the ends of the long 
bones; and the younger the child, the softer usually are the bones. The con- 
sequences of the bone disease thus becomes superadded to the general 
cachexia; and as the disease progresses, the muscles lose their power and 
begin to waste. The child cannot support itself; and if it has commenced to 
walk before it becomes the subject of extreme rickets, it loses its power of 
walking. Intellect is invariably deficient. The teeth are retarded in their 
development, and they fall from their sockets early. The back, arms, and 
sides of the face are often covered with downy hair. In short, as Sir William 
Jenner observes, " the general aspect of the rickety child is so peculiar that 
when the crooked limbs, the large joints, and the deformed thorax are con- 
cealed, you may even detect its ailment at a glance. Its square face, its 
prominent forehead, its want of color, its large staring and yet mild eyes, its 
placid expression, and its want of power to support itself like other children 
of its age, in its mother's arm, all conspire to form a picture which has no 
like in the gallery of sick children" (Med. Times, 1. c.). Laryngismus stridu- 
lus is a frequent result of rickets. 
Treatment.-Ventilation of the room in which the child lives is of first 
importance. Milk diluted with lime-water (about a fourth part), and a tea- 
spoonful or two of cream added, is the best of food. Sugar ought not to be 
added to the milk. Liebig's food for children, and Parrish's chemical food are 
both valuable agents in the dietary. About once a week a dose of rhubarb, 
soda, and calumba, in equal parts, should be given, followed next day by a 
teaspoonful or more of castor oil. Prepared chalk and soda may also be given 
twice or thrice a day. When the febrile disturbance is subdued, the child 
should live as much as possible in the open air. Vinum ferri ought then to 
be given in the following formula: 
R. Vin. Ferri f Ji-Jii; quiniee sulph., gr. i; acid sulph. dil. qgi-ii. 
This form is especially useful when the skin is flabby, covered with perspi- 
ration and ancemia well marked. Or small doses of the syrup of the phos- 
phates of iron, quinine, and strychnia, or syrup of the phosphate of iron and lime 
may be given along with the food, or just before meals. Cod-liver oil is of 
essential service; but the stools ought to be examined daily; and if any of 
the oil passes by stool its dose ought to be diminished, or its administration 
suspended for a time. (For more details on Rickets and its treatment, con- 
sult the admirable lectures of Sir William Jenner, in The Medical Times of 
1860, vol. i.) 908 
SPECIAL PATHOLOGY-CRETINISM. 
CRETINISM. 
Latin Eq., Cretinismus ; French Eq., Cretinisms; German Eq., Cretinismus; Italian 
Eq., Cretinismo. 
Definition.-A condition of imperfect development and deformity of the whole 
body, especially of the head. It is endemic in the valleys of certain mountainous 
districts, and is attended by feebleness or absence of the mental faculties and 
special senses; and is often associated with goitre. 
Pathology and Phenomena of Cretinism.-The condition of idiocy named 
cretinism (and associated with goitre in many districts) is of great interest; 
but the relations of the two are not yet clearly understood. The idiocy of 
cretinism is associated with deformity and imperfection of the bodily organs, 
the brain, in common with other parts, participating in the imperfection and 
deformity. The affection of the mind varies from mere obtuseness of thought 
and purpose to the most complete obliteration of all intelligence. 
Three varieties are to be distinguished: 
"(a.) Complete Cretinism-Synonym, Incurable Cretinism-Cretinism char- 
acterized by idiocy, deaf-dumbness, deficiency of general sensibility, and absence of 
the reproductive potver. 
"(bl) Semi-Cretinism-A degree of cretinism in which the mental faculties are 
limited to the impressions of the senses and the bodily wants; the general sensi- 
bility is obtuse, the head is badly formed and drooping, the speech is rudimentary, 
and the reproductive powers are feeble or absent. 
" (c.) Incomplete Cretinism-Synonym, Curable Cretinism-A degree of cre- 
tinism in which the mental faculties, though limited, are capable of development; 
the head is moderately well formed and erect, the special senses, the faculty of 
speech, and the reproductive potvers are present." 
Dr. Guggenbiihl, of Zurich, was the first to recognize the fact that the 
mental state of cretins could be improved by improving the growth and con- 
dition of the body. In 1842 he succeeded in buying the mountain of Abend- 
berg, which incloses the plain of Interlaken, and there he established an hos- 
pital for these unfortunate children. The infant cretins, removed from the 
low close valleys (in which the malady too often finds the circumstances 
most congenial for its development), are there fed and trained in "the free, 
dry, cool, and bracing air of the open but sheltered and sunny slopes of the 
Abendberg." 
With but few exceptions, cretins are goitrous; and it has been said that 
when both parents are goitrous for two generations in succession, the offspring, 
being the third generation, are sure to be cretins (Watson). 
The cretin is found chiefly in the valleys of the Pyrenees and the Alps, in 
the mountains of Syria, in the hilly parts of China, and in the Himalaya re- 
gions ; but the disease is not confined to the lower valleys of Switzerland, or 
to those other mountain districts of the Old and New World which resemble 
it in physical conformation. All over Europe the victims of this disease may 
be seen; and Virchow found, in his official inquiry into this subject, that no 
less than 133 decided cases were living in the villages of Lower Franconia; 
and in Germany, Sweden, Norway, England, and even in London, isolated 
cases of cretinism are to be met with. 
The stature of the cretin is diminutive ; his head is of great size, but flattened 
at the top, and spread out laterally ; while the countenance is vacant and void 
•of intelligence. The nose is flat, the lips are thick, and the tongue is large. 
The skin is dark-colored, coarse, and rough. The abdomen is sunken and 
pendulous; the legs are short and curved. 
Virchow's dissection of the heads of cretins has led him to conclude that the 
primary abnormality of the brain commences with the growth of the bones of VARIETIES of cretinism. 
909 
the basis cranii, and especially with the sphenoid and the adjoining parts. In 
the normal state the basilar part of the occipital bone, the sphenoid and eth- 
moid, with their intervening cartilages, form a portion of an arch; while the 
same parts in a cretin are early ossified into the form of a rectangle, early 
union of the bones taking place, with various lesions of the intervening carti- 
lages. With such early union, arrest of growth occurs at that part of the 
skull; but various compensatory developments continue in other parts. Hence 
the prognathous face, and the sinking of the root of the nasal bone. Irregu- 
lar and partial union of the sutures at an early age is a frequent morbid con- 
dition of the insane cretin, associated with an atrophic condition of the gyri 
below the site of union. The oblique downward direction of the orbit in 
cretins is brought about by the compensating growth of the skull generally, 
and more especially of the malar, the frontal, the temporal bones and zygomatic 
arches, in consequence of the deficient development of the sphenoid bone. The 
stunted development of the bones at the base of the skull gives a very short 
distance between the front and middle part of the cranium; while the dimin- 
ished growth of the nasal septum and of the jawbones gives a prognathous form 
of face alike to the cretin, the negro, and the monkey. 
It may generally, therefore, be concluded, from the cumulative nature of 
the evidence, that a poison exists in association with lime and magnesia in 
geological formation, whose action induces undue ossification and thickening 
of the base of the cranium, tending to diminish the size of the foramina for 
bloodvessels (Kolliker, Virchow) ; and it is fair to connect the unusual 
quantity of lime taken into the system with such premature and abnormal 
ossifications. Wherever chemical examination of the water used by the in- 
habitants of the different places where goitre and cretinism prevail has been 
made (as it has been especially in India), it has always been found to contain 
a large quantity of carbonate of lime; whereas the water derived from the clay- 
slate rock, and which was drunk by the inhabitants who did not suffer from 
goitre, contained none. Such observations as those described, and especially 
those of McLelland and Greenhow, show that neither the atmosphere, the 
elevation above the sea-level, the physical aspect of the country, nor locality, 
have anything to do with the production of goitre; but they prove almost to 
demonstration that the affection is due to some specific action of the drinking- 
water which flows from rocks of a particular geological formation named mag- 
nesian limestone. The circumstances under which these aflections wrere found 
by McLelland to exist in the low burning plains of Bengal, formed a striking 
corroboration to his observations in the hills of Kemaon. 
Cretinism and goitre are very prevalent in different parts of the district of 
Goruckpore. The soil of the district is of two sorts. One, to which the natives 
give the name of Bhat, characterizes the lands bordering the river Gunduk and 
its branches. This soil is remarkable for the large proportion of calcareous 
matter which it contains. One specimen, on analysis, yielded upwards of 
twenty-five per Cent, of carbonate of lime. Cretinism and goitre are very prev- 
alent in the villages built upon this soil. In some of them 10 per cent, of the 
population are affected; and of the, children in the villages where goitre pre- 
vails 10 per cent, are cretins. The dogs and cats of these villages are also often 
affected with the disease. On the other hand, the lands on the banks of the 
Gogra consist of a soil to which the natives give the name of Bangar. It is 
much less retentive of moisture than the Bhat land, and requires irrigation for 
the production of winter crops. This Bangar soil is very siliceous, and con- 
tains scarcely any lime. Goitre and cretinism are unknown in the villages 
built upon this soil (Brit, and For. Med.-Chir. Review, Jan., 1861). 
The natives of Oude ascribe their goitres to drinking certain waters; and 
they adduce cases to prove that by partaking of the water of certain wells 
they get the disease, and by deserting those wells they sometimes become cured 
of it (Greenhow). Thus almost all writers who have written on the subject 910 
SPECIAL PATHOLOGY-CRETINISM. 
agree that, in some way or other, the condition of the water has to do with 
the production of goitre. Remarkable instances are known wherein the ex- 
change of well for rain-water, for drinking purposes, has been followed by the 
best effects, and even by the disappearance of goitrous tumors. Dr. Greenhow 
states that in Oude, where the water of wrells believed to be injurious in con- 
sequence of their excessive impregnation with lime has been given up, and 
other water used instead for drinking, great benefit has been felt, and goitres 
have decreased in size, even though the subjects of them have continued liv- 
ing in the same village as before. He was assured also, by several of his pa- 
tients in Oude, that certain wells were known by them to be deleterious, and 
that the natives of the villages avoided them accordingly, having learned to 
do so from experience. He tested the water of the wells most shunned by 
the natives, and found it to contain a great excess of lime; and he concludes, 
from his own investigations, in connection with others, that the use of drink- 
ing-water containing lime is the main cause of goitre. How it acts on the 
system is as yet unknown. 
Symptoms.-Although it seems that some cases of cretinism are congenital, 
yet Dr. Tuke, from personal observation, and from the Report of the " Sar- 
dinian Commission," believes {op. cit., p. 104) that there is no pathognomonic 
sign by which cretinism can be recognized at birth, but that a certain combi- 
nation of symptoms permits the prognosis in childhood of the future develop- 
ment of cretinism. After the fifth or sixth month he describes the infant cretin 
as presenting the following symptoms: " The development of the body proceeds 
very slowly; the child, though weak, is remarkably stout, and appears swol- 
len ; the color of the skin is somewhat dusky, sometimes yellow, sometimes 
natural; the head is large, the fontanelles widely separated, and sometimes all 
the sutures disjointed. The expression is stupid; the appetite is voracious ; 
and much time is passed in sleep. The belly is swollen; the extremities 
are generally attenuated; the neck is thick, but not always goitrous; teeth- 
ing is not completed for many years, is generally accompanied by an offensive 
salivation, and frequently by convulsions. Usually the child cannot stand 
before its sixth or seventh year; and it is then that it begins to articulate cer- 
tain sounds, supposing it has not been deaf from birth. The voice is hoarse 
and shrill, and words are spoken with difficulty." His stature is diminu- 
tive. His head is of great size, but flattened at the top, and spread out lat- 
erally ; and the dissections of Virchow show that the parts at the base of the 
cranium are early ossified in the form of a rectangle. Early union of the 
bones takes place, and with such early union arrest of growth occurs at that 
part of the skull, while various compensatory developments continue in other 
parts. Hence the prognathous face, and the sinking of the root of the nasal 
bone. Thus the character of the face in the cretin, as Dr. Tuke observes {op. 
cit., pp. 105-6), remains unchanged from puberty to old age. The eyes are 
generally affected with strabismus ; the zygomatic arch is large, and the mouth 
of large size; the lips thick, and the lower one hanging down. The lower 
jaw is small, retreating, and its angle very obtuse. The predisposition to 
cretinism appears to be hereditary; and, as noticed by Dr. Watson, it has a 
close but ill-understood connection with 'goitre, so that, with few exceptions, 
cretins are goitrous; and he also observes, that " when both parents are goi- 
trous for two generations in succession, the offspring being in the third gen- 
eration, are sure to be cretins" (Leet, xliii, vol. i, p. 788). Fodere makes an 
observation to the same effect. 
Treatment.-The indications of treatment are those which suggest improve- 
ment in all hygienic measures for the prevention of the disease. Once estab- 
lished, the condition of the cretin can only be ameliorated by institutions 
similar to those founded by Dr. Guggenbiihl, of Zurich. The condition is be- 
yond medicinal remedies. 911 
PATHOLOGY OF DIABETES. 
DIABETES-Syn., DIABETES MELLITUS. 
Latin Eq., Diabetes-Idem valet, Diabetes mellitus; French Eq., Diabbte-Syn., 
Diabete sucre; German Eq., Diabetes-Syn., Zucker harnruhr; Italian Eq., 
Diabete-Syn., Diabete melito. 
Definition.-A constitutional disease obviously produced through errors in the 
processes of assimilation either in the stomach, in solid organs, or in the blood, and 
characterized especially by an excessive discharge of urine, more or less constantly 
saccharine, excessive thirst, and associated with progressive emaciation of the body. 
Pathology.-From the time of Charles II of England, when Dr. Thomas 
Willis first observed the saccharine character of diabetic urine, no disease has 
had its nature more inquisitively examined, and with more interesting and 
instructive results. The abnormal state of the urine naturally at first led the 
inquiry towards the kidneys. They have been industriously examined, both 
as to their structural and functional relations, but without elucidating the na- 
ture of the change in the urine. Dr. Matthew Dobson, of Liverpool, in 1779, 
first established by experiment the fact that the sweetness was due to the pres- 
ence of sugar. The next step in the inquiry was the detection of sugar in 
the blood of the diabetic patient. Ambrosiani, of Milan, in 1835, and Dr. 
Charles Maitland, in 1836, obtained crystals of pure sugar from the serum of 
the blood, and a large portion of fermentable crystallizable syrup. The late 
Dr. Robert Macgregor, of Glasgow, in 1837, confirmed these observations by 
experiments, followed by those of Dr. G. O. Rees, of London, and Dr. Chris- 
tison, of Edinburgh. Thus inquiry regarding the essential character of the 
disease was removed from the urine and the kidney to the blood ; and research 
took a new direction, so as to ascertain, if possible, the source of the sugar in 
the blood and in the urine. 
Although this disease has hitherto found a nosological place under diseases 
of the kidneys, the researches of Bernard, Parkes, Pavy, Ringer, and others, 
very clearly show that amongst them it is misplaced. If the disease is to be 
regarded as a local one, it should rather come under hepatic than nephritic 
diseases; but the weight of evidence clearly shows that diabetes mellitus belongs 
to the constitutional class of diseases. 
The unusual discharge of urine in this malady was originally ascribed by 
Mead to a morbid state of the liver and bile; but subsequently nutritive and 
assimilative functions connected with the digestive canal were considered by 
Cullen, Home, and Dobson to give rise to the morbid state. That the process 
of digestion and assimilation in the stomach was the source of the evil has 
been hitherto the prevailing theory regarding the nature of this disease. The 
belief received confirmation especially by the ingenious experiments of the' 
late Dr. Robert Macgregor, of Glasgow, who ascertained that sugar was found 
in the stomach of diabetic patients during the process of chymification, even 
when no saccharine matter had been swallowed. Sugar has now also been 
detected in the saliva, the sweat, and in the stools. To the ingenious M. 
Claude Bernard, of Paris, the science of medicine is indebted for the elucida- 
tion of the nature of the normal generation of sugar in the animal economy 
(glycogenesis) ; and thus we have been provided with data for the comparison 
and study of its morbid generation in melituria. He has shown us that one 
of the natural functions of the liver is to generate sugar; and thus the saga- 
cious speculations of Mead, which referred the phenomena of diabetes to a 
morbid state of the liver and bile, are now not only curious, but interesting 
and instructive. While our knowledge regarding the formation of sugar by 
the liver, and its physiological relations to the animal economy in health and 
in disease, have been especially illustrated by Bernard, in France, it is to be 
observed that Dr. George Harley, of University College, and Dr. Pavy, of 912 
SPECIAL PATHOLOGY-DIABETES. 
Guy's Hospital, London, have confirmed many points, and especially eluci- 
dated the interesting doctrines of Bernard. Much is still unsettled as to the 
significance of the phenomena; but the following statements will convey a 
summary of the present position of the inquiry regarding glycogenesis, as set 
forth in the Medico-Chirurgical Review for January, 1857. 
From the experiments just referred to, the fact was considered as an estab- 
lished one, that the food, and more especially its amylaceous and saccharine 
elements, had the power of forming sugar, which then passed into the blood 
and urine from the alimentary canal. The experiments of Bernard and 
others, however, have demonstrated that the animal organism has the power 
of forming sugar altogether irrespective of the nature of the food; and that 
sugar exists in a certain part of the circulation-namely, from the hepatic 
veins to the pulmonary capillaries-both in carnivorous and herbivorous ani- 
mals. The liver is found to be this sugar-producing organ ; and it is the only 
organ of the body which, in the normal state, is found to be impregnated with 
sugar-a fact established by Bernard,- by observations on a large number of 
animals in almost every department of the zoological series. In man he ex- 
amined especially the liver of five executed criminals, also that of a man who 
was killed by a gunshot wound, and that of a diabetic patient who died sud- 
denly from pulmonary apoplexy. In four of these he determined the absolute 
and the relative amount of sugar in the liver. The total weight of the three 
healthy livers was 4205 grammes, which yielded of sugar a total of 66.074 
grammes; so that the average weight of each liver being 1401.2 grammes, 
the weight of sugar yielded was 22.037 grammes, to compare with the liver of 
the diabetic case, which weighed 2500 grammes, and yielded 57.50 grammes 
of sugar. He shows that the relative quantity of sugar varies little when the 
system is in a normal condition, very seldom exceeding 4 per cent. He especi- 
ally demonstrated that sugar was secreted in the liver, and entered the blood 
from that organ ; for, by a comparative analysis of the blood of the portal 
vein as it enters, and the blood of the hepatic veins as they emerge from the 
liver, he found sugar in the latter, but not in the former. Sugar is not only 
found in the liver of adult animals, but it has been found in the livers of the 
human foetus, the foetal calf, and the unhatched chick-thus proving that it 
does not merely accumulate there as a product from the digestive canal. 
Further, it has been determined that the sugar is undergoing perpetual 
destruction and renovation. It can be observed to disappear, and its further 
formation may be prevented under the following conditions: (1.) By causing 
an animal to die slowly by starvation, or by dividing the pneumogastric 
nerve; (2.) When the function of the liver is disturbed by severe, and especi- 
ally by acute diseases. 
The following is the course described by Bernard as that taken by the sugar 
secreted in health by the hepatic cells: 
" It passes with the blood of the capillaries into the hepatic veins, and 
thence into the vena cava ascendens. It is at the point of discharge of the 
last-named vessel that the blood is the most strongly saccharine; it then be- 
comes mixed with the blood from the lower parts of the body, and passes up 
to the right auricle, where the sugar undergoes a new dilution from its admix- 
ture with the blood of the vena cava descendens. From the right auricle it 
passes into the right ventricle, and thence to the lung. In the whole of the 
route from the liver to the lung the blood is constantly saccharine, but the 
amount of sugar varies extremely, and is least at the greatest distance from 
the liver. In the lung the sugar, being brought into contact with the air, 
and mixing with the whole mass of the blood, sometimes completely disappears. 
" These two organs, then-the liver and the lung-stand in an inverse 
relation to one another, in so far as the saccharine matter is concerned. In a 
fasting animal, for example, the blood which arrives at the liver contains no PATHOLOGY OF DIABETES. 
913 
trace of sugar, while that which leaves it is distinctly saccharine. Inversely, 
the blood which arrives at the lung contains sugar, while that which leaves it 
contains no traces of this constituent. The sugar in this physiological state 
remains hidden between the liver and the lung, and this is the reason why its 
existence and formation within the animal body were not earlier discovered. 
The analysis of blood drawn from superficial veins would fail to detect it under 
these conditions" (Med.-Chir. Review, p. 32, January, 1857). 
But under some conditions even in health, and therefore called "physio- 
logical conditions," sugar may be found in the blood beyond the lungs. The 
activity of the glycogenic function being increased with an augmented flow of 
blood to the liver, such as that which takes place after a meal, it is found that 
four or five hours after the commencement of intestinal digestion the produc- 
tion of sugar in the liver attains its maximum. For three or four hours at 
this time the production of sugar exceeds its destruction, so that " at this period 
of digestion w'e find sugar in all the vessels of the body, both arteries and 
veins ; and we find it in the renal arteries, but in too small quantity to pass 
into the urine. This active and increased flow of blood through the liver 
thus displaces the sugar previously found there, and projects it into the circu- 
lation, and at the same time acts as a stimulus to the liver, which is still 
further excited by the nervous system under the influence of digestion. This 
increase of sugar is thus altogether independent of the nature of the food." 
The cases of so-called " intermittent diabetes " are partly explicable by this 
interesting observation, in which the urine of digestion is saccharine, while no 
sugar can be detected at other periods, as in old persons observed by Bence 
Jones {Med.-Chir. Trans., vol. xxxvi, p. 401). 
The influence of diet is thus far remarkable, that the formation of sugar 
diminishes when fatty kinds of food are used-a fact supposed to be explained 
by the circumstance that the fats are absorbed directly by the lacteals, and 
thus do not affect the portal blood. It is also observed that in health the 
ingestion of amylaceous or saccharine matter does not augment the quantity 
of sugar in the liver, nor in the animal economy generally, although in cases 
of diabetes the use of these saccharine substances commonly causes a great and 
immediate augmentation of the sugar in the urine. 
It does not yet appear clear how the sugar is destroyed in the blood in 
health. The destruction has been ascribed-(1.) To the oxidation or com- 
bustion of sugar in the lungs; (2.) To its combustion effected through the 
agency of an alkali; (3.) To the influence of extreme division in the blood, 
through which it may be converted into lactic acid by a simple molecular 
change. 
Connected with the formation of sugar in the liver, Bernard shows that two 
substances are concerned-(1.) One soluble in water; (2.) A substance slightly 
soluble in water, and which remains fixed in the hepatic tissue after all blood 
and sugar have been removed by prolonged washing. While, therefore, Ber- 
nard's observations showed that the blood which left the liver by the hepatic 
vein contains a peculiar substance of a saccharine nature, which does not exist 
in the blood brought to the organ in a state of health by the portal vein, the 
more recent researches of Dr. Pavy, of Guy's Hospital, have shown that the 
liver does not actually form sugar, but a substance that becomes sugar almost 
immediately on coming in contact with albuminous matters. " It is especially 
destined as a pabulum or fuel for the combustion process, being usually elimi- 
nated from the blood in the form of carbonic acid and water during its passage 
through the lungs, so as not to pass into the systemic circulation unless either 
its quantity be unusually great or its elimination interfered with by imperfect 
respiration. It appears to be elaborated by the converting power of the liver, 
either from materials supplied by the food or from the products of the waste of 
the system " (Carpenter, p. 308 ; Animal Physiology, Bohn's edition). 914 
SPECIAL PATHOLOGY-DIABETES. 
Connecting all these observations together-namely, Parkes, Lehmann, 
Bernard, Pavy, Basham-may it not be suggested, as a topic of investigation, 
whether or not the elaboration of this material by the liver is not arrested in 
Bright's disease and increased in diabetes, in the active stage of which disease 
it ultimately comes to be eliminated by the kidney as sugar in the urine ? 
The ultimate result of Bernard's investigations shows that the increased 
formation of sugar by the liver, and its presence in the blood, is the result of 
some exciting cause which, acting by reflex action, conveys the stimulus to 
the medulla oblongata, whence it is propagated by the spinal cord and filaments 
of the great sympathetic nerve to the liver, and so excites its glycogenic func- 
tion. This doctrine is supported by the following experiment of Bernard: 
"When we prick the mesial line of the floor of the fourth ventricle, in the 
exact centre of the space between the origins of the auditory and pneumo- 
gastric nerves, we at the same time produce an exaggeration of the hepatic 
(saccharine) and of the renal secretions; if the puncture be effected a little 
higher, we very often only produce an augmentation in the quantity of the 
urine, which then frequently becomes charged with albuminous matters; 
while, if the puncture be below the indicated point, the discharge of sugar 
alone is observed, and the urine remains turbid and scanty. Hence it appears 
that we may distinguish two points of which the inferior corresponds to the 
secretion of the liver, and the superior to that of the kidneys. As, however, 
these two points are very near to one another, it often happens that, if the 
instrument enters obliquely, they are simultaneously wounded, and the ani- 
mal's urine not only becomes superabundant, but at the same time saccharine" 
{Med.-Chir. Review, 1. c., p. 42). 
He found also that in cutting the pneumogastric nerves the secretion of 
sugar was stopped, but that it still took place when the floor of the fourth 
ventricle was irritated, after the division of the pneumogastric. Any irrita- 
tion conveyed through this nerve may thus induce the diabetic state. The 
following are the general circumstances under which the phenomena of meli- 
turia become developed: Any agents or conditions which cause a suspension 
of the functions of animal life, while the purely nutritive or organic functions 
remain intact, may bring about melituria^ Thus the Indian worari poison acts; 
so does apoplexy produced by a blow on the skull. Local irritation of the 
liver itself, as Dr. Harley has shown, may also induce the condition. By the 
injection of alcohol and ether into the vena portae, Harley was able to induce 
diabetes. The internal use of arsenic and quinine has also been said to have 
induced saccharine urine; and thus it is not improbable that irritant sub- 
stances absorbed from the bowels by the mesenteric veins may sometimes 
bring about the morbid state. 
In spite of all these theories, the immediate cause of diabetes still remains 
obscure, and its beginnings are a mystery. 
According to Griesinger, diabetes occurs much more'frequently in males 
than in females-nearly in the proportion of three to one. It occurs most 
frequently between the ages of thirty and forty in males, and in females 
between those of ten and thirty. The disease shows sometimes a hereditary 
origin and transmission. The usual recognized exciting causes are exposure 
to cold and wet, concussions of the body, immoderate use of sugar, new wine 
and fruit, great and continued mental exertion, mental depression, alcoholic 
intoxication. ' 
Morbid Anatomy.-No constant lesion is found. There is no remarkable 
lesion in any part of the nervous system. Sometimes the floor of the fourth 
ventricle is diseased and sometimes healthy-nothing is constant. 
The pancreas is very often hypertrophied. The walls of the stomach are 
thickened, chiefly through muscular hypertrophy, with the mucous membrane 
thickened and softened. SYMPTOMS OF DIABETES. 
915 
The lungs are almost always tuberculous, or contain caseous deposits, and 
not unfrequently there is pneumonia or gangrene. 
Of the secondary lesions the lungs are most frequently affected. In thirty- 
one out of sixty-four fatal cases, or in nearly a half, tubercle was found 
(Griesinger). But Pavy and Wilks do not believe the lesion to be that of 
tubercle, but the result of a chronic inflammation, by which the lung-tissue 
is broken down and cavities form. 
In about half the cases the kidneys are enlarged, and sometimes are in a 
state of chronic parenchymatous inflammation, as in some forms of Bright's 
disease. 
The liver usually appears normal, but is sometimes congested with blood. 
The bile resembles a mixture of rhubarb, and deposits a copious sediment of 
columnar epithelium and yellow amorphous granular-looking matter. 
Symptoms.-The early symptoms of diabetes mellitus are obscure. Dr. 
Prout believed that there is a stage which precedes the formation of sugar, 
and which is marked by a superabundant and highly dense urine, loaded with 
an excess of ilrea. But much uncertainty prevails on this point, and nothing 
is assured except that the constitution is not greatly affected till the saccharine 
matter forms and is eliminated by urine. In some very few instances the 
quantity of urine passed is hardly greater than in health; but more com- 
monly it is in great excess, amounting to eight, ten, sixteen, thirty, and even 
more pints during the twenty-four hours, so that the patient is incessantly 
disturbed in the night, and loses his sleep, while the urethra and its orifice 
become inflamed and sore. 
The onset of the disease is thus generally insidious and unobserved. There 
may be a sense of general discomfort, some emaciation may declare itself, 
while constant thirst and frequent micturition become well-marked symptoms. 
At this period the general health begins to give way; thirst is intense, and 
the patient often drinks many quarts, or even gallons, in the course of the 
day. The quantity of water drunk has been believed to be less than the 
quantity of urine passed-in some instances only as one to four; but this 
statement, however, is not now believed to be correct. From the careful 
experiments of Dr. Parkes and others to determine this point, it appears that 
the quantity of urine is actually less than the quantity of water taken in 
liquid and solid food, and this is more especially seen to be the case if long 
periods (ten or twelve days) are taken for examination. Water is often 
retained for some time in the body of diabetics, and if an observation be 
made in a single day, it may happen that some of the urine retained from 
the previous day is then poured out. It is such retention of water which 
may account for the apparent excess of urine over drink (Parkes On the 
Urine, p. 339). The appetite is capricious, but generally excessive and 
voracious, the skin harsh and dry, and the patient becomes greatly emaciated, 
and loses sexual desire and sexual power. Almost all the water drunk passes 
off by the kidneys, and the insensible perspiration is diminished both by skin 
and lungs. The intestinal excretion of water is also greatly lessened ; hence 
the bowels are costive and the faeces dry and hard. The water is not passed 
off by the kidneys so soon as in health. If a diabetic person drink water in 
the morning, the urine may not be increased till midday; but if grape-sugar 
be added to breakfast, the urine is passed as rapidly as in health. In ad- 
vanced cases the drain upon the constitution is so great that the alveolar pro- 
cesses are absorbed, and the teeth, loosened in their sockets, are apt to fall 
out. These symptoms are much relieved by medicine, and life much pro- 
longed ; but often, when the case appears most favorable, tuberculosis becomes 
apparent, and the patient sinks under this disease. 
The emaciation of diabetes is progressive, and the muscles become atrophied, 
as well as the adipose tissue. Even the heart is said to suffer. The skin is 
persistently dry, but on the appearance of fever, perspirations set in. 916 
SPECIAL PATHOLOGY DIABETES. 
The digestive organs become weak and feeble, the inordinate appetite 
diminishes, and food is loathed. Nausea is frequent-a sinking at the pit of 
the stomach is complained of-the bowels become constipated, and the faeces 
pale. A short dry cough becomes frequent, the index of commencing disease 
of the lungs, and the patient generally suddenly sinks from exhaustion or 
from coma or convulsions. 
Condition of the Urine.-When diuresis is considerable, the urine should 
invariably be examined, and its constituents determined. A faint sweetish 
odor may be perceptible in diabetic urine, comparable to fresh hay or milk. 
The chamber-vessel should be examined for crystals of sugar which may 
have been formed (Fig. 92). The best evidence, however, is that derived from 
chemical tests. 
A portion of urine, which is usually of a light-straw color, should be taken, 
and its specific gravity determined; and if greater than 1.020, it should be 
evaporated, and if sugar be present we shall have a dark-brown residue, some- 
thing like treacle. This extract, like the natural sugars, consists of crystal- 
lizable matter and of an uncrystalliza- 
ble syrup; and to separate them Dr. 
Christison recommends that the ex- 
tract be agitated with rectified spirit, 
and the residue boiled in another por- 
tion of the same fluid, when, on cool- 
ing, the crystallizable sugar will sepa- 
rate in light-grayish grains like grape- 
sugar. Again, if sugar should be 
suspected to exist, even in minute 
quantity, a small portion of yeast 
should be added to a small quantity 
of the urine, when, if sugar be present, 
fermentation will ensue, and each 
square inch of carbonic acid given off 
corresponds nearly to one grain of su- 
gar. This test is so delicate that one 
part of diabetic urine, according to 
Dr. Christison, may be detected in 
1000 parts of urine of the density of 
1.030. The most certain and approved test is that known as " Trommer's 
test," based on the reaction of the salts of copper. A portion of urine in a 
test-tube is to be treated with one or two drops of a solution of sulphate of cop- 
per, and afterwards a considerable excess of potash is to be added. The dark- 
blue solution which results is then to be held over the spirit-lamp, and boiled 
for a moment, when a yellowish-brown precipitate of the suboxide of copper 
is produced. Dr. Roberts expresses a want of certainty in the results of most 
of those tests. He recommends Fehling's copper solution as the best test. It 
consists of Sulphate of Copper, gr. viii; Tartrate of Potash, Jss.; Liquor Po- 
tassse, Ji. Some of this test solution is to be boiled, and some drops of the sus- 
pected urine added to it. If sugar be abundant, a thick yellowish opacity and 
deposit of yellow suboxide are produced, which changes to a brick-red at once 
if the blue color of the test remains dominant. If no such reaction ensues, more 
urine is to be added, until a quantity equal to the bulk of the test employed 
has been poured in. The whole must be again heated to the boiling-point; 
and if no change occurs, it is to be set aside without further boiling. As the 
mixture of the urine and test cools, if no milkiness is produced, the urine may 
be confidently pronounced free from sugar. No quantity above a fortieth of a 
grain can escape such a test, and any. quantity below that does not appear to 
be of clinical importance. It is important to bear in mind that Fehling's test 
Fig. 92. 
Crystals of diabetic sugar from diabetic urine 
(after Beale, p. 150). RELATION BETWEEN THE FOOD AND SUGAR IN DIABETES. 
917 
solution must always be freshly prepared. For the application of further 
tests, see Dr. Beale's tables, p. 21. 
The density of diabetic urine, however, is one of the best indications. This 
fluid varies in density from 1.030 to 1.074 (Becquerel); but on an average, 
and tolerably constantly, it is 1.040; and when the urinometer stands above 
1.030, we may suspect that sugar is present. The quantity of sugar present has 
been calculated by Dr. Henry, in urine of density 1.020, to be 402 grains in 
every pint, while at 1.050 it contains 958 grains of sugar-the increment being, 
as he conceives, one scruple or nearly so for every degree of specific gravity be- 
tween the extremes that have been mentioned. If these data be correct, a 
person passing sixteen pints of urine daily, of specific gravity 1.050, actually 
passes nearly two pounds avoirdupois of sugar. But the amount varies 
greatly, amounting sometimes to one pound or two pounds, or even two and a 
half pounds, in twenty-four hours. In a few months patients will pass their 
own weight in sugar (Parkes, 1. c.). Its amount is mainly influenced, in the 
first instance, by the saccharine and amylaceous nature of the food, which 
always augments the amount of sugar. The augmentation is quite percepti- 
ble about two hours after food, and continues for four or six hours, if the 
amount of starch taken has been considerable. It is probable, though it is 
not absolutely proven, that all the starch eaten is converted into sugar; and 
in cases accurately observed by Mr. Graham and Dr. Parkes for a considera- 
ble length of time, the quantity of sugar excreted by the urine never exceeded 
the amount of starch; and almost all the starchy food was accounted for by 
the diabetic sugar (Walshe, Parkes). It has been supposed by some that 
when the starch only is converted into sugar, it is the earliest stage of the dia- 
betic state; and it is certain that during the progress of some cases sugar 
begins to be formed from other sources and in other ways, and is no longer 
derived solely from the starch. 
In some cases the sugar may recognize no other origin than the starchy 
food for many years. Such seems to have been the case of the late Mr. Camp- 
lin, of Finsbury Square, who kept his disease at bay for ten or twelve years 
{Med.-Chir. Trans., vol. xxxviii, p. 69; Parkes, 1. c.). Complete fasting or 
abstinence from saccharine and starchy food for eight or twelve hours reduces 
the quantity of urine to the normal amount, and brings down the specific 
gravity to the usual figure. Sugar can then neither be detected in the urine 
nor in the blood, as was determined by Dr. Parkes after numerous analyses of 
blood under such circumstances ( On the Urine, p. 348). 
In the majority of advanced cases of diabetes, sugar is not only produced 
from starch, but also from nitrogenous foods, especially gluten and animal food. 
In such cases complete abstinence for a time from food lessens, but does not 
entirely remove, the sugar from the urine. Perhaps in all such cases the forma- 
tion of sugar from albuminous food indicates a more advanced or active stage 
of the disease than when the sugar is formed from starchy compounds only; 
and it is probable that the amount of sugar from this source increases as the 
disease advances. Dr. Parkes refers to a case related by Schultze, in which 
the amount of sugar in the urine when the patient was on mixed diet was one-third 
more than could have been furnished by the starch food alone ; and the amount 
can always be ascertained by keeping the patient strictly on a meat diet, and 
feeding him with starch from time to time as an experiment (1. c., p. 348). 
Thus, three conditions affecting food would seem to be present in cases of 
diabetes: 
The earliest and fundamental one continues to act throughout, and is dis- 
tinguished by complete arrest of the normal metamorphic changes of starch 
and sugar-an arrest probably associated with some substance in the diges- 
tive canal which absorbs the sugar. At first it affects the sugar derived from 
starch food, then it affects the sugar derived from nitrogenous food. Dr. 
Bence Jones suggests that in some cases the changes may pass one step be- 918 
SPECIAL PATHOLOGY-DIABETES. 
yond the conversion of starch into sugar, and produce "vegetable acid." He 
believes a disease exists which is thus allied to diabetes, and characterized by 
a great amount of acid, probably lactic, in the system and in the urine. The 
chief transitional changes of starch enumerated by Dr. Bence Jones are as 
follows: Starch into sugar, into vegetable acid, into carbonic acid; and he 
supposes the arrest to occur at the acid stage, instead of at the sugar stage, in 
the morbid condition he describes. 
The second condition is an abnormal production (probably in the liver) of 
sugar from nitrogenous food-i. e., an amount of production which is abnor- 
mal-combined with arrest in the transformation of sugar normally formed 
(Parkes). A diabetic patient, kept on the most rigorous meat diet, has been 
known to pass a quantity of sugar corresponding to two-fifths of the entire 
meat food, or three-fifths of the albuminate contained in the meat (Griesinger, 
quoted by Parkes). 
A third condition may be also distinguished-namely, one in which the 
tissues themselves, and especially the muscles of the body, contribute to the 
morbid formation of sugar. This occurs under circumstances of extreme 
inanition, when almost no food is being supplied to the body, and yet a con- 
stant quantity of sugar is eliminated. 
Traube, Parkes, and Kinger have each 
recorded such cases. In one of Dr. 
Parkes's cases, the blood, after seventeen 
hours' fasting, was found to be still very 
rich in sugar (Parkes, 1. c., p. 350). It 
is, however, a question whether this is 
an abnormal formation of sugar merely, 
or a further and more advanced stage of 
the disease. There are also cases which 
may be noticed here, in which the 
patients continue to lose ground al- 
though the quantity of sugar lessens, 
and in which the substance known as 
inosite or m/ttscfe-sugar is found in the 
urine (Fig. 93). It increases in quantity 
as the sugar lessens, and at last as much 
as eighteen and twenty grammes of pure 
inosite have been procured from the 
day's urine. The inosite may be ob- 
tained in the form of colorless prismatic crystals, which are efflorescent. It 
does not reduce the oxide of copper to the state of suboxide, as is the case 
with diabetic sugar and grape-sugar; and it is said to have not quite the same 
composition as the latter substance, but is represented by C3 H2 0.2; so that 
one atom of grape-sugar would thus represent six atoms of inosite. It may be 
detected by evaporation of the suspected fluid nearly to dryness in a platinum 
basin, when, if a little ammonia and chloride of calcium be added, a rose 
color is produced, especially if the mixture be again concentrated by evapo- 
ration. M. Hohl records a case of diabetes in which, while the proportion of 
sugar gradually diminished, the inosite gradually increased in amount till 
upwards of 300 grains were passed in the twenty-four hours (Parkes, 
Beale). The observation is one of great interest in connection with the 
pathology of this remarkable constitutional disease. 
Professor Sidney Kinger, of University College, has made some observa- 
tions of great interest, to show the amount of urea and of sugar respectively 
furnished by the tissues of the body and by nitrogenous food. (1.) During 
inanition one series of observations showed an enormous disintegration of 
tissues (48 grammes of urea and 105 grammes of sugar being passed in twenty- 
four hours), the relation between the urea and the sugar being tolerably con- 
Fig. 93. 
Inosite or muscle-sugar, crystallized partly 
from alcohol and partly from water (after 
Funke). complications in diabetes. 
919 
stant. In the second series, when nitrogenous food was taken, the urea in- 
creased about the third hour after food, and reached its maximum about the 
fifth hour, after which it continued to diminish, and reached the inanition 
amount in the eighth hour. The sugar followed the same rule, and almost in 
an exact ratio; but the urea was in slight relative excess to the sugar, show- 
ing that the nitrogenous food raised the urea slightly more than it did the 
sugar. During inanition the urea was to sugar as 1 to 2.235, while after 
nitrogenous food the urea was to sugar as 1 to 1.9. It thus appears certain, 
as Dr. Parkes observes, that there is some close connection between the 
amounts of urea and of sugar in such cases as diabetes. The amount of urea 
may be double or even treble the normal amount, and that to an extent much 
greater than can be accounted for by the food taken, and due probably to 
some peculiarity in diabetes, causing heightened metamorphosis of tissues, such 
as might arise from the excessive action of oxygen on them (Parkes, 1. c., p. 
342). The amount of sugar is still further increased if diabetic patients take 
more water than their thirst demands; and it is probable that the urea is also 
increased, although exact experiments are wanting. 
On standing, diabetic urine soon begins to ferment, with the appearance of 
lactic, butyric, acetic, or formic acids, and develops the yeast plant; and during 
this fermentation the urea entirely decomposes. Dr. Christison gives the fol- 
lowing formula for ascertaining the amount of solid matter in diabetic urine: 
"Multiply the excess of the specific gravity over 1.000 by 2.33, the result is 
the number of parts of solid matter in 1.000 of urine." 
Diabetes is chronic in its course, usually lasting from one to two years, 
though it may run on for six, eight, or ten years. Becquerel mentions the 
case of a boy, nine years old, who died in six days, and Roberts a child of 
three years, who died in three weeks. Of 100 fatal cases collected by Gries- 
inger, the duration was: 
Under 3 months, ....... 1 
Between 3 and 6 months, ..... 2 
" 6 " 12 " 13 
" 1 " 2 years, 39 
" 2 " 3 " 20 
" 3 " 4 " 7 
" 4 " 5 " 2 
" 5 " 6 " 1 
" 6 " 7 " 2 
" 7 " 8 " 1 
Undetermined, . . . . . . .12 
The most common complication is tuberculosis, it occurring in one-half of 
the cases of diabetes protracted to the first year (Roberts). It is often quite 
acute. " A low and fatal type of inflammation of the lungs, pleura, or peri- 
toneum is not infrequent after the disease has lasted some time." In every 
tissue of the body there exists a tendency to asthenic inflammation, apt to 
run into abscess, diffuse suppuration, sloughing, phagedenic ulceration, or gan- 
grene. Boils, in successive crops, and even carbuncle, may appear in the 
course of the disease. In one of Dr. Roberts's cases, boils were an initial 
symptom. Spontaneous gangrene of the lower extremities, with obstruction 
of one or more arteries of the limb, is not infrequent in diabetes (Marchal 
de Calvi). Defective vision is met with in a certain number of diabetic 
patients. Cataract occurs in some long-standing cases ; its frequency is vari- 
ously stated. Of 225 cases collected by Griesinger, there was cataract in 20, 
but of his own 7 cases, it was present in 3; Von Graefe states the proportion 
as 1 in 5; Bouchardat, 1 in 38; of 45 cases treated by Roberts, there was 
cataract in only 1; and Garrod says that in the large number of cases of dia- 
betes he has treated he has never once seen it. Diabetic cataract is nearly 920 
SPECIAL PATHOLOGY-DIABETES. 
always soft, though examples of the hard kind have been reported by Wilde, 
Von Graefe, and Guersant. Roberts thus describes it: "It comes on gener- 
ally after the diabetic state has lasted eighteen months or two years; but it 
has been known to appear in six months. Its course is rapid; the two eyes 
may become completely cataractous in a few days; sometimes it is developed 
more slowly." It begins in one eye-generally in the right,-but soon in- 
volves the two. Drs. S. Weir Mitchell, of Philadelphia, and B. W. Richard- 
son, of London, have endeavored to show that it was due to physical imbibi- 
tion by the lens of the saccharine matter of the aqueous humor; but there is 
no proof of this. Hepp and Fischer both failed to find sugar in cataractous 
lens removed from diabetic subjects, and there are other reasons against the 
reception of this theory, particularly the infrequency of its occurrence, the 
long delay of its appearance, and its being occasionally unilocular. 
Dimness of sight, from supposed functional disorder of some of the internal 
structures of the eye (amblyopia) happens, according to Bouchardat, in about 
one-fifth of the cases of diabetes. Fauconneau Dufresne found the sight more 
or less affected in 20 out of 162 cases. Generally it is slight, temporary, and 
often recurrent. It is rarely a permanent affection, and when so, ends in 
total blindness, and betokens a speedy fatal termination. In such cases the 
retina is said to be atrophied (Clymer). 
Prognosis.-The ultimate issue of every case of diabetes is probably fatal; 
at least the number of cases in which the urine is rendered permanently nat- 
ural is extremely small, and many of them at the moment the disease 
seems to have yielded, die of phthisis. Even when the presence of the sac- 
charine principle has been so far conquered that it alternates with lithic acid 
deposit, or that lithic acid becomes the prominent feature, the circumstance is 
anything but favorable, for such individuals generally die of some sudden and 
overwhelming attack of internal inflammation or of apoplexy (Prout). On 
the other hand, where the source and nature of the malassimilation can be dis- 
covered, and either rectified or held in check, and if the patient will submit to 
regimen, a favorable result may be hoped for in some cases. A " not inconside- 
rable number, however, recover completely, and many more attain to a state of 
conditional amelioration-that is, an amelioration which is conditional on the 
observance of a certain diet and regimen." Dr. Trousseau says: "By hygiene 
and a proper regimen, aided by the action of certain remedies, wisely and pru- 
dently used, we may hope to cure a few and to relieve a large number of dia- 
betic patients, if the disease has not reached the last period." The younger 
the patient the less is the chance of ultimate recovery. Dr. Roberts states that 
all the cases under twenty which he has seen have eventually died of the 
disease. In all persons the symptoms may continue for years, with a tolerable 
state of health. In corpulent persons the prognosis is more favorable than in 
those of spare habit. Saccharine urine, without excessive urinary secretion, 
is less serious than when the secretion is very great. " Coeteris paribus, the 
longer the disease has existed, the more unfavorable the prognosis; cceteris 
paribus, also, the greater the general severity of the symptoms, the less is the 
hope of amendment. Cases which can be traced to mental anxiety and trau- 
matic lesions appear to be somewhat more hopeful than those for which no 
tangible cause can be assigned" (Roberts). Great diminution in the amount 
of, or the total disappearance of, sugar in the urine, when saccharine and 
amylaceous articles of diet are not used, is a favorable sign; also a soft, 
perspirable skin, with a moderate appetite, or the symptoms generally remain- 
ing stationary. Albuminuria, thoracic and intestinal complications, and per- 
manent cataract or amblyopia, are always fatal (Clymer). 
Treatment.-There are few diseases in which the treatment has been more 
varied than in diabetes mellitus. Every conceivable medicine has been given, 
but exact quantitative determinations of the effect of them on the sugar have 
rarely been made. The emaciated state of the patient presents an insur- treatment of diabetes. 
921 
mountable obstacle to bleeding. Nevertheless, this mode of treatment has 
often been practiced, and as much as 160 to 170 ounces of blood have been 
taken in a few weeks. The late Sir Henry Marsh found bloodletting of ser- 
vice when the disease was recent, and the strength of the patient still main- 
tained. He found that it promoted the action of diaphoretic remedies; and 
especially when followed by the tepid bath. He found leeches to the epigas- 
tric region of benefit, when internal heat with fulness and tenderness pre- 
vailed there, with a "gnawing" feeling about the stomach. In the face,how- 
ever, of so high an authority, the pathology of diabetes, as given in the text, 
does not sanction general bloodletting as a mode of cure. 
Mercury, alike with lead, antimony, zinc, silver, and copper, are indifferent 
as to their influence on the formation of sugar (Parkes). Opium has been 
given to the extent of 100 grains in the twenty-four hours; but with an 
equal want of success, although it does seem to lessen the sugar, probably by 
lessening the appetite and hindering the taking of food (Parkes). The 
whole materia medica has been exhausted in search of a remedy for this dis- 
ease. The metals, the fixed and the volatile alkalies, the vegetable and 
mineral acids, the astringents, purgatives, tonics, diaphoretics, and diuretics, 
have in their turns been administered, and each has perhaps afforded some 
relief; but the disease has proceeded, and finally, it may be said, nearly 
every patient dies whose treatment is left entirely to drugs. Dr. Prout, who 
considered it merely as a form of dyspepsia, conceived that each case re- 
quires a different treatment. In the early stages of the disease the late 
Drs. Bullar, of Southamptom, have found great benefit from the tincture of 
the muriate of iron, now called the tincture of the perchloride of iron. Dr. 
Camplin speaks of the citrate of ammonia in the effervescent form, generally 
combined with the citrate of iron, as more useful than any other medicine; 
while bitters and alkaline remedies did him great service at one period of his 
attack. 
Opium combined with ipecacuanha is eminently useful as a sedative, espe- 
cially in the form of Dover's powder, while exercise, warm clothing, friction 
of the surface, hot bathing, and diaphoretics improve the cutaneous functions. 
The functions of the skin must always be inquired into, and must be kept 
active. The nitro-muriatic acid baths and the internal administration of the 
acid might also be employed with some prospect of benefit in cases requiring 
acid tonics. This is more generally the case in the young, and in the early 
stages of the disease, in which the tincture of the perchloride of iron is also of 
service, prescribed in the infusion of quassia or of calumba. But each case 
requires to be made a special study, considering that many, or at least several, 
organs may be concerned in the disordered working of the system (Prout, 
Camplin). The mistura ferri composita is another of the iron preparations 
which has been found of service. The administration of alkalies, as recom- 
mended by Miahle and Contour, is also occasionally successful. 
The little benefit derived from medicine induced Dr. Rollo to try the 
effects of an entirely azoted or animal diet, and out of nineteen cases two 
are said to have been cured by this means. A full and generous diet is 
unquestionably useful in these cases; but the patient soon gets disgusted with 
mutton or beef, or both, for breakfast, dinner, and supper; he consequently 
nauseates a meat diet, and abandons it altogether. A diet of salt fish has 
been attempted; but the patient in a short time so loathes it that it has to 
be given up. A mixed diet, therefore, if contraindicated by some theories, 
is at least the best to adopt in practice, and is consistent with the remarks 
made under pathology, if duly regulated and aided by other means. It will 
be evident, however, that those vegetables which contain a large quantity of 
saccharine matter should be avoided in some degree, as potatoes, grapes, or 
other very ripe fruit, and, a fortiori, sugar itself. 
"There are, therefore," as Dr. Camplin justly observed, "certain fixed 922 
SPECIAL PATHOLOGY-DIABETES. 
broad principles upon which the disease is to be treated." In all cases the 
various influences of the stomach, liver, skin, and kidneys on the nervous 
system and on each other ought to be sought out and determined, and the 
basis of treatment arranged accordingly. It is necessary to abstain from all 
amylaceous food, as well aS from every solid and liquid containing sugar, or any 
substance readily convertible into sugar. Fat meat and eggs may be taken, if 
biliary derangement is not induced by them, and fish is a most important 
article with which to vary the monotony of the dietary. Milk also may be 
indulged in occasionally, as it is not found that the sugar it contains is readily 
converted into glucose. Its influence, however, requires watching. It is 
desirable to vary the food as much as possible during the day, taking the 
lighter kinds in the later meals. When soups are taken, they ought to be 
really good, and flavored with aromatics or onions, to the exclusion of 
carrots, turnips, and pease. They may be thickened with some bran finely 
powdered. Lettuces Dr. Camplin found to agree well, when eaten sparingly 
with oil and vinegar, or with a little salt only, if the vinegar is likely to 
disagree. Pickles in small quantities may be permitted to convalescents. 
If cocoa agree, it may be taken, prepared from the nibs only. With regard 
to drinks, if milk is found to agree, it may be used as a drink, combined 
with half its bulk of lime-water, or in the form of what is known as "butter- 
milk" in Scotland and in Ireland, but which in England is generally given 
to pigs, not yet being sufficiently appreciated by natives of the country south 
of the Tweed. Dr. Camplin eventually found it necessary to abstain from 
all alcoholic drinks; but where they are found desirable or necessary, a 
selection may be made from those wines and spirits which are freest from 
sugars. Of these, clarets may be chemically considered the best, then Bur- 
gundy. The so-called " fruity wines" must be entirely interdicted, and of 
all alcoholic beverages weak brandy and water is the safest. The amount of 
brandy must be always measured and taken as directed by the medical 
attendant. A teaspoonful in a tumberful of water is generally sufficient for 
an ordinary dinner drink; and Dr. Camplin candidly and feelingly observes, 
from his own experience, that no diabetic need expect to recover or continue 
well who cannot exercise self-control, and make up his mind to be temperate 
in all tilings. 
Seeing that under this system of diet the patient is deprived of the use of 
ordinary bread, Dr. Camplin devised a form of bread prepared solely from 
bran; and the great value of bran cakes as a substitute for bread in cases of 
diabetes has now been established by the experience of so many individuals 
that its use ought to be insisted on. The bran used should be thoroughly 
washed, so that it may be as free from starch as possible, and finely powdered, 
so that it may not irritate the susceptible mucous membrane of the intes- 
tines. Such carefully prepared and finely powdered bran may be obtained 
from Mr. Batchley, of 362 Oxford Street, London, near the Pantheon; also 
of Mr. Donges, Gower Street, London, North. But if it is desirable to 
prepare the powder at home as it is required, a special mill and sieve for 
this purpose are necessary, and may be obtained of Messrs. Evans Brothers, 
54 Bricklane, Spitalfields, London, E. (Dr. Camplin's Monograph on Dia- 
betes). 
The formula for bran cakes is thus given by him : "Take a quantity of 
wheat bran (say a quart). Boil it in two successive waters for a quarter of 
an hour, each time straining it through a sieve; wash it well with cold water 
on the sieve, until the water runs off perfectly clear. Squeeze the washed 
bran in a cloth, as dry as possible, then spread it thinly on a dish, and place 
it in a slow oven. When it is perfectly dry and crisp it is fit for grinding 
into fine powder. 
" The bran thus prepared is ground in the mill for the purpose, and must be BRAN CAKES AND BREAD IN DIABETES. 
923 
sifted through a wire sieve of such fineness as to require the use of a brush to 
pass it through, and what remains on the sieve must be reground till it is 
sufficiently soft and fine. 
" To prepare a cake, take of this bran powder three or four ounces, three 
new-laid eggs, one and a half or two ounces of butter, and about half a pint 
of milk. Mix the eggs with a little of the milk, and warm the butter with 
the remainder of the milk ; stir the whole well together, adding a little nut- 
meg and ginger, or any other spice that may be agreeable. Bake in small 
tins (pattipans, which must be well buttered), in a rather quick oven, for 
about half an hour. The cakes when baked should be a little thicker than a 
captain's biscuit. 
" These cakes may be eaten with meat or cheese for breakfast, dinner, and 
supper, and require a free allowance of butter ; and the cakes are more pleas- 
ant if placed in the oven a few minutes before being placed on the table. 
" When economy is an object, when a change is required, or if the stomach 
cannot bear butter, the cakes may be prepared as follows : Take of the pre- 
pared bran four ounces, three eggs, about twelve ounces of milk, with a little 
spice and salt, to be mixed and put into a basin (previously well buttered). 
Bake it for about an hour ; the loaf may then be cut into convenient slices 
and toasted when wanted ; or, after slicing, it may be rebaked, and kept in 
the form of rusks. 
" Nothing has yet been discovered of equal utility to these bran cakes, com- 
bining, as they do, moderate cost with freedom from starch, and sufficient 
pleasantness as an article of food " (Camplin On Diabetes, third edition). 
Consistently with the experiments of Bernard, " cod-liver oil holds out some 
prospect of a natural plan of treatment by its use." 
Dr. Pavy recommends ground almond powder, made into biscuits, rusks, 
and bread, with eggs, as a substitute for ordinary bread. Mr. Hill, 60 Bish- 
opsgate Street, London, makes such biscuit. 
An abstinence from water lessens the formation of sugar ; but it probably 
accumulates in the body, so that when fluid is again given, an excessive 
elimination of sugar occurs (Ringer, Griesinger) ; and patients become 
extremely depressed and ill if water is withheld from them, probably from 
the impregnation of the body with sugar (Parkes). Coffee lessens the sugar, 
but increases the urea. Rennet, as recommended by Dr. Gray, of Glasgow, 
at first lessens the sugar and water; but they afterwards increase again. 
Warm baths lessen the amount slightly; so does bicarbonate of soda. Hence 
the recommendation of Miahle and Contour. 
When the diabetic symptoms subside, congestions, especially of the head, 
are apt to supervene. Such congestion Dr. Camplin found to subside gradu- 
ally under the use of citrate of ammonia and small doses of colchicum wine. 
The great difficulty in the treatment of diabetes is to manage the dyspepsia 
and impaired digestion, and, at the same time, to diminish and keep in check 
the formation of sugar. Warm flannel ought to be worn next the skin in all 
cases, and residence in a warm climate will often be of service as an aid to 
the means of cure employed. 
" However surely," writes Dr. Clymer, " an exclusive animal diet may 
lessen, or entirely remove, the sugar in the urine of a diabetic patient, it is 
certain that it cannot long be tolerated." In this opinion Niemeyer, Trous- 
seau, and many other physicians now concur: " Under its use, the appetite 
fails, and a loathing of all food soon happens. The necessity of a mixed diet 
for man is as necessary for him when suffering from diabetes as in a state of 
health. In this disease the nervous system is undoubtedly implicated, and a 
rigid adherence to animal food alone, were-it practicable, would soon be fol- 
lowed by an aggravation of the nervous troubles. There is, from the very 924 
SPECIAL PATHOLOGY-DIABETES. 
beginning, and throughout the course of the disorder, a strong tendency to 
devitalization, and this too must be guarded against. Fortunately the sugar 
in the urine may be kept down, and at the same time the general strength of 
the system maintained, by a properly adjusted diet of mixed food. Along, 
then, with the carnivorous dietary, whose importance is not to be undervalued, 
certain vegetables may be permitted, not only with impunity, but with advan- 
tage ; and these are cabbage, cauliflowers, onions, spinach, water-cress, sorrel, 
endive, lettuce, &c. Trousseau has found no ill consequences from eating 
acid fruits, as strawberries, gooseberries, cherries, and he has allowed apples, 
pears, and grapes. He even suffers his diabetic patients to eat a small quan- 
tity of bread, if they greatly crave it; for, as he remarks, there are many 
persons who are unable to make a meal without it. Such a regimen is more 
likely to keep the disease stationary, and secure the general comfort of the 
patient, by upholding his strength, than by confining him to one kind of diet, 
which his stomach soon revolts against, and which must result in innutrition, 
general debility, the development of intercurrent affections, and sooner or 
later death. Enforced daily exercise in the open air, when possible, just 
short of fatigue, is as of much importance in the treatment of diabetes as diet. 
Gymnastics should be practiced. Trousseau says that he has repeatedly seen, 
during the hunting season, diabetic patients, abroad with their gun and dog, 
cease both to drink and urinate to excess, and regain their strength, and even 
their virile powers. A suit of flannel or buckskin should be worn next the 
skin. Warm alkaline baths should be frequently taken, and an occasional 
Turkish bath will be found serviceable, if it produces no disposition to boils; 
or daily packing with the wet sheet may be tried, carefully watching the 
effects. The whole body should be hand-rubbed daily. Cream, so long as it 
agrees, may be permitted, and cod-liver oil is in many cases well borne, and 
would seem, as a nourisher, to do good. The alkaline theory has been proved 
to be false and absurd by Cl. Bernard and Poggiale ; still the benefit of small 
doses of the alkalies, not continued, however, longer than a week or ten days 
at a time, is incontestable. They are best given in the form of the Vichy, 
Marienbad Kreutzbrun, or Carlsbad Spoudel water. Legroux thought he 
derived benefit from the administration of arsenic. Dr. Richardson, of Lon- 
don, has recommended the respiration of oxygen, and Berenger-Feraud has 
shown that during its use there is great diminution in the amount of sugar in 
the urine (Bui. de Ther., t. Ixvii). The ethereal solution of the peroxide of 
hydrogen (ozonic ether) has been given with asserted benefit in half drachm 
doses in an ounce of distilled water. Dr. T. K. Chambers has prescribed 
iodide of potash on purely empirical grounds. On no pretext should any 
form of alcoholic drink be permitted. The preparations of iron are indis- 
pensable, and should be varied from time to time. To lessen the thirst and 
craving for food, small doses of opium are useful. By the use of the mixed 
diet recommended, particularly if fatty articles be taken, the obstinate consti- 
pation, so common in the earlier stages of the disorder, is often obviated with- 
out a recourse to drugs. Should this not be the case, castor oil in capsules, or 
rhubarb and podophyllin, must be prescribed. 
" This mode of treatment, which secures a proper but varied diet, one that 
will not disgust the patient, but will nourish his body, though it may not re- 
move the symptom glycosuria, will, in a large number of cases, give the diabetic 
a fair share of conditional health, so that, as Dr. Trousseau remarks, he would 
not know he had sugar in his urine, if an occasional chemical analysis did not 
remind him of its presence" (American edition). 925 
DEFINITION AND PATHOLOGY OF PURPURA. 
PURPURA. 
Latin Eq., Purpura; French Eq., Purpura; German Eq., Purpura; Italian Eq., 
Porpora. 
Definition.-J. disease not unusually attended by fever, characterized by pur- 
ple spots of effused blood, which are not effaced by pressure, and are of small size, 
except where they run together in patches. 
Pathology.-By some this disease has been considered identical with scurvy, 
and been named the " land scurvy." Others have considered it simply a dis- 
ease of the skin-the purpura simplex of Willan and Bateman. Authors 
generally have spoken of the disease under the name of petechioe sine febre, 
because the spots are not connected with continued fever. The disease is very 
closely related to hemorrhages as a morbid state on the one hand, and to scurvy 
on the other. 
Two varieties are distinguished, namely : 
(a.) Simple, and 
(6.) Hemorrhagic; which latter is thus defined by the College of Physicians 
of Loudon-" The disease when accompanied by hemorrhage from a mucous 
surface." 
It has not been determined what is the nature of the morbid state essential 
to purpura. In some cases the urine has been observed to contain an excess 
of albuminous matter, with a deficiency of urea (Combe).* The blood has 
been found deficient in coagulating power. An examination of the blood in 
two cases of purpura, by Dr. Parkes, showed that, with a somewhat diminished 
proportion of the solid constituents in general, there was a remarkable increase 
in that of iron. A peculiar source of danger attends this disease in the occur- 
rence of extravasation of blood into the internal organs. The lungs, the brain, 
the liver, and the alimentary canal are the most frequently affected. Purple 
spots and effusions of blood are to be found on the serous membranes, as in the 
arachnoid, the pleura, the pericardium, the peritoneum; and occasionally the 
blood lies coagulated in the cavities inclosed by these membranes. It has 
also been found in the bladder and in the calyces and pelvis of the kidney 
(Craigie). 
Instances occur in which blood oozes, or is discharged more or less copiously, 
from the mucous membranes without affection of the skin; and to this class of 
cases, as a form of disease now under consideration, are to be referred those 
cases of profuse or fatal hemorrhage from slight causes, recorded under the 
name of " hemorrhoea," which have been ascribed tQ a diathesis termed the 
hemorrhagic, and which is supposed to be hereditary {Edin. Med. and Surg. 
Journal, vol. xxv). When the disease is protracted the patient becomes of a 
sallow complexion, waxy colored, and dingy; anasarcous swellings, gangrenous 
and bad sores appear on the feet and legs, general anasarca prevails, and he 
dies exhausted. Dr. Craigie considers that the appearance of purple spots in 
such cases is connected with more or less disease of the heart, especially with 
hypertrophy or dilatation of the ventricles. The following observation by Dr. 
Watson puts the pathology of purpura in an interesting and practical light: 
" I have adverted to one peculiar source of danger in purpura,-the hazard 
that blood may be effused in some vital organ,, where even a slight amount 
of hemorrhage suffices to extinguish life. Dr. Bateman states that he had seen 
three instances in which persons were carried off, while affected with purpura,, 
by hemorrhage into the lungs. During the course of one week, in the year 
1825, I was present at two inspections in the dead-house of St. Bartholomew's 
* An interesting case may also be referred to, related by Dr. Goodfellow in his ad- 
mirable Lectures on Diseases of the Kidney, p. 74. 926 
SPECIAL PATHOLOGY-PURPURA. 
