A TEXT-BOOK t** 
OF 
PRACTICAL MEDICINE, 
WITH PARTICULAR REFERENCE TO 
PHYSIOLOGY AND PATHOLOGICAL ANATOMY. 
BY 
EELIX VOX NIEMEYER, 
u* ' 
PROFESSOR OF PA'. AND THERAPEUTICS, DIRECTOR OF TIIE MEDICAL CLINIC OF THE 
UNIVERSITY OF TUBINGEN. 
TRANSLATED FROM THE EIGHTH GERMAN EDITION, BY SPECIAL 
PERMISSION OF TnE A UTHOR. 
BY 
GEORGE H. HUMPHREYS, M. D., 
ONE OF THE PHYSICIANS TO TRINITY INFIRMARY, MEMBER OF THE NEW YORK COUNTY MEDICAL 
SOCIETY, FELLOW OF THE NEW YORK ACADEMY OF MEDICINE, ETC., 
AND 
CHARLES E. IIACKLEY, M. D., 
ONE OF THE PHYSICIANS TO THE NEW YORK HOSPITAL AND TRINITY INFIRMARY, MEMBER OF TIIE 
NEW YORK COUNTY MEDICAL SOCIETY, ETC., ETC. 
REVISED EDITION. 
VOLUME II. 
NEW YORK: 
D. APPLETON AND COMPANY, 
1, 3, and 5 BOND STREET. 
1881. Entered, according to Act of Congress, in the year 1869, by 
D. APPLETON & CO., 
In the Clerk’s Office of the District Court of the United States for the 
Southern District of New York. 
Entered, according to Act of Congress, in the year 1880, by 
D. APPLETON & CO., 
In the Office of the Librarian of Congress at Washington. TABLE OF CONTENTS OF VOL. II. 
DISEASES OF THE URINARY ORGANS. 
DISEASES OF THE KIDNEYS. 
PAGE 
Chap. I.—Ilyperaemia of the Kidney 1 
II.—Haemorrhage from the Kidney 7 
III. —Acute Bright’s Disease 10 
IV. —Chronic Diffuse Nephritis—Chronic Bright’s Disease ... 14 
Y.—Nephritis Vera—Interstitial Nephritis—Renal Abscess—Metastatic 
Deposits in the Kidney ......... 36 
YI.—Perinephritis........... 40 
VII.—Amyloid Degeneration of the Kidney 41 
VIII.—Granular Degeneration of the Renal Epithelium .... 43 
IX.—Carcinoma of the Kidney ......... 46 
X.—Tuberculosis of the Kidney 46 
XI.—Parasites in the Kidney 47 
XII.—Deformities of the Kidney—Irregularities of its Shape and Position 48 
XIII.—Addison’s Disease—Bronzed Skin 49 
SECTION I. 
DISEASES OF THE PEL VIS OF THE KIDNEYS AND URETERS. 
Chap. I.—Dilatation of the Pelvis of the Kidney, with Atrophy of the Renal 
Substance—Hydronephrosis 54 
II.—Inflammation of the Pelvis of the Kidney—Pyelitis ... 66 
III. —Stony Concretions in the Pelvis of the Kidney 59 
IV. —Carcinoma and Tuberculosis of the Pelvis of the Kidneys and of the 
Ureters 64 
SECTION II. 
SECTION III. 
DISEASES OF THE BLADDER. 
Chap. I.—Catarrh of the Bladder—Cystitis Catarrhalis 66 
II.—Croupous and Diphtheritic Cystitis *72 
III.—Pericystitis *72 IV 
TABLE OF CONTENTS OF VOL. II. 
PAGE 
Chap. IV.—Tuberculosis and Carcinoma of the Bladder . . . . 73 
V.—Hemorrhage from the Bladder—Hematuria Vesicalis ... 74 
VI.—Stony Concretions in the Bladder 75 
Neuroses of the Bladder 79 
VII.—Hyperesthesia of the Bladder ....... 80 
VIII.—Anesthesia of the Bladder . . . . . . . .80 
IX.—Hypercinesis of the Bladder—Spasm of the Bladder—Cystospas- 
mus . . . .' 82 
X.—Acinesis of the Bladder—Vesical Palsy—Cystoplegia ... 84 
Additions to the Revised Edition of 1880 87 
SECTION IV. 
DISEASES OF TIIE URETHRA. 
Chap. I.—Virulent Catarrh of the Male Urethra—Clap—Gonorrhoea ... 88 
II.—Non-virulent Catarrh of the Urethra 98 
DISEASES OF THE SEXUAL ORGANS. 
A.—DISEASES OF THE MALE SEXUAL ORGANS. 
Chap. I.—Nocturnal and Diurnal Pollutions—Spermatorrhoea .... 100 
II.—Impotence and Irritability, with Weakness of the Male Sexual Organs 104 
B.—DISEASES OF THE FEMALE SEXUAL ORGANS. 
SECTION I. 
DISEASES OF THE OVARIES. 
Chap. I.—Inflammation of the Ovary—Oophoritis (Ovaritis) .... 109 
II.—Ovarian Cysts Ill 
III.—Complicated Neoplasia and Solid Tumors in the Ovary . . . 120 
SECTION II. 
DISEASES OF THE UTERUS. 
Chap. I.—Catarrh of the Uterus and Catarrhal Ulcers of the Cervix Uteri. . 122 
II.—Parenchymatous Metritis—Acute and Chronic Infarction of the Uterus 131 
III. —Perimetritis and Parametritis . 135 
IV. —Contractions and Closures of the Uterus—Ilsemometra, Ilydrometra . 137 
V.—Curvatures of the Uterus—Flexions and Infarctions . . . 140 
VI.—Changes of Position of the Uterus 144 
VII.—Fibroid Tumors of the Uterus—Fibromyomata, Fibroids, Dermoids 147 
VIII.—Cancer of the Womb. . . . . . . . . .154 
IX.—Anomalies of Menstruation 158 
X.—Retrouterine Hematocele—Ilaunatoma Retrouterinum—Pelvic Hema- 
tocele 165 TABLE OF CONTENTS OF VOL. II. 
V 
SECTION III. 
DISEASES OF THE VAGINA. 
PAGE 
Chap. I.—Virulent Catarrh of the Vagina 170 
II.—Non-virulent Catarrh of the Vagina 171 
III.—Croupous and Diphtheritic Inflammation of the Vagina . . . 173 
DISEASES OF THE NERVOUS SYSTEM. 
SECTION I. 
DISEASES OF THE BRAIN. 
Chap. I.—Hyperaemia of the Brain and its Membranes . . . . .175 
II.—Partial Hyperaemia and Partial (Edema of the Brain . . . 198 
III. —Anaemia of the Brain and its Membranes 195 
IV. —Partial Anaemia and Partial Necrosis of the Brain—Thrombosis and 
Embolism of the Cerebral Arteries—Softening .... 201 
V.—Cerebral Haemori’hage—Apoplectic Stroke—Apoplexia Sanguinea . 215 
VI.—Haemorrhages of the Cerebral Membranes—Apoplexia Meningea— 
Haematoma of the Dura Mater 230 
Inflammations of the Brain and its Membranes .... 233 
VII.—Inflammation of the Dura Mater—Inflammation and Thrombosis of 
the Cerebral Sinus 233 
VIII.—Inflammation of the Pia Mater, with Puro-fibrinous Exudation—Menin- 
gitis of the Convexity—Meningitis Simplex .... 236 
IX.—Basilar Meningitis, Tuberculous Inflammation, and simple Miliary Tu- 
berculosis of the Pia Mater—Acute Hydrocephalus . ’ . . 240 
X.—Epidemic Cerebro-spinal Meningitis 247 
XI.—Inflammation of the Brain—Encephalitis 254 
XII.—Partial Sclerosis of the Brain 260 
XIII. —Tumors of the Brain and its Membranes 262 
XIV. —Serous Effusions in the Mature Skull—Hydrocephalus Acquisitus . 275 
XV.—Serous Effusions in the Incomplete Skull—Hydrocephalus Congenitus 278 
XVI.—Hypertrophy of the Brain 280 
XVII.—Atrophy of the Brain 282 
XVIII.—Aphasia—Asymbolia 285 
Additions to the Revised Edition of 1880 287 
SECTION II. 
DISEASES OF THE SPINAL MARROW AND ITS MEMBRANES. 
Chap. I.—Hyperasmia of the Spinal Marrow and its Membranes . . . 289 
II.—Haemorrhage of the Spinal Marrow and its Membranes—Spinal Apo- 
plexy 290 
III. —Inflammation of the Membranes of the Spinal Marrow—Meningitis 
Spinalis............ 292 
IV. —Inflammation of the Spinal Marrow—Myelitis .... 295 VI 
TABLE OF CONTENTS OF VOL. II. 
PAGE 
Chap. V.—Growths and Parasites of the Spinal Medulla and its Membranes . 299 
VI.—Hydrorhachis Congenita—Spina Bifida 300 
VII.—Consumption of the Spinal Cord—Tabes Dorsualis—Ataxie Loco- 
motrice Progressive {Duchenne)—Gray Degeneration of the Pos- 
terior Columns of the Spinal Cord (Leyden)—Locomotor Ataxy . 302 
Additions to the Revised Edition of 1880 310 
DISEASES OF THE PERIPHERAL NER VES. 
Chap. I.—Inflammation of the Nerves—Neuritis 313 
II.—Neuroma 315 
III.—Neuralgia 317 
IY.—Neuralgia of the Trigeminus—Prosopalgia—Tic Douloureux—Foth- 
ergill’s Faceache 327 
V. —Hemicrania—Migraine 331 
VI. —Cervico-occipital Neuralgia ....... 333 
VII. —Cervico-brachial Neuralgia 334 
VIII. —Intercostal Neuralgia 336 
IX.—Mastodynia—Irritable Breast (Cooper) 337 
X.—Lumbo-abdominal Neuralgia ....... 338 
XI.—Neuralgia Ischiadica—Iscliias—Ischias Nervosa Postica Cotunnii— 
Sciatica—Hip-Gout . 338 
XII.—Crural Neuralgia—Ischias Antica Cotunnii .... 342 
XIII. —Anaesthesia of the Cutaneous Nerves 342 
XIV. —Anaesthesia of the Trigeminus 348 
Spasm involving particular Peripheral Nerves . . .349 
XV.—Spasm of the Facial Nerve—Mimic Spasm of the Face—Tic Con- 
vulsif 351 
XVI.—Spasm in the region of the Spinal Accessory Nerve of Willis . . 353 
XVII.—Scriveners’ Spasm—Mogigraphia 355 
XVIII.—Idiopathic Cramp of the Muscles of the Extremities—Arthrogryposis 357 
XIX.—Peripheral Palsy 359 
XX.—Palsy of the Facial Nerve—Mimic Facial Palsy—Bell’s Palsy . 366 
XXI.—Palsy of the Serratus Muscle e 370 
XXII.—Progressive Palsy of the Cerebral Nerves, Tongue, Velum Palati, 
and Lips ........... 372 
XXIII.—Essential Palsy of Children—Spinal Infantile Palsy {Heine) . 373 
Additions to the Revised Edition of 1880 ..... 377 
SECTION III. 
SECTION iv. 
GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN. 
Chap. I.—Chorea—Chorea St. Viti—St. Yitus’s Dance 378 
II.—Lockjaw—Trismus—Tetanus . . . . ... . 384 
III. —Epilepsy—Falling Sickness 390 
IV. —Eclampsia Infantum ......... 405 
Y.—Hysteria ........... 409 
VI.—Catalepsy 424 TABLE OF CONTENTS OF VOL. II. 
VII 
PAGE 
Chap. VII.—Hypochondriasis 426 
VIII.—Paralysis Agitans—Shaking Palsy 431 
IX.—Delirium Tremens—Mania a Potu 432 
X.—Morphine Habit—Opium-Eating 435 
Additions to the Revised Edition of 1880 437 
DISEASES OF THE SKIN. 
I. —Hypertrophy of the Skin 440 
Chap. I.—Diffuse Hypertrophy of the Papillary Layer and of the Epidermis— 
Ichthyosis 444 
II.—Diffuse Hypertrophy of the Skin and Subcutaneous Connective Tis- 
sue—Pachydermia—Elephantiasis Arabum .... 446 
II. —Atrophy of the Skin 447 
III.—Hyperemia and Anemia of the Skin .... 460 
IY.—Inflammation of the Skin 462 
HI.—The Slighter Form of Acute Inflammation of the Skin without Vesi- 
cation—Erythematous Dermatitis—Erythema . . . 463 
IY.—Erysipelatous Dermatitis—Erysipelas ...... 456 
V.—Herpes—Acute Superficial Dermatitis, attended by Formation of 
Groups of Vesicles upon the Skin 462 
YI.—Urticaria—Nettle-Rash—Acute Superficial Dermatitis, with Forma- 
tion of Weals .......... 464 
VII.—Eczema—Diffuse Superficial Dermatitis, with Serous Exudation upon 
the Free Surface, and without Typical Course . . . . 466 
VIII.—Impetigo—Diffuse Superficial Dermatitis, with Formation of Small 
Pustules 479 
IX.—Ecthyma—Dermatitis, with Formation of Large, Isolated, Permanent 
Pustules .... - 481 
X. —Pemphigus—Pompholyx—Superficial Dermatitis, with Formation of 
Large Isolated Blebs 482 
XI. —Itupia—Dermatitis, with Formation of Isolated Flat Vesicles, from 
which Scabs of a peculiar Shape are formed .... 484 
XII.—Psoriasis—Chronic Dermatitis, with Infiltration of the Corium, and 
Abnormal Growth of Epidermis 485 
XIII. —Lichen—Dermatitis forming Groups of Persistent Conical Nodules 489 
XIV. —Prurigo—Dermatitis with Small, Scattered, Itching Nodules . 490 
XV.—Acne, Acne Vulgaris, Acne Disseminata—Inflammation and Suppura- 
tion of Obstructed Sebaceous Follicles 493 
XVI.—Mentagra—Sycosis—Inflammation and Suppuration of the Sebaceous 
Glands and Hair-Follicles of the Beard 495 
XVII.—Acne Rosacea—Gutta Rosacea—Chronic Inflammation of the Seba- 
ceous Glands of the Face, with Dilatation of the Blood-vessels and 
Growth of the Connective Tissue about them .... 497 
V.—Hemorrhages of the Skin—Purpura . . . 498 
VI.—Growths in the Skin 500 
XVIII.—Lupus—Lupus Exedens 600 VIII 
TABLE OF CONTENTS OF VOL. II. 
PAGC 
VII.—Parasites in the Skin 505 
Chap. XIX.—Favus—Porrigo Favosa, Lupinosa 505 
XX.—Herpes Tondcns 608 
XXI. —Pityriasis Versicolor . . . . . . . 510 
XXII. —Scabies—Itch 510 
VIII.—Derangements of Secretion in the Skin . . . 515 
APPENDIX TO DISEASES OF THE SKIN. 
Scleroderma 521 
Leprosy—Elephantiasis Grsecorum 522 
Additions to the Revised Edition of 1880 . . . . . 523 
DISEASES OF TIIE ORGANS OF LOCOMOTION. 
Rheumatism 526 
Chap. I.—Acute Articular Rheumatism—Rheumatismus Artieuloruin Acuta— 
Rheumarthritis Acuta—Flying Gout 527 
II.—Chronic Articular Rheumatism—Rheumatismus Articulorum Chronicus 
—Rheumarthritis Chronica . 535 
III. —Deforming Articular Inflammation—Arthritis Deformans, Arthritis 
Nodosa, Arthritis Pauperum—Arthrite Chronique Seche . . 540 
IV. —Muscular Rheumatism—Rheumatismus Muscularis . . . 542 
V. —Gout—Podagra—Arthritis . 545 
VI. —Rachitis—Rickets 557 
VII.—Osteomalacia 565 
VIII.—Progressive Muscular Atrophy—Atrophie Musculaire Graisseuse Pro- 
gressive—Paralysie Musculaire Progressive Atrophique . . 567 
IX.—Progressive Muscular Paralysis as a Result of Hypertrophy of the In- 
terstitial Fatty Tissue 570 
Additions to the Revised Edition of 1880 571 
CONSTITUTIONAL DISEASES. 
ACUTE INFECTIOUS DISEASES. 
Chap. I.—Measles—Morbilli—Rubeola—Rougeole . . . . . .673 
II.—Scarlet Fever—Scarlatina 685 
III. —Rose-Rash—Roseola Febrilis 595 
IV. —Small-Pox—Variola—Petite Verole . . . . • • 596 
V.—Cow-Pock—Vaccina .......... 608 
VI.—Wind-Pox, Water-Pox, Sheep-Pox, Varicella, Chicken Pox . . 612 
VII.—Typhus Fever—Exanthematic Typhus—Petechial Typhus—Spotted 
Fever ............ 614 
VIII.—Abdominal Typhus—Ueotvphus (Typhoid Fever) .... 623 
IX.—Febris Recurrens—Relapsing Fever 654 
SECTION I. TABLE OF CONTENTS OF VOL. II. 
IX 
PAGE 
Chap. X.—Epidemic Diphtheritis—Malignant Pharyngitis—Angina Maligna— 
Diphtheria 664 
Malarial Fevers 669 
XI. —Intermittent Fever 669 
XII. —Remittent and Continued Malarial Fever ..... 687 
XIII. —Yellow Fever 690 
XIV. —Sudor Anglicus — Suette Miliaire—Sweating-Sickness — Friesel 
Fieber 694 
XV.—Cholera Asiatica . . . . . . . 699 
XVI.—Bloody Flux—Dysentery ........ 722 
XVII.—Trichina Disease—Trichinosis ....... 731 
Additions to the Revised Edition of 1880 738 
SECTION II. 
CHRONIC INFECTIOUS DISEASES. 
Chap. I.—Syphilis ............ 742 
Appendix.—The Glandular Chancre—The Virulent Acute Bubo 750 
II.—Congenital and Hereditary Syphilis 784 
Appendix.—Infectious Diseases transmissible from Brutes to Hu- 
man Beings 788 
Chap. I.—Human Glanders 788 
II.—Hydrophobia—Lyssa—Rabies 793 
GENERAL DISORDERS OF NUTRITION WHICH DO NOT DEPEND UPON 
INFECTION. 
Chap. I.—Chlorosis 802 
II.—Scorbutus—Scurvy 810 
III. —Purpura Hmmorrhagica—The “Morbus Maculosus” of Werlhof . 815 
IV. —Progressive Pernicious Anaemia 817 
V. —Haemophilia (Haemorrhagic Diathesis) 819 
VI. —Scrofula 820 
VII.—Diabetes Mellitus—Mellituria 832 
VIII.—Diabetes Insipidus. 843 
Additions to the Revised Edition of 1880 847 
SECTION III. DISEASES OF THE URINARY ORGANS. 
SECTION J. 
DISEASES OF THE KIDNEY. 
CHAPTER I. 
HYPEREMIA OF THE KIDNEY. 
Hyperemia of the kidney and its consequences are not to be con- 
founded with inflammation of the kidney, although during life it is some- 
times quite impossible to distinguish between the two, and notwith- 
standing that similar symptoms appear in both disorders, such as the 
presence of blood and albumen in the urine, as well as the appearance 
in it of peculiar objects, generally called fibrinous casts (although it is 
probable that they are not composed of fibrin, and certainly are not 
pure fibrin, but consist in great part of mucin). 
Etiology.—A thorough knowledge of the normal circulation of 
the kidney is indispensable to a proper understanding, not only of the 
physiology, pathogeny, and etiology, but also of the symptoms of hy- 
pereemia of this organ. To Virchow the credit is due of having cor- 
rected some of our former ideas upon this subject, and of having ren- 
dered others more complete. 
According to the result of his researches, the branches oi one par- 
ticular portion of the renal artery (that, namely, which belongs to the 
middle and outer part of the cortical substance) go exclusively to 
form the afferent vessels, and, entering the Malpighian capsules as 
such, these divide to form the vessels of the glomeruli. Then, leaving 
the Malpighian capsule as efferent vessels, they again break up into 
branches, once more to reunite as renal veins. On the boundary be- 
tween the cortical and pyramidal substances there is a sort of “ neutral 
ground.” Here there are arteries from which branches arise, some 
forming afferent vessels, glomeruli, and efferent vessels, with long off- 2 
DISEASES OF THE KIDNEY. 
shoots running into the cortical and medullary substance, and others 
which act directly as nutrient vessels for the medullary substance. 
Finally, the renal artery has branches upon which there are no glome- 
ruli at all, and whose function is simply nutrition of the medullary 
substance. 
The resistance encountered by the blood which passes through the 
glomeruli is far greater than that met by the blood which merely flows 
directly from the arteries into the capillaries. Even under normal 
conditions the blood-pressure in the renal arteries is a very consider- 
able one, that vessel being both short and of disproportionately large 
calibre. When the pressure within these arteries is increased, hyper- 
aemia of course will first arise in that portion of the kidney where the 
blood encounters the greatest resistance, namely, in the cortical sub- 
stance, and, above all, in the glomeruli. Where the resistance is less, 
as in the medullary substance, although the circulation is accelerated 
there, the actual amount of blood which the part contains is not ma- 
terially increased. It is very different, however, when the escape of 
the blood from the renal veins is impeded. In such a case the quan- 
tity of blood in the veins and capillaries is augmented, but the en- 
gorgement cannot extend through the narrow efferent vessels into the 
glomeruli; and, as the contents of the arteries are abnormally reduced 
in most of the disorders in which there is an obstruction of the renal 
veins (as in cardiac and pulmonary diseases), the reason at once be- 
comes apparent why, even in cases of extreme obstructive hyperasmia 
of the kidney, the glomeruli are scantily supplied with blood, and the 
secretion of urine is proportionately small. Perhaps, too, nervous in- 
fluence may not be without effect in bringing about this condition, 
since it is possible that in the kidneys, just as in other organs, the ar- 
teries of the various vascular systems are not subject to the same land 
of innervation. 
The causes which induce fluxion to the kidney are: 
1. The transient plethora induced by every copious draught of 
liquid. This hypersemia is most pronounced in the secretory portion 
of the kidney, and the profuse transudation which takes place out of 
the overloaded glomeruli is the principal step in the process by which 
the general plethora of the system is relieved. 
2. There is a second cause of renal hyperaemia, which is closely 
analogous to the first, and which occurs when the left side of the heart 
is hypertrophied, and which also is confined to the arterial system, in- 
cluding the glomeruli. 
3. Collateral fluxion to the kidney may result from compression of 
the abdominal aorta, or iliac arteries, by a tumor or gravid uterus, as 
well as from derangement of the circulation in the capillaries of the HYPERAEMIA OF THE KIDNEY. 
3 
skin in the cold stage of intermittent fever. In the second stage of 
Bright’s disease, compression of the vessels of the cortical substance, 
by the distended urinary tubules, also gives rise to collateral fluxion in 
the medullary substance of the kidney ( Virchoic). 
4. Dilatation of the afferent vessels, from palsy of their muscular 
elements, seems to be the principal cause of that arterial hyperaemia 
of the kidney, the existence of which is revealed by the discharge of 
a large quantity of limpid urine in certain spasmodic diseases (urina 
spastica). 
5. Fluxionary hyperaemia is found in the vicinity of inflamed regions 
and deposits of morbid product. This form of hyperaemia we have 
already endeavored to account for, in treating of an analogous condi- 
tion in other organs, ascribing it to a loss of tone in the tissues, and 
to a dilatation of their capillaries, whose walls are ill supported by the 
surrounding relaxed parts. 
6. Renal hyperaemia complicates inflammatory disease of the urinary 
passages, especially disease of the pelvis of the kidney. 
7. The renal hyperaemia which sometimes attends the use of can- 
tharides, balsam of copaiba, and similar drugs, as well as that which 
accompanies certain infectious diseases, especially scarlatina, measles, 
typhus, and cholera, seems to be of similar origin. However, the affec- 
tions of the kidney which arise from the diseases above named cannot 
all be attributed to hyperaemia. Many of them belong to the class of 
maladies which we shall describe as parenchymatous degeneration of 
the kidney, in Chapter VII., and which, undoubtedly, are capable of de- 
veloping without the occurrence of hyperaemia. This io equally true 
of the renal affections which so often accompany pregnancy. 
Obstructive engorgement of the kidney arises from causes similar 
to those which induce engorgement of the liver (see Volume I.), so 
that the two diseases often accompany one another; but it will readily 
be understood, from what has already been said as to the peculiar 
character of the hepatic circulation, that engorgement of the liver 
usually is of earlier occurrence and greater intensity than engorgement 
in the kidneys. Engorgement of the kidney arises: 1. In uncompen- 
sated valvular disease of the heart; 2. In structural disease of the 
heart, which depresses the functional energy of the organ; 3. When 
the vigor of the heart is impaired by a condition of marasmus; 4. In 
disease of the lungs, which causes compression or wasting of the pul* 
monary capillaries; 5. In conditions in which the aspiration of the 
blood to the thorax is arrested; 6. In rare instances, contraction and 
closure of the vena cava or emulgent veins, by compression or throm- 
bosis, give rise to engorgement of the kidney, but the hyperaemia 
arising in such cases is of very great intensity. 4 
DISEASES OF THE KIDNEY. 
Anatomical Appearances.—A kidney in a state of recent hy- 
pergemia is of a more or less dark-red color. Sometimes it is enlarged, 
owing either to dilatation of its vessels or to serous infiltration. The 
oedema of its parenchyma and subcapsular connective tissue renders the 
hypergemic organ unnaturally moist and soft, and loosens its capsule. 
When cut into, and when the vessels of the glomeruli are much dis- 
tended by blood, the Malpighian coils dot the surface of the section, 
as dark-red points. 
When the hypergemia is of long standing, particularly when there 
is habitual engorgement, as occurs in chronic disease of the heart and 
lung, the changes which arise are of a different kind. The kidney is then 
but little enlarged, or remains of its normal magnitude, or may even 
be somewhat smaller than natural. It is more resistent in texture, 
and is of a uniform red color. Upon microscopic examination, the 
epithelium of the urinary tubules of the cortical substance is found to 
be swollen, the contour of the cells is ill-defined, and they are filled 
with finely-granular contents, which clear up upon the addition of 
acetic acid. Sometimes there is a desquamation of the degenerated 
epithelium here and there; and the tubules collapse after the epithe- 
lium is expelled, causing the surface of the kidney to become uneven 
by depressions of varying depth. Traube and Beckman have called 
particular attention to the difference between this condition and the 
degenerative chronic inflammation of the kidney, which we shall de- 
scribe in Chapter IV. as chronic Bright’s disease. 
While the alterations above described are going on in the epithe- 
lium of the cortical substance, the straight tubules of the medullary 
substance are usually found filled with a material which is sometimes 
transparent and pale, and sometimes of a more yellow color. By mod- 
erate pressure upon the pyramids, a large quantity of an opaque creamy 
liquid is discharged from the papillge, which contains a great deal of 
epithelium and a few of those casts of the tubuli, in the form of homo- 
geneous transparent tolerably firm cylinders. 
Symptoms and Course.—The kidney has so few nerves of sensa- 
tion, and its capsule is so distensible, that hypergemic swelling of the 
organ is never accompanied by pain. As the amount of urine secreted 
depends chiefly upon the degree of pressure within the vessels of the 
glomeruli, its secretion necessarily becomes more profuse in that form 
of renal hypergemia which involves the arterial system of the kidney, 
including the vessels of the Malpighian tufts. This is almost the only 
symptom caused by fluxion to the kidney, which arises from copious 
drinking, hypertrophy of the left heart, compression of the aorta o: 
inac arteries, and dilatation of the renal arteries. The urine is copi- 
ous in quantity, dilute in quality, of low specific gravity, and of a pale HYPERAEMIA OF THE KIDNEY. 
5 
x»lor. In such cases, the pressure in the glomeruli hardly ever is suf- 
ficient to occasion transudation of albumen, or to rupture the vessels, 
and cause extravasation of blood into the Malpighian capsules. This 
fact is in accordance with the results of physiological experimenta- 
tion. Ligation of the abdominal aorta below the origin of the renal 
arteries, in spite of the increase of pressure which ensues in those arte- 
ries, never results in albuminuria. 
A very different train of symptoms follows upon a moderate de 
gree of obstructive engorgement of the kidney. Since, as we have 
just shown, in almost every case of obstruction of the renal veins the 
degree of tension within its arteries is very small, there is a diminution 
instead of an increase of the secretion of urine. On the other hand, 
the strain upon the capillaries becomes exceedingly severe, since they 
cannot discharge their contents into the already overloaded veins until 
the pressure within them exceeds that within the veins. Hence, not 
only does the plasma of the blood readily escape from the capillaries 
into the urinary tubules, so that the scanty, concentrated, dark-colored 
urine contains albumen, and the so-called fibrinous casts (or, more 
properly speaking, exudation casts), but the delicate walls of the capil- 
laries give way before the strain, so that the urine is also full of blood- 
corpuscles. According to the recent observations of Liebermeister, the 
simultaneous appearance of blood and albumen is so usual in obstruc- 
tive hyperaemia of the kidney, that the appearance of albumen alone, 
without a trace of blood, almost excludes the idea of simple engorge- 
ment from the diagnosis, and indicates the existence of inflammation. 
This fact in pathology, which may be verified in almost every case of 
chronic disease of the heart, and traced through all its phases, agrees 
with the results of physiological experiment. Albuminuria and hsema- 
turia are the never-failing consequence of ligation of the renal veins, 
or of the vena cava above their point of entrance. The escape of 
plasma from the capillaries of the kidneys, in obstructive congestion, 
into the uriniferous tubules is analogous to the extravasation from the 
pulmonary capillaries into the air-vesicles, which occurs in engorgement 
of the lungs, and which is there called hypostasis. The so-called 
hypostatic pneumonia is quite as independent of genuine inflammatory 
action as is the disorder of the kidney at present under consider- 
ation. 
The form of renal hyperaemia which apparently proceeds from re- 
laxation of the tissues of the kidney and consequent dilatation of its 
capillaries, has no effect either in augmenting or diminishing the quan- 
tity of urine secreted. It is attended, however, by a more or less pro- 
fuse transudation of blood-plasma, as well as by a greater degree of 
shedding, and probably too by a more active reproduction of the cel- 6 
DISEASES OF THE KIDNEY. 
lular contents of the uriniferous tubules. Hence, when, after the abuse 
of irritating diuretics, or in disease which we know to be frequently 
complicated with this form of renal hyperemia, we find the urine to 
be albuminous and full of casts thickly studded with epithelial cells, 
our diagnosis may be renal catarrh. This name, which has been applied 
to the form of hyperaamia in question by most modern pathologists, is 
not quite appropriate, it is true, as the tubules have no mucous mem- 
brane, and as the term catarrh itself means an affection peculiar to such 
a membrane. However, it is quite as appropriate as is the term catar- 
rhal pneumonia. (See Vol. I.) 
The course of both fluxionary and obstructive hypersemia of the 
kidney, when the exciting cause is of a transient character, usually is 
favorable, and the disease in itself probably never causes death. Al- 
though, during the last few weeks of a case of heart-disease, this affec- 
tion appears in its most intense form, yet it is not renal hyperasmia of 
which the patient finally dies, but the respiratory derangement, the 
dropsy, and other symptoms which proceed immediately from the 
cardiac disorder. However, it cannot be denied that the albuminuria 
aggravates the dropsy and hydrmmia, and aids in undermining the 
strength of the patient. The renal catarrh also runs a favorable course 
as a rule, and, when the primary disease tends toward recovery, usually 
terminates in complete restoration to health. Far more rarely, diffuse 
parenchymatous inflammation of the kidney may develop from renal 
catarrh. 
Treatment.—The measures called for in treatment of the cause 
of hypersemia of the kidney may be inferred from the account above 
given of the causes themselves. When the hypersemia of the kidney 
is but a symptom of a more wide-spread and grave disease, it is to the 
latter rather than to the hyperaemia to which the treatment should be 
directed Where it has arisen from the abuse of irritating diuretics, 
their employment must be discontinued, and all application of vesi- 
cants, and use of irritating salves upon suppurating surfaces (a very 
common cause of fluxion to the kidney), must be abstained from.. Be- 
sides this, large quantities of drink must be administered, in order as 
much as possible to dilute the acrid matter which has been secreted in 
the kidneys. Pure water or the dilute acids are the most suitable for 
the purpose. The old practice of using barley-water, linseed-tea, milk 
of almonds, and the like mucilaginous or oleaginous liquids, must be 
regarded as obsolete, as it is well known that such articles have no 
effect upon the character of the urine. 
General and local blood-letting, and derivatives to the skin or intes- 
tines, are only to be resorted to in fulfilling the indications from the 
disease itself, when such remedies are indicated for other reasons, oi HAEMORRHAGE FROM THE KIDNEY 
7 
ivhen the hyperaemia is extreme, and there are no counter-indications 
against blood-letting. 
CHAPTEE II. 
HAEMORRHAGE FROM THE KIDNEY. 
Etiology.—The causes of haemorrhage from the kidney are: 1. 
Wounds, contusions, and other injuries of the organ. The presence of 
calculi in the pelvis of the kidney is one of the most common sources 
of such injury. Hayer tells about a patient with renal calculus who 
had haematuria whenever he was compelled to ride. 2. Haemorrhage 
from the kidney may proceed from intense hyperaemia, and rupture of 
the overloaded renal capillaries, and especially from that form of 
hyperaemia which accompanies the first stage of inflammation of the 
kidney, and which ensues after the employment of irritating diuretics, 
as well as in that form of the affection which follows scarlatina, small- 
pox, typhus, malarial fevers, and other infectious diseases. The hyper- 
aemia which exists about the seat of a parasite, or a neoplastic growth, 
especially cancer, often gives rise to haematuria. Finally, the exces- 
sive obstructive engorgement of the kidney, produced by disease of 
the heart and lungs, often results in an escape of blood from the ienal 
capillaries. 3. In rare instances renal haemorrhage depends upon a 
hcemorrhagic diathesis, that unknown disorder of the olood-vessels 
from which scorbutus and purpura haemorrhagica proceed. 4. In the 
Isle of France, Brazil, and some other tropical regions, haemorrhage 
from the kidney is endemic, there being no known cause for the disease. 
A peculiar form of renal haemorrhage, haemorrhagic infarction, arises 
under conditions similar to those in which haemorrhagic infarction takes 
place in the spleen. This can be traced in most cases to embolism. 
Genuine renal apoplexy is usually the result of severe injury, but 
in children may also proceed from severe hyperaemia (Rokitans/cy). 
Anatomical Appearances.—In haemorrhage from the kidney, the 
blood may be effused into the normal interstices of the tissues without 
detriment to the latter. In this way ecchymoses arise, in which there 
are spots of varying size stained of a deep red, and from which blood 
flows freely when they are cut into. They are situated sometimes 
under the albuginea, or within the tissues of the kidneys themselves. 
In variola and diseases of that class, besides ecchymoses in the 
renal tissue, the mucous membrane lining the pelvis of the kidney is 
usually of an even, dark-red color, decidedly thickened (haemorrhagic, 
infiltration), and rough on the surface. 
When recent, haemorrhagic infarction has the appearance of a dark- 
red deposit of a cuneiform shape, the point of the wedge being directed 
toward the hilus of the kidney. When of longer standing, the deposit’ 8 
DISEASES OF THE KIDNEY. 
loses its color, beginning at the middle, and becomes converted into a 
yellow, caseous mass, or else breaks down, forming a renal abscess, 
with yellow puruloid contents, which at first consist of detritus alone, 
but afterward are mixed with pus. Finally, these caseous or purulent 
masses also are reabsorbed, and at the site of the former infarction 
there is left a cicatricial contraction. 
The seat of renal apoplexy is generally the medullary portion of 
the kidney. Collections, of varying size, form in the lacerated paren- 
chyma, their contents consisting partly of clotted blood, and in part 
of crushed and broken-down debris of the tubules. It would seem 
that the contents, both of apoplectic extravasations and of haemor- 
rhagic infarctions, may undergo fatty degeneration and absorption, and 
that recovery may take place, leaving a depressed cicatrix. Part of 
the blood effused into the tubules coagulates, forming cylinders, which 
are densely studded with blood-corpuscles. Sometimes we find pig- 
ment in the tubules and Malpighian capsules, as the residue of some 
former extravasation of blood. 
Symptoms and Course.—The occurrence of renal haemorrhage 
does not become recognizable unless the blood be effused into the 
tubules, and discharged with the urine. Hence it not unfrequently 
happens, in post-mortem examinations, that haemorrhagic infarctions 
and apoplectic extravasations are discovered, which were quite undis- 
coverable during life, because the blood did not enter the uriniferous 
tubules. If the amount of blood mingled with the urine be very small, 
the color of the latter is a peculiar dirty red when viewed by reflected 
light, while by transmitted light it is a pure red of greater or less 
depth. After standing for some time, a somewhat characteristic, 
slightly flocculent, brownish sediment is precipitated. When urine 
containing blood is exposed to the action of heat and nitric acid, the 
albumen of the serum of the blood coagulates. If the sediment be 
examined microscopically, blood-corpuscles are found, some of which 
are well preserved, while others are somewhat altered. There are also 
the casts above described, studded with blood-corpuscles, which are 
peculiarly characteristic of renal haemorrhage. I strongly recommend 
Seller's test for blood as very simple and convenient, and by means 
of which the faintest trace of blood may be discovered. Heat the 
urine, then add caustic potash and heat anew. The phosphates are 
thus precipitated, taking with them the coloring matter of the blood, 
which imparts a dirty yellowish-red color to the sediment viewed by 
reflected light, and, when seen by transmitted light, gives a splen- 
did blood-red color. Neither the coloring matter of the blood nor 
that of the bile is precipitated with the phosphates, so that color- 
ation of urine which shows this reaction cannot be ascribed to the 
presence of the latter pigments. When the quantity of blood in the HAEMORRHAGE FROM THE KIDNEY. 
9 
urine is very large, it is of a dark or brownish red, and, after standing, 
forms a cake of blood at the bottom of the vessel. Not unfrequently, 
a partial coagulation of the blood takes place in the bladder, and the 
coagula thus formed can only be got rid of after great suffering on the 
part of the patient. Sometimes the blood coagulates while in the 
ureters. In such instances, the symptoms of renal colic, hereafter to be 
described, may arise, and long, worm-like coagula (casts of the ureters) 
may be voided. 
The course of renal haemorrhage necessarily depends upon the na- 
ture of the disease which causes the haemorrhage. When induced by 
renal calculus, bleeding occurs regularly after every violent exertion. 
Haemorrhage arising from the presence of a tumor, especially cancer, 
is usually very profuse and persistent. The bleeding which accompa- 
nies inflammation of the kidney and the infectious diseases, or which 
results from venous obstruction or scorbutus, is not often very severe 
Tn the endemic hasmaturia of the tropics there are periodical profuse 
flows of blood from the kidneys. 
In haemorrhagic infarction, if there be haematuria at all, it is always 
slight. It is usually ushered in by a chill, and is attended by pain in 
the region of the kidney, and by violent sympathetic vomiting. The 
occurrence of such a train of symptoms—a chill, lumbar pain, vomiting, 
and haematuria—in a case of heart-disease, would warrant the diagnosis 
of a rrtnal infarction, which otherwise generally escapes detection. 
Renal apoplexy is marked by similar symptoms, which, however, are 
of much greater intensity. 
The results of renal haemorrhage cannot be described in detail until 
after a more thorough discussion of the diseases whereon they depend. 
The hasmaturia arising from cancer, from renal calculus, and from the 
tropical disease, acts chiefly by producing exhaustion from loss of blood. 
Treatment.—The main point in the management of a case of renal 
hasmorrhage is the treatment of ,any hyperaemia, inflammation, or other 
constitutional disease from which it proceeds. In most instances, when 
the main disease is susceptible of efficient treatment, the haemorrhage 
does not require any especial attention. Sometimes, however, the 
danger of exhaustion arising fr om repeated attacks of profuse and per- 
sistent haemorrhage, such as occur in cancer and renal calculus, may 
require relief. Cold, in the form of a bladder of ice laid over the re- 
gion of the kidney, cold sitz-baths, or cold injections, should then be 
resorted to. Internal administration of styptics has been recommended, 
and the whole list has been given seriatim in many cases, each failing 
in its turn. Articles containing tannin, especially tannic acid itself, 
which is eliminated through the kidneys in the form of gallic acid, and 
thus is enabled to act directly upon the bleeding point, deserve the 10 
DISEASES OF THE KIDNEY. 
greatest amount of confidence. Next to it, secale cornutum, or ergotine 
may be given, but the doses must be large. The only effect to be ex- 
pected from the preparations of iron is the beneficial action which 
they exert upon the deterioration of the blood. 
CHAPTER III. 
ACUTE BKIGHT’s DISEASE. 
Etiology.—The name Bright’s disease is generally applied to two 
forms of inflammation of the kidney. The first, which is the subject 
of the present chapter, is closely allied to croup of the larynx and air- 
vesicles, not only in its anatomical lesions—consisting of a coagulating 
exudation, containing epithelial cells, and often extravasated blood- 
cells, and which fills up and occludes the urinary tubules—but in its 
course, which is always acute, like that of the other croupous diseases 
above mentioned, and nearly always terminates either in recovery or 
death within a few days. It is rare for the disease to pass into the 
second form of Bright’s disease, which we shall describe in the next 
chapter, under the name of “ parenchymatous nephritis.” This latter 
circumstance, indeed, seems to me to indicate that it is both right and 
practical to regard acute and chronic Bright’s disease as independent 
and distinct affections. I attach little value to the term “ croupous 
nephritis,” applied to acute Bright’s disease, in the previous editions 
of this work, as I must acknowledge that it is a matter of doubt 
whether the exudation which fills up and obstructs the uriniferous 
tubules consists of fibrin like the exudation of croupous laryngitis and 
croupous pneumonia, and as it cannot be denied that the epithelium of 
the uriniferous tubules takes a more active part in the nutritive disor- 
ders attending acute Bright’s disease than is taken by the epithelial 
cells of the larynx and air-vesicles in croupous laryngitis and croupous 
pneumonia. 
1. Acute Bright’s disease is a frequent complication of scarlatina. 
There is a prevalent notion among the laity that a child who dies of 
dropsy, after scarlet fever, “ has not been well taken care of; ” and 
many an unhappy mother, who has lost her child from this cause, re- 
proaches herself for years for having changed its linen too soon, or im- 
prudently opened a door, and thus brought about her child’s death. It 
is possible that chilling of the skin during scarlet fever may sometimes 
favor the occurrence of croupous inflammation, and may even actually 
produce it, but it is certainly not the case in the majority of instances. 
Besides the disturbance of the skin which it occasions, scarlatinous 
virus constantly induces disorders of the fauces and kidneys. In most ACUTE BRIGHT’S DISEASE. 
11 
epidemics they are of a hypersemic nature, and give rise to the weli- 
known symptoms of catarrhal angina in the throat, and in the kidneys 
cause renal catarrh, as described in the foregoing chapter. There are 
malignant epidemics of scarlatina, however, which give rise to much 
graver disorder of these organs. Instead of simple catarrh, there is 
nearly always a diphtheritic inflammation of the fauces, and, instead 
of a simple renal hyperaemia, the urinary tubules are attacked by 
croupous inflammation. In such epidemics, many children die of 
dropsy who have received the best possible care, while many, who 
have been actually neglected, escape unscathed. The virus of measles, 
typhus fever, and the poison of malaria, may also induce croupous 
nephritis, but they are far less frequent causes of the disease than is 
scarlatina. 
2. Acute Bright’s disease arises during the typhoid stage of chol- 
era, and by many is regarded as a constant complication, if not 
the actual cause, of this very common and obscure sequel of cholera. 
Although we cannot subscribe to this latter opinion, having witnessed 
the death of many patients from cholera typhoid, whose urine was 
abundant and free from albumen, yet the frequence of croupous ne- 
phritis, as a sequel to cholera, cannot be denied. It remains an open 
question whether the vascular engorgement and inspissation of the 
blood, which take place in the algid stages of cholera, induce obstruc- 
tion of the renal capillaries from crowding together of the blood-cor- 
puscles, and extravasation of plasma and blood into the tubules, or 
whether the inflammation of the kidneys, like the other inflammatory 
affections of the typhoid stage of cholera, be ascribable to infection 
of the blood. It, undoubtedly, is very rare for croupous nephritis, in 
healthy subjects, to proceed from contusions, the misuse of irritating 
diuretics, exposure to cold, or other unknown exciting causes. 
Anatomical Appearances.—The anatomical alterations found 
post mortem after croupous nephritis are identical with those* so ad- 
mirably described by Frerichs as the first stage of Bright’s disease, 
the “stage of hypermmia and incipient exudation.” The kidney is 
often enlarged to twice its proper size, and its surface is smooth. The 
tunica albuginea is opaque, injected, and is easily detached. The 
cortical substance, to whose swelling the increase in volume of the 
kidney is mainly due, is of a more or less dark-brown color, soft, and 
easily torn. When cut into, a bloody adhesive liquid bathes the face 
of the section. Both the superficial and deeper parts of the cortical 
substance are dotted with dark-red points. The pyramids also are hy- 
peraemic and striped with red, and an opaque and often bloody liquid 
is usually found in the calices and pelvis of the kidney, which like- 
wise are injected with blood. Microscopic examination does not 12 
DISEASES OF THE KIDNEF. 
exhibit any important change in the texture of the kidney. The 
glomeruli, being overloaded with blood, are very distinct. Extravasa 
tions of blood are almost always found in the Malpighian capsules and 
tubules, which account for the blood-red points above alluded to. 
There are likewise extravasations between the albuginea and the tu- 
bules. The uriniferous tubules, especially those of the cortical sub- 
stance, are filled with coagulated exudation. Upon microscopic ex- 
amination of the liquid expressed from the cut surface of the diseased 
kidney, we find the cylindrical masses of exudation covered with epi- 
thelium and blood-corpuscles, forming casts of the tubules. The epi 
thelium is not materially altered, only moderately swollen and clouded. 
Symptoms and Course.—Sometimes croupous nephritis is ushered 
in by a rigor, followed by fever and a sharp pain in the region of the 
kidney. In addition to this, there is almost always more or less 
violent (sympathetic) vomiting; indeed, vomiting is a more constant 
token of incipient disease of the kidney than either fever or pain, and 
it is well to warn parents of children with scarlatina of the serious 
nature of this symptom, and to require them to seek medical aid 
should it arise. The patient feels a constant inclination to pass water, 
but is unable to expel more than a few drops with each effort. The 
suppression of urine may be so complete that the whole amount se- 
creted in course of a day may not exceed an ounce or two. Its spe- 
cific gravity is high. Sometimes, and for a short time, it may be of the 
color of pure blood; more usually it is opaque, and of a peculiar dirty 
reddish-brown hue, and looks as though it really contained dirt. 
Both urine and sediment have this dirty appearance, which alone, to 
the eye of an expert, is a tolerably sure sign of acute Bright’s disease. 
There is a very large quantity of albumen in the urine, and, upon the 
application of heat and nitric acid, the half or even three-quarters of 
the liquid will coagulate. Upon microscopic examination of the sedi- 
ment, we find large quantities of epithelium from the tubules and 
urinary passages, as well as many blood-corpuscles, and casts stud- 
ded with blood-corpuscles. [Exact observation has taught us that 
the vascular walls, when inflamed, become permeable to substances 
which normally would not pass through them. Hence we may pre- 
sume that it is not the effect of mere pressure upon the Malpighian 
tufts, but rather of some change in their filtering power which gives 
rise to the albuminuria in acute Bright’s disease.] Dropsical symp- 
toms set in, and in most cases the dropsy soon becomes very se- 
vere. The face, hands, legs, and scrotum swell up, and the skin 
is so tensely swollen that an impression made upon it by the finger 
is soon effaced. The dropsy of croupous nephritis, like that of pa- 
renchymatous nephritis, as we shall presently see, shows a great ACUTE BRIGHT’S DISEASE. 
13 
tendency to shift its position, the swelling increasing in one part of 
the body, while it diminishes in another. 
When the progress of the disease is favorable, the coagula which 
block up the uriniferous tubules are washed away, the urine be- 
comes freer and more abundant, and the albumen diminishes. At 
the same time there is an abatement of the dropsy, which, in this 
disease, seems rather to depend upon suppression of the secretion of 
urine than upon that lack of the albumen in the blood which takes 
place in acute hydraemia. In the most fortunate cases, the dis- 
ease may terminate in from eight to fourteen days, recovery being- 
complete and without sequelae. In very many instances the nephri- 
tis is accompanied by acute inflammation of the lung, pleura, peri- 
cardium, or peritonaeum, and it is to one of these complications that 
the patient usually succumbs in fatal cases. 
It happens much more rarely that croupous nephritis, instead of 
terminating in the above manner, gives rise to the so-called uraemic 
intoxication. It is easy to comprehend that, in consequence of the 
suppression of the urinary secretion, substances may accumulate in 
the blood which act perniciously upon the nutrition and functions 
of the various organs. It used formerly to be supposed that the 
urea, which is the most abundant of the solid constituents of the 
urine, and which is the best known of all its organic ingredients, by 
accumulating in the blood, induced convulsions, coma, and ultimate 
palsy of the entire nervous system ; and when such symptoms ac- 
companied suppression of urine, they were called uraemic symptoms, 
or uraemic poisoning. Frerichs afterward supposed that this toxic 
effect was due to the presence of carbonate of ammonia, resulting from 
decomposition of the urea, rather than to the urea itself. This the- 
ory, however, cannot by any means be regarded as proved, and we 
must acknowledge that we are unacquainted with the excrementitious 
material retained in the blood, which exerts so pernicious an in- 
fluence upon the organism in cases of suppression of urine. How- 
ever, notwithstanding the rarity of uraemic poisoning in croupous 
nephritis, yet it is of great importance, as regards both the prog- 
nosis and treatment of the disease, not rashly to ascribe any con- 
vulsions or stupor which may arise to inflammation and exudation in 
the brain. Cases occur in which the convulsions and coma subside 
as the free secretion of urine is reestablished, and the attack termi- 
nates favorably. (For further details of the so-called uraemia, and of 
the frequent dependence of cerebral symptoms upon oedema of the 
brain, see Chapter IV.) I should finally state that cases of croup- 
ous nephritis occur in which the disease improves somewhat, but 
does not subside completely ; the albuminuria continues, and the 14 
DISEASES OF THE KIDNEY. 
character of the acute croupous nephritis (acute Bright’s disease) 
runs into that of chronic diffuse nephritis (chronic Bright’s dis- 
ease). I have never seen such a case, and they must be very rare. 
Treatment.—In recent cases, and in tolerably robust subjects, 
it is advisable to resort to local depletion over the region of the kid- 
neys, by means of leeches or cups. The effect of the first applica- 
tion will decide as to the propriety of its repetition in case of recur- 
rence of the symptoms. General blood-letting should be rejected, 
as liable to aggravate the already existing tendency to deterioration 
of the blood. The use of calomel and other so-called antiphlogistics 
is equally improper. Warm baths, followed by envelopment of the 
body in woollen blankets, are much preferable to the internal ex- 
hibition of diaphoretics. In treatirg of chronic Bright’s disease, 
we shall go more into detail upon this subject, and upon the brilliant 
results which are sometimes obtained from diaphoresis. If the bow- 
els be confined, a few powerful doses of drastic medicine should be 
given—jalap, senna, or even colocynth. The profuse serous tran- 
sudation into the intestine caused by these medicines may have a 
beneficial effect upon the dropsy ; but it sometimes happens that the 
patient has a violent diarrhoea, and yet the dropsy continues to in- 
crease rapidly. Mineral waters containing carbonic acid are the most 
suitable beverage. We should not be too sparing in their adminis- 
tration, as the increase of pressure in the glomeruli, and the aug- 
mented transudation, may assist in washing away the obstructing 
coagula. On the other hand, drastic diuretics are contraindicated, 
owing to the inflamed condition of the kidney. During convales- 
cence, and in tedious cases even prior to convalescence, the ten- 
dency to deterioration of the blood must be combated by the 
administration of quinine and iron, and a plentiful supply of albu- 
minous food. 
CHAPTER IV. 
CHRONIC DIFFUSE NEPHRITIS CHRONIC BRIGHT’s DISEASE. 
[Pathology and Etiology.—The following synopsis may serve 
to give the reader an insight into the present state of knowledge 
regarding Bright’s disease. We have long made use of Frerichs’s 
classification of the anatomical stages of the disease : 1st, the stage 
of hyperaemia ; 2d, that of exudation and of commencing conversion 
of the exudation ; 3d, the stage of retrogression and atrophy. But 
it has been found that the first of these conditions properly belongs 
only to acute diffuse nephritis ; so that for chronic nephritis there CHRONIC BRIGHT’S DISEASE. 
15 
remain only the stage of inflammatory swelling and that of atrophy 
and shrinkage. But even the connection between these two stages 
has been denied by certain authors—Johnson and other English 
writers—who maintain that these conditions, instead of being phases 
of one and the same disease, are the products of totally different 
pathological processes. 
The very great diversity of opinion regarding the histology of 
Bright’s disease may be summed up as follows : For some authors 
the essential primary lesions in all forms of the malady originate in 
the renal epithelium (Johnson) ; for others, the disease begins only 
in the interstitial connective tissue (Traube). Others again believe 
that it may commence in both or either of these tissues. Hence 
they recognize an intertubular or interstitial, and an intratubular 
or parenchymatous form of the malady ; but they admit the coex- 
istence of the two forms. Johnson first pointed out a hypertrophy 
of the muscular coat of the small arteries, not only of the kidney, 
but of other organs, and showed that under such circumstances the 
epithelium cannot remain intact ; and he traces back the hyper- 
trophy of the left ventricle of the heart, so often met with in Bright’s 
disease, to the greater resistance opposed in that affection by the 
hypertrophied vessels. Latterly there has been great controversy 
upon the views of Gull and Sutton, according to whom, in the con- 
tracting form of the disease, the primary lesion is not in the kidney 
at all, but the atrophied kidney is merely one of the lesions which 
accompany a general disorder of the minute arteries and capillaries, 
and which consists in a deposit of hyaline lymph in the adventitia 
of the arteries (seldom in the intima), and in the outer coats of the 
capillary walls. It must be admitted that shrinking of the kidney 
and degeneration of the arterial walls often coexist; but further 
research has shown that such coexistence of the two lesions is by 
no means constant.] 
In Bright’s disease the epithelium of the uriniferous tubules 
exhibits the alterations which we have repeatedly described as char- 
acteristic of all parenchymatous inflammations. Its cells first in- 
crease considerably in bulk, through imbibition of an albuminous 
liquid ; their contents then undergo fatty metamorphosis, by which 
the epithelial cells gradually become converted into cells of fatty 
granules. Finally, the cell-membrane perishes, and the fat-globules 
emerge free into the urinary tubules. 
While these are the essential changes which the kidney under- 
goes, in the majority of cases coagulating exudations are also formed 
in the tubules, and in many instances proliferation of the interstitial 
connective tissue occurs. Atrophy of the kidney, which sets in 16 
DISEASES OF THE KIDNEY. 
afterward, is the natural and necessary consequence of the inflam- 
matory process above described. 
Bright’s disease is a very common affection. Predisposition to 
it is far less in childhood than in more advanced life. Men are 
attacked by it somewhat more frequently than women ; persons 
of debilitated and depressed constitution more readily than those 
who are robust. Hence the poorer part of the community are more 
afflicted by the disease than the well-to-do class, being more ex- 
posed to the evils which produce it. 
1. Chief among the predisposing causes of Bright’s disease is 
the temporary, and in a still greater degree the continual exposure 
of the skin to the effect of cold and moisture. This accounts for 
the great frequence of the disease in England, Holland, Sweden, 
and on the German coasts ; and not only upon that of the North 
Sea, as Frerichs has assumed, but also upon the eastern shore. In 
the very moderate number of beds in the Greifswald clinic, there 
used always to be many cases of Bright’s disease. 
2. It would seem that the misuse of irritating diuretics and the 
incautious exhibition of cubebs and copaiba may sometimes lead to 
Bright’s disease, although, perhaps, this does not occur very fre- 
quently. 
3. On the other hand, the abuse of ardent spirits unmistakably 
plays a most important role in the etiology of the disorder, so that 
Bright’s disease appears almost as frequently among hard drinkers 
as does cirrhosis of the liver. We have no physiological explanation 
of this circumstance ; but as recent researches have proved that 
alcohol taken into the system is not all consumed in the blood, as 
used formerly to be supposed, but that at least a portion of it, pass- 
ing through the urinary organs, is eliminated from the system unal- 
tered, it is conceivable that the alcohol may act locally upon the 
kidney, just as we have shown it to act in cirrhosis of the liver. 
4. Bright’s disease very frequently is associated with tedious 
suppuration, with caries and necrosis of the bones, the surgical 
wards of the hospitals always furnishing a rich contingent of this 
malady ; although the latter causative agents lead to amyloid 
degeneration of the kidney with equal if not greater frequence. 
The connection between these exhausting affections and Bright’s 
disease is obscure. However, just as in other cachectic conditions, 
so the appearance of inflammation in the most diverse organs is so 
common an occurrence in these depressing maladies, that it becomes 
a question whether nephritis holds a closer relationship to such con- 
ditions than is held by pleuritis, pericarditis, peritonitis, and the 
like. CHRONIC BRIGHT’S DISEASE. 
17 
5. Finally, Bright’s disease often accompanies conditions of dys- 
crasia, resulting from gout, rachitis, syphilis, scrofula, and malarial 
cachexia, in which, however, besides the inflammatory degeneration, 
the lardaceous metamorphosis hereafter to be described is often 
observable. 
I agree with Traube, that it is improbable that simple obstructive 
hyperaemia from disease of the heart and the like gives rise to in- 
flammation of the kidney ; and I believe that, hitherto, there has 
been a great deal of confusion of this malady with that described 
in the preceding chapter. Nor can I regard pregnancy as one of 
the remote causes of Bright’s disease. The albuminuria so com- 
mon among pregnant women is not generally a result of inflamma- 
tion, but is rather due to a parenchymatous degeneration of the 
kidney, to be described in Chapter VIII. 
[Malarious poison predisposes to Bright’s disease, and, according 
to Bartels, is one of the most prominent of its causes. But an 
albuminuria arising during an acute febrile disorder has never been 
observed to terminate in chronic renal disease. On the other hand, 
chronic suppuration with continued fever may be followed not only 
by amyloid degeneration, but also by chronic inflammatory swell- 
ing of the kidney. 
Those observers who regard parenchymatous and interstitial ne- 
phritis as distinct diseases naturally ascribe each of them to differ- 
ent causes. The causes of that form which develops so insidiously 
and so very gradually in the interstitial substance are extremely 
obscure ; and Bartels remarks regarding these so-called “ contracted 
kidneys,” which he looks upon as a separate disease, that in scarcely 
one of his cases could his patients even guess at any cause for their 
malady over and above the influences which always more or less be- 
set them. English writers ascribe shrunken kidney largely to gout 
and to lead-poisoning. Dickinson states that twenty-six out of 
forty-two persons with lead-poison had died of shrunken kidney. 
While this form of renal disease is more common in advanced age, 
the other occurs more often between the ages of twenty and forty. 
In childhood it is rare, if we except cases of acute diffuse nephritis 
following scarlatina. 
Pathological Anatomy.—According to the present views of 
many, the term chronic Bright’s disease must be regarded as em- 
bracing two distinct forms of nephritis, the interstitial and the pa- 
renchymatous. The former, according to Klebs, begins with intense 
hyperaemia, with exudation of a lymph-like liquid throughout the 
whole cortical substance of both kidneys, which dilates the lymph- 
spaces of the interstitial tissue, and is accompanied by a constantly 18 
DISEASES OF THE KIDNEY. 
increasing emigration of the white blood-corpuscles. Under favor- 
able conditions these cells may undergo fatty degeneration, and a 
complete resolution of the process may ensue ; otherwise they may 
convert themselves into fibrous tissue, causing permanent thicken- 
ing with or without shrinkage of the intertubular substance. 
In such a case as this, the process drags on for years ; and we 
find after death both kidneys shrunken, sometimes even to a third 
of their normal size, and the capsule thickened and opaque, and 
firmly adherent to the parenchyma. The surface of the organ is of 
a dull brownish-red, here and there of a dirty-yellow hue. The 
atrophy being complete in some parts of the kidney and less ad- 
vanced in others closely adjacent to the first, the surface becomes 
studded with small nodules, some of the size of a pin’s head, and 
some as large as a pea. Hence the term granular kidney. Such a 
kidney is very hard and tough. Upon section, the cortical substance 
is often found to be so much wasted that the secreting parenchyma 
only forms a narrow rim around the pyramids, while the latter are 
often but little reduced in size, being but sligthly affected by the 
disease. Certain whitish stripes sometimes observed correspond to 
the straight tubules which have become obliterated for want of sup- 
ply of secretion. The general diminution of the kidney, with atro- 
phy of many of its glomeruli and tubules, is always in the main as- 
cribable to the compression exerted by the contracting newly-formed 
connective tissue ; but other factors also contribute to this, such as 
wasting of the epithelium and urinary tubules. It is sometimes 
found that the process of thickening of the tissues is much more 
pronounced in the Malpighian capsules and their vicinity ; or, on 
the other hand, the greatest change may be in the tunica propria of 
the tubules and in the connective tissue between them. Accord- 
ingly, Traube distinguishes two forms of interstitial nephritis, the 
circumcapsular and the intratubular, each of which presents certain 
peculiarities from a clinical point of view. Not unfrequently, in 
the cortical substance we find numerous small cysts having clear 
contents, and vai'ying in size from that of a millet-seed to that 
of a pea. These probably are the product of constriction and dila- 
tation of parts of a uriniferous tubule, particularly of one of the 
convoluted tubes. 
The chronic parenchymatous form is regarded by some observ- 
ers as an inflammation which occurs exclusively and entirely in the 
secretory cells of the tubules. We do not hold it proved that there 
is such a form, and think that there may be confusion with the so- 
called “opaque swelling” of the kidney epithelium (Chapter VIII.). 
But we find that in some cases the elements of the tubules take CHRONIC BRIGHT’S DISEASE. 
19 
little part in the inflammatory process which is going on in the in- 
tervening tissues, while in others it is the prevailing seat of the dis- 
order. We believe that it depends upon the degree of the inflam- 
mation whether the secretory or merely the interstitial part of the 
organ shall be invaded. We shall see by and by that chemical ob- 
servation also teaches that cases of a very tedious insidious course 
betoken an interstitial disease, w7hile, on the other hand, chronic 
cases of a more active and less protracted form indicate the exist- 
ence of the parenchymatous disease. In the acute diffuse nephritis 
above described, the implication of the renal parenchyma proper is 
most apparent both from a clinical and anatomical point of view. 
If we trace back the difference between the parenchymatous and 
interstitial forms to a gradual variation in grade of the inflamma- 
tion, the existence of many intervening forms will be easy of com- 
prehension. 
In the chronic parenchymatous form, the kidney, in consequence 
of swelling of the epithelium and of deposits of exudation in the 
tubules, becomes very soft and swollen, sometimes to double its nor- 
mal size. The vessels of the cortical substance are bloodless (in 
the cadaver at least), the capsule is opaque and easily detachable, 
and beneath it the renal surface looks pale or yellowish, except 
where one or two venous trunks remain filled with blood. Upon 
section it is seen that the enlargement is all due to swelling of the 
cortical substance, which is sometimes an inch thick ; and that the 
pyramids take no part in the pallid coloring of the cortical sub- 
stance, but often form a marked contrast with it by their deep-red 
hue. Here and there a Malpighian body still remains like a red 
point on the pale field. The chief seat of the morbid process is in 
the convoluted tubules of the cortical substance, while the straight 
tubules of the pyramid rarely, and in but small degree, exhibit the 
exudation which causes the swelling and softening of the cortical 
substance. The cylindriform deposits, which occlude and render 
varicose many tubules, consist partly of swollen fatty epithelium, 
partly of lymphatic elements (pus) and blood-corpuscles, but espe- 
cially of hyaline or granular cylindrical masses. 
Many observers assume that, after a certain duration, the en- 
larged kidney gradually shrinks and atrophies, and suppose the 
atrophy to arise from the perishing of the glomeruli, by pressure of 
the intracapsular exudation, and the collapse of their tubules which 
have lost their epithelial lining. Even admitting the occurrence of 
such obliteration of some of the tubules, it may be questioned 
whether atrophy of the kidney can really be brought about through 
such a process alone, and without the concomitant thickening of 20 
DISEASES OF THE KIDNEY. 
the intertubular tissue by interstitial nephritis. In fact, even the 
eminent authorities who believe in the distinct nature of the two 
forms of nephritis, nevertheless admit the possibility of the exist- 
ence of many intermediate or combination forms between the two. 
{Bartels.) 
To conclude our description of the pathological anatomy of 
this affection, it may be well to remark that in many instances the 
morbid changes which take place in the kidney are by no means 
easy of recognition by the naked eye. When the inflammation is 
of moderate extent, we often find merely a few pale-gray streaks 
lying in the renal tissue, which in all other respects looks perfectly 
healthy. Sometimes, when the disease is diffuse and scattered, 
it would be impossible without the aid of the microscope to de- 
termine with certainty its presence in the tubules and interstitial 
tissue. The numerous consecutive changes which chronic diffuse 
nephritis is apt to bring about in other organs and tissues will be 
duly mentioned when we come to discuss the symptoms of Bright’s 
disease.] 
Symptoms and Course.—Pain in the region of the kidney, which 
has been reckoned by most authors as among the most constant symp- 
toms of morbus Brightii, according to my observation, is wanting in 
the majority of cases throughout the entire course of the disease. It 
is true, that if we press with great force upon the kidney, the patients 
complain that the procedure is uncomfortable and distressing, but we 
shall hear a like complaint from well folk, whom we may subject to 
similar infliction. It is as unusual for the attention of the patient to 
be called to the grave nature of his disease by any marked diminution 
in the amount of urine which he passes, as it is for* him to suffer pain 
in the renal region. After the dropsy and the albuminuria have placed 
the diagnosis beyond a doubt, most patients, if asked whether they 
have passed too little urine in the course of their disease, will not only 
deny it, but will even declare that throughout the entire duration of 
their dropsy they have made a great deal of water. Such an account 
as this, from a patient with chronic dropsy, is in itself suggestive of 
the probable dependence of the dropsy upon chronic renal disease. On 
the other hand, if a patient assert that his dropsy has developed grad- 
ually, and that since its commencement he has always passed remark- 
ably little urine, there is a certain amount of presumption that the 
dropsy is of cardiac or pulmonary origin, and that it does not proceed 
from disease of the kidney. However, we must not ignore the fact 
that such statements from patients, as to their passing an unusual 
quantity of water, are often the result of a delusion upon their part. An 
inclination to pass water frequently, a symptom due to sympathy of CHRONIC BRIGHT’S DISEASE. 
21 
the urinary bladder, and common both to chronic and to acute Bright’s 
disease, but which is never very severe, impresses the patient with the 
idea that, in his frequent acts of micturition, he has discharged a large 
quantity of water. Accurate measurement of the amount passed in 
twenty-four hours shows that, in many cases, it does not quite reach 
the normal flow. In others it is normal; while in others, again, the 
proper quantum is really exceeded. A considerable diminution of the 
normal secretion or actual suppression of urine seldom occurs, and then 
merely forms, as it were, a short episode in the disease. This peculiar 
behavior of the urinary secretion, in chronic Bright’s disease, is alto- 
gether enigmatical. The slighter degree of suppression, which is the 
most frequently observed, admits of the easiest explanation; as the 
obstruction of numerous tubules by swollen and degenerated epithe- 
lium would obviously impede the outflow of the urine, and the com- 
pression of many of the glomeruli must effect a diminution in the 
amount of urine secreted. But how shall we explain the fact that, in 
many instances, in spite of this hinderance to the discharge, and in spite 
of the limitation of the secreting surface, the flow of urine still remains 
normal, or even is abnormally profuse ? Plow account for the fact 
that the increase in this secretion is peculiarly common in the third 
stage of the disease, at a period when the kidney is atrophied, and 
when many of its tubules and Malpighian capsules have collapsed and 
wasted away ? We admit that the hypertrophy of the left ventricle of 
the heart may perhaps assist in augmenting the secretion of urine bv 
increasing the pressure within the glomeruli, which still remain intact, 
thus hastening the filtration of liquid through them; but its influence 
is by no means to be so highly rated as to suppose that the absence 
of many defunct glomeruli can be more than compensated for by in- 
crease of internal pressure upon those which remain. Nor does the 
collateral fluxion to the remaining glomeruli, induced by obliteration of 
the blood-vessels in the affected portion of the kidney, do more than 
to explain why there is not a material decrease in the secretion of 
urine, and by no means accounts for its augmentation. There is some 
probability that privation of the blood of its albumen may have some 
effect in increasing the secretion from the kidney. As is well known, 
a liquid will pass more freely through an animal membrane from a 
dilute solution of albumen, than from a solution which is more concen- 
trated, the pressure being the same. But even this does not seem tc 
account for the increased production of urine which we so often observe 
in the third stage of Bright’s disease. 
Although, as before said, neither pain in the region of the kidney, 
nor any unusual flow of urine, calls attention to the grave disease 
which is going on, yet its recognition is no longer difficult, since it has 22 
DISEASES OF THE KIDNEY. 
become the practice of the better class of physicians to make careful 
examination of the urine. Hospital patients do not generally apply 
for aid until the dropsy has appeared. Exclusion of other causes of 
dropsy will establish a strong presumption that we have a case of 
Bright’s disease to deal with. Examination of the urine places the 
diagnosis beyond a doubt. In private practice, the observant and ex- 
perienced .practitioner will have recognized the disease before the 
dropsy sets in. The history of the case is almost invariably as follows : 
The patients have long remarked a failure of their strength, and a 
pallor and anaemic aspect of their skin, and visible mucous membranes. 
As all their functions are apparently normal, they are unable to ac- 
count for this paleness and debility. The physician, after careful ex- 
amination of all other organs, can find no appearance of disease to 
which the loss of strength and impoverishment of the blood can be 
ascribed. He examines the urine, and finds it to be loaded with albu- 
men, and the symptoms are accounted for. No elaborate demonstra- 
tion is required to show that, in addition to the other expenditures of 
the blood, a daily loss from the blood of large quantities of albumen, 
which may amount to from twelve to twenty grammes in the twenty- 
four hours, cannot be made good by the daily supply of nourishment; 
or, in other words, a person subject to a daily drain from his blood of 
from twelve to twenty grammes of albumen necessarily becomes pale, 
bloodless, and enfeebled. As an examination of the urine reveals the 
existence of the disease before the occurrence of the dropsy as well as 
after it, it will be well to give a more detailed account of the charac- 
teristics of the urine secreted in parenchymatous nephritis. It is gen- 
erally of a pale-yellow color, and often exhibits a somewhat opalescent 
reflection. As it is more viscid than common urine, on account of the 
albumen which it contains, it is more easily made frothy than urine 
free from albumen, and the froth lasts longer. When there is no in- 
tercurrent febrile disease, its specific gravity is remarkably low, and 
may sink to 1005. This is principally on account of a decrease in its 
urea, and in a lesser degree owing to a diminution of the salts, especial- 
ly the alkaline chlorides. The reduction in the amount of urea cannot 
at first be ascribed to its retention in the blood. It would seem 
rather that, just as in other hydraemic conditions in which the urine is 
abnormally light, the metamorphosis of material in the body is going 
on more slowly than is natural, thus retarding the production of urea. 
The explanation of Schmidt as to the decrease in the saline constitu- 
ents of the urine, especially its alkaline chlorides, is less satisfactory, 
namely, that the saline ingredients of the blood augment as its albu- 
men diminishes, and vice versa. When the patients are already drop- 
sical, the transfer of the chlorides into their dropsical effusion is a CHRONIC BRIGHT’S DISEASE. 
23 
phenomenon of far greater importance. The significance of this cir- 
cumstance consists in the fact that, as long as the dropsy keeps in- 
creasing, the saline contents of the urine are very small, but whenever 
any rapid diminution of the effusion takes place, the salts are elimi- 
nated into the urine more freely, much more freely, indeed, than under 
normal conditions. 
If a portion of the urine be heated, after addition of a few drops 
of acetic acid, in case its reaction should be alkaline, or if nitric acid 
be added, the albumen coagulates. According to Frerichs, its quan- 
tity ranges from about 2.5 to 15.0 p. M. This presence of albuminuria, 
which usually persists throughout the whole course of the disease, and 
only disappears now and then, for short periods, unfortunately cannot 
be satisfactorily accounted for. One might be led into mistaking the 
albumen and the exudation cylinders for the products of inflammation, 
excreted from the free surface of the tubules, were it not that, in other 
and non-inflammatory diseases of the kidney, the urine contains both 
tube-casts and large amounts of albumen. I believe the presence of 
albumen in the urine to depend upon the destruction or degeneration 
of the epithelium. That normal urine should not contain albumen is 
confessedly extremely perplexing to the physiologists. They are al- 
most forced to suppose that the albumen does transude into the kidney, 
together with the water and salts; and they are reduced to the hy- 
pothesis that its absence from normal urine is in some way connected 
with the epithelial lining of the uriniferous tubules, the transuded 
albumen either becoming assimilated for the nutrition of the epithe- 
lium, or else its diffusion into the tubules, receiving some other modifi- 
cation, as yet unknown to us, from the epithelium. The observation 
that albuminuria exists in all diseases of the kidney, in which its epi- 
thelium is either degenerated cr destroyed, fully confirms this physio- 
logical hypothesis. 
After the urine has been allowed to stand for a while, a light, 
whitish, flocculent precipitate falls to the bottom of the vessel. If this 
sediment be placed under the microscope (for this purpose it is best to 
let it deposit in the bottom of a pointed champagne-glass), the well- 
known casts are found. At the commencement of the disease they 
are covered by epithelium, in a state of fatty metamorphosis ; at a later 
period, they seem quite bare, or are merely covered with granules and 
globules of fat. Besides this, the sediment contains common epithe- 
lial cells from the urinary passages, and smaller round, slightly-gran- 
ular cells. 
[By many the so-called urinary cylinders are supposed to be a 
product of the blood ; others ascribe their origin to alteration of 
the epithelium. They probably originate in various ways. The 24 
DISEASES OF THE KIDNEY. 
cylinders should he distinguished from those so-called epithelial 
tubes formed by separation of long pieces of the lining of the 
straight tubes, and recognizable under the microscope as oblong 
rolls of epithelial cells. Such casts appear in the less serious dis- 
eases of the kidney ; hence their temporary presence warrants a 
favorable prognosis unless gainsaid by other signs. The cylinders 
proper belonging to the graver malady are solid plugs of exudation 
which have filled portions of tubes. There are two typical forms of 
them, with intermediate varieties : 1. Hyaline casts, which, though 
well defined, are transparent as glass, and hence are apt to be over- 
looked unless foreign matter adheres to them ; 2. Granular casts, 
more or less closely studded by minute fat-globules. Hyaline casts 
are probably formed by the exudation of a fibrogenous substance, 
which becomes fibrin within the tubules. Some ascribe their ori- 
gin to colloid metamorphosis of the epithelium. Another special 
modification of the hyaline cast is the waxy cast, which proceeds 
from the former, and is to be distinguished from it by its greater 
consistence, its yellowish color, and its more distinct outline. By 
many, granular casts are supposed to be the product of fatty meta- 
morphosis of hyaline cylinders ; others regard them as the result of 
croupous degeneration of the tubular epithelium. Other objects 
are often found adhering to the casts, such as pus, white blood-cor- 
puscles, blood-disks, degenerated epithelium, and clusters of fat- 
globules, vestiges of broken-down cells ; likewise the various crys- 
tals which are found in the urine. All the above-named objects 
are also found free in the urine of Bright’s disease. During an in- 
flammatory relapse an exceptionally large number of casts will 
appear in the urine ; otherwise they are not numerous, and some- 
times can only be found after filtering the urine and examining 
the dregs. Urinary casts are not a pathognomic sign of Bright’s 
disease, for they are found, as we shall see, in other renal affec- 
tions ; nor can we positively determine the form or stage of the 
disorder from the character of the casts. Nevertheless, the discov- 
ery of many casts, both hyaline and granular, with here and there 
an adhering lymph-cell or granular epithelial cell, favors a diagno- 
sis of an active progressive inflammation (a parenchymatous ne- 
phritis) ; while, if the casts are few, small, and hyaline, or if they 
are absent altogether, the urine being profuse, clear, and scant of 
sediment, we may suppose the disease far advanced, and that the 
kidney is shrunken (interstitial nephritis).] 
Dropsy is one of the most characteristic signs of Bright’s disease, 
excepting in a few rare instances, in which it has been absent through- 
out the entire course of the malady. It generally begins as anasarca. CHRONIC BRIGHT’S DISEASE. 
25 
At first the face and feet swell, the upper extremities, abdomen, and 
scrotum not becoming affected until a later period. The oedema often 
shifts its position in a peculiar manner, so that at one time the face or 
upper extremities may be the more swollen, at another the feet, ab- 
dominal walls, or scrotum, while the tumefaction subsides in the region 
at first affected. Moreover, if the patient be out of bed, the feet gen- 
erally show the greatest amount of swelling in the evening, while in 
the morning the feet are smaller again, and the swelling involves the 
hips, back, and hands. The more slowly the anasarca develops, so 
much the more does the skin lose its elasticity, and so much more 
slowly is the imprint of the finger effaced from the oedematous surface. 
The addition of ascites and hydrothorax to the anasarca does not take 
place until a more advanced period. In one exceptional instance, I 
have witnessed the appearance of hydrothorax and oedema of the lungs 
early in the disease, where previously there had only been a slight 
oedema of the integument, a condition of apparent security thus sud- 
denly becoming one of great danger. In cases which advance rapidly, 
the dropsy may attain great magnitude in a few weeks. I have seen 
a patient who weighed a hundred kilogrammes (i. e., two hundred 
and twenty pounds), who affirmed that, eight weeks before, he did 
not weigh fifty. Such extreme dropsical swelling, from the strain 
which it exerts, may be the cause of inflammation and gangrene of 
the skin, especially of the scrotum and labia majora. In the worst 
cases, the skin often bursts at several points, and the liquid trickles 
copiously from the rents. 
The pathogeny of the dropsy of parenchymatous nephritis is ex- 
ceedingly difficult of explanation. As is already stated, the dropsy 
often develops in the midst of a copious excretion of liquid from the 
kidneys, and hence cannot be ascribed to any increase of pressure 
upon the veins of this organ, although this must be regarded as the 
main cause of the dropsy of acute croupous nephritis, in which disease 
there is always a suppression of urine. It is true that, during any 
check to the secretion of urine which may occur in this disease, the 
dropsy makes rapid headway; and when the urine is scanty through- 
out the entire course of the malady, the dropsy soon becomes exces- 
sive, and the malady runs a subacute course. There is no doubt but 
that a “ hydraeinic crasis,” a lack of albumen in the blood, favors the 
occurrence of dropsy. Owing to the continual loss of albumen, which 
the blood is suffering, in Bright’s disease, a liquid which contains but 
little albumen flows through the capillaries of the system. Hence, an 
abnormal transudation takes place from the capillaries into the inter- 
stices of the tissues, and hence, too, the amount of serum returned to 
the veins is abnormally small. It is not to be doubted that the al> 26 
DISEASES OF THE KIDNEY. 
sorption of liquid from the interstices of the tissues into the vessels is 
more active, in proportion as the difference in concentration in the 
liquid contained in the vessels and that without them is greater. 
Now, as, in parenchymatous nephritis, this difference is abnormally 
small, it follows, of course, that not only more liquid should leave the 
vessels, but that less should return to them. I have observed cases 
at my clinic which confirmed the correctness of this in the most strik- 
ing manner. A girl, who had been suffering for a year from paren- 
chymatous nephritis, stated that, some time before the appearance of 
the oedema, she had felt exceedingly dull and miserable. Being con- 
sidered plethoric, she was advised to get bled. A week after the 
blood-letting, the first symptoms of anasarca showed themselves, and 
since then have never entirely disappeared. It may be inferred in this 
case that the hydrasmia, which, though extant in moderation, still had 
not as yet produced dropsy, was so much aggravated by the blood- 
letting as to cause the dropsical symptoms to appear. In another 
case, the patient became anasarcous after a haemorrhage, but the ana- 
sarca afterward disappeared for a while, and set in anew after the es- 
tablishment of profuse suppuration. Nevertheless, hydraemia is not 
the sole cause of Bright’s disease, and probably not even its chief 
cause. Dropsy, as severe as that seen in Bright’s disease, is hardly 
ever observed in any other form of hydnemia. It often occurs early, 
but does not keep pace with the privation of the blood of its albumen. 
The peculiar manner in which the oedema shifts from one region to 
another is another argument against its dependence upon simple 
hydraemia. If we abstract blood from an animal, and inject a corre- 
sponding amount of water into its veins in its stead, the animal does 
not become dropsical. Finally, the dropsy is so very often accompa- 
nied by attacks of inflammation as to indicate that, besides the thin- 
ning of the blood, there is another source both of the transudation and 
exudation, consisting in some disorder of the tissues as yet unknown 
to us. 
It sometimes happens that the continual aggravation of the symp- 
toms above described, and the excessive dropsy, which finally may in- 
volve the serous sacs and alveoli of the lungs, cause death without 
further complication. In most cases, however, remissions occur, in 
which the condition of the patient improves, the albumen in the urine 
diminishes, and the dropsy subsides. After a while he grows worse 
again, perhaps once more to improve at a later period, and thus the 
disease will fluctuate. In such protracted cases the above symptoms 
are seldom the only ones, but are accompanied by others which arise 
in part as complications of the main disease, and in part are immediate 
consequences of it. CHRONIC BRIGHT’S DISEASE. 
27 
Of these, inflammation of the lungs, of the pleura, pericardium, perito- 
naeum, and meninges, deserve the first mention, as they are extremely 
frequent complications of Bright’s disease, and because it is of these 
intercurrent affections that the patient most frequently dies, far more 
frequently, indeed, than of the so-called uremic symptoms—to be de- 
scribed presently—or even of excessive dropsy. Such inflammations 
of the lungs, pleura, etc., do not differ from similar inflammations in 
other conditions of anaemia. The patient seldom succumbs at once to 
the first attack; and we not uncommonly find vestiges of previous 
inflammation, such as adhesions of the pleura, pericardium, and peri- 
tonaeum, besides the marks of the final seizure. Parenchymatous 
nephritis is often complicated by catarrh, particularly by catarrh of 
the bronchi and intestine. There is nothing peculiar about the for- 
mer, although in some cases the secretion is tolerably copious. The 
latter, however, is almost always characterized by a very abundant 
serous transudation, and by its extreme obstinacy. It would seem 
that the same cause which induces the escape of such large quantities 
of liquid into the subcutaneous connective tissue also gives rise to this 
immense transudation upon the free surface of the bronchial and in- 
testinal mucous membrane. Nevertheless, since the dropsy is not in- 
variably accompanied by catarrh, it must be admitted that its origin 
is somewhat obscure. 
According to my experience, chronic oedema of the lung is of very 
common occurrence in Bright’s disease. It gives rise to great dyspnoea, 
to a tormenting cough, and, at the climax of the coughing-fit, not unfre- 
quently induces vomiting. I have had repeated opportunity of observing, 
whenever the vomiting caused the patient to eject much secretion, 
that his breath became freer for a while, his cough ceased, and that 
the fine subcrepitant rales subsided. Paroxysms of so-called urinous 
asthma, which are said to occur in Bright’s disease, are probably de- 
pendent in a great degree upon oedema of the lung. 
Many patients with parenchymatous nephritis suffer from disease 
of the heart. Besides the adhesions of the heart and pericardium 
from former pericarditis, and the valvular derangement resulting from 
endocarditis, none of which are uncommon in Bright’s disease, we 
very often find a hypertrophy of the heart, and more especially a 
hypertrophy of its left ventricle. Traube has advanced the theory 
that this hypertrophy is a result of derangement of the circulation 
of the kidney, which he claims should augment the labor of the 
heart. This theory is disputed by Bamberger and others, who reply 
that the hypertrophy develops in a stage of the disease when no 
obstruction of any importance to the circulation of the kidney ex- 
ists. A more extensive collation of facts will be necessary to decide 28 
DISEASES OF THE KIDNEY. 
this disputed point; but, at all events, enormous hypertrophy of the 
heart sometimes occurs even in the second stage of Bright’s dis- 
ease, and assuredly the circulatory disturbance of the kidney is not 
the sole cause of it. As is well known, the signs of the enlargement 
are not very striking, but, by paying attention, we can often detect an 
augmented heart-shock, or, in its absence, hear remarkably loud car- 
diac sounds. 
In a great number of cases, the symptoms of the so-called uraemic 
poisoning do not appear at all throughout the entire course of the com- 
plaint. Sometimes they develop slowly and gradually; sometimes 
they come on very suddenly. At times (but not always), the attack is 
preceded by a decrease in the secretion of urine, and in rare instances 
it has happened that, during or immediately prior to the appear- 
ance of the uraemic phenomena, the normal flow of urine has been 
largely exceeded (Liebermeister). It is a suspicious sign when pa- 
tients complain of severe headache, and become languid and apathetic, 
and still more so, if these symptoms be accompanied by vomiting, 
which occasionally is so very obstinate as to awaken apprehension of 
serious disorder of the gastric mucous membrane. All these sym{>- 
toms may subside again, without evil consequence; in other cases, 
however, the drowsiness increases to a deep stupor, or convulsions of 
an epileptic or more rarely of a tetanic character may arise. Even 
when the convulsions have not been preceded by drowsiness, they are 
usually followed by a condition of deep coma with stertorous breathing. 
The fits recur at longer or shorter intervals, the stupor meanwhile con- 
tinuing to grow deeper; and the patient may finally succumb to gen- 
eral paralysis. It is not at all rare, however, for the fits gradually to 
become less frequent, the intervening stupor less profound, and for the 
signs of “ uraemia ” to disappear, perhaps not to recur for weeks or 
months. In a previous section, we have already acknowledged that 
we are unacquainted with the nature of the poison causing uraemic 
intoxication. There is a. second difficulty in explaining the uraemia of 
parenchymatous nephritis, since certain well-attested cases of uraemic 
poisoning have been observed, in which there was no suppression of 
urine. If the urea and other material to be eliminated from the blood 
pass into the tubules by a process of pure endosmosis, it remains in- 
explicable how these materials can accumulate in the blood when the 
urine is secreted freely; hence we must assume that the epithelium 
of the urinary tubules has some important influence over the secretion 
of urine, and therefore that its disease or death may occasion an ab- 
normal state of the blood, even though the kidneys continue to dis- 
charge a sufficient quantity of liquid. Moreover, I think that it would 
be going too far to attribute all the grave nervous symptoms which CHRONIC BRIGHT’S DISEASE. 
29 
arise in parenchymatous nephritis—the headache, the convulsions, the 
coma, etc.—simply to a poisoning of the blood; and for many cases at 
least I agree to the equally one-sided views of Traube, according to 
whom the so-called uraemic symptoms depend upon oedema of the 
brain and cerebral anaemia. Since the first appearance of my text- 
book, I have been much gratified at the steady advance made by the 
doctrine which I propounded long ago, that the symptoms of the so- 
called cerebral pressure, due to encroachment upon the cavity of the 
cranium, whether by a depression of the skull, haemorrhage, tumor, 
abscess, inflammatory exudation, or serous transudation, all depend 
upon an arrest or obstruction to the flow of blood to the ganglion-cells 
and nerve-fibres of the brain. But, in spite of the experiments of Munk, 
I hold it to be unproved, and even improbable, that the acute oedema of 
the brain in Bright’s disease should have an origin different from that 
of oedema of other regions, or that it should be ascribable to an increase 
of pressure within the cerebral arteries. Moreover, it seems to me to 
be extravagant to endeavor to ascribe all cases of so-called uraemia to 
compression of the cerebral capillaries, and to anaemia of the brain. 
My position in this question is as follows: In chronic parenchymatous 
nephritis, various organs are subject to oedema, the precise cause of 
which is unknown. It is characteristic of this oedema, that it shifts its 
position. It may attack the lungs at any period, either early or late 
in the disease, sometimes causing death, and sometimes subsiding 
again after a short duration. In a manner precisely similar, and for 
the same unknown reason, the brain may become the seat of an acute 
or subacute oedema, to which many succumb, while in others the oedema 
changes its position, and the patients are restored to a state of tolera- 
ble comfort for a period of variable duration. Many cases of so-called 
uraemic intoxication, but by no means all, are the result of oedema of 
the brain, and consequent anaemia of the cerebral capillaries. We 
may infer that an attack of this kind depends upon such an oedema, 
and not upon blood-poisoning: 1. When the seizure takes the form 
of deep coma, with intercurrent eclamptic spasms. 2. When, at the 
time of its occurrence, the secretion of urine is normal or increased. 3. 
When the attack is accompanied by marked oedema of the face. 4. 
When the carotids pulsate strongly during the attack. As we shall 
see directly, this is a valuable but often ill-appreciated sign of repletion 
of the cranial space with blood, and of impediment to the exit of the 
blood from the same. 
[The temperature in uraemia may be either increased or dimin- 
ished. According to Bourneville, the average temperature is re- 
duced, but rises during the fits, and remains high during the inter- 
vals. In fatal cases it is very high, but it sinks gradually to the 30 
DISEASES OF THE KIDNEY. 
normal when the outlook is favorable. According to prevalent 
modern views, the cause of the uraemic symptoms is due to insuf- 
ficient elimination by the kidneys of certain products of the body 
which, when sufficiently concentrated in the tissues, have a poison- 
ous action upon them, especially upon certain parts of the brain. 
This poisonous effect is exercised chiefly by the urea and its prod- 
uct of decomposition, carbonate of ammonia. 
According to JRosenstein, however, poisoning by carbonate of 
ammonia alone induces but one of the trains of symptoms, that of 
epilepsy, while the agent which produces the uraemia occasions not 
only epilepsy, but coma, convulsions, and delirium. Moreover, we 
must remember that in cases of uraemia, even when the presence of 
carbonate of ammonia in the blood has been demonstrated, the de- 
pendence of the uraemic symptoms upon its presence has not been 
proved. The quantity of urea excreted in the course of a day is 
generally diminished in Bright’s disease. This diminution of the 
daily quantum of excretion is often considerable at the very time 
when the secretion of urine is also reduced ; while in patients with 
extreme polyuria, whose health is as yet unshaken, the quantity of 
urea excreted, in spite of the small percentage contained in the 
urine, may even exceed the normal. If the daily excretion of urea 
is very small, we are justified in fearing that the disproportion be- 
tween production and excretion may lead to uraemia.] 
In many cases of Bright’s disease, the patients observe a grad- 
ual failure of their power of vision ; in others, blindness, more or 
less complete, sets in suddenly. I have heard a patient, upon com- 
ing to himself, after a uraemic convulsion followed by coma, ask to 
have the gas lit, although it was burning brightly at the time. This 
partial or total extinction of vision, too, used formerly to be re- 
ferred to uraemic intoxication, and was called uraemic amblyopia or 
amaurosis. Latterly, however, the real source of this disorder has 
been found to be an extravasation into the retina, accompanied by 
inflammation. A diagnosis of Bright’s disease has repeatedly been 
made by means of the ophthalmoscope alone. In one case which I 
have watched, the impairment and subsequent improvement of vis- 
ion which occurred manifestly coincided with the formation and 
absorption of such extravasations. 
[This disturbance of vision is not to be confounded with another 
—urazmic amaurosis—which appears sometimes superadded to an 
already existing retinitis, and sometimes comes on suddenly with 
the other uraemic signs, without previous derangement of the sight. 
In a few days, or even in a few hours, the sight fails so that a light 
cannot be distinguished ; but should the uraemia subside, vision may CHRONIC BRIGHT’S DISEASE. 
31 
soon be completely restored again. The speedy abatement of this 
form of blindness argues against its dependence upon permanent 
lesions. Somewhat more rarely, deafness and roaring in the ears 
have been noticed in uraemia. 
Course.—The course of chronic diffuse nephritis varies greatly. 
In one class of cases the disease may last for ten or even for twenty 
years, and may be so latent that the patient is scarcely aware that 
he is ill, and so that a careless physician who neglects to examine 
the urine can make but little out of his patient’s persistent but 
vague complaints of loss of strength and energy, of impaired appe- 
tite and digestion. When the inflammatory process runs this slug- 
gish course, the urinary tubules take but little part in the changes 
which are going on in the interstitial connective tissue. There are 
but slight and merely transient inflammatory exudations into the 
tubules, whose epithelium suffers but little direct damage ; hence, in 
such a case, but few if any casts or other characteristic forms are 
found in the urine. This languid process results merely in thicken- 
ing of the renal connective tissue, followed by shrinking. It is this 
grade of inflammation, according to our view, which marks the dis- 
tinction, both anatomically and clinically, between the forms of 
Bright’s disease. Sometimes the disease maintains this insidious 
character throughout its course. The patient then preserves a tol- 
erable appearance of health for years. His urine, which is copious 
and pale, shows but little albumen ; but late in the disease he gen- 
erally presents signs of a hypertrophy of the heart. In such a 
death may take place suddenly in a ursemic convulsion, before there 
has been any dropsy whatever. In other cases attacks of eclampsia 
recur at irregular intervals. Still other patients die of apoplexy in 
consequence of the hypertrophy of the left heart and of the accom- 
panying disease of the arterial walls. 
In another and larger class the course of the disease is less slug- 
gish and insidious. The inflammation is more active, and involves 
the tubules directly, so that dropsy soon develops. In some instances, 
which nevertheless are rare, the disease progresses steadily and 
with unabated activity to the end, causing the death of the patient 
in a few months by dropsy, secondary inflammations, or uraemia. 
Much more commonly there are marked fluctuations in its intensity. 
There will be periods, sometimes long ones, in which the urine re- 
tains its normal volume, is but moderately albuminous, and show's 
few casts or none at all. The dropsy abates and disappears ; in a 
word, the symptoms of parenchymatous nephritis fade awray or dis- 
appear. But between these intervals come exacerbations, during 
which, in spite of the most urgent and incessant efforts of the 32 
DISEASES OF TIIE KIDNEY. 
patient to micturate, the daily secretion of urine is decreased, the 
percentage of albumen augments, numerous casts and cellular forms 
appear in the urine, and the dropsy makes further progress. Dur- 
ing these long remissions of the malady the diagnosis may be difficult; 
or beyond a moderate albuminuria, which alone affords no proof of 
Bright’s disease, the patient presents but vague symptoms, such as 
gastro-intestinal disturbance, anaemia, and loss of flesh. A patient 
is thus not unfrequently supposed to be convalescent, or even cured, 
until, sooner or later, relapses occur ; so that, after an average dura- 
tion of about two years, he succumbs to dropsy, to secondary inflam- 
mation of vital organs, or perhaps to uraemia. Should he escape 
all these dangers for a considerable time (as may happen exception- 
ally), then the active symptoms of the parenchymatous form of 
Bright’s disease may give place to that of shrinking and atrophy. 
There will be a very profuse pale urine, of low specific gravity, 
containing a moderate quantity of albumen (sometimes, though very 
rarely, absent), and but few or no casts. 
Prognosis.—While recovery from acute diffuse nephritis is by 
no means uncommon, the prognosis in the chronic form of the mal- 
ady is far less favorable ; and indeed it becomes almost absolutely 
bad as regards old or neglected cases, or when, from the condition 
of the heart and of the urine, an irreparable atrophy of the kidney 
can be made out. Nevertheless, even in some of these cases, though 
incurable, a hope may be held out of a tolerably comfortable exist- 
ence for some years, or at least so long as the dropsy is moderate 
and transitory, as the serous cavities are free, and as the secondary 
lesions and the uraemia do not appear, and while the patient main- 
tains his digestive powers. When the disease is recent and has 
been well and promptly treated, the prospects of complete cure are 
a little better. Sometimes the malady seems to run a medium 
course between that of the acute and chronic forms. The immedi- 
ate danger is then much increased, but the hope that, after many 
weeks or even months, a complete recovery may take place, is much 
more warrantable than in the chronic form. In a diffuse nephritis 
which is secondary to some other grave disorder, such as an old 
malaria or a tedious suppuration, the nature of the primary affection 
must be considered in the prognosis.] 
In respect to the duration and results of Bright’s disease, it 
may be said that there are cases which run their entire course in a 
period of from six weeks to three months, and others in which the 
malady drags on for years. I used to know a physician of large 
practice in Altmark, who only died within a few years, although he 
had all the symptoms of Bright’s disease as long as twenty years CHRONIC BRIGHT’S DISEASE. 
33 
ago. We have already alluded to the fluctuations in the intensity 
of the symptoms which take place in protracted cases. The most 
frequent termination of Bright’s disease is death ; although patients 
more commonly die of the intercurrent inflammations than directly 
of the disease itself. Complete recovery may possibly take place, 
but it is extraordinarily rare. The longer the duration of the mal- 
ady, so much the less is a favorable result to be looked for. In re- 
cent cases, the question always arises whether we have not to do 
with a croupous nephritis, which, as we have explained, admits of a 
better prognosis. 
Treatment.—The causal indications require that a patient with 
parenchymatous nephritis should wear flannel next his skin, and ex- 
change his dwelling, if damp and cold, for a dry and warm one ; and 
that he should be forbidden to go out at night or in bad weather, 
even during any temporary improvement. Well-to-do people, who 
dwell in bleak, damp, windy, seaside neighborhoods, should be in- 
duced to change their abode. Excesses in spirituous liquors, and 
the use of diuretics, cubebs, copaiba, and spices, are to be strictly 
prohibited. The discovery that Bright’s disease is an inflamma- 
tory affection has done but little toward an efficient treatment of 
it. The so-called antiphlogistic method is inapplicable to any of 
its stages. 
[The practice of blood-letting, the application of cold com- 
presses, and the use of calomel no longer find advocates. We 
possess no means of extinguishing this obstinate and refractory 
disorder. Our task is therefore by no means simple, nor can any 
uniform plan of management be adopted for all cases. Its treat- 
ment must be chiefly a treatment of symptoms. The main disor- 
der can only be attacked indirectly, by seeking to combat the indi- 
vidual pernicious or dangerous manifestations as they arise, and by 
striving to remove all influences tending to irritate the kidneys. 
From this point of view the scope and value of therapeutics in 
the varying phases of Bright’s disease, as tending to prolong the 
life and to ameliorate the condition of the sufferer, should not be 
underrated.] 
In fulfilment of the indications from the disease itself, derivation 
from the intestines by drastics, and from the skin by diaphoretics, 
has been proposed. We shall recur to the employment of this 
measure while treating of the management of the symptoms, as it 
often acts favorably upon the dropsy ; but we do not believe that the 
inflammation of the kidney can be arrested or allayed by such deri- 
vation. Frerichs speaks favorably of tannic acid, which he gives 
three times daily, in doses of from two to six grains, in combination 34 
DISEASES OF THE KIDNEY. 
with aloes and in the form of a pill. The elimination of tannic acid 
through the urine in the form of gallic acid and pyrogallic acid, 
to which we have alluded elsewhere, warrants this treatment from 
a theoretical point of view. French# himself admits that, although 
he has observed a diminution in the quantity of albumen excreted, 
yet, in chronic cases, he has but seldom seen a complete disappear- 
ance of it. My own experience does not speak at all in favor of 
tannic acid. 
Bad as we have represented the prognosis of parenchymatous ne- 
phritis to be, we have often succeeded quite brilliantly in palliative 
treatment, and, in fulfilling the symptomatic indications, the therapeu- 
tics of Bright’s disease are by no means to be regarded as powerless. 
We have recognized the loss of albumen from the blood as the imme- 
diate cause of most of the symptoms of the disease, and hence our 
most important task by far is to cover the loss of albumen by a diet 
rich in protein substances, and by appropriate medication. Soft-boiled 
eggs, milk, strong meat-broths, and roast-beef, in as large quantity as 
the patient is able to digest, are probably the best preventives of the 
dropsy; and, while patients in comfortable circumstances often with- 
stand the loss of albumen with impunity for years, the poor, on the 
other hand, succumb to it far more speedily, because the former have 
better means than the latter to supply the daily losses which they 
suffer. Besides this, a moderate amount of beer or good wine should 
be prescribed, as by the use of these articles the waste of tissue is 
retarded and the nutrition promoted. Quinine and iron are the most 
suitable medicines. The former was thrown overboard by many phy- 
sicians during the time of a generally prevailing nihilism in therapeu- 
tics, and its supposed tonic action upon the fibres has been much de- 
rided. But, in these days of reaction against such nihilism, tonics, and 
especially the preparations of quinia, have once more come into repute, 
and, indeed, it would seem that they do exert a beneficial action upon 
the state of nutrition by diminishing the consumption of material. 
Preparations of iron are equally appropriate, since their effect upon the 
formation of blood is most decided, and it is not the albumen of the 
blood alone but also the red blood-corpuscles which are reduced in 
quantity in this disease. Neglect of such directions as the above, a 
blind groping in search of a specific remedy, and a vague, planless ex- 
hibition of diuretics after the dropsy has set in, are merely so many 
tokens of incapacity on the part of the physician. In a series of cases, 
which have been described by Dr. Schmidt, in his inaugural thesis, I 
have obtained most brilliant results where all other treatment had 
failed, by putting the patients upon an exclusive diet of milk. The 
patients did not take a grain of any medicine whatever, but drank CHRONIC BRIGHT’S DISEASE. 
35 
from five to six pints of cows’ milk daily. After the “ cure ” had beeD 
continued in this manner for about four weeks, some of the patients 
who, prior to the treatment, had been in the most wretched condition, 
had got rid of their dropsy, recovered an appearance of health, and re- 
gained so much of their strength as to be able to resume their business 
and even to perform hard labor. The albuminous character of the 
urine, however, has disappeared in but one case; in all the others it 
persisted. I am unable to account for the eminently beneficial action 
of milk upon Bright’s disease. I propose to try whether it be possible 
to obtain a physiological explanation of these results by a careful 
analysis of the phenomena attending an exclusively milk diet, during 
health as well as disease, especially by careful weighing of the body 
and by taking accurate account of every thing taken into and ejected 
from the system. 
If the above measures prove unsuccessful in averting the dropsy, or 
in allaying that which already exists, the establishment of active dia- 
phoresis is strongly to be recommended. No benefit, however, is to 
be expected from the use of spiritus mindereri, the antimonials, and 
other so-called diaphoretics. I have known patients in an advanced 
stage of dropsy to rid themselves of it completely, in a few weeks, by 
the daily use of a hot bath, of a temperature of 80° to 100° F., fol- 
lowed by sweating for two hours in woollen blankets. The diaphoresis 
was so great in one case, that as much as 800 cubic centimetres of the 
sweat which had soaked through was collected in a wash-basin placed 
undei the bed. All these patients were weighed before and after the 
sweating, and the clinical journals show that, during the sweating, 
they had lost two, three, and even four pounds in weight. However, 
it cannot be denied that, in some cases, this procedure also failed, nor 
that debilitated patients sometimes suffered so much from the process 
that I was obliged to desist from it. Finally, I may state that, in one 
instance, the abatement of the patient’s dropsy was coincident with 
the first appearance of uraemic convulsions. The profuse drain of 
liquid from the skin naturally makes the blood more concentrated, and 
this accounts for the absorption of the interstitial effusion. Since, 
however, in parenchymatous nephritis, the effusion contains urea and 
perhaps other salts, it is readily conceivable that an active abstraction of 
liquid from the system would have the effect of overcharging the blood 
with these materials, and might thus give rise to uraemia. However, 
a closer investigation of the cases above mentioned has led to the con- 
clusion that the supposed connection between diaphoretic treatment 
and the uraemic symptoms is improbable. 
Whatever the theoretical objections against the employment of 
diuretics may be, yet, in desperate cases, recourse should always be 36 
DISEASES OF THE KIDNEY. 
had to them. Squills and other stimulating diuretics must not be em- 
ployed without the utmost caution, on account of the irritating action 
which they exert upon the kidneys; but there are certain salts, espe- 
cially cream of tartar, and the tartarus boraxatus (soluble cream of 
tartar), which are decidedly beneficial in their effect. The physician 
above alluded to has repeatedly freed himself of his dropsy through 
the free use of buttermilk, and the employment of cream of tartar and 
small doses of Dover’s powder. 
We have yet to mention the drastics as remedies against the drops}?-. 
Observations upon cholera have taught us that a heavy drain of water 
from the intestinal capillaries will render the blood more concentrated, 
and thereby promote absorption of dropsical collections. There was a 
very instructive case at the clinic of Tubingen, which has been de- 
scribed by Liebermeister, wdiere a patient with Bright’s disease was 
attacked by dysentery and died. In consequence of the thin, copious 
diarrhoea, the extensive general dropsy, from which this patient had 
long suffered, was reduced to a minimum a few days before his death. 
It may also be said in favor of the drastics that, during their employ- 
ment, the kidneys are saved from irritation. Nevertheless, we should 
never have recourse to them save in time of extreme need, since the 
patient is liable to be intensely affected by them, and since, by their 
persistent use, the digestion becomes impaired. The drastics most 
frequently employed in treatment of Bright’s disease are, elaterium, 
gr. I—colocynth, in form of decoction, 3 j— 3 ij, to water, § vj, or 
else in the form of tincture. 
As remedies against urasmic intoxication, Frerichs, who ascribes 
this condition to surcharge of the blood with carbonate of ammonia, 
has proposed the acids, especially benzoic acid, in order to form harm- 
less ainmoniacal combinations. In the cases observed by me, I have 
not been able to perceive any effect from this treatment which is based 
purely upon theory; whereas strong drastics, and iced applications to 
the head, always seem to produce a favorable impression. 
CHAPTER y. 
NEPHRITIS YERA INTERSTITIAL NEPHRITIS RENAL ABSCESS METAS- 
TATIC DEPOSITS IN THE KIDNEY. 
Etiology.—While in acute and chronic Bright’s disease the chief 
pathological changes take place in the uriniferous tubules, the altera- 
tions which occur in the intervening substance being altogether of a 
subordinate and secondary charactei, in the variety of renal inflamma- 
tion which forms the subject of the present chapter, the disease lies INTERSTITIAL NEPHRITIS—REN AL ABSCESS. 
37 
mainly in tlie scanty connective tissue which binds the tubules together. 
The most common causes of true nephritis are as follows: 
1. Wounds and contusions. The kidney is seldom subjected to 
external violence, owing to its sheltered position. It is far more liable 
to injury from the presence of stones within the pelvis of the kidney. 
2. Collections of decomposed ammoniacal urine in the pelvis of the 
kidney, the result of urethral stricture, enlargement of the prostate, 
palsy of the bladder from injury of the spine, and so forth. Here the 
irritation to which the kidney is subject is of a chemical instead of a 
mechanical nature. 
3. Propagation of inflammation from the urinary passages to the 
kidney. It is easy to comprehend that an inflammation of the pelvis 
of the kidney, a pyelitis, might readily extend into the parenchyma of 
the organ, and cause nephritis; but the fact that nephritis is sometimes 
associated with gonorrhoea, but is not a result of extension of the latter 
disease by contiguity, and where there is no accumulation of urine in 
the pelvis of the kidney, is altogether enigmatical. 
4. Propagation of the inflammation from the connective tissue of 
surrounding parts, the peritonaeum and other organs. This is the 
rarest of all the modes of origin. 
5. Embolism of small arteries of the kidney, and the introduction 
of septic or miasmatic material into the blood. This is the source of 
the so-called metastatic nephritis, observed in endocarditis, valvular 
disease of the heart, and in the various disorders classed under the 
general title of pyaemia, as well as in the infectious diseases. 
There is usually no doubt as to the embolic origin of the cuneiform 
deposits, which, in the disease of the heart above alluded to, ocour 
almost as frequently in the kidney as in the spleen ; but it is sometimes 
extremely difficult to trace the origin of the small metastatic deposits 
which form in the kidney during the later stages of septicaemia, puer- 
peral fever, typhus, etc., to the action of embolism. It is questionable 
whether interstitial nephritis ever arises from the effect of cold, or from 
that of acrid diuretics. 
Anatomical Appearances.—In traumatic nephritis, or in ne- 
phritis arising from an extension of inflammation from the pelvis of 
the kidney, or from other organs, the kidney at first is enlarged, and 
is of a deep-red hue, which is either diffused over its whole substance, 
or else is confined to single spots in the cortical or medullary portion. 
Its consistence is much less firm. The albuginea is injected, thickened 
by infiltration, and easily detached. Upon section, the structure is 
indistinct, and the boundary between the cortical and pyramidal sub- 
stance is effaced. A bloody, thick liquid can be expressed from the 
surface of the cut. At a more advanced stage the redness subsides. 38 
DISEASES OF THE KIDNEY. 
The color of the renal substance becomes of a dirty brown or gray, 
owing to compression of its vessels by the interstitial exudation, which 
already, here and there, contains pus. 
The discoloration usually begins at detached points, of the size of a 
hemp-seed. As it increases, these spots soften, until they finally break 
down into a purulent liquid. In this way small abscesses form, by the 
melting down of the renal substance, under the pressure of the con- 
stantly-accumulating pus-cells. In the cortical substance, the form of 
the abscess is more rounded; in the pyramidal, more elongated. The 
abscesses enlarge and coalesce, finally forming a great sac of matter, 
which may occupy one-half or even two-thirds of the kidney. Such 
an abscess may become incapsulated, and long remain embedded in 
condensed cellular tissue. In other cases, the deposits discharge in 
various directions, as into the pelvis of the kidney, the cavity of the 
abdomen, externally through long fistulous tracks, into neighboring 
parts of the intestine, which have become adherent to the wall of the 
abscess, or even, through the diaphragm, into an adherent portion of 
the lung. When the disease runs a more chronic course, it sometimes 
terminates differently. In such cases the interstitial substance of the 
kidney undergoes proliferation, while the peculiar tissues of the organ 
perish. At the close of such an attack of chronic interstitial nephritis, 
the kidney is irregular, and nodulated in shape. The elevations are 
more marked than those of the third stage of Bright’s disease, and 
the albuginea is firmly adherent in the sulci between them. Upon 
cutting into one of these depressed spots, instead of renal-tissue proper, 
we find nothing except the indurated substance of a cicatrice. 
The metastatic nephritis, which accompanies disease of the heart, 
shows no tendency to suppuration. In recent cases, distinctly circum- 
scribed, dark-red cuneiform spots are found in the kidney. The base 
of the wedge lies toward the periphery of the organ, the apex toward 
its hilus. Microscopic examination shows an intense engorgement of 
the vessels with dark masses of blood, blood being also effused into 
and between the tubules. Haemorrhagic infarction of the kidney, when 
of longer standing, undergoes metamorphosis similar to that already 
described as occurring in haemorrhagic infarction of the spleen. A dis- 
coloration commences in the middle of the point of infarction, which, 
having undergone a complete fatty metamorphosis, and all the fat 
having been absorbed, cicatrizes, leaving a depressed scar. The me- 
tastatic deposits which form in the kidney in infectious disease, and in 
consequence of the absorption of putrid matter into the blood, are 
generally much smaller, and far more numerous, than the infarctions 
which occur in disease of the heart. Moreover, their tendency to break 
down is very great, so that, upon examination, it is not usual to find INTERSTITIAL NEPHRITIS--REN AL ABSCESS. 
39 
solid spots, but merely abscesses in the kidney, surrounded by an area 
of redness. 
Symptoms and Course.—When not of metastatic origin, acute in- 
terstitial nephritis, like acute inflammation of other important organs, 
sometimes commences with a rigor. At the same time there are vio- 
lent pains in the region of the kidney, and, in this form of renal in 
flammation, there is a pain, which is hardly ever absent, which becomes 
almost intolerable upon the most moderate pressure, and shoots along 
the ureters to the bladder, and toward the testicle and thigh of the 
affected side. The sympathetic vomiting, which we have described as 
an almost constant accompaniment of acute parenchymatous nephritis, 
is nearly always present also in this form of nephritis. Owing to com- 
pression of the urinary tubules and Malpighian capsules by the inter- 
stitial exudation, the secretion of urine is repressed. That which is 
passed is concentrated, dark, and is often mingled with blood. The 
fever which accompanies this disease from the outset is very apt to 
assume a typhoid character. The patients become disturbed in mind, 
delirious, somnolent, and fall into a state of stupor, with convulsions; 
symptoms which are to be ascribed to a suppression of the urine, and 
to a surcharge of the blood with excrementitial matter. The disease 
may terminate fatally, in the course of a few days, through general pa- 
ralysis of the nervous system. 
The occurrence of suppuration in the kidney may be suspected 
when the disease continues without remission, and when its course 
is marked by numerous chills, and, above all, when pus is discharged 
with the urine. When an abscess forms in one part of the kidney, 
the rest of which has not been affected, or has regained its healthy 
condition, the disease takes a more chronic course; but the fever 
continues, and consumes the patient gradually, who almost always 
dies sooner or later of a phthisis renalis. To detail the various modi- 
fications of symptoms which arise from the complications of pyelitis, 
cystitis, and the bursting of renal abscesses in various directions, 
would lead us too far. The different courses which the matter may 
take have already been mentioned above. There is a form of inter- 
stitial nephritis, which is very difficult of recognition, in which the 
substance of the kidney gradually perishes, and is replaced by a new 
growth of connective tissue. A permanent derangement of the urinary 
secretion, a constant desire to pass water, dull pains in the region of 
the kidney, dropsy, great listlessness, which gradually increases to 
coma, with other indications of the so-called uraemic poisoning, are the 
symptoms of this form of disease, but they are very rarely properly 
interpreted. 
Metastatic interstitial nephritis, not having any characteristic symp 40 
DISEASES OF THE KIDNEY. 
toms, is usually overlooked during life. However, I have sometimes 
noticed that the formation of a large haemorrhagic infarction in the kid- 
ney is accompanied by a chill, that the patient complains of severe 
pain in the kidney affected, and that the urine is scanty and contains 
blood. When we encounter symptoms like these, in a case of disease 
of the heart, we may confidently diagnosticate the existence of an in- 
farction of the kidney, particularly wThen there is or has been evidence 
of embolism elsewhere. Renal metastases, which form during septi- 
caemia, puerperal fever, etc., are usually mere “accidental” discov- 
eries upon the dissecting-table. We cannot even suspect their exist- 
ence during life. 
Treatment.—As, in most cases of interstitial nephritis, it is im- 
possible to meet the causal indication when the affection proceeds 
from the presence of a stone, or from a collection of putrid urine in the 
pelvis of the kidney, or from embolism or infectious disease, we must 
confine our efforts to an antiphlogistic treatment, which is much more 
appropriate in this case than in those heretofore described. The repeat- 
ed application of leeches, cut cups, and of cold over the kidney, with 
the subsequent use of long-continued warm baths and warm poul- 
tices, and the exhibition of drinks containing carbonic acid, are the 
most approved measures. The sequelae, especially the abscesses and 
fistulas which may form, must be treated according to the symptoms. 
CHAPTER YI. 
PERINEPHRITIS. 
Etiology.—In rare instances tlie adipose tissue, in which the kid- 
ney is enclosed, becomes the seat of a primary, independent inflamma- 
tion, which is usually the result of an injury, or, as has been claimed 
now and then, of exposure to cold. Much more frequently the inflam- 
mation is secondary to a suppurative action within the pelvis or sub- 
stance of the kidney. I have seen one case in which a pericystitis 
extended along the ureter to the fat around the kidney. 
Anatomical Appearances.—As a rule, inflammation of the 
areolar envelope of the kidney soon results in suppuration. The tis- 
sues then become discolored, and their meshes are filled with pus. 
The small collections of pus coalesce and an abscess forms, often of very 
considerable magnitude, and which may point in almost any direction. 
In other cases there is no suppuration, but the loose cellular tissue be- 
comes condensed and indurated, and is converted into a thick fibrous 
rind. 
Symptoms iND Course.—When perinephritis is acute, its symp- PERINEPHRITIS. 
41 
toms bear a strong similarity to those of acute interstitial nephritis. 
A violent fever, which sometimes is ushered in by one or more rigors, 
and by severe pain in the region of the kidney, which becomes intoler- 
able whenever the adjacent muscles of the body contract, or are sub- 
jected to any strain by movement of the body, is a symptom common 
to both diseases. There is one important distinctive point between 
the two; in pure uncomplicated perinephritis, there is no suppres- 
sion of urine, nor does the urine contain either blood, albumen, or 
pus. If the disease goes on so as to give rise to a large abscess, a tu- 
mor appears in the renal region, which fluctuates with greater or less 
distinctness. If the abscess break into the cavity of the abdomen, it 
occasions an acute peritonitis, which speedily terminates in death. 
Recovery may take place where the abscess discharges into the intes- 
tine, or where it points externally, or is opened artificially. External 
opening of the abscess generally occurs in the back, below the false 
ribs, and is usually preceded by an excessive aggravation of the pain 
upon movement of the body, and by a more or less extensive oedema 
of the skin over the region affected. In other cases the pus descends 
along the psoas muscle, giving rise to a symptomatic abscess, which 
usually makes its appearance below Poupart’s ligament. 
Treatment.—The most appropriate treatment of a recent case of 
perinephritis is local blood-letting, and, in a later stage of the disease, 
the systematic .application of cataplasms and, the use of lukewarm 
baths. Abscesses must be opened as soon as possible, according to 
surgical rules, and should be kept open for a while. 
CHAPTER YII. 
AMYLOID DEGENERATION OP THE KIDNEY PARENCHYMATOUS NE- 
PHRITIS, WITH AMYLOID DEGENERATION. 
The kidney, like the liver and the spleen, not unfrequently under- 
goes a degeneration, by the deposit in the elements of its tissues of a 
material whose reaction against iodine and sulphuric acid resembles 
that of the cellulose of plants, but whose chemical constitution is more 
like that of the protein substances. Amyloid degeneration of the kid- 
ney takes place under conditions similar to those under which it oc- 
curs in the liver and spleen, its causes being severe chronic disease, 
such as syphilis, mercurial poisoning, rachitis, consumption of the 
.ungs, and long-standing suppuration, such as occurs in caries and 
necrosis. 
The degeneration probably always commences in the walls of the 
blood-vessels, particularly in those of the glomeruli, to which it usually 42 
DISEASED OF THE KIDNEY". 
remains limited; while, at the same time, the epithelium of the tubules 
undergoes the changes already described in Chapter IV. The name 
u parenchymatous nephritis, with amyloid degeneration,” is, therefore, 
more appropriate for this form of disease than the term “ amyloid or 
lardaceous degeneration of the kidney.” Even microscopic examina- 
tion is not by itself sufficient to enable us to distinguish between the 
affection in question and simple parenchymatous nephritis. But, if a 
thin slice of the specimen be treated for a few moments with a solution 
of iodine, the red color of the glomeruli becomes so distinct even to the 
naked eye, that, even before resorting to the microscope, the appear- 
ance of a multitude of small red dots, standing out in contrast to the 
surrounding yellow ground, makes the diagnosis almost certain. Under 
the microscope the loops of the glomeruli seem remarkably large, and 
present a peculiar dead lustre. The Malpighian capsules, too, often ex- 
hibit a broad, homogeneous, dull outline. If, prior to the examination, 
the preparation have been laid for a time in a dilute solution of iodine, 
the bodies above described will assume the characteristic yellowish- 
red color. Upon the subsequent addition of a few drops of sulphuric 
acid, they become of an indistinct violet or dark blue. It is very un- 
usual for the tunica propria, and still more so for the epithelium of the 
urinary tubules, to participate in the amyloid degeneration. 