Hospital, illustrative of the same point in respect to another vital organ, and 
involving a question in forensic medicine. The subjects of examination were 
both of them women of middle age, who had been brought into the hospital 
covered with purple spots and bruise-like discolorations, and suffering hemor- 
rhage from the mucous membranes. Each of these women declared that the 
apparent bruises were marks of beatings received from her husband. One of 
them became suddenly hemiplegic a little while before she died. Of the man- 
ner of dissolution in the other case I am not sure. In both instances a con- 
siderable quantity of blood was spread over the surface of the brain between 
its membranes; and in one of them blood had been shed also into the cerebral 
substance, which it had extensively lacerated. 
" It may be worth mentioning that in one of these corpses there were indi- 
cations either of unusually rapid putrefaction after death, or (what I think 
more probable) of some degree of decomposition even before life was extinct. 
This woman died in the evening, and the body was examined next day, twelve 
or fourteen hours afterwards. A quantity of fetid gas escaped from the cavity 
of the abdomen as soon as it was opened, and small bubbles of air were seen 
to ooze from the areolar tissue of various parts of the body. Even when in- 
cisions were made into the Zwerjair frothed up, as it might do under ordinary 
circumstances from a section of the lungs " {Lectures, vol. ii, p. 866). 
Symptoms.-Various symptoms, denoting general disorder of the constitu- 
tion, precede the appearance of the pet.echise, generally by some weeks, such 
as languor, which is oppressive, weariness, faintness, and gnawing pains at 
the pit of the stomach. The appetite is variable, generally weak, but some- 
times there is an inordinate craving for food, which, when eaten, is said to lie 
with a weight upon the stomach. The tongue is yellowish, and coated with a 
viscid fur, the countenance is sallow or dingy, or has a bloated, pale appear- 
ance, with swelling underneath the eyelids. The purple spots appear first on 
the legs, and afterwards, without any certain order, on the thighs, arms, and 
trunk of the body, and their presence is attended with much weakness and 
great depression of spirits. No degree of pressure alters the color of the spots, 
and they are distinguished from flea-bites by the absence of a central punc- 
ture. At first the spots are bright red, but in a day or two they become 
purple, afterwards brown, and when they are about to disappear they assume 
a yellowish tint. When the disease continues for a long time, all these varie- 
ties of color may be seen on a patient at the same time. 
The pulse is feeble, and generally a good deal quicker than natural. Deep- 
seated pains are felt about the epigastric region, as well as in the chest, loins, 
or belly. In some instances giddiness and lightness of the head prevail, 
especially when attempting to move or to stand erect, and there may be even 
dull pain in some part of the head. Constipation of the bowels, palpitation 
and irregular action of the heart, with a tendency to frequent syncope, are 
the most distressing and dangerous symptoms. 
Causes.-They are not well known. It is a disease more common in women 
than in men; and in boys before than after puberty. It has appeared under 
the long use of a poor diet, much sedentary occupation, watching, mental dis- 
tress and anxiety. It has also appeared under very opposite conditions; for 
example, in persons accustomed to the use of nutritious food and free living, 
but in whom there is reason to believe the digestive functions and the con- 
stitutional powers have been impaired by the persistent abuse of spirits or 
malt liquors. 
Diagnosis is generally between Purpura and Scurvy. The following are 
the principal distinguishing features of each contrasted: (1.) Scurvy is most 
common late in the winter or early in the spring; purpura in the first seasons 
of summer and autumn. (2.) In scurvy the gums are uniformly soft, sore, 
spongy, swollen, and hemorrhagic; this is no common feature in purpura. DIAGNOSIS AND TREATMENT OF PURPURA. 
927 
(3.) In scurvy tumors of a painful kind form in the extremities, with stiffness 
or contractions of the joints: such symptoms do not attend purpura. (4.) 
Scurvy is marked by extreme debility, and is rendered worse by bloodletting 
and by mercury, and is cured by the administration of lemon-juice: not so 
with purpura, which may require bloodletting for its cure, is not benefited 
by antiscorbutic remedies, and is sometimes speedily cleared away upon the. 
supervention of mercurial salivation and hypercatharsis (Watson and Wood). 
Dr. Graves, of Dublin, has described an exanthema hwmorrhagicum in which 
febrile symptoms ushered in the malady, with an exceedingly dry and brown 
tongue, and a pulse which conveyed the sensation of small sharp vibrations 
with each beat-a kind of wiry trembling, with an extraordinary thrill and 
hardness, "yielding only to the withering influence of approaching death." 
Bleeding from the intestines and urinary system quickly supervened. These 
phenomena continued to spread till the whole mucous system of the patient 
became the seat of copious hemorrhage. A peculiar exanthematous eruption 
appeared upon the skin, lasting for several days (five), and never presenting 
any signs of extravasation. Death followed in about four weeks. The pulse 
did not exceed its natural frequency (70), and there was no disturbance of 
the nervous system, such as headache, delirium, or want of sleep; and in the 
beginning of the disease the strength was not remarkably impaired; but sub- 
sequently yielded to loss of bloqd. The disease seemed almost exclusively 
confined to the arterial and capillary systems of vessels. 
Treatment.-To treat this disease with success, it is necessary to ascertain 
the circumstances under which it becomes developed in each particular case. 
Quinine or bark, stimulants, mineral acids, nutritious food, and wine, was the 
treatment adopted by Cullen, Duncan, and Willan. Subsequently this plan 
of treatment was questioned by Dr. Parry, of Bath, who found that in his 
cases a full bleeding from the arm was a much more speedy mode of curing 
the disease. Dr. Harty, of Dublin, confirmed this principle of treatment, 
and was successful with liberal doses of purgatives, so as to clear out the 
intestinal canal completely. Oil of turpentine, administered in moderate and 
repeated doses, has also been recommended. Dr. Hardy, of Dublin, recom- 
mends the tincture of larch bark. He has long used it as a styptic and car- 
minative tonic; and it is "one of the most elegant forms of prescribing a 
terebinthinate " (Moore). Fifteen-drop doses of the tincture may be admin- 
istered every hour, or eight or ten drops three times a day, afterwards increas- 
ing the dose according to the age of the patient and the necessities of the case. 
The treatment of purpura may be comprised in the following measures: The 
bowels ought invariably, and without exception, to be first thoroughly and 
effectually evacuated by means of senna, aloetics, or calomel and jalap. If 
several effectual doses of either or all of these medicines be not followed by less 
heat of skin, diminution of the frequency of the pulse, abatement of the 
internal pains, and a cleaner state of the tongue; if the spots continue to 
increase in number and size, and the hemorrhagic oozings do not cease,- 
blood, according to age, strength, and other circumstances, may be drawn 
from the arm, while the patient should abstain from animal food in every 
form, and should subsist on boiled rice with whey, or the light subacid fruits, 
as grapes, oranges, strawberries, gooseberries, baked apples, or the like. His 
drink may consist of tamarind-water, or water acidulated with sulphuric acid. 
Under this plan most cases of the disease will be speedily and readily brought 
to a favorable termination. If symptoms of local uneasiness continue after 
the urgent phenomena have disappeared, leeches should be applied in the 
neighborhood of the part; and it will be proper to continue the periodical 
and regular evacuation of the alimentary canal. When the spots have dis- 
appeared and the hemorrhage has ceased, the constitution recruits rapidly 
under the gradual but cautious use of light soups and fresh fruits and vege- 
tables (Craigie). 928 
SPECIAL PATHOLOGY-SCURVY. 
SCURVY. 
Latin Eq., Scorbutus; French Eq., Scorbut; German Eq., Scorbut; 
Italian Eq., Scorbuto. 
Definition.-A chronic morbid state, characterized by sponginess of the gums 
and the occurrence of livid patches under the skin, of considerable extent, which 
are usually harder to the touch than the surrounding tissue. It is ushered in by 
debility, lassitude, lowness of spirits, attended by fetor of the breath, and the gums 
swell by irritation, till they overhang the teeth in palmated excrescences. The 
livid subcutaneoxis patches and spots appear upon the skin, of considerable extent, 
especially on the loxver 'extremities, among the roots of the hair. Spontaneoxxs 
hemorrhages may take place from the mxicous canals; contractions of the muscles 
and tendons of the limbs occur, with pains, axxd sometimes superficial ulcerations. 
An altered state of the albumen of the blood is associated with this coxidition, and 
the phenomena are brought aboxd by a deficient supply of the organic vegetable 
acids, or of the salts of fresh vegetables. 
Pathology and Historical Notice.-Scurvy is mentioned by Pliny as having 
occurred in the Roman army commanded by Germanicus after a long encamp- 
ment in Germany beyond the Rhine. It •prevailed to a frightful extent in 
the army of Louis IX, when he was made prisoner in Egypt in 1260. With 
fish only for fresh provisions, dispirited by being obliged to act on the defensive, 
and harassed unceasingly by the Saracens, the Christian army was almost 
annihilated by a most terrible outbreak of scurvy. But it was not till navi- 
gation was improved, and long voyages undertaken, that this disease became 
well known from its general prevalence and formidable character. Vasco de 
Gama, in his first voyage to the East Indies by the Cape of Good Hope, in 
1497, lost 100 men out of 160 by this affection. James Cartier, in his second 
voyage to Newfoundland, in 1535, speaks of sufferings still more severe. Of 
110 people there were not ten whole. "This malady being unknown to us," 
he writes, " the body of one of our men was opened, to see if by any possible 
means the occasion of it might be discovered and the rest of us preserved. 
But in such sort did the malady increase, that there were not above three 
sound men left. Twenty-five of our best men died; and all the rest were so 
ill that we thought they would never recover again." A decoction of the 
leaves and bark of a tree, supposed to be a species of spruce fir, was the remedy 
which they found restored health and recovery. " It was scurvy which used 
to decimate our navy, and render long sea voyages almost impossible. It was 
mainly by scurvy that Anson, in his celebrated voyage of 1740-2, lost within 
the first ten months nearly two-thirds of his crew, and during the remaining 
period about half of the survivors. Scurvy continued to prevail with little 
abatement till 1764. The voyages of Sir R. Hawkins, Hosier, Anson, Drake, 
Cavendish, Dampier, Byron, and of numerous other navigators, furnish similar 
details, and show how recklessly the lives of sailors were sacrificed " (Copland). 
But at last it was against scurvy that Cook had attained his triumphant suc- 
cess, when, in 1775, after three years' absence, he brought back a healthy 
crew, which, out of 112 men, had lost only one by disease. During the six- 
teenth, seventeenth, and earlier part of the eighteenth century, the disease was 
endemic* in towns, fortifications, camps, and armies. , " Many thousands were 
often cut off within a few months in single armies and garrisons; and it is 
* It is a mistake to call scurvy epidemic, as has sometimes been done. The term 
cannot be applied with propriety to diseases other than those which we have seen to 
depend upon the presence of specific poisons which enter the blood by impalpable 
media, and 'Common, therefore, in a greater or less extent, to all classes of the com- 
munity. MORBID ANATOMY IN CASES OF SCURVY. 
929 
probable that more seamen perished from scurvy alone than from all other 
causes combined, whether sickness, tempest, or battle" (Wood). In this 
country and in America it is now very little known ; and many have never 
seen the disease, unless they have lived in seaport towns. 
Dr. Clymer states, in the American edition of this work, that scurvy has 
always prevailed in the United States Army to a considerable extent, and 
under the same circumstances,-a deprivation of fresh vegetables. From 1840 
to 1859, inclusive (excluding the years 1847-48-the period of the Mexican 
war-no reports having been made during that time), there were 4935 cases 
of scurvy reported and 52 deaths, in an aggregate strength of 187,144 men 
{Statistical Report, U. S. Army. By authority. 1860). In the column which 
marched on the city of Mexico, the men, for some time previous to their land- 
ing at Vera Cruz, during the siege, and afterwards, could obtain no vegetables; 
and the writer is informed, on reliable authority, that on their arrival at 
Jalapa, although there had been plenty of fresh beef, there was scarcely a 
man who did not have a scorbutic taint. During the late civil war, scurvy, 
in some form or another, was generally prevalent in the American armies. 
Though the statistics of the first two years show an extremely small number 
of cases, " unparalleled in the history of armies," it is not a true exhibit of the 
actual prevalence of the disorder. There were reported in the first year, 1328 
cases and 9 deaths, and in the second year, 7395 cases and 90 deaths; to which 
may probably be added 304 cases of purpura and 31 deaths ( Circular, No. 6, 
Surgeon-General's Office, War Dept., 1865). It first appeared to any extent 
in the Army of the Potomac, at Harrison's Lauding, Va., in July, 1862; and 
from that time forward, until the end of the war, in 1865, it continued an 
increasing and formidable disorder. " It occurred in all the armies subjected 
to hardships, especially in the West; and its worst and most fatal manifesta- 
tion was made after the war had closed, and during the occupancy of the 
frontier of the Rio Grande by the twenty-fifth Army Corps," and in conse- 
quence of the want of fresh vegetable food ( U. S. Sanitary Commission Memoirs'). 
" What has been written of scurvy," he continues, " in the British army, 
during the Crimean war, is equally applicable to our own during the late war. 
The returns convey but a faint conception of the disastrous part which it 
[scurvy] acted among the troops; for though it comparatively rarely pre- 
sented itself in well-defined forms, and as an independent affection, yet the 
prevalence of scorbutic taint was widespread, and in a vast proportion of 
cases evident indications of it existed as a complication of other diseases, 
especially fevers and affections of the bowels " {Medical and Surgical History 
of the British Army, 1858). 
" In the first years of the war scurvy did not prevail amongst the Confed- 
erate troops apparently to any extent; for with a monthly mean strength of 
160,231 officers and men, and with 1,056,349 cases of sickness and wounds 
entered upon the field reports in nineteen months, from January, 1862, to 
July, 1863, only 2203 cases of scurvy are recorded; and in 398,641 cases of 
sickness and wounds entered upon the hospital reports, there were only 2068 
cases. But it progressively increased, with a diminishing commissariat and 
increased hardships (J. Jones, in San. Com. Memoirs). The same authority, 
in his report on the diseases, &c., of the Andersonville prison, states that 
scurvy, arising from sameness of food and imperfect nutrition, caused, either 
directly or indirectly, nine-tenths of the deaths amongst the United States 
army prisoners confined there." 
Morbid Anatomy.-The days when scurvy was most prevalent were not 
those in which many post-mortem examinations were made; and our earliest, 
knowledge of the morbid anatomy of this disease is derived principally from 
Poupart and Lind. They tell us that in those cases in which flux or dysen- 
tery is absent the intestines have been found perfectly sound, however copi- 
ous the hemorrhage from them may have been. The principal effects of the 930 
SPECIAL PATHOLOGY-SCURVY. 
disease were observed in all cases in the cellular tissue of the extremities. 
The quantity of congealed blood effused in that part, even where no stain or 
mark could be perceived on the skin, was quite astonishing. " It often lies," 
says Lind, " in large concrete masses on the periosteum, while the bellies of 
the muscles of the legs and thighs seemed quite stuffed with it, often an inch 
in thickness." Haspel and Marmy confirm these accounts of Lind when they 
describe laminar masses of black grumous effusion in the subcutaneous and 
intermuscular connective tissue, compressing and breaking down the primi- 
tive fasciculi. He often found water effused into the cavities of the chest and 
abdomen, and no less frequently blood,-the quantity of blood effused in all 
parts sometimes amounting, in his opinion, to no less than a fourth part of 
that contained in the whole body. Poupart gives some further particulars, 
and says that on moving the limbs of some scorbutic patients a noise is heard ; 
and that on examining the joints the epiphyses had entirely separated from 
the bones; and in other cases, that the cartilages of the sternum had separated 
from their bones ; and bones that had united after being broken very often 
separated again at the site of fracture. He says that if we squeezed the ribs 
which had begun to be thus separated from their cartilages, " there came out 
abundance of corrupted matter, so that nothing was left of the rib but its bony 
plates." The mesenteric glands were usually enlarged; the spleen, often 
three times bigger than natural, fell to pieces, as if composed of coagulated 
blood. In two cases examined at St. Thomas's Hospital by the late Dr. 
Robert Williams, patches of ecchymoses were found under the pericardium 
covering the heart, and also under the arachnoid membranes covering the 
brain. 
In some endemics of scurvy there is a marked tendency to the effusion of 
dark liquid blood into the serous cavities, and of the synovial membranes, 
the most common site being into the pericardium, then the pleura, and next 
the peritoneum (Karawagen). The spleen is often enlarged, distended with 
blood, and soft. The texture of the muscular system is also soft and flabby. 
The blood appears to be deficient in red particles (Busk, Becquerel, Rodier, 
Andral, Fricks), and does not impart a stain to the lining membrane of 
the heart and great vessels. A fluid or dissolved condition of the blood has 
also been noticed, appearing often as "a mere gore, not separating into crassa- 
mentum and serum, and putrefying soon. It appears to be starved of some 
essential ingredient." It flows with difficulty from the vein, and, after stand- 
ing some hours, deposits a thick, muddy sediment, which subsides from a 
reddish serum; and in the last stage of the disease it becomes quite black 
(Rouppe). There does not, however, appear to be any evidence of deficient 
powers of coagulation in scorbutic blood; and so long ago as 1699, Poupart 
noted the large coagula found after death in the cavities of the heart. Three 
analyses of the blood were also made by Mr. Busk, before 1840, in all of 
which the quantity of fibrin was found to be above its normal standard. 
Stoeber, in 1845, came to the same conclusion ; and so did Andral, on repeat- 
ing analyses which at first led him to an opposite conclusion. Two facts of 
great importance, if confirmed, have been observed by Chatin and Bouvier. 
They have observed that the albumen of the blood does not coagulate under a 
temperature of 74° Cent., or 165.2° Fahr.-that is, from 5° to 8° Fahr, above 
the normal standard ; so that the albumen of the blood undergoes some 
change in scurvy which increases its solubility. They also observed that the 
force of cohesion of the fibrin was so much lessened that they were unable to 
isolate it thoroughly from the red corpuscles, and it was this attraction of the 
fibrin and the red corpuscles which the early writers on scurvy attempted to 
describe by the terms "agglutinated blood," "viscid and thickened crassamen- 
tum" (Parkes "On the Pathology and Treatment of Scurvy," Brit, and For. 
Med.-Chir. Review, Oct., 1848). Thus all the phenomena of scurvy, and the 
conditions under which it becomes developed, point to the blood as essentially CHEMICAL PATHOLOGY OF SCURVY. 
931 
altered. What the alteration definitely consists in has not been yet deter- 
mined ; but it appears that the condition of the blood in scorbutus does not 
consist in the want of a due proportion of either of its three prominent con- 
stituents. The proportion may in some cases be deranged; but it appears 
that in all cases there is a deficiency or altered quality of some essential in- 
gredient. The following statements by Drs. Copland, Watson, and Wood 
contain a summary of the opinions of the chemical pathologists of the present 
day who have specially investigated the nature of scurvy by analysis of the 
blood. 
Dr. Christison supposes that scurvy arises from the want of vegetable albu- 
men or animal casein in the food ; that it is the deficiency in the quantity of 
azotized aliment, and consequent insufficient nourishment of the body, which 
is the cause of scurvy. Dr. Garrod believes that the malady is caused by the 
absence of potash, and that potatoes and other antiscorbutics owe their virtues 
to the potash they contain. The following are his conclusions: (1.) That in 
all scorbutic diets potash exists in much smaller quantities than in those which 
are capable of maintaining health; (2.) That all substances proved to act as 
antiscorbutics contain a large amount of potash; (3.) That in scurvy the blood 
is deficient in potash, and the amount of that substance thrown out by the 
kidneys is less than that which occurs in health; (4.) That scorbutic patients 
will recover when potash is added to their food, the othei' constituents remain- 
ing as before, both in quantity and quality, and without the use of succulent 
vegetables or milk; (5.) That the theory which ascribes the cause of scurvy 
to a deficiency of potash in the food is capable of rationally explaining many 
symptoms of that disease. 
These propositions of Dr. Garrod's require much further investigation ; and 
they are not supported by the most elementary and important facts in the 
history of scurvy. Both soda and potash are constant constituents of the 
animal body, and it appears that they are not capable of replacing each 
other. For example, we always find the potash to exist in large quantities 
in the ash of muscle, soda in very small quantities (Berzelius, Liebig). In 
the ash of the blood we find the relation reversed. It appears, also, that the 
muscular system requires the presence of potash ; and we should therefore 
expect to find that where there is a deficient supply of this base, the effect 
would soon be manifested in the functions of that system. This we do not 
find to be the case in scurvy. Without any amount of wasting of the body, 
we may find marked muscular debility; but men in an advanced stage of 
scorbutus have been known to do severe labor, till even the approach of fatal 
syncope from the weakened action of the heart; and this, perhaps, is one of 
the earliest symptoms of the disease. " Opposed also to this theory," writes 
Dr. Wood, " are the facts that nitrate of potash has often failed to cure the 
disease, while it has been cured by the addition of pure citric acid; and that, 
after failure under treatment with the salts of potash, recovery immediately 
commenced when the patient was allowed to eat fresh vegetables." Trotter 
also always held the opinion that the real antiscorbutic principles in fruit 
and vegetables were the vegetable acids, particularly citric, oxalic, and malic 
acids; and to test the accuracy of his opinion, he made, in 1800, a series of 
comparative trials between lemon-juice and pure citric acid. Both these reme- 
dies were furnished to eight or ten ships, and reports were then obtained of 
their effects. The result was that citric acid was found the most efficacious. 
Sir William Burnett, also, was in the habit of supplying convict ships with 
citric acid and nitrate of potash, as well as with lemon-juice, in order that com- 
parative trials might be made of the relative value of these remedies; and 
the official documents bearing on this point were carefully examined by Dr. 
Parkes, who considered that nothing could.be more convincing than the evi- 
dence they contained, showing that the efficacy of citric acid was clearly proved,, 
while nitrate of potash was shown to be inferior in curative power ( On the Pa- 932 
SPECIAL PATHOLOGY-SCURVY. 
thology and Treatment of Scurvy, 1. c.). Dr. Clymer mentions that the Ottawa 
lumberers living on pork salted with nitre suffer severely. Dr. J. O. Grant 
found in one shanty, out of thirty-six of those men, that twenty-five were 
affected with scurvy. The astonishing effects of fresh lemon-juice have been 
evidently underrated by Dr. Garrod; and it is more probable that its virtues 
are due to citric and other acids than to potash. Dr. Aldridge contends for 
the influence which should be ascribed to a deficiency of phosphorus, sulphur, 
lime, and the alkalies, in occasioning scurvy. That something may be owing 
-a part merely-to the causes contended for by Dr. Aldridge is not improb- 
able. But it is unnecessary to pursue this subject any further than very 
briefly to state, that one of the most evident changes from the healthy condi- 
tion is seated in the blood, which is altered in composition either by the addi- 
tion to it of some ingredient or ingredients, or by the absence of something 
which ought to exist in it; and the deficient ingredient may be one of the or- 
dinary constituents of the blood, or it may be some principle or element enter- 
ing into their composition. This deficiency is due to the absence of certain 
articles of diet; and the disease is known by experience to be at once cured 
by supplying those articles. * 
Symptoms.-The earliest are a change of color of the skin, particularly of 
the face and eyelids. This is sometimes the first and only sign of the disease. 
The skin round the orbit may be puffed up into a bruised-colored swelling. 
At the same time there are vague, wandering, rheumatic-like pains in the 
limbs, weariness, depression of spirits, and a longing for fresh vegetables and 
fruits. With these pains, however, there is no fever; the pulse is soft and 
natural, and the temperature of the body lower than usual, and great disorder 
of the respiratory function may supervene. The countenance appears pale 
or yellow, and bloated; there is great depression of the physical powers, fol- 
lowed by swelling of the gums, which become soft, spongy, and hang ovei' 
the teeth in large fleshy-like palmated masses, very much disposed and readily 
excited to bleed; and the edges of the gums are purple where they are in 
contact with the teeth. Several old observers state, and Fauvel confirms the 
observation, that in old people without teeth these vegetations do not occur, 
and the gums remain comparatively unaffected. In one case he noticed that 
a single remaining tooth was surrounded by a mass of swollen gum ; the tooth 
was extracted, and the gum immediately became level and firmer, while the 
other symptoms preserved their intensity. The swollen and fungous gums, as 
Dr. Parkes observes, have always appeared to be much more intense in cases 
occurring on shipboard; and it is not improbable that they are affected pecu- 
liarly because they are exposed to pressure and attrition; sometimes they are 
.severely ulcerated. 
All parts suffer from pressure in cases of scurvy-the merest rub causes an 
'ecchymosis, the slightest possible blow produces an extensive bruise, and the 
gums may suffer most from the causes already noticed. A small eruption 
(like flea-bites) of a purple hue is next seen on the lower extremities; and 
about the same time the muscles of the leg or thigh become hard and painful, 
and in a day or two the skin over the pained part becomes first yellow and 
then purple. This discoloration forms patches sometimes as big as the palm 
of the hand, and may extend over half the leg and thigh. The popliteal re- 
gions are a frequent site of this pain and discoloration, sometimes attended 
with oedema, especially of the ankles and feet. The discoloration is especially 
apt to show itself in the situation of old cicatrices and injuries. " These ex- 
travasations are both superficial and deep-seated. The superficial are,-(1.) 
Dermic, and (2.) Subdermic. The dermic ecchymomata vary in size from small, 
dark-colored spots to large blotches; they may be distinct, or may come to- 
gether at some point of their circumference. The anatomical site of the spots 
is the hair-follicles or sudoriferous canals, and their structure hinders the dif- 
fusion of the sanguine serosity. The epidermis becomes dry, rough, and SYMPTOMS OF SCURVY. 
933 
raised in scales, resembling the skin of a recently-plucked fowl (H. Larrey), 
and the sudatory function is diminished or suspended. Subsequently desqua- 
mation takes place. The solid part of the blood may, however, remain infil- 
trated in the meshes of the derm, forming brown spots, which may last for 
months, the epidermis over these being smooth and shining." 
"In the subdermic ecchymomata the blotches are larger and of variable 
depth. They may invade the whole limb, but the most common site is the 
ham, groin above and below Poupart's ligament, the thigh, calf, and pterygo- 
maxillary region. If they compress superficial veins, they cause oedema and 
pain. They produce swellings in the flexures of the joints, most often in the 
ham or shin, in the pterygo-maxillary region, and bend of the elbow. They 
are hard, but pit on persistent and firm pressure. When on the shin and 
circumscribed, they may be mistaken for syphilitic nodes. Resolution is 
their usual termination, their hue changing from dark purple to green and 
yellow. When the dark color persists with a greenish-yellow border, it is 
evidence that the effusion is very thick. Should their termination be by 
ulceration, a sort of indolent boil forms, with a deep-red base and black 
summit, with oedema of the adjacent connective tissue. If the surface is 
galled, there is constant weeping of a sero-sanguinolent fluid; the tumor 
flattens a little, and a small, dark, ulcerated central point, with wine-red 
edges, appears: this is a gangrenous mass, which gains little by little, until 
an ulcer of variable size is established. The most frequent site of these 
scorbutic ulcers are the calves of the legs, the buttocks, thighs, sacrum, 
shoulders, arms, and more rarely the chest and abdomen. The deep-seated 
extravasations are-(1.) Subaponeurotic; (2.) Parenchymal, into the muscles, 
kidneys, heart, lungs, &c. These extravasations into the muscle-tissue never 
end in suppuration, but the tissue becomes atrophied, and undergoes a sort of 
gelatinous degeneration; resolution is very sluggish. When the effusion is 
beheath a resisting aponeurosis, as the fascia lata, there is no alteration in the 
integument immediately over it, but the swelling and discoloration happen at 
remote points, as the ham, about the knee, &c. The source of these extrava- 
sations would seem to be the softened capillary vessels, permitting the leakage 
of altered blood. There is no apparent solution of continuity except an ulcer 
exists" (Marmy, quoted by Dr. Clymer). 
The tongue is white, the breath fetid, and the stools generally pale. As the 
disease advances, all these symptoms are aggravated. The loss of physical 
power increases, the purple spots have a tendency to ulcerate, and the ulcers 
are distinguished from all others by their putrid fungoid appearance and 
great tendency to bleed ; old sores open, and the callus of broken bones has 
been even dissolved, and their ends separated. Profuse hemorrhages fre- 
quently take place from the mouth, nose, lungs, or bowels, sometimes from 
bailee, which form and burst (discharging blood) on the mucous surface. 
The teeth become loose, so that they either fall out or may be taken out by 
the finger and thumb. Ptyalism is not uncommon in scurvy, with swelling 
of the parotid and submaxillary glands. The pulse hurries on to 120 or 140, 
and at length the patient sinks from diarrhoea or dropsy, and with effusion so- 
sudden that he perhaps has walked a short distance and then died in a quarter 
of an hour afterwards. 
The duration of the disease is generally many weeks, and sometimes under 
the most favorable circumstances many months, the patient recovering his 
strength very slowly. When the disease follows ague, obscure or irregular 
remissions or intermissions of febrile symptoms are observable, and more or 
less enlargement, with pains in the region of the spleen, is often detected. 
From the commencement of the disease the al vine evacuations are more or 
less disordered, but the change may not attract attention. At first costive- 
ness prevails, but subsequently the stools'become much more frequent and 
very offensive. Diarrhoea, with colicky pains, supervenes, and, with more or 934 
SPECIAL PATHOLOGY-SCURVY. 
less attendant hemorrhage, rapidly sinks the patient beyond hope of remedy. 
Dysentery frequently supervenes upon the scorbutic state, more especially 
when dysentery is epidemic, and this combination of maladies is sometimes 
termed "scorbutic dysentery." The tongue, pale at first, becomes broad, flabby, 
and indented at the edges of the teeth. The great poverty of the blood 
causes the mucous membrane of the tongue and inside of the lips and cheek, 
as well as of the skin, to have a peculiar paleness, which contrasts remarkably 
with the appearance of the gums. The eyesight is frequently weakened, and 
night blindness (hemeralopia or nyctalopia) has frequently been observed as 
a commencing and concomitant symptom; and a most distressing state is the 
inability to sleep at night. 
" The tendency to swoon in the most severe cases is sometimes so great that 
the slightest motion, or the erect posture, or even any trifling exertion, may 
be followed by fatal syncope. It is stated in the account of Lord Anson's 
voyage, that many of the men, although confined to their hammocks, ate 
and drank heartily, were cheerful, and talked with much seeming vigor and 
in a strong tone of voice, and yet on their being the least moved, although 
it was only from one part of the ship to the other, and that in their ham- 
mocks, they have immediately expired; and others, who have confided in 
their seeming strength, and have resolved to get out of their hammocks, 
have died before they could reach the deck. And it was no uncommon 
thing for those who could do some kind of duty, and walk the deck, to drop 
down dead in an instant, on any endeavor to act with their utmost vigor" 
(Copland). 
There is an intercurrent chest affection which is apt to occur during cold 
and damp weather in scorbutic patients. 
" It begins," writes Dr. Clymer, " with slight rigors, followed by feverish- 
ness, and accompanied by lancinating pains in one or both sides. There is 
dyspnoea, and a feeling of constriction in the chest, as if a cord were drawn 
tightly round it. This condition is commonly caused by intrapleural effusion 
of blood, but sometimes blood escapes into the pulmonary tissue; in the 
latter case the expectoration becomes dark and sanious, and has a fetor 
resembling that of pulmonary gangrene, but which is due to decomposition 
of the sanguine fluid. Cold sweats, increasing dyspnoea, anxiety, and a fre- 
quent, thready pulse, precede death, the constant termination. Sometimes 
there is neither pain nor cough, but rapid increase of the breathlessness, and 
sudden death. The physical signs of the lung lesion are often wanting, 
though sometimes there may be dulness, mucous rhonchi, and bronchial 
respiration (Haspel). Chest dulness on percussion in scurvy may some- 
times be due to sanguineous effusions into the thoracic muscles " (Haspel, 
Buzzard). 
With our knowledge now of the phenomena of embolism, may not the sud- 
denly fatal end of such cases be due to the morbid condition of the fibrin of 
the blood already referred to ? 
Diagnosis.-The scorbutic state of the skin is to be distinguished from flea- 
bites, bruise, typhus fever, and from purpura hoemorrhagica. 
In purpura the blotches occur suddenly in persons previously to all appear- 
ance in good health: while the dingy hue of the skin is wanting, also artic- 
ular effusions, and pains in the limbs. 
Prognosis.-In the present day, when the patient can command medical 
vare and proper diet, scorbutus, though tedious, is seldom fatal. When these, 
however, have been wanting, the mortality has been terrible. Lord Anson, 
it should be remembered, in his voyage round the world, lost above 200 men, 
.and at last could not muster more than six fore-mast men in a watch fit for CONDITIONS WHICH BRING ABOUT SCURVY. 
935 
duty. At the commencement of our last war with France, on the fleet return- 
ing from sea, it often happened so many men were landed ill of scurvy that 
even Haslar Hospital, large as it is, could not contain them, and many were 
lodged in the chapel, others in tents, while others died in the boats before 
reaching the shore. 
Cause and Conditions under which Scorbutus is Developed.-In the Mid- 
dle Ages scurvy prevailed to so great an extent that it was said to be epidemic 
among the inhabitants of the low countries of Holland, Friesland, Brabant, 
Pomerania, Lower Saxony, and, indeed, all countries from the 50° to the 60° 
of north latitude. This has been attributed to the absolute want of winter 
food for the cattle, so that it was necessary to kill them on the setting in of 
the frost, and either to salt or dry the flesh. Food was deficient and of im- 
proper cpiality; and hence the large stores of salt provisions found in the 
larder of the elder Spencer in the days of Edward II, even so late in the 
spring as the 3d of May. Six hundred bacons, eighty carcases of beef, and 
six hundred of sheep, was his abundant supply. In all these countries, how- 
ever, in proportion as agriculture has advanced, and a succession of green 
crops has enabled the farmer to kill his best and fattest meats in winter, and 
in proportion as fresh vegetables have been introduced at our tables, together 
with a liberal use of wine and beer, so has this disease disappeared. The 
former universal prevalence of scurvy in the Navy, and its almost entire dis- 
appearance in the present day, necessarily has reference to a particular cause, 
-the too exclusive use of salt provisions and absence of fresh vegetables. 
"In 1797 the victualling of the Navy was changed, greatly improved, and 
strictly regulated; and immediately consequent to the change the health of 
the seamen improved strikingly. Scurvy, typhoid fever, dysentery, and 
putrid ulcer, which up to the period of the change produced great havoc, 
became comparatively rare in occurrence and light in impression." Since 
1797 the improvements have consisted in giving cocoa instead of gruel for 
breakfast, issuing salt meats at a much earlier period after being cured, the 
supply of better articles, and in greater abundance by one-third, the substitu- 
tion of tea in the afternoon instead of spirits; but, chief of all, the use of 
fresh vegetables as often as possible; and, with every improvement in these 
respects, there has been, as a general result, a further improvement in health, 
till these four forms of disease, at no distant date so destructive, are scarcely 
known except by name. 
It is now, however, completely established that salted meats are not more 
productive of scurvy than fresh meats, so far as concerns a monotony of diet. 
The experience of the Russians in 1720 and 1736, of the French in 1750-60, 
and of our own regiments at the Cape in 1836, sufficiently establishes this 
point. Nevertheless, salt meat has generally formed a large and important 
part of the food taken by the sufferers in all great outbreaks of scurvy. 
Besides the injurious effects of cold and moisture, as well as impure air, 
combined with the conditions already noticed as tending to favor the develop- 
ment of scurvy, it is now well known that exposure for a lengthened period 
to the pernicious influences of a malarious district greatly aids in developing 
scorbutus. By observations especially devoted to this subject, I have deter- 
mined that amongst our troops who had been in Bulgaria during the war 
with Russia in 1854, there were two and a half per cent, of admissions for 
scurvy amongst them more than among those who served in the Crimea 
only; and that the deaths among them reported from this disease were also 
greater by three per cent, than among those troops who served in the Crimea 
( Glasgow Med. Journal, July, 1857; and Trans, of the Royal Med.-Chir. Soci- 
ety, vol. xl). 
Recent combined researches have shown that scorbutic diseases were devel- 
oped amongst our troops in the Crimea under the following conditions: (1.) 
Deficiency of absolute nutriment; (2.) Improper adjudication of the nutrient 936 
SPECIAL PATHOLOGY-SCURVY. 
and respiratory principles of the diet-its monotony; (3.) Bad quality of the 
diet, and improper cooking, or none at all; (4.) Exposure to cold, combined 
with imperfect clothing, and labor beyond the strength of the best-fed men; 
(-5.) The persistent pernicious influence of residence in a paludal district (Bul- 
garia). But these circumstances are only to be regarded as the occasional 
antecedents, any one of which, or all combined, can never, per se, originate 
the disease. Looking to the history of scurvy, it will be seen that 
THE INVARIABLE AND INDISPENSABLE ANTECEDENT OF THAT DISEASE HAS 
BEEN A DEFICIENCY OR ABSOLUTE WANT OF FRESH VEGETABLE FOOD. Priva- 
tion of vegetable food is its one essential cause. There is no other invariable 
antecedent; and there are sufficient reasons why it may not always be followed 
by scurvy. It is this antecedent which is the vera causa of scorbutus; and the 
most successful methods of prevention and of cure are in accordance with the 
hypothesis which assumes it to be the cause (Budd, Curran, Laycock, 
Parkes). "The giving of vegetable food is its one essential counteractive" 
(Simon). 
On these questions Dr. Clymer gives the following interesting summary, in 
the American edition of this book : 
"In 1846, the potato crop failed in Great Britain and Ireland; and in the 
following year there was much scurvy amongst all classes. There was an 
outbreak of the disorder in Scotland, especially amongst the artisans and the 
laborers on the railways, in 1846-47, described by Drs. Christison, Ritchie, 
and Lonsdale (Edin. Mon. Jour., 1847), and the general fact with regard to 
the food of all was, that it failed in variety and in the quantity of its animal 
constituents. None had tasted potatoes after the harvest of 1846-a period 
of seven or more months-nor fresh vegetables; but animal food, fresh and 
salted, was* taken in large quantities, as well as pea-soup, suet puddings-, 
bread, and oatmeal. At Workington, a seaport town of 7000 inhabitants, 
there was no case of scurvy, turnips having been used in large quantities. 
Dr. Curran (Dublin Quar. Jour., 1847), describing the disorder as it appeared 
in Ireland, says: 'In no single instance could I discover that green vegeta- 
bles or potatoes had formed any part of the regular dietary;' grains, tea or 
coffee, flesh and fish, being the food. Dr. Shapter observes that in Exeter 
'the only difference in the usual diet of the sufferers consisted in the absence 
of the potato,' and that many of them had abundance of the necessaries of life, 
except fresh vegetables (Med. Gazette, vol. iv). 
" In the Crimean war, the allied armies suffered severely from scurvy. In 
the British army it first appeared in Bulgaria, where the diet was poor and 
the supply of vegetables scanty. When it arrived in the Crimea there was 
an abundance of grapes, cabbages, &c.; and though the ration was inferior, 
the disorder disappeared; but as winter set in, and vegetable food could no 
longer be got, it began again. When the supply of fresh vegetables and lime- 
juice became more constant, it gradually disappeared, and there were but few 
cases during the second winter. 
"The French army suffered'still more, no less than 23,000 cases of scurvy 
being recorded (Scrive). Good but lean fresh meat was issued, at first twice, 
then five times a week, with rice, and occasionally dried vegetables-chiefly 
peas, beans, and lentils-in small proportions, and bread irregularly. In the 
spring, with vegetation, the number of cases decreased; but in July, with a 
parching sun, the disease reappeared, and in the course of three months, the 
finest and warmest in the year in that region, no less than 5000 cases of scurvy 
occurred (Buzzard). The Sardinian army, on its arrival in the early part of 
the summer of 1855, was largely affected with scurvy, which was checked by 
the issue of fresh vegetables. Dr. Buzzard, who was a staff-surgeon in the 
army of Omar Pasha, says, that ' loss amongst the Turks from this disorder 
was still greater, and that the original force which formed part of the expedi- TREATMENT OF SCURVY. 
937 
tion from Bulgaria to the Crimea was almost entirely swept off by disease of 
which scurvy formed an important element' (Reynolds's System of Medicine, 
Art. 'Scurvy,' vol. i, 1866). During the winter of 1854-55, of Omar Pasha's 
troops, as many as 1000 were sent away monthly, all suffering severely from 
this disorder. During the summer of 1855, this army was encamped near Ba- 
laklava; and Dr. Buzzard remarks that, though 'their food was very imper- 
fect, they were supplied with onions, and consumed large quantities of water- 
melons,' and no cases of scurvy appeared, nor could he detect any scorbutic 
taint in patients suffering from other diseases. But during the winter all vege- 
table supplies ceased, and 'shiploads of sick were brought to Trebizond, all of 
whom were severely afflicted with this disease '-in some cases ' developed to 
an extent which recalled the terrible descriptions of the disorder contained in 
the narratives of our early voyagers.' This was explained by the fact that, 
besides the absence during the winter of fresh vegetables, they had not had a 
sufficient quantity of food, their diet consisting 'entirely of biscuit, a little 
rice, haricot beans, and yagh ' (a coarse butter made from mutton fat), and 
there was 'absolute starvation.' In 1836, over 100 cases of scurvy occurred 
in the 75th regiment while quartered at Caffreland, when not an onunce of 
salt provisions was issued, when the men had no harassing duties, and were 
abundantly supplied with fresh meat. The Hottentot troops doing duty with 
them were served with the same rations, but sought out for themselves pump- 
kins, melons, wild fruits, and esculents, and entirely escaped; as did also the 
27th and 72d regiments, encamped eighteen miles distant, fed with the same 
rations, but supplied with vegetables in addition. Dr. Buzzard states that 
scurvy is common in North Wales, where fresh meat and milk are abundant, 
but where there is little or no garden produce, and that he has met with many 
cases amongst the poor of London, who have eaten no meat of any kind for 
weeks, but had lived on tea, bread, and butter. At the close of'the Punjaub 
campaign (1848-49), the troops had abundance of excellent fresh meat and 
bread, but no fresh vegetables, yet suffered severely from scurvy; and in the 
Himalayan stations, during the second Burmese war, under the same circum- 
stances, scurvy was prevalent amongst the troops (Med. and Surg. Hist, of the 
British Army, vol. ii, 1858). 
"Scurvy prevailed to a great extent in the United States army during the 
civil war. This was not owing to any deficiency in the ration, or to the want 
of liberal provisions for fresh vegetables by the government and private or- 
ganizations, or the neglect of the medical department in issuing antiscor- 
butics. All these were most generously provided. But there were times when 
they could not be obtained, or used; when the men were obliged to live on 
marching rations; or when, through the ignorance or negligence of command- 
ing officers, they were not distributed. Scurvy, under these conditions, was 
the invariable sequence. At one time, in the Army of the Potomac, when 
' symptoms of scurvy began to appear,' and there was a general ' low vitality 
of the men,' Dr. Letterman found that he had rightly attributed it to ' want 
of fresh vegetables;' for, ' while large supplies of potatoes had been issued, the 
troops received in some cases a very small quantity, and in others none at all ' 
floc, cit., p. 106). Again he says (pp. 109-10), 'This favorable state of the 
health of the army, and the decrease in the severity of the cases of disease, 
are in a great measure to be attributed to the improvement in the diet of the 
men by the issue of fresh bread and fresh vegetables, which has caused the 
disappearance of the symptoms of scurvy that in January began to assume a 
serious aspect.' The testimony of Dr. F. Hamilton, with respect to the Army 
of the West, is to the same effect" (loc. cit.). 
Treatment.-The early history of navigation, as it records the greatest rav- 
ages of scurvy, so does it also record the best antidote to the disease. Of four 
ships which sailed from England in the beginning of April, 1609, for the 938 
SPECIAL PATHOLOGY-SCURVY. 
establishment of the East India Company, they were all so severely visited by 
scurvy as to have lost nearly one-fourth of their crews when they arrived at 
the Cape of Good Hope. The crew of the Commodore's ship was not attacked. 
This' immunity arose from three tablespoonfuls of lemon-juice having been 
served daily to each of his men. But notwithstanding this evidence of the 
success of lemon-juice in preventing scurvy-evidence the most conclusive- 
this valuable remedy and preventive was altogether slighted for a hundred 
and fifty years afterwards (Copland). Lord Anson's people, in 1740, on 
reaching the Island of Tinian, were recovered principally by eating oranges; 
and that noble, brave, and experienced commander was so convinced of their 
usefulness that before he left the island he ordered one man from each mess to 
lay in a stock for future security. Sir Charles Wager's people, also, were 
terribly afflicted with scurvy in the Baltic. Sailing, however, in the Medi- 
terranean, and having heard how effectual oranges and lemons were in the 
cure of this disease, he took on board at Leghorn a large quantity of them, 
ordered a chest each day to be brought on deck, and allowed the men, be- 
sides eating what they chose, to mix the juice with their beer, and to pelt each 
other with the rind, so that the deck was strewed with the fragrant liquor. 
By these means he brought his men home in good health. 
In the year 1747 Dr. Lind made some comparative trials between this and 
some other modes of treatment (as vinegar, sulphuric acid, and tamarinds) on 
board the "Salisbury," at sea. As a general conclusion from his experiments, 
he affirms that orange and lemon-juice, or more properly the citric acid ob- 
tained from all the species of the botanical genus citrus, or the natural order 
of fruits called hesperidee, are greatly more efficient than any other remedy in 
the cure of scurvy. 
Notwithstanding this strong opinion of Dr. Lind, the Navy continued to 
suffer severely from scurvy for half a century, till the Admiralty gave a gen- 
eral order for the supply of lemon-juice. This salutary measure was accom- 
plished by a representation from the Medical Board of the Navy, in the year 
1795, when Lord Spencer was First Lord of the Admiralty, after a trial made 
on board the "Suffolk," of seventy-four guns. This ship sailed from England 
on the 2d of April, 1794, supplied with a quantity of lemon-juice sufficient to 
serve out two-thirds of a liquid ounce daily to every man on board, and this 
was mixed with their grog, with two ounces of sugar. She arrived at the 
Madras roads on the 11th September, after a passage of twenty-three weeks 
and one day, without having had any communication with the land, without 
losing a man, and having only fifteen on the sick-list. Scurvy appeared in a 
few of the men during the voyage, but disappeared on an increased dose of 
lemon-juice being administured. ' "Let this fact," says Sir Gilbert Blane, "be 
contrasted with the state of the Channel fleet in 1780, when Admiral Geary's 
fleet returned into port, after a ten weeks' cruise in the Bay of Biscay, with 
2400 men ill of scurvy; and let the state of this fleet be contrasted with that 
of the Channel fleet in 1800, which, by being duly supplied with lemon-juice, 
kept the sea four months without fresh provisions, and without being affected 
with scurvy." 
In 1780 the number of cases of scurvy received into Haslar Hospital was 
1457; in 1806 one only; and in 1807 also one. While it is notorious that 
many medical men have never seen the disease, it is, as Dr. Budd has assured 
Dr. Watson, by no means rare in the hospital ship at Greenwich, which is 
often full of cases of scurvy; most of the patients so affected having just ar- 
rived in merchant ships from a long voyage; and some rumors are now abroad 
to the effect that scurvy is more frequent in the merchant service than here- 
tofore-and, if so, the least that can be said is, that it is a disgrace to the mer- 
chant princes of a nation like Great Britain. 
With regard to the prevalence of scurvy among sailors in the merchant ser- 
vice, Dr. Barnes (Physician to the "Dreadnought" hospital ship) reports in TREATMENT OF SCURVY. 
939 
1864 to Mr. Simon that "of the entire number of cases admitted during the 
last twelve years into the Sailors' Home at Poplar, nearly half are, at the 
time of their admission, suffering more or less from scurvy, and of these per- 
haps a twentieth part seriously diseased with it; that of the entire number of 
cases admitted during the last twelve years into the hospital ship ' Dreadnought,' 
cases of scurvy have formed a twenty-fourth part; that to these must, of course, 
be added sufferers who are not taken into such establishments-a large but 
uncertain number of cases taken into the low lodging-houses of the water-side; 
but that this is for London alone, and is not nearly all due to London ship- 
owners; that of eighty-six cases of scurvy treated in the 'Dreadnought' dur- 
ing 1863, only fourteen came from ships which had issued from the port of 
London, while thirty-one came from foreign ships, twenty-one from Liverpool 
ships, eight from Sunderland ships, and twelve from Glasgow and other Brit- 
ish ships; that Liverpool ships, besides furnishing to London a large propor- 
tion of the scurvy which is treated here, convey probably a much larger quan- 
tity of the disease to their own port of departure; that at all events, during 
1863, fifty cases (all probably severe) were admitted at the Liverpool hospitals, 
and during 1862 a dozen cases at the Glasgow and Greenock hospitals; that 
shipowners of Liverpool and other northern ports, and of Hamburg and 
America, are those who exhibit the greatest amount of disregard of the safety 
and health of their crews. The plight in which the poor sailors from certain 
services are admitted is pitiable to witness. Disabled by hardship, semistarva- 
tion, and ill-usage of every kind, they are cast out with the same indiffer- 
ence with which a worn-out block would be thrown overboard." When it is 
remembered that the security of this country has on several occasions been 
imperilled by the disablement of the Royal Navy through scurvy, it may be 
presumed that the same cause will imperil the safety of our merchant ships. 
And there can be no doubt that many ships have actually foundered at sea 
because the crews were so prostrate from scurvy as to be unable to handle 
them when overtaken by severe weather. It has been the custom to inquire 
what proportion of the crews were disabled from scurvy. As might be sup- 
posed in the case of a disease resulting from a cause operating upon the entire 
crew, this proportion is often very large. Thus there were recently admitted 
onboard the "Dreadnought" twelve cases of severe scurvy from one ship; 
two others were known to be seriously affected ; and the entire complement of 
officers and men was only nineteen, leaving but five men in all able for duty 
to work the ship. The proportion of crew disabled has ranged from 20 per 
cent, to 70 per cent.; and it is certain that scurvy ships have rarely a hand 
to spare. Deprive such ships of a fourth, a half, or two-thirds of their force, 
and the peril of a ship, cargo, crew, and passengers, in stress of weather, is 
obvious ; and it must not be forgotten that where scurvy has prostrated a large 
part of the crew, the vigor of the remainder is sure to be sapped, so that there 
may not remain a single sailor before the mast in a state of thorough efficiency 
(Simon, in Sixth Report on Public Health, p. 19). 
The disease, "so fatal when left to itself, is cured with the greatest facility. 
Symptoms apparently the most grave and serious vanish as if by magic, and 
without leaving behind them any serious injury to the constitution. The 
sanious discharge from scorbutic sores has been known to change color and to 
become healthy in a few hours after the commencement of treatment. In 
pure cases of scurvy the blood, and the blood only, is at fault" (Parkes, 1. c.). 
"Lemon-juice," writes Dr. Watson, "is really a specific against scurvy, whether 
it be employed as a preventive or as a remedy. It supplies something to the 
blood which is essential to its healthy properties." The potato seems to be 
no less efficacious as a remedy and preventive (Budd). The reader will find 
a most interesting account of the efficacy of potatoes and of onions in Dana's 
Two Years before the Mast-a book well worth reading. The antiscorbutic 
principle, whatever it may be, is in greatest amount in unripe fruits; it lessens 940 
SPECIAL PATHOLOGY-SCURVY. 
gradually as they ripen'; and if the juice be obtained, it disappears when fer- 
mentation occurs. When lime-juice becomes musty, a mucilaginous principle 
is developed at the expense of the citric and malic acids; and the percentage 
of citric acid gradually decreases (Sir William Burnett, Parkes). Good 
femon-juice seems to be more effectual, however, than pure citric acid; proba- 
bly from its containing malic and tartaric acids, besides citric, and from the citric 
acid being in the form most easily absorbed and decomposed by the digestive 
organs of man. The Materia Medica gives numerous analogous examples of 
the superior efficacy of a medicine in its natural combinations (Parkes). 
This is all we can yet say, however, regarding the actions of either of these 
means of cure, notwithstanding the researches of the chemists of the present 
day. Moreover, it is sufficient: and with such remedies at command, the 
prevalency of scurvy in merchant vessels, or in any Navy, ought not to exist. 
" The one thing wanted in order that scurvy should be entirely banished from 
the mercantile marine is proper provision for the dietary of the crew,-such 
provision as is enforced in emigrant ships, where each person's weekly allow- 
ance must have in it at least 8 oz. of preserved potatoes, and 3 oz. of other 
preserved vegetables (carrots, onions, turnips, celery, and mint), besides 
pickles and 3 oz. of lime-juice; where, also, there is considerable variety of 
bread stuff; and where, on two days in the week, preserved (not salted) meats 
must be given. With such a dietary as this, the details of which might be 
varied, provided its principle were adhered to, the occurrence of scurvy would 
be impossible. And even with dietaries inferior to that just described, scurvy 
would not occur as it does, if but the provisions of the 'Merchant Shipping 
Act' (17 and 18 Viet., c. 104) were obeyed,-that whenever a crew shall 
have been consuming salt provisions for ten days, lime-juice or lemon-juice 
and sugar shall be served out at the rate of half an ounce each per day; and 
if, during the voyage, the opportunities which offer themselves were fairly 
used for getting new supplies of fresh animal and vegetable food; but owners 
disobey the law, and captains neglect opportunities to counteract the results 
of this disobedience. Owners, notwithstanding the law, will send forth their 
ships on long voyages without any provision of lime-juice, or with lime-juice 
insufficient in quantity, or with lime-juice of which the quality is bad; 
and captains, with half their crews more or less disabled, are known to run 
past St. Helena or the Western Isles, when a few hours' delay would obtain 
sufficient provisions to repair the mischief occasioned by first neglect" (Simon 
and Barnes's Sixth Report on Public Health, 1864, p. 20). 
It is perhaps hardly fair to attribute the improved health of the Navy en- 
tirely to the introduction of a daily allowance of lemon-juice, considering that 
the quantity of the diet was greatly increased, and its quality greatly im- 
proved, contemporaneously with this addition. It is gratifying, however, to 
see how largely these combined measures have improved the health of the 
Navy, and rewarded the cares of those who superintend it; for during the 
nine years preceding these changes the sick seamen sent to the hospitals were 
1 in 3.9, while in the nine succeeding years the proportion was only 1 in 8.4; 
so that not only has scurvy almost disappeared from ships of war and naval 
hospitals, but the efficiency of the Navy has actually been increased threefold. 
Dr. Parkes advises that the following measures be adopted in time of war, 
or in prolonged sojourn on board ship, or at stations where fresh vegetables 
are scarce: 
"1. The supply of fresh vegetables by all means in our power. Even un- 
ripe fruits are better than none, and we must risk a little diarrhoea for the 
sake of their antiscorbutic properties. In time of war every vegetable should 
be used which it is safe to use, and when made into soups all are tolerably 
pleasant to eat. 
"2. The supply of dried vegetables, especially potatoes, cabbages, and 
cauliflowers; turnips, parsnips, &c., are perhaps less useful; dried pease and DEFINITION AND PATHOLOGY OF ANAEMIA. 
941 
beans are useless. As a matter of precaution these dried vegetables should 
be issued early in the campaign, but should never supersede the fresh vege- 
tables. 
" 3. Good lemon-juice should be issued daily (1 oz.), and it should be seen 
that the men take it. 
" 4. Vinegar oz. to 1 oz. daily), should be issued with the rations, and 
used in the cooking. 
"5. Citrates, tartrates, lactates, and malates of potash, should be issued in 
bulk, and used as drinks, or added to the food. The easiest mode of issuing 
these salts would be to have packets containing enough for one mess of twelve 
men, and to instruct the men how important it is to place them in the soups 
or stews. Possibly they might be mixed with the salt, and issued merely as 
salt" (Bract. Hygiene, 2d ed., 1866, p. 466). 
ANAEMIA. 
Latin Eq., Anosmia; French Eq., Anomie; German Eq., Anaemie-Syn., BLutar- 
muth; Italian Eq., Anemia. 
Definition.-A special morbid state in which there is either a relative diminu- 
tion of the mass of blood (Andral), with the general composition of the blood 
differing from the normal standard; or in which the mass of blood is diminished, 
and the liquor sanguinis is watery, poor in albumen, and containing an excess 
of salts. These conditions, coexisting with relative deficiency of the red blood- 
corpuscles (Vogel), and a diminution of the urine-pigment (Parkes), consti- 
tute ancemia. 
Pathology.-The term ancemia literally means absolute deficiency of blood- 
a condition of existence obviously not possible. A diminution in the quan- 
tity of blood, with an alteration in its composition, almost never occurs alone, 
but is generally a morbid state resulting from many exhausting morbid pro- 
cesses peculiar to such wasting constitutional diseases as scrofula and cancer. 
In many of these diseases the blood-mass is evidently diminished. We have 
indications of this diminution in the small pulse, in the pale bloodless appear- 
ance of the countenance and surface of the body generally, especially seen in 
the lips and gums, and in the small blue collapsed veins, particularly obvious 
by contrast on the pallid skin. In such cases one would never think of draw- 
ing blood to know whether or not its constitution was changed; but in cases 
where the opportunities for examination have occurred, the blood-corpuscles 
have almost always been found relatively diminished ; and accordingly the 
College of Physicians of London define anaemia simply as " deficiency of red 
corpuscles in the blood." The causes which lead to this diminution are ob- 
scure ; and at one time the spleen and glands have been held as concerned in 
bringing about the disease by some abnormal exercise of their functions. 
The result of this morbid condition of the blood chiefly betrays itself- 
(1.) Upon the vascular system generally ; and (2.) Upon the metamorphoses of 
tissues. 
The bloodvessels contract in proportion to the diminution of the blood- 
mass. The arteries contract generally ; and the pulse, whenever it can be 
felt, is found to have become small and tense. The capillaries also contract; 
the skin and mucous membranes becoming pallid and comparatively blood- 
less. The heart's action in extreme cases becomes irregular, and the whole 
circulation generally is disturbed. 
As regards the metamorphoses of tissues, the muscles and the nervous sys- 
tem appear to suffer first; debility and prostration, both bodily and mental, 
occur ; and in severe cases sensation may be lost, syncope is frequently apt to 
occur, and even death may result. 942 
SPECIAL PATHOLOGY - ANJEMIA. 
The disease seems to go through different changes, according to the causes 
which bring about the anaemic condition. After mere loss of blood in quan- 
tity, for instance, the water and the salts are renewed with most rapidity, the 
albumen later, then the colorless corpuscles, and last of all the red corpuscles. 
Hence it is that anaemia is frequently associated with a watery condition of 
the blood, as well as with a lessening of the number of the blood-cells. It 
is a matter of the greatest importance in practice to distinguish, if possible, 
between these conditions, with a view to a rational means of treatment. 
Those exhausting diseases which are attended especially with deranged 
nutrition and sanguification, such as Bright's disease, carcinomatous diseases, 
scrofula, and suppuration, lead also to the development of that form of anaemia 
in which the liquor sanguinis is in excess, in which the blood is poor in albu- 
men, containing an excess of salts, and in which the blood-cells ultimately 
become deficient. A tendency to general dropsy or to diarrhoea ensues, nu- 
trition becomes still more disordered, and new formations are apt to become 
developed. 
It is very important to know, in a practical point of view, that every acute 
disease which occurs in an anaemic individual assumes a peculiar character : 
a very high degree of debility and prostration ensues, convalescence is pro- 
tracted, and all severe intercurrent diseases acquire a lingering course. 
Symptoms.-In combination with an investigation of the blood, the symp- 
toms and signs of ancemia are already read in its pathology. It is only by 
general symptoms, however, that the physician is able circumstantially to 
conclude that relative diminution of the cells of the blood coexists with defi- 
ciency of the mass. Great debility is a prominent and striking feature. 
The skin is of a pale waxen color ; the " whites " of the eyes have a bluish 
aspect; the mucous membrane of the mouth is colorless ; the gums and lips 
are white ; and the tongue is pale, large, and flabby ; the pulse in general is 
about 80, but very feeble, and easily excited-the least stimulus, the least 
mental emotion or movement of the body produces great momentary accelera- 
tion of the pulse. 
The temperature in the axilla is usually normal; although an semi c patients 
generally suffer from cold extremities. Respiration is hurried on the least 
exertion. The appetite is bad, and thirst prevails. 
When the disease has existed for some time, oedema of the feet and ankles 
may supervene ; and, finally, sweating, in the extreme stage of ancemia. It 
occurs most frequently in the last stages of severe and exhausting sickness of 
a lingering and prolonged kind, where a high degree of paleness of the skin 
and mucous membranes exists, with a small weak pulse, collapse of the veins, 
and a small volume of the heart, spleen, and liver. 
Mental depression is usually distressing, the temper variable, and intelli- 
gence torpid. 
In recent days diagnostic characters of ancemia have been recognized in 
various murmurs which may be heard in some parts of the vascular system of 
anaemic patients. Although the seat, the causes, and the signification of these 
murmurs have been very much disputed, yet the following account may be 
given of them, based on numerous observations and investigations, especially 
those of Vogel and of Walshe. 
There are three kinds of anaemic murmurs which may be distinguished, 
namely-(1.) Cardiac murmurs; (2.) Arterial murmurs; and (3.) Venous 
murmurs. 
The cardiac anaemic murmur gives forth what is usually called a " bellows 
sound," sometimes intense, sometimes faint, and which generally accompanies 
the first ventricular sound of the heart. The position where these systolic 
cardiac murmurs is best heard is of some importance, as indicating anaemia 
rather than disease of the heart. They are heard towards the base of the 
heart in anaemia, rather than towards the apex, as in organic disease of the THREE KINDS OF ANEMIC "MURMURS." 
943 
valves (Walshe). The diastolic murmurs are really of venous origin ; and 
their intensity is more or less increased by suspension of the respiration. 
The cardiac anaemic murmur occurs most frequently in true ansemia, especi- 
ally if cardiac excitement is associated with it; and simultaneously with it we 
frequently hear arterial and even venous murmurs. It has been observed by 
Vogel and others, however, that while the presence of these cardiac murmurs 
may be employed as an auxiliary sign together with others in the diagnosis 
of ansemia, yet it is not to be concluded from their non-existence that ansemia 
is not present. Such murmurs are not heard in all anaemic patients; and, 
although present, they are not in every case due to anaemia, because they 
occur in organic diseases of the heart, such as valvular diseases and endo- 
carditis; and a physician trusting to and acting upon stethoscopic signs merely, 
without a due appreciation of general symptoms, seriously injures the patient, 
and does an injustice to the science of medicine. 
The arterial anaemic murmurs are seldom heard. They consist of an inter- 
mittent blowing, sometimes soft, sometimes sharp sound, perceived to be 
synchronous with the beat of the pulse, which give at the same time a thrill 
to the finger, so that the murmiir may be inferred by practice from the nature 
of the pulse. It is only in the larger arteries in which they are heard, such 
as the brachial, the subclavian, the femoral, the carotid, and abdominal aorta. 
They are most frequently heard after great losses of blood; and sometimes 
also in chlorosis. Vogel has heard them during the paroxysms of intermit- 
tent fever, while they are absent during the intermissions. They may be 
heard in typhus fever. No positive conclusion can therefore be formed from 
them alone regarding ansemia. 
The venous murmurs, or hums, significant of ancemia, are contimums, hum- 
ming, buzzing, occasionally musical, singing murmurs, easily distinguishable 
from the blowing intermittent arterial murmurs. They are most frequently 
heard on the right side of the neck, at the junction of the external and internal 
jugular vein; but they may also be heard in the femoral veins in their maxi- 
mum degree of intensity. They may be heard, also, over the course of the 
superior longitudinal sinus, and at the maximum intensity over the torcidar 
Herophili (Walshe). They are supposed to be produced by abnormal oscilla- 
tions of the venous valves, or by sharp collision among the blood-discs, pass- 
ing from sideward veins into a large vessel. When the venous murmurs are 
strong, they may not only be heard but also felt as a gentle thrill, by placing 
the finger on the part. 
These venous murmurs are seldom absent in well-marked anaemia. Never- 
theless, anaemia is not to be positively inferred from the mere presence of any 
one of these murmurs. 
The characters of the anaemic murmur are given by Dr. Clymer as follows: 
"(1.) It accompanies the first sound of the heart, which it commonly more 
or less masks; (2.) It is short; (3.) It is usually soft, but not always, for it 
may be harsh, though not absolutely grating; (4.) It is exceedingly local, the 
maximum of intensity being generally in the fourth intercostal space, near 
the sternum; more rarely limited between the fourth and fifth; beyond these 
points it is never heard; it follows the course of a line drawn from the point 
of greatest intensity to the inner portion of the right clavicle. Dr. Potain, in 
his article Anaemia (Diet. Encyc. des Sciences Medicales, t. iv, p. 392, Paris, 
1866), says, 'The site of the cardiac anaemic murmur is in the arterial orifices, 
and especially in the aortic orifice: no one doubts this.' This was the receiveci 
site of the murmur by all, except Hughes, until quite recently. He, remark- 
ing that it cannot be heard below the nipple, and in the axilla, as is the case 
in aortic murmurs depending upon organic disease, or generally on a level 
with the ascending aorta, or at the arch, was disposed to place it in the orifice 
of the pulmonary artery (Guy's Hospital Reports, 1851). Quite lately, Dr. 944 
SPECIAL PATHOLOGY-ANEMIA. 
Parrot has given some excellent reasons for believing the site of the anaemic 
cardiac murmur to be in the right auriculo-ventricular orifice {Archives Gen. 
de Med., Abut, 1866); its maximum of intensity, he observes, is in the fourth 
intercostal space, near the sternum, corresponding with the right auriculo- 
ventricular orifice; and its line of propagation is in the course of the superior 
cava, and not of the aorta; and he further assigns insufficiency of the tricuspid 
valve as the cause of the murmur. 
" The mechanism both of the cardiac and venous anaemic murmurs have 
generally been ascribed, (1.) To increased friction of blood, whose viscidity is 
diminished, against the walls of the vessels; (2.) To increased celerity of the 
blood, and consequent loss of relation between the contents of the ventricles 
and the area of the openings leading from them; (3.) The passage of thin 
watery blood through tense veins (Ogier Ward). Dr. Flint has suggested 
spasm of the papillary muscles, causing insufficiency of the mitral valve, as 
the cause of the cardiac murmur; and Marey believes it due to diminished 
arterial tension, and increased rapidity of the ventricular systole. 
"Whenever a proper examination can be made of the veins of the neck, 
particularly at the base, the seat of the two pulsations-and sometimes only one, 
synchronous with the beat of the radial artery-will be found to be limited 
to the course of the vein, to be from above downwards, to follow a line which 
makes an acute angle with the artery, and to cease to be heard immediately 
on the least compression above the point of pressure; all of which goes to 
prove that the pulsations are due to a reflux of blood into the right cavities 
of the heart-in fact, a true venous pulse. Now, Dr. Parrot has proved {Archives 
Gen. de Med., 1865), that the pulsations of the external jugular veins, double 
and single, provided the latter are synchronous with the radial pulse, are a 
sure sign of imperfect occlusion of the 'right auriculo-ventricular orifice by 
the tricuspid valve, at the moment of the ventricular systole. He has subse- 
quently {loc. cit.) attempted to establish a relation between the venous mur- 
murs and the cardiac murmur, which happen simultaneously, and he looks 
upon the latter as caused by the former, 'for,' he says, 'of all the conditions 
which can give rise to intra-cardiac blowing, no one is more favorable than 
insufficiency of the auriculo-ventricular valves, since the blood, driven with 
force and rapidity by the ventricle, passes from a cavity where it is subjected 
to great pressure, and through a narrow orifice, into the auricle, a thin-walled 
sac where the compressing force is feeble.' " 
One constant urinary character attends both amemia and chlorosis-namely, 
a diminution in the urine pigment, which is often reduced to one-fourth or 
one-sixth of its normal amount. Very generally there is also lessening of the 
free acidity; and urine which is pale and almost neutral during the whole of 
the twenty-four hours is almost as good an indication for the use of iron as 
the pallor of the skin itself. The amount of iron in the urine of anaemia is 
often very small. The quantity of urine may not be decreased, and may be 
in some cases large. Its specific gravity is low (Parkes, 1. c.). With regard 
to other constituents, such as urea and uric acid, the accounts are very con- 
tradictory. 
Causes.-As an independent constitutional disease, anaemia may be said to 
owe its origin to three sets of conditions,-(1.) Copious loss of blood, such as 
by hemorrhage or venesection, or oft-repeated small losses of blood. (2.) 
From loss of other fluids of the body besides blood, especially of such as con- 
tain albuminous, fibrinous, mucinous, or caseinous substances, such as the 
excessive secretion of milk in protracted suckling, suppuration, profuse blen- 
norrhoea, leucorrhcea, diarrhoea. (3.) From insufficient and improper nutriment, 
or from disturbances in the absorption and assimilation of food, and the pro- 
cess of sanguification ; or from repeated temporary interruptions to oxygena- 
tions of the blood, as by imperfect ventilation of sleeping-rooms or coal mines. TREATMENT OF ANEMIA 
945 
(4.) It may result from the co-operation of many influences; for example, 
excessive bodily and mental labor; continued excitement, pain, care, grief, 
hardships; many acute and chronic diseases, some of which augment the con- 
sumption of blood, while others impede its formation-this effect being pro- 
duced by an acute disease under certain circumstances, when its invasion is 
intense and its duration prolonged, such as by scrofula, carcinomatous diseases, 
diabetes; from poisoning by malaria-the malaria-chlorosis of Vogel, or palu- 
dal cachexia of Martin, as in the " used-up" condition of our Bulgarian troops, 
described by Dr. H. Mapleton in Parliamentary Paper 247, for 1856, p. 253. 
"It is the most general of all the conditions incident to tropical invalids" 
(Martin). Anaemia is often the result of such poisons as lead, mercury, iodine, 
aniline, tobacco, and of diseases such as syphilis, rheumatism, goitre. Tailors, 
shoemakers, cooks, firemen of steam-vessels, and female operatives in large 
factories are the most frequent sufferers from anaemia. 
Treatment.-The energies of the physician must be directed to discover 
and counteract the cause of the anaemia. Nutritious substances must be 
supplied for diet, in the shape of easily digested meat and broths. The purely 
tonic treatment, in the combination of air, exercise, and diet, must be carried 
out as far as practicable. A change of air is absolutely necessary, and gen- 
erally also of diet. Iron is one of the best medicinal remedies. The astringent 
preparations are pre-eminently tonic; and are especially useful when the 
anaemia is associated with or dependent upon inordinate discharges. Solution 
of the perchloride of iron, in the form of tinctura ferri perchloridi, in doses of ten 
to thirty minims, in water, or infusion of quassia or of calumba, has properties 
in common with the numerous salts of iron, and is one of the most reliable 
preparations. If the anaemia is associated with diarrhoea, or menorrhagia, or 
leucorrhoea, the solution of the pernitrate of iron in similar doses is attended 
with benefit. A preparation which is recently new to the Pharmacopoeia- 
the syrup of the phosphate of iron-possesses the general properties of the ferru- 
ginous compounds, and is of great service when the anaemia is associated with 
certain forms of dyspepsia, or with amenorrhaea. It invigorates and increases 
the powers of digestion, and may be given to the extent of one to three drachms 
for a dose in water. 
Another phosphatic preparation of very great value is that which has been 
devised by the late Dr. Easton, Professor of Materia Medica in the University 
of Glasgow. Although it is not in the Pharmacopoeia, and although its mode 
of preparation had not been published before Dr. Easton kindly sent it to me 
for publication in the previous editions of this work, yet the combination has 
become very popular throughout the country as a general tonic in anaemia 
and cachexies generally. As such, it has been largely used by my colleagues, 
Professors Maclean and Longmore, amongst the used-up cachectic and anaemic 
soldiers under treatment at the Royal Victoria Hospital at Netley ; and I 
would add my testimony to its being a most valuable medicine in general 
practice. The following is the original formula devised by Dr. Easton for 
the preparation of the phosphates of iron, quinine, and strychnia, in the form 
of a syrup (" Syrupus ferri, quinice et strychnias phosphatum,,y) : 
R. Ferri Sulph., $v ; Sodse Phosph., $vi ;* Quiniae Sulph., grs. cxcii; Acid 
Sulph. Dil., q. s.; Aquae Ammonise, q. s.; Strychnine, grs. vi; Acid. Phosph. 
Dil., ^xiv; Sacchar. Alb., ^xiv. 
" Dissolve the sulphate of iron in one oz. boiling water, and the phosphate of 
soda in two oz. boiling water. Mix the solutions, and wash the precipitated 
phosphate of iron till the washings are tasteless. With sufficient diluted sul- 
phuric acid dissolve the sulphate of quinia in two oz. water. Precipitate the 
* A little more phosphate of soda gives a better result-say ^i. 946 
SPECIAL PATHOLOGY - ANJEMIA. 
quinia with ammonia water, and carefully wash it. Dissolve the phosphate 
of iron and the quinia thus obtained, as also the strychnia, in the diluted 
phosphoric acid ; then add the sugar, and dissolve the whole, and mix without 
heat. The above syrup contains about one grain phosphate of iron, one grain 
phosphate of quinia, and one thirty-second of a grain of phosphate of strychnia 
in each drachm. The dose might therefore be a teaspoonful three times a 
day. 
" The amount of phosphate of quinia might be increased according to cir- 
cumstances ; and if eight grains of strychnia were employed in place of six, as 
in the above, the phosphate of strychnia would be in the proportion of the one 
twenty-fourth of a grain in every fluid drachm of the syrup. I would scarcely 
venture on a much larger dose. In cases of delicate children, with pale coun- 
tenances and deficient appetites, I have given, with great benefit, a combina- 
tion of equal parts of the above syrup and of that prepared by Mr. Edward 
Parrish, often called chemical food. To children between two and five years 
of age, the dose of this combination may be a teaspoonful three times daily. 
" The preparation ought to be kept as much as possible from light and air, 
otherwise the preparation Zoses its characteristic opaline appearance, and 
assumes a fawn color; a precipitate maybe thrown down." 
It is prepared by Messrs. Murdoch, chemists, in Glasgow; by Duncan and 
Flockhart, in Edinburgh ; by Randall and Sons, Southampton; and by 
Savory and Moore, in London. 
In some cases the astringent preparations of iron are not suitable, and are 
apt to irritate delicate stomachs, or those in whom any inflammatory local 
disease exists. For delicate females and children the saccharated carbonate of 
iron is a most valuable preparation, in the form of mistura ferri composita, 
to the extent of one to two ounces for a dose ; or in the form of the pilula ferri 
carbonatis, in doses of from five to twenty grains in the twenty-four hours. 
The citrate of iron and ammonia is another remedy which possesses scarcely 
any astringency, and may often be given in cases of anaemia when the stomach 
will not bear more astringent preparations. Five to ten grains of this salt 
may be taken during the twenty-four hours. It is best taken during efferves- 
cence, prescribed in solution of citric acid, and not in bicarbonate of potash, solu- 
tion. If it is put into the latter, carbonic acid will be given off, and probably 
burst the bottle. Tincture of orange-peel is the best flavoring agent; but as 
the salt will not dissolve in the tincture alone, it is necessary to dissolve the 
salt in water first, and then add the tincture, otherwise the division into doses 
is impracticable (Squire). 
When it is desirable to continue the use of iron for a long time, as in the 
anosmia of neuralgic affections or tic-douloureux, or to give it in large doses, 
the magnetic oxide of iron is the best preparation to administer in doses of five 
to twenty grains twice or thrice a day in water. The reduced iron-the fer- 
rum reductum of the British Pharmacopoeia-is also a remedy which does not 
possess the astringent properties of the other preparations, and is one of the 
most powerful remedial agents in cases of anaemia. One to five grains may 
be given several times a day in powder or in pill. It has no taste, and one 
grain is equal medicinally to five grains of the citrate of iron. The citrate of 
iron and quinine, either in solution or in the form of a pill, is a new and useful 
preparation, in doses of five to ten grains three times a day. Such a prepara- 
tion of iron must be found as will not check the digestion of other food. If 
loss of appetite and feverishness prevail, the form of the remedy is probably 
unsuitable, and requires to be changed. Chlorine, in the form of warm hydro- 
chloric acid baths, is highly spoken of by Dr. T. K. Chambers, as an agent 
of great value, and as a directly restorative medicine in anaemia (1. c., p. 332). 
The bowels are to be kept regular by four grains of the pills of aloes and 
myrrh taken at bedtime. PATHOLOGY AND SYMPTOMS OF CHLOROSIS. 
947 
Ferruginous remedies are always of use when we have reason to believe 
that there is a diminished energy in the formation of blood-cells; and if the 
urine be pale and almost neutral during the whole of twenty-four hours, it is 
as good an indication for the use of iron as the pallor of the skin in cases of 
ancemia (Parkes). Dr. Trousseau was of opinion, however, that for ancemia, 
complicated with tubercles, iron preparations were unsuitable, as tending to 
hasten their development. Dr. Clymer has found arsenic a valuable remedy 
combined in the form of chlorides of arsenic, iron, and quinine. 
chlorosis-Syn., green sickness. 
Latin Eq., Chlorosis-Idem valet, Pallor luteus foeminarum; French Eq., Qhlorose- 
Syn., Pales couleurs; German Eq., Chlorose-Syn., Bleichsucht; Italian Eq., 
Clorosi. 
Definition.-A deficiency of the blood-cells, with redundancy of the serous part 
of the blood, occurring in young girls at the age of puberty, and sometimes in the 
young of both sexes before the complete development of the distinctive characters of 
the sexes towards puberty has been effected. 
Pathology and Symptoms.-A very indefinite idea is associated with the 
name and nature of this disease. Many employ the term precisely in the 
same sense as anaemia; or they limit the term chlorosis to those forms of anaemia 
whose causes are unknown. The original use of the term is expressed in the 
first part of the definition, as limited to that form of anaemia which occurs in 
the female at the period of puberty. It is to be classed amongst the "func- 
tional diseases of the female organs of generation in the unimpregnated state." 
A change in the complexion constitutes the most striking symptoms of 
chlorosis. A marked pallor of the skin prevails, sometimes perfectly pale, at 
other times yellowish, greenish, or waxen colored. The lips and mucous 
membranes are also pale-symptoms which are the result of the deficiency of 
blood-cells, and so of blood-pigment. Slight dropsical swellings occur, such 
as oedema of the feet and ankles, the face and the eyelids, and a bluish halo 
sometimes encircles the orbit. 
The temperature of the body is generally diminished-the breath is cool, 
the lips, nose, ears, hands, and feet are cold; and chilliness of the body pre- 
vails, which is morbidly sensitive to external cold, and seeks warmth. As in 
other forms of anaemia, the patient suffers from great prostration of strength 
and debility; she is tired by the slightest exertion, and the weakness some- 
times becomes so great as to lead to fainting. The patient is languid, listless, 
sedentary, and indisposed to exertion. She is nervous, low-spirited, and fre- 
quently a prey to irregularities of temper. 
Hysteria may prevail with chlorosis. The patient frequently suffers from 
vertigo, headache, often recurrent, tinnitus aurium, especially of the right ear, 
sparks in the eyes, tendency to fainting, neuralgia, spinal irritation, and con- 
vulsions, or a "heaviness for sleep." The mind is sometimes morbidly im- 
pressed with grief, while despondency and frightful dreams prevail; there is 
the apprehension of nightmare, melancholy thoughts predominate, mania may 
become confirmed, and the insanity may assume a suicidal tendency. 
The nervous system generally is always more or less implicated. 
Disorders of digestion attend the disease. Appetite is diminished or per- 
verted, or even depraved. Acids and highly flavored foods are craved for, 
and sometimes such substances as chalk, paper, ashes, coal, plaster of Paris, 
hair, earth, and even excrements, are desired to be eaten. Substances also- 
very difficult of digestion are longed for, and are sometimes digested better 
than simpler kinds of food. Constipation frequently and obstinately coexists, 
but afterwards diarrhoea may alternate, and lead to hwmatemesis or melcena,. 948 
SPECIAL PATHOLOGY - CHLOROSIS 
when the evacuations are usually scanty, dark-colored, and fetid. A singular 
and peculiar pain of one or both sides, which suffer together or alternately, is 
a frequent symptom. It is referred generally to the region over the false ribs 
and the ilia. The recurrent nature, the particular situation, and the alter- 
nating character of the pain, are peculiar and characteristic. It is not aggra- 
vated by a deep inspiration, although it may seem to be so at first. 
Other functions are no less disordered-for instance, the respiratory, the 
generative, and the circulatory. 
Respiration is oppressed, or performed with difficulty, and the breath is 
offensive. Breathlessness prevails, and is experienced especially on any exer- 
tion ; sometimes also fits of dyspnoea ; and sometimes a sonorous cough occurs. 
Menstruation is generally absent or performed imperfectly, irregularly, and 
with pain, and the. flow is thin and watery, or leucorrhoeal. The condition 
of the menstrual discharge is generally very easily impaired. The catamenia 
become irregular in their return, inconstant, or of short duration in their flow, 
deficient in quantity, and pale in color, and terminating in a state of leucorrhoea. 
In some cases each return of the catamenia is preceded and attended with 
much pain in the back and in the region of the uterus. Later in the disease 
there may be complete amenorrhoea. 
The conditions of the vascular system are variable. The pulse is slow, feeble, 
and soft, but sometimes frequent, and always easily accelerated ; the heart 
and great vessels are irritable; palpitation is common; or, more frequently, 
a sense of fluttering in the prcecordia, with irregular action of the heart, or im- 
perfect syncope and murmurs, as already described, may prevail. It is to be 
observed, however, that, apart from mere lassitude and palpitation, patients 
are sometimes chlorotic for weeks, without any other marked symptoms; and 
the same complication of intercurrent acute diseases is apt to happen as de- 
scribed under anaemia. The condition of the urine is similar to that which 
prevails in anaemia. 
Causes.-The conditions which bring about this constitutional affection are 
similar to those already mentioned. The disease is frequent in females between 
the ages of sixteen and twenty-five years, is often of long duration, lasting for 
months, and even for years, with a tendency to relapse after cure. 
Diagnosis.-It is especially necessary that the physician should not con- 
found chlorosis with jaundice on the one hand, or disease of the heart on the 
other, or with scrofula with incipient deposit of tubercle, or inflammation within 
the chest or abdomen. 
Treatment is chiefly conducted by change of air and diet, and by medicines. 
All the functions of the body must be carefully observed, watched, and regu- 
lated. The residence of the patient must be a reputed healthy spot in the pure 
air of the country, rather than the town. Dry frictions of the back and limbs 
are also recommended, with bathing in the sea, where it can be borne. 
The food must be regulated so as not to be too stimulating nor disgustingly 
bland;-frequent change is demanded, with a due attention to the proper ap- 
portioning of nutritive and respiratory elements. The diet should be generous, 
and carefully apportioned to the powers of digestion. Any symptoms of dys- 
peptic oppression, impaired digestion, or offensive stools, demand a careful re- 
adjustment of the dietary. Three meals, or perhaps four, maybe taken during 
the day-the intervals between the meals being equal; and, half an hour 
before each of the meals, two grains of capsicum, with one grain of quinine, 
may be given in a pill. The breakfast should consist of biscuit, dry toast, or 
stale bread, with fresh butter, and perhaps an egg, and one small cupful-not 
more-of hot black tea. Five or six hours after breakfast, and after the pill, 
a dinner of well-done meat, such as mutton chops, may be eaten with potatoes ; 
porter, beef tea, or milk being taken for drink, according to taste and the 
powers of digestion. The evening meal may be similar to the morning. At 
first there may be a loathing of all kinds of food in the form of regular or TREATMENT OF CHLOROSIS. 
949 
" ordinary diets." In such cases no meals should be prescribed and no solid 
food ; but a cup of milk, with a third part of lime-water in it, may be given 
every two hours, prescribed as a medicine, and a pint of beef tea in divided 
doses may be taken as a drink during the day. This diet may be gradually 
added to as the appetite improves. 
Trousseau observes that " there are some chlorotic girls who would rather 
die from inanition than eat ordinary food. We should not hesitate in such 
cases to make those therapeutic concessions which we are so often obliged to 
submit to in the practice of our art. I allow alimentary substances, allowed to 
be very indigestible-caring not for the kind of food so long as it is eaten-as 
radishes, salads, fruits hardly ripe, highly-seasoned sausage meat, old cheese, 
vegetables, meats prepared with vinegar, acid drinks, and the like. All I re- 
quire in this whimsical diet is, that there be sufficient variety. By such means 
we often succeed in rousing the digestive functions, bring back the sensation 
of hunger, and gradually lead the patient to proper food. 
Change of air and bathing will also greatly aid in restoring health. If the 
patient lives in a town, she ought to be sent into the country; and, best of all, 
to the seaside, where sea-bathing may be prescribed, if the strength of the 
patient is sufficient. Should the patient have been living in the country, a 
change of air and scene to a lively town will be no less useful as a remedial 
agent. 
The much be-quacked use of water, in its varied modes of appliance to par- 
ticular cases, will be found a powerful restorative agent, if judiciously used by 
the patient under medical advice. 
Of medicines, the preparations of iron have most reputation. They seem to 
act by promoting the formation of the red blood-corpuscles; and they operate 
best in those cases in which the blood is rich in albumen. They also act as 
stimulants to digestion ; and, from what has been stated at page 945 et seq., it is 
not altogether immaterial which of the numerous officinal preparations of iron 
are to be prescribed. Almost every physician has some preparation of iron 
he fancies better than another; and some of them seem to be aided in their good 
effects by combination with carbonate of potash, such as the sulphate of iron, in 
doses of three to five grains, or of the ferri sulphas exsiccata, in doses of two to 
five grains, prescribed in pills. The use of ferruginous remedies must be per- 
severed in for months, and the general indications for prescribing the prepa- 
rations are the same as those given under anaemia, page 945. In pills, the 
iron preparations may also be combined with extract of nux vomica, or with 
strychnia, in suitable doses ; or the syrup of the phosphates of iron, quinine, and 
strychnia may be given (see page 945) ; or the eliminative action of the colon 
is to be promoted by four grains of the pill of aloes and myrrh taken every 
night at bedtime, or by a grain of the watery extract of Barbadoes aloes with a 
little gingerine as a pill. Simple bitter tonics are useful adjuncts to the 
chalybeate treatment, such as gentian, calumba, and the preparations of cin- 
chona. They aid feeble digestion. 
Where a high degree of serous plethora exists, and produces violent excite- 
ment of the vascular system, palpitation of the heart, and congestion of the 
head, venesection may be practiced. It not only acts as a sedative, but aids 
the radical cure of the disease, inasmuch as it causes the subsequently admin- 
istered ferruginous preparations to be borne more easily. Both general and 
local bloodlettings may be used; but the blood must be taken in small quan- 
tities, a couple of ounces at a time being quite sufficient (Vogel). 
Tartarated iron (Ferrum tartaratum) is also a useful remedy, and may be 
prescribed with alkalies, in doses of six to twenty grains, dissolved in water. 950 
SPECIAL PATHOLOGY-BERIBERI. 
GENERAL DROPSY. 
Latin Eq., Anasarca; French Eq_, Anasarque; German Eq., Wassersucht; Ital- 
ian Eq., Idropisia generate. 
Definition.-An accumulation of serum in the areolar tissue, with or withozd 
effusion into the serous cavities. 
Pathology and Symptoms.-It is a form of extensive or universal oedema, 
and means an infiltration with fluid serum of the general areolar or connec- 
tive tissue of the body, to which the name of anasarca has been given, from 
the Greek ava, "through," and cap%, "the flesh." 
The disease usually begins to manifest itself by oedema of the feet and 
ankles-appearing towards evening, and diminishing, if not disappearing 
altogether, towards the morning. 
Such oedema is known from its "pitting" under pressure-that is to say, it 
retains the impression of the thumb and finger when they are made to grasp 
firmly each side of the ankle over the swollen part. The fluid surrounding 
the ankle may have gravitated there; but by and by, as the morbid condition 
persists, which gives rise to the collection of fluid in the connective tissue, 
the swollen condition extends from the ankles up the limbs, encroaches on the 
abdominal and thoracic parietes, and lastly reaches the head and upper 
extremities. The whole body then exhibits a bloated, turgid appearance, 
sometimes to a very great extent. 
When effusion actually begins in the feet and ankles it is usually the con- 
sequence of extreme debility, with aneemia. But the oedema may be first 
observed in the face, especially about and underneath the eyes. Such a form 
is usual in heart and kidney disease. 
Where the connective tissue is loose, the local swelling from fluid is gener- 
ally the greatest; for example, over the dorsum of the foot and back of the 
hand, eyelids, scrotum of men, and labia pudenda of females. 
The lower extremities are often so enormously swollen as to become shining 
and tense; when the cuticle may rise like a blister, or even giving way, an 
erysipelatous inflammation may pervade the limb. Sloughs are then apt to 
form in the connective tissue; open sores follow and become the outlet of 
excessive discharges of serum, which greatly relieve the patient. 
Sometimes, but not always nor necessarily, the anasarca is attended with 
effusion of fluid into the serous cavities, thereby greatly increasing the danger 
and often proving fatal. 
The emaciation by such cases is often extreme; but is only manifest on the 
anasarca subsiding from any cause. 
Diagnosis.-The progress of general dropsy is as a rule continuous, with 
longer or shorter intervals, when the disease does not seem to advance. It 
may resemble general emphysema, which is distinguished from anasarca by 
its crackling underneath the fingers on handling the parts. 
The Treatment of the disease is regulated by the nature of the disease 
which causes the dropsical state, and will be considered under Heart diseases 
and Kidney diseases. 
BERIBERI. 
Latin Eq., Beriberia; French Eq., Beri-Beri; German Eq., Beri-Beri, Italian 
Eq., Beri-Beri. 
Definition.-A constitutional disease, expressed in the first instance by anaemia, 
culminating in acute oedema, and marked by stiffness of the limbs, numbness, and 
sometimes paralysis of the lower extremities; oppressed breathing (anxietas in 
paroxysms'); a swollen and bloated countenance. The urine is secreted in dimin- PATHOLOGY OF BERIBERI. 
951 
ished quantity. The oedema is general, not only throughout the connective tissue 
of the muscles, but the connective tissue of solid and visceral organs in every 
cavity of the body is bathed in fluid. Effusion of serum into the serous cavities 
very generally precedes death. 
Pathology and Historical Notice.-This obscure but very fatal disease is 
little known to pathologists in this country. Though common in various 
parts of India, the territorial range of its endemic prevalence seems limited 
in a peculiar manner. It has been chiefly met with on the Malabar coast, in 
Ceylon, and in that tract of country reaching from Madras as far north as 
Ganjam (Hamilton). It is principally endemic in that portion of Hindos- 
tan called the Northern Circars-a province lying on the west side of the 
Bay of Bengal, extending from 15° to 20° north latitude. Madras, in north 
latitude 13° 6', appears to be the southern limit of the disease in Hindostan. 
Towards the north of Madras, in the jails of Guntoor, Nellore, Masulipatam, 
Rajahmundry, Vizagapatam, Chicacole, Bellary, and Cuddapah, the disease 
is known to prevail. Towards the south it is never seen. It is said to extend 
from the coast not farther inland than forty to sixty miles. 
It is a disease of a peculiar nature; and it has been extremely frequent 
and fatal amongst all the troops, both Europeans and natives, at Ceylon 
(Christie) ; and although beriberi is a far more common disease among the 
natives of India than among the Europeans, yet the rate of mortality is 
nearly twice as great among Europeans as it is among the natives. Indeed, 
next to cholera, beriberi must be regarded as the most fatal disease ( judging 
of the proportion of deaths to admissions) to which Europeans in India are 
liable (Waring); while Mussulmans appear to be more subject to the disease 
than Hindoos (Malcomson). 
Among European soldiers in India the ratio of mortality or of deaths to 
admissions from beriberi is above 26 per cent., and amongst Sepoys it is 
nearly 14 per cent.; and large as these ratios seem, they are small compared 
with the ratio of mortality which obtains amongst the convicts in the Indian 
jails, where the percentage is as high as 36.5 (Waring). 
A residence of several months in a district where beriberi prevails is neces- 
sary to its development (Christie, Hunter, Evezard) ; and the greatest 
predisposition to the disease exists when troops have been about eight or ten 
months in a settlement. 
The influence of season in promoting the development of beriberi seems to 
be remarkable. Towards the close of the rainy season the admissions to hos- 
pitals are far more numerous than at any other period of the year; damp and 
moisture, combined with cold, seem .very favorable to the production of the 
disease; and the most severe cases at Trincomalee occur during the change 
from wet to dry weather (Ridley), when a strong and hot land wind prevails, 
when the atmosphere is extremely dry, and when the night temperature is 
many degrees lower than that of the day. From August to December, when 
heavy falls of rain occur, with occasional sultry days, and when the alterna- 
tions of temperature are at the greatest, and the exhalations the most concen- 
trated, then the admissions to hospital for beriberi are the most frequent 
(Wright). 
The name Beriberi was given by the Malabar physicians, and has been 
handed down to us by writers on Indian diseases as a name for almost every 
fatal disease of debility; paralysis of various kinds, reflex paraplegia, dropsy, 
anasarca, cachexia, scurvy, and ansemic rheumatism, with various diseases of 
the heart and pericardium, have all at some time been included under the 
common name of beriberi. It is therefore necessary to give to the term some 
degree of precision, by a definition which will embrace the leading phenomena 
of this remarkable disease. 
The majority of the phenomena which characterize the well-recorded cases 
of this disease are undoubtedly referable to anaemia. The debility, the cold 952 
SPECIAL PATHOLOGY-BERIBERI. 
extremities, palpitation, dyspnoea on exertion, frequent, small, and quick pulse, 
the bruit occasionally heard in the neck, the scanty urine, the torpid bowels, 
the deadly pallor of the tongue, all indicate a condition of anaemia (Evezard). 
The disease makes its advances in an insidious manner, as all forms of anaemia 
do, without any primary or well-marked train of symptoms; and the indispo- 
sition appears to be comparatively slight which exists as a stage precursory 
to the visible invasion of the fully expressed disease (Wright, EvezardJ. 
The approach of the final and characteristic features of the disease appears to 
be very gradually brought about, a constitutional state or diathesis is gradually 
established, and a form of anaemia sets in, combined with the cachectic dropsy 
of Andral-a condition allied to that of chlorosis in the female (Evezard). 
Many of the more early observers of the disease concur in regarding the fully 
expressed phenomena of beriberi as the result of exhaustion and debility 
(Farrell, Dick, Ridley). 
Morbid Anatomy.-More or less fluid is found in one or all the cavities of 
the chest; most commonly in the pericardium. The areolar tissue of the 
heart is in some instances loaded with fluid ; and hypertrophy of its substance 
is not unfrequent. The areolar substance of the lungs is loaded with water; 
likewise the substance of the brain. The ventricles contain an increased 
amount of fluid; and fluid is effused over the surface of the brain. 
The abdominal cavity and the general connective tissue of the body abound 
in fluid. In general, it may be said that in every case examined after death 
serous fluid in one or more cavities was found to exist; and the pericardium 
alone, or in conjunction with some other cavity, was the seat of effusion in 
above 83 per cent, of the cases-the quantity of fluid varying from two ounces 
to a pint. The spinal cord is variously altered, either by minute effusion of 
fluid into its substance, or by congestion of its vessels, thereby accounting for 
the phenomena of paralysis. The unsteadiness of gait and the paralysis of 
the lower limbs may be also in some measure explained by the mechanism of 
the spinal canal, combined with the presence of serous effusion in its connective 
tissue. When it is remembered that the spinal cord more completely fills the 
vertebral canal in the dorsal region than it does either above or below, it will 
be understood how symptoms of compression from serous effusion will most 
early manifest themselves by paralysis or unsteadiness of gait in the lower 
limbs. The kidneys have been found enlarged, softened, and ansemic; the 
heart is generally found enlarged, pale, flabby, and softened; the lungs are 
oedematous, and serous effusion into the minute connective texture is the only 
uniform appearance which exists in every case (Waring). 
Symptoms.-Like rheumatism and gout, the disease expresses itself under 
several forms, of which three may be noticed, namely: 
1. The acute, severe, or inflammatory form of this disease is generally the 
culmination of the constitutional and local phenomena in a first paroxysm. 
Numbness, paralysis, and oedema of the extremities are the leading symptoms, 
followed by dyspnoea, and oppression at the prcecordia. For a short time 
previous to any other obvious symptom, the patient, though robust-looking, 
may not have been able to exert himself in consequence of the partial loss of 
the use of the lower limbs. This rapidly increases, till he finds that there is 
inability to walk, accompanied with oedema of the extremities, which very 
soon passes into general anasarca, affecting the innermost recesses of the tex- 
tures-if such an expression may be permitted. Febrile symptoms are associ- 
ated with this acute or arterial anasarca. The skin is hot and dry, the urine 
is scanty and high-colored, the bowels are costive, and the stomach irritable. 
There are rapid and full pulsations of the large arteries, while the pulse may 
be variable at the extremities, accompanied generally with dyspnoea and 
symptoms of effusion within the chest. In other cases there may be headache, 
restlessness, and delirium, with a slow and full pulse, indicating serous effusion 
and pressure on the brain. When the oedema is general, and becomes rapidly SEVERAL forms and symptoms of beriberi. 
953 
developed, the condition of the blood is changed from its anaemic character. 
It becomes dark and ropy, resembling in some degree the appearance of the 
blood taken from a patient affected with cholera (Wright). 
2. In the second, the asthenic, or chronic form of beriberi, the patient is very 
often more or less worn out by some previous disease; or he may have had a 
previous acute attack of beriberi, of which there may be a relapse; and it 
appears that men in whom the disease has once manifested itself are the more 
subject to future attacks (Christie), for it is found that one attack predisposes 
to another (Wright) ; and then the dropsical symptoms more generally re- 
semble those observable after protracted fevers or other debilitating causes. 
Abdominal dropsy is most prevalent, accompanied with symptoms of general 
relaxation-a small and quick pulse, constipated bowels, scanty urine, loss of 
appetite, universal oedema, much pitting on pressure, and paralysis of the ex- 
tremities. 
The heart partakes of the general debility. It is flabby, and the venous 
circulation becomes retarded. Soon, perhaps, it dilates, when a temporary 
bellows-sound may be heard. After several such attacks and recoveries the 
heart becomes thickened, and hence we have the post-mortem appearance 
of either a large and flabby heart, or of one eccentrically hypertrophied (Eve- 
zard). 
3. In the third and mildest form of the disease the patients are first attacked 
with some stiffness or rigidity of the legs and thighs, succeeded by numbness, 
slight oedema, and sometimes paralysis of the lower limbs. The oedema is in 
general limited, with slight pitting on pressure. There is no unnatural heat 
of skin ; the pulse is seldom above the natural standard ; the urine is scanty; 
and the appetite unimpaired. There may be occasional palpitations of the 
heart, with costiveness, blanched conjunctivae, flabbiness and paleness of the 
tongue, and whiteness underneath the nails. Although such patients gener- 
ally say that they are well, they will sometimes acknowledge a slight feeling 
of numbness and coldness of the extremities-symptoms which would readily 
disappear under appropriate treatment; but after a close night, with either a 
fog or a shower of rain, such a patient would apply for medical aid in the 
morning, with a scared aspect, sighing, breathing, violent palpitation of the 
heart, sometimes with a diffused impulse, pain in the prsecordial region, and 
a variable fluttering pulse. In such cases there are also dyspeptic symptoms, 
with acid eructations and puffiness of the stomach. The scanty and high- 
colored urine has an acid reaction when voided, shows a specific gravity of 
from 1025 to 1040, and contains an excess of urea. It is such cases which 
are apt suddenly to become aggravated, and to pass into the acute form of the 
disease. The oedema then progresses from the lower limbs to the hands; the 
throat becomes swollen, anol the face bloated. A sense of numbness is expe- 
rienced round the mouth, and a general sense of numbness is experienced all 
over the body, particularly over the extremities, which appear to be unusually 
weighty and rigid (hence, when walking, the gait is unsteady). The urine, 
secreted in diminished quantity, is extremely hot when passing through the 
urethra; and as the disease progresses, a total suppression of the urine gen- 
erally takes place. A sense of pain and tightness is felt immediately beneath 
the inferior edge of the sternum, which sometimes becomes so distressing as 
to induce the patient to solicit that the part may be cut open, hoping to re- 
lieve the tightness by that means. (Dyspnoea becomes so urgent as to prevent 
the patient from lying down ; heavy sighing (suspirous breathing} occurs, with 
great anxiety and restlessness. The lips and tongue may now be seen to be 
livid, and the extremities become cold ( Ridley). / 
Universal debility, extreme prostration, anxiety, dyspnoea, numbness, oedema, 
anasarca, and paralysis, are the most characteristic phenomena of the disease. 
And in some instances, when those phenomena are fully expressed, the advent 
of the fatal event is so rapid that the patient may die within six, twelve, 954 
SPECIAL PATHOLOGY-BERIBERI. 
twenty-four, or thirty-six hours;' and in other instances the disease is more 
frequently prolonged over several weeks. Death is in some cases extremely 
sudden ; and from the anxietas, and the fact that obstructions sometimes occur 
in the veins (Evezard), it is not improbable that death in such instances may 
be due to embolism. 
Mr. Ridley especially notices the suddenness of dissolution in most of the 
cases which he observed among the troops in garrison at Ceylon in 1814. 
" Very frequently, when speaking to one man," he says, " I have been called 
to another, whom I had just before left under promising circumstances, and 
have found him gasping, his eyes protruding, his hands clenched; and in a 
few minutes he was dead ; and it has sometimes happened that the man I was 
addressing has been taken off in the same manner" {Dublin Hosp. Reports, 
vol. ii, p. 234). 
It is clear, therefore, that the disease cannot be referred to granular disease 
of the kidney with albuminuria, although albumen is sometimes present in 
the urine in a high degree, as Dr. Ranking attempts to show; nor yet with 
scurvy, as Dr. Morehead teaches. It seems rather to be a constitutional dis- 
ease sui generis. 
Causes.-The etiology of beriberi is but little known; but there are two 
points that seem well established in the history of the disease, and which must 
have a prominent recognition in all investigations relative to the causes which 
develop the disease. These points are,-First, The limited geographical range 
of beriberi; Second, The fact that the morbid train of phenomena is never 
developed till the patient has resided upwards of eight or twelve months in 
the settlement where the disease is endemic. 
Malaria, alternations of climate and temperature, noxious material in the 
waters of districts, have all been indicated as operative agents in bringing 
about the disease. But, looking to the fact that all the phenomena of the 
disease point to anaemia, it may be generally stated that whatever tends to 
induce this state will favor the development of beriberi. Accordingly, the 
disease will owe its origin in one place and in one person to the operation of 
a series of conditions which may not obtain in another place and with another 
person. 
Mr. Christie found in Ceylon that the aged and debauched were those most 
liable to the disease. A great proportion of his patients were men accustomed 
to lead a sedentary and debauched life, such as soldiers, tailors, shoemakers, 
and the like; who, working at their trade, were often excused military duty, 
and who, by double earnings, were able to procure a larger quantity of spirits 
than other men. 
With regard to oedema there is a great tendency, in almost every disease 
in Europeans, to result in serous effusions, after long residence in India. 
Indeed, Sir Ranald Martin observes, in his admirable introductory chapter 
to the second part of his great work on the Diseases of Tropical Climates, that 
of all conditions incident to tropical invalids, anaemia is the most common. 
With regard to some places-such, for example, as Masulipatam (where beri- 
beri abounds, in the jails especially)-it has been observed by Mr. Evezard 
that oedema is frequently one of the latest symptoms of anaemia outside the 
jail. He also observes that ansemia appears to be almost the normal state 
of about the third of the population, particularly the higher castes-a cir- 
cumstance which he states is partly due to the constitution of the Telugoo, 
and partly to the eliminating power of the drinking-water, which contains so 
much of chlorides and no iron. The natives are well aware of the effects of 
the brackish water which the majority of them are obliged to drink at the 
end of the rainy season, and when they find themselves suffering from the 
ansemia, they procure water from Goodoor, a village about six miles due west 
of Masulipatam. The water at Masulipatam seems to abound in saline ma- DIAGNOSIS AND PROGNOSIS OF BERIBERI. 
955 
terial, such as chlorides, lime, magnesia, and a trace of alumina and iron, in 
the form of a carbonate (Evezard). 
The sanitary condition of prisoners in jails is, it is presumed, much worse 
than the free population outside. The criminals in the jails of India have 
just sufficient food to keep them alive, and scarcely variety enough. They 
have not sufficient food to store up for fat or warmth, and none of those 
luxuries which are supposed to check waste of tissue, such as tea, coffee, 
tobacco, betel, and the like; and they have not sufficient clothing, many of 
the prisoners having only one cloth. Mr. Evezard, however, considers that 
the persistence of the anaemic state is more due to the damp and foul atmos- 
phere of unventilated cells than to food. The soil is for the most part salt. 
The water of the tank in the jail compound is salt, and its recession leaves a 
wide margin of saline substance in the soil, which reattracts moisture like a 
cloth that has been wetted in sea-wTater, and which afterwards retains and 
absorbs the moisture. The chunam and mud of the jail walls, and the walls 
of the cells too, are salt, and in the morning they may be seen dripping with 
moisture, even in the dry season. 
Since improvements have been made in drainage, and since the introduc- 
tion of a mass of iron, which is allowed to rust and corrode, into each chatty 
of water used by the prisoners for drinking and cooking, not a single case of 
beriberi has occurred during the wet season. It is lying on the wet ground 
in wet weather which, Mr. Evezard believes, brings on beriberi among Sepoys 
who have previously rendered themselves predisposed by voluntary starva- 
tion. 
Under conditions such as these, it is not difficult to understand how a state 
of ill-health is insidiously established; during which period some inbred morbid 
material is developed in the constitution, which at last produces the phenomena 
of beriberi when certain endemic circumstances favor the full expression of 
the disease. 
Diagnosis.-The most uniform phenomena in the fully expressed disease is 
the characteristic numbness of the surface generally, and the paralytic affec- 
tions of the lower extremities which accompany all the forms of the disease. 
The disease has been confounded with the barbiers-a chronic disease in 
which paralysis, tremors, spasms, contractions of the limbs, and emaciation 
are the most remarkable symptoms. Some, however, are inclined to regard 
the acute or first form described as the true beriberi, while others consider 
the second form described as the disease known by the name of barbiers. It 
is admitted, however, that the one is often associated with the other, either 
of them being the primary affection, for cases commencing in the form of 
barbiers often suddenly take on the more fatal and acute form of beriberi, 
while the latter frequently presents the symptoms characteristic of the former 
(Malcomson). The two classes of cases prevail in the same places, seasons, 
and circumstances, and require the same treatment. It is, therefore, more 
consistent to consider the disease under the three forms described in the 
text. 
The Prognosis is generally unfavorable, the disease approaching insidi- 
ously, the anaemia and constitutional state having often advanced so far as 
to be beyond the reach of repair. A temporary recovery may be established, 
but relapses are frequent and convalescence is lingering. A first attack 
generally leaves unpleasant phenomena behind. In the case of Mr. Ridley, 
a surgeon of the Royal Artillery, who wrote an excellent account of the 
disease as he saw it in Ceylon, and who suffered from it himself, the memory 
became considerably impaired, and an extraordinary fluttering of the heart, 
almost producing faintness, occurred at intervals after convalescence was 
established. Violent palpitation succeeded, which, on subsiding, left extreme 
lassitude and faintness; and when these phenomena first occurred, a violent 
beating of the carotids came on; and when this rapid pulsation ceased, he 956 
SPECIAL PATHOLOGY-BERIBERI. 
was left so extremely weak and languid as to excite considerable apprehension 
of a fatal result. 
In all cases of beriberi a suddenly fatal result may be apprehended at any 
period after the full expression of the phenomena, probably from embolism or 
cardiac affection. The symptoms which denote danger are general oedema, 
much anxietas, and palpitation of the heart, the respiration becoming more 
quick as the fatal termination approaches. It is labored, quick, and inter- 
rupted with sighs and groans, the pulse becoming weak and irregular at the 
extremities, with palpitations of the heart. If coma or delirium supervene, 
a fatal event may be expected. Much nausea, obstinate costiveness, a dry 
and black tongue, are all symptoms of danger. The prognosis is more favor- 
able if the oedema sets in very gradually, and is confined to the lower limbs, 
when the skin is moist and moderately warm, when the patient enjoys sleep, 
and when the principal natural functions are unaffected. 
Treatment.-Bleeding has been considered applicable to those cases where 
there is extreme difficulty of breathing and delirium, when the patient is 
robust, and when the oedema does not pit much on pressure, where there is 
rapid and full pulsation of the large arteries, and if the urine shows the ex- 
istence of albumen (Wright); but, judging from the pathology of this dis- 
ease, the constitutional influence of stimulants, of generous diet, and of tonics, 
ought undoubtedly to be the basis of treatment. Should there be irritability 
of the stomach, the effervescing draught with doses of laudanum and camphor 
mixture are useful. Saline drinks should be administered, and the extremi- 
ties should be rubbed with stimulating liniments, and rolled in flannel band- 
ages. In the asthenic or chronic form of the disease, the strength must be 
supported by the most nourishing diet that can be given in small bulk, aided 
by tonics, and wine if necessary; while doses of equal quantities of squill 
and digitalis (ten to fifteen drops of each) may be given twice or thrice daily. 
In the third and mildest form a native remedy called Treeak Farook is very 
useful. The ingredients of this medicine are unknown; but it professes to 
be the " Theriaca Andr omachi" of old writers. It is prepared in Venice, 
and transmitted to India through Arabia, and was first recommended by 
Dr. Herklotts, of the Madras Presidency, as a remedy in beriberi. It is a 
thick extract (in which some terebinthine material largely enters), which is 
only to be procured from the Moghuls, and in those towns which still keep 
up some communication with the Arabian Sea. Many observers bear testi- 
mony to its good effects in removing the oedema and subduing the pulse 
(Wright, Traill, Geddes, Malcolmson). In some recorded cases the 
pulse has fallen in four days from 108 to 84 beats per minute under its use. 
The prescription most approved of consists of pills of the following in- 
gredients : 
B. Treeak Farook, ^ss.; Pulv. Rhei., Jiiss.; Confectio. Aromat., Jss.; Meilis 
9, S., misce, et divide in pill xlviii (Malcolmson). 
The electuary form is also much used in India. The remedy does not seem 
to be an active medicine, except in combination. Four or five stools are ob- 
tained daily under its use, and its action is not accompanied by any violent 
purging, increase of pulse, or determination to the surface; and after it has 
been used from one to two weeks, the oedema generally disappears, when the 
numbness and paralysis subside. If it purges, the quantity of rhubarb must 
be diminished. 
The patient should feed on animal food, wheaten cakes, and milk. 
In instances where the native remedy has failed to produce a beneficial 
effect, nux vomica has been more successful, commencing with doses of two 
grains daily, and increasing the dose gradually according to the physiological 
result. The extract of nux vomica, in doses of half or a quarter of a grain, 
combined with iron or gentian in a pill, is the most convenient form. INFLUENCE OF FOOD ON SOME DISEASES. 
957 
Local abstractions of blood from the spine have also proved useful; and a 
blister applied over the loins has given relief in many obstinate cases. 
No single rule of treatment will apply in all cases. The anaemic condition 
must be counteracted, on the principles of treatment explained under that 
disease; and any specially abnormal state, such as diseased heart, must be 
treated accordingly. 
When the disease prevailed very generally in the Carnatic, in 1782, and 
1783, the cases were most successfully treated by a pill containing a quarter 
of a grain of extract of elaterium, combined with extract of gentian, given every 
hour until copious watery evacuations were procured; and this plan was 
repeated every third or fourth day till a cure was accomplished. At another 
time this plan of treatment was not so successful; the cases recovering best 
under large doses of spirits of nitre, antimonial wine, frictions with warm 
camphorated oil, aperient medicines, wine, and a nourishing diet. 
Mr. Evezard's method of medicinal treatment consists mainly in the ad- 
ministration of acetate of potash in gin, in the following formulse: 
B. Gin, ^ss.; Potass. Acet., gr. v; Aquse, ^iii; misce. To be given three 
times a day. If vomiting persists, Hydrocyanic Acid may be useful in 
relieving it; to the extent of one drop three times a day, given in milk. 
CHAPTER XII. 
INFLUENCE OF FOOD ON SOME CONSTITUTIONAL DISEASES DESCRIBED IN 
THE PREVIOUS CHAPTER. 
Rightly to understand the nature of many of the diseases of a constitu- 
tional kind which have now been considered, it will be necessary here to 
review to some extent the influence and effects of certain kinds of food on the 
human frame. Combined researches in chemistry, physiology, and pathol- 
ogy, during recent years, have cleared up much that was doubtful, and 
established certain principles on which proper scales of diet may be founded, 
so as to maintain the health of the body under a great variety of conditions 
as to labor, confinement, freedom, and exercise. Statistics have shown more 
decidedly now than hitherto how intimately disease and mortality are as- 
sociated with the supply of food to the people. The records of the Registrar- 
General of England, and those of Sir William Wilde in Ireland, the evidence 
of the Commissioners relative to the supplies in the Crimea during the war 
against Russia in 1854, 1855, and 1856, and many valuable reports relative 
to the health of the Navy before and after their diet was changed, fully sub- 
stantiate these statements. 
While physicians were well aware of the intimate connection that existed 
in a general way between food and disease, it is due to the labors of chemists 
and physiologists especially that this connection has been reduced to an in- 
telligible form, and that the principles which they have established are now 
put to a practical use. 
The great fact which recent chemical and physiological investigations have 
established may be expressed thus: " That the various alimentary substances 
made use of by man and animals contain at least four classes of constituents, 
each of which performs its oivn assigned function in the living animal economy. 
If the substance contains nitrogen, it seems most fitted for the nourishment of 
tissue, and has been called plastic or nitrogenous; if it is deficient in nitrogen, 
and has an excess of carbon or hydrogen, it appears to undergo combustion in the 
body, and is called a non-nitrogenous or a respiratory element of food fhydro- 958 
SPECIAL PATHOLOGY-FOOD AND DISEASE. 
carbons); if it is fatty in its nature, it performs the double duty of maintaining 
animal warmth, and of assisting in the assimilation of nitrogenous compounds; 
and, lastly, if it is saline in its quality, it goes to build up the solid textures of 
the animal frame, and aids the important work of carrying new materials into 
the system, and old or effete matter out of it" (Letheby). Man and animals 
cannot maintain health if their food does not contain all of these constituents; 
and common instinct, with experience, tells us that these classes must be as- 
sociated in due proportions, under a variety of modifying circumstances. 
There are undoubted habits of feeding which, while they appear to be dictated 
by common instinct, are also sanctioned by science. For example, white meat 
being deficient in fat, bacon is eaten with veal and with fowl; melted butter 
is used with fish; eggs and butter are mixed with sago, tapioca, and rice; 
cheese is eaten with maccaroni; salads and vinegar are eaten with cold or 
salted meat; a vegetable is mixed with an animal diet; bread is eaten with 
butter, bacon with greens, pork with pease pudding, and so on. Old habits 
and instincts not only declare that these combinations are compatible, but 
Science informs us now why such combinations are demanded for the main- 
tenance of health; and when they cannot be obtained, health is endangered, 
the constitution is gradually altered, temperament is modified, life is short- 
ened, families extinguished, armies are swept from their encampments, and 
races of men from the face of the earth. 
The experience of Dr. Christison (who has paid great attention to this sub- 
ject for the last twenty-four years) has shown,-(1.) That the most successful 
dietaries for bodies of men, deduced from practical observation, contain car- 
boniferous and nitrogenous food in proportion of about three of the former to 
one of the latter by weight. (2.) That while nitrogenous may replace carbon- 
iferous food for supporting respiration, though at a great loss, carboniferous 
food (without nitrogen) cannot replace nitrogenous food for repairing textu- 
ral waste. (3.) The daily amount of nutritive principles of both sets must 
increase with exercise and exposure, otherwise the body quickly loses weight, 
and ere long becomes diseased. If the above proportion between the two sets 
be maintained, the weight of real nutriment per day varies, for adults at an 
active age, between seventeen and thirty-six ounces; the former being enough 
for prisoners confined for short terms, the latter being required for keeping up 
the athletic constitution, or that which is capable of great continuous muscu- 
lar efforts. (4.) Dietaries ought never to be estimated by the rough weight of 
their constituents, without distinct reference to the real nutriment in these, as 
determined by physiological and chemical inquiry. 
Dr. Clymer gives the following summary of results from Parkes, Panum, 
and Ranke: 
"A man of average size and activity will, under ordinary conditions of 
moderate work, take in twenty-four hours from 2gth to ^-oth of his own weight 
in solid and liquid food; of so-called solid food (bread, meat, &c.), about 40 
ounces (f. e., with an average range of from 34 to 46 ounces), and of water 
from 50 to 80 ounces ; making in all from 80 to 120 ounces by weight of in- 
gesta. The rate of the solid to the liquid food greatly varies; in most cases 
it is 1 to 2, but in some only 1 to 1. Much bodily activity requires a large 
increase in the solid, but less in-the liquid food. But as the so-called solid 
food contains a certain percentage of water, if we consider only the water- 
free food, the average amount in the twenty-four hours for healthy men will 
be, water-free food 22 to 23 ounces, water 60 to 90 ounces. The relative amount 
of the water-free food to water is usually as 1 to 4 or 1 to 5. Assuming the 
average to be 23 water-free ounces daily, and the mean weight to be 150 lbs., 
the body receives j-J-g-th of its own weight in water-free solids. The range in 
different persons is g^th to jf^th of the body-weight. Each pound weight of 
the body receives about 0.15 ounces (range from 0.1 to 0.2 ounces) of water- 
free food, and 0.5 ounces by weight of water in twenty-four hours, the amount RELATION OF FOOD TO BODY-WEIGHT. 
959 
differing in rest and activity. The following tablb gives the average amount 
for men of mean height (5 feet 6 to 5 feet 10) and weight (140 to 160 lbs.) 
under different conditions of activity." 
" A man will take on an average in twenty-four hours: 
Water-free food in 
Water in 
ounces avoir. 
ounces. 
When nearly at rest, .... 
18.5 
70 to 90 
When in moderate and usual exercise, 
23 
70 to 90 
Under great exertion, .... 
. 26 to 30 
C 80 to 100 
I or more. 
Undergoing enormous exertion, 
130 to 36 1 
' ' ( or even 40 J 
Uncertain. 
" Much depends on the kind and digestibility of the food ; a larger quan- 
tity of indigestible food being taken, much passing undigested by the bowels. 
Of the water about fths or 4-ths is taken as water; the rest is water in the 
so-called solid food. A man's food must be increased in proportion to the 
work ; if not, one of two results follows: his usefulness as an agent of force 
lessens, being unable to do all his work; or he continues his work at the ex- 
pense of his tissues, his weight decreases, and morbific causes act upon him 
more easily." 
" The phenomena of nutrition are owing to the various chemical inter- 
changes of nitrogen and carbon, with the concurrent influences of oxygen 
and hydrogen (chiefly though not entirely in the form of water) and of va- 
rious salts. A man of mean weight, height, and activity, requires in twenty- 
four hours,- 
Nitrogen, about, ....... 250 to 350 grains. 
Carbon, " ...... 3500 to 5000 grains. 
Salts, not fixed, ....... 400 
"According to Ranke's experiments, the relative amount of nitrogen and 
carbon during rest and during activity was 1 N to 11 C, and 1 N to 15 C. 
On an average about |ths of the carbon are given in the starches and fats, 
and ^th in the albuminates. When we speak of nitrogenous and carbonifer- 
ous food, the proportions come out differently. One part of nitrogenous food 
to from 3 to 6 parts of carboniferous (1 to 4 being the mean) forms the usual 
proportion in apparently all nations (Parkes). 
" The histogenetic nature of food must be determined by direct physiological 
investigation, which should show comparatively the different influence of ali- 
ments upon the metamorphosis of matter in the essential animal tissues. 
"Professor Panum, of the University of Copenhagen, recently instituted a 
series of experiments to ascertain the degree of accuracy with which it is possible, 
by quantitative determinations of urea, to discover hoiv much albumen an indi- 
vidual can actually appropriate, digest, and decompose from an indefinite quantity 
of food, consisting solely of albuminous matter and water. His experiments were 
made on a dog, and he chose the purest albuminate which can be produced in 
the pure state,-the gluten of wheaten meal. The proportion between the dry 
albuminate taken and the urea produced was strikingly constant, being, in 
full feeding, 1 : 4.35; in medium feeding, 1 : 3.58; and in slight feeding, 
1 : 2.81. 
"Professor Panum also conducted a series of experiments with a view to 
the solution of the practical question, whether the production of urea can serve 
also as a measure of the histogenetic nutritive value of such foods as along with 
albuminates contain carbo-hydrates or fat in any considerable quantity? It 
would appear upon the whole that 1550 grains of starch with 500 grains of 
butter diminished the production of urea tolerably equally by about 31 grains, 
corresponding to about 172 grains of dry'albuminous matter." 960 
SPECIAL PATHOLOGY-FOOD AND DISEASE. 
Approximately, it may be concluded that a full-grown man of average 
weight (140 to 150 lbs., and height 5 feet 7 inches) requires one-twentieth part 
of his weight in food during the twenty-four hours; that is, seven or seven and 
a half pounds of food, including solids and liquids; one to one and a half pounds 
(16 to 24 ounces) being solids, the rest water (Parkes). 
On an average, it is found that a man requires four or five ounces of chemi- 
cally dry nitrogenous food daily;-that in a state of rest he will require 
three and a half ounces; under a state of considerable exertion five and a half 
ounces; and under extraordinary exertion he may require as much as six and 
a half or even seven ounces of dry nitrogenous aliment daily. The quantity of 
hydro-carboniferous aliment required to keep a man in health cannot be 
less than from fourteen and a half to fifteen ounces in twenty-four hours; and 
even nineteen to twenty-hvo ounces under great exertions. The amount of 
fatty matters ought to equal about half the quantity of the nitrogenous 
aliment. But in a state of rest about one ounce in the twenty-four hours will 
be sufficient; while under great exertion two and a half ounces may be required 
daily. The amount of water required varies from seventy to one hundred and 
thirty ounces; and the salts supplied in the food should amount to from half 
an ounce to an ounce daily, consisting of chloride of sodium, chloride of potas- 
sium, salts of lime and magnesia, carbonates, citrates, lactates, and acetates 
(Parkes). 
To determine by calculation the amount of these different aliments, and 
therefore the nutritive value of a given diet, the following scale is given 
(Table I). It shows the mean amount of water, nitrogenous substances, fat, 
and carbo-hydrates-starch and sugar-which ought to be contained in 100 
parts of each of the substances in common use mentioned in Table I.* 
Table I.-Nutritive Value oe Foods in 100 Parts (Parkes). 
Water. 
Nitrogenous 
Substances. 
Fat. 
Carbo-hydrates, Starch, 
and Sugar. 
Meat without Bone,f .... 
74 
16 
9 
- 
Fat of Meat,| 
63 
14 
14 
- 
Bread of average quality (White 
Wheaten), 
40 
8 
1.4 
51 
Starch, 
- 
- 
- 
100 
Fat, 
- 
- 
100 
240 of Starch. 
Pease, 
15 
24.4 
2.6 
49 
Potatoes, 
74 
1.5 
0.6 
29 
Bice, 
10 
3 8 
0.8 
85.2 
Milk, 
87 
4 3 
3 7 
52 
Maize (after Pozziate),. . . . 
13.5 
9.9 
6.7 
64.5 
" ( " Von Bibra), . . . 
10 6 
15.09 
3.8 
67.46 
It is important to bear in mind that the amount of nitrogen, carbon, hydro- 
gen, and salts, should not alone be considered in calculating the value of diet. 
The form in which these elements exist is equally important. The fats and 
starches are not interchangeable, and should not be confounded under the 
common head of carboniferous. The mean amount of the four classes of solid 
aliments had been calculated by Dr. Lyon Playfair,- On the Food of Man in 
Relation to his Useful Work, Edinburgh, 1865-from many diets, and is given 
in Table IV. 
* This table is used by Dr. Parkes in the Laboratory of the Army Medical School, 
and he kindly permits me to give it here. 
f The mean of usual statements. 
j Calculated by Dr. Parkes from the statements of Lawes and Gilbert. DIETARIES AND THEIR NUTRITIVE VALUES. 
961 
The following very interesting tables (II, III, and IV) of dietaries and their 
nutritive values, and of the nutritive values of foods, by Dr. Letheby and Dr. 
Lyon Playfair, are given here to show the actual proportions in which various 
substances used as food are associated in the several public dietaries of the 
country, and as a guide to the student of medicine when, as a practitioner, it 
may often be his lot to devise and construct scales of diet suited to various con- 
ditions of existence. 
The calamities which happened to our soldiers in the Crimea (in 1854) 
show that the dietaries of working men cannot be safely reduced below the 
physiological standard; and, in the words of Dr. Christison, "any person con- 
versant with the science of the present subject could have foretold, as a certain 
consequence, sooner or later, of their dietary, that the British troops would 
fall into the calamitous state of health which befell them in the Crimea." 
In cases where preserved food must be used for want of fresh food, there are 
difficulties to be overcome which experience and science have made to disap- 
pear in a great measure. It is known that salt meat has a tendency to engender 
disease, and to favor the development of disease under certain circumstances; 
but it is not known, either physiologically or chemically, what is the exact 
nutritive value of salt meat in a scientific point of view. There are three 
circumstances connected with its use which tend to diminish its value as an 
article of diet, namely,- (1.) The investigations of Liebig demonstrate that 
the process of salting meat is very improper, for the brine extracts the juices 
of the flesh, and so removes most of the important constituents. (2.) The salt 
Table II.-i 
■Dietaries and their Nutritive Values (Letheby). 
Diets. 
Weekly Consumption in Ounces. 
Daily Ditto. 
Bread 
or 
Biscuit. 
Meat. 
Potato. 
Meal, 
&c. 
Milk. 
Cheese. 
But- 
ter. 
Car- 
bonif- 
erous. 
Nitro- 
genous. 
Total 
solid 
Nutri- 
ment. 
Physiological 
140 
84 
3.5 
12.7 
4.0 
16.7 
Prison Punishment 
E. County & Borough Jails- 
112 
8.2 
1.4 
9.6 
Under 7 days 
121 
23 
39.5 
12.4 
2.2 
14.6 
Not hard labor 
172 
7.8 
3.2 
22.8 
15.4 
3.5 
15.7 
3.1 
18.8 
Hard labor 
Scotch Prisons- 
163 
14.6 
63.4 
27.2 
41.6 
1.5 
18.2 
3.5 
21.7 
Under 3 days 
112 
28 
11.2 
1.9 
13.1 
Not hard labor 
30 
7.5 
152 
73 
175 
19.0 
3.4 
22.4 
Hard labor 
Irish Prisons 
76 
10 
176 
100 
175 
27.0 
4.5 
31.5 
Under 1 month 
56 
192 
70 
70 
19.5 
2.9 
22.4 
Not hard labor 
56 
192 
60 
170 
20.5 
3.4 
23.9 
Hard labor 
Military Prisons- 
64 
219 
70.5 
170 
22.0 
3.6 
25.6 
Under 84 days 
56 
119 
210 
22.2 
3.8 
26.0 
Over 84 days 
56 
168 
210 
27.8 
4.7 
32.5 
Destitute Debtors 
156 
16 
52 
22 
21 
16.3 
3.1 
19.4 
Convict Prisons 
161 
36 
112 
12 
12.8 
18.4 
3.6 
22.0 
Unions (Adults) 
112 
15.5 
51 
17 
34 
5.2 
i.l 
14.2 
2.8 
17.0 
Unions (Children) 
90 
14 
32 
105 
3.5 
11.1 
2.3 
13.4 
Lunatic Asylums 
114 
23 
68 
16 
14 
7 
1.3 
13.2 
4.0 
17.2 
Public Hospitals 
Army- 
93 
52 
56 
14 
7 
3.2 
12.1 
3.5 
15.6 
Crimea 
112f 
112 
14.5 
4.8 
19.3 
Home 
168 
84 
112 
19.4 
4.8 
24.2 
Madras 
112 
112 
56 
4* 
16.5 
4.9 
21.4 
Bombay 
140 
112 
56 
56* 
22.2 
5.6 
27.8 
Field (India) 
168 
168* 
30.7 
3.8 
34.5 
Navy 
112f 
112 
56 
17.7 
5.0 
22.7 
iNavigator (Crimea) 
140 
140 
28 
17.8 
6.2 
24.0 
iNavigator (Home) 
Berwickshire Laborer 
320 
96 
64 
12 
4 
18.6 
7.7 
26.3 
122 
224 
224 
37.1 
7.0 
44.1 
Yorkshire Laborer 
280 
126 
28 
210 
49 
42.2 
8.8 
51.0 
In this table only the most important articles of diet are mentioned, although the others, excepting 
beer, spirits, tea, and coffee, are calculated in the daily consumption. (*) are rations of rice, and (f) are 
of biscuit. Gruel is calculated at the rate of two ounces of meal per pint. 