When an individual, who hitherto has enjoyed good health, is 
affected by albuminuria, dropsy, and deterioration of the blood, it is 
so very improbable that he is suffering from amyloid degeneration of 
the kidney, that that disease may confidently be excluded from the 
diagnosis. On the other hand, the appearance of similar symptoms in 
a person who has long been afflicted by syphilis, consumption, tedious 
suppuration, or any other exhausting malady, makes it extremely prob- 
able that we have to deal with an amyloid degeneration of the kidney, 
or, more properly speaking, with a parenchymatous nephritis with 
amyloid degeneration of the walls of the renal vessels. If the patient 
also have an enlargement of the liver and spleen, and if the portions 
of these organs accessible to palpation present the characteristic 
resistance of amyloid degeneration, the diagnosis is still more sure. 
In distinguishing between amyloid degeneration and simple parenchy- 
matous nephritis, Traube lays great stress upon the high specific grav- 
ity and dark color of the urine in the former disease. My own obser 
vations fully confirm the truth of Traube’s views, and I may add that 
1 have been struck, not only by the darkness of the urine, in amyloid 
renal degeneration, but also by its unnatural, yellowish-brown color; 
moreover, my colleague, Hoppe-Seiler, has shown that such urine con- 
tains extraordinary quantities of indican. There is nothing in the 
quality of the exudation-casts, or in the degree of frequence of uraemic GRANULAR DEGENERATION OF THE RENAL EPITHELIUM. 
43 
symptoms, whereon to base a differential diagnosis between a sim- 
ple parenchymatous nephritis and one which is complicated by 
amyloid degeneration. Moreover, the difference between the two 
conditions is a matter of but little practical interest. 
The treatment recommended for amyloid degeneration of the 
liver and spleen is equally appropriate in amyloid disease of the 
kidney. It is questionable whether a retrogression of the disease 
be possible. The preparations of iron and iodide of iron may act 
beneficially upon the primary disease, but can hardly cure a degen- 
eration of the kidney. 
CHAPTER VIII. 
GRANULAR DEGENERATION OF THE RENAL EPITHELIUM. 
[Frequently on autopsy we find the kidneys flabby, bloodless, 
of a pale, dirty, grayish-red color, somewhat enlarged, or of normal 
size. From their cut surface we may scrape off a cloudy grayish 
pulp. This pulp consists of epithelial cells swollen by albuminous 
infiltration and dotted with numerous fine granules, which render 
the nuclei indistinct, but which vanish in the presence of potash and 
acetic acid (thus showing that they consist of albuminous particles). 
At a later period fat-granules may appear. When the disorder is 
intense, the kidney becomes tender and flabby, and the epithelium 
falls off ; but, if of only a moderate degree, the cells may undoubt- 
edly be restored to their normal condition. Proliferation of the 
epithelium occurs, but very rarely, and then only late in the disease. 
Granular degeneration is not peculiar to the kidney, but is often 
found simultaneously in the cells and tissues of the most diverse 
organs, particularly in the liver, the heart, and the muscles. This 
widespread appearance of the disease shows that its cause must be 
a general one. In the bodies of persons who have died of infectious 
diseases—pyaemia, typhus, or acute miliary tuberculosis—more or 
less marked granular degeneration is found, as a result either of 
some abnormity of the blood, or perhaps as a consequence of the 
persistent elevation of the temperature which attends these diseases, 
and which, according to Schultze, exercises a most pernicious in- 
fluence upon cellular formations. But the disorder also is found 
when there has been no fever, in chronic anaemia, chronic disease 
of the heart or lungs, and in poisoning by phosphorus, sulphuric 
acid, and carbonic oxide. Sometimes the cause of the granular de- 
generation is purely local, and is limited to the kidney where it is 
found, supplementing other morbid conditions. Very important 44 
DISEASES OE THE KIDNEY. 
results are ascribed to the more intense grades of this lesion. Thus 
it is supposed in acute forms often fatally to cripple the action of 
the heart. 
The condition is also found in the bodies of pregnant and puer- 
peral women. At present we have no definite knowledge as to how 
pregnancy affects the minute structure of the kidney and other or- 
gans in these cases.] 
The most common and frequently the sole symptom of parenchym- 
atous degeneration of the kidney is the presence of albumen in the 
urine. We may say, too, that whenever there has been albuminuria 
during pregnancy or during grave disease, the renal epithelium will 
be found to be in a more or less advanced state of degeneration after 
death. How often the question is asked by the anatomist during the 
autopsy, whether the patient had albuminous urine! On the other 
hand, I will not venture to state positively that the albuminuria, which 
so often accompanies the conditions above referred to, is always the 
result of degeneration of the epithelium of the kidney, or that degen- 
eration of the renal epithelium is always attended by albuminuria. 
The quantity of albumen which the urine contains is probably never 
so great in parenchymatous degeneration as in amyloid degeneration, 
and parenchymatous inflammation of the kidney. When it arises after 
acute febrile disease, it never produces dropsy. This symptom is often 
absent, too, during pregnancy accompanied by parenchymatous renal 
degeneration and albuminuria. Sometimes, however, there is a mod- 
erate degree of dropsy, and in rare instances a very large one. When 
it accompanies pregnancy, it is sometimes a source of danger, owing 
to the eclamptic attacks which it provokes during and immediately 
after parturition, and of which we shall have more to say when we 
come to treat of diseases, of the nerves. 
If the original disease terminate in recovery, the nutritive disorders 
of the renal epithelium to which it has given rise are also completely 
repaired. Soon after delivery the albuminuria and dropsy disappear 
in almost all cases, another proof that the malady in question is not 
to be confounded with interstitial nephritis. We are quite ready to 
admit that in most cases of eclampsia puerperarum there is renal dis- 
ease ; but we deem it quite inadmissible to attribute the albuminuria, 
dropsy, and eclampsia to “ Bright’s disease.” 
After what has been said already regarding parenchymatous degen- 
eration, further discussion of its treatment becomes superfluous. We 
shall treat hereafter of the proper management of the eclampsia. CARCINOMA OF THE KIDNEY. 
45 
CHAPTER IX. 
CARCINOMA OR THE KIDNEY. 
Op the malignant neoplastic growths, carcinoma is the one most 
frequently seen in the kidney. Renal cancer is sometimes primary; 
sometimes it accompanies carcinoma of other organs, as a secondary 
formation. Young persons, and even children, are quite frequently at- 
tacked, although it is somewhat more common in advanced age. 
Cancer of the kidney generally assumes the medullary form. 
Scirrhus and colloid are far more rare. The former sometimes de- 
velops in the form of circumscribed nodules of varying size, which 
gradually replace the parenchyma of the kidney. Sometimes the can- 
cerous degeneration spreads farther and farther into the surrounding 
tissues from its original point of development, so that the kidney 
gradually becomes transformed into cancer (Rokitansky, infiltrated 
cancer). A carcinomatous kidney may attain an enormous bulk some- 
times, forming a nodular tumor of the size of a child’s head. The de- 
generation often involves the lymphatic glands in the hilus of the kid- 
ney, whence it spreads to the retroperitoneal and mesenteric lym- 
phatics, and to the ligaments and periosteum of the spinal column; or 
else it may grow inward into the cavity of the organ, and thence into 
that of the adjoining veins. The frequency with which cancer of the 
kidney is complicated with cancer of the testis is a matter of impor- 
tance, which calls to mind the still more common coincidence of tuber- 
culosis of these organs. Haemorrhages both within the tumor and on 
its periphery are very apt to occur. In the latter case, the blood is 
effused either into the peritonaeum or else into the urinary passages. 
The disease often remains latent for a long time. It is usually by 
the gradual advance of a marasmus, for which no other cause can be 
assigned, that suspicion is awakened of the existence of a malignant 
tumor in a region inaccessible to palpation. There may be no pain at 
all in the lumbar region, and, when it does exist, it is not character- 
istic. The renal secretion may go on undisturbed, and the urine may 
be quite free of blood and albumen. As the disease advances, the tumor 
formed by the cancerous kidney, which is often of enormous size, can 
generally be felt through the abdominal walls, especially when the 
latter have become wasted and relaxed. The form of the tumor, and 
especially its immobility, will prevent our mistaking the enlarged kidney 
for an enlargement of the liver or spleen. It cannot be moved from 
side to side, nor does it follow the motions of the diaphragm. Very 
large cancers of the right kidney sometimes produce a remarkable and 
peculiar displacement of the liver inward, causing it to turn upon its 46 
DISEASES OF THE KIDNEY. 
long axis, so as to bring a large part of its convex surface in contact 
with the abdominal wall. ILematuria and albuminuria are absent 
about as frequently as they occur. As already stated, part of the 
bleeding proceeds from the vessels of the growths which push into the 
urinary passages, while another part is the result of excessive hyper- 
cernia of the surrounding tissues. Owing to the large quantity of 
blood thus discharged, the hsematuria often forms one of the most 
prominent symptoms of this disease. The complexion of the patient 
assumes the dirty hue so common in cancer, and he dies of exhaustion 
which progresses all the more rapidly when the haemorrhages are 
frequent and profuse; unless, indeed, death ensue in consequence of 
some intercurrent disorder, or from the invasion of other vital organs 
by secondary cancer. Treatment is ineffectual, and must be limited to 
husbanding the patient’s strength, repression of the haemorrhages, and 
removal of coagula from the bladder, according to surgical rules. 
CHAPTER X. 
TUBERCULOSIS OE THE KIDNEY. 
Rokitansky recognizes two forms of renal tubercle. The first 
form is symptomatic of a tuberculosis involving several or even the 
majority of the organs. In acute miliary tuberculosis, gray nodules, sim- 
ilar to those found studding the lungs, pleura, peritonaeum, etc., are also 
found in the albuginea and parenchyma of the kidney. In extensive 
chronic tuberculosis, tolerably large, yellow, cheesy deposits of tubercle 
are sometimes met with in the kidneys, but they rarely contain collec- 
tions of softened tubercular matter or tubercular cavities. The first 
of these forms has but little effect upon the action of the organ. It is 
unrecognizable during life, and is of more moment in a pathological 
than in a clinical point of view. 
The second form of renal tubercle is generally complicated with 
tuberculosis of the testicle, prostate, seminal vesicles, and urinary pas- 
sages. It is not constantly preceded by pulmonary tubercle; but this 
disease almost always sets in at a more advanced period of renal dis 
order. In this second form the deposit is very copious, and the indi- 
vidual nodules soon coalesce into large tubercular masses. The organ 
becomes enlarged, assumes an irregular, knobby shape, and within it 
we find large cheesy collections, some of which are filled with tubercu- 
lous pus. This form of renal tuberculosis, too, would likewise frequently 
escape observation, were not the diagnosis almost always aided by the 
complications above mentioned. The longer a chronic disease of the 
urinary passages has coexisted with the admixture of pus, and now and PARASITES IX THE KIDNEY. 
47 
then of blood in the urine, the tuberculous character of which is in- 
dicated by the coexistence of an enlargement of the testicle, so much 
the more likely will it be that the lddney itself has become involved 
in the disease. The diagnosis receives further confirmation if we are 
able to feel an uneven tumor in the region of the kidney, through the 
flaccid walls of the abdomen. 
CHAPTER XI. 
PARASITES IN THE KIDNEY. 
The echinococcus is the parasite most frequently found in the kid- 
ney, although even there it is met with less frequently than in the liver. 
Its presence in this prgan is originally due to the existence of the 
embryo of the tenia echinococcus in the intestinal canal (see Yol. I.). 
We have no knowledge as to why the young brood, in their emigra- 
tion from the bowel into the other organs of the body, should some- 
times enter the kidney. The echinococcus sacs, which occasionally 
attain the size of a fist or of a child’s head, are quite like those found 
in the liver and spleen. They are embedded in a fibrous capsule be- 
longing to the kidney. They may atrophy and burst, discharging their 
contents in different directions. They may also occasion inflammation 
and suppuration in the parts about them, and the renal abscess thus re- 
sulting may burst into the peritonaeum, intestine, or pelvis of the kidney. 
The development of echinococci in the kidney may be entirely un- 
attended by symptoms. In some instances, however, the patients com- 
plain of a dull pain in the lumbar region, which we cannot well account 
for. A tolerably sure diagnosis may be made out if we can feel an 
i rregular nodular tumor in the region of the kidney, and at the same 
fime can exclude carcinoma, tuberculosis, and hydronephrosis, to be 
treated of hereafter. Certainty is only possible when cysts of the 
echinococci or traces of them are discharged with the urine. The 
hyaline walls of the daughter cysts, consisting of concentric layers, 
distinctly recognizable under the microscope, are not easily mistaken. 
Symptoms of renal colic may arise during their passage through the 
ureters, and their discharge from the bladder is often attended by the 
utmost distress, especially in men. 
[The strongylus gigas is the largest of known round worms. The 
female may attain the length of half a yard or more. Its mouth is 
bordered by six wart-like projections. The male is smaller, and at 
his tail-end has a cup-shaped appendix, at the bottom of which is 
the genital opening with the penis protruding from it like a hair. 
The method of development of this parasite has not been ascertained. 48 
DISEASES OF THE KIDNEY. 
Schneider found worms in certain fish which seemed to represent 
the early forms of a strongylus ; and the fact that the strongylus 
species most generally infest fish-eating animals argues in favor of 
this view. Its occurrence in man is very rare indeed. According 
to Davaine, but seven well-authenticated cases have been collected. 
We know, however, that in brutes the creature usually occupies the 
pelvis of the kidney, more rarely descending the ureter into the 
bladder, and that its presence causes symptoms similar to those of 
calculus, and may cause retention of urine and hydronephrosis.] 
CHAPTER XII. 
DEFORMITIES OF THE KIDNEY IRREGULARITIES OF ITS SHAPE AND 
POSITION. 
Absence of one kidney usually is accompanied by abnormal 
magnitude of the other, and the secretion of urine remains normal. 
Union of the two kidneys, which then are generally connected by a 
narrow bridge of renal substance at their lower ends—the so-called 
horseshoe kidney—is a matter of mere anatomical interest, and of no 
clinical importance. The same is true also of lobulation of the kid- 
ney, which depends upon a persistence after birth of the foetal con- 
dition of the organ, and is distinguishable from an acquired lobular 
state of the kidney by the healthy condition of the renal parenchy- 
ma and capsule at the depressed points. Irregularity of position is 
most common in cases of horseshoe kidney ; the united organs then 
usually lie much deeper than natural, sometimes as low down as the 
last lumbar vertebrae. But, even without the coexistence of this 
malformation, an unnaturally deep position of the kidneys is not an 
uncommon congenital deformity, and is usually accompanied by 
irregularity in the origin and number of the renal vessels, as well as 
by anomaly in the lengths of the ureters. 
Misplacement of the kidney, with abnormal mobility, is a mat- 
ter of greater importance. Quite a considerable number of cases of 
this anomaly have been observed since attention was first called to 
it. In Greifswald alone I know of three cases of movable kidney. 
The kidney (and almost always the right one) lies embedded in a 
loose areolar tissue. Its vessels are elongated, and have a sort of 
mesentery formed out of the reduplication of their peritoneal coat. 
Such anomalies are most common among women whose abdominal 
integuments have become greatly relaxed by repeated child-bearing. 
According to Ilayer, it may also result from violent concussion of ADDISON’S DISEASE. 
49 
the body—as from a fall from a great height. In other cases there is 
no other anomaly, nor is there any apparent cause for the mobility 
of the viscus. When the patient stands erect, the movable kidney 
may be felt usually below the liver, or even still deeper. Its char- 
acteristic bean shape is distinctly recognizable, and it often can be 
pushed a considerable distance to the right or left, but more easily 
upward and downward. A patient in my ward, by moving and 
shaking his body, was able to get his kidney into a great variety of 
positions. There are either no evil results whatever attending the 
affection, or they depend upon complications, although colics and 
slight, inflammations of the peritonaeum may result from pressure of 
the movable organ upon the other viscera. The knowledge that 
she has a tumor in her abdomen often acts very injuriously upon 
the spirits of the patient, who sometimes becomes hypochondriac. 
Little can be done by way of treatment for a movable kidney ; but 
the patient (particularly if she have very flabby abdominal walls) 
generally feels better when she wears an clastic bandage of gum 
elastic or knit cotton. 
CHAPTER XIII. 
addison’s disease—bronzed skin. 
[This disease, first described by Addison, still presents an obscure 
problem, notwithstanding the laborious researches of many of our 
most acute observers (Virchow, Meissner, Averbeck, Klebs, Eulen- 
burg, Guttmann, Risel, and others). All former doubts as to the 
real existence of such an independent affection are now dissipated ; 
but it has been shown that the lesions which used to be thought 
fundamental and characteristic of it, namely, the morbid state of 
the suprarenal capsules and the dark stain upon the skin, though 
commonly present, are not its essential features. The original as- 
sumption that Addison’s disease depends upon a degeneration and 
destruction of the suprarenal capsules is contradicted by the nega- 
tive results of experiments made in seeking out the hitherto un- 
discovered functions of these organs, as well as by the fact that the 
capsules have been found destroyed or in a state of disease in bodies 
of persons who during life presented none of the symptoms of the 
malady. Attention was thus directed to the sympathetic plexus of 
nerves adjacent to the capsules, the implication of which in this 
affection Addison himself had already pointed out; and the opinion 
was gradually reached by a number of English, French, and German 
observers that a morbid state of the abdominal sympathetic, par- 50 
DISEASES OF THE KIDNEY. 
ticularly of the coeliac plexus and semilunar ganglia, and of the 
nerves connecting them with the suprarenal capsules, is of essential 
importance in the disease. The circumstance which speaks most in 
favor of this view is, that in most of the cases in which the sympa- 
thetic has been examined, besides the suprarenal lesion usually present, 
there has been also found either redness, swelling, thickening, fatty 
degeneration, atrophy, pigmentation, or wasting of the ganglia. 
But out of twenty-nine cases collected by Guttmann and Eulenburg 
the sympathetic was found more or less altered in nineteen and nor- 
mal in ten. This negative result, though of only a minority of 
cases, reduces the above attempt at explanation to a mere theory ; 
the more so when we read that experiments by Adrian Schmidt, 
Lamanshy, Schiff, and others upon the abdominal ganglia give rise 
to no symptoms suggestive of Addison’s disease. A further hy- 
pothesis was then advanced, that the disorder depended upon 
derangement of the central nervous system and not upon that of 
the sympathetic ; and Rossbach describes it as a hitherto undefina- 
ble functional disturbance of the nervous system lying in close re- 
lation to, but not inseparable from, the suprarenal capsules, and 
characterized by psychic disorder, intense antemia, debility, and 
very often by a dark staining of the skin. 
In order to account for a connection between a nervous disturb- 
ance and a morbid stain upon the skin, the cases of albinism have 
been invoked in which the anomaly is very distinctly limited to a 
district of skin corresponding to a certain nerve-district, as have 
also the cases of sudden turning gray of the hair under the influence 
of mental emotion. The deposits of pigment which form in the skin 
of pregnant women, and in many who suffer from menstrual and 
uterine disease, have also been pointed out in support of the view 
that staining of the skin may proceed from disorder of the supra- 
renal capsules. 
The anatomical changes of the suprarenal capsules found in 
Addison’s disease are not always the same. In most cases there is 
a caseous fibrous degeneration resulting from chronic inflammation 
of the organ. The capsules are often of two or three times their 
normal size, sometimes even as big as a hen’s egg, and are converted 
into masses of dense connective tissue containing cheesy or calcare- 
ous nodules. Their surface is irregular and knotty, and often adhe- 
rent to adjacent structures. Their consistence is tough and hard. 
The inflammation, instead of being general, may however be only 
partial and limited to single spots. The disease is generally bilateral. 
The many cases in which both capsules have been found totally 
destroyed argue against the theory that the suprarenal capsules are ADDISON’S DISEASE. 
51 
secreting organs, and Addison’s disease a result of over-production 
of deleterious chemical matters in the blood (particularly tauro- 
cholic acid), which partially dissolves the blood, thus causing the 
anaemia, while a precipitation of the pigment of the blood occasions 
the bronze color. In rarer cases, instead of this degeneration, we 
have found carcinoma, extravasation of blood in the tissues of the 
capsules, and sometimes simple atrophy ; hence it must be concluded 
that the bronze color is not due to any special process. The imme- 
diate cause of the brown skin is a deposit of pigment in the rete 
Malpighii ; but pigment-cells are also to be found in the true skin, 
and are to be distinguished from those in the rete Malpighii by their 
containing iron. 
There are sometimes no lesions whatever of other important or- 
gans ; but more frequently there will be found enlargement of the 
spleen and of the intestinal follicles, cheesy degeneration of the mes- 
enteric glands, and sometimes caries of the vertebrae.] 
Symptoms Course.—The darkening of the skin, whence the 
malady derives one of its names, although it is by no means its most 
important or most dangerous symptom, occurs gradually. If the 
patient die before it has become very pronounced, it is apt to be 
overlooked entirely. Such cases, however, do not disprove the con- 
nection between disease of the suprarenal capsules and the deposit 
of pigment in the rete Malpighii. It is only by degrees that the 
discoloration of the linea alba and nipples' in pregnancy acquires a 
sufficient degree of intensity to become conspicuous, and indeed 
there are many persons in whom it is never very marked even at 
term ; and yet no one denies the existence of a connection between 
pregnancy and such pigmentary deposit. t 
In some instances the skin becomes so dark as to resemble that 
of a mulatto or negro. One of my patients, a baker, from Ileil- 
bronn, used to be generally known as “ Black R .” The color 
sometimes is a pure gray, inclining to black, like plumbago. At 
other times it has a brown or yellowish tinge. It generally com- 
mences upon the exposed parts of the body, but, although more in- 
tense upon those regions, is by no means confined to them, a cir- 
cumstance which might save us from errors of diagnosis in dealing 
with sailors, field laborers, and others whose hands and faces are 
often of an exceedingly dark grayish-brown tinge. The roots of the 
nails also remain white. The palms of the hands and soles of the 
feet are spotted here and there, but are not uniformly discolored. 
The sclerotica never participates in the discoloration, and its pearly 
hue often forms a marked contrast with the dark color of the face. 
Black spots upon the lips and mouth seem to me to be pathogno- 52 
DISEASES OF THE KIDNEY. 
monic of the affection. At all events, no mention is made of them 
in any of the negative reports of bronzed skin without disease o' 
the capsules. 
Its more serious symptoms consist in an extreme debility, ofter 
combined with deep depression of spirits. In some instances this 
debility increases from time to time into profound and long-con- 
tinued swoons. Sometimes the adynamic symptoms are so promi- 
nent as to remind one of a severe attack of typhus, or of some other 
acute affection, with so-called typhoid symptoms. Mistakes for 
typhus, however, may always be avoided if all the elements of the 
case be attentively considered, especially if the temperature be ob- 
served. If, however, the case has not been long under observation, 
and if the discoloration of the surface be not very distinct, it may 
be impossible to make a positive diagnosis. The great lassitude and 
insurmountable sense of weakness, unattended by any apparent 
cause of exhaustion, would seem to proceed from a disorder of in- 
nervation. The richness of the suprarenal capsules in nervous ele- 
ments, and the numerous communications existing between them 
and the various nervous plexus, especially the solar plexus, rather 
confirm such a supposition. 
Pain in the back, and still more frequently pain in the epigas- 
trium, is a very fi*equent but not a constant symptom. In one of 
my cases the pain was so violent that the patient for weeks was 
treated with poultices. In a second, severe pain in the epigastric 
region was one of the most conspicuous symptoms, wdiile in the 
third the patient never complained of pain at all. 
Dyspepsia and vomiting are reported as occurring in nearly 
every case ; yet even these symptoms are sometimes absent. The 
vomiting of Addison’s disease may be regarded as a so-called sym- 
pathetic vomiting ; since, in disease of other organs adjacent to 
the stomach, and even in such as contain fewer nerves than the 
suprarenal capsules, and whose nervous connection with the stomach 
is much less obvious, such sympathetic vomiting occurs. 
Diarrhoea has been observed in many cases. In two of my three 
cases the dirrahoea was very obstinate. It would be easy to account 
for this diarrhoea, could it be proved post mortem that the coeliac 
ganglion always was diseased ; since, according to the experiments 
of Budge, all the rabbits whose coeliac ganglia he removed suffered 
from diarrhoea. But independently of this, there is nothing sur- 
prising in the occurrence of diarrhoea in disease of the suprarenal 
capsules, these organs being richly endowed with nerves, and stand- 
ing in intimate relation with the nervous plexus of the abdominal ADDISON’S DISEASE. 
53 
organs, and since, too, there is no doubt as to the dependence of 
liquid discharges upon disturbance of innervation. 
The convulsions and other grave nervous disorders which some- 
times occur are difficult to account for. One of my patients had 
repeated epileptic attacks. Post-mortem examination usually affords 
no clew as to the origin of these symptoms. 
The temperature of the body is not increased, unless there be 
some complication of a febrile character. 
The beat of the heart and the pulse is accelerated, and toward 
the close of the malady is often extremely feeble. The great fre- 
quence of the pulse stands in striking contrast with the lowness of 
the temperature, and, if no note be taken of the latter, it is liable 
to cause an erroneous impression that there is fever. 
The progress of the disease is almost always chronic. There are 
but two or three known cases where the process has run an acute 
course, speedily terminating in death. 
Although there are a few cases in which a temporary improve- 
ment has been observed, yet we have no well-authenticated instance 
of complete recovery ; and death must be regarded as the most fre- 
quent, and probably, indeed, as the sole termination of this malady. 
Treatment.—Of course, the treatment of Addison’s disease 
must be a mere treatment of symptoms. In one of my cases it was 
very evident that good nourishment and careful nursing were not 
without a beneficial effect upon the course of the disorder. The 
patient, a poor servant, was repeatedly received at the clinic, in a 
state of extreme emaciation/and unfit for any labor. He always 
gained considerably in weight in the course of a few weeks, and so 
far recovered his strength that he could be employed in a variety 
of occupations ; until, three years and a half after his first recep- 
tion at my clinic, he suddenly and unexpectedly died in one of the 
above-mentioned epileptiform attacks. SECTION II. 
DISEASES OF TIIE PELVIS OF THE KIDNEYS 
AND URETERS. 
CHAPTER I. 
DILATATION OF THE PELVIS OF THE KIDNEY, WITH ATROPHY OF THE 
RENAL SUBSTANCE HYDRONEPHROSIS. 
Etiology.—Whenever the flow of the urine, through the ureters, 
into the bladder, becomes permanently obstructed, the urine accumu- 
lates in the pelvis and calyces of the kidney. If the pressure of the 
urme within the pelvis of the kidney be very great, the openings in 
the tubuli recti and papillae are closed, and the papillae themselves be- 
come compressed. The urine then ceases to flow from the kidney into 
it« pelvis, and distention of the latter would progress no farther were 
it not that the pelvis and calyces possess a mucous membrane, and still 
continue to produce mucus, which is mingled with the accumulated 
urine. Hence more and more liquid collects in the renal pelvis, dis- 
tending the latter, till finally the pressure flattens out the papillae, and 
induces a gradual atrophy, which may terminate in the total loss of the 
substance of the organ. 
Closure of the ureter may proceed from the impaction into it of a 
stone. Far more frequently, hydronephrosis depends upon compres- 
sion of the ureter by a tumor, or by a callous contracting cicatrix in 
the peritonaeum which covers it, or by a growth, especially by a cancer, 
of the subperitoneal connective tissue. In other cases, closure of the 
ureter is the result of inflammation, which has induced swelling of its 
mucous membrane, or adhesion of its walls. The lower and the closer 
to the bladder the obstruction is, so much the larger is the portion of 
ureter which takes part in the dilatation. 
Moderate degrees of dilatation of the uriniferous apparatus some- 
times arise from an impediment to the discharge of urine, which exists DILATATION OF THE PELVIS OF TIIE KIDNEY. 
55 
in the urethra or bladder, but, in such cases, the affection being bilat- 
eral, the dilatation of the renal pelvis can never become so great as to 
close the mouths of papilke of the kidneys without involving danger 
to life. It seems strange that, on autopsy, hydronephrosis of both 
sides, which seems to have existed a long time, is frequently found. 
Anatomical Appearances.—According to Rokitansky, in the 
milder degrees of hydronephrosis, the papillae are shrunken, hardened, 
and leathery. Gradually the papillae disappear in the concavity of the 
dilated calyx, while above it the renal substance diminishes, its tissues 
becoming compressed, leather-like, and tough. In extreme cases, the 
substance of the kidney is only a line or two in thickness, finally dis- 
appearing, leaving a membranous sac, of a lobulated appearance exter- 
nally, and cellular within. The cells communicate with each other, 
their wTalls having burst or atrophied ; they contain a urinous liquid, 
clear and serous, or turbid and containing a sediment, varying greatly 
in character. These sacs may attain the size of a child’s head, or even 
that of a man’s. A dilated ureter may attain almost any conceivable 
size, its calibre equalling or even exceeding that of the small intestine. 
The walls of the ureter are thickened, and the tube itself, instead of 
running straight to the bladder, is tortuous and convoluted, like a gut. 
Symptoms and Course.—Hydronephrosis cannot be detected, ex- 
cept in its most intense form, and, of course, this cannot exist when 
both ureters are obstructed. The secretion of urine is not diminished, 
as the active kidney acts vicariously for the disabled one. There may 
not be any pain in the lumbar region. Diagnosis is solely based upon 
the discovery of a somewhat soft and indistinctly-fluctuating tumor in 
the region of the kidney. If there be any temporary abatement of 
the obstruction to the escape of urine from the organ, the tumor may 
diminish from time to time, and such an occurrence sometimes aids the 
diagnosis. When the sac becomes inflamed (as has sometimes been 
observed), there is much pain, accompanied by severe rigors. The pus 
which forms may point in various directions, thus giving great diversity 
to the character of the symptoms. Should the impediment which has 
obstructed one ureter extend so as to prevent the flow of urine into 
the bladder from both kidneys, all secretion of urine wall cease, and 
the patient will speedily perish, under symptoms of uraemia. 
Treatment.—If the obstruction lie in the urethra only, diligent 
catheterization may prevent dilatation of the urinary passages, or arrest 
such dilatation when it has commenced. It is out of our power, how- 
ever, to arrest or to allay the graver forms of dilatation with atrophy 
of the renal substance, which proceed from obstruction of a ureter 
unless the obstruction of the ureter be caused by a tumor, susceptible 
of relief by medical or surgical interference. 56 
DISEASES OF THE PELVIS OF THE KIDNEYS AND URETERS. 
CHAPTER II. 
Etiology.—In rare cases, the pelvis of the kidney is the seat of a 
croupous or of a diphtheritic inflammation. This is usually accompa- 
nied by similar inflammation of other mucous membranes, and is usually 
a concomitant of infectious disease. It is most commonly observed in 
the typhoid stage of cholera, but may also proceed from catarrhal in- 
flammation, especially that arising from calculous pyelitis. 
Catarrhal pyelitis, in the great majority of cases, is the result of 
an irritation of the mucous membrane, induced by the presence of 
calculi in the pelvis of the kidney. In similar manner, the ammonia 
of stagnant and putrid urine may provoke a most intense catarrh of 
this region. Much more rarely, catarrh of the urinary passages is 
caused by acrid substances, such as cantharides, the balsams and resins, 
which have been taken into the .system, and excreted with the urine. 
Again, we frequently find pyelitis as the result of severe gonorrhoea, 
the inflammation having extended to the bladder and ureters. 
A mild form of catarrhal pyelitis is a common complication of 
Bright’s disease. It sometimes appears during pregnancy, and during 
the later stages of typhus, as well as during the desquamative period 
of the acute exanthemata. A hasmorrhagic form of this affection 
sometimes accompanies scurvy, and the morbus maculosus of Werlhof. 
Anatomical Appearances.—In croupous or diphtheritic inflam- 
mation of the pelvis of the kidney, its mucous membrane is found 
either to be covered by membranous exudation, or else is converted 
into diphtheritic eschars, which, upon separation, produce irregular 
losses of substance. 
In recent cases of catarrhal pyelitis, the mucous membrane is red- 
dened bv injection, and (especially in the scorbutic form) by ecchy- 
mosis. At the same time, it is relaxed, and covered by purulent mucus. 
When of longer standing the redness disappears, or becomes discol- 
ored, the tissue of the mucous membrane is swollen, and, in some cases, 
is incrusted with urates, or with salts of lime. The pelvis of the kidney 
usually is dilated, and its walls are thickened. Not unfrequently, the 
renal parenchyma has suffered atrophy, as in hydronephrosis. In cases 
of long-continued mechanical irritation, there often is ulceration of the 
mucous membrane, which may terminate in its perforation, followed by 
infiltration of urine into the surrounding areolar tissue, with suppurative 
destruction of the latter. The resulting abscesses may point in various 
directions, as into the cavity of the peritonaeum, or externally, forming 
long fistulous openings; or, previously forming adhesion, it may burst 
INFLAMMATION OF THE PELVIS OF THE SIDNEY PYELITIS. PYELITIS. 
57 
into some neighboring organ (such as an intestine). Now and then 
the liquid contained in the pelvis of the kidney is gradually absorbed. 
The pelvis shrivels into an indurated tissue, which incapsulates its in- 
spissated contents, the ureter becoming obliterated and converted into 
a tendinous cord. 
Symptoms and Couese.—Croupous and diphtheritic pyelitis are 
scarcely ever recognized during life, as in the majority of cases they 
are only partial manifestations of those grave and wide-spread disor- 
ders which attend the malignant infectious diseases, septicaemia, scar- 
latina, small-pox, or the typhoid stage of cholera. Sometimes wThen ca- 
tarrhal calculous pyelitis becomes aggravated into the croupous or diph- 
theritic form, shreds and lumps of fibrin are discharged with the urine 
Acute catarrhal pyelitis may commence with a rigor or with re- 
peated chills, and be attended by febrile symptoms. The patients 
complain of pain in the region of the kidney, which radiates along the 
ureters, toward the testicles, and which is increased upon pressure. 
When the inflammation has been severe, I have also repeatedly observed 
vomiting, even in the cases where the disease had spread from the 
urethra to the pelvis of the kidney. A frequent and sometimes pain- 
ful inclination to pass water is a constant symptom. According to 
Oppolzer, the secretion of urine increases ; this may to some extent 
be due to hypermmia of the kidney, in the parts supplied by the vasa 
afferentia; but if the pyelitis be complicated with interstitial nephritis, 
the secretion of urine may be diminished in amount. Very often at 
the outset the urine contains blood, in greater or smaller quantity; and 
it always contains pus, and in some cases, but not in all, tesselated epi- 
thelium, lying row upon rowr, detached from the pelvis of the kidney. If 
the disease be of long duration, still more pus appears in the urine. When 
recently passed, the latter is opaque; after standing a w hile, a wrell- 
defined sediment is deposited, of a yellowish-white color. Owing to 
the pus serum which it contains, the supernatant liquid shows the 
characteristic coagulation of albuminous urine upon the application 
of nitric acid and heat. The microscope shows the sediment to con- 
sist of innumerable pus-cells. In pyelitis calculosa, affecting one side 
only, the impaction of a calculus sometimes causes a temporary but 
complete arrest of the flow of urine from the pelvis of the kidney. 
Any urine which is then discharged from the bladder must, therefore, 
proceed from the healthy kidney. Hence, as long as the obstruction 
continues, the urine is usually quite limpid, although the symptoms are 
all aggravated. When the obstruction is removed, the urine again be- 
comes turbid. One patient, whom I have seen, had learned, by ex- 
perience, that her suffering would be more severe as long as her urine 
remained clear; and she used to long for the time when pus would be- 
gin to pass again. 58 
DISEASES OF THE PELVIS OF THE KIDNEYS AND URETERS. 
Owing to persistent suppuration, and to the slow fever which gen- 
erally accompanies it, chronic pyelitis may lead to marasmus and 
dropsy, terminating in death. When due to stones in the renal pelvis, 
the chronic disease is liable to acute exacerbations, particularly after 
any jolting of the body; or else periodical haemorrhages occur, which 
accelerate the exhaustion of the patient. Violent pain in the back, 
difficulty of motion of the spinal column, pain on drawing up the 
thighs, aggravation of the fever, and repeated chills, are indicative of 
threatening perforation of the wall of the renal pelvis. After per- 
foration has actually occurred, and when an abscess has formed in the 
surrounding tissues, the disease assumes the characteristics of perine- 
phritis. A tumor which fluctuates more or less distinctly is found in 
the region of the kidney, etc. (see Sec. I., Chap. VII.). When the ab- 
scess bursts into the peritoneal sac, the patient speedily perishes, with 
the symptoms of acute peritonitis. If the pus burrow downward, a 
cold abscess forms, which makes its appearance in the lower part of 
the back, beneath Poupart’s ligament, or in the perinasum. If the 
perforation take place into the intestine, masses of pus are discharged 
with the stools; the tumor which had formed diminishes or disappears 
entirely, and a more or less permanent recovery takes place. 
It is not always easy to decide if a pyuria originate in the bladder 
or in the pelvis of the kidneys. In a pyelitis without implication of 
the bladder, the desire to micturate may be very troublesome, and the 
act of urinating may be accompanied by pain in the urethra. In 
chronic pyelitis as well as in chronic cystitis, the urine contains 
quantities of pus-cells, which render it cloudy, and when it stands 
for some time they sink to the bottom as a whitish-yellow sediment. 
The idea that the acid reaction of such urine indicates a pyelitis, while 
alkaline reaction speaks for a cystitis, is not absolutely correct; for in 
chronic vesical catarrh even when of long standing it is generally acid, 
and only becomes alkaline in the bladder under certain circumstances, 
of which we shall speak when treating of catarrh of the bladder. 
Another criterion also, which I formerly considered valuable in the 
diagnosis of pyelitis from cystitis—namely, that in inveterate vesical 
catarrh the purulent sediment was usually mixed with quantities of 
mucus, while in chronic pyelitis the urine did not contain a trace of 
mucus—is not always true. The mucous masses evacuated in the urine 
in some cases of chronic vesical catarrh are the result of mucous trans- 
formation induced in the purulent secretion from the vesical mucous 
membrane by alkaline fermentation of the urine. If the urine does 
not undergo this decomposition in the bladder, when freshly passed, it 
will contain no mucous masses; but, if we leave urine with a simple 
purulent deposit (wnether it come from the bladder or the pelvis of STONY CONCRETIONS IN THE PELVIS OF THE KIDNEY. 
59 
the kidney) in an open vessel till it undergoes alkaline fermentation, 
the sediment will become tough and mucous. We can only be sure 
of disease of the pelvis of the kidney, when we find connected 
groups of spindle-shaped flat epithelium in the urine, especially 
after violent exercise. But, even in cases where the patient com- 
plains of pain in the region of the kidneys, extending thence to the 
pelvis and testicles, we must not be misled, by any existing dysuria, 
into the diagnosis of pyelitis. 
Treatment.—For acute catarrhal pyelitis we may refer to what 
has been said already concerning acute interstitial nephritis. At the 
outset, the application of leeches, cut cups, as well as of cold, over the 
region of the kidney, is advisable; and, when the pain and strangury 
are very severe, the exhibition of opium and the subcutaneous injection 
of a solution of morphine. In order to dilute the urine as much as 
possible, the patient should drink freely of liquids, avoiding the use of 
salted or spiced food or beverage. The employment of alkalines, and 
the alkaline-saline mineral waters of Vichy and Karlsbad is deserv- 
edly in repute in the treatment of pyelitis. If the malady assume a 
tedious form, let the patient use long-continued warm baths, and apply 
hot poultices to the lumbar region. The acratothermae are coming 
more and more into use in the treatment of pyelitis and its kindred 
complaints. At the baths and springs of Wildbad, I have seen the 
utmost benefit result from making the patient spend as long a time in 
the bath as possible, and causing him to drink as much of the pure 
lukewarm water of the springs as he could take without inconvenience. 
We do not attempt to decide whether camphor, which enjoys so high 
a reputation as a remedy for all irritations of the urinary passages, 
really exerts the beneficial action ascribed to it. Where there is 
tedious suppuration, astringents should be employed, especially tannin, 
for reasons already given. In order to diminish the production of pus, 
we may also try whether the patient will bear the exhibition of the 
balsams, especially copaiba. For this purpose, Oppolzer recommends 
the patient to drink lime-water and milk (aquae calcis, milk, aa lb. £ to 
lb. ij. daily). 
CHAPTER III. 
STONY CONCRETIONS IN THE PELVIS OF THE KIDNEY. 
[Etiology and Pathology.—Stony concretions may form in 
any part of the urinary passages, from the uriniferous tubules to the 
bladder. They may assume the shape of a fine powder (sand or 60 
DISEASES OF THE PELVIS OF THE KIDNEYS AND URETERS. 
gravel), or form masses varying in size from that of a mustard-seed 
to that of the fist. They are classified, according to their composition, 
into—1. Those composed of pure uric acid, or of uric-acid salts ; 
2. Those composed of oxalate of lime ; 3. Stones of phosphate of 
magnesia and ammonia and phosphate of lime ; 4. Stones of car- 
bonate of lime ; 5. Cystine calculi; 6. Xanthine stones. Besides 
these, there are stones of several components, which are often so 
formed that around a nucleus alternating strata are superimposed, 
which vary as the conditions for the excretion of the different ma- 
terials have varied from time to time. The most common of these 
stratified stones are composed of a nucleus of uric salts or of oxa- 
late of lime covered by shells of phosphatic matter. 
The causes of urinary calculus are many, and in part still un- 
known. The formation of uric-acid stones is ascribed to the long- 
continued over-acidity of the urine, due either to the actual increase 
in the quantity of the acid in the body as a result of imperfect oxy- 
genation, to a sluggish mode of life, to a diet too rich in flesh, or to 
lack of the supply of oxygen, or else to such an increase of the free 
acids of the urine that the soluble uric salts which it contains are 
decomposed, and the uric acid separated. This may proceed from 
an acid fermentation within the organ, in which the coloring and 
extractive matter of the urine turn into lactic acid, or else an acid- 
ification in the primary passages favors such an excretion. Con- 
ditions which produce a concentrated urine, as abstinence from 
water, persistent diarrhoea, or badly-compensated heart-disease, may 
also give rise to such excretion. 
Oxalate-of-lime stones, generally called mulberry calculi, have 
likewise various modes of origin. Sometimes, when the urine is 
alkaline, the acid forms in the urine itself, probably through decom- 
position of the uric acid. Sometimes the stone forms when the 
diet has been exclusively vegetable, from excessive use of sorrel, 
tomatoes, and the like. Again, these calculi may appear under con- 
ditions of body not fully understood ; but, as we know, the charac- 
teristic crystals of oxalate of lime are found in the urine of many 
patients of sluggish habit, disordered digestion, or derangement of 
the respiratory or nervous apparatus. 
Stones of phosphate of lime or ammonia, or of a mixture of the 
two, are apt to form wherever a long-continued alkaline condition 
of the urine produces alkaline precipitates in it. Such decomposi- 
tion of the urine may proceed from chronic inflammation or other 
diseases of the urinary tract, due to retention of urine. It may be 
caused by the use of foul catheters, or by the presence of a foreign 
body, such as a uric-acid or oxalate-of-lime calculus, which thus may STONY CONCRETIONS IN THE PELVIS OF THE KIDNEY. 
61 
furnish a nucleus for a phosphatic shell. From the experiments of 
Studensky, who inserted foreign bodies into the bladders of dogs 
and put lime into their food, it would seem that an excess of lime 
in the food predisposes toward phosphatic calculi. Even the phos- 
phates which properly exist in the body may by morbid and exces- 
sive transformation produce stones in the urine, as sometimes hap- 
pens in osteomalacia. 
Gravel and stones form at all ages of life. In childhood, how- 
ever, the disposition toward stones—perhaps through uric-acid in- 
farction of the new-born—seems the greater ; and in old age it is 
also common. That men should suffer more often than women 
would seem to be because of their different modes of life. How 
much geological and climatic influences have to do with endemic 
tendency to stone in certain countries, as England, Holland, and 
parts of Germany, has not been made clear. 
Concretions rarely form in the kidney-substance proper ; but 
cases like those of uric-acid infarction of the new-born have been 
seen in the adult, in which uric acid was found after gout, hsema- 
toidin crystals after haemorrhage, and bile-pigment after jaundice. 
Carbonate of lime, too, has been met with. Real stones are also 
found as very great rarities in the kidney proper, or rather in por- 
tions of the dilated uriniferous tubules. The ordinary seat of gravel 
and of stone is in the calyces or pelvis of the kidney. The smaller 
stones are roundish ; larger ones mould themselves to the shape of 
the region which they occupy, so that stones of the calyx acquire 
a pyramidal form.] 
Stony concretions form in the pelvis of the kidney, probably 
xmder the same conditions which cause them to form in the bladder. 
When treating of vesical calculus, we shall discuss the pathogeny 
and etiology of these calculous formations more fully. Many, and 
perhaps the majority of stones in the bladder, originate in the pel- 
vis of the kidney, and pass thence through the ureters into the blad- 
der, where they increase in size by precipitation from the urine. 
Anatomical Appearances.—In cases of uric-acid infarction, 
upon section through the pyramid, we see delicate yellowish-red 
stripes running in the direction of the tubules. Upon microscopic 
examination, these tubules are found to be filled with a blackish, 
coarsely-granular material. Upon the addition of an acid, these 
masses disappear, and are replaced by crystals of uric acid. Ac- 
cording to Virchow, dilatation of the tubules and the formation of 
cysts in the kidney of the foetus may arise from permanent obstruc- 
tion of the efferent tubules. In the luemorrhagic-pigmentous in- 
farction we also see red streaks, with a tinge of yellow in them, in 62 
DISEASES OF THE PELVIS OF THE KIDNEYS AND URETERS. 
the pyramidal substance ; and, under the microscope, the tubules 
are seen to be filled with granular, or globular, or lumpy masses, 
and with the well-known hsematoidin crystals. In calcareous in- 
farction, whitish-yellow stripes are found in the pyramids ; and, 
under the microscope, black masses are visible in the tubules, which 
dissolve with effervescence upon the addition of acid. The deposits 
of triple phosphate, which also produce yellowish-white stripes in 
the pyramids, sometimes coalesce into stones of the size of a hemp- 
seed, and may cause suppuration and destruction of the renal pa- 
renchyma. 
Calculous concretions which form in the pelvis and calyces of 
the kidney have the same chemical composition as vesical calculi. 
There is great variety in their size, shape, and number. The smaller 
ones are no larger than a grain of sand, and are of a rounded form, 
or else have the shape of a calyx of the organ. The larger ones, 
which may be of the size of a pigeon’s or hen’s egg, fill up the 
whole renal pelvis, often forming a complete cast of its shape, and 
of that of the calyces. 
Symptoms and Course.—Red gritty deposits upon the napkins 
of newly-born infants, which cease to appear in the course of a few 
weeks, constitute the sole and not very trustworthy sign of the ex- 
istence of uric-acid infarction. That of calcareous infarction and 
the presence of phosphatic deposit in the tubules cannot even be 
suspected during life. 
In many instances stony concretions in the pelvis of the kidney 
give rise to no symptoms whatever. We often enough see small 
urinary calculi, which certainly must have formed in the kidney, 
voided with the urine, the patient never having suffered the slight- 
est inconvenience prior to their discharge. In other instances there 
is renal haemorrhage, and in others the signs of pyelitis calculosa. 
(See Chapter II.) Some persons experience a sense of weight and 
of pain in the lumbar region whenever the body is jolted. As 
these symptoms are very ambiguous, we are not warranted in in- 
ferring even the probable existence of a renal calculus from them, 
unless from time to time the pain grow worse, with slight attacks 
of fever, and unless, after such exacerbations, the urine contain fine 
granular sediment, or small fibrinous clots incrusted with crystals, 
and a few blood-corpuscles, or perhaps perfect calculi. 
In two of my cases, the diagnosis of renal calculus wras strength- 
ened by the fact that, on examining some flocculi which swam in 
otherwise limpid urine, groups of connected epithelial cells, of the 
characteristic form of epithelium of the pelvis of the kidney, were 
recognized ; and they showed no signs of fatty metamorphosis, and STONY CONCRETIONS IN THE PELVIS OF THE KIDNEY. 
63 
bad sharp outlines and distinct nuclei, which rendered it probable 
that they had been detached by some mechanical force. 
The passage of a calculus through the ureter is sometimes at- 
tended by symptoms to which the term renal colic has been applied. 
Clots of blood and parasites passing through the ureter may like- 
wise give rise to renal colic ; and it is not impossible, though very 
improbable, that a mere spasm of the ureter may sometimes have 
like effect, but such cases are comparatively rare. It is incompre- 
hensible why large stones often pass unnoticed through the ureter, 
while much smaller ones (which are not always rough or angular) 
may cause intense anguish. In this affection, the patient (often 
after a severe jolting) suddenly feels a frightful pain darting from 
the kidney toward the bladder, and thence to the thigh and testicle. 
He screams and writhes with agony, and grows cold, prostrate, and 
demoralized. Though constantly striving to micturate, but little 
water flows. Vomiting is frequent, so that the seizure is apt to be 
mistaken for biliary colic or enteralgia. In irritable subjects there 
may be convulsions. Sometimes temporary remission interrupts the 
torment of the patient—soon, however, to be followed by renewed 
and violent exacerbations. In other cases the pain increases stead- 
ily, and then ceases as suddenly as it commenced ; and, unless the 
calculus give rise to fresh trouble by its presence in the bladder, a 
complete recovery ensues immediately. Such attacks may pass off 
in a few hours, and rarely last over twenty-four hours ; and, in spite 
of the formidable aspect of its symptoms, life is hardly ever en- 
dangered by renal colic. Sometimes, though not often, the im- 
provement is incomplete ; the pain diminishes, but does not cease 
entirely, the symptoms of colic becoming complicated with those 
of pyelitis. 
Treatment.—The treatment of uric-acid and calcareous infarc- 
tions is, of course, out of the question. In discussing the treat- 
ment of vesical calculus, we shall speak of the procedures theoreti- 
cally proposed for the purpose of dissolving stones, and shall then 
point out their inefficiency. 
In treating renal colic, it is merely necessary that the physician 
be sure of his diagnosis, in order to obtain the happiest results. 
He must not content himself by applying leeches, giving restora- 
tives for the small pulse and cool skin, or with other useless half- 
measures, but should boldly order opium every hour or two. The 
anaesthetic action of the opium alone is insufficient to account for 
the relief which usually follows this treatment. It is much more 
likely that the muscular fibres of the ureter, which have been 
thrown into a state of contraction by the irritation of the stone, 64 
DISEASES OF THE PELVIS OF THE KIDNEYS AND URETERS. 
which they have spasmodically grasped, are relaxed by the narcot- 
ism induced by the opium. If the opium given internally be vom- 
ited, a subcutaneous injection of morphine may be used. Inhala- 
tion of chloroform vapor seems to have an action similar to that of 
the opium, and is the next best remedy. In like manner, a copious 
blood-letting may be of service, from the relaxation to which it 
gives rise ; but in most cases this may be dispensed with. The 
patient, however, who is demoralized by pain and terror, will not 
be satisfied by the mere hourly administration of a powder and the 
inhalation of chloroform. He will loudly demand that something 
more be done for him, and, as a matter of humanity, we should 
yield to his entreaty. If circumstances permit, let him make use of 
a warm sitz-bath or complete bath. It has also often been recom- 
mended to seat the patient naked upon a stool, and to lay his bare 
feet upon a cold floor. As a beverage, copious draughts of some 
mineral wTater, containing carbonic acid, should be prescribed, in 
order, if possible, that the urine pressing after the stone may drive 
it before it into the bladder. 
CHAPTER IV. 
CARCINOMA AND TUBERCULOSIS OF THE PELVIS OF THE KIDNEYS 
AND OF THE URETERS. 
Carcinoma of the urinary passages is rare. It scarcely ever 
occurs except where cancer of other organs, especially of the kid- 
ney, extends into the walls of the renal pelvis. In rare instances, 
independent nodules of cancer appear in the pelvis of the kidney 
and ureters, accompanying carcinoma of the bladder or kidney. 
Tubercle of the uriniferous apparatus has already been alluded to 
in treating of tuberculosis of the kidney, and was there stated to 
be a partial manifestation of a general disposition to tubercle, in- 
volving the testicle, prostate, seminal vesicles, and kidney. The 
diffuse caseous decomposition, which the mucous membrane of the 
urinary passages presents, cannot always be referred to the forma- 
tion and softening of discrete tubercular granulations ; although 
sometimes nodules as large as a millet-seed, either in groups or dis- 
crete, and (where these have broken down) round or irregular ulcer- 
ations, are found upon the mucous membrane. Sometimes the uni- 
form proliferation of cells and their caseous metamorphosis convert 
the inner wall of the ureter and of the pelvis of the kidney into a 
yellow pultaceous mass. In other places the degenerated mucous CARCINOMA AND TUBERCULOSIS OF THE KIDNEY. 
65 
membrane is fissured and broken down, containing extensive losses 
of substance. Under sucb circumstances the urinary passages are 
always much dilated, and their wall thickened. Tuberculosis of 
the uriniferous apparatus is easy of diagnosis, when it can be ascer- 
tained by palpation that the prostate and testicle also are diseased, 
and when the urine is alkaline and mingled with pus and debris. 
Extension of tuberculosis from the bladder to the ureters is so com- 
mon an occurrence that it may always be anticipated in such cases. SECTION III. 
DISEASES OF THE BLADDER. 
CHAPTER I. 
OATAltRH OF THE BLADDER CYSTITIS CATARRHAL1S. 
Etiology.—Catarrh of the urinary bladder may arise: 1. From 
direct irritation of the vesical mucous membrane. Unskilful injections 
in gonorrhoea, frequent or rude catheterization, foreign bodies, espe- 
cially calculi, may also produce the affection. The admixture of acrid 
substances in the urine, or the formation of irritating matter in the 
bladder, owing to decomposition of the urine, may give rise to a most 
intense form of catarrhal cystitis. To this class the vesical catarrhs 
belong, which are induced by the misuse of cantharides and of balsam 
copaiba, as well as those which arise in cases of spinal disease, typhus, 
stricture, and enlargement of the prostate, and other conditions caus- 
ing retention of urine. In the same way, drinking of new beer will 
occasion a very transient catarrh of the bladder.* 2. In other cases 
catarrhal cystitis arises from the extension of an inflammatory irrita- 
tion from other organs to the bladder. First under this heading stands 
the cystitis which accompanies inflammation of the prostate, and in 
many cases of gonorrhoea, and which often long outlasts the original 
disease. 3. Chilling of the skin, especially of the feet and abdomen, 
not unfrequently results in catarrh of the bladder. 4. Finally, a symp- 
tomatic vesical catarrh is one of the concomitants of growths and 
other grave disorders of the bladder. 
Anatomical Appearances.—In acute cases the mucous mem- 
brane of the bladder is reddened, swollen, and relaxed. Its surface is 
covered with mucus, mixed with detached epithelium and young cells 
in variable quantity. 
In chronic catarrh of the bladder this redness of the mucous mem- 
brane fades, and the color sometimes becomes a dirty gray. The mu- 
cous membrane is swollen and thickened. The submucous and inter- 
* Or is this annoying but harmless and transient malady due to acute irritation of 
the urinary passages by large sharp crystals of oxalate of lime, which may appear after 
drinking bad beer containing much carbonic acid ? I have often urged my students 
(but hitherto in vain) not to miss an opportunity of examining microscopically the 
urine passed during such an attack. CATARRH OF THE BLADDER—C OSTITIS CATARRHALIS. 
67 
muscular connective tissue, and the muscular fibres themselves, are 
also thickened and hypertrophied. Upon the inner surface of the blad- 
der there lies a gray puriform mucus, or a yellowish purulent secre- 
tion. The urine contained in the bladder is often decomposed, is of 
an acrid ammoniacal odor, and alkaline reaction. 
Chronic catarrhal cystitis rarely terminates in recovery. Far more 
frequently, as the malady advances, the proliferation of cells upon the 
free surface of the bladder is complicated with a vast cell-growth in 
the tissues of its mucous, submucous, and muscular coats. In this 
way catarrhal mucous ulcers and submucous abscesses are formed. 
Perforation of the vesical wall sometimes takes place. Should this 
occur after the bladder and its neighboring organs have become con- 
solidated by pericystitis, abscesses may form around the former, which, 
under favorable circumstances, may open either externally, or into the 
rectum, or vagina, and, in unfavorable ones, may break into the ab- 
dominal cavity. Another, but not a very common, result of vesical 
catarrh is diffuse suppuration. This generally occurs in cases of reten- 
tion of urine, and arises from the corrosive action of the putrid contents 
of the bladder upon its mucous membrane. The mucous membrane is 
then found to be extremely soft, discolored, and of a brownish-red or 
blackish hue. It is covered with dirty exudation, or broken down into 
a ragged, pultaceous substance, infiltrated with fetid pus. The mus- 
cular fasciculi are pale and tear easily. The submucous and intermus- 
cular tissue is infiltrated with ichorous matter; within the bladder 
there is a blackish-brown, chocolate-like liquid, of an intensely ammo- 
niacal odor, consisting of decomposed urine, blood, pus, and shreds of 
detached mucous membrane. In the worst cases the destruction at- 
tacks all the coats of the viscus, whose contents escape into the al> 
dominal cavity. 
An enormous thickening of the walls of the bladder, a common 
result of the hypertrophy of the muscular fasciculi already referred to, 
may be mentioned as a third termination of chronic vesical catarrh. 
This condition, however, sometimes arises in cases of long-standing 
impediment to the passage of the urine, without vesical catarrh. In 
such cases the wall of the bladder attains a thickness of from several 
lines to half an inch or more. The muscular fasciculi have grown into 
rounded bars, and form rib-like projections upon the interior, the ap- 
pearance of which has been compared with that of the right ventricle 
of the heart (vessi'e d colonne). According as the capacity of the 
bladder is increased or diminished by this hypertrophy, it is called ex- 
centric or concentric. In the former case the bladder may rise into 
the abdomen as far up as the navel; in the latter it may be shrunken 
to the size of a walnut. In some cases of chronic vesical catarrh, es- 68 
DISEASES OF THE BLADDER. 
pecially when associated with impediment to the exit of urine, the 
mucous membrane, pressing asunder the muscular fasciculi, is forced in 
between them, forming diverticuli. At first small and round, these 
latter ultimately expand into large bottle-shaped pouches, of the size 
of a fist. Their communication with the bladder is at first a narrow 
chink, which afterward becomes round and sphincter-like. Owing to 
the incompleteness with which these diverticuli are evacuated, they 
often become the seat of urinary deposit, and of incapsulated calculi. 
Symptoms and Course.—Acute catarrh of the bladder is some- 
times accompanied by febrile symptoms. As a rule, however, there is 
neither elevation of temperature nor acceleration of pulse. In quite 
recent cases, the patients complain of an undefined pain in the hypo- 
gastric region and perinaeum, which extends upward toward the kid- 
ney, and along the urethra toward the glans penis. In the more 
severe forms of vesical catarrh, pressure exerted upon the region of 
the bladder gives rise to pain. The hyperaemic and irritable vesical 
mucous membrane evinces the utmost intolerance against its contents. 
The collection of a few drops of urine in the bladder occasions the 
most urgent desire for its expulsion. The sphincter vesicas also is in 
a constant state of spasm, thus causing a vesical tenesmus quite analo- 
gous to that of the rectum already described in catarrhal rectitis. 
The patient scarcely has the urinal out of his hand, micturition is ex- 
tremely painful, and the few drops of urine which are expelled in short 
spirts from the urethra produce a feeling as though molten lead were 
running through the penis. As in all recent catarrhs, at first the 
quantity of mucus formed is small, so that but a few flocculi are 
scattered through the urine. Afterward the urine passed becomes 
turbid, and lets fall a mucous sediment in greater or less profusion. 
The disease may run its course, and get well in a few days; and that 
form caused by drinking fresh beer usually passes off within a few 
hours. In other cases it is more protracted, or passes into the chronic 
form. Sometimes the spasmodic contraction of the sphincter vesicae, 
which occurs in acute vesical catarrh, gives rise to complete retention 
of urine, and in old persons especially, owing to secondary diseases 
(oedema and fatty degeneration of the muscles of the bladder), a my- 
opathic palsy of the detrusors arises, which also causes retention. It is 
this circumstance which renders simple vesical catarrh a dangerous 
disease to old persons. In chronic catarrh of the bladder, the pain 
usually abates after a while, but the intolerance of the viscus against 
its contents and the constant inclination to urinate continue. The 
quantity of mucus increases considerably. At first a somewhat trans- 
parent stratum of mucus sinks to the bottom of the vessel, after- 
ward the urine becomes thick and turbid, and its sediment is more CATARRH OF THE BLADDER—CYSTITIS CATARRIIALIS. 
69 
Dpaque, and of white or yellow color. If the urine undergoes the 
so-called alkaline fermentation in the bladder—the secretion of the 
diseased mucous membrane, full of pus-cells and disintegrating epi- 
thelium, suffers a peculiar transformation (already mentioned when 
treating of pyelitis) forming a gelatinous coherent mass, which, when 
poured from one vessel to another, holds together, and can be drawn 
into long threads. 
In previous editions of my text-book I have stated that this pro 
fuse secretion of mucus often acted as a ferment upon the urine, giv- 
ing rise to an “ alkaline fermentation; ” that in this alkaline fermen- 
tation the urea was decomposed into carbonate of ammonia, and that 
new ammoniacal combinations formed, namely, urate of ammonia and 
phosphate of ammonia and magnesia (triple phosphate). I was 
compelled to add that the mucus contained in the urine did not al- 
ways act as a ferment; and that, in many cases of protracted vesical 
catarrh, I had constantly found the reaction of the urine to be acid. 
In the course of the last year, from observations made by Traube, 
as well as from investigations and experiments of my own, which have 
Deen published by Teuffel, in the Berliner Klinischen Wochenschrift, 
I have become convinced that this alkaline fermentation is not pro- 
duced by the mucus, but is owing to the presence in the urine of or- 
ganisms of a low grade, which probably usually find their way thither 
through the introduction into the bladder of dirty catheters. A high- 
ly interesting observation, made in my clinic, upon a young girl with 
palsy of the bladder, affords striking evidence of the correctness of 
this opinion. In the bladder of this patient, who for weeks had been 
catheterized with an ill-cleansed instrument, there had developed a 
most typical alkaline fermentation. Her urine, which was of a pun- 
gent ammoniacal odor and alkaline reaction, contained the thorn- 
apple-like crystals of urate of ammonia, large coffin-lid-shaped crystals 
of ammonio-magnesia-phosphate, with many vibriones and fungi of a 
low order; but it contained neither cellular elements nor large quan- 
tities of mucus. A careful research into the history of the case showed 
that the patient never had had any symptoms of vesical catarrh. 
Chronic vesical catarrh drags on for weeks, months, and even for 
years. It is a remarkable fact, and one difficult to explain, that it usu- 
ally is accompanied by loss of appetite and by derangement of diges- 
tion. The longer the disease has lasted, se much the less are the 
chances of a perfect recovery. 
Ulceration of the vesical mucous membrane is to be suspected 
when the sediment of the urine grows more and more purulent, when, 
from time to time, blood is discharged with the urine, and when a slow 
fever arises, which consumes the strength of the patient. He then 70 
DISEASES OF THE BLADDER. 
ultimately dies of vesical-phthisis, especially if it be associated with 
abscess about the bladder, or tedious suppuration from fistulous pas- 
sages. 
When catarrhal inflammation of the bladder passes over into dif- 
fuse suppuration, the patient becomes collapsed, his countenance ap- 
pears sunken, the pulse is small and thready, and the skin cold. The 
urine is discolored, of a brownish or blackish hue, contains shreds 
of mucous membrane, and exhales a fetid odor. Even though the wall 
of the bladder be not completely destroyed, and though there be no 
escape of its contents into the abdominal cavity, yet malignant peri 
tonitis soon develops, and the patient dies within a few days, of gen- 
eral prostration. 
Thickening of the wall of the bladder, from hypertrophy of its mus- 
cular fasciculi, may be detected when the viscus also is dilated, by the 
appearance above the symphysis pubis of a firm tumor, which some- 
times extends as high as the navel, or even higher, and which in fe- 
males is apt to be mistaken for a distended womb. Generally speak- 
ing, patients are unable to empty a bladder thus thickened and dis- 
tended, even though there be no obstacle to its evacuation in the vesi- 
cal neck or urethra. It is only the excess of urine (for which, so to 
speak, there is no room left in the already enormously overfilled blad- 
der) that is passed by the patient, or which runs from him involuntari- 
ly if the sphincter be palsied. Thus it may happen that, in the course 
of twenty-four hours, he may pass a normal amount of water, and still 
retain from two to six pounds or more in his bladder, which can only 
be removed by means of the catheter. In concentric hypertrophy, the 
bladder can be felt through the wall of the vagina or rectum, as a hard 
tumor, which may give rise to all sorts of blunders. In these cases, 
the bladder being incapable of distention, there is a constant desire to 
pass water, wrhich does not give the patient a moment’s rest; and, 
when the sphincter is relaxed, there is an incessant dribbling of urine. 
Treatment.—The causal indication, first of all, demands the pro- 
tection of the vesical mucous membrane from the injuries which have 
occasioned the disease. This is most difficult of accomplishment 
where rude catheterization or careless injections into the urethra have 
provoked catarrh of the bladder; as well as where the exhibition of 
cantharides and the like, or the long-continued use of fly-blisters, or of 
irritating ointments, or where persistent retention and decomposition 
of the urine are the irritants which are acting upon the mucous mem- 
brane. When it proceeds from the extension of an inflammation of the 
urethra or 'svoinb, the application of a few leeches upon the pcrinceum, 
or portio vaginalis, is advisable. If the apparent cause be cold, we 
should resort to a diaphoretic course of treatment. It is onlv when CATARRH OP THE BLADDER—CYSTITIS CATARRHALIS. 
71 
quite recent and of great intensity that the indications from the dis- 
ease itself call for local blood-letting, which then is better performed 
upon the perinaeum than above the symphysis. In most cases of acute 
catarrhal cystitis, hot poultices upon the abdomen, and general warm 
baths, suffice to relieve the symptoms and to bring about a favorable 
termination. Besides this, we must take care that the urine enter the 
bladder in as dilute a condition as possible; but, if we strictly forbid 
the use of all salt and spices, it will be useless to mix oleaginous or 
mucilaginous materials in the patient’s drink. It is best to let tlm 
patient drink the artificial or natural mineral waters—the Seltzer, 
Wildunger, Fachinger, or Gailnauer waters, or soda-water, or lime- 
water, mixed with equal parts of milk. The semina lycopodii have a 
peculiar reputation as a remedy for vesical catarrh (sem. lycopod. 
3 ss—to mel. despumat. 3 jss. f. elect, s. 3 j every two hours), as has 
also camphor, where the complaint arises from the abuse of cantharides 
(camphor pulv. gr. vj, emulsion of almonds, § vj). The employment 
of small doses of opium in the form of Dover’s powder, given at night 
before bed-time, or in the form of tinctura thebaica, in divided doses, 
is not only harmless, but a most efficient remedy against pain and 
vesical tenesmus. The more the pain abates, and the more copious 
the admixture of mucus and pus in the urine, so much the more ur- 
gently are the astringents indicated. The astringent most commonly 
employed is a decoction of the folia uva ursae ( \ ss. to 3 vj, a table- 
spoonful every two hours). The continued use of tannin is still more 
efficacious: I have obtained some most happy results from it in cases 
which seemed almost desperate. In the later stages of acute vesical 
catarrh, and still more in the chronic form of the disease, the balsams 
and resins, which are of such striking benefit in catarrh of the urethra, 
also do excellent service. To this class belong the oil of turpentine, 
tar-water, Peruvian balsam, and, above all, balsam copaiba, which may 
be given in capsules of gelatine. If these remedies fail, we should 
have recourse to local treatment. I have repeatedly made injections 
with lukewarm water, the temperature of which I gradually bring 
down to 65° F. after the manner recommended by Civiale, and cannot 
sufficiently praise their efficacy, especially in treatment of women. 
Astringent injections, among which solutions of nitrate of silver, sul- 
phate of zinc, and tannic acid, are recommended, should be used wit! 
greater caution; so too with injections of emulsion of balsam copaiba 
( 3 j to | j), the efficacy of which is greatly extolled by some phy- 
sicians. No modification of this treatment is demanded where ulcera- 
tion of the bladder is detected. Suppurative destruction of the vesical 
mucous membrane is quite insusceptible of treatment. In excentric 
hypertrophy, the bladder must be emptied by the catheter regularly 72 
DISEASES OF THE BLADDER. 
every eight or twelve hours, and an elastic bandage should be fitted 
to the abdomen. In concentric hypertrophy, on the other hand, the 
patient must be charged to retain his water as long as possible, in 
order gradually to dilate the bladder. It has also been proposed to 
introduce an elastic catheter, closed by a cork, into the bladder, by which 
i he urine may be evacuated every two or three hours. 
CHAPTER II. 
CROUPOUS AND DIPHTHERITIC CYSTITIS. 
Croupous and diphtheritic cystitis scarcely ever occur, excepting 
tn cases of severe infectious disease—in septicaemia, typhus, small-pox, 
and scarlatina—and are accompanied by similar inflammation of other 
mucous membranes. Far more rarely it arises after the abuse of can- 
tharides, after difficult labor, or in consequence of very intense irrita- 
tion of the bladder from decomposed urine. In this form of inflam- 
mation a coagulating exudation of variable thickness and consistence 
is formed, a portion of it infiltrating the tissues of the mucous mem- 
brane, while another portion lies upon its free surface. The process 
rarely extends over the entire surface of the bladder. More usually it 
is confined to detached streaks and spots of a rounded form. After 
separation of the diptheritic slough, there remain losses of substance 
in the mucous membrane. The disease can only be recognized when 
whitish membranous coagula are discharged with the urine, with 
symptoms of severe tenesmus. In the croupous cystitis which some- 
times follows the abuse of cantharides, or difficult forceps deliveries, we 
occasionally see large tenacious false membranes discharged with the 
urine. The treatment of croupous and diphtheritic cystitis should be 
similar to what we have already advised in cases of violent and acute 
catarrhal cystitis. 
CHAPTER III. 
PERICYSTITIS. 
Besides the inflammation induced by perforation of the bladder, 
and by abscesses and suppuration of its walls, another and independent 
inflammation, which we call pericystitis, sometimes involves the connec- 
tive tissue which surrounds this organ, and connects it with the adja- 
cent parts. It is of far less frequent occurrence than the inflammation 
which takes place about the rectum, and is hardly ever observed 
excepting as an accompaniment of infectious disease, typhus, the acute 
exanthemata and septicaemia. As a still greater rarity, it arises idio TUBERCULOSIS AND CARCINOMA OF THE BLADDER. 
73 
pathically without known cause, in persons previously in good health. 
This inflammation shows great tendency to pass into suppuration, and 
to destroy the parts involved; it is very apt to spread into the tissues 
which attach the bladder to the other pelvic viscera, and to the sides 
of the pelvis. The pus may ultimately penetrate into the bladder, 
rectum, vagina, or externally into the perinaeum. There is also a form 
of chronic pericystitis, which not unfrequently accompanies chronic 
vesical catarrh, and vesical ulceration, and which creates induration 
of the surrounding connective tissue, and causes firm adhesion of the 
bladder and surrounding parts. Sometimes this also results in the 
formation of an abscess. 
The affection is generally difficult of recognition, as the resulting 
painful tenesmus of the bladder, the dull, continuous pain in the pelvis, 
the repeated chills, and the complete retention of urine, which occur 
when the urethra or the ureters are obstructed by an abscess, furnish 
insufficient data for a diagnosis. A diagnosis can only be in some de- 
gree certain when an abscess projects above the pubis from the ante- 
rior surface of the bladder, presenting a spherical prominence, which 
does not disappear when the bladder is emptied; or else when we can 
feel a tumor in the perineum, or through the rectum or vagina. The 
treatment of pericystitis belongs to the province of surgery. 
CHAPTER IY. 
TUBERCULOSIS AND CARCINOMA OP THE BLADDER. 
Tuberculosis of the bladder usually appears as a complication of 
tuberculosis of the ureters, renal pelvis, and kidneys. Discrete and 
conglomerate tubercles also form in the bladder sometimes, which, upon 
breaking down, produce rounded or irregular excavated ulcers. Some- 
times (but more rarely than in the ureters and pelvis of the kidney) 
there is a diffuse caseous' degeneration of the mucous membrane, which 
.occasions wide-spread destruction. 
The symptoms of tuberculosis of the bladder are very similar to 
those of chronic vesical catarrh and vesical ulceration. The copious 
admixture of mucus and pus in the urine, which is often in a state of 
ammoniacal decomposition, the tormenting desire to urinate, the fre- 
quent haemorrhages from the bladder, which are the signs of excentrio 
and concentric vesical hypertrophy, also attend vesical tuberculosis. 
Our only positive data for a differential diagnosis are the coexistence 
of degeneration of the prostate or testicle, and the appearance of elastic 
fibres, or of larger bits of tissue in the urine, from which we may infer 
the destructive nature of the process which is going on. In a female 74 
DISEASES OE THE BLADDER. 
patient of mine, suffering from tuberculosis of the bladder, urinary 
passages, and kidneys, I found an irregular eroded ulcer, with peculiar 
edges, in the vulva, surrounding the orifice of the urethra. 
The treatment of tuberculosis of the bladder is identical with that 
of chronic vesical catarrh, but is generally quite unavailing. 
Carcinoma of the bladder is not common. Sometimes it is primary, 
sometimes it occurs secondarily to similar disease of the uterus or rec- 
tum. It assumes the form of scirrhus, more often the medullary form, 
but the villous cancer is more frequent than either. The former twt 
sometimes produce diffuse degeneration of the wall of the bladder, 
which, upon breaking down, forms communicating openings with the 
vagina, uterus, or rectum. Sometimes they take the shape of circum- 
scribed and even pedunculated growths. The villous cancer forms 
soft tumors, consisting of thin, delicate villous excrescences, which float 
in water, and which often become detached during life, giving rise to 
haemorrhage. 
The most prominent symptoms of cancer of the bladder are, like- 
wise, those of chronic vesical catarrh. Haemorrhage is still more com- 
mon than in tuberculosis. Diagnosis must depend upon the continuance 
and constant aggravation of the symptoms, the early appearance of a 
bad cachectic condition, in the discovery of cancer of other and espe- 
cially of neighboring regions, and, above all, upon microscopic exami- 
nation of the detached particles of the growth discharged with the 
urine. Treatment is in vain, and should be limited to a repression of 
the haemorrhage, the relief of any retention of urine which may arise, 
and the combating of intercurrent symptoms. 
CHAPTER V. 
HAEMORRHAGE FROM THE BLADDER HEMATURIA VESICALIS. 
Haemorrhage from the vessels of the bladder is often of traumatic 
origin. Sharp-edged stones, or foreign bodies, which have entered the 
viscus, are the usual causes of the bleeding. In hysterical women, we 
must be prepared for the most extraordinary devices. Not at all un- 
frequently, they introduce foreign bodies into their genitals, or into 
their urethra, which may be the cause of the haemorrhage. In other 
cases, ulcers of the bladder cause erosion of its vessels, and consequent 
bleeding. Neoplastic formations also, tubercle, carcinoma, but espe- 
cially the villous cancer, give rise to losses of blood. Very rarely, 
such haemorrhages depend upon the misuse of cantharides (haematuria 
toxica), or upon a haemorrhagic diathesis. Finally, an excessive dila- 
tation ,>f varicose veins of the part may result in their rupture, with STONY CONCRETIONS IN THE BLADDER. 
75 
an effusion of blood. Haematuria from this cause, however, is very 
rare, although the laity are much inclined to ascribe all haematuria 
to “ haemorrhoids of the bladder.” The conditions producing impedi- 
ment to the circulation and dilatation of the vessels are far less favor- 
able in the bladder than in the rectum; and, as a rule, this last and 
rarest of the causes of vesical haemorrhoids is not to be thought of, 
unless, after a scrupulous review of all the symptoms, all other forms 
of the disease can be excluded from the diagnosis. 
In haemorrhage into the bladder, the blood and urine are less inti- 
mately mixed than when the bleeding comes from the ureters, renal 
pelvis, or kidneys. The clots which form are also of larger size. Nev- 
ertheless, both these signs may prove fallacious, and hence diagnosis 
of the region whence the bleeding proceeds is often a matter of great 
difficulty. The attendant symptoms furnish the most trustworthy aids 
lo diagnosis of the source of the haemorrhage. Vesical haemorrhage 
is almost always accompanied by evidence of change of structure in 
the bladder. During the intervals between the bleedings the urine 
contains mucus and pus, and there is dysuria, etc. 
Our main task in the treatment of vesical haematuria should be to 
combat the original disease. In severe cases, cold should be applied 
to the region of the bladder, and large doses of tannin should be given. 
Where the bleeding threatens to exhaust the patient, we must have 
recourse to injections of cold water, with a solution of alum, sulphate 
of zinc, or nitrate of silver. In vesical haemorrhoids as well as other 
forms of vesical haemorrhage, cold injections have the best effect. 
CHAPTER VI. 
Etiology.—The manner in which stones form in the kidney and 
bladder is obscure. None of the current explanations of the process 
have shown themselves proof against the various objections made to 
them. Especially is this the case with the theory that these concre- 
tions are the result of a peculiar derangement of assimilation, of a 
diathesis, wherein uric acid, oxalic acid, the phosphates, etc., form so 
profusely in the system, and are eliminated from the blood through 
the kidneys in such quantities, that they are precipitated in the urinary 
passages. 
The explanation of Scherer is very plausible. He believes that 
the substances deposited in the urinary passages, and which sometimes 
form stones, are not eliminated from the kidneys in their present shape,, 
and only form through the decomposition which the urine undergoes 
STOUT CONCRETIONS IN THE BLADDER. 76 
DISEASES OF THE BLADDER 
during its abode in the urinary passages. This decomposition is similar 
to that which takes place in urine when allowed to stand exposed to 
the air. There is at first an acid fermentation. The coloring and ex- 
tractive matter of the urine become converted into lactic acid, so that 
the urea is liberated from its soluble combinations, and is precipitated. 
The acid fermentation is followed by an alkaline one. The urea is 
converted into carbonate of ammonia, and, by a combination of the 
ammonia with the phosphate of magnesia, an ammonio-magnesian 
phosphate is formed—the so-called triple phosphate. The ferment 
which excites this decomposition in the urine, while yet in the bladder, 
is the mucus resulting from vesical catarrh; but, according to Scherer, 
besides this, the mucus plays another and most important role in the 
formation of calculi, by forming a cement to hold the sediment together, 
since coagula of mucus form the nuclei of most stones, to which the 
deposits afterward adhere by accretion. According to the theory of 
Scherer, the formation of stones, which consist of a nucleus of uric acid 
enclosed in layers of phosphates, is as follows: As long as the acid 
fermentation of the urine continues, uric acid is precipitated; when, 
however, the catarrh has continued for some time, and, perhaps, has 
become aggravated by the presence of a calculus in the bladder, alka- 
line fermentation sets in, and the phosphates are thrown down. 
According to a very brilliant hypothesis of Mechel, the formation 
of precipitates is not requisite for the production of a urinary calculus. 
He claims that almost all stones consist originally of oxalate of lime, 
and are formed as follows: The mucous membrane of the urinary pas- 
sages becomes the seat of a specific catarrh, called by Mechel the 
“stone-forming catarrh” (stein-bildenden catarrh). In this catarrh a 
tough adhesive mucus is secreted, which has a tendency to acid fer- 
mentation, and in which oxalate of lime appears when such fermenta- 
tion occurs. At first this oxalate-of-lime mucus is of a gelatinous con- 
sistence. Gradually, however, it takes up more and more oxalate of 
lime from the decomposed urine, and thus, growing more and more 
firm, finally becomes stony. As long as the urine remains decidedly 
acid, the stone enlarges, from the accretion and petrifaction upon it of 
fresh layers of oxalate-of-lime mucus. If the urine afterward become 
alkaline, the stone no longer grows from “ apposition,” but from “ in- 
tussusception,” combined with a “ metamorphimus,” that is to say. 
the oxalate of lime is at first displaced by uric acid, and urate of am 
monia, and afterward by the phosphates. In this manner an oxalic 
calculus becomes converted into a phosphatic calculus. 
To attempt to point out all the flaws in each of these theories, and 
the various objections which might be advanced against them, would 
take too long. Among other matters, the fact still remains unex- STONY CONCRETIONS IN THE BLADDER. 
77 
plained, I hat hereditary tendency should play so decided a part in the 
formation of stone in the bladder. All the different generations of 
one family have been observed to suffer from the same sort of stone. 
Males are attacked by stone more frequently than females. The age 
of childhood is by no means exempt; indeed, children are rather liable 
to the formation of calculi and gravel in their urinary passages. In 
some countries, as in England, the malady is much more common than 
in others. Drinking-water which contains lime seems to have some 
influence in the production of stone, and the use of fermenting bever- 
ages containing carbonic acid is quite decided, at least as to its effect 
in producing oxalate-of-lime calculi. Any irritation which occasions 
catarrh of the urinary passages may give rise to stone in the bladder ; 
but it is quite enigmatical why many catarrhs last so long without 
forming concrements, while others give rise to their formation very 
soon. 
Anatomical Appearances.—Urinary calculi vary in size, shape, 
and chemical composition. The smaller, which are usually extremely 
numerous, we call “ gravel.” Their form and color depend mainly 
upon their composition. They may be classified as follows : 
1. Stones consisting chiefly of uric acid and its salts. . They are 
round or oval; usually of a reddish-brown color, very hard and heavy, 
and with a smooth or nodular surface. 
2. Stones of oxalate of lime. They usually present a nodulated, 
gland-like surface, whence their name, “ mulberry calculus.” They are 
very hard, and of a dark-brown or blackish color (through the admix- 
ture of transformed hasmatine). Yet some oxalate-of-lime stones are 
small and pale, and in form bear a strong resemblance to hemp-seeds. 
3. Stones consisting of ammonio-magnesia phosphates. They are 
of a whiter or grayer color; have a round or oval shape; are light in 
weight, and are of friable, chalky consistence. 
4. Calculi of cystine. These are rare. They are usually of a yel- 
lowish-white color. Their surface is smooth, more rarely nodular. 
5. Stones formed of xanthin, which are more rare even than the 
cystine calculi. They are very hard, of a yellowish-red color, and usu- 
ally have a smooth surface. 
6. Stones, consisting of various layers and strata of diverse com- 
position, are very common. Sometimes, the nucleus is of uric acid and 
the outer layers of oxalate of lime; more rarely, the contrary arrange- 
ment obtains. The most common form of stratified calculus is that in 
which a nucleus of uric acid or of oxalate of lime is enclosed in a hull 
of phosphates, or in which there are several alternate layers of these 
substances. 
Stones often lie free in the bladder, changing their position as the 78 
DISEASES OF THE BLADDER. 
attitude of the body is varied. Quite frequently, too, they are lodged 
and embedded in pouches and diverticuli in its wall. The mucous 
membrane is either in a state of catarrh or of catarrhal ulceration. The 
muscular tunic is usually hypertrophied; yet, if the calculus be smooth 
and light, all of these appearances may be absent. 
Symptoms and Course.—Sometimes, but not very often, patients 
with “ stone ” have a distinct perception that there is a foreign body 
in their bladder which changes its place as the posture of the patient 
is altered. A more important and constant symptom is pain about the 
bladder, which is aggravated by walking, driving, or riding, and which 
is relieved by lying upon the back. The pain darts along the penis to 
the glans, and causes the patient, especially if he be a child, to pull 
upon the prepuce, so that in children an oedematous thickening or ab- 
normal length of the prepuce is to be regarded as a characteristic, or, 
at least, as a suspicious sign of vesical calculus. During micturition, 
the stream of urine is often suddenly interrupted, owing to obstruction 
of the neck of the bladder by the stone. If the patient change his 
attitude, his ability to pass water is frequently restored. Even though 
the beginning of the act of micturition be easy and painless, yet, tow- 
ard its close, there is usually the most acute suffering. This is com- 
bined with aching in the testicles, thighs, and lumbar region, with 
spasmodic contraction of the anus, and even with general reflex phe- 
nomena. The whole of these symptoms, however, together with occa- 
sional haematuria, are insufficient to establish a diagnosis; and we 
should make it a rule never to pronounce a positive opinion until the 
presence of a stone has been reduced to a certainty by means of the 
sound. 
Treatment.—The possibility of dissolving large vesical calculi, by 
means of internal medication, must be pronounced as hitherto un- 
proved, although theoretically such possibility cannot well be denied 
Means have been proposed of rendering the urine alkaline, or else of 
increasing its acid reaction, according to the chemical constitution of the 
stone. The former task, as is well known, is far easier of accomplish- 
ment than the latter, as the carbonates and vegetable salts supplied 
to the system are discharged with the urine as alkaline carbonates, 
while it is quite difficult to augment the quantity of acid in the urine. 
Theoretically, the benzoic acid, which is excreted in the form of hippu- 
ric acid, is adapted for the solution of a phosphatic calculus. But the 
continued exhibition of this remedy in large doses is forbidden, owing 
to its pernicious action upon the digestive organs. The administration 
of tartaric and citric acid might also have a good effect in the solution 
of phosphatic calculi; but these harmless articles have never come 
into use. Indeed, as soon as a stone in the urinary passages has been STONY CONCRETIONS IN THE BLADDER. 
79 
diagnosticated, it is usual to administer alkaline carbonates, quite re- 
gardless of the chemical nature of the stone, and to send well-to-do 
patients to Vichy or Karlsbad, those springs having a world-wide 
reputation as remedies against lithiasis. Perhaps the benefit derived 
from this mode of treatment depends upon the effect of the remedies 
upon the vesical catarrh, which is one of the main causes of the affec- 
tion. According to Meckel's theory, the exhibition of the alkaline 
carbonates and salts of the vegetable acids is indicated, because the 
urine is thereby rendered alkaline, and the metamorphosis of a stone, 
consisting of oxalate of lime, or of uric acid, into a softer and more 
friable phosphatic calculus, is promoted. At all events, we strongly 
advise that the old method of treatment be adhered to, and that no 
new “ cures ” be adopted, based merely upon a priori reasoning. Be- 
sides the alkaline carbonates, and the basic phosphate of soda, of 
which about two drachms may be taken daily, the carbonate of lithia 
has of late obtained a great reputation as an antilithic, and is warmly 
recommended by many. I should attach little weight to such recom- 
mendations, were they based solely upon the theoretical ground that 
the carbonate of lithia has a solvent power of uric acid six times as 
great as that of bicarbonate of soda. But, as we have some reports, 
upon good authority, of good clinical results obtained by its use, I 
admit the propriety of making further experiment with this drug 
(lithiae carb. gr. j — v t. d.). The Wildunger, Vichy, or Karlsbad 
waters may also be used as a beverage. 
We have already discussed the mode of treating the catarrh and 
haemorrhage of the bladder to which calculus gives rise. The opera- 
tion for stone in the bladder is a matter for the surgeon. 
NEUROSIS OF THE BLADDER. 
We are still in need of considerable physiological light as to the 
normal innervation of the bladder, and to the process of micturition. 
It is difficult satisfactorily to account for the well-known facts that a 
healthy man is often unable to pass water when required to do so in 
the presence of a stranger who watches him, and that the first attempts 
of a novice to make water while on horseback or in a wagon are often 
attended with difficulty, while these things are easy enough to one 
who is accustomed to them. Nevertheless, our comprehension of the 
nervous disorders of the bladder will be facilitated if we classify them 
into motor and sensory neuroses, and subdivide the latter class into 
hyperaesthesia and anaesthesia, the former into hypercinesis and acinesis. 80 
DISEASES OF THE BLADDER 
CHAPTER VII. 
hyperaesthesia of the bladder. 
Hyperaesthesia of the bladder is most commonly seen in indi- 
viduals addicted to sexual excess, especially to onanism—a very mod- 
erate degree of fulness of the bladder causing in them a most intense 
desire to urinate—“ castus raro mingitIf they have not opportunity 
to indulge their inclination to pass water, they suffer pain over the 
bladder and along the penis. The power of retaining the urine is not 
generally impaired in such cases, the hyperaesthesia being pure and 
uncombined with motor disturbance. Sometimes, however, this irri- 
tability of the bladder is accompanied by a diminution of power in the 
detrusors; and it is not without reason that a strong stream of urine 
passes for a sign of chastity among the laity, and a languid dribbling 
one for a token of the reverse. Extreme hyperaesthesia of the bladder 
sometimes follows gonorrhoea. Patients are sometimes met with who 
are quite unfitted for their previous occupation, being unable to hold 
their water for over a quarter of an hour at a time, and are thereby 
reduced almost to desperation. This form of hyperaesthesia, perhaps, 
is always accompanied by a slight catarrh. The intolerance of the 
bladder against its contents is the most prominent symptom of this 
form of catarrh; and I have never noticed any excessive production of 
mucus. 
For the milder form of hyperaesthesia of the bladder, such as affects 
dissipated persons and onanists, I recommend cold river and sea baths, 
cold sitz-baths, and cold douches. The more severe forms, which re- 
main after cure of a gonorrhoea—the cold-water-cure, injections into 
the bladder, and other active procedures, proving ineffective—I have 
in some instances seen disappear rapidly and without trace under 
large doses of balsam copaiba. 
There are no well-authenticated observations of neuralgia of the 
bladder, that is, of painful excitement of the sensory nerves, which 
cannot be traced to irritation of their peripheral extremities. 
CHAPTER Y 111. 
Some persons can suffer the accumulation of a very large amount, 
of urine in their bladder without feeling an urgent inclination to evacu- 
ate it. This condition, however, is hardly to be regarded as a morbid 
one. On the other hand, it seems to me admissible to ascribe tlx1 
ANAESTHESIA OP THE BLADDER. ANAESTHESIA OF THE BLADDER. 
81 
enuresis nocturna (nocturnal wetting the bed) to an imperfect anies- 
thesia and diminished irritability of the vesical sensory nerves. This 
extremely distressing affection, for which the patient not unfrequently 
is subjected to the most abominable treatment, and which often de- 
stroys the happiness of families whose older children are afflicted by 
it, is usually classed with palsy of the bladder. Many cases of enu- 
resis nocturna as I have seen, however, I have never been able to per- 
ceive that the sphincter vesica failed in its duty during the day, or that 
the children had any dribbling of urine, nor when the inclination to 
urinate came upon them were they ever in great haste to reach the 
urinal. Indeed, there are only two possible ways of accounting for 
enuresis nocturna. Either the sensation to which a full bladder gives 
rise is too feeble to awaken the child from his normal sleep, or else 
the sensation is of its normal intensity, but the sleep is unusually pro- 
found. In the latter case it would seem as though nocturnal incon- 
tinence of urine occurred somewhat as do those well-known cases in 
which children sometimes fall out of bed in their sleep without awak- 
ening. In the cases which I have seen, especially in adult patients, I 
have not been able to discover such unnaturally profound sleep. For- 
tunately, it is rare for enuresis nocturna (which usually affects chil- 
dren, and often lasts up to the time of puberty) to continue after the 
twentieth year. Knowledge of this fact is of importance, the best 
means of comforting the patient and his relatives in their distress be- 
ing the communication of this intelligence. 
It is customary to deprive children, suffering from this affection, of 
all drink or liquid food during the evening hours, and to waken them 
during the night once or twice to make them pass water. There is no 
objection to be made to these measures, excepting that they scarcely 
ever do the least good. I must protest most earnestly, however, 
against the cruelty of whipping or otherwise punishing a patient with 
nocturnal incontinence, unless the wettings of the bed manifestly be 
the result of laziness. In families, but still more in boarding-schools, 
orphan asylums, poor-houses, and prisons, punishment for this offence 
is inflicted all the year long, generally without effect; and if we only 
take the trouble to listen to the shocking stories of “ piss-a-beds ” of 
the lower classes, it will be clear to any one that the inefflcacy of the 
punishment was not due to its want of severity. Without attempting 
any explanation of the fact, I will merely call to mind that the dread 
of going to sleep often has a soporific effect, the desire to do so the op- 
posite, and that, if one wishes to awake at a certain hour, the fear of 
oversleeping is injurious, while the confidence that one will awaken in 
time is beneficial. In the same way, we find that children with noc* 
fcurnal incontinence, who have been severely chastised the day before, 82 
DISEASES OF THE BLADDER. 
and who go to sleep in dread of further punishment, still awake in the 
morning with their bed wet through. On the other hand, if we can 
excite confidence in the use of some entirely inert medicine, for which, 
however we promise great things, so that the patient can go to bed 
hopefully, and without fear, he is often awakened in the night by the 
inclination to micturate, and remains for some time, or even perma- 
nently, cured of his affection. From time to time secret remedies for 
nocturnal incontinence, with testimonials as to their efficacy, are adver- 
tised in the newspapers. That such testimonials are not all inten 
tionally false, is certain; but it is equally certain that the success 
of the remedies is due more to the psychical impression made by the 
confident commendation of the article, than upon the medicinal effect 
of the article itself. We must never tire of again and again exciting 
the hopes of the patient, and of writing harmless prescriptions for him, 
of the value of which he must be assured. Even in little children, 
and still more frequently in grown persons, I have seen at first a tem- 
porary and afterward a permanent effect produced in this way, which 
amazed both the patient and his friends. I have usually ordered small 
doses of carbonate of potash, and recently, according to a suggestion 
of Trousseau's, one-fifth to one-third of a grain of pulv. herb, bella- 
donna, with equal parts of the extract. Other remedies, such as 
strychnine, cantharides, large doses of syrup, ferri iodidi, and injec- 
tions of irritating matter into the bladder, are objectionable. It is of 
importance, however, to pay attention to any indications which may 
arise from the special condition of the patient.1 
CHAPTER IX. 
IIYPERCINESIS OF THE BLADDER SPASM OF THE BLADDER CYSTO- 
SPASMUS. 
Violent contraction of the muscles of the bladder frequently arises 
in consequence of the irritation which foreign bodies, especially stones, 
create within it. Such spasm is usually accompanied by organic dis- 
ease of the viscus. However, since abnormal irritability of the motor 
nerves of an organ arising as a reflex symptom, in consequence of ex- 
citement of the sensory nerves of that organ from structural disease, 
is not usually counted among the neuroses, the term spasm of the 
bladder is not to be applied to such symptomatic contractions of the 
vesical muscles, but should be reserved to designate the abnormal con- 
dition of the motor nerves, which exists independently of any struc- 
tural alteration in the wall of the bladder. SPASM OF THE BLADDER. 
83 
Romberg divides the causes of spasm of the bladder into cerebral, 
spinal, and reflex. With regard to the first, I would call to mind the 
fact that the irritability of the sympathetic nerve, though independent 
of the influence of the will, is by no means entirely independent of 
the irritability of the fibres and ganglia of the brain. Mental emotions 
have a distinct action upon the sympathetic system; and just as the 
muscles of the skin contract under the influence of terror, producing a 
“ goose-skin,” so we often, under like circumstances, see violent con- 
traction of the detrusor urinae muscles, with intense inclination to pass 
water. So, too, in inflammation of the spinal marrow and in struc- 
tural disease of the brain, spasm of the detrusors occurs, according to 
Romberg—a fact which is not easy to explain, as the innervation of 
the detrusor is derived from the sympathetic; although, indeed, we see 
an analogous condition in the occurrence of vesical spasm from mental 
emotion. Vesical spasm is generally of reflex origin. In an irritable 
subject the impression upon the sensory nerves of the urethra, pro- 
duced by the introduction of a catheter, will provoke spasm of the 
sphincter vesica. In other cases, irritation of the rectum and, very fre- 
quently, irritation from the womb give rise to spasmodic contraction 
of the bladder. Finally, there are cases of vesical spasm which are 
merely local manifestations of a general neurosis, and must be ascribed 
to a morbidly exalted irritability of the entire nervous system, which 
we usually call hysteria. 
The symptoms of spasm of the bladder vary according as the af- 
fection involves the detrusor urinse or sphincter vesicse muscles. In the 
former case, a very slight degree of fulness excites intense desire to 
urinate. The patient can scarcely prevent a constant escape of water 
by closure of the sphincter; or else he is quite unable to do so, so tha t 
the urine is constantly flowing away—a condition generally termed 
enuresis spastica. On the other hand, when the sphincter muscle is in 
a state of spastic contraction, the patient can only pass water drop by 
drop, or in a very fine stream, and with great effort (dysuria spastica). 
Sometimes the closure of the sphincter is absolute, and there is com- 
plete retention of urine (ischuria spastica). Finally, the antagonistic 
muscles, both detrusor and sphincter, may be attacked simultaneously. 
A condition of great distress then ensues, in which, in spite of violent 
desire to void the urine, there is inability, more or less complete, to 
satisfy such desire. In these cases the spasmodic affection sometimes 
extends to neighboring organs, giving rise to spasm of the rectum, to 
tremors of the entire body, and occasionally to general convulsions. 
One characteristic of spasm of the bladder is the alternation of violent 
paroxysms and intervals of exemption. The former often last but a 
minute or two, although sometimes they last half an hour or more. 84 
DISEASES OF THE BLADDER. 
They recur at longer or shorter intervals, and usually cease as suddenlj 
as they have begun. 
Diagnosis of spasm of the bladder in its stricter sense demands 
caution, as its occurrence is somewhat rare, and as it is often extremely 
difficult to distinguish it from other maladies of that viscus. It is only 
when the latter can be excluded from diagnosis, after careful examina- 
tion of the urine, and scrupulous attention to the attendant symptoms 
of the case, and after we have assured ourselves by repeated sound- 
ing that there is no foreign body lodged in the bladder, that we are 
warranted in supposing tne existence of a pure vesical hypercinesis. 
Treatment of spasm of the bladder, first of all, demands removal 
of the exciting cause. In some instances, the cure of a fissure of the 
anus, or of a chronic hyperaemia or inflammation of the womb, consti- 
tutes the chief, or, indeed, only remedy, for vesical spasm. In other 
cases, it will subside if we can succeed in altering the nutritive con- 
dition of the patient, by a thorough modification of external relations, 
and thus quiet the morbid irritability of the nervous system. For the 
paroxysms themselves we should have recourse to warm baths, clys- 
ters of camomile or valerian tea, with the addition of a narcotic; and, 
above all, to the internal exhibition of opium. In addition to this, 
Pitha warmly recommends the cautious and gentle introduction of a 
wax bougie into the bladder. 
CHAPTER X. 
ACIHESIS OP THE BLADDER VESICAL PALSY CYSTOPLEGIA. 
Palsy of the bladder may involve the sphincter muscle, the detru- 
sor urinrn, or both of these muscles simultaneously. Contraction of the 
detrusor is not dependent upon volition, but arises reflexly from the 
stimulus of the urine collected in the bladder. Contraction of the 
sphincter, on the other hand, is subject to the will. Up to a certain 
point of distention, the tone of the sphincter suffices to counteract the 
action of the detrusor, which presses upon the contents of the bladder 
and strives to open its outlet. If this point be exceeded, the tone is 
overcome, and the sphincter requires the action of volition to keep it 
closed. From these physiological facts, the causes of vesical palsy be- 
come somewhat more comprehensible. In the first place, it is quite 
plain, both in structural disease of the brain and in grave febrile consti- 
tutional disease, in which the function of the brain is overthrown, why 
palsy of the sphincter should be a very common symptom, and why 
palsy of the detrusor should be somewhat more rare. In apoplexy 
and in typhus, the number of patients who wet their bed is greater PALSY OF THE BLADDER. 
85 
than that in which the use of the catheter is required. If, however, 
the paralysis finally extend from the cerebro-spinal system to the sym- 
pathetic; if the power of involuntary movement be also impaired; 
if the patient can no longer swallow; if the abdomen become tympa- 
nitic from palsy of the intestinal muscles ; the detrusor urinae also takes 
part in the paralysis, and the distended bladder rises above the sym- 
physis. There is another very common circumstance, however, which 
also contributes to the occurrence of incontinence of urine in cases of 
disease of this kind, namely (as happens in a variety of conditions of 
other peripheral organs), the overfilling and overflowing of the bladder 
(Kohlrausch) make no impression on the consciousness, and hence no 
impulse is derived from the will to contract the sphincter and to close 
the bladder. At the same time, however, it must be admitted that, in 
some cases of apoplexy and of severe typhus, palsy of the detrusor sets 
in early, and before there is any general palsy, and without our being 
able to account for this phenomenon. In disease of the spinal marrow, 
likewise, palsy of the sphincter is of far more common occurrence than 
palsy of the detrusor. Most paraplegic patients have to wear a urinal, 
in order not to wet themselves, because the conducting power of their 
spinal marrow is iftterrupted. The use of the catheter, on the other 
hand, is but seldom necessary, on account of palsy of the detrusor. 
However, the fact that such necessity does sometimes occur, perhaps is 
owing to the locality of the lesion. It seems to be the ganglia which 
transmit the impression from the sensory nerves of the bladder to the 
motor nerves. It is possible that, if that portion of the spinal cord be 
destroyed at which this transmission takes place, the detrusor will be 
palsied; on the other hand, that, if the lesion of the spinal marrow be 
above this point, transmission of impressions from the brain to the 
sphincter will be interrupted, while that from the sensory nerves of 
the bladder to the motor fibres of the detrusor continues unimpaired. 
The result of comparison of a large number of cases of this kind, which 
I have examined within the last few years, fully supports this hy- 
pothesis. 
Besides this form of vesical palsy, the cause of which is central, 
there are others in which the peripheral expansions of the nerves 
have suffered lesions, through which they are deprived of their function; 
although, indeed, it is generally out of our power to furnish anatomical 
proof of such structural disorder. 
Finally, there is a myopathic palsy of the bladder arising from dis- 
ease in the minute texture of the muscular fibres of the organ, and in 
the nerve-tips which terminate in them. The most common cause for 
this form of vesical palsy is the severe stretching of the vesical mus- 
cles, and their participation in the affections of the mucous membrane. 86 
DISEASES OF THE BLADDER. 
A distention of the bladder, which perhaps has occurred but once, and 
to which a mechanical obstacle to the discharge of the urine, or a false 
shame in some over-modest person, has given rise, may result in perma 
nent vesical paralysis. It may also proceed from a vesical catarrh, 
especially in aged persons, from implication of the vesical muscles in 
the disease. 
The symptoms of vesical palsy vary according to the muscles 
affected. When the palsy is complete and is confined to the sphinc- 
ter, the urine flows away involuntarily as soon as the bladder has be- 
come full enough to overcome the tone of the sphincter. When the 
paralysis is incomplete, the patient is able to resist the pressure of a 
somewhat fuller bladder, but he must hasten to find some befitting 
place to pass water, as his sphincter will fail of its office if he wait too 
long and the pressure increase. This incomplete palsy of the sphincter 
is of very common occurrence in conjunction with partial paralysis of 
the lower extremities, and is attributable to an incomplete interruption 
of conducting power of the spinal marrow. 
In palsy of the detrusor, the tone of the sphincter is not overcome 
by such a degree of tension of the bladder as, under normal conditions, 
would excite contraction of the detrusors sufficient to overcome it. 
Unless artificially emptied, the bladder is distended excessively, and it 
is only after the distention has reached an extreme point, or by the 
action of the abdominal muscles (where they are not paralyzed also), 
that a portion of the contents of the bladder is expelled. If the 
palsy be pure and uncomplicated, the patient can arrest or postpone the 
outflow of urine. When incomplete, the bladder does not become so 
full before evacuating a portion of its contents as it does in complete 
palsy. The patient, however, endeavors to assist the action of the 
detrusor, by bringing his abdominal muscles into play, so that he 
often breaks wind while passing water. In spite of all his efforts, 
he cannot eject a strong arched stream, but the urine dribbles verti- 
cally down between his feet. This form of incomplete palsy of the 
detrusor is chiefly seen in marasmic subjects, and individuals weakened 
by sexual excess. 
Finally, in patients in whom both sphincter and detrusor are pal- 
sied, the bladder is in a state of permanent over-distention, the tone 
of the sphincter yielding later than it normally should do. Every ad- 
dition made to the contents of the bladder induces a corresponding out- 
flow from it, and the patient is unable to hinder or to arrest this flow. 
The patient usually, indeed, is quite unaware that his bladder is full, 
and only seeks medical aid on account of the continual enuresis, and 
generally is greatly surprised when we evacuate the urine from the 
1,ladder, which often contains an enormous quantity of it. TALSY OF THE BLADDER. 
87 
In treatment of palsy of the bladder, the causal indication can rarely 
be met. Especially is this the case in the forms of it arising from dis- 
ease of the brain or spinal marrow. When it is due to immoderate 
distention of the organ, it is of importance to use the catheter assidu- 
ously, partly in order to prevent further distention, which might aggra- 
vate the palsy, partly to excite more vigorous contraction of the de- 
trusor, by the irritation which the catheter induces. In cases of in- 
complete palsy, instead of passing a catheter, JPitha recommends the 
introduction of a solid wax bougie as far as the neck of the bladder, 
claiming that “ the catheter ” relieves the muscles of all exercise, and 
thus encourages “ their indolence.” The indications from the disease 
call for the use of cold baths, douches, and clysters. If these fail, and 
if the source of the palsy be peripheral, we should proceed with due 
precaution to the injection of water into the bladder, which at first 
should be lukewarm, and afterward should gradually be reduced in 
temperature. If this be of no avail, the application of electricity, as 
recommended by Duchenne, will also prove ineffectual. We shall 
hardly find a well-authenticated case of cure of vesical palsy by the 
use of strychnine, which has also been recommended. 
ADDITION TO THE REVISED EDITION OF 1880. 
SECTION III. DISEASES OE THE BLADDER. 
1.—P. 82. 
I have now and then earned the thanks of an adult by recom- 
mending to him a contrivance which has been advertised in the 
newspapers. A bit of leather or caoutchouc, of the size of a bean, 
is to be pierced through its middle by a fine opening, through 
which the loop of an elastic band is to be drawn, so as to slide 
stiffly. Upon going to bed, the prepuce, having been stretched 
over the glans, is to be inserted into this loop, which must then be 
tightened just enough to close its orifice, but not closely enough to 
cause discomfort, and so that upon urinating the prepuce will be 
put on the stretch by the water which is held back. The patient 
will be awakened by 'the distention of the prepuce if he passes water 
during sleep, and may then take off his apparatus, confident that 
for that night his bed will not be soiled. One young man tells me 
that only since obtaining this contrivance has he ever dared to sleep 
awav from home. SECTION IV. 
DISEASES OF THE URETHRA. 
According to the plan of our book, we omit without notice all 
affections of the urethra pertaining to the department of surgery, and 
which are treated of in detail in surgical works, and shall merely de- 
scribe the inflammation of the urethra. 
CHAPTER I. 
VIRULENT CATARRH OF THE MALE URETHRA CLAP GONORRIKEA. 
Etiology.—The urethral mucous membrane does not undergo any 
specific change in gonorrhoea. The process which takes place in it is 
identical with that which arises in any other mucous membrane, under 
the action of other irritants, and bears the name of catarrh or blen- 
norrhoea. Nevertheless, gonorrhoea is a specific disease. Its course 
distinguishes it plainly from all other catarrhs which affect the urethral 
mucous membrane, or that of other regions. The difference is all the 
more especial in an etiological point of view, for a gonorrhoea never 
arises otherwise than by contagion, in spite of the persistent denial of 
some authorities, and the lying assertions of shame-faced patients. 
Of the nature of the virus of gonorrhoea we know as little as we 
do of that of small-pox or other infectious matter; but we do know 
that the matter exerts a specific influence upon the system—that it 
always produces a clap, never a chancre or syphilitic ulcer. True, 
opinions are still divided as to whether this disease is followed by 
secondary disorders, and by a general implication of the system; but 
even authors who still believe in metastatic gonorrhoea and gonorrhoeal 
constitutional infection now agree that the consecutive diseases are 
altogether different from the sequelae of syphilis, with which they have 
nothing in common. The gonorrhoeal virus is a contagium jixum, its 
vehicle is the secretion of the diseased mucous membrane, and it is GORORRIKEA. 
89 
only by contact of this secretion with a mucous membrane susceptible 
of infection that the complaint can be transmitted from one person to 
another, or from the mucous membranes of one organ to that of another 
in the same individual. As in other infectious disorders, between the 
time of infection and that of the outbreak of the disease there is a 
certain interval, known as the period of incubation. The length of 
this period is from three to eight days. The appearance of a gonor- 
rhoea as early as twenty-four hours after an impure coitus, or as late 
as three or four weeks afterward (Simon), if it occur at all, is to be 
regarded as a rare exception. Credulous persons will hit upon cases 
where the period of incubation has lasted longer still. Every physician 
who has had much to do with venereal patients, especially with patients 
from the better classes of society, will have found out that it is much 
easier for a patient to confess to excesses perpetrated six or eight 
weeks ago than to those of which he has been guilty but recently. 
The more reason he has to be ashamed of himself, so much the more 
is he disposed to antedate his delinquency. Least of all are married 
people to be trusted in this respect, and their assurance that “ they 
would just as lief confess to sins of a week’s standing as those of six 
weeks ” is not to be relied upon. 
Contact of a mucous membrane with gonorrhoeal virus does not 
always result in infection. Indeed, the susceptibility to contagion 
varies greatly in different individuals. Daily experience teaches us 
that two men may have intercourse with a woman having virulent 
fiuor albus, one of whom may contract gonorrhoea, while the other may 
escape. We do not know by what causes this predisposition to gon- 
orrhoeal infection is increased or diminished. It cannot be attributed 
either to the greater or less degree of venereal excitement during 
coitus, nor to incomplete introduction of the penis, nor to the degree of 
“ acclimatization ” of the exposed individual to the person of the other. 
It is idle to indulge in unsupported theories upon this question. We 
do not even know why it is that, of all the various mucous membranes 
of the human body, only that of the urethra, those of the female gen- 
itals, the eye, and in some degree those of the rectum, are susceptible 
of gonorrhoeal inflammation, while all others are quite proof against 
the infection. Even different portions of one mucous membrane ex- 
hibit different degrees of susceptibility to gonorrhoeal poison. Al- 
though the infecting secretion acts first upon the orifice of the urethra, 
the gonorrhoea is most apt to develop in the fossa navicularis. 
Anatomical Appearances.—Opportunities of making post-mor- 
tem examination of patients with gonorrhoea are rare, and it was long 
ere we could obtain positive knowledge that the seat of gonorrhoea 
was the urethra. In recent cases of the disease the mucous membrane 90 
DISEASES OF THE URETHRA. 
is reddened, injected, swollen, and coated with punform secretion. It 
is a matter of importance for the prognosis and treatment of gonorrhoea 
to know that, in the first and second week of the complaint, the ana- 
tomical changes only involve the anterior portion of the urethra— 
the fossa navicularis—which is very richly endowed with glands; 
and it is not until afterward that the lesions extend to the mem- 
branous and prostatic portions of the urethra. In very severe cases, 
the inflammation of the mucous membrane is accompanied by inflam- 
mation and infiltration of the corpora cavernosa, which not only dimin- 
ish the calibre of the urethra, but render a uniform enlargement 
of the penis during erection impossible. Far more rarely submucous 
abscesses form in severe gonorrhoea, or, what is a much more serious 
accident, inflammation and suppuration of the prostate occur. The 
lymphatics of the penis may also become implicated in the inflamma- 
tion, and sympathetic swellings of the inguinal glands are not unfre- 
quent complications of the disease, although suppuration in such cases 
is quite exceptional. 
The most common complications of gonorrhoea are inflammation 
of the epididymis and catarrh of the bladder. These affections both 
make their appearance about the end of the first or second week, that 
is, at the time when the pars prostatica becomes involved in the in- 
flammation, and when opportunity is afforded for the extension of the 
inflammation to the vasa deferentia and neck of the bladder. 
In chronic gonorrhoea the mucous membrane is swollen and stud- 
ded here and there with fungous granulations. Its follicles are en- 
larged and its secretion is more mucous. In many cases, circumscribed 
spots, and sometimes extensive tracts of the submucous tissue, are 
hypertrophied, indurated, and firmly attached to the mucous mem- 
brane. It is to this that most urethral strictures are due. 
Symptoms and Cottkse.—The commencement of a clap is an- 
nounced by an itching sensation at the mouth of the urethra, which 
does not amount to pain, accompanied by a scanty secretion of a trans- 
parent, clear mucus. At the same time the meatus seems slightly 
reddened, and its lips are usually agglutinated by the dried secretion, 
a thin scale of which is also spread over the tip of the glans. An in- 
creased desire to pass water then sets in; the patients often have noc- 
turnal pollutions, and during the day suffer from frequent erections, 
which often induce thoughtless persons to indulge in further excesses. 
Gradually, generally in the course of a day or two, the sense of itch- 
ing in the urethra gives place to a burning pain, extending from the 
meatus to the fossa navicularis. This pain increases, and, during the 
act of micturition, is extremely severe. The inclination to pass water 
becomes more frequent than before, so that -with each effort a few GONORRHOEA. 
91 
drops only are voided, and those with the utmost suffering. The se- 
cretion, formerly scanty, tenacious, and transparent, gradually becomes 
more copious, thicker, and purulent, making yellow, stiff stains upon 
the patient’s linen. The lips of the meatus are red and swollen ; the 
entire penis also, especially the glans, is more or less swollen, and the 
urethra throughout its entire length is sensitive to pressure. At this 
period, the prepuce, irritated by the discharge, or else owing to propa- 
gation of the irritation, often becomes excoriated and oedematous ; so 
that the product of a balanitis is added to the secretion which flows 
from the urethra. If the outlet of the prepuce be small, a phymosis is 
very apt to occur, or paraphymosis, if the patients imprudently re- 
tract the prepuce behind the glans. At this stage erections occur 
with still greater frequence than at the outset of the disease; but the 
stretching and expansion which the organ undergoes during the pro- 
cess cause the most intense pain to the patient, deprive him of his 
rest at night, and induce him to resort to the wildest expedients to 
arrest his suffering. All these symptoms, the painful micturition, the 
flow of thick, yellowish-green pus, the redness and swelling of the 
urethra, and the painful priapism, usually continue to increase for a 
period of about eight or fourteen days. After attaining their acme, 
the pain upon micturition usually begins to abate, the redness and 
swelling of the meatus gradually subside, the erections are less fre- 
quent and less painful; but at this time the discharge is often more 
profuse than ever, so that the laity regard this as a favorable sign, 
and think that the “ clap must be made to run ” in order to relieve 
their suffering. 
After a lapse of a week or two the discharge gradually diminishes, 
becomes mucous, and may finally cease altogether in the course of five 
or six weeks without any treatment whatever, as has been proved by 
the results of homoeopathic practice. Much more frequently, however, 
there remains a stationary scanty mucous discharge which may last for 
months and years. During the day, if the intervals between the acts 
of micturition be long, this secretion glues the lips of the urethra 
together. When the patient awakens in the morning, a tolerably 
large drop of it has collected, and runs out between the adherent lips 
of the meatus as soon as they are separated. The stiff stains upon 
the linen are now of a more grayish color, although generally there is 
a small but distinct yellow spot in their middle. A discharge of this 
kind is called “ gleet ” or “ goutte militaire.” If, while it lasts, tho 
patient exposes himself to further exciting cause, the gonorrhoea not 
unfrequently breaks out again; that is, the pain does not return 
but the discharge once more becomes abundant and more purulent. 
Excess in wine or sexual intercourse is the most apt to cause such 92 
DISEASES OF THE DRETI1RA. 
relapses, but exposure to cold and over-exertion seem to have a similar 
effect. 
The symptoms and course of gonorrhoea present a good deal of 
variation. First of all, they vary in the degree and duration of the in- 
flammatory symptoms, and the pain, redness, and swelling of the ure- 
thral mucous membrane. A classification of the affection into various 
species, such as the erysipelatous, synochal, erethetic, and torpid, has 
been based upon this variation, without, however, any practical advan- 
tages being derived from such arrangement. Generally the inflam- 
matory symptoms of a first clap are far more severe than those of the 
second and third, but there are exceptions to this rule. In severe 
gonorrhoea, with intense hyperaemia, rupture of small blood-vessels 
with haemorrhage often occurs, imparting a reddish or brownish hue to 
the discharge. Although this haemorrhage is not at all dangerous, yet 
the “ bloody,” or “ black,” or “ Russian clap,” has a terrible reputation 
among the laity. The flexion which the penis undergoes during erec- 
tion (known as chordee) is of greater moment. These flexions result 
from a loss of elasticity on the part of the inflamed portion of the cor- 
pus cavernosum, which prevents it from participating in the enlargement 
of the penis. It sometimes happens that the inflamed portion of the 
corpus cavernosum undergoes permanent atrophy, and that thenceforth 
the penis when erect is distorted. Sometimes, too, when the atrophy 
extends entirely through the corpus cavernosum at one point, ever 
afterward erection is only practicable from the root of the organ up to 
that point. Among the less serious accidents which may occur during 
gonorrhoea, is the formation of small abscesses about the urethra. 
Severe pain, increased by pressure, and a hard circumscribed swelling 
about the urethra, are the characteristic signs of the formation of such 
abscesses. They nearly always run a favorable course, whether they 
perforate externally or into the urethra. A much more dangerous but 
also a more rare complication of gonorrhoea is inflammation of the 
prostate. We may infer that the prostate is the seat of hyperaemic 
swelling, from the unpleasant sense of pressure in the perinaeum 
of which the majority of patients with gonorrhoea complain, as well as 
from the enlargement and induration of the prostate so often seen in 
old persons, chiefly in those who have had gonorrhoea in their youth. 
If the prostate be much inflamed, there is an extremely unpleasant 
sense of pressure, or a dragging, throbbing pain in the perinaeum, extend- 
ing into the bladder and rectum, which is greatly aggravated upon the 
passage of the urine or the faeces. Both in the perinaeum and through 
the rectum we can feel a tumor of varying size. Micturition becomes 
more and more difficult, and the dysuria may increase to absolute 
retention of urine. If the inflammation go on into suppuraf ion, an al> GONOKREKEA. 
93 
scess forms, which may point either externally or else inwardly, giving 
rise to symptoms of the most serious and varied character, for further 
description of which we refer to the text-books of surgery. Gonor- 
rhoeal lymphangitis and lymphadenitis present no extraordinary features. 
Resolution is the more frequent termination of a gonorrhoeal bubo. 
Suppuration of such a bubo indeed is so rare an occurrence, that it 
always should excite suspicion of the existence of a glandular chancre. 
Finally, gonorrhoeal orchitis, the most common of all the complications 
of this disease, is undoubtedly the result of propagation of the inflam- 
mation from the urethra to the seminal vesicles and vas deferens. 
At first the pain in the cord, testicle, and epididymis is not very 
severe, the patient complaining rather of a sense of weight in the 
testicle. Soon, however, the pain augments, and the epididymis, which 
is the chief seat of the inflammation, becomes very sensitive to the 
slightest touch. To the hard irregular tumor formed by the inflamed 
epididymis there is soon added an effusion into the tunica propria tes- 
tis, so that in a few days the testis may become as large as a goose- 
egg or fist, or even larger. The enlarged testicle is less movable 
than before, as the thickened and indurated spermatic cord has become 
less flexible than when healthy. The greater the effusion into the 
tunica vaginalis becomes, so much the more does the tenderness, 
upon pressure of the swollen organ, concentrate itself at the point 
where the epididymis is situated. Generally the disease terminates in 
resolution, but a slight induration of the epididymis almost always 
remains for some time, or even during life, occasionally proving an 
object of groundless hypochondriacal anxiety to the patient. Some- 
times, especially in persons suffering from varicocele, the gonorrhoeal 
orchitis recurs several times. The discharge from the urethra almost 
invariably subsides during the continuance of the inflammation, but as 
invariably reappears when the orchitis abates. Far more rarely, the 
affection terminates in suppuration, tuberculous degeneration, or in- 
duration. 