J A name given to those laborers who are employed in excavating, and such like laborious work, chiefly 
connected with the construction of railways. They are also sometimes called " navvies." 962 
SPECIAL PATHOLOGY-FOOD AND DISEASE. 
Table III.-Nutritive Value of Foods (Letheby). 
Substances, 100 Parts. 
Water. 
Fibrin, 
Albu- 
men, &c. 
Starch, 
Sugar, 
&c. 
Fat. 
Salts. 
Carbon- 
iferous. 
Nitro- 
genous. 
Total 
Nutri- 
ment. 
Human Milk 
89 
3.5 
4.2 
3.0 
0.2 
11.4 
3.5 
14.9 
Cows' Milk 
86 
4.5 
5.0 
4.1 
0.7 
14.8 
4.5 
19.3 
Skimmed Milk 
87 
4.5 
5.0 
2.7 
0.7 ' 
11.5 
4.5 * 
16.0 
Buttermilk 
87 
4.5 
5.0 
0.5 
0.7 
6.0 
4.5 
10.5 
Beef and Mutton 
73 
19.0 
5.0 
2.0 
12.0 
19.0 
31.0 
Veal 
77 
19.0 
1.0 
0.6 
2.4 
19.0 
21.4 
Poultry 
74 
21.0 
3.0 
1.2 
7.2 
21.0 
28.2 
Bacon 
20 
0.8 
70.0 
1.3 
168.0 
0.8 
168.8 
Cheese (Chedder) 
36 
29.0 
30.0 
4.5 
72.0 
29.0 
101.0 
" (Skimmed) 
44 
45.0 
6.0 
5.0 
14.4 
45.0 
69.4 
Butter 
15 
83.0 
2.0 
199.0 
199.0 
Eggs 
74 
14.0 
10.5 
1.5 
25.0 
14.0 
39.0 
White of Egg 
78 
20.0 
1.6 
20.0 
20.0 
Yolk of Egg" 
52 
16.0 
30.6 
1.3 
72.0 
16.0 
88.0 
White Fish 
79 
19.0 
1.0 
1.2 
2.4 
19.0 
21.4 
Salmon 
78 
17.0 
4.0 
1.4 
9 6 
17.0 
26.6 
Eel 
80 
10.0 
8.0 
1.3 
19.2 
10.0 
29.2 
Wheat Flour 
15 
11.0 
70.0 
2.0 
1.7 
. 74.8 
11.0 
85.8 
Barley-meal '.. 
15 
10.0 
70.0 
2 4 
2 0 
75 8 
10.0 
85.8 
Oat-meal 
15 
12.0 
62.0 
6.0 
3.0 
76.4 
12.0 
88.4 
Rye-meal 
15 
9.0 
66.0 
2 0 
1 8 
70 8 
9.0 
79.8 
Indian-meal 
14 
9.0 
65.0 
8.0 
1.7 
84.2 
9.0 
93.2 
Rice 
14 
7.0 
76.0 
0 3 
0.3 
76.7 
7.0 
83.7 
Haricot 
19 
23.0 
3 0 
3.6 
52 2 
23.0 
75.2 
Pease 
13 
22.0 
58.0 
2.0 
3.0 
62.8 
22.0 
84.8 
Beans 
14 
24.0 
44.0 
1.4 
3.6 
47.4 
24.0 
71.4 
Lentils 
14 
29.0 
44.0 
1 5 
2.3 
47.6 
29.0 
76.6 
Wheat Bread 
44 
9.0 
49.0 
1.0 
2.3 
51.4 
9.0 
60.4 
Rye Bread 
48 
5.0 
46.0 
1.0 
1.4 
48.4 
5.3 
53.7 
Potatoes 
74 
2.0 
23.0 
0.2 
0.7 
23.5 
2.0 
25.5 
Green Vegetables 
86 
2.0 
4.0 
0.5 
0.7 
5.0 
2.0 
7.0 
Arrowroot. 
18 
82.0 
82.0 
82.0 
In this table the carboniferous matter is calculated as starch; 10 of fat being equal to 24 of starch. 
Table IV -Amount in Ounces (Avoir.) and Tenths of Ounces for Male 
Adults (Playfair). 
Subsistence Diet- 
i. e., sufficient for 
the mechanical 
force necessary 
to carry on the 
internal work of 
the body. 
Diet in 
quietude. 
Adults 
in full 
health, 
but with 
easy work. 
Adults 
in 
active 
Work. 
Adults 
in 
laborious 
work. 
Nitrogenous Substances,. . . 
2. 
2.5 
4.2 
5.5 
6.5 
Fat, i 
0.5 
1. 
1.4 
2.5 
2.5 
Starch, 
12. 
12. 
18.7 
20. 
20. 
Mineral Matters, 
. . . 
.71 
.9 
. . . 
Carbon (total), 
6.7 
7.4 
11.16 
13.7 
14.3 
meat for the navy and for soldiers in the field is always highly salted, in order 
to keep for two years or more in every climate; and such highly salted meat 
must be thoroughly steeped in cold water, to remove the salt, before it is eat- 
able in large quantity, that much of its most nutritive constituents must be 
washed out-namely, its albumen and sapid extract, called osmazome (Chris- 
tison). (3.) The sarcolemma of salted meat is always hardened; and hence 
those foods require a long time for digestion, and frequently disagree with the 
stomach (Letheby). Few can eat a pound of salt meat daily for any length 
of time, even when fed on rations by no means liberal. Nitrogenous elements 
must therefore be added to a diet where salted meat predominates, rather OVERFEEDING- AND CORPULENCE. 
963 
than increase the amount of that substance; and this is best done by adding 
pease, flour, currants, raisins and oil, butter, or lard, to the ration. 
"Experience has shown," says Dr. Letheby, "that there are certain articles 
of food which are not particularly nourishing in themselves, but which serve 
some very important purposes in the animal economy. This is the case with 
tea and coffee: in fact, the use of a vegetable infusion, containing astringent 
matter and an active principle rich in nitrogen, has been almost universal 
among mankind from the earliest times." , 
"The physiological action of these beverages appears to be of a somewhat 
singular kind; for while they excite the brain, they calm the nervous system 
generally, and though they produce a state of wakefulness and activity, yet 
they also induce a species of languor and repose. Lehmann has ascertained by 
experiment that coffee greatly diminishes the wTear and tear of the system: 
it oils the machinery, as it were, and checks the waste of friction; for those 
who use it find that during active exercise the destruction of tissue is pre- 
vented, and that there is less demand for food; in fact, with a maximum of 
work to perform, and a minimum of food to accomplish it, he will best sustain 
his vital power who resorts now and then to a cup of tea or coffee. Hence its 
value as a means of economizing food, and hence its importance to the poor 
laboring man." In many of our large merchant ships the crews are engaged 
on the condition that coffee shall take the place of grog; and those captains 
who are careful of the health of the men give them warm coffee before or 
after they have been aloft in cold and stormy weather-a practice which can- 
not be too much overvalued. 
Effects of Overfeeding.-Too much respiratory food favors the development 
of fat, and checks the proper nutrition of the muscular tissues; hence it is that 
rice feeders and potato eaters, and those who indulge in fermented liquors, are 
often bloated in their appearance, become extremely fat, and are not capable 
of prolonged exertion. The brewer's drayman is a bad subject for the wards 
of an hospital; for though he usually has all the appearance of a man pos- 
sessed of great muscular strength and vital endurance, yet he is not so in 
reality, for the muscular tissues have been encroached upon by fat, and the 
general power has been weakened by an undue influence of the respiratory 
element. Most of the animals in our menageries, from a too liberal allowance 
of respiratory food, die from fatty degeneration. Accumulation of the nitro- 
genous elements in the blood is often also a prolific source of disease, and their 
non-elimination (as shown in previous pages) is conducive to the propagation 
and development of many general diseases. Attention has now been drawn 
to the influence of such a condition in establishing the characteristic diseases 
of overfed convicts (Letheby, Thompson). 
Corpulence.-One of the most distressing results of overfeeding from a 
wrongly adjusted dietary is corjnilence. It is to be considered a disease 
when "it renders persons, from a difficult respiration, uneasy in themselves; 
and, from inability to exercise, unfit for discharging the duties of life" 
(Cullen). 
Dr. T. King Chambers, from observations of thirty-eight persons, whose 
weight varied from 224 to 504 pounds, comes to the following conclusion: 
In the' corpulent (1.) The bony framework of the body is less massive 
than in the spare, as indicated especially by the smallness of the hands and 
feet. 
(2.) The skin is usually fresh-colored and thin. 
(3.) The respiratory function presents the following well-marked peculiarity 
-namely, the volume of air the lungs are capable of containing in the chest 
and expiring from it, is considerably less than the average quantity contained 
and expired by healthy persons of the same height. The vital capacity is 
diminished and less carbon expired. 964 
SPECIAL PATHOLOGY-FOOD AND DISEASE. 
Hence, the wind becomes short and the mental powers inactive from corpu- 
lence ("Gulstonian Lectures," 1850). 
Much has been written on the subject of corpulence; and the attention of 
the public has been recently successfully arrested by one who appreciated the 
relief he obtained by following the directions of a physician who happened to 
take a scientifically correct view of his case. Mr. Banting (whose pamphlet 
on the subject of "corpulence" is now well known) managed to reduce his 
physical proportions under the following dietary : 
Breakfast-Four or five ounces of beef, mutton, kidneys, boiled fish, bacon, 
or cold meat of any kind (except pork), a large cup of tea (without milk or 
sugar), and one ounce of dry toast. Dinner-Five or six ounces of any fish 
(except salmon or eels), any meat (except pork), any vegetables (except 
potatoes or rice), one ounce of dry toast, fruit out of any pudding, any kind 
of poultry or game, and two or three glasses of good claret, sherry or Madeira 
(champagne, port, or beer forbidden). Tea-Two or three ounces of fresh 
fruit, or a rusk or two, and a cup of tea without milk or sugar. The tea may 
be very much enjoyed when taken in the Russian fashion-i. e., with a thick 
slice of lemon floating on the top, instead of milk. Supper-Three or four 
ounces of meat or fish, similar to dinner, with a glass or two of claret. Night- 
cap-if required, a tumbler of grog (gin, whisky, or brandy, without sugar), 
or a glass or two of claret or sherry. 
The quantities of the different articles specified in this liberal diet-roll, Mr. 
Banting states, must be left to the natural appetite; but for himself he took 
at breakfast six ounces of solid and eight of liquid food ; at dinner, eight ounces 
of solid and eight of liquid ; at tea, three ounces of solid and eight of liquid ; 
at supper, four ounces of solid and six of liquid ; and the nightcap he introduces 
to show that it is not injurious; whilst, for the encouragement of smokers, it 
may be mentioned that tobacco is allowable. 
When Mr. Banting began this treatment in August, 1862, he weighed 202 
lbs.; and after a year's perseverance in it, in September, 1863, he had lost ' 
46 lbs.; and had reduced his girth 12^ inches. The sound dietetic principles 
on which corpulence ought to be treated had been previously enunciated by 
Dr. T. K. Chambers, in his excellent monograph on that subject; and Mr. 
Banting's dietary is in exact accordance with what is there stated, and with 
what has been stated in the text. A still more varied dietary might be pre- 
scribed on similar principles by reference to the tables at pages 960 to 962. 
Effects of Deficient Food.-" A deficiency of food, especially of the nitro- 
genous part, quickly leads to the breaking up of the animal frame. Plague, 
pestilence, and famine are associated with each other in the public mind, and 
the records of every country show how closely they are related. The medical 
history of Ireland is remarkable for the illustrations of how much mischief 
may be occasioned by a general deficiency of food. Always the habitat of 
fever, it every now and then becomes the very hotbed of its propagation and 
development. Let there be but a small failure in the usual imperfect supply 
of food, and the lurking seeds of pestilence are ready to burst into frightful 
activity. The famine of the present century is but a too forcible illustration 
of this. It fostered epidemics which had not been witnessed in this genera- 
tion, and gave rise to scenes of devastation and misery which are not surpassed 
by the most appalling epidemics of the Middle Ages. The principal form of 
the scourge was known as the contagious famine fever (typhus), and it spread, 
not merely from end to end of the country in which it had originated, but, 
breaking through all boundaries, it crossed the broad ocean, and made itself 
painfully manifest in localities where it was previously unknown. Thousands 
fell under the virulence of its action, for wheresoever it came it struck down 
a seventh of the people, and of those whom it attacked one out of nine per- DEATH FROM STARVATION. 
965 
ished. Even those who escaped the fatal influence of it were left the miserable 
victims of scurvy and low fever. Another example, not less striking, of the 
terrible consequences of what may he truly called famine, was the condition 
of our troops during the early part of their sojourn in the Crimea, in 1854. 
With only just enough of food to maintain the integrity of the system at a 
time of repose, and at ordinary temperatures, they were called upon to make 
large muscular exertions, and to sustain the warmth of the system, in the 
midst of severe cold" (Letheby). 
Death from Starvation is unfortunately not uncommon. In February of 
1862 a man, thirty-six years of age, was discovered lying in a stack of corn 
or hay, near Morpeth, dying from this cause. All attempts to rally him 
failed, and he ultimately died. He was an intelligent man, and had been 
editor and proprietor of a penny journal, called the Falkirk Liberal. A 
diary was found in his possession, containing entries of his condition from 
the 8th to the 25th of February; from which it appeared that during seven- 
teen days he had twice tasted a piece of bread ; but for the last thirteen days 
he had been entirely without food. During the first ten days of the thirteen 
he was able to obtain water, but on the eleventh day he found his legs were 
useless, and he lost all motor power in the lower extremities, so that " one- 
half of his body appeared to be dead." The case is of interest to the patholo- 
gist, as showing the length of time during which existence can be maintained 
if water alone be taken. 
In cases of very gradual starvation an urgent feeling of hunger is not a 
prominent symptom ; and even when it exists at first it usually soon dimin- 
ishes, and is succeeded by a feeling of exhaustion and faintness, and even 
loathing of food, if abstinence has been long protracted (R. B. Holland). 
The mental condition connected with poverty may in part account for this 
deficiency of appetite. A depression produced on the nervous system is very 
early manifested in the impaired energies of all the vital functions, the weak- 
ened conditions of the intellectual faculties and moral feelings, and diminu- 
tion of the general sensibility. Disturbance of the cerebral functions is at 
first shown by an unnatural languor, despondency, and listlessness, slowness 
and hebetude of intellect, with an inability to employ the thoughts steadily 
and profitably on any subject. Notwithstanding all this general languor, 
however, the patient sometimes manifests a highly nervous state; he is startled 
by any sudden noise, and hurried by the most trifling occurrences. He is 
liable to attacks of giddiness, " swimming in the head," staggering, dimness 
of sight, with temporary delirium, and either falls as in an apoplectic fit, or 
lapses gradually from a lethargic state into one of stupor, or even of complete 
coma. In many respects the symptoms in these cases have a considerable 
resemblance to the effects of exposure to cold. In consequence of the torpor 
of the brain and intellectual faculties, it is often extremely difficult to obtain 
the requisite information from patients. Instead of showing any anxiety to 
communicate the symptoms and cause of their illness, or to relate the priva- 
tions they have undergone, they generally have an unwillingness to be ques- 
tioned, lie in a listless or lethargic state, without taking any notice of what is 
going on, and seem desirous only not to be disturbed. Such listlessness and 
torpor of the mental faculties, the tendency to fainting, or to perfect syncope, 
and, finally, a state of cerebral oppression, amounting in some cases to coma, 
are among the most characteristic symptoms of defective nutrition, and the 
surest indications of its existence to a serious extent. 
When privations of clothing and lodging are added to insufficient diet, long 
exertion, insufficient repose, intemperance, and the miseries of poverty, the 
symptoms already detailed are of the most aggravated kind. " Long before 
insufficiency of diet is a matter of hygienic concern-long before the physiolo- 
gist would think of counting the grains of nitrogen and carbon which inter- 
vene between life and starvation-the household will have been utterly desti- 966 
SPECIAL PATHOLOGY-FOOD AND DISEASE. 
tute of material comfort;-clothing and fuel will have been even scantier 
than food ; against inclemencies of weather there will have been no adequate 
protection ; dwelling-space will have been stinted to the degree in which over- 
crowding produces or increases disease; of household utensils and furniture 
there will have been scarcely any,-even cleanliness will have been costly or 
difficult; and, if there still be self-respectful endeavors to maintain it, every 
such endeavor will represent additional pangs of hunger. The home, too, 
will be where shelter can be cheapest bought,-in quarters where commonly 
there is least fruit of sanitary supervision, least drainage, least scavenging, 
least suppression of public nuisances, least, or worst, water supply, and, if in 
town, least light and air. Such are the sanitary dangers to which poverty is 
almost certainly exposed, when it is poverty enough to imply scantiness of 
food" (Simon, Sixth Report on Public Health, 1864, p. 14). But a multitude 
of cases of minor degrees of suffering occur in which the symptoms are less 
marked than those described. Such cases are indicated by a sallow and 
dingy appearance of the skin, a soft and flabby feeling of the flesh, more or 
less emaciation, general debility, feebleness of the circulation, and frequently 
swelling of the ankles. The stomach becomes disordered, the appetite de- 
fective, and digestion impaired. The individual feels languid and despond- 
ing, is soon fatigued, incapable of exertion, and has an irresistible desire to 
fall asleep, from which he is apt to awake suddenly and in a fright. The 
body is easily chilled, breathlessness and palpitation are experienced after 
slight exertion, attacks of vertigo, tinnitus aurium, and transient blindness, 
are common, and there is a peculiar forlorn and dejected aspect of counte- 
nance which is very characteristic. This state of things is commonly soon 
succeeded by some specific disease ; though it may continue, with only slight 
variation, for a very protracted period, until the patient falls by slow degrees 
into a state of mental as well as physical incapacity ; and, being no longei' 
able to procure any employment, is completely invalided, and applies for 
medical relief. It may perhaps be thought that these remarks apply to cases 
of deficient nourishment which are less frequent; but the experience of those 
who have practiced extensively among the wretched purlieus and miserable 
abodes which exist in every large metropolitan town can testify to the con- 
trary. I well remember listening to the interesting clinical lectures of Dr. 
Christison, of Edinburgh, on the cases of scurvy which prevailed in that town 
and its vicinity in 1847, and hearing the melancholy recitals of misery and 
starvation under which the poor suffered at that time ; some under the hard 
taskmasters of the illegal "truck system,"* and others from absolute want at 
home. Among many, pf whose cases I have preserved notes, a shoemaker 
had to support his wife and five children on eight shillings a week ; and, in 
order to feed his children better than himself, he subjected himself to priva- 
tions which in time developed scurvy. His daily diet consisted of one penny- 
ivorth of bread, with tea, but no milk, in the morning-no dinner-and one pen- 
nyworth of bread, zvith tea, and no milk, in the evening. After existing three 
months on this diet the disease broke out. But, apart from these extreme 
cases, the instances are innumerable in which deficiency of food acts as a pre- 
disposing cause of many diseases. It is now generally known that plethora 
* The " truck system" became developed chiefly during the formation of our great 
lines of railway throughout the country. The laborers (navvies) were poor, and came 
to work without money to buy provisions, and their field of labor was often far re- 
moved from anyplace where food could be bought in quantity. The contractors, their 
employers, then established provision stores, and in place of paying the men in money, 
they compelled them to take remuneration for their labor by value received in food. 
By this method, now declared illegal under all circumstances, the laborers often suf- 
fered from a deficient and bad supply of provisions. 
It has been found necessary this year (1871) to inquire by Parliamentary Commis- 
sion into the extent of this system, still carried on in some places. MANAGEMENT OF DISEASE BY DIET. 
967 
and symptoms of an opposite state very nearly resemble each other, and a 
discrimination of these differences is of the greatest importance. While 
coma is often an attendant on plethora, it is not to be forgotten that it is 
one of the most severe and fatal signs of exhaustion from defective nutrition ; 
and when it supervenes towards the termination of diseases of exhaustion, 
and the pulse becomes slower, it often acquires a degree of fulness, and gives 
an idea of strength, quite at variance with its previous character, and little 
to have been anticipated from the debilitated state of the system. 
But in degrees far short of what is popularly known as starvation or 
famine, insufficiency of nourishment may bring very hurtful consequences to 
health. Local defects or local peculiarities of diet may exercise an impor- 
tant influence in determining or coloring particular localizations of disease; 
and generally it may be said, that in order justly to estimate the sanitary cir- 
cumstances of a people, sufficient regard must be had to the quantity and 
quality of the people's meat and drink (Simon, Report on Public Health, p. 
11, 1864). 
The injurious effects produced by improper nutrition require to be studied 
both in relation to food and drink; and the diseases now considered, which 
form section B of General Diseases, are greatly influenced by the nature of 
the food on which the people live. 
CHAPTER XIII. 
GENERAL MANAGEMENT OF THE SYSTEM LIABLE TO CONSTITUTIONAL 
DISEASES. 
Important general indications for the treatment of the constitutional 
diseases are suggested by their pathology as expounded in these pages. This 
general treatment ought to be directed towards the management of the sys- 
tem for the prevention, control, or arrest of the development of such affections, 
or to maintain them within such limits as are consistent, at least, with the 
well-being of the individual. 
The topics to be noticed under this head are of so comprehensive a scope 
that they can only be indicated as shortly as possible, with the object of direct- 
ing the mind of the student to their more extended study. They embrace, 
in fact, the whole subject of general and individual hygienic management. 
The student is therefore referred at once to two standard authorities, with 
whose maxims and practice his mind ought to become most thoroughly im- 
bued, in order to direct successfully the measures for the prevention and 
arrest of the constitutional diseases. The works here referred to are- 
(1.) The Management of Infancy, by Dr. Andrew Combe, ninth edition, 1860, 
edited by the late Sir James Clark; (2.) Practical Hygiene, 1864, the work of 
my colleague, Dr. E. A. Parkes, which has passed through three editions. 
From the first of these books the student will learn how he must begin at the 
very beginning. He will learn to appreciate the influence of the constitu- 
tion of parents on the health of their children, and will learn from it how to 
direct the management of infant life. From the second work he will learn 
how he may carry out the details of practical hygiene. This work of Dr. 
Parkes brings together an amount of material which shows the extent to 
which exactness and certainty have been imparted to the Science of Medicine. 
It is a work which marks a new era in Practical Medicine. 
From the nature of the constitutional diseases (fully expressed at 
pages 373 to 375, and described in the preceding pages), it is to be noticed 968 
SPECIAL PATHOLOGY-DIET IN DISEASE. 
that there are three periods in the history of these diseases necessary to be 
recognized in the pathology and treatment of them. 
The first period may be described as the period of their constitutional devel- 
opment. During this period the physician is rarely if ever consulted, unless 
a constitutional tendency to the disease is suspected, obvious, or perhaps hered- 
itary. 
The second period may be described as the period during which the consti- 
tutional disease is fully expressed by the phenomena and symptoms already 
described as peculiar to each of them. 
The third period in the history of these diseases may be described as a 
series of intervals, during which the health seems to be improved between the 
febrile paroxysms, or fully expressed conditions of ill-health. 
It is for the cure of the fully expressed disease that the physician is gener- 
ally consulted-a period when he knows he can do the least good. But when 
the public are aware of the extent to which health may be preserved, and 
constitutional diseases averted and mitigated by judicious management and 
treatment during the first and last periods here noticed, the physician will be 
more frequently consulted as to how the health is to be so preserved and im- 
proved as to ward off constitutional diseases. 
Whenever the physician has to treat any of these constitutional affections 
in their fully expressed condition, if he is successful in subduing the symptoms 
for the time, by means of the treatment already mentioned under each of 
them, the interval of comparative freedom from the paroxysmal expressions of dis- 
ease is a time most precious, which ought not to be wasted, but which ought to be 
taken advantage of in preserving and improving the general health. To effect 
this end there are three things to be considered in the management of the 
system during the intervals of comparative freedom from constitutional affec- 
tions. These are-(1.) Diet; (2.) The use of Water; (3.) The use of Wines 
and other alcoholic beverages. 
1. With regard to diet, one of the highest problems in physiology, as Dr. 
Parkes clearly enunciates, is so to regulate the supply of the nitrogenous sub- 
stances-the albuminates-that the digestive power of the stomach and intes- 
tines may be increased, together with the formative power in the nitrogenous 
tissues, and the eliminating powers in the after-stages of assimilation (1. c., p. 
132). All these three parts of the process must be duly balanced, otherwise 
health is destroyed. Half-digested food in the stomach or intestines produces 
irritation. It undergoes chemical changes in the alimentary canal, and quan- 
tities of gas are given off. Dyspepsia or constipation may be produced, or an 
irritation causing a diarrhoea which fails to empty the bowels. The faeces 
then contain a large amount of nitrogen, especially after eating vegetable 
albuminates. The tissues are unable to appropriate the excess which remains 
in the blood. Urea and carbonic acid, which ought to be eliminated in normal 
abundance, fail to be provided for from the imperfectly oxidized products of 
disintegration, and irritation of eliminating organs is set up. It is highly 
probable that gouty affections arise in this way, and partly from the use of 
liquids which delay metamorphosis. A great excess of albuminates without 
other food produces marked febrile symptoms, malaise, and diarrhoea; and 
ultimately albumen may appear in the urine, or extensive irritation of the 
skin may supervene. To increase the adaptation of the albuminates, fats and 
salts must be added to the diet; and the supply of oxygen must be increased 
by exercise, or the supply of starchy foods which appropriate oxygen must be 
diminished. Lessening the supply of the albuminates effects a decline or loss 
-first, of the muscular system ; and, at a later period, of the nervous system 
and mental powers. Such decline or loss may be delayed by increasing the 
supply of fats and starches, which, by absorbing oxygen, limit disintegration ; 
and by perfect rest the loss of flesh may be still further delayed. 
In the management of the system, therefore, the albuminous tissues can be, MANAGEMENT OF DISEASE BY DIET. 
969 
to a certain extent, brought under the control of the physician by a judicious 
adaptation of diet and exercise alone, without the employment of drugs. 
Drugs, however, when judiciously employed, are important aids at two ends 
of the intestinal canal-namely, to aid primary digestion and to assist elimi- 
nation. 
Fatty aliments are essential to the formation of muscular, and especially also 
of nervous tissues. With the nitrogenous substances or albuminates, they are 
essential to the production of mechanical force. Animal fats appear easier of 
absorption than the vegetable fats; and the relative proportion of fat to albu- 
minates ought to be as 1 or 1^ to 2. 
Starchy and sugary food saves the albuminates and fats from too rapid disin- 
tegration, so that, by a judicious employment of them in a dietary, the elimi- 
nation, and perhaps the formation of the albuminates and fatty tissues can be 
so modified that the administration or withholding of starches and sugars as 
articles of food must enter largely into the management of the system, accord- 
ing to the circumstances of the case and the nature of the constitutional 
disease. 
The production of lactic acid in the system seems probably connected with 
the metamorphosis of starch. To the constant introduction of an excess of 
alkali in the food, and the no less constant production of acid during the 
digestion of foods (especially starches, sugars, and fats), associated with the 
effects of respiration, are to be ascribed the singular alternation of acid and 
alkaline fluids in the body. The relative amount of starch foods to the nitro- 
genous or albuminate substances ought to be as 2^ or 3| to 1. Excess of 
starches, sugars, and fat produce excess of fat; sometimes also acidity and 
flatulence; and the urine may become saccharine under excess of starch as an 
article of diet. Salts and water are essential articles of diet. Lime, in the 
form of phosphate, is absent from no tissue; and when tissues degenerate and 
morbid growths are overgrown, or begin to decay, or when cells grow rapidly, 
as in enchondroma, lime is present in large amount. Both lime and magnesia 
are essential to the growth and repair of bone; and the judicious withholding 
or administration of lime and magnesia in food is an important element in the 
constitutional management of diseases where the bones are affected, and in the 
repair of fractures. Potash and soda, in the form of chlorides and phosphates, 
are not less important constituents of diet. They form part of almost all the 
tissues; and, being especially concerned in the molecular currents amongst 
the elements of texture, seem to be less fixed than the magnesian and lime 
salts. The potash seems especially associated with the formed elements of 
texture, such as the blood-cells and the muscular fibres ; while the soda salts 
are more largely concerned with the fluids which encompass these elements. 
These two alkalies {potash and soda) have been seen to be most important 
remedial agents in many diseases. Chlorine, chloride of sodium, phosphoric 
acid, sulphur, and iron, must be furnished in all food, either separately or com- 
bined with the foods already noticed. 
The salts which form carbonates in the system, such as lactates, tartrates, 
citrates, and acetates, exist chiefly in fresh vegetables; and although their 
nutritive power otherwise is small, it is absolutely necessary that they be sup- 
plied in the food. Scorbutic states inevitably ensue if they are withheld. 
These are the main points to be inquired into and provided for in adjusting 
the diet best adapted for the management of constitutional diseases. Every 
intelligent patient may aid his physician, however, thus far-namely, that if 
he consider the subject bond fide for himself, he will become the best judge of 
the'exact diet which suits him. Dr. Parkes observes that probably 30 per 
cent, of the persons who consult physicians owTe their diseases in some way to 
food, and in many cases they are perfectly aware themselves of their error or 
bad habit; yet, with the singular inconsistence of human nature, either conceal 
it from the man to whom they are professing perfect openness, or manage to 970 
SPECIAL PATHOLOGY-DIET IN DISEASE. 
blind themselves to its existence (1. c., p. 461). Individual hygienic manage- 
ment must be inculcated upon the patient; while, by regulating diet on the 
principles laid down by Dr. Parkes in Chapter V of his work On Practical 
Hygiene, the physician will find he can exercise a great power in the control 
and limitation of constitutional disease. Most valuable information respecting 
the adjustment of the dietary will be found in Dr. Edward Smith's Practical 
Dietary; and in A Manual of Diet and Regimen for Physician and Patient, by 
Dr. Horace Dobell. 
2. With regard to the use of Water, its influence as an agent in the manage- 
ment of certain conditions of constitutional ill-health is apt to be too much 
neglected, or not sufficiently appreciated. Ever since the powerful agency of 
water, under the popular name of the " water cure," has been so much be- 
quacked, the medical profession have almost allowed themselves to be seized 
with a kind of hydrophobia. Nevertheless, there can be no doubt that water 
has a most powerful influence for good or evil in the treatment of constitutional 
diseases. Under its influence as a fluid of daily consumption considerable 
chemical changes are promoted in the body. In the intervals between the 
extreme expressions of constitutional diseases, such as gout, rheumatism, asthma, 
and the like, it is a useful and most efficient remedial agent, not only as a 
diuretic, but also as a local application, especially in obviating the congestions 
of the viscera associated with these constitutional affections (Simon). " To 
accelerate the defective textural metamorphosis or waste is very often the 
practical result to be aimed at, and such means exist in the simplest and most 
manageable form in many of the appliances of the so-called 1 water cure.' 
With increased water-drinking there is increased discharge of solids by the 
urine. External appliances, such as the cold sitz bath, lasting a quarter of an 
hour, increase for a time the elimination of urea and uric acids. The pro- 
tracted sudorific packings produce a still more considerable waste of tissue. 
Generally, therefore, in cases where the use of water is suitable, and conducted 
under competent medical advice and direction, the healthy nutrition of the 
body is promoted, in proportion as refuse materials are actively disengaged " 
(Simon, in Holmes's Surgery, vol. i, p. 118). 
3. The properties of Wines, and of alcoholic beverages generally, offer a wide 
and important field for the careful study of the physician. Although so ex- 
tensively used as beverages, with our daily food, aud so generally recognized 
as valuable agents in the treatment of disease, there is not only great diversity 
of opinion as to their precise effects, but as yet very little is certainly known 
of the action of alcohol when administered in the forms of wine, beer, or spirits. 
None of the general statements so frequently met with as to the composition 
or effects of any particular class of beverages can be relied on as a guide to 
the physician in prescribing; and much error seems to prevail on the subject, 
not only in the popular mind, but amongst medical men. 
Alcohol is the most potent agent for good or evil in all of these beverages; 
and, therefore, its amount and its effects challenge attention in the first in- 
stance. A pint of beer (twenty ounces) may contain one or two or more ounces 
of absolute alcohol, or less than a quarter of an ounce. This alcohol may be 
associated in the beer with an amount of free acid varying from fifteen to fifty 
grains, and with an amount of sugar varying from half an ounce to three or 
four times that quantity. A glass of sherry (two ounces) may contain from a 
quarter to half an ounce or more of absolute alcohol, with sugar varying in quan- 
tity from a mere trace to twenty or thirty grains, associated with a very variable 
amount of free acid, and with other ingredients. Even in brandy or whisky 
the amount of alcohol is widely different in different specimens. 
It is impossible, therefore, for a physician to know what his patient is drink- 
ing, unless he is acquainted with the chief constituents and their amounts con- 
tained in the identical liquor which he may prescribe; and of course, before USE OF ALCOHOL IN MEDICINE. 
971 
sound conclusions can be arrived at, the conditions under which these bever- 
ages are administered or taken must also be very precisely observed. 
The physiological effects of alcohol have been investigated and inquired 
into with considerable care by Rudolf Masing, Bocker, and Mulder; by MM. 
Lallemand, Perrin, Duroy ; by Percy, Ogston, Bence Jones, Carpenter, Spen- 
cer Thomson, Hammond, T. K. Chambers, Edward Smith, Anstie, and Parkes. 
All the observations and inquiries on this subject tend to the conclusion 
that alcohol passes through the body unaltered in chemical constitution, and 
does not, so far as we know, leave any of its substance behind. At the same 
time, there is ample evidence to show that a very large amount may be re- 
tained in the fluids of the brain for an indefinite length of time (Percy, Ait- 
ken, and others, see Alcoholism). During that period of retention it exerts 
an influence for good or for evil; and although it may not be regarded as an 
" aliment " in the strict sense of that term, it undoubtedly aids the appropria- 
tion of aliment under some circumstances; and so far may be regarded as an 
"accessory to food" in comparative health, or as a " medicine " in disease. 
Under this aspect of the subject, Dr. T. K. Chambers, in his interesting clinical 
lectures (p. 570), lays down the following rules for the administration of 
alcohol: 
1. Alcohol may be given with advantage when the nervous system is ex- 
hausting itself, and when the tissues of the body generally are being exhausted 
by an activity in excess of the other bodily functions. It lessens the destruc- 
tive metamorphosis which goes on; and chemical changes in the blood are 
partially arrested (Harley, quoted by Parkes). 
2. It must be given, increased in amount, or left off, under the guidance of 
the appetite for food. As long as a person in ill-health takes and digests 
food better with alcohol than without, so long will alcohol be of service to 
him. Beyond this general statement there is no evidence. In very small 
quantities it appears to aid digestion in the stomach; in larger amounts it 
checks it. A moderate use of beer or of the weaker wines (i. e., of pure unr 
brandied well-fermented wdnes) may increase appetite and improve nutrition. 
On the other hand, the use of malt liquors (even when pure and good) is in- 
jurious to persons of sedentary habits, or unless much exercise be taken in the 
open air; but sound, well-fermented beer is the best of all dinner drinks for 
persons of good digestion, who work hard in the open air (Druitt). 
3. When the marked features of disease consist in the retention of effete 
matters which ought to be discharged, the use of alcohol must be totally ab- 
stained from, as for example in Bright's disease. 
4. The daily allowance of alcohol ought to be divided into two or three 
doses only. 
Under all circumstances its effects must be watched; for while it may 
sometimes be desirable to diminish the metamorphosis of tissue by its use, it 
must not be forgotten that large quantities of alcohol tend to cause an accu- 
mulation in the system of imperfectly oxidized bodies, such as uric and oxalic 
acid. 
The general evidence also tends to show (but does not absolutely prove) 
that pure alcohol has its pernicious effects greatly lessened, and its good effects 
more powerfully developed, when highly diluted, and still more so by ad- 
mixture with other substances, as the carbo-hydrates and salts contained in 
beer and wines. The use of strong wines (15 to 23 per cent.) undiluted should 
therefore be discouraged as much as possible; and if such an amount of 
alcohol is found necessary for the due preservation of the wine, and naturally 
results from the fermentation of the grape, the wine ought to be diluted with 
wTater when used as a beverage. On the other hand, light wines cannot be 
long exposed to the atmosphere without acetous fermentation commencing in 
them. Light wines with a small amount of alcohol for the use of invalids 
must therefore be preserved in bottles of such a size that the whole may be 972 
SPECIAL PATHOLOGY - ALCOHOL IN DISEASE. 
consumed in a day; for much mischief may arise if wines are used by invalids 
after acetous fermentation has commenced. Besides alcohol and ethers, wine 
contains several substances of great value as articles of diet,-namely, some 
albuminous substances, such as sugar, as well as other carbohydrates, and 
abundant salts. The vegetable salts are most valuable, and in this respect 
are highly antiscorbutic (Parkes, 1. c., p. 227). 
For the purposes of the physician, the prominence of certain substances in 
wines renders some more desirable than others, or more useful as "medicines." 
These substances are-(1) alcohol, (2) acids, (3) sugar, (4) solids or extracts. 
Of these in their order: 
Alcohol, to a variable amount, ought to exist in wines as a natural product 
of the fermentation of the grape; and the conditions of its existence in the wine 
are then very different from those which obtain when alcohol (distilled even 
from wine) has been added to wine. It is highly desirable, therefore, to avoid 
adventitious alcohol; but it is impossible to prove that spirit has been added 
to a wine unless the amount is absurdly excessive. One vintage sometimes 
produces a wine with a considerably greater amount of alcohol than another 
of the same vineyard. For example, the samples tested in London (for duty) 
of Chateau Lafite, of vintage 1858, showed 16.5 per cent, of proof spirit; the 
same vineyard in 1859 showed 17.7; and in 1860 it gave 14.8;-the three 
years varying about 3 per cent. The samples of common St. Emilion in 1858 
showed 16.5 per cent, of proof spirit; in 1859 the same vineyard showed 15.4 
per cent.; and in 1860 it gave 16 per cent.;-thus not differing more in the 
three years than about 1 per cent. 
The amount of the alcohol by measure may be most readily estimated by 
the vaporimeter of M. Geisler, of Bonn, which indicates the amount of the 
alcohol by the tension of vapor at a certain temperature, from the fluid con- 
taining the alcohol forcing up a column of mercury. Dr. Parkes gives also a 
very ready process by evaporation, and the use of a urinometer {Practical 
Hygiene, p. 220). 
Having thus ascertained the percentage of alcohol in wine, beer, or spirits, 
it is easy to calculate by simple proportion the dose of alcohol administered. 
For example, a pint bottle of Claret (thirteen ounces) of the strength of eleven 
per cent, of alcohol, will be found to contain 1.43 ounces of absolute alcohol, 
thus: 
100 : 11 : : 13 = 1.43. 
It is the basis of the rule laid down by Dr. Parkes (1. c., p. 224), which 
says,-" To tell how much pure alcohol is taken in any definite quantity of wine, 
measure the wine in ounces, and multiply it by the percentage of alcohol with a 
decimal point before it." 
Acidity.-Free acid in wine is a necessary result of its fermentation. Its 
presence is likewise necessary for the evolution of the bouquet, for the agree- 
ableness of the wine, and for its wholesoineness. It is, therefore, a popular 
error to denounce absolutely the existence of acidity in wine. The relative 
amount of free acid present in any particular wine is a very important point 
to determine. Much error prevails respecting the relative amount of acidity 
in different wines, and an excessive amount of free acid is very easily dis- 
guised by the relative sweetness of the wine. The estimation of the free acid 
may be measured by a solution of carbonate of soda, containing 530 grains in 
the 10,000 grain measure = 53 grammes in the litre; and the amount of 
acidity is represented by determining how many grains of crystallized oxalic 
or acetic acid a certain quantity of the soda solution will neutralize. The 
details of the process are as follows: 
(1.) Take 50 or 100 c. c. of recently opened wine; (2.) Add from a burette 
a standard solution of soda, in small portions at a time (say 5 c. c., or drop 
by drop); (3.) After every addition, test the fluid by moistening a thin glass SUGAR AND SOLIDS IN WINE. 
973 
rod or feather with the mixture, and streak it acipss some well-prepared violet 
litmus paper;-when the streaks cease to become red, the analysis is com- 
plete; (4.) Estimate how much of the standard solution has been used, and 
express the acidity as equal to so many grains of crystallized oxalic or acetic 
acid. Good wine contains a quantity of acid that is equivalent to from 300 
to 450 grains of crystallized tartaric acid in a gallon. Wines with less than 
300 grains of acid in a gallon are too flat to be drinkable with pleasure. 
Wines with more than 500 grains in a gallon are too acid to be pleasantly 
drinkable; and wines with more than 700 grains in a gallon are undrinkably 
sour (Druitt's Report on Cheap Wines, p. 178). 
It is also very important to get at the quality of the acid,-to the extent, at 
least, of dividing the volatile from the non-volatile (and less digestible acids). 
A large amount of acid and acid salts may not be readily digested ; and in 
many diseases the supply of acid to the system is a thing to be desired or 
prevented (see also Parkes, 1. c., p. 219). 
The necessary standard solutions and burette apparatus are supplied by 
Mr. Griffin, 119 Bunhill Row, who has prepared a set of apparatus which 
shows all that chemistry can teach of the quality of wine; by Messrs. Bul- 
loch & Reynolds, Hanover Street, London; also, Harper & Sutton, Opera- 
tive Chemists, Norwich. 
Sugar is characteristic of all the sweet wines, and of many wines in their 
immature condition. Its amount tends to diminish with age, so that old wines 
of the siveet sort may be less pernicious, as regards sugar, than the new. Sweet 
wines, or wines which contain a large percentage of sugar, are to be avoided 
by those who are disposed to corpulence; and they are extremely injurious to 
those who are disposed to the formation of oxalic acid, or to the discharge of 
sugar in the urine. Its amount in any particular sample of wine is best de- 
termined by Soleil's saccharimeter. The principle on which the process 
depends is that the varieties of sugar possess the power of twisting the plane of 
polarization of a ray of polarized light which is transmitted through solutions 
containing these varieties of sugar. Cane sugar and glucose twist it to the 
right hand ; fruit sugar twists it to the left hand. All gradation lists given in 
books as to the amount of sugar in wines are purely empirical, and apply only 
to the particular sample of wine examined. In stating the sweetness of 
Champagne, for example, nobody seems to notice that it is a manufactured 
article ; and that the quantity of syrup added to it actually varies from four 
to twenty per cent. The Champagne known as "still" has no sugar. Some 
sorts of Madeira are also nearly free from sugar; and some sorts of Sherry are 
much sweeter than well-fermented Ports. 
The correlation of sweetness with acidity and with alcohol are most impor- 
tant points to be determined with reference to the easy digestion of wines ; 
and hence they are all-important for the physician to know. 
The Amount of Solids may be learned (approximately) by determining the 
specific gravity after the alcohol is driven off. A low specific gravity shows 
that alcohol has been added, or that the solids are in small amount (Parkes, 
1. c., p. 226). 
The following table gives a standard for the determination of the solids 
(Parkes, 1. c., p. 218): 
Specific Gravity after 
Per cent, of 
loss of Alcohol. 
Extract. 
1004, 
1 
1008, 
2 
1012, 
3 
1016, 
4 
1020, 
5 
Specific Gravity after 
Percent, of 
loss of Alcohol. 
Extract. 
1024, 
6 
1028.1, . 
7 
1032.2, . 
8 
1036.3, . 
9 
1040 4, . 
10 
It is much to be regretted, especially for the sake of invalids, that so few 
wine merchants are acquainted, or care to be acquainted, with the chemical 974 
SPECIAL PATHOLOGY-WINE IN DISEASE. 
constituents of their different wines. Medical men should, therefore, deal only 
with those wine merchants who will tell them the amount at least of the sev- 
eral constituents in their wines that have been referred to-namely, of alco- 
hol, acids, sugar, solids-and who will guarantee the wine they supply as being 
in accordance with the sample of which they give the analysis. The sale 
room of every wine merchant ought to be provided with the means and appli- 
ances here indicated for ascertaining the exact amount of the substances con- 
tained in the samples of wine they offer for sale. The amount of alcohol, of 
free acid, of sugar, and of solids should be recorded also of every wine on 
importation, so that the wine merchant may be able to watch the metamor- 
phoses, in respect of these constituents, effected on them by lapse of time. 
Wine merchants could thus materially assist the efforts of medical men in the 
cure of disease, and physicians could then prescribe with some knowledge of 
what they were prescribing; and to that extent at least the welfare of inva- 
lids and the sick would be better cared for. 
But although by ascertaining these facts a physician may prescribe with 
better knowledge of what he is prescribing, and to that extent at least be better 
able to care for his patients, it must not be concluded that chemistry can de- 
tect every form of adulteration in alcoholic beverages. As Dr. Druitt justly 
observes,-" The only real test for wine is the empirical one. It is impossible to 
say that such a wine must be good in such and such cases, because it contains 
certain ingredients The stomach is the real test-tube for wine; and 
if that quarrels with it, no certificate of Liebig and no analysis are worth a 
rush " {Report on Cheap Wines, p. 6). With all possible aids, the one safe- 
guard against fraud is to deal only with wine merchants and brewers of estab- 
lished character and reputation, who will be above attempting to dispose of 
unsound or adulterated liquors ; and to avoid being tempted by the low prices 
of amateur dealers in wine, or of advertising companies and others, obviously 
more anxious to sell than to sell only the purest and the best. 
The principal analyst of the Inland Revenue Department reports that he 
found illicit ingredients in no less than twenty out of twenty-six samples of 
beer tested in 1865 ; and he believes that, owing to the difficulty of detection, 
the practice of adulterating beer with poisonous ingredients is much more 
prevalent than might be inferred from the small number of discoveries made. 
These samples were all from the stores of licensed brewers; and although, 
doubtless, further adulterations are practiced by the retailers, they are proba- 
bly for the most part with less noxious materials, and chiefly with the object 
of increasing bulk-known as "stretching." As to wines, the following adver- 
tisement, frequently appearing in the Times, shows that there is a trade 
openly carried on in this country in the treatment or cure of bad or spurious 
wines: 
" Wine merchants having wines turned acid may have them returned to 
their original wholesome perfection in two or three days, by applying to 
," &c., &c. 
It is well known that the same practices prevail abroad, so that "pure as 
imported" is now no guarantee for purity of production. Hambro' wine has 
been shipped from London to Cadiz and back-an operation which raises the 
price of the stuff 100 per cent. The custom-house officers in 1865 stopped a 
large quantity of stuff imported as " Sherry," which had not a drop of grape- 
juice in its composition; and it cannot be doubted that the increased consump- 
tion and increased competition for low prices have greatly added to the 
temptations to adulterate. Such liquors, for any medicinal purposes, must be 
worse than useless; and whenever wine, brandy, or beer is prescribed medi- 
cinally, they ought to be obtained from wine merchants or brewers of the 
highest respectability. Wine merchants are generally quite willing to sell 
in small quantities either wine or spirits-a recent change in licensing laws GENERAL NATURE OF LOCAL DISEASES. 
975 
enabling them to do so, and so making it no longer necessary to send to the 
public house when only a single bottle is wanted. 
The blindly empirical and routine mode in which alcoholic beverages are 
generally prescribed, in absolute ignorance of their constitution and genuine- 
ness, and the importance of them in the treatment of disease or of ill-health, 
renders it advisable in a text-book to insist fully on these topics, believing 
that the physician cannot cope successfully with diseases, and especially with 
constitutional diseases and the ill-health with which they are associated, 
unless he learns judiciously to use the immense power at his disposal in the 
influence of diet, water, and alcoholic beverages, as agents in the management 
of the system during the intervals between the paroxysms of these diseases. 
For much valuable information on wines, given in a very pleasing form, the 
reader is referred to Report on the Cheap Wines from France, Italy, Austria, 
Greece, and Hungary; their Quality, Wholesomeness, Price, and their Use in 
Diet and Medicine, by Robert Druitt, Esq., F.R.C.P., 1865. 
CHAPTER XIV. 
GENERAL NATURE OF LOCAL DISEASES. 
This class of diseases is intended to comprehend all those which affect the 
structure of special organs or particular parts of the body, and which lead to 
marked disturbance of their functions. 
Local affections are often accompanied by constitutional symptoms. Such 
symptoms, when they succeed to and depend upon the existence of the local 
lesion, are to be regarded as secondary to that lesion. 
Many diseases, however, where the lesions are strictly localized and defined 
are really the results of constitutional or specific disease; and many lesions 
have been already described under the several general, diseases that have 
been considered in the previous pages of this work. The local affection in such 
cases is often so striking and important that it h$s especially challenged 
attention, while the constitutional state from which it may have sprung is as 
yet concealed and unknown. The lesion here is secondary to the general 
affection. Not a few cutaneous eruptions are of this nature; so also are some 
forms of dropsy. 
The diseases about to be considered are essentially characterized by more 
or less defined local lesions. 
These lesions, with reference to each organ, may be most fitly considered in 
the following order or arrangement of their anatomical forms: 
(a.) Catarrh, or increased flow of secreted fluid. 
(b.) Inflammation of the suppurative, ulcerative, plastic, pycemic, rheumatic, 
gouty, syphilitic, scrofulous, or gonorrhoeal. 
(c.) Gangrene. 
(d.) Passive congestion. 
(ef) Extravasation of blood, or hemorrhage. 
(f.) Dropsy. 
(g.) Fibrous deposits. 
(h.) Altered dimensions, as dilatations, contractions, hypertrophy, atrophy. 
(i.) Degenerations, amyloid or lardaceous, fatty, atheromatous, pigmental, cal- 
careous, fibroid. 
(k.) Syphilitic. 
Cancer. 976 
SPECIAL PATHOLOGY-DISEASES OF THE NERVOUS SYSTEM. 
Non-malignant tumors. 
Cyst. 
Scrofula, with or without tubercle. 
Parasitic lesions. 
Calculus and concretions. 
Malformations. 
Injuries. 
Functional diseases. 
The elementary nature of these lesions has been already considered in Part 
I, under Topics relative to Pathology, pp. 67 to 240. 
CHAPTER XV. 
DISEASES OF THE NERVOUS SYSTEM. 
Section I.-Introduction to Pathology of Diseases of the 
Nervous System. 
It is with nerve-texture, as composing the essential parts of the nervous 
system contained within the cranium, and distributed as nerves throughout 
the body, that we have to deal in describing the local diseases of this section. 
The interest which attaches itself to the study of the nervous system cannot 
be surpassed either in a physiological or pathological point of view. The 
truth and force of this statement will be more especially apparent when it is 
remembered that the nerves are the channels of Sensation; that nervous tex- 
tures compose the organs which conduct the influence of the will to the muscles, 
before motion can take place; and that while the textures which constitute 
the nervous centres associate Sensation on the one hand, they at the same time 
balance and co-ordinate the motions of the body on the other. And that, 
lastly, being the seat of the various mental processes through which Sensation, 
Volition, Memory, Judgment, and all mental acts are expressed, the pathological 
relations of the nervous texture contained within the cranium, or distributed 
throughout the body, are perhaps the highest and most important, in a scientific, 
philanthropic, and sanitary point of view, to which the mind of the physician 
can be directed. 
The student is therefore called upon to give the diseases of the ner- 
vous system generally a large share of his study, because they are confessedly 
difficult. 
The varied phenomena connected with the morbid conditions of the nervous 
system must be examined from the following points of view, namely-(1.) 
The purely anatomical structure of the brain and nerves; (2.) The chemical 
composition and properties of the nervous substance; (3.) The physiological 
relations of the several parts; (4.) The morbid and pathological relations. 
Each of these methods of study and investigation will mutually illustrate one 
another; and it is only from a consideration of all of them conjointly that we 
can arrive at the natural history of a case, and so act for the best in diagnosis, 
prognosis, and treatment. Every student knows how very many physiological 
doctrines regarding the brain and nerves receive elucidation from accurately de- 
termined anatomical information; and so such knowledge tends to explain vari- 
ous points in the pathology of cerebral diseases. He need only be here reminded 
of the phenomena explained by the decussation of the pyramids in the medulla 
oblongata; how the continuity of the fibres of the spinal cord upwards to the ABSOLUTE WEIGHT OF THE BRAIN. 
977 
cephalic centres explains various secondary lesions of the brain as a consequence 
of lesions in the spinal cord altered by paralysis (Drs. Brown-Sequard, Turek, 
and Waller): and lastly, the interesting observations made by Drs. Walshe 
and H. Bence Jones regarding the excretion of sulphates and phosphates by 
the urine in acute chorea, delirium tremens, and inflammation of the brain itself'. 
These observations show, to some extent, how accurate chemical and anatomical 
investigations may become valuable in the elucidation of morbid phenomena 
occurring in living bodies. 
Anatomical Constituents of the Brain and Nerves.-The nervous texture 
may be simply considered as arranged into three great divisions: 
1. A large quantity of nervous matter collected into one mass and contained 
in one cavity, the cerebro-spinal. This mass is called the Brain and Spinal 
cord, or Encephalon, or Cerebro-spinal axis, or central part of the nervous system; 
and is composed of the cerebrum, cerebellum, sensori-motor ganglia, and spinal 
cord. 
2. A nervous texture, arranged in the form of long continuous cords or 
threads, mutually connected, and running in every direction throughout the 
body. These are simply called the Nerves. 
3. An accumulation of peculiar nervous substance, in the form of small, 
round, and somewhat oval masses, called "ganglia," variously connected with 
each other, and with the surrounding parts, and forming what is known as the 
Sympathetic system. 
Chemical Composition of Brain and Nerve-Tissue.-The white or gray 
matter of the brain has been generally taken to represent pure nerve-substance. 
It consists of albumen, fatty matter, salts, and from |ths to |ths of water. 
The fatty constituents are remarkable, inasmuch as two of them, being acid 
compounds, contain a large amount of phosphorus, from 8 to 10 parts in 
1000 of the mass, or j^tli to y^-th of the whole solid matter. This is con- 
tinually being metamorphosed during functional and morbid changes of the 
nerve-substance; and the amount of alkaline phosphates in the urine may be 
taken in some measure as an estimate of the amount of nerve-tissue disinte- 
grated, the earthy phosphates being disregarded, inasmuch as they have been 
shown mainly to depend on the quantity taken in the food. The phosphorus 
set free by disintegration of the nervous tissue unites, in the form of an acid, 
with the alkaline basis in the blood, and is thence separated by the kidneys 
and discharged with the urine. 
Weight of the Brain and its Parts.-In appreciating morbid states of the 
brain and nervous textures after death, it is useful to remember that the ab- 
solute and specific weights of the brain range within certain limits, consistent 
with the healthy exercise of function. The following statements are made of 
standard numbers for reference and comparison illustrative of this point: 
Absolute Weight.-The absolute weight of the brain or encephalic mass 
varies in concurrence with variations of age, body-weight, and height of persons; 
and generally it may be stated as in the following table (page 978), compiled 
from the valuable records communicated to the Royal Society on the 28th 
February, 1861, by Dr. Robert Boyd, the Physician to the Somerset County 
Lunatic Asylum. 
It is by accurate observations such as these that the gradual growth of every 
organ of the body is demonstrated to advance slowly and in concurrence with 
advancing age and increase of body-weight. It is now also a matter of ex- 
perience, although too often overlooked, that the functions and organs of the 
body, and by no means rarely the brain and the Intellect, may be injured for 
life by pressing upon them too hardly and continuously in early years. What- 
ever theory we hold (as to the functions of the brain or Mind), "it is certain 
that the powers of the brain are only gradually developed; and that if forced 
into premature exercise, they are impaired by the effort. This is a maxim, 
indeed, of great import, applying to the condition and culture of every faculty 978 
SPECIAL PATHOLOGY-DISEASES OF THE NERVOUS SYSTEM. 
or function of body and of Mind, and singularly so to the Memory, which 
forms in one sense the foundation of intellectual life. A regulated exercise 
short of fatigue is improving to it (and to all faculties or functions), but weare 
bound to refrain from goading it by constant and laborious efforts in early 
life, and before the instrument is strengthened to its work, or it decays under 
our hands " (Sir Henry Holland's Mental Pathology'). 
Table Showing the Relative Averages of Body-weight and the Weight 
of Cerebral Organs as to Age and Height. 
Age. 
Sex. 
Body- 
Weight. 
Height of 
Body. 
Weight 
of 
Cerebrum. 
Weight 
of Cere- 
bellum. 
Weight of 
Pons and 
Medulla. 
Weight of 
Encepha- 
lon. 
Years. 
1 
to 
2 
Male, 
Female, .... 
Lbs. Oz. 
14 6 
13 2 
Inches. 
28.5 
27.7 
Ounces. 
29.21 
26.19 
Ounces. 
3.54 
3.15 
Ounces. 
.5 
.46 
Ounces. 
33.25 
29.8 
2 
to 
4 
Male, 
Female, .... 
20 0 
18 7.5 
31.6 
31.6 
34.03 
30.77 
4.02 
3.7 
.66 
.5 
38.71 
34.97 
4 
to 
7 
Male, ■ 
Female, .... 
25 8 
24 9 
37.5 
37.0 
35.44 
35.04 
4.17 
4.19 
.62 
.68 
40.23 
40.11 
7 
to 
14 
Male, 
Female, .... 
42 6 
38 6 
47.0 
45.0 
40.36 
35.86 
4 84 
4.27 
.76 
.65 
45.96 
40 78 
14 
to 
20 
Male, 
Female, .... 
68 0 
63 14 
60.5 
57.7 
41.77 
38 88 
5.32 
4.65 
1.0 
.85 
48.54 
43.94 
20 
to 
30 
Male, 
Female, .... 
92 14 5 
86 13 
66.75 
62.0 
41.98 
38.0 
5.19 
4.82 
.93 
.88 
47.9 
43.7 
30 
to 
40 
Male, 
Female, .... 
98 3.5 
87 0 
66.5 
62.0 
42.06 
37.92 
5.15 
4.74 
.98 
.91 
48.2 
43.09 
40 
to 
50 
Male, 
Female, .... 
102 0 
84 9.5 
66.8 
62.0 
41.48 
37.12 
5.22 
4.69 
1.06 
.89 
47.75 
42.81 
50 
to 
60 
Male, 
Female, .... 
102 0.5 
86 0 
66.0 
62.0 
41.09 
37.38 
5.13 
4.62 
.98 
.86 
47.44 
43.12 
60 
to 
70 
Male, 
Female, .... 
103 13 
86 14 
65.7 
61.5 
40.21 
37.13 
4.98 
4 68 
.97 
.83 
46.4 
42 69 
70 
to 
80 
Male, 
Female, .... 
106 13 
80 4 
65.7 
61.0 
39.6 
35.58 
4.97 
4.47 
.94 
.88 
45.5 
41 27 
80 
to 
90 
Male, 
Female, .... 
99 0 
79 0 
66.7 
60.0 
39.62 
34.47 
4.79 
4.47 
.89 
.82 
45.34 
39.77 
Bulk.-The bulk of the encephalon varies from 65 to 84 cubic inches. 
Specific Gravity.-The result of recent observations in Germany, France, SPECIFIC GRAVITY OF THE BRAIN. 
979 
and Britain, shows that any considerable change in the specific gravity of 
the cerebral substance is incompatible with a healthy exercise of the nervous 
functions. 
To Dr. John Charles Bucknill, Physician to the Devon County Lunatic 
Asylum, medical science is indebted for the first most extended account of 
the specific gravity of the cerebral substance, and its relation to disease, and 
more especially to atrophy and paralysis. The following are the general re- 
sults of his observations as detailed in The Lancet, 25th December, 1852, and 
for the most part made upon patients laboring under different forms of mental 
disease : 
(1.) Average specific gravity of healthy brain, 1.036. (2.) In paralysis 
of a chronic character, complicated with insanity, the specific gravity ranged 
between 1.036 to 1.046. (3.) In some acute cases the specific gravity was as 
high as 1.052. (4.) In paralysis terminating by coma, 1.040. (5.) In pa- 
ralysis terminating by syncope or asthenia, 1.036 to 1.039. (6.) In general 
terms, a higher specific gravity was found when life terminated by coma or 
asphyxia, than when it ended by syncope or asthenia. 
In addition to these observations, an able and elaborate paper has since 
been published by Dr. Sankey, showing the relative specific gravity of the 
gray and white matter of the brain, and of so extensive a nature as to furnish 
very copious data for comparing morbid states with the standard of health. 
The following are the general results of his researches, as given in The Brit- 
ish and Foreign Medico-Chirurgical Review for January, 1853, p. 257 : 
(1.) Mean specific gravity of the gray substance of the brain in either sex, 
1.034. (2.) In the earlier and later periods of life the specific gravity of the 
gray matter is below the mean. (3.) The cerebral substance acquires its 
greatest density in males between the ages of fifteen and thirty, and in females 
between the ages of twenty and thirty. (4.) The density diminishes with 
prolonged illness. (5.) It decreases with a lapse of time after death in the 
ratio of .001 for every twenty-four hours. (6.) A density of .006 above the 
average indicates the existence of the following conditions during life : Acute 
cerebral symptoms, or chronic disease with no cerebral symptoms, or only 
slight delirium ; also with conditions associated with hypersemia. (7.) Mean 
specific gravity of white matter, 1.041. 
Both sets of observations referred to above have been made upon the brain 
as a whole ; and as the observations of Dr. Sankey show that no constant 
relation exists between the absolute weight of the brain and its specific gravity, 
it is necessary to examine the brain as we do its anatomy-namely, by com- 
parative observations on its central parts or ganglia. 
At the time Dr. Bucknill published his observations I was engaged in 
determining the specific gravity of the central parts of the brain, which are 
sometimes called the central ganglia, and which are now generally regarded 
as the parts more immediately related to the combined exercise of sensory and 
motor functions. These centres consist of the corpora striata; thalami optici; 
tub er citla quadrig emina; and the large mass of vesicular nervous matter associ- 
ated with the convolutions of the hemispheres and the substance of the cerebellum. 
While these parts are the immediate seats of the origins of the nerves, they 
may be looked upon as parts where some changes in connection with the func- 
tions of special nerves are constantly going on, of such a kind that a result 
is expressed through "Volition, Perception, or Emotion, or the balancing or 
co-ordinating of movements " (Todd). 
These parts have a specific gravity as follows: The central ganglia, 1.040 to 
1.047; the cerebrum, 1.030 to 1.048; the cerebellum, 1.038 to 1.049. 
The same kind of morbid states which modified the specific gravity of the 
brain-substance, as recorded by Drs. Bucknill and Sankey, also manifest their 
influence on the central parts. Thus death by coma, and especially in typhus 
fever, was indicated by an extremely high specific gravity; and while it was 980 
SPECIAL PATHOLOGY-DISEASES OF THE NERVOUS SYSTEM. 
observed that a slight difference was common in most cases when similar parts 
on opposite sides were compared, it is presumed that further observation, 
extended in this direction, especially in cases of hemiplegia, may lead to 
important results. In one case of choreic hemiplegia which I had an oppor- 
tunity of carefully investigating, the specific gravity of the corpus striatum and 
optic thalamus on the right side was found to be 1.025, while the specific grav- 
ity of the corresponding parts on the left side was observed to be 1.031 (^Glas- 
gow Med. Journal, No. I, 1853). 
Pathological Relations of the Nervous Organs and Texture.-Our knowl- 
edge of these relations is necessarily imperfect, and for the following reasons: 
(1.) The functions of the various parts which, connected together, constitute 
the encephalon, are not yet determined accurately. (2.) The inconstancy and 
irregularity of the functional disorders which accompany the morbid state of 
the nerve-substance render it difficult to interpret the value of the symp- 
toms by which the nervous diseases are manifested. (3.) Some of the diseases 
of the brain and nervoys system which are marked by the most violent symp- 
toms during life, such as epilepsy, chorea, tetanus, and hydrophobia, leave after 
death no constant lesion capable of being detected with the unaided eye, or 
even by microscopic examination; while tumors and serious destruction of the 
nervous mass may exist during life without producing any severe or pathog- 
nomonic symptoms whatever. (4.) We have no means of applying physical 
diagnosis to the cranium, as we have to the chest, although it has been pro- 
posed by some (Drs. John Fisher and Whitney) to found diagnosis upon Cere- 
bral Auscultation. For an abstract of the nature of the investigations "On the 
Auscultation of the Brain" the reader is referred to Wood's Practice of Medi- 
cine, vol. ii, p. 621, and also to a notice of Henning's "Inaugural Dissertation 
on the Sounds perceptible about the Head and at the upper portion of the 
Spinal Column in Children," in Med.-Chir. Review for 1857, p. 528. 
The general principles on which the pathological relations of the brain dis- 
eases are determined, rest upon the anatomical, chemical, clinical, and physio- 
logical facts now accurately known. An accurate knowledge of anatomy is 
most essential in the study of disease of the nervous system. 
In connection with the physiological view of the subject there are several 
cardinal facts which must be constantly kept in remembrance, and which may 
be shortly referred to here. 
There are separate and distinct functions performed by the gray and white 
matter which enter into the structure of the nervous centres and organs. 
Reasoning from the general properties known to be possessed by cells in other 
structures, it is now a generally received doctrine, that the cells of the gray sub- 
stance of the brain and nervous centres are the seat or source of that force which 
has received the name of the " nervous force, nervous power, or nervous influence," 
and which makes itself known by sensation and motion, as also by the various 
ways in which the mental acts are expressed. The white nerve-fibres are in con- 
nection with the gray or cell-elements of the nervous tissue, conducting from 
and to these centres the "influences" which are sent to, or which originate 
there and are thence sent forth. 
The union of the nerve-tubes with the nerve-corpuscles is supposed to be 
connected with the transference of action from one nerve-fibre to another, as 
in reflex action. 
It is likewise a remarkable fact that each nerve-fibre in a fasciculus acts 
quite independently from end to end,-quite isolated from the others in its 
vicinity; and thus at once we have the enunciation of three distinct sets 
of physiological phenomena associated with the diseases of the brain and 
nerves. 
First,-Phenomena of Isolated Conduction.-Exalted or diminished action 
is presented by that nerve-fibre only which is affected by the irritating or DIFFERENTIAL DIAGNOSIS OF BRAIN DISEASES. 
981 
depressing cause, and the adjoining fibre, though in ever such close approxi- 
mation, is not implicated. 
Second,-Phenomena of Sympathy or Irradiation of Sensations.-That irri- 
tation is propagated from a fibre originally excited to other centripetal 
nerves. 
Third,-The Phenomena of Intelligence.-The brain furnishes the condi- 
tions necessary for the manifestation of the intellectual faculties', properly so 
called, such as the Emotions, Passions, Volition, and is at the same time essen- 
tial to Sensation. 
That the evolution of power or nerve-force immediately connected with 
Mind is dependent on or emanates from the hemispherical ganglia, is rendered 
probable by the following facts: (1.) In the animal kingdom generally a cor- 
respondence is observed between the quantity of gray matter, the depth of the 
convolutions, and the sagacity of the animal. (2.) At birth the gray matter 
of the cerebrum is very defective, so much so that the convolutions are, as it 
were, in the first stage of formation, being only marked out by superficial fis- 
sures, confined to the surface of the brain; and as the gray substance increases, 
Intelligence becomes developed. (3.) The results of experiments have shown 
that, on slicing away the brain, the animal becomes more dull and stupid in 
proportion to the quantity of gray substance removed. (4.) Clinical observa- 
tion points out that in those cases in which the disease has been found to 
commence at the circumference of the brain, and proceed towards the centre, 
the mental faculties are affected first-e. g., meningitis and the like; whereas 
in those diseases which commence at the central parts of the organ, and pro- 
ceed towards the circumference, the mental faculties are affected last-e. g., 
tumors in the central white substance. 
The white tubular matter in the form of the diverging fibres of the brain 
conduct influences, originating in the hemispherical ganglia, to the nerves of 
the head and trunk; while they also conduct, in an inverse manner, the im- 
pressions made on the peripheral parts up to the cerebral convolutions. 
The spinal cord, by its connection with the brain, furnishes the conditions 
necessary for combined movements; and that its nervous force is also depen- 
dent upon its gray matter is rendered probable by the following facts: 
(1.) The universal connection of the gray matter with all motor nerves. (2.) 
Increased quantity of the gray matter in those portions of the spinal cord 
whence issue large nervous trunks. (3.) The collection of gray matter in com- 
paratively large masses at the origin of such nerves in the lower animals as 
furnish peculiar organs requiring a large quantity of nerve-power, as in the 
Torpedo, Gymnotus electricus, and Silurus. (4.) Clinical observation shows 
that in cases where the central portion of the cord is affected previous to the 
external portion, the individual retains the sensibility and power of moving 
the limbs, but wants the power to stand or walk ; whereas, when disease com- 
mences in the meninges of the cord, pain, twitching, convulsions, numbness or 
paralysis indicate lesion in the white conducting matter. 
Independent endowment of nerves is shown by the fact that, whatever be 
the stimulus which calls their power into action, a uniform functional result 
is obtained ; and hence it is inferred that the nerves are not altogether the 
mere conducting tubes of a stimulus from one place to another, but are in 
some respects the seats, or agents, oi' apparatus of power. 
As far as we know, the brain alone furnishes conditions necessary for Intel- 
ligence, the spinal cord conditions essential to Movement; and together they 
furnish conditions connected with the balancing and co-ordination of motor and 
sensific power. 
In dealing with the diseases of the Nervous System, it is incumbent on 
the physician to ascertain, as correctly as possible, the locality of the lesion, the 
nature of the affection, and the anatomical condition of the part affected. Although 
it has been sometimes asserted that it is of little practical importance to dis- 982 
SPECIAL pathology-DISEASES of the nervous system. 
criminate accurately between diseases of one part of the brain or of its mem- 
branes and those of another, because the treatment may be the same for all, 
yet, for the sake of science-because "knowledge is power," and because the 
acquisition of such knowledge must eventually alleviate the sufferings and 
lessen the sorrows of humanity-the sooner such doctrines are ignored the 
better for the Science of Medicine ; and, moreover, the majority of the medical 
profession are beginning to appreciate the principle that diagnosis should be 
carried as far as possible. To the advanced student, who would desire more 
minute information to guide him in the differential diagnosis of brain diseases 
than can be given in a text-book of medicine, he is recommended to study the 
work of Dr. J. Russell Reynolds, Professor of Clinical Medicine in University 
College, on the Diagnosis of Diseases of the Brain, Spinal Cord, and Nerves, as 
well as the writings of Dr. Sanders, of Edinburgh, Dr. H. Jackson, of the 
London Hospital, and Mr. Lockhart Clark, and the comprehensive manual 
of Tuke and Bucknill On Insanity. From these and other works the general 
remarks and descriptions of brain diseases have been mainly compiled. 
Section II.-Guides to the Diagnosis of Diseases of the Nervous 
System. 
I. As to Locality or Site of Lesion.-As yet we are able only in some cases 
of tumors of the encephalon to define their locality, as to whether they are in 
the cerebrum, cerebellum, or central ganglia. 
With regard to the cerebrum, it may be determined in the majority of struc- 
tural diseases which lateral half is affected, and in particular cases it may be 
predicated with strong probability that the lesion is situated in some one of 
the following sites : (1.) The substance of the hemispheres (cortical or central); 
(2.) The ventricles,-hemorrhage into these cavities, for example, may some- 
times be distinguished from effusion into the substance of the hemisphere; (3.) 
The base of the brain; or (4.) Its superior surface. Inflammation of the 
brain-substance and of the meninges presents different symptoms when occur- 
ring in the two last-mentioned situations. 
In the present state of science we are unable to localize exactly either the 
diseases of the cerebellum or of the central ganglia of the brain from symptoms 
during life. 
Diseases of the pia mater and arachnoid may be discovered by the history 
and progress of a case from those of the dura mater; and sometimes it is pos- 
sible to distinguish meningitis of the base from that of the convexity of the 
brain, chiefly from the influence which the diseased meninges exercise upon 
the functions of the parts beneath. Disease of the dura mater, for example, 
may often also be inferred from morbid conditions discoverable in the organs 
of special sense, or from disease in the bones of the cranium, or of the integu- 
ments or scalp. 
With regard to diseases of the spinal cord, similar grounds for diagnosis 
exist; and the locality of the lesion may often be correctly referred to the 
anatomical regions of the cord, to certain columns of its substance, to the white 
or gray nerve-substance of which it is composed, or to the coverings. It is of 
importance in cases of diseases of the nervous trunks to know which set of 
the cranial nerves are affected; and in relation to the spinal nerves it is nec- 
essary to distinguish diseases of the anterior from those of the posterior roots, 
as well as the region of the cord from which the diseased roots proceed. 
The grounds of diagnosis of the locality of nervous diseases generally may 
be summed up as follows: 
(A.) The brain is presumed to be the seat of lesion when several of the 
special senses are simultaneously affected ; when Perception, Ideation, Volition, 
and special Sensation, are affected; when the muscles and general sensory DIAGNOSIS OF CEREBRAL AND MENINGEAL DISEASE. 
983 
nerves are implicated longitudinally and unilaterally (hemiplegia) : when 
muscles situated so high as those of the face and tongue are involved, and the 
orbicularis of the eyelids does not share in their affection. In these rare cases 
of bilateral (or transverse) paralysis {paraplegia') resulting from some cerebral 
change, the symptoms at some period of the case have generally referred to 
the head (by their special character), so that, by a combination of the two 
classes of observations, the general diagnosis may almost universally be estab- 
lished. 
(b.) The spinal cord is presumed to be the organ affected when the symp- 
toms of motory and sensory character are distributed transversely or bilater- 
ally, inducing paraplegia or transverse spasms; when the mental functions 
are unchanged. The precise locality may be estimated sometimes from anat- 
omy of the spinal nerves. If the lesion or disease is high, speech, deglutition, 
or respiration may be impaired. There is often erection of the penis, and 
the retention or voluntary discharge of fseces or urine. 
(c.) The nerve-trunks are presumed to be the seat of lesion when the symp- 
toms are referable to an isolated muscle, or group of muscles, or to a small 
portion of the sensory surface. When paralysis is the symptom, the irrita- 
bility of the muscles to electric stimulation is quickly lost, and the symptoms 
show no disposition to wander from the special localities affected (Reynolds). 
The distinguishing characters of meningeal from cerebral diseases may be 
arranged in the following tabular form, for comparison and reference: 
CEREBRAL DISEASE. 
1. From the outset, or from a very early 
stage of development, there is loss of some 
one or more of the proper nervous func- 
tions, such as paralysis, anaesthesia, loss of 
memory. 
2. Cerebral disease is not commonly 
attended by high-marked exaggeration of 
function, such as furious delirium, con- 
vulsions, intense hyperaesthesia, pain, or 
tenderness. 
3. Little vascular excitement attends 
cerebral disease, nor is there frequently 
any highly marked general disturbance. 
4. Paralysis and Anaesthesia, losses of 
Volition, Ideation, Perception, and the 
like, characterize cerebral disease. 
MENINGEAL DISEASE. 
1. It is not till some time after the detec- 
tion of signs of disease that diminution or 
loss of nervous function takes place. 
2. The subsequent diminution or loss of 
nervous function which succeeds the pro- 
longed existence of "head symptoms" is 
generally preceded, in cases of meningeal 
disease, by extremely severe excitement or 
exaggeration of functions, such as pain, 
tenderness, furious delirium, or convul- 
sions. 
3. In meningeal affections there is usu- 
ally much local vascular excitement, with 
general disturbance. 
4. Spasms, convulsions, pain, and delir- 
ium, are the general features of menin- 
geal disease. 
In diagnosing the locality of diseases of the brain generally, it is necessary 
to distinguish, in the first instance, the intrinsic diseases of the nervous system ; 
also local diseases from nervous complications of other diseases not of a local 
kind. It is necessary also to distinguish affections of the brain, spinal cord, 
and nerves, as much as possible from each other; and, lastly, to separate dis- 
eases of the meninges from cerebral lesions. 
It is chiefly by the history of the case that nervous symptoms peculiar to 
the specific or constitutional class of diseases are to be distinguished. It is 
also generally worthy of notice that symptoms referable to altered nervous 
functions are the earliest indications of intrinsic or local diseases of the 
organs of the nervous system; and that when general disease exists of a spe- 
cific or constitutional kind, the nervous symptoms are secondary in relation to 
the time of their appearance, compared with the earliest manifestation of 
symptoms of ill-health. 
The diagnostic value of vomiting, as a symptom of cerebral disease, is one 984 
SPECIAL PATHOLOGY-DISEASES OF THE NERVOUS SYSTEM. 
which must be thoroughly appreciated. Regarding this symptom, Dr. Rey- 
nolds makes the following remarks: "The intimate sympathy subsisting 
between the stomach and the head is a matter of daily observation. Head- 
ache from gastric disturbance is as common as vomiting from cerebral 
derangement. In children especially, the existence of obstinate vomiting is 
indicative of head rather than of stomach disease. A consideration of the fol- 
lowing points (for comparison tabulated) may lead to the discrimination of 
the pathological significance of this symptom: 
GASTRIC OR HEPATIC VOMITING. 
1. There is nausea, which is relieved, at 
all events temporarily, by the discharge. 
2. The tongue is foul, the conjunctivae 
often yellowish, and the headache secon- 
dary in respect of time. 
3. Griping pain in the abdomen, diar- 
rhoea, and disordered evacuations frequent- 
ly attend the gastric or hepatic vomiting. 
4 Retching and increased salivation at- 
tend gastric or hepatic vomiting. 
CEREBRAL VOMITING. 
1. Little or no nausea, and the vomiting 
continues, in spite of the complete dis- 
charge of its contents by the s.tomach, so 
soon as anything (liquid or solid) is intro- 
duced. 
2. The tongue may be clean, the conjunc- 
tivas colorless or injected, and the head- 
ache primary. 
3. Obstinate constipation generally at- 
tends cerebral vomiting. 
4. In cerebral vomiting the stomach is 
emptied almost without effort, and without 
any increase of the salivary secretion. 
Thus, while vomiting may depend upon derangement in the gastro-intesti- 
nal canal, it may also depend upon increased sensory or reflex action, and is 
thus a valuable indication of cerebral disease." 
II. As to the Nature of the Affection.-The nature of the intrinsic dis- 
eases of the nervous system may be shortly stated to be- 
(a.) Acute but non-febrile, to distinguish them from the nervous symptoms 
which attend the febrile state of many of the diseases already noticed, as pecu- 
liar to the Specific and Constitutional classes. They are of such a kind as are 
marked by-(1.) Diminution or loss of functional activity (apoplectic and 
paralytic diseases); (2.) Increase or excess of action, such as of sensibility 
(neuralgia), of mobility (convulsions, spasms'), ideation (delirium). 
(b.) Chronic diseases, the character of chronicity depending not only on 
the time such diseases last, but also on the severity of their course. 
Such chronic diseases are marked by-1. Excessive functional activity, as 
by neuralgia, hallucination, chorea, hypochondriasis. 2. Diminution or loss of 
functional activity-for example, anaesthesia, paralysis, dementia, epilepsy. 3. 
Combinations of these conditions, such as-(1.) Loss of mobility, with in- 
creased sensibility, as in paralysis with pain. (2.) Loss of mental, with 
increased motor activity, as in coma with spasms. (3.) Loss of sensibility, 
with increased mobility, as in anaesthesia with reflex spasms. 
It is of great importance to recognize, as Dr. Brown-Sequard points out, the 
necessity of distinguishing between the symptoms of (1.) Loss of function; and 
(2.) Irritation. 
The most frequent cause of local paralysis or loss of function is an irrita- 
tion in certain parts of the nervous centres, or in the trunk or periphery 
of nerves. Such circumstances may produce paralysis in very different parts 
in different cases, according to the particular fibres on which the irritation 
has acted. Thus there are now numerous cases, capable of clinical recogni- 
tion, where paralysis of the upper and lower limbs, and of the face, as well 
as of contractions and rigidity, which are traceable to the influence of reflex 
action. 
Symptoms of irritation may be arranged in two groups, according as the 
irritation acts-(a.) In the central parts, as in convalescence from such 
serious illnesses as enteric fever-overtaxing the mental powers, as in the case STRUCTURAL CHANGES IN THE NERVOUS SYSTEM. 
985 
of weak children; or (6.) In the peripheral parts of nerve-fibres, as in the 
neuralgic headache of dyspeptic children during the second dentition, when 
the symptoms frequently resemble those of the first stage of tubercular menin- 
gitis. Convulsions are not rarely due to the irritation of ascarides; and they 
also occur concomitantly with the second dentition, just as they occur in the 
first. 
III. As to the Anatomical Condition.-Although some of the diseases of 
the nervous system are marked by excessive severity of symptoms during life, 
such as tetanus, epilepsy, chorea, hysteria, neuralgia, and the like, yet no char- 
acteristic or constant structural change can be detected in the nervous centres 
after death, either as a consequence or as a cause of such diseases; and although 
the belief is daily extending, that no morbid conditions of function can exist 
without some correspondent change in the organs, yet, so long as we have no 
means of appreciating such changes, the diseases now noticed must be regarded 
as "neuroses," "dynamic," or "functional" diseases. 
But there are many other diseases of the nervous system which are attended 
by some physical changes in the organ, expressed by undoubted symptoms 
during life, and which leave evidence of their existence after death. For 
example, very different apparent vascularity is discoverable after death in the 
nervous masses and texture; and there are two very common classes of ner- 
vous symptoms during life which evidently depend upon the variable amount 
of blood in the brain. These symptoms are referable to active arterial hyper- 
cemia, and are distinguished by the well-known phrase of "determination of 
blood to the head;" or they are referable to passive venous hypercemia, com- 
monly called "congestion." The question has been much discussed and ex- 
perimented on as to whether more than a fixed proportion of blood can find 
its way into the brain. It was at one time supposed that the amount of blood 
contained in the closed cavity of the adult cranium could neither increase nor 
diminish, but was a constant quantity. There can be no doubt that all con- 
siderations of the subject lead to the conclusion that the quantity of blood 
within the cranium is extremely variable at different times and under different 
circumstances; and (as clearly stated by Dr. Sieveking) there is a peculiar 
property belonging to the white matter of the brain which has a strong bear- 
ing on the question-namely' the great elasticity of the medullary tissue, so 
much so that the resiliency afforded by this property is a sufficient counter- 
poise to the rigid structures which envelop the brain, and which do not, as is 
erroneously supposed by some, remove the intracranial contents entirely from 
the influence of atmospheric pressure. That pressure is exerted on a large 
surface, composed of columns or tubes of blood in innumerable small curved 
vessels which maintain, through the scalp and diploe of the skull, a direct com- 
munication with the blood within the cranium; and which is thus directly in- 
fluenced by atmospheric pressure, while every anatomical arrangement of the 
parts within the cavity of the skull illustrates provisions made to counter- 
balance the varying interchange of bulk between the solid and fluid contents 
of that cavity. Among these may be noticed the ventricular and subarachnoid 
spaces, with their varying amount of contained serosity, as furnishing most 
prominent evidence of provision to accommodate the varying amount of fluids 
within the cranium. 
Morbid states of the brain are also due to a poisoned state of the blood ; 
although such a condition cannot be proved in all cases-such, for example, 
as occurs in many of the general diseases already noticed, such as Typhus, 
Variola, Rheumatism, as well as from the action of Alcohol, Opium, and Urea. 
IV. As to Urea in the Blood and Brain.-It is often of importance to de- 
termine whether urea circulating in the blood is contaminating the brain and 
impairing its functions. 
The following instructions are given for the detection of urea in the brain 
after death, as well as for its discovery in the blood during life: 986 
SPECIAL PATHOLOGY DISEASES OF THE NERVOUS SYSTEM. 
"1. In the Serum.-Take the serum from a good-sized blister, and evaporate 
it to dryness over a water-bath. The residue is to be extracted with alcohol, 
which is a ready solvent of urea. This alcoholic extract is then to be evapo- 
rated to dryness, and a little water added, so as to make a syrupy mass, which 
should be plunged into a freezing mixture, and a few drops of pure nitric acid 
added to it. If urea be present, the characteristic crystals of nitrate of urea 
are soon found in the solution, and may be recognized either by the naked eye 
or by the microscope (Fig. 94). 
Fig. 94. 
" 2. In the Substance of the Brain.-Take about three-fourths of a whole 
brain, and cut it up into small pieces. Then treat it with four successive por- 
tions of boiling distilled water, each portion, consisting of about ten ounces, 
being allowed to stand six or eight hours before the next is added. The brain 
while thus macerating should be frequently stirred and mashed about with a 
glass rod. The washings, after being poured off, are to be mixed together and 
filtered. The filtered aqueous extract so obtained must be evaporated to dry- 
ness over a water-bath, and the dry residue, after being powdered, is to be again 
treated with four successive portions of boiling distilled water, observing the 
same precautions as before. The washings, after being mixed together as be- 
fore, are to be filtered, and the clear solution evaporated to dryness over a 
water-bath ; and after being thoroughly dried in a hot-water oven, the residue 
obtained in this manner should be finely powdered, and the powder boiled in 
five successive portions of ether. The ethereal extract so obtained should be 
evaporated to dryness at a low temperature, and then treated with a little 
tepid water, and allowed to get quite cold. It is then to be filtered through 
paper previously moistened with water, and the clear solution again evapo- 
rated to dryness at a low temperature, when a small quantity of the extract 
procured in this way (which would contain all the urea present in the brain 
operated upon) is to be placed on a glass slide, treated with' a drop of strong 
nitric acid, covered with a bit of thin glass, and allowed to stand a little time, 
and then examined under the microscope. A few crystals will then be seen, 
having all the characters of those of nitrate of urea" {Clinical Lectures, by 
Dr. Todd, 1859). 
V. As to the Morbid Textural Changes of the Brain.-These consist 
chiefly of inflammation and its productive consequences, or in softening, de- 
Nitrate of Urea (after Beale). No. II. Urinary Deposits, Plate III. LESIONS OF THE BRAIN-SUBSTANCE. 
987 
generation, or atrophy of the nerve-substance; and in heterologous products, 
such as result from tuberculous or carcinomatous infiltration. The nervous 
centres are also known to waste, harden, and lose weight as age advances, 
and the nerves participate in these changes. Hardening seems less constant 
than wasting and loss of weight; but it is a change very generally observed 
in old people; and its characters are thus described by Dr. Maclachlan: 
"The cortical portion is thinner and darker than in adults, and the medullary 
portion is often void of its glistening white appearance, which gives place to a 
dull white or gray, and frequently to a pale drab color in old age." The 
membranes of the brain are also thicker, more opaque, and more resisting in 
the aged. This is especially the case with the arachnoid, and is associated 
with enlargement of the Pacchionian glands or villi. The condensed dura 
mater acquires immense strength, and adheres firmly to the calvarium, es- 
pecially along the margins of the longitudinal sinus. 
When the brain shrinks, as in atrophy, there is a marked increase in the 
cephalo-rachidian fluid, according to the degree of atrophy. Instead of two 
or three ounces, there may be ten or twelve ounces; and the subarachnoid 
areolar tissue is then also frequently infiltrated with serum (Maclachlan). 
The ventricles contain more than the usual quantity of serosity, and the 
lateral ventricles especially are filled with limpid fluid. Flattening of the 
surface of the convolutions becomes apparent, while the sulci are widened and 
diminished in depth. 
It is of importance to study every disease of the nervous system as present- 
ing-(1.) Disease or changes in tissues; (2.) Damage of organs generally; 
(3.) Disorder of function (H. Jackson). 
The object has been, in most cases, to discover the seat of the disease, rather 
than its cause. A softening, a sanguineous effusion, and an abscess may pro- 
duce exactly the same symptoms if seated in the same part of the brain; 
whereas when seated in different parts of the cerebral structures, affections of 
the same nature have little in common, so far as effects are concerned. 
For the purposes of diagnosis it may be useful also to arrange in groups 
the diseases of the nervous system as follows: (1.) Those attended by a febrile 
state, and where delirium is often a prominent symptom, such as encephalitis 
and meningitis. (2.) Those characterized by a group of symptoms commonly 
called " apoplectic,where loss of consciousness and of voluntary motion takes 
place as if by a "sudden stroke," such as in the various forms of apoplexy. 
(3.) Those diseases characterized by exalted, perverted, or suspended functional 
activity; as by convulsions, spasms, or derangement of motion-such as chorea, 
hysteria, catalepsy, epilepsy, hydrocephala, sunstroke, diseases of the Intellect. 
Many words in common use also require definition, e. g.: 
Convulsion.-The occurrence of universal involuntary muscular contrac- 
tion, generally of paroxysmal or temporary duration. 
Spasm.-Involuntary convulsive actions of less extent. Of these there are 
several varieties: 
(a.) Clonic Spasm-Consists in rapidly alternating contraction and relax- 
ation, as in subsultus tendinum. 
ft.) Tonic Spasms or Spastic Contractions-Consist in contractions having a 
certain duration, attended with rigidity or hardness of the muscles, as in 
common cramps and tetanus. 
Epileptoid or Epileptiform Attacks-Imply a sudden loss of Perception and 
voluntary power, with more or less generally distributed spasmodic move- 
ment. The movements are quasi-tonic at first, then clonic, and appear to im- 
pede the respiratory process. The attack lasts from two to twenty minutes, 
followed by some exhaustion and sleep (Reynolds). 
Coma-Denotes the loss of Perception and Volition; in other words, the 
loss of Consciousness, with the appearance of profound sleep, from which the 
patient may be partially roused. 988 
SPECIAL PATHOLOGY-DISEASES of the nervous system. 
VI. As to Physical Conditions.-The investigation of certain physical con- 
ditions materially helps the diagnosis of diseases of the nervous system. The 
physical conditions to be particularly inquired into are- 
(a.) Perversion of the sense of touch and power of discrimination. 
(b.) Perversion of muscular power. 
(c.) Perversion of body-heat. 
(d.) Perversion of the powers of expressing thought (Aphasia). 
Of these in their order. 
(a.) Perversion of the Sense of Touch.-The physical diagnosis of perver- 
sion of the sense of touch and power of discrimination is based on the fact, 
that "if two points of a hard substance touch an unmoved cutaneous surface, 
they can only be perceived separately when the distance between them exceeds 
a certain limit." Weber has shown that the minimum of distance thus estab- 
lished varies in different parts of the skin. By this experiment he constructed 
a scale of the sensibility possessed by the several tactile surfaces; and to do so, 
he used a pair of compasses, the points of which were armed with suitable 
pieces of cork, to find out the shortest distance at which the points are recog- 
nized as separate. A shorter distance than this will give rise to an indistinct 
impression of a long-drawn point; and finally, on approximating the points 
still more closely, the perception of the two points becomes completely the 
perception of one point only. 
Dr. Sieveking devised an instrument of this kind suitable for such physical 
diagnosis of tactile sensibility, which he called the AEsthesiometer (Fig. 95). 
He applied it in paralysis, to ascertain the amount and extent of sensational 
impairment in paralysis, as a means of diagnosis between actual paralysis of 
sensation and mere subjective anaesthesia, in which the tactile powers are unal- 
tered, and as affording a means of determining whether a case of palsy was 
progressing for better of for worse (Brit. and For. Med.-Chir. Review, vol. xxi, 
p. 280, 1858). 
Fig. 95. 
Instruments on a similar principle have been devised by Drs. Brown-Sequard 
and John Ogle; but the best instrument is said to be that of Dr. Jaccoud, 
made by Colin & Robert of Paris, about nine centimeters long, with a mova- 
ble scale in the form of an arc of a circle, the whole folding up so as to be 
easily carried in the pocket. 
For those who treat nervous diseases this instrument is as indispensable as 
is the stethoscope to those who treat diseases of the chest. It not only meas- 
ures the degree of tactile sensibility, and ascertains its perversions, but it aids 
in making out the precise site and nature of the disorder, particularly if the 
lesion be at the base of the brain, and in the spinal cord. 
As it is necessary to know the normal distance limits, Weber's results may 
be stated as a standard for comparison,-premising that a delicate skin and 
an active mind admit of shorter distances than are here given (Valentin's 
Physiology, p. 493): 
" (1.) The point of the tongue has a more delicate sense of touch than any USE OF THE ESTHESIOMETER. 
989 
other part of the body. Here the minimum distance is .0433 inch. The skin 
of the middle of the back gives a minimum distance of 2.13 to 2.68 inches, 
and is the region where touch is dullest. Hence the extremes may differ 
from fifty to sixty-fold. 
"(2.) Assuming that the average for the tongue is = 1, the distance for the 
terminal phalanx of the index finger is 1.2, and for that of each of the remain- 
ing fingers 1.8. At the thumb side of the first and second phalanges, it is 3.3; 
and on the dorsal surface of the last phalanx, 4.4. 
"(3.) The red part of the lips gives 3.1, and the white 4.6. This difference 
is chiefly due to the unequal thickness of their coverings, and perhaps to their 
nervous relations. The remainder of the face has a still duller sense of touch. 
On the outer surface of the eyelids it is 7.9; on the skin of the cheeks, 9.4 to 
10.9; and in the inferior frontal region, 12.4. 
" (4.) The tactile sensibility of the foot is in every respect inferior to that 
of the hand. For example, the volar side of the terminal phalanx of the 
thumb gives 1.5; and that of the great toe, 6.7. The dorsal surface of the 
hand gives from 4.4 to 14.4; and that of the foot 12.2 to 25.9. 
"(5.) The extremities of the limbs, such as the hand and foot, have a more 
delicate sense of touch than their middle segments, such as the forearm and 
leg; while these again are more sensible than the segments connected with the 
trunk, such as the thigh and upper arm. The two latter belong to those 
parts which do not possess a high development of tactile capacity. The vicin- 
ity of the elbow and the knee-joint is more sensitive, being easily excited to 
pain. 
"(6.) The face has a more accurate sense of touch than the crown of the 
head or the neck. The dorsal surface of the trunk is inferior to the abdominal 
in this respect. 
" (7.) It would seem that, in the adult, these minimum distances alter very 
little by lapse of time. At least the author finds that his skin gives about the 
same numbers as it did eleven years ago. 
" (8.) The friction of some parts of the skin gives rise to peculiar feelings of 
tickling, or to voluptuous sensations. But such parts do not necessarily rank 
high in the scale of tactile sensibility. Thus the axilla gives 26.9, and the 
foreskin 10.6, as the minimum of distance. 
"(9.) The tactile sensibility is capable of being increased by habit to an 
extraordinary degree. In this way some blind persons are able to recognize 
different colors by inappreciable differences in their grain. The Bengalese 
spinning women can distinguish the threads of the cocoon with a tactile deli- 
cacy which is almost incredible. And persons devoid of arms may educate 
the sensibility of the toes, until it corresponds with that of the fingers of an 
ordinary individual. 
"(10.) In judging of the delicacy of touch, we usually take the minimum 
distance at which two points can be recognized as the unit from which to start. 
This fact explains a peculiar illusion, to which attention was first drawn by 
Weber. When we draw the protected points of the compasses downwards from 
the cheek to the lips, it seems as if the distance between them gradually 
increased in consequence of our thus proceeding from a less sensible part to 
one which is more so." 
The following are the rules laid down by Dr. Brown-Sequard for the use of 
the Esthesiometer: 
(1.) Fix the two points of the instrument at the distance which is normal 
to the part of the skin to be inquired into. 
(2.) Cover the points of the instrument by pieces of cork, as the slightest 
prick producing pain interferes with the perception of tactile sensation. 
(3.) The points must be applied simultaneously. If the patient feels only 
one point, when both points touch the skin at the same time, the two points 990 
SPECIAL PATHOLOGY-DISEASES OF THE NERVOUS SYSTEM. 
must be gradually separated from each other, and reapplied to the part until 
both points are felt. This arrangement will indicate the anaesthesia. 
If, on the other hand, the two points are each distinctly felt at the normal 
distance limit, they are to be gradually brought nearer to each other till one 
point only is felt. This arrangement indicates hyperaesthesia. 
(4.) The patient ought not to be allowed to see whether one or both points 
of the instrument are applied, nor should he be made cognizant of the object 
of the experiment. 
(5.) The instrument should first be applied upon a healthy portion of skin, so 
as to ascertain how far he can discriminate the sensation of one or of two points. 
(6.) If the patient knows that both points are in contact he may imagine he 
feels both, no matter how short the distance may be between the points. In 
such cases one point only should be applied ; and after he has asserted that he 
feels both, let him see that one only has been used : otherwise preconceived 
notions will destroy the value of the experiment. 
(7.) In anaesthesia of considerable extent, the two points of the instrument 
may be applied one after the other after an interval of forty or fifty seconds, 
and yet give the sensation of only one point: this is due to the slowness of the 
transmission of the impression; and the aesthesiometer in this way may mark 
the rapidity of the transmission of tactile impressions. 
(8.) When the degree of anaesthesia is great, the two points of the (Esthes- 
iometer are felt only as one, no matter how great the distance between them, 
provided that they are applied upon the same longitudinal line. Brown- 
Sequard has known one point to be put upon the wrist and the other upon the 
forearm, and yet there was the sensation of one point only. 
(9.) Cutaneous hyperaesthesia may be of such an amount that, however 
close the two points may be, both continue to be felt. In a case of chronic 
spinal meningitis, tactile sensibility was so much heightened that the patient 
felt both points applied to the thigh at the distance of one millimeter apart; 
whilst, in health, there should have been a space of from five to six millimeters 
between them for both to have been distinctly felt. 
(10.) To avoid the mistake of finding either anaesthesia, or hyperaesthesia, 
when there is really neither, it should be borne in mind that strychnia increases 
tactile sensibility, whilst belladonna lessens it. If then it is necessary to find 
out the exact state of the cutaneous sensibility of any one part of the body in 
patients using either of these drugs, the state of tactile sensibility in the healthy 
parts should be first explored, and the actual normal type of the individual 
under the influence of these drugs be ascertained. 
(11.) In certain cases when two points of an aesthesiometer are applied there 
is a distinct sensation of three points ; or two points may be felt when one only 
is applied. In the instances in which this perversion of tactile discrimination 
has been met with, there has always been inflammation or congestion, some- 
times the result of an intracranial tumor at the base of the brain, and especially 
in one of the cerebral peduncles, or in one of the lateral halves of the annular 
protuberance. The sites of this phenomenon are the face, neck, and the hand, 
but particularly the face, for, in nine cases in which it was observed, in six it 
was limited to the face. When the distance between the two points of the in- 
strument was two centimeters, two, or sometimes only one, point was felt; but 
at two and a half, or three, and even at four, centimeters, there was a distinct 
sensation of three points touching the skin (Brown-Sequard, Archives de 
Physiologic, t. ?., 1868). 
(b.) Perversion of Muscular Power.-On this point Dr. Clymer makes the 
following remarks in the American edition of this work: 
" Muscle is the instrument, and not the producer, of force; the genetic factor 
of all muscular power being in the nervous system. Hence damage to the 
nervous centres is followed by derangement of muscular function-diminished PERVERSION OF POWERS OF EXPRESSING THOUGHT. 
991 
or total loss of power being one of the most common consequences of cerebral 
and spinal disease. 
" To measure the strength of paralyzed muscles of the upper extremity, the 
dynamometer of Mathieu, a surgical cutler of Paris, will be found a useful in- 
strument. The usual plan of making the patient grasp the physician's hand 
gives an imperfect indication, nor does it allow of any correct estimation of 
changes for better or for worse in the progress of the palsy. This simple in- 
strument consists of an elliptical steel spring, to which is attached a semicircle 
of gilt brass, upon which a scale is marked. An indicator, with a small cog- 
wheel at one end, may be moved 
freely around the arc of the circle 
by a steel arm, upon one side of 
which cogs are cut, fitting into those 
of the indicator. The lower end of 
this arm touches the elliptical spring, 
when the indicator points to zero on 
the scale; a brass sheath on the 
under side of the scale keeps this 
arm in place, at the same time let- 
ting it move freely (Fig. 96). 
" When the dynamometer is taken into the hand and pressed, the two sides 
of the spring are approximated, and the steel arm, the cogs being pushed by 
the lower side of the spring, turns the indicator. When pressure is taken off, 
the indicator does not return to 0, but remains at the point to which it has 
been carried by the muscular power of the patient. 
" It may also be used to measure tractile force, for if two hooks with cords 
attached be fastened to the spring at the points a and b, traction on the cords 
will approximate the two sides of the ellipse, and thus push the steel-arm so as 
to move the indicator. 
" Dr. W. A. Hammond has found it useful in determining the effect of 
electricity upon the irritability of paralyzed muscles, and thus enabling the 
physician to decide whether the proper time for its use has yet come, by ob- 
serving whether the strength of the muscles is increased or diminished after 
the application of this agent." 
(c.) Perversion of Body-heat.-In cases of hemiplegia the temperature of 
the paralyzed side is raised by half a degree to one degree. It is rarely nor- 
mal and never lessened. The thermometric equilibrium is restored on the 
cure of the paralysis. The general body heat of hemiplegic patients is not 
as a rule increased, and is usually below the normal-92.5° Fahr. During 
the last hours of life it may rise to 96° Fahr. Well-marked paralytic atro- 
phy is attended by lowering of temperature in the parts affected. Becquerel's 
discs, in connection with a galvanometer, are the best means to determine 
differences of body temperature in paralytic parts. They are composed of 
two thin plates of copper, soldered to a thin rod of bismuth, contained in a 
small tube of hard rubber, furnished with a handle. One disc is placed on 
the sound limb, and the other on the corresponding part of the paralyzed 
limb. Both are in connection, by means of delicate silk-covered wires, with 
the poles of a galvanometer. If the temperature of both limbs be the same, 
the needle of the galvanometer remains at rest. If the heat of either limb 
is raised, the needle is deflected to the north or south pole, according as one 
or other limb has the highest temperature. A difference of less than TJn of 
a degree can thus be determined. 
(d.) Perversion of the Powers of Expressing Thought.-This physical 
sign of cerebral disease has been elevated by some writers into a substantive 
affection under the name of Aphasia. It implies an inability to communicate 
Fig. 96. 992 
SPECIAL PATHOLOGY-DISEASES OF THE NERVOUS SYSTEM. 
thoughts, ideas, or names of things either by words or by writing, the Intel- 
lect being more or less perfect otherwise, and the organs of phonation free of 
paralysis. Every shade of deficiency or inability characteristic of this affec- 
tion is to be met with, from temporary loss of memory of certain words, the 
names of common objects, and their misuse in conversation, up to persistent 
and complete inability to give expression by words, writing, signs, or gestures, 
to thoughts or ideas. " In some cases a mere inability to articulate, whilst 
the patient is able to write; in others a loss of memory of words until they 
are suggested ; and in yet others a total forgetfulness of names-the patient 
giving everything a wrong appellation" (Wilks). The non-expression of 
the names of things, or the substitution of wrong ones, are among the most 
common forms of this inability. " Hand me the to stir the ." 
" Poker " and " fire " are the words which are incapable of being spoken. 
" Give me my ; you know," pointing to his head. " Your hat?" " Yes, 
my hat." Many other examples are given by Trousseau. The substitution 
of one word for another is another form of this affection-e. g., " boots " for 
" head." Forgetting your own name, or the name of the person you go to 
visit, is another form. In another series of cases there is a sudden loss of the 
general faculty of speech, without paralysis or incapacity of thought. In a 
third set of cases there is unilateral palsy or unilateral spasms ; and sometimes 
it occurs after an attack of apoplexy, or after an attack of severe typhus or 
typhoid fever. 
In some cases, however, the thought or idea which leads to verbal expres- 
sion, as Dr. Gairdner shows, is not absent, so that the faculty remains of com- 
municating by the usual written signs. 
The several theories of localization of the brain lesion believed to be present 
in cases of aphasia are not capable yet of positive demonstration. The dis- 
order may exist in any of the typical forms, and yet no appreciable change 
be detected in any part of the cerebral substance or its bloodvessels. The 
following are the general results of clinical and post-mortem investigation : 
(1.) In a large majority of cases of aphasia the peculiar inability of speech is 
associated with unilateral palsy, indicating disease of the central ganglia, or 
immediate surroundings of the corpora striata. (2.) In numerous cases, but 
not in all, there is disease of the third left frontal convolution of the cerebrum, 
or in the left anterior lobe, very near to this convolution. (3.) The whole of 
this convolution and the left anterior lobe of the brain may be wholly or par- 
tially destroyed, and yet no loss of speech has been observed. (4.) Aphasia 
may exist with apparent integrity of the left anterior lobe of the cerebrum, 
and indeed of the whole brain. (5.) In all the cases Dr. Wilks has seen there 
has been disease in the central ganglia-a necessary lesion for the production 
of hemiplegia-and loss of speech seems to accompany, and is usually found 
in connection with right hemiplegia, when a small spot of disease in the left 
central ganglia is sufficient. It may also occur from disease of the pons Varolii 
{Guy's Hosp. Reports, vol. xii, p. 174). 
As a separate and distinct disease due to a specific lesion, aphasia cannot 
yet find a place in nosology. The phenomena are complex in the extreme; 
and the connecting link between the mental defect and loss of speech, with 
material change in the brain, is both clinically and anatomically still incom- 
plete. Mental co-operation is defective in all the cases. morbid anatomy in cases of encephalitis. 
993 
Section III.-Diseases of the Brain and its Membranes. 
ENCEPHALITIS. 
Latin Eq., Encephalitis; French Eq., Encephalite; German Eq., Gehirnentzilndung 
-Syn., Encephalitis; Italian Eq , Encefalitide. 
Definition.-Inflammation of the brain, or of its membranes, the precise seat 
of the inflammation not being known before death. 
Pathology.-The most general fact that has been determined regarding 
this morbid state is that there are two very distinct forms of cerebritis to be 
recognized both anatomically and clinically. While dissection demonstrates 
the fact that inflammation may exist either in the brain alone or in the mem- 
branes alone, yet clinically it is found that meningitis generally complicates 
cerebritis, and thus the phenomena proper to each of these morbid states be- 
come combined ; and especially in that form of the disease in which the lesion 
is extensive, commonly known as "general cerebritis," " phrenitis," or "en- 
cephalitis." 
There is little interstitial exudation in cases of this disease, connective tissue 
is scanty, and the most important changes take place in the nerve-filaments 
and nerve-ganglionic cells. They swell up, in the first instance, and gradually 
break up into a detritus, with more or less abundance of the compound inflam- 
matory corpuscle of Gluge. 
Causes.-Inflammation of the substance of the brain is a rare disease, and 
may be caused by any of the morbid poisons associated with the specific or 
constitutional diseases, such as pycemia, glanders, typhus fever. 
Most cases result from mechanical injuries (fraumatic encephalitis'), not only 
from direct injuries affecting the brain after the skull has been penetrated; 
but numerous cases occur where the cranium has remained uninjured, and 
where there has only been an apparently slight contusion. In such cases 
concussion has been so great that the brain-substance has sustained a bruise, 
small vessels being ruptured, so that blood escapes. Such a lesion may not at 
first induce any signs of injury; but afterwards causes encephalitis. Other 
cases result from the excitement of insanity and uncontrolled moral feelings. 
In some instances encephalitis has followed the suppression of a cutaneous 
eruption, or the accidental inclusion of a nerve by a ligature applied to a 
bloodvessel (Lallemand, quoted by Sieveking). In others, caries of the 
bones of the cranium, and especially of the petrous portion of the temporal 
bone caused by otitis. Intemperance in alcoholic fluids also is a frequent 
cause of this, as well as of every other disease of the brain. The disease is 
sometimes brought about idiopathically, by exposure to the sun's rays in very 
hot summer days, especially in tropical climates. As a secondary disease, 
encephalitis is produced by cancer, tubercle, and by every other structural 
disease incidental to the brain textures. 
Encephalitis occurs at every age; in childhood during the tendency to 
hydrocephalus; in adult age from the action of morbid poisons, and from 
mechanical and moral accidents; and in old age from the natural decay of 
the frame. Ramollissement of the brain has occurred at the following ages: 
In a few cases from birth to fifteen ; 39 cases occurred from fifteen to forty ; 
54 cases from forty to sixty-five; and 60 cases from sixty-five to eighty-seven. 
The frequency of this disease, therefore, increases with age. Men are supposed 
to suffer in a larger proportion than women, probably from their greater ex- 
posure to the exciting causes. 
Morbid Anatomy.-The lesion is generally confined to certain parts; the 
entire brain is rarely if ever involved. The spots of inflammation vary from 994 
SPECIAL PATHOLOGY-ENCEPHALITIS. 
the size of a pea to that of a turkey's egg, and are usually of an irregular 
spherical shape. There may be only one spot or several. Usually there is 
only one; but if there are many, they are generally small and located in the 
cerebrum or cerebellum, most frequently in the gray substance, and very near 
the surface. The brain-substance affected is at first swollen by infiltration 
and hypertrophy of growth, then it softens, and becomes dotted over with red 
spots of extravasated blood. One section of the morbid part rises above the 
level of the cut surface. The softening resolves itself into a red pulp, of a 
rusty-brown or yellow color. It is so diffluent that it may be washed away 
by a light stream of water, leaving remains of nerve-tubes, blood-corpuscles, 
compound granule-cells, and fine granular detritus, in single particles, or in 
masses. Cyst-like cavities are sometimes the result of such changes, filled 
with a sero-gelatinous fluid. Sometimes a characteristic cicatrix takes the 
place of all, which is at first pale, red, and vascular, and which afterwards 
becomes white and callous. 
The Symptoms and Cause of encephalitis have considerable latitude. 
The symptoms are partly the result of destruction of the part of the brain 
affected, and partly the result of disturbance of the cerebral circulation, 
especially in the vicinity of the part, and therefore greatly influencing the 
functions of the brain. 
In twelve severe cases related by M. Paroisse, and resulting from wounds, 
he states that the symptoms were nearly the same in all, and were as follow: 
The men all stated that after the sabre wound they had felt no other incon- 
venience than local pain of the injured part, and that for two or three days 
afterwards they had all been able to march five or six leagues a day. On 
the third day, however, they had all been seized with fever, which terminated 
on the evening of the fourth day; but from that period they had suffered 
little, always preserved a good appetite, and prayed not to be put on a low 
diet. About the seventeenth day they became downcast and dejected, owing, 
probably, to many sloughs being detached, and much suppuration taking place 
about this time. On the following day they first lost the sense of smell, and 
then the senses of sight and taste. With these symptoms, but without fever 
or convulsions, they fell into an easy sleep; and, as if they had no further x 
strength to contend with the disorder, they died between the nineteenth and 
twenty-second days from the infliction of the wound. 
The symptoms which have been related by Paroisse agree entirely with 
those observed by John Hunter. He observed that trifling wounds of the 
membranes of the brain were often followed by severe and extensive inflam- 
mation of those tissues, and by very dangerous symptoms; but if the injury 
had been great, so as to have excised a portion not only of the arachnoid, but 
also of the substance of the brain, that the symptoms which followed were 
comparatively slight-a circumstance which he attributed to the brain in the 
latter case having room for expansion; and he therefore suggested the pro- 
priety of extensively incising the arachnoid and pia mater in all cases in 
which the dura mater alone had been wounded. Large portions of the brain 
may be destroyed without causing perceptible functional disturbance. 
In idiopathic inflammation the case may be acute or chronic. The first 
stage of the acute form is generally of short duration, and in so far the attack 
may be said to be sudden; and if there have been preliminary symptoms of 
ill-health, the symptoms have generally been headache or long-continued 
derangement of the digestive organs. 
The general symptoms of the first stage of encephalitis may be but feebly 
marked (unless meningitis predominates). There is usually, in the first in- 
stance, some heat of head and of surface generally. The face is pale, and the 
pulse low and irregular. The breathing is variable and sighing. There is 
slight feverish oppression, with headache and vomiting. The nervous symp- 
toms are generally highly marked, and so are those of diminished functional PREMONITORY SYMPTOMS OF CEREBRAL SOFTENING 
995 
activity in cases where the cerebral affection predominates as distinct from 
the meningeal. They consist of- 
1. Mental Phenomena.-The patient is sullen, and his faculties become 
obscured. There is confusion of thought rather than delirium, which occurs 
only in a mild form when the patient dozes. 
2. Sensorial Phenomena.-Unless meningitis is present, there is no hyperses- 
thesia ; but there is deepseated, violent, oppressive pain, frequently described 
as shooting from the centre to the vertex, the temples, eyes, or ears; and it is 
out of all proportion to the intensity of the febrile phenomena; and while the 
febrile phenomena subside (as they very generally do in the course of twelve 
or twenty-four hours) the local pain does not diminish. 
The second stage may be ushered in by convulsions; or, after the first stage 
has lasted two or three days, the pulse usually becomes rapid and weak. The 
cerebral nervous functions become inactive; anaesthesia, paralysis, and coma 
commonly follow two or three convulsive paroxysms, and death follows after 
the first stage has lasted two or three days. 
When the signs of meningitis coexist and are unusually severe, the pain is 
deepseated, and followed, after twelve or twenty hours, by convulsions and 
coma, and there is commonly meningo-cerebritis of considerable extent. 
When the cerebritis is local or partial, the symptoms are those 'which are 
usually regarded as indicating " inflammatory softening," " red softening," as 
it is commonly called, or " acute ramollissement." Premonitory symptoms 
are common, and consist of- 
1. Mental Symptoms-namely, some loss of intellectual vigor, failure of 
memory, confusion of ideas, irritability of temper, and a consciousness of 
weakness-these symptoms becoming gradually persistent. 
2. Sensorial Symptoms, such as pain of the head, dull, deepseated, fixed, and 
protracted; tingling or numbness in one limb or side; imperfection of the 
special senses; dimness of sight; dulness of hearing. 
3. Motorial Symptoms, as evinced in the loss of power of one limb or side- 
the most important of all the premonitory symptoms. 
There is more or less fever in proportion to meningitis: there is heat of 
head, vomiting, and general malaise. The signs of meningitis, on the other 
hand, may be feebly marked; but there may be convulsions, followed by 
coma, partial paralysis, with rigidity returning more or less rapidly, and end- 
ing fatally in a day or two, or from two to three weeks. Thus there may be 
the symptoms of meningitis, or of cerebritis, of both together, or alternately; 
and, occurring with such premonitory symptoms as have been indicated, they 
leave little doubt of the existence of a partial cerebritis. 
Diagnosis.-If symptoms of local brain disease commence after an injury, 
or if there be disease of the bones of the skull, such as the petrous bone, fol- 
lowed by "head symptoms," as they are called, it is probable that encephalitis 
has commenced. 
Treatment.-So soon as there are any circumstances which may lead to 
"head symptoms" after injury, it is well to commence treatment at once with 
local antiphlogistics, leeches, and evaporating lotions, such as muriate of am- 
monia in solution with vinegar, applied by cloths, which are to be frequently 
changed. The patient must be made to observe a rigidly abstemious regimen, 
and rest with the head elevated above the shoulders. 
MENINGITIS. 
Latin Eq., Meningitis; French Eq., Meningite; German Eq., Gehirnhautentzun- 
dung-Syn., Meningitis; Italian Eq., Meningitide. 
Definition.-Inflammation of the immediate coverings of the brain, the dura 
mater, pia mater, and arachnoid. 996 
SPECIAL PATHOLOGY-MENINGITIS. 
Pathology and Morbid Anatomy.-The inflammation may be simple and 
idiopathic, or it may supervene as the result of some specific or constitutional 
disease, such as of some of the fevers, or of the syphilitic, rheumatic, gouty, ra- 
chitic, or scrofulous cachexiae. It is also known to occur in convalescence from 
pneumonia and pleurisy, or from acute exanthemata and erysipelas, and from 
protracted diarrhoeas, and especially also as intercurrent with Bright's dis- 
ease. Three several forms (in addition to the general involvement of all the 
membranes) may be distinguished: 
(1.) Inflammation of the dura mater. This is almost invariably the result 
of injury or disease of the bones of the skull; and in such cases the injury or 
disease by which it is caused may be readily distinguished. 
(2.) Inflammation of the pia mater and arachnoid. In diffuse arachnitis the 
arachnoid has seldom any considerable redness or congestion, but is thickened 
and opaque; while the transparent serum naturally contained in the cavity 
of the arachnoid being now scanty, or wholly wanting, it has neither the 
polish nor the moisture which is natural to it in health, so that the membrane 
appears brown and dry. 
The principal phenomena of arachnitis are most obvious in the pia mater, 
so that the large vessels of that membrane are greatly congested; but still, 
according to Dr. Baillie, the redness is not so general nor so continuous as in 
inflammation of other serous membranes. Also, if the pia mater be attempted 
to be removed, it is easily torn, and separates from the brain in small frag- 
ments. The arachnoid covering the dura mater seldom participates in this 
affection. These are the appearances observed in diffuse arachnitis, supposing 
it to terminate by resolution. The inflammation, however, often proceeds, 
and may terminate by effusion of serum, lymph, or pus. 
When serum is effused into the arachnoid cavity, the opacity of the arach- 
noid gives the serum a gelatiniform appearance; but when that membrane is 
divided, the serum is found to be fluid, and to diffuse itself in every direction; 
sometimes, however, it may be turbid, from an admixture of a small portion 
of free albumen. It is also not unusual to find a few points of lymph, of pus, 
or of blood, either at the exterior surface or within the arachnoid, effused 
along with the serum, and almost in juxtaposition with each other. The 
quantity of fluid effused is variable,-from two to three drachms to as many 
ounces. The effusion most commonly takes place at the upper surface of the 
hemisphere, but sometimes at the base, and sometimes into the ventricle of 
the brain. Lymph is the form which the exudation usually assumes ulti- 
mately if life continues, varying in density and thickness, dipping down 
between the convolutions; and commonly it is most abundant on the upper 
portions of the hemispheres. Foville says he has met with cases in which the 
effused lymph covered the whole of the brain, or nearly so, as far as the ten- 
torium. The lymph was deposited in the arachnoid sac in two layers-one 
adherent to the cranial arachnoid, and the other to the cerebral arachnoid ; 
while between them was a stratum of serum. He mentions having had six 
cases of this description under his care for several years, and that they were 
all in a state of the dullest stupidity, and apparently laboring under paralysis 
of every sense. They were like statues, with this difference, that, placed up- 
right, they preserved their balance; if pushed, they walked; and if food was 
placed in their mouths, they swallowed it. Were these cases of "paralysis of 
the insane," as now so called ? (Art. "Meningite," p. 406, Diet, de Medecine.) 
Lymph also may be effused into the arachnoid cavity, but it is generally in 
small quantity. 
Suppurative inflammation may take place either into the subarachnoid 
spaces or into the arachnoid sac. It is, however, by no means a frequent 
occurrence. Rostan gives several cases of effusion of pus into the arachnoid 
cavity, likewise Morgagni, Cruveilhier, and Dr. Bright. Dr. Baillie states 
that he once saw pus effused into the cavity to such an amount as to cover CHARACTERS OF CHRONIC ARACHNITIS. 
997 
the entire upper surface of the brain. Two cases are given by Dr. Hodgkin 
of cut wounds of the head in which pus was found in the arachnoid sac. Dr. 
Sieveking relates a remarkable instance of purulent exudation of the arach- 
noid, occurring in a young woman aged twenty-seven, under his care, at St. 
Mary's Hospital, in whom sudden and unexpected coma supervened, and ter- 
minated, after thirty-six hours, in death. She had previously suffered from 
otorrhoea; but on her admission she gave no signs of cephalic disease; nor was 
any direct connection traced after death between the affection of the ear and 
the meningitis. 
The characters of chronic arachnitis are,-a similar opacity and thickening 
of the membranes, together with granulations of a pearly color and more 
especially along the longitudinal sinus, and also an augmentation of the glan- 
dular Pacchioni. Much serum is effused into the cavity; and the connective 
tissue by which the pia mater is attached to the brain acquires considerable 
strength, so that portions of the brain come away with the membranes. The 
membranes acquire considerable tenacity; and so marked are their characters 
in some cases, that Dr. Maclachlan notices an instance in which a portion of 
the arachnoid nearly an inch square was fully an inch thick, in appearance 
like the boiled white of an egg, and equal to the peritoneum in toughness. 
The surface of the brain is pale, and sometimes slightly atrophied. Much 
serum abounds in the arachnoid cavity, in proportion generally to the atrophy 
of the brain; and the ventricles contain serum (Maclachlan). Ossification 
of the pia mater is extremely rare; but it also becomes thickened, opaque, 
and injected. Dr. Baillie, however, mentions one case of ossified pia mater, 
on the authority of Soemmering; and Dr. Hodgkin speaks of a specimen in 
the museum of Guy's Hospital. 
In acute arachnitis of the ventricles the membrane becomes thickened, semi- 
transparent, pulpy, and sometimes sprinkled with minute spots of blood. It 
is rare to find lymph effused, but occasionally old adhesions are seen between 
the opposite surfaces of the ventricle. Pus has also been occasionally found 
in these cavities. With regard to the effusion occurring in the ventricles in 
" meningitis," it is correctly remarked by Dr. Sieveking that " it offers many 
relations different from the arachnoidal effusions occurring on the surface of 
the brain; nor is it quite intelligible why the secretion into the cavity of the 
ventricles should so rarely be found to communicate with the superficial arach- 
noidal space." The anatomical relation of these parts may in some measure 
explain the differences; for it is very doubtful that the arachnoid lines the 
ventricles of the brain-an arrangement which Kolliker considers impossible. 
Nevertheless, there is in meningitis generally an increase in the ordinary 
amount of the fluid in the ventricles, to the extent of several drachms, which 
may perhaps be regarded rather as a result of contiguous sympathetic effusion 
than as an extension by continuity of the inflammatory exudation. 
A microscopic examination of the smaller vessels of the pia mater in men- 
ingitis shows that they are studded with the exudation-corpuscles described 
by Gluge and Bennett, and with oily-like vesicles; and these appearances are 
found both within and without the vessels (Sieveking). 
(3.) Tubercular meningitis-Syn., Acute hydrocephalus. The meningitis 
which accompanies the cachexia associated with tuberculosis is of a very dis- 
tinctive kind, and frequently terminates the lives of tuberculous children.. 
Its essential morbid character consists in the growth of tubercle on the arach- 
noid, generally in the shape of small miliary granules. They are found most 
frequently and most abundantly within the fissure of Sylvius, between and 
upon the convolutions of the brain, and at the base of the brain, and very 
rarely on the cerebellum. They are generally of the nature of the gray granu- 
lations imbedded in the vascular network of the pia mater. The effusion into 
the ventricles and the softening of their walls are secondary, but not invaria- 
ble results of the meningeal lesion. 998 
SPECIAL PATHOLOGY-MENINGITIS. 
Causes.-Every age is liable to meningitis. Children are often attacked 
by it whilst teething, under the form described as hydrocephalus acutus, and 
also when laboring under scarlatina, measles, or other disease caused by a 
specific poison. Adult age, as well as the middle periods of life, is still more 
liable to this affection, both from the greater exposure to the action of the 
typhus, typhoid, and paludal poisons, to syphilis and to mechanical injuries, 
as well as to the greater intemperance and greater excitement incident to this 
age. In old people meningitis is likewise common; and two forms of the dis- 
ease are met with in the aged,-namely, the acute and the chronic, both of 
which present great varieties in their character and progress (Maclachlan), 
and both sexes perhaps suffer in nearly equal proportions. 
Meningitis is also apt to occur as the result of gout or of rheumatism, con- 
stituting gouty or rheumatic meningitis (Maclachlan) ; and it is an occasional 
if not a frequent consequence of Bright's disease (Chambers, Goodfellow, 
Maclachlan). 
Meningitis is indeed a disease which most commonly occurs from the action 
of some specific morbid poison; and there are few agents of that class which 
are not apt to act on the membranes of the brain. There are many instances 
also of persons suffering from arachnitis after exposure to the heat of the sun, 
or to what is in common language called the "coup de soleil," and which will 
be considered under the head of insolatio. Intemperance, as well as great 
mental work and anxiety, is also a frequent cause of the chronic forms of the 
disease; but the abuse of alcoholic liquors is perhaps the most common pre- 
disposing cause; while fits of intemperance occasionally are the direct agents 
which induce the disease. It is especially apt to be associated with or to 
follow delirium tremens in the aged, and likewise gout or rheumatism. It is 
also especially connected with insanity, and with every structural disease of 
the brain; and to these causes must be added mechanical injuries, diseases of 
the bones, and morbid growths, especially in cases of primary implication of 
the dura mater. 
Symptoms and Diagnosis.-Meningitis has usually been described in three 
stages. The symptoms of the first stage are those of excitement, resulting 
from diffuse inflammation. The symptoms of the second stage are those of 
compression, marking that effusion has taken place; while those of the third 
stage are associated with progressive recovery, or with the modes in which 
death may occur. 
But there are symptoms characteristic of several forms of this disease, 
which may be classed as follows: 
(a.) Simple Meningitis.-The type of this morbid condition is that in which 
the membranes covering the convexity of the hemispheres are the parts gen- 
erally affected. The most important facts to be ascertained in the previous 
history of the case, before the development of cephalic symptoms, relate to 
the general health, and especially to any signs of cachexia or diathetic states, 
such as tuberculosis, rheumatism, gout, or of the specific action of implanted 
poisons, such as syphilis. It is important also to ascertain whether any blow 
on the head has been sustained, or if the patient has been much exposed to 
the sun; whether any disease of the ear or nose exists; whether application 
to study has been intense, or to the cares of business. 
Premonitory symptoms may be trifling, or absent altogether. The most 
■common are slight but increasing pains of the head, sensorial disturbance, 
irritability of temper, or restlessness, with some general malaise. Rigors 
quickly supervene, or simple chilliness, with cutis anserina and pallor of the 
surface, quickly followed by febrile reaction. An attack of convulsions may 
supplant the rigors, especially in children. Such, however, are by no means 
common in the adult, and are not necessarily indicative of any severe or ad- 
vanced lesion. The fever is commonly high; the pulse sharp, hard, and fre- SYMPTOMS AND DIAGNOSIS OF MENINGITIS. 
999 
qUent; the respirations are irregular, performed with a sigh, and often with a 
moan. 
Niemeyer observes, that in scarcely any other disease of the brain is the 
fever of a similar character and equal in severity to that of meningitis, and 
consequently it is of great importance in diagnosis. 
If the frequency of the pulse subside after the disease has lasted for some 
time-if it fall from 120 or 140 beats to 60 or 80, while the other symptoms 
of fever and the functional disturbance of the brain increase-the evidence is 
almost pathognomonic of meningitis. The skin is hot; the bowels obstinately 
constipated; and evacuations, when they occur, are dark and offensive. In 
this stage there is little or no prostration of strength. The headache of fever 
is supplanted by acute and intense pain; the face flushes and turns pale 
alternately; the eyeballs stare, and the conjunctivae become injected. 
The functional disturbance of the brain is partly of the character of irrita- 
tion, and partly of depression, or of complete paralysis. 
The purely nervous symptoms, expressed by mental, sensorial, and motorial 
phenomena, are thus classified by Dr. Reynolds: 
1. Mental.-The temper is extremely irritable. There is marked somno- 
lence, or wakefulness, and the two sometimes alternate for several days. The 
most marked feature is delirium, commencing early, and of a furious charac- 
ter, the patient screaming and gesticulating in the wildest 'manner; the ex- 
pression of countenance is savage and malignant, or sometimes it has the 
fierce aspect of the brute. 
2. Sensorial.-Marked and continuous headache {cephalalgia} prevails, with 
exacerbations of a darting violent character, eliciting from the patient, and 
especially from children, a sharp piercing cry. Pain is increased by move- 
ment, and the patient holds the head with the hands; or, if a child, fre- 
quently carries them to the head. The headache is increased by sensorial 
impressions, and hence the eyes are obstinately closed, and the ears, if possi- 
ble, kept covered with the bedclothes. Double vision, tinnitus aurium, formi- 
catio, and subjective sensations of various kinds are present. The sensorial 
disturbances are highly marked. 
3. Motorial.-Restlessness is incessant, sometimes general or partial. The 
muscles of the face and limbs twitch involuntarily. There is strabismus, or 
the eyeball is unsteady, and with a contracted or oscillating pupil. Vomit- 
ing is frequent, without epigastric pain or tenderness, and often without 
nausea. 
This stage generally lasts from one to four days, and its characteristics may 
be shortly expressed as consisting of-the combination of great nervous hyper- 
action, with marked fever, a peculiar cry, cephalalgia, vomiting, and constipation. 
The second stage is one of a transition from the first to the third. The 
fever diminishes. The pulse sinks in frequency and force, becoming variable 
in frequency between very wide limits, and in very short intervals of time. 
Respiration becomes peculiarly irregular. The bowels continue constipated. 
The tongue becomes furred and dry. The heat of the head persists, but the 
body generally is cool. 
The nervous phenomena present remarkable intermissions during the 
further progress of the affection, especially in the following points: 
1. Mental.-Delirium becomes quieter, or passes into coma; or the patient 
may appear collected and well. 
2. Sensorial.-Excitement diminishes and disappears, and drowsiness is the 
most common feature. 
3. Motorial.-Muscular twitchings generally are increased on both sides of 
the body. Convulsions are common in the child, and spasms often alternate 
with paralysis. A violent general convulsion may throw the patient at once 
into 
The third stage.-It may come on almost immediately, or a week of transi- 1000 
SPECIAL PATHOLOGY MENINGITIS. 
tion symptoms may intervene. The face becomes sunken, the extremities 
cold, and the abdomen retracted. Sordes form on the gums and teeth. The 
pulse flutters, becomes thready, feeble, and uncountable. Great prostration 
of strength supervenes. 
The nervous functions are gradually suspended. 
1. Mental.-Perception, Volition, and Ideation become lost, so far as can be 
ascertained by corporeal signs. 
2. Sensorial.-Anaesthesia is complete. 
3. Motorial.-There is absolute paralysis to almost every form of stimulus, 
observed first in the eyelids and eyeballs and then in the limbs. Muscular 
relaxation becomes complete, as evidenced by the dilated pupil, stertorous 
breathing, involuntary micturition and defecation. 