For some time the term gonorrhoeal metastasis has been applied to 
a variety of morbid processes affecting individuals who had had gon- 
orrhoea. In the majority of cases, it cannot be proved that there is 
any relation of cause and effect between these affections and the dis- 
ease in question. Gonorrhoeal ophthalmia and the well-known inflam- 
mation of the joints known as gonorrhoeal rheumatism, or gonorrhoeal 
gout, are the only ones of these maladies in any sense of the word 
entitled to such name. The former proceeds from a direct transfer of 
the virus to the conjunctiva, and is one of the most dreadful con- 
sequences of the disease. I have seen an instance in which a married 
man, having contracted a clap, abstained from all sexual intercourse 94 
DISEASES OF THE URETHRA. 
with his wife, but communicated a gonorrhoeal ophthalmia to her and 
to his child, whereby both mother and child lost their sight, the man 
escaping. That the inflammation of the joints above referred to ac- 
tually stands in genetic relation to gonorrhoea may be inferred from 
the fact that it occurs in individuals who have not been exposed to 
any other cause of disease; that it attacks patients who have never 
suffered from such symptoms before, and who never have them after- 
ward, and that it sometimes recurs with every gonorrhoea which the 
patient contracts, and disappears as the gonorrhoea subsides. This 
arthritis has no particular effect upon the progress of the main disease, 
nor do the anatomical lesions of the affected joint, or the symptoms 
and termination of the affection, present any peculiarity. The seat 
of gonorrhoeal arthritis is almost always in the knee, more rarely the 
foot or hip-joint, never in the joints of the upper extremity. 
Treatment.—The only reliable prophylactic measure which I can 
recommend is the avoidance of all danger of infection. I do not feel 
called upon to make further suggestions for the benefit of dissolute 
men, who merely desire to continue their irregularities unpunished. 
We shall spare ourselves any detailed enumeration of the various 
methods and means employed in the treatment of gonorrhoea, and con- 
fine ourselves to a description of the most important and desirable 
ones. 
The best therapeutic results are to be obtained in a perfectly recent 
gonorrhoea before the symptoms have become severe, as it then gen- 
erally can be cured in a few days. In order that the number of trac- 
table cases of this kind may be increased—for it is only now and then 
that we see one—we should make all our patients aware that the dis- 
ease is continually increasing in extent and violence, so that each day 
of delay only makes it worse. Such opinions, delivered by physicians 
who have the confidence of that portion of the public among whom 
gonorrhoea is most common, have marked effect. It is scarcely 
credible how coolly and with what cynicism these people talk of their 
debaucheries and their consequences, what an extensive knowledge of 
the subject is shown by some of the laity, and how much one can learn 
from them. For instance, in Magdeburg, where the innumerable com- 
mercial travellers of the various mercantile houses meet annually at the 
hotels, report is always made as to whose pox has relapsed, and who 
remained cured, and wThat injections have answered the best for gon 
orrhoea, etc. Only a short time after I had begun to prescribe injec 
tions of tannin in recent claps, where the symptoms were still trifling 
(and I had been very successful with this treatment), the number of 
recent gonorrhoeas which sought my aid multiplied considerably. 1 
usually ordered three powders, each of which contained half a drachm GONORRH(EA. 
95 
of tannin. One of these was to be dissolved in a half pint of red wine, 
and the solution was to be used as an injection. If the result was un- 
satisfactory, the two other powders were to be put into the same quan- 
tity of wine, and the injection to be continued with this doubly-strong 
solution. It has repeatedly happened to me that a patient has pulled 
one of these very powders out of his pocket which I was about to pre- 
scribe for him, and which he had obtained from a friend, and has asked 
whether he might try that first. In order that these injections may be 
of service, we must give them once or twice ourselves, or let a skilled 
assistant give them. If we neglect this precaution, it often happens 
that the liquid does not enter the urethra at all, or perhaps is merely 
thrown under the prepuce, and flows back past the syringe. Gon- 
orrhoea syringes must be so small that they will not hold more liquid 
than the urethra is capable of containing. It is then unnecessary to 
compress the posterior end of the canal. The best plan is to have a sup- 
ply of suitable syringes at some particular instrument-maker’s, and to 
give them some unobjectionable name, since many patients, feeling too 
much embarrassed to ask for a “ penis-syringe,” get an “ ear-syringe,” 
or other unsuitable article instead. I have cut short a large number 
of recent virulent gonorrhoeas in two or three days by injection of 
tannin. Even where the disease is not quite recent, but where the in- 
flammation is not very violent, I have often used the tannin, and ob- 
tained excellent results, although the cure was less rapid. I have no 
idea of claiming especial qualities and merits for tannin; but I have 
employed this article much more often than nitrate of silver, sulphate 
of zinc, sugar of lead, and other astringents. I have never had occa- 
sion to prescribe the strong solution of nitrate of silver (gr. x—xv. to 
§ j), for its effects can hardly be better than those obtained from tan- 
nin, and since even its introducers admit that it sometimes causes 
severe and even violent symptoms, such as I have never seen in my 
treatment. When the inflammation is very severe, it is well to wait 
for its abatement before resorting to injections. A restricted but not 
over-restricted diet and a strong cathartic of calomel and jalap art' 
also advisable in such cases. The customary prescription of milk ol 
almonds makes the patient unnecessarily conspicuous, without being 
of the slightest benefit to him. When there is extreme tenderness to 
pressure along the urethra, but only then, we should apply from ten to 
fifteen leeches to the perinaeum. Cold applications are also service- 
able ; but, to do good, they must be kept up continuously. Cold com- 
presses must be changed industriously, or the patient must be allowed 
to sit for a long time in a sitz-bath. Compresses which are allowed to 
remain until they grow warm, and sitz-baths continued for a short 
period only, merely increase the tendency to erection, and aggravate 96 
DISEASES OF THE URETHRA. 
the pain. After the inflammation has subsided somewhat, we should 
proceed to the use of injections of tannin in these cases also. The 
fact that their .action is less certain in this stage of the disease is 
probably because, when of long standing, the inflammation is no longer 
confined to the more accessible anterior portions of the urethra, but 
has spread into the posterior regions, where an injection can reach it 
less easily. In tedious cases, in which injections of tannin are more 
apt to fail, I have often made use of the other astringents above men- 
tioned, without, however, obtaining any better success. When astrin- 
gent injections remain without effect, it is time to have recourse to cu- 
bebs and balsam of copaiba. There is no doubt but that these articles 
are also efficacious in the earlier stages of the disease, and that many 
a clap has been “ aborted ” by their use in free doses. If, however, we 
can succeed without them, it is better to do so, rather than to subject 
the stomach and intestine to the action of these noxious substances. 
It not unfrequently happens that protracted gastric and intestinal 
catarrhs result from the abuse of cubebs and balsam of copaiba. More- 
over, the abortive action of these remedies, according to my experience, 
is often merely temporary—much oftener than is that of injections— 
so that patients, who have supposed themselves well of their disease, 
in a few days have as free a discharge again as they had before using 
the medicine. The idea, that strictures are more liable to occur under 
the use of injections than where gonorrhoea is treated by internal 
medication, is based upon an error. It is true that formerly a great 
many patients who were treated by injections had strictures after- 
ward ; but the reason of this was, that injections were only resorted 
to in very chronic cases of the disease, while cubebs and copaiba were 
given in the more recent ones. 
The long duration of a gonorrhoea is the most frequent cause of 
strictures. The early use of injections, and consequent speedy stoppage 
of the blennorrhoea, is the best preventive of their occurrence; just as 
permanent thickening of the conjunctiva is best averted by the early 
and active applications of astringents. Where cubebs and copaiba are 
used, it should be in full doses, which, however, must not be kept up 
too long; that is, not longer than three or four days after the discharge 
has ceased. Large doses are relatively better borne than is the long- 
continued administration of smaller ones, while the latter do not ac- 
complish the object better, even when kept up for weeks. Cubebs 
alone can be taken very well, if finely powdered and stirred up in 
soda-water. Four or five heaped teaspoonfuls of the powder may be 
given in the day. Balsam of copaiba is best prescribed in gelatine 
capsules, four, six, or eight of which may be taken daily. Should we 
wish to combine the two articles, we recommend the pills of cubebs. GONOERHffiA. 
97 
3 ss., bals. copaibas 3 ij, cera alba q. s. u. f. pil. 120. About three 
boxes of such pills will be required; ten of the pills to be taken at 
first three times a day, and afterward four times a day. The gelatine 
capsules, containing extract of cubebs and balsam of copaiba in com- 
bination, are also to be recommended. If there should be a diarrhoea, 
with severe scalding pain about the anus, or if an eruption—spots of 
roseola—appear upon the face and body (which is not uncommon), the 
use of the medicine must be suspended. 
The results of treatment in a recent gonorrhoea are most satisfac- 
tory; that of an old inveterate gleet, however, is quite the reverse, 
and the longer it has lasted so much the worse will the prognosis be. 
Before all else, we must satisfy ourselves, by the introduction of a 
catheter, as to the existence or non-existence of an urethral stricture. 
When there is such a stricture, the inflammation often lurks just be- 
hind it, and no benefit is to be expected from the use of injections 
which cannot well reach the affected point, until the stricture has been 
relieved by the use of bougies. Where there is no stricture, or where 
the existing stricture has been dilated, we should inject a strong solu- 
tion of tannin or of nitrate of silver, and, when this fails, should intro- 
duce a sound, smeared with an ointment of lunar caustic, into the ure- 
thra. Guthrie’s unguent, opthalmicum magicum may also be employed 
(arg. nit. gr. ij—g. x, ung. cetacei 3 j, liq. plumb, gtt. xv.) 
The haemorrhage which sometimes occurs during gonorrhoea scarcely 
ever requires particular attention. If it be exceptionally profuse, we 
may apply cold, or endeavor to stanch the bleeding by compression 
of the point whence it proceeds. In order to prevent the painful erec- 
tions which occur chiefly during the night, the patient should eat but 
very little food toward evening, and, above all, should avoid drinking. 
If, nevertheless, his rest be disturbed, and if the customary popular 
remedies fail of effect (such as walking barefoot about the room or 
jumping from a chair), we may give a Dover’s powder in the evening. 
I have no personal experience of the effect of lupuline, which has also 
been recommended. If chordee develop, apply leeches (but rather to 
the perineum than to the penis), and give an opiate at night. Ab 
scesses forming in the urethra require poultices, and the prompt punc- 
ture of any fluctuating point. Upon the first signs of inflammation of 
the prostate, apply a large number of leeches to the perinmum, and, 
after the leeches have fallen off, encourage the bites to bleed, by the 
application of hot stupes. Sometimes the leeching has to be repeated. 
Internally give calomel with opium, in divided doses. Whether this 
last prescription really be of service I do not venture to say. The 
catheter is never to be applied without the utmost caution, and in 
some cases it must be laid aside altogether for a while. If the 98 
DISEASES OF TIIE URETHRA. 
retention of urine be absolute, puncture of the bladder may be neces- 
sary. Fluctuating abscesses of the perinseum are to be opened 
promptly. For further information regarding inflammation of the 
prostate, we refer to the books of surgery. 
The lymphangitis and lymphadenitis usually subside quickly under 
simple rest in bed. If, after the gonorrhoea has entirely abated, there 
still remain a swelling in the inguinal region, we should resort to com- 
pression, a practice which has often and very improperly been applied 
to syphilitic buboes. If the patient be walking about, let him wear a 
hernia truss with a large pad. If he be confined to his bed, a heavy 
bag of shot, which, not being quite full, yields and makes a uniform 
pressure over the tumor, is the best means of compression. In order 
to avert gonorrhoeal orchitis, it is desirable to cause all patients with 
gonorrhoea to wear a suspensory bandage, to which suitable appliances 
may be attached to save their linen from becoming soiled. This latter 
precaution is necessary, as the envelopment of the penis in rags, made 
fast with bandages, does harm. We should select and apply the sus- 
pensory ourselves, so as to make sure that it does not “ bind ” any- 
where. Badly-fitting ones, of course, do more harm than good. Upon 
the first sign of orchitis the patient must betake himself to bed, and 
there remain, with a wedge-shaped cushion between his thighs, upon 
which the scrotum is to be so arranged that there shall not be the 
slightest strain upon the spermatic cord. Besides this, a large number 
of leeches should be applied to the cord, the after-bleeding from 
which should be encouraged. The pain almost always subsides after 
the depletion. When this has been accomplished, hot poultices must 
be applied night and day to the scrotum, and, should there be any 
fresh attack of pain, the leeching must be repeated. Much benefit 
has also been ascribed to the internal exhibition of calomel combined 
with opium in this affection. Compression of the testicle, by means of 
which abatement of the pain and rapid subsidence of the tumor are 
sometimes effected, is a procedure which often fails, and which, accord- 
ing to my experience, generally can be dispensed with. 
CHAPTER II. 
NON-YIKULENT CATARRH OF THE URETHRA. 
Simple non-virulent catarrli of tlie urethra is a somewhat rare af- 
fection. Local irritation of the urethra by foreign bodies, irritating 
injections, sexual excess, especially coitus practised during the men- 
strual period, are its most usual causes. A symptomatic catarrh also 
accompanies urethral ulcers, particularly urethral chancres. In other XOX-YIRULEXT CATARRH OF THE URETHRA. 
99 
instances, tlie inflammation of other organs, as the prostate or bladder, 
spreads to the urethra. 
The symptoms of non-virulent urethral catarrh are swelling and 
redness at the meatus, painful burning along the urethra, especially 
during micturition, and the discharge of a scanty mucous secretion. 
All this usually subsides in a day or two without medical aid. The 
more intense and protracted catarrh which accompanies a urethral 
chancre however, is attended by purulent discharge, and may easily 
be mistaken for a gonorrhoea. We shall have more to say as to the 
distinction between the two conditions, in treating of urethral chancre. 
Avoidance of the causes from which the affection proceeds, and 
removal of the conditions by which it is kept up, are the sole treatment 
requisite for this unimportant and mild disease. 
Occasionally a simple catarrh of the urethra only shows itself by 
adhesion of the lips of the urethra in the morning. Then the patient, 
annoyed at the idea of having a gleet, presses and squeezes the penis 
till he brings out a little mucous discharge. This may be relieved by 
warning him against thus irritating his urethra. DISEASES OF THE SEXUAL ORGANS. 
A.—DISEASES OF THE MALE SEXUAL ORGANS. 
In this section we shall speak only of spermatorrhoea and impo- 
tence, leaving the other diseases of the male sexual organs to surgery. 
CHAPTER I. 
NOCTURNAL AND DIURNAL POLLUTIONS SPERMATORRHOEA. 
From the occurrence of puberty till the virile power has been lost, 
most men have occasional nocturnal emissions, without our being able 
to say that they are a sign of disease. If the emissions are repeated 
at unusually short intervals, if they come without lascivious dreams, if 
mey are accompanied by incomplete erections, or if they occur during 
the waking state (diurnal pollutions), the condition is a pathological 
one. 
The persons who consult physicians on account of pollutions are 
chiefly young men from seventeen to twenty-five years of age. They 
complain of having emissions of semen one or more nights each week, 
which weaken them greatly, and that they feel particularly dull and list- 
less the day after an emission. We should not have too much confidence 
in these patients, or rather we should mistrust that they are concealing 
some important fact. The first glance at these confused and embar- 
rassed young men usually shows that they have a bad conscience; in 
many cases we may tell what the trouble is from the mysterious letters 
in which they request a consultation. It is not generally difficult to 
obtain from these patients a confession that they have previously mas- 
turbated, and some even appear to be relieved by making the acknowl- 
edgment. We must not be satisfied with this confession, however, 
but should carefully seek to find out if they do not still continue the 
practice. This confession is generally far more difficult for them ; but 
1 shall not exaggerate in saying that full two-thirds of the patients SPERMATORRHOEA. 
101 
a ho have consulted me for their pollutions have at last acknowledged 
that they still masturbated. These persons seek aid because they 
have been frightened by reading the miserable books which give such 
overdrawn pictures of the results of onanism. They hope that it will 
only be necessary to tell of the frequent occurrence of the emissions, 
and that they may be silent concerning the cause. 
The case is somewhat different with a second class of persons who 
seek medical aid for their pollutions. These also have masturbated 
during youth, but have subsequently ceased to do so; they also, how- 
ever, have come across some bad book describing the terrible results 
of the habit, and they have been greatly terrified, and have become 
very hypochondriacal. They do not have nocturnal emissions oftener 
than healthy persons, but each recurrence gives new stimulus to the 
hypochondriasis; they are considered very dangerous, and the patients 
imagine they are experiencing the evil effects of which they have read. 
The letters that such patients write often form a wonderful contrast 
to their personal appearance. From the account of their case as given 
in the letter, we may be prepared to meet a deplorable-looking being, 
instead of whom comes in a hearty, robust man, that it is difficult to 
recognize as the writer of the letter. 
A third class of persons who consult the physician for their pollutions 
do suffer from general debility, are badly nourished and anaemic. They 
have never been given to onanism; nor do the emissions occur fre- 
quently, but the day after their occurrence the patients feel peculiarly 
dull and relaxed, and are inclined to refer the cachexia from which 
they are suffering to their pollutions. It is well known that, in dis- 
eased, exhausted persons, the excitability of the nervous system is 
more apt to be abnormally increased than it is in strong and healthy 
ones, and that inclination to pollutions, as one symptom of erethism, is 
more frequently seen in the former than in the latter. We often find 
that persons, who have never suffered from pollutions while in health, 
are afflicted with them when attacked by severe disease or during con- 
valescence. 
Besides the last class of persons, in whom the pollutions are not the 
cause but the result of the diseased and exhausted constitution, and in 
whom this exhaustion with its causes must be the objects of treat- 
ment, there are patients in whom the repeated pollutions are the only 
reasons we can find for a feeling of great debility and an unconquer- 
able lassitude. Such patients are very peculiar: they cannot think 
acutely, are sad, cannot work; they are cowardly, easily frightened, 
complain of trembling, noises in the ears, dizziness, neuralgic pain in 
the back of the head, etc. Their complaints remind us most strikingly 
of those of hysterical women, and it is perfectly justifiable to designate 102 
DISEASES OF THE MALE SEXUAL ORGANS. 
this collection of symptoms as hysteria. It is difficult to understand 
why pollutions should have so injurious an effect on the organism in a 
few persons, while by most they are borne without observable harm. 
We cannot consider the loss of semen as the cause of the exhaustion and 
nervous disturbance. The sexual excesses to which young husbands 
generally give way very rarely have any injurious effect on their 
health; even if they have daily intercourse, most of them remain just 
as strong as they were previously while perfectly continent. In such 
persons the loss of seminal fluid is so very much greater than in those 
who suffer from occasional pollutions, that injurious results would 
occur much more frequently in them if the loss of the fluid were the 
cause of the injury. From the favorable results that I have had of 
late years in treating this affection, and patients with spermatorrhoea 
by repeated cauterizations of the caput galinaginis, I believe that the 
hysterical symptoms occurring in it are exactly analogous to those 
occurring in women who have erosions of the os uteri; or in other 
words, that they do not depend on loss of semen, but that morbid irri- 
tability of the sexual organs may excite extensive disturbances of 
innervation in men just as it does in women. When speaking of hys- 
teria I shall explain more in detail that erosions of the os uteri do not 
necessarily induce hysteria, but that this is only apt to occur where 
there is a decided predisposition for it. The case is just the same in 
men who masturbate or who have pollutions or spermatorrhoea from 
irritation of the genital organs. I must, however, warn my readers 
against taking it for granted that all men who have hysterical symp- 
toms masturbate or suffer from pollutions or spermatorrhoea. Hys- 
teria does not depend exclusively on affections of the sexual organs, 
either in men or women. 
By spermatorrhoea, in the strict sense, is understood a condition 
where the semen is not regularly ejected during a complete or incom- 
plete erection, but where it is washed out by the urine, or flows out 
slowly while the bowels are being evacuated. The statements of 
Lallemand and several other authors, concerning the frequency of 
spermatorrhoea, are exaggerated. Increased excretion of prostatic 
fluid is often mistaken for spermatorrhoea. In the white, frothy, or 
transparent viscous fluid which sometimes collects in considerable 
quantity at the mouth of the urethra after sexual excitement without 
coitus, there are usually no spermatozoa or they are very few in 
number. Frequently also the frothy fluid secreted from the urethral 
mucous membrane during a gleet, or the mucous filaments in the 
urine when there is catarrh of the bladder, are mistaken for semen. 
The microscope alone can render the diagnosis positive. 
The causes of true spermatorrhoea are obscure. Relaxation or SPERMATORRHOEA. 
103 
dilatation of the excretory ducts of the vesicular seminales and other 
morbid but not well-known changes (probably catarrh and erosions), 
in the caput galinaginis, appear to be at the root of the disease. 
Lallemand and others have exaggerated the injurious results as 
well as the frequency of spermatorrhoea. I knew a railroad agent in 
Magdeburg who, for at least ten years, lost a considerable quantity of 
semen with every stool, without any observable bad effect on his gen- 
eral health. He was married, and his wife had several children by 
him while he was affected with the spermatorrhoea; he also acknowl- 
edged that, during his daily trips to Leipzig, he not unfrequently 
committed sexual excesses. In some persons, it is true, the same 
symptoms occur that we described when speaking of pollutions. 
Treatment is comparatively powerless against a morbidly-increased 
inclination to pollution. The best results are attained by paying par- 
ticular attention to the constitution of the patient, and seeking to rec- 
tify any thing that is out of order. This may be the reason why fer- 
ruginous preparations and the natural chalybeate baths are so popular 
for pollutions, and why some patients are improved or cured by sea- 
bathing, others by the cold-water treatment. Cold sitz-baths and 
washing the genitals with cold water have the reputation of strength- 
ening the sexual organs and arresting pollutions; but these should 
not be used in the evening, especially just at bedtime, for, if used at 
that time, they absolutely favor the occurrence of pollutions. Heavy 
suppers and drinking freely of. tea, etc., just before bedtime, should 
be forbidden. It is improper to prescribe camphor, lupulin, and sim- 
.lar medicines. 
Greatly as cauterization of the caput galinaginis, by means of 
Lallemand’s porte-caustic, was esteemed for a time, it has since gone 
out of fashion. When Lallemand"'s work first became known, every 
practitioner considered it necessary to have one of his instruments, 
but most of them have been laid on the shelf for years. However, 
where the emissions of semen are abundant, and the constitution of 
the patient undermined, and where, by excluding other anomalies, we 
may regard relaxation or dilatation of the ducts of the vesiculae semi- 
nales, or chronic inflammation in the back part of the urethra, as the 
probable causes of spermatorrhoea, we may cauterize the caput galina- 
ginis, lege artis. In other cases we may confine ourselves to prevent- 
ing constipation, ordering the genitals to be washed in cold water, and 
treating any existing complications. 104 
DISEASES OF THE MALE SEXUAL ORGANS. 
CHAPTER II. 
IMPOTENCE AND IRRITABILITY, WITH WEAKNESS OF THE MALE 
SEXUAL ORGANS. 
During the period of manhood, complete and permanent inability 
of performing coitus successfully is rarely seen. Even some deformi- 
ties of the penis, loss of one testicle, or disease of both, often will not 
cause absolute impotence. On the other hand, cases of diminished 
power and of temporary impotence are very frequent, and it is of the 
utmost importance for the practitioner to be thoroughly acquainted 
with the various and peculiar forms under which these states may 
occur. Unhappy marriages, barrenness, divorces, or perhaps an occa- 
sional suicide, may be prevented by an experienced physician, who has 
the entire confidence of his patient, if he can give him comfort and 
consolation when consulted concerning impotence. The persons that 
come to the physician for counsel are chiefly young husbands, filled 
with despair at the discovery that they cannot cohabit with their wives. 
Not only sensual women, but all, without exception, feel deeply hurt, 
and are repelled by the husband whom they may previously have loved 
dearly, when, after entering the married state, they find that he is im- 
potent. The more inexperienced and innocent they were at the time 
of marriage, the longer it often is before they find that something is 
lacking in their husband; but, once knowing this, they infallibly have 
a feeling of contempt and aversion for him. And it is not the lost 
pleasure or the fear of remaining childless that brings the young hus- 
bands to the physician, but a sense of shame, and the knowledge that 
they are becoming contemptible and disgusting to their wives. This 
sad secret is often concealed from the nearest relatives, and confided 
only to the physician, in whose art and discretion the patient has full 
confidence. 
The next most frequent class of persons that consult the physician 
for impotence are young men engaged to be married, who, previous to 
their wedding-day, have experimented w'th lewd women to see whether 
they were impotent, and who have not succeeded on that occasion. 
Impossible and disgusting as this may sound to the student, when he 
acquires a moderate practice he will often encounter persons who will 
relate such things to him with perfect unconcern. 
Under proper treatment the great majority of these cases terminate 
well, so that, when the desperate spouses fall into the right hands, in 
the course of time they almost always become happy husbands and 
fathers. The most frequent cause of temporary impotence is lack of 
self-confidence, and a consequent straining of the mind for the success IMPOTENCE. 
105 
of the coitus. Erections not only come without the influence of the 
will, but the ardent desire for them interferes with their occurrence. 
The more unconcerned the individual, the less attention he pays to the 
erections, the more certain and permanent they will be when there is 
sexual excitement. The patients usually volunteer the information, 
that they have powerful and continued erections at times when they 
are of no use, but have none when there is an opportunity for coitus, 
or that, if erections occur, they pass off even during the coitus, before 
the ejaculation has taken place. Even when such patients have re- 
gained their self-confidence by one successful coitus, and have then re- 
tained their virile power for some time, they often have long relapses 
of their impotence from a single failure of the act. There arc also 
cases where the virile power of the patients returns perfectly when 
they have intercourse with their wives, and they can even visit them 
at very short intervals ; but it always fails if they make the attempt 
with some other women with whom they have not previously had con- 
nection. 
The most frequent cause of this diminished power is onanism; 
sexual excess or repeated pollutions far more rarely cause it. But the 
diminished power of the onanist is usually first increased to temporary 
impotence by reading popular and medical treatises on the results of 
masturbation. In those writings the loss of manhood is described as 
the inevitable result of onanism, and the readers are thus robbed of 
all self-confidence. If both the depressing effect of onanism and the 
despondency from reading these papers act on the same person, the 
first attempt at coitus almost always fails. But, as we have already 
said, the effect of this first failure is to induce subsequent ones for a 
long time. Other persons, not debilitated by onanism, and under- 
taking coitus with perfect confidence, fail in the act from being intox- 
icated at the time; but even such persons may become temporarily 
impotent from the disturbance of self-confidence by the failure, and 
from paying too much attention to the success of the next attempt, 
for fear it also will fail. 
In still other cases the only causes for the failure of the first coitus 
are excessive excitement and a certain embarrassment and anxiety. 
Such persons have often led an unusually chaste life, and, with a rare 
innocence after marriage, they have attempted coition, being perfectly 
ignorant of the process. In the first weeks of their married life they 
are greatly depressed and troubled by their sad experiences. If we 
meet them a few years subsequently, when they have healthy, bloom- 
ing children, they laugh freely over the mishaps of their honey-moon. 
Besides the numerous cases of deficient power and temporary im- 
potence under the above classes, we must mention the rarer cases, 106 
DISEASES OF THE MALE SEXUAL ORGANb. 
where the impotence depends on actual functional debility of the 
sexual organs during the age of manhood. They are distinguished 
from the above by the fact that, during sexual excitement, even when 
there is no psychical impediment, there are no erections; nor do these oc- 
cur, as they usually do even in children, without a feeling of desire, when 
the patient wakes up with a full bladder. Occasionally examination 
of the genitals in such cases shows something abnormal: the testicles 
are atrophied, small, and soft; the scrotum hangs relaxed, or else the 
penis is flabby and cool, or very small and hard. In other cases the 
most careful examination of the genitals shows nothing abnormal. 
Some years since, a farmer consulted me for his impotence. As he 
was somewhat over thirty years old, and a strong, muscular man, 
without excess of fat, and as I found nothing wrong about his gen- 
itals, the penis being well-developed, the testicles large and hard, I 
considered it certain that his impotence was of the first variety, and 
consequently gave a good prognosis. But the case turned out differ- 
ently from what I had expected; and, after being married a year, the 
man was divorced, the impotence having continued all this time. This 
second form of impotence must also remain unexplained until our 
knowledge of physiology and pathological anatomy advance beyond 
their present state. 
We shall pass over the cases where congenital malformations, cas 
tration, or other imperfections, are the cause of the impotence, as well 
as those where it is only one symptom of general debility in exhaust- 
ing diseases, especially in diabetes, and shall only add a few words 
concerning irritability with weakness of the male sexual organs. 
Some authors include the form of impotence first described under the 
head of irritable weakness, and, in fact, the persons there described 
are on the one hand irritable, as they are very readily excited by con- 
tact with women or other causes; and, on the other hand, they are 
weak, for the erections are not strong and do not last long. But by 
irritability with weakness, in the strict sense, we understand a condi- 
tion where, during sexual excitement, the ejaculation occurs before 
actual copulation has taken place, or even before the erection is 
perfect. This weakness also occurs chiefly among persons who have 
previously masturbated. As long as strong erections still take place 
occasionally, the prognosis in these cases is almost always good. Even 
when, from masturbation, this affection has lasted for a long time be- 
fore marriage, and continues during the first weeks of wedded life, it 
generally disappears if the mode of life be regulated, and the sexual 
desire be moderately gratified, but not artificially excited. 
In the first form of impotence the causal indications require chiefly 
i psychical treatment. It is often enough to tell the patient of the IMPOTENCE. 
107 
nappy results in similar cases that we have treated, and to assure him 
that, according to all experience, his disease is unimportant and only 
temporary. Others are cured by having coitus forbidden. The non- 
chalance that they thus acquire during sexual excitement and the in- 
attention to the strength and duration of the erections render co- 
habitation possible, and they have the first successful coitus during 
the time it was forbidden, while previously it had always failed. For 
ignorant persons we may order some harmless substance, and promise 
the best results from it, but, at the same time, forbid coitus for a sea- 
son. In such cases the patients will often come back in a few days 
and confess deploringly that they could not abide by the restriction. 
We should particularly warn all persons, suffering from impotence, 
against artificial excitement, especially against fingering and rub- 
bing the genitals, and thus attempting to excite erections ; we 
should represent to them most earnestly and continuously both the 
injurious effects and the indecency of such a procedure. All the so- 
called aphrodisiacs are useless and injurious. Washing the genitals 
with cold water, cold hip-baths, and cold douches, occasionally appear 
beneficial, and we should employ these remedies in the second form 
of the affection also. In some cases of impotence, and particularly in 
cases of irritability with weakness, cauterization of the prostatic por- 
tion of the urethra, by means of LallemancTs porte-caustic, has been 
remarkably beneficial. Probably in these cases the disease depended 
on spermatorrhoea due to relaxation and dilatation of the ducts of the 
vesiculae seminales; occasionally, also, the operation may have had a 
favorable psychical influence. In the latter cases, reading LallemancPs 
book would greatly aid the cure, for there the result of the cauteriza- 
tion is pictured in such glowing colors that the description must re- 
store courage to the most faint-hearted. Recently some electro-thera- 
peutists have strongly recommended electricity for impotence; and 
this treatment (besides which these men, according to their own ac- 
counts, advise the impotent husbands to refrain from seeing their 
wives, and to try coitus with lewd women [!]) is said to be very 
beneficial. In men of full virile power I have often induced erections 
by faradisation of the inner surface of the thigh, but, where there was 
impotence even after using electricity for weeks, I have seen no re- 
sults worth mentioning. But, as my own observations have not been 
very numerous, I will not pronounce decidedly on the subject, and 
shall simply give a short account of the plan of treatment advised by 
Benedict and Schultz. According to Benedict we should place the 
copper pole of a constant battery over the lumbar vertebras, and pass 
the zinc pole forty or fifty times in the direction of the spermatic cord, 
then transversely over the different zones of the upper and lower sur- 108 
DISEASES OF THE MALE SEXUAL ORGANS. 
faoe of the thighs, and then lengthwise in the perineum. Such a sit- 
ting should last two or three minutes. Moreover, about three times a 
fortnight the copper pole should be applied, by means of a catheter- 
shaped rheophore, to the vicinity of the ejaculatory duct, and passes 
should be made with the zinc pole in the direction of the spermatic 
cords. If there are any particularly insensible places, Benedict uses 
Faraday's galvanic brush, and, if the testicles are peculiarly insensible, 
he passes a strong current through them. The sittings should take 
place every day, and be continued for some time, as improvement did 
not take place for months in some cases: 
Schultz, in Vienna, has for a long time used the induced current 
for pollutions and impotence. Under this treatment the success was 
very poor; but he claims that it is much greater since he has com- 
menced using a constant current. He places the positive pole over 
the fifth dorsal vertebra, the negative over the sacrum or to the peri- 
naeum. Each sitting lasts from one to three minutes, and they are re- 
peated three or four times a week. Schultz employs a battery with 
twenty or thirty DanieVs elements of medium size. B. —DISEASES OF THE FEMALE SEXUAL ORGANS 
SECTION I. 
DISEASES OF TIIE 0 VARIES. 
CHAPTER I. 
INFLAMMATION OF THE OVARY, OOPHORITIS [OVARITIS], 
Etiology.—The Graafian follicle, the stroma of the ovary, and its 
serous coating, may become the seat of inflammation. The first two 
forms occasionally lead to suppuration of the parenchyma, the last 
almost always leaves thickening- of the serous coat and adhesions to 
neighboring organs. 
Parturition, with its sequelae, most frequently causes oophoritis; 
but, as we exclude the diseases caused by pregnancy, delivery, or child- 
bed from discussion in this section, we shall here pass by puerperal 
oophoritis. Next to childbed, the disease appears to begin most fre- 
quently at times when the ovary is hyperasmic, and is the seat of a 
physiological injury from the rupture of a Graafian vesicle. The best- 
known causes of non-puerperal oophoritis are injurious influences act- 
ing on the body at the time of menstruation, such as catching cold, 
getting the feet wet, coitus during menstruation, etc. One attack of 
the disease predisposes to another. 
Anatomical Appearances.—Ovaritis attacks only one ovary. If 
the inflammation start from the follicles, we find one, or more rarely 
several, of the Graafian vesicles swollen to the size of a pea or a 
cherry, filled with a variegated exudation, and their external envelopes 
reddened by capillary injection. At the same time the ovary is usu- 
ally but little enlarged; except a slight oedema, the stroma appears 
normal; the serous covering usually participates in the inflammation. 
In most cases the disease runs a favorable course; the exudation is 110 
DISEASES OF THE OVARIES. 
reabsorbed and the follicle atrophies; in other cases it degenerates to 
a serous cyst, and exceptionally ends in suppuration and formation of 
an abscess. If the inflammation start from the stroma of the ovary, 
the process is usually limited to a decided hyperaemia, an inflammatory 
oedema, and a proliferation of the connective tissue, which subsequent- 
ly leads to thickening and shrinking of the ovary. Suppuration and 
formation of abscesses, or diffuse destruction of the ovary, rarely occurs 
in these cases. In non-puerperal ovaritis, Kiwisch has only twice 
seen this rare termination. Inflammation of the peritoneal covering 
is sometimes primary, sometimes secondary to that of the parenchyma. 
In recent cases the ovary is usually covered by a scanty fibrinous ex- 
udation, which unites it loosely to the neighboring parts, particularly 
to the broad bands of the uterus and the Fallopian tubes, whose peri- 
toneal covering usually participates in the inflammation. Subsequent- 
ly firm adhesions, by means of fibrous bands and filaments, readily 
form between these parts ; not unfrequently these closely envelop the 
ovary and openings of the tubes. Exceptionally, peritoneal ovaritis 
causes abundant exudation, and encapsulated foci are formed in the 
pelvis. 
Symptoms and Course.—The symptoms of a partial peritonitis 
in the neighborhood of one of the ovaries are the only signs usually 
furnished by ovaritis. If the peritoneal covering be not inflamed, 
the disease almost always remains latent. The ovary lies so deep in 
the pelvis, and is so completely covered by intestines, that pressure 
downward from above the symphysis pubis does not affect the ovary, 
unless the abdominal walls are very much relaxed and distensible. 
Hence it is important to decide, by vaginal examination, whether 
the ovary be really the origin of the pain. Occasionally the diseased 
ovary may be reached through the rectum. The etiology, also, may 
confirm the diagnosis. If we meet the above symptoms in a patient 
who has caught cold, or received injury in some other way at the 
menstrual period, and the menses have suddenly ceased, the presump- 
tion that the partial peritonitis starts from the ovary is more tenable 
than that it depends on disease of some other organ, covered by peri- 
tonaeum. The symptoms may be modified by an extension of the in- 
flammation to neighboring organs. Uterine blennorrhoea and bloody 
or bloody serous discharge from the uterus, pain in passing water 01 
faeces, neuralgic pains or numbness in the corresponding extremities 
may accompany ovaritis, while in other cases they do not occur. 
Oophoritis is only exceptionally accompanied by fever. The course ot 
the disease varies greatly. In favorable cases the symptoms pass off 
in a few days, without leaving a trace. Probably the combination of 
symptoms called colica scortorum (colic of prostitutes) depends on OVARIAN CYSTS. 
slight ovaritis, which runs a rapid course, and terminates favorably. 
At least, in women of suspicious character, I have often seen severe 
pain in the lower part of the abdomen, which appeared to originate 
in the ovaries, and was increased by slight pressure, rapidly dis- 
appear after the application of leeches. If the disease lasts long; 
if it causes adhesion of the ovary with neighboring parts, and thick- 
ening of the peritoneal covering, the symptoms of ovaritis will fre- 
quently recur periodically for a long time, particularly at the men- 
strual periods. As the opening of a Graafian vesicle, even under nor- 
mal circumstances, is accompanied by symptoms like those of inflam- 
mation, it may be readily understood that, under the above-described 
normal circumstances, it is often accompanied by those of actual inflam- 
mation. I know a lady who was treated over ten years ago by a cele- 
brated gynecologist for severe ovaritis, and who has had returns of her 
disease several times a year ever since. The copious exudations in 
peritoneal ovaritis, and the perforation of abscesses in the parenchym- 
atous forms, may cause the above-described encapsulated effusions 
in the pelvis, or even diffuse peritonitis, with rapid course and fatal 
results. 
Treatment.—In acute ovaritis we should apply ten to fifteen 
leeches in the inguinal region, or, where it can be done readily, we 
may apply a smaller number to the neck of the womb. Cataplasms 
and warm baths aid their action. We should also secure copious 
evacuations from the bowels; but should avoid drastics, and limit our- 
selves to giving castor-oil and enemata. Calomel and mercurial oint- 
ment are not needed in the treatment of ovaritis. If the disease be 
protracted, the blood-letting should be repeated occasionally. The 
systematic use of brine-baths and the internal administration of prepa- 
rations of iodine and iodine mineral waters also appear beneficial. 
CHAPTER II. 
OVARIAN CYSTS. 
[There are various forms of ovarian cyst. 
1. Hydrops follicularis. Here one or more Graafian vesicles 
are transformed into cysts, which is proved by the fact that in 
young cysts of this kind the ovulum is still to be found. It is sup- 
posed that such cysts owe their origin to an abnormal thickness of 
the walls of the ripe follicles, which, under the influence of the 
menstrual afflux, swell up to the size of a pea, but do not burst, as 
physiologically they should do. But the appearance of these cysts 
before puberty, and even in newly-born children, proves that a mere 112 
DISEASES OF THE OVARIES. 
indisposition to burst is not the sole cause of their formation, and 
that a morbid state of the secretion within the follicle may be the 
real cause. Sometimes these cysts are solitary ; sometimes they 
exist in great numbers. They are generally small, and hence often 
remain undetected until after death. Exceptionally, a cyst or a 
cluster of cysts makes a tumor of the size of a fist, very rarely of 
the size of the head. Such a cyst has thick walls, is smooth within, 
and contains a yellow, serous liquid. In young cysts traces of fresh 
or altered blood can be perceived. Communication between several 
cysts due to atrophy of the intervening tissues is rarely seen. 
2. The so-called cystomata, or cystoids—that is to say, prolifer- 
ating cysts—are by far the most common and important form of 
ovarian tumor. By most new authors the histogenesis of a cystoma 
is sought in the epithelial components of the ovary. According to 
Waldeyer's graphic account, a cystoma does not originate from the 
ordinary egg containing a Graafian follicle, but rather from the 
more rudimentary forms of the epithelial portion of the ovary, 
from the rounded balls of epithelium, and from the tubular struc- 
tures, the so-called llPflilyer,s tubes” which have probably origi- 
nated at the embryonal period of the organ. Instead, however, of 
normally developing into Graafian follicles, from the very commence- 
ment they have developed into cystomata ; or else the follicle is 
converted into a cystoma by repeated proliferation of the epithelium 
of its inner surface. As in all mixed tumors in their later periods, 
there is in a cystoma an intergrowth of epithelial, dermoid, and 
vesicular structures, out of which the various types of tumor are 
built. This growth by proliferation of the interior of the cyst the 
author classifies in two groups, glandular and papillary. In the 
glandular form sections through the cyst-wall everywhere exhibit 
small, simple, tubular epithelial pits (almost always cylinder-epithe- 
lium) in the substance of the wall, which present the character of a 
glandular formation. The mouths of these tubes soon become 
stopped up by tough secretion, and then, almost exactly as other 
“ retention-cysts ” form, they become first distended pouches and 
then small sacs. Upon the interior of the walls of these sacs new 
depressions form, which in their turn deepen and form pouches and 
cysts, and so on ; thus a honeycomb appearance is produced. In 
the papillary cystoma the proliferation of the connective tissue of 
the cyst-wall is the main feature. From their inner surface numer- 
ous ramifying, shaggy, highly-vascular vegetations sprout. Some- 
times these are circumscribed, growing only within a certain limit; 
sometimes they increase incredibly, filling the whole sac. There 
are many intermediate forms. OVAKIAN CYSTS. 
113 
Many of the smaller, more recent cystomata are of a more solid 
structure, and upon section show numerous vesicles filled with gelat- 
inous matter. Older tumors, which are often as large as the head, 
and which sometimes widely distend the whole abdomen, and con- 
tain fifty litres or more of liquid, consist mainly of a principal cyst, 
in which the accessory cysts grow, and, as their walls become thin- 
ner, finally hurst. Thus the multilocular cysts tend to become uni- 
locular. 
The contents of a cystoma are not always the same, but consist 
generally of a stringy, thick, dirty-brown or yellowish-green liquid, 
of specific gravity 1018 to 1024. More rarely, it is a thin liquid or 
a stiff jelly. According to E. Eichwald, the chemical contents con- 
sist of two series of organic substances : 1. Mucous matter, derived 
from direct conversion of the cell-protoplasm of the epithelium. 
Mucin is gradually converted into what is known as colloid matter, 
and further is changed into mucopeptone {Eichwald), a substance 
analogous to the albuminpeptone of albumen. 2. Albumen appears 
either free or combined with soda. The latter is converted into 
paralbumin (which then no longer coagulates upon heating), and 
further into metalbumin, which will not precipitate with nitric acid. 
Finally it becomes albuminpeptone, the last of the series. TVal- 
deyer considers paralbumin and metalbumin as of value in a diag- 
nostic point of view. The former is never wanting in ovarian cysts, 
and never present in ascites. A more convenient test of the liquid 
obtained from the abdomen by puncture is by the microscope, under 
which the discovery of cylinder-cells is of the greatest importance. 
Colloid globes (degenerate, swollen cells), blood, pigment, and cho- 
lesterin-crystals are often found. Wandering cells are not found 
unless the cyst-wall suppurates, which, however, is not very uncom- 
mon. The liquid of ascites is usually of a clear, light-yellow color, of 
specific gravity 1010 to 1015, and contains amoeboid corpuscles and 
pavement-epithelium ; and upon standing exposed to the air, if any 
blood has become mingled with it during the puncture, it often, 
after a lapse of twelve or twenty-four hours, throws down a clot of 
fibrin, which never occurs in ovarian liquid. If a viscid substance 
of a somewhat dark color and a specific gravity of about 1018 or 
1024 be drawn from an abdominal puncture, it is hardly necessary 
to seek any further proof that ovarian cyst is its source. 
Ovarian cysts are attached by a pedicle, which is sometimes long 
and narrow, sometimes short and thick, and which includes the 
ovarian ligament, the tube, and the broad ligament of the womb. 
Sometimes the seat of the tumor is upon the side of the womb it- 
self. The main cyst-wall embraces the entire tumor, and in the 114 
DISEASES OF THE OVARIES. 
larger cystomata adhesions more or less extensive to the neighbor- 
ing serous sui’faces are often found—a matter of great importance 
in a question of ovariotomy. 
Regarding the causes of ovarian cysts little that is trustworthy 
is known. In exceptional instances such growths are met with even 
in childhood, and it is probable that many which are not detected 
until adult age have existed during youth. Of three hundred and 
forty-eight cases observed by Lee, West, Scanzoni, and Schroeder, 
ninety-seven were prior to the thirtieth year, one hundred and 
forty-five between the thirtieth and fortieth years, seventy between 
the fortieth and fiftieth years, thirty-one between fifty and sixty, 
and two between seventy and eighty. Both ovaries are very often 
found diseased (fifty out of ninety-nine times, /Scanzoni); but the 
changes in the less affected ovary are usually stationary, and both 
ovaries are seldom found simultaneously in such a state of cystic 
degeneration as to form large tumors, and it is equally rare for the 
extirpation of one ovary to be followed by the growth of a tumor 
upon the other. 
3. Dermoid cystomata are always congenital. From the sketch 
given by His and Waldeyer of the embryonal development of the 
so-called axischord, from which the rudiments of the genitals de- 
velop, it will be seen that in this part, in which the different ele- 
ments of the embryonal rudiments grow into one another, and in 
which especial germinal lamina) are no longer distinguishable, ele- 
ments of skin, fat, nerves, muscle, and bone might stray into the 
sexual sphere. Dermoid cysts do not. usually become developed 
until after puberty ; they are rare during childhood. As a rule, 
they are relatively small (about the size of an apple or fist), but 
sometimes grow as large as the head. The structure of the interior 
wall of the cyst closely resembles that of the skin. There is an 
epidermic covering, beneath which is a layer of connective tissue 
resembling the cutis, and in which irregularly-arranged papillae can 
sometimes be found. A layer of fat (panniculus adiposus) is very 
constantly found beneath the cutis. Sometimes deposits of true 
bone are found in the connective tissue, which may even contain 
rudimentary teeth embedded in alveolar processes. More rarely a 
growth of gray nerve-substance or of transverse striped muscular 
fibres is made out. The wall of the cyst, like the skin, contains 
sebaceous hair-follicles, sometimes even sweat-glands ; and the cav- 
ity of the cyst is filled with the products of these organs, a mixture 
of epidermic cells, sebaceous secretion, masses of fat and choles- 
terin, and of hair either still growing or cast off and rolled into a 
ball.] OVARIAN CYSTS. 
115 
Symptoms and Course.—In some few cases the symptoms as- 
cribed to ovaritis in the last chapter precede hydrops ovarii. More 
frequently there are no premonitory symptoms, and even the cysts 
themselves excite no symptoms as long as they are small and do not 
press against any neighboring organ. It depends on the position 
of the cyst whether it will cause trouble on attaining some size, and 
as to what the nature and amount of this trouble will be. Cysts of 
even moderate size, situated behind the uterus in Douglas’s cul-de- 
sac, and pressing the uterus against the bladder, may cause severe 
urinary difficulty ; this may be either strangury or dysuria, accord- 
ing to the part of the bladder pressed upon. Defecation may also 
be hindered by small tumors ; and pressure on the nerves running 
along the posterior wall of the pelvis may cause pain in the small 
of the back, or signs of pressure on the nerves of the extremities; 
these are sometimes pains, sometimes a feeling of numbness. Last- 
ly, oedema and varices of the lower extremities sometimes result 
from pressure of an ovarian cyst on the venous trunks in the pelvis. 
Besides the above symptoms, there are sometimes changes in the 
breasts, particularly swelling, discoloration of the areola, and even 
secretion of colostrum. Occasionally, too, there is sympathetic 
vomiting, and a general disturbance like that which takes place at 
the commencement of pregnancy. 
As the tumor gi-ows and rises out of the pelvis, the symptoms 
of pressure on the pelvic organs usually subside. Many patients 
then feel quite well, and the disease can only be recognized by ex- 
amination, of which we shall speak hereafter. In some cases, how- 
ever, the inconveniences continue. For instance, in spite of the 
enlargement of the other parts, the wedge-shaped, thin portion of 
the cyst may extend far down into the pelvis, and continue to cause 
the symptoms of pressure on the pelvic organs. On the other hand, 
as it rises, the cyst may stretch the bladder, and thus induce more 
trouble with the urine. 
As the tumor continues to enlarge, the space in the abdomen is 
gradually lessened ; the movements of the diaphragm are hindered, 
and it is pressed upward. Then we have the symptoms of com- 
pression of the abdominal viscera and of the lower lobes of the 
lungs. Even a moderate fulness of the stomach, or a slight disten- 
tion of the intestines by gas, becomes very annoying ; vomiting is 
easily excited ; the patient becomes short of breath, and bronchial 
catarrh results from the collateral fluxion to the upper lobes of the 
lungs. Even the secretion of urine maybe interfered with by com- 
pression of the kidneys and their vessels. Finally, the general nu- 
trition, which has usually been unimpaired up to this time, suffers 116 
DISEASES OF THE OVARIES. 
from the various disturbances of the organs engaged in the forma- 
tion of blood. Anaemia and hydraemia are developed ; the patient 
loses strength and emaciates ; the menses, which have previously 
been regular, cease ; even where there is no compression of the 
veins, the lower extremities become cedematous as a result of the 
hydraemia ; finally, the patient dies, with the symptoms of general 
marasmus. 
The duration of the disease before its fatal termination varies 
greatly. It often continues for years ; some patients, however, die 
much sooner from intercurrent diseases, and not a few as the result 
of their treatment. The tumor does not usually grow steadily, but 
increases at intervals. Scanzoni has observed cases whei'e the liquid 
in the cyst increased and decreased periodically. Just before men- 
struation, the tumor increased in size, as a result of increased secre- 
tion from the wall; when the menses ceased, it diminished again. 
Some cysts only attain a moderate size, and then remain stationary. 
In one case that I saw, an ovarian cyst, which developed when the 
patient wTas eighteen years old, and rapidly attained a considerable 
size, remained for twenty years without growing any more. It has 
not been clearly proved that ovarian cysts can entirely disappear 
from reabsorption of their contents, but a diminution in size seems 
to occur occasionally from metamorphosis of the walls, such as 
ossification. 
Among the complications that may arise during the disease, we 
shall first mention the peritonitis which is so frequent; this some- 
times occurs spontaneously when the cyst grows very rapidly, some- 
times it is the result of operation. It is characterized by more or 
less pain, which is increased by pressure, and by fever. Since it 
causes adhesion of the ovary to the neighboring parts, it is very im- 
portant for the prognosis of ovariotomy. Inflammations of the inner 
surface of the cyst-wall are rarer and more difficult to recognize 
than inflammation of the external surface. They are usually caused 
by tapping, and induce a change in the quality of the contents of 
the cyst. This inflammation is generally painless, and a slight fever 
is usually its only symptom. Occasionally ovarian cysts burst from 
excessive distention, or from the action of external forces, and their 
contents enter the abdominal cavity. This accident may be favor- 
able, or the reverse, according to the quality of the contents. There 
have been cases where purely serous fluid was evacuated into the 
abdomen, and was quickly absorbed, and the cyst did not fill again 
for a long while, and in some cases it never filled. But even in such 
cases the escape of the fluid into the abdomen is accompanied by 
severe pain and constitutional disturbance. Where the ruptured cyst OVARIAN CYSTS. 
117 
contained a more irritating liquid, or fat, hairs, etc., death resulted 
from severe peritonitis. In the case above mentioned, rupture of 
the cyst was caused by concussion of the body twenty years after 
the formation of the cyst. At first only a moderate peritonitis was 
induced by the escape into the abdomen of the thick, almost pulpy, 
contents of the sac, which contained quantities of cholesterin. It 
seemed as if the fall the woman had was really a piece of good 
luck. The abdomen was entirely collapsed just after the rupture, 
and only filled slowly ; but the fulness increased steadily, and, after 
a few weeks, the abdomen was more distended than ever before. 
It was evident that the inner wall of the ruptured cyst continued 
to secrete liquid, which was emptied into the abdomen ; and, besides 
this, there was peritoneal exudation. Tapping was repeatedly nec- 
essary. At the first tapping there were drawn off twenty thousand 
cubic centimetres of a mixture of the secretion of the cyst and of 
peritoneal exudation, which weighed fifty-one pounds, being one- 
third the entire Aveight of the patient before tapping. Death from 
exhaustion took place a few weeks after the fourth tapping. Au- 
topsy entirely confirmed the diagnosis made during life. Lastly, 
instead of rupturing suddenly, ovarian cysts may be gradually 
opened by inflammation of their walls, and their contents may be 
evacuated into the abdomen, unless the cyst has pre\Tiously become 
adherent to some neighboring organ, in which case they are emptied 
into it. Such perforations most frequently occur into the rectum, 
and atrophy of the cyst has been observed in a few cases as a con- 
sequence of this. 
Not unfrequently ovarian cysts may be recognized by physical ex- 
amination, even before they have risen out of the pelvis. If situated 
in Douglas’s cul-de-sac, or between the uterus and bladder, or even 
to the side of the uterus, a distinct, sharply-bounded, and more or less 
movable tumor may usually be felt through the vagina ; it displaces 
the uterus in various directions, according to its position. Occa- 
sionally, also, we may feel the tumor through the rectum. The 
more distinctly we can perceive that the tumor does not perfectly 
follow the movements of the uterus, the more certain is the diag- 
nosis. If the ovarian cyst rises out of the pelvis, it usually forms a 
round, movable, painless tumor, with a distinct upper border, and 
there is more or less evident fluctuation. If Ave move the tumor 
with one hand, while the other is in the vagina, we find that the 
uterus only moves Avith the tumor Avhen the movements are very 
extensive, and vice versa. 
[When the tumor is adherent to the uterus, this test, of course, 
fails ; and then, unless its want of hardness gives the right clue, it 118 
DISEASES OF THE OVARIES. 
is liable to be mistaken for a fibroma of the womb. It is also diffi- 
cult sometimes to distinguish between such a growth and a cyst of 
the ligament, or dropsy of the tube. Parametritic and perimetritic 
exudations, especially 'when situated in Douglas’s space, can be felt 
through the vagina as rounded masses ; but under conjoined manip- 
ulation, it can be ascertained that they are not well-defined ball- 
like tumors. Moreover, they are accompanied by the symptoms of 
an inflammation of which they are the product, and after abatement 
of the inflammation increase no further, but rather tend to diminish. 
Faecal masses which are often to be felt through the vagina can be 
indented like putty by the finger, and disappear after unloading the 
bowel. As it grows, the tumor rises out of the pelvic cavity, unless 
held down by adhesions in Douglas’s cul-de-sac, in which case vio- 
lent symptoms arise like those which are presented by the retro- 
flexed gravid womb in a case of incarceratio uteri. 
The tumor first appears as a round body in one or other iliac 
fossa, recognizable by percussion and palpation, sharply marked 
above, and painless. It may be confounded with sundry other 
pelvic tumors. From a distended bladder it may be distinguished 
by the introduction of a catheter. From haemometra, from inter- 
stitial fibroid, and from pregnancy, it may be distinguished by care- 
ful palpation per vaginam, showing that the latter tumors are all 
directly in connection with the vaginal portion of the womb, besides 
possessing other peculiarities. 
As the tumor grows larger it rises in the belly, assuming a mid- 
dle position, so that when the pedicle is long it is difficult to decide 
whether the growth springs from the right or left side of the pelvis. 
Since the bowels are attached to the back of the abdomen, they 
necessarily yield backward as the tumor mounts in the cavity, so as 
to lie behind and beside it, although sometimes a coil of bowel lies 
in front of it. Upon making the patient lie upon her back, the 
tumor may be grasped more or less distinctly, and fluctuation sooner 
or later becomes perceptible, notwithstanding the fact that these 
growths are generally multilocular, because many of the small cysts 
gradually coalesce so as to form large ones. The tumor may present 
a uniform surface, or its multilocular character may be disclosed by 
the distinct ball-like prominences on the abdomen. Its consistence 
is sometimes uniform, and sometimes elastic and fluctuating in one 
portion, while at others solid masses may be felt, consisting of 
papillary growth or extensive proliferation of the cellular tissue. 
It is easy to distinguish an ovarian cystoma from corpulence of 
the abdomen and from meteorism. In such cases the percussion- 
sound is tympanitic. An ovarian sac with its walls not very tightly OVARIAN CYSTS. 
119 
distended, and lying closely in contact with a large part of the ab- 
dominal wall, may be so difficult to feel, and its fluctuation is some- 
times so marked, that it may be mistaken for an ascites ; of course, 
only with that extreme grade of ascites in which the tympanitic 
sound of percussion is extinguished even in the very highest part of 
the belly, and in which therefore the patient cannot by sudden 
changes of attitude cause dull and tympanitic sounds to be heard 
alternately upon percussion, a very characteristic mark of ascites of 
moderate degree. The distinctive signs usually given—that when 
the patient lies upon the back the abdomen is rounded when there 
is a cyst and flattened in-ascites ; and that when there is a cyst, 
the percussion in the lumbar region will be tympanitic because the 
bowels are displaced downward and backward, but that in ascites 
the percussion-sound is dull—deserve attention, but may cause error. 
The vaginal portion of the cervix often gives no positive informa- 
tion, since the tumor cannot always be touched from below through 
the vagina. The womb, although at times grown fast to the tumor 
and dragged up with it into the belly, and at others pushed down, 
displaced, or bent, now and then presents no change of position. 
The state of the lower extremities deserves great attention in 
the diagnosis. If but little swollen, then the fluctuating abdominal 
tumor is probably a cyst. In obscure cases exploratory puncture 
and aspiration, although not quite free from risk, give valuable aid, 
both by rendering an exact palpation of the tumor practicable, and 
by furnishing the material for chemical and microscopic tests. 
The diagnosis of a dermoid cyst is based chiefly upon its small 
size and slow growth. Not unfrequently it remains undiscovered 
during the life of the patient. If, however, it continues to grow, it 
may lead to perforation into the bladder, intestine, or vagina, or 
else through the abdominal wall. The discharge of its peculiar 
contents will then reveal its character. In one or two instances a 
complete recovery has followed such an evacuation of a dermoid 
cyst. Malignant degeneration sometimes occurs.] 
If the tumor grows, it usually approaches the median line. Very 
large ovarian cysts, which rise to the costal cartilages on both sides, 
and fill both sides of the abdomen, can no longer be distinctly 
bounded and distinguished as separate tumors. The abdomen, which 
is enormously distended and very tense, is usually more prominent 
than broad, and changes its shape very little with change of the 
position of the body. At the same time both inspection and palpa- 
tion show the irregular shape of the distended abdomen, which is 
due to the fact that these large tumors do not consist of one tumor, 
but of a union of several cysts. Wherever the tumor comes in con- 120 
DISEASES OF THE OVARIES. 
tact with the abdominal wall, percussion is absolutely dull. Since 
the intestines are pushed upward and to the side by ovarian tumors, 
the dulness becomes most decided at the prominent parts of the 
abdomen, where it is full in ordinary ascites ; at the most dependent 
lateral portions, on the contrary, the tone is less dull and is tympa- 
nitic. The uterus may be dislocated in various directions by large 
ovarian cysts. Hence the result of vaginal examinations varies 
greatly in different cases. The uterus may be pushed downward so 
much as to constitute a prolapse ; it may be displaced forward, or 
the vagina may be elongated, and the uterus elevated, so that the 
os uteri cannot be reached by the finger. 
Treatment.—The treatment of ovarian cysts belongs almost 
exclusively to surgery. All absorbent remedies are useless, and, as 
most of them are active, they are injurious. This is particularly 
true of the preparations of iodine and mercury. Occasionally we 
may retard the growth of the cyst by laxatives and derivatives ; 
but, as we can only carry out this treatment for a short time, the 
effect is only temporary, and it is no advantage to the patient to 
have the tumor remain stationary for a few weeks, and then con- 
tinue its growth. But we cannot hope by internal remedies to 
cause a change in the inner wall of the cyst that shall deprive it of 
its expansibility. In spite of the slight prospect of benefit from 
medicinal treatment of ovarian cysts, humanity requires us to give 
the patients a chance at the renowned baths and springs in Kreuz- 
nach, Tolz, etc. [When the tumor threatens life, ovariotomy should 
be performed. The success of certain specialists of late years is 
remarkably good. Out of five hundred ovariotomies, Spencer Wells 
has saved three hundred and seventy-two patients, and lost one hun- 
dred and twenty-eight.] 
CHAPTER III. 
COMPLICATED NEOPLASIA AND SOLID TUMORS IN THE OVARY. 
From the excessive formation of new connective-tissue cells that 
accompanies the development of cysts, we have cystosarcoma. This 
forms tumors which rarely attain the size of those described in the 
last chapter. 
Fibroid tumors, unaccompanied by the formation of cysts, rarely 
develop alone in the ovary, but they have occasionally been obsei’ved 
of very large size. For several years past I have been treating a 
patient, aged fifty-five years, who has a very hard, nodular fibroid SOLID TUMORS IN THE OVARY. 
121 
tumor, as large as a child’s head, in the right ovary ; it can he 
moved to the right or left, and is easily rotated on its axis. 
Carcinoma of the ovary is of somewhat more frequent occur- 
rence, but it also is rare. Medullary carcinoma is almost the only 
form that occurs here ; scirrhous and colloid cancer of the ovary 
are very rare. From complication with formation of cysts, carci- 
noma of the ovary may form immense tumors. This neoplasm 
almost always extends over large portions of the peritonaeum. 
Occasionally we may decide with more or less certainty that 
there is not a simple cyst of the ovary, from the hardness of the 
tumor, and from the course of the affection differing from that usual 
to ovarian cysts. In most cases the diagnosis is obscure. If ascites 
accompany a nodular tumor of the ovary, and we can discover no 
other cause for it, the chances are that there is cancerous degenera- 
tion. In one case of excessive ascites I made the diagnosis of car- 
cinoma of the peritonaeum starting from the ovary, even before 
feeling the nodular tumor of the ovary (which was rendered very 
perceptible by tapping), by excluding other causes of ascites, and 
from the account the patient gave of having had pain in the lower 
part of the right side of the abdomen and right thigh, as well as of 
varicose veins of the right leg that had preceded the abdominal dis- 
tention . The treatment of these ovarian tumors is the same as that 
of ovarian cysts ; but the hope of success is even less than it is in 
the latter disease. SECTION II. 
DISEASES OF THE UTERUS. 
CHAPTER I. 
CAT A RKTI OF THE UTERUS A XI) CATARRHAL ULCERS OF THE CERVIX 
UTERI. 
Etiology.—During menstruation the hyperasmia of the uterine 
mucous membrane is so excessive that the overfilled vessels are ruj>- 
tured. Before the hyperaemia attains this grade, and when it is di- 
minishing, the mucous secretion from the uterus is increased and 
changed. This catarrh, which is physiological as it were, becomes 
pathological if the hyperaemia of the uterine mucous membrane and 
the change of the secretion last beyond the normal duration of men- 
struation, or come at a time when no ripened ovum has been detached. 
Remembering this, we may readily finderstand why catarrh of the 
uterus is among the most frequent of diseases, being at most excelled 
in frequency by catarrh of the stomach, an organ subjected to the 
same conditions. 
The tendency to uterine catarrh varies greatly with the age. It is 
rare in childhood, when periodical recurrence of physiological conges- 
tion of the uterus does not yet exist; during the age for child-bearing 
it is very frequent; in old age the predisposition is decidedly less. 
Among the exciting causes are : 
1. Congestion in the vessels of the uterus ; in diseases of the heart 
and lungs, where the return of blood to the right heart is impeded, the 
hinderance to the flow of blood from the veins of the uterus usually ap- 
pears as catarrh of the mucous membrane, and is analogous to cyanosis 
and dropsy of other parts of the body. Still more frequently the ob- 
struction to the escape of blood is nearer the uterus. In many cases, 
compression of the hypogastric veins by tumors, or, more often, by col- 
lections of hardened fasces in the rectum or colon, are the causes of UTERINE CATARRH. 
123 
catarrh of the uterus ; we have before said, that some patients suffer- 
ing from uterine catarrh, dissatisfied with the treatment of their phy- 
sicians or even of celebrated gynecologists, fall into the hands of 
charlatans, or use Morrison’s pills, and for a certain time are benefited 
by the continued use of these laxatives that are vaunted as panaceas. 
2. Many cases of uterine catarrh are caused by direct irritation of 
the uterus, and, from what was said above, it is evident that any nox- 
ious influence acting on the uterus, when in a state of congestion, 
will prove more injurious than at other times ; hence that imprudence 
during menstruation most readily induces uterine catarrh. The uterus 
is directly irritated by too frequent or too energetic coitus, by mastur- 
bation, or by wearing pessaries, etc. The uterine catarrh accompany- 
ing other diseases of the uterus, such as parenchymatous inflammation, 
neoplasia, etc., and which is usually called symptomatic catarrh, also 
depends on the direct irritation. 
3. Like other catarrhal affections, this also may depend on consti- 
tutional disease. Acute catarrh of the uterus occurs in typhus, cholera, 
variola, and other infectious diseases; chronic catarrh usually accompa- 
nies chlorosis, scrofula, and tuberculosis. As we have often said, the 
connection between the local disturbance and these general diseases is 
not understood. 
4. When we read of the epidemic appearance of uterine catarrh, 
it simply means that, without any known cause, the disease occurs 
more frequently at one time than at another. 
Anatomical Appearances.—Acute catarrh of the uterus is rarely 
seen post mortem. The changes of the mucous membrane of the uterus 
in acute catarrh do not differ from those of other mucous membranes 
in the same disease. There are hyperaemia, swelling, succulence, and 
relaxation of the tissue; the secretion of mucus is diminished at first, 
but subsequently increased; in the first stages this mucus is clear and 
deficient in solid constituents; subsequently it becomes yellowish, and 
contains quantities of young cells. 
In chronic catarrh the mucous membrane is more swollen and hy- 
pertrophied ; it is brownish red or slate gray; the secretion from the 
cavity of the uterus appears more or less purulent, and is often mixed 
with blood. The secretion from the cervix uteri, on the other hand, is 
usually tough, coherent, and forms gelatinous plugs. Where the pro- 
cess has lasted a long while, the structure of the mucous membrane is 
changed. The ciliated epithelium is replaced by cells without cilia. 
Part of the glands is destroyed, while others swell up like cysts. In 
many cases the surface of the uterine cavity, particularly of the poste- 
rior wall, is covered with granulations that bleed readily, or with poly- 
poid growths. The swollen and granulated mucous membrane often 124 
DISEASES OF THE UTERUS. 
projects from the gaping os uteri, particularly when a large speculum 
is introduced [noser’s ectropion of the os uteri). 
The ovula Nabothi are very frequently found. These are round 
translucent nodules, from the size of a millet-seed to that of a pea, and 
tilled with liquid, which are seated in the cervical canal and about the 
os uteri. They are the distended follicles of the portio vaginalis, 
whose excretory duct is closed, but whose secretion continues. 
Both forms of catarrhal ulcers that come on other mucous membranes 
also occur very frequently in catarrh of the uterus, and are very readily 
observed, as they occur chiefly at the os uteri. Diffuse catarrhal ulcer 
or catarrhal erosion is most frequently found at the posterior lip of the 
uterus; it may thence spread to the anterior one. The loss of sub- 
stance is very superficial, irregular in shape, has a dark-red base, and is 
usually covered with puriform secretion. Follicular ulcers, which re- 
sult from the suppuration or rupture of obstructed follicles, form small 
round losses of substance, which show no inclination to spread laterally. 
Granulating ulcers of the os uteri are almost as frequent accompani- 
ments of uterine catarrh as are the ovules of Naboth, simple erosions, 
or follicular ulcers, and are more important than these. They are dis- 
tinguished from simple erosions, from which they appear to proceed, 
by their irregular, granular, readily-bleeding surface. The softness 
of the granulations prevents our mistaking them for simple erosions oc- 
curring over a thick group of ovules of Naboth, which have a nodulated 
granular appearance. 
Symptoms and Course.—If we except the virulent form, of which 
we shall hereafter speak, severe catarrh of the uterus running an acute 
course is rare. The disease usually begins with symptoms of severe 
congestion of the pelvic organs, -with pains in the sacral and inguinal 
regions, with a feeling of fulness and weight in the pelvis, often also 
with dysuria and tenesmus. Pressure on the lower part of the abdo- 
men gives the patient pain, although we cannot feel the uterus. When 
the disease is mild, these symptoms usually appear without fever; 
when it is more severe, especially in irritable subjects, they are not 
unfrequently accompanied by fever. After three or four days, the 
patients notice a discharge from the genitals; this is at first transparent 
and somewhat glutinous; it leaves gray spots on the underclothes; 
subsequently it becomes cloudy, more or less purulent, and leaves yel- 
low spots on the clothes. If we introduce the speculum (a measure 
which causes great pain if the vagina participate in the disease), we 
find the portio vaginalis swollen, dark red, and the secretion above 
described is escaping from the os uteri. While the reaction of the 
vaginal secretion is acid, this is alkaline. In most cases the pain 
and any accompanying fever disappear in from eight to fourteen davs. CHRONIC UTERINE CATARRH 
125 
The discharge also generally becomes less copious about this time, 01 
a little later; it loses its purulent appearance, and finally disappears 
entirely. In other cases these symptoms of acute catarrh are followed 
by those of chronic catarrh of the uterus. 
The latter cases, where chronic uterine catarrh is developed from the 
acute form, are far rarer than those where only the symptoms peculiar 
to the former were developed at first. In these cases the commence- 
ment of the disease can rarely be recognized with certainty. As long 
as it is not abundant, the patients do not usually attach much importance 
to the discharge, which is the most prominent, and for a long time the 
only, symptom of their disease. If asked how long they have had it, 
they are almost always unable to tell exactly. The daily amount of 
the discharge varies: sometimes it is slight; in other cases the patient 
must change the underclothes daily, and must even lay folded napkins 
under her at night. The dependence of the discharge on catarrh of 
the uterus may be inferred when glairy plugs are evacuated from time 
to time, or if we find in the underclothes the gray, stiff spots that this 
form of secretion leaves. It is uncertain whether a discharge that 
leaves yellow spots comes from the uterus or vagina. The more readily 
it chafes the inner surface of the thighs, the more probable that part of 
it at least is vaginal secretion. Later in the disease it not unfrequently 
happens that the secretion from the uterine cavity is retained there by- 
swelling of the mucous membrane, and by tough plugs of mucus that 
obstruct the canal. The retained secretion collects in large quantities, 
and distends the uterus. Under these circumstances, there are occa- 
sionally pains like labor-pains, very painful contractions of the uterus, 
that are usually called uterine colic. The longer the catarrh lasts, and 
the more change it has caused in the mucous membrane, the more fre- 
quently we see abnormal symptoms accompanying the physiological 
congestions of the uterine mucous membrane that occur during men- 
struation. Among these, the most frequent are severe xnolimina before 
the occurrence of menstruation, and pain while it lasts, dysmenorrhoea. 
In other cases there is too much blood lost, or, on the contrary, too 
little or none at all. Conception is not always prevented; the fact, 
that occasionally women with very obstinate and excessive catarrh of 
the uterus conceive, appears to indicate that it is not the uterine 
catarrh, but the extension of the disease to the oviducts and their 
closure by the secretion of the mucous membrane that lie at the root 
of the sterility which is so common in the disease. When women with 
chronic catarrh of the uterus do conceive they abort easily, and are in- 
clined to placenta praevia. Veit believes that both the deep seat of 
the placenta in the uterus and the sterility common in this disease are 
due to the circumstance that it is difficult for the ovum to become em 126 
DISEASES OF THE UTERUS. 
bedded in the uterine mucous membrane. In the former case the ovule 
does not become attached near the opening of the ovary, but at a deeper 
point; in the other case it is not even arrested at the os uteri, but falls 
through and is lost. The symptoms of uterine catarrh are not much 
altered by the development of the ovules of Naboth, and catarrhal and 
follicular ulcers at the os uteri. Granulating ulcers, on the contrary, 
cause pain, and bleed readily during coitus, and are most apt to induce 
the nervous symptoms of which we shall hereafter speak. 
The influence of chronic uterine catarrh on the general health varies 
greatly. Some women bear even high grades of the complaint well; 
their nutritive condition, strength, and blooming appearance is all that 
could be wished for. But some soon emaciate, become dull, relaxed, 
and pale or dirty-colored, with blue rings around the eyes. 
From the anaemia and hydraemia, but particularly from irritation of 
the nerves of the uterus having a reflex action on other nerve-trunks, 
we find anomalies of innervation in many patients with chronic uterine 
catarrh. Most frequently there is general hyperaesthesia; but neuralgic 
and spasmodic affections, and decided hysteria, not unfrequently accom- 
pany chronic uterine catarrh. Proving the frequent association between 
these so-called “ hysterical ” symptoms and catarrh and other diseases 
of the uterus, and carefully studying them up, were certainly steps 
in advance; but recently there is great tendency to fall into the error 
of referring all hysteria to uterine disease without due examination, 
thus neglecting the other causes of hysteria. Since in this disease the 
whole attention has been paid to the portio vaginalis, and both laity 
and physicians have almost exclusively given over the treatment to 
gynecologists, it cannot be denied that many cases are cured which 
would formerly have remained uncured; but many also remain uncured 
now, which would formerly have received aid. Hence it is important 
that every physician should have a certain acquaintance with “ the 
diseases of women,” and particularly that he should understand the 
use of the speculum. If he do not wish to enter on the local treat- 
ment, he may turn the case over to a gynecologist; but he should be 
able to determine whether local treatment is advisable or not. The 
fact, that the objection women have to the use of the speculum is 
almost overcome, is due to the specialists. In the upper classes the 
women and their husbands consider it as a matter of course that, when 
there is fluor albus, the speculum must be introduced; but among the 
middle classes also, a physician who has the confidence of his patients 
will find but little difficulty if he says that it is necessary to make a 
careful examination with the speculum. It is only by introducing this 
instrument that we can attain any certainty as to the source of the 
discharge, and concerning most of the changes of the os uteri above CATARRH OF THE UTERUS. 
mentioned. Exploration with the finger alone can, at most, decide 
that there is swelling of the portio vaginalis, which, as we shall here- 
after see, accompanies most cases of uterine catarrh, and that the ovules 
of Naboth are present. Catarrh of the uterus generally runs a very 
tedious course. The disease may drag on for years, and it often defies 
all treatment. In the proper place we shall speak of chronic paren- 
chymatous metritis, flexion and closure of the cervical canal, as the 
frequent results of this disease, which, in other cases, is due to this 
closure, and is kept up by it. 
Treatment.—In the treatment of catarrh of the uterus it is most 
important to fulfil the causal indications. Grateful as we should be 
for the labors of recent gynecologists, and brilliant as the results of 
their treatment of uterine catarrh appear when compared with the 
results of former treatment, still some of them are not free from the 
reproach of neglecting the causal indications while attending to the 
indications from the disease. Where catarrh of the uterus is one of the 
symptoms due to general venous congestion, dependent on disease of 
the heart or lungs, very often the causal indications cannot be fulfilled, 
and the remedies that have a beneficial effect on catarrh of the uterus 
are not employed for the uterine disease, but for some other disturb- 
ance. If the congestion of the uterine mucous membrane be due to 
habitual constipation, proper treatment of this disease, as previously 
advised, has the best results. We do not treat catarrh of the rectum, 
which depends on congestion of the hemorrhoidal veins due to habitual 
constipation, with local remedies till we have tried whether “ sublata 
causa cessat effectus; ” nor should we employ local treatment for 
catarrh of the uterus till we are satisfied that removal of the existing 
constipation is not sufficient for the cure. Then the peculiar conditions, 
of which we shall hereafter speak, will preponderate. After active local 
treatment, laxative mineral waters are often prescribed as after-treat- 
ment ; and these do more good than the actual treatment, because they 
fulfil the causal indications. A woman named Graff‘ living in Thurin- 
gen, has an enormous practice among patients with leucorrhoea. They 
all drink complicated infusions of manna, rhubarb, senna, and other 
laxative remedies, and many bless the result of this treatment, to which 
they were driven by the lack of success of all previous treatment. 
Plrysicians, who do not pay sufficient attention to the causal indications 
in treating catarrh of the uterus, deserve the blame for this. Of course, 
any thing, that could have induced or can keep up irritation of the 
uterus,, must be carefully removed and kept away. Hence the causal 
indications may require the removal of tumors of the uterus, or the cure 
of other changes of structure which induce the catarrh of the uterus 
Where the uterine catarrh depends on constitutional disease, it is noi 128 
DISEASES OF THE UTERUS. 
always possible to remove the cause; but frequently the original dis- 
ease is so important, or other dangerous results of it are so prominent, 
that we cannot attend to the uterine catarrh. This is particularly true 
of tuberculosis. 
Finally, it is not always possible to say whether anaemia aud chlo- 
rosis are the results or cause of this disease. If we think that the 
sequence in which the symptoms occur and other causes justify us in 
the latter supposition, we may often obtain the best results from the 
use of iron, quinine, a moderate amount of wine, and nutritious diet. 
Moreover, the good result of cold-water treatment, sea-bathing, and 
different mineral waters in uterine catarrh, is due to the fact that they 
have fulfilled the causal indication. Any practitioner will bear witness 
that the constitution suffers in many cases without our being able to 
discover the cause; and that anomalies of the constitution, which show 
themselves by a change in the secretion and function of different or- 
gans, cannot always be cured by preparations of iron and nourishing 
diet, even if there are evident coexistent signs of anaemia and hydrae- 
mia. Under such circumstances, all we can do is, to change and im- 
prove the constitution by placing the patient under the most different 
circumstances, changing the entire mode of life, and particularly by 
modifying as much as possible the exchange of tissue by baths and 
douches, by giving quantities of water with or without the addition 
of salts, and by other means. Among the anomalies of secretion that 
occur in the different organs of such patients, catarrh of the uterus is 
very frequent; and it often disappears very quickly when we succeed 
in improving the constitution, while it does not yield to exclusively 
local treatment. I have seen the most surprising results from such 
treatment in the Greifswalder clinic, where the arrangements to some 
extent replaced the treatment by mineral waters and baths, and where 
Professor Liebermeister, at that time assistant physician of the medi- 
cal clinic, kept account of the effect of the changed diet, increased ex- 
ercise, and copious supply of salty liquids, of the baths and douches, by 
weighing the body and examining the urine. 
The indications from the disease may be far more readily fulfilled 
in catarrh of the uterus than in catarrh of other organs that are less 
accessible. The uncertainty of internal remedies for catarrh has been 
repeatedly mentioned. They may be dispensed with in the treatment 
of uterine catarrh, and muriate of ammonia (which many physicians 
consider just as efficacious foi bronchial catarrh as for gastric and in 
testinal catarrh) is not used in uterine catarrh because we have bettei 
and more certain remedies for it. I should be entirely misunderstood, 
if it were supposed that I considered the local treatment of uterine 
catarrh as superfluous, or underrated its results; in what was said CATARRH OF THE UTERUS. 
129 
above, I only intended to show that one indication should not be 
followed to the neglect of the othei’s. In all cases where the cause 
of the catari’h cannot be discovered, as is most frequently the case, 
local treatment must be used ; and where it has existed for a long 
time, and is complicated with ulcers, particulai'ly granulating ulcers, 
local treatment should be ixsed with that for fulfilling the causal 
indications. Among the local remedies we shall fii*st mention in- 
jections into the vagina. It is not long since these constituted the 
only local treatment for “ leucori’hoea,” no matter whether it came 
from the uterus or vagina. They aid the treatment and are re- 
quired for cleanliness, although they are of far less use than the 
procedures to be hereafter mentioned. In acute catarrh we inject 
lukewarm water ; in chronic catari'h, at first lukewarm, and after- 
ward cold water, or solutions of sulphate of zinc, tannin, or alum. 
[Thomas, Emmet, and other eminent gynecologists of America 
prefer to' employ vaginal injections of water, of as high a temper- 
ature as the patient can comfoi’tably bear, the action of heat upon 
the tissues being more enduring than that of cold.] Instead of 
using an enema syringe with a uterine nozzle, it is well to employ 
a clysopompe (Davison’s syringe), so that we may throw in a large 
amount of liquid without irritating the vagina by frequent intro- 
duction of the nozzle. The application of leeches to the os uteri 
in acute catarrh is indicated when it begins with great severity, and 
in chronic catarrh when the substance of the uterus pai’ticipates in 
the inflammation, or when there is acute exacerbation of the disease 
with symptoms of severe congestion in the pelvis. Scanzoni also 
recommends them when there are granulating ulcers on the os 
uteri. We should apply leeches to the os uteri ourselves, or have 
it done by a nurse skilled in the operation. Gynecologists of the 
pi’esent day are refraining more and more from the use of leeches 
in the treatment of catarrh of the uterus and ulcers of the os, while 
formeily they were used far too often. The local application of 
nitrate of silver, in substance or in strong solution, is by far the 
most effective treatment of chronic uterine catarrh, and particu- 
larly for catan'hal erosions and follicular ulcers of the vaginal por- 
tion of the uterus. To prevent the caustic from breaking off in the 
cervical canal, we should employ sticks of double-annealed nitrate 
of silver, or have it hardened by the addition of a few grains of 
niti’ate of potash. When thus prepai’ed, we may push it boldly 
into the ceiwical canal. If cautei’izations with solid nitrate of sil- 
ver cause haemorrhage, which is often the case even in simple ulcer, 
we should use in its place concentrated solutions (one part to two 
or four of water), which should be poured in through the speculum 130 
DISEASES OF THE UTERUS. 
rather than used on a brush. I should employ these solutions much 
oftener, if it were not so difficult to protect the fingers and clothes 
from being soiled. The application should be repeated once a week 
or oftener, till the discharge diminishes and the portio vaginalis 
has regained its normal appearance. The result of this treatment 
is so striking, that touching the os uteri and its cervical canal, in 
chronic catarrh of the organ, must be classed among the most grati- 
fying operations in medicine. The pain induced by the cauteriza- 
tion is usually very insignificant, but in some cases it is quite se- 
vere. If the nitrate of silver be passed far into the cervical canal, 
some women will have painful contractions of the uterus, that may 
continue for hours. Besides nitrate of silver, the remedies most 
frequently used for catarrhal erosions and follicular ulcers of the 
os uteri are pyroligneous acid, liquor hydrargyri nitrici, and cuprum 
aluminatum (lapis divinus). Pyroligneous acid is particularly bene- 
ficial where the ulcers have a great tendency to bleed ; the liquor 
hydrargyri nitrici, and still more the lapis divinus, are to be tried 
when the nitrate of silver has failed. In such cases the actual cau- 
tery is a very effective remedy, and the opposition to its use is 
ascribable to its psychical effect rather than to the pain or danger 
accompanying it. Pyroligneous acid poured through the speculum 
is an invaluable remedy for the granulating ulcers of the os uteri 
that bleed readily. In most cases it arrests the haemorrhage more 
certainly than sesquichloride of iron or alum ; the latter is applied 
to the os uteri in substance more readily than in solution. We 
should only use injections into the cavity of the uterus in cases of 
absolute necessity, i. e., only when the above treatment fails, and 
we are forced to believe that the cavity of the uterus chiefly is dis- 
eased. In such cases we should use the ordinary solutions of nitrate 
of silver (3 ss. to water f j). The effect of these injections is 
much more severe than that of touching the os uteri with nitrate 
of silver ; they not unfrequently induce severe inflammatory symp- 
toms ; where the cervical canal is contracted, they should never be 
employed. 
[Injections into the cavity of the uterus are never to be prac- 
tised except in cases of the utmost urgency, when other treatment 
fails, and when the chief seat of disease is known to be within it. 
For this purpose nitrate of silver (0’5 to 30‘0) may be employed, 
or, when there is a tendency to bleed in consequence of prolifera- 
tion of the mucous membrane, the liq. ferri chloridi, tincture of 
iodine, alum, tannin, or carbolic acid. It is well known that the 
liquid injected may possibly pass through the tubes into the peri- 
tonaeum ; but aside from this danger, the operation not only excites PARENCHYMATOUS METRITIS. 
131 
severe uterine colic, but in many instances has induced a fatal 
metritis or peritonitis. Hence the operation demands the utmost 
precaution. A ready escape for the liquid injected must be secured 
by dilating the cervix by means of sponge-tent, and the quantity of 
liquid used must be very small. When the womb is tender to the 
touch, and when we suspect that there is a parenchymatous metri- 
tis or other complication, intrauterine injection must not be at- 
tempted.] 
C II A P T E E II. 
PARENCHYMATOUS METRITIS—ACUTE AND CHRONIC INFARCTION OF 
THE UTERUS. 
Etiology.—The changes of the substance of the uterus in acute 
and chronic parenchymatous inflammation rarely go beyond exces- 
sive hyperaemia, inflammatory oedema, and proliferation of its con- 
nective-tissue elements, in which the muscular elements usually par- 
ticipate but little or not at all. There is rarely suppuration or for- 
mation of abscesses. We do not include the puerperal form here. 
For the etiology of parenchymatous metritis we may refer to 
that of the catarrhal form. The injurious influences there men- 
tioned sometimes cause inflammation of the substance of the uterus ; 
at others, of its mucous membrane ; but most frequently of both. 
These influences also cause parenchymatous metritis more readily if 
they act while the uterus is in a state of physiological congestion. 
Lastly, the parenchymatous metritis of an unimpregnated uterus 
must often be regarded as the continuation of a puerperal metritis ; 
or at least a large number of cases date from the period of a con- 
finement or of an abortion. 
Anatomical Appearances.—In acute parenchymatous metritis, 
we find the uterus increased in size, particularly in thickness. It 
may attain the volume of a hen’s egg or larger. The over-filling 
of the blood-vessels causes its substance to appear more or less 
dark, and usually irregularly reddened. These changes are most 
marked in the layers lying next the mucous membrane. Occasion- 
ally there are effusions of blood into the parenchyma. The mu- 
cous membrane almost always shows the signs of acute catarrh. 
The serous coat also often participates in the inflammation, and is 
covered with deposits of fibrin. 
In chronic infarction, the uterus is often enlarged to three or 
four times its normal size ; its cavity increases, particularly in the 
long diameter ; its walls may become an inch thick. The hyperse- 132 
DISEASES OF THE UTERUS. 
mia which is at first present subsequently disappears, as the vessels 
are compressed by the neoplastic shrinking connective tissue. Then 
the substance appears very pale and dry, and becomes denser and 
harder, often to such an extent that it creaks under the knife. In 
rare cases we find hypersemic spots and veins that have become 
dilated as a result of the obstructed flow of blood. If the vaginal 
portion be chiefly affected, the os uteri is greatly swollen, and occa- 
sionally elongated like a snout. The mucous membrane almost in- 
variably shows the changes described in the previous chapter. On 
the peritoneal surface we often find firm adhesions to neighboring 
organs. 
Symptoms and Course.—Acute parenchymatous metritis begins 
with a chill more frequently than the catarrhal form does, and is 
more apt to be accompanied by symptoms of fever in its subsequent 
course. The pain in the sacral and inguinal regions, the feeling of 
pressure in the pelvis, the sensitiveness of the lower part of the ab- 
domen, the dysuria and tenesmus, are present in the former as well 
as in the latter, and almost always attain a higher grade than they 
do in the simple catarrh. The uterus can rarely be felt above the 
symphysis pubis, but through the vagina we may usually detect en- 
largement and tenderness of the inferior segment, and a moderate 
shortening and thickening of the portio vaginalis. There are also 
anomalies of menstruation. If, as is commonly the case, the dis- 
ease begins during menstruation, the bleeding usually ceases sud- 
denly ; if the time for menstruation occurs during the progress of 
the disease, we either have metrorrhagia (metritis haemorrhagica), 
or, as more frequently occurs, there is no bleeding. Except during 
the period of menstruation, the discharge characteristic of uterine 
catarrh (the constant companion of parenchymatous metritis) is 
present. In favorable cases the disease runs its course in from 
eight to fourteen days, the symptoms subside gradually, and the 
disease ends in perfect recovery ; in unfavorable cases, chronic in- 
farction remains. There have been some very rare instances where 
an abscess formed and perforated into the abdomen, and the dis- 
ease thus terminated fatally. 
Except at the menstrual periods, the symptons of chronic in- 
farction of the uterus are often not very prominent. Frequently 
the patient complains only of a feeling of weight in the pelvis and 
a sensation of “ bearing down.” The pressure of the enlarged 
uterus on the rectum and bladder usually causes constipation, as 
well as a frequent and annoying inclination to go to stool and to 
urinate. At the commencement of the disease, menstruation is 
often free and prolonged ; but the more the vessels of the uterus PARENCHYMATOUS METRITIS. 
133 
are compressed by the neoplastic connective tissue, the more diffi- 
cult menstruation becomes and the scantier the flow. Finally, the 
menses are often absent for months or years, while the regularly 
recurring molimina seem to indicate that the ripening and throwing 
off of the egg takes place at normal periods. In this form of me- 
tritis also—which, moreover, is always accompanied by the catarrhal 
form—the nutritive state of the patient usually suffers after a time, 
and the hypersesthesia and other disturbances of innervation, men- 
tioned in a previous chapter, usually develop. On physical exami- 
nation we may often feel the enlarged uterus through the abdominal 
walls above the symphysis pubis, particularly if we push it up a lit- 
tle with the finger introduced into the vagina. On vaginal exam- 
ination, we also discover that the vaginal portion is enlarged, indu- 
rated, and more or less painful. On introducing the uterine sound 
(which should not be employed unless the practitioner is skilled and 
experienced in its use), the increase in the long diameter may be 
ascertained. Although not dangerous, the disease is very obstinate 
and tedious. Even in its advanced stages it cannot be regarded as 
absolutely incurable ; the decrease after confinement of the uterus, 
which had been greatly enlarged during pregnancy, renders it not 
improbable that there may also be a retrocession of the pathologi- 
cally increased tissues of the uterus. Occasionally improvement 
and cure of infarction of the uterus have been seen directly after 
pregnancy, and in such cases it seemed as if, with the involution of 
the uterus after confinement, there had been at the same time a 
diminution of the physiologically and pathologically increased tissue. 
Treatment.—According to the variety of the exciting cause, 
the causal indications are fulfilled by the different rules prescribed 
in the preceding chapters. In many cases the continued use of 
slight laxatives is very beneficial, particularly the laxative waters 
of Marienbad, Franzenbad, Kissingen, etc. 
The indications from the disease are best answered by the repeated 
application of leeches (four to six) to the portio vaginalis. Although 
I have seen a most favorable effect from this treatment, in my own 
practice and in that of others, where the disease was recent, it has 
seemed of little use in protracted cases. Theoretically, also, we may 
expect better results from abstraction of blood while the connective- 
tissue formation is still new, and the catamenia are plentiful and con- 
tinued, than when the capillaries have been compressed, the uterus 
deprived of blood, and the menses have ceased. Before convincing 
ourselves by personal observation of the brilliant results of abstraction 
of blood in the first stages of parenchymatous metritis, and finding 
how well the patients bear the loss, it is usually difficult to make up 134 
DISEASES OF THE UTERUS. 
our minds to increase the copious loss of blood by applying leeches 
to the vaginal portion of the uterus every week or two. A more 
irritating treatment, particularly the continued use of warm douches 
to the uterus, seems preferable in the later stages of the disease. 
These douches should be used about ten minutes every day ; the 
water employed should not be over 99° or 108° F. It is also worth 
while trying the use of Kreuznach and other saline baths, as well as 
the baths and waters of Krankenheil. The internal administration 
of iodide of potassium and of bromide of potassium, as recommended 
by Simpson, is also beneficial. 
[Acute metritis demands absolute rest in bed, the pelvis being 
kept somewhat elevated. When, from the tenderness of the belly, 
we suspect a complication with peritonitis, leeches should be applied 
to the abdomen and followed by cold compresses. When the inflam- 
mation seems limited to the womb, local depletion of that organ 
should be practised by leeching the vaginal portion of the cervix, 
unless the virgin condition of the patient forbids it. Scarification 
by means of Mayer’s lance-knife has, however, in a great measure 
supplanted the leech applied to the womb. It has the advantages 
over leeching that the procedure is quite painless, and that the 
amount of blood to be drawn can be nicely regulated by making the 
incisions deeper or shallower. Moreover, many observers believe 
that the suction of a leech may set up an irritation which tends 
rather to augment the fluxion toward the affected part than to check 
it. According to Schroeder, scarification should be repeated about 
every third or fourth day, not more than half an ounce of blood 
being drawn at one operation as a rule ; but if the patient is ple- 
thoric and the womb enlarged, an ounce may be taken. Syringing 
the parts with cold water is a practice which should never follow 
scarification ; for, although the cold produces a momentary con- 
traction of the vessels, a relaxation quickly follows, which brings 
with it a renewed congestion and thwarts the purpose of the op- 
eration. 
The demonstration by Emmet, of New York, that the majority 
of so-called ulcerations of the womb are really the effect of laceration 
of the cervix, is an important advance in the pathology and thera- 
peutics of this subject. He holds that lacerations occur during labor 
more often than has been hitherto supposed. They occur most fre- 
quently in the median line, and then heal readily, and generally 
escape notice. But if the rent is extensive, and runs in a lateral 
direction, the weight of the womb tends to force the lips of the 
wound asunder, so that union by first intention cannot take place. 
When the woman assumes an erect posture, the flaps diverge still PERIMETRITIS AND PARAMETRITIS. 
135 
further, and the mucous membrane of the cervical canal becomes 
everted and chafes against the vaginal walls. Through the irritation 
thus set up, the angle of the laceration becomes the seat of an ero- 
sion, which may spread over the everted surfaces. Such an ulcer 
heals with great difficulty, and only by granulation and by the for- 
mation of a dense cicatrix. The womb usually suffers subinvolution 
with all its consequences, and the cicatrices are a fruitful source of 
neuralgia and other forms of uterine irritability. As long as the 
fissure remains open, the ulceration is most refractory to all treat- 
ment. It is necessary to close the laceration by a surgical opera- 
tion. This i» judicious hands is neither difficult of accomplish- 
ment nor dangerous, and yields most satisfactory results.] 
CHAPTER III. 
PERIMETRITIS AND PARAMETRITIS. 
Inflammations of the parts about the uterus occur very fre- 
quently just after confinement, and not unfrequently at other times. 
In the latter case they usually depend on disturbance of the menses. 
If the inflammation starts from the serous coat of the uterus and its 
appendages, and the case is one of partial peritonitis, the disease is 
called perimetritis ; if, on the contrary, the inflammation is in the 
subperitoneal connective tissue, it is called phlegmon periuterina, 
or, according to Virchow, parametritis. 
Perimetritis leads to more or less copious exudation on the free 
surface of the peritonseum. Scanty fibrinous exudations cause adhe- 
sions with the neighboring organs. Even large fluid exudations are 
usually encapsulated by adhesions at their edges. After absorption 
of the exudation, adhesions to the pelvic organs often remain. In 
parametritis there is infiltration of the subperitoneal tissue, which 
is firm from the first. The infiltration may be reabsorbed ; but a 
firm induration often remains as the result of connective-tissue pro- 
liferation. In other cases the inflammation goes on to suppuration, 
and abscesses form, whose contents may perforate into the rectum, 
vagina, bladder, or abdomen. 
It is often difficult to distingnish between perimetritis and para- 
metritis during life ; they begin and run their course with more 
or less severe subjective and objective symptons of fever. The 
patients complain of pain deep in the pelvis, which is increased by 
pressure on the lower part of the abdomen. Generally, also, there are 
symptoms of compression of the pelvic organs, the bladder, rectum, 136 
DISEASES OF THE UTERUS. 
and, according to my experience, of the nerves along the walls of 
the pelvis. The presence or absence, and the degree of severity and 
obstinacy of dysuria and difficult defecation, as well as of the pain 
extending along the sacral, sciatic, and crural nerves, depend in 
each case on the seat and amount of the exudation. Where there 
has been extensive exudation, on examination we may find a tumor 
of variable size above the pubis. Examination through the vagina 
or rectum usually shows that the uterus is displaced and firmly 
wedged in. Intraperitoneal exudations usually fill Douglas’s cul- 
de-sac, and may be readily felt. Subperitoneal infiltrations and 
abscesses are generally somewhat higher, but they aiso can mostly 
be reached by the finger. 
[Unless the two conditions should happen to coexist, the results 
of physical exploration show differences in many respects which can 
be made out by bimanual palpation. A peritoneal exudation sinks 
into Douglas’s space, as being the lowest level in the abdominal 
cavity. The cul-de-sac becomes distended and pushed downward. 
If the exudation has coagulated, or when a liquid exudation is incap- 
sulated so that it cannot yield to the finger, we can feel a more or 
less voluminous tumor, such as a retrouterine hasmatocele presents, 
lying behind the uterus and vagina, displacing the one upward and 
forward, and bulging the other forward and downward. On the 
other hand, the extraperitoneal exudation of parametritis is found 
as a rule toward the side of the womb, sometimes on both sides ; 
and through the vagina it feels at first like a resisting infiltration, and 
afterward like a hard, sharply-defined tumor, which seems to spring 
from the lateral edges of the womb, the boundary-line between the 
two being sometimes difficult to determine. In exceptional cases— 
as when Douglas’s cul-de-sac is closed by adhesions—a perimetritic 
exudation may likewise form in a more lateral region of the pelvic 
peritonaeum, and bulge downward ; and conversely, there have 
been rare cases of parametritic exudation into the areolar tissue, 
behind and even in front of the uterus and the upper vaginal region. 
In such instances, when the intra- and extra-peritoneal exudations 
exist together, a diagnosis becomes extremely difficult.] The disease 
may continue for weeks, and greatly exhaust the patient by the 
accompanying fever. 
[Extraperitoneal abscesses tend by preference to find an outlet 
at the surface of the body, especially in the groin, or from the iliac 
fossa, or after passing under Poupart’s ligament to appear upon 
the front surface of the thigh, or else to perforate backward through 
the ischiatic foramen and muscles of the buttock. On the other 
hand, intraperitoneal abscesses open moi’e often into the cavities of CONTRACTIONS AND CLOSURES OF THE UTERUS. 
137 
the body, particularly into the intestine and vagina. As a diagnos- 
tic hint, we will here mention that pain in a limb, really caused by 
pressure of an exudation upon a nerve, has now and then been mis- 
taken for a pure sciatica. 
Schultze also describes a latent parametritis posteriori, of insidi- 
ous, tedious course, usually due to mechanical causes, and said to 
produce a shortening of Douglas’s folds, and to be a most important 
factor in the production of anteflexion and anteversion.] 
The perforation of subperitoneal abscesses or of intraperitoneal 
exudations into the intestines or bladder is marked by the sudden 
decrease in size of the tumor, and by the evacuation of purulent 
masses with the stools or urine ; perforation into the abdomen causes 
severe general peritonitis, which quickly proves fatal. Even in 
favorable cases the patients generally recover slowly. In many of 
the patients under my observation the neuralgic pains lasted for 
months. 
Treatment.—[Treatment of an acute recent perimetritis de- 
mands absolute confinement to the bed, leeching to the groins, the 
application of ice-bags to the abdomen, mercurial inunction, confine- 
ment of the bowels by opium—in short, the treatment of a peritoni- 
tis. A recent parametritis calls equally for complete repose, but 
in other respects the treatment may be less active. The bowels 
should be gently moved, while cleansing and disinfecting injections 
should be frequently repeated, to clear away all putrid secretions, 
which are the common exciting cause of this form of inflammation.] 
Local abstraction of blood and the application of cataplasms to 
the lower part of the abdomen act well in the treatment of recent 
cases of perimetritis and parametritis. We should continue the use 
of the latter as long as there is any swelling left, even if there be 
no pain. In protracted cases I have found great benefit from the 
use of warm salt baths, with an addition of mother-liquid, and the 
internal administration of iodide of iron. At the same time, we 
must keep up the nutrition and strength by proper diet, and treat 
any existing fever by antipyretics. 
CHAPTER IV. 
CONTRACTIONS AND CLOSURES OF THE UTERUS—HJ)MOMETRA, 
HYDROMETRA. 
In young persons who develop late, moderate degrees of contrac- 
tion of the os uteri are quite frequent. They hinder conception, 138 
DISEASES OF THE UTERUS. 
without rendering it impossible. Moreover, they impede the escape 
of the menstrual blood, and cause it to collect temporarily in the 
uterus, and to be expelled by painful contractions (uterine colic). 
I have frequently known women to menstruate without difficulty 
after their first confinement, who, during their maidenhood and the 
first years of married life, had severe uterine colic during menstrua- 
tion. Great flexions and angular curvatures cause contraction of 
the cavity of the uterus at the point of flexion, which also impedes 
conception, and occasions uterine colic during menstruation. Final- 
ly, neoplasia, Avhich encroach on the calibre of the uterine cavity 
and the cervical canal, have the same effect. Perfect closure, atre- 
sia of the uterus, is very rare. It is sometimes congenital, some- 
times the result of erosions and ulcers, which, in cicatrizing, have 
caused adhesions. The seat of congenital closure of the uterus is 
usually at the external orifice, that of the developed form at the 
internal orifice. 
As long as the women continue to menstruate, the menstrual 
blood collects behind the point of closure, causing hcemometrci. If 
the closure does not take place till the menses have ceased, the 
catarrhal secretion from the mucous membrane occasionally collects 
in the closed cavity, and distends the uterus. Sometimes this secre- 
tion resembles serum or synovia, doubtless because the excessive ten- 
sion destroys the secreting glands in the mucous membrane, and 
the latter becomes like a serous membrane. The above state is 
called hydrometra. 
In hcemometra, which, moreover, depends upon atresia of the 
vagina oftener than upon atresia of the uterus, the uterus may 
be gradually distended till it becomes as large as it does in the later 
months of pregnancy, and the blood contained in it, which is usually 
black and tarry, may amount to eight or ten pounds. According to 
the observations of Scanzoni and Veit, when the distention takes 
place rapidly, the walls of the uterus are thinned ; if it comes on 
slowly, they are thickened by hypertrophy. In the early stages it 
is difficult to diagnose liEemometra. During childhood closure of 
the uterus or vagina is hardly ever discovered. The first morbid 
symptoms occur about the commencement of puberty. At intervals 
of four weeks there is severe uterine colic, with a feeling of pressure 
and weight in the pelvis, and signs of severe congestion of the other 
pelvic organs, or of perimetritis. At first the patients feel well 
again after these symptoms have continued a few days ; but after 
four weeks there is a relapse. After a time the intervals are no 
longer free from pain. The abdomen increases in size ; the uterus 
rises above the symphysis pubis, and may rise as high as the navel. CONTRACTIONS AND CLOSURES OF THE UTERUS. 
139 
In the monthly attacks the pains become very severe. The patients 
emaciate, and may become marasmic ; or, if no mode of escape be 
furnished for the blood, the uterus may rupture, or they may die of 
peritonitis. The latter disease is particularly apt to occur if the 
tubes be also filled with blood, and their contents escape into the 
abdomen. Haemometra cannot be recognized with certainty, or 
distinguished from other forms of amenorrhoea or dysmenorrhcea, 
particularly at its commencement, without a careful local examina- 
tion. If, at the commencement of puberty, there be uterine colic 
at regular intervals of four weeks, while there is no escape of blood, 
and if there be, at the same time, a distention of the abdomen, 
which periodically increases slightly, wTe should suspect the develop- 
ment of a hcemometra, and urge an examination. If the haemome- 
tra depend on atresia of the vagina, we find the latter distended to 
a tense tumor, whose lower end extends into the vestibide. If the 
external os uteri be closed, the vaginal portion is often entirely 
obliterated, and the position of the os uteri may not be recogniza- 
ble. If, on the other hand, the internal os uteri be closed, the vagi- 
nal portion may retain its normal length. Besides this, we find the 
uterus distended to a considerable size ; sometimes, but not always, 
there is fluctuation. The treatment of hsemometra is purely sur- 
gical. 
It is rarely that a hsemometra terminates favorably without the 
intervention of skilled assistance. In such exceptional cases the 
blood finds a way either through the normal passages or else into 
one of the abdominal cavities. Sometimes menstruation ceases pre- 
matux-ely, or the climacteric arrives, when the symptoms abate, and 
the bloody contents of the uterus assume the character of hydro- 
metra. The treatment of haemometra is purely surgical, and con- 
sists in opening the sac between two menstrual periods. The mode 
of operation must necessarily vary greatly according to the circum- 
stances of the case. The procedure is a somewhat dangerous one, 
and demands attentive study in the books of surgery and gyne- 
cology. 
Of course, hydrometra can only result from acquired closure of 
the os uteri or vagina, and after the menses have ceased. Mild 
cases of the disease are seen quite often ; severer cases, where the 
uterus is distended to the size of a head or larger, are rare. The 
most important symptom of hydrometra is an enlargement of the 
uterus, which usually occurs gradually, and without exciting atten- 
tion, while in some few cases it is quite rapid and decided. This 
may be detected on physical examination, and is often even per- 
ceived by the patient. If the walls of the distended uterus be 140 
DISEASES OF THE UTERUS. 
thinned, there is occasionally distinct fluctuation ; if they be hyper- 
trophied, we do not find this most important sign for distinguishing 
hydrometra from almost all other uterine tumors. Occasionally 
there is uterine colic, particularly during severe congestions of the 
uterus. If the closure be incomplete, these contractions sometimes 
force out the collected fluid, and, according to Scanzoni, occasion- 
ally also gases that have formed from them. The treatment of hy- 
drometra consists in surgically making a passage for the liquid, and 
in attempting, by astringent injections, to limit the secretion of the 
mucous membrane. 
CHAPTER V. 
CURVATURES OF THE UTERUS FLEXIONS AND INFARCTIONS. 
Etiology.—[Any abnormal change between the directions in the 
axis of the neck of the womb and that of its body is called a flexion; 
but it must be borne in mind that when the bladder is empty the 
womb is normally bent slightly forward. The bend or angle is 
nearly always at the internal os. When the deformity is such that 
the fundus inclines forward, and the curve or angle included be- 
tween it and the cervix is anterior, wre have an anteflexion ; the con- 
trary constitutes a retroflexion. There may also be lateral flexions, 
but they are rare.] 
There are various views regarding the pathogeny of these dis- 
tortions. Most authors think that the causes of the flexure lie in 
the uterus itself, and support their view on the fact that, at the 
point of distortion, the wall of the uterus is always flattened, and 
its parenchyma loose and reflexed. Virchow considers the changes 
at the point of flexion as secondary symptoms, due to the pressure 
on the walls of the uterus at this point, and to the amemia of the 
parenchyma caused by this pressure. It is his opinion that most 
distortions of the uterus, particularly anteflexions, are caused by 
congenital or developed shortening of the ligament of the uterus, and 
by its consequent fixation on distention of the bladder and rectum. 
It is most probable that the causes of the flexions are not always the 
same—that they are sometimes within, sometimes outside of the 
uterus. [Schultze believes that a posterior parametritis of insidious 
course and somewhat frequent occurrence causes a shortening and 
rigidity of the fold of Douglas, thereby producing a displacement 
backward and upward and fixing of the cervix, which is the com- 
monest cause of anteflexion as well as of anteversion.] 
Hetroflexions, the most frequent form in women who have had CURVATURES OF THE UTERUS. 
141 
children, are, on the other hand, rare in those who have had none ; 
they almost always date from the time of a confinement or an abor- 
tion. If the involution of the uterus go on slowly after its contents 
have been evacuated, if it remain enlarged and relaxed, the fundus 
readily sinks down on account of its weight, or is pressed down by 
the other contents of the abdomen. As the greater part of the ute- 
rus remains in the posterior wall after delivery, it is natural that it 
should most frequently sink backward ; but we cannot wonder if 
there are deviations from this, as they may readily be induced by 
different positions of the distended intestines in the vicinity, and by 
other accidental causes. At this period a complete return to the 
normal state is certainly possible. The bending of the uterus is 
straightened out when it contracts early. But, if this do not take 
place soon, the parenchyma, at the point of curvature, becomes 
anaemic and atrophied from the continued pressure, or the fundus 
uteri forms some abnormal attachment. In either case we have a 
permanent anomaly—a distortion in the strict sense. Scanzoni men- 
tions, as the most frequent cause, the slow and incomplete involu- 
tion of the uterus, and, as the most important etiological factors of 
the retroversion, early marriages, frequent and quickly repeated 
pregnancies, abortion, artificial delivery, etc. 
Anteflexions chiefly occur in those who have had no children. 
In young persons the most frequent cause seems to be a relaxation 
of the substance of the uterus by chronic catarrh ; in aged persons 
it is a senile atrophy of the uterus, at the point wrhere these distor- 
tions always occur, that is, near the internal os uteri. It is easy to 
understand that anteflexion should be the more frequent form of 
distortion in women who have had no children, if we remember that 
a virgin uterus has normally a slight inclination forward. In this 
case also, it seems to me, there is no doubt that the flattening of the 
wall of the uterus, and the atrophy of the tissue at the point of 
flexion which takes place after a time, are due to the pressure and 
anaemia. 
Besides these flexions, caused by anomalies of the substance of 
the uterus, there are others which are undoubtedly caused by short- 
ening of the uterine ligaments, as is proved by the cases observed 
by Virchow, where there were flexions without any structural change 
in the parenchyma. In the same way, distortion may result from 
fibroid tumors in the anterior or posterior wall of the uterus, from 
tense adhesions, or from the pressure of tumors. The more securely 
the lower portion of the uterus is held in place by a rigid vagina, 
the more readily flexions occur; the less firmly it is held, the more 
often displacements will occur instead. 142 
DISEASES OF THE UTERUS. 
Anatomical Appearances.—On autopsy, flexions of the uterus 
may be readily recognized, as part of the anterior or posterior wall 
of the body, instead of the fundus, forms the highest part of the 
uterus. Generally we may readily restore the sunken fundus to its 
position, but it sinks back again to its former place when we let go 
of it. In some cases it cannot be restored to its normal position on 
account of peritoneal adhesions with the surrounding parts. Be- 
sides the flexion, there is almost always a slight anteversion or re- 
troversion. If we cut the uterus out of the body, and hold it erect 
by the vaginal portion, the fundus sinks down, either anteriorly or 
posteriorly ; if it be held horizontally, it not unfrequently holds its 
weight if the flexed portion be upward, but it bends together if we 
reverse it. The point of flexion is always near the internal os uteri. 
Here the flexion is sometimes slight, sometimes at right angles, or 
even at an acute angle. The os uteri is almost always moderately 
open, even in women who have had no children ; this is a natural 
result of the tension on the anterior lip in retroflexion, on the pos- 
terior lip in anteflexion. The internal orifice, on the contrary, is 
contracted partly by the flexion itself, partly by the swelling of the 
mucous membrane. In older women, we occasionally find complete 
atresia of the internal os uteri. The contraction or closure of the 
internal os uteri causes more or less hydrometra. The disturbance 
of circulation at the point of flexion sufficiently explains the almost 
constant complication with catarrh of the uterus, ulcers of the os, 
and parenchymatous metritis. 
Symptoms and Course.—The most constant symptoms of flexion 
depend on the impeded escape of the contents of the uterus. Hence 
the patients usually suffer severely from dysmenorrhoea as long as 
they continue to menstruate. Small clots of blood that has coagu- 
lated in the uterus are often mixed with the menstrual blood, which 
is evacuated with severe uterine colic. Uterine colic may also be 
caused, in the interval between the menses, by the impeded escape 
of the mucous and serous secretions, retained above the point of 
flexion. In many cases there are also the symptoms of uterine 
catarrh, as described in the first chapter, the fluor albus uterinus, 
decided loss of blood during menstruation, etc. Difficult and pain- 
ful evacuation of the rectum, desire to urinate and pain while doing 
so, the signs of ana3mia and bad nutritive condition, and finally the 
disturbances of innervation that have been so often mentioned, com- 
plete the description given by many women suffering from flexion 
of the uterus. But we must add that sometimes women with very 
decided flexions of the uterus never have any, or have but few, of 
these symptoms ; or, if they do occur, they soon pass off without CURVATURES OF THE UTERUS. 
143 
the disappearance of the flexion. Sterility itself, although very fre- 
quent, does not constantly accompany flexions of the uterus. Hence 
it appears that it is not the flexions, but the other anomalies of the 
uterus, which complicate them, that cause the symptoms above de- 
scribed. These complications are so frequent that their absence is 
an exception. This is partly because the same injurious influences 
that induce the flexions also excite the different forms of metritis ; 
partly because the disturbances of circulation at the point of flexion 
cause hyperfemia and exudation in the parenchyma, mucous mem- 
brane, and serous covering of the uterus. The course of flexions is 
very tedious. The disappearance of the condition is exceedingly 
rare, if it ever takes place. Flexion can only disappear completely 
if new parenchyma is formed in place of the flattened and atrophied 
uterine tissue. When, with advancing years, the periodical recur- 
rence of physiological congestion of the uterus ceases, all the symp- 
toms usually moderate ; and when, in aged persons, the uterus and 
part of its blood-vessels become atrophied, the patient may feel 
pretty well. 
On physical examination, the finger introduced through the va- 
gina first feels a dislocation, anteriorly or posteriorly, of the portio 
vaginalis, caused by the coexistent anteversion or retroversion. We 
also generally find the os so patulous that the point of the finger 
may be readily passed into it, even in women who have had no chil- 
dren. From the vagina, either before or behind the vaginal portion, 
wTe may find the body and fundus of the uterus, forming a round, 
firm, movable tumor. Usually, also, we may reach the point of 
flexion. The fact that the opposite part of the vagina is empty 
prevents our mistaking a flexed uterus for one that is enlarged, or 
diseased in some other way. The introduction of the uterine sound 
aids the diagnosis ; but when the uterus is flexed this operation is 
peculiarly difficult, and we again repeat that, in the hands of an 
unskilful physician, or even in those of a skilful one, the uterine 
sound is a dangerous instrument, which should be used as little as 
possible. 
Treatment.—We have already said that total disappearance of 
a flexion must to a certain extent be considered as a physiological 
impossibility, as it is almost always accompanied by atrophy of the 
parenchyma of the uterus at the point of flexion. “ Flexion instru- 
ments,” sounds, redressers, and intra-uterine pessaries, which were 
for a time much used for flexions, do actually no good, but much 
harm. Scanzoni has stated plainly that in his large gynecological 
practice he has never cured a flexion, and that he considers the use 
of flexion instruments as of no use, and dangerous. Tonics also, 144 
DISEASES OF THE UTERUS. 
whether used locally or internally, promise no benefit. The advice 
that patients with anteflexion should hold their urine as long as 
possible, so that the distended bladder may raise up the fundus, and 
that patients with retroversion should retain the fieces for the same 
reason, is given from theoretical grounds, and has not proved correct. 
( Virchow says that anteflexion results from great distention of the 
bladder while the uterus is fixed.) Most gynecologists advise wear- 
ing a firm girdle around the pelvis and lower part of the abdomen, 
and many patients praise the results of this treatment. It is diffi- 
cult to understand that, even in retroflexion, pressure on the lower 
part of the abdomen should relieve the patient. Perhaps their 
greater ease may be due to the compression of the uterus and its 
consequent bloodless state. 
Little as we can do to remove the flexions, we may do much to 
relieve the sufferings of the patient if we treat the catarrh and pa- 
renchymatous inflammation of the uterus, which first call attention 
to the flexion, according to the rules laid down in previous chap- 
ters. Occasional abstractions of blood from the portio vaginalis 
are peculiarly beneficial, and are almost always effective in cases 
of flexion. 
[To allay the distressing menstrual colic caused by retention of 
clots at the constricted point of flexure, most gynecologists resort to 
mechanical dilatation of the cervical canal. According to the expe- 
rience of Sims and others, bloodless dilatation by means of bougies 
is less beneficial than, and fully as dangerous as, incision of the neck 
by the metrotome.] 
CHAPTER VI. 
CHANGES OF POSITION OP THE UTERUS. 
The uterus, which is very movable, may be dislocated in any 
direction. The most important deviations in position are antever- 
sion, retroversion, descent, and prolapse. 
Anteversion most frequently occurs in women with strongly 
curved pelvis. The natural inclination forward of the uterus may 
be increased by the pressure from above of fluids in the peritoneal 
sac or of tumors, and anteversion may thus be caused. More fre- 
quently the uterus sinks forward from its own weight ; hence al- 
most always moderate degrees of anteversion accompany infarc- 
tions and new formations in the fundus uteri. Anteversion rarely 
becomes excessive, since each distention of the bladder restores the 
uterus to place, if some peculiar circumstance does not interfere with CHANGES OF POSITION OF THE UTERUS. 
145 
the reposition. Corresponding to this, the annoyance caused by the 
disease is usually slight, and it is only when the uterus is otherwise 
diseased and enlarged, or when it swells up at the menstrual period, 
that compression of the pelvic organs and tension of Douglas’s liga- 
ments cause pain in the small of the back, pressure in the pelvis, 
difficult micturition, desire to go to stool, and pain during defeca- 
tion. On vaginal examination, we find the portio vaginalis directed 
backward toward the hollow of the sacrum, and passing the finger 
forward we come without interruption upon the body and fundus, 
which lie against the anterior part of the vagina. 
Retroversion depends on the same causes as anteversion. A con- 
tinued pressure from before backward, tense adhesions on the pos- 
terior surface of the uterus or tumors in its posterior wall, cause a 
sinking of the fundus uteri into Douglas’s space, and a prominence 
of the vaginal portion toward the symphysis pubis. The retrover- 
sion that occurs independently during the first months of preg- 
nancy, and soon after confinement, is a very important disease ; 
that occurring at other times is generally only a subordinate result 
of other diseases of the uterus or other pelvic organs. The symp- 
toms of retroversion are analogous to those of anteversion, and they 
also depend on the pressure of the horizontally-displaced uterus on 
the pelvic organs, particularly on the rectum and bladder. 