Generally there is absence of nervous action, and organic life gradually 
dies out. 
The duration of these stages is various. For the most part each lasts a 
week ; but one or more stages may be wanting. 
The tongue in the first stage is white; in the second it becomes brown; in 
the third it again cleans, if the patient does not die. The pulse, likewise, in 
the first stage is from 90 to 100 ; in the second from 110 to 130 ; and in the 
last stage it either gradually returns to its natural standard, or runs on too 
rapidly and too feebly to be counted. 
The-symptoms which have been described are those which especially mark 
arachnitis at the superior portions of the brain. When, however, it occurs at 
the base, or in the ventricles, some differences are observable, although the 
condition cannot always be distinguished; but in some cases such a location 
of the malady is rendered probable if the intellect is less impaired, the pas- 
sions more excited, and the patient lies fretful, impatient, morose, and 
although somnolescent, he occasionally cries out and grinds his teeth very 
early in the disease; while the parallelism of the axis of the eye is frequently 
affected at an early period. 
(6.) Tubercular Meningitis in the Child.-It is an object to ascertain the 
existence of the scrofulous cachexia in the first instance, as described at page 
887, ante, et seq. If such exists, tubercular meningitis may supervene on the 
occurrence of any febrile disturbance, with slight thirst and anorexia ; irregu- 
lar and somewhat quick pulse ; vomiting and constipation; clayey evacua- 
tions deficient in bile; red and moist tongue; dry and hot skin, and other 
phenomena of general derangement. The temperature, as measured by the 
thermometer, will be found to be persistently above the normal amount 
(Ringer). 
The special nervous phenomena are generally feebly marked. 
1. Mental.-There may be irritability of temper and peevishness, with some 
slight delirium at night, rarely commencing early in the disease, disturbed 
sleep and restless manner. 
2. Sensorial.-Pain in the head prevails, with intolerance of light and 
sound. Vertigo is also indicated by staggering, or clinging to objects for 
support. 
3. Motorial.-Grinding of the teeth prevails, occasional vomiting, unsteady 
restless movements, and dragging of the limbs. After three or four days of 
these premonitory symptoms, 
The second stage commences, with heat of head and flushings of the face, 
alternating with pallor. The pulse is irregular, and commonly, when the 
child is still, it is of little frequency, but it rises rapidly if the child is dis- 
turbed. The vomiting ceases, but the constipation persists, with retracted 
abdomen. 
The following special nervous phenomena become more marked: 
1. Mental.-The child inclines to lie quiet, and resists being moved, as if TUBERCULAR MENINGITIS IN THE CHILD. 
1001 
pain was increased by motion. There is delirium, which is sometimes fugi- 
tive and sometimes persistent. 
2. Sensorial.-The cephalalgia increases. The expression of countenance 
bespeaks great suffering, and the face looks aged. A peculiar piercing cry is 
now and again given by the child. The eyes are closed, and there is a ten- 
dency to drowsiness. 
3. Motorial.-Strabismus and muscular twitchings occur. The pupils are 
variable, and often oscillate, and the eyeballs are unsteady. 
The third stage of tubercular meningitis is ushered in by the general symp- 
toms of approaching dissolution, such as coldness of the extremities, clammy 
perspiration, and an excessively rapid but feeble pulse. 
The special nervous phenomena are first those of exalted spinal action, and 
then those of general prostration. 
1. Mental.-Drowsiness passes into stupor, with an idiotic expression of 
face. There is loss of perception and volition. 
2. Sensorial.-All signs of activity give place to anaesthesia, and the eyes 
are half open. 
3. Motorial.-Death approaches by convulsions, with partial paralysis, sub- 
sultus tendinum, clenched hands, retracted head, and automatic movements, 
giving way to general relaxation. 
(c.) Tubercular Meningitis in the Adult.-The symptoms occasionally as- 
sume an apoplectic, sometimes a convulsive form, at the commencement; and 
the febrile character is generally imperfectly marked. The premonitory 
symptoms are those associated with the scrofulous cachexia, and meningitis 
may occur at any stage of the lung disease. The following are its features: 
After some remission of chest symptoms, special nervous phenomena refera- 
ble to the head may supervene. 
1. Mental.-The patient looks bewildered, with a dull, heavy, expression- 
less face, often highly characteristic. There also appears to be some intellectual 
incapacity to speak; the patient, seeming to understand what is said or asked, 
looks at the inquirer for a few seconds, and then turns the head away without 
a reply. There is often marked somnolence. 
2. Sensorial.-Pain in the head, fixed to one spot (generally the forehead), 
is the most striking symptom, of considerable intensity, and is persistent for 
many days. 
3. Motorial.-An attack of convulsions may precede every other symptom, 
but paralysis is rare. 
The second stage is of very variable duration, the pulse is highly irregular, 
while alternate flushings and pallor of the countenance are common, and all 
the symptoms already noticed become more intense, mild delirium prevails, 
and the face becomes increasingly stupid-looking. 
Paralysis of volition alternates or coexists with clonic or tonic spasms, 
strabismus, or prolonged convulsive attacks. 
The third stage of tubercular meningitis in the adult is marked by increas- 
ing stupor, immobility, and involuntary defecation and micturition. 
The general characteristics of tubercular meningitis thus consist in the 
occurrence of fixed pain, vomiting, dulness of intellect, and duskiness of the 
face, with partial paralysis or convulsions, slight fever, and diminution of the 
chest symptoms in a patient demonstrably tuberculous. The indications of 
inflammatory action are only feebly marked, not only during life, but after 
death; and very often the febrile state which had existed before becomes less 
noticeable at the onset of cerebral symptoms. Still, heat of head, injected 
conjunctiva}, and flush of face, denote a condition of vascular excitement; 
while persistent headache with febrile symptoms in a patient otherwise 
phthisical, when it can be traced to no other known cause, is strong presump- 
tive evidence of impending tiibercidous meningitis (Hill). The aid of the 
thermometer should invariably be sought in diagnosis (see p. 242, et seq.). 1002 
SPECIAL PATHOLOGY-MENINGITIS. 
But there are also cases in which the disease of the brain is marked by the 
absence of ordinary symptoms. The premonitory phenomena already noticed, 
for example, may be absent, especially in children; and then the steady per- 
sistence of any one symptom becomes of great importance in diagnosis-for 
example, sickness, headache, constipation, drowsiness, heat of head (West). 
(d.) Acute Meningitis of the Aged.-Dr. Maclachlan gives the best account 
of this form; and the phenomena he describes may be classified as the pre- 
viously described forms have been. It seldom occurs suddenly, nor with the 
intense symptoms which prevail in the meningitis of early manhood. It com- 
mences insidiously, without rigors, and very frequently some days elapse 
before it can be recognized, even by persons familiar with the diseases of old 
age. The pulse is natural, the tongue remains clean, the bowels regular, and 
there is little or no vascular excitement, local or general, but the symptoms 
at the outset are purely of a nervous character. 
1. Mental.-The temper is peevish or irritable, with more or less confusion 
of thought, inattention, and forgetfulness. "If infirm, and already an inmate 
of an hospital, the patient commits strange mistakes-takes possession of 
another's bed, uses the spittoon instead of the chamber-pot, and is frequently 
found lying outside the clothes, or with his feet where his head ought to be. 
When addressed, his answers are rational, but still there is a peculiarity in 
his manner and expression of countenance, an apparent slowness of compre- 
hension, and a vacancy of the eye, that warns the physician of the approach 
of some cerebral disease" (The Diseases and Infirmities of Advanced Life, p. 
85). 
2. Sensorial.-The appetite is slightly if at all impaired, and the skin 
remains of normal temperature. 
3. Motorial.-Restlessness prevails, although prostration is apparent. In 
walking, the gait is unsteady, and in lifting anything to the mouth the hand 
trembles. In a few rare cases the disease commences with convulsions. 
While such symptoms are being developed, after twelve, forty-eight, or 
sixty-two hours, but generally within twenty-four hours, more or less febrile 
reaction is expressed by slight increase of temperature merely, and without 
any marked redness of the face or acceleration of the pulse. The nervous 
symptoms are now of the following kind: 
1. Mental.-Wandering, low muttering delirium and incessant talking 
become frequent and characteristic symptoms. Maniacal excitement is un- 
common. For a day or two the patient may answer questions rationally, 
though slowly and hesitatingly, when roused from the reverie in which he is 
generally wrapped. At a still more advanced stage there is coma. 
2. Sensorial-Headache is not a prominent symptom. It is so slight or 
unfrequent that unless the patient is pointedly asked the question, there is 
never any allusion either to it or to giddiness, or to tinnitus aurium. This 
absence of headache is pointedly noticed by Dr. Maclachlan as a remarkable 
character; for, even in the most acute pus-forming or false-membrane-forming 
meningitis, headache may be entirely absent from the beginning. The eyes 
are suffused, the pupils either slightly contracted or natural. Knitting of the 
eyebrows, intolerance of light, acuteness of hearing, and vomiting,-common 
and characteristic phenomena of the disease in early life,-are comparatively 
rare in the aged. The scalp may be hotter than natural, and, combined with 
the suffusion and injection of the eyes, is the only physical indication present 
of vascular excitement within the cranium. The feet are frequently cold, and 
the surface generally moderately warm. There is usually great thirst, the 
patient drinks greedily, but seldom asks for liquid. He is apt to refuse food, 
or takes but a small quantity at a time, when it is presented to him. 
3. Motorial.-Nervous twitchings and convulsions are observed in the worst 
cases; and if the patient be raised in bed, these symptoms are frequently DIAGNOSIS AND TREATMENT OF MENINGITIS. 
1003 
induced when otherwise absent, and the head trembles, as well as the upper 
extremities. AV hen coma prevails, there may be sometimes slight convul- 
sions of the limbs. 
The general features of the disease resemble typhus fever. The tongue 
becomes very dry, and generally brown in the centre. The bowels cease to 
act without medicine, but are not obstinately confined. Towards evening 
thece is generally increased febrile disturbance, denoted by flushing of the 
face, where it had been previously pale and dejected; dryness of the skin, 
greater heat of the scalp, and acceleration of the pulse. In numerous exam- 
ples, while dulness of intellect and somnolence are the first symptoms observed, 
in others great and unusual loquacity, with redness of the face and heat of the 
scalp, ushers in the disease. The progress of the disease is equally inconsist- 
ent. In not a few cases the symptoms of febrile excitement are wanting; but 
dulness of intellect and stupor, with more or less insensibility of the limbs 
and relaxation of the sphincters, are frequently prominent symptoms through- 
out the whole course of the disease, as if the medullary substance of the brain 
were congested or suffered compression from early exudation on its surface. 
Such examples of an apoplectic character are more frequently met with in 
old persons addicted to fermented liquors, in whom the cerebral vessels are 
enlarged from repeated engorgement. Excessive venous congestion of the 
brain prevails in such cases during life; and the symptoms of meningitis are 
marked, and apt to be confounded with effusion into the brain, or softening 
of its texture (Maclachlan, 1. c., p. 87). 
' (e.) Chronic Meningitis of the Aged is extremely subdued in its symptoms 
and insidious in its approach. It is not unfrequent as a result of albuminuria, 
or of repeated attacks of delirium tremens; or it follows gout or rheumatism. 
The characteristic phenomena may be arranged as follows: 
1. Mental.-It is almost uniformly accompanied with great impairment of 
the mental faculties. There is very marked loss of memory, slowness of 
comprehension, periodical fits of passion. 
2. Sensorial.-Vertigo prevails, with ringing in the ears; and occasional 
attacks of headache occur, with or without vascular excitement. 
3. Motorial.-iSpeech is thick. There is paralytic weakness of the lower 
limbs, and the gait becomes tottering and feeble. All movements, whether of 
the upper or the lower limbs, are performed slowly, awkwardly, and with more 
or less of uncertainty. 
The energies of the whole system are reduced. The functions of organic 
life are impaired. The appetite may be good, but digestion is slow, the bowels 
being inactive, and the various secretions vitiated or diminished. " Sooner or 
later the aged invalid takes to bed reluctantly. There he lies uncomplaining, 
vegetating, the mere wreck of what he formerly was, both in mind and body, 
gradually sinking, and dying often in consequence of sloughing of the hips and 
nates" (Maclachlan, 1. c., p. 93). 
Diagnosis.-Meningitis is distinguished from encephalitis by the headache- 
always severe-the early delirium, and by the general absence of hemiplegia. 
It must be admitted, however, that disease of the brain and of its membranes 
is often conjoined, so that meningitis is not in all cases a simple affection, but 
is ultimately conjoined with cerebritis, the inflammation of the membranes 
usually extending to the cortical portion of the brain. 
From delirium tremens meningitis is mainly distinguished by the character 
and mode of accession of the delirium, and the tremor, and by the mental, sen- 
sorial, and motorial phenomena. 
From typhus fever it is mainly distinguished by the absence of the charac- 
teristic eruption or mulberry rash (see p. 461). 
Treatment.-As a general principle, remedies have little influence over 
those forms of the disease which arise during the progress of any specific or 
constitutional disease, independent of the general treatment indicated for that 1004 
SPECIAL PATHOLOGY - TUBERCULAR meningitis. 
disease. When arachnitis arises from mechanical injuries, the treatment is 
generally by bleeding, active purgatives, especially by calomel and scammony, 
and by cold applications to the head. In chronic cases Foville strongly rec- 
ommends the cold douche-pouring cold water over the head from a pitcher 
held some distance above it. 
This remedy must be used with caution, as being a powerful depressant, yet 
producing less ultimate debility than bleeding. It acts, doubtless, by cooling 
down the general mass of the blood; and patients almost always recover con- 
sciousness under its influence. To secure a lasting result it must be repeated 
at intervals of a few hours. 
In children I have certainly seen good results from inunction with mercurial 
ointment. (See remarks under the treatment of " Hydrocephalus.") 
In advanced life it rarely happens that the symptoms are so intense as to 
demand general bloodletting; but in vigorous constitutions this measure is 
sometimes necessary. Dr. Maclachlan gives a well-marked instance of its 
usefulness (1. c., p. 90). The cases which demand it are those attended by 
high cerebral excitement and vascular action. But as a rule local bloodlet- 
ting is not only infinitely more safe but more beneficial, and it can be repeated 
from time to time, as the nature of the symptoms may indicate; while general 
bloodletting can very rarely be resorted to more than once, and that only at 
the commencement of the attack. The beneficial effects of local bloodletting 
may be greatly aided by keeping the head well raised, and by the constant 
application of cold water to the scalp; or the occasional use of bladders filled 
with crushed ice. 
The bowels should be opened as rapidly as possible, unless the patient is 
feeble, emaciated, or greatly exhausted. The most active and searching purge 
is obtained by calomel and jalap; or four or five grains of the compound extract 
of colocynth should be given, combined with two or three grains of calomel, in 
cases uncomplicated with gout or Bright's disease, and followed in a few hours 
with a dose of salts and senna. A fair proportion of nutriment must be given, 
in the form of milk, strong beef tea, sago, tapioca, or arrowroot; and the patient 
should be kept in a quiet and darkened room, and with cold compresses con- 
stantly applied to the head. 
The more active symptoms being subdued, but not till then, a blister should 
be placed on the nape of the neck, if coma should ensue. The bowels should 
be kept open regularly, and the strength supported by mild unstimulating 
nutriment. When nervous irritability continues during convalescence, hen- 
bane, or muriate of morphia may be given (Maclachlan, 1. c., p. 92). 
In the chronic form the periodical attacks of headache or of insanity may 
generally be relieved by a brisk purge; and the head should be kept cool by 
cloths dipped in vinegar and cold water. If vascular excitement prevails, 
leeches may be applied behind the ears. The bladder must be kept empty of 
urine by the catheter, and although wine must be withheld during the active 
stage of the disease, it is beneficial when the vital energies begin to fail (Mac- 
lachlan). 
The dietetic treatment should be strictly antiphlogistic, the patient espe- 
cially avoiding all mental excitement; and, if not secluded, he should at 
least be kept tranquil, not only in body, but also in mind. 
TUBERCULAR MENINGITIS-Syn., ACUTE HYDROCEPHALUS. 
Latin Eq., Meningitis tuberculosa-Idem valet, Hydrocephalus acutus; French Eq., 
Meningite tuberculeuse; German Eq., tuberculose Hirnhautentziindung-Syn., 
Acuter wasser-kopf; Italian Eq., Meningitide tubercolare-Syn., Idrocefalo acuto. 
Definition.-An effusion of serous fluid between the membranes of the brain, 
or into its ventricles, associated with miliary tuberculosis of the meninges, or at 
the base. PATHOLOGY OF TUBERCULAR MENINGITIS. 
1005 
Pathology.-The meningitis of acute hydrocephalus may be limited to the 
membranes of the base of the brain ; the effusion into the subarachnoid space 
and the ventricles of a readily coagulating exudation, containing few pus- 
globules. Nodules of tubercle may generally be detected by their opacity 
over the translucent arachnoid. When the meninges generally are affected, 
miliary tuberculous growths are to be seen, and effusion is general in the ven- 
tricles. These lesions are part of an acute attack of scrofula, with deposit of 
tubercles in the meninges. They occur generally in children who are of such 
a scrofulous disposition that in later life they would be likely to suffer from 
pulmonary consumption ; or they are the offspring of consumptive or otherwise 
debilitated parents-badly nourished, physically ill-developed; but mentally 
often very sharp and bright. " Too wise and clever to live long," is a com- 
mon saying regarding such children. 
They generally have a fine skin, very perceptible veins, long eyelashes, and 
a clear bluish sclerotic. (See page 887, ante, et seq.} 
The brain affection is often apt to be regarded as the primary disease; but 
on post-mortem examination it will generally be found that caseous degenera- 
tion of bronchial, lymphatic, and mesenteric glands, with tubercles in the 
lungs or intestinal canal, bespeak the general constitutional state of scrofula 
with deposit of tubercle. 
In adults the development of acute hydrocephalus is generally subsequent 
to acute miliary tubercle of the lungs, or chronic pulmonary consumption, 
forming an acute complication to these diseases. The disease may also be a 
sequence to typhus, enteric fever, measles, or scarlet fever (Niemeyer). 
The age of childhood exercises a most remarkable predisposing influence 
upon this disease. At that period the rapid growth of the brain, the irritation 
of dentition, and the great susceptibility of the nervous system generally, are 
all powerful causes of determination of blood to the head. The greatest num- 
ber of attacks, according to Percival, occur between the second and the fifth 
year; or, as a more general law, the disease occurs from infancy to twelve 
years of age. During the first year of life, however, the disease is rare. 
Children with large heads and precocious intellects, and more especially those 
of a scrofulous diathesis, are its most frequent victims. One warning may 
be learned from this disease-namely, that it is said to be most common in 
the children of parents addicted to drunkenness, and from this cause it often 
runs in families. 
Although it has been stated that hydrocephalus may occur during fcetal 
life, and is more common in the early periods of infancy and childhood, yet 
adult age is not altogether free from it; and Golis has mentioned three cases 
of persons attacked in old age, two of whom were above seventy, while the 
other, perhaps less advanced in life, suffered from this affection for ten years. 
It seems sometimes to run in families; at least, Frank mentions a family of 
seven children, all of whom were born with this disease; and Golis another, 
in which six children were aborted hydrocephalic at six months; while three 
others, born at the full period, were attacked shortly after birth. 
Unless in the form of tubercular meningitis, acute hydrocephalus is undoubt- 
edly a rare disease. But it is no less certain that a disorder occasionally 
occurs, which is really an acute hydrocephalus, due to certain changes of nutri- 
tion of the nature of inflammation in the membranes or ependyma of the ven- 
tricles, followed by more or less effusion into their cavities. 
This form of acute hydrocephalus is rapid in its course, ending within two, 
three, or four to fourteen days. 
The morbid anatomy of such cases has been described by Dr. Beveridge, of 
Aberdeen. The surface and substance of the brain appears natural, and the 
fluid in the ventricles may be clear, but a granular layer of lymphy exuda- 
tion covers the floor of the ventricles. This layer of exudation appears thin, 
soft, and gray in color, and is easily overlooked on account of its resemblance 1006 
SPECIAL PATHOLOGY - TUBERCULAR MENINGITIS. 
to the parts which it rests upon. It is composed of granules, exudation-cor- 
puscles, and imperfectly formed cells. It may be seen covering the optic 
thalamus and corpus striatum. It is most abundant towards the fore part of 
the ventricles, where, in the angle between the rounded anterior end of the 
corpus striatum, and the crura of the fornix, it accumulates to the greatest ex- 
tent, so as sometimes almost to fill it. At or opposite the foramen of Monro 
it causes a very peculiar appearance. There the exudation, so far from closing 
the opening, prolongs it on either side into the ventricle, converting it into a 
sort of short canal, which opens by oval apertures with sharply defined 
borders, placed not vertically, but so obliquely as to be nearly horizontal, 
quite clear of the edge of the fornix, and visible at once on opening the ven- 
tricle from above; so that, instead of its being necessary to look underneath 
the apex of the fornix to see the foramen, the openings of it appear like two 
oval eyes between the fornix and corpus striatum, and are in full view, with- 
out disturbing or touching the parts in any way. This appearance gives the 
impression as if a soft granular layer had settled down on the floor of the ven- 
tricle, filling up its angles and interstices, but prevented from covering the 
foramen of Monro by the steady set of a current through that opening (Med. 
Times and Gazette, vol. ii, 1868). 
Premature or excessive mental exertion and blows on the head may be, 
and often are, alleged as the exciting cause of this disease. It does not always 
follow, however, that such is the case. The blow may only be a means of 
directing attention to the child, after which the discovery is made that symp- 
toms of cerebral irritation exist, which had already commenced. 
Morbid Anatomy.-A yellowish opaque exudation is usually conspicuous 
over the base of the brain, and within the subarachnoid spaces; and is generally 
plentiful in the meshes between the pia mater and arachnoid. It is especially 
abundant about the chiasma of the optic nerves, the larger fissure of Sylvius, 
and cerebral fissures towards the convexity of the brain. The pia mater is 
generally covered with whitish granulations, like particles of sand or a hemp- 
seed, most abundant and distinct in the vicinity of the bloodvessels. (See 
Bastian, Ed. Med. Jour., April, 1867.) 
The ventricles, especially the lateral and the third, are sometimes con- 
siderably distended with serous fluid-occasionally quite clear, but sometimes 
clouded with flocculi. The walls, especially the fornix and commissural parts, 
are generally so softened that they break down at the least touch, as the re- 
sult of maceration, rather than of inflammatory softening, which may spread 
indefinitely far beyond the immediate vicinity of the ventricles. The larger 
the amount of fluid the more bloodless and pale is the brain, and the whiter 
the softened parts (Niemeyer). 
Symptoms.-Acute hydrocephalus is divided into three stages; the first 
stage, according to Dr. Cheyne, being that of increased irritability; the second, 
that of diminished sensibility; and the third, that of convulsions or palsy. 
The first stage may be either sudden in its attack, or be preceded for several 
days by insidious and indefinite symptoms, such as giddiness, so that the child 
stumbles or falls at play; by a furred tongue, constipated bowels, and perhaps 
offensive breath. The child shows some change in manner, declines play, de- 
sires to sit apart, and rest the head. At length the senses of sight and of hear- 
ing become morbidly acute; he starts at slight noises-complains of intermit- 
ting headache-rests his head on his nurse's lap-occasionally complains 
momentarily of his head-and then, after a time, rises up and plays again. 
As this stage advances, the pulse rises, the skin is hot and dry, the urine 
scanty, the stomach irritable, the bowels constipated, perhaps painful, the 
stools black and offensive, while the brow is knit, and the pupil of the eye con- 
tracted or expanded. The most remarkable feature, however, is a great fret- 
fulness of temper, so that the child is not merely pettish, but quarrelsome. If 
he sleeps, his sleep is short, uneasy, moaning; he also grinds his teeth, rolls DIAGNOSIS OF ACUTE HYDROCEPHALUS. 
1007 
his head, and when he wakes up it is with a scream. He is generally sleepy, 
and dreams a great deal. "We are led to suspect some deeply-seated evil 
from the frantic screams and complaints of the head and belly, alternating 
with stupor, or rather lowness, and unwillingness to be roused" (Cheyne). 
These symptoms may extend over several weeks; and the child becomes 
emaciated by fever and impaired digestion. 
In much of this description some of the phenomena of meningitis may be 
recognized, and, doubtless, a great number of the acute cases are associated 
with this morbid state already described (page 998, ante), and especially with 
meningitis at the base, for at the commencement the lesion is localized there, 
and the characteristic peculiarities in the sequence of its symptoms are so dis- 
tinctly traceable to the functions associated with these parts as to give grounds 
for very certain diagnosis. The numerous nerves starting from the base of 
the brain and passing through the foramina, so that (1) irritation, and (2) 
paralysis in the parts supplied by the nerves of the eye, the vagus, and medulla 
oblongata, direct attention to the child. Among the first signs are contraction, 
and then later, dilatation of the pupil, ptosis of the upper eyelids, vomiting, slow- 
ness, and subsequent frequency of the pulse, peculiar changes of respiration, and 
depression of the abdomen (Niemeyer, Budge). 
The second stage commences when effusion has taken place. The pulse, 
instead of being rapid, is then as slow, perhaps slower, than natural-sixty 
beats a minute, or less; but this is chiefly when the patient is in a horizontal 
position, for if he attempts to sit up, it again becomes rapid. The sickness is 
also abated; nevertheless, the child lies in a state of stupor and of great un- 
willingness to be moved, with his eyes half-closed, dull, and heavy, or perhaps 
staring or squinting; the pupil being still contracted begins to expand-first 
one and then the other-so that he often suffers from double vision. Loud 
noises do not now disturb the child, nor light influence the eyes. The stupor, 
however, is still interrupted by exclamations or shrill piercing screams, which 
are reflex, while the tremulous hand of the little sufferer is incessantly engaged 
in picking his nose or mouth. As the disease thus advances, the capillaries 
of the brain are compressed by the effusion, loss of consciousness begins, epi- 
leptiform convulsions supervene, and paralysis of the extremities. For a time 
the inspirations are imperfect, and then the lungs are filled by a deep sighing 
inspiration; coma becomes deeper, the face assumes a dark color, and appears 
pinched, with sunken eyes; and often tetanic contractions of the body cause a 
painful feeling to those unaccustomed to such a disease. 
In the third stage the patient either sinks or recovers, and temporary ap- 
pearances of improvement excite deceitful hopes. If the event is unfavorable, 
the pulse again rises, the eye becomes red and dim, and the child, delirious, is 
often attacked by partial or general convulsions, or one limb or one side may 
be palsied. From this point the powers of life gradually sink, till at last death 
closes the scene; but for days and days the child may linger on the very brink 
of the grave. If the patient should fortunately recover, the stupor subsides, 
the countenance becomes more natural, the bowels more regular, the secretion 
of urine perfectly restored, and at length his health, though long broken, is 
gradually re-established. The duration of this acute form of the disease is 
estimated at about three weeks, each stage averaging about a week. 
The pulse becomes very frequent just before death, and the skin copiously 
perspires, urine and feces being passed involuntarily. 
Diagnosis.-The vomiting in this affection is characteristic, and has been 
described as cerebral vomiting (p. 984, ante). It is not traceable to errors of 
diet, nor does it occur after eating, but when the child is raised up, or the head 
is elevated. When the child is also seen to bend the head backwards, or bore 
it into the pillows, with the muscles of the neck contracted, and perhaps the 
cervical glands swollen, the circumstances are very suggestive of the onset of 
acute hydrocephalus. 1008 
SPECIAL PATHOLOGY-TUBERCULAR MENINGITIS. 
Acute hydrocephalus is to be distinguished from enteric fever by the scream- 
ing, rolling of the head, grinding of the teeth, and by the absence of the pecu- 
liar state of the tongue which marks the lattei' disease. There is always intense 
marasmus, although food may be taken. 
There is a morbid state resembling the disease which is neither acute nor 
chronic, to which Sir Thomas Watson has given the name of spurious hydro- 
cephalus. To three great men of the past we owe our knowledge of this con- 
dition-namely, to Gooch, Abercrombie, and Marshall Hall. In children, 
from a few months to two or three years of age, of small make and of delicate 
health, from exposure to debilitating causes, this morbid state not uncom- 
monly supervenes. It is indicated by heaviness of the head and drowsiness. 
The child lies on its nurse's lap, unable or unwilling to raise the head. It 
seems half asleep, one moment opening its eyes and the next closing them 
again, with a remarkable expression of languor : the eyes are unattracted by 
any object put before them, and the pupils remain unmoved on the approach 
of light. The breathing is irregular, sighs are occasionally expressed, and 
the voice is husky. The tongue is slightly white, the skin is not hot, but 
sometimes colder than natural. In some cases there is now and then a slight 
and transient flush. Diarrhoea has often existed for some time, or the child 
has been severely purged by medicines, or having been weaned, has ceased 
to thrive since its change of food. The peculiar green color of the stools, so 
frequent in this disease, seems to be imparted to them in the lower portion of 
the intestine, the fecal contents of the upper portion being of a pale drab color, 
while the bile in the gall-bladder is of a yellow color. When this condition 
of things occurs in a more elderly child, it has been generally brought about 
by depletion, by loss of blood or by medicines. As the more marked symp- 
toms are sometimes ushered in by extreme irritability and a feeble attempt 
at reaction, cases of this kind (which Dr. Marshall Hall named " the hydro- 
cephaZoid disease ") have not unfrequently been mistaken for acute hydro- 
cephalus, and treated accordingly, the patient being generally leeched out of 
its life. In very young children the diagnosis is sometimes very difficult be- 
tween congestion and exhaustion, between fulness and emptiness. 
Sir Thomas Watson, from whose lectures these characteristic notes are 
taken, suggests the following test: " As a guide to diagnosis, take notice of 
the state of the unclosed fontanelle. If the symptoms proceed from plethora, 
or inflammation, or an approach to inflammation, you will find the surface 
of the fontanelle convex and prominent, and you may safely employ and 
expect benefit from depletion. If, on the other hand, the symptoms originate 
in emptiness and want of support, the surface of the fontanelle will be con- 
cave and depressed ; and in that case leeches or other evacuants will do harm, 
and you must prescribe better diet,-ammonia," brandy in arrowroot, milk 
from the mother's breast, if possible, and all such means as will tend to foster 
and nourish an infant. 
Prognosis.-Most physicians are agreed that if acute hydrocephalus shall 
unequivocally declare itself, it will be rapid, and almost inevitably fatal. 
Treatment.-Tuberculous meningitis in the form of acute hydrocephalus 
can only be successfully combated in the first or earliest stage. As the first 
symptoms are those characteristic of inflammation of the brain, and especi- 
ally of its meninges, and as we can only conjecture to what it may turn, 
leeches behind the ears ought to be applied in the first instance. If this local 
abstraction of blood proves beneficial, it may be repeated during subsequent 
relapses. At the outset of the disease laxatives and ice compresses may also 
be used (Niemeyer). 
There is, perhaps, no class of cases in which the sanative powers of judicious 
bloodletting become so apparent as in children in whom the disease has been 
observed early and carefully watched. When the inflammatory symptoms 
are less decided, and the headache slight, and the disease drags on slowly, TREATMENT OF TUBERCULAR MENINGITIS. 
1009 
a single venesection is admissible. Dr. Alison relates the following highly 
illustrative case, confirmed now by the teaching of Niemeyer: 
" A boy aged eight years, of rather delicate habit, and who had complained 
occasionally for some weeks of headache and disordered bowels, temporarily 
relieved by laxatives, calomel, antacids, and a careful regimen, but recurring, 
and attended with gradually increasing febrile symptoms, and shooting pain 
of head ; impatience both of light and sound; pulse gradually rising to 108, 
distinctly sharp, and beginning to intermit, and then nausea and vomiting, 
not referable to any medicine taken, but gradually increasing, until it recurred 
every time that he sat up in bed, for nearly twenty-four hours ; and a slight 
but quite perceptible squint showing itself. The full action of laxatives and 
one application of leeches, as well as cold to the head, having failed to make 
any impression on this course of things, he was bled at the arm (which in such 
circumstances and at that age has often appeared to me distinctly preferable) 
to twelve ounces, and the blood was sizy. I do not know what further evi- 
dence we could have had of the existence of such inflammation within the 
cranium as would infallibly, if let alone, have gone on within a few days to 
delirium, stupor, dilated pupil, slow pulse, succeeded by very frequent pulse, 
convulsions, and death, and have left after it the usual appearances of the 
acute hydrocephalus (of Whytt, Cullen, and Abercrombie, now described), dry- 
ness of the membranes on the surface of the brain, distension of the ventricles 
of the brain with serum, and some of the marks of inflammatory action either 
on the membranes or surface of the brain. Instead of this, however, I am 
quite certain that from the time of the bleeding at the arm this boy never 
once vomited, that the intermission of the pulse was never again observed, noi' 
did he again complain of lights or sounds. The pain of the head, although 
less violent, continued in the evening of the same day, and twelve leeches were 
applied within eight hours after the bleeding; and from that time he never 
once complained of this symptom, nor admitted that he felt it; and/rom this 
moment he recovered perfectly, and much more rapidly than he had done from 
much slighter febrile attacks previously; neither has he suffered from that 
time to this (now thirty years) any return of serious disease " (Edin. Med. 
Journal, p. 777, March, 1856). 
In short, all the symptoms vanished in twenty-four hours, most of them 
during the flow of blood, and never recurred,-a change, under the circum- 
stances, so sudden and sanative as is rarely if ever seen after the use of any 
other remedy for the same combination of symptoms. With reference to the 
sanative influence of general bloodletting in children for inflammatory dis- 
eases, if performed at the outset, Dr. West observes, that such depletion is as 
important a remedy as in the adult; nor will the most energetic employment 
of any other antiphlogistic measure enable us to dispense with bloodletting. 
In a healthy child two years old, a vein (if easily found) may be opened in 
the arm, and four ounces of blood allowed to flow, if faintness be not earlier 
produced, without our having any reason to apprehend that the plan adopted 
is too energetic. The immediate effect produced is greater than that which 
follows local depletion, and the quantity of blood abstracted is less (West,. 
Diseases of Children). 
Bleeding in children and in adults exercises an influence quite different- 
because under totally different circumstances-not yet inquired into; but cer- 
tainly bloodletting at ages under adult life is soon repaired compared to its 
reparation after that period. Hasse recommends very small doses of morphia 
(^th of a grain) in the early stages. 
The first thing to be done by way of medicine is to purge the patient. The 
purgative is not of great moment, provided it acts freely. Some prefer two 
to five grains of gamboge, others five grains of calomel with thirty grains of 
compound jalap powder. Such doses are to be followed up by a black draught. 1010 
SPECIAL PATHOLOGY-INFLAMMATION OF THE BRAIN. 
or the sulphate of magnesia. So difficult is it to obtain the action of purga- 
tives in this disease, that doses of three times the strength for adults have 
been in some instances required; but such large doses are never to be given 
until the inefficiency of smaller ones has been ascertained (Sir Thomas Wat- 
son's Lectures, No. xxvi). 
The stools are generally black, or extremely offensive; and, this state of the 
bowels corrected, the disease, if sympathetic, often ceases. If, however, the 
head be not relieved, some leeches should be applied to the temples, and the 
head should be shaved and surrounded with some cold evaporating lotion, 
such as a towel dipped in cold spring water, or in vinegar and water, or in 
solution of the muriate of ammonia, with vinegar. 
If the disease be advanced, no efficient treatment has as yet been deter- 
mined. The symptoms do not yield to the lancet like those of simple 
inflammation. Mercury has also been used to a great extent, but with little 
success. In urgent cases, for instance, mercurial ointment has been rubbed on 
the back and thighs, even in very young children, to the extent of half a 
drachm to a drachm three or four times in the twenty-four hours. Calomel 
also has been rubbed on the gums to the extent of three or four grains every 
four or five hours, and it has likewise been given by the mouth in doses of 
two grains every third or fourth hour. Mercury given in these large doses, it 
must be remarked, seldom produces salivation; for Dr. Clark says he never 
saw that effect in children under three years of age except in three cases. 
But the remedy is not successful, and more generally produces spinage- 
like stools, and irritates the alimentary canal. In France the mercurial 
treatment has been so unsuccessful that some practitioners have even tried a 
most opposite remedy, namely, quinine, but the result has been equally fatal. 
Blisters, moxas, and other modes of cauterization have been used as auxiliary 
treatment, but without apparent benefit. 
During the course of the disease the diet should be slops and light puddings. 
In congenital hydrocephalus the unassisted efforts of nature seem incapa- 
ble of effecting a cure, and it is extremely problematical if medicine is of 
any use. When, however, the case is deemed hopeless, the propriety of 
evacuating the water by means of an operation may be entertained. Golis 
has given the names of twenty-seven writers who have expressed themselves 
in favor of it, especially if the fluid be slowly evacuated, and at several repeti- 
tions of the operation; yet he himself, along with seven or eight others, pro- 
scribe it altogether as cruel and useless. But it has been successful; and 
■when the operation is performed, it seems an axiom that the fluid should be 
allowed to escape gradually, for otherwise extreme faintness and collapse may 
be expected. In such cases small doses of ammonia, or a few teaspoonfuls 
of brandy and water may revive the little patient. Should reaction take 
place, however, at a subsequent period, a few leeches and a cold lotion ought 
to be applied to the head. It seems also determined that the younger the 
child the greater are the chances of success; for if it lives a few years the 
sutures of the cranium, though open at the top, are united by bone towards 
the base of the skull, and thus present a mechanical obstacle to their closure; 
consequently, the operation is more apt to fail. If this disease, though exist- 
ing at birth, should not develop till later in life, blisters, mercury, and iodide 
of potassium to salivation, are the remedies mostly relied on. 
INFLAMMATION OF THE BRAIN. 
Latin Eq., Inflammatio cerebri; French Eq., Cerebrite; German Eq., Entziindung 
der Hirnsubstanz; Italian Eq., Inflammazione del cervello. 
Definition.-Inflammation of the brain-substance, with or without implication 
of the membranes, usually partial, and in many cases dependent on local injury 
or foreign deposit. SYMPTOMS OF INFLAMMATION OF THE BRAIN. 
1011 
Pathology.-Acute inflammation of the substance of the brain is rarely 
uncomplicated and primary. As a rule, it results as a consequence of pre- 
vious diseases, especially specific fevers, exanthematica, diseases of the ears, extrav- 
asations of blood, tumors or tubercles of the brain, alcoholic poisoning, or external 
injury. The most intense in degree, and at the same time often the most limited 
cerebritis, is from injury. The whole of the brain-substance is rarely if ever 
affected, but one limited portion or several separate portions may be affected 
simultaneously in the white, gray, or membranous parts. The affected part 
acquires first increased vascularity, which increases to a bright red tint, deep- 
ening as the disease advances, until it assumes a reddish-brown, and occa- 
sionally even a brownish or green shade. In keeping with the inflammatory 
process the parts affected lose cohesion, and become softer than natural, and 
may proceed to the formation of pus-a result more common in chronic or 
subacute forms of cerebritis rather than in the acute, and most apt to occur 
in persons of scrofulous and unhealthy constitution, or as the result of injury 
or local disease, especially of bone (Craigie). 
Vascular turgescence and extremely red congestion of the brain, as seen in 
typhus, exanthemata, epilepsy, delirium tremens, tetanus, convulsions, hydropho- 
bia, bring the lesion very nearly, if not altogether, to the condition of inflam- 
mation. 
Morbid Anatomy.-As to hypersemia of the brain, characteristic of or ap- 
proaching to inflammation, it is invariably found that the amount of blood in 
the vessels and the amount of cerebro-spinal fluid are in inverse ratio. Ves- 
sels greatly distended with blood are accompanied by a decrease of arachnoid 
fluid. It is only in cases where the finest vessels of the brain are distinctly 
seen injected with red blood, out of proportion to the congestion of central 
vessels in other parts, that hypersemia can be said to exist. Distension of the 
large bloodvessels (which are veins), always seen on the surface of the brain 
when the calvarium is removed, is a normal appearance. The first fine rami- 
fications of vessels are those supplying the 791a mater; passing thence into the 
substance of the brain. It is in such vessels that hypersemia is to be recog- 
nized, mainly by their number visible and their distension with red blood. In 
the normal condition they can scarcely be recognized by the naked eye. But 
the congestion of acute cerebritis goes a stage farther. The coloration is gen- 
eral, effusion of blood actually takes place in spots or foci, and the consistence 
of the texture is changed. 
Various results follow the inflammatory process, just as in inflammation of 
other textures; and in the brain there are chiefly three to be recognized, 
namely, (1.) Red softening; (2.) Yellow softening; and (3.) Abscess. 
It is in the subacute or chronic inflammation of the brain that these 
results are most common. It is the long duration of the process which gives 
rise to those peculiar modifications to which these names have been given. 
A green shade in the color of the morbid part of the brain is suggestive of 
the formation of pus; and in proportion as the color passes from red to yel- 
low or gray, before greenness sets in, associated with pulpiness or a semi-fluid 
condition, the lesion of red or of yellow softening is to be recognized. It is 
rare to find perfect purulent matter in a distinct cavity. Effusion of serous 
fluid generally attends the softening (Morgagni, Rostan, Lallemand, Bou- 
illaud, Bright, Craigie). The lesion may be either on the convoluted 
surface, to the extent of two or three square inches, or at the septum lucid,um 
or central ganglia, the cerebellum or cruces cerebri; or the whole brain softened 
to a pulp. 
Symptoms.-In general cerebritis they may be almost negative, or a little 
more than a gradual failure of all bodily and mental power, as in cases of 
typhus fever. If one part of the brain should be affected more than another, 
there will be a special paralysis ; otherwise the symptoms are little more than 
weakness of the limbs, strange feelings, and interference with the intellectual 1012 
SPECIAL PATHOLOGY-RED SOFTENING OF THE BRAIN. 
faculties, with perhaps giddiness, sickness, headache, and other symptoms 
common to all febrile disorders (Wilks). 
Usually the symptoms of cerebral irritation precede those of depression. 
Cerebral irritation expresses itself more prominently, sometimes in the sen- 
sory, at another time in the motory, or at another time in the mental functions. 
Sensory symptoms are manifested by headache, which is a frequent but not 
essential symptom of all cerebral diseases. How headache occurs is still unex- 
plained. Increased sensitiveness to impressions on the part of the senses may 
have an explanation similar to what may account for headache-namely, that 
the brain generally, as well as organs of special sense, may have such hyper- 
sesthesia, that irritations or impressions may annoy or excite, which in other 
normal circumstances would not have been noticed. Light causes inconve- 
nience ; a slight sound, or irritation of nerves by touch, cause unpleasant sen- 
sations. The excitation is morbid ab initio. 
Expression of cerebral irritation by motorial symptoms consist of restlessness, 
sudden starting, gnashing the teeth, crying out, twitching of single muscles, 
and general convulsions. 
Mental Phenomena.-The expression of cerebral irritation by mental states 
mainly consist in a rapid change and loose connection between the thoughts, 
so that clear thinking is impossible. Ideas are thus confused, so that the pa- 
tient has false notions about himself and the world generally. He is, in a 
word, " delirious." So real and intense is the delirium that it cannot be dis- 
tinguished from true perceptions. Hence he has hallucinations and illusions. 
Dizziness is a form of hallucination. It is a vivid representation of the move- 
ment of bodies surrounding the patient, or of the body of the patient himself 
-all being really at rest at the time (Niemeyer). Conditions directly op- 
posed to these are indications of cerebral depression. 
The extreme local lesion of actual cerebritis is indicated by partial ancesthe- 
sia, partial paralysis, and loss of certain mental functions. 
Treatment.-What has been said regarding encephalitis and meningitis can 
only be repeated here. 
RED SOFTENING OF THE BRAIN. 
LatIn Eq., Cerebrum fluidum rubens; French Eq., Ramollissement rouge; Ger- 
man Eq., Rothe-Erweichung des Gehirns; Italian Eq., Rammollimento rosso. 
Definition.-Softening of the texture of the brain, as a result of inflammation, 
to the consistence of pulpiness or of cream-like consistence. 
Pathology.-From what has been stated under the preceding subjects there 
are several states to be distinguished within the cranium connected with in- 
flammation, namely,-(1.) "Inflammation of the brain substance," with or 
without implication of the membranes, usually partial, and in many cases 
dependent on local injury, or specific deposits, or growths, or specific fevers; 
(2.) Inflammatory red softening, or acute ramollissement, as contradistin- 
guished from (3.) " White softening of the cerebral substance," the result of 
an atrophic process and impaired nutrition ; and (4.) Abscess. 
The red diffuse inflammation of the substance of the brain appears to have 
many degrees. In the first degree the substance of the organ, when cut into, 
exhibits more bloody points than usual, so that the medullary portion appears 
as if sprinkled with blood, while the color of the cortical substance is increased 
in intensity. If the inflammation assumes a higher degree, the most mark- 
edly red appearances generally only partially affect one of the convolutions of 
the brain, or a small portion of a hemisphere; and the inflamed part varies 
from a bright rose to a deep red dusky color. This increase of color is sup- 
posed by many pathologists not to arise from any greater vascularity of the 
part, but from blood escaping from the vessels and becoming effused or infil- SOFTENINGS OF THE BRAIN. 
1013 
trated into the substance of the brain, forming so many apoplectic spots 
(Boyer). The inflamed part is generally swollen, and sometimes consider- 
ably so, and is generally softer, though it may appear firmer than usual. 
As the lesion advances the exudation ultimately assumes an appearance 
like pus, or becomes more or less softened, approaching in character the con- 
dition of pus as it appears to the naked eye. Without suppuration, however, 
having actually taken place, the mere effect of inflammatory exudation 
amongst the brain-tissue is to soften its texture and increase its specific grav- 
ity, whereas in "white non-inflammatory softening of the brain" the specific 
gravity is diminished. When the softening results from the exudation merely, 
before it has undergone any subsequent change, there are traces of congestion, 
which give to the affected part a red appearance; and the microscope shows, 
as Bennett first demonstrated, a large amount of exudation-corpuscles inter- 
spersed among the broken-down nerve-matter, as well as coating the inner and 
outer surface of the minute bloodvessels. Wherever exudation-matter exists, 
although there may be no palpable indication of changed consistence in the 
tissues, yet the specific gravity will be found increased; and without micro- 
scopic examination we Oannot tell whether or not congestion of the brain-sub- 
stance exists, combined or not with the exudation-corpuscles of red softening. 
The inflammations of the substance of the brain have thus much in them 
that is peculiar, depending on the nature of the tissue; and, independent of 
physical appliances (such as the test for specific gravity and the microscope), 
the unaided senses cannot enable us to appreciate the exact pathological sig- 
nificance of morbid changes. It is only in a small number of cases that the 
red color of the brain is characteristic of inflammation; for in by far the 
greater number there is no increase of redness; and on account of the frequent 
occurrence of such cases, ramollisement has been described by many authors 
as a distinct idiopathic disease. The liberation of phosphoric acid and of 
fatty acids seems to be associated with yellow softening; and there is decided 
acid reaction of the fluid contained in the soft part (Rokitansky). 
The varieties of softening, as characterized by their color merely, cannot 
be regarded as essentially different; they are peculiarities due to the nature 
of the tissue and the effects of the morbid process upon its component parts. 
It appears to be the liquor sanguinis, rather than the corpuscular part of the 
blood, which takes the chief part in cerebral inflammations where softening is 
the prominent phenomenon. The characteristic of the part thus affected is, that 
it is generally whiter or grayer than the natural color of the brain, and also 
softer than its natural substance; and, accordingly, a rough way to appreciate 
the presence of this softening is to allow a gentle stream of water to flow upon 
the suspected part; if softening exists, the softened parts will be gradually 
washed away. This softening, however, has many degrees, and in some cases 
can be only accurately determined by a microscopic examination. In its 
extreme form the softened portion of the brain is absolutely diffluent, so that it 
can be poured out of the cranium with as much facility as a thickened cream 
or a thin jelly can be poured from one cup into another. Sometimes nearly 
a whole hemisphere has been thus destroyed (Brodie, Maclachlan). In 
this semi-liquid state much serum can often be expressed from it. 
Extreme softness of the brain, unattended with inflammatory coloration, 
may be well seen in those cases where the brain has been extensively injured, 
as by sabre wounds. Many such cases are related by our army surgeons. In 
cases of hernia cerebri, also, not only does the protruded portion become soft- 
ened, with red particles of blood intermixed in it, but in acute cases, which ter- 
minate fatally in a few days after the injury, " the medullary structure, interven- 
ing between the base of the protruded part and the anterior cornu of the lateral 
ventricle, had entirely lost its natural structure, and become soft and pulpy. 
Around this disorganized mass, and extending across the corpus callosum into 
the medullary substance forming the roof of the opposite ventricle, the brain 1014 
SPECIAL PATHOLOGY RED SOFTENING OF THE BRAIN. 
had undergone a change from its natural color to a grayish-blue white, while 
it still retained its natural consistency " (Stanley). It was remarked, also, 
in this case, during the last three days of life, that a very considerable quan- 
tity of fluid constantly oozed from the centre of the protrusion, whence it 
trickled down the cheek in a continued stream. Such cases show the acute 
and rapid nature of the softening process as an inflammatory phenomenon, 
but without any obvious discoloration. In fact, most of the phenomena con- 
nected with the inflammatory process in the nervous substance are character- 
ized by the apparent want of increase of the red part of the blood. 
Symptoms.-Although the anatomical conditions of the brain-substance in 
acute ramollissement may not be associated with an appearance of much red 
blood, yet the clinical history of the diseasd seems closely to resemble that of 
cerebral hemorrhage, and it is very often impossible to tell whether the 
physician has to deal with a case of apoplexy, as commonly understood, or a 
case of cerebral softening. The premonitory symptoms peculiar to softening 
appear to be absent in a half, or more than a half, of these cases (Rostan, 
Durand Fardel). In some instances, however, the premonitory symptoms 
afford strong probability of softening, and are of much value; the absence of 
them, however, cannot be regarded as equivalent to the absence of softening 
(Reynolds). 
The attack itself may be gradual or sudden. Thus, after the progressive 
development, during some hours or days, of such premonitory symptoms as 
have been mentioned in the previous affections of the nervous system, the 
patient gradually becomes apoplectic, or he may at once appear to become so 
suddenly and instantaneously, without the premonitory symptoms. In the 
latter case, however, the attack is due to congestion; it gradually passes away, 
and the patient recovers intelligence for a time, but the confirmed symptoms 
of softening remain. They are as follow: 
1. Mental Symptoms.-Transient excitement or mild delirium may precede 
the abolition of Perception; and when this does occur it is highly character- 
istic. Goma is frequently developed abruptly, and is often of the following 
peculiar character: The patient lies still, as if in a profound sleep, but im- 
mediately gives the hand or puts out the tongue, if told to do so, Intelligence 
remaining intact. The loss of Perception and Volition, however, is not re- 
covered from. Dulness and obscuration of Thought and Perception prevail 
often to a marked degree. 
2. The Sensorial Symptoms are not so well marked as the motorial. Hy- 
permsthesia has erroneously been considered pathognomonic of ramollisse- 
ment, perhaps because it is more common in softening than in any other 
apoplectic disease. Numbness and a sensation of cold are not at all un- 
frequent. 
3. The Motorial Symptoms are of two kinds-namely, paralysis, and spas- 
modic contractions of muscles. The face-muscles act unequally, producing 
deviation of the features, sometimes very slight, at other times highly marked. 
Speech is almost constantly impaired, and after slight recovery it continues 
to be so. Paralysis is commonly limited to one side, sometimes to one limb, 
but in rare cases it is general. The spasmodic contractions are either of a 
tonic or of a clonic kind, rigidity or occasional spasm being found in either 
the paralyzed or non-paralyzed limbs,-most commonly in the former. 
The physician, however, will not derive much information from the mere 
recognition of the presence of single symptoms: it is by a close observance of 
their combinations that exact diagnosis will be insured. The following com- 
bination of symptoms are those which may with most probability be referred 
to softening: 
(1.) Imperfect coma, partial loss of Perception and Volition, with rigidity 
of the limbs; (2.) Perfect coma without rigidity; (3.) Paralysis without loss DIAGNOSIS OF INFLAMMATORY SOFTENING. 
1015 
of Consciousness; (4.) Paralysis with hypersesthesia; (5.) Rigidity, coming 
on after the return of Perception and Volition. 
The after-symptoms of softening are also strikingly different from those of 
apoplexy. The morbid phenomena do not suddenly disappear, nor is there 
the gradual improvement which takes place after apoplexy. Enfeeblement 
of the mental powers most commonly persists, and the motorial phenomena 
remain. Slight apoplectic-like seizures occur, convulsive movements and 
rigidity increase, and some little febrile excitement becomes developed, which 
in severe cases generally assumes a typhoid type, with brown tongue and rapid 
pulse. From such a condition recovery is rare. 
The duration of life in ramollissement of the brain is various; but in 109 
cases the disease terminated within the periods indicated in the following- 
table : 
DURATION OF LIFE IN CASES OF SOFTENING OF THE BRAIN. 
1 died in 12 hours. 
1 " 15 " 
1 " 24 " 
1 " 32 " 
5 " 2 days. 
9 " 3 " 
5 " 4 " 
4 " 5 " 
7 " 6 " 
8 " 7 " 
8 " 8 " 
3 " 9 " 
5 " 10 " 
4 " 11 " 
2 died in 12 davs. 
3 " 13 " 
3 " 15 " 
1 " 16 " 
2 " 17 " 
4 " 18 " 
5 " 20 " 
3 " 21 " 
1 " 22 " 
1 " 23 " 
1 " 25 " 
1 " 29 " 
4 " 30 " 
1 died in 35 days. 
1 " 36 " 
1 " 47 " 
1 " 49 " 
1 " 60 " 
1 " 65 " 
1 " 68 " 
1 " 190 " 
1 " 220 " 
1 " 5 months. 
2 " 6 " 
1 " 1 year. 
2 " 3 years. 
It thus appears that ramoUissement of the brain is more frequently an acute 
than a chronic disease, the greater number dying before the twelfth day, 
while at the end of a month only sixteen cases out of the 109 were living. 
In the thirteen cases which have been collected of ramoUissement of the 
cerebellum, the impairment of Intellect was trifling, while motion was greatly 
affected in all except one doubtful case. In ten cases there was palsy with 
or without contraction of the muscles of the opposite side of the body; in two 
others, convulsive actions of both sides of the body; and in the last case ob- 
served by Rostan the palsy was on the same side. In this case the disease 
depended on an exostosis of the petrous portion of the temporal bone. In no 
instance is it said that any sexual desire troubled the patient. 
Diagnosis.-The great difficulty in the diagnosis of acute ramoUissement is 
to distinguish it from apoplexy. In most cases it is not possible to make the 
distinction. "On the other hand," writes Dr. Maclachlan, "there are numer- 
ous cases of acute softening which can scarcely be mistaken for cerebral hem- 
orrhage. In such a combination of symptoms as the following-and I do not 
group them artificially, but as I have repeatedly observed them-the prob- 
abilities are, that the case is one of acute softening, and not sanguineous 
apoplexy: After several days' suffering from headache, giddiness, drowsiness, 
dulness of comprehension, tingling or numbness in the toes or fingers, fol- 
lowed by sudden hemiplegia, without loss of consciousness, the probabilities 
are, that the symptoms are due to softening instead of hemorrhage. If to 
these symptoms succeed pains in the palsied limbs, and diminution or exalta- 
tion of the cutaneous sensation, while the symptoms maintain a variable 
rather than a fixed character, whether the palsied limbs are contracted or 
relaxed, or alternately contracted, the chances are still greater that the case 
is one of softening; and the diagnosis may be considered as established should 
the paralytic symptoms, and with them the associated stupor, preserve this 
vacillating, impulsive peculiarity, there being periods of amelioration, followed 
by increasing coma and increasing palsy " (1. c., p. 193). 1016 
SPECIAL PATHOLOGY-RED SOFTENING OF THE BRAIN. 
Prognosis.-The prognosis in every case of encephalitis is grave; but, as 
far as we can judge, even acute cases recover, and live for many years after- 
wards, notwithstanding the unfavorable opinion expressed by Rostan. In- 
flammatory ramollissement of the brain is looked upon as an essentially fatal 
disease, and the patient seldom survives the formation of an abscess; but it is 
apprehended that the pus may be occasionally absorbed, and that the oppo- 
site walls may unite by granulations, and leave an areolar-tissue cicatrix. 
Nevertheless, there is some evidence, also, that inflammatory ramollissement 
is capable of being cured. The post-mortem evidence of this fact is the dis- 
appearance of one or more layers of the cortical substance, probably by 
absorption, while the pia mater adheres to this part of the brain. The evi- 
dence of the cure of ramollissement in the gray matter of the corpora striata 
and other central parts is the presence of a number of "holes," resembling 
Parmesan cheese, of a red color when there has been transudation from the 
bloodvessels, and of a fawn color in other cases. The part is atrophied and 
softened; while the holes may be filled with a limpid fluid, sometimes lined 
with a membrane (Dr. Simms, Med. and Cliir. Trans., vol. xix, p. 413). 
Treatment.-In diffuse inflammation of the brain arising from mechanical 
injuries there can be no doubt that bleeding and antiphlogistic treatment 
generally are most beneficial, when employed with a wise discretion and at 
an early period. When, however, inflammation occurs during the progress 
of a general disease of the system, it is necessary that such measures be em- 
ployed with the greatest caution, and in the majority of such instances they 
are better omitted altogether; for we find in many cases of typhus fever, in 
which the brain is probably partially impaired in consistence, that the patient 
recovers under a stimulant treatment. 
In acute idiopathic ramollissement of the brain the treatment can hardly be 
said to be yet determined; but there is good reason to believe that general 
bleeding is only to be practiced with benefit when the disease is associated 
with general congestion of the braim 
Most advantage is to be derived from the use of tonics, and of a nutritive 
diet. As a general rule, cerebritis does not admit of so copious depletory 
measures as meningitis. In acute cases, where the premonitory symptoms of 
congestion are obvious and urgent, bleeding may be carried to a considerable 
extent, consistent with the nature of the case and the individual; and after a 
reasonable quantity of blood has been taken without producing nausea or 
fainting, the bleeding may be again repeated till some decided impression is 
made. In many cases, on the other hand, cupping, or bleeding by means of 
leeches to the temples or back of the ears, may be more useful than venesec- 
tion. Such cases are indicated by the signs of determination of blood to the 
head, heat of the scalp, suffusion of the eyes, redness of the face, with or with- 
out inordinate action of the carotids. Such cases are also more likely to be 
benefited by the cautious repetition of this treatment than by general blood- 
letting, which can very seldom be required in softening of the brain occurring 
in persons turned of fifty (Maclachlan). 
Even when the pulse may seem to warrant bleeding, and at a time when 
bleeding may seem safe and proper, it is advisable, before having recourse to 
this measure, carefully to examine the state of the heart, the state of the 
arteries at the wrist, and the condition of the cornese. By such examination, 
assisted by the previous history of the case, the condition of the cerebral 
arteries will best be indicated, and the readiest clue gained to the probable 
nature of the cerebral affection. If the heart's action and sounds are feeble, 
■or if signs of valvular insufficiency are present, it is probable that the softening 
is ansemic, atrophic-a consequence of partial inanition, and not of partial 
cerebritis. This conclusion is still more probable if the radial arteries are 
rigid, and if the arcus senilis is fully developed. To bleed under such circum- 
.stances is unwarrantable. PATHOLOGY OF YELLOW SOFTENING OF THE BRAIN. 
1017 
In severe seizures resembling apoplexy the bowels should be opened by an 
enema of castor oil and turpentine. In less urgent cases, where there has not 
been loss of consciousness, or where it has been restored and the patient is 
able to swallow, a purgative of colocynth and calomel, with or without croton 
oil, may be substituted for the enema. Perfect rest in the recumbent posture 
must be enjoined, with the head slightly elevated, and all constrictures of 
dress removed from the neck. The scalp should be kept cool by rags dipped 
in cold vinegar and water, or iced water. If much reaction supervene, leeches 
may be applied to the head ; and should the pulse be weak, twenty or thirty 
drops of the spiritus ammonice aromaticus may be administered. The catheter 
may require to be used; and the bladder must always be examined, in ease 
the urine may be retained. Nourishment must be given in small and oft- 
repeated quantities. 
If sanguineous effusion has actually happened, calomel, to the extent of 
permitting the mouth to be made slightly tender, is believed by not a few to 
encourage the absorption of the fluid. It can only, however, be given in 
healthy subjects, free from gouty or renal disease; and Dr. Maclachlan rec- 
ommends that it may be given in the form of three or four grains of blue pill 
and two of James's powder every evening for ten clays or a fortnight, the 
effects being carefully watched, so that the gums should not be more than 
touched. 
To allay the pains in the palsied limbs opiates are of great value. They 
procure sleep and moderate tetanic rigidity of the flexor muscles. Muriate of 
morphia may be given in doses of one-sixth to one-fourth of a grain at bed- 
time ; and the doses may after a time be increased, if necessary; and may be 
combined with extract of colocynth or croton oil, to counteract the tendency 
to constipation (Maclachlan, 1. c., pp. 195, 196). 
In chronic cases local bleedings from the temples, or from behind the ears, 
combined with moderate purgatives every three or four days, are demanded 
in most cases, with a blister applied now and again to the nape of the neck; 
and as much as possible the currents of blood must be diverted from the brain. 
Headache and stupor are generally relieved by full feculent evacuations. 
The diet ought to be strictly that of a vegetarian, and as little stimulant as 
possible (Wood). 
In the more chronic, and although ultimately fatal, forms of the disease, 
life is evidently prolonged by mild tonics, attention to the bowels, and by a 
liberal and nutritious diet, with such a graduated allowance of alcoholic bev- 
erages as the case may require. Beyond this the medical treatment of ramol- 
lissement of the brain is still a problem, with only a few unsure data to guide 
us for its solution. 
YELLOW SOFTENING OF THE BRAIN. 
Latin Eq., Cerebrum fluidum flavens; French Eq., Ramollissement jaune; German 
Eq., Gelbe Erweichung {des Gehirns)-, Italian Eq., Rammollimento giatlo. 
Definition.- Yellow softening of the brain, as a result of death of a portion 
of its tissue. 
Pathology.-This form of softening is usually in the greater hemispheres, 
in their medullary portion. The lesion may vary in size from that of a bean 
to that of a hen's egg. In the extreme condition of softening the cerebral 
substance is changed to a moist gelatinous pulp, varying in color from gray- 
ish-white to yellow. The surrounding portion of brain is generally reddish, 
from dilated vessels or hemorrhagic infarction. The yellow color of the softer' 
portion generally depends on the changes which go on in the blood extrava- 
sated in such capillary hemorrhages. The softened and disintegrated brain- 
substance becomes charged with the coloring matter of the blood; eventually 1018 
SPECIAL PATHOLOGY-YELLOW SOFTENING OF THE BRAIN. 
the lesion is converted into an areolar network, filled with a yellow, chalky, 
milk-like fluid. 
The medullary structure above the lateral ventricles is very often the seat 
of this species of lesion. When the softening approaches near the external 
surface of the hemispheres there is usually flattening of the convolutions, 
with a sensation of pulpiness or fluctuation beneath. 
This yellow softening is in reality a form of gangrene. 
Symptoms.-It comes on suddenly, and as if without any preliminary in- 
flammatory or hemorrhagic stage, and at once proceeds to complete disorgani- 
zation of a portion of the brain, which so dies. The entire duration of this 
form of softening may not exceed three or four days. The effects of the sev- 
eral forms of softening on the system are not well defined, and cannot be con- 
sidered as in any way distinctive, so that those already indicated embrace all 
that can be detailed. Softening in the crura is generally speedily fatal, death 
usually taking place within two or three days, and is rarely prolonged to the 
sixth day. Within the substance of the medulla oblongata it is still more 
rapidly fatal. 
Much confusion exists regarding the nature of the several softenings of the 
brain and spinal cord. It has always been difficult practically to distinguish 
one kind of softening from another. Professor J. H. Bennett, of Edinburgh, 
describes six conditions under which softening-as seen post-mortem-may 
arise, as follow: 
(1.) Exudation or inflammatory softening, from exudation which has been 
infiltrated among the elementary nerve structures. 
(2.) Hemorrhagic softening, from a mechanical breaking up of the nerve 
texture by hemorrhagic extravasations, either in large masses or infiltration 
by small isolated points. 
(3.) True fatty softening, from fatty degeneration of the nerve-cells, inde- 
pendent of exudation. 
(4.) Serous or dropsical softening, from the imbibition of serum, which loosens 
the connection between the nerve-tubes and cells. 
(5.) Mechanical softening, from violence in exposing the nerve-centres. 
(6.) Putrefactive softening, occurring especially in warm weather. 