Descent and prolapse of the uterus depend chiefly on relaxation 
of the parts that maintain the uterus in position, particularly its 
ligaments, the pelvic fascia, and the vagina. If, during this relaxa- 
tion, a stronger pressure from above downward act on the uterus, 
the latter is pressed down, inverts the vagina, and passes deeper 
into it, and the result is a descent. If part of the uterus protrude 
from the vulva, we speak of a prolapse ; when the entire uterus lies 
outside of the vulva, it is called a prolapsus completus. Relaxation 
of all the parts that should maintain the uterus in position occurs 
most frequently in the puerperal state ; and it is the abdominal 
pressure that most often presses the uterus downward. Poor wo- 
men, who cannot take care of themselves after confinement, but are 
obliged to do hard work that causes abdominal pressure a few days 
subsequently, are peculiarly liable to descents and prolapses. As 
every descent of the uterus inverts the vagina, and each prolapse of 
the uterus induces prolapse of the vagina, so, on the other hand, 
prolapse of the vagina may give rise to descent or prolapse of the 
uterus. If the lower end of the vagina be prolapsed, as a result 
of rupture of the perinseum during delivery, or from some other 
cause, the upper end exercises traction on the uterus, which either 
results in elongation of the vagina or descent of the uterus. De- 146 
DISEASES OF THE UTERUS. 
scent or prolapse of the uterus only exceptionally occurs in women 
who have had no children. When they do occur, it is because the 
same conditions exist as after confinement, and particularly because 
the vagina is relaxed by blennorrhoea and venereal excesses, or the 
uterus is pressed downward by heavy tumors in the pelvis. If 
prolapse of the uterus take place suddenly, as occasionally happens 
from lifting heavy weights, from severe coughing, or strong bear- 
ing-down efforts, the stretching of the ligaments causes severe pain 
in the abdomen, and great general disturbance, fainting, nausea, 
etc. If the descent or prolapse develop slowly, there is usually but 
little annoyance at first ; this consists chiefly in an undecided feel- 
ing of pressure downward, and in stretching pain in the lower part 
of the abdomen and small of the back. The deeper the uterus de- 
scends, the more annoying these symptoms become ; they increase 
when the patient stands up, Avalks, coughs, etc ; they diminish dur- 
ing rest, and in the horizontal position. There are also inconven- 
ience and pain during urination and defecation, and there are con- 
stipation, colic, and other symptoms due to dislocation, pressure, 
and tension of the abdominal organs. If the uterus project from 
the vulva, it at first forms a round or oval tumor, as large as a wal- 
nut, which may be easily replaced ; but soon the uterus covered by 
the vagina advances, the tumor rapidly increases in size, and is re- 
placed with difficulty ; it feels doughy, but on firm pressure we 
may distinguish a hard body more deeply seated. If, with the 
anterior wall of the vagina, the fundus and posterior wall of the 
bladder be drawn through the vulva (cystocele), on the anterior 
wall of the prolapse we may see a tense and sometimes fluctuating 
tumor, which swells and subsides again several times during the 
day, and into which, by exercising some skill, we may introduce a 
male catheter through the urethra. On introducing the finger into 
the rectum, we find it bulged forward. The os uteri gapes open, 
because the vaginal portion is averted ; it is reddened and covered 
with glairy mucus. The prolapsed vagina is dry, parchment-like, 
thickened ; the epithelium resembles epidermis ; frequently it is ex- 
coriated by the friction of the clothes and the irritation of the urine 
that trickles over it, and not unfrequently deep ulcers form in it. 
The treatment of dislocations of the uterus is purely surgical ; 
and it would lead us too far to speak even of the choice of certain 
pessaries, and of the rules for their introduction and employment. FIBROID TUMORS OF THE UTERUS. 
147 
CHAPTER VII. 
FIBROID TUMORS OF THE UTERUS FIBROMYOMATA, FIBROIDS, 
DERMOIDS. 
[Pathology and Anatomical Appearances.—These growths 
are to be regarded as partial hyperplasias of the uterine parenchy- 
ma, and consist of masses of smooth muscular fibres intermingled 
in varying proportion with connective tissue. In their original form 
they always present rounded, sharply-defined tumors. They are 
non-malignant in their character, and are far more common than 
any other form of uterine growth. They rarely appear before pu- 
berty, and their liability to develop increases up to a certain point 
with the age, so that they are most commonly found in persons from 
thirty to fifty years old, while beyond this age they are compara- 
tively rare. They are met with both in the married and unmarried, 
and are often associated with menstrual disorder and sterility, 
which, however, must be looked upon as consequences rather than 
as causes of the disease. Nothing certain is known regarding 
their cause. Fibromyomata vary greatly in size. They may be no 
larger than a pea, or may form a tumor as large as the head, and 
may weigh several pounds ; but this is somewhat rare. They are 
sometimes solitary and sometimes multiple, and in the latter case 
they are usually small. 
The constitution of a fibromyoma varies. Sometimes the fibrous 
element preponderates, giving it more the character of a pure fibro- 
ma ; sometimes (but rarely) the growth consists almost purely of 
unstriped muscular fibres, thus approaching the true myoma in na- 
ture. Upon section, their structure is found to consist of more or 
less regular concentric layers of wTavy connective tissue, between 
which the finer bundles of muscular fibres are arranged. The more 
the firm, tendinous, fibrous tissue preponderates, so much the harder 
is the tumor and the paler its cut surface. When the muscular ele- 
ment prevails, the section presents more of the grayish-red coloring 
of the normal uterine tissue. As a rule, fibromyomata are but spar- 
ingly vascular, and very seldom contain large blood-vessels. There 
is, however, one form in which these tumors consist, either partially 
or totally, of enormously dilated blood-vessels. Sinuses filled with 
blood may even form, giving to the tumor a likeness to the erectile 
tissue of the corpus cavernosum, and also its capacity to swell and 
shrink ; so that sudden changes of volume in such a tumor can be 
observed ( Virchow's telangiectatic or cavernous myoma). 148 
DISEASES OF THE UTERUS. 
Fibromyomata often exist in a conglomerated form. The tumor 
is then irregular and knobby in contour, instead of l’ounded. This 
shape is sometimes attributable to the blending of several indepen- 
dent tumors ; but more commonly the self-same morbid process 
which causes the original growths in their simpler form again re- 
peats itself in the substance of the new growth. Each vessel, with 
its appertaining connective tissue and muscular fibres, proliferates, 
and begets, as it were, a second generation of nodules within the 
older ones. Although the fibromyoma springs from the uterine paren- 
chyma, yet at a later stage it no longer remains closely connected 
with it, but lies within the uterine substance, though quite isolated 
from it by a layer of loose areolar tissue, so that it can very easily 
be enucleated. Sometimes, however, old fibroids of large size main- 
tain their connection with the womb by a pedicle, or even by a 
broad fibromuscular band. Such an attachment usually contains 
large blood-vessels. The womb is usually hypertrophied, but in 
advanced age it is atrophied. Now and then it is elongated and 
thinned, and it is often out of place. 
Fibromyomata rarely spring from the cervix, but rather from 
the fundus or body. Their classification according to their more su- 
perficial or deeper seat in the uterine wall is of great practical im- 
portance. Thus we distinguish (1) the subserous, (2) the submucous, 
and (3) the interstitial fibroids, although many tumors present in- 
termediate forms. In the subserous fibroma, the tumor, which 
usually has originated in the outer layers of the womb, tends to- 
ward the abdominal cavity, into which it projects in strong relief. 
Its base, at first wide, may by degrees grow narrower, and ultimately 
even present a mere stalk of the peritonaeum. Total detachment, 
indeed, has been observed ; but in such cases the growth has soon 
formed new adhesions, either in the vicinity of its point of origin 
or in Douglas’s cul-de-sac. Subserous fibroids are often multiple, 
and usually are small ; but if their vascular connection with the 
uterine parenchyma, by which they are nourished, should happen 
to be kept up, they may attain a great size, and rise into the abdo- 
men. By these large subserous tumors the womb is misplaced, 
distorted, and stretched ; but it is almost never hypertrophied. 
When springing from the side of the womb, they may penetrate 
between the two folds of the broad ligament, forcing them asunder 
so as eventually to lie quite outside of the peritonaeum. The sub- 
mucous fibroid, on the contrary, tends to grow inward, toward the 
cavity of the womb, into which it juts like a globe, distending it, 
and displacing it to the side opposite to that whence it springs. Its 
surface is covered either by mucous membrane alone, or by a thin FIBROID TUMORS OF THE UTERUS. 
149 
layer of parenchyma. The womb itself is usually hypertrophied as 
if pregnant, and the portio vaginalis is soon obliterated. Practically 
it is of great importance to distinguish between submucous growths 
having a broad attachment to the womb, and those which project 
into it so completely as to be held by a mere pedicle. The latter, the 
so-called fibrous polypi, are a subject for surgical treatment. The 
interstitial, intraparietal, or intramural tumors tend less to project 
from the uterine wall; but, where they become large, they cause a 
bulging of both inner and outer wall, thus taking an intermediate 
position between the two extraparietal forms of fibromyoma. 
The same variation as to seat holds good with regard to the far 
rarer fibromyomata of the neck and vaginal portions of the womb. 
Submucous fibromata of the cervix usually appear as fibrous polypi. 
These must not be confounded with the more common mucous poly- 
pus, which is merely a product of catarrhal relaxation of the mu- 
cous membrane with cystic enlargement of the follicles (ovula Na- 
bothi). The latter are easily distinguishable from the fibromyomata 
by their softness and smallness, rarely exceeding a hazel-nut in size. 
Uterine fibromyomata may undergo many further transforma- 
tions. The commonest one is an accumulation of liquid in the lymph- 
spaces, which dilates them, causing an oedematous softening of the 
tumor, and sometimes a cystic metamorphosis. In the latter case we 
find either numerous small cysts, or else a large cavity whose ragged 
sides and trabeculae announce it to be the product of the blending 
of several smaller cysts. Heteroplastic action may also arise, such 
as myxomatous or colloid degeneration, sarcoma, or cystosarcoma. 
True cancer probably does not occur, except as a secondary disease, 
by metastasis or by propagation in continuity from a cancer of the 
uterus proper. 
Symptoms and Course.—The symptoms of a fibromyoma vary 
greatly, according to the size and seat of the tumor. Small subse- 
rous growths, or those which are completely extraparietal, and 
which, being merely attached by a thin stem, have ceased to grow, 
often give no symptoms at all. Sometimes a small growth flexes or 
upsets the womb by its weight, either backward or forward, accord- 
ing as its .seat is in the front or back wall of the organ. A large 
extraparietal tumor, on the other hand, displaces the womb in the 
direction away from its seat, or sometimes draws the womb up with 
it into the abdomen. The pressure exerted by a dislocated womb 
or by a voluminous tumor upon adjacent parts may cause various 
evils—backache, incontinence or retention of urine, obstruction of 
the rectum, swelling of the feet, neuralgia, or even paresis of a leg. 
The irritation often causes local peritonitis, with consecutive incap- 150 
DISEASES OF THE UTERUS. 
sulated exudation, or with adhesions ; and these latter may by and 
by hinder the tumor from lifting itself as it grows out of the pelvis, 
so that the pressure upon the other pelvic organs may give rise to 
the symptoms of incarceration. All these pressure-symptoms usu- 
ally grow worse during the menstrual period. 
The submucous fibromyomata also soon create serious distress. 
In this form the distended and hypertrophied womb itself forms the 
tumor, and when large it naturally produces the same pressui’e-symp- 
toms as those caused by subserous tumors. But the growth, being 
enclosed in muscular masses, excites the latter to strong contraction. 
The tumor, projecting into the womb, stretches and irritates its mu- 
cous lining, thus inducing leucorrhoea and haemorrhages of great 
frequence and severity. These metrorrhagias occur even when the 
tumor itself is very poor in blood-vessels, and proceed entirely from 
the mechanically overladen vessels of the mucous membrane. At 
first the bleedings seem to attend the menstrual periods, which are 
then excessive and followed by a mucous discharge. By 
and by the haemorrhages recur irregularly, and with ever-increasing 
frequence and severity, so that the patient’s life may be jeoparded 
by sheer loss of blood. Great suffering during menstruation also 
arises in this form of fibroma. There is pain, which is sometimes 
continuous, and sometimes an intermittent uterine colic, like labor- 
pain, due to the obstruction by the tumor to the menstrual flow. 
If the catamenial function ceases permanently—and this is apt to 
take place quite late in life in these cases—this distress is 
abated or ceases entirely. Interstitial tumors occupy a middle posi- 
tion both as regards seat and symptoms. Being well surrounded by 
uterine tissue, and being under more favorable conditions for growth 
than the subserous and submucous tumors generally are, their de- 
velopment is often quite rapid, and they sometimes attain colossal 
dimensions. 
The existence of a fibromyoma cannot be made out without man- 
ual examination, and even then it is sometimes very difficult. The 
subserous tumor is felt as a hard ball-like or nodular lump, which, 
if it spring from the fundus, can be felt more easily through the ab- 
dominal wall, and if from the lower part of the womb, is best found 
through the fornix vaginae. The examination should aim to prove 
that the tumor really proceeds from the womb, and does not merely 
lie next to it. Sometimes an ovarian cyst or an old parametritic or 
perimetritic exudation adheres so closely to the uterus that nothing 
will shed light upon the case but a due weighing of other facts, 
such as the consistence of the mass, which, if a fibroma, should be 
hard, and never is soft unless it be in a state of cystic degeneration, FIBROID TUMORS OF THE UTERUS. 
151 
when it is more like an ovarian cyst in consistence ; or else the his- 
tory of the case would show a preexisting pelvic inflammation, had 
any occurred. Subserous fibroids attached only by a thin fibrous 
stem are often thought not to belong to the womb, and, although too 
hard to be mistaken for ovarian cysts, may be difficult to distin- 
guish from a solid ovarian growth. The examination should further 
determine that the object felt is not the womb itself, displaced and 
enlarged. An anteflexed or retroflexed womb may simulate a tumor 
lying in the uterine wall; but conjoined manipulation will demon- 
strate that beside the tumor in question a second one exists, which, 
in situation, form, and consistence, corresponds to the womb ; and, 
if necessary, the introduction of a sound will show by its direction 
that it does not enter the tumor, but takes an entirely normal course. 
Sometimes by means of the sound we can tell that the uterus, al- 
though distorted and displaced, by no means corresponds in length 
with the volume of the tumor. 
Submucous fibroids lie hidden within the womb, and distend it; 
hence they may be confounded with other conditions which cause 
uterine enlargement—above all, with pregnancy, uterine infarction, 
and hfemometra. Unless the history of the case and other circum- 
stances distinctly preclude the supposition, the tumor may be mis- 
taken for a gravid womb, because the same general disorders which 
characterize pregnancy, as well as the changes in the breasts which 
then arise, may likewise be met with now. The condition of the 
vaginal portion is of great value in the diagnosis. In pregnancy it 
is remarkably soft and flabby. In a case of fibroma the cervix 
rapidly disappears, and the os uteri will gape so that the tumor 
within it can easily be found. The uterine souffle so regularly 
heard in pregnancy is, nevertheless, not a sure sign of that condi- 
tion ; for it also is heard in cases of fibroma, and in rare instances 
where there is an ovarian growth. In chronic metritis the tender- 
ness of the womb to pressure stands in contrast to the insensibility 
of a fibroma. Moreover, in infarction the vaginal portion is thick- 
ened and not obliterated, and the sound enters easily ; whereas a 
fibroma opposes an obstacle to its passage, not always readily over- 
come. 
After excluding pregnancy, the diagnosis may be sometimes 
facilitated by the introduction of a sponge-tent into the cervix. 
The canal being thus dilated, it becomes practicable to examine 
precisely the tumor with the finger and sound, and particulai-ly to 
determine whether the tumor is attached by a broad base or by a 
slender pedicle—a matter of the utmost importance as regards 
therapeutics and prognosis. Interstitial tumors bulge less distinctly 152 
DISEASES OF THE UTERUS. 
into the uterine cavity, and the enlargement of the organ is not so 
general and uniform. Very large interstitial fibromata, which rise 
into the abdomen, may be mistaken for other abdominal growths ; 
not for ovarian cysts, however—which, though hard in places, also 
as a rule present elastic, fluctuating portions to the touch—but rath- 
er for solid ovarian tumors and for subserous fibromata. But in 
these two cases the womb itself does not form part of the tumor, 
but is merely displaced by it; and we must strive to ascertain if the 
two bodies can be made to move independently of one another. If 
so movable, the growth is probably ovarian ; if attached, it is most 
likely a subserous fibroid ; but no absolute certainty of this can be 
attained, because an ovarian growth may be bound fast to the womb, 
and a subserous fibroid with a long pedicle may float freely. When 
the uterine sound 'passes deeply into a tumor, or when its tip can 
be felt through the walls of the growth, we may infer that the mass 
is not merely attached to the uterus, but is the uterus itself. An 
expert with the sound can also determine that the enlargement of 
the organ is not uniform, but chiefly affects one or other wall. This 
decidedly points toward the presence of an interstitial fibroid. 
Fibromyomata of the cervix, which are more rare, are easy of 
diagnosis. They present either rounded, hard, circumscribed lumps, 
which distend one of the lips of the os, or else appear as fibrous 
polypi protruding from the cervix. 
Prognosis.—The prognosis of uterine fibromyomata has its good 
and its bad points of view. The fact is well attested that such 
tumors have now and then shrunk away and disappeared, but such 
good fortune must never be counted on ; the more so, because these 
rare cures seem never to be due to treatment, but rather to favor- 
able accidental conditions—parturition, the climacteric, or the like. 
The affection is generally to be regarded as incurable ; yet the 
prognosis is so far favorable that life is seldom immediately imper- 
illed by it. Sometimes, indeed, the envelope of the tumor suppu- 
rates, causing peritonitis or pyaemia ; and the general nutrition has 
been known to suffer seriously through the pressure of an enormous 
fibrous tumor upon adjacent abdominal organs. The tumor some- 
times ceases to grow so early as never to cause any symptoms ; 
while others by their development render life a burden, until the 
attainment of the climacteric brings about an arrest of development, 
or until a sort of imperfect retrogression takes place by calcification 
of the tumor. Spontaneous expulsion of the growth through the 
uterine canal has been observed in a series of cases. A few times it 
has been known to be expelled into the abdomen or into the blad- 
der, and even to be discharged through the abdominal walls. Such FIBROID TUMORS OF THE UTERUS. 
153 
an event is either the result of sloughing and suppuration of the 
capsule, with subsequent bursting of the resulting abscess, in which 
case the danger to life is very great, or else the extrusion conies to 
pass by the less dangerous method of spontaneous enucleation. A 
tumor juts from the os ; at its apex an opening forms by sloughing 
of the mucous membrane, and through this opening, which enlarges 
more and more, the tumor is gradually pushed by the uterine con- 
tractions. It sometimes happens that, pregnancy occurs notwith- 
standing the presence of a fibromyoma. Childbed in such a case is 
beset with peculiar dangers. 
Treatment.—Very little reliance is to be placed upon medical 
treatment of a fibromyoma with a view to its dispersion, arrest, or 
atrophy. Iodide of potassium, bromide of potassium (first proposed 
by Simpson), chloride of calcium (Rigby), arsenic and phosphorus 
(Gueniot), seem to effect very little ; while the brine-baths, particu- 
larly those containing bromine and iodine (Kreuznach, Munster am 
Stein, and Adelheidsquelle in Bavaria), seem sometimes to bring 
about a certain reduction in bulk of the tumor. Hildebrand claims 
that by means of subcutaneous injections of ergotine, employed 
originally to control the bleeding, not only the haemorrhage, but 
also the tumor, was made to disappear; but, in spite of other 
corroborative testimony, the value of this treatment is not yet es- 
tablished. Some fibromyomata are curable by surgical treatment ; 
and by following nature’s suggestion of spontaneous enucleation, 
not only submucous tumors, but even interstitial ones, have been 
removed through the vagina by a surgical operation, though at 
considerable risk to life. As a last resort, indeed, to save life, when 
the rapid growth of the tumor was obviously about to kill the pa- 
tient, extirpation of the tumor, either with or without the womb, 
has been successfully accomplished. 
The surgical treatment of pedunculated submucous tumors is 
more satisfactory ; and we not seldom meet women, who have been 
brought almost to death’s door by persistent haemorrhage from 
fibrous polypi, restored in a few months after their removal to a 
state of blooming health. 
As a rule, however, we must renounce the expectation of actually 
curing a fibromyoma, and content ourselves with enjoining a quiet 
mode of life, with little physical exertion or excitement, forbidding 
frequent sexual intercourse, and with practicing small local blood-let- 
ting upon the vaginal portion, with regulation of diet; also with the 
recommendation of a treatment during the summer-time by baths 
calculated to retard the growth of the tumor. Regarding the treat- 
ment of the bleeding, we refer to the article upon menorrhagia.] 154 
DISEASES OF THE UTERUS. 
[CHAPTER VIII. 
CANCER OF THE WOMB. 
Etiology and Anatomical Appearances.—Primary cancer 
appears more frequently in the womb than in any other organ of 
woman, not excepting the breast. Secondary cancer of the womb, 
on the other hand, is rare. Nothing certain is known as to the 
cause of this miserable disease, and its assumed hereditary trans- 
missibility is not proved. It is met with chiefly among married 
persons, especially among multipara, and with increasing frequency 
from the thirtieth year up to the climacteric period, which age fur- 
nishes the most victims. Beyond it cancer is common enough still, 
and does not become a rarity until the seventieth year. 
The point of origin of primary cancer is almost always in the 
neck of the womb, very rarely in its body. According to Waldeyer, 
all forms of cancer spring from the true primordial epithelium of 
the organism, and hence are to be regarded generally as epithelial 
growths ; and even the smootli and papillated cancroids formerly 
distinguished as carcinomata are to be included in this category. 
The development of cancer of the cervix is as follows : The super- 
ficial epithelium of the mucous membrane proliferates, throwing 
offshoots into the connective and muscular tissue beneath it. These 
sprouts, ramifying in all directions, everywhere form new nests of 
cancer-cells, and encroach more and more upon the normal tissues, 
which finally break down and ulcerate through pressure and arrest 
of circulation. The cancerous infiltration meanwhile continues to 
invade new tissues around it, which in their turn ulcerate. This is 
often accompanied by considerable development of the papillae of the 
mucous membrane, and this is in the beginning liable to be confound- 
ed with the non-malignant papillary outgrowth due to catarrh. In- 
deed, it has been assumed that papillomata, originally simple, might 
change into cancer by consecutive ingrowth of their epithelium into 
their basement-tissue. At a later period the malignant papilloma 
is distinguishable from the simple form by the rapidity and luxuri- 
ance of its growth, and by its early ulceration. At other times, in- 
stead of papillae, there develops a smooth, knotty group of swellings 
in one or other lip, or perhaps throughout the whole circumference, 
of the os. These nodules, unless they prematurely break down by 
ulceration, may form a tumor which fills the upper part of the va- 
gina. But there are cancers which do not begin at the surface, but 
originate deep in the interior of the neck, and develop as circum- CANCER OF THE WOMB. 
155 
scribed knots pushing toward the surface. Even this form of can- 
cer, however, must derive its origin from preexisting epithelium, 
probably from isolated cervical glands, and from abnormally dis- 
tributed vestiges of the primordial epithelial germ. Sometimes the 
disease takes the form of a firm scirrhus, but more commonly it 
assumes that of a soft medullary cancer, with a predominance of 
epithelium and with scanty connective tissue. The infiltration and 
ulceration travel upward to the internal os, and sometimes even in- 
vade the body of the womb. Thus not the neck alone, but a large 
part of the body of the organ, may disappear. An extension of the 
disease to the vagina imparts to the latter a hard, puffed-up, brawny 
quality, so that the finger can no longer recognize the os uteri. Still 
later, the cancerous infiltration of the ureters often causes obstruc- 
tion of the urine and hydronephrosis (even to the extent of fatal 
uraemia), and, by invasion of the bladder and rectum, with conse- 
quent destruction of the septa separating these cavities, large fistulae 
are formed ; and it has even happened that all three cavities have 
been blended into one horrible cloaca. The tubes, ovaries, and 
other pelvic organs, and the muscles, areolar tissue, and even the 
bones, are finally attacked, either by contiguity or by metastasis ; 
so that at last the womb is, as it were, walled up by cancerous in- 
filtration and peritoneal adhesions. More distant regions finally arc 
invaded—the inguinal and retroperitoneal glands, the peritonaeum, 
omentum, mesentery, intestine, liver, and perhaps even the breast. 
Symptoms and Course.—In the earliest stages of uterine can- 
cer there is slight pain in the back and abdomen, the menstrual 
flow is augmented, and there is leucorrhcea, which is not at first 
profuse, except in a case of malignant papilloma. So little is pre- 
sented to distinguish it from the more unimportant disorders of the 
sexual organs, that in the beginning the malady is rarely recognized. 
It would seem, indeed, that that form of it wdiich commences by 
deep-seated nodules presents no symptoms whatever so long as the 
mucous membrane remains intact. In many cases no serious symp- 
toms arise until the cancerous mass begins to ulcerate and break 
down ; so that the period for operative interference has already 
passed ere the nature of the malady has been recognized. Indeed, 
even in the earlier stages, while the mucous membrane remains 
sound, a local examination will not always reveal the existence of 
cancer, and the most experienced gynecologists admit that the dis- 
tinction between a cervix enlarged by cancerous infiltration and a 
simple hypertrophy of the neck may at first be impossible. Schroe- 
der describes a condition of the mucous membrane as characteristic 
of cancer even before the period of ulceration. The membrane is 156 
DISEASES OF THE UTERUS. 
tightly adherent to the tissues underlying it. As Waldeyer has it, 
the mucous membrane seems to be tacked down by the ingrowing 
epithelial sprouts, which penetrate the tissues beneath them like so 
many brads. After' it has attacked the vagina and surrounding 
connective tissue, the recognition of cancer is easy. 
When the period of ulceration sets in, a series of grave and often 
very distressing symptoms arise. The leucorrhcea becomes more 
profuse, and somewhat sanguinolent (like meat-washings), and final- 
ly, by admixture of gangrenous particles, acquires an ichorous char- 
acter, and assumes a darker dirty-brown or greenish-black color, 
and emits so foul and putrid an odor as to disgust not only the 
neighbors but the patient herself. Haemorrhage is rarely absent. 
In the beginning there is merely an augmentation of the menstrual 
flow, but the bleeding afterward becomes irregular, and is often 
the first symptom which alarms the patient. Elderly women, how- 
ever, are prone to ascribe such bleedings to the irregularities com- 
mon at the menopause, and hence give themselves little concern 
over it. Only in cases of hard cancer is haemorrhage ever absent. 
It is most profuse in the papillary form. Notwithstanding its fre- 
quence and abundance, which often reduces the patient to the low- 
est stage of anaemia, a fatal haemorrhage is rare. 
The abdomiqal and lumbar pains are sometimes insignificant 
throughout the disease ; while at other times the patient suffers in- 
describable agony, especially during the night. This violent pain 
does not depend upon the ulceration, but upon extension of the can- 
cerous growth into the connective tissue and other parts of the body, 
and appears to be due to pressure of the indurated mass upon the 
nerve-twigs which it encloses. Besides this, there may be sharp 
pain from pressure set up by a secondary peritonitis, arising from 
the irritation of the cancerous nodules. Finally, the pain may as- 
sume a paroxysmal form—-a uterine colic—in consequence of an ob- 
structed outflow of blood and secretion from the womb. Incessant 
and painful urinary irritability indicates invasion of the bladder, 
while a suppression of the urine makes it probable that the ureters 
are occluded by the growth. Obstinate constipation, followed by 
tenesmus, haemorrhoids, and diarrhoea, indicates an implication of 
the rectum. 
Prior to the stage of ulceration the general health of the patient 
is fairly comfortable ; afterward she grows pale, anaemic, cedema- 
tous, and emaciated, and the countenance often presents that dirty- 
yellow coloring so commonly seen in cancer, although not a trust- 
worthy sign of it. The more frequent trie bleedings, the more 
profuse the discharge, and the more constant and severe the pain, CANCER OF THE WOMB. 
157 
so much the sooner does the general health of the patient give way. 
There is also almost always a derangement of the stomach, with 
loss of appetite and loathing of food, and a tendency to nausea 
which contributes to break down the strength ; and it is often hard 
to determine whether the vomiting is due to a sense of disgust, or 
arises from gastric catarrh or gastric irritation reflected from the 
genital organs, or from the effect of uraemic poisoning. 
Ulceration usually first attacks the inner surface of the lips of 
the os. After this has once begun and loss of substance has taken 
place, the diagnosis by digital and ocular examination is no longer 
difficult. One source of error might be the destruction of the va- 
ginal portion of the cervix by that very rare form of ulcer {ulcus 
phagedoznicum corrodens) first described by Clarice, and identified 
with certainty in a few instances only by Klebs and JCoerster, and 
the cause of which is still unknown. In a doubtful case, nothing 
hut the microscopic examination of an extirpated portion of the 
cervix can determine whether the base of the ulcer contains traces 
of carcinoma or not. But, after all, the prognosis of a corroding 
ulcer is scarcely better than that of cancer; for our experience has 
shown that neither by the strongest caustics, nor even by the hot 
iron itself, can the ravages of the latter he checked and the ulcer 
healed. 
As we do not generally know how long the latent stage of cancer 
has existed, its duration can rarely be stated with certainty. Dating 
from the time of first discovery, Gusserovj estimates that most pa- 
tients succumb in about a year or a year and a half. Yet there are 
examples of a rapid course of only a few months, and others again 
of several years’ duration. Death usually takes place from exhaus- 
tion, or else the patient dies of complications. These are acute or 
chronic uraemia, gradual or perforative peritonitis, miliary carci- 
nosis of the peritonaeum, septicaemia, dysentery, diphtheritic inflam- 
mation of the vagina or bladder, pneumonia, or (what is more rare) 
embolism of the pulmonary artery, embolic gangrene of the lungs, 
fatty degeneration of the heart, pyelonephritis, or pylephlebitis as 
a consequence of putrid thrombosis of the portal vein. 
Treatment.—The treatment of cancer of the womb is essen- 
tially surgical, and an operation, although it very rarely cures the 
patient, yet affords the only chance of effecting even a temporary 
improvement. Unfortunately, the malady is seldom brought under 
treatment until the vagina has become implicated, or until so much 
of the cervix is involved that an amputation can no longer he made 
through healthy tissue. Yet even then the operation is justified as 
affording a last chance for prolonging life. This is best done by 158 
DISEASES OF THE UTERUS. 
removing all parts which seem affected by knife or scissors, and by 
scooping away the less accessible portions by means of Simon’s 
sharp spoon, and then by cauterizing the wound with the hot iron, 
or by means of the alcoholic solution of bromine first recommended 
by Mouth, and approved by Schroeder and Ilenneberg. Otherwise 
the escape of cancerous offshoots which often exist in parts seem- 
ingly healthy, or of remnants of the ulcer which often extend up to 
the inner os, may render the operation abortive. The relief of pain 
is the most important duty in treatment of the symptoms. Hypo- 
dermic injections of morphine and opiate enemata are often quite 
indispensable. When the flow is profuse, copious astringent vagi- 
nal injections are demanded ; and for the foul odor we must employ 
disinfectants, such as carbolic acid, permanganate of potash, and 
chloride of lime. The haemorrhage is to be combated by the use 
of ice, or of cold or very hot injections, or of dilute liquor ferri ses- 
quichloridi; or else we must tampon with sponges, or plugs of cot- 
ton charged with strong liquor ferri cliloridi. For the insomnia 
which is so common, chloral furnishes an invaluable remedy.] 
CHAPTER IX. 
ANOMALIES OF MENSTRUATION. 
[It has generally been assumed that the menstrual flux is inti- 
mately connected with the ripening and bursting of a Graafian ves- 
icle, and with the escape therefrom of one or more eggs ; but this 
view of the subject has latterly been contested, and the complete 
independence of ovulation and menstruation has been asserted (Bei- 
get). According to our present information upon the subject of 
ovulation, the uterine mucous membrane at puberty undergoes cer- 
tain periodical metamorphoses, the nature of which has been ascer- 
tained by the researches of Kundrat and Engelmann. They find 
that at the menstrual period the uterine mucous lining swells up and 
develops ; its glands elongate and dilate, and a proliferation of the 
round cells of its basement-tissues takes place. This process is fol- 
lowed by a retrogressive one, based upon a fatty degeneration of 
the upper layers of the mucous membrane, so that the bleeding is 
caused, not, as is generally supposed, by a menstrual fluxion and hy- 
peraemia, but by destruction of the mucous membrane through fatty 
degeneration. The purpose of the increased development of the 
mucous membrane is that the egg may be received into it, and only 
at this time of so-called nidation is the growth of a fructifying egg ANOMALIES OF MENSTRUATION. 
159 
possible ; while in the remaining period, that of so-called denida- 
tion,, during the menstrual flow and during the exfoliation of the 
mucous membi’ane, any egg which may reach the uterus will perish. 
Hence it would at first seem as though conception could only 
take place after a coitus immediately preceding menstruation, and 
never from coitus following it ; but we should bear in mind that 
the ripened egg which leaves the ovary at the menstrual epoch re- 
quires a certain period of time, not precisely known, for its passage 
through the tube, at the end of which period the state of denidation 
may have passed over. According to the newest views, those of 
John Williams, based upon examination of twelve wombs, the re- 
generation of the fatty mucous lining begins immediately after ces- 
sation of the bleeding, and progresses steadily until the next retro- 
gressive period commences. Thus the womb would seem never to 
be at rest, but to be either in a state of evolution lasting about three 
weeks, or of involution lasting about one week. Only at the period 
of involution would implantation and fixing of the ovum (as far as 
the womb is concerned) seem to be impossible, while impregnation 
might take place at any part of the period of evolution. Bischoff\ 
however, doubts if an egg be capable of fructification during the 
latter part of the period of evolution. More probably the egg must 
receive an impulse toward further development from the seminal 
fluid while still in the tubes, and only in the improbable event of an 
egg’s requiring three weeks to traverse the tube would there be no 
period of intermenstrual unfruitfulness.] 
Anomalies of menstruation are not independent diseases, but are 
symptoms of affections of the sexual organs, or of other diseases 
impairing the general health. Hence the discussion of amenor- 
rhcea, dysmenorrhcea, menorrhagia, etc., does not properly belong 
to a text-book of special pathology and therapeutics, but to a work 
on semeiology and diagnosis. Following the example of most au- 
thors, for practical reasons, we will give a short account of the most 
important menstrual disturbances. 
Too early menstruation—menstruatio prcecox—is not frequent, 
if by this term we mean only those cases of haemorrhage from the 
female genitals before puberty that are accompanied by the expul- 
sion of a ripe ovum. As we have no certain means of finding out 
whether this complication exists or not, we must note whether the 
haemori’hage recurs at regular intervals ; whether it is accompanied 
by disturbance of the general health, by pains in the back, and 
other symptoms which almost always accompany menstruation 
proper. Haemorrhage occurring once, or at irregular intervals in 
the course of acute diseases, particularly of acute infectious dis- 160 
DISEASES OF THE UTERUS. 
eases, as well as in chronic dyscrasia and venous congestions, has 
nothing to do with menstruation. If, in our climate, menstruation 
begins between the twelfth and fourteenth years, instead of the 
fourteenth and sixteenth, it is only a morbid symptom if the girl he 
undeveloped. Many girls at this age, who still go to school and 
wear short clothes, have full breasts and hair on the pubes. We 
may say that they have developed too early, but not that they have 
any anomaly of menstruation ; in them the absence of the menses 
would be pathological. But, besides these cases, we not unfre- 
quently find apparently undeveloped girls, aged eleven or twelve 
years, with regularly-recurring haemorrhages from the genitals, and 
such characteristic symptoms of congestion in the pelvis that we 
cannot doubt there is a case of early ovulation—a true menstruatio 
praecox. Experience shows that almost all such girls subsequently 
suffer from obstinate chlorosis. Cases where menstruation has been 
observed in small children are only partially reliable. 
It is very rare indeed for menstruation to cease several years 
too late. Among us, women usually menstruate till forty-five or 
forty-eight years old. If menstruation has begun early, it usually 
ceases somewhat sooner ; if the reverse, it continues a few years 
longer. Scanzoni has seen only one case, in his practice, where an 
unmistakable menstrual haemorrhage continued to the age of fifty- 
two years. Even very old women are inclined to regard all haemor- 
rhage from their genitals as menstrual. 
Of course, we can only speak of amenorrhoea when the menses 
are absent in a woman who lias attained the age of puberty, and 
has not passed the climacteric, and who is not pregnant or nursing. 
[Above all, be it observed that the absence of menstrual flow does 
not warrant the inference that ovulation has ceased. We know, in- 
deed, that conception may take place during amenorrhoea. On the 
other hand, the cessation of ovulation after destruction of the ova- 
ries is not always followed by absence of the menses. In excep- 
tional cases menstrual bleeding has been observed to continue for 
some time after the sexual function has been destroyed.] 
Tardy menstruation is one form of amenorrhoea ; too early ces- 
sation is another form. If a girl sixteen or eighteen years old be 
no more developed than one of ten or twelve years, she can no 
more be said to have retarded menses than a fully-developed girl of 
twelve or thirteen who menstruates can be said to have menstru- 
atio prrecox. Except in cases of tardy menstruation or too early 
cessation of the menses, amenorrhoea more frequently depends on 
constitutional disease than on local affections of the genitals. It 
is chiefly chlorosis, scrofula, and tuberculosis that retard the occur- ANOMALIES OF MENSTRUATION. 
161 
rence of menstruation, or cause its arrest. It is not always easy 
to determine, in these cases, whether the ovum does not ripen, or 
whether only the haemorrhage that usually accompanies the expul- 
sion of the ovum is absent. If, at intervals of four wTeeks, we no- 
tice more or less decided molimina, accompanied by swelling of the 
breasts and increased discharge of mucus from the genitals, it 
would seem as if only the haemorrhage were wanting ; in the reverse 
cases, we may suppose that ovula do not ripen. Among the dis- 
eases of the sexual organs, degeneration of the ovaries rarely causes 
amenorrhoea, and only does so when both ovaries are at the same 
time the seat of organic disease. Among the various diseases of 
the uterus, chronic catarrh, and especially chronic infarction, in 
which the blood-vessels are compressed by the shrinking connective 
tissue, most frequently induce this disease. Amenorrhoea occasion- 
ally occurs in strong, healthy girls, in whom the genitals have not 
developed so rapidly as the rest of the body. Lastly, Scanzoni 
concludes, from the cases where the menses (which had previously 
been normal) ceased on the occurrence of paraplegia, that amenor- 
rhcea may result from abnormal innervation. 
The sudden arrest of the menstrual flow—suppressio mensium— 
is most frequently the symptom of acute metritis. It depends on 
the same injurious influences that we mentioned in the etiology of 
that disease, and is accompanied by the same symptoms. More 
rarely the menses cease suddenly, if the amount of blood in the 
uterine vessels be lessened by a diminution of the entire amount of 
blood in the body by venesection, or by excessive fluxion to some 
other organ. 
[Sometimes, at the period when the menstrual flow should appear, 
instead of it a bleeding occurs from some other region, from a 
haemorrhoid, from a wound or ulcer, from the nose, the bronchi, or 
the stomach. Such bleeding, it would seem, might properly be 
called “ vicarious ” so long as it was supposed that the menstrual 
flux had the effect of evacuating effete matter from the system. 
It might then have been inferred that refuse which was not voided 
by legitimate methods might be advantageously got rid of by un- 
usual processes. Nowadays, however, with our present conceptions 
of the nature of menstruation, it is difficult to And a reason for a 
vicarious menstrual haemorrhage. When we remember that the 
amount of the flow in all is only from about eight ounces to (at the 
utmost) about thirty ounces, the theory that the omission of an 
habitual menstruation can give rise to a general plethora must seem 
very rash. Most probably vicarious haemorrhages stand in close 
relation to a very active general nervous and circulatory excite- 162 
DISEASES OF THE UTERUS. 
ment, accompanying ovulation, under the influence of which bleed- 
ings may take place at points predisposed to it, both when the 
menses are absent and when they are present. 
The direct treatment of amenorrhoea by emmenagogues has un- 
dergone great limitation of late years. Many of the ancient physi- 
cians (mistaking cause and effect) were disposed to ascribe divers 
disorders to amenorrhoea as a cause, and to consider the reestablish- 
ment of the menstrual flow a matter of great importance ; where- 
as, in many a broken-down subject, it is rather to be wished that 
she may not be still further prostrated by loss of blood. Some- 
times, however, in exhausted, bloodless patients, the growth of the 
Graafian vesicle is arrested, and the periodical ovulation with its 
uterine hyperoemia does not take place. Such amenorrhceas, arising 
from defective nutrition and anaemia, can only be successfully 
treated by allaying the main disease by tonics, iron, strengthening 
diet, fresh air, and the like. All the different emmenagogues pos- 
sess in common the property of inducing hyperaemia of the pelvic 
organs, and especially of augmenting a congestion which already 
exists, and thus of producing a haemorrhage. This object is most 
certainly obtained at the time when the menses should naturally 
return. This period is not, however, invariably one of twenty- 
eight days ; for it may vary by several days in the same woman. 
Accepting the results of recent researches, that menstrual flow does 
not proceed from engorgement alone, but is also the effect of a fatty 
degeneration and exfoliation of the uterine mucous membrane, it 
becomes impossible to admit that the flux can be induced by em- 
menagogues at any other time than that of nidation. 
Artificial induction of the menstrual flow may be called for 
when certain disturbances (pain in the back, local congestion, and 
the like) which normally accompany menstruation indicate a con- 
gestion of the pelvic organs, and that the haemox*rhage which should 
promptly relieve them has failed to arise. Measures calculated still 
further to augment the hyperscmia of the womb may then be re- 
sorted to to bring on the bleeding. These are irritating foot-baths, 
w'arm sitz- or full-baths, dry cups or mustard-plasters to the thighs, 
a hot or even a cold douche to the sacrum, clysters of aloes, or direct 
irritation of the womb by irritating vaginal douches. More rarely, 
painting the os with iodine, passage of a sound, or electricity may 
be tried ; but we should be slow to resort to the internal exhibition 
of aloes or of savin, on account of their undesirable secondary ef- 
fects. We must bear in mind, too, that, if we fail to induce the 
flow by these means, we may nevertheless so augment the uterine 
congestion as to aggravate the existing distress. Hence the use of ANOMALIES OF MENSTRUATION. 
163 
emmenagogues is only proper when the amenorrhoea is due solely 
to feebleness of the uterine congestion. In other cases the conges- 
tion is to be relieved by local depletion, leeches, or scarification of 
the vaginal portion, or in virgins by cups applied to the inner side 
of the thighs.] 
Menorrhagia, or too copious menstrual hajmorrhage, has been 
already mentioned as a symptom of various structural changes and 
of tumors in the uterus. But it also occurs without perceptible dis- 
turbance of nutrition, where the escape of blood from the uterus is 
hindered in heart and lung diseases, etc., as well as in fluxions in- 
duced by irritation of the uterus from sexual excess, perhaps also 
by sensual excitement. In very rare cases menorrhagia depends on 
a haemorrhagic diathesis, being a symptom of scurvy, purpura 
hsemorrhagica, acute infectious diseases, such as haemorrhagic small- 
pox or measles,- or of typhus, etc. Where it is due to obstructed 
efflux or increased afflux of blood to the uterus, it is usually pre- 
ceded by symptoms similar to, but more marked than, those with 
which normal menstruation usually begins. Part of the blood 
passes off in a fluid state, part coagulates in the vagina, forming 
irregular clots ; rarely it coagulates in the uterus, and there forms so- 
called fibrinous polypi, such as frequently appear after abortions. 
Plethoric patients often bear very decided loss of blood without 
injury ; anaemic patients have the symptoms of increased anaemia. 
The treatment of menorrhagia requires great attention to the origi- 
nal disease. The occasional application of leeches to the cervix is 
often of surprising benefit in those cases dependent on chronic in- 
flammation of the uterus. As soon as the loss of blood is decided 
and threatens to impair the strength, it is important to prevent all 
bodily exertion and mental excitement, and to keep the patient in a 
horizontal position during menstruation. At the same time we for- 
bid all stimulating food and drink, and order mineral or vegetable 
acids. It will only rarely be necessary to employ cold water or ice- 
compresses, or to have recourse to styptics. In some cases, how- 
ever, the bleeding threatens life, and then it is necessary to act 
energetically, and even to inject hot-water solutions of chloride of 
iron, etc., into the uterus. 
[The term dysmenorrhcea is applied to the conditions under 
which, instead of the trifling disorders which are almost normal, 
grave and distressing symptoms arise, especially violent pain in the 
back, belly, groins, and thighs, and sometimes sympathetic derange- 
ment of remote organs, such as cramp in the stomach, vomiting, 
diarrhoea, numbness, headache, dizziness, and convulsions. The 
causes of dysmenorrhcea are numerous. It has been assumed that 164 
DISEASES OF THE UTERUS. 
a menstrual congestion of extraordinary activity might give rise to 
pain in the womb and ovaries, by irritating the nerves of those or- 
gans (congestive dysmenorrhoea). In other cases we are reduced to 
assuming that an unnatural irritability of the nerves—either gen- 
eral and combined with hysteria, or else local and limited to the gen- 
ital region—is the cause of the suffering (nervous dysmenorrhoea). 
But there is no doubt that we more often have to do with organic 
disease of the womb or ovaries or other pelvic organs, or with a 
fibromyoma, an infarction, a dislocation, or a degeneration of the 
ovaries. One form of dysmenorrhoeal pain proceeds from spasmodic 
contractions which the womb sets up in order to expel some foreign 
body from its cavity—a polypus, a blood-clot, or a collection of 
liquid blood. The obstacles to the menstrual outflow are stricture 
of the cervical canal, either congenital or acquired, acute flexion of 
the womb, and growths blocking up the channel; perhaps also spasm 
of the internal os (obstructive dysmenorrhoea). In this form the 
pains present a characteristic intermitting type, like those of colic 
or like labor-pains, the spasms corresponding with the periods of 
uterine contraction (uterine colic); and these attacks, which are 
more severe before the flow begins, subside after the contractions 
have expelled the stagnant blood from the uterine cavity. 
Membranous dysmenorrhoea is a special form of obstructive 
dysmenorrhoea. Under normal conditions at the period of deni- 
dation, the outer layers of the proliferating mucous lining of the 
womb undergo fatty degeneration, and are cast off impercepti- 
bly and in minute particles. Sometimes, however, by a morbid 
exaggeration of this process, there arises an exfoliation more or less 
profound of the mucous membrane, which then comes away in 
sheets. Indeed, the entire menstrual decidua may be cast off, in the 
form of a complete three-cornered sac corresponding to the form of 
the uterine cavity, with its smooth inner surface riddled by holes 
(mouths of the uterine glands), and its outer surface rough and rag- 
ged. Microscopic examination of the connective tissue of the mu- 
cous membrane, and the finding of the glands embedded in it, will 
prevent confusion of such an object with a mere fibrinous clot ; 
while the more difficult distinction between this process and that of 
an early abortion will be aided by the circumstance that the expulsion 
of menstrual decidua is seldom confined to a single menstruation, 
but is often repeated for months and years, even up to the climac- 
teric period. 
The chronic metritis and endometritis which often accompany 
this form of exfoliative menstruation are regarded by many as the 
cause of the process. The affection is attended by colic of greater RETROUTERINE HEMATOCELE. 
165 
or less violence, according as the expulsion of the membrane and 
blood is retarded or accelerated. The diagnosis depends upon dis- 
covery of the membrane. 
The prognosis and treatment of dysmenorrhoea must of course 
depend mainly upon a true understanding of its cause. Obstructive 
dysmenorrhoea is best treated by artificial widening of the cervical 
canal, either by bloodless dilatation, or else by incision or divulsion, 
which give far better results. For details we refer to the text-books 
on surgery. In membranous dysmenorrhoea, the objects of treatment 
should be the metritis and endometritis, regarded by some as the 
causes of the symptoms. When no complication forbids it, after 
subsidence .of the period we may resort to applications of nitrate of 
silver, liquor ferri sesquichloridi, carbolic acid, or tincture of iodine 
in the cavity of the uterus, always observing the precautions given 
elsewhere. Although the result will probably not be perfect, yet a 
thinning or temporary arrest of the membranous formation may be 
obtained. Here, too, in obstinate cases, dilatation of the uterine 
neck may facilitate the escape of the decidua, and thus diminish the 
uterine colic. Violent pain is to be allayed by opiates, either by 
the mouth, rectum, or hypodermic injection, and by hot compresses 
to the belly. If there be fever, and the pain assume an inflamma- 
tory type, an acute metritis or perimetritis is to be feared, and 
proper steps should be taken to meet it.] 
CHAPTER X. 
RETROUTERINE HEMATOCELE HEMATOMA RETROUTERINUM PEL- 
VIC HEMATOCELE. 
[The French were the first, and Nelaton was the foremost, 
who investigated the subject of retrouterine hsematocele, and fixed 
its position as a form of disease. The seat of a hsematoma may be 
either within or without the peritoneal sac. The latter is very rare, 
occurring from haemorrhages into the areolar tissue surrounding the 
cervix and vagina, and into that between the folds of the broad 
ligaments of the womb. These extravasations do not present any 
very definite symptoms, but merely form a tumor of variable char- 
acteristics. As regards the intraperitoneal haBmatoma, of wThich 
alone we now treat, let us premise that it is not every free accu- 
mulation of blood in the peritoneal sac that is included under this 
term ; for a free collection of blood, like a free effusion of serum, 
cannot at first present to the touch a well-defined tumor. We limit 166 
DISEASES OF THE UTERUS. 
the term to those bloody effusions which are cut off from the peri- 
toneal sac above them, and which are completely enclosed by inflam- 
matory exudation and adhesion, so that they may exhibit all the 
qualities of a tumor. It is true that a free extravasation, after the 
blood has coagulated, may present to the examiner’s touch an object 
of a certain solidity and firmness ; but it does not offer the resist- 
ance opposed by the tensely-stretched walls of the encapsulated 
blood-tumor, into the cavity of which more and more blood is es- 
caping, nor does it displace the neighboring organs. The effused 
blood usually collects in the most dependent part of the peritoneal 
cavity, the deep pouch between womb and rectum knowm as Doug- 
las’s cul-de-sac. It pushes the womb forward and upward, and the 
rectum backward. Douglas’s fold is forced downward upon the 
posterior vaginal fornix, thus forming a large tumor, which may 
even extend upward above the brim of the pelvis. 
An anteuterine haematocele, which is a very great rarity, con- 
sists in an encapsulated blood-tumor situated in the shallow anterior 
pouch between the bladder and the womb. An intraperitoneal 
haematoma may form in one of two ways : Either the haemorrhage 
takes place within a closed pouch already formed by previous peri- 
tonitic adhesions, or else the bleeding may come first, and the encap- 
sulation follow as a result of adhesive peritonitis which the contact 
of the effused blood excites in the peritonaeum of the superimposed 
coils of intestine. The capsule once closed, a further extravasation 
may distend the sac and gradually displace the neighboring organs. 
The sources of pelvic haemorrhage are many and diverse, and 
during life they can, as a rule, only be conjectured. The bleeding 
proceeds most often from the ovarian vessels, and the insignificant 
physiological loss of blood which accompanies rupture of a Graafian 
vesicle may be aggravated into a profuse and alarming haemorrhage. 
This may take place as a consequence of an excessive hyperaemia of 
the sexual organs, caused by violent exertion, or by blows, falls, 
mental excitement, masturbation, or coitus. Various diseases of 
the ovary, such as inflammation with abscess, bursting of a haemor- 
rhagic cyst, or rupture of a superficial varicose vessel, may have a 
like effect. In certain disorders of the tubes, so large an accumula- 
tion of blood or of inflammatory exudation may form in them as 
to result in rupture or perforation of their walls. It is less pi’obable 
that the blood can accumulate in the tubes (as it does in the womb 
in haemometra), and thence can pass through the abdominal opening 
into the peritonaeum in sufficient quantity to form a tumor. It has 
long been known that by the bursting of a tubal or extrauterine preg- 
nancy, if the resulting haemorrhage is not speedily fatal, a haematoma RETROUTERINE HEMATOCELE. 
167 
may form. ' Rupture of varicose veins of tlie broad ligaments may 
lead to intra- or extra-peritoneal hsematoma, according as the blood 
passes into the pelvic cavity or into the areolar tissue between the 
serous folds. Finally, the pelvic peritonaeum itself is a not unfre- 
quent source of the bleeding. Dolbeau first announced that the 
blood might flow from vessels in a pseudomembrane, the product 
of a slow peritonitis. Virchow shares his views, which are in some 
measure supported by the fact that in a slighter degree a similar 
process may take place in men. The predisposing factors in pelvic 
haemorrhage are the catamenial periods, the disorders giving rise to 
the so-called haemorrhagic diathesis, scurvy, purpura, icterus gravis, 
and the haemorrhagic exanthemata. Gynecologists differ greatly as 
to the frequence of the affection. Schroeder found it in five per 
cent, and Seyfert in seven per cent, of his cases. Beigd thinks 
that mild cases are very common, but that they run their course un- 
detected except by accident. The disease is liable to arise at any 
time throughout the whole period of sexual activity ; it is most 
common between the ages of twenty-five and forty, and in women 
who have borne children. 
The formation of a pelvic hasmatocele is usually preceded by 
symptoms arising from the remoter fundamental disturbance which 
causes the haemorrhage. The establishment of the hsematoma itself 
is in most cases attended by unmistakable signs of internal bleeding, 
sudden pain in the belly, faintness, pallor, feeble pulse, coldness of 
the extremities, nausea, vomiting, and the like. Sometimes these 
symptoms recur again and again, whenever, as may happen from 
time to time, the bleeding is renewed. The history of an obscure 
case of this kind may furnish important data toward forming a 
diagnosis. The hajmorrhage having taken place, there ensues a 
more or less severe peritonitis, excited by the presence of the effused 
blood. This has the effect of encapsulating the effusion, unless in- 
deed it be already included within an envelope, the result of ancient 
adhesions. Then follow the symptoms of pressure and crowding of 
neighboring organs by the tumor, tenesmus or impediment at stool, 
vesical pressure, and neuralgia from pressure upon the nerves of the 
lower extremities or engorgement of the dislocated womb, some- 
times of such intensity as to cause metrorrhagia. The most impor- 
tant diagnostic test is by vaginal and rectal touch, whereby we may 
detect a retrouterine tumor of rapid growth, which often rises above 
the pelvic brim, but which also bulges downward into Douglas’s cul- 
de-sac, and more or less against the posterior vaginal wall. The tu- 
mor is soft, elastic, even fluctuating to the touch, but grows more 
firm after a few days, when the blood has coagulated. Should re- 168 
DISEASES OF THE UTERUS. 
absorption take place as the weeks or months go by, it becomes very 
hard and uneven, and at the same time shrinks, becoming smaller 
and smaller, until it finally vanishes altogether, save a small lump 
close to the hack of the womb. In unfavorable cases, as when the 
haematoma is very large, the size and tension of the tumor continue 
to increase ; the fever, the tenderness upon pressure, and other signs 
of local peritonitis are aggravated ; so that a distinction between an 
inflammatory exudation and a haematocele may at this period be 
very difficult, unless the sudden onset of the attack and the precur- 
sory signs of internal haemorrhage can he taken into account. In 
such cases the blood is generally discharged spontaneously through 
the rectum or vagina, and the sac may finally close up after grad- 
ually evacuating its black, grumous, tarry contents. In exceptional 
cases a haematoma proves fatal through sloughing of the sac-wall 
and blood-poisoning, or through general peritonitis after bursting 
of the sac into the abdominal cavity ; for it would seem that the 
altered blood is far more irritating to the peritonaeum than that 
which is recently effused. Long-continued suppuration of a fistu- 
lous sac may finally wear out the patient. 
The treatment of a haematoma requires, above all, perfect and 
continued rest, and avoidance of anything which can accelerate the 
circulation. If the bleeding persists or recurs, we must apply ice 
to the abdomen or insert it into the vagina, at the same time giving 
the liquor ferri sesquichloridi internally, and injecting ergotin be- 
neath the skin. Should the symptoms of haemorrhage threaten life 
itself, transfusion of blood or milk is indicated, as in all other 
haemorrhages. Pain is best allayed by hypodermics of morphine. 
The inflammatory symptoms and local peritonitis are to be met by 
striving, by full doses of opium, to arrest movement of the bowels, 
and thus to favor the adhesions by which the haematoma is becom- 
ing enclosed. Only after the inflammation has abated should the 
bowels be cautiously moved by enemata or by irrigation [Ilegar's 
method). Gynecologists differ as to the merit of evacuation of a 
haematoma by puncture. Since opening the sac entails the danger 
not only of renewal of the bleeding, but also of putrefaction within 
the sac and its consequences, it should not be lightly attempted, nor 
until all hope seems lost of resorption, or else until violent symp- 
toms make it seem hazardous to await spontaneous evacuation. 
The sac is to be punctured with a small trocar—or, better still, by 
the aspirating needle—the entrance of any air being carefully pre- 
vented. Puncture is most commonly made through the vagina or 
rectum. Should the contents prove to be suppurating or putrid, 
the opening must be freely enlarged, and the putrescent matter as RETROUTERINE HEMATOCELE. 
169 
completely as possible removed by disinfectant irrigation, in order 
to prevent the consequences of septic absorption. 
When the symptoms of a haematoma are mild, and it seems in- 
clined toward absorption, the patient is merely to be kept at rest, 
with a light, nutritious diet, and impediments to the stools or urine 
are to be properly relieved.] SECTION III. 
DISEASES OF THE VAGINA. 
In this section we shall only treat of the inflammations of the 
vagina, leaving the congenital anomalies, tumors, and other diseases 
of that organ, to the text-books on obstetrics and surgery. 
CHAPTER I. 
VIRULENT CATARRH OF THE VAGINA. 
Etiology.—For the pathogeny and etiology of gonorrhoeal catarrh 
of the vagina, we may refer to what we have said of virulent catarrh 
of the male urethra. Anatomically, it is not distinguishable from non- 
virulent catarrh, but its course and origin are different. The disease 
is not induced by sexual excess, or any other cause than infection with 
gonorrhoeal matter. 
Anatomical Appearances.—In women the chief seat of virulent 
catarrh is the mucous membrane of the vulva and vagina; more rarely 
it extends to that of the uterus. But in almost all cases the catarrh 
extends to the urethra, and this is important in the diagnosis. The 
affected mucous membrane at first shows the changes peculiar to the 
most severe form of acute catarrh; subsequently those of chronic ca- 
tarrh. The secretion, which, in the beginning, is usually scanty, sub- 
sequently becomes very copious, purulent, irritates the vulva and inner 
surface of the thighs, but is only peculiar in that it is the bearer of the 
contagion. 
Symptoms and Course.—The first symptoms of gonorrhoea in the 
female, a feeling of itching and warmth in the sexual organs, and a 
scanty mucous discharge, are not very characteristic, and are often un- 
noticed. A few days after the commencement of the disease, there are 
severe burning pain in the genitals, swelling of the vulva, ardor urinoc. ; 
but these troubles rarely become so severe as to interfere greatly with NON-VIRULENT CATARRH OF THE VAGINA. 
171 
walking, sitting, and moving the body. The secretion, which in this 
stage is yellowish-green, thick, and purulent, often oozes up in large 
quantities between the labia; in the vulva and its vicinity, even to the 
anus, we find shallow ulcers, which are not to be confounded with 
chancres. We may almost always press pus out of the urethra. Af- 
ter the disease has lasted a fortnight or three weeks, the pain abates 
and ceases; the discharge loses its purulent appearance, but continues 
a long while till the secretion, which constantly becomes more mucous, 
dries up, and loses its power of inoculation. 
Treatment.—The local treatment, which we preferred to internal 
remedies for gonorrhoea in men, is almost exclusively used for the dis- 
ease in women. Considering the different seats of gonorrhoea in the 
two sexes, it may be readily understood that copaiba or cubebs, whose 
active constituents are excreted with the urine, may have an effect on 
gonorrhoea in the male urethra that it cannot have on the disease in 
the female, where the vagina is chiefly affected. While there is se- 
vere pain, we prescribe scanty diet, laxatives, long-continued sitz- 
baths, during which a speculum should be left in the vagina, if its in- 
troduction be not too painful. If there be no symptoms of inflamma- 
tion, or if they have been allayed, we may employ injections of solu- 
tions of tannin, nitrate of silver, alum, sulphate of zinc, acetate of 
lead, etc. Injections of plumbi acet. crystall. 3 iij.—Aqua? conj. j, as 
recommended by Ricord, are very efficacious; instead of being inject- 
ed, this solution may be poured in through a speculum, and the latter 
slowly withdrawn, so that the fluid shall come in contact with all parts 
of the vagina. In very obstinate cases we may introduce wads of 
charpie, sprinkled with alum, into the vagina, or touch the parts with 
solid nitrate of silver. 
CHAPTER II. 
NON-VIRULENT CATARRH OP THE VAGINA. 
Etiology.—JKbllik&r and Scanzoni, who have carefully examined 
the secretion from the vaginal mucous membrane, both in health and 
disease, found perfectly healthy secretion in very few women, and only 
in those who had had no children, and had not frequently indulged in 
coitus. It was so scanty that the surface of the mucous membrane was 
<*nly lubricated by it; it was nearly as clear as water, fluid, only viscid, 
white or yellowish in spots; it was almost always acid, and, besides a 
small amount of pavement epithelium, it contained no noticeable solid 
constituents. Shortly before and after menstruation the secretion was 
more copious, always fluid, and almost always acid; at this time if 172 
DISEASES OF THE VAGINA. 
contained more epithelial cells, and, after the cessation of the menses, 
as long as it retained its red color, there were more or less blood-cor- 
puscles in it. In catarrhal affections they found the secretion either 
milky and thin, or more yellowish and thicker. The more opaque, 
white, or yellow, the secretion appeared, the more numerous were its 
pavement epithelium and young cells (mucous and pus-corpuscles), 
often also the infusoria discovered by Donne (trichomonas vaginalis), 
and some few fungous filaments and vibriones. Hence we see that 
these observers rarely found a perfectly normal secretion, and that 
catarrh of the vagina is one of the most common of female diseases. 
Irritation of the vagina, by sexual excess, is the chief cause of catarrh 
of that part, it is true; but it is often induced by other causes, which 
were mentioned when speaking of uterine catarrh. It is particularly 
to be borne in mind that catarrh of the vagina, like that of the uterus, 
depends as often on constitutional as on local causes. A consideration 
of the exciting causes shows that this disease must be rare during 
childhood; and this is true, except in the cases where oxyuris have 
passed over the perinaeum from the anus to the vagina, and have there 
caused great irritation. 
Anatomical Appearances.—In acute catarrh we find the mucous 
membrane bright red, swollen and relaxed; in many cases we see 
small prominences on it, which give the membrane a granular appear- 
ance, and which are not, as was formerly supposed, due to distention 
of the follicles, but to swelling of the mucous papilke. Sometimes 
these changes affect the entire vagina, at others only parts of it. At 
first the secretion is scanty, but, after the disease has lasted a very 
short time, it becomes more copious and more or less opaque. 
[The inflammation usually spreads all over the vagina, and over 
the vulva as well. Sometimes, however, a portion only of the va- 
gina is involved. For instance, at the beginning of a vaginal gon- 
orrhoea the lower part only will be attacked, while a catarrh caused 
by disease of the cervix or uterus will be confined chiefly to the up- 
per part of the canal. 
Hildebrand describes a peculiar ulcerous form of inflammation 
of the upper vagina, caused by loss of the epithelium and slight 
hypertrophy of the papillae, and finally adhesion of the vaginal por- 
tion to the vaginal walls, so that the fornix vaginae is obliterated, 
and the os uteri is to be felt at the top of a funnel-shaped tube. 
Schroeder has also seen this disease, which in one case resulted in 
complete atresia, in another in partial closure of the vagina below 
the vaginal portion, and in a third case in complete contraction 
(stenosis) of the entire upper vaginal region.] 
In chronic catarrh the walls of the vagina appear distensible and NON-VIRULENT CATARRH OF THE VAGINA. 
173 
flaccid. The membrane is more bluish red and its surface more fre- 
quently granular than in the acute variety ; the secretion is some- 
times more milky, sometimes more yellow and thick. Not unfre- 
quently the relaxation of the vagina induces prolapse, particularly 
of the anterior wall. 
Symptoms and Course.—In non-virulent catarrh also, if it begin 
acutely, the patient complains of prickling and burning in the pri- 
vate parts ; but, as the mucous membrane of the urethra is unaffect- 
ed, she has no pain on urination. In chronic catarrh the discharge 
of the abnormal secretion, the leucorrhoea (fluor albus vaginalis), is 
often the only symptom of the disease. The chief means of decid- 
ing whether the discharge be from the vagina or uterus is by exam- 
ination with the speculum. Many women bear the drain without 
any injury ; in others it induces anaemia, pallidity, weakness, and 
emaciation. 
Treatment.—In treating non-virulent vaginal catarrh, just as 
in uterine catarrh, we must first attend to the causal indications. 
But we cannot often cure the disease without accompanying local 
treatment. We would chiefly recommend the hip-baths and injec- 
tions mentioned in the last chapter ; in obstinate cases, the introduc- 
tion of a tampon sprinkled with alum, and even the application of 
solid nitrate of silver. 
CHAPTER III. 
CROUPOUS AND DIPHTHERITIC INFLAMMATION OF THE VAGINA. 
Croupous and diphtheritic inflammations of the vaginal mucous 
membrane are common during puerperal fever, but are rare except 
in the puerperal state. They either depend on local irritation or on 
constitutional disease. Thus, the discharge from a sloughing can- 
cer of the uterus, the urine constantly flowing through a vesico-vag- 
inal fistula, a bad pessary, or a large uterine polypus projecting into 
the vagina, may induce croupous or diphtheritic inflammation of the 
vaginal mucous membrane ; while the disease is also often observed 
in the later stages of typhus, cholera, measles, and small-pox, and 
accompanying similar affections of other mucous membranes. 
Usually only certain spots of the vagina are covered with croup- 
membrane, or changed to diphtheritic sloughs. In the vicinity of 
these spots the mucous membrane is dark red ; after the slough has 
been thrown off, irregular losses of substance remain ; these are 
sometimes superficial, at others deep. Our attention is called to 
the disease by severe pain in the parts, and by a fetid, often bloody 174 
DISEASES OF THE VAGINA. 
discharge, which begins in a few days. Local examination is the 
only means of certain diagnosis. Where a large or putrefied pes- 
sary has caused the inflammation, its removal, and the use of luke- 
warm, and later of cold and astringent, injections, ordinarily suffice 
to cure the disease. The affection usually disappears readily also if 
a large polypus, that has forcibly distended the vagina, be removed. 
On the other hand, where sloughing cancer or ve'sico-vaginal fistula 
has caused the disease, we must limit ourselves to a palliative treat- 
ment. In those cases occurring in the course of infectious diseases, 
it is usually sufficient to attend to cleanliness, as the secondary dis- 
ease generally passes off with the primary. DISEASES OF THE NEKVOUS SYSTEM. 
SECTION I. 
DISEASES OF THE BRAIN. 
CHAPTER I. 
HYPERAEMIA OP THE BRAIN AND ITS MEMBRANES. 
Etiology.—For a time the fact was ignored that on autopsy the 
nlood-vessels within the skull were sometimes found distended and at 
others empty, and it was supposed that the amount of blood contained 
m the closed cranium of an adult could neither increase nor diminish, but 
was constant; and that anaemia or hyperaemia was only supposable 
when the brain-substance was increased or diminished, that is, when 
there was hypertrophy or atrophy of the brain. This view was based 
on the following reasoning: The brain is not compressible, at least not 
by the pressure to which it is subjected from the contents of the 
blood-vessels; and it is surrounded by walls which do not expand; 
consequently only the same amount of blood can enter the skull as 
passes out from it, and conversely only as much blood can pass out ot 
the skull as enters it. This reasoning is false, as it starts with the 
supposition that the contents of the cranium consist only of the mem- 
branes of the brain, the brain-substance and the blood-vessels with 
their contents; it leaves the cerebrospinal fluid out of consideration. 
This, which is a simple transudation, can rapidly increase or diminish, 
and can at least partly pass into the spinal canal, which is not entirely 
enclosed by rigid walls. In almost all autopsies it may be seen that 
the amount of blood contained in the vessels and the amount of cere- 
brospinal fluid are in inverse proportion ; that a distention of the ves- 
sels of the meninges is accompanied by a decrease of arachnoid fluid, 
and conversely that, when the vessels are less full, the meshes of the 176 
DISEASES OF THE BRAIN. 
textus cellulosus subarachnoidealis contain a greater amount of serum. 
Only when the brain is atrophied do we find oedema of the membranes 
with overfilling of the vessels ; and only when an effusion of blood, a 
tumor, or a collection of fluid in the ventricles, has contracted the space 
in the skull do we find, along with anaemia, dryness of the membranes, 
and disappearance of the sulci between the cerebral convolutions. 
The division of cerebral hyperaemia into active and passive, or, to 
retain the expressions previously used, into fluxionary and congestive, 
is practically valuable not only on account of the consideration being 
easier, but because the symptoms of one form differ from those of 
another. 
Fluxionary hyperaemia results—1. From increased heart-action. 
It is true that, in this case, while the arteries are fuller than usual, the 
veins are less so; hence the entire amount of blood in the vessels of 
the brain and its membranes is not increased by the stronger action 
of the heart. But the increased lateral pressure induces increased ful- 
ness of the capillaries, and it depends chiefly on these (not on the 
amount of blood in the large vessels) whether or not the brain acts 
normally and is normally nourished. This form of cerebral hyper- 
emia occurs temporarily from augmented energy of contraction of a 
healthy heart, as in fever and great bodily or mental excitement; it is 
habitual in the permanently increased activity of a hypertrophied 
heart, but only when the hypertrophy is an independent disease, or in 
case it accompanies an obstruction to circulation, when it has become 
greater than is necessary for the compensation. Simple, non-com- 
plicated hypertrophy of the heart is not frequent, and occurs almost 
exclusively in topers and persons who continually do hard work. On 
the other hand, hypertrophy that has become greater than was neces- 
sary to compensate the obstruction to the circulation is quite frequent. 
Examples of this are the occasional enormous hypertrophies of the left 
ventricle when there is insufficience of the aortic valves, and perhaps 
also the hypertrophy of the heart in morbus Brightii. 
2. Fluxionary hyperaemia of the brain results from too slight resist- 
ant power of the afferent blood-vessels, whether this be congenital or 
acquired. When the cerebral arteries have delicate, thin walls, so 
that they yield to an increased pressure of the blood sooner than the 
other arteries of the body do, and hence, when the action of the heart 
is only moderately increased, fluxionary hyperaemia of the brain is in- 
duced, it is customary to say that the person so affected has a tendency 
to “ rush of blood to the head.” 
3. Fluxionary hyperaemia to the brain results from an increase of 
the lateral pressure in the carotids as a consequence of obstructed 
escape of blood from the aorta into other branches. As a type of this HYPERAEMIA OF THE BRAIN AND ITS MEMBRANES. 
177 
“ collateral fluxion ” to the brain, we may mention the habitual cere- 
bral hypermmia where there is contraction or closure of the aorta at 
the point where the arterial duct terminates in the aorta (Volume L, 
page 363). It frequently results from compression of the abdominal 
aorta and its branches, by the distended intestines and by exudations. 
In the same way obstruction of the cutaneous circulation during the 
cold stage of intermittent fever, and from the action of severe cold, 
induces collateral fluxion to the brain. According to Watson, in cold 
nights many unfortunates are arrested in the streets for being drunk, 
when they are only suffering from cerebral hyperaemia as a result of 
disturbance of the cutaneous circulation. It is not improbable that 
severe muscular exertion may also induce increased fulness of the 
carotids and fluxionary cerebral hypenemia, by the pressure of the con- 
tracted muscles on the capillaries. 
4. A fourth cause is paralysis of the vasomotor nerves of the cere- 
bral vessels. Physiological experiments show that, if the cervical por- 
tion of the sympathetic nerve be divided, the vessels on the correspond- 
ing side of the head become dilated. The cerebral vessels appear to 
be similarly affected by the use of spirituous liquors, by some poisons, 
as well as by great emotions and excessive mental activity. I would 
particularly call attention to the last cause, as I have frequently seen 
dangerous hyperaemia of the brain after too prolonged mental labor, 
which resulted fatally from the occurrence of oedema. We can hardly 
give any other explanation for these cases, than that the walls of the 
vessels are paralyzed by the above influences, their calibre dilated, and 
the supply of blood consequently increased. 
5. Lastly, fluxion to the brain results from atrophy of that organ. 
The space left in the skull by the disappearance of the brain-substance 
is partly filled by the dilatation of the vessels. We shall find this 
dilatation of the vessels to be a frequent cause of their rupture; and, 
as atrophy of the brain often follows apoplexy, it is also a cause of 
returns of apoplexy. We shall not attempt to say whether or not the 
fluxionary hyperaemia of the brain, occasionally observed during con- 
valescence from severe disease, is the result of atrophy of the sub- 
stance of the brain or of the neuroglia and consequent dilatation of 
the vessels. 
Passive hyperaemia, congestion of blood in the brain, depends— 
1. On compression of the jugular veins and vena cava descendens. 
As a type of this form, we may mention the excessive cerebral con 
gestion caused by strangulation. The jugular veins are most fre 
quently compressed by enlarged thyroid or lymphatic glands, the vena 
cava descendens by aneurisms of the aorta. 
2. Congestion of the brain results from energetic expiratory move- 178 
DISEASES OF THE BRAIN. 
ments while the glottis is contracted. In coughing, straining, playing 
wind-instruments, etc., as we have often shown, the flow of blood into 
the thorax is hindered; the pulmonary circulation contains too little, 
the general circulation too much blood. Under such circumstances, 
the brain must sufler fai more from hyperaemia than other organs sup- 
plied by the general circulation, particularly the liver, spleen, and 
kidneys; because the passage of blood through the upper aperture of 
the thorax is more impeded than it is through the lower, since these 
abdominal glands undergo the same compression from the abdominal 
muscles that the veins of the thorax and the heart do. 
3. We have cerebral congestion in all those diseases of the heart 
where the function of that organ is impaired, if they are not compli- 
cated by other anomalies of opposite effect, and so compensated. In 
non-compensated valvular disease of the left ventricle, the whole 
amount of blood in the vessels of the brain and its membranes is not 
increased, it is true, since, while the veins are overfilled, the arteries 
are less full; but the overfilling of the veins obstructs the flow of blood 
from the capillaries, thus inducing capillary hyperaemia, which, as we 
have shown, is the most important cause of the cerebral hyperaemia. 
The affection caused by valvular disease of the right heart is far greater 
than that from valvular disease of the left heart; for, in the former 
case, not only is the escape of venous blood from the brain impeded, 
but the entire amount of blood in the skull is increased. 
4. The same state of affairs occurs in extensive compression or 
atrophy of the vessels of the lungs as in pleuritic effusions, emphy- 
sema, or cirrhosis of the lungs. In these diseases also, when the right 
ventricle is not hypertrophied in proportion to the impediment to the 
circulation, the systemic circulation is overloaded at the expense of the 
pulmonary, and the amount of blood in the skull is increased. Since 
the contents of the cerebral veins and sinuses cannot pass into the 
overfilled jugular veins, the same excessive cyanosis occurs in the brain 
that is so evident in the skin, and which is almost pathognomonic of 
the diseases in question. The last stage of emphysema gives us an 
excellent opportunity of studying the gradual development, steady in- 
crease, and, finally, the severest symptoms of congestion of the brain. 
Lastly, we must mention a form of cerebral hyperaemia which is 
neither fluxionary nor congestive, and which is peculiarly important, as 
it should be very carefully avoided by persons suffering from disease of 
the blood-vessels, and having a tendency to apoplexy; I mean those 
cases of hyperaemia that appear as one symptom of temporary general 
plethora induced by a very free supply of food and drink. 
Anatomical Appearances.—On post-mortem, examination, it is 
often difficult to decide whether the vessels of the cerebral membranes HYPERH2MIA OF THE BRAIN AND ITS MEMBRANES. 
179 
and still more so whether those of the cerebral substance, have been 
more than normally filled with blood during life. Mistakes in the 
account of the autopsy are frequent. 
The mistakes regarding the amount of blood in the cerebral mem- 
branes depend partly on the fact that, when unaccustomed observers 
find the vessels much distended at the dependent parts of the surface 
of the brain, they diagnose a hyperasmia of the cerebral membranes, 
even if the blood has only sunk downward, and the vessels in the upper 
part be empty. Still more frequently another error is committed even 
by practised observers: that is, from a similar distention of the vessels 
on the convex surface of the cerebrum, hypermmia of the cerebral 
membranes is decided on without looking further. It should be borne 
in mind that the arteries supplying the cerebral membranes with blood 
lie at the base of the brain, and that only very fine arterial twigs reach 
the convexity of the greater hemispheres. All the large blood-vessels 
usually seen on the surface of the brain, when the skull is opened, are 
veins. Distention of these veins is a normal appearance, if the indi- 
vidual has died of an acute disease by which his blood was not con- 
sumed, or, if he has died suddeidy from suffocation, acute poisoning, 
or from some other accident involving no loss of blood. Hence it is 
entirely wrong, in such cases, to decide, from the overfilling of the 
veins, that there has been hypermmia of the brain or its membranes 
during life, and to connect this pretended hyperaemia with the symp- 
toms that have been observed. In the history of the post mortem, 
accounts of excessive hyperaemia of the brain and its membranes are 
often combined with others of a similar excessive hyperaemia of the 
lungs, liver, kidneys, etc. If there were no mistake here, did we not 
have to suppose that, in the body of a previously healthy person, who 
had died neither from exhausting disease nor loss of blood, the normal 
amount of blood was often considered pathological, these accounts 
of post mortem would only convey the absurd idea that the entire 
amount of blood in the body was increased by poisoning, suffocation, 
etc. We must make it a rule to consider hyperaemia of the cerebral 
membranes as proved only in those cases where the finest vessels also 
are injected, and where the overloading of the cerebral vessels is not 
at all in proportion to the amount of blood in other organs. 
The great difficulty of detecting, in the cadaver, a hyperaemia of the 
substance of the brain, that has existed during life, depends chiefly on 
the fact that the first fine ramifications of the vessels supplying the 
brain take place in the pia mater, and that the vessels passing thence 
to the substance of the brain are mostly capillary (I/uschka). As 
these can scarcely be recognized with the naked eye, it is customary 
to use the size and number of the drops of blood oozing up on a cut 180 
DISEASES OF THE BRAIN. 
surface of the brain as a means of determining the amount of blood 
contained in the cerebral vessels. I do not deny that this sign has 
some value, particularly in judging of passive cerebral hyperasmia; 
but I must add that the size and number of these drops of blood de- 
pend far more on the fluidity of the blood than on the fulness of the 
vessels. At all events, in cases where there can be no doubt of death 
having resulted from increased flow of blood to the head, or from its 
obstructed escape thence, on a section through the brain, its substance 
is often found very pale, and on its cut surface only a few small blood- 
drops ooze up. This circumstance, and the symptoms of paralysis 
occurring in the severer cases of cerebral hyperaemia (of which we shall 
speak more fully in the next paragraph), cause it to appear to me very 
probable that, when there is increased lateral pressure in the small 
arteries and veins of the brain, a transudation of serum from them 
into the perivascular spaces and interstices of the brain may very 
readily take place, and cause compression of the capillaries. It is only 
in yielding and distensible organs and tissues, which are not enclosed 
by firm envelopes, that any considerable oedema can coexist with a 
normal fulness of the capillaries. In all tissues enclosed by fascia or 
other firm capsule, oedema causes ansemia of the capillaries. If the 
size of the brain be not diminished by atrophy, and if the skull be 
closed, or, it remaining opened, if the dura mater be tense, there is no 
doubt that a slight transudation of serum will suffice to completely 
compress the capillaries of the brain. It is true, we cannot be sure, 
from post-mortem examination, that there is such a secondary oedema; 
but the supposition that such is the case appears to us perfectly justi- 
fiable when a patient has died with the symptoms of cerebral paralysis, 
and if, on autopsy, we find that the very white hue of the brain-sub- 
stance and the slight number of small blood-points appearing on its 
cut surface contrast strongly with the distention of the large vessels 
in the meninges. 
Where the hyperasmia is often repeated, atrophy of the brain and 
decided dilatation of the vessels result. The vessels of the meninges, 
which are unmistakably dilated, run a tortuous course; on section 
through the brain, we may distinctly see the gaping mouths of the 
vessels; the dilatation may even be observed in the capillaries on 
microscopical examination. There is plenty of serum in the sub- 
arachnoid spaces, the brain-substance is moist and shining. This ap- 
pearance, which is frequent in topers, is readily understood, if we 
remember that, in atrophy of the brain, the fluid contents of the skull 
must increase so as to fill the cavity. It is doubtful whether the de- 
velopment of the Pacchionian bodies can also be considered as a result 
of repeated hyperaemia; they are sometimes solitary, sometimes HYPER.EMIA OF THE BRAIN AND ITS MEMBRANES. 
181 
grouped as whitish, opaque excrescences of the arachnoid, coming par- 
ticularly along the sides of the longitudinal sinus. The pressure that 
they exercise on the dura mater separates its filaments, so that they 
perforate it; by further pressure they also cause atrophy of the bone, 
and they are then found embedded in little fossae in the skull. Micro- 
scopically, they consist of connective tissue; occasionally they contain 
fat and chalky salts. 
Symptoms and Course.—Before taking up the symptomatology 
of hyperaemia of the brain, I shall warn against the wide-spread error, 
so injurious to ihe patient, of considering all cases of disturbance of 
function of the brain, where severe structural changes can be excluded, 
as due to hyperaemia (or anaemia). 
Thus, the disturbance of the cerebral functions in fever is not due 
to increased afflux of blood to the brain from excited action of the 
heart; but, as we have repeatedly pointed out, it depends partly on 
the high temperature of the blood in the cerebral vessels, partly on its 
abnormal quality, the “ feverish state,” a necessary result of the in- 
creased transformation of tissue during the fever. Delirium and other 
severe cerebral troubles are most common in the so-called asthenic 
fevers, just where the increase of bodily temperature and the produc- 
tion of warmth attain the highest grade, while the heart’s action is 
hastened, but weakened, and there is no fluxion to the brain. 
According to the observations made during the last war, as well 
as from the valuable investigations and experiments of Obernier, the 
symptoms of sun-stroJce, or insolatio, do not, as was formerly sup- 
posed, depend on hyperasmia of the brain, induced by the action of 
the sun’s rays on the head. The symptoms of this disease consist in 
a paralysis of all the functions of the brain, occurring either suddenly 
or gradually. In the latter case the paralysis is preceded by excite- 
ment, delirium, and other symptoms of cerebral irritation. It has been 
determined that, in our zone at least, the action of the sun’s hot rays 
is not alone sufficient to induce these severe attacks, but that they 
only occur when individuals are subjected to great fatigue, on a very 
hot day, particularly if, at the same time, they sweat very little, be- 
cause they do not drink enough. We may assume that, under such 
circumstances, while the radiation of heat is limited on account of the 
high temperature of the surrounding atmosphere, while the production 
of heat is increased by the active muscular exercise, and the coolness 
induced by free perspiration is limited, there is an overheating of the 
body, an increase of the bodily temperature to a height incompatible 
with life. We have already sufficiently explained the significance of 
the fulness of the veins of the meninges, which is found on autopsy ic 
cases of sun-stroke. 182 
DISEASES OF THE BRAIN. 
[The condition known under the term “ sunstroke,” or better, 
“ heatstroke ” (for the direct action of the sun’s rays is by no means 
essential to it), used formerly to be ascribed to a hypersemia of the 
brain ; a belief which has now been conqjletely exploded by experi- 
ments upon animals and by post-mortem examinations. It is now 
known, from the researches of Obernier, that in this disease there is 
a serious derangement of the heat-producing function and a great 
rise in the bodily temperature, which in extreme cases may reach 
109° or 110° Fahr. Absolutely nothing as yet is known, however, 
of the anatomical lesions upon which sunstroke depends. It was 
formerly ascribed to grave alterations in the blood, to its over-acidity 
by overloading with carbonic and lactic acid, to destruction of its 
red corpuscles, to accumulations in it of urea, and the like. Koester 
in one case has found a hemorrhage in the right superior sympa- 
thetic ganglion, and in the right sympathetic itself, as well as 
smaller extravasations about and in the two vagi, and thinks we 
should look for the derangements in the vasomotor and respiratory 
nervous systems. Arndt seeks for an anatomical basis for the disease 
in the so-called “turbid swelling” (triiben Schwellung) developed 
in the brain, liver, kidneys, and other tissues, under the influence 
of the enormously high temperature, just as it occurs in high fever 
from other causes. The different symptoms presented during life 
may depend upon the degree in which the turbid swelling has at- 
tacked individual organs. In milder cases the temperature is below 
104° ; the mind is muddled, the chest oppressed and uneasy, the pulse 
very frequent, the heat great, the skin moist, and there is a general 
but moderate feeling of languor. If relief cannot be gained through 
water-drinking and quiet, graver symptoms appear. The temper- 
ature then rises above 104°, the pulse to 130 or 140 ; the sweating 
becomes profuse and the thirst distressing. The patient loses con- 
trol over himself, and is oppressed by fulness of the head, dizziness, 
sensory delusions, and precordial distress. He is forced to sit down, 
or else sinks suddenly unconscious, and lies with flickering imper- 
ceptible pulse and sunken features. Sometimes there are epilepti- 
form fits. Although under proper treatment many very severe cases 
recover, yet the number which end fatally, particularly during the 
marches of armies in hot weather, is sometimes large. Many pa- 
tients improve at first, and then relapse unexpectedly. This fact, as 
well as the experience that recovery after sunstroke is slow, that it 
has many sequelae, such as vague pains, disposition to faint, indi- 
gestion, unnatural drowsiness, and the like, which are often obsti- 
nate, and the circumstance that sometimes there remains a psychical 
irritability or a permanent impairment of intellectual function, all HYPERJGMIA OF THE BRAIN AND ITS MEMBRANES. 
183 
indicate that the disorder has a definite material basis, which in bad 
cases is not always repaired.] 
Lastly, the symptoms of acute alcoholic poisoning, as well as that 
from opium and other narcotics, do not depend at all, or at any rate 
depend to a very small extent, on over-fulness of the cerebral vessels, 
although in them the brain is liyperaemic. The case appears to be 
different in the symptoms induced by the immoderate use of liquor 
for a length of time, or the continuous misuse of narcotics, a practice 
which has greatly increased since the introduction of subcutaneous 
injections of morphine. In such cases cerebral hyperaemia plays a 
more important part, at least, than it does in the symptoms of intoxi- 
cation and of acute opium-poisoning. 
[Abnormal fulness of the brain and its membranes is a common 
enough affection. Its symptoms may vary greatly. Not unfre- 
quently they are so insignificant as to attract little or no attention ; 
so that many persons with habitual plethora about the head are fa- 
miliar with the sensation which it causes, and do not consult a phy- 
sician. But there are other cases in w7hich hyperaemia causes symp- 
toms of the utmost gravity ; and between the mere sense of giddi- 
ness after stooping which one man may feel, and the formidable— 
nay, fatal—apoplectiform seizure which may befall another, there is 
a long series of interchanging types, whose differences, however, by 
no means always correspond to differences in grade of the hyperae- 
mia. Most of the symptoms bear the character of a morbid nervous 
excitement with exaltation, although others take on the form of 
depression and paresis. The psychical, the sensory, or the motor 
functions may be especially disturbed, according to the seat of the 
hyperaemia and to the receptivity of the individual. One might at 
first suppose that the symptoms of an active hyperaemia of the brain 
should be widely different from those of a passive congestion ; since 
in the first there is an increased afflux to the brain of arterial blood, 
the constant supply of which is so essential to the continuance of 
the brain-function, whereas in the latter this arterial supply must be 
more or less diminished, and the symptoms of carbonic-acid poison- 
ing should also be present. But in reality the two forms of hyperae- 
mia bear a close resemblance ; and this is due to the fact that a lack 
of blood in the brain is capable of causing like symptoms with those 
from overloading of the brain with arterial blood ; and it is well 
known to the practitioner that the distinction between cerebral hy- 
peraemia and cerebral anaemia may present obstacles at the bedside 
only to be surmounted by prolonged observation of the patient. 
The symptoms of the mildest grade of hyperaemia of the brain 
consist in a feeling of pressure and weight in the head, or of an 184 
DISEASES OF THE BRAIN. 
actual headache, often accompanied by dizziness and an extraordi- 
nary susceptibility of the special senses. There is a buzzing in the 
ears, and a dazzling light before the eyes. This latter usually be- 
gins at a spot in the eccentric field of vision, with a quivering as 
though smoke were rising. It advances to the middle of the field, 
obscuring the whole, and renders accurate seeing impossible. The 
part first affected begins to clear, and in half an hour all is over. 
The arteries of the eyeball are branches of the internal carotid, and 
would naturally participate in an intracranial hyperasmia. Hence, 
in an obscure case the ophthalmoscope should aid us.] 
Hyperasmia of the brain is marked partly by symptoms of increased 
excitability of the nerve-filaments and ganglion-cells and by their mor- 
bid excitement (symptoms of irritation), partly by symptoms of dimin- 
ished or lost excitability of these nerve-elements (symptoms of depres- 
sion). Usually the -symptoms of irritation precede those of depression, 
in other cases the former do not occur, and the latter begin from the 
outset. It is commonly supposed that this difference of symptoms 
depends on difference of pressure on the brain from the more or less 
distended blood-vessels, and reference is made to the analogous action 
of the peripheral nerves, which are also irritated by a moderate pressure 
and paralyzed by a stronger one. This explanation appears very suit- 
able as regards the symptoms <of irritation. Experience shows that 
nerves, passing through bony canals in company with blood-vessels, 
are thrown into a state of increased excitability and morbid excite- 
ment by overfilling of these vessels; the nerve-elements of the brain, 
enclosed by the dura mater and skull, are in a like condition wThen the 
cerebral vessels are overfilled. On the other hand, the reference of 
the symptoms of paralysis to an increase of the “ intravascular pres- 
sure ” appears to me erroneous, for even in the severest forms of hy- 
peraemia this pressure does not nearly approach the grade necessary 
to induce paralysis of a peripheral nerve. In -support of the above 
view, it has been said that paralysis is also caused by the scarcely 
greater “ extravascular pressure ” of small extravasations on the brain; 
but I shall hereafter show that the apoplectic symptoms from cerebral 
haemorrhage do not depend on contusion of the brain from the extrav 
asation. It is much more probable that the symptoms of depression 
and paralysis arise because the requisite supply of arterial, oxygenated 
blood to the nerve-filaments and ganglion-cells of the brain is limited 
or entirely stopped in excessive cerebral hyperasmia. In congestive 
hyperasmia the escape of venous blood from the brain is checked; and 
it is evident that, when the veins finally become filled to a certain 
point, no new arterial blood can enter the capillaries. It is often as- 
serted that the symptoms of cerebral hyperasmia are very similar to 01 HYPEILEHIA OF THE BRAIN AND ITS MEMBRANES. 
185 
exactly identical with those of cerebral anaemia; this is true in regard 
to congestive hyperagmia and anaemia, and the explanation of the cor 
respondence is easy. In both cases the brain lacks its new supply of 
arterial blood. To explain the symptoms of paralysis occurring in 
fluxionary hyperaemia also, we must take the hypothesis that, during 
its course, there is a secondary oedema of the brain, as a result of 
which we have capillary anaemia, a condition directly opposite to the 
original hyperaemia. The symptoms of cerebral hyperaemia are ren- 
dered more varied by the fact that, in different cases, the irritation or 
paralysis is more prominent at one time in the sensory, at another in 
the inotory, and again in psychical functions. We cannot give any 
satisfactory explanation of this difference. 
Among the symptoms of irritation in the sensory functions are 
headache, great sensitiveness to external impressions, and simple sub- 
jective impressions from the nerves of special sense. The headache, 
a very frequent symptom in all cerebral diseases, is very difficult to 
explain; we do not even know if it is of central origin (that is, if it 
originates in the parts of the brain where irritation causes symptoms 
of pain after the insensible greater hemispheres have been removed), 
or whether, as I think is more probable, it depends on irritation of the 
filaments of the trigeminus going to the dura mater. The great sen- 
sitiveness to impressions on the senses depends on the increase of ex- 
citability caused by the cerebral hyperagmia on the hyperaesthesia of 
those portions of the brain through which peripheral irritations are 
perceived. The patients do not exactly feel, see, and hear more sharply 
than ordinarily, but they are annoyed by irritations far weaker than 
such as usually annoy them. Light troubles them; a slight sound, or 
an insignificant irritation of the nerves of touch, excites disagreeable 
feelings. Morbid excitation (which .must not be identified with in- 
creased excitability) of the same central parts causes the dazzling be- 
fore the eyes, seeing sparks, roaring and buzzing in the ears, the sen- 
sation of formication, or of undefined pain, which are not induced by 
peripheral irritation. Among the motory symptoms of irritation we 
have restlessness, sudden starting, gnashing the teeth, crying out, 
without the expression of pain, the automatic movement of the ex- 
tremities, twitching of single muscles, and lastly the general convul- 
sions which are observed in the course of cerebral hyperaemia. In re- 
gard to the first of these symptoms, particularly the restlessness, the 
constant tossing around in bed, we may often be doubtful whether it 
depends on increased excitability of those portions of the brain through 
which the motor nerves and muscles are excited and motions induced, 
or on morbid states of excitement in the organs affected. On the 
other hand, there is no doubt that the twitching of individual muscles, 186 
DISEASES OF THE BRAIN. 
occurring independently of mental influences, and convulsions affecting 
the whole body, are the results of a morbid excitement of the cerebral 
motor centres. It is very remarkable that general convulsions occur- 
ring in cerebral hypersemia and other affections of the brain, as well 
as in epilepsy and eclampsia, are not accompanied by other symptoms 
of cerebral irritation, but, on the contrary, are constantly combined 
with symptoms of cerebral paralysis, especially with complete loss of 
consciousness. By a series of valuable experiments, Kussmaul and 
Tenner have shown that the same combination of general convulsions, 
with loss of consciousness, may be induced by artificially obstructing 
all the arteries supplying the brain with blood; but it is entirely un- 
explained, and it is enigmatical, how it happens that the same patho- 
logical process induces a state of the greatest excitement in some parts 
of the brain and paralysis in others. Until this contradiction is ex- 
plained, the investigations as to whether the above symptoms depend 
directly on the lack of oxygenated blood, or indirectly on changes oc- 
curring in the blood, which remains unrenovated on account of the ob- 
struction, are of little value. Since these attacks of convulsions are 
constantly accompanied by symptoms of paralysis, and since we do not 
believe that the latter can proceed from the pressure of the distended 
vessels on the nerve-elements of the brain, and, lastly, since we may 
artificially induce loss of consciousness and general convulsions by 
preventing the flow of arterial blood to the brain, we consider the fol- 
lowing decisions justifiable: The general convulsions and loss of 
consciousness occurring during hyperaemia of the brain, which are usu- 
ally termed epileptiform attacks, either occur because in passive hy- 
peraemia the veins become so full that more arterial blood cannot en- 
ter, or because the hyperaemia has induced a transudation of serum 
into the perivascular spaces and interstitial tissue of the brain, with 
consequent anaemia. Among the symptoms of psychical irritation, 
there is first such a rapid change and loose connection between the 
thoughts, that clear thinking is impossible. Along with this confusion 
of ideas, the patient often has false notions about himself and the out- 
side world, or delirium. 
Delirium is sometimes so real and intense that the patient cannot 
distinguish it from true perceptions. This is the origin of hallucinar 
Cions and illusions. By the former we understand erroneous impres- 
sions, which are considered as the product of direct perceptions, with- 
out there being any actually existing external object corresponding to 
the impression. The patients think they see animals and other ob- 
jects which are not present, and that they hear voices when all is 
quiet. By illusions, on the other hand, Ave understand the misappre- 
hension or false interpretation of external objects which really exist. HYPEREMIA OF THE BRAIN AND ITS MEMBRANES. 
187 
As a result of illusion, the most harmless things may become objects 
of great terror to patients suffering from hyperaemia of the brain, par- 
ticularly to children. Dizziness, which is one of the most frequent 
symptoms of hyperaemia of the brain, and of many other cerebral dis- 
eases, is, as a rule, a simple hallucination, since it consists in a vivid 
representation of a movement of the body of the patient himself, or of 
the bodies of surrounding objects which the patients imagine they see 
or feel, although they are actually at rest. We shall hereafter speak 
of other forms of dizziness. Closely related to the symptoms of in- 
creased mental excitement are sleeplessness and the disturbance of 
sleep by vivid dreams, symptoms which are very common in hyperae- 
mia of the brain. 
Among the symptoms of depression observed in the sensibility in 
cerebral hyperaemia, we must first mention a certain insensitiveness, a 
tolerance to external irritation, bright light, loud noise, etc. There is 
no reaction to slight irritation. On an increase of this in complete anaes- 
thesia to complete cerebral anaesthesia, the patients do not perceive 
even the severest irritation. The excitability of the portions of the 
brain through which external impressions are perceived is lost. The 
motor symptoms of depression are decided slowness and sluggishness 
in the motions of the patients; “ their limbs are as heavy as lead.” 
If this state increases, there is complete inability to make any volun- 
tary movement (cerebral paralysis). The excitability of the motor 
centres is extinguished. The psychical symptoms of depression are: 
loss of interest, and indifference; great slowness of thought, and limi- 
tation of the ideas; inclination to sleep, from which the patient is 
aroused with difficulty, and subsequently cannot be aroused at all. 
When this state is increased to the highest point, consciousness is com- 
pletely lost. 
In hyperaemia of the brain there is not unfrequently, also, a devia- 
tion from the normal in those movements that are excited by the cere- 
bral nerves, independently of the will. Thus, in states of irritation the 
pupil is contracted, because the oculo-motor nerve is more excited; in 
depression it is dilated, because then thp sympathetic filaments of the 
iris act more strongly. In the same way, just as, in physiological 
experiments, increased excitement of the vagus causes the heart to 
beat slower, while in central paralysis of the vagus, as well as after its 
division, the heart’s action is more frequent. In paralytic states of the 
brain, respiration is often very slow, deep, and stertorous. Although 
we cannot give an exact explanation of this symptom, we may still 
call attention to the fact that, after division of the vagus in animals, 
besides other symptoms, there is always retardation of the respiration. 
Lastly, we must mention vomiting as a very frequent and importani 188 
DISEASES OF THE BRAIN. 
symptom of irritation of the brain. Without understanding the pro- 
cess in the central organs, by which the motions of vomiting are brought 
about, we nevertheless know that it is artificially induced in animals 
by dividing the vagus, and then irritating the central end. 
The above symptoms of morbid excitement, and of increased, 
diminished, or lost excitability of the brain, which we shall also meet 
in many other cerebral diseases, occur in the most varied groups in 
cerebral liyperasmia. When speaking of general convulsions, we called 
attention to the constant coincidence of this symptom, which is due to 
morbid increase of excitement in the medulla oblongata, with loss of 
consciousness, which indicates loss of excitability of the other central 
ganglion-cells and nerve-filaments ; and we must add that, not unfre- 
quently we meet other complications of symptoms of irritation with 
those of paralysis, in hyperasmia of the brain. For instance, the power 
of motion is occasionally lessened while the patient is under great 
mental excitement, complaining of headache, sparks before the eyes, 
etc. Hence, from the state of the pupil, the slowness or rapidity of the 
pulse, etc., we may recognize the state of excitement in which the 
central organs of the nerves governing these states are at the time, 
but we cannot come to any conclusion regarding the condition of other 
parts, or of the entire brain. The variety of appearances, resulting from 
the different combination of symptoms, is so great, that Andral has 
represented, as different forms, eight different combinations of symp- 
toms which appear in cerebral hyperasmia. We shall only give a 
short account of the most frequent and important forms. 
In many cases of liyperasmia of the brain, disturbances of sensibility, 
of an irritating character, are the most prominent symptoms. Such 
patients complain of the head feeling contracted, of more or less severe 
headache; they are sensitive to bright light and loud noises ; have 
flashes of light before the eyes, and noises in the ears. They go to 
sleep with difficulty, and the sleep is disturbed by unquiet dreams. In 
severer cases, there are often dizziness and a feeling of formication in 
the extremities. The face and conjunctiva are usually reddened, the 
pulse full and rapid. But we must not consider these symptoms as 
constant; for, in the most dangerous cases of hypersemia of the brain, 
in those induced by excessive mental labor, continued night-watching, 
etc., the amount of blood in the external organs does not at all cor- 
respond to the supply in the brain ; and frequently the conjunctiva is 
not at all injected in such patients, nor is the face flushed ; on the con- 
trary, it is pale. Occasionally the above symptoms only last a few 
minutes. In some patients a few glasses of wine, or some hot coffee, 
suffice to induce these symptoms of “ congestion in the head; ” while 
they remain exempt from them if they keep quiet, and avoid excitement HYPEREMIA OF THE BRAIN AND ITS MEMBRANES. 
189 
The symptoms of hypeitemia of the brain in children, where the 
motor disturbances are usually greatest, may very much resemble those 
of meningitis. The two diseases are often confounded, and occasionally 
they can only be distinguished by their course. Such children have 
usually suffered from constipation for a few days, have had restless 
sleep, gnashed their teeth during sleep, or have been frightened out of 
it by dreams, which disquieted them after waking, and prevented their 
sleeping again. Then there were vomiting, contraction of the pupil, 
and twitching of some of the limbs. But these symptoms are often 
only preliminary to far severer ones, which cause great anxiety. They 
are followed by general convulsions. In rare cases, these convulsions 
also occur without premonition, as the first symptoms of great hyper- 
mmia of the brain. The twitching usually begins in one extremity, or 
one half the face, and rapidly spreads over the body. Occasionally the 
convulsive movements alternate with tetanic contractions, or certain 
muscles, particularly those of the back of the neck, are tetanically con- 
tracted, while the face twitches, and the extremities are tossed about 
by clonic spasms. The children do not respond when called, or when 
the strongest irritants are applied to their skin. They are bathed in 
perspiration, the abdomen is puffed up, the respiration impaired; the 
saliva, made frothy by the movements of the masticatory muscles, flows 
from the mouth. Occasionally there is a pause in the severity of the 
convulsions, and we hope the attack will pass off; but, after a short 
remission, the spasms begin again with their former severity, and, in 
severe cases, the attack may continue, with varying intensity, for many 
hours. In one child I saw the spasms last over twenty-four hours, 
with only slight occasional interruptions. Still, in the great majority 
of cases, the attack ends in half an hour or an hour. In spite of the 
terror that patients in this state cause the laity and inexperienced 
physicians, we may give a favorable prognosis, if we can exclude a 
meningitis. This can usually be done with certainty. Purulent menin- 
gitis is, on the whole, a rare disease, which, as we shall hereafter show, 
only exceptionally occurs in previously healthy children without pre- 
cedent injury of the head, or disease of the cranial bones. Tubercu- 
lous basilar meningitis, a far more frequent disease, often escapes ob- 
servation till the children have convulsions; but, if we inquire carefully, 
we shall find that the attack has been preceded by a long illness, 
and by other symptoms that have been overlooked, or at least under- 
valued, which we shall hereafter describe. If the child has been well 
the day before the attack, except some signs of cerebral hyperaemia; 
if it has had no injury of the head, no otorrlioea, etc., we may be 
pretty certain that it will be better, if not quite well, the next day. 
The attack is usually followed by a deep sleep, from which the child 190 
DISEASES OF THE BRAIN. 
awakens fatigued, but otherwise free from threatening symptoms. In 
a moderately extensive practice, there is occasion every year to see 
cases of cerebral hyperaemia in children, which take the above-described 
very regular course. Not unfrequently several children of the same 
family will have these attacks at different times, or the same child may 
have repeated attacks. It is rare for epilepsy to develop from them; 
but, as we shall hereafter show, repeated hyperaemias may induce 
hydrocephalus. 
In a third form of cerebral hypenemia the mental symptoms pre- 
dominate to such a degree that the disease is often mistaken, and, to 
the great injury of the patient, is sometimes considered as an attack 
of melancholy; at others, as mania. In the former case, after a few 
days of headache, disturbance of sensibility, and sleeplessness, the 
patients are seized with an undefined feeling of anxiety and disquiet. 
They cannot stay long in one place, go about restlessly, are worried, 
and are conscience-stricken about slight oversights. There is also 
delirium, which has the same character as the above-described frame 
of mind, and results from the attempts to explain it. At first the 
patients struggle against this delirium, which they occasionally recog- 
nize as such, and which they fear, as they think they are “ out of their 
minds; ” but they soon weary in this struggle, and give it up. In 
such cases the sleeplessness is almost absolute; opiates, given by 
ignorant physicians, have no effect, or, after the exhibition of this rem- 
edy, which is injurious and dangerous to the patient, there is a short, 
restless sleep, from which the patient awakes with all the symptoms 
increased. In this form of cerebral hyperaemia, which develops chiefly 
as a result of excessive mental labor, there is usually frequent pulse 
and other symptoms of fever; but in these very cases a greater amount 
of blood in the face, etc., does not correspond to the greater amount 
in the brain; the patients are not high-colored, but are often even pale. 
From the fever and sleeplessness they rapidly lose strength, emaciate, 
and, if they do not fall into the right hands, they are in great danger 
of dying from their disease. Finally, the excitement gives way to 
apathy, the insomnia to deep sleep, from which the patient cannot be 
aroused, and in which they die. Far more rarely, there is permanent 
mental disease. 
In other persons, where the psychical disturbance is in excess, it ap- 
pears in maniacal attacks, with corresponding delirium. This form is 
especially seen after a long-continued excessive use of spirituous 
liquors, in that class of topers who for a year will use very little liquor, 
but when they have begun to drink do not know when to stop. This 
cannot be easily mistaken for an attack of delirium tremens. The 
patients are sleepless, run about, fight and bite if they are held, de- IlYrERiEMIA OF THE BRAIN AND ITS MEMBRANES. 
191 
stroy any thing- that comes in their way, cry, laugh, or sing. There is 
also delirium of varying character; usually the patients consider them- 
selves as injured and betrayed, and rage against their enemies and 
persecutors. The continued muscular exertion throws them into a 
perspiration, the heart-beat and pulse are accelerated and stronger, 
the face is usually reddened. This form is also very dangerous if it be 
mistaken and improperly treated, for then an apoplectic attack, a true 
apoplexy, or an excessive hyperaemia of the lung with acute oedema, 
causes death. According to my observation, cases exactly like the 
following, detailed by Andral, are by no means rare; in the Mag- 
deburg hospital, and in the Greifswalder clinic, I have seen several of 
them within a few years: “For several days a middle-aged man kept 
up a series of cries sufficient to disturb the whole hospital-ward. 
These cries ceased suddenly, and on approaching his bed he was found 
dead. He would not have died more suddenly if struck by lightning. 
On opening the body, the only lesion found was a lively injection of 
the cerebral substance.” 
Lastly, we must mention those forms of cerebral hyperaemia where 
symptoms of general depression and paralysis appear, and by their 
sudden occurrence so resemble an apoplexy than an exact diagnosis is 
often impossible. In some cases the attack is for a time preceded by 
headache, disturbance of sensibility, dizziness, sleeplessness or psychi- 
cal disturbances; in others, it occurs without premonitory symptoms. 
The patient suddenly becomes dizzy; “ every thing whirls around with 
him; ” he staggers, all looks dark before him; he loses consciousness 
and sinks to the ground, either with or without slight spasm. Such 
an attack, where all activity of the brain is lost, may cause death by 
the paralysis extending from the brain to the centres of the organic 
nervous system. More frequently the patients recover consciousness 
after a time, with an indistinct remembrance of what has passed or 
without any recollection of it. These apoplectiform attacks, occurring 
in the course of hyperaemia of the brain, correspond with the above- 
mentioned epileptiform attacks, as regards the cerebral anaesthesia and 
the paralysis of the psychical functions, and like them appear to 
depend partly on obstructed escape of the venous blood, partly on 
secondary oedema of the brain. As we have previously shown, both 
states prevent the supply of oxygenated arterial blood, which is indis- 
pensable for the excitability of the brain and the entire nervous sys- 
tem. Traube, who refers the epileptiform attacks in jBright's disease 
also to oedema of the brain, has advanced the theory that an oedema, 
limited to the greater hemispheres, induces simple loss of conscious- 
ness ; when it affects both the hemispheres and medulla oblongata 
there are loss of consciousness and convulsions. We shall not discuss 192 
DISEASES OE THE BRAIN. 
the correctness of this hypothesis; it has something seducing about it, 
but opposed to it is the fact that, if it be true, the same pathological 
change (compression of the capillaries by serous exudation) has a par- 
alyzing effect on the greater hemispheres and an irritant effect on the 
medulla oblongata. 
Treatment.—Although, in the treatment of hypermmia of the 
brain, general and local blood-letting, cold to the head, and derivation 
to the skin and bowels justly enjoy a good reputation, we must not 
use one or the other indifferently, or employ all at the same time, in 
any case that arises. In fact, there is no disease where it is more im- 
portant to fulfil the causal indications, and to attend to the causes of 
the disease when prescribing the remedies required by the indications. 
In those forms where increased action of the heart and a coincident 
diminution of resistance in the vessels of the brain have induced fluxion 
to that organ, the same, regimen must be observed as wras recom- 
mended in the first volume, in the treatment of habitual fluxions to the 
lungs. If danger threatens, we should bleed; in such cases venesec- 
tion cannot be replaced by ice-compresses to the head, or by leeching 
Dehind the ears. 
If there be collateral fluxion to the brain, we must first of all 
attempt to remove the obstructions to the circulation by which the 
pressure of blood in the carotids is increased. Evacuating the intes- 
tines, by laxatives or by enemata of water and vinegar, often has a 
marvellous effect, which is induced by nothing else, both in adults who 
are constipated and suffering from headache, tinnitus, dizziness, etc., 
and especially in children where constipation is accompanied by con- 
vulsions, etc. If these remedies are insufficient and symptoms of de- 
pression occur, from which we fear danger, it is proper to draw blood 
here also, in adults by venesection, in children by leeches to the head. 
The treatment must be quite different when the cerebral hyper- 
aemia has resulted from the continued misuse of alcohol or of narcotics, 
or from excessive mental excitement. In such cases nothing is to be 
expected from general bleeding, and large venesections are often in- 
jurious ; on the other hand, the indications are, to apply a bladder of 
ice to the head, or else moist compresses, that have laid under a tin 
vessel filled with ice and salt, till they were frozen. In some cases of 
this variety derivatives are good; by these we attempt to remove the 
fluxion from the brain by inducing fluxion to the skin, intestines, geni- 
tals, or rectum. The most common remedies used with this object are 
irritant foot-baths, among which those of ice-water, in which the patient 
only passes a short time, are better than those of hot water, with mus- 
tard or salt, and wood-ashes. In acute cases, blisters to the nape of 
the neck, and in chronic ones the establishment of an issue in the arm— PARTIAL HYPERAEMIA AND (EDEMA OF THE BRAIN. 
193 
an old remedy, from which I have seen great benefit—and, lastly, the 
administration of active purges, are also among the more common 
remedies. In acute threatening hyperaemia of the brain, croton-oil is 
peculiarly in repute, while, in chronic cases, pills of aloes, colocynth, 
jalap, etc., are usually prescribed. If, as occasionally happens, there 
be fluxion to the brain, instead of to the pelvis, at the menstrual period, 
we may apply leeches to the cervix of the uterus, or cups to the inside 
of the thighs. Occasionally, also, the application of leeches about the 
anus has a wonderful effect, as is shown by the well-known histories 
of the patients that Goethe so much ridicules under the name of 
“ proktophantasmisten.” 
In congestive hyperaemia resulting from compression of the jugular 
veins or vena cava, as well as in that occurring from heart and lung 
diseases, venesection or leeches behind the ears may be employed, if 
the obstruction to the flow of blood cannot be removed. We have 
shoAvn that congestion, by arresting the supply of arterial blood to the 
brain, diminishes or removes the excitability of the brain filaments and 
ganglia. The greater freedom of escape we give the venous blood, 
the sooner we shall succeed in removing the symptoms of depression 
and the paralysis. This may be done by the application of leeches 
behind the ears, since this moderates the tension in the veins outside 
of the skull, with which the emissaria Santorini communicate; or by 
venesection, by which the tension in the anonymous veins is dimin- 
ished, because less blood enters them from the arm. In such cases we 
cannot expect any thing from the employment of cold, or from laxatives 
and blisters. 
In hyperaemia of the brain resulting from too much nourishment, 
instant diminution of the quantity of blood may be urgently indicated, 
and a well-timed venesection not unfrequently prevents a threatening 
apoplexy. It is very important to regulate the mode of life of such 
patients, to show them the danger of prolonged, luxurious meals, and to 
let them eat little, drink water instead of wine, and walk a great deal. 
Of course, in each case, peculiar circumstances will require some 
deviation from the plans of treatment advised, and different directions 
as to regimen. 
CHAPTER II. 
PARTIAL IIYPERA5MIA AND PARTIAL (EDEMA OF THE BRAIN. 
A short consideration of partial hyperaemia of the brain will do 
cidedly facilitate the comprehension of the symptoms of diseases oi 
the brain limited to circumscribed spots. 194 
DISEASES OF THE BRAIN. 
The causes of the partial hyperaemia are to be sought for within 
the skull. Fluxions and congestions result from extravasations of 
blood, points of softening and inflammation, tumors, and all other dis- 
eases of the brain that affect the circulation at circumscribed spots. 
If an artery or a great number of capillaries be compressed, or other- 
wise closed, there is fluxion in the collateral branches; if, on the other 
hand, a vein be contracted or closed, there is congestion in the capil- 
laries supplying it. Of course, there will usually be fluxion at one 
place, congestion at another, and anaemia at still others, at the same 
time. But the circumscribed diseases of the brain not only induce 
hyperaemia by compression of the vessels, but most of them also excite 
it by irritation of the surrounding parenchyma. Just as we see hyper- 
aemia and oedema result in the vicinity of tumors, inflammations, ex- 
travasations of blood, etc., in all other parts of the body, so they also 
develop in the brain when it is the seat of these diseases. 
On autopsy, it is just as difficult to discover a partial hyperaemia 
of the brain as it is to make out a general hyperaemia, particularly if 
the hyperaemia has led to oedema, without the oedema having softened 
the brain-substance. In some cases, however, in the vicinity of tumors, 
points of inflammation, etc., we see clearly that the parenchyma is 
more infiltrated and relaxed, or that there have been small extravasa- 
tions from the vessels. 
The symptoms of partial hyperremja of the brain are those of irri- 
tation and depression, but they are much more limited than the sjrmp- 
toms of general hyperaemia of the brain, and come under the head of 
so-called local symptoms (“ Herdsymptome,” Griesinger). Among 
these are circumscribed headache, glimmering or sparks before one 
eye, or blindness of one eye, contraction or dilatation of one pupil, 
noise or deafness in one ear, neuralgia or anaesthesia limited to one 
nerve, but especially spasms, contractions, or paralysis, affecting only 
one-half of the body, one extremity, or a single group of muscles, and, 
lastly, partial disturbance of the mind. 
The grade and extent of the partial hyperaemia of the brain vary 
with the greater or less amount of blood contained in the organ, and 
with the phases and stages of development of the point of disease 
that they surround. This explains why the local symptoms depending 
on partial hyperaemia of the brain are sometimes more prominent than 
at others, or may even disappear and return again. Since, in all severe 
structural disease of the brain there is complete loss of function of the 
affected part, whether the trouble there be the development of a tumor, 
or that the nerve-filaments and ganglion-cells have been broken down 
or destroyed by an extravasation of blood, the only symptoms that we 
can consider as immediately due to severe local disease of the brain ANJEMIA OF THE BRAIN AND ITS MEMBRANES. 
195 
ere partial anaesthesia, partial paralysis, and the loss of certain mental 
functions. 
If, in the course of an apoplexy, of an abscess of the brain, or of a 
cerebral tumor, etc., we have symptoms of partial irritation, as well as 
those of partial paralysis, the former cannot possibly depend on the 
disease itself, but must be due to the anomalies of circulation in its 
vicinity. Moreover, all temporary symptoms of paralysis occurring in 
the course of local destructive diseases do not depend on the disease 
itself, but mostly on the disturbances of circulation around it. (When 
speaking of diseases encroaching on the space in the skull, we shall 
show that temporary paralysis may also result in other ways.) The 
fact that in apoplexies, tumors, abscesses, etc., where complete or 
even partial restitutio ad integrum is not conceivable, paralysis not 
unfrequently decreases or entirely disappears, seems at first difficult to 
explain, but the explanation is simple when we bear in mind that the 
symptoms of paralysis may depend on a collateral oedema in the vi- 
cinity of the disease, and that the extent of this oedema varies greatly. 
Lastly, the most varied diseases of the brain would induce the 
same symptoms, if they had similar locations and extent, if the dis- 
turbances of circulation in the vicinity of the different diseases did not 
vary. But the disturbances of circulation in the vicinity of a tumoi 
are different from those in the vicinity of an abscess, and these again 
differ from those about a portion of brain broken down by an extrava- 
sation of blood. This, to some degree, explains the difference of 
symptoms in different diseases of the brain that have the same seat 
and extent. 
The treatment of partial hyperaemia is to be conducted on the same 
plan as that for general hyperaemia of the brain. If we lessen the 
supply of blood, or facilitate its escape, we moderate the local fluxion 
or congestion. 
CHAPTER III. 
ANEMIA OF THE BRAIN AND ITS MEMBRANES. 
Etiology.—For a time the possibility of anaemia ol the brain was 
denied, just as that of hyperaemia was, and on the same grounds which 
were given in the first chapter. We have already called attention to 
the errors in these conclusions, and shall only mention here that, inde- 
pendently of the numerous autopsies where the brain has been found 
anaemic, Donders, Kussmaul and Tenner have observed excessive 
anaemia through an opening (covered by a glass plate) in the skull of 
living animals. 
The causes of anaemia of the brain are—- DISEASES OF TIIE BRAIN. 
196 
1. Those that diminish the entire amount of blood in the organ. 
Among these belong not only abstractions of blood and spontaneous 
haemorrhages, but extensive losses of fluid, considerable exudations, 
and tedious, particularly feverish, diseases. Unfortunately, it occasion- 
ally happens that, in internal haemorrhage, anaemia of the brain is mis- 
taken for hyperaemia, and treated accordingly. The form of the dis- 
ease which, since the time of Marshall Hall, has been known as hy- 
drocephaloid, is particularly common in children who have suffered 
from continued diarrhoea. Typical examples of this are not unfre- 
quently seen as a result of extensive hepatization in weak persons 
with pneumonia. But protracted fevers also consume the flesh and 
blood of the patient, induce general poverty of the blood, and, as one 
symptom of it, anaemia of the brain. In all of these diseases, blood 
and the fluids of the body are lost or used up too rapidly; on the 
other hand, the amount of blood may be diminished by its formation 
being limited from insufficient supply of nourishment. Thus, in per- 
sons who have died of starvation, the most marked symptoms of anae- 
mia of the brain have been observed before death (as Gerstenberg has 
described in his “ Ugolino,” in very vivid terms, it is true, but still 
quite accurately). 
2. This affection not unfrequently results from the overloading of 
other organs with blood. The best example of this form are the cases 
where it is induced by the application of Junod's cupping-boot, by the 
injudicious use of which the anaemia may readily become dangerous. 
This also explains why, when the heart’s action is weak, a person 
faints more readily when standing up than when lying down. It is 
evident that, in the upright position, the lower extremities will become 
overloaded with blood, if the propelling power is insufficient to over- 
come the obstruction caused by the weight of the venous blood in this 
long course. On the other hand, in diminished action of the heart, 
the obstruction from the weight of blood in the short carotid artery 
must have a very inferior influence on the occurrence of anaemia of the 
brain in the upright position. 
3. Another cause is compression or obstruction of the arteries sup- 
plying the brain. In almost all of the cases of this class that have 
been reported, the obstruction was artificially caused by ligation of the 
carotid. In a few cases only the carotid or vertebral arteries were 
compressed by tumors or closed by emboli. 
4. Cases where, from mental excitement, without lessening of the 
heart’s action, there are paleness of the cheeks and even loss of con 
sciousness and other symptoms of insufficient supply of blood to the 
brain, seem to indicate that anaemia of the brain may also be caused 
by abnormal innervation or spasmodic contraction of the arteries. ANAEMIA OF THE BRAIN AND ITS MEMBRANES. 
197 
5. Anaemia of the brain is the necessary result of diminution of the 
space in the skull by exudations, extravasations, or tumors of the brain 
and its membranes. Under this form would come a variety which 
does not belong in our domain, that is, the cases of anaemia which 
necessarily result from depressed fractures of the skull. We lay pe- 
culiar stress on the anaemia of the brain resulting from encroachment 
on the cranial cavity, which is the most frequent form of the disease, 
because we believe that the so-called symptoms of pressure in apo- 
plexy, tumors, the various forms of hydrocephalus, and other diseases 
encroaching on the intercranial space, are not immediately referable 
to the pressure on the brain-substance, but to the consequent anaemia. 
Other observers also, among them Traube and Leyden, have recently 
come to my conclusion. 
Since it is not merely the presence of blood in the vessels of the 
brain, but the supply of oxygenated arterial blood that is indispensa- 
ble for the normal functions of the organ, it is evident that, even 
where the absolute amount of blood in the brain is not diminished, 
but where its circulation and distribution are changed so that only a 
small amount of blood enters through the arteries, and but little es- 
capes through the veins, the same symptoms must arise as in true 
anaemia. And the experiments of ILussmaid and Tenner entirely con- 
firm the experience of pathologists, that, in degeneration of the heart 
from non-compensated valvular obstruction, and in other diseases im- 
pairing its action, there is an overloading of the veins at the expense 
of the arteries, and a retardation of the circulation, that is, the same 
symptoms that occur in anaemia of the brain. 
Lastly, we must mention that, without a diminution of the amount 
of blood in the brain, and where that fluid is normally distributed in 
the arteries and veins, symptoms very similar to those of anaemia may 
result from the blood being too poor in red corpuscles. This symptom 
also is readily explained, for we are fully justified in considering the 
red corpuscles as the “ bearers of oxygen.” Now, if this be so, a dim- 
inution of red corpuscles will affect the supply of oxygen to the brain, 
just as a diminution of the blood would. 
Anatomical Appearances.—The substance of the brain is dis- 
colored ; the gray substance appears paler and more resembles the 
white. The latter is very milky and shining. On section, few if any 
blood-points are seen on the cut surface. The vessels of the cerebral 
membranes are empty and collapsed. We do not always find a con- 
siderable amount of fluid in the subarachnoid space. Kussmaul and 
Tenner could not prove, on examination, any increase in the cerebro- 
spinal fluid which, on theoretical grounds, they had expected to find. 
Symptoms and Course.—The symptoms of anaemia of the brain 198 
DISEASES OF THE BRAIN. 
that comes on suddenly, and quickly attains a high grade, differ from 
those due to one which comes on slowly and is less severe. In the 
former case the patients become dizzy; every thing appears dark be* 
fore them; they become insensible to impressions and incapable of 
movement; their pupils dilate, their respiration becomes slow, and 
they lose consciousness; they sink to the ground, usually with slight 
spasms. In most cases the patients come out of this fainting-fit in a 
short time; in other cases, usually termed apoplexia nervosa, con- 
sciousness does not return, the swoon ends in death. Anrnmia of the 
brain artificially induced in animals by free bleeding, or by ligation of 
all the arteries supplying the brain, has just the same symptoms; only 
the convulsions are usually more severe and more prominent than in 
persons whose brain has suddenly become anaemic. The symptoms of 
paralysis in sudden, extensive anaemia of the brain are more easily ex- 
plained than are the convulsions. The former unmistakably depend 
on the arrested supply of oxygen to the brain. It is known that liga- 
tion of the abdominal aorta immediately induces paralysis of the lower 
half of the body, whose nerves are thus deprived of arterial blood. 
But how shall we explain the convulsions ? Herile thinks that in 
anosmia of the brain the blood from the venous plexuses of the spinal 
marrow and the cerebro-spinal fluid from the spinal canal press toward 
me brain, and that the medulla oblongata and parts at the base of the 
brain are thus thrown into a state of excitement. But JTiissmaul and 
Tenner, after ligating the afferent vessels, found not only the greatei 
hemispheres, but also the medulla oblongata, bloodless; hence the 
convulsions cannot be referred to congestion of the medulla. But it 
is just as remarkable, and as contrary to all experience, to suppose 
that there should be increased excitement of the nerve-filaments and 
ganglion-cells, with consequent convulsions, from absolute anaemia. 
Kiissmaul and Tenner distinctly state that, on autopsy of animals 
whose cerebral arteries had been ligated, the arteries at the base of 
the brain contained a “ slight amount of blood,” while all others were 
found “ entirely empty; ” this observation gives a small point on 
which to hang an explanation. For we might suppose that the liga- 
tion of those vessels caused absolute anaemia in the greater hemi- 
spheres and their consequent paralysis, but (from the anastomosis of 
the cerebral and spinal arteries) in the parts at the base of the brain 
it only induced oligsemia and consequent morbid excitement. 
In anaemia of the brain that comes on slowly, just as in hyperremia, 
at first there are usually symptoms of irritation, subsequently those of 
paralysis. To explain tins correspondence, the hypothesis has been 
advanced that a certain tension of the molecules of the brain is neces- 
sary for its normal activity and that an increase or diminution of this ANAEMIA OF THE BRAIN AND ITS MEMBRANES. 
199 
tension, by too great or too slight a fulness of the vessels, modifies 
the excitability of the brain in the same way. I have already said 
that this is a hypothesis, and, I may add, that it is difficult for me to 
believe that, in anaemia of the brain, the symptoms of irritation depend 
on an inconsiderable, and those of paralysis on a decided, diminution 
of the normal pressure of the blood-vessels on the brain. On the other 
hand, it is a physiological fact that the excitability of a nerve is in- 
creased a short time before it is entirely lost, and that the greatly- 
increased excitability of a nerve is not a sign of increased normal nu- 
trition, but, on the contrary, of its diminution. It is true we do not 
know’ why this is, but the knowledge that it is so renders it less 
strange that, in gradually-developing anaemia of the brain, symptoms 
of irritation should, as a rule, precede those of paralysis, and that, 
where the anaemia does not attain a high grade, only the symptoms of 
irritation should be seen. 
Occasionally the symptoms of anaemia consist chiefly or exclusively 
of disturbances of sensibility. The patients complain of severe head- 
ache, either in the forehead or occiput; they are sensitive to light and 
sound, have flashes before the eyes, noises in the ears, dizziness, eta 
These symptoms occur most typically after severe metrorrhagia and 
other extensive losses of blood, and frequently only the consideration 
of the cause, the pulse, color of the skin and lips, and the symptoms of 
want of blood in other organs, enable us to decide that there is anae- 
mia, and not hyperaemia, of the brain. 
In other cases of anaemia of the brain, particularly in children, the 
motor disturbances are more prominent. The symptoms of anaemia 
of the brain in children from exhausting diarrhoea and other debilitat- 
ing causes, so-called hydrocephaloid, often so closely resemble those 
of acute hydrocephalus, that the distinction of the two states may be 
very difficult. Marshall Mall divides hydrocephaloid into two stages, 
one of irritation, one of torpor. In the first stage the children are very 
restless and capricious, constantly toss about in bed; readily fright- 
ened, they cry out in their sleep, gnash their teeth; the face is usually 
flushed, the pulse frequent, and temperature elevated. There is al 
most always slight twitching of some limbs, frequently also there are 
general convulsions. In the second stage the children collapse, be- 
come entirely apathetic, no longer attend to objects held before them; 
the eyelids are half closed, the pupils insensible to light; respiration 
becomes irregular and rattling; finally death occurs with symptoms of 
coma. Since we regard the so-called symptoms of pressure in diseases 
of the brain and its membranes (among which are effusions into the 
ventricles), which encroach on the cranial cavity, as due to compres- 
sion of the capillaries and obstruction of the supply of arterial blood 200 
DISEASES OF THE BRAIN. 
to the nerve-elements of the brain, we do not consider the great simi- 
larity of the symptoms of hydrocephalus to those of hydrocephaloid as 
very strange. Different as are the modes of origin of the two dis- 
eases, we believe that in both of them there is ultimately the same 
pathological disturbance, that is, capillary anaemia. 
Lastly, in ansemia of the brain, morbid symptoms in the mental 
functions preponderate; there are sleeplessness, great excitement, deliri- 
um, etc. In some cases this state increases to paroxysms of frenzy and 
decided maniacal attacks. The latter are seen in persons who have 
had no food or drink for a long time, but they are also not unfrequently 
seen in weakly, bloodless patients, if their anaemia has been greatly 
increased by exhausting diseases and abstractions of blood. 
Treatment.—If the anaemia of the brain be one symptom of gen- 
eral impoverishment of the blood, this is to be treated by limiting the 
consumption and increasing the supply of suitable nourishment. A 
consideration of the etiology and other circumstances of each case gives 
the indications for treatment. If profound and continued faintness, 
convulsions, and other signs of excessive hyperaemia of the brain come 
on after extensive loss of blood, even transfusion may be necessary. 
In treating the exhausting diarrhoea of infants, should think early 
of the danger of hydrocephaloid, and attempt to prevent it by giving 
raw flesh, wine, etc. If, nevertheless, the symptoms above described 
come on, a false interpretation of them is very dangerous. If the 
practitioner be misled into applying leeches or employing debilitating 
treatment, the children usually die. But if he sees through the con- 
dition and, in spite of the restlessness, twitching, and consequent 
sopor, gives concentrated broths and large doses of stimulants, cam- 
phor, ether, but especially of strong wine, he often attains the hap- 
piest and most surprising results. In the form of anaemia of the brain 
which occurs as one symptom of general impoverishment of the blood, 
it is also very important that, until the normal quantity and quality of 
the blood is reestablished, we see that the heart does not receive too 
little blood; and it is just as important for us to combat any tempo- 
rary weakness of the heart, that prevents it driving its blood energet- 
ically into the arteries. Very many patients, with impoverished blood, 
and convalescents die, solely because the physician has neglected to 
give them the strictest orders to maintain a horizontal position. If 
we permit exhausted patients to rise to stool, or to leave the bed too 
soon, the feet are readily overloaded with blood, the heart receives tco 
little; consequently a sufficient supply does not go to the brain; the 
patient swoons, and not unfrequently does not awake from the fainting- 
fit. On this very point I have had an experience in my private prac- 
tice which will always prove a warning to me, not to permit convales- PARTIAL ANiEMIi OF THE BRAIN. 
201 
cents to leave their beds too early. To prevent the second danger from 
temporary lessening of the heart’s action in anaemic patients, besides 
the horizontal position, we may order irritating remedies both by in- 
halation and internally. The patients should not use these remedies 
constantly, but only occasionally when they feel an attack threatening. 
Indeed, it may be important to have Cologne-water or Hoffman’s ano- 
dyne instantly at hand on such an occasion. Trephining is occasion- 
ally the only remedy for anaemia caused by encroachment on the cra- 
nial cavity ; however, in recent times this is very properly limited to 
those contractions of the space caused by depression of the cranial 
bones. Paradoxical as it may seem on superficial observation, we must, 
nevertheless, say that a venesection often has the best effect on the 
course of anaemia of the brain due to a contraction of the intracranial 
cavity. We shall give the reasons for this assertion more fully when 
speaking of apoplexy, and shall only say here, that a venesection 
hastens the escape of venous blood from the brain, and thus facilitates 
the entrance of arterial blood. 
CHAPTER IY. 
PARTIAL ANAEMIA AND PARTIAL NECROSIS OP THE BRAIN, THROMBOSIS 
AND EMBOLISM OP THE CEREBRAL ARTERIES SOFTENING. 
Etiology.—Partial anaemia of the brain occurs—1. When the 
access of blood to certain sections of that organ is prevented by closure 
of the afferent vessels. 2. When collateral oedema develops in the 
vicinity of apoplexies, of points of inflammation, and softening, and of 
tumors, etc. 3. When the capillaries of certain sections of the brain 
are compressed by extravasation of blood, by tumors, or other diseases 
contracting the cranial cavity. 
In regard to the pathogeny of the first form of partial anaemia of 
the brain, which develops in the parts supplied by obstructed arteries, 
we must call attention to the following points: 
In rabbits, the symptoms of anaemia of the brain do not occur til] 
both carotids and both vertebral arteries have been ligated. If all 
these vessels be not ligated, those that have been left free supply 
plenty of blood, and the free anastomosis of the cerebral arteries 
among themselves prevents anaemia even of those parts which draw 
their blood chiefly from the vessels ligated. In the human being it is 
somewhat different; here, after ligation of one carotid, there is occasion- 
ally a symptom which certainly depends on anaemia of one side of the 
brain, that is, paralysis of the half of the body on the opposite side. 
In other cases of ligation of the carotid in man, this symptom does no/ 202 
DISEASES OF THE BRAIN. 
arise, which proves that in these cases the endangered hemisphere 
receives a sufficient amount of blood from collateral branches, particu- 
larly through the circle of Willis. The reason for this difference is 
not fully known. Hasse thinks that in the former case the continua- 
tion of the thrombus from the point of ligation beyond the circle of 
Willis prevents the formation of a collateral circulation. On closure 
of the internal carotid or of the vertebral artery on one or both sides, 
partial anaemia does not generally occur, since a collateral circulation 
is usually quickly established through the circle of Willis. On the 
other hand, closure of an artery originating above the circle of Willis, 
e. g., the arteria fossae Sylvii, almost always induces anaemia of the 
part supplied by the obstructed vessel, since here circumstances are 
much more unfavorable for the formation of a collateral circulation. 
The pathological processes that chiefly induce closure of the arte- 
ries of the brain are in some cases compression by tumors, but in most 
cases obstruction by thrombosis formed at the spot or by emboli from 
some other part. 
It is only exceptionally that the blood coagulates in cerebral ar- 
teries whose walls are healthy (marasmic thrombosis). As a rule, the 
thromboses form at points where, as a result of chronic endarteritis, or, 
as is usually said, of atheromatous degeneration, the calibre of one of 
the vessels of the brain is diminished and its inner wall roughened. 
The emboli by which cerebral vessels are closed are almost always 
detached clots of fibrin, that have been deposited, in endocarditis or 
valvular disease, on rough parts of the valves, or else portions of the 
valves themselves, that have been washed off by the current of the 
blood. These rarely come from necrotic points in the lungs, or from 
thromboses of the pulmonary vein. In one very instructive case, pub- 
lished by Esmarch, an embolus obstructing the internal carotid came 
from an aneurism of the carotid, having been set free by the manipu- 
lations during an examination. 
We have but little to add in regard to the etiology of this form of 
anaemia of the brain. Since the atheromatous affection, which most 
frequently causes thrombosis of the cerebral vessels, generally occurs in 
advanced age, the stoppage of the arteries of the brain by thromboses 
is almost exclusively seen in aged persons, and plays an important 
part in the diseases of old age. The case is different with embolism 
of the cerebral arteries; this is seen in young persons also, since en- 
docarditis and valvular disease of the heart occur at all ages. 
The pathogeny of the partial necrosis, which results in many cases 
of thrombosis and embolism of the cerebral arteries, is perfectly evi- 
dent. This form of softening of the brain is analogous to the gangrene 
of the extremities induced by closure of the vessels. In both cases PARTIAL ANiEMIA OF THE BRAIN. 
203 
the death of the tissue is due to abstraction of the supply of nutritive 
material; but the pecrosed parts within the skull, not being exposed 
to the action of the atmosphere, are rarely decomposed. This only 
happens when the embolus, that has stopped the vessel, comes from a 
suppurating spot, and transfers with it a tendency to suppuration. 
Closure of a vessel induces necrosis more readily the later and more 
incompletely a collateral circulation is established. If the degenera- 
tion of the walls of the vessels that has induced a thrombosis of the 
cerebral arteries be extensive, the collateral branches, the elasticity 
of whose walls is diminished, cannot dilate sufficiently to supply the 
place of any large arteries that may be closed, hence the partial anae- 
mia is only partly removed, and the anaemic part softens. Whether 
or not closure of a cerebral artery by an embolus shall induce necrotic 
softening depends chiefly on the seat of the obstruction, since in such 
cases the walls of the vessels are usually healthy and distensible. If, 
as rarely happens, there be anaemia in the parts chiefly supplied by a 
vessel which has been obstructed by an embolus before reaching the 
circle of Willis, it will generally pass off soon, and no necrosis results ; 
if, on the other hand, a vessel be closed by an embolus beyond the 
circle of Willis, necrosis is the usual termination of the partial anae- 
mia. 
The second form of partial anaemia of the brain, due to develop- 
ment of collateral oedema around an apoplexy, or a point of inflam- 
mation or softening, or a tumor, etc., has already been mentioned as 
the not unfrequent termination of excessive fluxionary hyperaemia. 
When speaking of the different diseases of the brain, we shall fre- 
quently recur to this form. 
The third division that we have made of partial hyperaemia of the 
brain, resulting from compression of the capillaries in certain sections 
of the brain by extravasations of blood, tumors, and other diseases 
contracting the space in the skull, has hitherto been too little appre- 
ciated. Along with the best authorities, I myself denied the occur- 
rence of “partial cerebral pressure.” From the fact that the brain is 
incompressible and is enclosed by an inelastic capsule, I reasoned 
that an increased pressure, acting on any part of the brain, would 
spread evenly over the entire organ. In support of this view, I ad- 
vanced the popular illustration that, if a cork be driven forcibly into a 
bottle, the latter is not by any means always broken at the neck, but 
just as often at some distance from the point where the force was ap 
plied, perhaps at some particularly weak part. However, a series of 
observations where there was no doubt that those portions of the 
brain where the disease was located were far more bloodless than the 
rest of the brain, and a careful consideration of all circumstances af- 204 
DISEASES OF THE BRAIN. 
fecting the space in the skull, have shown me that, in the above rea 
soning, I overlooked an important fact and hence came to a false conclu 
sion. Indeed, in spite of the brain being incompressible, and being 
surrounded by an unyielding capsule, partial pressure on it may occur: 
this is so, because the cranial cavity is divided into three chambers by 
two tensely-stretched membranes, because the falx and tentorium pro- 
tect, to some extent at least, parts of the brain lying on one side of 
them from pressure acting on the other side. 
The three chambers of the skull communicate with one another, it 
is true, and, if the cerebral substance were liquid, pressure on any part 
of it would affect the whole organ equally, in spite of the tense septa 
traversing it. But the consistence and tenacity of the cerebral sub- 
stance, which only permit a slight protrusion of a section of brain 
pressed from an opposite chamber of the skull toward the excavation 
of the tentorium or the lower border of the falx, cause portions of 
the brain lying in one chamber to be protected to some extent from 
pressure on those lying in one of the other chambers, in spite of the 
openings in the septa, particularly the large opening in the falx. The 
protection afforded by the tentorium is greater than that given by the 
falx, and the posterior lobes of the cerebral hemispheres are far better 
protected against a pressure acting on the opposite hemisphere than 
the frontal lobes are, because the falx is much broader posteriorly, and 
hangs much farther down than it does anteriorly. In subsequent chap- 
ters we shall frequently refer to these circumstances also, whose great 
significance in the explanation of the symptoms of disease encroaching 
on the cranial cavity I was, to the best of my knowledge, the first to 
point out. 
Anatomical Appearances.—Partial anaemia of the brain cannot 
by -any means always be definitely made out in the dead body. The 
distribution of blood after death and during life is not the same; 
places which, during life, were distinguished by their vascularity from 
other less vascular parts, often become just as bloodless as the latter 
after death. In the cutis, where we have an opportunity for compari- 
son, we may see this daily; in the brain the state of affairs is just the 
same. It is remarkable that emboli are almost always found in the left 
arteria fossae Sylvii. Perhaps this is partly because the left carotid ar- 
tery leaves the arch of the aorta almost in the direction of the current of 
blood, while the innominate forms a considerable angle with it (Rtthle). 
The necrosis resulting from obstruction of the vessels and insuffi 
cient development of collateral circulation induces relaxation and soft- 
ening of the brain-substance; hence necrosis caused by anaemia is 
designated as a peculiar form of softening of the brain, as “ simple ” or 
“ yellow ” softening. Corresponding to the most frequent and obsti- PARTIAL ANEMIA OF THE BRAIN. 
205 
nate obstructions of the vessels, the softening is usually in the greatei 
hemispheres and chiefly in their medullary substance. It varies in 
size from that of a bean to a hen’s egg. The grade of the softening 
differs. In the highest grades the cerebral substance, at the point of 
necrosis, is found changed to a moist, gelatinous trembling pulp. The 
color of the softened point is sometimes white or grayish-white, some- 
times more yellowish. In the former case there is usually a reddish 
tint about the periphery, due partly to dilatation, partly to rupture of 
the capillaries and escape of blood from them. In the first of the 
three forms of partial anaemia which we have described, that due to 
thrombosis or embolism of a cerebral artery, on autopsy we do not find 
the parts supplied by the plugged artery remarkably pale, but they 
are not unfrequently studded with small capillary haemorrhages, par- 
ticularly at the periphery. This exactly corresponds with what is 
found in other organs when there is stoppage of the vessels by throm- 
ses or emboli; but, as we said when speaking of haemorrhagic infarc- 
tions of the lung, it is difficult to explain. On account of the difficulty 
of deciding whether a portion of brain has been anaemic during life, 
we should make it a rule to seek most carefully for any obstruction of 
the cerebral arteries, particularly of the arteria fossae Sylvii, in any 
cases where the patient has died from a chronic brain disease or from 
an acute one beginning with a sudden occurrence of hemiplegia, unless 
the autopsy gives some other satisfactory explanation of the symp- 
toms. Before attention was called to the occurrence of this anomaly, 
autopsy, in cases of severe brain-disease with hemiplegia, often fur- 
nished nothing satisfactory. There was nothing left but to suspect an 
“ intravascular apoplexy,” which did not at all explain the occurrence 
of the hemiplegia. The yellow color of the affected part often de- 
pends on this capillary hasmorrhage, and is due to the infiltration of 
the disintegrated brain-substance with escaped and altered coloring 
matter of the blood. After the disease has existed some time, we 
find the affected part changed to a cellular network filled with a 
chalky, milky fluid (.Durand-FardeVs infiltration celluleuse). On 
microscopical examination of necrosed portions of brain, we usually 
find only remains of nerve-filaments, granular cells, which correspond 
to the ganglion-cells or neuroglia-nuclei that have undergone fatty 
degeneration, ooloring matter, and masses of detritus. 
Partial anosmia of the brain caused by collateral oedema, occurring 
in the vicinity of circumscribed disease, can occasionally be recognized 
on autopsy by the affected part having a peculiar moist lustre and di- 
minished resistance, as well as by its becoming very slightly promi- 
nent on a section through the brain. When the disease is more se- 
vere, the brain-substance is still more relaxed, and finally a state maj 206 
DISEASES OF THE BRAIN. 
occur which is usually designated as white (hydrocephalic) softening. 
Small capillary extravasations are often found in the vicinity of tu 
mors, abscesses, or along with collateral oedema. 
The form of partial anaemia of the brain, induced by diseases en- 
croaching on the cranial cavity, is the variety piost readily recognized on 
autopsy. The pressure exercised by large extravasations of blood and 
extensive tumors is so great that, not only the capillaries and finer 
arteries and veins of the brain-substance, but also the larger vessels of 
the meninges, that are subjected to this pressure, are compressed and 
bloodless. If the disease be in one of the large hemispheres, this be- 
comes more prominent after the skull is opened, so that on the affect- 
ed side the dura mater appears more tense than on the other side. If 
the dura mater be opened and turned back, we see that the surface of 
the diseased hemisphere is remarkably even, that there is very little, 
if any, liquid in the subarachnoid space, that the convolutions are 
lower, the furrows shallower, and that the vessels of the pia mater are 
not so full or are quite empty. Lastly, also, on section through the 
brain, we cannot fail to see a decided difference in the two hemi- 
spheres in regard to their color and as to the number of blood-points 
appearing on the cut surface. In those cases where the falx and 
tentorium have to a certain extent given way to the pressure propa- 
gated to them, the falx showing a convexity toward the healthy side, 
the tentorium being flattened, or, when the disease is in the posterior 
cranial fossa, being more strongly curved, it is certain that the capil- 
laries are compressed in those portions of the brain where the disease 
encroaching on the space is located. But at the same time it is found 
that the anosmia does not remain limited to the part first affected, but 
extends to other parts subsequently, although to a less extent. 
Symptoms and Course.—Anosmia limited to one portion of the 
brain induces the so-called “ herdsymptome ” (page 194) ; if the anae- 
mia be absolute, these consist of symptoms due to complete loss of 
excitability in the anaemic portions of the brain; if it be not absolute, 
there may even be signs of increased excitability, or morbid excite- 
ment of the affected portion of the brain. In the vicinity of the 
anaemia, often even through the .entire brain, the circulation is dis- 
turbed, so that, besides the direct symptoms of partial anaemia, we 
may have those of more or less extensive secondary disturbances of 
circulation. However, neither the “ herdsymptome,” nor the symptoms 
of secondary disturbance of the circulation in the brain, nor a combina- 
tion of the two, are pathognomonic of partial anaemia of the brain; 
on the contrary, we must distinctly state that each of these also occurs 
in many other diseases of the brain. Not unfrequently, we can recog- 
nize one or other form of partial anaemia of the brain, and exclude PARTIAL ANJ3MIA OF THE BRAIN. 
207 
other local diseases there, by basing our diagnosis on the etiological 
conditions, the sequence of the symptoms, the existence of symptoms 
corresponding to the peculiar frequence of certain forms of disease in 
certain sections of the brain, as well as on the course of the disease. 
We shall first describe the symptoms of the occurrence and course 
of partial anaemia of the brain due to obstruction of the vessels, and 
show how it is often possible to diagnose this form of partial anaemia 
with probability or with certainty by attending to the inducing causes. 
However, the etiology of thrombosis of the cerebral vessels differs 
from that of embolism, and the other factors also, which might be of 
aid in diagnosis, are not exactly the same in thrombosis and embolism 
of the cerebral arteries; hence we shall speak of them separately. 
Since thrombosis of the cerebral vessels most frequently depends 
ultimately on atheromatous degeneration of the vascular walls, and as 
this occurs chiefly in old age, we are more apt to suspect thrombosis, 
and consequent softening of the brain, in an old, decrepit person, who 
has the symptoms of severe brain-trouble, than in a young, vigorous 
one, having the same symptoms. If the peripheral arteries be rigid 
and tortuous, there is still greater presumption that the arteries of the 
brain are also degenerated, and that the brain-symptoms are due to 
this degeneration. However, the condition of the peripheral arteries 
does not furnish any certain proof of that of the cerebral arteries. In 
many cases the degeneration is confined to the latter; in other, rarer 
cases, while the peripheral arteries are extensively degenerated, the 
cerebral arteries remain free. Moreover, partial anaemia of the brain, 
and softening of the brain due to necrosis of the anaemic portion, is 
not the only brain-disease caused by atheromatous degeneration of the 
cerebral arteries. Experience shows that atheromatous degeneration 
of the walls of the vessels usually induces dilatation of the larger 
arterial trunks, and, on the contrary, contraction of the smaller arteries. 
The atheromatous arteries of the brain are also usually contracted for 
a long while before they are closed by thromboses. Hence the symp- 
toms of thrombosis, or, rather, of the partial anaemia and partial ne- 
crosis of the brain depending on it, are almost always preceded by 
premonitory symptoms, either of disturbance of circulation, induced 
by the contraction of certain cerebral vessels, or by symptoms of 
senile cerebral atrophy, which has been caused and hastened by de- 
generation of the cerebral vessels. The patients complain of pain in 
the head, dizziness, ringing of the ears, flashes before the eyes, loss of 
memory and power of thought; they are apathetic and indifferent, 
and much inclined to sleep, but their sleep is disturbed by uneasy 
dreams. As a rule, very small arteries are at first obstructed, either 
by the atheromatous process causing their entire obliteration, or be- 208 
DISEASES OF THE BRAIN. 
cause their calibre is contracted, and then obstructed by a thrombosis. 
The anaemia resulting from closure of these small vessels is limited in 
extent, and hence may readily be removed by an increased supply of 
blood through neighboring vessels. We must bear this in mind when, 
in a marasmic patient, who for some time has had the brain-symp- 
toms that we designated as premonitory, limited regional symptoms 
(herdsymptome) occur, and, after lasting for a time, disappear again. 
Among these symptoms are inability to say different words, loss of 
memory for certain names and numbers, pain, or a feeling of formica- 
tion, or of certain limbs going to sleep, occasionally only of certain 
fingers or toes, contractions and paralysis, which are also occasionally 
limited to certain fingers or toes, etc. 
Many authorities have explained this variation of symptoms, par- 
ticularly the occurrence and disappearance of paralysis, as a peculiar 
symptom of softening of the brain. This is a false view of the matter. 
In cases where the symptoms have presented this variation, if soften- 
ing of the brain be found on autopsy, the softening did not occur at 
the time the symptoms changed, but at a later period, when they were 
constant. On the other hand, the occurrence and disappearance of 
circumscribed paralyses are certainly, to some extent, characteristic of 
partial anaemia of the brain resulting from atheromatous degeneration 
and thrombosis of small-cerebral arteries, and are rapidly removed again 
by the establishment of collateral circulation. (The occurrence and 
disappearance of circumscribed paralyses do not render it certain that 
there is thrombosis of small arteries of the brain; the same symptom 
is also seen from small extravasations. See Chapter V.) If a large 
artery, or several small ones going to the same part of the brain, be 
closed by thrombosis, as we have already shown, a collateral circula- 
tion cannot be established, particularly if the degeneration of the 
walls of the vessels be extensive, and then the affected portion of 
brain loses its functional power forever. There are some parts of the 
brain—for instance, the large medullary masses of the hemispheres— 
that may be destroyed without any apparent loss of function. This 
fact, which is proved by numerous examples, explains the occurrence 
of those cases of softening during whose course there have never been 
any symptoms of paralysis. We must know this in order to under- 
stand that it is occasionally quite impossible to diagnose softening 
of the brain, and to distinguish it from simple senile atrophy, because 
the most important point for the differential diagnosis is wanting. 
But, far more frequently, the results of thrombosis of a large artery, 
or of numerous small ones, extend to parts of the brain, whose loss of 
function induces paralysis, and even hemiplegia, particularly to the 
corpus striatum and thalamus. The arteries supplying the great hemi- PARTIAL ANAEMIA OF THE BRAIN. 
209 
spheres, and the above-mentioned large ganglia lying in them, with 
blood, are the ones that are most frequently closed by thromboses; 
and, even if the anaemia directly resulting from the obstruction, and 
the consequent softening, do not extend to the corpus striatum and 
optic thalamus, these parts will readily lose their functional power 
from the collateral oedema about the point of softening, or from the 
capillaries of the entire hemisphere being compressed by it. If a large 
vessel be closed by a thrombosis originating from the walls, and grow- 
ing slowly, or if numerous smaller arteries be closed one after the 
other, the paralysis comes on slowly, and increases gradually. Cases 
running this course are the most readily recognized; for, although 
gradually-forming and slowly-progressing paralysis also occurs in many 
other cerebral diseases, if this symptom arise in an old marasmic pa- 
tient, who has had the previously-described symptoms, we must first 
think of thrombosis of the cerebral vessels, and of the form of soften- 
ing of the brain at present under consideration. While the symptoms 
of paralysis, which are very often and unaccountably accompanied by 
contractions of the paralyzed part, gradually increase and extend, the 
patients become more apathetic, grow imbecile, pass their excrements 
involuntarily, have bed-sores, and finally die of marasmus and coma. 
The course is different when a large vessel or numerous small ones are 
rapidly closed by thrombosis. In such cases hemiplegia occurs sud- 
denly, and the symptoms may be very similar to or identical with those 
of cerebral haemorrhage. This correspondence is easily explained. 
In cerebral haemorrhages, also, most frequently, the corpus striatum 
and thalamus are either broken up, or their functional activity is ar- 
rested by the compression that capillaries of the whole hemisphere 
suffer from large effusions. In cerebral haemorrhages also, hemiplegia 
usually occurs suddenly. Moreover, ruptures of the cerebral arteries 
usually occur in old persons, and are most frequently due to the same 
disease of the vascular walls that generally induces thrombosis. We 
shall not enumerate the symptoms given for a differential diagnosis, 
and shall only refer to an assertion of Bamberger's, for which science 
is indebted to such an undisputed authority on diagnosis. Bamberger 
says that, in his notes, he finds seven cases where there was an error 
of diagnosis, and the real state of affairs was only discovered at the 
autopsv; he considers it impossible to avoid this error, and says he 
seldom ventures to make an absolute diagnosis of cerebral haemorrhage 
from an apoplectic attack. 
Partial anaemia and necrosis of the brain due to embolism are 
also almost always preceded by characteristic premonitory symp- 
toms. But these are not brain-symptoms, as they were in the pre- 
vious form of anaemia of the brain; they are those of the diseases which 210 
DISEASES OF THE BRAIN. 
almost exclusively cause embolism of the cerebral arteries, that is, oi 
valvular disease of the heart, of endocarditis, or of severe destructive 
disease of the lungs. The occurrence of these premonitory symptoms, 
and the presence or absence of valvular disease, endocarditis, or severe 
disease of the lung, have such an effect on the diagnosis betweem em- 
bolism of a cerebral artery and other brain-diseases, that with the 
same set of symptoms we may diagnose embolism if we find them, and 
exclude it with certainty if they are absent. The sudden shutting off 
of arterial blood from the part of the brain supplied by the obstructed 
artery, instantly arrests its functional power. Experience shows that 
emboli almost always lodge in the arteria fossae Sylvii, particularly 
the left one; as the closure of this large artery causes great anaemia 
of the parts supplied by it, we may readily see that sudden hemiple- 
gia, especially of the right side, is the most important symptom from 
which we can diagnose embolus in the cerebral arteries, if it occur in 
a patient with valvular disease, etc. The entire loss of consciousness, 
the apoplectic attack, which usually accompanies the commencement 
of hemiplegia, when the arteria fossae Sylvii is stopped by an embolus, 
is more difficult to explain. I think that this symptom is most prob- 
ably due to the diseased hemisphere being decidedly swollen by col- 
lateral oedema, and that, as occurs in large extravasations of blood, the 
opposite hemisphere is not sufficiently protected from the pressure by 
the falx, which only offers a limited amount of resistance. In embo- 
lism of peripheral arteries at least, I have always found a very decided 
and wide-spread oedema in the vicinity of the obstructed vessel, and 
have witnessed considerable enlargement of the spleen from embolism 
of the splenic artery. It is evident that a hemiplegia occurring sud- 
lenly with an apoplectic attack may readily be mistaken for a cerebral 
haemorrhage. In some cases, it is true, the age of the patient gives 
grounds for distinguishing a haemorrhage from an embolism. Haemor- 
rhages occur chiefly, although not exclusively, in advanced age, embo- 
lism comes in persons of any age; hence, in young persons, the pre- 
sumption is in favor of embolism. However, the only way of avoiding 
error is the careful examination of the heart and lungs. The certainty 
that the diagnosis receives from the discovery of valvular disease is 
still more increased if we can also find a coincident embolism of a pe- 
ripheral artery or of one of the internal organs, such as the spleen or 
kidney. In most cases death occurs sooner or later after the attack, 
with the symptoms of general paralysis; in other cases consciousness 
returns after a time. The symptoms of paralysis rarely disappear; this 
is sufficiently explained, as we have previously shown, by the difficult 
establishment of a collateral circulation. 
Partial anaemia of tne brain, due to collateral oedema in the vicinity PARTIAL ANAEMIA OF THE BRAIN. 
211 
of abscesses, tumors, and other local diseases, induces symptoms of 
irritation or paralysis, according to the degree of the anaemia; these 
symptoms complicate those directly depending on the original disease, 
and are due to functional disturbance of portions of the brain lying 
beyond the actual disease. On autopsy, it is usually difficult or even 
entirely impossible to decide, whether oedema and capillary anaemia 
exist in the vicinity of an abscess, tumor, etc., and how far they ex- 
tend. But we have a right to suppose that the vicinity of these points 
of disease is in a similar state to that of parts affected in the same 
way, which are exposed to observation; and we are the more justified 
in this supposition, because for a long time it has not escaped the more 
accurate observers that, in many cases of partial disease of the brain, 
symptoms occur that cannot depend on the coarser structural changes 
of the brain found on autopsy, but must be referred to an impercep 
tible participation of other portions of the brain lying in the vicinity 
of the affected part. It is most probable that this participation 
depends on disturbance of the capillary circulation and the occurrence 
of oedema, because in other parts of the body also these anomalies 
often leave no traces. Occasionally the symptoms observed during 
life give a better means of judging of the extent of the secondary dis- 
turbances of circulation, or of the collateral oedema, than the autopsy 
does. For instance, if paralysis and spasm accompany a disease of the 
cortical and medullary substance of the cerebrum, which does not 
encroach on the cranial cavity, and whose destruction does not induce 
paralysis and spasm, there is probably an anaemia extending to por- 
tions of the brain lying far deeper. As numerous examples have 
proved that an entire half of the cerebellum may be destroyed without 
inducing hemiplegia, we cannot refer a hemiplegia, observed along 
with structural changes confined to the cerebellum, directly to that 
organ, but must consider it due to the extension of collateral oedema 
to portions of the brain whose loss of function causes paralysis of half 
the body. The strange experience, that, in disease of one side of the 
cerebellum, there is sometimes no hemiplegia, at others there is hemi- 
plegia of the same side, and in still other cases that it occurs on the 
opposite side, is doubtless due to the fact that, in the latter cases, a 
collateral oedema extends along the crura cerebelli ad frontem to the 
lateral regions of the pons; while, in those cases where the same side 
is affected, the oedema extends along the crura cerebelli ad medullam 
oblongatam to the lateral branches of the medulla oblongata; and 
where there is no hemiplegia the collateral oedema has not advanced 
in either direction to regions whose loss of function involves that symp- 
tom. These examples may suffice to show how important a r61e par- 
tial anaemia of the brain, due to collateral oedema, plays in the symp- 212 
DISEASES OF TIIE BRAIN. 
tomatology of brain-diseases confined to certain points. I have alreadj 
remarked that the variation of symptoms, the temporary improvement 
or exacerbation, observed in the course of some brain-diseases, depend 
greatly on the increase or decrease of the collateral oedema about the 
point of disease. 
The third form of partial anaemia of the brain, the result of com- 
pression of the capillaries of portions of the brain from diseases caus- 
ing pressure, induces constant and characteristic symptoms, which of 
course vary according as the anaemia is in one of the greater hemi- 
spheres or is below the tentorium. If the capillaries of one of the 
greater hemispheres be compressed by an effusion of blood, by a 
tumor, or any other local disease contracting the space in the skull, 
there will be hemiplegia, no matter where the said disease be located. 
This hemiplegia is limited to the lower half of the face, and to the 
two extremities of the opposite side. It has often been considered as 
enigmatical, that in many cases diseases above or below one of the 
greater hemispheres, as well as within it, led to hemiplegia, while in 
other cases the same diseases at the base, convexity, or in the medulla 
of a great hemisphere did not induce hemiplegia; and tables have 
been made out which show at a glance this want of correspondence. 
I consider these tables as utterly worthless, unless the variety of the 
disease be stated in them; and I think it very important to distinguish 
between two classes of disease, whose effect is very different; namely, 
tiiose which occupy more space than the brain-filaments and ganglion- 
cells which they supplant, and those which do not. Diseases at the 
base, convexity, or in the medullary portion of the cerebrum only in 
duce hemiplegia when they lessen the space, in other cases they do 
not cause it (unless collateral oedema in their vicinity extend to the 
thalamus and corpus striatum). There are exceptional cases where 
hemiplegia does not occur in disease of one of the greater hemispheres 
whose products certainly contract the space. When tumors grow 
very slowly the brain usually atrophies, and as much space may be 
gained in the skull by the disappearance of brain-substance as is lost 
by the slow growth of the tumor. In such cases there is no anaemia 
of the affected hemisphere from compression of the capillaries, and 
consequently, if the tumor be not in the immediate vicinity of the 
corpus striatum and thalamus, hemiplegia does not occur. We must 
also remember the extensive communication between the two uppei 
chambers of the skull at their anterior part. It is evident that at thir 
place pressure on one hemisphere may more readily be propagated tc 
the other than at any other part. But, the more pressure is divided 
up, the weaker its action becomes. In accordance with these consid- 
erations, diseases of the anterior lobes, which do not encroach too much PARTIAL ANEMIA OF THE BRAIN. 
213 
on the space, do not entirely compress the capillaries of the affected 
hemisphere, so that they do not cause hemiplegia, or at least it is only 
slight, while the propagation of pressure to the other hemisphere is 
shown by psychical disturbances, which are usually absent where the 
affection is limited to one side of the brain. Perhaps this may partly 
explain the aphasia, which is found with disease of the frontal lobe of 
one side, particularly (but not constantly) of the left side; since, in 
the region of the frontal lobes, pressure acting on one side is very 
readily propagated to the other. As the two sides of the brain are so 
symmetrical, it is difficult to believe that there is any organ in one 
which does not exist in the other. 
Even more characteristic and more constant is the combination of 
symptoms accompanying compression of the capillaries of the parts of 
brain in the posterior cranial fossa. This is apparently because the 
tentorium can offer greater resistance to pressure acting on it than the 
falx can; also because the communication from the posterior and lower 
chamber of the skull, bounded by the tentorium and occipital bone, 
with the upper chambers, is far less free than that which exists be- 
tween the two upper chambers. As is well known, we may readily 
err in diagnosis of diseases of the brain, but I do not remember to 
have made a mistake when I have given a diagnosis of disease con- 
tracting the space in the posterior cranial fossa. Many of my former 
pupils also have assured me that, from experience in their own practice, 
they must regard the diagnosis of diseases limiting the space in the 
posterior cranial fossa as easy, and that they have repeatedly diag- 
nosed them according to my instructions, and have verified the diag- 
nosis by autopsy. The combination of symptoms from which we may 
diagnose compression of the capillaries of the parts lying in the pos- 
terior cranial fossa is as follows: Pains in the back of the head, sym- 
pathetic vomiting, a peculiar dizziness, diminution of sensibility and 
motor power, but no complete paralysis and anaesthesia regularly 
spread over the body, and impaired articulation and deglutition. The 
pains at the back of the head doubtless proceed from the filaments of 
the trigeminus going to the tentorium. As the sympathetic vomiting 
occurs in various brain-diseases, it alone has no diagnostic value, but, 
in combination with other symptoms, it greatly aids to render the pic- 
ture of the disease characteristic. The dizziness accompanying dis 
eases contracting the space in the posterior cranial fossa is not a hallu- 
cination, a subjective sensation of movement of the patient’s own body, 
or of surrounding objects, that does not really take place. Unlike 
this far more frequent hallucinatory form of dizziness, it does not occur 
while the patient is quietly lying or sitting down, but results from 
certain bodily movements. When a patient complains of dizziness, 214 
DISEASES OF THE BRAIN. 
we should make it a rule to ask at once whether the attacks come on 
during rest, or only during walking, rising, etc.; if the latter points 
be answered affirmatively, we have obtained an important diagnostic 
point. The dizziness observed in diseases encroaching on the posterior 
cranial fossa depend, as Immermann has fully proved, on actual move- 
ments of the body, which the patient does not perfectly perceive, but 
which only have a general influence on his feeling of equilibrium. In 
healthy persons, vibratory movements of the body would also occur in 
walking, rising, etc., if they were not prevented by contraction of the 
muscles which straighten and curve the spinal column. When a 
person is walking stiffly and uprightly, we may readily see, by the in- 
creased prominence of the bellies of these muscles, that he is uncon- 
sciously using them. This facility of limiting, by muscular action, the 
movements and vibrations conveyed to the trunk is very much im- 
paired in persons with disease encroaching on the posterior cranial 
cavity, a circumstance which is apparently supported by the supposi 
tion that the cerebellum chiefly causes innervation of the body, and is 
the prop of the spinal column ( Gf riesinger). The diminution of sensi- 
bility and that of motor power, which render the patient awkward and 
uncertain, without increasing to complete paralysis and anaesthesia, are 
simply explained by the fact that the nerve-filaments, passing from the 
cerebrum through the foramen occipitale superius, enter the posterior 
cranial fossa, again leave it by the interior occipital foramen, and are 
thus subjected to a compression which impairs the propagation of ex 
citement from the brain to the motor nerves, and of peripheral excite- 
ment of the sensory nerves to the brain. In the disturbance of speech 
it may be readily seen that it does not depend on lack of thoughts, or 
on the impossibility of finding words for the thoughts, but on the un- 
certainty and clumsiness in executing the movements necessary for 
distinct, rapid, and connected articulation. The disturbance of deglu- 
tition is occasionally designated as difficulty of swallowing; it usually 
manifests itself by slight choking while drinking. I shall not attempt 
to decide whether this disturbance of articulation and deglutition de- 
pends on disturbance of the function of the hypoglossal and glosso- 
pharyngeal nerves at their origin, or in the nerves themselves, by dis- 
eases affecting the space in the posterior cranial fossa. Besides the 
above-mentioned symptoms, there are usually others depending on the 
injury of certain nerves, and, if the orifice of the venae Galeni into the 
straight sinus be compressed, and the escape of blood from the ventri- 
cle prevented, we have the symptoms of chronic hydrocephalus. We 
shall hereafter speak of this when treating of tumors and abscesses of 
the cerebellum, pons, medulla oblongata, and of chronic hydrocepha- 
lus. Here will be the place to mention those symptoms which are APOPLEXY 
215 
observed, with remarkable regularity, in diseases affecting the space 
in the posterior cranial cavity, no matter what their nature or location. 
Among my pupils I have noticed that the interest in brain-diseases 
rapidly increases when it becomes evident that, in many cases, a sure 
diagnosis can only be made within certain limits. Not unfrequently 
we are obliged to stop at the diagnosis of a disease encroaching on 
one side of the cerebrum, or on the posterior cranial fossa. In the 
following chapters we shall show under what circumstances we can go 
further, and how, in other cases, a certain diagnosis may be made of 
the nature and exact seat of the disease. 
Tkeatmext.—As may be readily understood, the treatment of 
partial anaemia and necrosis promises little benefit. In thrombosis and 
embolism of the cerebral arteries, the obstruction to the supply of 
blood cannot be removed by therapeutic remedies. Hence the indica- 
tion would be to favor the development of a collateral circulation, 
without exposing the patient to new danger from too great collateral 
fluxion. It is very difficult to fulfil these indications, and we may 
readily do harm instead of good. The purer the symptoms of partial 
paralysis, the more obstinate they remain; if no symptoms of irrita- 
tion accompany them, the more a strengthening and stimulant ‘treat- 
ment is indicated. Hence we always find the administration of stimu- 
lants recommended in the treatment of softening of the brain. If, on 
the other hand, the symptoms of irritation caused by fluxionary hyper- 
aemia, such as severe headache, contractions, etc., are prominent, it is 
advisable to use cold, and apply leeches behind the ears repeatedly. 
We should be careful about venesection, as it is readily followed by 
collapse. From what has been said, it is evident that we can give no 
general rules, but the treatment must be suited to each case. We 
shall speak of the treatment of partial anaemia of the brain, induced 
by collateral oedema and compression of the capillaries, when we treat 
of the diseases that this form of partial anaemia accompanies. 
CHAPTER Y. 
CEREBRAL HEMORRHAGE APOPLECTIC STROKE APOPLEXIA SAN- 
GTTHSTEA. 
By the term stroke, or apoplexy, was originally meant, as the word 
indicates, the sudden occurrence of complete functional inactivity of the 
brain. Apoplexy is divided into various forms, according as the paral- 
ysis is induced by an extravasation of blood or by a serous effusion, 
or as organic diseases can or cannot be found as the cause: thus we 
have Apoplexia sanguinea, A. serosa, A. nervosa, etc. In the present 216 
DISEASES OF THE BRAIN. 
chapter we treat of the lesion of the brain characterized by rupture of 
the blood-vessels and escape of their contents, whether it induces the 
symptoms of sudden paralysis of the brain or not. 
Etiology.—Cerebral haemorrhages almost always occur from the 
smaller arteries or the capillaries of the brain, and are caused partly 
by structural disease of the arterial walls, partly by an anomalous con- 
dition of the part of brain surrounding the vessels, partly by increased 
pressure of the blood against the wall of the vessel. The bleeding 
most frequently occurs when several of the factors act together.1 
The structural changes in the Avails of the vessels, to wThich their 
abnormal fragility is due in most cases, are the results of endarteritis 
deformans, which was treated of in the first volume. This explains 
the frequency of apoplexy in persons over forty years of age, which 
was noticed even by Hippocrates. Next to this, simple fatty degen- 
eration of the arterial walls, not dependent on inflammation, but occur- 
ring in badly-nourished cachectic and chlorotic persons, also induces 
greater fragility and ruptures of the cerebral vessels. Still Ave must 
say that fatty degeneration of the finer cerebral arteries is found far 
more frequently than would be expected from the proportionately rare 
occurrence of apoplexy. Occasionally rupture of the entire arterial wall 
is preceded by rupture of the inner and middle coats, Avhile the adven- 
titia still resist. In such cases the blood escapes betAveen the external 
and middle coats, and small dissecting aneurisms are formed. Lastly, 
there are cases Avhere abnormal Aveakness of the cerebral vessels must 
be supposed, although it cannot be proved. These are the rare cases 
Avhere cerebral haemorrhages are found in convalescents from typhus 
and other acute infectious diseases and during scorbutus. 
We have already mentioned that, in necrotic softening of the 
brain, capillary haemorrhages not unfrequently occur along the borders 
of the softened part. Frequently, gradual atrophy of the brain causes 
dilatation and final rupture of the vessels. While the brain-substance 
disappears, a vacuum cannot form in the skull; hence increase of the 
cerebro-spinal fluid and dilatation of the vessels are necessary results 
of senile or any other form of atrophy of the brain, Avhich is a frequent 
sequel of the most varied forms of disturbance of nutrition. Perhaps 
the frequency of apoplexy in advanced age depends at least partly on 
this circumstance, and there is no doubt that the atrophy of the brain, 
which is in many cases caused by the first apoplectic attack, has some- 
thing to do with the frequent recurrence of apoplexy. 
The increased pressure of the blood on the Avails of the vessels, by 
Avhich the latter are ruptured, may depend on any of the causes which 
Ave indicated in the first and second chapters as causes of hypersemia. 
The frequent occurrence of apoplexy during long and luxurious meals CEREBRAL APOPLEXY. 
217 
tends to show that the hyperaemia of the brain induced by temporary 
plethora is one of the most dangerous forms. Hypertrophy of the 
left ventricle, particularly that form resulting from any extensive en- 
darteritis deformans, plays an important part in the ruptures of cere- 
bral vessels. In the latter case two dangerous factors unite—the mor- 
bid fragility of the vessels and the increased pressure of the blood on 
them. Moreover, small arteries, in which there is otherwise a regular 
pressure of the blood, and whose walls also maintain a nearly equal 
tension during the systole and diastole of the heart, pulsate when 
there is extensive atheromatous degeneration, and at every systole of 
the heart the normal medium tension of their walls is decidedly in- 
creased. It will be readily understood that this circumstance also in- 
creases the liability of the vessels to rupture. Cerebral haemorrhages 
so often depend on the complication in question, that, in doubtful 
cases, the discovery of hypertrophy of the left ventricle and of an 
atheromatous degeneration of the arteries may decide the diagnosis. 
Apoplexies occur at all times of the year ; occasionally, without 
any known cause, cases accumulate remarkably. They have also 
been observed at all times of the day, and statistical tables have been 
made of their comparative frequency at morning, mid-day, and even- 
ing. Although advanced age furnishes the largest number of cases, 
apoplexy does occur even among children. Men are somewhat oftener 
attacked than women. There is no such thing as an apoplectic con- 
stitution, indicated by a short neck and broad shoulders. 
Anatomical Appearances.—The distinction is made into capil- 
lary haemorrhage and haemorrhagic clots, according as the bleeding 
consists of numerous small, closely-packed effusions, or of a larger 
quantity of blood. 
In capillary haemorrhages the cerebral substance appears dotted 
with dark-red punctate extravasations at some point of variable size. 
The cerebral substance between the small extravasations either re- 
tains its normal color and consistence, or is colored yellow or reddish 
to a variable extent by imbibition; it is relaxed and moist, or, lastly, 
it is broken down to a red pulp by the extravasation (red softening). 
Small haemorrhagic spots sometimes press the brain-filaments 
apart; but larger ones break up and become mixed with the brain- 
substance. In the former case the effusion is sometimes elongated in 
the direction of the filaments; in the latter it is more roundish or irreg- 
ular. In the former case the walls of the effusion are to some extent 
smooth; in the latter they oftener appear ragged, and are frequently 
surrounded, for a space some lines thick, by a broken-down pulpy 
brain-substance discolored with blood. The size of the clot varies 
from that of a hemp-seed to that of the fist. If it be in the vicinity 218 
DISEASES OF THE BRAIN. 
of a ventricle, it often breaks through the wall of the latter, and its 
blood escapes into the ventricle. Haemorrhagic effusions, lying near 
the surface of the brain, not unfrequently break through the cortical 
substance and pia mater, so that the blood enters the subarachnoid 
space. Usually there is only one haemorrhagic effusion in the brain, 
rarely several. Their most frequent locality is the corpus striatum, 
the thalamus opticus, and the large medullary masses of the hemi- 
spheres ; less frequently they occur in the cortical substance of the 
cerebrum, in the cerebellum and pons. Apoplexies in the corpora 
quadrigemina and medulla oblongata are rare, and they hardly ever 
occur in the corpus callosum and fornix. The contents of a recent 
apoplectic clot consist of blood and broken-down brain-substance. The 
blood either remains fluid or is partly coagulated, and then 'the fibrin 
is occasionally deposited at the periphery, while the middle of the clot 
consists of fluid blood. Changes of the contents and walls of the clot 
soon begin. The fibrin of the blood and the portions of brain mingled 
with the effusion break down into a detritus, the contents become 
more fluid, the dark-red color becomes brown, then saffron yellow. 
Granular pigment and often also hematoidin crystals are formed from 
the hematin. At the same time, in the immediate vicinity of the clot, 
there is a new formation of connective tissue starting from the neu- 
roglia, which develops into a thick, hard layer that encloses the clot. 
In the same way there is a new formation of delicate connective tissue, 
colored yellow by the pigment contents and serous infiltration, which 
covers the wails and traverses the clot as a fine network. After the 
elements of the effusion have broken down, all its remains disappear, 
while their place is gradually supplied by serum ; and then we find in 
the brain a cavity filled with clear liquid, surrounded by a callous sub- 
stance, and covered and traversed by delicate yellow-colored connec- 
tive tissue—an apoplectic cyst. The cysts usually remain permanently. 
But occasionally the serum is reabsorbed, the walls approximate, and 
finally are only separated by a stratum of pigment. These callous 
spots, enclosing pigment stria?, are called apoplectic cicatrices. The 
cicatrization of a hemorrhagic effusion in the cortical substance is 
somewhat different. The effusion of blood under the pia mater, which 
is usually flat and extended, undergoes the same changes as do the 
contents of central clots. The red pulp gradually becomes a reddish- 
brown or saffron-yellow crumbly mass, which is bounded below by 
callous brain-substance, above by the pia mater. Lastly, we find an 
excavated pigmented plate, above which a serous effusion fills the cav- 
ity resulting from the depression. While the above terminations of 
cerebral hemorrhages must be regarded as the most favorable, in 
some cases the reactive inflammation in the vicinity of the broken CEREBRAL APOPLEXY. 
219 
down portion of brain is not limited to a new formation of connective 
tissue, but there is extensive destruction from inflammatory softening, 
or the apoplectic clot is even transformed to an abscess of the brain. 
The parts untouched by the haemorrhage are bloodless if the extrava- 
sation has been considerable, and the more so the larger the extrava- 
sation ; small capillary haemorrhages have no influence on the amount 
of blood in the rest of the brain. In large effusions the hemisphere 
containing the clot is particularly anaemic. The subarachnoid spaces 
also are empty, the convolutions flattened, and the furrows have dis- 
appeared. Since the uneven appearance of the surface of the brain is 
to a great extent due to the presence of cerebro-spinal fluid and of 
vessels containing blood between the convolutions, the surface of the 
brain appears very smooth and even when there is a large extravasa- 
tion. The brain rarely endures the injury from an apoplexy without 
impairment of the general nutrition. The gradual diminution of men- 
tal power seen in almost all apoplectic cases corresponds to a general 
atrophy of the brain; which, according to the examinations of Turk, 
is associated with a degeneration, extending into the spinal medulla, 
of those filaments communicating with haemorrhagic effusion. 
Symptoms axd Course.—Sometimes apoplexy occurs unexpect- 
edly in persons who have previously felt quite well; in other cases it 
is preceded by premonitory symptoms that excite in the physician, and 
even in the laity, the apprehension that the patient is threatened with 
apoplexy. The patients complain of headache, or of heaviness and 
fulness of the head, of noise in the ears, flashes before the eyes, and 
attacks of dizziness; they sleep badly, are excited and irritable. There 
are also, as peculiarly ominous symptoms, occasional temporary feel- 
ings 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. Thus we see the premonitory symptoms 
of apoplexy are those that we gave in preceding chapters, as due to 
general and partial hyperaemia of the brain, and to partial anaemia of 
the brain resulting from degeneration of the walls of the vessels; a 
condition that entirely corresponds with the frequent dependence of 
cerebral haemorrhages on increased lateral pressure in the cerebral 
vessels, and on degeneration of their walls. In general it cannot be 
determined whether the temporary partial paralysis and anaesthesiae, 
the “warnings” preceding the apoplectic attack, depend on throm- 
bosis of small vessels, or on small capillary haemorrhages. In the 
latter case, of course they could not be classed among premonitory 
symptoms. 
The destruction of brain-filaments, whether they be broken up by 
large extravasations or be softened by small capillary haemorrhages, 220 
DISEASES OF TIIE BRAIN. 
can, as we have often shown, have no other direct result than partial 
paralysis. Since the destruction of certain portions of the brain, par- 
ticularly in the medulla of the cerebrum, does not cause any perceptible 
disturbance of function, we may readily understand that small heemor 
rhages, as well as other diseases of those parts, may occasionally es- 
cape recognition during life. 
We have designated the corpus striatum and thalamus opticus as 
the most frequent seat of haemorrhage; a destruction of these parts, or 
of the pedunculi cerebri, induces paralysis of the opposite half of the 
body. We may readily determine that the paralysis, resulting from 
destruction of the above parts, only depends on interruption of the 
conduction between the organs acting in thought and will and the 
motor nerves and muscles; the power to think and will is unimpaired. 
After the apoplectic seizure, during which there is complete loss of 
consciousness, has passed off, if we ask the patients to give us the 
affected hand, they show their desire to fulfil the request, by taking the 
paralyzed hand in the other one, whose nerves and muscles are under 
the control of their will, in order to accomplish the act. On the other 
hand, in recent cases, every motor nerve on the paralyzed side, to which 
we apply the induced current, causes contraction in the muscles sup- 
plied by it. Hence the only failure is in the communication between 
the central excitory apparatus and the motor nerves. This interrup- 
tion has no effect on those movements of the paralyzed side that occur 
in a reflex manner without the influence of the will; for patients, who, 
as a result of apoplexy on the left side, cannot move the right arm or 
leg, move the right side of the thorax just as well as the left during 
respiration. And the connection between the motor nerves and those 
nerve-filaments and ganglion-cells which are excited during certain 
states and feelings of the mind is not always removed with the inter- 
ruption of conduction at present under consideration. This is shown 
by the fact that some patients who cannot make the motions of laugh- 
ing or crying on the one side of the face, at our request, can do so 
when they do not will to do it, but when their feelings lead them to 
do so. In the same way, the interruption of conduction of the impulses 
of the will, from the central organs to the motor filaments, does not 
necessarily imply that the communication of the latter with sensory 
and with other motor filaments is interrupted. On the contrary, we 
find that occasional reflex movements sometimes remain undisturbed 
in the paralyzed parts, or even occur more readily, so that it appears 
as if, when the excitement of the motor filaments is no longer subject 
to the will, it occurs more readily than it otherwise would. Paralysis 
of half the body, due to destruction of the corpus striatum and thalamus 
of one hemisphere, is characterized by its limitation to the muscles of CEREBRAL APOPLEXY. 
221 
the extremities, to those muscles of the face going to the angle of the 
mouth and the nose, and to the muscles that protrude the tongue. 
The patients can almost always chew normally on the affected side, 
they can wrinkle the forehead, open and close the eyelids, move the 
eyes in any direction, etc. On the other hand, the patient frequently 
cannot lift the paralyzed arm and foot an inch from the bed; the mouth 
hangs down on the affected side, and the nostril is contracted, occasion- 
ally the cheek flaps about like a loose sail at every expiration, while, 
on the sound side, the angle of the mouth is drawn up and the nostril 
dilated. If the patient protrude the tongue, its point goes toward the 
paralyzed side, because only the muscles of the opposite side push for- 
ward the root of the tongue and elongate that organ. In most cases, 
along with the hemiplegia, there is also anaesthesia of half the body, but 
after a time this usually passes off partially or entirely. This course 
of the anaesthesia, as well as the experience that animals have no sensa- 
tion after destruction of their corpus striatum and thalamus, and that, 
after taking them away, the power of feeling peripheral pain continues, 
appears to indicate that the temporary anaesthesia of the paralyzed 
half of the body does not depend immediately on destruction of the 
corpus striatum and thalamus, but on the compression of the capil- 
laries in the sections of brain lying below them, caused by the effusion 
of blood. 
The same symptoms as are caused by effusions of blood into the 
thalamus and corpus striatum, are induced by effusions at other parts 
of the cerebrum, provided they are extensive enough to compress the 
capillaries of the thalamus and corpus striatum. After the discussion 
in the previous chapter concerning partial anosmia of the brain and its 
influence on the cerebral functions, this similarity cannot appear strange 
to us, but must rather be regarded as evident and necessary. The 
only difference is the following: A large apoplectic clot, destroying 
the corpus striatum or thalamus, leaves a hemiplegia that never dis- 
appears ; only small clots in these parts, by which the filaments and 
ganglion-cells are not broken down, but only pressed apart, leave 
paralysis which is occasionally temporary. Hence we may conclude 
that the apparatus for exciting the motor nerves, which doubtless exists 
in the brain, although it may itself be excited by the will, is located in 
the vicinity of the corpus striatum and thalamus. On the other hand, 
extensive apoplectic clots at other parts of the cerebrum not unfre- 
quently leave paralysis, which sooner or later disappears again. From 
this course we may suppose that the capillaries of the motor centres, 
being relieved of the pressure by the partial resorption of the extrav- 
asation, have again become permeable to the blood; or that the col- 
lateral oedema in the vicinity of the broken-down part of brain, which 222 
DISEASES OF THE BRAIN. 
extended to the motor centres, has disappeared with the cicatrization 
of the apoplectic clot. 
Hemiplegia occurs in some, but not in all, of the cases where the 
effusion is into the cortical substance of the cerebrum; these are gen- 
erally accompanied by haemorrhage into the tissue of the pia mater. 
The difference, doubtless, depends on how far the frequently-mentioned 
results of the haemorrhage, compression of the capillaries, or collateral 
oedema, extend inward; whether they reach the corpus striatum and 
thalamus or not. When the clot is in this position, general convulsions 
are often observed, and in most cases there is severe disturbance of the 
psychical functions. Since experience shows that persons with very 
advanced and extensive degeneration or atrophy of the cortical sub- 
stance (if it be only on one side) often have no psychical disturbance, 
the frequent occurrence of the latter in apoplexy on one side is prob- 
ably because haemorrhages readily affect the other hemisphere; and 
particularly because this is likely to occur in the complicating inflam- 
mation of the pia mater, which has a great tendency to spread. 
Haemorrhages in the pons, if of any considerable size, and in the 
medulla oblongata, even if very slight, usually cause death. In small 
effusions in the lateral portions of the pons, there are anaesthesia and 
paralysis on the opposite side of the body; in small extravasations in 
the middle of the pons, there is paralysis of both sides. 
In haemorrhages of the cerebellum we often find paralysis of the 
opposite side. But this cannot depend on the affection of the cerebel- 
lum, for there is often no paralysis observed when this is extensively 
destroyed. 
We must not think that, because haemorrhages are found at very 
different parts of the brain, the different cases of paralysis dependent 
on cerebral haemorrhages will differ widely from each other. On the 
contrary, the large majority of cases show a great similarity, as they 
induce the hemiplegia above described. It is, of course, of great prac- 
tical importance to know this, which is simply explained by the fact 
that, according to statistics, seven-eighths of all cerebral haemorrhages 
are located in the cerebrum and particularly in the vicinity of the cor- 
pus striatum and thalamus. There are some very wonderful excep- 
tions to the one-sidedness of the paralysis and to its occurrence on the 
opposite side, in haemorrhage of the cerebrum, which we are at present 
unable to explain satisfactorily. However, we must add that, of late, 
since all anomalies existing with the haemorrhage, particularly plugging 
of the cerebral arteries, are more carefully attended to, and used in 
explaining the symptoms, the number of such cases published has 
greatly decreased. 
Another series of symptoms in cerebral haemorrhage, which is CEREBRAL AROPLEXY. 
223 
called a stroke of apoplexy, and is only absent when the haemorrhage 
is slight, do not depend directly on the local injury of the brain, but 
on its effect on the rest of the brain. We shall hereafter show that 
the apoplectic fit usually occurs at the outset, but sometimes does not 
come on till after the appearance of the paralysis. The stroke of 
apoplexy rarely develops gradually and probably only does so when 
the haemorrhage occurs slowly; in most cases it comes on suddenly, 
and the patient falls to the earth (often with a cry) as if “ knocked 
down.” During the attack, consciousness is entirely lost, as well as 
the power of feeling and moving. The sphincters also are generally 
paralyzed, so that faeces and urine are passed involuntarily. Respira- 
tory movements alone, which depend on the medulla oblongata, are 
continued; but the inspirations follow at long intervals, and are usually 
loud and stertorous, since the paralyzed and pendulous soft palate is 
thrown into vibration by the air. The patient has a peculiar appear- 
ance, from the relaxed cheeks being puffed out with every expiration. 
There is often vomiting at the commencement of the attack; the 
pulse is very slow, the pupils contracted. 
It is usually supposed that the apoplectic fit is a result of the pres- 
sure or bruising of the nerve-filaments and ganglion-cells of the entire 
brain by the extravasation. However, it is evident that this pressure 
can never exceed that of the blood in the cerebral arteries; for, as 
soon as the pressure in the parts around the arteries is as great as that 
of the blood in the vessels, no more blood can escape from the latter. 
But, from experiments that we can make on peripheral nerves, there 
is no doubt that such a pressure is entirely insufficient to annul the 
excitability of the nerve-filaments. The following fact also tends to 
disprove the current explanation: If the symptoms of paralysis de- 
pended on the pressure to which the filaments of the brain are sub- 
jected in apoplexy, bleeding should remove these symptoms not only 
in some but in all cases, provided enough blood be drawn to lessen 
the pressure in the whole vascular system, particularly in the arteries. 
JETyrtl, who also speaks most decidedly against referring these symp- 
toms to pressure on the brain, thinks that the accidents generally re- 
ferred to “ pressure on the brain ” are due to a slight amount of con- 
cussion ; but, apart from the fact that there is no such concussion in 
cases of extravasation which are not of traumatic origin, no anatomi- 
cal changes referable to such a cause can be found. We refer the 
apoplectic fit to sudden compression of the capillaries, that is, anemia 
of the brain-substance. In all large hemorrhages this anemia may 
not only be recognized with certainty after death, but even during life 
it shows itself by a very important symptom which is usually falsely 
interpreted, that is, by a remarkable pulsation of the carotids. This 224 
DISEASE3 OF THE BRAIN. 
symptom is very generally regarded as a sign of “ increased pressure 
of blood to the head,” although it really indicates that the flow of blood 
into the skull is obstructed; we may at any moment induce the same 
phenomenon in the artery of the finger by tying a string tightly 
around the end of the finger. All diseases of the brain and its mem- 
branes affecting the space in the skull enough to obstruct the afflux 
of blood from the afferent vessels, hence not only large effusions of 
blood, but also abundant exudations and transudations, large tumors, 
etc., are accompanied by increased pulsation of the carotids. If we 
find this symptom, when there is no hypertrophy of the left ventricle, 
nor corresponding pulsation in other arteries, it will, in doubtful 
cases, be a great aid to the diagnosis of some brain-disease encroach- 
ing on the cranial cavity. In my clinic my pupils have frequently had 
an opportunity of satisfying themselves of the correctness of the indi- 
cation and of the great diagnostic value of this symptom. If we re- 
gard the physical conditions, we see that anaemia, at all events arte- 
rial anaemia, of the brain can never result from rujeture of the capil- 
laries ; for the escape of blood from the ruptured capillaries can only 
last till the tension of the contents of the skull equals that of the 
blood in the capillaries. In accordance with this we see that the apo- 
plectic fit does not occur in capillary haemorrhage. If, on the other 
hand, an artery be ruptured, and the bleeding does not soon cease 
from some other cause, the tension in the surrounding parts finally 
becomes as great as it is in the artery; and, as it is greater there than 
in the capillaries, the latter must be compressed and become impassa- 
ble for the arterial blood. In accordance with this, apoplectic fits al- 
most always accompany arterial haemorrhages of any extent. If we 
anahTze the above symptoms of the apoplectic fit, we find that, while 
it lasts, the functions of both sides of the cerebrum are lost. The pa- 
tients have no feeling, even on the strongest peripheral irritation; 
they cannot make the slightest motion, and consciousness is entirely 
lost. On the other hand, those portions of the brain through which 
acts indispensable to life, especially respiration, are performed, retain 
their functional power. This is, apparently, because the falx protects 
the opposite hemisphere less, from the compression of the capillaries 
by the extravasation, than the tentorium does the medulla oblongata. 
Effusions of blood below the tentorium, even when slight, are very 
dangerous, because in them the medulla oblongata is not thus pro- 
tected, and its functions are readily disturbed by compression of its 
capillaries. I shall not attempt to decide whether or not the slowness 
of the pulse, the diminished frequency of respiration, and the contrac- 
tion of the pupil, observed during apoplectic fits from effusions above 
the tentorium, are due to increased excitement of the vagus and oculo- APOPLEXY. 
225 
motor nerves as a result of pressure acting on them, but somewhat 
modified by the tentorium. 
If the patient does not die during the apoplectic fit, but recov- 
ers consciousness, he shows signs of a more or less severe encepha- 
litis in a few days. This depends on the injury to the brain from 
the haemorrhage, hence must be regarded as traumatic. When it 
does not reach a great height, and only leads to new formations of 
connective tissue about the clot, the symptoms are increased fre- 
quence of pulse and other signs of fever, headache, sparks before 
the eyes, delirium, occasionally also twitchings and contractions of 
the paralyzed parts. After a time these “ symptoms of reaction ” 
moderate and finally disappear, and the patient is well except for 
the remaining paralysis. But, if the inflammation in the vicinity of 
the clot is of considerable intensity and induces inflammatory soft- 
ening, the above symptoms are accompanied by those of general 
paralysis, and the patient dies as a result of too great severity of 
the so-called symptoms of reaction. 
[Hemiplegia caused by cerebral apoplexy shows the peculiarities 
of all cerebral palsies (as contrasted with spinal and peripheral pal- 
sies). The loss of sensation is less marked and more transitory than 
that of motion, and the reflex action is almost always preserved or 
even increased through irritation from the apoplectic centre. Hence 
a slight increase of electrical irritability argues in favor of a cere- 
bral palsy. The arm is usually more affected than the leg, and, for 
a time at least, the tongue and facial muscles are often likewise in- 
volved. Cerebral palsy of the face especially affects the nervous 
twigs which supply the muscles of the ake nasi, those of the angle 
of the mouth, and the buccinator muscles ; while the nerves of the 
orbicularis palpebrarum almost always escape, so that the eye can 
always be closed (in contrast to what occurs in peripheral facial 
palsy). A facial palsy of cerebral origin is upon the same side as 
that of the hemiplegic limbs ; whereas peripheral palsy of intracra- 
nial origin (like that by compression of the facial nerve along its 
course in the base of the skull) is upon the side where the lesion 
exists. There are often vasomotor disturbances, and the paralyzed 
side (Eulenburg) shows by the sphygmograph that the arterial 
tone is sunken and the current retarded, and that the temperature 
is lower than upon the healthy side ; moreover, the hand and foot 
are often swollen. The psychical functions also are apt to be more 
or less altered. 
The derangements which remain after an apoplectic attack has 
abated may continue to improve for weeks and months ; but where 
a perfect recovery does not promptly take place, it seldom does so 226 
DISEASES OF THE BRAIN. 
afterward, so that a paresis of the arm and leg is apt to remain. 
The palsied limbs often move sympathetically, particularly during 
the acts of coughing and sneezing. Several weeks after the fit 
there generally occurs a gradually increasing .contraction of the 
crippled limbs (of the hand and arm especially). Thus all the 
joints of these members become permanently flexed, and this may- 
go so far as to require that the palm of the hand be protected 
from the impression of the finger-nails. This change from flaecid- 
ity to stiffness is an evil prognostic sign, meaning that the case is 
incurable. 
Arthropathy of the hemiplegic, described by Scott Alison, 
Brown-Sequard, and Charcot, is confined to the palsied limbs, and 
prefers the arm, and especially the shoulder. This complication, 
like the contractions, appears several weeks after the fit, and the 
pain, redness, and swelling are sometimes so marked that the at- 
tack might be mistaken for acute articular rheumatism, did not 
the seat of the disease upon a paralyzed limb indicate its true sig- 
nificance. 
A very rare sequel of apoplexy is a permanent hemi-ansesthe- 
sia, which persists even after the motor derangement has been 
restored. This anaesthesia may be complete or incomplete ; it in- 
volves not merely the skin, but the deeper parts of the lip, tongue, 
and palate. 
The consequences of an apoplectic stroke, however, are by no 
means always alike. The situation of the clot may affect the char- 
acter of the symptoms. While a small extravasation upon the cor- 
tical substance may cause no recognizable symptoms, a large one, 
or numerous extravasations in the cerebrum, would be apt to cause 
mental derangement. There may be stupor, convulsions, delirium, 
mania, and permanent insanity. Large clots in the posterior brain 
may cause paralysis or prove speedily fatal. 
Haemorrhagic, embolic, and other lesions affecting the third 
frontal convolution, particularly those of the left anterior lobe, cause 
the well-known disturbance of speech knowm as aphasia, of which 
more hereafter. Numerous dissections would seem to show that 
the whole region involving the fossa Sylvii, the island, and the cor- 
pora striata may be similarly affected by injuries. Apoplexy of 
the crura cerebri is said to be characterized by marked anaesthesia, 
slight facial palsy, and squinting, while the psychical functions 
remain unchanged. 
Apoplexy may result in paraplegia when the lesion is bilateral. 
In such cases the two sides are usually affected in unequal degree. 
This very rare consequence of cerebral apoplexy is to be distin- APOPLEXY. 
227 
guished from paraplegia of spinal origin by the presence of mental 
derangement or of palsy of one of the facial cranial nerves ; it 
being borne in mind, however, that cerebral and spinal palsies may 
coexist. 
When an apoplectic effusion bursts its way to the meninges or 
into one of the ventricles, death usually ensues. As a rule, such 
penetrations are attended by convulsions, and by the very early 
appearance of contractions upon the palsied side, sometimes even 
upon the other. There are also epileptiform fits. Apoplexies of 
small extent often are purely local in their effect, causing paresis of 
a single extremity, thickness of speech, facial palsy without hemi- 
plegia, sudden amaurosis or amblyopia of one eye, ptosis, etc. 
Such small extravasations may form without the symptoms of a 
fit, so that doubts as to the real nature of the disease may exist 
until a subsequent grave apoplectic stroke clears up the mystery.] 
From the varied size and number of the haemorrhages, their dif- 
ferent seats, the greater or less rapidity of their occurrence, as well 
as from the more or less severe inflammation of the surrounding 
brain, we have many varieties in the course of cerebral haemor- 
rhages, of which we shall mention only the more important. 
A rather frequent appearance of the disease, which corresponds 
to a rapidly-occurring extensive haemorrhage, or to the coincident 
occurrence of several haemorrhages, is the following: After some 
premonitory symptoms, or even without them, an apoplectic fit 
suddenly occurs ; the patient does not again recover consciousness, 
the paralysis extends to the medulla oblongata, the breathing be- 
comes irregular, the pulse intermittent and slow, the pupils dilated, 
and death occurs in a few minutes (apoplexie foudroyante), or after 
some hours. 
In a second class, which is most frequently seen, and which is 
also due to a rapidly-occurring but probably less extensive haemor- 
rhage at the usual places, there is also first an apoplectic fit; even 
during unconsciousness we may see by the distortion of the face, by 
the peculiar relaxation of the muscles on one side, sometimes also 
by the dilatation of one pupil, which is the paralyzed side. After 
a few minutes or some hours, or occasionally not till next day, the 
patient gradually arouses from the stupor ; but he speaks indistinct- 
ly, and hemiplegia, with the peculiarities above described, becomes 
evident. On the second or third day there are fever and the other 
symptoms of traumatic encephalitis. After these have disappeared, 
the patient remains for the rest of his life paralyzed on one side of 
his body, although the part of the paralysis due to oedema in the 
vicinity of the apoplexy disappears after a time. 228 
DISEASES OF THE BRAIN. 
In other cases, most probably when the haemorrhage ceases for a 
time and returns again, and continues moderately, the disease begins 
with an apoplectic fit, from which the patient arouses after a time. 
We note the hemiplegia, but hope that this time the patient will es- 
cape with his life. But, after a few hours, consciousness again begins 
to disappear, and finally is lost entirely, does not return, and the pa- 
tient dies comatose. 
A slowly-occurring haemorrhage, which finally becomes very abun- 
dant, appears to induce the cases where an apoplectic fit does not open 
the scene, but where there is first hemiplegia, and, later, loss of con- 
sciousness and general paralysis of the brain. 
It would require too much time to fully describe other appearances, 
particularly the modifications resulting from the different severity of 
the reactive inflammation in the vicinity of the clot, and from the 
varied grades of the consecutive atrophy of the brain. 
Treatment.—For the prophylaxis of apoplexy, we may refer to 
Chapters I. and IY. of this section, since the prophylaxis of cerebral 
hmmorrhage demands the same general rules that we gave for the 
treatment of cerebral hypersemia, and for the disturbances of circulation 
resulting from disease of the arteries. If a patient has had one attack 
of apoplexy, he must be particularly careful to avoid all causes by 
which the cerebral vessels may be overfilled and distended; he must 
especially avoid long, luxurious meals, and must keep his bowels 
regular. 
If cerebral haemorrhage has occurred, it becomes our object to pre- 
vent axontinuarice of the bleeding, to induce reabsorption of the ex- 
travasation, and the formation of an apoplectic cicatrix. But we must 
not deceive ourselves as to our power, and must understand that we 
have no remedy for arresting the haemorrhage, or for hastening the 
reabsorption and cicatrization. In the treatment of this disease we 
are restricted to combating the more dangerous symptoms as well as 
possible. Not a few patients, in apoplectic fits, recover consciousness 
during venesection, and it seems as if we could, not unfrequently, pre- 
vent the extension of the paralysis from the cerebrum to the medulla 
oblongata, which is indispensable to life, and so save the patient by 
bleeding. On the other hand, there is no doubt that, in many cases, 
bleeding during an apoplectic fit hastens a fatal result; collapse occurs 
immediately after the venesection, and the patient never arouses. We 
have previously said that bleeding must always prove beneficial, if the 
symptoms given as signs of pressure on the brain were actually in- 
duced by the pressure to which the brain is subjected by the extrava- 
sation ; and we have also said that the want of success in venesection, 
in many cases, spoke against this explanation. From the explanation APOPLEXY. 
229 
that we have given of the apoplectic fit, it is evident that, under some 
circumstances, venesection is a very useful remedy; under others it is 
very injurious, and the indications for it may be very exactly given. 
In order that as much arterial blood as possible may enter the brain, 
we must try to facilitate the escape of the venous blood, without, how- 
ever, diminishing the propelling power too much. If the impulse of 
the heart be strong and its sounds loud, if the pulse be regular, and 
no signs of commencing oedema of the lungs exist, we should bleed 
without delay. Local bleeding by leeches, behind the ears, or to the 
temples, or by cups to the back of the neck, cannot replace general 
bleeding, but may be used as adjuvants. If, on the contrary, the 
heart’s impulse is weak, the pulse irregular, and rattling in the trachea 
has already begun, we may be almost certain that bleeding would only 
do harm, since the action of the heart, which is already weakened, 
would be still more impaired, and the amount of arterial blood going 
to the brain would thus be still more decreased. When the latter 
state occurs, the symptomatic indications require just the contrary 
treatment, in spite of the original disease being the same, and being 
due to the same causes. We must strive with all our skill, by the use 
of stimulants, to prevent paralysis of the heart. If we cannot give 
wine, ether, musk, etc., internally, we should apply large sinapisms to 
the chest and calves of the legs, rub the skin vigorously, sprinkle the 
breast with cold water, or drop melted sealing-wax on it. 
If the patient has recovered consciousness after the apoplectic fit, 
we simply prescribe a mild, unirritating diet, keep the bowels open, 
and cover the shaved head with cold compresses, so as to prevent, if 
possible, too severe inflammatory reaction. According to the severity 
of the inflammatory symptoms which, nevertheless, occur, we may 
continue this simple treatment, and at most give a purge, or apply 
leeches behind the ears, and repeat the application if necessary. In 
this stage venesection is superfluous and dangerous. On the other 
hand, especially when the fever-symptoms have moderated, good is 
done by derivatives to the nape of the neck, such as blisters and pus- 
tulating ointments, which subsequently are no more to be used. 
If the stage of inflammatory reaction has happily passed, and the 
patient is pretty well, except the paralysis, we should avoid prescribing 
strychnia and other remedies, which are neither theoretically nor prac- 
tically useful, but should regulate the diet and bowels, and place the 
patient under the best possible hygienic influences. Well-to-do pa- 
tients may be sent to Wildbad, Gastein, Pfafers, or Ragatz. We must 
not hope that the destroyed filaments of the brain will be restored by 
the use of these waters, but experience shows that, at these places, 
both cerebral and spinal paralysis often improve; probably this im- 230 
DISEASES OF THE BRAIN. 
provement is due to the favorable influence of the baths on the inflam- 
mation about the clot, and on that portion of the paralysis due to it. 
Lastly, it cannot be denied that paralyses are generally improved 
by the employment of the induced current of electricity. This is doubt- 
less solely because “ faradisation localisee ” is one of the most powerful 
means of therapeutic gymnastics. After paralysis has lasted some 
time, its degree almost always depends partly on diminished excita- 
bility of the nerves, and on commencing atrophy of the muscles from 
long disuse. For both of these states the methodical excitement of 
the nerves by the induced current is certainly the best remedy, and, 
at all events, it deserves the preference to irritating liniments, salves, 
and tinctures. 
CHAPTER VI. 
HAEMORRHAGES OF THE CEREBRAL MEMBRANES APOPLEXIA MENIN- 
GEA HaE M ATOM A OF TIIE DURA MATER. 
Etiology.—Excepting traumatic haemorrhages of the meninges, 
among which are to be classed those occurring during birth, this is a 
rare affection. Effusions of blood in the subarachnoid space, or be- 
tween the dura mater and arachnoid, result mostly from the breaking 
through of a cerebral haemorrhage. Occasionally, ruptures of aneu- 
risms, or of degenerated arteries, cause the meningeal bleeding; in 
other cases, the cause cannot be found. 
The extensive capsulated collections of blood occasionally found, 
on autopsy, on the under surface of the dura mater, are not, according 
to Virchow's instructive examinations, as was formerly supposed, 
simple extravasations of blood, at whose periphery the fibrin has been 
precipitated and the fluid part capsulated, but they are the remains 
of chronic inflammations of the dura mater (pachymeningitis), with 
haemorrhagic exudations. Virchow calls this blood-sac haematoma of 
the dura mater. The blood filling it comes from the numerous large 
and thick-walled capillaries that have formed in the pseudo-membrane 
of the dura mater during this variety of chronic inflammation, and it 
has been effused between the layers of the pseudo-membrane. The 
causes of chronic pachymeningitis, with haemorrhagic exudation, are 
not perfectly known. The disease occurs chiefly in old age, and re- 
markably often in persons with mental disease, and in drunkards. It 
appears to develop sometimes as an independent, sometimes as a sec- 
ondary disease, due to injuries of the brow. In the latter case it is 
said that years may intervene between the injury and the first symp- 
toms of haematoma (Griesinger). 
Anatomical Appearances.—If the blood be effused in the sub JELEMATOMA OF THE DURA MATER. 
231 
arachnoid space, we usually find it as a more or less tliick layer spread 
over the surface of the cerebrum and cerebellum. If the arachnoid be 
not torn, of course we cannot wash off the extravasation by turning1 a 
stream of water on it. Usually part of the extravasation reaches the 
ventricles, and there also we find more or less blood. In haemorrhages 
between the dura mater and arachnoid the extravasation is generally 
collected, more particularly on the tentorium and at the base of the 
skull, and thence extends into the vertebral canal. But on the con- 
vexity of the hemispheres we also find bloody masses, which may be 
washed off by squeezing out the sponge over them. In both forms of 
haemorrhage there is either simply flattening of the convolutions and 
anaemia of the brain-substance, or else the layers of brain-substance 
next to the haemorrhage are suffused with blood and softened. 
Haematoma of the dura mater is usually located near the sagittal 
suture and has the form of an oval flat sac, which may attain consid- 
erable size, and may be four or five inches long, two or three broad, 
and half an inch thick. The walls of the sac are colored rusty-brown 
by altered hsematin; its contents are partly fresh fluid or coagulated 
blood, partly dirty reddish-brown clots, that are unmistakably older. 
The corresponding half of the cerebrum is flattened, or even shows a 
depression. Not unfrequently the haematoma is on both sides. We 
have the opportunity, rather frequently, of observing the commence- 
ment of a pachymeningitis hasmorrhagica; for, in many autopsies, we 
lind a delicate yellow or brown connective tissue, larger on the inner 
surface of the dura mater and firmly adherent to its surface. 
Symptoms and Course.—Haemorrhages in the subarachnoid space 
or on the free surface of the arachnoid, do not belong to the “ local ” 
but to the “ diffuse ” diseases of the brain. Hence, when there is no 
complication with cerebral haemorrhage, they are not accompanied by 
the regional symptoms characteristic of this, especially hemiplegia; 
on the other hand, the apoplectic fit is usually uncommonly severe, as 
the bleeding is generally very abundant, and is spread over both sides. 
Frequently the apoplectic fit occurs suddenly without any premonitory 
symptoms, and the patients die with the above-described symptoms of 
apoplexie foudrojrante. When this occurs, we can, at most, make only 
a probable diagnosis, which depends solely on the absence of hemi- 
plegia, the symptoms of which may, as a rule, be distinguished, even 
in the severest fits, from cerebral haemorrhage. In other cases the 
apoplectic stroke is preceded by severe headache, and in some cases 
by general convulsions. Since these symptoms, particularly the latter, 
only occur exceptionally in cerebral haemorrhage, and are often seen 
in extensive disease at the convexity of the hemisphere, they, in con- 
nection with the absence of all signs of hemiplegia, enable us to decide 232 
DISEASES OF THE BRAIN. 
with greater certainty that the case is not one of cerebral but of me- 
ningeal hajmorrhage. 
Heematoma of the dura mater often runs its course with symptoms 
from which the disease cannot be certainly diagnosed, and when it 
occurs in the course of mental affections, as so often happens, we can- 
not usually make even a probable diagnosis. In other cases, the fol- 
lowing factors, to which Griesinger has called attention, enable us, 
with more or less assurance, to make a diagnosis of haematoma of the 
dura mater; if circumscribed headaches, gradually increasing to great 
severity, in the vicinity of the vertex and forehead be the first, and, for 
a long time, the only trouble of which the patients complain ; and if, 
between the appearance of these pains and that of other severe brain- 
symptoms, there be an interval not so short as in acute diseases of the 
brain and its membranes, but shorter than in most chronic diseases of 
these parts, particularly in the different cerebral tumors, the first sus- 
picion falls on inflammation of the meninges, particularly of the dura 
mater, since inflammation of the other membranes has so great a ten- 
dency to spread, that it is accompanied by diffuse, not by circumscribed, 
headache. We are the more justified in this, as the form of pachy- 
meningitis in question occurs just at the point where the patients com- 
plain of pain. If the patient had been mentally diseased before the 
commencement of the headache, or given to drinking excessively, or it 
he had had an injury of the head, particularly of the forehead, some 
time previously, there is still more reason for supposing the case one of 
pachymeningitis, as is evident from the etiology. But we also know 
that this form of meningitis usually leads to a large effusion of blood, 
encroaching on the cerebral cavity, and that then the effusion is cap- 
sulated on one or both sides of the sagittal suture. Hence, if the 
headaches be subsequently accompanied by the signs of compression 
of the capillaries of the cerebrum, by mental disturbances, loss of mem- 
ory, diminished power of thought, increased inclination to sleep, which 
finally increases to coma, a slowly-developing and usually not pure 
hemiplegia, after excluding various brain-diseases, we must think of 
haematoma of the dura mater as being in the first rank of those that 
may possibly be present. Since, in hsematoma of the dura mater, there 
may be reabsorption of the blood and consequent freedom of the brain 
from the pressure on it, a favorable course of the disease and recovery 
of the patient speak for haematoma in doubtful cases. If the effusion 
of blood does not take place gradually, as in the course of the disease 
above described, but occurs suddenly; if it is large and limited to one 
side, the symptoms are those of an abundant haemorrhage in one side 
of the cerebrum. On superficial examination it may appear remarkable 
Lhat, even in large haematomata of one side, there is occasionally no INFLAMMATION OF THE DURA MATER. 
233 
hemiplegia, or else it is very incomplete; but we must bear in mind 
that limmatoma occurs just at the place where the increased pressure 
on one hemisphere is most readily transferred to the other, through 
the free communication between the two sides in the anterior portion 
of the skull, particularly when the haemorrhage comes on slowly. 
Among the symptoms of haematoma, Griesinger also lays stress on 
the almost constant contraction of the pupil, and is inclined to regard 
this as a “ symptom of irritation of the surface.” In the previous 
chapter I attempted to give another explanation of the contraction of 
the pupil (which was also hypothetical) in diseases encroaching on the 
space above the tentorium. 
Treatment.—In the treatment of meningeal haemorrhages, the 
same rules hold good as were given for that of cerebral haemorrhages, 
and we may the rather refer to the former chapter, as it is impossible 
to make an exact diagnosis between the two. 
If we consider the diagnosis of a haematoma as certain, we may, in 
recent cases, apply leeches behind the ears, ice-compresses to the head, 
and give a purge occasionally. In the latter stages, blisters or pustu- 
lating ointments to the nape of the neck suffice. With this treatment 
I have had very good results in two cases that I have observed; still, 
in spite of the very characteristic symptoms in these cases, there may, 
possibly, have been an error of diagnosis. 
INFLAMMATIONS OF THE BRAIN AND ITS MEMBRANES. 
In the following chapters we shall speak—1. Of inflammation of 
the dura mater and its sinus. 2. Of inflammation of the pia mater, 
with puro-fibrinous exudation. 3. Of tuberculous inflammation of the 
pia mater, including acute hydrocephalus. 4. Of epidemic cerebro-spi- 
nal meningitis; and 5. Of inflammation of the brain-substance. Since 
inflammation of the arachnoid cannot be distinguished from that of the 
pia mater, we shall not treat separately of arachnitis. 
CHAPTER YII. 
INFLAMMATION OF THE DURA MATER, INFLAMMATION AND THROM 
BOSIS OF THE CEREBRAL SINUS. 
In the previous chapter we spoke of one form of pachymeningitis, 
because, on account of the haemorrhage it causes, and its clinical 
course, it is most suitably classed among meningeal haemorrhages. 
Now we have only to speak of that form which, since Virchow's studies 
on haematoma of the dura mater, is called pachymeningitis externa. 234 
DISEASES OF THE BRAIN. 
Etiology.—It is very doubtful whether pachymeningitis occurs, as 
a primary and independent disease, from cold and other causes. At 
all events, it is generally secondary, and as such accompanies fissures, 
fractures, and especially caries of the cranial bones, particularly of the 
petrous and ethmoid bones, as well as caries of the upper cervical 
vertebra. In periostitis of the outer surface of the skull also, pachy- 
meningitis occasionally occurs, without our being able to distinguish 
any continuity between the two diseases by changes in the cranium. 
Inflammation of the cerebral sinus, with consequent thrombosis, or 
even thrombosis of the sinus, with subsequent inflammation of its walls, 
occurs proportionately often, being most frequent in the sinus lying on 
the petrous bone, the lateral and petrosal. This is evidently because 
inflammation and thrombosis of the cerebral sinuses are induced, in the 
great majority of cases, by caries of the petrous bone advancing to the 
base of the skull. The numerous patients suffering from tedious 
otorrhoea, as a result of otitis interna, are constantly threatened, as 
with a Damocles’ sword, by inflammation or thrombosis of these si- 
nuses. Not unfrequently there are suppuration and breaking down of 
the thrombus, and then particles of it may enter the efferent veins 
and lead to embolism and metastatic inflammation. 
Anatomical Appearances.—The anatomical changes in mild and 
chronic cases of pachymeningitis externa are limited to a gradual 
thickening of the dura mater as a result of proliferation of connective 
tissue on its outer surface; the dura mater thus becomes firmly 
attached to the cranium, and subsequently the neoplastic tissue partly 
ossifies. In acute and severe cases the dura mater is usually reddened 
by vascular injection and small ecchymoses, is thickened and infiltrated 
in circumscribed spots corresponding to the point of injury or caries 
of the cranial bones. Later, this membrane becomes discolored, its 
tissue is relaxed and softened; finally, there is suppuration, and, if pus 
collects between the dura mater and cranium, the inflamed part be- 
comes detached from the bone. In the latter case the pia mater also 
is almost always inflamed, and generally to a great extent. Even on 
autopsy it is often difficult to decide whether the inflammation of the 
wall of the sinus preceded the thrombosis, or the reverse. If the 
thromboses be not disintegrated, they adhere firmly to the relaxed 
rough inner surface of the thickened wall of the sinus, and occasionally 
extend backward to the torcular Herophili, and in rare cases down to 
the internal jugulars; as has been shown by the observations of Lebert, 
who has very greatly advanced our more accurate knowledge of this 
disease. More frequently on autopsy we find the thrombus already 
broken down, and the inflamed sinus filled with a purulent or sanious, 
occasionally gray-green and stinking fluid, mixed with flocculi. Along INFLAMMATION OF THE CEREBRAL SINUSES. 
235 
with these changes we generally find those of otitis interna, and ex- 
tensive caries of the petrous hone ; viz., destruction of the drum, 
absence of the ossicula, polypoid proliferations of the mucous mem- 
brane, the tympanum full of pus, which also infiltrates the labyrinth, 
cochlea, and mastoid cells. 
Symptoms and Course.—Chronic pachymeningitis, wThich causes 
thickening of the dura mater, and its firm adhesion to the cranium 
and ossification of the thickened layer, may be accompanied by 
headache and other symptoms ; but these are not at all characteristic 
and do not show us what the disease is. The symptoms and course 
of acute pachymeningitis externa also are almost always so modified 
by the symptoms of the original disease, by complications with ex- 
tensive ■infiammation of the pia mater, and by extension of the in- 
flammation to the cerebral sinus with its results, that it is impossible 
to give a pure description of the disease. If an injury of the skull, 
or, still more, if a caries of the temporal bone, due to otorrhcea, be 
accompanied by unusually severe and extensive pain in the vicinity 
of the diseased bone, by fever, vomiting, dizziness, noises in the ear, 
twitching, delirium, and other symptoms of irritation of the brain, 
which are subsequently followed by those of depression, and finally 
by general paralysis, we may conclude that the disease of the bone 
has at first caused inflammation of the dura mater, and later, diffuse 
inflammation of the pia mater. The first stage is often short and 
indistinct, and, on the first visit or at their reception into the hospi- 
tal, we find the patients in deep sopor. But even in such cases the 
above diagnosis may be made with tolerable certainty, if we find an 
injury of the skull, or particularly a chronic otorrhcea, and can dis- 
cover no other causes for the brain-disease. 
The symptoms induced by inflammation and thrombosis of the 
cerebral sinuses are always accompanied by those of meningitis as 
given above; hence it will be enough to limit ourselves to pointing out 
under what circumstances we are to suspect inflammation or thrombo- 
sis of a cerebral sinus, when we have a meningitis or encephalitis ac- 
companying caries of the petrous bone. From the great frequency 
of this complication, I think it is well to keep in view its possibility 
and even its great probability, although the very doubtful signs of the 
disease should be absent. The suspicion will acquire more probabil- 
ity, should we observe a symptom of thrombosis of the transverse 
sinus that was given by Gerhardt with great acuteness, namely, less 
fulness of the jugular vein drawing its blood from the obstructed sinus. 
The same would be true if we found a symptom given by Griesinger, 
which was only observed in one case, a circumscribed painful oedema 
behind the ear ; although, in caries of the mastoid process, this oedema 236 
DISEASES OF THE BRAIN. 
(which Griesinger calls a phlegmasia alba dolens en miniature) may 
arise from other causes than from the extension of the thrombus 
1 hrough the emissaria santorini which pass out in the sigmoid fossa. 
In most cases it is only from the occurrence of rigors and the signs of 
metastatic deposits in the lungs that we can conclude that caries of 
the petrous bone has not only induced meningitis and encephalitis, 
but has also led to thrombosis in the cerebral sinuses. 
Treatment.—On the signs, or even suspicion, of inflammation of 
the dura mater, we should use energetic antiphlogistic treatment by 
repeated application of leeches behind the ears. At the same time, if 
there be any otorrhoea, we should make warm injections into the af- 
fected ear and cover it with cataplasms. Active purges and large 
blisters to the back of the neck are also useful. In other respects, the 
treatment of pachymeningitis corresponds with that of inflammation 
of the pia mater. 
CHAPTER VIII. 
INFLAMMATION OF THE PIA MATER, WITH PURO-FIBRINOUS EXUDA- 
TION—MENINGITIS OF THE CONVEXITY—MENINGITIS SIMPLEX. 
Etiology.—In acute meningitis, an exudation containing man}' 
pus-cells is effused into the subarachnoid space; in chronic meningitis 
there are diffuse cloudiness and thickening of the pia mater and arach- 
noid, from proliferation of the connective tissue. 
Acute meningitis, with puro-fibrinous exudation, is in many cases a 
secondary disease, and as such accompanies injuries and diseases of 
the skull and of the dura mater or other inflammations and other dis- 
eases of the brain. Except in the epidemic form, of which we shall 
speak in Chapter IX., it rarely occurs as an independent disease in pre- 
viously healthy persons, but is somewhat more frequent in cachectic 
individuals or in those exhausted by long illness. Thus it is observed 
in convalescence from pneumonia and pleurisy, or from acute exanthe- 
mata and other infectious diseases, and from protracted diarrhoeas, but 
especially during Bright's disease, etc. Although in these cases we 
frequently cannot discover any new source of injury acting on the 
body, we have no right to consider this inflammation of the pia mater 
as metastatic or even as secondary. The action of the sun’s rays or 
of a very high or even of a very low temperature on the head, chilling 
the body, or getting wet, misuse of liquor, etc., are mentioned among 
the exciting causes of meningitis. But only the last of these causes 
has been proved to have any influence in exciting this disease. Re- 
cently Griesinger has called attention to a form of meningitis which MENINGITIS SIMPLEX. 
237 
appears as one symptom of constitutional syphilis ; and in the Greifs- 
walder clinic I have seen a case of this kind, which has been fully de 
scribed by Professor Ziemssen, at that time my assistant. 
Anatomical Appearances.—Meningitis, with puro-fibrinous exu- 
dation, occurs chiefly on the convexity of the cerebrum. In the acute 
form we there find the small vessels of the pia mater more or less dis* 
tinctly injected, and in the subarachnoid space, especially between 
the convolutions and around the large vessels, we find a yellowish, 
generally firm exudation, consisting of pus-corpuscles and fine granular 
fibrin. In milder grades of the disease the exudation is chiefly in the 
perivascular spaces. Occasionally the arachnoid is at the same time 
covered with a more fibrinous or more purulent coating. The cortical 
substance of the brain is sometimes of normal consistence, sometimes 
it is softened by inflammation. The ventricles which, in tubercular 
basilar meningitis, are almost always filled with fluid, are generally 
found empty in purulent meningitis of the convexity. In chronic me- 
ningitis we usually find the arachnoid adherent to the dura mater 
either by a few points or throughout a considerable extent; the pia 
mater is thickened and cloudy, the subarachnoid spaces filled with 
turbid fluid; or else we find the pia mater also transformed to a firm, 
decidedly thickened membrane, which cannot be removed from the 
brain without tearing. 
Symptoms and Course.—Acute inflammation of the pia mater is 
accompanied by symptoms of severe fever, particularly by a very fre- 
quent pulse, and, like acute and extensive inflammation of other or- 
gans, occasionally begins with a chill. Fever of similar character and 
equal severity occurs in scarcely any other disease of the brain, and 
consequently is very important in the diagnosis of meningitis. If the 
frequency of the pulse disappear after the disease has lasted some 
time, if it fall from 120-140 beats per minute to 60-80 beats, while 
the other symptoms of fever and the functional disturbance of the 
brain increase, the evidence is still more in favor of meningitis. The 
other symptoms of the disease are headache and the repeatedly-men- 
tioned functional disturbance of the brain, partly with the character 
of irritation, partly of depression or complete paralysis. In acute me- 
ningitis, the headache becomes very severe ; patients not only com- 
plain of it while they retain consciousness, but even when this is im- 
paired they frequently grasp the head and moan slightly, so that we 
may suppose they still feel pain. In almost all cases there are psychi- 
cal disturbances even at the outset of the disease, probably from the 
vicinity of the cortical substance; the patients are very excited and 
restless, usually quite sleepless, and soon become delirious. In the 
sensory functions also there is more irritability, so that the patient 238 
DISEASES OF THE BRAIN. 
is very sensitive to light, sound, and even to slight friction on the 
skin. [A mere touch, especially upon the skin of the legs, will make 
the patient cry out; and even after the stage of stupor has set in 
he will wince if touched, showing that reflex irritability still con- 
tinues. This hyperesthesia of the extremities is a sign that the 
meningitis has extended to the spinal cord. Autopsies conducted 
by Gerhardt, both in children and in adults, uniformly support this 
interpretation of the symptom. On the other hand, the contraction 
of the neck-muscles so common in meningitis, which has also been 
ascribed to the coexistence of cerebral and spinal meningitis, is 
found more frequently in pure cerebral meningitis than when com- 
plicated with meningitis of the cord. In some cases a marked draw- 
ing-in of the belly affords a noticeable diagnostic mark.] Finally, 
there are noises in the ears, sparks before the eyes, restlessness, 
gnashing of the teeth, twitchings, and often also contraction of the 
pupil, and vomiting. We have had to mention all these symptoms 
in treating of simple hypergemia of the brain and of hydrocepha- 
loid ; indeed, there is no pathognomonic sign of meningitis which 
is present in this and absent in other brain-diseases. It is true, the 
etiology, the grade of the fever, especially the height of the pulse 
and the unusual severity of the headache, occasionally speak, even 
in this stage, with great probability against simple hypersemia 
or anaemia of the brain ; but frequently it is only the subsequent 
course, the severe accidents that characterize it, the want of success 
in treatment, and the usually fatal result, that render the diagnosis 
certain. 
If any of the characteristic symptoms be absent in the first stage, 
we must give a guarded diagnosis. Frequently only the effect of a 
laxative or of local blood-letting verifies the diagnosis between hy- 
persemia of the brain and meningitis. An attack of convulsions, 
usually preceded by stiffness of the neck, from tonic contraction of 
the muscles of the nape of the neck, often indicates the passage into 
the second stage. In this the patient falls into a deep sopor, becomes 
entirely insensitive to the irritation, and cannot move his limbs, 
although certain muscles, particularly those on the back of the neck, 
are in a state of tonic contraction, and there are general convulsions 
from time to time. [For some time after the commencement of the 
stage of stupor, periods of excitement recur, with delirium and loud 
screaming and convulsive paroxysms. It is remarkable that even at 
this stage of the malady fluctuations occur, with temporary improve- 
ment in the patient’s condition ; sometimes even the consciousness 
returns, and other deceptive signs inspire a hope of final recovery. 
The most important diagnostic marks of depression are the palsies, MENINGITIS SIMPLEX. 
239 
which by their appearance often set at rest any remaining diag- 
nostic doubts. These palsies are rarely complete hemiplegias, and 
seldom are they so marked as when arising from local disease of the 
brain ; but they ought not to escape the attention of any but a su- 
perficial observer. Sometimes an arm or a leg loses its strength. 
More commonly, however, there is a partial palsy of the face, such 
as dilatation of the pupil with insensibility to light, squinting, or the 
like.] The pulse also is usually, but not always, retarded. While 
the stupor and general paralysis increase, the patient generally dies 
of coma in a few days, more rarely not till the second or third week. 
These stages in the clinical course, between which there is occasion- 
ally a slight improvement, cannot be referred to any perceptible 
change in the pathologico-anatomical course ; as if, for instance, the 
first stage corresponded to the hypersemia of the meninges, and the 
second to the exudation in the subarachnoid space. Nor must we 
omit to mention that not unfrequently, especially where the menin- 
gitis is due to caries of the petrous bone or to disease of the brain, 
the first stage is very little marked or not at all noticed. In these 
cases the symptoms begin with an attack of convulsions, which is 
repeated several times, and is followed by deep coma and general 
paralysis, usually accompanied by contraction of certain muscles. 
[Stories of recovery from acute meningitis must be accepted 
with hesitation, error of diagnosis being a more probable event. 
Nevertheless, limited and mild inflammations of the pia mater un- 
doubtedly have got well, but convalescence is very slow, and various 
derangements of the nervous apparatus persist for a long time. In 
chronic cases, and less often in acute ones, there may be imperfect 
recoveries, with permanent damage to the meninges and cortical 
matter of the brain—with trembling paresis, numbness of a limb, 
squinting, or deafness ; sometimes there are epileptic fits. The pro- 
gressive palsy of the insane appears to depend upon a creeping 
inflammation of the meninges and upon periencephalitis, with occa- 
sional exacerbations and rises of temperature. The periods of men- 
tal excitement, headache, and convulsions correspond to those of 
elevation of temperature. Many other cases of insanity, character- 
ized by psychical depression and ending in idiocy, must also be 
attributed to permanent injury to the cortical substance and menin- 
ges from inflammation. 
The diagnosis of meningitis may present great difficulties. It 
has no pathognomonic symptom, and it is only by a careful grouping 
of the signs and a history of the case that a positive determination 
can be made.] 
The symptoms of chronic meningitis are not accurately known, fre- 240 
DISEASES OF THE BRAIN. 
quently as its remains are found on autopsy of drunkards and insane 
patients. This is especially true of the commencement of the disease. 
It is probable that it is accompanied by headache and functional dis- 
turbance of the brain of an irritative character; but in drunkards, for 
instance, it will always be doubtful whether these are symptoms of 
inflammation of the brain or of alcoholic poisoning. The advanced 
stages of the disease may be more readily made out. If, in a patient 
who has been exposed to the above causes, and in whom we can ex- 
clude other brain-diseases, we find decided impairment of memory, dul- 
ness of intellect, disjointed frame of mind, if there be also trembling 
of the limbs, tottering gait, and other symptoms of gradually-progress- 
ing paralysis, we may diagnose chronic meningitis. 
Treatment.—There is no doubt that favorable results are some- 
times attained by active treatment in acute meningitis with puro-fibri- 
nous exudation. It is not generally proper to bleed from the arm, but 
we may apply leeches to the brow and behind the ears, and, if the 
strength of the patient permit, may repeat the application. We may 
also cover the shaved head with cold compresses, and give an active 
purge of calomel and jalap. In the later stages of the disease, if, in 
spite of the previous treatment, there be coma and other signs of cere-. 
bral palsy, w'e may apply a large blister to the nape of the neck, and 
rub pustulating ointment on the head. Still more efficacious than 
these derivatives are douche baths, pouring cold water over the head 
from a pitcher held some distance above it. The patients almost al- 
ways recover consciousness as this is being done; but, it must be re- 
peated at intervals of a few hours, to secure a permanent result; with 
each successive employment of the douche we must increase the num- 
ber of pitcherfuls. I shall lastly mention that frictions with mercurial 
ointment, and the continued administration of calomel, are much em- 
ployed. In chronic meningitis, Kruekenberg also recommended cold 
douche baths as the most efficacious treatment. He particularly quoted 
the case of an old official, over whose head he daily poured as much as 
fifty pitcherfuls of cold water. 
CHAPTER IX. 
BASILAR MENINGITIS, TUBERCULOUS INFLAMMATION, AND SIMPLE MIL- 
IARY TUBERCULOSIS OF THE PIA MATER ACUTE HYDROCEPHALUS. 
Etiology.—In basilar meningitis there is a deposit, in the sub- 
arachnoid space at the base of the brain, of a readily-coagulating exu- 
dation, containing few pus-corpuscles. At the same time, there are 
almost always tubercular granulations in the meninges, causing a form ACUTE HYDROCEPHALUS. 
241 
of disease designated as tuberculous basilar meningitis. This must be 
distinguished from simple miliary tuberculosis of the meninges, where 
the development of tubercle is not accompanied by inflammation and 
exudation, because the symptoms and course of the two diseases differ 
in some respects. Both basilar meningitis and simple tuberculosis of 
the meninges almost always cause effusions of fluid in the ventricles, 
and softening of their walls and the surrounding parts. The latter is 
the result of maceration, or destruction of the brain-substance by a 
simple transudation or inflammatory exudation. 
Tuberculous basilar meningitis, as well as miliary tuberculosis of 
the meninges, rarely occurs, as a primary and independent disease, in 
persons previously healthy. We must bear this in mind, as it is very 
important for the differential diagnosis of the various forms of menin- 
gitis. These diseases are most frequently parts of a general acute or 
chronic miliary tuberculosis, or, at least, of one affecting most of the 
organs of the body. This form of the disease has many victims among 
those children of whom, when speaking of pulmonary tuberculosis, we 
said they had a strong predisposition to pulmonary consumption, if 
they did not die early of croup or hydrocephalus. These are not only 
children with marked scrofulous diseases, but also the offspring of con- 
sumptive or otherwise debilitated parents. They are badly nourished, 
and not well developed physically, but are often very bright men- 
tally ; have a fine skin, very perceptible veins, long eye-lashes, and a 
blue sclera. Caseous degeneration of the bronchial and mesenteric 
glands, caseous deposits in the lungs, and other old disturbances of 
nutrition, which, along with fresh deposits of tubercle in different 
organs, are found on autopsy of these children, if they finally die of 
hydrocephalus, cannot usually be recognized with certainty during life; 
hence the brain-affection is regarded as a primary disease. The case 
is different when the tuberculous inflammation or miliary tuberculosis 
of the meninges attacks adults. For then the symptoms of meningeal 
tuberculosis have either been preceded, for a short time, by those of 
acute miliary tuberculosis, or, more frequently, for a long time, by those 
of chronic consumption of the lungs. In other cases, tuberculous me- 
ningitis and miliary tuberculosis of the meninges accompany old 
tuberculous affections, such as chronic pulmonary or cerebral tubercu- 
losis, and cheesy degeneration of the bronchial and mesenteric glands, 
but are not accompanied by fresh deposits of miliary tubercle in other 
organs; they form the only acute complication of these chronic tuber- 
culous affections. Lastly, although rarely, tuberculous meningitis or 
miliary tuberculosis of the meninges occurs, without any precedent 
tuberculosis of other organs, in previously healthy persons, or during 
convalescence from severe diseases, such as typhus, measles, etc. 242 
DISEASES OF THE BRAIN. 
During the first year of life, tuberculosis of the meninges is rare; 
.ater, during childhood, it is proportionately frequent; in adults, only 
solitary cases occur, except where it complicates chronic pulmonary 
consumption. Among the exciting causes, premature or excessive 
mental exertion is blamed most frequently for exciting hydrocephalus 
in children; this is probably unjust. Cliildren not predisposed to it 
may be mentally stimulated to any extent without inducing h}?dro- 
cephalus; and the early development of children falling a prey to this 
disease is due to their predisposition, not to their bringing up; this is 
not the cause of their hydrocephalus. The same is true of the asser- 
tion that a blow or fall on the head induces tuberculosis of the menin- 
ges and acute hydrocephalus. It is almost always easy to make out 
that the sick child has, some time or other, fallen on its head; but it 
does not thence follow that this fall is to be regarded as the cause of 
his disease. 
Anatomical Appearances.—In basilar meningitis we find a yel- 
lowish, opaque exudation, which is sometimes very plentiful, in the 
meshes between the pia mater and arachnoid, especially about the 
optic chiasm, as well as in the portions of the meninges extending 
toward the pons and medulla oblongata, and thence along the larger 
cerebral fissures, particularly the fossa of Silvius, toward the convex 
surface of the brain. At the same time, we almost always find the 
pia mater covered with whitish granulations, the size of a grain of 
sand or a hemp-seed, most distinctly so in the vicinity of the blood- 
vessels. 
In simple miliary tuberculosis of the meninges the changes are less 
marked, and it is only on careful examination at the above places that 
we find numerous, usually very small, whitish, granular opacities of 
the pia mater, whose significance is often only rendered evident by the 
coincident occurrence of hydrocephalus and the presence of tubercle 
granulations in other organs. 
. In both forms, the ventricles, especially the lateral and the third 
ventricles, are sometimes moderately, sometimes considerably dilated 
by serous fluid. The latter is occasionally quite clear, but is usually 
clouded by flocculf. The walls of the ventricle, but especially of the 
fornix and commissures, are at the same time so softened that they 
usually break down on the slightest touch. This (hydrocephalic) soft- 
ening spreads indefinitely, often far beyond the immediate neighbor- 
hood of the ventricle. The larger the effusion in the ventricles, the 
more bloodless and pale the brain becomes, and the whiter the soft- 
ened parts. 
Symptoms and Course.—There is no symptom pathognomonic cf 
Dasilar meningitis, and which alone will render a diagnosis possible. ACUTE HYDROCEPHALUS. 
243 
Nevertheless, the disease is almost always easy to recognize and to 
distinguish from other diseases. Characteristic peculiarities in the 
sequence of the symptoms, distinct signs from which the original seal 
of the affection and its subsequent extension may be determined, as 
well as the very regular subacute course of the disease, almost always 
give sufficient grounds for a certain diagnosis. At the commencement 
it is a local disease, situated at some point on the base of the brain, 
where numerous nerves start from that organ and run to the foramina 
through which they leave the skull. Later, when the disease extends 
to the ventricles, the local disease at the base becomes complicated, by 
the excessive effusion in the ventricles and by extensive hydrocephalic 
softening of the brain-substance, with diffuse disease of the cerebrum. 
In accordance with this, among the most constant symptoms of basilar 
meningitis are such as indicate irritation and afterward paralysis in 
the parts supplied by the nerves of the eye, the vagus and medulla 
oblongata. Among these are contraction and, later, dilatation of the 
pupil, ptosis of the upper eyelids, vomiting, slowness and subsequent 
frequence of the pulse, the peculiar changes of the respiration, and de- 
pression of the abdomen, according to the results of Budge's observa- 
tions. In the same way, corresponding to the course of the patho- 
logico-anatomical changes, the functions of the cerebrum at first show 
no marked disturbance, except the symptoms of so-called general cere- 
bral irritation, while, as the disease advances, there is severe disturb- 
ance, of the character that we have frequently mentioned as due to 
compression of the capillaries by diseases encroaching on the space; 
such as loss of consciousness, epileptiform convulsions, paralysis of the 
extremities, etc. In cases where this second set of symptoms is not 
very marked, we may even conclude that the effusion in the ventricles 
is not very large. Lastly, when the symptoms of paralysis are limited 
to one side in certain cases, or are more decided on one side than on 
the other, it is usually because the hydrocephalic softening is more ad- 
vanced on one side than on the other. 
Although basilar meningitis, particularly its tuberculous form, and 
miliary tuberculosis of the meninges, very rarely occur in persons pre- 
viously healthy, we must not count among its premonitory symptoms 
those of the diseases which it usually accompanies. On the other 
hand, in most cases, especially in children, the violent symptoms char- 
acteristic of a later stage of the disease are usually preceded for a time 
by insidious and indefinite symptoms, which may correctly be consid- 
ered as premonitory. Such children show a change of manner, have 
no desire to play, like to sit in a corner, rest the head on the hands, are 
sieepy, and dream a great deal. They do not always complain of 
severe headache, and when they do it is especially in cases where therr 244 
DISEASES OF THE BRAIN. 
£ not simple miliary tuberculosis, but a tuberculous inflammation of 
the meninges. During these symptoms, which usually last for several 
weeks, the children become emaciated because their digestion is im- 
paired, and probably also because they have fever. Nevertheless, it 
often happens that the mother overlooks or pays little attention to 
this period, and subsequently, when severe symptoms appear, assures 
the physician that the child was suddenly taken sick. We must know 
how important it is to decide whether there is the beginning of a new 
disease, or the commencement of the final stage of an old one, so as to 
make a more accurate examination. I have often found that the rela- 
tives and neighbors had noticed the altered manners of the child, while 
the mother had entirely overlooked them. 
If the above symptoms be accompanied by vomiting, which cannot 
be traced to errors of diet, and does not occur after eating, but when 
the child is raised up, if the patient at the same time suffer from con- 
stipation and the abdomen is sunken, the physician must regard the 
case as very serious, although the parents usually think it free from 
danger. The little patients soon begin to complain more of their 
heads; they become sensitive to light and sound, gnash their teeth 
during sleep, and occasionally give a piercing cry (crie hydroceplxa- 
lique). From time to time we see twitchings of certain limbs, or sud- 
den spasm of the entire body. The patients start from their sleep 
with terror at some dream, and do not find relief from it even in wak- 
ing. They are very much excited, and often repeat the same word or 
phrase innumerable times. At this time the pupils are usually con- 
tracted and the pulse is more frequent. When these symptoms succeed 
the premonitory stage, and when we at last see the child bending its 
head backward, boring into the pillows, with the muscles of its neck 
contracted, and the cervical lymphatic glands swollen, we become cer- 
tain of the sorrowful fact. 
After a few days, or even sooner, the scene usually changes very 
suddenly. The passage into the second stage is generally marked by 
an attack of general convulsions, such as we have already described. 
The vomiting then becomes rarer or ceases entirely, the children no 
longer complain of pain, but put their hands to their heads in a pecu- 
liar way; loud noise does not disturb them, and they do not turn the 
face away if a bright light be held before it; the peculiar cry and the 
gnashing of the teeth continue. We often find the muscles of some 
of the limbs or of one half the body slightly contracted, while those of 
the other side are relaxed. Now the previously-contracted pupils be- 
come dilated, occasionally first one, then the other; the children no 
longer regard objects held before them, and they begin to squint. The 
previously-frequent pulse becomes sloAver, falling to sixty beats a ACUTE HYDROCEPHALUS. 