Only the first three, and perhaps also the fourth, may occur during life. 
Dr. Craigie considers softening of the brain to succeed at least four morbid 
states, as follow: 
(1.) The consequence of the blood-stroke (coup de sang). 
(2.) The consequence of effusion of red blood, which separates and breaks 
down the delicate texture of the part in which it is effused. 
(3.) As a consequence of the process which accompanies or follows hydro- 
cephalus. 
(4.) It may take place in the cerebral substance surrounding tumors. 
Whatever therefore may be the circumstances under which softening is de- 
veloped during life, or the form it assumes after death, the lesion is not so 
much a substantive disease as the effects of a morbid process taking place 
under several different conditions of the brain. 
Diagnosis.-Whenever hemiplegia, complete and absolute, occurs suddenly, 
without loss of consciousness, softening of the brain may be diagnosed, and 
that the softening is of the colorless kind (Recamier, Trousseau, Todd). 
Whenever, on the contrary, complete loss of motor power is attended by loss 
of consciousness, especially when coma is sudden, hemorrhage may be diag- 
nosed, and that to a considerable amount. When the intellect is effaced to 
some extent, but not entirely,-when there is obtuseness but not complete loss 
of sensibility,-whilst there is absolute loss of motor power, capillary hemor- 
rhage coexists with softening (Recamier, Trousseau). 
Treatment must be by restoratives and food, and perhaps wine. Blood- 
letting and lowering treatment are now not to be thought of. PATHOLOGY OF ABSCESS OF THE BRAIN. 
1019 
ABSCESS OF THE BRAIN. 
Latin Eq., Abscessus cerebri; French Eq., Abscis du cerveau; German Eq., Abscess 
des Gehirns ; Italian Eq., Ascesso. 
Definition.-Suppurative inflammation of the brain, terminating in a collec- 
tion of pus. 
Pathology.-Collections of purulent matter have often been found in the 
substance of the brain (Apostema cerebri). 
Suppuration of the brain occurs in three forms, and in by far the greater 
number of cases no trace of redness can be seen in any part of the brain; 
and probably this want of vascularity may account for the rare development 
of pus-corpuscles in the fluid of what appears to be abscesses, and which other- 
wise looks like pus. Pus is not always present in undeniable abscesses of the 
brain, but molecular granules, exudation-corpuscles, and pyoid bodies, evi- 
dently the result of the exudation-process, are generally the sole objects which 
the microscope can detect (Lebert, Bennett). Exudation in the softened 
state of the brain-substance, resembling pus, may be thus-(1.) Collected into 
the form of an abscess; (2.) It may be infiltrated into the substance of the 
brain; or (3.) It may be detected on the convolutions, in the shape of a ragged 
ulcer, varying in size from a fourpenny-piece, or less, to that of half a crown. 
It is in this latter form and site of the suppurative process that well-formed 
pus-corpuscles can most frequently be detected. 
In abscess of the brain the surrounding substance is generally of the natural 
color, except in a very few cases in which it succeeds to apoplectic effusion, 
when the walls of the cavities are dyed by the previously extravasated blood. 
Dr. Baillie says, when the abscess is of large size, the weight of the pus breaks 
down the neighboring parts, and they look simply as if they had been destroyed 
or very much injured by the pressure; and also when the abscesses are small 
there is an ulcerated appearance of the cavity in which the pus is contained. 
In other cases the usual membrane of an abscess forms. This membrane is at 
first extremely delicate and easily torn ; but as the patient continues to live, 
the membrane lining the abscess becomes of greater consistency, and even of 
considerable density, so that in some cases it is fibrous, fibro-cartilaginous, 
and even ossified, thus laying the basis for the formation of bony tumors of 
the brain. 
Recent abscesses of the brain form irregular round cavities, filled with 
yellow, grayish, or reddish thick fluid ; and the walls of the abscess consist of 
ragged masses infiltrated with pus. In the immediate vicinity of the abscess 
there is usually inflammatory softening, and beyond that oedema of the brain. 
Such abscesses increase till they open into a ventricle, or reaching the 
meninges, extensive meningitis may occur. In other instances ulceration 
may take place through the cerebral membranes as far as the calvarium or 
skull bones. The ulcer may perforate the bone, or open into the cavity of the 
tympanum. If the ulcers be incorporated by new connective tissue forma- 
tions, they have a regular form and smooth walls. If it has lasted a long 
time, the corpuscle is dense, and the contents thickened by reabsorption of 
the fluid part, the remainder being converted into a cheesy chalk-like mass 
(Niemeyer). 
Of eighty instances of abscess of the brain, collected by Professor Lebert, 
twenty-two of them, or above a quarter, were cases of scattered abscesses in 
various parts of the brain; the remaining fifty-eight were cases in which 
solitary abscesses were found in some part of the encephalon, distributed as 
follows: 
Left hemisphere, . . in 23 cases. 
Kight " . . in 18 " 
Corpora striata, . . in 2 " 
Cerebellum, . . . . in 12 cases. 
Pituitary body, ... in 2 " 
Medulla oblongata, . in 1 case. 1020 
SPECIAL PATHOLOGY - ABSCESS OF THE BRAIN. 
In the case of multiple abscesses there were never more than five, some- 
times three, or two only. 
The abscesses generally occupy the white substance, and only affect the 
gray matter by extension. In form the abscesses are generally oval, and vary 
in size from a pea to the size of a hen's egg or larger; so that one entire 
hemisphere has been found converted into a pouch filled with pus. The pus 
is generally of a greenish color, of considerable density, and rarely containing 
blood. Sometimes it is very fetid. It is generally granular, not containing 
many well-formed corpuscles; and the older the abscess the more the pus- 
corpuscles are found to be degenerating. Pus is generally found infiltrating 
the cerebral tissue surrounding the abscess; and in the zone beyond, the tissue 
is softened, while, if the process be recent, a zone of vascular redness surrounds 
the whole. Connective tissue ultimately grows in a condensed form round 
the site of abscess, and closes the whole with walls of considerable thickness 
(1 to 4 millim.). Often these walls are very vascular. There does not seem 
to be any evidence that these encysted abscesses are ever cured. 
The lateral ventricles are the parts into which the abscesses most frequently 
burst. Thickening of the ependyma follows, and scattered spots of inflamma- 
tory softening may be found in the neighboring tissue. In some cases the 
abscess makes its way outwards through the petrous portion of the temporal 
bone or the aural passages. 
The most frequent cause of cerebral abscesses is internal otitis-a lesion 
which often results from scarlet fever, typhus fever, small-pox, measles, or scrofula. 
The ear affection which causes the discharge is usually either (1) disease of 
the tympanic cavity, or of the dura mater investing the temporal bone. The 
inflammation which terminates in abscess of the cerebral substance is usually 
the effect of inflammation of the membranes, and in some instances of the dis- 
charge being suddenly checked, and the chronic external inflammation being 
suddenly converted into an acute internal disease. The inflammation is 
generally observed to succeed quickly the suppression or disappearance of the 
external discharge. It is generally observed in cases of scrofula (Craigie). 
Abscesses also occur as the sequelae of inflammations of distant parts, as of 
pneumonia, pericarditis, enteritis. They may also occur as so-called metastatic 
abscesses, pyaemia, and as a result of traumatic injury. 
The symptoms of abscess of the brain are likewise extremely obscure. In 
a case treated for disease of the nose, the man made no complaint of his head, 
and was able to sit up in bed, and to assist himself in every way. He died 
suddenly in the night. An abscess of considerable size was found in the left 
hemisphere above the ventricle. In other cases pain, delirium, coma, palsy, 
and sometimes convulsions, were the symptoms observed. The convulsions 
were observed most frequently to occur when the abscess formed in the tuber- 
culum annulare or in the medulla oblongata, or so close to these structures that 
the growth of pus would affect their functions simply by its pressure (Baillie, 
Morbid Anatomy, p. 450). 
The latent character of brain abscess is important in diagnosis. Sudden 
headache is the symptom which most frequently excites attention; and it is 
generally accompanied by febrile symptoms and vomiting. The patients 
become heavy, morose, and may be delirious, with contraction of the pupils 
and photophobia. Difficult articulation, numbness, formication, and convul- 
sive attacks may supervene. While the intellect may suffer comparatively 
little, sensibility suffers more frequently; and headache, generally at first 
diffused, is more or less intense, and subsequently becomes unilateral. Coma 
occurs frequently, is often temporary, and paralysis occurs in about one-half 
the cases. The paralysis is generally local; but it may assume the form of 
general muscular debility. The duration of such cases fluctuates from two or 
three weeks to two months (Lebert, Sieveking, in Med.-Chir. Review, 1857, 
p. 526). DEFINITION AND PATHOLOGY OF APOPLEXY. 
1021 
Schott has analyzed forty cases of abscess of the brain. He finds otitis, 
pyaemia, and injuries to be the most frequent causes. In cases of otitis the 
abscess formed mostly in an imperceptible manner; and in cases of injury the 
symptoms were very transitory. Encephalitis was present in acute cases. 
{New Syden. Soc. Year-Book, 1862, p. 79.) 
APOPLEXY. 
Latin Eq., Apoplexia; French Eq., Apoplexie; German Eq., Apoplexie-Syn., 
Hirnschlag; Italian Eq., Apoplessia. 
Definition.-A disease essentially characterized by the sudden loss, more or 
less complete, of Volition, Perception, Sensation, and Motion, depending on sudden 
pressure upon the brain (the tissue of which may be morbid'), originating within 
the cranium. 
Pathology.-The literal meaning of the term apoplexy conveys the idea of 
a sudden stroke; and it has been usual to confine the term to the results pro- 
duced by extravasations of blood into the nervous tissue of the brain, a portion 
of which is thus destroyed. More comprehensive pathological doctrines teach 
us to give a wider signification to the term. It is now used to characterize a 
group of symptoms irrespectively of the anatomical conditions upon which 
they may depend. These symptoms consist of-(1.) Premonitory warnings, 
extending over variable periods (seconds, weeks, months, or years), marked 
by sundry derangements of the nervous functions, such as loss of memory, 
dulness of sensation, or diminished power; (2.) The individual is more or less 
suddenly deprived of volition and perception in their relation to sensation and 
motion. Consciousness is thus more or less lost, and paralysis is more or less 
complete. The patient may fall to the ground completely insensible, or he 
may only stagger and cling to some object for support. The respiration and 
circulation may be unaffected, or the former may be stertorous and the latter 
labored. Some group of muscles, a side of the body, or the whole body, is 
paralyzed, flaccid, motionless ; or it may be rigid with tonic, or convulsed with 
clonic spasm. From this state the patient may never recover. Life becomes 
gradually extinguished, or the sufferer may recover partially or entirely; in 
the former case leaving some mental, motorial, or sensorial faculty impaired 
for weeks, or for the whole of after-life. 
The essential phenomena of an apoplectic seizure consist in the severance of 
the brain-functions, namely, volition and perception, from motion and sensa- 
tion; the other symptoms that occur are additional phenomena, depending on 
secondary changes subsequently induced in the part, or its vicinity, which has 
been the primary seat of lesion. These essential phenomena of the apoplectic 
state are found to be due to a variety of local lesions, or complex morbid states, 
and not to any constant lesion. One or more of the following local lesions or 
complex morbid states may induce the apoplectic condition, namely,- 
(1.) Congestion of the brain, or what is commonly called determination of 
blood to the head-congestive apoplexy. 
(2.) Hemorrhage, or extravasation (a) into the substance of the hemispheres or 
cerebellum, (b) into the ventricles, or (c) into the arachnoid cavity. 
One or other of these lesions constitutes apoplexy in the common acceptation 
of the term-sanguineous apoplexy or cerebral hemorrhage. 
(3.) Sudden serous effusion in large guantity is equally efficient in bringing 
about the apoplectic state commonly called serous apoplexy. 
(4.) Local cerebritis, or softening of the brain, produces, as already shown, 
symptoms, in the first instance, of an apoplectic kind. So also do 
(5.) Tumors of the brain, or meningitis. 
(6.) Tuberculous meningitis. 1022 
SPECIAL PATHOLOGY - APOPLEXY. 
(7.) The progress of various specific and constitutional diseases from blood- 
poisoning. 
(8.) Anaemia, as in the hydrocephaloid disease of children, disease of the heart, 
and vascular obstructions. 
To the phenomena produced by the first three of these conditions only has 
it been common or usual to apply the term apoplexy. 
This disease was well known in the Greek and Roman schools of medicine, 
and is of too frequent occurrence, and of too striking a character, to have 
escaped observation even in the rudest ages of society. Patients have died 
with undoubted apoplectic symptoms when nothing has been found but con- 
gestion of the vessels of the scalp, of the membranes of the brain, and of the 
brain itself, but without the extravasation of a particle of blood. More gen- 
erally, however, a greater or less quantity of blood has been effused either 
into the cavity of the arachnoid, into the substance of the brain, or into some 
of the ventricular cavities. Thus it is that the lesions found in cases which 
die of undoubted apoplectic symptoms vary much, Sometimes the evidently 
congested state of the brain during life leaves no trace visible after death. 
Such cases have been described as " nervous apoplexy " (Sandras). 
Although much stress is laid upon the fact that " a sudden pressure upon 
the brain is necessary to produce the apoplectic state," yet it is difficult in all 
cases to account for the proximate cause of the disease by such an explana- 
tion; for when the quantity of blood extravasated has been not larger, for 
instance, than a barley-corn, it is difficult to account for all the phenomena 
by mere pressure. The ideas or theories which have thus been formed to 
account for the apoplectic state may be shortly stated as follows: 
(1.) The result of sudden pressure, effected by causes within the cranium. 
(2.) From a peculiar morbid state of the nervous matter of the brain, and 
which predisposes to the extravasation of blood (Drs. Robert Williams, 
Wood, Sieveking)-an apoplectic orgasm, as it has been called by some, 
but which is probably of the nature of softening (Rochoux). 
(3.) A morbid condition of nerve-matter and minute bloodvessels, also 
probably of the blood itself (Bouillaud, Paget), and in connection with 
chronic renal disease (Bright, Burrows, Christison, Kirkes). 
Cerebral hemorrhage generally takes place from the smaller arteries or cap- 
illaries of the brain, and there is generally structural disease of the arterial 
walls as well as a morbid condition of the brain-substance surrounding the dis- 
eased vessels, combined with increased pressure of blood from some temporary 
cause-temporary plethora-such as occurs during prolonged and luxurious 
meals. 
When the quantity of blood extravasated is small, the disease is seldom 
fatal from the first attack; but the rapidity of the fatal issue appears to bear 
some relation to the vicinity of the hemorrhage to the medulla oblongata; and 
the effusion of blood into the ventricles is also generally most rapidly fatal. 
But in all cases impairment of general nutrition is the result of injury to the 
brain from apoplexy; and a gradual diminution of mental power is seen in 
almost all apoplectic cases, corresponding to a general atrophy of the brain; 
and degeneration extends into the spinal medulla of the filaments communi- 
cating with the apoplectic effusion (Turk). 
In examining apoplectic cases it is not unusual to find a cavity scarcely 
bigger than a barley-corn in the substance of the brain, the evidence of the 
primary attack, and containing a clot of blood variously changed. If the 
blood be effused among the membranes, it may be altogether absorbed, and 
not a trace of disease be found. In severe cases still greater quantities of 
blood are effused; and if the apoplexy destroy the patient in a few minutes 
or a few hours, the quantity of blood effused will sometimes fill the whole 
cavity of the arachnoid, or extensively rupture the substance of the brain, PATHOLOGY OF APOPLEXY. 
1023 
forming a cavity as large as a nut or an egg, or even lay the ventricles into 
one cavity. 
It is rare that sanguineous effusion occupies both cerebral lobes, or the whole 
extent of the membranes of the brain, although such instances are occasion- 
ally seen. More commonly it is limited to the substance of one hemisphere, 
or to the membranes covering it, or to the cavity of a ventricle. When the 
membranes of the brain are affected, the more immediate seat of the hemor- 
rhage is usually that portion covering the convexity of the brain. This varies, 
however, so that the portion covering the base, or that investing the cerebel- 
lum, or, indeed, any other part, may be its seat. 
The superficial membranes of the brain are not the only membranes of that 
organ which are the seat of apoplectic effusion. Hemorrhage may take place 
from the membrane lining the ventricles, and which sometimes bleeds so pro- 
fusely as not only to fill the lateral ventricles, but even to enlarge their cavi- 
ties. As death in these severe cases is usually sudden, the walls of the ven- 
tricles are generally healthy ; but in some very few instances the septum luci- 
dum has been found ruptured, and the ventricles have freely communicated. 
The smaller ventricles are in a very few instances also the seat of apoplectic 
effusion. Dr. Abercrombie gives a case in which the third and fourth ventri- 
cles were filled with blood. The patient was not at first insensible, but grad- 
ually became so, and died in a few hours. 
The appearance of the blood effused into the membranes of the brain varies 
according to the time which elapses before the patient dies, thus affording op- 
portunity for its examination. If that event takes place in a few hours after 
the attack, the blood is still fluid, or is found in black clots, while the mem- 
branes, except being infiltrated with blood, are as yet healthy. The substance 
of the brain, likewise, has no other appearance of disease than that of being 
flattened, from the presence of the extravasated blood. If the patient, how- 
ever, survives a few days, the membranes show marks of inflammatory action. 
They are injected, thickened, and although dry and pitchy-like in the imme- 
diate neighborhood of the clot, have yet some serum effused in other parts of 
the space they inclose. The convolutions of the affected part of the brain are 
likewise now not only flattened but softened. Thus various processes imme- 
diately commence in the blood after it is extravasated, as well as an inter- 
change of processes between the blood and the surrounding parts. The most 
obvious of these phenomena are the formation of a coagulum or clot; its solu- 
tion, and the formation of blood-crystals ; the gradual absorption of the more 
fluid constituents; the formation of an organized membrane round the clot; 
continuous absorption of the exudation; induration of the surrounding cere- 
bral parts ; contraction of the cavity, and ultimately the formation of a cica- 
trix. These changes are effected with various degrees of rapidity, depending 
on the site and extent of the extravasations, the healthy state of the nervous 
texture, and of the patient constitutionally. 
When effusion has taken place into the substance of the brain, if the patient 
has died in the fit, or shortly after, the hemorrhagic cavity is found filled with 
half-coagulated blood, its walls irregularly softened, and dyed to the extent of 
some lines deep with the coloring matter of the blood ; and a small stream of 
water directed upon this part at once removes the extravasated blood, and 
also a layer of softened cerebral matter. Again, if the patient has survived a 
week, the blood is found coagulated, and the serum set free; but the presence 
of the clot has caused inflammation, so that the walls of the cavity are not 
only discolored, but more decidedly softened, and are softer in proportion as 
they are nearer the clot. If life be prolonged till the fifteenth day, the 
serosity is absorbed, but the walls of the cavity are still of a deep red. About 
the seventeenth day Virchow has discovered blood-crystals, or hsematoid crys- 
tals, in the cavity. These blood-crystals were first discovered by Sir Everard 
Home, and have been more recently described, and their nature explained, by 1024 
SPECIAL PATHOLOGY - APOPLEXY. 
Funke, Kunde, Lehmann, Beale, Parkes, and Sieveking. It appears that 
these crystals do not form from clotted blood until the blood-corpuscles have 
become ruptured by endosmosis. Their contents then escape and crystallize as 
the solution gradually becomes concentrated (Beale). Thus another guide 
to the age of the clot exists in the presence of these crystals. About the thir- 
tieth day, if the patient lives so long, the clot is isolated, and a membrane 
forms, by the new formation of connective tissue growing from the neuroglia. 
At first this membrane is muciform, fragile, intermixed with particles of cere- 
bral matter, and also with some of the coloring matter of the clot; but by 
degrees it becomes more consistent, thick, and hard, and incloses the clot, 
which diminishes, and some serum is probably secreted by the new membrane 
surrounding it. Eventually a new formation of delicate connective tissue, col- 
ored yellow by the pigment of the clot and by serous infiltration, covers the walls 
of the clot-cyst, and breaks up the clot into a fine network. The cyst has also 
been found fully formed, organized, and nearly empty, by the thirteenth day 
(Macintyre) ; and by the seventeenth day after extravasation it has been 
found to contain sanguineous fluid (Moulin, Sieveking). The cerebral 
walls surrounding the cyst, previously softened, now become indurated, and 
are stained yellow, from the usual changes which the extravasated blood with 
which they are penetrated undergoes-a color, however, which they ulti- 
mately lose. The cavity thus formed may be filled at length with serum only; 
or, the serum being absorbed, the membranous cyst may ossify, and may be 
thus converted into a bony tumor. At other times the opposite sides of the 
cavity unite by a kind of areolar membrane, inclosing pigment, which thus 
forms a species of apoplectic cicatrix, but possessing so little power of conduct- 
ing nervous influence that the patient seldom recovers from his palsy. Such is a 
short outline of the effects of hemorrhage into the substance of the brain. The 
size of an apoplectic cavity varies from a barley-corn to that of an egg, and 
their number is as variable as their extent. Sometimes we find but one, some- 
times two, and in a very few instances three or more cavities. When many 
apoplectic cavities exist in the brain, it is rare to find them all in the same 
state. Some are old and almost obliterated, others are fresher, and others 
again quite recent, their different stages marking a distinct and different 
period of attack. An account of a most interesting case of this nature is given 
by Dr. Fuller, in which there were six clots, each of a different date, and 
in different stages of discoloration, and corresponding to each of six well- 
marked apoplectic seizures in the course of nine months {Diseases of the Chest, 
p. 602). 
Some of the most exact data we possess regarding the pathology of apo- 
plectic seizures are to be found in the Transactions of the Pathological Society of 
London. 
In fourteen cases in which lesions of the brain connected with apoplectic 
seizures have been shown at the Society, the position of the blood effused was 
as follows: (1.) Superficial meningeal effusions, five cases; (2.) Within the 
substance of the hemispheres or the central ganglia, four cases; (3.) In the 
pons Varolii, two cases; (4.) In the pons Varolii and crura, one case; (5.) In 
the pons Varolii and cerebellum, one case; (6.) In the pons, crura, and cerebel- 
lum, one case. 
Superficial or ventricular extravasation occurred in five cases; that is, the 
blood lay in a more or less coagulated mass under the arachnoid over the 
hemispheres, and was most abundant at the base and about the roots of the 
nerves. In two of the cases there was some evidence of previous meningeal 
disturbance. This evidence consisted of adhesion of the cerebral arachnoid 
and pia mater to the cerebral convolutions along the anterior margin of the 
middle line of the hemisphere: the history of the other case recorded the 
occurrence of two previous apoplectic seizures. In it post-mortem evidence extravasation into the central ganglia. 
1025 
of previous irritation also existed, in the adhesion of the dura mater to the 
calvarium. 
The conditions as to general health of those in whom these attacks occurred 
were as follow: One was convalescent from a uterine disease, the nature of 
which is not stated; another had chronic bronchitis and asthma; in a third 
intemperance was predominant; and in the fourth there had been two pre- 
vious attacks of apoplexy. In three of these cases the condition of the heart 
is recorded as being larger than natural-in one of them weighing Ilf ounces, 
in another 15 ounces, where the hypertrophy was general, tn the case of the 
repeated attacks the heart was fatty, as well as the coronary arteries and those 
of the pia mater. The kidneys also were fatty. In all of them the attack 
was sudden-followed in one by instantaneous death, in the others by insensi- 
bility, collapse, and blanched surface. In one case the pupils were dilated ; 
in another, where the septum lucidum, corpora striata, and optic thalami were 
broken down, there were paralysis and rigid contraction of the right arm. 
Death followed in thirty-four hours; another died in twenty-two hours ; one 
on the third day, and another on the fourth. In none of these cases is there 
noticed any lesion of the brain-substance itself. In all, the hemorrhage ap- 
peared to proceed from the tomentose or vascular surface of the pia mater. 
In this variety of meningeal hemorrhage the vessels of the pia mater become 
inordinately injected, and the effusion consisted of blood, or merely blood- 
serum (Dr. Williams). While this effusion of blood or serum lies on the 
convoluted surface generally, it occasionally, as in this instance, is effused into 
the ventricles, so that the brain was compressed both from the peripheral or 
pericranial surface and from the ventricular or internal surface. There was 
no connection of these cases with external injury, the most common cause of 
extravasation between the pia mater and brain. They all appear to have 
been the result of morbid states of the vessels of the pia mater. Cases of this 
kind are recorded by Craigie in the Edinburgh Medical and Surgical Journal, 
vol. xviii, p. 487 ; also by Morgagni, Epist. iii, 2 and 4, quoted by him from 
Valsalva, Epist. xi, 19 (see Craigie's Pathological Anatomy, p. 730). 
Extravasation into the Substance of the Hemispheres or Central Ganglia.-In 
four cases some part of the cerebral substance contained the extravasated 
blood, more or less free, or surrounded by a cyst. In two of the cases the 
clot was surrounded by a cyst, in one of which, death taking place thirteen 
days after the seizure, the cyst was found nearly empty, disintegration and 
absorption having thus early taken place (Macintyre). These cysts seem to 
be formed of fibrilloid tissue like condensed fibrin, more or less hyaline, or 
stained with coloring matter of the blood; and in one case, where death oc- 
curred twelve weeks after the fitr blood-crystals were found in abundance in 
those parts of the wall of the cyst, and most abundantly on the yellow parts. 
In this case, at the end of twelve weeks, the cyst was filled with slightly turbid 
yellow fluid, a small portion of coagulum only remaining (Bristowe). In 
the case where the extravasation occurred into the corpus striatum it protruded 
into the lateral ventricle of the right side, and nearly filled it, and the nervous 
substance around was broken down and soft. Death occurred in half an hour 
(Gibb). The position of the clot in the fourth case was above the lateral 
ventricles, separated from the longitudinal fissure only by the gray matter. 
Some ecchyniosis existed in the neighborhood, and there was yellow discolora- 
tion on the surface of the left corpus striatum, where two cysts existed with 
fibrous walls, the remains of old extravasations (Ogle). 
The conditions as to general health of the patients are not stated. One 
case occurred during convalescence from an attack of delirium tremens, after 
having been apparently benefited by a dose of morphia amounting to one 
grain of the acetate. There was extensive cardiac, pulmonary, and gastric 
disease in this case, and the patient lived thirteen days after the seizure. A 
bloated florid look was the only circumstance to indicate the general state 1026 
SPECIAL PATHOLOGY - APOPLEXY. 
of the case where the extravasation occurred in the hemisphere above the 
lateral ventricle. In three of the cases the heart is specially noted as fatty, 
its weight in one instance being thirteen ounces, in which case, also, the liver 
was enormously enlarged, containing sugar. In all the cases the arteries at 
the base of the brain were diseased. The symptoms were generally those of a 
fit, in one case lik<j syncope, when the extravasation was into the ventricles 
and corpora striata, death following in half an hour, preceded by a feeble 
pulse, the pupils being slightly dilated. In the other case, in which there 
was post-mortem evidence of previous extravasation by the remains of cysts 
on the surface of the left corpus striatum, together with a thickened and 
opaque arachnoid with subarachnoid fluid, a fit occurred with paralysis of 
right side, a feeble and quick pulse, followed by convulsions, contracted pupils, 
and incoherent speech, breathing becoming stertorous, death following by 
coma on the sixteenth day. 
Extravasation into the Pons Varolii and other parts.-Five cases are noted 
in which the extravasation took place into the pons Varolii. In two of 
the instances the pons alone was implicated. In one, the pons together 
with the crura cerebri; in another, the pons together with the cerebellum; 
and in a third, the pons together with the crura and cerebellum were im- 
plicated. Of the cases where the pons alone was implicated, a clot the 
size of a pea occupied its centre. It occurred in a lunatic, taking his walk 
out of doors in his usual health. Sudden paralysis indicated the seizure, 
and death followed in twenty-four hours. In the other case (age thirty- 
four) the pons contained a clot as large as a filbert shell, seated in the 
middle line, the blood having burst through into the fourth ventricle. Sur- 
rounding the clot the nerve-tissue was softened and shreddy. The seizure 
was sudden, with right hemiplegia and anaesthesia. Paralysis of the left side 
remained with feeble circulation, and death followed in five days. In the 
instance in which the crura as well as the pons was affected, the blood was 
partially coagulated, breaking up the nervous matter, and distending the 
parts into a bag. In the instance in which the crura and cerebellum as 
well as the pons were implicated, the clot was similarly inclosed in a bag of 
nervous matter. In the other instance the lesions in the pons' and cerebellum 
were confined to the left side. 
These cases were distinguished by rapid and extensively increasing difficulty 
of breathing-in two amounting to stertor-and by contraction of the pupil; 
features placid; convulsions of pectoral muscles; coma becoming more and 
more perfect; and death followed in from four to twelve hours. In three of 
the cases extensive disease of the vessels, both large and small, especially 
towards the brain, is noted. 
These cases have been related, from the supposed rarity of the lesion as 
to its seat. And although the greater number of the cases are deplorably 
meagre in the details recorded in the Society's Transactions, yet they are 
exceedingly interesting on the whole, when thus classified, establishing as 
they do several facts, not accurately determined before, relating to the pa- 
thology of cerebral apoplexy or cerebral hemorrhage. They confirm the obser- 
vation that, when the extravasation is extensive, although superficial, the 
result is rapidly fatal by the coma, resulting from compression over a large 
surface; that when effusion is sudden and extensive in certain parts of the 
brain, such as in the corpora striata, or optic thalami, or the pons Varolii, the 
result is rapid death; and generally they confirm the belief that the more 
nearly the extravasations approach the medulla oblongata, the more rap- 
idly fatal is the result. The symptoms which were associated with irritation 
of the parts connected with the pons Varolii were peculiarly well marked in 
three instances. So delicate are the sensibilities of these parts in the exer- 
cise of their functions, that it has been taught that blood is rarely found 
effused in them as a lesion after death, because simple vascular injection of LIABILITY OF PARTS OF THE BRAIN TO APOPLEXY. 
1027 
such parts was considered sufficient to disturb the functions of the brain so 
much as to produce the fatal result before such changes can be effected 
(Craigie's Prac. of Physic, p. 309, vol. ii). 
The cases are much too few to found any general conclusion upon relative 
to the numerical frequency of lesion in any particular part of the brain, asso- 
ciated with the apoplectic seizure. 
Site of Effusion. 
Andral. 
Tach- 
eron.* 
Serres.f 
Lermi- 
nier.f 
Path. 
Soc. of 
London. 
Total. 
Level of corpora striata and into them, 
Corpora striata, 
Thalami optici, 
Portions of hemisphere above centrum 
ovale, 
Lateral lobes of cerebellum, .... 
Before corpora striata, 
Mesocephalon,. 
Spinal cord, 
Posterior lobes, 
Middle lobe of cerebellum, .... 
Peduncle of brain, 
Peduncle of cerebellum, 
Corpora olivaria, 
Pituitary gland, 
Pons Varolii, 
Meningeal hemorrhage, 
202 
61 
35 
27 
16 
10 
9 
8 
7 
5 
3 
1 
1 
1 
3* 
2 
9 
i 
2 
2 
2 
2 
2 
V 
i 
2 
3 
i' 
3 
'5' 
5 
202 
66 
39 
44 
16 
10 
12 
8 
11 
5 
3 
1 
1 
1 
10 
5 
Total, 
386 
19 
9 
6 
14 
444 
It is well established (notwithstanding statements to the contrary, founded 
on experiments of a certain kind) that the brain-substance is liable to com- 
pression from vascular injection generally, and increased turgidity of its ves- 
sels. There are also parts of the brain so constituted anatomically that hemor- 
rhage more readily occurs in them than in other parts. The anatomical 
constitution which favors this consists in the increased provision for the transit 
of bloodvessels. For instance, through the white perforated spot at the com- 
mencement of the fissure of Sylvius, the sylvian or middle artery of the cere- 
brum sends its numerous branches of various size into the substance of the 
brain. These in the first instance penetrate the corpus striatum, which lies 
immediately over this anterior perforated spot. The corpus striatum, and the 
parts at its level, from their anatomical position and relations, are thus the 
most vascular parts of the whole brain; and most pathologists agree in con- 
sidering these to be the parts most liable in the substance of that organ to 
effusion of blood, more especially when the vascular system of the brain is 
overloaded (Bonetus, Morgagni, Rochoux, Andral, Craigie. Opposed 
to this belief were-Howship, Lerminier, Serres, Tacheron). A summary 
of the facts recorded may be stated, as in the preceding table. 
The result of these observations shows that the comparative liability of parts 
of the brain to extravasations of blood may be stated in the following order, 
commencing with the parts most frequently implicated: 
(1.) Corpus striatum, opticus thalamus, and hemisphere at the level of these 
parts. 
(2.) The corpus striatum alone. 
* Recherches Anatom. Pathog., par C. F. Tacheron, tome xiii, Paris, 1823, Ordre 
xiv, An. 31. 
f Annuaire Med.-Chir., p. 324, sect. xi. J Ibid , p. 213. 1028 
SPECIAL PATHOLOGY-APOPLEXY. 
(3.) The hemisphere above the centrum ovale. 
(4.) The thalamus opticus alone. 
(5.) The lateral lobes of cerebellum. 
(6.) The mesocephalon. 
(7.) Posterior lobe of cerebrum. 
(8.) Before the corpora striata. 
(9.) Pons Varolii. 
(10.) Middle lobe of cerebellum; meningeal hemorrhage. 
(11.) Peduncles and olivary body. 
Much more extensive records, however, are required to determine these 
points accurately; and Rokitansky does not consider as yet that we can state 
such a result in other than general terms. 
The ages of those whose cases are recorded varied from thirty-three to sixty- 
nine, the average age being fifty-four. The disease is known to occur even in 
children. 
Circumstances under which the Lesion occurred.-In two of the cases the 
arteries are stated to have been healthy. In three of the cases no mention is 
made in regard to them; but in three there was hypertrophy of the heart, 
amounting in one case to fifteen ounces. In all the others (nine in number) 
the arteries were in a diseased condition; and in seven cases there was evidence 
of concurrent disease in other organs. 
Thus far these cases rather tend to confirm the observation of Paget in 1850, 
namely, that sudden death from apoplexy is most generally associated with 
fatty degeneration of the minute cerebral bloodvessels; while, at the same 
time, the associated morbid states of other organs are such as to lead to the 
belief of a more general morbid state, and perhaps more especially of the 
nervous matter-an apoplectic orgasm which predisposes to the extravasation 
of blood from diseased bloodvessels-the belief now most generally entertained 
regarding the nature of the apoplectic lesion. 
Another interesting feature in the pathology of the lesions demonstrated to 
the Society is the organization of a wall round the extravasation, and the 
future changes of the blood-clot, as shown by its examination at various periods 
after the extravasation. Cysts existed in two of the cases, in one of which, on 
the thirteenth day after the seizure, the cyst was found nearly empty, the ab- 
sorption having thus early taken place (Macintyre). On the other hand, 
again, at the end of twelve weeks a portion of coagulum still remained in- 
closed in a cyst, and blood-crystals existed in abundance on its walls (Bris- 
towe). Even at a still longer interval bloody fluid has been found in a cyst 
otherwise nearly empty, as recorded by a French physician of the name of 
Moulin, who mentions such a morbid state existing seventeen years after the 
extravasation (Sieveking). The age of the clot may thus, in some measure, 
be indicated by the cyst, the condition of its contents, and especially as to 
blood-crystals. Virchow has recorded their existence in the cavity by the 
seventeenth day; and as shown by Beale, they do not form from clotted blood 
until the blood-corpuscles become ruptured by endosmosis. The contents of 
the blood-cells then escape and crystallize, as the solution gradually becomes 
concentrated. 
Symptoms.-Whatever may be the pathological doctrines taught regarding 
the morbid state of the cerebral parts in apoplectic states, we are able prac- 
tically during life to do little more than merely recognize the apoplectic state 
itself. The diagnosis between the congestive, the hemorrhagic, and the serous, 
or merely morbid nervous state, can only be arrived at approximatively by a 
careful comparison of symptoms closely observed, such as are detailed in the 
treatise of Dr. Russell Reynolds, already noticed, and from which the following 
statements are condensed: 
I.-Symptoms of Apoplexy from Congestion.-The face, scalp, and con- 
junctivse are increased in vascularity; the skin generally is of a dusky venous SYMPTOMS OF APOPLEXY FROM CONGESTION. 
1029 
hue, and the surface is warm. There is fulness of the jugular veins, with in- 
creased pulsation in the carotids. The tongue is foul, and nausea prevails, 
with constipated bowels. Respiration and the pulse are both labored, and 
the extremities are cold. Such are some of the general symptoms which in- 
dicate the approach of an attack of the congestive form of apoplexy. 
The symptoms peculiar to the brain itself are,- 
1. Mental.-The activity and power of the intellect are diminished. General 
confusion of thought prevails, with deficient memory. Any attempt at mental 
exercise increases the expression of these signs; so does the recumbent position 
and emotional disturbance. Sleepiness, also, with labored respiration, is com- 
mon, especially after meals; and there is a general tendency to inaction of 
body as well as of mind-a " not-to-be-disturbed " sort of desire is experienced. 
Such mental phenomena, however, are not permanent; and while there is a 
readily induced state of general confusion, there is no persistent, special, or 
permanent loss of power of intellect. 
2. Sensorial.-The senses generally are obtuse. The hearing is dull; and 
heavy rumbling noises are constant auditory illusions. The sight is dim, or 
amaurosis is complete, and often black or variously-colored spots are seen 
floating in the field of vision ; flashes before the eyes, or other spectral illu- 
sions are more or less constant. The patient may see only half of an object, 
or halves of objects of different colors. Attacks of dizziness also occur, with 
a sense of fulness and oppression in the head ; numbness and weight of the 
limbs ; dull and heavy cephalalgia. There may also be occasional feelings of 
formication and numbness in certain limbs, momentary loss of memory for 
some words and figures, or temporary paralysis, confined to certain groups of 
muscles. These symptoms, however, are only of occasional occurrence, and 
change their localities. While the absence of pain is not now considered of 
much diagnostic value, yet the occurrence of severe acute pain is generally 
indicative of something more than congestion. 
3. Motorial Symptoms.-Little jerkings of the muscles, and irregular or 
sluggish movements of the eyeballs, are occasional. 
These precursory symptoms having generally been more intense for a few 
minutes or hours, an attack takes place, distinctly apoplectic. These " warn- 
ings " which precede an attack of apoplexy may, in some cases, depend on 
thrombosis of small vessels, or on small capillary hemorrhages. Thrombosis 
and embolism (lesions to be afterwards described) now take a prominent 
place in cerebral pathology, both as regards cerebral softening and hemor- 
rhages. By occlusion of a cerebral artery, or of capillaries, clots in blood- 
vessels are capable of producing apoplectic symptoms, even when the brain- 
substance is otherwise sound. There is always paralysis of motion in the side 
opposite to the obstructed vessel, general sensibility, as a rule, being unim- 
paired ; sometimes it may be lessened, but is never altogether absent. Loss 
of consciousness is also less complete, and the mind is less affected after cere- 
bral embolism than after hemorrhage. Aphasia sometimes happens. The 
middle artery of the brain is the most frequent seat of embolism, also the 
anterior, basilar, and vertebral. Apoplectic symptoms, hemiplegia, and death 
have also followed plugging of the carotid (Hasse) ; and of the innominata, 
right common carotid, and left internal carotid, and middle cerebral (Mark- 
ham). The seizure commonly occurs during some muscular exertion, such 
as lifting a heavy weight, pulling on a pair of boots, blowing the nose, strain- 
ing at defecation, or the like ; or even upon a simple change of posture, such 
as stooping, or suddenly assuming the erect attitude. 
The special nervous symptoms of the attack in the congestive form are- 
1. Mental.-Some evidence of the existence of Perception may generally be 
obtained by loud noises, speaking to the person by name, or pinching him. 
If, however, Perception is quite extinct for a few seconds or minutes, it soon 1030 
SPECIAL PATHOLOGY-APOPLEXY. 
again partially returns, and there is confusion of Thought, with little Volition 
as to the direction either of Thought or movement. 
2. Sensorial.-Except during the first few moments of the attack, when 
sensation generally is gone, the changes are slight. Sensation,-indicated at 
least by reflex action (the limbs being withdrawn if pinched),-is generally 
present. 
3. Motorial.-There is more or less paralysis of all the limbs to a slight 
degree, and for a short time. It is very rare to have either hemiplegia or 
paraplegia. Short or involuntary evacuations do not occur unless there 
have been some convulsions. There is no rigidity of the limbs, but clonic 
spasms are not unfrequent. Generally, and in the course of a few minutes, 
the symptoms begin to abate rapidly, and they rarely last even for an hour. 
With the return of consciousness paralysis disappears, and sensibility rarely 
remains deficient. 
The manner of appearance and proportion between the three groups of 
nervous symptoms is of great diagnostic value; and, as indicative of conges- 
tion, rather than of hemorrhage or softening, any one of the following combi- 
nations or groups of symptoms are of importance to be noticed : 
1. The simultaneous development of the three groups of nervous symptoms. 
There being either- 
2. Distinct loss of Perception, profound coma, and general paralysis, without 
rigidity or convulsion. 
3. Imperfect loss of Perception, with general paralysis. 
4. General paralysis, incomplete in degree, and sensation unimpaired, or but 
little affected; or- 
5. Paralysis complete in degree, but without stertor or rigidity. 
II. Symptoms of Apoplexy from Hemorrhage.-A. Into the cerebral sub- 
stance of the hemispheres. Very different statements are made as to whether 
or not premonitory symptoms are present; and the practical point in diag- 
nosis which such discrepancy of statements has taught is, " that the non-exist- 
ence of precursory symptoms in a given case is in favor of the belief that hemor- 
rhage rather than congestion is the cause of the lesion or softening." 
The attack is generally sudden, and rapid in its development. Sometimes 
after a few hours there may be sudden aggravation of the symptoms, generally 
due to a renewed extravasation. The patient, if standing, generally falls in- 
stantaneously, often with a cry, as if knocked down, and constitutes the 
" stroke of apoplexy," commonly so called. It is the nervous symptoms, how- 
ever, which are of the utmost importance. 
1. Mental.-Loss of Consciousness (of Volition and Perception) is com- 
monly complete at the outset. For a few seconds at least the patient is 
utterly deprived of intellectual power, which in slight cases partially returns 
in a few minutes. In severe cases, however, Perception does not return till 
after some hours, and with vague ideas of things ; expressions of Thought are 
confused, amounting to delirium ; and after the first few minutes or half hour 
has passed, the degree of intellectual obscuration may be taken as an approxi- 
mate measure of the amount of extravasation, although it is to be remembered 
that there are some exceptional and rare cases on record of hemorrhagic apo- 
plexy in which the mental faculties were very slightly, if at all, impaired. 
After some days the intellectual powers are often entirely restored ; but in 
many cases confusion of Thought and partial loss of Memory remain. After 
recovery of consciousness the power to Think and to Will is generally unim- 
paired, so that if the patient is asked to give the affected hand, he shows 
his desire to fulfil the request by taking the paralyzed hand in the sound 
one, whose nerves and muscles are under the control of the Will, in order to 
accomplish the act (Niemeyer). If the case does not terminate fatally, the 
well-marked character of the recovery is a strong presumption that the symp- SYMPTOMS OF APOPLEXY FROM HEMORRHAGE. 
1031 
toms resulted from hemorrhage, and were not due to softening of the cerebral 
substance. 
Destruction also of certain portions of the brain in the medulla of the cere- 
brum does not cause any perceptible disturbance of function; small hemor- 
rhages there may escape recognition during life. 
2. Sensorial.-Sensibility is usually less commonly affected, and less in- 
tensely, than mobility. In most cases with hemiplegia there is anaesthesia of 
half the body; but after a time this usually passes off partially or entirely. 
When cutaneous anesthesia is complete, although the surface so affected may 
be limited in extent, the occurrence indicates severity of lesion. In slight 
cases there is generally only numbness and tingling of the tips of the fingers. 
Evidence of Sensation may be obtained when there is no proof of distinct 
Volition. During the profound coma of the attack at the commencement, 
the dilated pupil and the half-opened eye indicate that the retina has lost its 
impressibility; and if hearing and smell are similarly affected, the persistence 
of such symptoms are signs of evil omen. 
3. Material.-As the corpus striatum and the thalamus opticus, with the 
parts of the brain on that level, are the most frequent seats of hemorrhage, 
any destruction of those parts or of the pedunculi cerebri induces paralysis of 
the opposite half of the body, called hemiplegia. Paralysis is present in the 
immense majority of cases of apoplexy, its characteristic form being hemiple- 
gia; but sometimes it is general, the proportion of cases being as .84 to .16 
per cent. When the paralysis is general, the hemorrhage is rarely limited 
to the substance of the hemispheres. Paralysis of half the body, charac- 
terized by its limitation to the muscles of the extremities, to those muscles 
of the face going to the angles of the mouth, and to the nose, and to the 
muscles that protrude the tongue, is due to destruction of the corpus striatum 
and optic thalamus of one hemisphere. Such patients can generally chew nor- 
mally on the affected side; they can wrinkle the forehead, open and close the 
eyelids, and move the eyes in any direction. But they cannot use the par- 
alyzed arm or foot, the mouth hangs down on the affected side, and the nostril 
is contracted. Occasionally the cheek flaps on expiration; while on the 
sound side the angle of the mouth is drawn up, and the nostril dilated. 
When the patient protrudes the tongue, its point is directed to the paralyzed 
side, because only the muscles of the opposite side push forward the root of 
the tongue, and elongate that organ. During profound stupor the deviation 
of the face indicates paralysis on one side. In less severe cases the condition 
of the limbs as to Volition is the guide. The tongue commonly deviates to 
the paralyzed side; and any extreme movement of the face, such as crying 
or laughing, renders the inequality of action more apparent. The orbicularis 
oculi generally escapes paralysis, or is less affected than the other facial mus- 
cles. The loss of motion is commonly absolute at first, especially in the arm, 
wrhich is generally more profoundly affected than the leg, the one being more 
completely paralyzed than the other. Stertor, with involuntary defecation 
and micturition, are common. Involuntary contractions of a tonic or clonic 
kind are extremely rare from hemorrhage limited to the cerebral substance. 
Reflex movements continue, and the respiratory acts of the thoracic muscles 
are duly performed. 
The more common combinations of symptoms by which the existence of 
cerebral hemorrhage limited to the medullary substance might be inferred 
are- 
1. Profound coma, with hemiplegia on one side, of marked intensity, and with- 
out rigidity. 
2. Paralysis of both sides, but one more profoundly affected than the other-a 
rare occurrence in limited hemorrhage. 
3. Slight coma, but paralysis hemiplegic and complete. 
A large apoplectic clot which destroys the corpus striatum or thalamus 1032 
SPECIAL PATHOLOGY-APOPLEXY. 
leaves a hemiplegia that never disappears; but small clots in those parts by 
which nerve filaments and unbroken and ganglionic nerve-cells are unim- 
paired, but only temporarily pressed apart, leave paralysis which is only tem- 
porary. 
Extensive apoplectic clots at other parts of the cerebrum not unfrequently 
leave paralysis w'hich sooner or later disappears again, the capillaries of the 
motor centres being relieved of pressure by the partial reabsorption of the 
extravasation, and so become again permeable to blood; or that the collat- 
eral oedema in the vicinity of the broken-down part of the brain which ex- 
tended to the motor centres has disappeared, with cicatrization and contrac- 
tion of the apoplectic clot (Niemeyer). 
B. Hemorrhage into the Ventricles cannot in some cases be distinguished 
from arachnoid extravasation, or in others from effusion into the cerebral sub- 
stance only, especially when in the vicinity of the ventricles. The cases, 
however, which are less doubtful are marked by the following characteristics, 
in addition to the general signs of apoplexy: 
1. The Mental State.-Coma is very profoundly marked at the commence- 
ment, and remains of equal intensity; or the patient, after partially recover- 
ing from a slight seizure, is again suddenly plunged iuto profound coma, 
from which there is no recovery. This second attack is presumed to indicate 
the rupture of the hemorrhage either into the ventricles or the arachnoid 
cavity, from its original site of extravasation in the medullary substance of the 
brain near the ventricles or near the surface. 
2. Motorial Symptoms.-Paralysis is complete in degree, and is developed 
simultaneously on both sides; or after having been hemiplegic for a short time 
it becomes general; when the coma of the second attack above noticed comes 
on, stertorous breathing is strongly marked. Involuntary evacuations follow. 
The pupils remain dilated. Deglutition is dangerous and difficult. When 
the paralysis is general and the coma profound, it is almost a sure sign that 
hemorrhage has taken place to a considerable extent iuto the ventricles. 
Rigidity or tonic contraction of the muscles is present in many cases of hemor- 
rhage, and, in nineteen out of twenty-six cases, occurs in the paralyzed limbs; 
and in about four out of twenty-six cases may be seen in those of the healthy 
side (Dr. Russell Reynolds). Its presence is a sign of extensive hemor- 
rhage, with laceration of the brain. The most frequent combination of symp- 
toms indicative of hemorrhage into the ventricles may be shortly stated to be 
profound coma, with general paralysis and rigidity. 
C. Arachnoid Hemorrhage occurs when the extravasation bursts through 
the pia mater and arachnoid into the space between the membranes, and such 
cannot be distinguished from the ventricular extravasation just noticed. If, 
however, the extravasation is immediately subarachnoid at first, and of limited 
extent, it may be approximately diagnosed-First, By the nature of the pre- 
monitory symptoms having partaken of meningeal inflammation, such as by 
severe pain in the head, with impaired intelligence and power of movement. 
Second, The attack is less sudden than in cases of congestion or of central 
hemorrhage, and the symptoms are progressively developed. 
The following are the combinations of symptoms which indicate the occur- 
rence of subarachnoid hemorrhage: 
(1.) Complete and profound coma without paralysis; or with general pa- 
ralysis very slightly developed in intensity. (2.) Complete loss of conscious- 
ness without paralysis; but combined with rigidity or clonic contractions of 
the limbs. (3.) Paralysis of hemiplegic distribution as regards the limbs, 
but without deviation of the features, the muscles of the face not being impli- 
cated. (4.) An apoplectic attack without anaesthesia. (5.) Imperfectly de- 
veloped coma with general paralysis. (6.) An apoplectic attack, of which the 
symptoms are somewhat interchangeable or remittent. 
It is generally believed that the apoplectic fit is due to pressure or bruising SYMPTOMS AND CAUSES OF SUBARACHNOID HEMORRHAGE. 
1033 
of the nerve-filaments and ganglions cells of the entire brain by extravasation. 
Niemeyer, however, refers the apoplectic fit to sudden compression of the 
capillaries-that is, to anaemia of the brain-substance. 
In all large hemorrhages such antemia of the brain is a constant post-mor- 
tem appearance; and during life it is indicated by a remarkably increased 
pulsation of the carotids. 
This symptom is sometimes regarded as a sign of increased pressure or flow 
of blood into the head; whereas he considers that it really indicates an ob- 
struction at its entry, on the same principle that if a string is tightly tied 
round the end of the finger, the artery of the finger passing to its end will 
have its pulsation visibly increased. 
Hence it is that large effusions of blood, exudations, transudations, and large 
tumors encroaching on the skull space are attended with increased pulsation 
of the carotids. 
Where this symptom exists, without hypertrophy of the left ventricle, and 
without increase of pulsation of other arteries, it must be held as diagnostic 
of brain disease encroaching on the cavity of the cranium. 
Causes.-Among the most frequent causes of apoplexy, especially in some 
constitutions, is an intemperate use of fermented liquors-a class of substances 
which powerfully excites, mainly by inducing paralysis of functions, thus 
allowing the evidences of excitement to appear as the prominent phenomena 
(Anstie). Alcohol also acts specifically on the heart and arteries, causing 
not only temporary energetic actions of those parts, but also organic altera- 
tions in their structure. In the latter case the powers of the heart are often 
permanently augmented, while the coats of the arteries, thickened, thinned, 
or ulcerated, have their elasticity destroyed, and thus the tendency to hemor- 
rhage in the brain is increased. The excessive use of narcotics, as opium or 
tobacco, is also supposed to predispose to congestion of the brain, and conse- 
quently to cerebral hemorrhage. 
The following conclusions have now been arrived at from a comprehensive 
view of numerous cases: (1.) That in by far the greater number of cases 
cerebral hemorrhage is due to degenerations of the cerebral arteries as its 
predisposing cause. In the smaller arteries these consist of fatty metamor- 
phosis, or simple atrophy, with the various forms of consecutive dilatation; 
while in the larger arteries of the base there is arteritis, issuing in ossification, 
or fatty degeneration, or atheroma, or passive calcification. (2.) A not entirely 
rare cause are true aneurisms of the large cerebral arteries. (3.) Hypertrophy 
of the left ventricle will only favor cerebral hemorrhage when it permanently 
increases the normal tension of the aortal system ; but this is not the case in 
compensating hypertrophy of valvular disease of the heart. (4.) In about 
one-seventh of all cases of apoplexy, neither predisposing diseases of the heart 
nor of the vessels could be demonstrated (Eulenberg in Virchow's Archiv., 
vol. xxiv, p. 329; and Syden. Soc. Year-Book for 1862, p. 81). 
The connection of apoplexy with advanced disease of the kidney has occa- 
sionally attracted the attention of pathologists; and the late Dr. S. Kirkes 
recently brought forward some facts in proof of the frequency with which the 
kidneys are found diseased in fatal cases of apoplexy; and which, to a certain 
extent, explain the connection between the renal and cerebral affections {Med. 
Times and Gazette, 1835, p. 515). In all the cases except one the heart was 
found enlarged-an enlargement due to the prolonged disease of the kidney- 
and generally in the form of hypertrophy of the left ventricle, without valvular 
disease. The primary disease is that of the kidney; then the heart and then 
the bloodvessels become diseased in consequence of the primary affection. The 
disease of the bloodvessels is chiefly in the form of the well-known yellowish- 
white thickening and deposit within the coats of the bloodvessels; and Dr. 
Kirkes believed that the disease of the vessels is in a great measure the result 
of the continual over-distension and straining to which the arteries are sub- 1034 
SPECIAL PATHOLOGY-APOPLEXY. 
jected by the unwonted energy with which an hypertrophied heart propels the 
blood along them : the full force of the hypertrophied ventricle, independent 
of valvular disease, will be exercised upon the arterial current. 
Extremes of temperature are likewise powerful predisponents to apoplexy. 
In summer the fluids of the body tend to produce turgidity of the vessels in 
some constitutions, and the tone of the capillaries is impaired; while in winter 
the cold drives the blood from the periphery of the body to its central organs, 
and consequently to the brain. Sudden and great vicissitudes of the weather, 
as they rapidly exhaust the nervous power, are more frequently fatal than the 
uniform continuance of its extremes. 
The powerful effects of moral causes in producing this fatal disorder are wrell 
known. Mechanical obstruction is also a frequent occasion of apoplexy. If 
an obstacle, for example, be opposed to the course of the blood, as when the 
valves of the heart are diseased, the blood accumulates in the capillary system 
generally, and consequently in the brain; or errant clots of fibrin choke up 
the minute cerebral vessels. Apoplexy is still more common when the aorta 
is diseased, the force of the heart, unchecked by the elasticity of that vessel, 
acting directly on the brain, so that its vessels often give way from this cause. 
Mechanical violence, also, may produce apoplectic effusion. Thus, concussion 
of the brain, however slight, always produces more or less congestion of that 
organ ; and, if severe, effusion may take place below the dura mater, or 
between the membranes, or into the substance of the brain, which may be 
extensively ruptured, or the septum lucidum torn. 
Apoplexy has been known to occur even in childhood. Billard gives the 
case of a child three days old that died apoplectic from effusion into the left 
hemisphere and about the lateral parts of the corpora striata. Serres saw a 
similar case in a child three months old. Apoplexy, however, is extremely 
rare till puberty, and only a few cases are met with before twenty. It is not 
unfrequent between thirty and fifty, while after fifty it is one of the most fre- 
quent causes of death. There are many circumstances which favor the dispo- 
sition to apoplexy in old age. At that period the capillary system becomes 
impaired in most organs, and thus the veins are filled with a greater quantity 
of blood, or they become congested. The cerebral arteries also are often dis- 
eased; the heart has frequently acquired an abnormal power, driving the 
blood with great violence and with an increased momentum towards the 
brain, while the lungs have their functions so impaired that the blood is only 
imperfectly oxygenated; and all these are causes of congestion, and of tendency 
to rupture of the vessels of the brain. 
Both sexes are liable to this affection, and in nearly equal proportion. 
Those most liable to attack are the florid in complexion, of short-necked con- 
formation, with prominent eyes, broad chests, and protuberant bellies, and 
sometimes enormously fat, especially if high livers, sedentary, and indolent. 
Many thin persons, with spare long necks, however, frequently die from 
apoplexy; but it is probable that in these cases the heart or large vessels have 
been diseased. 
The act of digestion, or rather fulness of the stomach, appears to predispose 
to apoplexy. Numbers are attacked after dinner. Sleep, also, associated 
with a temporary congestion of the vessels of the brain, is another predispos- 
ing circumstance. Thus, of 176 cases examined by Gendrin, 97 had been 
attacked during sleep. In the sleep of a healthy person the brain is anaemic 
(Durham). 
Many diseases, or conditions of the body, predispose to apoplexy, as mania, 
epilepsy, suppressed hemorrhoids, amenorrhoea, and especially the " turn or 
change of life." 
Diagnosis.-See previous subject, under " Softening." 
Prognosis.-Apoplexy is always a grave disease, and the more grave in 
proportion, generally, as the respiration is stertorous and the deglutition dif- PROGNOSIS OF APOPLEXY. 
1035 
ficult. Each succeeding attack is more dangerous than the former. The 
practitioner should also be guarded in h'is prognosis till after the first week or 
ten days, lest inflammation should come on, or a fresh attack destroy the 
patient. Popular opinion (and it is useful in pronouncing an opinion to know 
what are popular beliefs) supposes the patient to suffer three apoplectic at- 
tacks-the first being mild, the second followed by paralysis, while the third 
is fatal. It is only in a few instances that this number is exceeded. If a 
patient does not die in the fit of apoplexy, a more or less severe encephalitis 
will set in after a few days, as a result of the traumatic injury done to the 
texture of the brain. 
Increased frequency of pulse, with other signs of fever, headache, sparks 
before the eyes, delirium, twitchings and contractions of the paralyzed parts, 
indicate "symptoms of reaction," which may be moderate and finally disap- 
pear, leaving the patient more or less permanently paralytic. If inflamma- 
tion in the vicinity of the clot progresses, however, inflammatory softening 
will be the result, the end of which has been described in previous pages. 
In the congestive form of apoplexy, if active and judicious measures of 
treatment are employed, the recovery may be rapid and complete; but if this 
is not the case, there is a liability to a more aggravated form, from which 
nothing is more variable than the time of recovery. In a very few instances 
the patient is restored in a few days, or in a few weeks, or in a few months, 
but more commonly the lesions of motion are permanent, or nearly so. In 
general, however, some slight improvement takes place even in the worst 
cases, so that the patient recovers some use, first of his leg, and then, per- 
haps, of his arm, so that he is able to walk with a straight leg and a dragging 
foot. The use of his arm returns more slowly and more imperfectly. This 
recovery is often preceded and accompanied by very severe pains, especially 
of the upper extremity, marking the still irritated state of the brain. The 
limb, however, uniformly wastes, and its vital powers are so impaired that, 
if inflamed, the inflammation seldom terminates by resolution, but has a great 
tendency to gangrene, while cicatrization is slow and difficult. 
If, on the other hand, after a severe expression of hemiplegia, the patient 
begins to recover the use of his arm more rapidly and completely than he 
does the use of his leg, it is a fatal sign (Trousseau, Todd, Bazine). Also, 
when the fingers of the paralyzed hand continue flexed into the palm, through 
contraction of the flexors after cerebral hemorrhage, the use of the hand will 
remain permanently lost, and no hope of improvement can be held out 
(Trousseau). 
The commonest occurrence is the perfect recovery of the mental faculty, 
and the progressive but much more gradual return of motion and sensibility. 
Paralysis of motion sometimes persists in groups of muscles, such as those of 
the tongue, the forearm, or hand. Sensibility is generally first restored, then 
the motion of the lower extremity, then the arm, and lastly that of the fore- 
arm and hand. Discordant opinions are entertained relative to the influence 
of the electric stimulus on the paralyzed muscles. The late Dr. Marshall 
Hall was of opinion that the muscles of the non-paralyzed limb were the more 
irritable. The late Dr. R. B. Todd entertained precisely the reverse opinion. 
These were the highest authorities of their day in this country. Duchenne 
draws attention to two conditions of paralysis after apoplexy-namely, one 
directly dependent on the central lesion, the other the mere result of inaction 
for some time. In the former case there is contraction of the muscle as the 
result of increased spinal action, uncontrolled by the central ganglia of the 
brain-in the latter form the muscles are flaccid. Active tonic contraction 
of the muscles, distinct from simple shortening of the flexors, he considers as 
indicating inflammatory action in the walls of the cyst; but this distinction is 
one which requires corroboration or contradiction by subsequent observation 
(Dr. Russell Reynolds). 1036 
SPECIAL PATHOLOGY-APOPLEXY. 
No doubt the principal adverse circumstances attending recovery from 
apoplexy are, that although the patient appears to be doing well the first few 
days after the attack, yet towards the close of the first week the brain, irri- 
tated by the presence of the clot, inflames and softens, and thus induces 
another and a fatal attack of apoplexy. Should the patient, however, survive 
this dangerous period, he may continue to live many months or years, accord- 
ing to his age; but he is generally at length cut off by a fresh attack of 
apoplexy, or his brain ultimately inflames and softens, and he dies in a 
typhoid state, as already described. 
Although it is the general rule that the patient, on recovering from the 
attack, has the good fortune to recover all the faculties of his mind, yet his 
memory is not unfrequently impaired, often to such a degree that he has for- 
gotten all dates, the names of his friends, or even the names of things. 
Broussonet, Professor of Medicine at Montpellier, had entirely lost the re- 
membrance of all substantive nouns, and another case is on record in which 
the patient lost the recollection of all his adjectives. In some instances the 
power of association is also so destroyed that although many remember both 
names and things, they are unable to connect the thing with the proper word, 
so that they call that which is cold, hot, or speak of night when they mean 
day, or call a coffee-pot a wash-hand basin (aphasia). Others again have 
forgotten how to read, and the power thus lost either returns suddenly, or 
they are obliged to learn de novo. 
The attention generally is very greatly impaired, and the patient is no 
longer able to transact business, or if he begins a sentence is unable to finish 
it, or he repeats the same idea over and over again. The emotions and 
passions also are little under control. Some weep like children, others laugh 
immoderately, and all are easily terrified, or otherwise easily influenced 
through the emotions. 
All these circumstances must be remembered in giving a prognosis regard- 
ing an apoplectic patient. 
Treatment.-The patient, if seen during the fit, may be bled if the tendency 
to death is by coma, and if the pulse be full, or hard, or thrilling; if the 
vessels of the neck be congested, the heat of the scalp increased, and if the 
face be full and turgid. The state of the heart ought to be examined into 
first. If its action be vigorous, its impulse strong, and its sounds loud but 
normal, and the heat of the skin preserved, bloodletting is still more required. 
Slow and deep respiratory movements, with stertor, add greatly to the neces- 
sity of immediate venesection, if there be no signs of commencing cedema of 
the lungs. The beneficial action of the remedy is shown by the pulse be- 
coming softer, more subdued, and more regular. The bleeding may then be 
allowed to proceed till an obvious impression of this kind is made, or even 
until the pulse begins to flag. Large bleedings, however, are to be avoided. 
Ten ounces will generally be sufficient, if taken at the first outset of the 
attack; but if the pulse does not improve, and other symptoms remain unre- 
lieved, sixteen to twenty ounces may be taken. The indications for blood- 
letting being thus strongly pronounced, "we ought not to hesitate to open a 
vein, regardless of the age of our patient" (Maclachlan). The bleeding 
ought to be permitted to flow from a large opening, in order to relieve the 
congestion, to check, if possible, a further effusion of blood, and to divert its 
active flow from the head. The quantity taken should be proportioned to 
the degree of stertor, and to the powers of the patient. The head and shoul- 
ders should be raised while the blood is flowing. 
On the other hand, in some cases bleeding during an apoplectic fit hastens 
a fatal result-collapse occurring immediately after venesection, from which 
the patient never recovers. 
If, therefore, the pulse be small and slow, feeble, or almost imperceptible, 
the skin cold and clammy, with a tendency to death by syncope; if the TREATMENT OF APOPLEXY. 
1037 
heart's action be feeble or weak, and the pulse irregular; if the patient has 
been of intemperate habits, or is suffering from organic disease of the heart 
and arteries; or if there is a gouty or rheumatic history, then no advantage 
is to be gained by the abstraction of blood at this time and in this way. 