245 
minute or even less. The respiration generally shows very peculiar 
changes; for a time the inspirations are very superficial, and it almost 
looks as if the child forgot to breathe; then there is a deep sighing in- 
spiration with which it repairs the neglect, as it were. The coma 
gradually becomes deeper; the lucid intervals that at first interrupted 
it grow more incomplete and shorter; the eyelids are either not 
closed, and the eye stares into space, or else the upper lid droops, and 
the eyeball is rolled up, so that the pupil is half covered by the upper 
lid. At the same time the color of the face often changes in a short 
time, and such a child, with its blooming cheeks, widely-open eyes, 
which have a peculiar dark and brilliant appearance from the dilata- 
tion of the pupil, has, to an uninitiated person, the appearance of not 
being very sick. During this stage there usually are attacks of con- 
vulsions at intervals; these are sometimes on one side of the body, 
sometimes on both. We must not conclude, from the convulsions on 
one side the body, that the opposite side of the brain is chiefly affected. 
The tetanic contractions of the muscles on the back of the neck, and 
the backward curvature of the neck, usually continue in this stage. 
The stage of the disease last described occasionally continues a 
week or more. In spite of the hopelessness of the patient’s state, the 
physician must continue his visits, and at each one he is asked anew 
if there is no chance of averting the danger; at last the parents are 
utterly overcome, but even then the disease occasionally continues for 
days, or a temporary appearance of improvement again excites deceit- 
ful hopes. These are hard times for the physician, especially as he is 
almost powerless against the slowly-advancing but inevitable result; 
and as, for days, he has but little to do except prepare the parents for 
the child’s death. We must note that death is not imminent till some 
decided changes occur in the symptoms, to which it is well to call the 
attention of the attendants. Almost always twelve to twenty-four 
hours before death the pulse becomes very frequent, the skin is covered 
with copious perspiration, the previously-sunken belly becomes puffed 
up; defecation and urination are involuntary, and we may hear exten- 
sive moist and uneven rdles in the chest. 
Most cases of tuberculous basilar meningitis, and of miliary tuber- 
culosis of the meninges in children, run their course in the above man- 
ner and resemble each ’other very much. Slight differences result from 
the predominance of certain symptoms, and from the different dura- 
tions of certain stages or of the whole disease. But we must add that 
in some cases the disease runs a much more rapid course, and is accom- 
panied by symptoms so similar to those of acute meningitis, that it is 
impossible to distinguish them. On the other hand, we must mention 
that occasionally, on autopsy of patients who have died of consump 246 
DISEASES OF THE BRAIN 
tlon, we find miliary tuberculosis of the meninges, and slight amounts 
of hydrocephalus, which were not indicated by any prominent symp- 
toms during life. These cases seem to show that, in the description 
of the disease first given, the premonitory stage belonged to the com- 
mencement of the cerebral affection, and not to its complications or to 
the general tuberculosis. Lastly, we must point out that tuberculous 
basilar meningitis, and miliary tuberculosis of the meninges, develop- 
ing during advanced pulmonary consumption in adults, have no dis- 
tinct premonitory symptoms, but are first recognized from the occur- 
rence of contractions of the muscles of the nape of the neck, coma, 
slow pulse, dilatation of the pupil, and the other symptoms of the fully- 
formed disease. Death is the most frequent termination. Well- 
proved cases of recovery are very rare; but, even excepting the cases 
where the diagnosis was somewhat uncertain, there is no doubt that it 
has occurred. Neither the ordinarily variable course of the disease, nor 
the surprising remissions that usually occur, should induce us to give a 
more favorable prognosis; only a continued improvement of all the symp- 
toms dare excite the hope that the disease will take a favorable course. 
Treatment.—Until within a short time, the treatment of tuber- 
culous meningitis and acute hydrocephalus presented no difficulty to 
the physician. The inflammation of so important an organ naturally 
required the employment of all kinds of antiplilogistics. At the out- 
set of the disease, venesections were ordered, calomel and flor. zinci 
were administered, and mercurial ointment was rubbed in the nape of 
the neck, then the occurrence of calomel stools, or the first signs of 
salivation, were anxiously awaited, for they were a guaranty for the 
efficacy of the treatment. In the later stages, absorption of the exuda- 
tion was to be induced; hence the mercurial frictions were continued, 
and diuretics and active derivatives, even moxa on the shaved scalp, 
or pustulating ointments to it, wTere prescribed. If, in spite of all this, 
the paralysis continued to advance, an infusion of arnica and camphor 
was given. The more this disease was recognized as one symptom of 
extensive tuberculosis, the more antiphlogistic treatment was aban- 
doned ; then the opposite error was fallen into, either nothing was 
done (expectant treatment), or else all the efforts were directed to the 
cure of the tuberculous dyscrasia. The best mode of treatment of 
tuberculous meningitis and miliary tuberculosis of the meninges 
's as follows: At the commencement of the disease, especiallj 
when severe headache indicates tuberculous inflammation rathei 
than simple miliary tuberculosis, we should apply leeches behind 
the ears. This is the more urgently to be advised, as in this stage 
an exact diagnosis of the different forms of meningitis is scarcely 
possible, and we do not certainly know whether the disease EPIDEMIC CEREBRO-SPINAL MENINGITIS. 
247 
is not at first a simple inflammation of the meninges, which is sub- 
sequently accompanied by the development of the tubercle, after 
repeated relapse of the inflammation. When the local abstraction of 
blood proves beneficial, it may be repeated during subsequent relapses. 
In these cases, at the onset of the disease, laxatives and ice compresses 
may also be used. Otherwise the treatment is the same as that for 
meningitis, with puro-fibrinous exudation. But the treatment must be 
entirely different when the inflammatory symptoms are less decided, 
when the headacne is slight, and the disease drags on slowly. Then 
a single venesection is admissible, it is true, but it rarely has even a 
temporary effect, and its repetition is almost always injurious. On 
the strength of two successful cases, opposed, it is true, by a large num- 
ber of unsuccessful ones, I recommend large doses of iodide of potas- 
sium, continued for a long time. In the cases above mentioned, where 
recovery took place under this treatment, there was a very extensive 
iodine eruption, and an iodine catarrh of the nose. These signs of 
iodism were absent in the unsuccessful cases. It cannot be denied 
that cold douches have a palliative effect, but I would advise against 
their use in marked cases of tuberculous basilar meningitis, and con- 
sequent acute hydrocephalus. During the affusion, the children almost 
always recover consciousness, but it is only for a short time. More- 
over, when not successful, the operation is very painful, not for the 
children, but for the persons around. The latter feel very much 
pained that the child was worried at the last, when it could not be 
assisted. The same is true of the application of moxse, and of frictions 
to the scalp with tartar-emetic ointment. Ilcisse recommends very 
small doses of morphia of a grain) even in the early stages, as he 
has seen undoubtedly beneficial effects from it in some cases. 
CHAPTER X. 
EPIDEMIC CEREBRO-SPINAL MENINGITIS. 
From the fatal epidemics of this disease which have occurred of 
late years in Germany, cerebro-spinal meningitis has acquired a great 
interest for German physicians, to whom it was previously almost ex- 
clusively known from the accounts of French observers. In 1865, 1 
wrote a treatise on epidemic cerebro-spinal meningitis; this article was 
ivell received on many sides, but also caused some opposition, because, 
m spite of the small number of my observations, I had ventured to 
make various hypotheses concerning the nature of the disease and the 
indications of the symptoms. But, on careful examination of the ex 
tensive literature on the subject, of late years, I have found nothing 248 
DISEASES OF TIIE BRAIN. 
decidedly new, and have satisfied myself that my views had been gen- 
erally received; so, in the present chapter, I shall chiefly follow my 
previous work. 
Etiology.—We are unacquainted with the injurious power whose 
action induces this form of meningitis, and whose spread over greater 
or less extents of country excites more or less extensive epidemics of 
the disease. But we may regard it as very probable that epidemic 
cerebro-spinal meningitis does not depend on atmospheric or telluric 
influences, but is rather due to an infection of the body wTith a specific 
poison. It is true, the occasional frequent occurrence of a disease in 
regions generally free from it, and even the affection of several mem- 
bers of the same family, do not alone justify the conclusion that the 
disease depends on infection. But the passage of an epidemic from 
place to place, as is often seen in epidemic cerebro-spinal meningitis, 
is an important evidence of miasmatic extension. Apparently there 
is no transfer of the disease by contagion, although solitary instances 
are brought up to prove the infection of one person from another. 
But cerebro-spinal meningitis does not, by any means, belong to 
that class of infectious diseases, of which we may take typhus as an 
example, and of which we shall hereafter speak in a separate section. 
The consideration of this disease as a peculiar form of typhus, which 
was formerly so common in France, has been entirely disproved 
during the late epidemic in Germany. I separate this affection from 
classes of infectious diseases to which the different forms of typhus 
belong, on the following grounds: In the latter, the severe con- 
stitutional symptoms, especially the fever, for the most part, depend 
immediately on the reception of the infecting material into the blood, 
and the anatomical changes in the organs, caused by the infection, are 
very peculiar; they are induced only by infection with the specific 
poison. In epidemic cerebro-spinal meningitis, on the contrary, the 
fever and all other symptoms depend solely on the local disease in- 
duced by the infection, and on its injurious effect on the body, just as 
they do in croupous pneumonia or in erysipelas; and the changes in 
the meninges of the brain and spine are just the same as those some- 
times induced in other ways. This circumstance also induces me to 
treat of cerebro-spinal meningitis amcng the local diseases, in spite of 
its miasmatic origin. 
Epidemics of this disease are more frequent in winter than in sum- 
mer, and usually disappear as warm weather begins. But there are 
exceptions to this, which contrast very remarkably with most epidemic 
diseases. Among the different ages, childhood has the greatest quota 
of cases and deaths. Persons of middle age are often attacked also, 
while the aged are rarely affected. Unfavorable hygienic influences EPIDEMIC CEREBRO-SPINAL MENINGITIS. 
249 
of all kinds, among which are crowding of barracks, dwellings, etc., 
favor the outbreak of the disease. Persons exposed to these influences 
are in greater danger, at times of epidemics, than those who live under 
more favorable circumstances. 
Anatomical Appearances.—In recent cases, the result of au- 
topsy is almost always as follows: The subjects show no emaciation, 
protracted rigor mortis, or extensive hypostasis; there are often groups 
of dried herpes vesicles on the face and other parts of the body; the 
muscles are dark; in rare cases they are pale (Ziemssen). 
The cranium contains much blood; in the longitudinal sinus there 
is abundant fluid, or softly-coagulated blood; the dura mater is more 
or less tense, and occasionally covered with small haemorrhagic or pa- 
chymeningitic deposits. There is usually no effusion between the dura 
mater and arachnoid; in the subarachnoid space there is an exudation, 
which, both in extent and character, occupies about a medium position 
between the pure purulent exudation in meningitis of the convexity 
and the puro-serous exudation in basilar meningitis. In almost all 
cases, the convexity of the cerebrum and the base of the brain are 
affected at the same time, the latter usually the more severely. The 
exudation appears to be peculiarly plentiful about the chiasm, in the 
fossa Sylvii, at the base of the cerebellum, and in the fissures of the 
cerebrum. The nerves, from the base of the brain, are often entirely 
embedded in it. The brain itself is more or less vascular, almost al- 
ways less resistant, even becoming pulpy in the vicinity of the ventri- 
cles; the latter generally contain small amounts of purulent fluid, 
rarely large quantities of clear serum. 
The dura mater of the spine is more or less vascular, occasionally 
very tense, especially at the lower part. Between the dura mater and 
spinal arachnoid there is rarely a clear or purulent opaque fluid. The 
arachnoid usually presents no peculiarity except a decided opacity. 
There is more or less purulent fluid between it and the pia mater. 
The tissue of the pia mater is infiltrated with sero-purulent exudation. 
This infiltration extends very irregularly; in most cases the cervical 
portion is free; the process first begins in the dorsal region, thence 
extends toward the cauda equina, and is almost exclusively on the pos- 
terior surface. The purulently-infiltrated spots form irregular humps, 
broader in the middle, smaller at the ends, which are usually connected 
together by small striae accompanying the larger vessels. Even where 
the pia mater does not contain this puro-serous infiltration, its tissue 
appears thickened and cloudy. The spinal medulla itself is more or 
less vascular, occasionally infiltrated and relaxed. In a case related 
by Ziemssen, the central canal was dilated and filled with purulent 
fluid. 250 
DISEASES OF THE BRAIN. 
Except some accidental complications, there are no particular anom- 
alies of the other organs; we should especially note here that the 
spleen is almost always normal. 
The post-mortem appearances, in protracted cases, are known only 
from a very few observations. In one such case I found the exudation 
thickened, and partly affected with caseous metamorphosis, as well as 
considerable fluid in the ventricles. The same appearances have been 
noted by other authors. 
Symptoms and Course.—I must again repeat that the symptoms 
and course of epidemic cerebro-spinal meningitis may be fully explained 
by the changes in the meninges of the brain and spine, and that, on 
this account, the malady differs from most other infectious diseases. 
Every thing that has been advanced in opposition to this view may be 
refuted by the simple fact that, in genuine croupous pneumonia, which 
no one classes among the infectious diseases, certain symptoms, such 
as the frequent herpetic eruptions, albuminuria, etc., are just as diffi- 
cult to explain, from the inflammatory changes in the lung and the 
copious exudation in the alveoli, as are some of the occasional symp- 
toms of epidemic cerebro-spinal meningitis. 
Only in rare cases is the outbreak of the disease preceded by a 
premonitory stage, characterized by slight headache and pain in the 
back. Usually the scene opens Avith an unexpected chill of variable 
duration, \vhich is soon accompanied by severe headache, and in most 
cases by vomiting. The headache rapidly becomes very severe, the 
patient grows very restless, tosses about constantly, the pupils are con- 
tracted, the intellect remains clear. The pulse is 80-100, the bodily 
temperature moderate, the inspirations increase to 30-40 per minute. 
Even at the end of the first or second day, rarely later, Ave notice 
that the head is draAvn backAvard. At this time there is often a 
herpetic eruption near the mouth, on the cheeks, eyelids, ears, and oc- 
casionally on the extremities. The complaints about severe headache 
continue; the pain extends from the head to the nape of the neck and 
the back. The restlessness becomes excessive, the ideas confused, the 
pupils remain contracted, the belly is sunken, and the bowels are con- 
stipated. The pulse and respiration become more frequent, occasion- 
ally the pulse is over 120 and the respiration over 40 per minute; 
the bodily temperature still remains proportionately Ioav, or rises to 
103° or over. The third or fourth day of the disease the tetanic con- 
tractions of the muscles of the neck and back become more eAddent, 
and are occasionally accompanied by trismus ; there is excessive opis- 
thotonus ; consciousness is lost, but the patient still tosses about in bed, 
the pupils remain contracted, constipation continues, the belly is sunk- 
en, urine is passed iiwoluntarily, or else the bladder becomes distend- EPIDEMIC CEREBRO-SPINAL MENINGITIS. 
251 
ed, and must be evacuated with the catheter. The now unconscious 
patient falls into deep stupor, the moaning respiration is accompanied 
by moist rales, and death occurs with the symptoms of acute oedema 
of the lungs. 
In some particularly severe cases the above symptoms develop far 
more rapidly; consciousness is lost even during the first day, while 
severe tetanic spasms of muscles of the neck and back draw the head 
far backward. Death may occur even on the first or second day, when 
the disease is very malignant. 
Lastly, in some few cases (of which there can be no doubt) the dis 
ease runs a still more rapid course, and causes death in a few hours, 
from general paralysis, occasionally even without the appearance of 
the most characteristic tetanic symptoms {m'enmgite foudroyante). 
But the disease does not by any means always terminate fatally 
when it has commenced and run its course for the first few days in the 
manner above described. As favorable signs, v?e usually first notice 
that there is less jactitation, and the mind becomes clearer, while the 
complaints of pain in the head and back and the tetanus of the cervi- 
cal and dorsal muscles continue, or only slightly decrease. If the im- 
provement progresses, all symptoms of the disease may disappear in 
a few days, and the patient begin his tedious convalescence. 
Occasionally improvement begins, but does not continue, and the 
disease drags on. In such cases convalescence may not occur for 
weeks. Headache, contraction of the neck or opisthotonus continue. 
Paralysis of the motor and psychical functions causes a complicated 
series of symptoms, and the majority of such patients finally die of 
gradually-increasing marasmus. 
Lastly, I must mention the occasionally intermittent course of the 
disease. I have only seen one such case. Hirsch distinguishes three 
forms of the intermittent course: in the first it only occurs in the first 
stage; one or more attacks of evident premonitory symptoms pass 
away, but another follows which is immediately succeeded by the out- 
break of the disease. In the second form there is a sudden remission 
of the symptoms; these again grow worse the next day, and occasion- 
ally this alternation occurs several times, usually with a more or less 
regular quotidian type. In the third form, which is far the most fre- 
quent (to which my case belonged), perfect intermissions are seen 
during convalescence. The symptoms remaining after the disease, 
particularly headache and stiff neck, regularly increase very consider- 
ably for some time, usually with a quotidian type, while in the inter- 
val the patient feels quite comfortable. 
To the above view of the symptoms and course of cerebro-spinal me- 
ningitis I will now add a short description of the individual symptoms, 252 
DISEASES OF THE BRAIN. 
noth of those that I have already mentioned, and of others of which 1 have 
not yet spoken, as they are less constant. Severe headache occurs even 
in those cases which, as meningite foudroyante, terminate in death in a 
few hours. In the cases that run the usual course, as long as the pa- 
tients retain consciousness they complain of headache, either sponta- 
neously or on being questioned, and it also seems as if the restless- 
ness, groaning, and complaints of the patients, after the intellect is 
clouded, were partly due to the headache. Lastly, during an epidemic 
of this disease, there are almost always a few cases where, without 
the disease actually occurring, persons complain of very severe head- 
ache continuing for several days without any other apparent cause. 
We may consider such cases as abortive forms. 
Cervical and dorsal pains usually begin very early either with the 
headache or very soon after; they are generally increased by pressure 
on the spinal processes of the vertebrae; with rare exceptions, this 
pain is far greater when the patients make voluntary movements of 
the spine or on passive motion being made. If the disease be pro- 
tracted, the dorsal pains and their increase by movements of the spine 
may continue for weeks. 
Painful sensations in the extremities, unmistakably neuralgic in 
their nature, and caused by irritation of the posterior roots of the spi- 
nal column, are not constant symptoms; occasionally they only occur 
on motion of the spine. 
Ilypercesthesia and Anaesthesia of the Shin.—Usually for the first 
days of the disease, and in some cases during its whole course, the pa- 
tients are very sensitive to any rough handling; their restlessness, 
groaning, and complaints are increased when they are turned over in 
bed, occasionally even if they be percussed. Later, we often see no 
reaction even when the skin is greatly irritated; but in such cases, 
when the patients are in a state of stupor, there is cerebral anaesthesia. 
Far more rarely, there is peripheral anaesthesia, during which, while 
the patient is quite conscious, he feels irritation of the skin very little 
or not at all. This symptom apparently depends on loss of excitabil- 
ity of the posterior roots from inflammation. 
Tetanic spasms of the cervical and dorsal muscles are only absent 
in some few cases of mdningite foudroyante. At first the head is only 
slightly retracted, later it may form almost a right angle with the 
body. This position of the head and the addition of opisthotonos in 
the dorsal and lumbar regions usually render it impossible for the pa- 
tient to lie on the back. If the tetanus attain a high grade, it almost 
always affects the respiration. Occasionally it disappears shortly be- 
fore death; more frequently it continues more or less severe till death 
or convalescence. EPIDEMIC CEREBEO-SPINAL MENINGITIS. 
253 
Epileptiform convulsions are rare, which is very remarkable, con 
sidering the exudation is often widely spread over the convexity of the 
hemispheres. 
jParalysis.—Usually there is no actual paralysis till death; but 
there are a few cases where hemiplegia or paraplegia, and quite a 
number where paralysis of the facial, oculomotor, or of the abducens, 
were observed. It is not at all difficult to explain these paralyses; on 
the contrary, it is almost wonderful they are not more frequent. 
Psychical Disturbances.—At the commencement of the disease, 
the intellect is almost always unclouded; the patients answer ques- 
tions correctly. But they soon become ill at ease and very restless. 
Then questions prove annoying, and they will only give short and in- 
complete answers. The incessant jactitation, which is scarcely inter- 
rupted by pauses of a few minutes, is very characteristic in the first 
stage of the disease. Subsequently most patients have delirium of 
variable intensity, which finally gives place to a soporose condition. 
Disturbances in the Organs of Special Sense.—Patients not un- 
frequently become blind from keratitis, which is probably induced by 
incomplete closure of the eyelids, due to paresis of the orbicularis 
palpebrarum, or from exudative choroiditis and neuro-retinitis, prob- 
ably a result of direct propagation of the purulent infiltration along 
the optic nerve from the cranium to the eye. Deafness is remarkably 
frequent, so that we are almost obliged to suppose that it has several 
causes, among which, however, the most important, doubtless, is the 
propagation of purulent infiltration along the auditory nerve to the in- 
ternal ear. 
Among the eruptions, groups of herpes vesicles in large numbers 
are very often seen, and more rarely erythema, roseola, urticaria, pete- 
chia, and sudamina. The frequency of the exanthemata, and particularly 
the occasional symmetry of their occurrence, have led to the supposition 
that they might depend on irritation of the cutaneous nerves, as Dcir 
rcnsprung has shown to be the case in herpes zoster from neuralgia. 
According to Ziemsserfs numerous and accurate observations, the 
fever has no regular course. Very few temperature curves resemble 
each other; sudden leaps and exacerbations of short duration often 
occur. But generally a remitting type, with exacerbations of half a 
degree to a degree, is most frequent. Very high temperatures are al- 
most exclusively seen in severe cases that terminate fatally. In most 
cases the temperature does not rise above 103°. The intermittent 
fever that occasionally accompanies the other symptoms during conva- 
lescence is regarded by Ziemssen as a reabsorbing fever, while he re- 
fers that occurring during the first and second weeks to an interrupted 
progress of the meningitis. The frequency of the pulse does not at 254 
DISEASES OF TIIE DRAIN. 
all accord with the height of the fever; with moderate fever it is oc- 
casionally very high; slowness of the pulse is only rarely observed at 
the commencement of the fever. 
Treatment.—Just as in other malignant and fatal epidemics, in 
deciding the best means of treatment, we must only consider cases 
where there is at least a slight hope of recovery. Whoever tries any 
proposed plan only on the severest cases will attain negative results 
by any procedure. The customary treatment of sporadic meningitis, 
consisting of the energetic use of cold as ice-compresses to the head, 
the application of leeches behind the ears, and the internal adminis- 
tration of calomel, is also advisable in epidemic cerebro-spinal menin- 
gitis, as is very evident from its excellent effect in patients attacked 
by the premonitory symptoms of the disease, severe headache, and 
pain in the neck, during an epidemic. 
But, according to most observers, this mode of treatment has pre- 
served its reputation even in marked cases of the disease; there is but 
little opposition to it, and even this is based on its want of success in 
the severest forms. I have no personal knowledge of the success of 
morphium when given internally or hypodermically. But a number 
of trustworthy observers, Ziemssen and Mannkopff among others, 
speak most favorably of it, especially in the form of subcutaneous in- 
jection. Ziemssen says: “ Although we have used morphia frequent 
ly, we have never seen any injurious effects from it, but, on the con- 
trary, such a decidedly palliative action that, along with cold, it seems 
the most indispensable remedy in the treatment of meningitis.” Al- 
most all observers agree that quinine is entirely useless even in deci- 
dedly intermittent cases. 
CHAPTER XI. 
INFLAMMATION OF THE BRAIN ENCEPHALITIS. 
Etiology.—In encephalitis, just as in the inflammation of other 
organs containing little connective tissue, there is not much interstitial 
exudation, but there are most important changes in the nerve-filaments 
and ganglion-cells and their scanty interstitial tissue. These tissue- 
elements swell from absorption of nutrient fluid and subsequently 
break down, partly to simple detritus, partly after precedent fatty de- 
generation ; in the latter case, in the inflamed parts we find quantities 
of fatty granular cells (the formerly so-called Gluge's inflammation 
globules), which we have a right to suppose come directly from fatty 
degeneration of ganglion-cells and neuroglia nuclei. In the subse- 
quent course of encephalitis there is often an extensive formation of INFLAMMATION OF THE BRAIN—ENCEPHALITIS. 
255 
pus-cells; abscesses are formed, which, besides the usual constituents 
of pus, often contain some remains of disintegrated brain-substance. 
Cerebral abscesses are either surrounded by brain-substance softened by 
extension of inflammation to tne surrounding parts, or by newly-formed 
connective tissue; in the latter case they are said to be capsulated. 
Encephalitis is a rare disease, and is not induced by the causes 
which usually excite inflammation in other organs. 1. The most fre- 
quent form is traumatic encephalitis ; it results not only from direct in- 
juries affecting the brain after the skull is opened, but there are nu- 
merous cases where the cranium has remained uninjured, and where 
there wras apparently only slight contusion. It is most probable thaf 
in such cases the brain has been bruised by the vibrating cranium, and 
some small vessels have been ruptured and ecchymoses formed. It 
also appears as if the small extravasations of blood occasionally in- 
duce no symptoms at first, but excite inflammation in the surround- 
ing parts, and thus subsequently cause encephalitis. At least, the 
first signs of the inflammation are occasionally not observed till long 
after the injury. Among the cases of traumatic origin we must in- 
clude those where breaking down of the brain by an extensive extrav- 
asation of blood has caused inflammation in the vicinity. 2. In other 
cases the encephalitis depends on the irritation of the brain from neo- 
plasia and necrosed spots. 3. Among the most frequent causes of en- 
cephalitis are diseases of the cranial bones, especially of the petrous 
bone. As we shall hereafter show, the presence of an otorrhoea may 
decide the question between an abscess of the brain and a tumor. 
Cases are also known where caries of a superior maxillary extended to 
the brain and caused encephalitis. I remember a clergyman in Mag- 
deburg who died of abscess of the brain a few years after a large por- 
tion of the upper jaw had been exsected on account of extensive ca- 
ries. 4. Occasionally the disease occurs in the course of acute and 
chronic infectious diseases, such as pyaemia, glanders, typhus, etc., 
without our being able to give any plausible explanation for it. 5. 
Lastly, but rarely, encephalitis occurs without any known cause in 
persons previously healthy. 
Anatomical Appearances.—This disease never attacks the entire 
brain; it is always confined to certain points. The size of these spots 
varies from that of a bean to that of a fist, or larger. They are usually 
of an irregular spherical shape. Ordinarily there is only one, but 
sometimes there are several. They may be located either in the cere- 
brum or cerebellum; they are most frequently in the gray substance 
and very near the surface, if they do not quite reach it. In the com- 
mencement of the disease at the affected parts, we find the brain-sub- 
stance swollen, infiltrated, softened, and pointed with red spots from 256 
DISEASES OF TIIE BRAIN. 
small extravasations of blood. The swelling of the inflamed parts may 
be recognized by the surface of the brain on the affected side appear- 
ing smooth, just as in apoplectic effusions, and the brain itself being 
anasmic from encroachment on the cranial cavity. On incision also 
the diseased portion not unfrequently rises above the level of the in- 
cised surface. After long existence, the relaxation of tissue gets the 
upper hand, and a red pulp results, which gradually acquires a rusty- 
brown or yellow color, from change of the hcematin, or when there is a 
slight admixture of blood it becomes grayish. This pulp, which may 
be washed off by a slight stream of water, consists of remains of nerve- 
filaments, blood-corpuscles, granular cells, and fine granular exudations 
or masses of detritus. The subsequent changes in the inflamed parts, 
which are usually called the results of inflammation, vary. Occasion- 
ally, in the vicinity of the inflammation, there is a new formation of 
connective tissue, which is also continued through the inflamed spot 
as a delicate network; the contents of the abscess are absorbed, and 
there remains a cavity, filled with a chalky milky fluid, the “ cellular 
infiltration” of Durand-Far del, previously mentioned in apoplexy. 
In some cases, especially when these cysts lie near the surface of the 
brain, their walls gradually approach each other, while the contents 
disappear, and in place of the abscess there is formed a cicatrix, at first 
pale red and vascular, subsequently white and callous. When ence- 
phalitis terminates in suppuration, the appearances are different. Re- 
cent abscesses of the brain form irregular round cavities filled with 
yellow or gray, occasionally also reddish, thick fluid; their walls con- 
sist of ragged masses infiltrated with pus. In the immediate vicinity 
of the abscess we usually find inflammatory softening; farther off there 
is oedema of the brain-substance. Such abscesses increase till they 
break into a ventricle, or reach the meninges; or, if extensive menin- 
gitis do not occur in the latter case, the ulceration extends to the cere- 
bral membranes and the skull, and finally the pus may perforate out- 
wardly or into neighboring cavities, especially into the cavity of the 
tympanum. If the cerebral abscess be capsulated by new formations 
of connective tissue in its wall, it has a more regular form and smooth 
walls. If it has lasted a long time, we occasionally find the capsule 
much denser, and the contents thickened by reabsorption of the fluid 
part, and changed to a cheesy chalky mass. 
Symptoms and Course.—Like the symptoms of cerebral hemor- 
rhage and of partial necrosis, those of encephalitis are partly the im- 
mediate result of destruction of the portion of brain affected, and 
partly the result of disturbances of circulation in the brain, especially 
in the vicinity of tlie seat of inflammation. 
Since large portions of the brain may be destroyed without caus- INFLAMMATION OF TIIE BRAIN—ENCEPHALITIS. 
257 
mg perceptible functional disturbances, and since encapsulated ab- 
scesses frequently do not decidedly affect the circulation in the skull, 
we may readily understand that we should occasionally find abscesses 
of the brain on autopsy, which had not been suspected during life. 
With this knowledge we may also understand those cases of cerebral 
abscess which run their course without any symptoms except the inju- 
rious influence they exercise on the general nutrition of the brain. It 
,‘s not at all rare for a patient to have dull headache, increasing 
apathy, loss of thinking-power, even advancing to idiocy, a blunting 
of the senses, increasing weakness, and uncertainty of movement- 
symptoms which indicate the existence of severe brain-disease, it is 
true, but which do not by any means justify a diagnosis of abscess of 
the brain. Even the most experienced and accustomed observers 
occasionally mistake abscesses of the brain. But these and similar 
mistakes, which unfortunately are made public far less frequently 
than brilliant diagnoses, can only seem strange to the ignorant, and 
to those who are not thoroughly acquainted with the physiology and 
pathology of the brain, and with the diagnosis of brain-diseases. 
These latent cases of encephalitis are far less frequent than those 
where the disease may be very strongly suspected or recognized with 
certainty. If the abscess be located at a point where it destroys the 
centres of special sense, or interrupts the conduction of the impulse of 
the will to the motor nerves, or the impressions of special sense to the 
organs, we have partial anaesthesia and partial paralysis, sometimes of 
the cerebral nerves, again of the cerebro-spinal, at others of both. These 
anaesthesias and paralyses not unfrequently extend to both extremities 
of one side of the body; in other cases they are confined to the parts 
supplied by certain cerebral or cerebro-spinal nerves, but in the latter 
case also they are always on one side. Bilateral anaesthesias and paral- 
yses only occur exceptionally, and in cases where the abscess is in the 
middle portion of the brain, which is not double, or where different 
abscesses are in the same parts of the brain on opposite sides. From 
the occurrence of these symptoms we can only determine that there 
is some local disease; but we cannot decide on its nature, for they 
occur in the most varied forms of local disease where nerve-filaments 
and ganglion-cells are destroyed. To come to a conclusion on this 
point, we must pay particular attention to the etiology, to the course 
of the disease, and to those symptoms which show the effect of the 
local disease on the rest of the brain. 
If we can make out that the symptoms of a local disease of the 
brain have begun after an injury of the head, or if the patient has 
caries of the petrous bone, the case is most probably one of ence- 
phalitis. If, on the other hand, there has been no injury of the head, 258 
DISEASES OF THE BRAIN. 
and no caries of the temporal bone can be found, it is almost equally 
improbable that there is encephalitis. While these points are gen- 
erally true, they have in some cases led to erroneous diagnosis. 
Autopsy has revealed abscesses of the brain where there had been no 
injury of the head or caries of the cranial bones. There have also 
been cases where patients with cerebral tumors have had a blow on 
the head, and occasionally the previously latent brain-disease had 
not become manifest till after this injury. (These cases are analo- 
gous to those where women first have their attention directed to a 
carcinomatous mamma by a blow on it, and then consider it beyond 
a doubt that it is due to the injury they have received.) But, prac- 
tically, it is best only to think of these exceptional cases where there 
is sufficient reason. 
Encephalitis never affects the entire brain, but is always limited 
to certain points; nevertheless, at the commencement of the disease, 
there are almost always signs of temporary irritation of the entire 
brain or meninges, such as increased frequency or great slowness of 
the pulse, increased bodily temperature, headache, dizziness, sleepless- 
ness or restlessness, exciting dreams, psychical irritation, even mild 
delirium, great sensitiveness to slight irritation of the organs of special 
sense, bodily disquiet, and great weakness, etc. According to Gries- 
inger, this violent commencing stage, which may be followed by quiet, 
is almost pathognomonic of encephalitis and abscess of the brain. In 
the criminal records there are numerous cases where the above symp- 
toms were considered by the attending surgeon as traumatic fever, be- 
cause they apparently disappeared without any traces, and the complete 
recovery of the patient from the injury received was officially certified 
to, while, after a time, there were unmistakable signs of a severe brain- 
disease, and autopsy showed abscess of the brain as the fatal termina- 
tion of the injury. Even in those cases where an injury of the skull 
is followed at first by the symptoms of general irritation of the brain 
and meninges, and subsequently by the above-described decrease of 
all the cerebral functions, we should first think of abscess of the brain, 
and attribute the absence of local symptoms to the location of the ab- 
scess at a point where it does not interrupt the conduction of excite- 
ment, in the centripetal and centrifugal cerebral filaments. 
The influence that local inflammations in the brain have on the rest 
of the organ consists partly in their encroachment on the cranial cavity, 
and chiefly on those chambers of the skull where they are located, 
partly on the collateral hyper,'emia and oedema in their vicinity, and, 
lastly, partly on their injurious effect on the nutrition of the entire 
brain. On the first of these factors depend the headache, the attacks 
of dizziness and vomiting, as well as the evanescent occurrence of pain, INFLAMMATION OF THE BRAIN—ENCEPHALITIS. 
259 
indefinite feelings, anaesthesia, twitchings, contractions, paralyses in 
some parts of the body, which, in many cases, accompany the symp- 
toms previously mentioned, and which we fully described in the second 
and fourth chapters, as the results of partial hyperaemia and partial 
anaemia of the brain. These do not continue unchanged, like the local 
symptoms, which are the immediate results of partial destruction of 
the brain from the inflammatory process, but are rather apt to have a 
variable course; this is partly due to occasional enlargement of the 
abscess, by which the space is more contracted, partly on the occasional 
increase and decrease of collateral hyperaemia and collateral oedema. 
It is evident that such a variation in the symptoms would occur oftener 
in encephalitic inflammations than in slow and steadily-growing tumors 
of the brain. 
The attacks of epileptiform convulsions, which not unfrequently 
occur during encephalitis, are more difficult to explain, and we shall 
not even offer a hypothesis as to the mode of their occurrence. Sta- 
tistics have been made as to how often headache, contractions, epilep- 
tiform convulsions, etc., were present or absent in a large number of 
cases of cerebral abscesses. In individual cases, the results of these 
statistics are, of course, of but little value in the diagnosis of abscess 
of the brain, or in its differential diagnosis from tumor of the brain. 
The injurious influence of the local inflammation on the general nutri- 
tion of the brain, which may occur earlier or later, but never fails when 
the disease is protracted, evinces itself by the previously-described 
symptoms of a general paralysis of all the cerebral functions. I think 
I have fully shown, by this description, that, in many cases, it is possi- 
ble to recognize an abscess of the brain, although it has no constant or 
pathognomonic symptom. 
The duration of encephalitis varies; some cases terminate in death, 
after a few days or weeks, while in others this does not occur for years. 
Occasionally, while the symptoms of cerebral paralysis increase, so 
that the patient becomes idiotic, we find a remarkable development of 
fat. Death occurs either suddenly and unexpectedly, from the devel- 
opment of meningitis, from sudden increase of the abscess, and, occa- 
sionally, without our being able to find, on autopsy, any cause for the 
sudden catastrophe; or else it occurs with the symptoms of gradually- 
increasing sleepiness, finally becoming deep coma, or else it is induced 
by intercurrent diseases. Recovery is very rare. Even in the most 
favorable cases, where the cellular infiltration forms a cicatrix or en- 
capsulates the abscess, while its contents calcify, we can only speak of 
a relative cure, since both the remains of the inflammation and the 
atrophy of the brain, which usually develops under such circumstances, 
affect the functions of the brain for the rest of life. 260 
DISEASES OF TIIE BRAIN. 
Treatment.—The treatment of encephalitis cannot be very suc- 
cessful, from the simple fact that the disease is not generally recog- 
nized until it has induced irreparable destruction of the brain. In very 
recent cases, particularly in those of traumatic origin, we should em- 
ploy local antiphlogistics, leeches, and cold compresses. Later, but 
little can be expected from this treatment. Moxae and setons, which 
were formerly much used in protracted cases, have been abandoned, 
and very justly so, as has the administration of mercurials. The prepa- 
rations of iodine also, which have been recently recommended, promise 
but little benefit; hence, in most cases, there is little to do but have 
•he patient observe proper regimen, particularly to guard him from 
every thing that can increase the pressure of blood to the head, and to 
confine ourselves to combating the most urgent symptoms. Among 
the latter, the apoplectiform attacks are to be treated according to 
the rules given for the treatment of cerebral haemorrhage, while any 
intercurrent meningitis demands the employment of energetic anti- 
phlogistic remedies. 
CHAPTER XII. 
PARTIAL SCLEROSIS OP THE BRAIN. 
In previous chapters we have repeatedly mentioned the formation 
of indurations in the brain as the results of cicatrization of apoplectic 
and inflammatory deposits. Besides these, partial scleroses, which 
occur as a result of other processes, indurations from new formations 
of connective tissue, and displacement of the normal elements, occur 
at circumscribed spots in the brain, whose pathogeny is entirely ob- 
scure, and of which it is even doubtful whether they are of inflamma- 
tory origin or not. These idiopathic forms of partial sclerosis of the 
brain have been almost solely observed early in life, and more fre- 
quently in males than in females, but their causes have never been 
discovered. 
On anatomical examination the points of disease are found oftener 
in the white than in the gray substance ; their number varies; some- 
times they are solitary, occasionally several are present. They form 
irregular nodules, or rough spots as large as a lentil or an almond, 
which may be distinguished from the parts around by their hardness 
and toughness. On the cut surface they appear bloodless, dull, and 
milk-white; after remaining exposed for a while, they are covered 
with a scanty serum, and become somewhat depressed. In the midst 
of the nodules there are usually small blue or grayish-red spots, 
which contract strongly and exude a quantity of serum, after being PARTIAL SCLEROSIS OF THE BRAIX. 
261 
divided. On microscopical examination we find amorphous fine gran- 
ular masses along with well-preserved nerve-elements in the milk-white 
indurated spots. In the grayish-red prominences, on the other hand, 
there are no nerve-elements; they consist of a filamentary mass and 
the remains of capillary walls, in which fat granules are embedded 
( Vcilentiner). 
The symptoms and course of partial sclerosis of the brain are not 
so characteristic as to render the disease easy of recognition; on the 
contrary, it must be regarded as a triumph in diagnosis, that this has 
been done in a few cases (Frerichs). Since the sclerosis is limited to 
scattered and circumscribed points and develops slowly, the paralyses 
accompanying the disease have the peculiarity that, in the commence- 
ment at least, they do not extend over one-half the body, but always 
begin in single groups of muscles, or in a single extremity (always 
one of the lower extremities), and thence extend gradually to other 
groups of muscles and other extremities, till finally the central parts 
governing respiration, deglutition, and the actions of the heart, are 
affected. This extension is not regular: for example, paralysis of the 
right hand does not necessarily follow that of the right foot, but it is 
entirely lawless. This fact in itself speaks in any case for the depend- 
ence of the paralysis on numerous separate points of disease, and 
not on one gradually-increasing spot. Besides the paralyses, which 
are the most constant, and, from their peculiar mode of extension, the 
most characteristic symptoms of partial sclerosis of the brain, there are 
also disturbances in the other functions, but these are far less distinc- 
tive and less characteristic of the disease. Headache is absent in most 
cases; but there are often peripheral pains, and a feeling of formica- 
tion in the extremities which is followed by a diminution of sensation, 
increasing to perfect anaesthesia. The special senses are rarely affected, 
and among these that of sight almost exclusively. In most cases there 
are moderate symptoms of irritation in the psychical functions; but 
these are soon followed by a gradually-increasing deep depression, 
which in some cases exists from the first. Convulsions only occur 
exceptionally; but trembling is a very constant symptom. The nutri- 
tion of the body is not generally affected till late in the disease, and 
in some patients, just as in encephalitis, there is even a remarkable 
development of fat. The course of the disease is very tedious; most 
of the cases observed lasted from five to ten years. During this time 
the disease occasionally appeared to remain at a stand-still, but no 
existing paralysis was ever observed to disappear. No instances of 
recovery are known. In the cases that have been described, death 
resulted partly from the extension of the disease to the medulla ob- 
longata and consequent disturbance of the respiration, partly from 262 
DISEASES OF THE BRAIN. 
marasmus and hydraemia which developed toward the end, partly from 
ntercurrent diseases. 
Treatment is fruitless against, this affection; it can only be of use 
in combating the more severe symptoms. 
TUMORS OF THE BRAIN AND ITS MEMBRANES. 
CHAPTER XIII. 
Under the head of tumors of the brain are included growths and 
parasites occurring in the skull, and aneurisms of the cerebral arteries. 
We shall follow this custom, since it is very convenient on account of 
the great correspondence of the symptoms due to these otherwise dif- 
ferent diseases. 
Etiology.—The pathogeny and etiology of cerebral tumors is very 
obscure. This is true not only of carcinoma, sarcoma, glioma, and myx- 
oma, but also of the rarer tumors, cholesteatoma or pearl tumors, lipoma, 
and cystoid growths. Cancer of the brain occurs chiefly in advanced 
age; it is sometimes primary, and then usually remains the only carci- 
nomatous disease in the body; sometimes it is secondary to carcinoma 
of other organs. The other neoplasia that we mentioned above, also 
occur chiefly, but not exclusively, in advanced age, and according to 
statistics are more frequent in males than in females. We know 
nothing of the morbid predisposition or the exciting causes to which 
these neoplasia are due. They have been frequently observed after 
precedent injuries of the head; but in such cases there is no certainty 
of a genetic connection between the injury and the growth. We must 
bear in mind how frequently slight injuries of the head occur, and how 
carefully they are inquired after, in any patient suffering from symp- 
toms of brain-disease, and, when found, how strong the inclination is at 
once to refer the disease to them. 
Tubercles in the brain with rare exceptions occur in children, and 
chiefly in those over two years old. They are rarely primary; but 
almost always form complications of the so-called tuberculosis of the 
lymphatic glands, and of pulmonary tuberculosis. 
Cysticerci and echinococci of the brain, as of other organs, depend 
on the emigration of the embryos of these parasites. 
Aneurisms of the cerebral arteries are usually due to degeneration 
of the arterial walls from endarteritis deformans. 
Anatomical Appearances.—Carcinoma of the brain is usually in 
the form of round or lobulated, generally circumscribed tumors, with 
the softness and other peculiarities of medullary cancer; more rarely 
they have the firm tissue of scirrhus, and then they usually pass into 
the neighboring cerebral substance without having any distinct bound TUMORS OF THE BRAIN AND ITS MEMBRANES. 
263 
aries. They sometimes start from the brain itself, sometimes from the 
dura mater and cranial bones, or they develop originally from the 
external soft parts of the skull and neighboring cavities, especially in 
the orbit, and thence press into the skull. On the other hand, it rarely 
happens that carcinoma occurring in the brain perforates the meninges 
and cranial bones. There is usually only one carcinomatous tumor of 
the brain, and this is generally located in the cerebrum; where there 
have been several, they have occasionally been found symmetrically 
located on the two sides of the brain. Cerebral carcinomata, which 
may attain the size of the fist, never suppurate unless they perforate 
outwardly; on the other hand, they readily undergo partial retrogres- 
sive metamorphosis, become yellow and cheesy in the middle, shrink, 
and thus cause umbilicated depressions on the surface of the brain, if 
the cancer had advanced so far. 
Sarcomata occur as often as carcinomata in the brain. They are 
often attached to the meninges, and the tumors of this variety, at the 
base of the brain, usually attain greater size than those of the dura 
mater that covers the convexity. (Just as often sarcomata are em- 
bedded in the midst of the brain-substance, in the majority of cases in 
the cerebrum.) They form round or lobulated tumors, from the size of 
a hazel-nut to that of a good-sized apple ; their cut surface is smooth, 
dirty white, or grayish red; they are usually soft, even medullary, more 
rarely hard and fibrous. Occasionally they contain cavities filled with 
fluid. Sarcomata consist chiefly of spindle-shaped cells, arranged in 
filamentary striae. They differ from cancer, and especially from glioma, 
not only in being sharply bounded, but in being often surrounded by a 
vascular envelope, from which they can be turned out. Small lumps 
of carbonate of lime not unfrequently occur in sarcoma of the dura 
mater ; on rubbing the tumor between the fingers, these lumps cause 
a sandy feel. Virchow has designated tumors, containing numbers 
of the chalky lumps, as psammonea, or sand-tumors. Their mode of 
origin is not yet exactly known. 
Myxom,ata consist of mucous tissue—that is, of variously-formed 
cells, embedded in a homogeneous, mucous, hyaline, intercellular sub- 
stance. They are not very rare in the brain. Like sarcomata, they 
are located most frequently, but not exclusively, in the medullary sub- 
stance of the cerebrum, where they generally appear as circumscribed 
tumors, more rarely as infiltrations of soft gelatinous substance. The 
tissue of myxoma is somewhat translucent, and of a weak yellowish 
or red color, but may acquire a varied hue from extravasated blood. 
Myxomata also correspond with sarcomata in regard to the size they 
may attain; and, between these two forms of tumors, there are all 
possible grades of transformations (gelatinous sarcoma). 264 
DISEASES OF THE BRAIN". 
Gliomata result from a local proliferation of the neuroglia, or con- 
nective tissue of the brain, at the expense of its nervous elements. 
Microscopically they consist of roundish nuclei, distributed through a 
finely-reticulated basement substance. By the naked eye they are 
distinguishable from not forming circumscribed tumors, but passing 
gradually into the healthy brain-tissue; also from the fact that they 
never pass from the brain to its membranes. Gliomata may attain the 
size of a fist; they most frequently originate from the medullary sub- 
stance of the cerebrum. Haemorrhages into or partial retrogression 
of glioma may take place after precedent fatty degeneration of its ele- 
ments. The consistence of these tumors varies between that of a me- 
dullary cancer and of healthy brain. The cut surface varies in color 
from whitish yellow to bright grayish red, and usually shows a number 
of cut vessels. Formerly glioma was regarded as infiltrated cancer, 
and, as it occurs chiefly in young persons, or, at least, in those under 
forty years of age, we see why it was said that cancer of the brain 
has been observed at all ages. 
Cholesteatomata, or pearl tumors, are rare. They sometimes start 
from the cranial bones, at others from the meninges, again they de- 
velop in the brain itself. They form irregular tumors, of variable size, 
of a pearly lustre; they are enclosed by a delicate membrane, and con- 
sist of concentric layers of epidermic cells. 
JLipomata, as small lobulated tumors, starting from the dura mater, 
cysts filled with fluid, or fat and hairs, and cystoid neoplasia, with 
cauliflower excrescences from the walls, belong to the rarities, and 
have more pathologico-anatomical than clinical interest. 
Tubercles of the brain are the most frequent form of cerebral tu- 
mors. Usually we find only one collection of tubercles, occasionally 
two, more rarely a greater number. The size varies from that of a 
hemp-seed to that of a cherry, or, in rare eases, to that of a hen’s egg. 
They are located most frequently in the cerebellum or cerebrum, more 
rarely in the mesencephalon. Tubercles of the brain form irregular, 
roundish, non-vascular tumors, of a yellow, dry, and cheesy character. 
They are sometimes surrounded by a layer of loose connective tissue, 
which separates them from neighboring parts of the brain; sometimes 
ihe main portion of the yellow nodule gradually passes into the brain- 
substance as a gray-white, slightly-translucent, narrow margin, consist- 
ing of young tubercle elements. In the latter case the tubercle has 
been growing till death; in the former, where it can be readily turned 
out of its capsule, growth has ceased long before death. From soft- 
ening of its centre, the tubercle nodule is occasionally transformed into 
a vomica, filled with tubercle pus. 
Syphilomata only rarely occur in the brain in the form of nodules TUMORS OF THE BRAIN AND ITS MEMBRANES. 
265 
(gummata) ; they are more frequent as diffuse infiltrations. Nodulai 
syphiloma always passes from its edges very gradually into the healthy 
brain-substance. Since such nodules become changed by atrophy, and 
fatty metamorphosis of the cells commencing in the centre, to a sub- 
stance resembling yellow tubercle, syphiloma has probably been occa- 
sionally mistaken for tubercle. This may be avoided by bearing in 
mind that, in syphiloma, the passage from the cheesy centre to the 
broad, grayish-white, peripheral zone, is very gradual, while, in infil- 
trated, growing tubercle, these zones follow each other more closely 
and, in tubercles that can be turned out, they do not exist. In regard 
to consistence, and the character of the cut surface, syphilitic infiltra- 
tions greatly resemble old, simply sclerosed parts; indeed, even the 
microscope cannot always decide between them. 
Cysticerci are not very rare in the brain, and, when found, they 
are usually in large numbers; they generally occur in the gray sub- 
stance. Occasionally some of these parasites are found dead, and 
changed to a mortar-like concrement, in which some of the hooks from 
the circle can usually be recognized. 
Echinococci of the brain are much rarer. They form large vesicles, 
enclosed by a very delicate adventitia, with the well-known peculiari- 
ties of which we have often spoken. 
Aneurisms of the cerebral arteries are not frequent. They chiefly 
occur in the vessels at the base of the brain, in the arteria basilaris, 
a. corporis callosi, a. fossas Sylvii, and in the a. communicantes of 
the circle of Willis. In rare cases, they attain the size of a small 
hen’s egg, wThile usually they only reach that of a pea or a small 
hazel-nut. 
Symptoms and Course.—The symptoms of cerebral tumors have 
the greatest resemblance with those of the local diseases of the brain 
previously described. There is no symptom, occurring during the 
course of a cerebral tumor, that does not sometimes occur from soft- 
ening of the brain, from abscess, or from some other local disease. 
This resemblance cannot astonish us; on the contrary, we could not 
understand how it should be otherwise, since, like other local diseases, 
a tumor of the brain destroys a circumscribed portion of the organ, 
encroaches on the intracranial space, and interferes with the circulation 
in the vicinity of the diseased part. Nevertheless, it is only in rare 
cases that it is difficult or impossible to recognize a cerebral tumor, 
and to distinguish it from an abscess, or other local disease of the brain. 
(According to my experience during the last ten years, I must hesitate 
about agreeing with the first part, at least, of Bamberger's assertion, 
which I have previously quoted, where he says, “With few exceptions, 
die diagnosis of tumors of the brain is rather a guess than a diagnosis. 266 
DISEASES OF THE BRAIN. 
and the determination of its locality, likewise with certain exceptions, 
is impossible.”) This apparent paradox is due to the fact that, in spite 
of the absence of constant symptoms pathognomonic of tumors of the 
brain, in most cases the diagnosis may be made partly from the eti- 
ology, partly from the location of the disease at a point where other 
local diseases are rare and tumors common, and, lastly, partly from the 
peculiarities of the entire course of the disease. 
The important evidence furnished by the etiology is chiefly nega- 
tive. In every case of brain-disease we should make it a rule to seek 
for the exciting cause by obtaining an exact history of the case. If 
we thus find that the patient has had no injury of the head, that he 
has no caries of the petrous bone, no hypertrophy or valvular disease 
of the heart, and probably also no degeneration of the arteries; in 
short, if we can find no cause for the disease, our suspicions must first 
turn to a tumor of the brain. Before speaking of the cases where 
cerebral tumors can be recognized with facility and certainty, I shall 
say a few words concerning the rare cases where they induce no symp- 
toms, or else have those of severe brain-disease, but do not give any 
means of determining that they are caused by a tumor. The tumors 
with latent course can only be located at parts of the brain where they 
do not disturb the intercerebral centres of the cranial nerves, or inter- 
rupt the conduction of excitement in the centripetal and centrifugal 
brain-filaments, that is, chiefly in the extensive medullary masses of the 
cerebrum. At this part tumors often attain a large size without in- 
ducing local symptoms (herdsymptome), while at most parts of the 
base of the brain, and in the vicinity of the large ganglia, even the 
smallest tumors are accompanied by these symptoms. But even in 
the cerebrum only those tumors run a latent course which grow slowly, 
and are not so vascular as to swell at times from the vessels being 
overfilled, and at others to decrease in size from containing less blood. 
To explain the remarkable but very certain fact that the symptoms ac- 
companying rapidly-growing tumors are not unfrequently absent in 
those that grow slowly, a certain “ power of accommodation ” has been 
ascribed to the brain, which enabled it to accustom itself to gradually- 
increased pressure. I consider the following explanation more satis- 
factory : In tumors that grow rapidly there is a compression of the 
capillaries and a loss of function of those parts of the brain where 
they are located. On the contrary, in the vicinity of slowly-growing 
tumors there is atrophy of the brain-substance, and its shrinkage sup- 
plies as much room as is lost by the growth of the tumor. Under these 
circumstances the capillaries of the affected part of the brain are not 
compressed, and its function not disturbed. Perhaps the presence or 
absence of local symptoms (herdsymptome), in tumors of the cere- TUMORS OF THE BRAIN AND ITS MEMBRANES. 
267 
brum having the same location and equal size, depends partly oil 
whether the tumor has displaced the brain-filaments or has developed 
at their expense and has substituted them. My colleague, Prof. 
Schilppel, who has given me some other valuable points on the histol- 
ogy of cerebral tumors, asserts that the different forms of tumors vary 
in the above respect. Naturally, tumors, rich in vessels which increase 
and diminish in size according to their fulness, are not apt to run their 
course without symptoms; but, as a rule, are at least occasionally ac- 
companied by symptoms of irritation and paralysis. Lastly, I shall 
mention that tumors running a perfectly latent course are proportion- 
ately more frequent than those having the symptoms of a severe in- 
explicable cerebral disease. In abscesses of the brain, just the opposite 
is true. This difference is probably due to the entire nutrition of the 
brain being generally more severely impaired by the presence of an 
abscess than by a tumor. 
Even those tumors of the brain of which we succeed in making a 
certain diagnosis during the course of the disease, do not always begin 
with the symptoms which play the most important part in the diagno- 
sis, that is, with the partial paralysis and anaesthesia, which we have 
designated as local symptoms (.Herdsymptome), and which we have 
repeatedly and fully described. In many cases the first, and often for 
a long time the only, symptom indicative of brain-disease, is a severe 
headache. Although this occurs during the most different brain-dis- 
eases, and although we may even say there is no disease of the brain 
which is not, under some circumstances, accompanied by it; still there 
is no cerebral disease where continuous, unusually intense, and severe 
headache is so prominent a symptom, and there is no other disease 
where it is so often observed as in tumor of the brain. The cases 
where patients with cerebral tumors do not complain of headache are 
such rare exceptions, that its absence in a doubtful case rather speaks 
against a tumor. The fact that headache occurs even in those tumors 
of the brain which are located at a distance from the sensitive parts, 
supports the view we advanced, that in cerebral diseases the pain in 
the head started from the filaments of the trigeminus supplying the 
dura mater. We must be very careful about localizing the tumor 
from the seat of the pain. Only pains constantly confined to the back 
of the head permit us to conclude that very probably the tentorium is 
stretched, and that the tumor is probably situated in the posterior 
cranial fossa. 
In many patients, attacks of dizziness and vomiting accompany the 
headache, particularly the severe exacerbations which occur, from time 
to time, with or without perceptible cause. This may facilitate tho 
correct interpretation of the headache, and show its dependence on 268 
DISEASES OF TIIE BRAIN. 
disease of the brain, if it should have been doubtful, in spite of the 
duration, severity, and obstinacy of the pain. 
Among the local symptoms of tumors of the brain, those of partial 
irritation (hyperaesthesia, neuralgia, indefinite sensations of formica- 
tion, twitching, etc.) very frequently precede the partial anaesthesias 
and partial paralyses, and there are cases of cerebral tumors where 
these symptoms, and not the headache, open the scene. We have 
seen that partial symptoms of irritation, occurring in severe structural 
diseases of the brain, are only to be regarded as secondary effects, and 
are referable to disturbances of circulation in the vicinity of the affected 
part. Also that they occur in the most varied diseases, and alone are 
not pathognomonic of any of them. However, in cerebral tumors, 
there is one circumstance which is characteristic of the hyperaesthesia, 
neuralgia, and twitchings, and the anaesthesia and paralysis which 
usually follow them, namely, that these local symptoms are observed 
more frequently, even among the cerebral nerves, than in any of the 
previously-described forms of brain-disease. But we cannot say that 
symptoms of irritation and paralysis of the cerebro-spinal nerves, such 
as hemiplegia, etc., are rare, or do not occur; but only that, apart from 
other symptoms, the occurrence of neuralgia, hyperaesthesia, or anaes- 
thesia, or of spasms and paralysis in the parts supplied by the cerebral 
nerves, goes to prove, in doubtful cases, that there is a tumor in the 
brain. The simple explanation of this peculiarity is as follows: In 
all the local diseases hitherto treated of, in necrotic softening of the 
brain, in cerebral haemorrhage, in encephalitis, and its results, the mor- 
bid process is, with rare exceptions, limited to the brain, and does not 
attack the nerves passing from it. The case is quite different -with 
tumors, which not only often pass from the brain to the nerves origi- 
nating from it, but which, in many cases, start from the meninges or 
skull, and then not unfrequently destroy the cerebral nerves before 
attacking the brain. Let me call attention to another point, which 
was first published by my friend Ziemssen, at that time assistant in my 
clinic. Most paralyses of cerebral nerves are peripheral, when due to 
tumors, whether these have originated in the brain, or have advanced 
to the brain from the meninges or cranial bones. On the other hand, 
most of the few cases of paralyses of cerebral nerves occurring in the 
other forms of brain-disease are of central origin. Now, it is well 
known that the state of the nerves and muscles, on electrical irritation, 
is a certain means of distinguishing central and peripheral paralyses. 
In central paralysis, the muscle contracts normally when an induced 
current is passed through the nerve; in peripheral paralysis, on the 
contrary, the contraction does not take place. Hence we may thus 
amplify the above proposition: In cases of local disease of the brain, TUMORS OF THE BRAIN AND ITS MEMBRANES. 
269 
paralysis in the parts supplied by the cerebral nerves (especially if 
the paralyzed muscles do not contract on passing an electric current 
through their nerve) renders it very probable that there is tumor of 
the brain. The assertion that, other things being equal, paralysis of a 
cerebral nerve favors the idea of a tumor, and that most paralyses of 
cerebral nerves are of peripheral origin, is not actually true of the facial 
nerve. Paralysis of the facial, as one symptom of hemiplegia, occurs 
just as often in other local diseases of the brain as in cases of tumor, 
and is unmistakably of central origin. What was said above is not 
true of these cases, but of the other peripheral facial paralyses. Next 
to the facial, among the motor-cerebral nerves, the oculo-motor and 
abducens are most frequently attacked. Paralysis of the pars minor 
trigemini is rare; this is also true of complete paralysis of the hypo- 
glossal and motor filaments of the glosso-pharyngeal; while incom- 
plete paralysis of these nerves, as shown by disturbances of articulation 
and deglutition, is rather common. Peripheral facial paralysis, due 
to tumors of the brain, is occasionally preceded by twitching of the 
facial muscles; while twitching of the muscles of the eye precedes 
paralysis of the oculo-motor, which is characterized by dilatation of 
the pupil, ptosis, disturbance of mobility of the eye; often, also, by 
diplopia and strabismus. If the oculo-motor be unaffected, paralysis 
of the abducens induces diplopia and strabismus convergens. Before 
the destruction of the filaments of the trigeminus has caused anes- 
thesia of the half of the face, of the conjunctiva, mouth, and nose, 
most patients complain of severe pain in all the parts supplied by the 
nerve, and not unfrequently these pains continue during the anesthesia 
(anesthesia dolorosa). Hardness of hearing, or complete deafness, 
from destruction of the acousticus, is usually preceded, for a time, by 
troublesome noises in the ears. Disturbances of vision, even to com- 
plete blindness, are very frequent in tumors of the brain, but they are 
not, by any means, always due to direct lesions of the optic nerves, 
chiasm, tractus opticus, or corpora quadrigemina. Not unfrequently, 
the tumor is at a distance from these parts, as in the cerebrum or cere- 
bellum. I consider it a mistake to suppose that, in such cases, the 
pressure has extended, through the intervening substance, to the optic 
nerve, and, by pressing this against the base of the skull, caused its 
atrophy. The correctness of this view appears to be opposed, among 
other things, by the fact that, in blindness from tumors in the cere- 
brum or cerebellum, the motor nerves of the eye, which are under 
abou+ the same conditions as the optic nerve, are rarely paralyzed. 
Many of the cases of amblyopia and amaurosis, caused by cerebral 
tumors, depend on venous congestions in the eye, and the consequent 
structural changes in the retina and optic nerve, and are due to com 270 
DISEASES OF THE BRAIN. 
pression of the cavernous sinus and obstructed escape of blood from 
the veins of the eye. Tumors in the posterior cranial fossa only have 
this effect after they have caused abundant effusions in the ventricles, 
by compression of the openings of the venae Galeni into the straight 
sinus. Since tumors, which destroy the optic nerve, very rarely spare 
the oculo-motor, I consider the presence or absence of disturbances 
of mobility of the eye as an almost certain means of distinguishing 
whether the amaurosis, caused by cerebral tumor, is due to destruction 
of the tractus opticus, chiasm, optic nerves, or to interference with the 
intraocular circulation. Ophthalmoscopy also gives important informa- 
tion on this point. The changes of the optic nerve, in blindness from 
cerebral tumors, as revealed by the ophthalmoscope, and the conclu- 
sions that may be deduced from them, are about as follows, according 
to Graefe: 
1. Simple swelling of the optic papilla, with great tortuosity of the 
vena centralis. It is indicative of obstructed venous circulation, and, 
in its purer forms, is most frequently seen with tumors that encroach 
on the cavity. 
2. Slight inflammatory swelling of the optic papilla, with less dis- 
tinct venous hyperasmia and inflammatory participation of the retina. 
It occurs as a result of an inflammation of the perineurium, and of the 
optic nerve itself, which extends to the retina (neuritis descendens), 
and accompanies those intracranial processes, which, from their ana- 
tomical character or location, are suited to induce irritation in the parts 
above named. 
3. Atrophy of the optic nerve. This may occur primarily, from 
direct lesion of the optic nerve by a tumor, meningitis, etc., or second- 
arily, as a final result of either process. 
The partial disturbances of sensibility and motility in the parts 
supplied by the cerebro-spinal nerves, that occur in cerebral tumors, do 
not differ from those accompanying other local affections of the brain. 
Neuralgic pains, or indefinite sensations of prickling, formication, furri- 
ness, etc., as well as complete anesthesia, occur, both over large sur- 
faces and limited to very narrow bounds. The same is true of mus- 
cular twitchings, of contractions, and paralyses, although, among the 
latter, hemiplegia far exceeds the other paralyses. 
If there be morbid symptoms in the parts supplied by the cerebro- 
spinal and cerebral nerves at the same time, they almost unexception- 
ally show the peculiarity of being on opposite sides of the body. 
This “ alternation ” is simply because the paralysis, anaesthesia, etc., 
of the cerebro-spinal nerves are caused by a lesion of the nerve-fila- 
ments before they cross, while those of the cerebral nerves depend on 
destruction of nerve-filaments that have already crossed. TUMORS OF THE BRAIN AND ITS MEMBRANES. 
271 
In accordance with the slow growth of most cerebral tumors, the 
development and extension of the local symptoms of irritation and 
paralysis are usually slow and gradual. Many patients cannot state 
exactly when their disease began. In doubtful cases this may de- 
cidedly aid in the diagnosis, since, from such a course, we may exclude 
most other local diseases of the brain. But not very rarely these local 
symptoms come on suddenly; this is chiefly the case where vascular 
tumors are suddenly increased in size by overfilling of their vessels, 
or by haemorrhage from them, or where the parts around them are at- 
tacked by inflammation or softening, or by capillary haemorrhages. 
If the tumor have previously run a latent course, and these symptoms 
of paralysis come on suddenly, the case will most probably be mis- 
taken for one of cerebral haemorrhage, and there are numerous in- 
stances where the best diagnosticians have made mistakes in such cases. 
If, on the other hand, there has been a suspicion of tumor of the brain, 
the frequency of such incidents in the course of this disease should 
prevent our being deceived. 
Attacks of epileptiform convulsions occur more frequently from 
tumors of the brain than from any other local disease of that organ ; 
but it is very remarkable and inexplicable that they occur almost 
solely when the tumors are in the cerebrum, and especially when they 
are near the cortical substance. 
In many cases psychical disturbances do not present themselves 
throughout the disease. Indeed, it seems that the psychical functions 
of the brain only suffer when the cortical substance of both hemi- 
spheres is affected by organic disease, or by disturbance of circulation. 
The correctness of this view is proved by the peculiarities of those 
cases where the state of the psychical functions forms an exception to 
the above. For the general mental ruin that we described when 
speaking of abscess of the brain also occurs in cerebral tumors, when 
they are accompanied by extensive chronic meningitis of the convex- 
ity, or when the cortical substance of both hemispheres is the seat of 
numerous tumors (cysticerci), or when their capillaries are compressed 
by encroaching tumors in both hemispheres, or by extensive secondary 
effusions in the ventricles. 
In the rare cases where the tumors perforate the skull, the symp- 
toms above described are accompanied by other symptoms, which are 
very characteristic. The perforation usually takes place through the 
parietal or temporal bones, near the root of the nose, more rarely 
through the occipital bone. At the point of perforation the hair is 
lost, the skin becomes red, and is traversed by varicose vessels; ulcera- 
tion of the integument is rare. We may often feel a bony margin at 
the border of the tumor, which is generally soft and nodular. It is a 272 
DISEASES OF TIIE BRAIN. 
characteristic but not a constant symptom for the tumor to move with 
respiration; occasionally it may be replaced. Attempts to do this, 
which suddenly contract the space in the skull and prevent the en- 
trance of arterial blood to the brain, usually induce loss of conscious- 
ness and convulsions. 
The nutrition, general condition, and the functions of the body in- 
dependent of the brain, often show no anomaly for a long time. In 
other cases it seems as if the organic processes went on with a certain 
sluggishness: the heart and pulse beat slowly, respirations are rare, 
the bowels constipated, secretion of urine scanty, and, perhaps as a 
consequence of this, the body often increases remarkably in size. In 
other cases, on the contrary, marasmus occurs early, the patients ema- 
ciate, the skin becomes dry and scaly, the mucous membranes, espe- 
cially the conjunctiva, are affected with blennorrhoea. Lastly, there 
are bed-sores and dropsy of the feet. 
The course of cerebral tumors shows many variations which we 
shall not discuss in detail. At first, there are generally exacerbations 
and remissions of the symptoms, which subsequently become constant 
and steadily grow worse. 
In carcinomatous tumors the disease usually lasts only a few 
months, but occasionally a year or more. Non-carcinomatous tumors 
often run on for several years. 
The most usual, and perhaps the only, termination is death. If it 
be not induced early by complications or intercurrent disease, the 
symptoms of general limitations of the space in the skull become more 
and more marked. The patients fall into deep coma, followed by 
death. 
It is rarely possible to recognize the seat and size of a tumor ex- 
actly ; but it may often be approximately decided in what part it is 
xocated, whether in the cerebrum, medulla oblongata, or in the cerebel- 
lum, at the base or at the convexity. The “ brilliant diagnoses,” 
where the precise localization of a tumor is fully confirmed by autopsy, 
are not usually due to acumen of the observer, but are cases of lucky 
diagnosis. If a basilar tumor destroys the function of several cerebral 
nerves, one after the other and in regular sequence, while it spares 
neighboring nerves, any one, having a knowledge of only the coarse 
anatomy of the brain, can decide the seat and extent of the tumor 
with almost absolute certainty. However, such cases, which are pub- 
lished with much self-satisfaction, are exceptions, as said before. 
It would occupy too much time to speak fully of all the factors, be- 
sides the participation of the different cerebral nerves, which are to be 
considered when deciding the location of the tumors. We must limit 
ourselves to the following short hints. The presence of hemiplegia TUMORS OF THE BRAIN AND ITS MEMBRANES. 
273 
indicates that the tumor is either in one side of the cerebrum (the most 
frequent seat) or in one crus cerebri, in one side of the pons or in one 
side of the cerebellum. In tumors of the cerebrum the hemiplegia is 
usually pure, that is, the other half of the body is entirely free from 
paralysis. In tumor of one crus cerebri, the paralysis of the opposite 
side of the body is almost always accompanied by paralysis of the 
oculo-motor of the same side. In tumors of the lateral portions of the 
pons, besides the hemiplegia and very common anaesthesia of the oppo- 
site half of the body, there is usually facial paralysis or anaesthesia of 
the side of the face corresponding to the tumor. In tumors of the 
cerebellum, as we have previously shown, hemiplegia ■ is not constant, 
and when present is not pure, but extends to the other side of the body 
to a less extent, especially affecting the muscles of the spinal column. 
Paresis of the muscles inducing bending, erection, and lateral move- 
ments of the spinal column, first shows itself by a peculiar form of diz- 
ziness, which we have already fully described, and referred to vibra- 
tions of the spine in walking and similar acts; subsequently, it often 
evinces itself by an utter inability of the body to maintain itself, so 
in the sitting position the patients collapse and cannot move the body, 
unless held by both shoulders. Paralysis of both sides results from 
tumors in both sides of the cerebrum, in the middle parts of the 
pons and in the medulla oblongata. In the above description of 
the different symptoms it has already been shown that epileptiform 
convulsions indicate that the tumor is near the cortical substance 
of the cerebrum; pain in the back of the head shows that it is in 
the posterior cranial fossa; and severe psychical disturbance either 
indicates numerous tumors in the cortical substance of both hemi- 
spheres, or that there is secondary meningitis or hydrocephalus. It 
appears to me that too little attention has been paid to the fact that 
the intelligence which is at first intact is very much impaired in the 
later stages of tumors encroaching on the posterior cranial fossa, 
which impede the escape of blood from the ventricles and induce ex- 
tensive transudations into them. 
Even on most carefully weighing all the symptoms, many errors 
occur, and it is very desirable that observers, who have access to a 
large number of cases, should publish their errors of diagnosis, as well 
as their successes, more than has hitherto been done. The trust- 
worthiness of the different aids to the diagnosis and localization of 
cerebral tumors cannot become perfectly clear till this is done. 
The wide-spread error of designating the various forms of neopla- 
sia, aneurisms of the brain, and even parasites, by the common name 
of cerebral tumors, is undoubtedly due to the fact that there are very 
few cases where the nature of the tumor can be certainly determined 274 
DISEASES OF THE BRAIN. 
daring life. If the symptoms of cerebral tumor occur in a person who 
shows signs of carcinoma, tubercle, aneurism, or parasites in some 
other organ, we are justified in presuming that the cerebral growth is 
of the same nature as the other tumor, neoplasia, or parasite ; but this 
aid to diagnosis fails in most cases, except where there are tubercles 
of the brain in persons with tuberculosis of the lungs, and syphilomata 
of the brain in persons with the same affections of other organs. Car- 
cinoma of the brain is, as a rule, primary and solitary; aneurism of a 
cerebral artery is usually the only one in the body, and, when cysti- 
cerci and echinococci enter the brain, as a rule they also are limited 
to that organ. 
The age of the patient gives some indication as to the nature of 
the tumor. Most frequently children are affected with tubercle, young 
adults with benignant tumors, especially sarcoma and glioma, and per- 
sons of advanced years with carcinoma. In his classical observations 
on brain-diseases, Griesinger has shown that, under some circum- 
stances, it is possible to make a diagnosis of cysticerci in the brain, 
even when there are none in other parts of the body. The large num- 
ber of these small parasites, and their customary seat in the superficial 
layers of the cerebrum, explain the severe psychical disturbances and 
the epileptiform attacks, while the absence of a large compressing 
body explains the non-occurrence of symptoms of paralysis, on which 
factors Griesinger founded the diagnosis in his case. On the other 
hand, I regard Griesinger1 s experiment, of compressing both carotids 
firmly against the transverse processes of the cervical vertebrae, as entire- 
ly useless for the diagnosis of basilar aneurism, and he, too, says it is 
“ purely theoretical.” The occurrence of convulsions during this act 
is not at all significant of an aneurism, even of an obliterated one. In 
many other diseases, also, where there is any thing encroaching on the 
intracranial space, compression of both carotids causes dizziness and 
loss of consciousness with or without convulsions. 
Treatment.—We can do but little to remove carcinoma, sarcoma, 
and the neoplasia generally, in other organs, by the hunger-treatment, 
by the administration of iodine, arsenic, etc., and these remedies are 
of no more benefit in tumors of the brain. They hasten the fatal re- 
sult instead of retarding it. The treatment can only be palliative and 
symptomatic. It is useless, and annoys the patient, to apply a seton 
or issue to the nape of the neck. On the contrary, it is advisable to 
guard him in every way from hyperasmia of the brain, by which 
acute swelling of the tumor and threatening attacks are most fre- 
quently caused; to regulate the nutrition and mode of life; to attend 
to the bowels, etc. Apoplectic or inflammatory attacks must be com- 
bated by venesection, local bleeding, ice-compresses, etc., as before HYDROCEPHALUS ACQUISITUS. 
275 
advised. When the pain in the head is unusually severe, we may or- 
der local abstraction of blood and cold-compresses or derivatives to 
the nape of the neck. If these fail, we should not be too timid about 
giving narcotics, and particularly small doses of morphia. When there 
is the slightest suspicion of syphiloma of the brain, instead of this 
symptomatic treatment, we should institute an energetic antisyphilitic 
course. It is unpractical to delay this treatment, or to neglect it al- 
together, if the syphilitic nature of the disease be not accurately deter- 
mined. Experience teaches that even very severe structural changes 
are capable of recovery, and often disappear under proper treatment, 
and, on the other hand, that treatment is powerless against carcinoma, 
sarcoma, etc. Hence, we risk little and may gain much, if, on the mere 
suspicion of syphiloma of the brain, we treat the patient as if there 
was no doubt about the diagnosis. 
CHAPTER X IY. 
SEROUS EFFUSIONS IN TIIE MATURE SKULL—HYDROCEPHALUS ACQUI- 
SITUS. 
We have already spoken of one form of hydrocephalus, that which 
almost constantly complicates basilar meningitis, and, in the next 
chapter, when treating of congenital hydrocephalus, we shall also 
treat of the effusions occurring shortly after birth, before the sutures 
are closed. In the present chapter we shall only consider those serous 
effusions into the cranial cavity which occur without basilar menin- 
gitis and after the skull has closed. 
Etiology.—Serous effusions into the arachnoid sac (hydrocephalus 
extemus) are rare, and hardly ever become extensive. Effusions into 
the subarachnoid space and ventricles and oedema of the brain are 
more frequent. 
Hydrocephalic effusions are due partly to increased lateral pressure 
m the vessels, partly to an abnormally slight amount of albumen in 
the blood, partly to disturbances of nutrition, which render the walls 
of the vessel more permeable. As one symptom of general dropsy, 
whether dependent on disturbance of circulation or on abnormal quality 
of the blood (morbus Brightii), the hydrocephalus rarely attains a high 
grade, although, perhaps, some sudden deaths occurring in the dis- 
eases inducing the dropsy are to be referred to slight effusions in the 
ventricle and to a slight oedema of the brain. Tumors and other dis- 
eases in the posterior cranial fossa, by compressing the vena; Galeni or 
straight sinus, and obstructing the escape of blood from the ventricle, 
sometimes induce high grades of hydroceohalus. Hydrocephalus, do- 276 
DISEASES OF THE BRAIN. 
pendent on certain disturbances of nutrition in the capillaries, is more 
of an independent disease than the other forms; it closely resembles 
the inflammatory processes, and may be ranked with the inflammations 
of the skin that cause serous blebs. This view is supported by an in- 
teresting observation of Iloppe, who, on examining the fluid from a 
chronic hydrocephalus, found it differently constituted from the normal 
cerebro-spinal fluid, particularly that it contained more albumen. This 
form of hydrocephalus occurs chiefly among children, and, when seen 
later in life, it almost always dates from childhood. 
We must mention, as a peculiar variety of the disease, hydrocepha- 
lus ex vacuo, which develops as a necessary result of diminution of the 
size of the brain, whether from general, especially senile, involution 
(hydrocephalus senilis), or from partial atrophy of the brain. 
Anatomical Appearances.—The amount of fluid effused into the 
arachnoid sac is difficult to decide, since, on removing the brain from 
the skull, the fluid from the subarachnoid space is always mixed with 
it; but, as we have before said, it never becomes considerable. 
The fluid effused in the subarachnoid space is sometimes regularly, 
sometimes irregularly spread over the surface of the brain; in the latter 
case the arachnoid often forms a vibrating sac filled with serum. When 
slight, oedema of the brain shows itself by the moist lustre of the cut 
surface; Avhen more decided, the coherence of the brain is decreased, 
and, if we press on some part, the resulting pit is filled with liquid 
after a time. When of very high grade, the brain-substance is broken 
down by the oedema, and changed to a thin white pulp (hydrocephalic 
softening). 
In acute hydrocephalus interims the fluid effused into the ventricle 
rarely exceeds half an ounce or an ounce; it is either clear, or, as is 
usually the case, slightly clouded by a scanty admixture of cast-off 
epithelium, flocculent clots, and fragments of the surrounding brain- 
substance. The walls of the ventricle, especially the septum, fornix, and 
commissures, are in a state of hydrocephalic softening. 
In chronic hydrocephalus internus we generally find the ventricles 
considerably dilated: they may contain ten or twelve ounces of fluid, 
which is usually clear. The ependyma of the cerebral cavities is thick- 
ened and often strewn with fine granulations. The surrounding brain- 
substance is also more dense and tough. 
Symptoms and Course.—Of course, the cavity of the skull is as 
much encroached on by serous effusions as by extravasations of blood 
or products of inflammation. As a necessary result of this, we have 
mentioned obstruction to the entrance of arterial blood, and have given 
attacks of convulsions and loss of consciousness as the symptoms of 
complete and sudden arterial anaemia; general symptoms of irritation HYDROCEPHALUS ACQUISITUS. 
277 
and depression as those of incomplete and gradually-developing anaemia. 
If, at the same time, we remember that those portions of the brain 
bounding the ventricles are destroyed, in acute hydrocephalus, by soft- 
ening, in the chronic form by atrophy, and that this may induce partial 
paralysis, we may construct a picture of the disease, either in the acute 
or chronic form, exactly corresponding with direct observation. 
Sudden and large effusions of serum into the cerebral substance 
and ventricles lead to a combination of symptoms which, from its re- 
semblance to the apoplectic attack induced by extravasation of blood, 
is usually termed apoplexia serosa. 
After what was said above, it is hardly worth mentioning that a 
distinction between serous and sanguineous apoplexy is not by any 
means possible in all cases, and that, if a diagnosis be made, it is 
chiefly from the etiology, which indicates one form rather than another. 
In children, acute hydrocephalus almost always runs its course with 
the symptoms that we ascribed to high grades of cerebral hyperaemia, 
and to the first stages of acute meningitis. Severe attacks of convul- 
sions, with loss of consciousness, are the most frequent and character- 
istic symptoms. If these attacks occur very often, and last unusually 
long, they should excite the fear that the hyperaemia has induced con- 
siderable transudations in the ventricles, and it is to be feared that the 
transudation will not be absorbed, or, at least, only partly so, and that 
chronic hydrocephalus will remain. 
The symptoms of chronic hydrocephalus either succeed those of the 
acute form, or they develop insidiously and gradually. They consist 
of headache, dizziness, weakness of the special senses, particularly of 
the eyes, very often of a general paresis, preceded by a tottering gait 
and trembling of the limbs. Among the constant symptoms are dis- 
turbances of the intellect, especially its gradual loss, even to idiocy. 
This is sometimes accompanied by convulsions, and occasional vomit- 
ing. The patients usually have a slow pulse, are readily chilled, are 
occasionally ravenous; they have a puffy look, and varicose vessels on 
the cheeks. Of course, these symptoms only render the diagnosis of 
chronic hydrocephalus certain when other cerebral diseases, accompa- 
nied by similar symptoms, can be excluded, and, consequently, that 
the diagnosis can rarely be made with absolute certainty. The course 
of the disease is usually very tedious. If death do not sooner occur 
from some intercurrent disease, it finally results, sometimes rapidly and 
unexpectedly, from acute increase of the effusion, sometimes slowly, 
from its gradual increase, being usually preceded, for some days, by 
continued deep sopor. 
Treatment.—The treatment of acute hydrocephalus is the same 
as that of acute hypermmia of the brain and acute meningitis. In 278 
DISEASES OF THE BRAIN. 
chronic hydrocephalus, the continued employment of cold douche baths 
deserves most confidence. 
CHAP TEIi XV. 
SEROUS EFFUSIONS IN THE INCOMPLETE SKULL HYDROCEPHALUS 
CONGENITUS. 
Etiology.—It is most probable that congenital dropsy of the brain 
is due to inflammation of the ventricular walls that lias occurred during 
foetal life. The etiology of the disease is entirely obscure. Some 
women have had several hydrocephalic children, without any apparent 
cause. 
Anatomical Appearances.—In congenital hydrocephalus the 
amount of serum, usually clear and limpid, effused into the cerebral 
cavities, is occasionally very small, while it sometimes amounts to six 
or ten pounds. In such cases the ventricles are distended to large, 
thick-walled sacs, the brain-substance around them is thinned, and 
often atrophied to a layer only a few lines thick; the corpora striata 
and optic thalami are flattened and pressed apart, the corpora quad- 
rigemina flattened, the commissures stretched and thinned. The sep- 
tum is occasionally broken through, and the floor of the third ventricle 
is often thinned and projecting. The pons and cerebellum appear 
compressed from above downward. 
Where the effusion is not large, the skull preserves its normal size; 
where it is large, on the other hand, it is almost always decidedly dis- 
tended. Even at birth the head is usually enlarged, but becomes still 
larger after birth, and may be distended to two feet in circumference. 
In such cases the cranial bones, especially the frontal and parietal 
bones, are very large, and are, at the same time, very thin. The mem- 
branous interstices also, especially the fontanels, are very wide. The 
forehead is prominent, the roofs of the orbits are depressed, and they 
are transformed into narrow, transverse slits; the squamous portions 
of the temporal bones and the occipital bone are more horizontal. The 
ossification, which is delayed, takes place from formation of points of 
ossification in the membranous interspaces, or even from the formation 
of innumerable small bones. The cranium, which, previous to the 
ossification, was very thin, often becomes thick subsequently, and, in 
many cases, such a skull retains an asymmetrical or remarkable spheri- 
cal form. 
Symptoms and Course.—Many children, born with hydrocephalus, 
die at birth or shortly after. In others, during the first weeks of life, 
if the skull be not enlarged, no symptoms of the disease can be 
observed. This is due partly to the difficulty of judging of the cere- HYDROCEPHALUS CONGENITUS. 
279 
bral functions at this age, partly to the yielding natv_re and gradual 
distention of the skull. If an equal amount of transudation occurred 
in the mature skull, the severest symptoms would arise. 
Even during the first years of life, the increasing size of the skull 
and the growing difficulty that the child finds in holding its head up- 
right are the most prominent and only characteristic symptoms. If 
the head be not enlarged, or so slightly so as not to be noticed, the 
disease is generally overlooked in the first year also. It is true the 
mother wonders that, when the child is nine months old or over, it still 
remains uncleanly, makes no attempts to walk, and does not even try 
to speak; she hardly asks the physician’s advice, and, when she does 
finally consult him, he also reassures her. But gradually the child 
appears more strange. First of all, there is an idiotic manner with 
outbursts of pleasure or fear, in which the child often shrieks out, dis- 
torts the face into horrible grimaces, and drums with the extremities. 
The first year passes, and the child eontinues to stick all toys, for 
which other children of the same age seem to understand the use, into 
its mouth, because it does not know what else to do with them. The 
eye does not regard any object held in front of it, but rolls about un- 
steadily. The face has no expression, but is empty and silly; often 
saliva flows constantly from the half-open mouth. And gradually 
comes the sorrowful conclusion that the child does not develop intel- 
lectually, or even loses ground. Many such children do not learn to 
walk. If we attempt to teach them to walk, they often cross the legs 
instead of setting them forward. Others, who do learn to walk, have 
such an uncertain and helpless gait that they readily fall, and fre- 
quently cannot step over any elevation. There are usually no anom- 
alies in the organs of special sense. On more careful observation, 
apparent deafness generally turns out to be deficient attention. It is 
difficult to come to any decision regarding the senses of smell and 
taste; the sense of sight usually remains intact, though there is often 
strabismus or dilatation of the pupil. 
In those cases where the head quickly becomes very large, the dis- 
ease is recognized sooner and more easily, although in them the above 
symptoms are usually less developed than where the head is mod- 
erately or not at all enlarged. The little old face, which does not 
agree with the large skull, and forms with it a triangle pointing toward 
the chin, the distended veins traversing the skin, especially in the 
frontal and parietal regions, the thin hair covering the broad skull, the 
often rachitic bones or a general dwarfy appearance, the vain attempts 
of the child to hold up the heavy head, which sinks again every time 
it is raised, give the disease an appearance as melancholy as it is 
characteristic. 280 
DISEASES OF THE DRAIN. 
Apart from the intercurrent attacks of convulsions, which are quite 
frequent, the course of the disease is sometimes regular and steady, so 
that the symptoms increase gradually till death results from general 
paralysis, or it is irregular, so that the symptoms are worse at times, 
while at other times there is a temporary stand-still or even improve- 
ment. Lastly, it is not rare for the disease, after attaining a certain 
point, to remain permanent, or even for part of the existing disturbances 
to disappear. This disappearance probably never goes on to recovery; 
some intellectual weakness always remains, though it may be only a 
slight amount. 
The most frequent termination of the disease is death; this often 
occurs during the first years of life, partly from the disease itself with 
convulsions and consequent coma, partly from complications. 
The increasing encroachment on the cranial cavity shows its effects 
earlier in the mature skull than in the opposite case, and the life of 
the child is in greater danger when the skull remains of the normal 
size than when it is considerably dilated. In rare cases death results 
from rupture of the distended ventricle and soft parts covering it, 
either spontaneously or from a fall or blow. Few patients live beyond 
puberty, and it is very rare for them to attain mature age. 
Treatment.—In congenital hydrocephalus nothing can be accom- 
plished by absorbent remedies, diuretics, drastics, preparations of 
iodine, calomel, or mercurial salve. Compression of the distended 
skull by strips of adhesive plaster is not free from danger, and in cases 
hitherto observed has proved of little use. Nor are the results of 
evacuating the serum by operation very encouraging. Most patients 
died soon after the first puncture or after its repetition, so that the 
operation should be limited to those cases where the head has attained 
a colossal size, and where a steady progress of the enlargement is 
observed. In the treatment of congenital hydrocephalus as in the 
acquired form, the treatment is mostly symptomatic, and the patients 
are to be protected as much as possible from all injurious influences. 
CHAPTER XYI. 
HYPERTROPHY OF THE BRAIN. 
Etiology.—Since, in so-called hypertrophy of the brain, there is 
not an increase of the true tissue-elements of the brain, the nerve-fil- 
aments, and ganglion-cells, but only a proliferation of the delicate 
insterstitial substance which unites the nerve-elements, the name 
hypertrophy of the brain is not exactly correct. It is sufficient, how- 
ever, to have noticed this point, and we may preserve the old name HYPERTROPHY OF THE BRAIN. 
281 
without fear of being misunderstood. We do not know whether the 
proliferation of the neuroglia is the result of frequently-recurring hyper- 
emia, or of some other cause. 
Hypertrophy of the brain is occasionally congenital, and then often 
accompanies dwarfishness; more frequently it develops after birth, is 
chiefly limited to childhood, and becomes rarer with advancing years. 
Hypertrophy of the brain acquired after birth is usually accompanied 
by rachitis, deficient involution of the thymus gland, and hypertrophy 
of the lymphatics (Rokitansky). Mental excitement, abuse of liquor, 
and lead-poisoning, are mentioned as exciting causes of the disease, but 
it is very doubtful whether they act in this way. 
Anatomical Appearances.—The brain, almost exclusively the 
cerebrum, is larger and heavier than normal. On autopsy, if the top 
of the skull be removed it is difficult to replace it, because the brain 
bulges out so, and protrudes between the sawed edges of the bone. The 
cerebral membranes are very thin and bloodless. We often find no trace 
of liquid in the subarachnoid space. The convolutions on the surface 
of the cerebrum are flattened and pressed together; the sulci between 
them are scarcely perceptible. The centrum semiovale is unusually 
large, the ventricles are small on section; the brain-substance, like the 
membranes, appears bloodless and dry. Its consistence and elasticity 
are increased. 
If hypertrophy of the brain develop before closure of the skull, the 
latter is distended, just as in congenital hydrocephalus. If, on the 
other hand, it does not begin till the sutures are closed, the cranial 
wall is often thinned by absorption, and the inner lamella loses its 
smoothness. More rarely, when the disease increases rapidly, the 
closed sutures are opened and pressed apart. 
Symptoms and Course.—Of course, hypertrophy of the brain has 
the same influence on the intracranial circulation as any other increase 
of the contents of the skull has; hence it is accompanied by extensive 
symptoms of irritation and of paralysis. And it may readily be un- 
derstood that these symptoms often do not occur, or only attain a low 
grade, as long as the sutures of the skull are not closed, and the skull 
can distend in proportion to the enlargement of the brain. The cir- 
cumstance that children with hypertrophy of the brain are not always 
deficient in intellectual development, but are sometimes remarkably 
sharp and competent in proportion to their physical development, 
forms a strong point in diagnosis between hydrocephalus and hyper- 
trophy of the brain in children with very large heads. Among the 
symptoms most frequently seen, when there is no enlargement of the 
head, or when it does not correspond to the increase of the brain, the 
most important are attacks of epileptiform convulsions. These at' 282 
DISEASES OF THE BRAIX. 
tacks seem to occur principally when the one constantly present cause, 
arterial anaemia, is accompanied by any other, often a very slight one, 
which suddenly and temporarily greatly increases the anaemia. Head- 
ache, dizziness, photophobia, general hyperaesthesia, mental irritability, 
occasional vomiting, and subsequently anaesthesia, general muscular 
debility, mental hebetude and drowsiness, are much less frequent and 
far less characteristic of the disease. The malady can only be diag- 
nosed with an approach to certainty where the skull is enlarged and 
hydrocephalus can be excluded, while in most cases only a probable 
diagnosis can be made. The course of hypertrophy of the brain is al- 
ways chronic. It is doubtful whether it ever ends in recovery. Death 
results either from the disease itself, generally not from a gradually 
increasing paralysis, but during a severe attack of oonvulsions, or else 
from complication with haemorrhages and inflammatory exudations; 
as may readily be understood, even when very slight, these are ex- 
tremely dangerous for such patients. 
We cannot speak of treatment of hypertrophy of the brain, for, 
even where the disease is recognized, we cannot expect any remedy to 
remove the existing disturbance. 
CHAPTER XVII. 
ATROPHY OF THE BRAIN. 
Etiology.—We must not term every diminution of the brain-sub- 
stance, particularly those due to destruction of its tissue and to develop- 
ment of shrinking cicatricial tissue in the place of the destroyed por- 
tion, atrophy of the brain. True atrophy of the brain consists rather 
in a diminution of the size or number of the elements, without any per- 
ceptible previous destruction of them. 
It is convenient to distinguish two forms of atrophy of the brain. 
In the first, the so-called agenesis, there is incomplete development; 
in the second there is a retrogression, a disappearance of the previous 
ly well-developed constituents of the brain. 
We pass over those forms of agenesis where the brain is so incom- 
pletely developed that there is either complete idiocy or that life can- 
not continue, and turn our attention to the interesting and not very 
rare form of one-sided atrophy of the brain, occurring during foetal life 
and the first years of childhood, in which not only may life continue, 
but there may be a certain amount of intellectual development. The 
etiology of monolateral agenesis is obscure. It is probably due to in- 
flammation of the brain, meninges, or skull, during foetal life or early 
childhood. ATROPHY OF THE BRAIN. 
283 
The atrophy occurring after complete development of the brain is 
sometimes primary, sometimes it accompanies other affections of the 
brain as a secondary disease. Among the primary atrophies we must 
first mention that form which occurs as a symptom of senile marasmus. 
Other senile changes attain unequal grades in different persons, and 
we also meet very aged individuals who do not show the least sign of 
cerebral atrophy, while it advances to the highest grade in mucli 
younger persons. Next to this comes the atrophy of the brain, which 
develops in the course of exhausting and consuming diseases. In 
many cases which are quoted as examples of great resignation and 
wonderful firmness at the approach of death in tedious diseases, the 
facts were really badly interpreted; very often the resignation is cer- 
tainly due to the dulness and apathy induced by cerebral atrophy. 
Local diseases of the brain are the chief causes of secondary atrophy. 
We have already mentioned it as the result of precedent apoplexy, 
partial necrosis, and partial encephalitis. The paralytic form of idiocy 
appears to depend on an atrophy of the brain caused by chronic me- 
ningitis or inflammatory processes in the cortical substance. In other 
cases the atrophy is the result of continued pressure on the brain. 
Under this head come the cases where the size of the brain gradually 
decreases under the pressure of cerebral tumors and hydrocephalic 
effusions. In meningitis, also, perhaps part of the atrophy is due to 
the pressure of the inflammatory exudation in the subarachnoid space. 
Lastly, we must mention that injury and destruction of peripheral 
nerves occasionally induce secondary atrophy of their centres. 
Anatomical Appearances.—When cerebral agenesis is limited 
to one side, the left is the one generally affected; sometimes the 
whole hemisphere is affected, sometimes only parts of it. In high 
grades of the disease, the cerebral substance between the ventricles 
and convex surface has become a thin layer only a few lines thick. The 
convolutions are scarcely perceptible, or else are very small. The large 
cerebral ganglia are usually atrophied, and the atrophy extends from 
them through the crura cerebri to the spinal marrow. The consistence 
of the atrophic brain is usually increased, its color is somewhat dirty. 
The space created by the atrophy is filled with fluid that has collected 
partly in the ventricles, partly between the meninges. The skull is 
often unsymmetrical, and is thickened at the atrophied part. 
Atrophy of the brain occurring late in life is usually total, but, 
when it results from partial destruction of the brain, it is generally 
further advanced on the side corresponding to the disease than on the 
other. The medulla of the cerebrum is diminished, the convolutions 
appear thinner, the furrows broader and deeper. The medullary sub- 
stance is dirty white, more dense and tough, the cortical substance ia 284 
DISEASES OF THE BRAIN. 
thinner, harder, and of a pale or light-brown color. The ventricles 
are dilated and filled with serum. There is also a quantity of fluid in 
the subarachnoid meshes (hydrocephalus ex vacuo). 
Symptoms and Coukse.—Although, as we have previously men- 
tioned, agenesis of one side is not always accompanied by psychical 
disturbances, still it is rare to find eases where we dare assert that one 
side of the brain fully replaces the other. Far the greater number of 
patients suffer from weakness of intellect, and many from decided 
idiocy. The organs of special sense, particularly the eye, are usually 
very insensitive, and the excitability of the sensory nerves of the par- 
alyzed half of the body is diminished. The most important and ap- 
parent symptoms are paralysis and a peculiar and excessive atrophy 
of the side of the body opposite to the atrophied brain. The paralysis 
is not usually complete, so that the patients can generally perform 
some imperfect movements. The paralysis is ordinarily combined 
with contractions. The atrophy of the paralyzed side affects all the 
tissues, the bones not excepted, so that the thin and short extremities 
of a grown person appear like those of a child. Most patients suffer 
from epileptic attacks. As the other functions of the body are usually 
well performed, the disease itself is rarely fatal. But the patients 
seldom attain old age. Their power of resistance to intercurrent dis- 
eases is lessened, and they succumb to them more readily than other 
persons would. 
The primary atrophy of the brain, which develops chiefly m old 
persons, and secondary atrophy, which accompanies apoplexies, partial 
necrosis, and other local brain-diseases, are characterized by gradual 
weakening of the psychical functions, loss of memory, slowness of 
thought, absent and childish manners, as well as dulness of the senses, 
and gradual weakening of the motor power, unsteadiness of motion, 
trembling, incomplete control of the sphincters, etc. 
The atrophy of the brain found on autopsy of insane patients, who 
have suffered from paralytic idiocy, belongs to the terminal symp- 
toms observed in that form of insanity during life, to the symptoms of 
mental weakness and idiocy, but not to the monomania which pre- 
ceded the mental paralysis, or to the intercurrent maniacal and apo- 
plectiform attacks. These are rather to be referred to the precedent 
meningitis, Avhich is rekindled from time to time during the subse- 
quent course. At the stage of the disease when the psychical exalta- 
tion of the patient decreases, when the insane ideas and hallucinations 
lose their richness and reality, when the thoughts are confused, mem- 
ory defective, symptoms of paralysis also begin to appear in the motor 
sphere; and the more the signs of psychical weakness increase, the 
more extensive and marked become the signs of motor paralysis. The APHASIA—ASYMBOLI A. 
285 
first symptom of the latter is always impaired articulation, which 
gradually becomes sheer mumbling. The attitude is negligent, the 
gait uncertain and tottering, the patient easily falls, and his hands 
tremble when held out. Later, he cannot leave the bed, lies mo- 
tionless, does not react to the strongest irritation, and finally dies 
of marasmus. 
Treatment.—We cannot expect to treat atrophy of the brain 
successfully. Treatment must be directed against the original dis- 
ease, to prevent the progress of the atrophy, if possible. On this 
occasion we shall again call attention to the cold douches which 
we recommended as peculiarly efficacious in chronic meningitis. 
For the rest, we have to limit ourselves to combating the more 
threatening symptoms. In monolateral agenesis, Ave may attempt 
to arrest the atrophy and fatty degeneration of the muscles by 
using the induced current of electricity, which, in this case, is of 
course to be regarded only as a gymnastic remedy. 
[CHAPTER XVIII. 
APHASIA ASYMBOLIA. 
There is a disease of the brain which, while it impairs or even 
totally destroys the power of speech, does not in the least disable 
the apparatus for speaking, nor derange the faculty of thinking. 
This incapacity to express thoughts in words, although the mind be 
clear and the muscles of speech in good order, is called aphasia. 
Trousseau and Broca observed that such disorders of speech stood 
in close connection Avith a lesion of the third frontal convolution, and 
that nearly always an affection of the left third, and quite excep- 
tionally a similar one of the corresponding convolution of the right 
side, was at the root of failure of speech. This relation the French 
authors first explained by assuming that in most persons the organ 
of speech is developed only upon one side, and that usually the left 
one ; while among left-handed persons the right third convolution 
should represent the function of speech. Besides the third convo- 
lution, however, there seem to be other spots in the brain which 
have to do with the speaking faculty; and in a good many cases 
the diseased point has been found elsewhere, in the fissure of Syl- 
vius, the island, or nearer to the corpora striata, or even in the pos- 
terior lobes of the brain. 
The lesions which may cause aphasia are Ararious—apoplexies, 286 
DISEASES OF THE BRAIN. 
inflammatory and embolic points of softening, injuries of the head 
followed by inflammatory growths, and the like. When the lesion 
is extensive, of course other functional derangements of the brain 
will accompany the aphasia. These coarse structural changes, how- 
ever, are not the only causes of aphasia. It has appeared during 
the course of acute infectious disease, such as typhus, and as a con- 
sequence of poisoning by lead, belladonna, and chloroform. It has 
also arisen in hysteria and epilepsy, as well as after violent mental 
emotion. 
Generally only one or two words remain at the command of an 
aphasic person. With these he in vain strives to express his 
thoughts, repeating them malapropos on all occasions. In some 
cases the speech is quite lost, or the patient can only utter unintel- 
ligible sounds. Although this lack of power to clothe the thoughts 
in words is the commonest and most marked phenomenon, yet it is 
not the only one. Very often the patient cannot write (agraphia) 
nor read (alexia); sometimes even the power to communicate ideas 
by gesture is also lost. Hence the term asymbolia (Finkelburg) 
would seem more suitable to the disease than aphasia. Finkelburg 
defines asymbolia as an affection in which the faculty of conveying 
ideas by means of signs, or else the ability to understand such signs, 
is impaired or lost. Indeed, aphasic persons are very often incapa- 
ble of reading or understanding either written or printed words. 
In very exceptional cases the speaking faculty has been preserved, 
while the ability to make or to comprehend signs has failed. To this 
condition the term aphasia certainly does not apply. An aphasic 
patient now at the Giessen clinic for some weeks presented the odd 
peculiarity of being unable to open his mouth when told to do so. 
He would make awkward and vain attempts to open it with his fin- 
gers ; but the moment a spoonful of food was presented to his lips, 
the mouth would gape to the verge of its ability. 
We have not as yet any satisfactory explanation of the physiol- 
ogy of aphasia. Trousseau ascribed the loss of speech to two con- 
ditions : 1. To partial lack of memory. In such cases the patients 
do not speak because they cannot remember the words ; but they 
can still repeat words spoken to them (amnestic form). 2. To for- 
getting the art of articulation, so that repetition of words spoken to 
the patient is difficult or impossible to him {atractic form). 
It is very easy to recognize an uncomplicated, well-pronounced 
case of aphasia ; but the diagnosis of an ill-marked case, or of one 
combined with other mental disorders, may be very difficult. Hemi- 
plegia often exists on the side opposite to that of the brain-lesion 
(hence generally upon the right side); and since the aphasia in such ADDITION TO THE REVISED EDITION OF 1880. 
287 
cases probably depends upon destructive local disease of the brain, 
the prognosis should be unfavorable, although improvement may 
perhaps take place. When there is no paralysis, and when we have 
reason to ascribe the attack to a transitory derangement of the cir- 
culation, to a watery exudation, or the like, we may hope that the 
affection may pass away. 
Treatment of aphasia should be mainly a treatment of its cause. 
Later in the disease the attempt may be made to develop the speak- 
ing faculty from the opposite half of the brain, by judicious prac- 
tice of reading, writing, and elocution. Such vicarious compensa- 
tion is, however, not to be relied on.] 
ADDITION TO THE REVISED EDITION OF 1880. 
SECTIOX I.—DISEASES OP THE BEAIX. 
1.—P. 216. 
The discovery that the bursting of a vessel is preceded by an 
aneurismal dilatation of its walls is most important in the etiology 
of apoplexy. It used to be assumed that the fatty degeneration at- 
tacked only the inner and middle coats, causing an escape of blood 
into the adventitia, which then bulged out under the blood-pressure 
(ICollikeCs and JPestalozzi’s spurious aneurism ; Virch.ow’s dissecting 
ectasy). Charcot and Bouchard take quite a different view of the 
vascular dilatation which plainly lies at the root of most apoplexies. 
According to them, a periarteritis, or inflammation of the lymphatic 
sheath, forms the starting-point of the process, and the morbid 
changes progress from without the vessel inward (the reverse of 
what occurs in atheroma), the adventitia thickens more or less, or 
at least shows a multiplication of its nuclei, while the muscular 
coat tends to atrophy. At points where the thickening of the ad- 
ventitia has failed while the muscular coat has atrophied, the vascu- 
lar wall yields before the blood-pressure ; thus there form small 
round knots (miliary aneurisms), situated on the vessels, and hav- 
ing the diameter of \—1 millimetre. If these little aneurisms con- 
tain liquid blood, their color will be red ; if the blood be coagulated, 
they present a brown or blackish appearance. If the thickening of 
the wall be considerable, the sac may attain the consistence of a 
grain of sand. 
Zenker, while supporting the Frenchmen regarding the fre- 288 
DISEASES OF THE BRAIN. 
quence and importance of miliary aneurism, believes that they 
originate in a sclerosis of the tunica intima, like that which attacks 
the larger vessels. 
Apoplexies which arise during scurvy, morbus maculosus, and 
malignant infectious disorders, appear to depend upon a morbid 
tenderness of the vascular walls caused by fatty degeneration. SECTION II. 
DISEASES OF THE SPINAL MARROW AND ITS 
MEMBRANES. 
CHAPTER I. 
There is hardly any doubt that the amount of blood contained in 
the spinal marrow is subject to variation, and that hyperaemia and 
anaemia modify its functions just as they do those of the brain. Never- 
Iheless, the symptoms which we are in the habit of referring to an 
abnormal amount of blood in the spine are not directly deduced from 
comparison of the symptoms observed during life with the results of 
autopsy, but from a priori reasoning. Moreover, in most autopsies no 
attention is paid to the amount of blood in the spinal marrow, and its 
estimation offers even more difficulty than is the case in the brain. 
Remarkable vascularity of the spinal medulla and its membranes 
is most frequently found on autopsy of new-born children and of per- 
sons who have died of spasmodic affections or of acute febrile diseases. 
We also find varicose dilatations of the venous plexus in the lower 
part of the spinal canal, as one of the symptoms of abdominal plethora 
accompanying cirrhosis of the liver and other diseases that impair the 
circulation in the abdomen. 
Hyperaemia of the spinal medulla itself leads to swelling and relax- 
ation of its substance, and to the formation of small ecchymoses; in 
higher grades there is softening of the medullary substance. Accord- 
ing to Hasse, hyperaemia of the membranes induces increased transu- 
dation, as a result of which there may be overfilling of the subarach- 
noid space, extending from below upward as far as the skull. 
As symptoms of hyperaemia of the spinal medulla and its mem- 
branes, the above author mentions a dull pain, mostly limited to the 
sacral and lumbar regions, a feeling of numbness and formication in the 
HYPEREMIA OF THE SPINAL MARROW AND ITS MEMBRANES. 290 
DISEASES OF TIIE SPINAL MARROW AND ITS MEMBRANES. 
lower extremities and their incomplete paralysis. These disturbances 
of sensation and motility, proceeding from below upward, rarely extend 
to the upper extremities; when this does occur, the respiration is also 
said to be occasionally affected, while the bladder and rectum hardly 
ever participate in the paralysis. From this combination of symptoms 
we cannot decide on hyperaemia of the spinal marrow with any cer- 
tainty, unless there are other symptoms of it, and the symptoms dis- 
appear after bleeding from the haemorrhoidal or uterine veins, which 
anastomose with those of the spinal medulla, or after local abstraction 
of blood. It is at least doubtful whether convulsions result from ex- 
cessive hyperaemia of the spinal marrow, since the hyperaemia found 
on autopsy after severe convulsions may just as well be the result as 
the cause of the spasm. The same is true of the association between 
the spinal hyperaemia, found after febrile diseases, and the symptoms 
of the fever. “ Spinal irritation,” which for a time caused a good deal 
of talk, is a term used to indicate a condition chiefly characterized by 
sensitiveness of certain spinal processes to pressure, great inclination 
to reflex movement, and a general hyperassthesia. We find these 
symptoms just as frequently as we do headache in many acute and 
chronic diseases, without its being possible to interpret them. At all 
events, we are not justified in deciding from their presence, without 
further proof, that there is hypermmia of the spinal marrow, any more 
than we are in diagnosing cerebral hyperaemia in patients who have 
only headache. 
If the causes of the spinal hyperaemia be made out, we should, in 
the first place, attempt to fulfil the causal indications. When the hy- 
peraemia has attained a certain grade and we cannot hope for its sub- 
sidence without therapeutic aid, we may employ local blood-letting by 
wet cups and leeches. We should apply the former along the spinal 
column, the latter about the anus, especially when there is coincident 
abdominal plethora. The effect of the abstraction of blood is sup- 
ported by cathartic medicines, particularly the neutral salts. 
HAEMORRHAGE OP THE SPINAL MARROW AND ITS MEMBRANES 
SPINAL APOPLEXY. 
CHAPTER II. 
Except small ecchymoses, which accompany excessive spinal hyper- 
oemia, extravasations between the meninges and into the substance of 
the spinal marrow are very rare. Degeneration of the walls of the 
vessels, and increased pressure of blood in the arteries, which are the 
chief causes of cerebral haemorrhages, appear to have no effect on HYPEREMIA OF THE SPINAL MARROW AND ITS MEMBRANES. 
291 
spinal haemorrhage. Intermeningeal haemorrhages may almost always 
be traced to injuries of the spinal meninges from wounds, contusions, 
or stretching. Their occurrence chiefly among the newly-born is due 
to the severe tension to which the spinal column of the child is so 
often subjected during severe labor. Extravasations of blood in the 
medulla spinalis are usually terminal symptoms of chronic destructive 
processes of the cord, and are only rarely due to injuries of the spinal 
column. 
The extravasations of blood from meningeal haemorrhage are usu- 
ally considerable; they collect chiefly in the lower part of the spinal 
canal, but often fill large portions of the subarachnoid space. Where 
the haemorrhage is into the medulla, we find it containing a bloody 
pulp. The changes undergone by the apoplectic clot, when it has ex- 
isted a long time, are little known, but seem to resemble those under- 
gone by the brain under similar circumstances. 
Apparently intermeningeal haemorrhages only gradually compress 
the vessels of the spinal cord sufficiently to entirely cut off the supply 
of arterial blood, and so remove the excitability of the nerve-filaments. 
In effusions of blood between the meninges, symptoms of severe irrita- 
tion, pains in the back, and spasms, especially tonic spasms in the 
parts supplied by the nerves going off below, opisthotonos, rigid con- 
traction of the extremities, etc., usually precede the paralysis. But 
where there are large extravasations, there is perfect anaesthesia, and 
paralysis of the parts receiving nerves from the compressed portion of 
the spinal cord. If the respiratory muscles be among these parts, 
death soon occurs; if they remain unaffected, death may be delayed. 
It is doubtful whether the conduction can be restored and recovery 
take place after disintegration and reabsorption of the extravasation. 
From the above symptoms we can only make a diagnosis of meningeal 
spinal apoplexy when they have been preceded by an injury of the 
spinal canal. If the history be imperfect, and we find no causes ren- 
dering haemorrhage probable, the disease cannot be recognized with 
certainty. 
Since the substance of the spinal marrow is usually entirely broken 
down by haemorrhages into it, the conduction from the brain to the 
peripheral nerves, and from them to the brain, is generally interrupted 
at the moment of the haemorrhage. The more sudden the symptoms 
of this interruption—anaesthesia, and loss of voluntary motion in the 
lower half of the body, combined with paralysis of the bladder and 
rectum—appear, the more probable it is that the communication has 
oeen interrupted by a rapid breaking down of the spinal medulla from 
an extravasation of blood, and not by its gradual destruction from in- 
flammation, softening, or paralysis. When the apoplexy is high up, so 292 
DISEASES of the spinal marrow and its membranes. 
that respiration is affected, death occurs quickly. If, on the other hand, 
a part far down be destroyed, death does not result for years, and is 
generally caused by large bed-sores, or cystitis, induced by paralysis 
of the bladder. 
Since we cannot, by therapeutic means, hasten the reabsorption of 
the effused blood, or aid the regeneration of the broken-down nerve- 
filaments, the treatment of spinal apoplexy can only be symptomatic. 
At first, as long as there are severe pains in the back and symptoms of 
inflammation, the proper treatment is local bleeding, and the applica- 
tion of an ice-bladder to the part where the haemorrhage is suspected. 
Subsequently there is usually little to do but to guard the patient 
against bed-sores, to carefully empty the bladder at regular intervals, 
and to maintain the strength of the patient. Well-to-do persons, who 
remain paralyzed from spinal apoplexy, may be sent to Wildbad, 
Pfaffers, or Gastein. But, the more certain the diagnosis, the more 
improbable it is that these baths will prove beneficial. 
CHAPTER III. 
INFLAMMATION OF THE MEMBRANES OF THE SPINAL MARROW 
MENINGITIS SPINALIS. 
Etiology.—Inflammation of the dura mater probably never occurs 
as an independent disease, but it very frequently follows injuries, and 
especially inflammations of the spinal column. Acute inflammation of 
the arachnoid is also almost solely observed as an accompaniment of 
inflammation of the dura and pia mater; but chronic inflammation of 
the arachnoid, resulting in partial thickening and ossification, occurs as 
a primary and independent disease, without perceptible cause. Acute 
inflammation of the pia mater from epidemic influence has already 
been described, among the diseases of the brain, as meningitis cerebro- 
spinalis. Besides this form, there are sporadic cases of inflammation 
of the pia mater of traumatic origin, or due to inflammation of the 
dura mater; and, lastly, although rarely, cases that must be referred 
to catching cold, or some other injurious influence acting on the body 
Anatomical Appearances.—Inflammation of the dura mater is 
never spread over large surfaces, but is always more or less circum- 
scribed. At first the inflamed spot appears injected, infiltrated, and 
relaxed; later it becomes discolored, friable, and is occasionally cov 
ered with purulent exudation. The results of pachymeningitis spinalis 
are permanent thickening of the dura mater, and its adhesion to the 
bone; more rarely there is perforation of the dura mater by the pus col- 
lected between it and the bone, and, as a consequence, diffuse meningitis. MENINGITIS SPINALIS. 
293 
We must regard as remains of chronic inflammation ff the arach- 
noid, milky opacities of that membrane, and cartilaginous or bony 
plates, about the size of a millet-seed, which have a rough inner and 
smooth outer surface, and which are generally very numerous, espe- 
cially in the lower portion of the spinal cord. 
Inflammation of the pia mater is usually very extensive. In the 
acute form we find the pia mater injected, swollen, and relaxed. In 
the subarachnoid space there is a copious, purulent, flocculent exuda- 
tion, or else the pia mater and arachnoid are covered with membranous 
deposits. The spinal medulla is usually pale and bloodless; rarely it 
is injected, relaxed, or softened. Most cases of so-called hydrorhachis 
acquisita appear to be due to chronic inflammation of the pia mater. 
We spoke of opacities and oedema of the cerebral membranes as very 
frequent post-mortem appearances in topers, and referred them to a 
chronic meningitis; it is also probable that inflammatory disturbance 
of nutrition of the meninges induces the collections of large amounts 
of fluid in the subarachnoid space of the spine, when they do not de- 
pend on general dropsy or atrophy of the spinal marrow (in which 
case they are unimportant, and do not cause any symptoms). More- 
over, it is difficult to decide, from the tension of the dura mater before 
it is incised, or by estimating the amount of liquid that escapes after 
it is incised, whether the amount of subarachnoid fluid is abnormally 
increased. The more cloudy or bloody the escaping fluid, the more 
probable it is that the hydrorhachis is due to chronic inflammation of 
the meninges. 
Symptoms and Course.—Inflammation of the dura mater is not 
accompanied by very prominent or characteristic symptoms when it 
does not lead to perforation, and, by escape of pus into the subarach- 
noid space of the spine, induce diffuse meningitis. When patients, 
who have had an injury of the back, or have caries of the spine, com- 
plain of pain in the back, it is difficult to decide whether it is due to 
inflammation of the dura mater or of the bones and ligaments. 
The symptoms of chronic inflammation of the arachnoid, and during 
the formation of the little plates above described, are perfectly ob- 
scure. 
Acute inflammation of the pia mater is accompanied by symptoms 
of severe irritation in the parts supplied by spinal nerves, which are 
subsequently generally followed by symptoms of paralysis; it is usu- 
ally distinctly characterized and readily recognized by these symptoms 
and their sequence. Occasionally after a chill there is fever, and the 
patients complain of severe pain in the back, which becomes insup- 
portable on motion, and usually on pressure over the spine. It is 
ordinarily accompanied by pains in the extremities. Both the pain in 294 
DISEASES OF THE SPINAL MARROW AND ITS MEMBRANES. 
the back and the peripheral pain are to be referred to the irritation of 
the sensory nerves within the spinal canal, from the inflammation of 
their envelopes. Tonic spasms in the muscles of the back and extremi- 
ties, causing opisthotonos and contraction of the limbs, are just as 
constant symptoms as tne morbid excitement of the sensory spinal 
nerves. These tonic spasms, which, as is well known, we may induce 
artificially in animals, by irritating the spinal medulla with the in- 
duced current, usually remit and exacerbate. The exacerbations are 
not, as in tetanus, induced by irritating any part of the skin, but by 
movements of the spinal column, a fact which indicates that the tonic 
spasms in meningitis spinalis are not due to increased reflex excitabil- 
ity, but are direct results of irritation of the motor nerves from the 
inflammation of their envelopes. The rigidity and tension of the body, 
which prevent the patient, who is not at first paralyzed, from moving, 
are from time to time interrupted by convulsive starts. If the respira- 
tory muscles participate in the tetanic rigidity, breathing becomes im- 
possible, and the patient soon dies as a consequence. If the res- 
piratory muscles remain unaffected, there is occasionally a gradual im- 
provement ; but more frequently paraplegia is developed, or the fever 
increases, and the patient succumbs to the paralysis, which advances 
to the medulla oblongata, or to the exhaustion induced by the fever. 
In the chronic form of inflammation of the pia mater, whose symp- 
toms we described with those of hydrorhachis acquisita, since we con- 
sider a distinction between them as impracticable, the pain in the back 
is usually inconsiderable and is easily overlooked. On the other hand, 
at the onset of the disease, the pain in the extremities is often such a 
prominent symptom, that the affection is mistaken for peripheral rheu- 
matism. The most important symptoms are those of paralysis, which, 
commencing in the lower extremities, extend to the bladder, rectum, 
and subsequently to the upper extremities. The paralysis is usually 
incomplete at first, and only gradually increases to complete para- 
plegia ; along with it there is usually a feeling of formication and fur- 
riness in the lower extremities, the precursor of anaesthesia, which, 
however, rarely attains a high grade. In some of these cases the 
paraplegia develops quickly, occasionally in a few days after being 
preceded only for a short time by pain, which is considered as rheu- 
matic (hydrorhachis rheumatica). The paralysis then often remains 
stationary at the height it has attained, or may entirely disappear. In 
other cases the paraplegia develops more slowly and insidiously. In 
such cases the hope of a permanent decrease of the paralysis is 
slighter, although the disease almost always shows remarkable varia- 
tions in its course. Most patients die sooner or later from extension 
of the paralysis to the medulla oblongata, from bed-sores, or from MYELITIS. 
295 
catarrh of the bladder. Paraplegia occurs in some othei spinal dis- 
eases as well as in chronic meningitis. The gait of the patient is not 
characteristic, and does not differ from the gait in other forms of para- 
plegia. The old belief that the symptoms of paralysis, due to a col- 
lection of fluid in the spinal canal, grew worse when the body was 
upright and less when it was horizontal, from the fluid being dis- 
tributed more evenly, was purely theoretical and not derived from 
direct observation. The most important points, in distinguishing 
chronic meningitis and hydrorhacliis acquisita from other diseases of 
the spinal cord, are the symptoms of irritation, particularly the painful 
sensations which precede the paralysis; also the gradual advance of 
the paralysis from below upward, which does not occur in the disease 
limited to certain points, and particularly the varying course of the 
disease, the exacerbations and remissions, which do not occur in dis- 
eases destroying the spinal medulla. 
Treatment.—Acute spinal meningitis requires energetic antiphlo- 
gistic treatment, particularly the application of leeches and wet cups to 
both sides of the spine. If the disease be of traumatic origin, we should 
at the same time use cold to the back by means of an ice-bladder, or the 
frozen compresses before mentioned. In very recent cases, as there is 
danger in delay, and not much can be lost, we may employ the much- 
lauded frictions with meieurial ointment, and give calomel internally. 
If the acute stage passes off and the disease is protracted, we may 
apply flying-blisters to both sides of the spine; commencing with them 
at the neck, we gradually descend to the sacrum, and then begin again 
at the neck. In meningitis, flying-blisters appear to be more efficient 
than moxa3 and the hot iron, which deserve the preference in diseases 
of the vertebrae, and in inflammations of the spinal medulla limited to 
certain points. In protracted cases, or at the commencement of those 
running a chronic course, cold plunge-baths and douches, and particu- 
larly continued warm baths, are very serviceable. The reputation of 
these remedies, in paraplegia generally, depends chiefly on their results 
in chronic meningitis spinalis, which is the most amenable to treat- 
ment of the diseases of the spinal medulla and membranes. Such 
patients are also benefited by the bath-treatment at Wildbad and 
other similar thermal springs. 
CHAPTER 1 V. 
INFLAMMATION OF THE SPINAL MARROW—MYELITIS. 
In the present chapter we discuss also softening and hardening of 
the spinal medulla, myelomalacia, and myelosclerosis, since we shall 
consider these degenerations (except where the softening is due tc 296 
DISEASES OF THE SPINAL MARROW AND ITS MEMBRANES. 
haemorrhage and oedema, as already described) as results or forms of 
myelitis until we shall have learned some other mode of origin for 
them, as we have for the analogous changes in the brain. 
Etiology.—Myelitis induces the same structural changes as en 
cephalitis does. In it there is no abundant interstitial exudation, but 
the nerve-elements undergo inflammatory disturbances of nutrition, and 
finally break down, just as the ganglion-cells and nerve-filaments of 
the brain do in encephalitis. 
Apart from the cases due to propagation of inflammation from the 
vertebra? to the medulla, myelitis must be regarded as a rare disease. 
But this extension occurs quite frequently. Most paraplegias which 
come on during vertebral disease are not results of the curvature of 
the spine, but of inflammation extending from the vertebra? to the 
and thence to the medulla. This view is supported by 
the fact that in vertebral disease there is frequently paralysis before 
the spine is curved, and, on the other hand, great curvature often exists 
for years without symptoms of paralysis, till these at last accompany 
the deformity without any increase of the curvature, but usually after 
}.ain in the back. More rarely, wounds and contusions of the spinal 
column, or the development of syphilitic exostoses, induce myelitis. 
Occasionally the disease develops about neoplasia and extravasations 
of blood. Lastly, sexual excesses, excessive straining, catching cold, 
suppression of the perspiration of the feet, etc., are given as causes of 
myelitis. We do not know whether in such cases the disease is 
really due to these causes or to other unknown influences. Patients 
with paraplegia, besides their other misfortunes, are usually subjected 
to the unfounded suspicion that they have brought on their disease by 
dissolute habits. 
Anatomical Appearances.—Myelitis is sometimes confined to 
circumscribed spots, and then, usually starting from the gray sub- 
stance, it attacks the whole thickness of the medulla; sometimes, as 
“ central softening,” it extends widely through the gray substance, and 
then affects the white substance but little. 
In the circumscribed spots we find the spinal medulla swollen in 
recent cases. If we cut into it, a more or less consistent red pulp (red 
softening) rises above the cut surface. In older cases, the color of 
the pulpy soft spot becomes more brown or yellow (yellow softening), 
from change of the haematin and fatty degeneration of the broken-down 
nerve-elements. Far more rarely than in the brain, the inflamed spot 
in the spinal medulla is converted into an abscess by the extensive 
formation of pus-cells. The inflammation in the meninges usually ex- 
tends beyond .that of the medulla. From disintegration and reab- 
sorption of the disintegrated elements in circumscribed myelitis a MYELITIS. 
297 
cavity, filled with serum and traversed by delicate connective tissue, 
may be formed in the spinal medulla. In other cases there is in- 
duration from connective-tissue proliferation. These sclerosed spots, 
which are usually somewhat retracted and colored yellow by pigment, 
form analogues to the yellow plates, which we found as remains of 
peripheral encephalitis. 
In the second (central) form of myelitis we find the medulla but 
little swollen at first. On section, the contours of the gray substance 
appear lost; it is somewhat darker in color, reddened, and less con- 
sistent. In older and typical cases the spinal medulla is decidedly 
swollen, and in its centre wTe find a thin reddish, rusty, or yellow pulp. 
In this form, also, the tissue-elements, which have broken down to a 
fine detritus, are sometimes reabsorbed, and fluid exuded in their place, 
so that, at last, in the axis of the spinal medulla, there is a cavity filled 
with serum, and surrounded by delicate connective tissue, or traversed 
by a framework of the same. 
Symptoms and Course.—Since acute myelitis is always accom- 
panied by meningitis, it is also accompanied by the symptoms of spinal 
meningitis described in the last chapter, and we can only decide, from 
certain modifications of the symptoms there described, that the me- 
dulla itself, as well as the meninges, is inflamed. In the commence- 
ment of the disease there is usually severe fever and more or less ex- 
tensive pain in the back and extremities, tetanic rigidity of the mus- 
cles of the back and nape of the neck, contractions of the extremities, 
alternating with convulsive attacks, and where the respiratory muscles 
participate in the tetanic tension there is great dyspnoea. The more 
circumscribed the pain in the back, the more distinctly the peripheral 
pains and spasms are limited to the parts supplied by nerves from a 
certain portion of the medulla; but especially the earlier and more 
completely paraplegia follows these symptoms of irritation, the more 
probable it becomes that the spinal medulla itself is inflamed. In very 
malignant cases these symptoms may get the upper hand very quick- 
ly, and, even in the first days of the disease, the patient may die from 
disturbance of the respiration. In other cases the storm passes over, 
but a paraplegia remains, which hardly ever recovers. Cases running 
the above course are rare, and are almost always of traumatic origin, 
or result from perforation of an abscess into the vertebral canal. 
Chronic myelitis, also, is generally preceded by symptoms of irrita- 
tion ; but, as the participation of the meninges in the tedious inflam- 
mation of the spinal medulla is slighter and less extensive, they are 
jsually limited to vague pains, formication, momentary twitching, or 
painful contractions of the extremities. At the same time many pa- 
tients complain of a dull pain in the part of the spine corresponding 298 
DISEASES OF THE SPINAL MARROW AND ITS MEMBRANES. 
to the point of inflammation, which is increased by pressure on the 
spinous processes, but not by movements of the spinal column, which 
is an important point in the diagnosis between myelitis and meningitis 
spinalis. This pain is sometimes accompanied by the feeling of a cord 
tied firmly around the waist. In other cases there is no spontaneous 
pain, but the corresponding vertebras are sensitive to pressure. If 
we pass a sponge, previously dipped in hot water, along the spine, the 
part at the seat of inflammation is generally more sensitive than else- 
where. These symptoms, which are usually little thought of, are ac- 
companied by a heaviness and helplessness in the lower part of the 
body, which sooner or later become perfect paraplegia. The higher 
up the seat of the inflammation, the more extensive the paralysis. If 
the lumbar region be diseased, the lower extremities are paralyzed; 
if the thoracic region be affected, the sphincters participate in the pa- 
ralysis ; if the cervical region suffer, the paralysis extends to the upper 
extremities and corresponding respiratory muscles; with the para- 
plegia there is generally also anaesthesia of the lower part of the 
body, but this rarely extends to entire loss of sensitiveness to irrita- 
tion. While the paraplegia and anaesthesia, slowly increasing, attain 
a high grade, the affected muscles are still occasionally attacked by 
spasmodic twitchings, and, if the anaesthesia be incomplete, by painful 
contractions. This symptom is readily explained by the irritation in- 
duced in the motor nerves of the extremities from the progress of the 
inflammation, even after their connection with the central filaments is 
lost. In cases where the connection between the motor nerves and 
central filaments is completely broken, so that no muscular contrac- 
tions are induced by the will, it is not at all impossible for an excite- 
ment to pass from the sensory to the motor filaments, and for reflex 
movements to occur. On the contrary, we often see the reflex excita- 
bility increased in the parts of the spine below the interruption. This 
pathological experience exactly corresponds with experiment. It is 
well known that, in decapitated animals, reflex movements occur more 
readily than in those whose motor nerves are under the influence of 
the brain. In Greifswald I saw a young woman, who was paraplegic 
as a result of vertebral disease, in whom the reflex symptoms in the 
paralyzed part were so severe that the slightest touch on the skin of 
the lower extremities caused their muscles on both sides to contract 
spasmodically. It Avas very interesting to observe that, in this case, 
when, contrary to all expectation, the paralysis improved, and the pa- 
tient was able to make voluntary movements of her extremities, the 
inclination to reflex symptoms entirely disappeared. The course and 
results of chronic myelitis vary. The disease may run on for years; 
frequently it advances to a certain point, and remains stationary. If GROWTHS IN THE SPINAL CANAL. 
299 
such patients belong to the educated classes, or to the mechanics 
proper, they often continue their occupation in spite of their para- 
plegia. Those cases of paraplegia, where improvement and recovery 
take place, as I before said, appear to belong to meningitis spinalis, 
not to myelitis, as it is very improbable that nerve-elements, which have 
been extensively destroyed, can be regenerated; the favorable course 
of incised wounds of the nerves does not disprove this assertion. In 
chronic myelitis, death most frequently results after the patient has 
been confined to bed a long while by the increasing paralysis. The 
consequent bed-sores, or the cystitis caused by stagnation of the urine, 
generally form the terminal symptoms, if the patient do not sooner die 
of tuberculosis or intercurrent diseases. 
Treatment.—The treatment of myelitis promises little. It is to 
be conducted on the principles laid down for meningitis spinalis. Only, 
instead of flying blisters, it is well to apply mox® or the hot iron near 
the supposed seat of inflammation. 
CHAPTER y. 
GROWTHS AND PARASITES OP THE SPINAL MEDULLA AND ITS 
MEMBRANES. 
Except the cartilaginous and bony plates of the arachnoid, which 
we have already described, growths rarely occur in the spinal canal. 
Carcinomata, which are usually of the medullary variety, either form 
primarily in the spinal medulla or dura mater, or extend from the ver- 
tebrae! to the meninges and medulla. When they grow considerably, 
they may at last fill the spinal canal, as the medulla atrophies from 
pressure, or is transformed into cancer substance. Occasionally, after 
destruction of the vertebrae, they have been seen to spread outwardly, 
so as to lie just under the skin. Only a few cases of sarcoma and 
glioma have been observed in the spinal canal. They almost always 
started from the inner wall of the dura mater, and rarely attained any 
considerable size. Tubercles in the medulla itself only occur when 
•■here is advanced tuberculosis of other organs. Just as in the brain, 
they usually form yellow nodules, the size of a pea or hazel-nut. They 
are usually in the cervical or lumbar regions. Somewhat more fre- 
quently we meet tuberculous degeneration of the dura mater, under 
the form of so-called infiltrated tuberculosis, along with tuberculous 
caries of the vertebrae. Cysticerci and echinococci have also beer 
very rarely found in the spinal canal. The latter had either devel- 
oped between the membranes, or an echinococcus sac, near the spinal 300 
DISEASES OF THE SPINAL MARROW AND ITS MEMBRANES. 
canal, had penetrated ii.to the canal, after destroying the vertebrae or 
their processes. 
Tumors in the spinal canal interrupt the communication between 
the brain and peripheral nerves; hence they cause paraplegia and 
anaesthesia of the lower part of the body. According as they simply 
induce atrophy of the spinal medulla by pressure, or cause inflamma- 
tion of it by the irritation of the parts about them, the paraplegia and 
anaesthesia are preceded by moderate or by very severe symptoms of 
irritation. Of course, the seat of the growth modifies the extent of 
the symptoms. The fact that, in tumors, there is usually less pain in 
the back, but more peripheral neuralgia preceding the paralysis, and 
that the paralysis often did not begin at the same time on both sides, 
but gradually extended from one side to the other, is not absolutely 
decisive in the differential diagnosis between tumors of the spinal me- 
dulla and chronic myelitis. We can only make an absolute diagnosis 
in those cases where the cancer extends from the spinal marrow out- 
ward. The development of carcinoma, tubercles, or parasites in other 
organs, at least justifies the suspicion of a similar disease in the spinal 
canal being the cause of a slowly-progressing paraplegia. Treatment 
is entirely powerless against all tumors of the spinal medulla. 
CHAPTER VI. 
HYDEOEIIACIIIS CONGENITA SPINA BIFIDA. 
Hydrorhachis congenita is divided into internal and external. 
The former depends on a collection of serum in the dilated foetal cen- 
tral canal. It causes atrophy or entire destruction of the spinal me- 
dulla (amyelia) by pressure, or else splits it more or less completely. 
Hydrorhachis externa consists in an abnormal collection of water in 
the subarachnoid space. In both forms the vertebral canal may eithei 
remain closed (hydrorhachis incolumis), or there is, at the same time, 
a more or less extensive opening of the canal (hydrorhachis congenita 
dehiscens). 
In spina bifida we find a sac filled with serum, and covered by the 
spinal membranes on the spinal column, which communicates with the 
spinal canal, as a result of rudimentary formation of one or several 
vertebral processes. Such tumors are usually located in the sacral oi 
lumbar regions, more rarely in the cervical or dorsal. Their size varies 
from that of a walnut to a child’s head. The skin covering them is 
sometimes normal, sometimes thinned; occasionally, at the summit, if 
has entirely disappeared; then the sac is exposed, the place appears 
excoriated, and is occasionally covered with pus and granulations. HYDRORHACHIS CONGENITA- SPIN A BIFIDA. 
301 
When the spina bifida results from hydrorhaehis externa, the wa.l of 
the sac consists of the arachnoid and dura mater; the latter is occa- 
sionally thinned or perforated, and then the wall consists of the arach 
noid alone. If, on the other hand, the spina bifida result from liydro- 
rhachis interna, the pia mater also assists in the formation of the wall. 
The contents of the sac are pure serum, of the same constitution as 
the cerebro-spinal fluid. When the spina bifida has resulted from hy- 
drorhachis interna, the spinal medulla is either altogether absent, 01 
is undeveloped. On the other hand, if it be due to hydrorhaehis ex- 
terna, the medulla may be perfectly normal; but occasionally, even in 
such cases, it is defective [Forster). 
The pathogeny and etiology of hydrorhaehis congenita are obscure. 
The collection of water is probably the primary disease, the incom- 
plete formation of the spinal canal the secondary. 
The symptoms of hydrorhaehis, complicated with partial spina 
bifida—of which alone we shall speak, as, in all cases combined with 
great defect of the spinal medulla and extensive opening of the canal, 
the children die before birth, or very soon after—consist chiefly of the 
objective signs due to the above-described tumor. There is usually 
distinct fluctuation in it. At its base the edges of the bone may be 
felt. It increases on expiration, still more on crying and straining, 
and diminishes on inspiration. Occasionally it may be replaced, but 
attacks of loss of consciousness and general convulsions are readily in- 
duced by these attempts. In some cases the innervation of the lowe' 
extremities, bladder, and rectum, is normal; in others, especially where 
the lower part of the medulla is defective, or has disappeared, the 
lower extremities, bladder, and rectum, are paralyzed. The tumor usu- 
ally increases rapidly in size and tension soon after birth. If the skin 
reddens, becomes thin, and finally perforated, death, preceded by con- 
vulsions and subsequent sopor, generally quickly follows the perfora- 
tion. But, even where perforation does not take place, most of the 
children die early of general marasmus, and it is very exceptional for 
patients with spina bifida to attain or pass the age of puberty. 
Operative procedures are to be abstained from wrhen complete pa- 
ralysis and decided emaciation of the lower extremities indicate that 
the spinal medulla is incompletely developed. In other cases we may 
attempt careful compression, and, where this fails, proceed to the opera- 
tions described for spina bifida in the text-books on surgery. 302 
DISEASES OF THE SPINAL MARROW AND ITS MEMBRANES. 
CHAPTER VII. 
CONSUMPTION OF THE SPINAL COED TABES DOKSUALIS ATAXIE LO- 
comoteice progeessive (Duchenne)—GRAY DEGENERATION OF 
THE POSTERIOR COLUMNS OF THE SPINAL CORD [Leyden)—LOCO- 
MOTOR ATAXY. 
Tabes dorsualis, which was discovered and described by JJuchenne 
as ataxie locomotrice progressive, long after it was generally known in 
Germany from the classical description of Romberg, has recently ex- 
cited much discussion. The views regarding the significance of the 
symptoms especially vary. According to the plan of my book, I can 
only criticise the views of others, so far as is necessary to support 
my own. The following description is, in the main, the same as was 
given in the dissertation of my former assistant, Dr. Ernst Spaeth, 
which was written under my supervision, and which has not, by any 
means, received the attention it deserved. (The dissertation of Dr. 
Spaeth was published under the title of “ Beitrage Zur Lehre von der 
Tabes dorsualis,” at Tubingen, 1864, by Aug. Ludwig.)1 
Etiology.—In some few cases of decided tabes dorsualis, on 
autopsy we find no palpable changes in the spinal medulla. This 
a negative appearance ” does not by any means prove that the spinal 
medulla is normal, but only that its functions may be impaired by 
molecular changes that escape observation, just as they are by the 
coarser changes found in other cases. The latter consist in a peculiar 
degeneration and atrophy affecting particularly the posterior columns 
and the posterior roots, but occasionally the gray substance also and 
other columns. In some cases there is no doubt that the degeneration 
in question is the result of inflammation of the spinal medulla, but 
in other cases no inflammatory origin can be made out. 
The predisposition to tabes dorsualis is occasionally hereditary, as 
is shown by a number of cases, where several brothers and sisters were 
attacked by the disease. On the other hand, I only know of two 
cases where it was inherited, that is, where the parents of the patient 
had tabes dorsualis. Children are not inclined to tabes, persons of 
mature age are most so, while in the aged the tendency almost disap- 
pears. Men are far more disposed to it than women. 
The exciting causes are almost always said to be—1. Venereal 
excess. The great physiologist Johannes Muller, usually very careful 
and discreet in his assertions, says directly that tabes dorsualis comes 
only from venereal excess. Besides their other sufferings and mis- 
fortunes, these poor patients are made to bear the accusation which in 
many cases at least is unjust, that they have themselves to blame for LOCOMOTOR ATAXY. 
303 
their disease. There is no doubt that many of the patients attacked 
have been addicted to excess in venery, but there is just as little doubt 
that many patients with tabes dorsualis have led an exemplary life, while 
others who have been unbounded in their excesses escape the disease. 
From the great frequency of lewd habits, and from the difficulty of 
deciding the amount in any given case, I consider the dependence of 
tabes on venereal excess as not yet proved. 2. On the other hand, 
there appears to me no doubt of the influence of catching cold and 
bodily fatigue, especially when they act together, in inducing tabes 
dorsualis. The disease occurs with remarkable frequency among those 
who, wearied and heated by severe marches or other bodily exertions, 
have stretched themselves on the damp earth to rest. 3. Many patients 
ascribe their disease to suppressed perspiration of the feet. We can- 
not generally lay much weight on these accounts, for the laity give 
suppression of habitual perspiration as a very common cause of dis- 
ease. Doubtless in most cases -where the occurrence of a disease is 
accompanied by the absence of habitual perspiration of the feet, it is 
because the latter has ceased with the appearance of the disease. But 
I think it is going too far to deny the possibility of a genetic connec- 
tion between the arrest of perspiration of the feet and tabes dorsualis. 
At all events, many patients with tabes have previously suffered much 
from perspiring feet. 4. Lastly, the disease appears occasionally to 
be of syphilitic origin, a supposition chiefly supported by the fact that 
some tabes patients who had previously suffered from syphilis were 
benefited by an antisyphilitic treatment. 
Anatomical Appearances.—The usual appearance of the spinal 
medulla and its membranes, in decided cases of tabes dorsualis, is as 
follows: The dura mater is either unchanged or its posterior half is 
slightly thickened, the arachnoid is moderately opaque, if the medulla 
be atrophied the fluid in the subarachnoid space is increased; on the 
posterior surface the pia mater is constantly thickened, clouded, and 
more or less adherent to the posterior columns. 
In the early stages, where no decrease of volume of the spinal medulla 
is as yet observable, there is a peculiar degeneration of the posterior 
columns; this always begins in the immediate vicinity of the posterior 
fissure, close under the pia mater, and thence spreads toward the sides 
and the gray commissure; the diseased part always retains the shape 
of a wedge, with the base directed toward the pia mater. The degen- 
eration consists in a transformation of the white substance of the pos- 
terior columns into a gray or grayish-red, half-translucent, soft mass. 
On microscopical examination of the latter we only find a few nerve- 
filaments, partly in various stages of atrophy; most of them have com- 
pletely disappeared, and between the atrophied cells there is a richly 304 
DISEASES OF THE SPINAL MARROW AND ITS MEMBRANES. 
nucleated connective-tissue substance, corresponding1 to the ordinary 
neuroglia and resulting from its proliferation, in which we find only a 
few granular cells, molecular fatty masses, and numerous corpora 
amylacea. The vessels passing out from the pi a mater have a greatly- 
thickened adventitia, and thus cause the firm adherence of the pia 
mater to the surface of the medulla. Corresponding to the extent of 
the degeneration in the posterior columns, the posterior roots of the 
spinal nerves are atrophied. They resemble thin, vascular, translucent 
connective-tissue cords, far more than they do nerves with medulla. 
This is especially true of the posterior roots of the cauda equina. The 
anterior roots of all the nerves, cauda equina included, are normal, cor- 
responding to the general nutritive condition of the spinal medulla. 
In the later stages the degenerated gray parts of the medulla 
shrink greatly. They become a hard tissue, and are less transparent. 
If the degeneration be limited to the posterior columns, the medulla 
acquires a cylindrical form. The points of exit of the posterior roots 
are approximated. If, on the other hand, the degeneration extend to 
the posterior parts of the lateral columns, the medulla shrinks more in 
an antero-posterior direction, and we may readily receive the impres- 
sion that it has become broader. The neuroglia, which in the early 
stages of the degeneration corresponds exactly with the normal neu- 
roglia, during the shrinking acquires the appearance of a fine filament- 
ary substance. A secondary atrophy and induration succeed the 
growth of the neuroglia.2 
Symptoms and Course.—Although Duchenne is to be reproached 
for ignorance of Romberg's works, or else for ignoring them, when he 
published his first writings on ataxie locomotrice progressive, we cannot 
deny that he has done much for the correct interpretation of the symp- 
toms of tabes dorsualis. He originated the doctrine, at present almost 
generally adopted, that in tabes there is not paralysis, but disturbed 
coordination of muscular movements. To use our muscles properly, it 
is not enough that we can contract each muscle, we must also be able 
to cause a harmonious action of all the muscles participating in any 
motion. Acts apparently the most simple fail or are clumsily performed, 
if any of the muscles participating in them be contracted too much or 
too little, too quickly or too slowly; or if the antagonists be not re- 
laxed just enough or exactly at the right moment. This power of 
causing the muscles to act properly together, or, as it is usually called, 
the power of coordination, is much impaired in patients with tabes; 
and the symptoms resulting from this anomaly are peculiarly charac- 
teristic of the disease. But, along with this, there is almost always a 
decided diminution of the cutaneous and muscular sensibility, which 
Romberg has excellently described : “The floor is no longer distinctlv LOCOMOTOR ATAXY. 
305 
felt; the foot seems to rest on wool, soft sand, or on a bladder filled 
with water. The horseman no longer feels the resistance of the stir- 
rup, and has the strap shortened .... If the patient do not see his 
movements, they will be still more uncertain; if, while erect, he closes 
his eyes, he immediately begins to sway about and totter. If his eyes 
be closed while in the horizontal position, he cannot tell the location 
of his limbs; he cannot say whether the right foot be crossed over the 
left, or the reverse.” 
If, as some celebrated authorities assert, the posterior spinal col- 
umns have the function of coordinating the movements, the anatomical 
changes found on autopsy of tabes patients fully explain the symptoms 
observed during life. We have said that the degeneration and atrophy 
of the spinal cord constantly start from the posterior columns, and 
that the posterior sensory roots almost always participate in the de- 
generation. Leyden, who does not believe in a peculiar power gov- 
erning the coordination of movement and its location in the posterior 
spinal columns, has advanced a theory for the explanation of the disturb- 
ances of coordination in tabes dorsualis, which, at first sight, is very enti- 
cing. He explains the loss of power of coordination as due solely to 
the diminished cutaneous and muscular sensibility. We must, indeed, 
admit that Longet is correct in saying that a person, who has lost the 
perception of his actions, who cannot judge of the position of his 
limbs, who does not even know whether they are present, and, lastly, 
who does not feel the floor under his feet, cannot walk erect, preserve 
his equilibrium, and move his limbs with certainty and accordance. 
Moreover, the peculiarities of the anomalies of movement observed in 
tabes patients, the energetic lifting of the foot and its passive fall 
when walking, the spasmodic, uncertain movements, their shooting 
beyond the mark, all give the impression that the patient is so awk- 
ward because he does not know what he has done till he has done too 
much. Lastly, the fact that the helplessness of the patients is greatly 
increased when they close the eyes, and cannot control their move- 
ments by the sight, is favorable to the view that the anomalies of 
movement in tabes dorsualis result from diminution of the cutaneous 
and muscular sensibility. Nevertheless, Leyden’s theory is false. Its 
correctness is opposed by the following facts : first, that in many pa- 
tients the disturbances of sensibility are in marked disproportion to 
the impairment of coordination of movement; second, that in persons 
whose cutaneous and muscular sensibility is far more diminished than 
is the case in any tabes patients, there is often no indication of dis- 
turbance of coordination. In Spaeth's work there is a full histcry of a 
peasant, from Wurmlingen, who is known to all my students, as I 
show him in my clinic almost every half year. This interesting pa- 306 
DISEASES OF THE SPINAL MARROW AND ITS MEMBRANES. 
tient has a very marked and extensive anaesthesia of the skin and 
muscles. He is insensible to the severest injuries. He does not know 
if he bathes in warm or cold water. On loading his extremities with 
a weight of twenty-five pounds, he perceives no difference of pressure. 
On being requested to estimate weights, by lifting them, he cannot 
distinguish between weights of one pound and a hundred pounds. 
When his eyes are closed, he cannot tell whether his limbs are flexed 
or'straightened to the greatest possible extent by strong electric cur- 
rents. When standing erect or sitting up, if he closes the eyes he 
immediately falls. He perceives the resistance of his bed so little 
that, when the light is extinguished at night, he feels as if he were 
swimming in the air. But this patient has no marked disturbance of 
cobrdinative power; he does not in the least remind us of a tabes pa- 
tient ; as long as it is light he walks very well, although carefully; he 
travels on foot, without a stick, the mile between Wurmlingen and Tu- 
bingen. A single such case is enough to prove that the disturbance of 
coordination of the tabes patient does not depend, certainly not solely, 
on the diminished sensibility, but that it exists along with the latter. 
In many cases the above symptoms are accompanied by disturb- 
ances of the excretion of urine. Most patients are obliged to attend 
to the call to urinate as quickly as possible, as they can only stand it 
a few moments, and hence, when their means allow it, they buy uri- 
nals, which they wear in their trousers during the day. I think this 
symptom arises because the patient does not perceive the fulness of 
the bladder, and the desire to urinate does not occur till a few drops 
are pressed out of the bladder into the urethra. Far more rarely than 
this incomplete enuresis we find retention of urine, and it becomes 
necessary to draw it off with the catheter. In such cases there is 
probably paralysis of the bladder, from its having been distended too 
much or too long. 
It is asserted that, at the commencement of the disease, sexual de- 
sire is usually increased but the energy and duration of the erections 
lessened, as well as that, in the later stages, the virile power is en- 
tirely lost. The latter assertion alone is certain. 
We must also mention the paresis of the oculo-motor and ab- 
ducens, which occasionally occurs in tabes, which is shown by diplopia, 
more rarely by strabismus and ptosis of the upper lid; and, lastly, the 
amaurosis and psychical disturbances which are sometimes met with. 
There is no doubt that these symptoms are due to the disease advan- 
cing to the cerebral filaments, but hitherto autopsy has failed to show 
what course this advance takes. Atrophy of the optic nerve was only 
'bund in some of the few cases where there was disturbance of vision; 
but even here the atrophy only extended to the corpora quadrigemina, 
and could not be followed further. LOCOMOTOR ATAXY. 
307 
After having described and analyzed the most important symptoms, 
L shall attempt to give a general description of tabes dorsualis, and pic- 
ture the most frequent course of the disease as briefly as possible. 
In many patients, the characteristic disturbances of coordination, 
and the decrease of cutaneous and muscular sensibility are preceded 
for a long time, even for years, by attacks of severe tearing pain in 
the lower half of the trunk, and in the lower extremities; these are 
generally considered as rheumatic. In other patients, on the contrary, 
the first complaints are that the lower extremities become fatigued 
very easily and very soon. Persons accustomed to walking notice that 
they tire sooner and more easily than formerly. These symptoms, 
which are not usually very suspicious, either to the patient or physi- 
cian, may precede the decided symptoms of tabes for a long time. 
But this difference in the initial symptoms is not so marked or decided 
as it seems to be on superficial examination. The attacks of pain are 
unmistakably neuralgic, and depend on morbid excitement of the pos- 
terior roots, while the tendency to fatigue depends on their hyperaes- 
tliesia—that is, on their morbidly-increased excitability. Under physi- 
ological circumstances, the feeling of fatigue depends on the amount 
of work done by the muscles. The state of the muscles resulting from 
overwork is perceived through the sensory muscular nerves. If the 
excitability of the posterior roots be increased, slight exertion of the 
muscles will produce the same effect, which would otherwise only be 
induced by far greater exertion. Hence the tendency to fatigue in 
tabes is perfectly analogous to the increased sensitiveness, at the com- 
mencement of certain brain-diseases, to light, sound, and other irrita- 
tions, which are not generally unpleasant. The tearing-pain and ten- 
dency to fatigue in the lower extremities are not recognized to be 
serious and threatening until they are accompanied by other disturb- 
ances of sensibility, such as formication, a feeling of furriness, numb- 
ness, and the sensation of a ligature around the abdomen. Gradually 
the gait becomes uncertain and awkward; at first this is so only in the 
dark, so that the patients prefer remaining at home in the evening; 
afterward it is the same in day-time. The feet are lifted too high, and 
thrown forward and outward, and then brought heavily down on the 
floor. If the patient closes his eyes while standing erect, he begins tc 
totter, and, unless supported, falls to the ground. And, even at this 
time, he must usually be on his guard when the desire to urinate seizes 
him, so that he may reach a convenient place in season. After a time, 
walking becomes impossible, even with the aid of a stick or crutches, 
although, when the body is fixed, the patient can generally make un- 
complicated movements of the extremities with nearly normal force. 
The same uncertainty and awkwardness come on in the upper ex- 308 
DISEASES OF THE SPINAL MARROW AND ITS MEMBRANES. 
tremities much later than in the lower. Then, when eating or drink- 
ing, the patients shake out the contents of the spoon or glass, they 
can no longer dress without aid, especially the buttons trouble them; 
finally, they cannot write, knit, or do any other work. The enuresis 
now often attains such a grade that the patient voids his urine in bed. 
If, in consequence of this, a constant moisture of the parts be added to 
the patient’s indistinct perception of the irregularities of the bed and 
his helplessness in changing his position, we may readily have bed-sores. 
The course of the disease is always tedious. We see most patients 
drag on for years in a miserable state, the objects of pity, which is not 
unfrequently pliarisaical. Occasionally the disease remains stationary; 
in other cases it appears to improve temporarily. Perfect cures are 
certainly very rare. 
Nutrition is frequently not impaired till late; the lower extremities, 
the nates, and muscles of the back emaciate first, so that the spinous 
processes project. It is not till toward the end of the disease that the 
emaciation extends to the rest of the body. Death generally results 
at last from the increase of the bed-sores, from severe cystitis, from 
pulmonary consumption, or from intercurrent diseases.3 
Treatment.—Romberg's assertion, that there is no hope of cure 
for a tabes patient, that they are all doomed, contrasts strongly with 
the views of Remak, as published by Cyon, according to which the 
former is said to claim that his treatment was successful in the ma- 
jority of cases, and that, therefore, he cannot be reproached for not 
having autopsies on his cases. The truth probably lies between the 
two. Of late, few authorities regard the treatment of tabes so hope- 
less as Romberg. But very few would agree with Remak, Renedikt, 
and others, in saying that tabes is a disease where very favorable re- 
sults can be attained by treatment. 
We may hope for the best results when there is a suspicion that 
the disease is of syphilitic origin. In such cases an antisyphilitic treat- 
ment should be instituted, on the plan to be described hereafter. 
The more probable it is that the disease has resulted from taking 
cold, the more acute its occurrence, the more severe the pains in the 
lower extremities which preceded the symptoms of disturbance of coor- 
dination and diminished sensibility, the more probable is it that the 
disease is of inflammatory or congestive origin, and the stronger the 
indications to begin the treatment with the local abstraction of blood 
by leeches, and derivation to the skin by blisters along the spine. 
Subsequently we may order for such patients the waters of Wildbad, 
Gastein, Ragaz, Pfaffers, Tbpfitz, etc. There is no doubt that tabes 
patients have been decidedly benefited by the treatment at these 
daces. On the other hand, I must warn against the careless employ- LOCOMOTOR ATAXY. 
309 
tnent of the cold-water treatment, which, especially in the form of cold 
douches to the back, has not come up to the expectations entertained 
of it at the time it was fashionable, and the water-cure establishments 
are now rarely patronized by tabes patients, who, for a time, all rushed 
to them for treatment. In very recent cases only, sweating in moist 
oloths and a subsequent short bath appear to be beneficial. 
If it be not a favorable time of year to send the patient to Wild- 
bad, etc., or if these mineral waters do not seem indicated, or if they 
nave done no good, we should try the administration of nitrate of 
silver as recommended by Wunderlich. Nitrate of silver has long 
held the reputation of being one of the most effective nervines; and it 
is not at all impossible or improbable that it exercises a modifying 
influence on the nutrition of the nervous system; it is not these 
reasons, however, but the fact that reliable observers have found some 
benefit from the employment of the remedy in tabes dorsualis, that 
induce me to use it in most cases of the disease. My experience of the 
efficacy of the remedy, which I have given in a large number of cases, 
in doses gradually increasing to half a grain daily as advised by 
Wunderlich, has not been particularly favorable. It is true that most 
of my patients at the clinic have praised their state a time after using 
the remedy, but I suspect that many did so to induce me to keep them 
longer at the hospital. In other cases, the patients actually seemed 
to move forward more nimbly; but here also it was possible that 
either greater confidence or increased attention of the patient, with 
the view of showing me improvement, had a favorable effect on the 
attempts to walk. I shall continue for a time to prescribe nitrate of 
silver to my tabes patients. 
My experience of the constant current of electricity is about the 
same as it is in regard to nitrate of silver. I have no reason to doubt 
that HemaJc, Benedikt, and others, have had some success with the 
constant current which I consider to be a very active remedy, but thus 
far I cannot claim any success from its use in tabes, although I have 
had an excellent apparatus in my clinic these four years, and have 
treated all my tabes cases with it in the manner advised by Bemak 
This want of success will not prevent my continuing the use of galvan 
ism in tabes for a time; and, instead of letting the current act on the 
spinal column as hitherto, I shall try the current through the spinal 
nerves, as advised by Benedikt, not because I attach much importance 
to the theories and the indications he gives for the treatment of dif- 
ferent diseases, with the current through the roots of the spinal nerves 
(Ruckenmarks-Wurzelstromen), through the spinal nerves (Rucken- 
marks-Nervenstromen), etc., but simply because I have no reason to 
ioubt what he says on the subject. 310 
DISEASES OF THE SPINAL MARROW AND ITS MEMBRANES. 
ADDITIONS TO THE REVISED EDITION OF 1880. 
SECTION II. DISEASES OF THE SPINAL MARROW AND ITS MEMBRANES. 
1— P. 302. 
Some diseases may affect the entire cross-section of the spine 
unequally, while others are limited to certain parts. In the latter 
only certain physiological functions are affected, so that their symp- 
toms must differ. Infantile spinal paralysis and progressive mus- 
cular atrophy are affections of certain parts of the anterior portion 
of the medulla spinalis, while in locomotor ataxy the posterior part 
is affected. 
2. P. 304. 
It is doubtful whether the disease starts from the nerve-fila- 
ments or from the intervening substance ; the fact of the process 
being generally limited to the posterior columns favors the former 
view. The vessels are sometimes unchanged, at others their adven- 
titia is thickened and fatty, their calibre diminished or closed. 
Some observers think the affection is due to disease of certain 
limited portions of the posterior roots—two lateral, thin, gray striae, 
corresponding to the intermedullary extensions which Kolliker terms 
inner root-filaments. According to Charcot, sclerosis of these lat- 
eral striae is the only constant anatomical change. The sclerosis 
may spread from the posterior columns to other parts, as the poste- 
rior nerve-roots, or even to different nerves, as the sciatic, crural, 
and brachial, but especially to some cerebral nerves, as the optic, 
oculo-motor, trochlear, and hypoglossal. It may also extfcnd to the 
posterior horns of the gray substance, and to the lateral columns, 
or to the gray anterior horns ; in which cases, of course, the symp- 
toms will be varied. The disease may begin at any point of the 
spine, but generally spreads in the long axis ; usually it begins in 
the lumbo-dorsal region, and spreads along the lateral strise of the 
posterior columns to the cervical region, or even to the cerebral 
nerves and brain, as is shown by psychical changes and depression. 
On the other hand, primary cerebral disease may be followed by 
tabes, and it has been asserted that the progressive paralysis of the 
insane sometimes chiefly affects the posterior roots. 
3. P. 308. 
In many tabes patients, sometimes as the first symptom, there is 
impairment of vision, beginning as concentric limitation of the vis- 
ual field in one eye, or sometimes as achromatopsia, gradually grow- ADDITIONS TO THE REVISED EDITION OF 1880. 
311 
ing worse and ending in double amaurosis, with gray degeneration 
of the optic nerve. Other cerebral nerves are more rarely affected, 
but there may be ancesthesia of the trigeminus, impairment of hear- 
ing, deglutition, or speech, and periodical rapidity, irregularity, or 
dicrotism of pulse due to the vagus. Implication of the sympa- 
thetic is often shown by inequality of the pupils. On the side of 
the contracted pupil there may be signs of vaso-motor paralysis, 
such as red cheeks, chemosis, and increased temperature. Among the 
early symptoms there may be a painless swelling of the joints, most 
frequently of the knee, then in the shoulder, elbow, etc. Charcot 
regards this as allied to arthritis deformans, and refers it to impli- 
cation of the gray anterior horns. In a case recently observed, the 
anterior horns were intact, but the spinal ganglia were very large 
and perceptibly changed. 
The neuralgias are due to inflammatory irritation of the poste- 
rior roots of the nerves ; there may be formication, tearing, con- 
tracting, and especially shooting pains, which may recur weekly or 
monthly, and are worse at night; they are rarely entirely absent. 
The period of pain varies in duration ; in incomplete cases the latter 
characteristic symptoms may never occur. As the disease pro- 
gresses, the pains, which might readily be regarded as rheumatic or 
neuralgic, spread from the legs to the body, and the sensation of a 
girdle about the body is noticed ; there may be painful contraction 
of the rectum or bladder, or incomplete erections and pollutions. 
Later there is neuralgia of other nerves in upper parts of the body, 
arms, etc.; but there is rarely spinal pain or tenderness. An occa- 
sional early symptom is an attack of gastralgia and obstinate vomit- 
ing, lasting several days ; these attacks often accompany the shoot- 
ing pains, and seem due to irritation of the sensitive gastric fila- 
ments of the vagus. 
Perfect cure of tabes is only possible when the sclerosis is but 
slightly advanced, and even then is probably very rare ; though 
Benedikt asserts the contrary, claiming that mild cases are often 
mistaken for other diseases. Incomplete cures are more common, 
the progress of the symptoms being arrested and life made endur- 
able. But most cases progress, though some symptoms improve 
temporarily. As the disease advances, the upper limbs may be af- 
fected ; formication and neuralgic pains in the arms and fingers 
precede uncertainty of the grasp in writing, etc., till the patient 
becomes entirely helpless. Exceptionally, the arms may be first 
affected ; and when the prominent symptoms indicate the part 
affected to be high in the spine or in the cerebral nerves, a cer- 
vical or basilar tabes has been spoken of ; but the symptoms are 312 
DISEASES OF THE SPINAL MARROW AND ITS MEMBRANES. 
usually so combined that these regional forms cannot be distin- 
guished. 
Although one of the most tedious of diseases, tabes usually 
shortens life. It may continue five or ten years, or longer ; but the 
symptoms, especially the motor disturbances, may progress rapidly 
and death occur early. As the disease advances, the patient may 
attain a pitiable condition ; the nutrition of the body, which has 
been good, may suffer, the legs emaciate, the feet become oedema- 
tous ; the previous irritable weakness of the sexual function gives 
Avay to entire impotence ; urination and defecation are impaired, 
sensibility blunted, and vision lost ; more especially the power of 
motion is lost from ataxia and paraplegia. Death is rarely directly 
due to paralysis of respiratory muscles, and not so often to bed-sores 
and purulent cystitis as it is in spinal paralysis ; but more frequent- 
ly it is due to consumption, pneumonia, bronchitis, etc. 
In well-developed typical cases diagnosis is easy. The periodi- 
cal lancinating pains in the legs or arms, quick fatigue, gastralgia, 
paralysis of ocular muscles, disturbance of vision, and ophthalmo- 
scopic appearances, and especially the ataxia of motion, give the 
disease a decided character. Diseases of the cerebellum also induce 
an uncertain tottering gait when the eyes are closed, and dizziness ; 
but there are usually other symptoms, occipital pain, occasional 
vomiting, epileptic or tonic spasms, hemiplegia, etc.; while the lan- 
cinating pains, ready fatigue, girdle feeling, and anaesthesia are ab- 
sent. Amblyopia and amaurosis occur from tumors of the brain 
as well as from tabes ; but the ophthalmoscope may show whether 
the papilla indicates tabes or the optic neuritis and choked disk due 
to tumors. Electro-muscular contractility gives no certainty to 
diagnosis, as the excitability of the muscles may be increased, nor- 
mal, or lessened ; although in the first stages it is generally in- 
creased, while in other spinal diseases it is apt to be lessened very 
early. When incompletely developed, tabes may be mistaken for 
neuralgic, rheumatic, hypochondriac, hysterical, or syphilitic affec- 
tions. Errors may also occur where the posterior columns are im- 
plicated in diseases of other parts of the spinal cord. SECTION III. 
DISEASES OF TEE PERIPHERAL NERVES. 
INFLAMMATION OF THE NERVES—NEURITIS. 
CHAPTER I. 
Etiology.—Inflammatory disturbances of nutrition rarely occur in 
the peripheral nerves. They sometimes affect the nerve-filaments, 
sometimes the neurilemma. The first form ranks among parenchyma- 
tous inflammations, and ends in the destruction of the nerve-medulla 
to a fine granular, fatty detritus. In the second form there is an inter- 
stitial exudation, and a proliferation of connective tissue, by which the 
neurilemma is decidedly thickened. There is rarely any formation of 
pus. We shall hereafter speak of the diffuse hyperacmia of the neu- 
rilemma of a wounded nerve, without any perceptible exudation, 
observed in some cases of tetanus. 
Among the exciting causes of neuritis, the most important are 
injuries of the nerves, particularly punctured wounds, contusions, or 
lacerations. In other cases neuritis is due to the propagation of in- 
flammation from neighboring organs. Lastly, some few cases of spon- 
taneous or so-called rheumatic inflammation are said to have been 
observed. 
Anatomical Appearances.—Inflammation of the neurilemma is 
characterized by a more or less intense redness, which sometimes de- 
pends on overfulness of the blood-vessels, sometimes on the presence 
of small extravasations. The neurilemma also appears relaxed, swol- 
len, and infiltrated. If the neuritis has taken on an acute course, and 
led to suppuration, there is usually more or less pus in the loose con- 
nective tissue around the nerve. When the disease is chronic, the 
neurilemma usually appears much thickened, hard, and firmly adherent 
to the surrounding parts. 
Inflammation of the nerve-substance is shown by its redness, swell- 
ng, and relaxation; in severe cases it is transformed to a red pulp, 314 
DISEASES OF THE PERIPHERAL NERVES. 
The neurilemma is always affected at the same time, and consequently 
we find the different bundles of nerve-filaments separated by the swell- 
ing of their envelopes and by interstitial exudation. Occasionally, 
after reabsorption of the disintegrated medulla of an inflamed nerve, 
only a simple cord of connective tissue is left. 
Symptoms and Course.—The symptoms of neuritis cannot be 
clearly distinguished from those of neuralgia, or rather neuritis is one 
of the various causes of neuralgia. The most important symptom of 
neuritis is pain in the course of the inflamed nerve, extending to its 
peripheral terminations. The pain is increased by pressure on the 
nerve, and its exacerbations and remissions are usually less distinct, 
and the paroxysms and intervals particularly are usually less marked 
than in other forms of neuralgia. While this pain lasts, the sense of 
touch is usually lost in the parts supplied by the inflamed nerve; and 
this symptom may be easily explained, although it seems paradoxical 
on superficial examination. The morbid excitement of the trunk of 
the nerve, caused by the inflammation in the medulla or neurilemma, 
is conducted to the brain, and excites the sensation of severe pain; 
but the inflamed part of the nerve has become a bad conductor ; hence 
irritation of its peripheral termination and the papilla? of touch are 
conducted to the brain either incompletely or not at all, and cause 
either no sensation or an indistinct one. At first, at the correspond- 
ing portion of the periphery, the patient has a feeling of numbness; 
subsequently, if resolution of the inflammation do not take place, there 
is complete anaesthesia to external injuries, while the pain continues. 
If the inflamed nerve contain motor fibres, the pain is accompanied by 
twitching and contraction, while the patient’s power of voluntarily 
contracting the muscles is much affected or entirely lost. This also 
depends on the morbid excitability of the motor nerves being increased 
by the inflammation while their conducting power is lost. If the in- 
flamed nerve lie near the surface, it may occasionally be felt as a hard 
cord; and we often find the skin covering it slightly reddened and 
oedematous. In most cases there is no fever, unless there be some 
other inflammation besides the neuritis. 
The course of neuritis may be either acute or chronic. The more 
acute it is, the sooner amesthesia and paralysis follow the neuralgia 
and contractions, and the more probable it is that these symptoms 
were caused by an acute neuritis that has destroyed the nerve. Even 
after resolution of the inflammation, the nerve usually remains to some 
extent incapable of function for a long time. When the neuritis runs 
a chronic course, if the nerve be destroyed, anaesthesia and paralysis 
occur in the same way; but, if the nerve be preserved and is only sub- 
jected to pressure from the swollen and thickened neurilemma, the NEUROMA. 
315 
patients suffer for years from neuralgic pain or spasmodic attacks in 
the parts supplied by the inflamed nerve. 
Treatment.—In the first place the causal indications must be ful- 
filled ; with this view foreign bodies driven into the nerve must be re- 
moved, and inflammations in its vicinity must be carefully treated. 
Leeches or wet cups may also be applied along the course of the 
nerve; cold applications may be made, or, if the disease continue long, 
mercurial ointment may be rubbed in if the nerve lie near the surface. 
Chronic neuritis may be treated by derivatives, such as blisters, and, 
in obstinate cases, moxse, and superficial linear cauterizations of the 
skin with hot iron. If the disease has run its course, and the nerve has 
not been destroyed, but its functional activity is affected, we may use 
electricity to restore its normal excitability, if possible, by methodical 
excitement of the nerve. 
CHAPTER II. 
NEUROMA. 
Etiology.—Strictly speaking, we can only designate as neuromata 
those tumors originating from nerves which are chiefly, or at least to a 
great extent, made up of nervous elements. The tumors, not unfre- 
quently occurring on nerves, which have developed without hyperpla- 
sia of the nerve-elements, and in which consequently the number of 
nerve-elements has remained the same or even actually diminished, 
are not neuromata, but, according to their structure, come under the 
head of carcinoma, fibroma, or glioma, etc. (Virchow). Neuromata 
which consist chiefly of nerve-filaments, or where these exceed the 
intercellular substance in amount, are termed pure neuromata, in con- 
tradistinction to those where the intercellular substance is in excess; 
this division, however, has more pathological-anatomical than clinical 
interest. 
The etiology of neuromata is obscure. Occasionally they may be 
referred to a congenital or hereditary predisposition. Such cases, as 
well as the frequent occurrence of numerous neuromata on different 
nerves, and their repeated recurrence after removal, speak for the con- 
stitutional orgin of some neuromata. Others unmistakably result 
from injury of the affected nerve, by a puncture, contusion, etc. In 
most cases no cause can be discovered. 
Anatomical Appearances.—Neuromata generally form hard, elas- 
tic tumors, from the size of a hemp-seed to that of a fist, or larger; 
they are usually round or oval; in the latter case their long axis lies 316 
DISEASES OF THE PERIPHERAL NERVES. 
in the course of the nerve. Virchow divides them into fibro-, glio, 
and myxo-neuromata, according as the interstitial tissue between the 
nerve-filaments resembles fibrous tissue, neuroglia, or mucous tissue. 
They sometimes contain small cavities filled with fluid. Neuromata 
are occasionally seated on the nerve; again they originate from its 
interior, and contain more or less nerve-filaments in proportion to the 
distance of their origin from the centre of the nerve. The most fre- 
quent seat of neuromata is the spinal nerves; but there are examples 
of their occurrence on the sympathetic and cerebral nerves, particularly 
on the auditory. Usually there is only one neuroma, and its size is 
not at all in proportion to that of the nerve from which it originates. 
In other cases there are several neuromata on the same nerve, in still 
others there are great numbers, originating from the most varied 
nerves. Under the head of neuromata appear also to belong the pain- 
ful tumors, about the size of a pea or bean, readily moved about under 
the skin, which are also called tubercula dolorosa, painful tubercle, or 
neuromantia; although their connection with a cutaneous nerve or the 
presence of nerve-elements in them cannot always be proved. 
Symptoms and Course.—Peripheral neuromata, which alone can 
be recognized, show themselves as a more or less elastic tumor, seated 
in the course of one of the cutaneous nerves, which is only movable 
laterally, and is covered by the unaltered skin. Large multiple neu- 
romata occasionally cause neither pain nor other inconvenience, so that 
their diagnosis can only be made by the apparent connection between 
the tumors and a cutaneous nerve. The case is different with the 
customary single small neuroma. It is often accompanied by ex- 
cruciating pain extending along the course of the nerve and to its 
peripheral termination. This is not usually continuous, but has par- 
oxysms with intervals of ease. Slight pressure on the tumor, often 
even the contact and rubbing of the clothes, increases the pain in the 
tumor to an unbearable extent. Severe paroxysms of pain are also 
induced by movement, catching cold, etc. In neuroma, as well as in 
neuritis, the conducting power of the nerve may be impaired, so that, 
besides the pain, there may be a feeling of numbness or even of more 
or less complete anaesthesia of the skin supplied by the nerve affected. 
Rarely, when the motor filaments are affected, there are twitchings 
and contractions and subsequently paralysis. The extension of the 
pain from the diseased nerve to other trunks, as well as the increased 
disturbance of innervation that occasionally complicates the local 
symptoms, is common to neuroma, neuritis, and to neuralgias of the 
most varied origin; we shall therefore defer their discussion to the 
next chapter. Neuromata generally grow slowly, and, after attaining 
a certain size, often remain stationary. They are among the most NEURALGIA. 
317 
painful of diseases, and may wear the patient out by the loss of sleep 
and restlessness induced by the pain. 
Treatment.—We can never cause resolution of neuroma. The 
only true and trustworthy remedy is removal by the knife. 
CHAPTESR III. 
NEURALGIA. 
As we have thus far made use of the anatomical changes lying at 
the root of the disease as grounds of distinction, it is inconsistent to 
treat of neuralgia as a disease, and to class it with neuritis and neu- 
roma. Neuralgia , is a combination of symptoms, which does not de- 
pend on constant anatomical changes. Since no anatomical changes 
can be discovered in many cases of neuralgia, and since, in many cases, 
where changes have occurred, they alone are not enough to explain 
the neuralgia, we seem driven to the above-mentioned inconsistency, 
and we shall be unable to escape it in other morbid processes of the 
nervous system, which are not due to certain anatomical causes. 
Etiology.—The sensation of pain depends on the conduction to 
the brain of the excitement of a sensory nerve by an abnormal irrita- 
tion. Those sensations of pain, also, that arc called neuralgic, depend 
on a propagation of this excitement to the brain. If neuralgic pains 
be distinguished from others, it is because they are due to the excite- 
ment of the sensory nerves by different irritations, or by the action of 
irritants at different places, from those causing ordinary pain. If a 
blow, heat, cold, or other cause acting on the termination of the nerves, 
induce pain, or if this be due to inflammation or other structural change 
of the skin, mucous membrane, or of the parenchyma of different or- 
gans, we do not call it neuralgia. But if we can discover no irritation 
of the peripheral termination of a nerve as the cause of the pain, or 
if it be probable that the irritation has affected the trunk of the nerve, 
the pain felt in the distribution of the nerve is called neuralgia. We 
mg,y mention neuralgia of the supra-orbital branch of the trigeminus 
which is not unfrequently induced by malarial infection, as the type of 
the form where the pain occurs in the distribution of a nerve, without 
the perceptible action of an irritant on the nerve itself, or on its termi- 
nations. As a type of the second form, where the pain in the parts 
supplied by a nerve is unmistakably due to an irritation of the nerve- 
trunk, we may mention the very temporary neuralgia induced by 
bruising the ulnar nerve near the elbow, at the part known as K the 
crazy-bone.” It is most probable that, in those cases, also, where the 
injurious influence acting on the nerve escapes observation (as in neu- 318 
DISEASES OF THE PERIPHERAL NERVES. 
ralgia caused by malarial poisoning), the action affects the trunk rather 
than the peripheral termination. This view is favored first by the 
exact limitation of the neuralgic pain to the peripheral expansions of 
a single nerve, and the freedom of the parts immediately adjacent, if 
these are supplied by other sensory nerves. This limitation would be 
quite inexplicable if the irritation acted on the periphery. How should 
we explain the constant freedonl of the radial side of a finger, or the 
supra-orbital region of one side, from the injury that so severely af- 
fected the ulnar side of the same finger or the supra-orbital region of 
the other side ? The view that neuralgia starts from the nerve-trunk 
is also supported by the fact that no idea of the variety of the irrita- 
tion accompanies the pain. It is well known that the cutaneous pa- 
pillrn connected with the terminations of the nerves are the chief 
source of the sensation of pressure and temperature. If the neuralgic 
pain were induced by the action of an imperceptible cause on the skin, 
the patients would have some impression of the quality of this irrita- 
tion ; they would complain of burning, piercing, or some other kind of 
pain. • But, on the contrary, if a very cold or very hot bod}'- be applied 
to an exposed nerve-trunk, if we puncture or squeeze it, there is al- 
ways the same sort of pain, just as in neuralgia; and, from the pain, 
the patient cannot tell what cause induced it. Finally, the want of 
benefit, in most cases, from division of nerves, indicates that the seat 
of the disease is to be sought for in the trunk or branches, not in the 
peripheral expansions of nerves. We do not know what physical or 
chemical changes of the nerves cause their morbid excitement in neu- 
ralgia. We may even suspect that they do not consist in any very 
evident deviations from the normal, for these remove the excitability, 
but that injuries only act as causes of neuralgia, when they exercise a 
comparatively slight irritation on the nerves. If we find a nerve, 
which was affected with neuralgia, much changed at some point, we 
may be sure that this was not the starting-point of the pain, but that 
it originated from some point higher up, where no changes of structure 
can be made out with the naked eye or with the microscope. 
The predisposition to neuralgia varies with the person. A morbid 
increase of excitability of the entire nervous system, so-called nervous 
debility, of which we shall speak hereafter, and which is seen more 
frequently in women than in men, in bloodless and debilitated persons 
than in the full-blooded and strong, appears to lead to the occurrence 
of neuralgia in some persons more readily than in others. 
The exciting causes—that is, the irritations which, by their action 
on the nerve-trunk, induce the neuralgia—are partly known, partly un- 
tcnown. We are not justified in distinguishing cases from unknown 
causes as “ genuine ” or “ pure ” neuralgia. The pain caused in the NEURALGIA. 
319 
finger by striking tlie ulnar nerve near the inner condyle of the hu 
inerus, or in the toes by a blow on the sciatic nerve where it escapes 
from the sciatic notch, is also a genuine, pure neuralgia. Practically, 
it would be better to designate as pure neuralgia those cases that con- 
tinue after the cause that induced them has ceased to act. Among the 
injuries that may be regarded as direct causes of neuralgia, the most 
frequent are: 1. Wounds of the nerves from sharp instruments, such 
as lancets, needles, etc.; a complete solution of continuity is far less 
dangerous than these punctured wounds. 2. Irritation from foreign 
bodies that have entered and become incapsulated near the nerve; ob- 
stinate neuralgia has very often been observed as a result of the irrita- 
tion caused by pieces of musket-balls. 3. Compression of the nerves 
by contracted cicatrices. 4. Pressure on the nerves by aneurisms, ex- 
ostoses from bones and teeth, and tumors, particularly carcinoma. 5. 
Neuroma, described in the last chapter. 6. Overfilling of the veins in 
the vicinity of the nerves where they pass through bony canals. From 
the predisposition of the left side of the body to intercostal neuralgia, 
Henle concludes that the latter cause has a material influence on the 
occurrence of neuralgia. The left side differs from the right in the 
arrangement of the venous circulation, so that the blood must make a 
circuit (from the hemiazyos vein‘into the azyos) to pass from the veins 
of the spinal cord into the vena cava; if there be any obstacle to the 
escape of blood from the heart, it must necessarily have a worse effect 
on the left side than on the right. The theory that neuralgia often 
depends on dilatation of the venous plexuses surrounding a nerve where 
it passes through an opening in the bone, is also supported by the fact 
that the first branch of the trigeminus (whose relation to the venous 
plexuses in its vicinity resembles that of the intercostal nerves) is far 
more frequently the seat of neuralgia than the second or third branch, 
where this is not the case. In the so-called rheumatic neuralgias, 
caused by catching cold, we can find no material changes in the neu- 
rilemma to explain the irritation of the nerve; nevertheless, although 
nypothetical, it is very probable that this rheumatic neuralgia is due 
to a hyperajmia and oedematous swelling of the neurilemma, which 
disappears after death. Lastly, we may mention, as causes of neu- 
ralgia, poisoning by metallic substances, such as mercury, lead, copper, 
etc., as well as by malarial infection. It is perfectly inexplicable, in 
these cases, why the irritation from a constitutional disease should 
only affect a very circumscribed nerve-tract. 
Symptoms and Course.—In neuralgia we may distinguish two 
forms of pain: one continuous, increased by pressure, confined to cir- 
cumscribed points in the course of the nerve (points douloureux, Val- 
leix's), not very severe but annoying pain; the second occurs in paro^« 320 
DISEASES OF THE PERIPHERAL NERVES. 
ysms, spreading from a point along the course of the nerve; the pain 
is terrible and almost unbearable. The points douloureux occur par- 
ticularly where the nerve escapes from a bony canal, or from fascia 
that it has perforated, and approaches the surface. These spots seem 
larger to the patient than they prove to be when we mark them out 
by pressing the linger around. Budge made some very interesting 
observations on the excitability of the motor nerves of frogs at differ- 
ent places; he found some spots very excitable while the parts im- 
mediately next to them were very slightly so; perhaps Vdlleix's points 
douloureux on the sensory nerves correspond to those that Budge 
found peculiarly excitable in the motor nerves. While Valleix almost 
always found the points douloureux in neuralgia, other observers have 
just as constantly failed to find them. The paroxysmal pains some- 
times pass downward, sometimes pass upward along the course of the 
nerve, so that there has been a division made into neuralgia descendens 
and ascendens, the latter being far the more rare. Patients usually 
say that the pain is not superficial but deep. It is rare for the parox- 
ysms of pain to be limited to one small twig of a nerve; usually 
several twigs of one branch, but only rarely all the twigs of one nerve 
participate in the affection. It is very remarkable that not unfre- 
quently the neuralgia extends from one nerve to another that has a 
different origin. From the laws of conduction we should suppose that 
such a transfer could only occur in the central organs, through the 
ganglia; but the observation that neuralgia not unfrequently extends 
from a cerebral nerve, as the trigeminus, to a spinal nerve, as the 
occipital, renders the transfer in that way very improbable; and we 
must content ourselves with having mentioned the curious fact. 
Anomalies in the distribution of blood, in the secretion and in the 
nutrition of the parts supplied by the affected nerve, are not unfre- 
quently observed without our understanding how the morbid excite- 
ment of the sensory can cause abnormal excitement of the vasomotor 
nerves. At the commencement of neuralgic attacks we occasionally 
see the skin become pale, more frequently at the height of the attack 
that it reddens, that the secretion from the nasal mucous membranf, 
conjunctiva, and from the lachrymal and salivary glands, is increased 
In the same category come the exanthemata that develop in the course 
of the affected nerve in some neuralgias, particularly in intercostal 
neuralgia (herpes zoster), and lastly, the atrophy or excessive develop 
ment of fat in parts supplied by the affected nerve, when the disease 
has lasted a long while. The morbid excitement of the sensory nerve 
is rarely transferred through a gland to a motor nerve. We must 
beware of carelessly considering the twitchings of patients, during theii 
attacks of pain, as reflex symptoms. NEURALGIA. 
321 
Except in the cases resulting from malaria, the course of the dis- 
ease is chronic. It is rarely regular, the individual attacks are marked 
by paroxysms of pain interrupted by free intervals, and in the general 
course of the disease we are apt to see remissions and exacerbations. 
At times the attacks of pain are more frequently repeated and are 
more severe, at others, they return less frequently and are less severe. 
It is only in the neuralgia caused by malaria, in the so-called febris 
intermittens larvata, that the paroxysms of pain show a regular type. 
In other cases the type is irregular, and the attacks not only recur 
spontaneously, that is without assignable reason, but they are excited 
by various recognizable causes. Among these are irritation of the 
skin which the affected nerve supplies, by pressure, friction, cold, heat, 
etc. Slightly touching the skin often appears to induce attacks of 
pain more readily than heavy pressure does. Movements of the parts 
where the pain is located, i. e., chewing in neuralgia of the trigeminus, 
walking in neuralgia of the sciatic, coughing and sneezing in that of 
the intercostals, excite attacks of pain. Mental excitement occasion- 
ally has the same effect. I treated one old gentleman, with neuralgia 
of the trigeminus, who had such a severe attack of pain every time I 
entered his room, that he could not salute me for some time. Each 
attack of pain usually lasts only a few seconds. But these short at- 
tacks are often repeated several times in the course of one or a few 
minutes, and then cease for a while, so that in fact we may say that 
in neuralgia long attacks occur which are composed of a number of 
short paroxysms. As we are almost compelled to believe that the 
irritation acting on a nerve, which causes the neuralgia, acts continu- 
ously, the intervals between the pains appear enigmatical: for their 
explanation we must refer to the physiological fact that the severe 
irritation of a nerve exhausts its excitability for a time; then in neu- 
ralgia, states of great excitement would alternate with states of dimin- 
ished excitability. This hypothesis is to some extent supported by 
the observation that, after severe attacks of pain, the peripheral ter- 
minations of the nerve are for a time less sensitive to irritation, as if 
their excitability were diminished, as well as by the observation that, 
after inducing a severe neuralgic attack by continued pressure on a 
painful point, a repetition of the pressure does not induce a second 
attack. The gentleman above mentioned also had attacks of pain as 
soon as he began to eat. In order that he might be able to eat at 
meals, he began them by biting vigorously on some hard bread; this 
induced a severe attack, but after it passed over he remained free from 
pain during the remainder of the meal. 
Neuralgia may continue for many years. Except in the cases 
caused by malaria or the so-called rheumatic neuralgia, complete cure 322 
DISEASES OF THE PERIPHERAL NERVES. 
is by no means frequent. Even the termination in permanent anaes- 
thesia is comparatively rare, although we should a priori regard it as 
the most frequent, since it would seem very probable that continued 
irritation must finally destroy the nerve. In many cases neuralgia, 
particularly certain forms of it, remains stationary and lasts till death. 
This is not apt to result from the neuralgia itself, but from accidental 
complications, or from the disease causing the neuralgia. 
Treatment.—Where the neuralgia is induced by pressure on, ox 
compression of, the nerves by foreign bodies, tumors, or contracted 
cicatrices, the causal indications require surgical interference. The 
circumstance that neuralgia occasionally continues after the removal 
of foreign bodies and tumors from the vicinity of nerves, should not 
deter us from operation; since we cannot know beforehand whethex the 
neuralgia has become “ habitual,” that is, whether the injurious influ- 
ences that have acted on the nerve have affected it permanently, and 
have induced a state that will not subside after removal of the cause. 
The so-called antirheumatica are of little use in rheumatic neuralgias. 
These would be more successfully treated by the methodical use of 
artificial or natural warm-baths. Numbers of patients with rheumatic 
neuralgia seek relief, and some find it, at Wildbad, Baden-Baden, 
Wiesbaden, and other warm springs. Where the disease is due to 
malaria and has a regular type quinine, the antidote to malarial poison- 
ing has a very brilliant effect. Sulphur-baths and the internal admin- 
istration of sulphur have a peculiar reputation in the neuralgias caused 
by poisoning with copper, mercury, and lead. Finally, the causal 
indications require the treatment of the disposition for neuralgia; and, 
as we know, to some extent at least, what it depends on, we cannot 
unfrequently fulfil this indication successfully. We cannot regard car- 
bonate of iron as a specific for neuralgia, but, when poverty of the 
blood is one of its chief causes (or, as Hademacher has it, “ when the 
neuralgia is an iron affection of the constitution”), the carbonate and 
other preparations of iron often have a surprising effect. In the same 
way neuralgia may often be benefited by modes of treatment that 
greatly modify the change of tissue and the nutrition. Where we 
cannot remove the causes of neuralgia, the indications from the disease 
require that we should attempt to equalize the disturbances of nutri- 
tion on which it depends, or to destroy the excitability of the nerves, 
or finally to prevent the propagation of the morbid excitement to the 
brain. 
Among the most effective modes of treatment for this purpose is 
the use of electricity. Excellent results are not unfrequently attained 
both by the induced and constant current. Dr. leube, in his inaugu- 
ral dissertation in 1862, reported a number of cases of obstinate neu- NEURALGIA. 
323 
ralgia that were cured at my clinic by the induced current. Since 
then, my experience in the result of this treatment has greatly in- 
creased, and I may combine the results in the following propositions: 
1. In treating neuralgia with the induced current, it is best to em- 
ploy the metallic electrodes known as the electric brush: while one 
electrode containing a moistened sponge is held in one of the patient’s 
hands or against any part of his body, we stroke the brush along the 
course of the affected nerve; if there are any points douloureux we 
allow the brush to remain over them rather longer (electric moxae). 
2. Many cases of neuralgia, which had been previously treated with- 
out benefit by the most varied remedies, wTere completely and perma- 
nently cured in from twelve to twenty applications, or even sooner. 
In other cases no benefit or cure was effected. 3. The first sitting 
shows whether the neuralgia can be cured by the induced current. 
We can only expect a cure where the pain is decidedly relieved or 
entirely disappears immediately after the first electrization, even if 
it should only be for a short time; if this temporary result do not take 
place, the continuation of the treatment wfill also prove ineffectual. 
The application of the induced current as above directed is very pain- 
ful ; and it is only after the patient has actually experienced benefit 
that he suffers it with patience, and even then he moans and whimpers 
during the application. An erythema, that lasts for some time, forms 
where the current is applied. I shall not attempt to decide whether 
the induced current acts by derivation to the skin like the linear cau- 
terizations advised by Valleix, or as blisters and irritating frictions, or 
whether it acts in some other way. 
The constant current is far more effective than the induced in neu- 
ralgia. Some cases that have been treated without result by the 
induced current have been cured by the constant, while I have never 
seen the reverse. I place both poles along the affected nerve, and, 
without attending to the course of the current, hold the zinc pole on 
the most painful part, and on those parts where the nerve approaches 
nearest to the surface, as at the supra or infra-orbital foramen, or at 
the zygomatico facial foramen, or at the sciatic notch. If it be possible 
to get the nerve between the poles, as in the cheek or nose, I introduce 
one pole into the mouth or nose to the point whence the pains radiate, 
while I place the other at the corresponding point on the skin. A+ 
first, the application of the constant current is not particularly painful, 
but an unpleasant, burning, piercing pain soon commences and grad- 
ually increases; where the number of elements is large, it may become 
unbearable. The changes induced in the skin at the point of applica- 
tion of the constant current, if the electrodes be applied for a length 
of time, are far greater than those caused by the induced current 324 
DISEASES OF THE PERIPHERAL NERVES. 
They not only consist in a lively erythema, a decided swelling of the 
skin, and an increase of the subjacent tissue, but papules and blebs 
arise on the skin, particularly at the positive pole ; if the action con- 
tinues long, the surface of the elevations sloughs off. These changes 
take place not only at the point of application, but occur equally or at 
least similarly in the deeper parts, as is shown not only by the increase 
in volume of the subcutaneous tissue and muscles, but also by the fol- 
lowing experiments (Erb\ which show a great deal about the mode 
of action of the constant current in neuralgia and other neuroses, as 
well as in some diseases of the muscles, joints, etc. If we cross the 
forearms, placing the volar surfaces in contact, and apply the electrodes 
to their dorsal surfaces, there will be reddening not only of the parts 
to which the electrodes are applied, but of the corresponding points 
on the anterior surfaces. Generally, relief immediately follows the ap- 
plication of the constant current just as it does that of the induced 
current; but occasionally the pain is at first increased, and that should 
not always induce us to stop the treatment. There seems to me no 
doubt that the curative action of the constant current, in most cases 
of neuralgia, is to be explained by the modification of the circulation, 
endosmosis or change of tissue in the diseased nerve, its neurilemma, 
or the parts around; this “ catalytic action ” may result from the 
chemical disintegration induced through the nerves, or the attraction 
of the constituents of the nutrient fluids toward the pole, or it may 
occur in some other way. The swelling of the skin, and the eruption 
of nodules and blebs on it after the application of the constant current, 
do not prove its action on the vasomotor nerves any more than the 
redness of the skin after a mustard plaster shows a similar action in oil 
of mustard. I consider it perfectly unjustifiable, in most of the recent 
writers on electrotherapeutics, to make a distinction between the effect 
of the constant current in neuralgia, paralysis, etc., and its effect in dis- 
turbances of nutrition. In most cases of neuralgia or other nervous 
diseases, just as in the affections of the muscles, joints, etc., where 
galvanism has proved useful, there is no molecular change or any alter- 
ation in the electrical state of the nerves, but, as Rcmdk distinctly 
asserts, there are disturbances of nutrition, anomalies of circulation 
and structure, exudations, etc. For the sake of the good cause, I can- 
not help regretting the numerous attempts that have been made to 
explain the benefits from the constant current in disease of the nerves 
and muscles, by referring to the laws concerning the contractions at 
the opening and closing of the current, concerning anelectrotonus and 
catalectrotonus, or concerning the results of irritation and division of 
the sympathetic, instead of resting solely on the evident results of clin- 
ical observation. These very imperfect doctrines, which are founded NEURALGIA. 
325 
on tlie results of experiments made on healthy frogs and rabbits, fur 
nish no useful data for the explanation of cures induced in diseased hu- 
man beings by the employment of electricity. Supposing, in a paral- 
ysis, neuralgia, or anaesthesia, we can succeed in changing the electro- 
tonus of the affected nerve, which Ido not at all deny, there is not the 
slightest probability that we shall thus remove the textural changes 
which lie at the root of the existing paralysis, anaesthesia, or neuralgia. 
On the contrary, if cure results, we may make up our minds that, besides 
the changes of the electrotonus, some other action has been induced. 
And supposing we succeed, by a few minutes’ irritation of the sympa- 
thetic, in contracting the vessels supplied with nerves from that part, 
for the length of the sitting, which I also shall not deny, it is just as 
improbable that we should thus remove a disturbance of innervation 
existing in the parts supplied by the contracted vessels. If application 
of the constant current to the sympathetic causes a cure, we may sup- 
pose that the disease depended on some disturbance of nutrition of the 
sympathetic, that has been removed by the catalytic action of the cur- 
rent. The marked difference between the constant and induced current 
in regard to their chemical action on water, solutions of salt, albumen, 
etc., has long been known, and I am fully convinced that the introduc- 
tion of the former into practice is one of the most valuable advances 
of modern times, and that in the constant current we have a means, 
more powerful than any other, of modifying the nutritive conditions 
of parts that are deeply situated. But I fear that the rationalistic and 
doctrinal teachings about galvanotherapeutics, which are recently so 
popular, and the attempts to make this so “ exact,” may interfere 
with moderate and experimental observation, and injure the popularity 
cf an important remedy. 
In the same class as electrical treatment come the blisters, mox£e, 
actual cautery, and cutaneous irritants, which are used as derivatives 
to the skin, and which are being more and more supplanted by elec- 
tricity. Superficial linear cauterization is considered, particularly in 
France, as one of the most effective of remedies. 
Among the means by which the excitability of the nerves is de- 
stroyed, we shall first mention cold. Besides compresses of cold water 
and ice, lotions with ether and liquor Hollandicus are used; these in- 
duce cold by their rapid evaporation. If they are more effective than 
ice-compresses, it is because they are breathed in at the same time, 
and to some extent stupefy the patient. Cold is a valuable pallia- 
tive ; we cannot generally continue its use long enough for a radical 
cure. The narcotics, particularly in the form of hypodermic injections 
of solutions of morphia, are at present the most common remedies for 
neuralgia. Formerly, if the local action of morphia was desired, a 326 
DISEASES OF TIIE PERIPHERAL NERVES. 
blister was applied, the resulting vesicle was opened, and the desired 
dose of morphine was sprinkled on the denuded spot, or else the mor- 
phine was mixed with saliva and inoculated into the skin. The intro- 
duction of hypodermic injections, instead of these troublesome proce- 
dures, was a great event, and was regarded as an immense advance in 
treatment. It was thought that the affected nerves might now be 
narcotized with facility. The results were perfectly surprising. In 
numerous cases, instead of writing a prescription of doubtful efficacy, 
the physician could free the patient from his pain in a few minutes. 
Moreover, it soon became evident that, not only in neuralgia, but in 
many other painful diseases also, this effect followed the hypodermic 
injections of morphine; and, secondly, that it did not make much dif- 
ference whether the injection was made at the seat of the pain or at 
some other point. I know many physicians who never go out to their 
practice without a Pravaz's syringe and a solution of morphine in their 
pocket, and who usually bring the morphine-bottle home empty. It 
cannot be denied that the hypodermic injection of solution of morphia 
is sometimes abused. From this abuse we have become acquainted 
with a form of chronic morphine-poisoning that was previously little 
attended to. If injections of morphia have been made for some time, 
and the dose has been increased more and more, independent of the 
return of the pain, the patients begin to feel an absolute need of the 
injections. They feel dull, and complain of an undefinable weakness, 
discomfort, trembling, etc. Some describe their state as resembling 
that after a debauch. Indeed, the condition before and after the injec- 
tion often reminds us most strikingly of that of a toper, before and after 
his first glass of spirits in the morning. But these bad results may be 
avoided by the careful use of hypodermic injections of morphia. It is 
doubtful whether they have any local action; but it is certain that the 
general effect of the morphine is much more complete and precise, if it 
be injected under the skin, than if it be administered internally, and 
we must regard the hypodermic injection of £ to of a grain of mor- 
phine as an invaluable palliative for neuralgia. Next to the employ- 
ment of cold and narcotics, come frictions of the skin with veratrine 
ointment (gr. iv—x to fat § j), or aconite ointment (gr. j to fat 3 j). 
After using veratrine ointment, the patients feel a peculiar prickling 
in the skin, which occasionally benumbs the pain. [A mixture of 
equal parts of chloral hydrate and camphor forms a clear liquid, 
which painted on the part relieves pain.] 
We have stated that a third requirement of the indications from 
the disease is to prevent the conduction of excitement from the irri- 
tated nerves to the brain. The most effective mode of doing this is 
by dividing the nerve between the brain and the affected part, or by NEURALGIA OF THE TRIGEMINUS. 
327 
cutting out part of the nerve, since it readily heals up if simply di- 
vided. The want of success in this operation is chiefly due to a di- 
vision of the wrong nerve, or to its being divided at the wrong place, 
that is, to the distal side of the point whence the pain orginates 
(Bruns). Unfortunately, the division at “ the right spot ” is in most 
eases entirely impossible, because the pain originates from a point 
above which the nerve cannot be reached. Cauterization of the nerve, 
for the purpose of disconnecting it from the brain, should be given up; 
compression is only to be used as a palliative. The least benefit is 
obtained from the specifics recommended in neuralgia, such as arsenic 
in the shape of Fowler’s solution, the preparations of zinc, particularly 
the valerianate and hydrocyanide, nitrate of silver, and other metallic 
and vegetable nervines. There are cases recorded where each of these 
remedies is said to have produced brilliant results, but these examples 
are few, and are far outweighed in number by those where they have 
had no effect. Up to the present time it is absolutely impossible to 
determine exactly in what eases these remedies are useful. 
CHAPTER IV. 
NEURALGIA OP THE TRIGEMINUS—PROSOPALGIA—TIC DOULOUREUX— 
fothergill’s PACEACHE. 
Etiology.—Next to the sciatic, no nerve is so often the seat of 
pain as the trigeminus. This is partly because many branches of the 
trigeminus pass through narrow canals and openings, where they may 
readily be compressed, partly from the distribution of the nerves to 
portions of the skin where they are more exposed to cold than other 
nerves are. Hyrtl is doubtless correct in supposing that the passage 
of the branches of the trigeminus through narrow openings of the 
bones has much to do with the occurrence of facial neuralgia; for see 
the great immunity to the disease of those brandies which pass 
through the wide sphenopalatine foramen to the nose, compared with 
its frequent occurrence in the infraorbital, zygomaticus malm, and su- 
perior and inferior dental branches. 
Only in a few cases have foreign bodies under the skin (in one 
celebrated case of Jeffreys there was a piece of porcelain) and tumors 
pressing on the branches of the trigeminus been found as causes of 
prosopalgia. Somewhat more frequently changes in the bony canals 
can be found to explain the morbid excitement of the nerves traversing 
them; among these are exfoliations of a bony wall in neuralgia of the 
infraorbital, exostosis of the root of a tooth in neuralgia of the in- 
framaxillary, general thickening of the bones of the skull with con- 328 
DISEASES OF THE PERIPHERAL NERVES. 
traction of the foramina through which the nerves pass, or even inflam- 
mation and projections on the bones. Finally, in some cases, aneurisms, 
tumors, thickening of the dura mater, exostoses within the skull, which 
pressed on the trigeminus, have been found as evident cause for ob- 
stinate and extensive neuralgia of the branches of that nerve. I do 
not know a single case that shows an unequivocally central origin of 
facial neuralgia. Among the cases described by liomberg, in one 
case of neuralgia of the trigeminus that had lasted for twenty-six 
years, it is true there was a small diseased spot in the pons, but there 
was at the same time an aneurism of the carotid compressing the tri- 
geminus, which would fully have accounted for the neuralgia. 
Far more frequently no material causes can be found for facial neu- 
ralgia. In such cases it is very probable, but cannot be proved, that 
the disease is occasionally caused by catching cold, which induces hy- 
peremia and slight oedema of the neurilemma that disappear after 
death. Cases of hemorrhoidal facial neuralgia and those from sup- 
pression of perspiration and exanthemata are very problematical; 
arthritic cases are somewhat less so. Neuralgia of the trifacial is the 
most frequent form when the disease is due to malaria. 
The rather worthless results of statistics show that facial neural- 
gia is rare in childhood, most frequent between the thirtieth and 
fiftieth years, and somewhat more common in women than in men. 
Symptoms and Course.—Of course, the pain from which patients 
with neuralgia of the trigeminus suffer is more extensive in proportion 
as the branch of the nerve affected is larger; and conversely, from the 
limitation of the pain to a circumscribed spot, we may decide that a very 
small branch is the seat of the disease. Moreover, as the filaments of 
a nerve are the more numerous the nearer we go to its origin in the brain, 
and become fewer as it approaches the surface, it follows that, when 
the pain is very limited, we may consider its origin as peripheral; where 
it is very extensive, we may decide that the injurious influence is in the 
skull itself. In fact, in neuralgias caused by pressure on the trunk of 
the fifth pair, pain has been observed in all parts supplied by its sen- 
sory filaments, in the anterior surface of the ear, in the skin of the 
forehead, temple, face, in the orbit, nose, palate, body of the tongue, 
floor of the mouth, teeth, and probably in the dura mater. Valleix 
mentions numerous points douloureux in facial neuralgia; we shall 
only call attention to three of them, which lie nearly in a vertical 
straight line, and correspond to the supraorbital foramen, the anterioi 
opening of the suborbital canal, and the mental foramen. If the neu- 
ralgia be seated in the first branch of the trigeminus, the pain spreads 
particularly in the branches of the supraorbital, and affects the forehead, 
eyebrows, and upper eyelid. In some rare cases the pain is chiefly ic NEURALGIA OF TIIE TRIGEMINUS. 
329 
the eye, and, from participation of the infratrochlearis, at the inner 
canthus and caruncula lachrymalis. The twigs of the first branch, 
which go to the lachrymal gland and conjunctiva, explain the increased 
secretion of tears and redness of the conjunctiva, almost always ob- 
served m neuralgia of that branch, particularly on remission of the 
paroxysms. If the second branch of the trigeminus be the seat of the 
neuralgia, the pain is usually most severe in the parts supplied by the 
infraorbital, that is, in the lower eyelid, alae nasi, upper lip, and teeth 
of the upper jaw. The attacks of pain in these cases are sometimes 
accompanied by watery or mucous secretion from the nasal mucous 
membrane. Neuralgia is rare in the course of the third branch of the 
nerve: this is particularly true in the course of the auriculo-temporal 
and lingual branches; it is somewhat more frequent in the inferior 
alveolar, especially in the mental, after it escapes from the foramen; 
then the patient has pain in the chin and lower lip. Salivation often 
accompanies neuralgia of the third branch; this symptom agrees per- 
fectly -with the experiments of Ludwig (see vol. i.). Occasionally the 
neuralgia chiefly affects those twigs of the second and third branches 
that accompany the ramifications of the facial nerve. This explains 
why the facial nerve itself was formerly often considered as the seat 
of the neuralgia. 
In facial, as in other neuralgias, the patients suffer partly from a 
permanent dull pain located at different points of the trigeminus; 
partly from attacks of agonizing pain, which occur suddenly, then 
cease as suddenly, in half a minute or so, and again return till the 
attack, composed of these short twinges, “ Tics,” is over. The face 
often twitclxes during these attacks, but does not usually do so invol- 
untarily. Parson Barth, who has given a very careful account of his 
own. facial neuralgia, was even able to continue preaching during the 
attack. The attacks sometimes occur spontaneously, and, except in 
the cases due to malaria, they are irregular; sometimes they are in- 
duced by the causes previously mentioned, such as speaking, sneezing, 
gaping, blowing the nose, by using too cold or too warm food, occa- 
sionally even by any attempt to chew. During the attack the face is 
usually reddened, its temperature increased, and there is active pulsa- 
tion of the arteries. To the cases observed by Brodin and Bomberg. 
where, after long duration of severe facial neuralgia, the countenance 
of the patient was greatly disfigured by swelling and development of 
fat, I may add the case of one of my Magdeburg colleagues, in whom 
there was decided disfigurement, particularly by swelling of the lower 
lip, from facial neuralgia of one year’s duration. In old cases of the 
disease other disfigurements of the face have also been observed, such 
as increased thickness and prickliness of the beard, acne pustules, etc. 330 
DISEASES OF THE PERIPHERAL NERVES. 
The duration of the disease is rarely short, except in the regular 
intermittent malarial affection; in almost all other forms it usually 
lasts a long while, even half a lifetime, or more. Among the termi- 
nations, besides recovery, severe melancholy occurs, which may drive 
the patient to suicide. Death also occasionally results from the cause 
of the disease, but not from the disease itself. 
Treatment.—For the treatment of facial neuralgia we have little 
to add to the rules given for the treatment of neuralgia in general. 
Only in a few cases can we cure prosopalgia quickly, by the removal 
of foreign bodies, tumors, and contracting cicatrices. Extraction of 
teeth does not often prove of benefit. Usually the unfortunate patient 
has one tooth after the other drawn, without the slightest relief to the 
pain. 
In recent cases, caused by catching cold, Valleix urgently recom- 
mends flying blisters and superficial cauterizations with the hot iron. If 
the disease be due to malaria, large doses of quinine are almost always 
of service. The administration of Fowler’s solution (four to six drops 
every three hours) is only indicated when quinine has failed. In de- 
cided anaemia, we may give preparations of iron, and, when we con- 
clude that there is some other constitutional disease, whose nature we 
cannot determine, we may order alterant mineral waters and baths. 
Concerning the employment of electricity, cold, veratrine, and 
aconite, as well as of morphine, particularly in the form of subcutane- 
ous injection, the same is true in facial as in other forms of neuralgia. 
I have seen two cases of tic douloureux cured by the constant current; 
one of them was of thirty years’ standing, and in the other eleven 
operations, some of them severe ones, such as the ligation of the 
carotid, resection of the superior maxilla, etc., had been performed 
without benefit. In no form of neuralgia is division of the nerve, or 
excision of part of it, more frequently done. After this operation had 
for a time almost gone out of use, Bruns has shown, by a careful ex- 
amination of the cases where it had been done, that, after excluding 
the cases where its want of benefit depended on error of diagnosis or 
operation, and after excluding the cases where the recurrence of the 
pain was to be regarded as a new attack, not as a relapse, there was 
a considerable number of cases wrhere the neurotomy caused either a 
complete and permanent benefit, or at least a temporary one, for a 
few months or years. According to Bruns, the operation (whose per- 
formance we will not describe) is indicated when the pain is very 
limited, and it is probable that its exciting cause is situated at a point 
beyond which the nerve is accessible to the knife, when other treat- 
ment has proved fruitless, and when the pain renders the patient unfit 
for business. There is also an indication to operate when we cannoi HEMICRANIA—MIGRAINE. 
331 
hope to divide the nerve between the point of disease and the brain, 
but when the pain never occurs spontaneously, being always the result 
of some external irritation acting on the peripheral terminations of the 
nerve. In such cases the operation may, to some extent, protect the 
patients from the exciting causes of their attacks of pain. The tem- 
porary compression of the affected nerve and the artery supplying it 
has also sometimes proved an excellent palliative, and deserves a 
trial in suitable cases. Among the so-called specifics, Romberg speaks 
most highly of arsenic; under its use he saw the most evident and 
speedy benefit in those cases that occurred in hysterical women, or 
from disease of the sexual organs. Its effect was the more certain, the 
more anaemic the patient. Romberg also saw temporary benefit from 
nitrate of silver in large doses (gr. j). Rett, who, as Watson says, 
“ shot an arrow at random,” claims to have had excellent results from 
the internal administration of croton-oil with compound extract of 
colocynth. Among the narcotics, besides the preparations of opium 
and morphine, belladonna, stramonium, conium, and their alkaloids, 
particularly Meglin’s pills (consisting of equal parts of extract of hy- 
oscyamus and flowers of zinc), have a good reputation; we begin with 
a two-grain pill, morning and evening, and increase to twenty or thirty 
of them daily.1 
CHAPTER Y. 
HEMICEAISriA MIGRAINE. 
The combination of symptoms designated as migraine is difficult 
to explain. It is even doubtful if we are justified in classing it among 
tbe neuralgias, as is almost universally done. The almost constant 
occurrence on one side, of the headache (to which hemicrania owes its 
name), the paroxysms and free intervals observed in the disease, the 
negative results of anatomical examination, are the chief reasons for 
this view. On more carefully examining into the general course of the 
disease, and the course of individual cases, however, this view is not 
supported. There is no variety of neuralgia which, beginning, like 
migraine, in childhood, and lasting into advanced age, only attacks the 
patient a few times a year during this period, and, in these attacks, 
shows a steady increase and diminution of the pain, but never an in- 
stantaneous occurrence or disappearance. Still other objections to the 
consideration of migraine as neuralgia will appear from the description 
of the symptoms and course. Whether migraine be a neuralgia or not, 
the pain must result from excitement of sensory filaments, but it is 
doubtful whether this excitement occurs in the filaments from the 332 
DISEASES OF THE PERIPHERAL NERVES. 
trigeminus to the dura mater, in the sympathetic filaments accompa- 
nying the vessels, or in the brain itself. According to a fanciful hy- 
pothesis of Du Bois-Reymond, which Dr. Mbllendorf has carried still 
further, the attack of migraine depends on a dilatation of the branches 
of the internal carotid, the result of abnormal innervation of the vessels 
from the ganglion supremum of the sympathetic. According to this 
view, the brain would, during an attack, be in the same condition as 
the ear of a rabbit that has had the cervical portion of the sympathetic 
divided. 
Migraine is a very common disease, so that, in a moderately-exten- 
sive practice, we may usually observe a series of cases for years, and 
be again and again reminded by them of the impotence of our art. 
The disease occurs in both sexes, but is far more frequent among 
women than men. Like gout, migraine is considered a fashionable 
disease, but it also occurs among the lower classes, and is for them a 
peculiarly-distressing disease, as they cannot lie by for it. In most 
cases its commencement dates from the time of going to school, if not 
from early childhood. Probably in half of the women affected with 
migraine, the attacks occur at the menstrual period, or immediately 
before it. In other cases the attacks are unmistakably due to mental 
excitement. I treated one lady, who never had a party without suf- 
fering from migraine next day; another was affected in the same way 
after each visit to the theatre. In some cases a severe attack, particu- 
larly if it end with sick stomach, results in a certain immunity to re- 
lapses. The first lady above mentioned had her guests invited the 
day she had migraine, so that she might be certain of being able to 
receive them the following day. In the cases that I have seen, the 
attack could rarely be referred to an error of diet; but, on the other 
hand, the pain and general disturbance were almost always increased 
if the patient took any food, no matter how digestible, during the 
attack. 
After feeling perfectly well the day before an attack of migraine, 
the patients peroeive the first symptoms as soon as they awake, or im- 
mediately afterward. They feel heavy and depressed, are uneasy and 
irritated, complain of slight chilliness, are inclined to gape, usually 
have no appetite, and have a slimy taste in the mouth. Besides the 
above, there is headache, which is almost always limited to one side, 
increases rapidly, and becomes almost unbearable. The relaxation 
and pain drive the patients to bed; they arc very sensitive to light 
and noise; hence they seek the darkest and most retired chambers. 
They dislike all visits, even that of the physician, during the attack 
The pulse is usually slower. In many cases, at the height of the at- 
tack (in some patients at every attack), there is nausea, and, after great CERYICO-OCCIPITAL NEURALGIA. 
333 
retching, vomiting, by which quantities of a very bitter greenish fluid 
are evacuated. Patients who have frequent attacks of migraine, usu- 
ally long for the commencement of vomiting, and even try to excite 
it by irritation of the pharynx. Generally, toward evening, rarely 
earlier, the patient falls asleep, and awakes next morning free from 
pain, although much depressed. The disease never threatens life; 
but, although the attacks sometimes occur at shorter or longer inter- 
vals, patients rarely entirely recover from the disease. In women 
alone, particularly those who have the migraine at their menstrual pe- 
riods, the disease occasionally ceases at the change of life. 
Watson asserts that “ four to six drops of liquor arsenicalis, given 
three or four times daily, with attention to the digestion, effected a 
cure in ten cases of hemicrania; ” but this assertion is a solitary one; 
most other observers say that the disease generally resists all treat- 
ment. Nor have I seen any decided benefit from arsenic, pulsatilla, 
marsh-trefoil, or from the very expensive citrate of caffein (which is 
also called a specific), of which we prescribe pills (Ijf caffein citr. gr. x, 
ext. grani [ Triticum, repens] 3 j ; ft. pil. 10), and, to cut short the at- 
tack, give one or two of these pills every hour on the first symptoms, 
or from the paulinia sorbilis, which is prescribed in the form of pasta 
guarana 3ss—3 j. One patient prepared for herself an infusion of 
unroasted coffee, and, as long as she drank this daily, appeared to have 
the attacks more rarely and less severely. Another patient escaped 
the attacks as long as she took sea-baths at Haringsdorf; but, when 
she returned home, they began again. In most cases we can do noth- 
ing but attend to existing disturbances of the general health and of 
the digestion, and the chances of benefit from treatment are much 
greater where we can discover any such disturbances. During the 
attack we should spare the patients from the use of any remedies, and 
let them take nothing but water. It is best for the patient not to trv 
to defy the attacks, but to go to bed early. 
CHAPTER VI. 
CERVICO-OCCIPITAL NEURALGIA. 
Ceryico-occipital neuralgia, or neuralgia of the sensory nerves of 
the occiput, neck, and nape of the neck, which originates from the first 
four cervical nerves, is far more rare than facial neuralgia. . The cases 
known, up to the present time, are not sufficiently numerous to give 
us any thing definite concerning the etiology. From the observations 
of Valleix, according to which the disease often began after prolonged 
exposure to cold, and from one case where relapses often occurred, and 334 
DISEASES OF THE PERIPHERAL NERVES. 
came only in Avinter, as well as from the generally favorable course 
and good result of treatment, it seems probable that this disease most 
frequently results from catching cold. Diseases of the vertebras also 
appear to induce this form of neuralgia, in some few cases, by pressing 
on the veins as they pass out of the vertebral canal; and swollen lym- 
phatic glands, deep in the neck, may cause it by pressing on the cervi- 
cal plexus and the occipitalis major. 
In cervico-occipital neuralgia, patients also complain of a continued 
dull pain, limited to small spots, which is, from time to time, accompa- 
nied by attacks of very severe lancinating pain shooting out in various 
directions. According to Valleix, these isolated painful spots are: 1. 
An occipital point located below the occipital bone, between the mas- 
toid process and the first cervical vertebra, corresponding to the point 
where the nervus occipitalis major [posterior occipital] perforates the 
complexus muscle and becomes subcutaneous. 2. A superficial cervical 
point, somewhat aboAre the middle of the neck, between the trapezius 
and sterno-cleido-mastoid muscles, corresponding to the point of exit 
of the chief cervical nerves. 3. A mastoid point, lying behind the 
mastoid process, corresponding to the occipitalis minor and auricularis 
major nerves. 4. A parietal point near the parietal protuberance. 5. 
An auricular point in the auricle. In the attacks the pain darts from 
these points toward the occiput, the posterior, and upper part of the 
neck, anteriorly to the face, and, occasionally, doAvnward, toward the 
shoulder. Cervico-occipital neuralgia is not unfrequently complicated 
with prosopalgia and neuralgia of the brachial plexus. The attacks 
sometimes occur at irregular intervals, sometimes from movements of 
the head, or other slight causes. They are rarely so severe as the at- 
tacks of tic douloureux. Disturbances of nutrition in the territory of 
the cervical nerves are exceedingly rare, if they ever occur. Cervico- 
occipital neuralgia is far less obstinate, and is rarely so permanent as 
facial neuralgia. 
In this affection division of the nerves has not been tried. In 
recent cases blisters are recommended, particularly by Valleix, as Avell 
as Megliri’s pills and all other remedies that are used in prosopalgia. 
CHAPTER VII. 
CERVICO-BRACHIAL NEURALGIA. 
By cervico-brachial neuralgia we mean a neuralgia located in the 
sensory twigs of the brachial plexus, which is composed of the lower 
four cervical and the first dorsal nerves. 
This form of neuralgia has perceptible causes far more frequently CERVICO-BRACHIAL NEURALGIA. 
335 
than other forms. Among these are injuries of the peripheral branches 
of the brachial plexus in the arm or hand from lancets and other 
pointed instruments, pressure on the nerves from fragments of bullets, 
contusions, neuromata, etc. The brachial plexus itself is occasionally 
compressed in the axilla by swollen lymphatic glands, under the clavi- 
cle by the callus of a fractured rib, by aneurisms of the subclavian or 
arch of the aorta. Finally, the nerves forming the brachial plexus may 
be pressed upon and irritated just at their escape from the spinal 
canal, by diseases of the vertebrae. In other cases the irritation act- 
ing on the brachial plexus or its branches cannot be perceived, and we 
have to refer the neuralgia to a rheumatic affection of the neurilemma, 
or to an imperceptible alteration in the nerves, from over-use of the 
muscles in knitting, playing the piano, etc. Lastly, we must mention 
that attacks of angina pectoris are usually complicated with pain in the 
course of the brachial plexus. The transfer of the morbid excitement 
from the nerves of the heart to those of the arm is best explained, 
according to my idea, by the intervention of the nervus cardiacus mag- 
nus and parvus, as they originate from the middle and inferior cervical 
ganglia which are connected by many twigs with the inferior cervical 
nerves. 
In some cases the pains spread over a large part of the sensory 
filaments of the brachial plexus, in other cases they are limited to the 
axillary region and the upper part of the arm; occasionally they fol- 
low exactly the distribution of the ulnar, radial, or musculo-cutaneous 
nerves. Valleix most frequently found a point douloureux in the 
axilla, and one for the ulnar nerve, the point between the inner con- 
dyle and the olecranon, and another near the ulna above the hand 
where the ulnaris becomes superficial; and for the radial nerve the 
point in the arm where this nerve winds around the humerus, and a 
second one at the lower end of the radius just above the hand. The 
lancinating pains, particularly those extending to the fingers supplied 
by the affected nerve, are severe and recur very frequently, so that 
the intervals of perfect freedom from pain are usually shorter than in 
other neuralgias. The pain is generally accompanied by a sense of 
formication and numbness in the fingers, which lasts longer than the 
attack. Disturbances of nutrition in the parts supplied by the mor- 
bidly-excited nerve occur in some cases of brachial neuralgia in the 
shape of exanthemata (pemphigus, urticaria), or inflammations of the 
fingers. There are very often complications with neuralgias of other 
nerves, particularly with cervical, intercostal, and sciatic neuralgia. 
The course, duration, and termination of cervico-brachial neuralgia are 
about the same as in other neuralgias. 
If injuries of the finger, venesection, or similar injuries have in- 336 
DISEASES OF THE PERIPHERAL NERVES. 
duced brachial neuralgia, neurotomy proves triumphant, particularly 
in recent cases, and when the neuralgia has not become “ habitual.” 
Besides other remedies that we have already mentioned, the internal 
administration of oil of turpentine has some reputation ; we shall refer 
to it again when speaking of sciatica. 
CHAPTER VIII. 
INTERCOSTAL NEURALGIA. 
We designate as intercostal neuralgia the morbid excitement of 
one or several spinal nerves, particularly of those which as intercostal 
nerves pass along the upper intercostal spaces to the sternum, and 
along the lower spaces to the epigastrium. 
Intercostal neuralgia is among the most frequent forms of neural- 
gia. It is met more frequently in women than in men, shows a sur- 
prising predisposition for the sixth, seventh, and eighth intercostal 
nerves. We have already spoken of the shrewd explanation that Ilenle 
gives for this peculiarity. The fact that the inferior intercostal nerves 
are chiefly affected, that is, the ones that empty their blood into the 
hemiazygos vein, supports the view that one of the chief causes of inter- 
costal neuralgia is dilatation of the venous plexus, which most readily 
occurs at these places, and exercises pressure on the roots of the spinal 
nerves. In some cases the dorsal nerves are pressed upon, -where they 
pass through the intervertebral foramina, by inflamed vertebras, or, after 
they have passed through, by carious ribs and swollen glands. Inter- 
costal neuralgia not unfrequently occurs after recovery from pleurisy. 
Within a year I have seen two cases which undoubtedly had this 
origin. It is doubtful what anatomical changes in the neurilemma or 
in the parts surrounding the nerves, during a pleuritis or the reabsorp- 
tion of the pleuritic exudation, have occurred in these cases. The 
same is true of those cases of intercostal neuralgia that 
accompany tuberculosis of the lungs. Lastly, as the disease is par- 
ticularly liable to occur in hysterical women with chronic uterine dif- 
ficulty, it has also been referred to a propagation of the morbid excite- 
ment from the nerves of the uterus through the spinal medulla to the 
brachial plexus (Bassereau). 
In intercostal neuralgia, the three painful points mentioned by 
Valleix are more frequently observed than in most other forms of 
neuralgia. The first or vertebral point is in the posterior part of the 
intercostal space, somewhat outward from the spinous process, and 
about on a level with the point of exit of the nerve from the interver- 
tebral foramen. The second or lateral point lies in the middle of the MASTODYNIA—IRRITABLE BREAST. 
337 
intercostal space; it corresponds to the point of division of the inter- 
costal nerve; from it the nerves pass toward the surface. The-third 
point is near the sternum between the costal cartilages in the upper 
intercostal nerves, in the lower ones it is in the epigastric region some- 
what outward from the median line; it is called either the sternal or 
epigastric point, and corresponds to the place where the terminal 
branches of the intercostal nerves approach the skin. These usually 
very circumscribed points are generally so sensitive to pressure, that 
the patient cries out as soon as they are touched. The patients 
often discover the points themselves, and voluntarily point out their 
position to the physician, and, as the pain very much resembles that 
from a contusion, they are sure they must have struck themselves 
somehow. This constant pain is increased by deep inspiration, cough- 
ing, sneezing, occasionally also by moving the arms, as well as by 
touching the points; and attacks of lancinating pain are excited, which 
generally start from the vertebral point and pass anteriorly along the 
iijtercostal space; occasionally they pass forward and backward from 
the lateral point. Hard pressure often relieves the pain. Homberg 
tells of a man whose coat had become threadbare at the point where 
lie was in the habit of pressing his hand. The frequent complication 
of intercostal neuralgia with herpes zoster is very interesting, although 
just as obscure as the disturbances of nutrition in the parts supplied 
by other nerves affected with neuralgia. The disease runs a very 
irregular course; it usuallj- develops slowly and passes off gradually 
after variable duration. Occasionally it is very obstinate and hangs 
on for years. 
For the treatment of intercostal neuralgia we would advise the re- 
peated application of blisters to the points douloureux, and particular- 
ly the employment of the induced, or, still better, of the constant, cur- 
rent of electricity. During the treatment any anomalies of constitution 
are to be looked after, and, where the pain is very severe, morphia 
should be used internally or subcutaneously as a palliative. 
CHAPTER IX. 
MASTODYNIA IRRITABLE BREAST (Cooper). 
It is doubtful whether mastodynia be a neuralgic affection of the 
branches of the intercostal nerves going to the mammary gland, or 
of the nervi supraclaviculares anteriores. According to Romberg1 $ 
excellent description, women, about the period of puberty, or from 
then to the thirtieth year, without any perceptible cause, become sen- 
sitive to the slightest touch at one or more points over the mammary 338 
DISEASES OF THE PERIPHERAL NERVES. 
gland. Severe pain, like tic douloureux, occasionally shoots out tow- 
ard the shoulder, axilla, or hip. Occasionally, at the height of these 
attacks of pain, vomiting comes on. The patients cannot , lie on the 
affected side ; they are unable to bear the weight of the breast. The 
pain usually increases shortly before the appearance of the menses. 
The disease often lasts for months or years without any perceptible 
change in the mammary gland. In other cases, sharply-bounded, very 
movable tumors, as large as a pea or a hazel-nut, develop in the mam- 
ma and form the starting-point for the pain, occasionally they cease to 
be painful; they consist of connective tissue, not of the substance of 
the gland; they have been previously mentioned as tubercula dolo- 
rosa or neuromata. Fur worn on the breast, a plaster of equal parts 
of einplas. saponat. and extr. belladonna, recommended by Cooper, and 
pills of ext. conii, ext. papaver (ana gr. ij), ext. stramonii (gr. |—|), 
are mentioned by Romberg as the most trustworthy remedies. 
CHAPTER X. 
LUMBO-ABDOMINAL NEURALGIA. 
Neuralgia lumbo-abdominalis is the form that affects the cuta- 
neous nerves of the lumbar plexus, going to the lower part of the 
back, to the nates, anterior abdominal wall, and genitals. In this 
neuralgia, also, there are constantly pains at circumscribed points, 
which are occasionally accompanied by lancinating pains. These 
points are: 1. The lumbar points, somewhat outward from the first 
lumbar vertebras. 2. The hip point, somewhat above the middle of 
the crest of the ilium, where the ilio-hypogastric nerve perforates the 
transversalis muscle. 3. The hypogastric point, somewhat inward 
from the anterior-superior spine, where the ilio-inguinal nerve per- 
forates the transversalis muscle; and, lastly, some points on the mons 
veneris, vulva, or scrotum at the terminations of the cutaneous nerves. 
Where the posterior branches are affected, the lancinating pains chiefly 
pass toward the nates; where the anterior are affected, they chiefly 
pass toward the external genitals. The etiology, course, and treat- 
ment of lumbo-abdominal neuralgia are exactly the same as in inter- 
costal neuralgia. 
CHAPTER XI. 
NEURALGIA ISCHIADICA ISCHIAS ISCHIAS NERVOSA POSTICA COTUN- 
NII—SCIATICA—HIP-GOUT. 
By sciatica we mean a neuralgic affection of the sensory nerves of 
the sciatic plexus, which is formed from the fourth and fifth lumbar 
and first and second sacral nerves. SCIATICA. 
339 
Etiology.—The nerves forming the sciatic plexus may be pressed 
upon by carious or carcinomatous vertebrae:, just where they pass through 
the intervertebral foramen, and may thus be morbidly excited. And 
sciatica not unfrequently depends on pressure, which acts on the sci- 
atic plexus in the pelvis. In a patient with lymphatic leuchaemia, 
whom I had the opportunity of observing at Greifswald, a severe in- 
termittent neuralgia, which was undoubtedly caused by the pressure 
of the immensely-swollen retroperitoneal glands on the sciatic plexus, 
was for years the most prominent symptom. Tumors in the pelvis 
occasionally act in the same way, by pressure on the sciatic plexus, 
particularly ovarian cysts, collections of hard faeces, or, as in a very 
instructive case of Bamberger's, collections of cherry-pits in the sig- 
moid flexure, also the gravid uterus, particularly if the child’s head 
remain long impacted. Cases of sciatica that are very obstinate, but 
usually terminate in cure, result from the pressure of exudations of 
parametritis and perimetritis in the subperitoneal tissue or in capsu- 
lated intraperitoneal spaces on the sciatic nerve. 
Lastly, irritation of the peripheral branches of the sciatic may 
sometimes be found as a cause of the sciatica. In this class belong 
the cases due to pressure from tight boots, from phlebotomy, an- 
eurisms of the arteries of the lower extremity, tumors near the nerve, 
etc. 
Among the causes of sciatica that leave no perceptible anatomical 
changes are excessive straining, suppression of habitual perspiration 
and exanthemata, and catching cold. It is quite natural that the lat- 
ter should occur. Indeed, the majority of cases of sciatica are of rheu- 
matic origin, as they result from exposure to cold of the skin covering 
the sciatic nerve, as occurs particularly in windy privies. It is not at 
all astonishing that, among the cutaneous nerves, the trigeminus and 
sciatic should be affected most frequently; the former being all day 
exposed to the danger of catching cold, and the latter being exposed 
for a short time once or twice daily. 
Statistics show that sciatica is one of the most frequent forms of 
neuralgia, that it rarely occurs among children, is most frequent be- 
tween the ages of twenty and sixty years, and that it occurs more fre- 
quently in males and the lower classes than in females and the higher 
classes. 
Symptoms and Course.—Most cases of sciatica support Rom- 
berg''s assertion that there is no cutaneous nerve of the lumbar and 
sacral plexus, from the hip-joint to the ends of the toes, which may 
not be affected with neuralgia, and that it is only tradition that locates 
the pain in the trunk of the nerve. The most frequent seats of the 
neuralgic pain are the nervus cutaneus femoris posterior, in which 340 
DISEASES OF TIIE PERIPHERAL NERVES. 
:ase the posterior and outer part of the thigh becomes painful; the su- 
perficial branch of the peroneal nerve, where the pain is in the outer 
and anterior surface of the leg and dorsum of the foot; the sural 
nerve (communicans tibialis), where the pain is in the outer side of 
the ankle and foot. The sensory filaments going to the sole of the 
foot are rarely the chief seat of pain. In the heel and back part of 
the sole of the foot severe neuralgia, proceeding from the terminal 
branches of the tibial nerve, is sometimes seen. Valleix gives, as the 
most frequent points douloureux, some points behind the trochanter, 
about three points in the thigh corresponding to the course of the 
chief trunks, some points on the knee, one below the head of the 
fibula, one above the outer ankle, and a few points on the ankle and 
dorsum of the foot. 
Sciatica rarely begins with great severity; it usually develops grad- 
ually and slowly attains its height. The patients are never free from 
pain, but complain of its constant presence deep in, particularly near 
the tuberosity of the ischium, at the point where the sciatic nerve 
passes out, and of pains in the small of the back. As the latter do 
not come from the branches of the sciatic, but from the posterior 
sacral nerves, Romberg calls them sympathetic. Besides these con- 
stant pains, there are convulsive pains, particularly in the course of the 
above-named nerves. A division into ascending and descending sciatica 
is made, from the direction of these pains being from below upward or 
the reverse. The pains sometimes begin spontaneously, especially after 
going to bed, so that they not unfrequently drive the patient out of 
bed; sometimes they are caused by outward pressure and movements 
of the legs. Even moderate tension of the fascia may have this effect; 
consequently the patient usually lies with his legs slightly flexed. 
Greater tension of the fascia in coughing, sneezing, or straining, is often 
accompanied by severe pain. In walking, the patient places the foot 
of the affected side very carefully, because any quick motion or mis- 
step usually causes severe pain. Participation of the motor filaments 
in the disease, or a transfer of the irritation from the sensory to the 
motor filaments through the spinal marrow, not unfrequently causes 
cramps in the calf or other muscular contractions. Disturbances of 
nutrition in the parts supplied by the affected nerve are not found in 
sciatica as they are in other neuralgias. If the disease prove chronic, the 
limb which the patient favors not unfrequently emaciates decidedly. 
Occasionally the excitability of the sciatic is gradually impaired, and 
we have anaesthesia and partial paralysis. 
Sciatica is a very obstinate affection. Even in favorable cases 
several weeks usually elapse before the disease disappears, and it 
generally subsides as gradually as it developed. In less favorable SCIATICA. 
341 
cases it often lasts for months or years. Even after the disease has 
disappeared, relapses very readily occur. 
Treatment.—The causal indications can rarely be fulfilled. If 
disease of the vertebras be the cause of the sciatica, we may use moxa. 
the hot iron, etc., to the back. Of the injurious influences that act on 
the sciatic plexus in the pelvis, overfilling' of the sigmoid flexure is 
almost the only one that is accessible. Although rarely the sole cause 
of sciatica, this is a frequent complication, hence the old habit of be- 
ginning the treatment with a laxative is quite proper. If sciatica 
remain after difficult delivery, and if we have reason to refer it to a 
para or perimetritis, we may employ frequent abstractions of blood, 
and use cataplasms for a long while. In rheumatic sciatica warm- 
baths are useful, particularly the systematic treatment with baths at 
Teplitz, Warmbrunn, Wiesbaden, or Wildbach Among the antirheu- 
matics administered, iodide of potassium in large doses appears to do 
most good. I saw relief of the pain occur particularly in those cases 
where the running from the nose, and the eruption caused by the 
iodine, came on early. 
In recent cases, the indications from the disease are best answered 
by the local abstraction of blood, and wet cups are preferable to 
leeches. The almost universal mention in text-books of one or more 
venesections, in the treatment of sciatica, appears to be merely out of 
respect to old medical authorities, particularly Cotugno, for at present 
no one ever bleeds for sciatica. In cases not very recent we should 
use derivatives to the skin, particularly blisters. We apply the first 
blister to the small of the back near the vertebra, on a level with the 
points of exit of the nerves forming the sciatic plexus; the second 
behind the trochanter, and so gradually pass down to the foot, applying 
blisters to the places where the nerve lies close under the skin. Be- 
sides blisters, superficial linear cauterizations of the skin in the course 
of the nerve, the energetic application of the hot iron and of moxa to 
certain points in the course of the nerve, as well as the actual cautery 
to the dorsum of the foot and between the outer toes, and finally, 
even the cauterization of the ear, particularly of the helix, have often 
been tried. After the use of the last-mentioned remedy there is 
almost always temporary benefit, which it is difficult to explain. Even 
in the most obstinate cases of sciatica, the induced, or still more the 
constant, current of electricity rarely fails. Among specific remedies, 
oil of turpentine as an electuary (ol. terebinth. 3 i, mell. 3 i, a table- 
spoonful twice daily), plays a very important part in the treatment of 
sciatica. Among others, Romberg speaks very highly of it. Neurot- 
omy should only be performed on small branches, in whose peripheral 
terminations we can clearly locate the starting-point of the morbid 342 
DISEASES OF THE PERIPHERAL NERVES. 
excitement. Regarding the use of veratrine, aconite, and morphine as 
palliatives, we may refer to what we said in the treatment of neural- 
gias in general. 
CHAPTER XII. 
OKURAL, NEURALGIA—ISCIIIAS ANTICA COTUNNII. 
Besides the branches of the lumbar plexus whose neuralgic affec- 
tions wre have described as lumbo-abdominal neuralgia, the sensory 
filaments going to the thigh and leg are occasionally affected by neu- 
ralgia. This affection has received the peculiar name of ischias antica, 
because in it the pain is along the anterior and inner surface of the 
thigh, leg, ankle, and dorsum of the foot, and in the great and second 
toes, instead of being along the outer and posterior surface as in sci- 
atica. Ischias antica, or crural neuralgia, is far more rare than ischias 
postica. Like the latter, it may be caused by pressure on the nerves 
at their point of escape from the spinal canal, or by injuries to the 
sacral plexus in the pelvis, or to its peripheral branches. Irreducible 
inguinal hernia, sprains of the thigh, hip-joint disease, not unfrequently 
induce morbid excitement of the cutaneous branches by pressure on 
or tension of the crural nerve. The course and results of crural neu- 
ralgia are analogous to those of sciatica, and the treatment must be 
according to the same general laws. 
In very rare cases the obturator nerve is also affected with neural- 
gia. This is characterized by the extension of the pain to the inner 
surface of the thigh, and, as the motor filaments of the obturator sup- 
plying the adductor muscles usually participate in the morbid excite- 
ment, the. function of these muscles is frequently disturbed. The sudden 
occurrence of these symptoms, together with those of acute obstruction 
of the intestines, with ileus and peritonitis, are the only means of 
diagnosticating strangulated hernia through the obturator foramen. 
CHAPTER XIII. 
ANAESTHESIA OF THE CUTANEOUS NERVES. 
Anaesthesia—that is to say, lack of sensitiveness to external im- 
pressions—arises: 
1. When the portion of the brain by which the excitement of sen- 
sory nerves is recognized has been destroyed or incapacitated. In 
such a case, notwithstanding that the patient is entirely insensible to 
external impressions, the excitability of the sensory nerves may still 
oe normal. For the present, we shall, without notice, pass over this ANAESTHESIA OF TIIE CUTANEOUS NERVES. 
343 
form of anaesthesia, which we have mentioned as one of the symptoms 
of many of the diseases of the brain, as this section of the work is to 
be devoted to a study of diseases of the peripheral nerves. 
2. Anaesthesia may occur when, owing to destruction of the con- 
ducting fibres of the spinal cord, transmission of the impressions from 
the peripheral nerves to the brain is interrupted. In this form, like- 
wise, the excitability of the peripheral nerves may be normal. In 
treating of myelitis, we have already mentioned that, while the stronger 
stimulants, acting upon the periphery, fail to call forth any excitement 
at the centre, even a very feeble stimulus is frequently transmitted 
from the sensory to the motor fibres, and gives rise to reflex symptoms. 
Such phenomena as these prove that th*e excitability, both of the motor 
and sensory nerves, still remains unimpaired below the point at which 
the conducting power is interrupted. This form of anaesthesia, also, 
is not the subject of the present section. 
3. Anaesthesia occurs when there is nutritive disorder capable of 
destroying the irritability of the peripheral nerves, as well as when 
their connection with the brain and spinal cord has been interrupted 
mechanically. It is with this form alone that we are at present con- 
cerned. We shall here observe that we consider all sensory and motor 
nerves as peripheral as soon as they leave the brain, no matter whether 
they continue to lie within the skull or spinal canal, or whether their 
track be outside of the same. This is by no means an arbitrary dis- 
tinction. It depends chiefly upon the fact that the portion of nerve 
lying within the skull or spinal canal is in just the same state as 
the peripheral portions, as regards extinction of its irritability upon 
interruption of its connection with the central organs. In the 
motor nerves this can be proved with ease. In a patient who is 
unable to move the right side of his face at will, owing to an apo- 
plexy of the left corpus striatum, the nerves of the palsied side retain 
their irritability for weeks, and all the muscles of that side may be 
made to contract under the influence of the induced electric current. 
On the other hand, if the facial be destroyed within the skull after its 
departure from the brain, its irritability soon becomes extinct, just as 
though its peripheral branches had been divided, and it is impossible 
to make the muscles of the palsied side contract by the influence of 
the induced current. With regard to the sensitive nerves, the proof 
cannot be made so plain, yet we are warranted in inferring that the 
conditions are very similar. At all events, in central anaesthesia, the 
trigeminus long remains sensitive, as is proved by the continuance of 
the power of reflex action, for instance, as is shown in winking when 
the conjunctiva is touched. 
Etiology.—The nutritive disorder, whereby a nerve is deprived of 344 
DISEASES OF THE PERIPHERAL NERVES. 
its irritability, is often so subtle in character as to escape our direct 
observation. The moment a nerve loses its supply of arterial oxy- 
genated blood, it loses its functional power. There is no doubt but 
that this loss of irritability is due to physical or to chemical changes 
within the nerve. Not unfrequently, in the region of an artery oc- 
cluded by an embolus or thrombosis, we find anaesthesia to exist until 
the collateral circulation has been established. The action of continued 
cold induces anaesthesia of the skin. Part of this is undoubtedly due 
to the contractile power of cold upon the skin, and to the anaemia of 
the cutaneous nerves thus produced. Of the anaesthesiae of peripheral 
origin—that is, depending upon extinguished irritability of periph- 
eral nerves, without appreciable alteration of their structure—there is 
the so-called rheumatic anaesthesia, which not unfrequently takes place 
after exposure to cold, as well as a form which Romberg has noticed 
in the hands and forearms of washerwomen. It is doubtful whether 
the anaesthesia arising from lead-poisoning be due to impalpable nutri- 
tive lesion of the peripheral nerves, or to a morbid state of the central 
organs. This is also true of the locally anaesthetic action imputed to 
ether and chloroform. It does not seem to me to be proved that the 
action of these substances is purely local, when locally applied; and I 
think it more likely that their influence is more or less centric at such 
times, if not entirely so. Can we expect to find a perfect anaesthetic 
action from such agents, the cerebral function remaining intact mean- 
time ? It bears a peculiar relation to hysterical anaesthesia, of which 
we shall treat in our chapter upon hysteria. 