Bloodletting is therefore contraindicated under the following circumstances: 
(a) anaemia; (6) aortic valvular disease; (c) in cases commencing with 
syncope. In such case the use of stimulants must be had recourse to in order 
to prevent paralysis of the heart. 
If the bloodletting is not followed by some degree of consciousness, it may 
be inferred that the amount of blood effused is considerable, and that the 
patient in all probability will not recover. Still an additional chance of 
recovery may be given by applying to the head cold cloths, or crushed ice in 
a bladder, leeches to the temples, and mustard cataplasms to the feet; also by 
placing a drop or two of croton oil on. the tongue, and by throwing up a 
cathartic enema of castor oil or other purgative. 
At one time every case of apoplexy was treated by bloodletting, and sta- 
tistics prove, of such indiscriminate practice, that the more freely the blood 
was taken away the greater was the mortality (Copman). Some physicians 
are opposed to any considerable bleeding during the fit, considering that the 
bony structure which contains the brain removes all atmospheric pressure so 
entirely as to cause that organ at all times to contain an equal quantity of 
blood. A space within the head for a very sensible expansion and contraction 
at each pulsation of the heart is opposed to such a belief, while post-mortem 
examination shows the brain to contain very different quantities of blood, 
being sometimes gorged and sometimes blanched of that fluid; but the 
amount contained in the vessels and the amount of cerebro-spinal fluid are 
always in inverse proportion-that distension of vessels is accompanied by 
decrease of arachnoid fluid, and conversely, when the vessels are less full, 
the meshes of the arachnoid contain more fluid. These facts distinctly show 
that some arrangement exists for regulating the quantity of blood sent to the 
brain, and we ought, therefore, in a disease of this moment, to follow the 
dictates of a long experience rather than the conclusions of a fallacious 
reasoning. 
Bloodletting, therefore, in apoplexy is not to be adopted as a matter of 
course. In the majority of cases the hemorrhage is not of a kind likely to be 
arrested by bloodletting (Todd). 
When, also, the symptoms of cerebral hemorrhage are slight, bloodletting 
is not to be thought of; and Trousseau at last came to believe that in all 
cases, grave or slight, patients did better without either bloodletting or pur- 
gatives. He considers the part played by congestion of the brain to have 
been much exaggerated. Instead, therefore, of bleeding and putting patients 
on low diet, Trousseau recommends that the patients be fed and made to get 
up, if they can. He considers also that bloodletting is not called for even in 
the stage of reaction. 
When emetics are now spoken of, it is generally with the view of condemn- 
ing them. The physiological phenomena which attend their action increase 
the determination of blood to the head, as is now well known ; and the action 
of vomiting may be fatal in such cases. After the patient has in some degree 
revived, and the congestion removed, some time for the absorption of the 
blood effused should be allowed before deciding upon the future treatment. 
Any very large depletion after that point is gained would rather facilitate 
extravasation than prevent it. A few hours, then, having elapsed, the con- 
duct of the practitioner should be guided by the occurrence or not in the 
patient of pain of the head, which may be taken as a measure of the fulness of 
the brain, and its tendency to inflammation. If, therefore, there be pain in 
the head, ten to twelve leeches should be applied from time to time till that 
symptom is entirely relieved; or, supposing the pulse to be full and strong, 1038 
SPECIAL PATHOLOGY - APOPLEXY. 
and the patient free from headache, yet, under these circumstances, leeches 
should be applied to the head, to subdue that reaction which so generally 
takes place from the fourth to the seventh day. 
The further treatment of the case is by moderately purging the patient, 
both as a means of relieving the head and of improving the secretions of the 
alimentary canal, which are often black and fetid. Active and searching 
purgatives generally do good. Five grains of calomel, with a drachm of com- 
pound jalap powder, given as soon as the patient can swallow, and followed 
up by black draught, or by an ounce of sulphate of magnesia with camphor mix- 
ture every four or six hours, and continued, according to its effects, for a 
greater or less length of time, are the best means we have for promoting re- 
covery, and for preventing a relapse. 
These prescriptions are recommended on the supposition that the attack 
has been associated with simple plethora. In many cases, however, it is a 
consequence of hypertrophy of the heart, without valvular disease. And in 
such cases less blood should be taken, and eight to ten minims of digitalis may 
be added to each dose of the purgative medicine. If the power of swallowing 
is in abeyance, then three or four drops of croton oil should be put on the 
back part of the tongue, and stimulating enemata thrown up the rectum. The 
following are recommended by Dr. Tanner: 
1. Enema of Turpentine and Castor Oil.-B. Olei Ricini, Olei Terebinthinse, 
aa §iss.; Tincturse Asafoetidse, 3ii; Decocti Avense, ^xii; misce, fiat enema. 
To be thrown up the rectum by means of a long stomach-pump tube. 
2. Croton Oil Enema.-B. Olei Ricini, Olei Terebinthinse, aa ^i; Olei 
Crotonis, wj/vi; Decocti Avenge, ^iv ; misce, fiat enema. 
Although turpentine is objected to by some on account of the intoxicating 
effects which it is sometimes apt to produce, it is nevertheless an efficient 
remedy where torpor and insensibility exist. It is of great importance to 
empty the rectum and lower bowel. In cases where the ability to swallow is 
lost, a drop or two of croton oil, with five grains of calomel, rubbed up with 
fresh butter, may be laid on the back of the tongue. 
If the intestines are distended by gases, an enema of castor oil and rue may 
be given: 
3. Castor Oil and Rue Enema.-R. Confectionis Rutse, Ji; Olei Ricini, 
§i; Tincturse Asafoetidae, Jii; Decocti Avenae, ^vii; misce (Practice of Medi- 
cine, 4th edition, p. 653). 
All apprehension of a relapse being at an end, the patient is in general 
most willing to believe that the palsy which may remain is a mere local dis- 
ease, and to submit to any treatment for its removal. The ancients applied 
the actual cautery to the extremities, to the coronal suture, or to the occiput, 
but without any beneficial success. The moderns have had recourse to blisters, 
to friction, to electricity, and to strychnine ; but every attempt to act locally 
on the muscular system is prejudicial so long as any central irritation exists. 
Such remedies are neither theoretically nor practically useful. (See " Pa- 
ralysis.") Active or passive exercise of the muscles are remedies highly 
beneficial. 
Dietetic Treatment.-The diet of the patient should be low, till all appre- 
hension of a relapse is past, and limited to milk, boiled vegetables, light pud- 
dings, and fish. At no subsequent period ought he to indulge in a full animal 
diet, or to drink undiluted wines. At the same time, too lowering a regimen 
is to be avoided, as thereby the irritability of the system and the heart's action 
generally is increased. All the causes of the disease already fully referred to 
should be avoided, counteracted, or overcome. The diet and the bowels 
should be carefully regulated, and the patient placed under the best possible DEFINITION AND PATHOLOGY OF HEMATOMA. 
1039 
hygienic influences. Niemeyer recommends a sojourn at the waters of Wild- 
bad, Gastien, Pfafers, or Ragatz, where he considers that gradually both cere- 
bral and spinal paralysis often improve. The induced current of electricity is 
also beneficial. It seems to improve the nutrition of the paralyzed muscles, 
which tend to atrophy from long disuse, and paralysis tends also to get worse 
from diminished excitability of the nerves. Local faradization by induced 
currents of electricity gives artificial exercise to these muscles, and thereby 
improves their functional and nutritive properties. 
H2EMAT0MA OF THE DURA MATER.* 
Definition.-Sanguineous encapsuled flattened masses, composed of fine layers 
of fibrin, spread to a greater or less extent over the under surface of the dura 
mater, accompanied by repeated small extravasations of blood, which are converted; 
into pigment. By repetition of the process several layers come to be deposited one 
upon the other. Numerous and large bloodvessels form in these layers; and from 
these vessels renewals of the hemorrhages occur. The disease is chronic, and ter- 
minates, after continued cephalic suffering, generally suddenly, with symptoms of 
apoplexy. 
Pathology.-These tumors of bloody formation seem to occur in connection 
with more or less inflammation of the dura mater. The effusion of blood be- 
tween the dura mater and the arachnoid is not in most cases a primary oc- 
currence, but the productive results of inflammation first occur; and the new 
growth is developed into a fibrous membrane traversed by a copious network 
of new-formed bloodvessels. It is from the rupture of these vessels that ex- 
travasations proceed (Virchow, Weber). The lesion is sometimes described 
as due to intrameningeal apoplexy, with false membranes on the dura mater; 
but the false membranes which are the result of the chronic inflammation 
precede the apoplectic phenomena. The hoematoma often attains a considera- 
ble size. It may be from four to five inches long by two and a half, inches 
broad, and one-half to three-quarters of an inch thick. It is generally of a 
flattened circular form, with a central elevation, and usually located near the 
saggital suture. The long diameter is parallel to the falciform process. The 
tumor generally occurs on one side only; or, if bilateral, one is more devel- 
oped than the other. The walls of the sac are generally of a rusty color, 
from the altered coloring matter of the blood, and the contents of the sac are 
partly fresh fluid or partially coagulated blood, in the form of dirty red-brown 
clots. The cerebrum below is flattened, and may even show a depression. 
The affection appears to occur only in the adult, and generally after the age 
of fifty. In recent cases very fine layers of fibrin are found to a greater or 
less extent spread over the surface of the dura mater. By repetition of the 
inflammatory process, numerous layers of fibrin become deposited one upon 
the other; and much more numerous and larger bloodvessels form in these 
layers than are to be met with in the dura mater itself. From these new- 
formed vessels the hemorrhage proceeds which gives rise to the formation 
of the hoematoma, and its cystic inclosure is formed by the extravasation taking 
place between the layers of the false membrane (Virchow). 
The lesion is comparatively rare, and was at one time believed to have been 
the result simply of an apoplectic effusion of blood at the periphery, of which 
the fibrin had been precipitated and the whole encapsuled. The lesion is 
now believed to be the remains of repeated chronic inflammations of the dura 
mater, with hemorrhagic exudations. The blood comes from the large thick- 
* This disease is not mentioned by the College of Physicians, in their nomenclature, 
as distinct from inflammation of the dura mater. 1040 
SPECIAL PATHOLOGY-SUNSTROKE. 
walled capillaries which form in the pseudo-membrane deposited in the dura 
mater during the chronic inflammation, and the blood is effused between the 
layers of this exudation. 
Old age, disorders of the intellect, especially general paralysis, chronic 
alcoholism are the kind of cases in which the lesion is found ; and sometimes 
it seems traceable to external injury. In such cases years may intervene be- 
tween the injury and the symptoms of haematoma (Griesinger). Of several 
specimens of the lesion preserved in the museum of the Army Medical De- 
partment at Netley Hospital, one occurred in a soldier thirty-three years of 
age, with tropical service, a history of epilepsy, fever, and lunacy, and finally 
death with apoplectic symptoms; a second occurred in a soldier twenty-seven 
years of age, with a history of epilepsy; a third in a soldier thirty-eight years 
of age, also with a history of epilepsy, tropical service, chronic alcoholism, 
injury by a fall into the trenches at St. Mary's Barracks, Chatham, and death 
from paralysis. 
Symptoms may extend over several months, and consist in general weaken- 
ing of the Memory and of the Intelligence ; the occurrence of giddiness ; and 
of continuously intermittent general or local pain in the head. At a later 
period an aggravation of all these phenomena occurs, with transitory losses 
of consciousness from the momentary arrest of cerebral circulation. Somno- 
lence and apathy prevail, with weakness, and generally one-sided paralysis of 
the extremities, which may soon disappear. 
Treatment-Is more or less expectant. The newly-formed membranes tend 
to undergo retrograde change, and thus finally disappear. To effect this end 
is therefore the object of any rational treatment, which must be based on the 
special history of the individual case, especially as to the previous existence 
or not of syphilis or injury. 
SUNSTROKE. 
Latin Eq., Solis ictus; French Eq., Coup de soleil; German Eq., Sonnenstich; 
Italian Eq., Colpo di sole. 
Definition.-An affection of the nervous system, associated with vertigo, and 
sometimes with headache, or the gradual accession of listlessness and torpidity, 
with a desire to lie down (Longmore, Barclay). These febrile phenomena 
may culminate in more or less sudden and complete insensibility, without the power 
of sense or motion, the breathing rapid, and getting more and more noisy as death 
approaches. Convulsions of the extremities usher in a complete state of coma, in 
which the patient gradually dies. The approach of death is indicated by the 
failure of the heart's action, the fluttering of the pulse, the irregularity of the res- 
piration ; and the fatal event may supervene within five minutes to a few hours 
after the disease has become fully expressed. Death is either by syncope, apnoea, 
or by a combination of the two. In cases which recover, various sequela; are apt 
to supervene, such as forms of paralysis, more or less complete, choreic movements, 
melancholia, and other forms of disorder of the Intellect. 
Pathology and Symptoms.-This singular and fatal affection of the nervous 
system has been described under a great variety of names-e. g., Heat apo- 
plexy, Heat asphyxia, Coup de soleil, Insolatio, Ictus solis, and lastly, Erythismus 
tropicus. Notwithstanding that sun heat and the sun's rays have been con- 
sidered the main agent in producing this disease, it is not less true that the 
full expression of the disease not unfrequently occurs at midnight. The name 
implies a common, and certainly a most powerfully exciting cause of a disease 
which has been variously and erroneously described as of the nature of apo- 
plexy, or of some form of continued fever. 
A very great variety of views have been put forward regarding the pa- PATHOLOGY AND SYMPTOMS OF SUNSTROKE. 
1041 
thology of this remarkable disease; and the following account of its nature is 
based upon the very interesting accounts which have been given by many In- 
dian medical officers, and especially by Deputy Inspector-General Longmore, 
C.B., and now Professor of Surgery in the Army Medical School, when on 
duty with the 19th Regiment at Barrackpore; by Surgeon Butler at Mean 
Meer; and by Dr. Barclay, of the 43d Light Infantry, while on the march 
from Jubbulpore to Calpee. 
Instances of the occurrence of sunstroke, and the circumstances under which 
it has been observed to occur, will best convey any idea of the nature of this 
disease. 
One of the earliest accounts of sunstroke, in which its nature was distinctly 
recognized, is that given by Mr. Russell, of the 73d Regiment, while in medical 
charge of the 68th, in May, 1834. The regiment had then recently arrived 
in Madras-a line corps of men in robust health. The funeral of a general 
officer being about Jo take place, the men were marched out at an early hour 
in the afternoon, buttoned up in red coats and military stocks, at a season, too, 
when the hot land winds had just set in, rendering the atmosphere dry and suf- 
focating even under the shelter of a roof, and when the sun's rays were exces- 
sively powerful. The funeral procession forthwith advanced, and after hav- 
ing proceeded two or three miles, several men fell down senseless. As many 
as eight or nine were brought into hospital that evening, and many more on 
the following day. Three men died-one on the spot and two within a few 
hours. The symptoms observed (and they were alike in the three cases) were, 
first, excessive thirst and a sense of faintness; then difficulty of breathing, 
stertor, coma, lividity of the face; and in one whom Dr. Russell examined, 
contraction of the pupil. The remainder of the cases (in which the attack 
was slighter, and the powers of reaction perhaps greater, or at all events suffi- 
ciently great) rallied; and the attack in them ran on into either an ephemeral 
or more continued form of fever. The symptoms of these cases did not more 
nearly resemble each other than did the post-mortem appearances. The brain 
was healthy in all; no congestion or accumulation of blood was observable. 
A very small quantity of serum was effused under the base of one; but in all 
three the lungs were congested, even to blackness,through their entire extent; 
and so densely loaded were they, that complete obstruction must have taken 
place. There was also an accumulation of blood in the right side of the 
heart, and in the great vessels fMedical Gazette, " Graves's Clinical Lectures," 
vol. i, p. 181). 
A nearly parallel example is related by Sir Ranald Martin as having oc- 
curred in the experience of Dr. Milligan, of the 63d Foot, from the exposure 
of his corps to the sun during a military funeral at Madras. The greater 
number of the men were in the prime of life ; but there were some old soldiers 
who had served twenty years and upwards in the West Indies, and who were 
much broken down by service and intemperate habits. The entire corps had 
just arrived from the Australian colonies, where spirituous liquors can be had 
on easy terms. The regiment landed at Madras in the month of May; and 
from the date of the "untoward circumstance" of the funeral, the hospital 
became filled with cases of fever. Two men dropped down and died on the 
very day of the funeral, and for several days afterwards the fever cases aug- 
mented considerably ( The Influence of Tropical Climates, p. 205). 
The dreadful march of the 43d Light Infantry from Jubbulpore to Calpee 
furnishes the most instructive and melancholy examples of sunstroke. It must 
be remembered that the regiment had previously marched throughout the 
greater part of the length of the Madras Presidency-a march extending from 
the 24th December, 1857, to the 17th of April, 1858, when the regiment ar- 
rived at Jubbulpore. During this first march the regiment enjoyed great 
immunity from sickness, owing to the sanitary precautions which had been 
taken. The march, however, told seriously upon the men in general. They 1042 
SPECIAL PATHOLOGY-SUNSTROKE. 
lost condition, and in a great measure their robust appearance, and were 
in urgent need of rest. But after a rest of five days only, they had to com- 
mence the march from Jubbulpore to Nagode, a distance of 163 miles, arriv- 
ing there on the 8th of May. The heat on the march was excessive, and it 
told very much on the health of the men, already exhausted as they were by 
a previous march of almost unexampled length. After having been four 
months and thirteen days in the field, and after they had marched 969 miles, a 
fatal case occurred ; and from that date cases of sunstroke gradually increased 
in frequency. At Nagode the regiment remained eight days ; and although 
the indications of exhaustion in the altered looks of the men, their loss of 
flesh and their evidently failing strength, were so obvious that they forced 
themselves on the observation of every one, yet the men were ordered to con- 
tinue their march to Banda. The periodical hot winds were blowing at the 
time day and night, with scarcely any intermission, and the heat of the 
weather was almost unbearable. After leaving Nagode they were obliged to 
encamp for four days in the bottom of a deep and narrow ravine, with nearly 
precipitous sides upwards of a mile in height. The heat in this valley was 
insufferable, and exceeded anything the regiment had ever been exposed to 
before, or that they were exposed to afterwards. The thermometer varied 
during the day from 115° Fahr, to 118° Fahr, in the largest tents, and in the 
smaller ones it reached 127° Fahr. Night brought but little relief. On one 
occasion Dr. Barclay observed the thermometer standing at 105° Fahr, at 
midnight. Such was the overpowering effect of the heat in this " valley of 
the shadow of death," that even some of the natives were struck down, and 
died with all the symptoms of sunstroke in less than an hour. The number of 
cases among the men of the regiment, especially during the first day, was 
very great. They were carried into the hospital tents at every hour of the 
day and night; and although a large proportion of them recovered, two 
officers and eleven men were buried under one tree in the neighborhood of the 
camp. Marching was resumed on the 24th of May. On the 27th the regi- 
ment arrived at Banda, a distance of about 100 miles from Nagode, having 
lost during the march two officers and nineteen men. 
The health of the regiment improved daily during a short stay at Banda; 
but the men were still in a miserable state of exhaustion when the regiment 
again began to march for Kirwee on the 3d of June. At Kirwee five men 
died from sunstroke, and on the return to Banda two more died. The regi- 
ment now marched for Humeerpore on the 28th of June, en route for Calpee. 
The weather was again excessively hot, and the men suffered very severely. 
They were by this time completely worn out and prostrated. There was 
scarcely a man in the regiment whose strength was not reduced to a level 
with that of a child; and the officers were not in a very much better plight. 
Many men broke down altogether, and had to be carried as it could best be 
managed-in doolies, in sick carts, or on baggage and commissariat carts after 
they were filled. It was painful to see many others who, a few months be- 
fore, had been in robust health and full of vigor, staggering from weakness as 
they endeavored to keep up with the column, throwing themselves down com- 
pletely exhausted at every halt, and scarcely able to rise from the ground 
when the "assembly" sounded. Calpee was reached on the 5th of July, and 
between the 28th of June and the 7th of July one officer and five men had 
■died. 
These details are given for the purpose of showing the effects of protracted 
exposure to intense heat in a body of men in the field debilitated by fatigue and 
want of rest. It may now be shown how the effects of protracted exposure to 
intense heat in a body of men may operate upon them when in quarters; as 
described by Deputy Inspector-General Longmore. He records sixteen cases 
of sunstroke as having occurred in the 19th Regiment between the 23d of May 
and the 14th of June, 1858, when they were quartered at Barrackpore. The PATHOLOGY OF SUNSTROKE. 
1043 
period was marked by an unusually elevated degree of temperature, and gen- 
erally by great dryness of the atmosphere. The quarters were of a temporary 
and imperfect nature, some of them being merely hired bungalows. 
Of the sixteen cases, five occurred in non-commissioned officers, and eleven 
in privates of the regiment, the proportion attacked being greatly more among 
the former than among the latter; their occupations, especially when on 
orderly duty, caused them to be more exposed than the men with whom they 
lived. Simple exposure to the external atmosphere and the solar rays were 
not of themselves sufficient to induce the disease. Of the five non-commis- 
sioned officers attacked, two were on duty at the time as orderly sergeants; 
one had had fever for several days, but had not been exposed to the sun on 
the day of attack; one had been slightly exposed; the fifth not at all. Of 
the privates, eight were attacked by the disease within doors, and three while 
on sentry. No cases occurred of sudden sunstroke-i. e., of insensibility in- 
stantly induced by the direct rays of the sun in a man previously healthy. 
The characteristic feature with regard to atmospheric temperature, when 
Mr. Longmore's cases were observed, was the little variation of it night or 
day. There was no rain; and the ground and buildings became so heated 
that, long after sunset, the radiation of heat maintained a high temperature 
within doors. Prolonged high atmospheric temperature was recognized as the 
essential cause of the attack; but nervous depression from solar exposure, 
fatigue, and previous illness were associated with that prime or essential cause. 
But a most important element of causation is still to be mentioned-namely, 
the influence of vitiated air when men are congregated without sufficient ventila- 
tion. One-third of the cases, and nearly half the deaths, occurred under such 
circumstances; so that, in quarters, the predisposing causes of sunstroke may 
be comprised in the following conditions: (1.) Prolonged atmospheric heat, 
with a dry and rarefied state of the air; (2.) Nervous exhaustion; (3.) A con- 
taminated atmosphere (Longmore, Taylor); while (4.) An increase of the 
average prevailing temperature sufficed to act as the more immediate exciting 
cause for the development of sunstroke. 
The experience of Surgeon Butler at Mean Meer has led him to write, that 
"when the thermometer ranges beyond 98° Fahr, in crowded barracks, cases 
of apoplexy almost invariably occur." Dr. Crawford also, in writing on sun- 
stroke, notices an electric condition of the atmosphere as influencing the respir- 
ability of the air, and refers especially to that peculiar state "in which the 
hairs of a horse's tail repel each other, in which the hairs of the head stand on 
end, in which a man exposed to its influence becomes irritable, headachy, and 
restless, without knowing exactly what is the matter with him. Such a state 
of atmosphere will generally be found to exist in localities where cases of sun- 
stroke occur, whether such localities be the crowded barrack, in the still more 
crowded cantonment, the tented field, or the march in column through the 
still valley, the deep gorge, or the thick forest." Dr. Barclay notices that 
cases of sunstroke occur with increased frequency immediately before a thunder- 
storm, and that they cease as soon as the electrical discharge has taken place. 
From the accounts given by these several observers it seems clear, as Dr. 
Barclay observes, that the symptoms of the disease are liable to be greatly 
modified by accidental causes, and that those phenomena which are most 
prominent under one set of circumstances are either absent altogether under 
another, or so very much less urgent as scarcely to attract observation-that 
the disease, in fact, varies in several important points according to the nature 
of the circumstances in which it occurs. 
The phenomena which at any time have presented themselves under the 
various circumstances detailed by Mr. Longmore, Dr. Barclay, and others, 
may be summed up as follows: When careful observations are made, the 
affection seems gradually induced by protracted exposure to extreme heat in 
a dry and rarefied air, combined with a vitiated atmosphere from defective 1044 
SPECIAL PATHOLOGY-SUNSTROKE. 
ventilation, or with physical exertions of an arduous character, implying ex- 
cessive fatigue of extreme duration, so as to bring about great debility .and 
weariness of the body. Sleep at last cannot be obtained, or it is greatly inter- 
rupted, and of short duration. Deterioration of the general health is thus 
progressive, while altered looks and loss of flesh indicate extreme exhaustion. 
The skin becomes rough and scaly, and perspiration ceases. The heat of the 
surface increases to an intense degree; but accurate records of'the temperature 
of the body in cases of sxmstroke are not yet in existence. The bowels tend to 
become obstinately constipated. The urine becomes copious, and the calls to 
pass it are frequent; or even incontinence may prevail (Longmore, Barclay). 
Under such circumstances those morbid phenomena intervene which are noticed 
in the definition. 
Most observers are agreed that intemperance cannot be charged with 
being the immediate exciting cause of the disease, although it is a universally 
acknowledged predisposing cause. The men of Dr. Barclay's regiment were 
extremely temperate, robust, and well-formed men; and Mr. Longmore gives 
a no less favorable account of his men as to temperance. The drunkard, 
indeed, is rarely to be found in the ranks under circumstances favorable to 
the development of sunstroke. He is either in prison, or skulking at some 
depot, or in some hospital, where he may be left for want of transport; or, if 
with a regiment, "the pains" come on opportunely, to save him from fatigue 
and danger. The vascular system of a habitual drinker soon shows unmis- 
takable indications of over-stimulation in the suffused eye, the bloated counte- 
nance, the profound sleep which follows the slightest indulgence, and the sub- 
acute meningitis which sooner or later supervenes in India (Crawford). Such 
are not the kind of cases which furnish the deaths from sunstroke. When 
exposed to the stimulus of a tropical sun, such cases may sink under it, as 
they would under any other great excitement; and a debauch or an ephem- 
eral fever will alike predispose a man to an attack of sunstroke, inasmuch 
as both may bring about that state of nervous depression which seems essen- 
tial to the occurrence of this disease. 
In Dr. Barclay's experience the deterioration of the health of his men in 
the field was progressive. For a long time before the occurrence of the first 
case of sunstroke every one had suffered more or less from "prickly heat," the 
severity of the affection being, as a rule, in proportion to the amount of per- 
spiration from each individual; and when the heat of the weather became 
still more intense, one of the first symptoms of its producing an injurious 
effect was the gradual disappearance of this cutaneous eruption, the skin 
becoming rough and scaly, and the perspiration ceasing. In many cases 
the interruption of perspiration appeared to be complete-not the slightest 
feeling of dampness being perceptilile in any part of the dress at any period 
of the day. On this point Dr. Simpson observed to Dr. Morehead,-"Every 
man seized with sunstroke, and who could answer questions, informed me 
that he had not perspired for a greater or less extent of time,-sometimes not 
for days,-previous to being attacked, and that he had enjoyed good health 
as long as he perspired; but that on the perspiration being checked, he 
felt dull and listless, and unable to take much exertion without making a great 
effort" (Researches on Disease in India, p. 617). The heat of the surface 
became at the same time much increased. The bowels became obstinately 
constipated. The appetite gradually failed; and a feeling of nausea was gen- 
erally complained of, the sight of food often exciting loathing. In other 
instances there was nearly complete anorexia. 
The urine became copious and limpid, and the calls to pass it frequent; so 
much so that Mr. Longmore especially notices a frequent desire to micturate 
as constant in all the cases in which there was an opportunity of ascertaining 
the point; and he justly remarks-"If this symptom should prove to be a gen- 
eral precursor of the attack, it might be rendered valuable as an indication CAUSES OF SUNSTROKE. 
1045 
of the approaching danger, which, by early and proper care, might then prob- 
ably be averted; and its presence at a time when heat-apoplexy was prevalent 
would make the surgeon alert to obviate the more serious symptoms which 
might be expected to follow" (^Indian Annals, vol. vi, 1860, p. 399). Sleep 
from the first was much interrupted, and the periods during which it could be 
obtained became gradually shorter, until at length no sleep could be got dur- 
ing the night. The pulse was frequent, sharp, and small. The tongue white 
posteriorly, but seldom foul or dry. Thirst was seldom very urgent. Ver- 
tigo was frequently complained of, but headache rarely; and, as a general 
rule, there was no complaint of pain. The general complaint was extreme 
debility, weariness, and prostration on any exertion; vertigo, nausea, and in 
many cases incontinence of urine, more particularly after exposure to the sun, 
"I cannot hold my water," being a very general answer to the first inquiries 
of the medical officer. These premonitory symptoms were attended with 
rapid and progressive emaciation. No one during the march (in the ravines 
of Northern Bundelcund, so well described by Dr. Barclay) became the sub- 
ject of sunstroke without having previously suffered from some or all of these 
premonitory phenomena. Such phenomena, however, prevailed in a much 
larger proportion of cases in which symptoms of sunstroke did not supervene 
at all; and they seem to stand somewhat in the same relation to sunstroke that 
the premonitory diarrhoea does to cholera. 
The attacks of sunstroke came on generally when the men were in their 
tents, during the day sometimes, but in several instances during the night, 
and also on the line of march. During the night the patient had generally 
laid himself down, often seemingly asleep, or trying to induce sleep, when the 
attention of his comrades would be directed to him by his hurried and heavy 
breathing, and on attempting to rouse him he was found to be insensible. In 
other instances he started up suddenly, and attempted to escape from the tent, 
staggering about, and struggling violently when laid hold of, evidently much 
alarmed, and anxious to escape from some imaginary object of terror; but in 
a very few minutes he became insensible. 
In one or two instances the first symptom of the disease was reputed to have 
been an uncontrollable burst of laughter, without any apparent cause, and 
in sad enough circumstances,-insensibility and death speedily following. 
In a few instances the patient would come to hospital himself, or with the 
assistance of his comrades, exhibiting some of the symptoms (premonitory) 
already detailed, when insensibility or a tendency to sleep would gradually 
supervene. The time of the day at which most of the cases occurred is im- 
portant in connection with the elevation of temperature. Ten out of sixteen 
cases occurred between the hours of 2 and 5 o'clock p.m., and five cases be- 
tween 5 and 9.30 p.m. (Longmore). In Mr. Cotton's experience at Meerut 
the seizure usually happened towards evening. The thermometer generally 
indicated the maximum temperature of the twenty-four hours to be about 
4 p.m. ; and the variation in the thermometer-range was very slight from 2 p.m. 
to sunset; and even for some hours after sunset the temperature scarcely at 
all declined (Longmore). 
Dr. H. S. Swift records, in the New York Journal of Medicine for 1854, 
some interesting particulars regarding sixty cases of sunstroke observed at the 
New York Hospital during that year. The seizure in all was sudden, in the 
midst of work, and was characterized by pain in the head, a sense of fulness 
and oppression in the epigastrium, occasionally nausea and vomiting, general 
feeling of weakness, especially of the lower extremities, vertigo, dimness of 
vision, and insensibility. Surrounding objects appeared of uniform color, 
generally blue or purple. In one case everything was red, in another green, 
in another white. 
In three cases the attacks occurred between 8 and 11 A.M., in forty cases, 
between 11 a.m. and 4 p.m., and in seventeen cases between 4 and 9 p.m. 1046 
SPECIAL PATHOLOGY-SUNSTROKE. 
The general result being that the majority of cases occurred during the maxi- 
mum of the day's temperature. 
When the disease was fully expressed, the symptoms were constant and 
regular. The patient lay on his back, without sense or motion, breathing 
rapidly, and as death approached, more and more noisily, from the vibration 
of the uvula and the velum pendulum palati; and although such stertor was 
present in most of the fatal cases, yet it never approached in degree to that 
which is common in true apoplexy. The eyes were fixed, and turned slightly 
upwards, becoming gradually more and more glassy, as if from the formation 
of a film over the cornea ; the pupils greatly contracted (generally to the size 
of the head of a pin) ; the conjunctivae pinky, the color gradually becoming 
deeper;, the congestion at first deepseated, and the first Symptom of it a 
pinky zone around the cornea, the superficial vessels afterwards becoming 
affected. 
In Dr. Barclay's cases the face was invariably pale; the surface dry, harsh, 
and burning to the touch, far beyond what he ever felt in any other disease. 
In Mr. Longmore's cases the heat of skin greatly exceeded that occurring 
in pneumonia, and was without parallel in his experience. 
Dr. Clymer has collected together a number of records of body-temperature 
in this disease, some of them observed after death ; and in other instances, as 
they are not noted, it is presumed the observation is during life. Separating 
the two series of records, the observations stand as follow: 
After death. 
Observer. 
99°, 104° . 
Dowler. 
105°, 110° . 
108° 
H. C. Wood. 
109c 
u 
112° 
Levick. 
105.5° 
u 
During life, or at 
moment of death. 
Observer. 
111°, 112°, 113° . 
. Dowler. 
109° 
1 6 
106° 
It 
108° 
' H. C. Wood. 
109° 
ll 
109° 
ll 
104° 
ll 
106° 
ll 
109.5° . 
. Levick. 
109° 
ii 
106° 
ii 
109°. 108°, 108.8° . 
. Baumler. 
Sudden and remarkable elevations of temperature are also recorded by 
Wunderlich. In 1867 Schneider observed a temperature above 104° Fahr., 
in a fatal case, two and a half hours after admission to hospital. Helbig 
records three similar cases. Ferber observed a temperature of 104° Fahr, in 
a case which recovered. Baumler (in Med. Times and Gazette, August 1, 
1868) observed a temperature of 109.22° Fahr, in a fatal case, one hour after 
admission. Levick records a temperature of 109.04° Fahr, in a man fifty-five 
years of age, who recovered from " Heat-fever " in the Pennsylvania Hospital 
{Report for 1868), and a similar record in a man aged forty, in the same place 
and year. He communicates also a number of similar observations, amongst 
which, one by Dowler is said to have reached as high as 113° Fahr. Tem- 
peratures of 103°, 104°, and 105° Fahr, are not uncommon a few hours after 
the attack commences (Woodman). See also Dr. Levick (in American Jour- 
nal of Medical Science, vol. xxxvii, p. 40), who publishes cases with tempera- 
tures as high as 109.04° Fahr., ending in recovery. 
The heart's action was very rapid and sharp (Barclay), excited and irreg- 
ular (Longmore), the impulse and pulsation in the carotids being perceptible 
to the eye from a considerable distance. The pulse was frequent and sharp, 
and at first moderately full, giving the idea of a thinner fluid than blood cir- 
culating beneath the finger. Frothy mucus, sometimes clear, at other times 
of a brown color, was in most instances ejected from the mouth and nose for 
some time before death, and often in large quantity. MORBID ANATOMY OF SUNSTROKE. 
1047 
When the disease was about to terminate fatally, the heart's action soon 
began to fail, the pulse to flutter, and the breathing to be irregular ; and in 
a period varying from a few minutes to a few hours, death closed the scene. 
In nearly all the fatal cases, there was occasional convulsive muscular move- 
ments of the extremities up to the time of death. These generally ushered 
in a state of complete coma, in which the patient gradually sank (Long- 
more). 
In a large proportion of the cases, however, from the commencement of the 
attack to its termination in death, the patient never moved a limb, or even 
an eyelid ; and a comparatively small number of the cases on the march from 
Jubbulpore to Calpee were from the first attended with convulsions. These 
generally began in the upper extremities, or in the muscles of the face ; and 
in some cases they did not extend farther, the patient either becoming rapidly 
insensible or recovering. In other instances they extended to the whole of 
the voluntary muscles, and were of the most violent description, ceasing fre- 
quently for from two or three to fifteen or twenty minutes, and recurring again 
with increased severity. In a few instances the nervous irritability seemed 
as much increased as in hydrophobia ; and some patients appeared to be in 
a state analogous to somnambulism,. Although unconscious, and incapable of 
understanding or of answering questions, yet the countenance indicated the 
greatest terror,-the eyes rolled wildly about; and a few drops of water poured 
on the ground near him were sufficient to throw him into the most violent 
convulsions, and to elicit from him screams of agony. In most of these cases 
the convulsions ceased some time before death. The symptoms then became 
identical with those which characterize the ordinary course of the disease. 
In a few, however, the convulsions continued to the last; and in one or two 
death took place when the body was still contorted with them (Barclay). 
The mortality from insolatio is equal to 42.734 per cent. (Barclay) ; or 
43.3 per cent. (Butler) ; one half the cases (Swift) ; 560 per 1000-the 
result of the following extension of Dr. Morehead's statistics: 
Observer. 
Cases treated. 
Deaths. 
Sir Charles Napier, 1843, June 15, Nussurpoor, 
. 44 
43 
Dr. Joshua Jones, 1864, Andersonville, 
. 53 
53 
Mr. Hill (collected cases), .... 
. 504 
259 
Dr. Taylor, Gazeepore, 
. 115 
16 
Mr. Longmore, Barrackpore, .... 
. 16 
7 
Mr. Lofthouse, 14th Light Dragoons, 
. 80 
10 
Dr. Simpson, 71st Regiment, .... 
. 25 
6 
Mr. Ewing, 95th Regiment, .... 
. 60 
17 
Field Hospital, Hansi, . ... 
. 29 
10 
926 
521 
Ill the cases which terminate favorably a gradual remission of the urgent 
symptoms takes place; but the irregularity of the heart's action and oppressed 
breathing may persist during the next day; and if the patient has been 
exposed to the influence of malaria, paroxysmal febrile phenomena may 
supervene. 
The patient cannot be considered free from danger till the skin becomes 
cool and moist (Simpson, Barclay) : indeed, a relapse of all the worst phe- 
nomena may occur even after free perspiration and sleep has been procured. 
Dr. Crawford relates such a case: An orderly being left in charge of the 
patient during the night, with instructions to keep a cold lotion to his head, 
and to call the surgeon in the event of any change occurring, no matter how 
slight; the surgeon, visiting the hospital at one in the morning, when sum- 
moned to see another patient then taken ill, found the orderly asleep, and, to 
his horror, his patient moribund,-the face swollen, of a dark livid color, the 
eyes protruding from their sockets, with stertorous breathing and spasmodic 1048 
SPECIAL PATHOLOGY-SUNSTROKE. 
twitchings of the muscles of the chest and arms. The patient died shortly 
afterwards. 
Morbid Anatomy.-In Mr. Longmore's cases, in which a vitiated atmos- 
phere, from the want of ventilation, was associated with the extreme heat, the 
appearances after death were those usually found in death by asphyxia- 
namely, excessive engorgement of the lungs, amounting to complete obstruc- 
tion of the pulmonary circulation. Some parts of the lungs had all the 
appearance of true interstitial apoplexy. Cerebral congestion was less marked 
in character and less constant in amount, and it seemed to be secondary to 
the failure of the due performance of pulmonary functions, resulting, perhaps 
(as Mr. Longmore suggests), from loss of tone in the vessels, and from the 
enfeebled action of the heart, consequent upon the imperfectly oxygenated 
blood it was receiving. The congestion of the head was generally expressed 
by engorgement of the vessels of the pia mater and choroid plexus, and by 
numerous blood-puncta in the substance of the cerebrum, as shown on section. 
The appearance of the brain indicated generally sanguineous determination 
without serous effusion ; and when serous effusion had taken place, it was gen- 
erally into the cavities of the lateral ventricles, and sometimes into the sub- 
arachnoid space. Other observers record engorgement of cerebral meninges, 
but no congestion of brain-substance (H. C. Wood). Others again record 
marked cerebral congestion (Flint) ; or the vessels of the dura mater full of 
dark liquid blood, easily pushed along by the handle of the scalpel. Others 
record the brain softened and breaking down by its own weight, or by the 
slightest pressurp, with myriads of minute red points (torn vessels?) on its 
broken surface. The choroid plexus of a dark purple hue. No effusion into 
the ventricles. Uncoagulated blood on the under surface of the brain. Liver 
full of liquid blood, which poured from it on pressure like water from a satu- 
rated sponge (Levick). Veins of the membranes of the brain greatly con- 
gested. Brain moist, with large blood spots (Baumler). 
The blood is always fluid (Morehead). Its reaction has been recorded as 
faintly alkaline (Levick), and also as acid (H. C. Wood). Levick, Gerhard, 
and H. C. Wood hold, that the most obvious, constant, and essential lesion in 
sunstroke is an altered state of the blood. That alteration indicates a loss of 
its life as shown by the change in its physical properties, especially in the 
inability of the fibrin to coagulate, the shrunken condition of the corpuscles, 
their escape from the bloodvessels, forming myriads of petechial spots, and 
rapid putrefaction, beginning before actual death has taken place. 
Various opinions are entertained with regard to the mode of action of the 
various agents which combine to produce this singular affection of the nervous 
system. The phenomena during life and the post-mortem appearances are in 
accordance with death from coma, slowly induced, or from syncope. 
The manner in which heat acts in the production of such asphyxia as is 
seen in cases of sunstroke has been variously interpreted by writers on the sub- 
ject ; and observations are very much to be desired as to the exact range of 
temperature of the body-heat in such cases. It is known, however, to be ex- 
cessive, as already shown at p. 1046; and the increased temperature of the 
blood, which results from prolonged exposure to great heat, must have a dele- 
terious influence upon the constitution during the metamorphosis of tissue 
going on under such circumstances. Intense heat applied to the whole body 
tends to produce death by syncope, as in concussion of the brain (Alison). 
Heat acting on the peripheral distribution of the nerves, and accumulating in 
the system, as it seems to do in sunstroke, produces such an effect on the heart, 
the lungs, and the brain, as to produce the phenomena of syncope and coma. 
The pre-existing cutaneous derangement in all the cases, the total inaction 
of the skin, its dryness and intense heat, betoken an accumulation of heat in 
the blood which cannot fail to influence the delicate textures of the brain and 
lungs. The " embarrassed and heavy breathingthe " sense of weight over MODES OF DEATH IN SUNSTROKE. 
1049 
the sternum " (Longmore) ; the " hurried and heavy breathing " (Barclay) ; 
the " catching at the chestthe " constricted feeling, as if of approaching 
suffocation, caused by wind at a temperature of 112° Fahr." (McGrigor), in- 
dicate that physiological state of " anxietas" which prompts to such acts of 
inspiration as are seen on the approach of syncope, or of apnoea, from depression 
of the nervous influence of the medulla oblongata. 
Pollution of the blood, from the prolonged continuance of function under 
such circumstances as impair the normal action of the skin, the lungs, and 
the kidney, produced by the atmospheric conditions already described, and 
the phenomena of the disease in its severe form, denote the culmination of 
functional efforts to get rid of the rapidly accumulating elements of disinte- 
gration which must have resulted-as indicated by progressive emaciation, 
augmentation of animal heat, and total suppression of the cutaneous function. 
Cases of sunstroke occurring " in quarters " seem, under such circumstances, 
to die from coma, inducing apnoea; and the most common complication is un- 
doubtedly pulmonary congestion from oppression of the medulla oblongata, 
evidences of which are found on post-mortem examination in the majority of 
fatal cases, as originally pointed out by Dr. Marcus Hill {Indian Annals, vol. 
iii, October, 1855); and afterwards by Mr. Longmore (1. c., vol. vi, July, 1859, 
p. 396). In those cases of death by coma, the most striking point in the post- 
mortem appearances is the enormous congestion of the lungs; in which Dr. 
Parkes remarks, that although he has dissected men in a very large number 
of diseases, both in India and in England, he has never seen anything like 
the enormous congestion observed in two or three cases of this kind {Practical 
Hygiene, p. 345). 
Pulmonary engorgement, however, is not always present. On the march 
and in the field the functional phenomena are chiefly of the cerebral, spinal, 
and sympathetic systems, as indicated by a painful state of nervous irritability 
from over-stimulation of intense heat. The long exposure of the eyes to the 
glare of the sun in camp may account for the more constant occurrence of 
their congested state in cases of sunstroke in the field, compared with such 
cases occurring in quarters. 
The pallor of the face and of the surface generally seems also to be more 
an attribute of the disease in the field than in quarters, the cases being proba- 
bly more amemic in the field and more pletlioric in quarters (Barclay). 
Practically, it has been observed, as Dr. Barclay points out, that there are at 
least four different ways in which death may occur in cases of sunstroke, which 
are necessary to be borne in mind with regard to the line of treatment neces- 
sary to follow. 
(1.) The affections of the nervous system alone, more particularly those 
which occur during active exertion "in the sun," when the intense heat acts 
on the surface with the greatest power, producing at last a condition similar 
to severe concussion, and more or less instantaneous death by syncope (Alison, 
Crawford, Barclay, Morehead). (2.) Death may be prolonged, when 
pulmonary complication may occur from destruction, more or less complete, 
of the pulmonary circulation, and death by asphyxia ensues. Or, (3.) There 
may occur cerebral congestion, and death by coma. These states may, and 
generally do, coexist together; and symptoms of either may predominate. 
(4.) Recovering from the immediate effects of these conditions, the patient 
may die two or three days afterwards, a febrile attack succeeding, with serous 
effusion within the cranium. 
Two distinct pathological conditions are set forth by Dr. Levick, and de- 
scribed as " sunstroke," namely: 
(1.) Cases in which there is simple loss of nerve-force, caused by over- 
exertion during exposure to a high heat. Such cases may happen in the open 
air, under the vertical rays of the sun, or in the close and heated atmosphere 
of furnace-rooms, laundries, or of crowded barracks in India. The symp- 1050 
SPECIAL PATHOLOGY-SUNSTROKE. 
toms of such cases are, a feeble and moderately frequent pulse, moist skin, 
head generally hotter than the trunk, little or no change in the pupil-a ten- 
dency to syncope on the slightest exertion. Such cases generally recover. 
(2.) Cases of a severer form, as a result of exposure to the sun's rays, or to 
a high temperature of the atmosphere, either within or out of doors. The 
attack is sudden, like a stroke, or with such slight premonitory symptoms as 
giddiness, confused blending of colors, and sharp pain in the head. The 
patient then falls unconscious, with stertorous breathing, restlessness, and 
convulsions. The skin is pungently hot, body-temperature from 104° Fahr, 
to 110° Fahr., and the pulse so quick that it cannot be counted. Death may 
be immediate, or within six hours of seizure, finding its victims generally 
among the young, the robust, and the unacclimated (^Pennsylvania Hosp. 
Reports, vol. i). 
Causes.-Heat, and atmospheric conditions of the nature already indicated, 
seem to concur with the following predisposing circumstances to induce cases 
of sunstroke: (1.) Plethora and unacclimation; (2.) Debilitating causes of 
every kind, particularly such as lower the tone of the nervous system or 
increase its irritability-e. g., excessive fatigue and prolonged exposure in 
extreme temperature, prolonged marches, bad ventilation in tropical tempera- 
tures ; (3.) A febrile state, from whatever cause. As a general rule, Dr. Bar- 
clay found that plethoric men incur greater danger from exposure than others; 
(4.) Intemperate habits; (5.) Exposure to an atmosphere highly charged with 
electricity (Crawford, Barclay) ; (6.) During the season of prevalence of 
sunstroke the temperature would seem to have ranged from 96° to 120° Fahr, 
in the shade-extremes of atmospheric heat chiefly observed on the Coroman- 
del Coast, Central India, the Northwest Provinces, Scinde, and the Punjaub 
(Morehead, 1. c., p. 615). 
The effects of the constant stimulation of excessive heat in producing 
nervous irritability and pervigilium cannot be doubted (March, Barclay), 
and Indian medical officers can bear witness, from personal experience, to the 
extreme misery resulting from such excessive stimulation, in combination with 
the conditions already mentioned. 
The investigations and experiments of Obernier show that the symptoms of 
sunstroke or insolatio, do not, as was formerly supposed, depend on hypersemia 
of the brain. The characteristic symptoms consist in paralysis of all the func- 
tions of the brain, occurring either suddenly or gradually. In the latter case 
the paralysis is preceded by excitement, delirium, and other symptoms of cere- 
bral irritation. In our country, latitude, and climate, the action of the sun's 
rays is not alone sufficient to induce such severe attacks as are seen in the 
tropics, but if great fatigue is superadded to a very hot day; and if, at the 
same time, the action of the skin is in abeyance, sweat being very little, then 
a severe attack may be the result. Radiation of body-heat is reduced to a 
minimum, while the production of body-heat is increased by active muscular 
exertion, there is overheating of the body and increase of body temperature 
to a degree incompatible with the continuance of life. Fulness of the veins 
of the meninges is no indication of a hypersemic brain; under such conditions 
of fulness the brain-tissue is generally anaemic. 
Treatment.-Keeping in view the nature of this disease, and the various 
modes in which death may approach, the line of treatment may be indicated 
as follows, on the authority of Dr. Barclay: 
With regard to the class of cases in which death tends to occur suddenly 
from syncope, there is little opportunity afforded for treatment; but the meas- 
ures indicated are-the cold douche, keeping the surface wet and exposed to a 
current of air, or assiduously fanned, exclusion of light as far as possible, the 
immediate employment of stimulants, external and internal, by the rectum 
as well as by the mouth. Depletory measures of any kind are not to be thought of. 
In the less rapidly decisive cases prompt treatment is of the greatest use; while TREATMENT OF SUNSTROKE. 
1051 
delay is fraught with the greatest clanger. The patient must be immediately 
stripped of his outer clothing; and, being placed in a semi-recumbent position, 
the cold douche is to be applied, from a height of three or four feet, over his 
head and along his spine and chest, his extremities being at the same time 
sponged over with cold water. Relaxation of the pupil is the first symptom 
that shows the good effect of the treatment, which may require to be repeated 
several times, on account of returning insensibility; but if there is any evi- 
dence of failure of the pulse, this treatment must be discontinued, and the 
application of cold to the head is then all that can be borne. Stimulants 
administered by the rectum are recommended by Dr. Levick, to counteract 
the tendency to prostration. The hair is to be cut short as soon as possible, and 
a blister applied to the nape of the neck, the surface having previously been 
well sponged over with the acetum lyttce. When the first violence of the 
attack is subdued, increasing confidence in the ultimate result may be in- 
dulged in so soon as vesication takes place; and in cases where insensibility 
recurs, after an interval of ten or twelve hours, it may be removed by the 
application of a second blister to the vertex; and which may be again re- 
peated, there being no doubt as to the good effect it produces. A blister may 
also sometimes be applied along the spine in the worst cases. Stimulation by 
the use of the electro-galvanic current, with the moist sponges applied along 
the sides of the neck, chest, and epigastrium, ought also to be employed. 
Sinapisms ought generally to be applied to the extremities, and to the chest or 
sides. 
As soon as possible after the employment of the douche, a strong purgative 
enema ought to be given, those of a stimulant nature being preferred. But 
as the enema may have to be repeated several times before any effect is pro- 
duced on the bowels, it may be advisable to let the first enema be of a simple 
purgative character; and afterwards let it be followed up by turpentine 
enemata. 
If cerebral congestion is indicated by the state of the eyes already described, 
a few leeches to the temples may relieve the congestion (Longmore, Bar- 
clay) ; but the prevailing opinion among medical officers of experience in 
the treatment of this disease is against the employment of bloodletting by 
venesection, even in severe cases. In all the cases which have been recorded, 
in which it has been employed, it seems to have been generally hurtful, and 
to have hastened the fatal termination. 
In cases where the breathing is much oppressed, and the bronchial tubes 
loaded with mucus, the patient should be turned occasionally over on his face 
and side. 
In the convulsive form of the disease, where the greatest irritability of the 
nervous system prevails, the douche is found to be inadmissible, from the 
agony which it occasions; and in such cases Dr. Barclay has found great bene- 
fit from the inhalation of chloroform. After a few inspirations the convul- 
sions for the most part ceased, and sleep was very easily induced; but in one 
or two instances, after a considerable interval of consciousness, febrile symp- 
toms increased in severity, coma supervened (probably effusion having oc- 
curred within the cranium), and was followed by death. But the cases in 
which chloroform can be used are comparatively few; and very great care is 
necessary in its employment, so that the inhalation may be suspended at once, 
as soon as any effect is produced upon the pulse. 
In the most severe forms of the disease the principle of management is to 
reduce as quickly as possible the blood-heat. This is best effected by rubbing 
the body over with ice, as large as can be handled, as recommended by Dr. 
Levick, and as has been proved to be successful by Baumler and Dr. Wood- 
man at the London Hospital. Tepid body baths, with cold affusion to the 
head and back of the neck, or general cold affusion may be employed; also 
injections of iced water. Keeping pieces of ice in the axilla until there is 1052 
SPECIAL PATHOLOGY-SUNSTROKE. 
returning consciousness, which may not be for several hours, and, therefore, 
great caution is required in such use of ice, so as not to induce gangrene of 
the skin. 
The sequehe of sunstroke are generally persistent headache, fixed or shift- 
ing pain in the back, choreic movements of the forearm and hand, convulsive 
disorders, mental weakness. These symptoms are suggestive of haematoma of 
the dura mater, as a probable lesion in such cases, and indicate rest, atten- 
tion to the functions of the skin, and change of air. When the pain is fixed 
and severe, long-continued counter-irritation at the nape of the neck, and a 
course of iodide of potassium may benefit the patient; but many cases are 
quite unrelieved by treatment, as the records of the invaliding hospital at 
Netley show every year (Dr. Maclean). 
Measures for the Prevention of Sunstroke.-(1.) All weak and sickly 
men should be weeded out and left behind, if a march is to be undertaken 
during hot weather in India; (2.) The costume should be suitable for the 
early morning hours before sunrise, as well as for the scorching period which 
follows, when the men are for the most part in their tents. It should consist 
of materials of slow conducting power, of a color by which heat is not readily 
absorbed, and should be as loose and light as possible. A flannel shirt should 
be worn, to prevent the men being exposed to sudden chills, and a flannel 
belt round the loins may be worn with advantage, except in the hottest 
weather. The shirtcollar should either be open, or made so wide as to pre- 
vent all risk of its pressing injuriously on the veins of the neck. Above all, 
some other form of knapsack should be devised than that hitherto in use. 
The authorities, strongly urged by Dr. Parkes, have adopted a valise equip- 
ment, which is a great improvement, and which does away with the use of 
cross-belts, so injurious to the functions of the organs within the chest. The 
march ought not to be commenced too early in the morning. The troops 
should be on the new ground about an hour after sunrise, and the pace should 
never exceed three and a half miles an hour. There should be a halt for 
seven or eight minutes every hour, or oftener if the men are exhausted, and 
a longer halt half way, when each man should have a cup of coffee and a 
biscuit. They ought also to have their ration before starting in the morning. 
An ample supply of water should be provided for the men by "bheesties" 
being attached to each company, and always compelled to march with it. No 
man should be allowed to fall out without being accompanied by a non-com- 
missioned officer, whose duty it should be to bring him to a medical officer at 
once, if sick, and if not, to bring him up to the column at the halt. All 
men so falling out should be brought up to hospital tents for examination 
immediately on the arrival of the regiment in camp. The men should carry 
nothing on the march but their rifles and ammunition-the quantity of the 
latter being kept as small as is consistent with safety. They should be al- 
lowed to march "easily" and loosely clad, more particularly in passing through 
jungles or ravines. No halt should ever take place on such ground when bet- 
ter may be had within a moderate distance. When the sun is up, halts should 
be so timed that shelter may be obtained by open topes of trees. Camps should 
be formed on as high and open ground as possible. The sites for camps in 
India, marked out by the "official" pillars, are generally the most objection- 
able that could have been selected (Barclay, Indian Sanitary Commis- 
sioners, and others). As much space should be allowed between the tents 
as the ground will admit of. Tents should be pitched as speedily as pos- 
sible, camels and elephants being provided for their transport-carts never. 
" Kus-kus" mats should be kept constantly wet. 
Troops in the field during the continuance of the hot winds in India should 
have the best description of tents that can be got for hospital purposes, and 
be provided with the best known means for keeping them cool. An abundant 
supply of water in camp is of the utmost importance, care being taken that PREVENTION OF SUNSTROKE, 
1053 
the bags containing it are in good repair, hung up within easy reach of the 
men, and kept always filled with water. Sentries should be under cover 
during the heat of the day, and the men should be instructed, whenever they 
go out in the extreme heat of the sun, to put a wetted towel or thick hand- 
kerchief over the head, under the cap, and around the back of the neck and 
face. The men should be encouraged to take exercise during the cool of the 
evening, or, at all events, to leave their tents, so as to permit of their thor- 
ough ventilation; and, wherever it is practicable, bathing should not be 
omitted. 
Rations of spirits ought certainly to be discontinued in India. It may be 
a question as to what should be substituted instead; but all authorities are 
agreed that the system of " spirit rations " tends to convert young soldiers 
into drunkards. 
The sleeplessness which sometimes is a premonitory symptom of the dis- 
ease has been relieved by opium, provided there is no evidence of commencing 
insensibility, and followed by a purge, if necessary (M. Wrench, late 12th 
R. Lancers). APPENDIX TO VOL. I. 
Specific Yellow Fever, p. 564. 
Letter from Dr. Albert A. Gore to Dr. Aitken. 
Tower Hill Barracks, 
Sierra Leone, June 20, 1870. 
My dear Dr. Aitken : The following circumstances, which I cannot see 
any mention of in either "Bryson," or your review of the causes of the origin 
of the fever which committed such ravages on board the "Eclair," may be of 
interest to you. I have only recently been made aware of the facts by a 
countryman of your own-a patient of mine-the Honorable Charles Heddle, 
senior member of the Legislative Council of this colony. Mr. Heddle's state- 
ment was corroborated by two other merchants, old residents, whom I men- 
tioned the matter incidentally to. 
As you are aware, the "Eclair" arrived here on the 5th July, 1845, and 
sailed on the 25th of the same month. During the whole period she remained 
in harbor the crew were healthy, with the exception of a seaman (Thomas 
Smith) who was admitted into the Military Hospital for a mild attack of the 
endemic remittent. He was discharged cured on the 30th of August. After 
the "Eclair" left, three cases of yellow fever proved fatal in Freetown, with 
black vomit-viz., those of Babbage, Pringle, and Elliott; these occurred 
between the 15th and 20th of August. The first of these individuals only 
arrived in the colony on the 28th of July, the second, in an empty slaver, on 
the 2d of August, and the third was a seamen from on board H.M.S. " Star." 
That this was the case, I have verified by the records in my office; consequently 
the supposition that the disease arose from communication with the shore must 
fall to the ground, for no disease was on shore when she was in harbor. The 
fact is, she took the disease on board in another way; and in this opinion the 
late Dr. Bahai agreed when the circumstance was mentioned to him by Mr. 
Heddle, a most agreeable and well-read person. On the arrival of the " Eclair," 
in 1845, there was only a very small quantity of coal obtainable at Sierra 
Leone, and at a very high price-£5 a ton was asked for it. In consequence 
of this, the captain stated he would sooner sail all the way to England than 
pay such a price. Instead of doing this, he unfortunately made a contract with 
a Mr. Lemon, a merchant who lived next door to Mr. Heddle, for wood in 
lieu of coal. Lemon sent to the sheiks and Ranee princes, and collected a 
quantity of cast timber, and the ends of the logs, after these were cut in proper 
lengths for the Admiralty vessels. This timber had been lying for an in- 
definite time on the mud banks and timber reaches of these rivers-a timber 
reach being nothing more than an assembling together of every sort of filth you 
can imagine-principally vegetable debris. This timber, lying as it did for 
such a length of time on these muddy malarious banks, must have become 
thoroughly soaked with the malarious poison which they undoubtedly generate. 
This timber was brought to Freetown, cut into logs, and placed on board the APPENDIX. 
1055 
"Eclair" for fuel, in very large quantities. While being put on board, Mr. 
Heddle, who was standing on the wharf, used these remarkable words to the 
officer superintending the embarkation,-"You will kill every man on board 
your ship, if you take that timber on board." The sequel proved the correct- 
ness of his opinion; for what did they do? Nothing more than take into their 
vessel wood which must have been impregnated with concentrated malaria. 
The danger to the crews of vessels lying off the mud banks from which this 
timber was taken has been so often proved, up to the present time, by numer- 
ous examples; and that the poison wafted from the shore is capable of giving 
rise to remittent fevers, with black vomit, &c., and which, if the mortality is 
taken as a gauge between the two, cannot be distinguished from yellow fever, 
is so well known to West Africa, that it would be mere repetition to refer to 
them. Every day, on the coast of Africa, merchant ships sail away from the 
coast, or lie in the rivers, losing a portion, in some cases the whole, of their 
crew. The more recent instances have been stated in the Times-viz., the 
"Mary Campbell," which left Lagos in August, 1869, and the "Florence 
Page," which left the same port on the 4th of September. It is most curious 
that this circumstance was never mentioned during the controversy which 
arose after the fever on board the "Eclair," had committed such frightful 
ravages. I can only account for it by the fact that, on the score of economy, 
having taken into the vessel this wood, they suppressed all mention of it; 
either that, or they ignored the possibility of fever arising from such a cause, 
although the well-authenticated case of the "Huskisson," as well as the 
notoriously unhealthy condition of all timber vessels, was known to every one 
of experience on the coast. 
Passing over a long interval of time, we have two other instances-one 
fully detailed in the Naval Medical Reports, the other not generally known- 
neither of which may have come under your notice-where a virulent form of 
yellow fever occurred in the harbor of Freetown, Sierra Leone, the ships 
again being the infecting medium; only instead of timber vessels, they were 
coal hulks, and where the individuals residing on board, or communicating 
with them, were the only persons attacked; and where, as in the case of the 
"Huskisson," the disease subsequently appeared on shore. I allude to those 
of the "Iris" and "Balcarras," the former a naval receiving-ship and coal 
hulk, the latter a similar vessel belonging to the Royal Mail Steam Company. 
On the 28th December, 1865, a party, consisting of 112 men and officers, 
went on board the "Iris" from H.M.S. "Bristol," which had just arrived from 
England. The party worked on board the "Iris" for two days, returning 
each evening to the "Bristol"-were not exposed to the sun-and each man 
had served out to him four grains of quinine before leaving in the morning. 
On the 31st a seaman belonging to the party was attacked, and died on the 
3d of January, with symptoms of yellow fever. An engineer officer, who 
had remained only four hours on board the " Iris" on the 29th, was attacked 
on the 31st, and on the 1st of January twenty cases of yellow fever occurred; 
on the 2d, six cases; on the 4th, three; 5th, two; on the 6th, one; on the 
12th, one; a total of thirty-eight-twenty-seven of which presented symptoms 
of yellow fever. Of these twenty-one died. No one was attacked in this epi- 
demic outbreak except those who had been on board the "Iris." One of the suf- 
ferers had only been on board for a quarter of an hour. In no case did the 
disease spread to the medical officers or crew of the "Bristol," on the deck of 
which the cases were treated. 
The "Balcarras" was lying during the same period in the harbor; every 
one of the mail steamers which communicated with her for the purpose of 
coaling lost some of their officers and ' crew. The United States corvette 
" Kearsarge," after coaling alongside, soon after sailing to the southward as far 
as Cape Calmas, lost fourteen men. She then ran to the north as far as 
Madeira, finally going straight across to America. Altogether during the 1056 
APPENDIX. 
voyage she lost five officers and forty-seven seamen. These hulks were after- 
wards cleared out by natives, their holds whitewashed, and they were removed 
to the Bony River, since which time they have remained healthy. 
These coal hulks are at first perfectly innocuous, but, after a varying 
period, appear to become saturated with fever poison, capable of giving rise 
to most deadly outbreaks of disease. I think the reason is that they are 
being constantly partially filled and emptied; the lower portion of the coal is 
consequently never changed or the hold cleared out; the lower stratum of 
coal becomes saturated with bilge-water; and, owing probably to the high 
temperature, gives rise to the same emanations as a marsh would do, differing 
only in the fact that the poison of the former, owing to want of ventilation, 
must be much more concentrated and deadly, as proved by its effects. 
I have not alluded to the " Pandemic wave theory " of Dr. Lawson, as ac- 
counting for outbreaks of such diseases; but in West Africa you have some 
years which are much more unhealthy than others, and when the ordinary 
endemic is more fatal. Such periods not unfrequently precede or coexist with 
the development of yellow fever, whether of the malarial or more contagious 
variety. 
I recently came across an extract from some old chronicle of the early 
voyages to this coast, quoted by a reviewer of the life of Prince Henry of 
Portugal in the Edinburgh Review, which shows that these outbreaks have 
not been confined to recent times, and were then as now more frequent in the 
rainy season of the coast. Captain Jehan le Rouenois, a French adventurer, 
who visited the coast of Africa in 1379 in the "Notre Dame de Bon Voyage," 
states that he only launched his ship early in September; "for he knew, as 
has been said, that the tempestuous rains which poured down on these 
foreign coasts, three months before, were very furious; and that there had 
died of the pestilence and illness a great number of men in their houses, as 
the water and air at that season had a bad smell, and burn with continuous 
thunder." He does not appear to have been particularly fortunate in his 
voyage after all, for he lost a number of his valiant seamen, "without finding 
a single physician in the country." 
Albert A. Gore, S. T.