Anaesthesia due to permanent and uniform pressure of an over- 
tight bandage or piece of clothing, constitutes a connecting link with 
those forms of anaesthesia where structural lesion of the peripheral 
nerves is not merely a matter of supposition, but can be absolutely 
demonstrated. In such cases we find all the tissues, subjected to pres- 
sure, to be in a state of atrophy and fatty degeneration, and, of course, 
the peripheral nerves are by no means exempt. The irritability of a 
nerve is not unfrequently suspended, and its continuity is finally inter- 
rupted by the pressure of a tumor, an exudation, or extravasation. In 
other cases of anaesthesia, portions of the nerve are destroyed by in- 
flammation. It would be superfluous further to continue the enumera- 
tion of the structural alterations capable of producing anaesthesia, as 
it would be but a repetition of what we have already stated in treat- 
ing of the etiology of neuralgia. The very causes which, excited mildly, 
or for a short time, serve to exalt the excitability of a nerve, have a 
more pernicious effect should their action be prolonged or intensified, 
as the nervous excitability is then arrested, or even the nerve itself 
may be destroyed. ANAESTHESIA OF THE CUTANEOUS NERVES. 
345 
Symptoms and Course.—Anaesthesia is either complete or in- 
complete. In the first case, irritants acting from without, especially 
pressure and change of temperature, produce no sensation whatever. 
In the second case, though an impression is produced, it is indistinct 
and inaccurate. Where the anaesthesia is incomplete, there is often a 
numb or muffled sensation. The patient feels as though a foreign body 
lay between his skin and the object which he actually touches. Henle 
believes that this state of affairs is due to an extinction of sensibility of 
the peripheral terminations of the nerves, and a retrocession of the 
sensibility in the direction of the centre, so that there actually is a 
layer of passive substance between the nerve and the object touched. 
Upon this hypothesis, it is very easy to explain why cold, whose im- 
mediate action is upon the tips of the sensory nerves, should make the 
skin feel numb and muffled. There is a peculiar form of anesthesia 
called analgesia. In these cases there is no pain, even under the most 
intense irritation of the nerve, although the sense of touch is not im- 
paired. We have no satisfactory means of accounting for analgesia. 
With Henle, we might suppose it to be a low grade' of anaesthesia, 
and might assume that excessive irritation, instead of producing the 
usual amount of perception, namely pain, merely gives rise to that 
normally induced by moderate stimulation of the nerve, were it not 
that, under such a condition, moderate irritation should be impercepti- 
ble, which is not the case in analgesia. The modifications of anaes- 
thesia, known as partial losses of sensation, are still more obscure. 
Here the effect of certain irritants is extinguished, while that of other 
irritants of no greater power continues. For instance, there may be a 
loss of the sense of touch, with unimpaired sense of temperature, or 
conversely. 
The so-called “law of excentric impression,” according to which 
the excitement of a sensory nerve, even though produced by irritation 
of its trunk, always produces the impression of an excitement of its 
peripheral extremity, fully explains why patients often suffer pain in 
regions which are entirely insensible to external irritation, a phenome- 
non to which the name of anaesthesia dolorosa has been applied. 
Anaesthesia dolorosa arises, first, in all cases in which a nerve has lost 
its sensitiveness throughout a certain portion of its length, while, at 
the same time, a severe irritation is made to act, above this point, upon 
that portion of the nerve which still remains in connection with the 
brain. It is easy to see that both of these factors often coexist, as 
when a tumor presses upon a nerve. Here the tract of nerve, lying 
between the compressing growth and the brain, remains excitable and 
receptive of lasting impressions, while from the tumor to the periphery 
ihe nerve has lost its irritability. 346 
DISEASES OF THE PERIPHERAL NERVES. 
In anaesthesia of the muscular nerves, perception of the degree of 
contraction or relaxation of the muscles is diminished or destroyed. 
Sometimes such patients are capable of making every motion required 
of them, but are unable to tell, without the help of vision, to what ex- 
tent they have moved. They can hold fast to an object as long as 
their eyes serve them as “check-lines of motion” (Romberg), but let 
it fall as soon as their eyes are closed. If anaesthesia of the muscular 
nerves affect the lower extremities, the patient is often able to move 
about tolerably well during the day, but in the dark he will stagger 
about, and is quite unable to walk even a step or two (see chapter on 
tabes, page 305). 
Very often anaesthesia is complicated with derangement of circu- 
lation and nutrition in the insensible region. The temperature of the 
part is often depressed several degrees, its function is impaired, and 
its secretions are diminished. Besides this, there is an increased vul- 
nerability of the region. A comparatively trifling degree of heat or 
cold suffices to burn or freeze the part. Wounds and ulcers heal more 
slowly, or not at all; bed-sores are very apt to form. The epidermis 
and nails become fissured and liable to scale off; the skin becomes 
livid, and oedema develops in the subcutaneous areolar tissue. This 
peculiar state of the insensible region is in some degree attributable to 
the retardation of the circulation, but the cause of this retardation is 
obscure. From experiments made by Axmann, it seems probable that 
it is due to an implication of the sympathetic fibres which accompany 
the spinal nerves. In frogs, whose spinal nerves had been divided be- 
tween the spinal marrow and the spinal ganglion, Axmann only found 
anaesthesia and palsy, but no nutritive disorder of the palsied part. 
If, however, the nerves were divided at a point beyond that at which 
they are joined by the communicating branches of the sympathetic, in 
addition to the anaesthesia and palsy, there was desquamation of the 
epidermis, obstruction of the capillary circulation, and oedema. 
If the nerve, which has been cut off from its central organ, or which 
has lost its irritability from any other cause, contain both motor and 
sensory fibres, partial anaesthesia and partial palsy are combined. It 
would almost seem as if a nerve which had lost its irritability could 
transmit this passive condition through its ganglion to other nerves, 
just as an excited nerve can communicate its excitement by means of 
its ganglion-cells to other nerves. It is in this way that we account 
for the impairment of the sense of taste and smell in anaesthesia of the 
-rigeminus, and for the anaesthesia of the auditory organs in cases of 
nervous deafness, as well as for the partial paralysis which sometimes 
supervenes upon long-continued anaesthesia. 
It is not always easy to distinguish peripheral from central anaes- ANAESTHESIA OF THE CUTANEOUS NERVES. 
347 
thesia. We may rely for a diagnosis, in some degree, upon tlie fol- 
lowing points: 1. Upon the extension of the anaesthesia and its com- 
plication oi non-complication with motor palsy. If the anaesthesia be 
confined to one side, and be combined with hemiplegia, it is probably 
of the cerebral form. If, however, it extend over the lower half of the 
body, and be combined with paraplegia, the case is almost always one 
of disease of the spinal marrow. The coexistence of palsy of the face 
with facial anaesthesia indicates a central cause of disease, while anaes- 
thesia, with normal motion, indicates its peripheral origin. 2. The 
character of the reflex symptoms are of great importance as a means 
of distinguishing between the two forms. When the anaesthesia is 
peripheral, the nerve being either separated from the brain, or having 
lost its power of excitability, no stimulus can be transmitted from it to 
the motor nerves, and there can be no reflex symptoms; but if the 
anaesthesia be central, that is, if the region of the brain in which we 
become conscious of impressions be disabled, the route by which the 
excitement is transmitted from sensory to motor fibres may still re- 
main quite perfect, and reflex symptoms may readily appear. It is 
just the same, in cases of circumscribed disease of the spinal mar- 
row, as in spondylarthrocasis, and partial myelitis. On the other 
hand, in diffuse inflammation, as in tabes dorsualis, reflex symptoms 
are not apt to be seen. The following is a striking example of the 
difference of these two conditions. When anaesthesia of the conjunc- 
tiva occurs from apoplexy, the eye may be touched without the pa- 
tient’s perceiving it, and yet he involuntarily closes the eye because a 
stimulus is transmitted from the sensory fibres of the trigeminus to the 
motor ones of the facial. But if the anaesthesia be dependent upon 
loss of the ganglion of Gasser, or of the ramus-ophthalmicus, the pa- 
tient neither feels the touch, nor does he involuntarily close his eye, 
since transmission of the excitement to the facial has then become im- 
possible. 
The course of an anaesthesia depends upon the main disease. If a 
nerve be divided by an incision, sensation is sometimes restored after 
a while. If, however, a large portion of a nerve have been destroyed, 
the anaesthesia will remain during life. Rheumatic anaesthesia, as well 
as that occasioned by a moderate and uniform pressure over the course 
of the entire nerve, warrants a better prognosis than the other forms. 
Treatment.—The treatment of anaesthesia is never satisfactory, 
excepting when it is possible to remove the cause. Sometimes a sur- 
gical operation is indicated, sometimes a course of antirheumatic 
treatment. It does not always immediately happen that cessation 
of the cause is followed by removal of the effect. In such cases 
spirituous and ethereal embrocations may be used, as well as eleo 348 
DISEASES OF THE PERIPHERAL NERVES. 
tricity, cold douches, the baths of Gastein, Wildbad, or Pfaffers, and 
even the disgusting so-called Tliierbader. The reestablishment of ex- 
tinguished sensibility of sensory nerves by such means, however, is a 
verv uncertain matter. 
CHAPTER XIV. 
ANAESTHESIA OP THE TRIGEMINUS. 
Etiology.—According to an explanation given in a previous chap- 
ter, the same pernicious agents which we have found to be the causes 
of prosopalgia, when of greater severity or of longer duration, may 
give rise to anaesthesia over the region of the trigeminus. In anaes- 
thesia of one-half of the face, the Gasserian ganglion of that side has 
been found compressed, degenerate, or destroyed by a tumor or in- 
flammatory process. In other cases but one of the three branches has 
suffered permanent pressure or other injury within the skull, or else in 
the passage through the sphenoid bone. In still others, which indeed 
are the most common of all, a few twigs only of the trigeminus have 
been cut through, or have been destroyed by the pressure or suppura- 
tion of glands or tumors, or torn during the extraction of teeth (espe- 
cially the inferior alveolar branch). The favorable course taken by 
some cases shows that anaesthesia of the trigeminus may also proceed 
from transitory affections of the neurilemma, or of the nerve itself, 
which probably are due to cold. 
Symptoms and Course.—When all the fibres of the trigeminus 
have lost their irritability, it may be assumed that its main trunk or 
the ganglion of Gasser is degenerated or destroyed. In such cases 
the face is divided into halves, standing in abrupt contrast with one 
another, the one being sensitive, the other insensible. The various 
cavities of the face, whose supply of nerves comes from the trigeminal, 
are in similar condition. Upon the affected side the eye may be 
touched, the bulb pinched or pricked, the nose irritated with a sharp 
instrument, with snuff, or with acrid vapors, without the patient’s feel- 
ing it. If the patient put a glass to his lips, he feels but one side of 
it, and receives the impression that it is broken. Half of the tongue 
also is insensible. The saliva flows from the mouth at the affected 
side, and the remains of food hang to the lips without the patient’s 
being aware of it. Upon irritating the conjunctiva, there are none of 
the reflex movements referred to in the previous chapter. If, how- 
ever, the eye be exposed to a strong light, reflex action occurs, as irri' 
tation of the optic nerve transmits its impression to the facial nerve 
Not only do the patients fail to wink when the conjunctiva is touched SPASM OF PERIPHERAL NERVES. 
349 
but they do not sneeze when the nasal mucous membrane of the af- 
fected side is irritated, since no reflex action upon the respiratory ap- 
paratus can be set up in this region. Nutritive disorders of the affect- 
ed side are associated with these symptoms, similar to those which 
may be provoked artificially in the lower animals by extirpation of the 
ganglion of Gasser, such as varicosities of the eye, with ulceration and 
atrophy, fungous flabbiness of the gums, bleeding from the mouth and 
nasal cavities, blueness and oedema of the cheeks. In contrast to the 
observed cases of “ ageustia,” there are a good many others in which 
the sense of taste remained normal. The sense of smell and of vision 
often suffers; but in such cases it is difficult to say what part the 
disorders of the nasal mucous membrane and bulb above referred to 
play in producing such impairment of function. If both portio major 
and portio minor of the trigeminus be destroyed, in addition to the 
palsy of sensation of one side of the face, there will be palsy of the 
muscles of mastication upon that side. If the destruction of the gan- 
glion be caused by the presence of a large tumor or other extensive 
disease affecting the base of the skull, the function of other cerebral 
nerves is likewise usually disturbed, especially that of the oculomoto- 
rius, the facial, the acoustic, and there are ptosis, dilatation of the pupil, 
palsy of the corresponding side of the face, and deafness of the ear of 
that side. 
If but one branch of the trigeminus, instead of the whole nerve, be 
diseased, the anaesthesia is limited to the region of the face which is 
supplied by that branch; if it be the first branch, to the socket of the 
eye, the second to the nose, the third to the cavity of the mouth. If 
the affection be confined to a few twigs alone, the insensible parts of 
the face are still smaller, and the cavities may be normal. 
An isolated central anaesthesia of the trigeminus without, simultane- 
ous anaesthesia of the corresponding half of the body, is one of the 
greatest of rarities. In a previous chapter we have stated the chief 
means of distinguishing such a case from a peripheral anaesthesia. 
With regard to treatment, we must also refer to what has alreadv 
been said of the treatment of anaesthesia in general. 
SPASM INVOLVING PARTICULAR PERIPHERAL NERVES. 
In the following chapter we shall treat of the morbid conditions of 
excitement to which the various motor nerves are subject. Just as ex- 
citement of a nerve of sensation is evinced by a feeling of pain and by 
reflex symptoms, so that of a motor nerve is indicated by contraction 
of the muscle which it supplies. If the motor nerve be acted upon bv 350 
DISEASES OF THE PERIPHERAL NERVES. 
a series of morbid impressions in quick succession, the muscular con- 
traction resulting from the first impression will continue until the second 
one succeed it. In this way permanent muscular contractions occur 
which are called tonic spasms. If the nerve be irritated at somewhat 
longer intervals, so that the muscle relaxes ere another impression 
make it contract again, thus causing alternate spasm and relaxation, we 
speak of clonic spasms. 
In the healthy subject the motor nerves receive a portion of their 
stimulus from the grand centre of the will, thus producing the voluntary 
movements; another portion of it is obtained from parts of the brain, 
which, when thrown into excitement, are independent of the action of 
the will. To this class belong the movements which occur during the 
painful emotions, and in anger, and which we call outbursts of pain 
and anger. It is not through our will that we contort the face in 
weeping, when we are in grief; we do not voluntarily clinch the fists 
when angry; these events occur in spite of our will. Finally, in the 
healthy subject, there is another series of motions which are likewise 
brought about without the action of the will, and even against the 
will, by the transmission of a centripetal impression to a centrifugal 
channel. These are called normal reflex movements; and a distinction 
is made between those induced by a regularly recurring stimulus of 
moderate intensity, such as the respiratory movement which is called 
forth by the collection of carbonic acid in the blood, and the act of 
deglutition which follows upon the introduction of a bolus into the 
oesophagus (these being called automatic movements), and those in- 
duced by stronger but less frequent impressions, such as sneezing, 
winking, and the like. 
The terms cramp, spasm, and hypercinesis, are applied to certain 
morbid conditions in which excitement of the motor nerves is produced 
by an irritant of unusual and generally speaking of unknown origin, 
and entirely independently of the volition, or else to a condition in which 
the action of an ordinary stimulus calls forth an excitement of extraor- 
dinary extent and violence in the motor tract. 
It is impossible in the present state of science to classify spasms 
according to the kind of irritant which gives rise to the nervous ex 
citement, or according to the region in which the irritant operates 
Spasms of which we are about to treat are the result of a variety of 
causes, and often of unknown causes; and although in some instances 
the affection is confined to the province of a single motor nerve, yel 
we are not at all certain that it proceeds from direct irritation of the 
fibres of that nerve. SPASM OF THE FACIAL NERVE. 
351 
CHAPTER XY. 
SPASM OF THE FACIAL NERVE—MIMIC SPASM OF THE FACE—TIG 
CONVULSIF. 
Etiology.—A morbid irritability involving the twigs of the facial 
nerve which go to the muscles of the face, but which does not involve 
the fibres running to the stylohyoid and digastric muscles, is called 
tie convulsif whenever it is not combined with general convulsions. 
The cause of this affection of the facial is obscure. Probably the cases 
of isolated irritation to which alone we refer at present are never de- 
pendent upon lesions of the brain. Nor does the cause of tic convul- 
sif seem ever to be an irritation of the facial within the skull, or during 
its passage through the canal of Fallopius. Whenever the morbid 
excitement of this nerve is due to the action of some noxious influence 
upon the face itself, such as cold, a contusion, or the pressure of a 
tumor, it becomes a matter of doubt whether these influences act 
directly upon the fibres of the facial nerve, or whether their immediate 
effect is not upon the filaments of the trigeminus, the facial merely 
becoming irritated by reflex action. Sometimes, too, tic convulsif has 
been viewed as a reflex neurosis, arising from the irritation of remote 
organs, such as the rectum in helminthiasis, or the uterus in hysteria. 
Finally, mental emotion and the imitative instinct are set down among 
the causes of tic convulsif. The affection seems to be somewhat more 
common among men than among women. 
Symptoms and Course.—In almost all cases of tic convulsif, but 
one side of the face is affected; sometimes the spasm is clonic, some- 
times tonic. Romberg, in a few brief but graphic lines, gives the fol- 
lowing description of the mimic spasm: “ Grimaces occur, either inter- 
mittent or constant, involving one side of the face, and, more rarely, 
both sides. In the former case they consist chiefly of elevation or de- 
pression of the occipito-frontal muscle, corrugation of the eyebrows, 
blinking and closure of the eyelids, twitching and snuffling of the alae 
nasi, and drawing up and down of the corners of the mouth. These 
attacks set in suddenly, and as suddenly subside, to recur, with equal 
suddenness, at short intervals. In permanent tonic contraction of the 
facial muscles, the furrows and hollows in the affected side of the face 
are deeper; the tip of the nose, the commissure of the lips, and the 
chin are drawn toward the convulsed side. The muscles feel hard and 
tense, and so impede motion that the one eye cannot be as completely 
closed as the other.” The patient is unable to prevent or to control 
these motions at will. As a rule, any individual motion, made volun- 
tarily, is accompanied by involuntary contractions of other muscles. 352 
DISEASES OF THE PERIPHERAL NERVES. 
Iii the beginning of the disease the affected side of the face is often 
somewhat painful. Afterward the pain abates, and, as a great rarity 
it is followed by incomplete anaesthesia. In some cases, instead of all 
the nerve-fibres of the facial, a few only are involved in the morbid 
irritability, as the palpebral branch, the malar, or the labial, or, as in a 
case reported by Romberg, the auricular branch. The affection of the 
rami palpebrales causes a series of rapid openings and shuttings of the 
eye—nictitatio, or a rigid, violent closure of the lids—blepharospas- 
mus. The derangement of the buccal and labial branches gives rise 
to a movement of the lips, upon one or both sides, as if from laughter, 
the so-called risus caninus, or sardonicus. In the case of tic convulsif 
of the auricular branches, described by Romberg, repeated fits of 
twitching of the ear set in daily, during which the ears were drawn 
up and down for fifteen minutes at a time. Sometimes the tic con- 
vulsif spreads to other nervous trunks, as does the tic douloureux; so 
that movement is excited in the muscles of mastication, or those in the 
region of the hypoglossal nerve, and of the accessory of Willis, or of 
some of the spinal nerves. 
The course of the disease is usually chronic, and of uncertain dura- 
tion. Commencing suddenly (or gradually, which is rather more com- 
mon), it generally continues during the remainder of life. In order 
not to mistake the tonic form of mimic facial spasm for the distortion 
of the face arising from hemiplegia, we must observe the unimpaired 
muscular power of the undistorted side, and the normal behavior of 
its muscles under the induced current. Moreover, according to JBruns, 
in hemiplegic palsy, upon handling the healthy side of the face, we do 
not find the smallest trace of permanent contraction of the muscles, 
and, by stroking and drawing upon the skin of the face, the mouth 
may be brought into proper position. 
Treatment.—In recent cases of tic convulsif, a diaphoretic and de- 
rivative procedure always seems to do good, while, according to my 
experience, an old case resists all treatment, even the application of 
electricity. Where the morbid irritation of the facial manifestly is of 
reflex origin, and if we can tell from which filaments of the trigeminus 
the disturbance proceeds, division of those twigs from the brain by 
neurotomy is indicated. In two cases reported by Romberg, where 
the supra-orbital nerve was divided, great benefit was obtained. On 
the other hand, division of branches of the facial nerve is not advisable, 
as that procedure gives rise to another deformity scarcely less un- 
pleasant than the former one, namely, mimic facial palsy. In one ob- 
stinate case of tic convulsif, subcutaneous incision of the facial muscles 
nas been practised by Dieffenbach, with good result. SPASM OF THE SPINAL ACCESSORY NERVE. 
353 
CHAPTER XVI. 
SPASM IN THE REGION OF THE SPINAL ACCESSORY NERVE OF WILLIS. 
Etiology.—Like the facial, the accessory nerve of Willis is some- 
times the seat of morbid irritability. The pathogeny and etiology of 
this condition are as obscure as are those of tic convulsif. Violent 
twisting of the neck, cold, disease of the cervical vertebras, have been 
the assigned causes. The nodding spasm, or salaam convulsions, seen 
in children, particularly at the period of dentition, does not seem to be a 
genuine affection of the spinal accessory nerve and the cervical nerves. 
Indeed, from its complications and course, it seems probable that it is 
symptomatic of cerebral disease, or of an eclampsia. 
Symptoms and Course.—Morbid excitement of the spinal acces- 
sory nerve is manifested by spasm, either of a tonic or clonic character, 
in the muscles supplied by that nerve, the trapezius, and the stemo- 
cleido-mastoideus. 
In the former case, in each paroxysm, the head is drawn obliquely 
downward several times in succession, the occiput approaching the 
shoulder, and the ear the clavicle. The direction assumed by the head 
is more forward or backward, according as the contractions are greater 
in the trapezius or sterno-cleido-mastoideus. In the same way the 
shoulder-blades and shoulders are drawn up during the contractions of 
the trapezius. If the irritation spread to the facial, the face twitches 
also; if it involve the portio minor of the trigeminus, the jaws are 
convulsively set. If the cervical nerves be also implicated, the head 
is twisted, and the arms are thrown into convulsive agitation. Such 
paroxysms, which are usually accompanied by pain in the muscles or 
their attachments, usually last but for a second or two. At the outset 
of the disease the attacks are less frequent; as it advances, they recur 
oftener; so that as many paroxysms as thirty may occur in a minute, 
driving the patient almost to desperation (Ilasse). They do not come 
on during sleep. These clonic spasms of the region of the accessory 
nerve generally develop in a very slow and gradual manner. They 
rarely cease, but, as a rule, endure through life, without endangering it. 
The term “ salaam convulsion ” of children is applied to solitary 
or periodically-recurring paroxysms of clonic spasm of both sterno- 
mastoid muscles, whereby the child is made to nod its head incessantly, 
like a Chinese image. The nodding is very rapid, and sometimes in- 
creases in rapidity as the attack goes on, making occasionally eighty 
to a hundred nods a minute. Generally speaking, the muscles 
of the face, especially the orbicularis palpebrarum, sympathize in the 
movement. Epilepsy and idiocy develop in some children affected 354 
DISEASES OF THE PERIPHERAL NERVES. 
in this way, while in others it is said to disappear when dentition is 
complete. 
Tonic spasm of the accessory nerve of 'Willis is the cause of the 
spastic form of torticollis or caput obstipum. The spasm is usually 
confined to the sterno-cleido-mastoideus, so that the head is inclined 
forward and downward. The affection occurs more frequently in chil- 
dren than in adults, and perhaps, too, it sometimes affects the foetus 
if congenital torticollis be attributable to an intra-uterine foetal tonic 
spasm of this muscle. Sometimes the tonic spasm is preceded by a 
brief attack of clonic convulsions; more generally, however, the muscu- 
lar contraction is of a tonic character from the first. At the com- 
mencement the disease is apt to be considered of little moment, and, 
as it is usually attended by pain, is looked upon as of rheumatic char- 
acter. An embrocation of opodeldoc is ordered for the “ stiff neck,” 
or else some other equally harmless prescription. Finally, however, 
the obstinacy of the attack and its gradual aggravation furnish evi- 
dence of its more serious nature. The head is drawn more and 
more to one side, the stemo-mastoid muscle of that side, particularly 
its sternal portion, stands out like a hard cord, while upon the up- 
turned side of the neck the skin is stretched and the muscles are not 
prominent at all. If the disease last long, the face becomes distorted, 
the hypertrophied muscles drawing their corresponding half of the face 
downward. In the same way the permanent obliquity of the attitude 
often leads to curvature of the spine, and to sinking of the thorax of 
the affected side. 
Treatment.—Treatment of clonic spasm of the spinal accessory 
nerve is seldom very successful. It is true that Moritz Meyer, in five 
sittings, completely cured a soldier affected with tic convulsif and 
clonic spasm of the neck, by faradizing each one of the contracted mus- 
cles. The negative results, however, which I myself as well as others 
have witnessed in the treatment of tic convulsif, by faradization and 
galvanism, would imply that such brilliant cures were exceptional. 
So, too, the internal use of sulphate of zinc, and of carbonate of iron, 
and the application of moxas to the back of the neck, would seem to 
have sometimes been of service. Section of nerves has not succeeded, 
although, in two cases, division of the muscles was successful. In a 
third case, in which the division of the muscles was practised more 
than once, no benefit was derived. 
We can give no rules for the treatment of the salaam convulsion, 
since the nature of this affection, and especially its etiology, is entirely 
unknown. The treatment of tonic spasm, which belongs to the prov- 
ince of orthopedic surgery, can boast of some success in cases which 
were not of too long standing. SCRIVENERS’ SPASM—MOGIGRAPHIA. 
355 
CHAPTER XVII. 
SCRIVENERS’ SPASM—MOGIGRAPHIA. 
Etiology.—The term scriveners’ spasm is employed to denote a mor- 
bid excitement of the motor fibres of the nerves which supply the muscles 
of the figers, and which renders further writing impossible, by inducing 
spasmodic contraction of the muscles to which they belong. If such 
spasms are provoked by other kinds of manipulation, and not by writing, 
for instance, by shoemaking or by milking, they receive other names, such 
as “ cobblers’ ” or “ milkers’ spasm.” Numerous as are the hypotheses 
as to its origin, we know nothing positive as to the pathogeny of this 
disease, which is not at all uncommon, and which often deprives the 
individual afflicted of his means of subsistence. The theory of Fritz 
is in some respects satisfactory. He regards it as a reflex neurosis, in 
which, however, excitement of the motor nerves is not derived from 
the cutaneous nerves, as in most reflex neuroses, but proceeds from the 
muscular nerves. The observation that the touch of a feather or paper 
is not of itself sufficient to excite the cramp, although holding the 
hand in the attitude of writing, even though it touch neither pen nor 
paper, will do so, argues in favor of this view. The theory is equally 
probable, however, that the morbid irritation is not reflected from the 
sensory to the motor nerves, but proceeds from transmission of the im- 
pression of the nerves excited by the will to other motor nerves. 
Scriveners’ cramp would then resemble the convulsive movements of 
chorea, and stammering, and the movements which disturb the writer 
would have to be regarded as sympathetic movements. 
With regard to its etiology, it is to be observed that the affection 
is much more common among men than among women, in whom it 
has only been observed occasionally. Will it not turn out upon ex- 
amination that, just as in many other diseases (although perhaps less 
strikingly so), the apparent difference of tendency to the disease in the 
two sexes is really due to a difference of habit and occupation ? Wri- 
ters’ cramp is most liable to occur between the ages of thirty and fifty 
years, that is, during the time of life when occupation is most intense. 
Professional penmen, clerks, teachers, and merchants are most subject 
to the affection. Narrow coat-sleeves, which compress the muscles of 
the arm during writing, an inconvenient attitude, but, above all (since 
scriveners’ spasm has only come into notice since the introduction of 
steel pens), the use of a hard steel pen seems to favor the devel- 
opment of the affection. Why the disease should develop under these 
causes alone is unknown. 
Symptoms and Course.—The usual precursory signs of writers’ 356 
DISEASES OF TIIE PERIPHERAL NERVES. 
cramp are a feeling of slight fatigue of the hand, and a sense of inse- 
curity as if the writer must grasp his pen more firmly. Sometimes the 
affection does not advance beyond this stage. When the disease is 
fully developed, the muscles of the first three fingers become convulsed 
during writing, and, in bad cases, upon every attempt to write, some- 
times the flexor muscles, sometimes the extensors, are the most con- 
tracted. Various forms of this spasm have been recognized according 
to the predominance of one or other convulsive movement, such as 
convulsive flexion of the thumb, jerking of the index-finger, loss of 
control of the hand, and a form made up from the last two of these 
varieties. During these spasms the pen is rapidly twitched up and 
down, but, instead of regular, distinct letters, it forms grotesque inter- 
rupted scribbling. The occurrence of the paroxysm is favored by ap- 
prehensive attention to the subject and fear of its arising. The harder 
the patient tries to continue his writing, so much the stronger is the 
spasm, as so much the more is it apt to extend up the forearm and 
arm. It is usually painless, although sometimes it is attended by a 
feeling of tension in the arm. The moment the patient suspends his 
attempt to write, the cramp ceases, and he can execute all other move- 
ments undisturbed. In a case of this kind, described by Romberg, a 
nailsmith, as soon as he grasped his hammer and prepared to strike, 
was seized by painful spasm of the forearm. He was obliged to give 
up his trade, and afterward become a useful and skilled painter. Wri- 
ters’ spasm is a very obstinate and tedious disorder. Recovery is 
very rare, and its uniform persistence is hardly ever broken even by a 
temporary improvement of the symptoms. Some patients, who are 
ready for any sacrifice in order to be rid of their burdensome disease, 
and from their anxiety for this means of subsistence, learn to write 
with the left hand. Unfortunately, however, sometimes in such cases 
the left hand is also attacked by the disease. 
Treatment.—The treatment of scriveners’ spasm is as a rule unsuc- 
cessful. Experience has shown that very little benefit is to be derived 
from the long-continued prohibition of writing, and by only allowing 
the patient to resume the practice cautiously, and only permitting him 
to use goose-quills, or by the use of cold douches, sea-baths, and stim- 
ulating friction. Division of the nerves is of no benefit to the patient, 
as it causes paralysis of the finger. In one case only has section of 
the muscles been followed by benefit. In all other instances there 
was either no improvement at all, or it was a merely transient one. 
In one case of scriveners’ spasm, when, without hoping for success, I 
applied the constant galvanic current in a manner almost rude, I 
nave succeeded in curing the disease, so that the patient, who for years 
had written with the left hand, now uses his right once more. The IDIOPATHIC CRAMP. 
357 
treatment proposed by JSenediJct, by which he has obtained some suo 
cess, and which consists in the application of “ spinal-root, and spinal 
nerve-streams,” has utterly failed in my hands; and in one or two 
cases it has aggravated the disease. If the pathogeny of scriveners’ 
spasm be really as I have suggested above, my treatment of it was an 
entirely rational one, although I myself was not aware of it at the 
time. I applied the current to the muscle of the thumb and index- 
finger, and hence to the sensory muscular nerves running into them: 
thus if the explanation be correct, the cure would be accounted for by 
an abatement of the morbid nutritive state, and of the morbid exci- 
tability of the sensory nerves of the muscles, from whose reflex action 
the cramp proceeds, by the catalytic action of the constant current. 
Sometimes apparatus, by means of which the patient writes without the 
aid of his fingers, also are of service for a while. 
CHAPTER XVIII. 
IDIOPATHIC CHAMP OP THE MUSCLES OP THE EXTREMITIES— 
ARTHROGRYPOSIS. 
Etiology.—According to the example of the French authors, the 
term idiopathic spasm (spasmes musculaires idiopathiques) is applied 
to tonic contractions which sometimes attack the muscles of the ex- 
tremities, without being attributable to disease of the brain or spinal 
marrow. They are analogous to the neuralgias, but we are still less 
able to point out the anatomical cause of this morbid condition of the 
motor nerve, causing idiopathic muscular spasm, than to discover that 
which acts upon the sensory nerves in neuralgia. The harmless course 
usually taken by the disease makes it probable that idiopathic cramps 
of the extremities are due to trifling and transient lesions of the 
nerves and their sheaths. By many observers, these affections are 
regarded as a form of rheumatism, and are attributed to hyperaemia 
and oedema of the neurilemma. In some cases, this may be the truth, 
especially in such as occur in children previously healthy. However, 
the occurrence of idiopathic muscular spasm during the course of and 
convalescence from acute and chronic disorders, which have an exceed- 
ingly pernicious effect upon the assimilation and nutrition of the body, 
and which often lead to great functional disturbance, such as typhus, 
intermittent, Bright’s disease, and epidemic diphtheritis, makes it 
quite probable that in other instances idiopathic muscular cramps are 
the result of derangement of the tissues, the character of which is 
almost unknown, and which develops during the diseases above men- 
tioned, giving rise to a great variety of functional disturbance. 
The muscular spasms which arise during pregnancy, during laboi 358 
DISEASES OF THE PERIPHERAL NERVES. 
and after it, must be regarded as of this character. The affection 
is most common during childhood, especially the primitive form in- 
duced by cold. The statement of Valleix, that the disease is so rare, 
that few physicians ever see it, strikes me as strange, as not only have 
I myself observed a great number of such cases, but I well remember 
that Krukenberg used to describe it as a by no means uncommon 
form of rheumatism among children. 
Symptoms and Course.—Sometimes the disease is preceded by 
a feeling of illness, languor, and depression of several days’ duration. 
The actual commencement of the disease is marked by pain, which 
apparently shoots along the courses of the nerves, sometimes involving 
the upper and lower extremities simultaneously, sometimes only the 
hands and forearms, sometimes the feet and legs. In addition to this, 
there is a sense of formication, and of stiffness and sluggishness in the 
suffering members. These symptoms having lasted for a variable 
period of time, fugitive cramps, in the calves of the legs and other 
muscles, set in, which soon are converted into continued tonic contrac- 
tions. The upper extremities are usually brought into a state of per- 
manent flexion, the lower into permanent extension. If we are unac- 
quainted with the malady, and see a child thus affected for the first 
time, we shall be deeply impressed by the aspect of the rigid immov- 
able limbs, the extended knees, the heels drawn up, the thumbs forced 
into the palms of the hands, and shall be inclined to ascribe it to some 
serious lesion of a central organ. The attempt to extend the upper 
extremity or to flex the lower is extremely painful to the patient. 
The contracted muscles are hard and prominent. Generally the joints 
seem somewhat swollen by a slight oedema of the skin. Sometimes 
the tonic contractions extend to the muscles of the back and belly, 
and even to those of mastication and to those of the face. The affec- 
tion is either entirely free from fever or else the fever is of but little 
intensity. In some patients the commencement of the contraction is 
accompanied by a sensation of oppression and of rush of blood to the 
head. In many instances the course of the disease is brief; the con- 
tractions ceasing after a lapse of a few days, and free mobility becom- 
ing reestablished. In other instances it is more protracted. Some- 
times, too, relapses occur after some days or even some weeks have 
passed. Certain observers, as Delpeche and Ilasse, state that the dis- 
ease consists of a series of spasmodic attacks, that these paroxysms last 
for some minutes, some hours, or a day or more, and that in the inter- 
vening period there is merely a certain degree of stiffness and swelling 
of the limbs, accompanied, perhaps, by anaesthesia of the skin and mus- 
cles. In the cases which I have had opportunity to observe, no such 
paroxysms and intervals were discoverable. PERIPHERAL PALSY. 
359 
Treatment.—The course of the disease, which usually is favorable, 
renders active therapeutic interference superfluous. Krukenberg used 
to recommend fumigation with juniper-berries. The pain in the limbs 
and the contractions of the muscles certainly subside quite as soon 
jnder this simple treatment as under the use of other stimulating and 
antispasmodic embrocations, and by the internal use of remedies for 
convulsions, such as flores zinci, henbane, opium, and the like. If the 
idiopathic muscular spasm be the effect of some grave general disease, 
the case is different. The spasms do not then cease until the normal 
assimilation and nutrition have once more become reestablished; and 
treatment must be regulated accordingly. 
CHAPTER XIX. 
PERIPHERAL PALSY. 
The term palsy—acinesis—of the province of the cerebro-spinal 
nerves is applied to a morbid condition, in which the motor fibres are 
no longer acted upon by volition, so that the muscles cannot be made 
to contract at will. Derangements of the voluntary motion having 
another origin, especially those caused by disease of the bones and 
joints, are not counted as palsy. Myopathic palsy shall be treated of 
hereafter. 
In treating of disease of the brain, we have already described that 
class of paralysis proceeding from destruction or derangement of the 
grand centre of volition, whereby the motor impulse to the peripheral 
nerves is arrested. Under the same heading, also, we have treated of 
those palsies due to general derangement of the cerebral circulation 
and nutrition, in which, the entire mental function having become arrest- 
ed, no impression is made, and no voluntary motion can take place. 
Besides this, in a previous chapter, we have already considered the 
subject of paralysis arising from destruction of the fibres of the spinal 
marrow, through which the impulse from the seat of volition is con- 
veyed to the motor nerves. The present section is exclusively devoted 
to the variety of palsy arising either from separation of the peripheral 
nerves from the brain or spinal marrow, or from a loss of irritability on 
the part of these nerves owing to alteration in their structure. 
Etiology.—Separation of motor nerves from the central organs is 
not unfrequently the result of injury, and in this class belong the cases 
of section of nerves by a surgical operation, and by wounds of other 
kinds. In other instances the disturbance of continuity depends upon 
the extension of an ulceration or other destructive process to a neigh- 
boring nerve. The destruction of the facial nerve, during its corns' 360 
DISEASES OF THE PERIPHERAL NERVES. 
tlirougn the canal of Fallopius in caries of the petrous bone, may be 
regarded as a prototype of this variety. A peripheral end of a nerve 
may also be separated from its central organ by the continued pressure 
of a tumor, an aneurism, or an exostosis which gradually consumes it. 
Sometimes even a temporary pressure upon a nerve has the same ef- 
fect, which is probably owing to the continuity of the nerve’s having 
become broken at the compressed point. Thus JETasse has seen a mo- 
tor palsy of the arm which proved refractory to all treatment, in a per- 
son who had slept some time with his arm resting over the back of a 
chair. In very rare cases the disturbance of continuity of the nerve is 
due to a primary partial neuritis. 
The structural changes whereby the motor nerves lose their excita- 
bility, without undergoing solution of continuity, are as unknown as are 
those which destroy the function of the sensory nerves. Thus cutting 
off the supply of arterial blood will arrest the irritability of the motor 
nerves without producing in them any structural alteration. It is 
probable, although not proved, that rheumatic palsy is due to hyper- 
aemia and oedema of the neurilemma, causing compression of the nerve- 
fibres. Physiological experiment warrants the supposition that the 
paralysis, which sometimes arises after violent attacks of cramp, is 
the result of over-exertion ; but a nerve which has lost its excitability 
through undue exertion does not differ appreciably from an excitable 
nerve. It is the same in case of a paralysis arising in consequence of 
a moderate pressure or strain. Here, from its favorable course, we 
must attribute the palsy to a diminution of the irritability of the nerve, 
and not to its destruction. Finally, the structural changes of the 
nerves are unknown, which give rise to the paralysis of lead-poison- 
ing and of miasmatic poisoning, as well as in the so-called essentia 
palsies. (See Chapter XXI.) 
Although hysterical palsy has not been counted either among the 
cerebral diseases or among those of the spinal marrow, it probably 
does not belong to the class of peripheral paralyses, but rather de- 
pends upon some impalpable anatomical abnormity of the centre of 
volition, as we shall explain more in detail when treating of hysteria. 
Symptoms and Course.—Complete separation of a nerve from 
its central organ renders the muscles which it supplies incapable of 
motion, producing complete palsy or paralysis. Textural changes, 
which absolutely destroy the irritability of the nerve, have the same 
effect. When the nervous irritability is merely diminished, but not 
annihilated, feeble contractions still remain possible. This condition 
is called incomplete palsy or paresis. 
A paralysis or paresis of peripheral origin is usually distinguishable 
from a central palsy: 1. By its extent. As we have seen, the charao- PERIPHERAL PALSY. 
361 
teristic forms of cerebral and spinal palsy are hemiplegia and paraple- 
gia, while a palsy limited to the range of influence of some particular 
nerve is an almost pathognomonic symptom of peripheral paralysis. 
It is only as a symptom of incipient sclerosis, and in rare instances, 
that the power of volition is suspended in single nerves owing to dis- 
ease of the brain, or that the connection between the spinal marrow 
and any particular nerve is broken. The converse of this proposition 
is not true, however, as there are many peripheral palsies which in- 
volve large numbers of nerves. Even in such cases, however, the 
mode of extension of the malady often reveals its source. When a 
tumor of the brain causes palsy of the region supplied by the various 
cerebral nerves, the palsy does not arise in all of the nerves simulta- 
neously, but extends gradually from one to another as the tumor 
grows. I shall mention one case observed in the Greifswalder clinic, 
as a striking example of how extension of the palsy may be of great 
importance as a means of distinction between spinal and peripheral 
paralysis due to caries of the vertebrae. The patient suffered from 
caries of the vertebrae, and his upper extremities were in a state of al- 
most complete paralysis with anaesthesia, while the mobility and sen- 
sation of the lower limbs was quite normal. From the manner in 
which this palsy had developed, it could be decidedly inferred that it 
was the nervous trunks of the brachial plexus which were affected by 
the vertebral disease, and not the spinal marrow. Rheumatic palsy, 
which likewise not unfrequently affects a large number of nerves, does 
not present any peculiarity with regard to its manner of extension, 
and for a differential diagnosis we can only avail ourselves of the fact 
that it is not apt to assume the form of hemiplegia or paraplegia. On 
the other hand, the mode of development of lead-palsy is very charac- 
teristic, so that from it alone the real nature of the disease may be de- 
termined, and other forms of peripheral palsy, as well as the central 
palsies, may be excluded from the diagnosis. Lead-poisoning always 
affects the upper extremities first, attacking the extensors of the fin- 
gers, hands, and arms in succession, while the flexors remain quite free 
from disease. 
2. If, from the outset of an attack of palsy, there have never been 
any derangements of the cerebral function, the origin of the disease 
is, in all probability, peripheral. The converse of this proposition 
also does not hold good; for a paralysis may be combined with serious 
cerebral disorder, and the paralysis may still be a peripheral one. 
Ample proof of this condition is given in cases of tumors at the base 
of the brain. 
3. When the affected nerve is a nerve of mixed function, the com- 
plication of palsy with anaesthesia of the region known to be supplied 362 
DISEASES OF THE PERIPHERAL NERVES. 
by its sensory fibres, is an important criterion of the peripheral origin 
of the disease. 
4. The absence of reflex and sympathetic movements in the region 
of the palsied nerve is of similar import. If the continuance of the 
normal sensibility informs us that the function of the sensory nerves 
of a part is still preserved, and that its connection with the brain re- 
mains intact; and if, nevertheless, no reflex signs arise when the sen- 
sory nerves are irritated, there can remain no doubt that an interrup- 
tion exists in the motor nerves, and hence that the palsy is peripheral. 
For instance, if a patient be unable to close his eye at will, and do 
not even wink when the bulb is touched, although the sensibility of 
the conjunctiva be normal, the palsy is certainly peripheral. The re- 
verse of this condition is a still better proof of the central origin of a 
palsy. If a patient be unable voluntarily to bring a certain nerve into 
excitement, and, hence, unable to contract the muscles supplied by 
that nerve (for instance, if he cannot close the eye when told to do so; 
and, on the other hand, if the nerve be excited, and all its muscles 
made to contract if a sensory nerve be irritated, as when we touch the 
conjunctiva -with the finger), we have to do with a central palsy. In 
such a case the irritability of the motor and sensory fibres is perfect, 
as is also the path by which the impression is conveyed from the cen- 
tripetal to the centrifugal nerves; but the centre of volition in the 
brain, or the channel through which the influence of the will is im- 
parted to motor nerves, is destroyed. 
5. Finally, the early extinction of electric contractility in a nerve— 
that is, the absence of contractility of its muscles upon application 
of the induced current—is an important sign that the paralysis is of 
oexipheral origin. The induction apparatus, the exaggerated and in- 
liscriminate employment of which, for therapeutic purposes, should be 
liscouraged, deserves a much greater employment as a means of diag- 
nosis, especially in private practice, than it has obtained hitherto. 
In recent cases of peripheral palsy, which come under our notice 
tolerably often in private practice, and where, owing to the greater 
prospect of successful treatment, it is of peculiar importance to know 
whether the disease be of peripheral or central origin, examination 
with the induced current will decide the matter almost with certainty. 
In many cases of peripheral palsy, the electric contractility of the mus- 
cles sinks to a minimum, even within a few days after the occurrence 
of the palsy, and soon afterward ceases entirely. In cerebral paratysis 
it is quite otherwise. There the electric contractility often continues 
unimpaired for months. Hemiplegic patients, indeed, are apt to be 
much impressed when the faradizer, by application of the electrodes, 
readily causes contraction of muscles, which for months have been be- PERIPHERAL PALSY. 
363 
yond the power of tlieir will, and they spare neither time nor money 
in order to subject themselves to a treatment in which—ineffectual 
though it be—they place the utmost confidence. The degeneration 
of peripheral nerves, which soon follows upon their separation from 
the central organs, and which we are able to demonstrate anatomically, 
accounts, in some measure, for the early extinction of electric contrac- 
tility in peripheral palsy. Nor, for the same reason, should we wonder 
that it soon ceases in rheumatic palsy, and in cases of lead-poisoning. 
No matter how slight the disease from which the nerve suffers in such 
a case, it will always suffice to bring about in it such a change that 
neither the will nor the application of the induced current is capable 
of producing excitement in it. In cerebral palsy, also, a degeneration 
of the peripheral nerve finally sets in, as well as an atrophy and fatty 
degeneration of the unemployed muscles. Hence, in very old cases, 
loss of electric contractility can no longer be made use of as a means 
of distinction between central and peripheral palsy. In spinal palsy 
the electric contractility is sometimes long retained, while at other 
times it speedily ceases. Hence, it is of little worth in a diagnostic 
point of view. I believe that these differences may be accounted for, 
in some degree, from the results of the investigations of the structure 
of the spinal marrow by Schroeder van der Kolk. Where centrifugal 
fibres exist in the spinal marrow, which, instead of passing to the pe- 
ripheral nerves, first go to the ganglion-cells from which the peripheral 
nerves spring, it would seem (arguing from analogy) that, upon de- 
struction of this first set of fibres, a similar condition, as regards the 
electric contractility, exists, as obtains in cerebral palsy, while, upon 
destruction of the fibres proceeding from the ganglion-cells, the condi- 
tion is analogous to that of a peripheral paralysis. It is remarkable 
that, in many cases of peripheral palsy, the muscles can be made to 
contract, by means of the constant current, while the induced current 
will fail of effect, and, still more strange, that streams so feeble as to 
excite no contraction upon the unaffected side wfill induce it upon the 
paralyzed side. We have no satisfactory explanation of this circum- 
stance, which I have met with in two cases of rheumatic palsy in the 
course of a single semester. One thing, however, may be deduced 
from our previous remarks: that the character of the irritation pro- 
duced in a nerve by the constant current, with its catalytic action, is 
essentially different from that caused by the induced current. 
Separation of a motor nerve from the central organs and the ex- 
tinction of its irritability induce the same derangements of circulation 
and of nutrition which we have described while treating of the pe- 
ripheral anaesthesias, and such derangements are particularly severe in 
cases where anaesthesia and acinesis exist together. Lowering of the 364 
DISEASES OF THE PERIPHERAL NERVES. 
temperature in paralyzed regions depends upon a retardation of the 
circulation. The quicker new blood reaches the peripheral region, 
which is constantly giving off heat, so much the less readily does it 
become cooled. On the other hand, the slower new warm blood enters 
the part, so much the sooner will its temperature assimilate itself to 
that of the surrounding region. Retardation of the circulation seems 
to me to be dependent upon a contraction of the arteries; at all events, 
the pulse is often smaller upon the palsied side than upon the sound 
one. We are as yet unable to account for this narrowing of the artery 
upon the paralyzed side. When a palsied part becomes inflamed, an 
elevation of its temperature is observed in it, instead of a depression. 
We do not attempt to decide whether the incomplete anaesthesia, 
which usually develops by degrees in palsied parts (even where origi- 
nally the disease has been a motor paralysis), depends upon retarda- 
tion of the circulation, or whether it is to be ascribed to a transmission 
of the passive condition, through the ganglion-cells, from the motor to 
the sensory fibres. 
The course of peripheral palsy exhibits great variety, according to 
the cause which produces it. Where a nerve has been cut through, 
the interrupted connection not unfrequently becomes restored, and the 
palsy gradually and completely disappears. If, however, a large por- 
tion of a nerve be destroyed, the palsy remains stationary throughout 
life. The progress of rheumatic palsy usually is favorable, and it gen- 
erally terminates in complete recovery. This is also the case with the 
exhaustion of irritability resulting from convulsions, and from the in- 
complete traumatic palsy caused by slight injuries. The paralysis 
which sometimes remains after recovery from typhus also admits of 
favorable prognosis, while that arising from lead-poisoning is exceed- 
ingly intractable, and often proves incurable. 
Treatment.—The fulfilment of the causal indication in peripheral 
palsy is but rarely possible, and even then is seldom followed by bene- 
ficial results. Thus the extirpation of a tumor, which has caused pa- 
ralysis by pressure upon a nerve, scarcely ever restores normal motion 
of the part. 
Rheumatic paralysis forms an exception to this rule, when not of 
too long standing, as a proper treatment of the primitive disease in 
such cases often furnishes the best results. However, this is not to 
be anticipated from the use of those very uncertain remedies, colchi- 
cum, quina, and aconite, but rather from the methodical employment 
of warm baths. Every year troops of paralytic patients, curable and 
incurable, crowd to Teplitz, Wiesbaden, Wildbad, or Pfaffers. The 
reputation which these watering-places enjoy, especially in the treat- 
ment of palsy, is mainly due to their really surprising efficacy in rheu PERIPHERAL PALSY. 
365 
matic paralysis. As corroborants of the bath-treatment, but only in 
cases where, owing to unfavorable circumstances, bathing is impracti- 
cable, we recommend the application of stimulants to the skin, applied 
along the course of the affected nerve. The usual prescription of an 
embrocation of aromatic tinctures, which irritate the nose more than 
the skin, should be set aside in favor of rubefacients and issues. 
Of the remedies called for by the indication from the disease itself, 
the application of the constant electric current is that which deserves 
our greatest reliance. We have already expressed our opinion that 
cures effected by the constant current probably depended solely upon 
its catalytic action, and that, by means of the galvanic treatment, it is 
in our power greatly to modify the circulation, the process of endos- 
mosis, and nutrition itself, even in tissues lying deep beneath the skin. 
The induced current does not have this effect, and we have seen many 
cases of peripheral palsy, which had been treated unsuccessfully by 
the induced current, healed when the constant stream was applied. 
This is especially the case with the rheumatic and traumatic palsies, 
and those induced by lead and other poisons. 
The symptomatic indication demands : 1. That we should preserve 
what remains of irritability in a partially paralyzed nerve, and avert, if 
possible, its complete extinction. 2. That we should prevent atrophy 
and fatty degeneration of the palsied muscles, or check them where they 
have already begun. Both complete extinction of the already reduced 
irritability, and the atrophy and degeneration of the palsied muscles, 
are mainly due to continued rest, and to lack of excitement, which thus 
constitute a new factor, whereby a palsy, dependent upon other causes, 
is rendered more severe and intractable. It may even furnish the sole 
reason why a paralysis merely improves sometimes, without disappear- 
ing entirely. For the prevention of such a mishap, localized faradiza- 
tion is an invaluable remedy. It is an important rule, in its employ- 
ment, not to protract the sittings too much, and not to employ too 
strong a current. Since we know that the excitability of a nerve is 
quite as liable to impairment or destruction from too much exertion as 
from too much rest, this rule needs no comment. It is equally evident 
that, in traumatic, rheumatic, and toxic palsy, the induced current is 
not to be employed before the disturbance of continuity has been al 
layed, and the excitability of the affected nerve has begun to return; 
or, in other words, that the current is not to be applied until we find 
that the muscles begin to contract under its influence. It is very de- 
sirable that every physician should make himself so familiar with fara- 
dization localizee that he need not leave its employment to some one 
else. The labors of Ziemssen have rendered this task quite an easy 
one. A few days of practice upon the healthy subject, under the in- 366 
DISEASES OF THE PERIPHERAL NERVES. 
structive guidance of this book, suffices to impart the degree of skill 
requisite to impress the uninitiated. 
The curative effect of strychnine upon peripheral palsy may be 
placed by the side of that of the induced current. Nor does strych- 
nine at all tend to promote the union of divided nerves, nor repair the 
structural changes which have caused the palsy. On the other hand, 
it is probable that this drug, by exciting reflex action in the spinal 
column, and through the augmented reflex excitement thereby induced 
in the motor nerves, may stimulate the irritability of the latter, where 
it is not already completely extinguished. In order to obtain results 
from strychnine, doses must be given of sufficient size, and must be 
kept up long enough to produce visible effect upon the reflex action of 
the spinal marrow—that is, until slight twitching is induced. We 
prescribe either the alcoholic extract of nux vomica, one-third of a 
grain, gradually increasing up to two grains, or the nitrate of strych- 
nine, in dose from the twelfth to the fourth of a grain. Other medica- 
ments, such as arnica and rhus toxicodendri, scarcely have any effect 
upon peripheral palsy. 
FALSY OF THE FACIAL NERVE MIMIC FACIAL PALSY BELL’S PALSY. 
CHAPTER XX. 
Etiology.—In the coming chapter we leave unnoticed the variety 
of facial palsy arising from suspended volition, which is almost always 
accompanied by hemiplegia, and constitutes a common symptom of 
apoplexy, and of other diseases of the brain. 
The irritability of the facial, or of its attachment to the brain, may 
be impaired: 1. By causes which act upon it prior to its entrance into 
the internal auditory meatus. 2. By such as affect it during its course 
through the petrous bone. 3. By agents which involve the peripheral 
ramifications upon the face. Within the cranium the facial nerve is 
most frequently compressed or destroyed by cerebral tumors springing 
from the base of the skull, or Avhich have advanced toward its base. More 
rarely it proceeds from exudation, from thickening of the dura mater, 
or from exostoses. In the canal of Fallopius the nerve is more fre- 
quently destroyed by caries of the petrous bone, although one or two 
cases have been observed in which fractures and gunshot wounds have 
caused injury of the facial within the petrous bone. The peripheral 
Dranches are sometimes cut, either by accident or intentionally, during 
surgical operations. Thus it was with the coachman who was so 
thankful to Bell for the successful extirpation of a tumor about his 
ear, but who complained that since the operation he could no longer 
whistle to his horses. The continuous pressure which the ramifications BELL’S PALSY OF THE FACIAL NERVE. 
367 
sometimes are subjected to by enlarged lymphatic glands, or other 
tumors, as well as contusions and concussions, resulting from blows 
upon the ear, may give rise to facial palsy. It is not unfrequently ob- 
served in newly-born children, when branches of the nerve have been 
bruised by the forceps during labor. Sudden chilling of a warm face, 
however, is a much more common .source of facial palsy than any other 
agent. Many patients acquire it by looking out of the window imme- 
diately after rising in the morning. Holla attributes the increasing 
frequence of facial paralysis to the railroads. People hurry to the 
station, arrive there warm, enter the carriage, and expose their face to 
the draught of the window. The result is a palsy of the face. 
The affection is a somewhat common one, so that J. Frank has 
seen twenty-two cases of it in the course of fifteen years. Statistics 
as to its frequence at various ages, and in different sexes, and different 
sides of the face, have not led to any important conclusions. If it be 
true that the affection is more common upon the left side of the face, 
it is not on account of any predisposition of the left facial nerve, but 
because of the greater exposure of the left cheek to blows on the ear, 
and to other injuries. 
Symptoms and Course.—The symptoms of facial palsy consist in 
an immobility and relaxation of the facial muscles, which are supplied 
by the affected nerve-fibres. Palsy of the frontal muscle, and of the 
corrugator supercilii, makes it impossible to wrinkle the forehead. 
Romberg says : “ The old man’s forehead becomes as smooth as that of a 
child, and there is no better cosmetic for old women.” Palsy of the 
orbicularis palpebrarum prevents the patients from shutting the eye 
completely. If told to do so, they lower the lid a little, by relaxing 
the levator palpebrae superioris, over which they still have control, and 
roll the bulb upward, so as to hide the cornea. The tears are no longer 
conducted to the lachrymal puncta, but flow down over the cheek. 
The eye, being imperfectly closed, and exposed to all manner of inju- 
ries, readily inflames. The levator labii superioris, alaeque nasi, the 
levator anguli oris, and the zygomaticus, are unable to draw up the 
upper lip, nose, or commissure of the mouth, and to dilate the nostril. 
The buccinator being disabled, the cheek puffs out during expiration, 
like a loose sail. Some of the purposes for which the facial muscles 
are employed, the pronunciation of the labial letters, whistling, blow- 
ing, and expectorating, now fail. Even in chewing, which process, 
being independent of the facial, goes on undisturbed, the morsel, when 
on the affected side of the mouth, often falls between the teeth and 
the cheek, and has to be disengaged thence by the fingers. When 
the paralysis involves the whole of one side, there is a remarkable dis- 
tortion of the countenance with every play of expression. This arises 368 
DISEASES OF THE PERIPHERAL NERVES. 
partly from the fact that muscular contractions only occur on the sound 
side, while the other remains motionless, and partly because the con- 
tracting muscles upon the sound half of the face are not counterbal- 
anced by the palsied half, so that the countenance is drawn to one side. 
Even during rest the face remains more or less distorted and unsym- 
metrical. The palsied angle of the mouth is lower than the healthy 
one, the nostril is narrower, and all the pits and depressions are ef- 
faced. The point of the nose and the mouth are drawn over toward 
the sound half of the face. All this deformity is due to the want of 
balance between the healthy muscles of one half the face and their 
palsied antagonists. In the same way there is lagophthalmos of the 
affected side, from a preponderance of the unpalsied levator palpebrm 
superioris over its palsied antagonist, the orbicularis palpebrarum. 
When paralysis of the facial is bilateral, the face becomes void of all 
expression, and the patient laughs and weeps without exhibiting any 
play of countenance. I have never seen such a case myself, but can 
easily believe that the aspect of a person whose face remains motion- 
less, even while he is laughing loudly, will present the hideous appear- 
ance of a mask. The impairment of the sense of taste, the distortion 
of the uvula, and deviation of the tongue, though less obvious symp- 
toms, are equally constant. It is uncertain whether the obtuseness of 
the sense of taste depends upon diminution of the secretion of saliva, 
and consequent dryness of the mouth, or whether the chorda tympani 
nerve, by erecting the papilla of the tongue, aids the gustatory sense. 
Displacement of the uvula to the sound side is accounted for by the 
fact that the motor nerve-fibres, passing through the nervus petrosus 
superficialis major to the sphenopalatine ganglion, from which the de- 
scending palatine branches proceed, only contract the muscles of the 
uvula upon the side which is not palsied. This explanation, however, 
is not absolutely satisfactory.2 
Regarding the deviation of the tongue, we refer to what we have 
already said while treating of apoplexy, as this symptom is of more 
common occurrence in cerebral than in peripheral paralysis. In a pre- 
vious chapter we have given a detailed explanation of why the reflex 
motion should be impossible in complete peripheral palsy of the facial, 
and why the electric contractility of the muscles of the face soon be- 
comes extinct. In recent and uncomplicated cases, the sensibility of 
the paralyzed half of the face is normal. When of longer standing, 
it generally becomes somewhat blunted, probably in consequence of 
nutritive disorder of the region supplied by the affected nerve. This 
shows itself chiefly through emaciation and flabbiness of the palsied 
part of the face, by the disappearance of the fat, and by the shrivelled 
condition of the skin. BELL’S PALSY OF THE FACIAL NERVE. 
369 
According to Romberg, the following are the signs whereby we 
may recognize whether the source of the paralysis is to be sought 
within the cranium, in the petrous bone, or upon the face itself: 1. 
We may infer that the affection originates in disease at the base of 
the skull, when there is participation of other cerebral nerves in the 
palsy, as shown by squinting, deafness, anaesthesia, etc., as well as by 
the simultaneous occurrence of palsy of the extremities of the other 
side of the body. 2. Evidence that the palsy originates in a disease 
or destruction of the facial nerve within the canal of Fallopius con- 
sists in long-standing otorrhoea, hardness of hearing or complete deaf- 
ness, obliquity of the uvula, dryness of the mouth, perversion of the 
sense of taste, which depends upon implication of the nervus petrosus 
superficialis minor and chorda tympani, which are never affected except 
in this form of the disease. 3. We know that the palsy proceeds from 
the peripheral ramifications, when the disease is plainly dependent 
upon exposure to cold, or upon some violence done to the face, or upon 
the pressure of a tumor upon the facial nerve, especially in the region 
of the stylo-mastoid foramen, the ear itself meantime being sound, the 
taste normal, and the uvula straight. 
The course of facial palsy varies greatly, according to the seat and 
nature of its cause. Where the nerve has been destroyed by a tumor 
at the base of the skull, or by caries of the petrous bone, the palsy is, 
of course, incurable, as is also the case when a tumor has broken the 
continuity of the nerve by continued pressure upon its peripheral 
branches. When the affection proceeds from exposure to cold, or from 
slight injuries, the prognosis is better. This is especially true of the 
congenital palsy induced by pressure of the obstetric forceps. But, 
even in adults, it by no means invariably happens that traumatic or 
rheumatic paralysis disappears in the course of a few weeks or months. 
Treatment.—From what has been stated regarding the prognosis 
of facial palsy, the rheumatic and traumatic forms of the complaint 
are the only ones susceptible of treatment. Although they usually 
recover without interference, it is better, in recent cases of traumatic 
origin, to employ local antiphlogistics. Whenever an adult has a 
palsy of one side of the face, caused by a blow or shock, we should 
prescribe leeches and cold compresses, and should rub the part with 
mercurial ointment. Congenital paralysis, also, when of traumatic 
origin, may be left alone. When the disease arises from cold, and is 
recent, the affected side of the face is to be covered with well-wrung 
cold compresses, covered with oil-silk or india-rubber cloth, which are 
not to be changed until after the lapse of several hours. The face may 
also be enveloped in cotton wool, and a vapor-bath may be taken. At 
a later period stronger irritants may be used: lotions of essence of 370 
DISEASES OF THE PERIPHERAL NERVES. 
mustard, mustard-plasters, embrocations of croton-oil, blisters, etc. A 
great number of cases are on record in which rheumatic facial palsy 
has been cured by the application of the constant galvanic current. 
In two cases, I myself have succeeded in effecting a cure, although bui 
a gradual one, by employment of galvanism. In each of these cases, 
treatment by the induced current remained without effect. Where 
the electric contractility can be reestablished by localized faradization, 
the cure will be promoted and hastened by the methodical use of the 
induced current. 
CHAPTER XXI. 
PALSY OP THE SERRATUS MUSCLE. 
Etiology.—In rare instances, two of which have come under my 
personal observation, palsy of the serratus has formed part of a myo- 
pathic paralysis, involving many of the muscles, the result of the so- 
called progressive muscular atrophy (see appropriate chapter). The 
affection is much more commonly confined to the serratus alone. This 
fact, and the circumstance that the long thoracic nerve is not distrib- 
uted to any other muscle except to the serratus anticus magnus, would 
imply that most cases of palsy of the serratus are neither of cerebral 
nor of myopathic origin. We have laid it down as an important sign 
of the peripheral nature of a palsy, that the affection involves the re- 
gion supplied by some particular nerve, and while neighboring muscles 
supplied by other nerves remain sound. Besides this is the well-known 
fact that peripheral palsy and peripheral neuroses by preference affect 
the region supplied by nerves which pass through long, narrow chan- 
nels and holes, like the long thoracic, which runs through the scalenus 
medius. This very important point in the pathogeny of palsy of the 
serratus, and the proof of the fact that, in most of such cases, we have 
to deal with a peripheral neuropathic affection, have not hitherto ob- 
tained the notice which they deserve. 
The exciting causes of palsy of the serratus are usually obscure. 
It is plain that the long thoracic nerve, in its passage through the 
scalenus medius, may suffer injuries which escape our attention. In 
some instances, over-exertion of the upper extremities, or cold, has 
been the assigned cause. In one observation, reported by Neuschler, 
the palsy of the serratus was preceded by a fall, and a tumor afterward 
formed in the neck, which the physician in charge proposed to open by 
incision. In one very interesting case, which came under my own ob- 
servation, a carpenter, who used to carry the heavy beams for build- 
mgs upon his right shoulder, had to employ the left shoulder instead, PALSY OF THE SERRATUS MUSCLE. 
371 
on account of the development of a palsy of the right serratus muscle. 
Some time afterward, palsy of the left serratus also began to appear. 
Symptoms and Course.—Palsy of the serratus muscle is easy of 
recognition, as the absence of its function and the undue action of its 
antagonistic muscles occasion characteristic deformities and disorders 
of motion. The function of the serratus is to press the scapula against 
the thoracic wall, and to draw its lower angle downward and outward. 
The serratus is especially required in the act of elevating the arms 
above a horizontal line, as it then draws the lower angle of the scapula 
outward, and turns the glenoid cavity of the joint upward. It is by 
this act alone, and not by the contraction of the deltoid, that we are 
enabled to lift the arm above the shoulder. When the serratus is 
paralyzed, the inner border of the scapula, and particularly its lower 
angle, instead of lying against the chest, stands up like a wing, draw- 
ing up a three-cornered fold of skin before it, and admitting of our 
reaching deeply into the subscapular fossa. At the same time, the 
lower edge of the scapula stands up too high, and too far inward. 
The antagonistic muscles, the trapezius and the levator scapulas, have 
drawn the superior angle upward, and the weight of the arm and the 
pectoralis minor have depressed the external angle, and thrown it for- 
ward. The patient is unable to lift his arm above a horizontal line, 
and is thus rendered extremely awkward. Any one, who has often 
watched a patient with this affection put on or take off his coat or 
shirt, will be able to make a diagnosis in the next case he meets with, 
from these acts alone. If we press the inferior angle of the scapula 
against the chest, and, at the same time, push it in, the patient is once 
more enabled to lift his arm above his shoulder without difficulty. 
Palsy of the serratus is an obstinate complaint. In none of the cases 
which I have seen was a complete cure effected. In many in- 
stances, however, the patients so far improved as to be able to do 
easy work. 
Treatment.—The most commendable remedy, in recent palsy of 
the serratus, is local blood-letting and derivation to the skin, applied 
over the point where the long thoracic nerve passes through the sca- 
lenus medius. In chronic cases, according to our present experience, 
faradization does not promise much benefit. On the other hand, the 
constant current is strongly to be recommended. Unfortunately, how- 
ever, hitherto I have had but one opportunity of applying it. The 
cures obtained by means of the constant current, in cases of peripheral 
facial palsy, which I consider to be quite analogous with palsy of the 
serratus, urgentlv demand the treatment of the latter by galvanism. 372 
DISEASES OF THE PERIPHERAL NERVES. 
CHAPTER XXII. 
PROGRESSIYE PALSY OP THE CEREBRAL NERVES PROGRESSIVE PALSY 
OP THE TONGUE, VELUM PALATI, AND LIPS—GLOSSOLARYNGEAL 
PALSY. 
A series of observations have recently been made, particularly by 
French writers, of a paralysis, which, commencing at the lips, extends 
successively to the tongue, palate, pharynx, and sometimes to the 
muscles of the glottis, more rarely to those of the eyes. In all cases 
hitherto observed no coexistent derangement has been perceptible in 
the sensory nerves, nor in those of special sense. 
The pathogeny of this peculiar disease is obscure. The only lesion 
constantly found post mortem is an intense fatty atrophy of the pal- 
sied nerves, especially the hypoglossal nerve. In some cases a diffuse 
sclerosis of the medulla oblongata has also been found. According to 
an hypothesis which is as yet unproved, advanced by Wachsmuth, who 
proposes to call the malady in question “ bulbar palsy,” the disease 
consists in a “ central affection of the medulla oblongata, having its 
seat in the olivary bodies, and in the gray matter lying far back be- 
tween the diverging lateral and posterior columns, and which forms 
the floor of the fourth ventricle. According to Wachsmuth, the atro- 
phy of the nerves is secondary, and a consequence of the degeneration 
suffered by the nuclei at the points above named. In some cases the 
palsy of the region supplied by the cerebral nerves was preceded by 
the symptoms of an incipient, progressive muscular atrophy, and the 
majority of French authorities regard the two diseases as closely 
related, although, in the progressive palsy of the cerebral nerves, no 
diminution in size is observable in the affected muscles. At the out- 
set the patient makes but little complaint. He cannot pucker up his 
mouth, and hence cannot blow, whistle, nor spit. The saliva wdiich 
collects in the mouth runs from it involuntarily. The expression of 
the countenance becomes blank and strange, as the muscles of the lips 
cannot take part in the play of expression. Pronunciation of the 
labial letters is difficult, and gradually becomes impossible. If the 
malady extend to the tongue, not only does articulation become still 
more embarrassed, but the acts of chewing and swallowing become 
impeded; and afterward, when the tongue has become still more help- 
less—lying quite motionless in the mouth—these acts are no longer 
practicable. Palsy of the palate shows itself from the nasal tone of 
the voice, and, as long as the pharyngeal muscles remain sound, by the 
regurgitation, through the nose and mouth, of food and liquids which 
enter the pharynx. If the pharynx also become palsied, the patient, INFANTILE PALSY. 
373 
when offered to drink, rejects a large portion of the liquid with violent 
expiratory motions, so that at last it often becomes necessary to feed 
him by means of the oesophagus tube. The choking-fits thus pro- 
voked by attempting to drink, and the rejection of the liquid amid 
spasmodic coughing, might awraken the suspicion that a communication 
exists between the larynx and pharynx, or oesophagus. In one case 
of this kind, my colleague Bruns demonstrated, by means of the la- 
ryngoscope, that, “ if the patient merely was fed with small spoonfuls 
of milk or porridge, the swallowed portion only passed as far as the 
pouch which lies behind the larynx. If, by further swallowing, the 
level of the liquid rises so as to pass the bottom of the notch between 
the arytenoid cartilages, the so-called rima glottidis posterior, the soft 
liquid mass immediately flows forward through this opening into the 
larynx, and instantly gives rise to a fit of coughing.” 
This disease is generally a tedious one. Death is the usual result, 
either from impairment of the general nutrition of the patient, owing 
to the difficulty with which he obtains nourishment, or else from vio- 
lent bronchitis, or pneumonia, in consequence of the repeated intru- 
sion of liquid into the air-passages. Hitherto no authentic case of im- 
provement or cure has been reported. Benedikt is the only one who 
claims that, by galvanization of the sympathetic, and at the mastoid 
process, he has obtained important success and even a cure, and in 
advanced cases has relieved dangerous symptoms, such as difficulty 
in swallowing. For this purpose he applied the copper-pole to the 
spinal column, and strokes with the zinc-pole upon the pomum adami 
and neighboring parts, so that in each sitting he is able to induce some 
twenty or thirty acts of deglutition. May there not have been some 
confusion with hysterical dysphagia in these almost miraculous cures ? 
T have cured a hysterical patient by a treatment almost purely psychi- 
cal, who for months previously had been fed through a tube, and had 
carried a canula in her trachea for an equally long period of time. 
CHAPTER XXIII. 
ESSENTIAL PALSY OP CHILDREN—SPINAL INFANTILE PALSY {Heine). 
Etiology.—Whether the essential palsy of children be a disease 
of the brain, of the spinal marrow, or of the peripheral nerves, or 
whether it proceed from all or any of them in turn, as Vogt supposes, 
.s a matter which, in our present ignorance of its post mortem lesions, 
cannot be positively decided. The name “ essential palsy ” I hold to 
oe a most appropriate one. Although the paralysis originally may 
have been due to an inflammation or effusion in the spinal marrow, 374 
DISEASES OF THE PERIPHERAL NERVES. 
yet, at the time when the palsy is called an essential palsy, all such 
processes have long since subsided, and it is not the primitive disease, 
but the paralysis and its consequences, that we have to treat. Essen- 
tial palsy as a rule is the permanent product of a very acute process; 
for all observers agree that the affection develops within a few hours, 
and that it never extends from the limb first attacked to the other 
limbs. 
The causes of the disease are as obscure as is its pathogeny. It 
occurs almost exclusively among children during the period of denti- 
tion, and for a short time afterward; that is, from the sixth month to 
the third year of life. Girls and boys are equally liable, as are also 
scrofulous and cachectic subjects, and those previously robust. The 
assigned causes have been the acute exanthemata, and cold, especially 
allowing children to sit upon cold stories. The latter idea is unworthy 
of attention, as innumerable children sit daily upon the stones, while 
essential palsy is not at all a common disease. 
Symptoms and Course.—In many instances the attack commences 
with febrile symptoms, and signs of cerebral hypermmia or meningitis. 
Mental excitement, convulsions, loss of consciousness, gnashing of the 
teeth, are common to this, as well as to the other two maladies above 
mentioned; and as in such cases it often happens that it is only by 
the course of the disease that we can decide whether we have a me- 
ningitis or a cerebral hyperaemia to deal with, so here, too, we have no 
means of distinguishing the primary stage of an essential paralysis 
from that of hyperaemia of the brain, save that, after subsidence of the 
convulsions and return of consciousness, a total paralysis of one or 
more extremities remains. Sometimes one foot, sometimes one hand 
is affected, sometimes both lower extremities; but it never happens 
that both extremities of the same half of the body are paralyzed, a fact 
which very plainly implies the independence of the disease from cere- 
bral apoplexy or encephalitis. The bladder and rectum never take 
part in the palsy. A mode of commencement of the malady, which is 
scarcely less common than that by violent cerebral symptoms, consists 
in an undefined attack of feverish symptoms, during which, without 
precursory convulsions or stupor, an arm, or leg, or both legs, suddenly 
hang useless, and are entirely incapable of voluntary motion. 
The subsequent course of the disease may vary. Sometimes the 
palsy disappears in a day or two, and the disease ends in complete 
recovery. Heine, who indisputably has seen the largest number of 
cases, doubts whether such examples (to which the name “ temporary 
infantile palsy ” has been given) proceed from the same causes which 
give rise to the stationary, permanent essential paralysis. Duchenne 
noticed that, in recent cases of the temporary form, the electric con- INFANTILE PALSY. 
375 
tractility of the muscles was retained; whereas, in recent cases of the 
permanent form, a few only of the muscles of the paralyzed limb 
maintained their electric contractility, while in the others it was lost. 
These observations may be summed up as follows: that the prognosis 
of an essential palsy is favorable, and that a cure is to be hoped for, 
when the affected muscles preserve their contractility; but that it is 
unfavorable, and that degeneration and atrophy ensue, when the elec- 
tric contractility is extinct. 
When the disease passes into the so-called second stage, the re- 
laxed flexible soft limbs, which may readily be placed in any required 
position, gradually lose their original plumpness. They suffer an 
atrophy which involves the skin, fat, muscles, and even the bones. In 
the course of a year the circumference of the limb, and even its length, 
is far smaller upon the crippled than upon the sound side. The pulse 
is small, corresponding to the deficient nutritive condition and marked 
depression of temperature of the paralyzed limb. It has a livid hue, 
and is liable to bed-sores, chilblains, and ulceration. As the disease 
progresses, deformity and contractions of the crippled limb are added 
to the atrophy. The wasted deltoid muscle is often no longer able tc 
hold the head of the arm-bone in its socket on the shoulder-blade ; sc 
that the arm sinks, stretching the capsule of the joint by its weight. 
We then find a depression immediately beneath the acromion, the 
head of the bone lying farther downward and backward. It is easy 
to replace the bone; but, as soon as the arm is permitted to hang 
down, it is immediately redislocated by its own weight. When the 
lower extremities are attacked, particularly if it be at the period when 
children try to move themselves about by shuffling, permanent short- 
ening takes place in the muscles which still retain some degree of con- 
tractile power and encounter no resistance from their antagonists. 
This is the mode of origin of a variety of forms of clubfoot, flexions of 
the hip, and the deformities of the knee-joint known as genu valgus. 
In advanced periods of the disease, the electrical contractility of the 
degenerated and wasted muscles is extinct. No conclusion as to the 
origin of the affection can be drawn from this condition, as it occurs in 
all forms of paralysis (even in the cerebral form) after it has lasted 
long enough for the nerves and muscles to degenerate. 
The general health usually remains unimpaired in essential paraly- 
sis. Many patients attain a great age, and, when they belong to the 
lower classes of society, are often seen as mendicant cripples on the 
high-roads. 
Treatment.—It is only in very recent cases of essential palsy that 
any benefit is. to be expected from local blood-letting, or from deriva- 
tives by the side of the spine. In old cases we have as little reason 376 
DISEASES OF THE PERIPHERAL NERVES. 
to expect the resolution of the remains of a process which has long 
since subsided, as to restore the apoplectic cicatrix of the brain after 
an attack of apoplexy, and thus to cure the hemiplegia. Indeed, 
where the electric contractility is extinct, and the nerves and muscles 
have degenerated, the restitution of the spinal marrow to a state of 
health would be of no benefit to the palsy. 
Although we scarcely ever are able to fulfil the causal indications 
or the indications from the disease, yet a treatment of the symptoms 
of the disease has been followed by comparative success. As long as 
any of the muscles maintain the slightest trace of their contractility, 
the systematic and active application of the induced current is indicated 
as being the best and surest means of preserving and increasing what 
remains of the irritability, and of arresting the atrophy and degenera- 
tion of the muscles. It is proved, moreover, by the results which 
Heine has obtained at his institution, that, even in cases apparently of 
the most desperate nature, the lot of the unfortunate patient may be 
materially alleviated by means of tenotomy and other expedients of 
rational orthopedic surgery. 
ADDITIONS TO THE REVISED EDITION OF 1880. 
SECTION III. DISEASES OF THE PERIPHERAL NERVES. 
1.—P. 331. 
Neuralgia is occasionally so obstinate that, besides exhausting 
the patient, it exhausts the physician’s list of remedies ; and it may 
not be out of place to record some of the numerous modes of treat- 
ment recommended. 
Apply ice to the seat of pain as long as the patient can bear it, 
while he holds brandy in the mouth. 
In periodic cases, where quinine fails, try salicylic acid in 30- 
gr. doses repeated two or three times ; or hypodermic injections of 
Fowler’s solution—arsenic ttl v-x, with the same quantity of dis- 
tilled water. 
Granules of gr. of aconitia, repeated three times daily till 
they cause tingling, are said to give relief ; not to be used in cases 
of heart disease. 
Inhalations of ether, of chloroform, or of nitrite of amyl (gtt. iij); 
if the latter is not effectual, it may be repeated in fifteen minutes 
and increased to six or eight drops ; it is more apt to give relief in 
cases where the face is pale. ADDITIONS TO THE REVISED EDITION OF 1880. 
377 
Either the induced or constant currents of electricity may do 
good, though the latter is most reliable in neuralgia. Change of 
air ; where there are spasmodic contractions of the muscles of the 
face, compression of the carotid on that side ; and where there is 
paresis on the neuralgic side, compression of the opposite carotid, 
are said to do good. 
Phosphorus gr. m mucilage, may be given ten minutes after 
something has been taken into the stomach, and repeated thus every 
two hours for three doses, then every three or four hours. 
Implication of the chorda tympani causes change in the sense of 
taste, especially for sour or salty things, on the anterior two-thirds 
of that side of the tongue. If it he true that the gustatory fila- 
ments of the facial only belong in the short portion between the 
entrance of the chorda tympani and the departure of the petrosus 
superficialis major, and pass with the latter to the second branch of 
the trifacial, loss of taste in facial paralysis would show that the cause 
must be at this part. Diminution of saliva has also been observed. 
Deafness may occur from disease of the internal ear or auditory 
nerve. There may be excessive sensitiveness of hearing (hyperaku- 
sis). In rheumatic paralysis this is said to occur especially for the 
deeper musical tones, and is probably due to paralysis of a small 
twig going to the stapedius muscle, and a consequent preponderance 
of the tensor tympani muscle. 
Althaus says that in rheumatic paralysis the farado-muscular 
excitability is generally normal; there may be slight anaesthesia of 
the skin ; the supinators and flexors are equally affected. In trau- 
matic paralysis the farado-muscular contractility is lost ; there is 
anaesthesia of the skin ; the supinators and extensors are equally 
affected. In lead palsy the farado-muscular excitability is lost; 
there is no anaesthesia of the skin ; the supinators are healthy. In 
cerebral paralysis the electro-muscular contractility continues. These 
diagnostic points are true in other paralyses as well as in that of the 
facial nerve. 
2.—P. 368. SECTION IV. 
GENERAL. NEUROSES, OF UNKNOWN ANATOM- 
ICAL ORIGIN 
CHAPTER I. 
% 
Etiology.—St. Vitus’s dance may be called a purely motor neu- 
rosis, all of its symptoms being attributable to a morbid irritability of 
the motor nerves, while no derangement, or,-at least, no constant de- 
rangement of the sensory or intellectual function can be detected. 
The pathogeny of chorea is obscure. None of the anatomical re- 
searches hitherto made upon the subject, nor any study of its symp- 
toms, give us any positive information as to the real point whence the 
morbid irritation of the motor nerves proceeds. The results of the 
somewhat rare autopsies which have been made upon subjects who 
have died of chorea have been either negative, or else so discordant 
that any lesion discovered in the central organs of the nervous system 
cannot be referred to the chorea, but rather to some accidental com- 
plication, or to the disease of which the patient died. The general 
implication of nearly all the cerebro-spinal motor nerves altogether 
contradicts the supposition that the origin of the disease lies in the 
peripheral nerves. The complete integrity of the other cerebral 
functions makes it improbable that the movements of chorea originate 
in the brain. On the other hand, certain pauses in the muscular rest- 
lessness which occur, particularly during sleep and during the action 
of chloroform, would seem to imply that the motor influence is derived 
from the brain rather than from the spinal marrow. There is no good 
ground for the hypothesis that chorea is dependent upon a dispropor- 
tion in size between the spinal canal and the spinal marrow, or upon 
inflammation of the vertebra, or upon spinal irritation, for we do not 
even know that the seat of the malady really lies in the soinal 
marrow. 
CHOREA CHOREA ST. YITI ST. VITUS’S DANCE. CHOREA. 
379 
In considering its etiology, in the first place, we are struck by the 
prevalence of the disease at the time of the second dentition and at 
the period of puberty. It often happens that an individual suffers 
from the disease at both these periods, and remains free from it during 
the interval. This accounts for the belief of the laity, that the com- 
plaint returns every seven years. Before the sixth year of life the 
disease is rare; and it is equally uncommon after the age of fifteen. 
Even the most advanced old age, however, is not entirely secure from 
it, and in such cases the affection exhibits a peculiar intractability. 
The predisposition to the disease is far greater in the female sex than 
in the male; and in certain cases an almost unmistakable hereditary 
tendency to St. Vitus’s dance has been observed. Moreover, hydraemia, 
anaemia, and rheumatism seem to augment the tendency to this affection. 
It undoubtedly is going too far to regard the connection between 
chorea and rheumatism as constant; but it cannot be denied that a 
remarkable number of chorea patients have already suffered from acute 
or chronic rheumatism, or else, during the disease or after it has sub- 
sided, a rheumatic attack sets in. In like manner, inasmuch as false 
heart-murmurs are very often heard in the hearts of chorea patients 
(and although many of them may be considered as blood-murmurs, 
and due to anaemia and to nervous derangement), yet the number 
which are certainly dependent upon valvular disease is large enough 
to enable us to judge how many of the patients have already suffered 
from rheumatic pericarditis and endocarditis. One of the most severe 
cases of chorea which I have ever witnessed was in a girl fifteen years 
of age, each one of whose joints successively became swollen; and 
another was in a girl, twenty years old, who had bad disease of the 
heart. Besides the mimic instinct, various mental emotions, especially 
fear, have been assigned as causes of chorea, as have also the irritation 
of worms in the intestines, onanism, pregnancy, and other agents. In 
particular instances it of course is very difficult to determine the 
causal connection between chorea and such influences, which so often 
exist without perceptible effect upon the health. The effect of exam- 
ple, which plays the principal role in the chorea major as well as in 
chorea minor, is instanced in the epidemic appearance of the disease 
sometimes observed in boarding-schools. The influence of pregnancy 
is inferred from the fact that, among adult patients, very many of them 
are pregnant women. Chorea rarely appears before the end of the 
second month of pregnancy, and its appearance is equally rare in the 
later half of the term. Once established, it usually lasts until after 
delivery. 
Symptoms and Course.—St. Vitus’s dance is characterized by 
movements of the voluntary muscles, which, however, are not excited 380 
GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN. 
by volition, but take place against the will of the patient, his con- 
sciousness meantime being perfectly unclouded. These movements go 
on not only at times when the patient does not intend to move, but 
also when he moves voluntarily. In the latter case, as the voluntary 
motion is complicated by the involuntary, the proposed action of the 
patient either is frustrated or carried out imperfectly or awkwardly. 
The involuntary movements of chorea are distinguished from the more 
simple and monotonous jerking muscular contractions of epileptic or 
hysterical attacks, by a great degree of variety, and by a sort of com- 
bination which imparts the aspect of design to the motions. A cursory 
and superficial observer would be much more apt to overlook and mis- 
take the former than the latter. 
In most instances the disease begins very gradually, and is not 
recognized for some time. It may be noticed, perhaps, that the sick 
child drops and breaks things a good deal; that it does not sit still; 
that it writes badly, or makes more mistakes than usual in playing on 
the piano, and it is accordingly scolded or punished that it may be 
more careful and correct its awkwardness. The poor child often 
does not know what it has done, and, in consequence of the unjust re- 
proaches, becomes either depressed and sad, or else grows irritated and 
perverse. The restlessness of the muscles, meantime, becomes more 
and more apparent. The acts of awkwardness become more frequent, 
and are grosser than ever. The child misses in reaching for its tum- 
bler, pricks itself with its fork, or makes extraordinary grimaces. The 
morbid character of this condition often becomes apparent to the minds 
of its relatives quite suddenly, and without the occurrence of any 
special change in the symptoms. It is much more unusual for the dis- 
ease to develop suddenly, and from the outset to present the remark- 
able symptoms which characterize St. Vitus’s dance in its later stages. 
In pronounced chorea, the utmost variety of motions follow each 
other, in a manner so manifold and grotesque that the term “ insanity 
of the muscles,” which has been applied to it, seems quite appropriate. 
In the face, the eyebrows are alternately contracted and separated, 
the forehead wrinkled and smoothed, the eyelids rapidly winked, and 
now and then are fast closed for a moment. The eyes roll hither and 
thither, the mouth is successively pursed up, closed, then suddenly 
opened and shut, now spreading into a smile, now drawn down as if 
to weep, while the tongue is often and suddenly thrust forward. The 
head itself is turned, now forward, now backward, now sideways; the 
shoulders are raised and sunken. The upper extremities are flourished 
about. In the elbows, hands, and finger-joints, flexion and extension, 
pronation and supination, abduction and adduction, alternate with 
one another. Similar movements, which, however, usually are of less CHOREA. 
381 
active character, are observed in the lower extremities. The muscles 
of the trunk also take part in the general restlessness, so that the spi- 
nal column is inclined either forward, backward, or sideways; some- 
times in one direction, sometimes in another. If the patient be lying 
in bed, he often is tossed upward, or toward the foot of the bed, or is 
even pitched out of it. In the worst forms of chorea, the patients are 
quite unable to sit upon a chair, but immediately slide off from it to 
the ground. This morbid restlessness grows all the more intense and 
general, if the patients pay attention to it, especially if they know that 
they are being watched. Sometimes it is stronger upon one side than 
upon the other, or is chiefly confined to one or more limbs. The mus- 
cles of the larynx and those of respiration but seldom take part in the 
disease, and the sphincters and the muscles of the pharynx probably 
never do so. Owing to the constant motion, it is difficult for the pa- 
tients to go to sleep; when once asleep, however, the muscular twitch- 
ing ceases. Occasional exceptions to these rules are now universally 
ascribed to dreams of movement, ever since Marshall Hall originally 
suggested the idea. 
Nearly all the motions of the body, with exception of those of 
respiration and deglutition, are seriously embarrassed by this restless- 
ness of the muscles. The articulation becomes indistinct, as the inten- 
tional movements of the mouth and tongue are accompanied by others 
which are unintentional. In eating, the fork misses the lips; in drink- 
ing, the beverage is spilt, so that a patient often has to be fed. Some 
of them have great difficulty in offering their hand, others are unable 
to dress and undress themselves. Even in slight cases all occupations 
requiring delicacy of manipulation become impossible, as, even in 
walking, the feet only touch the ground by a circuitous route, and, as 
the entire body is constantly making superfluous and irregular move- 
ments, there is something very remarkable and characteristic in the 
gait of the patient. 
The other functions and the general health suffer comparatively 
little. It is easy to comprehend why the patient should be dispirited, 
sensitive, and wilful, when we consider that for weeks he has not been 
master of his motions, and that he has been constantly taunted about 
the mistakes he makes. Not unfrequently the grimaces of the pa- 
tient are so at variance with his actual humor, or so unsuitable to the 
subject of conversation, as to give him a foolish, imbecile look, although 
his mind is quite sound. When of long duration, however, the accu- 
racy of judgment seems really to be impaired, and other intellectual 
disorder arises. Sometimes, but not always, there is complaint made 
of headache and pain in the back. Although, strange to say, there is 
no especial fatigue of the muscles, the joints of the limbs are some- 382 
GENERAL NEUROSES, Oi UNKNOWN ANATOMICAL ORIGIN. 
times swollen and painful from the constant strain and motion. Un 
less there be some complication, there is no fever, although the pulse 
usually is accelerated. The appetite, digestion, secretion, and excre- 
tion do not present any constant peculiarity. When the disease has 
been of long duration, the nutrition of the patient suffers in conse- 
quence of the loss of rest, and he becomes anaemic and thin. 
The course of chorea is chronic. It rarely terminates before the 
end of six or eight weeks, and it often continues for three or four 
months. In rare instances it becomes habitual, and lasts throughout life. 
Its course either is marked by remissions and exacerbations, or else the 
malady increases constantly to its acme; then remains stationary for 
a while, after which it gradually abates. Recovery is the most usual 
termination of the complaint. The cases are exceptional in which 
chorea becomes habitual; but it often happens that, in certain of the 
patient’s motions, a trace of the former disease remains for years, as 
well as a tendency to relapse. Permanent mental derangement is 
also rare. Death scarcely ever occurs, unless through complications. 
There are, however, a few instances on record where it ha* been the 
result of the disease itself. In these cases the muscular contractions 
rapidly become extremely violent and general. This was followed by 
collapse and coma, in which the patient perished. 
Treatment.—Our scant knowledge as to the causes of chorea 
puts a fulfilment of the causal indication almost out of the question. 
When the disease has been preceded by symptoms of anasmia and 
hydrasmia, the ferruginous preparations are to be selected from the 
long list of reputed remedies against chorea. We do not attempt to 
say whether carbonates of iron (gr. v—gr. x pro dosi), or ferr. hydro- 
cyanic (gr. ij—gr. iij pro dosi), which are the favorites, possess any 
real advantage over the other preparations. When the patient has 
suffered from rheumatism, the sulphur-baths (as recommended by 
Baudeloque), an ounce of sulphuret of potassium to twelve gallons of 
water, in which the patient is to spend an hour at a time, are as much 
to be recommended as are the chalybeates, when there is anaemia. 
Where worms are known to exist in the intestine, the treatment may 
be commenced by a dose of santonin or other anthelmintic. 
The number of remedies proposed for the cure of the disease itself 
is very large. As, however, the disease usually subsides spontaneous- 
ly, in the course of six or eight weeks, and as it very rarely is possible 
to cut the malady short in a less period of time, we are very apt, it 
quite candid and circumspect in measuring our success in special in- 
stances, to be in doubt as to whether the chorea abated in consequence 
of a six weeks’ administration of the medicine prescribed, or whether 
it “got well of itself.” Fortunately, most of these remedies, if cau- CHOREA. 
383 
liously given, can do no harm. This is especially true of the prepara- 
tions of zinc, particularly of the oxide. The sulphate, the valerianate, 
and the hydrocyanate of zinc, are less innocent, but not more to be 
relied upon, nor are the ammonio-sulphate of copper and nitrate of 
silver. Romberg's valuable opinion is in favor of arsenic; and, indeed, 
where we have determined to employ the metallic nervines, Fowler's 
solution (gtt. iij—gtt. v t. d.) is to be preferred to all others. The 
narcotics may be dispensed with, as a rule, in treatment of chorea, and, 
moreover, are apt to be so ill-borne that we often have regretted the 
administration of an evening dose of Dover’s powder or morphine to 
insure the rest of the patient. My experience as to the action of 
opiates is, however, in opposition to that of one of our great authori- 
ties. Trousseau urgently recommends the administration of large 
doses of morphine, and claims, too, that they are remarkably well 
borne. Strychnine, another medicine for chorea, strongly recommended 
by Trousseau, and which has been given, as directed by him, at first 
in very small doses, afterward in larger ones, until slight signs of 
poisoning set in, has met with little approval in Germany. Their in- 
troducer’s own experience, which by no means resulted in sudden or 
even in rapid cures, offers no encouragement to make use of these 
noxious remedies. This is also true of the proposed hypodermic in- 
jection of curare. With this article the certainty of benefit is by no 
means proportionate to the dangers incidental to an overdose. When- 
ever the vertebras are sensitive to pressure, a few leeches or cups may 
be applied by the side of the spine, to be followed by counter-irritants 
to the skin. Care should be taken, however, not unnecessarily to dis- 
figure the necks of young girls by scars; hence we should avoid the 
use of tartar-emetic ointment. Cold affusion upon the back, which is 
probably the best method of producing determination to the skin, 
seems to be of decided benefit in some cases, especially in cases of 
long standing, although it sometimes aggravates the disease!? The in- 
halation of chloroform is an excellent palliative for the severer forms 
of the chorea; but further experience only can determine whether the 
repeated and long-continued exhibition of this article, pushed to the 
point of complete narcotism, has the effect of abbreviating it. A more 
careful trial will be requisite ere the general adoption can be sanctioned 
of the practice of forcibly holding or tying patients, a practice which 
has been proposed by several authorities. Benedikt declares that, 
“ out of more than twenty cases of chorea, treated by him by the con- 
stant galvanic current, not one has failed to recover.” The current 
which he employs is just strong enough for the patient to feel it dis- 
tinctly, and he applies it along the spine, the patient standing erect. 
Painful currents aggravate the symptoms. During convalescence we 384 
GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN. 
should endeavor to teach the patient, by a systematic and humane 
system of discipline, to resist the involuntary motions by the force 01 
his will. 
CHAPTER II. 
LOCKJAW—TRISMUS—TETANUS. 
Etiology.—Like chorea, lockjaw is a derangement of the motor 
function. The symptoms of this disease are ascribable to a morbid 
excitement of the motor nerves, the participation of the sensory nerves 
in the disease being but slight, and, for the most part, of a secondary 
character. In this malady, however, we know, with much greater cer- 
tainty than we do in chorea, that the morbid irritation of the motor 
nerves proceeds from the spinal marrow. This hypothesis is supported 
rather than contradicted by the fact that the results of post-mortem 
examination of the spinal marrow usually are negative in cases of 
tetanus, and that real tetanic spasms are seldom observed in cases of 
grave organic disease of the spinal cord. It would be quite impossible 
for motor impulses to originate from a spinal marrow reduced to a mass 
of debris, or whose elements were otherwise degenerate or destroyed, 
while experience teaches that the lesions from which abnormally-active 
impulses proceed are insusceptible of anatomical demonstration. At 
the outset of the disease, tetanic spasms are generally produced by 
the action of trifling but still appreciable irritants, which, acting upon 
the extremities of the peripheral nerves, throw the spinal marrow into 
a state of excitement, so that, at this period, the spasms, although dis- 
tinguishable from other reflex symptoms by their greater violence and 
longer duration, may be called reflex spasms. As the malady advances, 
however, such causes are not required in order to give rise to the 
cramps. The spinal marrow then remains permanently in the condi- 
tion of intense excitement into which it is thrown by the motor nerves. 
With regard to the etiology of the disease, a number of noxious 
agents may be enumerated, which can be proved capable of inducing 
the morbid state of the spinal marrow to which tetanus is due. First 
among these are wounds, especially lacerated, punctured, and gunshot 
wounds, and wounds in which foreign bodies remain lodged. Injuries 
of this kind are more dangerous upon the extremities than upon other 
parts of the body; but they never give rise to tetanus except under 
certain conditions, of which, sudden change of temperature (such as 
hot days followed by cold nights) is known to be one, while others are 
unknown. Bardeleben aptly sums up this condition as follows: that 
the wound is the predisposing agent, and the chilling the exciting 
cause. We do nit know, however, what the changes in the nerve- TETANUS. 
385 
tissues are which induce tetanus, nor how they affect the. spinal marrow. 
The injection and swelling in the course of the nerve, between the 
wound and the spinal marrow, which have sometimes been observed, are 
by no means constant. In other cases, lockjaw occurs from the effect 
of cold, without any previous wound, as when a man has slept upon 
the moist earth, or been wet while his body is heated. This form of 
rheumatic tetanus is much more rare than the traumatic form. Here, 
too, we are completely in the dark as to the ways and means by which 
the lesion, suffered by the cutaneous nerves in rheumatic tetanus, is 
transmitted to the spinal marrow. The tetanus observed sometimes 
in newdy-born infants (tetanus neonatorum) is usually regarded as a 
third form of the disease, although it should properly be reckoned as 
belonging to the traumatic variety. Tetanus neonatorum never occurs 
excepting between the first and the fifth day after the fall of the navel- 
string. Hence it has always been immediately preceded by a wound 
(ligation and binding of the cord). The objection that, in some cases, 
there is inflammation of the umbilicus, while in others there is none, 
is not valid; for, even in the wounds of adults which have caused lock- 
jaw, although, in most cases, they are violently inflamed, and other- 
wise affected, yet there have been instances in which the wound was 
doing perfectly well, and was healing, or even was completely cica- 
trized. Besides, in infantile tetanus, the ligation and division of the 
umbilical cord can only be considered as the remote cause, while the 
chilling of the skin, or other unknown agent, which sometimes seems 
to be of an epidemic nature, must be regarded as the immediate cause. 
Finally, a morbid condition of the spinal cord is induced by poisoning 
with strychnine, which exhibits precisely the same symptoms as those 
of lockjaw, so that the toxic signs induced by strychnine and brucine 
have been called tetanus toxicus. 
Traumatic and rheumatic tetanus is of far more frequent occurrence 
m men than in women. Vigorous constitutions are more liable to it 
than feeble ones. In the tropics the disease is more common than 
with us; and certain races, especially negroes, seem to be more prone 
to the disease than Europeans. 
Symptoms and Course.—Tetanus is characterized by continuous 
tonic spasms, which principally involve the muscles of the trunk and 
those of mastication, and which are marked by paroxysmal periods 
of aggravation of extreme intensity. 
The malady is usually preceded by signs consisting of a febrile 
condition of no great severity, and pain, and stiffness in the back of 
the neck, which may readily be mistaken for a trifling fit of rheuma- 
tism. If such symptoms make their appearance after receipt of a 
wound of the character above given, and if at the same time the 386 
general neuroses, of unknown anatomical origin. 
aspect of the wound change, and should it become dry and pain- 
ful, we may already fear great danger to the patient. When the 
disease has fairly set in, the head at first is almost always fixed and 
drawn backward, by rigid contractions of the muscles of the neck. 
Tonic spasms of the muscles of mastication press the jaws firmly 
together (lockjaw, trismus), and at the same time deglutition is im- 
peded or prevented by spasm of the pharynx. From the nape of the 
neck the disease extends over the muscles of the back. Thus the 
entire body is bent backward in the shape of a bow. The abdominal 
and thoracic muscles, however, are also involved in the spasm. Hence 
the belly is tense, contracted, and hard as a board, and there is a sense 
of constriction at the pit of the stomach, which is very painful to the 
patient. More rarely the muscles of the extremities, particularly those 
of the forearms, legs, hands, and feet, are attacked by cramps. The terms 
opisthotonos, emprostliotonos, andpleurosthotonos, are severally applied 
to the disease, according as the contractions preponderate in the poste- 
rior muscles of the neck and back, in the anterior muscles of the neck 
and trunk, or in those of the side, and according as the body is drawn 
forward, backward, or sidewise. When there is no such preponderance, 
so that the body lies rigid as a statue, the condition is called orthoto- 
nos. Opisthotonos is by far the most common form of the malady; 
the other varieties are rare. The contracted muscles remain upon the 
stretch throughout the whole disease. From time to time, however, 
paroxysms occur, in which the cramps are so severe that the muscles 
sometimes are torn asunder. At such times the middle of the body is 
suddenly jerked into the air, so that no part of it touches the bed ex- 
cept the head and heels. The muscles are hard as stone, and are the 
seat of frightful pain, which can generally be compared to that of a 
severe cramp of the leg. The contours of the temporal and masseter 
muscles stand out in bold relief, imparting a peculiar expression of 
countenance. This is still further increased by contractions of the 
mimic muscles of the face. The forehead is wrinkled, the brows knit, 
the eyes rigidly fixed, and sunken deep into their sockets. The angles 
of the mouth are drawn outward, and the lips are drawn apart, expos- 
ing the clinched teeth. The muscles of the extremities are affected 
last; this is an important point in diagnosis. At the outset of the 
disease the paroxysms do not occur spontaneously, but are provoked 
by the most trifling causes. Just as in a frog poisoned by strych- 
nine, in which tetanic spasms may be induced by merely tapping upon 
the table on which he lies, so the slightest touch upon the. skin or 
breath of air upon it, a faint jolt of the bed, the sound of shutting 
a door, every movement which a patient desires to make, the acts 
of chewing or swallowing, or even the suggestion of the idea, suf- TETANUS. 
387 
lice to bring on a new attack. The inability to swallow, and the spas- 
modic seizures induced by every effort to drink, create a certain resem- 
blance between tetanus and hydrophobia. The paroxysms are of 
variable duration. At first they are brief, but at the height of the 
disease they may continue for a quarter of an hour, or even an hour, 
ere the remission set it. Consciousness and the intellect generally 
remain unimpaired until the last in this frightful malady, nor are many 
of the other functions materially deranged. The unhappy patient 
suffers from hunger and thirst, which he is unable to relieve. As in all 
other violent muscular exertion, the skin is bedewed with sweat, and 
the pulse is frequent and small. The enormous elevation of the tem- 
perature, first pointed out by Wunderlich, is a matter of great interest. 
Now and then it has been observed as high as 110° F., and immedi- 
ately after death a further rise has been observed almost up to 112° F. 
[This may be due to the muscular activity. Leyden and others 
have shown that the same elevation of temperature occurs in tetanus 
artificially induced in dogs. But similar rises are said to occur after 
injury of the cervical medulla and other cerebral and spinal diseases 
of the warmth-producing centres ; as in J. W Teale's case, where 
the temperature was 108°-122° for some weeks, as witnessed by 
several physicians.] The bowels are usually somewhat constipated, 
and sleep, though ardently longed for, is impossible. Another source 
of anguish, as well as of the greatest danger, consists in the derange- 
ment of the respiration. There is no obstacle to the entrance of the 
air, but, as Watson aptly remarks, the chest is compressed as in a vice, 
and respiration is made extremely difficult by reason of the rigidity 
of the muscles. There are instances where the victim perishes only a 
few hours after the outbreak of the disease. In such cases, the spas- 
modic contraction of the diaphragm and other respiratory muscles so 
increases as to completely arrest respiration and cause suffocation. 
The majority of patients are not relieved from their sufferings so soon. 
For three or four days, the cramps, and the frightful pain and dread of 
suffocation which accompany them, continue to increase in duration 
and frequence, the remissions becoming more and more imperfect; 
until the sufferer expires, either poisoned by carbonic acid resulting 
from the imperfect manner in which respiration is carried on, and from 
the augmentation in the consumption of the oxygen, or else dying 
during some very severe paroxysm, through sudden and absolute inter- 
ruption to the respiration. Sometimes the breathing is not so much 
interfered with as to cause death from lack of oxygen. The disease 
may then go on for weeks ere the patient, in a state of extreme emacia- 
tion, and exhausted by privation of nourishment, succumbs to starvation. 
Recovery is extremely rare. Transitory remissions, in which the 388 
GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN. 
patient may even enjoy a brief refreshing slumber, should not be 
allowed to deceive us. After such pauses the malady generally breaks 
out with all its former severity, or even with increased violence. We 
must not indulge m the hope of recovery unless the seizures continue 
to diminish in length and frequence, distinct relaxation of the con- 
tracted muscles occurring during the intervals, and unless the patient 
become able to take food and nourishment. Even in the most fortu- 
nate cases this takes place with extreme slowness; and it is not until 
after the lapse of weeks that the muscles entirely lose their tension, 
and the patient is completely well. 
The symptoms of tetanus neonatorum are but little modified by the 
peculiarities of the infantile organism. Here, too, the outbreak of the 
disease usually is heralded by indistinct prodromata. The child cries 
out frequently during sleep; has blue rings around the eyes and lips; 
and lets go the breast which it has just seized with avidity. The 
mother first becomes aware of the onset of the disease itself when she 
finds that neither the nipple nor the finger can be inserted into the 
mouth. The jaws stand several lines apart, but it is impossible to 
separate them further. The malady increases rapidly. The muscles 
of the face are also contracted spasmodically. The forehead is wrin- 
kled, the eyelids firmly shut, and surrounded by converging wrinkles. 
The aim nasi are dilated, the lips compressed and puckered, while the 
tongue usually is fixed between the jaws. Besides this, there is opis- 
thotonos, the head is drawn backward, and the spine arched like a 
bow. A touch, or an attempt to move or swallow, provokes a violent 
spasm; but the remissions usually are more complete than they are 
in the tetanus of adults. Respiration is impeded, during the seizures, 
by the rigidity of the thorax and the tension of the abdominal mus- 
cles. Attacks of suffocation arise, of which the child often dies in 
from twelve to twenty-four hours. In other cases the breathing grad- 
ually becomes insufficient, and the child succumbs to overcharge of the 
blood with carbonic acid. Death then takes place more slowly, but 
still within a few days, during which the child loses flesh rapidly. 
Recovery from tetanus neonatorum is likewise extremely rare. 
Treatment.—For the fulfilment of the causal indication, a series 
of surgical operations—even amputation of the wounded member— 
have been proposed and practised. The success of these operations, 
however, was by no means what had been anticipated of them, and 
more recently they have been abandoned. From the prominent part 
which is unmistakably played by exposure to cold, both in rheumatic 
and in traumatic tetanus, warm and stimulating baths, as well as Russian 
vapor-baths, would seem to be indicated. The objection, that the 
manipulation necessary in giving such baths tends to aggravate the TETANUS. 
389 
symptoms, only held good in two of Ilasse’s cases, and that only at 
the very commencement, and not after the manipulation had been con- 
tinued. This circumstance and the relief which the baths afford to the 
patients imperatively demand their employment. 
Upon the supposition that tetanus was an inflammatory affection 
of the spinal marrow, the attempt was formerly made to fulfil the indi- 
cation of the disease itself by blood-letting, local and general, and by 
the exhibition of calomel to the point of salivation. Such procedures, 
however, have been abandoned more and more in later times. Unfor- 
tunately we do not possess any remedy capable of bringing back the 
irritable state of the spinal cord to its normal condition. Even the 
narcotics do not have this effect, although they are indispensable for 
the purpose of alleviating the sufferings of the patient. To accomplish 
this, large doses must be given ; so that, unless the approach of narco- 
tism be vigilantly watched, there is danger of hastening the fatal 
termination. If the patient cannot swallow, morphia should be given 
hypodermically, or else clysters, containing twenty or thirty drops of 
laudanum. Injections of tobacco are not of much greater service than 
opium-clysters, and, unless the dose be regulated with extreme caution, 
they are much more liable to give rise to a fatal collapse than the lat- 
ter. The anaesthetics, if possible, are of still greater importance than 
the narcotics; but, unfortunately, their effects likewise are merely pal- 
liative. Too free use of them must be avoided, and the patient must 
not be kept in a state of permanent insensibility from chloroform. 
The English recommend the stimulants, especially carbonate of ammo- 
nia, brandy, and wine, to which they give much greater credit than to 
blood-letting and the narcotics. Trustworthy observers have obtained 
very great benefit from the hypodermic injection of a solution of curare 
in tetanus. This treatment certainly deserves further trial. However, 
owing to the very variable character of the curare, it will be necessary, 
prior to the exhibition of the preparation to be used, to ascertain, by 
experiment upon animals or upon the healthy human being, how large 
a dose may safely be administered. When this precaution has not 
been taken, we must commence with very small doses (gr. -J to gr. 
and gradually increase them to gr. % to gr. 1|-. Demme advises that 
a solution of one or two grains in one hundred drops of water be em- 
ployed, ten drops of this to be injected as a dose. According to 
Demme, the action of curare lasts four or five hours, and then begins 
to abate; and upon this fact the repetition of the dose may be reg- 
ulated. It is most important that the patient should be kept in a 
quiet chamber, with a uniform temperature, and that his eyes should 
be screened from too bright a light. 
For the tetanus neonatorum we may prescribe camomile-baths, 390 
GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN. 
clysters containing a drop of laudanum, and, if the spasms be very 
severe, chloroform may be administered, but Avith great caution. 
EPILEPSY—FALLING SICKNESS—MOKBUS SACER—HAUT-MAL. 
Etiology.—Unlike chorea and tetanus, epilepsy cannot be called 
a purely motor neurosis; since the interruption which takes place, both 
in consciousness and insensibility, is quite as essential an element of 
an epileptic fit as the convulsions. The absence of one or other of 
these symptoms renders the seizure imperfect. 
We may assume that the excitement of the motor nerves, of which 
the convulsions are the exponent, proceeds from the medulla oblongata 
and the portion of the brain lying upon the base of the skull. This is 
shown. 
1. By the interruption of the functions of the hemispheres, which 
accompanies the convulsions. It is not probable that motor impulses 
proceed from the hemispheres at a time when the irritability of the 
other ganglion-cells and nerve-fibres is extinguished. 
2. Because convulsions, similar to epileptic convulsions, can be ex- 
cited by continuous excitement of the basilar portion of the brain by 
means of the induction apparatus, while no such result is obtained by 
a like irritation of the various parts of the hemispheres. 
3. Because Kussmaul and Tenner, in their experiments upon ani- 
mals, could still produce convulsions of a decidedly epileptiform char- 
acter after extirpation of both hemispheres. 
4. Schroeder van der Kolk has found that, in all bodies of epilep- 
tics where the disease had been of long standing, besides numerous 
inconstant lesions, there was alway a dilatation of the arterioles and 
capillaries of the medulla, with thickening of their walls. The influences 
which tend to produce this condition of the medulla oblongata, where- 
by it throws the nerve-fibres passing through it or originating from 
it into such intense excitement, and which, for brevity’s sake, we call 
a state of irritation, are probably of a manifold character. It is true 
that the experiments of Kussmaul and Tenner have proved that 
epileptiform convulsions may be induced by cutting off the supply of 
arterial blood from the brain; but they do not prove that arterial 
anaemia of the brain is the sole cause of epileptic fits. Schroeder van 
der Kolk believes that epileptic convulsions depend mainly upon an 
increased afflux of arterial blood to the medulla oblongata. There is 
no doubt, moreover, that the morbid irritability of the medulla which 
occasions epilepsy may arise without any increase or diminution of its 
CHAPTEK III. EPILEPSY. 
391 
supply of blood, merely from the improper character of its nutriment 
and from the admixture of certain materials in the blood. It must 
also be admitted that the medulla may be thrown into an irritated 
condition by the transmission of a morbid impression from remote re- 
gions of the nervous system, whether central or peripheral. It is well 
known that neuromata and cicatrices, or tumors pressing upon periph- 
eral nerves, have sometimes occasioned epilepsy (although, indeed, 
such instances are not common), and that the epilepsy has ceased 
after section of the affected nerve or after removal of the cause. Per- 
haps, also, cerebral tumors and other diseases of the brain and spinal 
marrow may induce epilepsy in a similar manner by gradual transmis- 
sion of a morbid irritability to the medulla oblongata. This supposi- 
tion has received strong support from the result of recent experiments 
by JBrovm-Sequard, in which dogs, whose spinal marrows had been 
injured, suffered from convulsions, although not immediately, but 
some time after the receipt of the injury. It is difficult to say why 
the morbid irritability of the motor nerves is not continuous, but mere- 
ly occurs in paroxysms, with intervals which frequently are of very long 
duration. Are we at liberty to suppose that it is only now and then 
that the medulla oblongata falls into this morbid state ? Is there 
really ground for the hypothesis that the cause of epilepsy is a tran- 
sitory spasm of the muscular fibres of the arteries, with consequent ar- 
terial anaemia ? Is it true that poisons, or the irritation of remote 
tumors, or other agents which give rise to epilepsy, act by the occa- 
sional provocation of the spasm of the muscles of the blood-vessels ? 
May we, with Schroeder van der Kolk, compare the ganglia of the 
medulla oblongata to a Leyden jar, or to the electric organ of certain 
fishes ? May an epileptic fit be likened to the spark from the Leyden 
jar, or to the discharge of the electric organ of the electric fish ? and 
do the ganglia reload themselves, as it were, for a fresh explosion 
during the intervals ? Or, finally, is the morbid state of the medulla 
constant, but requiring the additional stimulus of some new transitory 
irritant transmitted to it from some remote point in the brain, the spi- 
nal cord, the peripheral nerves, or the intestines, in order that the 
fit may occur ? Of all these conditions we as yet have no accurate 
knowledge, and it were idle to advance other hypotheses in explana- 
tion of the foregoing ones. 
Equally inexplicable is the constant coexistence of irritability of 
the spinal marrow with palsy of the cerebral hemispheres. The arrest 
of sensation and consciousness has sometimes been regarded as a sec- 
ondary condition, resulting from the convulsions. It has been attrib- 
uted in part to venous engorgement of the brain, arising from com- 
pression of the cervical veins by the contraction of the cervical mus 392 
GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN 
cles, and in part to surcharge of the blood with carbonic acid, in con- 
sequence of spasmodic closure of the glottis. The fact that the loss 
of consciousness and sensation and the occurrence of the convulsions 
are almost always simultaneous; and that the former sometimes pre- 
cedes the latter; and that in many cases of incomplete epilepsy it is 
the sole symptom of the seizure, is a sufficient refutation of both hypoth- 
eses. In like manner it must be declared that there is no proof as 
to the truth of the theory of Schroeder van der Ifolk, that, in an epi 
leptic fit, the ganglion-cells of the medulla excite a spasm of the vaso- 
motor nerves of the brain, simultaneously with that which they induce 
in the cerebro-spinal nerves, and thus cause cerebral anaemia and 
palsy. So, too, with Ilenlds theory, which supposes the existence 
of a plethoric and an anaemic form of epilepsy. He suggests that, in 
the former, besides the more intense hyperoemia of the hemispheres 
which induces the palsy, a lesser degree of hyperaemia, capable of in- 
ducing symptoms of mere irritation, arises in the medulla oblongata; 
while, in the anaemic form, he imagines that the lack of blood in the 
cerebral vessels occasions an increased blood-pressure upon the me- 
dulla oblongata, inducing in it a degree of engorgement sufficient to 
cause signs of irritation. Here, too, we shall refrain from further 
theorizing, preferring to admit that to us the antagonism existing in 
epilepsy, between the condition of the hemispheres and that of the 
basilar portion of the brain, is entirely inexplicable. 
Owing to the scantiness of our knowledge as to the pathogeny of 
epilepsy, the statistics regarding its predisposing and exciting causes 
are of but secondary importance. We do not know of one single 
agent of which we can certainly predict that it will produce epilepsy ; 
yet, besides this, we must admit that all the assigned causes of this 
disease by themselves are incapable of inducing it, and that the co- 
operation of a second and unknown factor is always requisite. Statis- 
tics show epilepsy to be a very common disease, about six epilep- 
tics being found in every thousand individuals. Females suffer from 
it somewhat more frequently than males. There is no age which is 
completely exempt from it; but the majority of cases occur between 
the tenth and twentieth years of life; next to this, between the sec- 
ond and the tenth year, and between the twentieth and thirtieth year. 
It seldom commences during old age, and its congenital occurrence, 
as well as its appearance in the first months of life, is equally rare. 
Hereditary predisposition plays an unmistakable part in its produc- 
tion ; its existence is demonstrable in nearly a third of all cases. It 
is especially apparent in persons descended from epileptic parents, par- 
ticularly from epileptic mothers, as well as in individuals whose par- 
ents or ancestors have been insane or intemperate. In some families EPILEPSY. 
393 
epilepsy afflicts many of its members throughout several generations. 
Sometimes the disease skips a generation, and the grandchildren are 
attacked, but not the children. Cachectic subjects, drunkards, and 
onanists, are more liable to it than healthy, vigorous persons, although, 
the latter are by no means exempt. The chief of its exciting causes 
are violent mental emotions, sudden fear, terror, and the sight of an 
epileptic fit. In more than a third of all cases the first attack has fol- 
lowed upon some violent fright. The most common structural altera- 
tions found in the skull and brain, which, however, like the mental 
emotions, are not constant, and only give rise to epilepsy under cer- 
tain unknown conditions, are asymetry, imperfect development of the 
skull, diffuse thickening or exostosis of the skull, thickening, adhesion 
and ossification of the dura mater, tumors and deposits in the brain, 
chronic hydrocephalus, and cerebral hypertrophy. Alteration in the 
appendages of the brain, which Wenzel mentions as a constant lesion 
in epilepsy, is absent in the majority of cases. Changes of structure 
in the spinal marrow are not so frequently found in epilepsy as similar 
changes in the brain; but perhaps this is because the former have 
been less diligently examined than the latter. We have already 
alluded to the neuromata, tumors, and scars, which sometimes give 
rise to the disease by the pressure which they exert upon peripheral 
nerves. In a similar manner, epilepsy may arise from an abnormal 
irritability of the sensory nerves, induced by some severe irritation at 
their peripheral extremities. Thence, according as the irritation in- 
volves the nerve-tips of the thoracic organs, those of the organs of 
digestion, or those of the urinary or sexual apparatus, the epilepsy is 
classified into epilepsia cardiaca, pulmonalis, abdominalis, nephritica, 
uterina, etc. It is manifest that we may easily err in attributing the 
disease to irritability of one or other of these organs. Uterine epi- 
lepsy is perhaps the least ambiguous of all, as a gradual transition 
from hysteria to epilepsy may sometimes be observed, and as some 
women become epileptic upon their first coitus. The presence of 
worms in the intestines also is sometimes an unmistakable cause of 
the disease. 
Symptoms and Course.—Epilepsy is a chronic disease, character- 
ized by convulsive attacks, accompanied by loss of consciousness, with 
intervening periods of exemption of variable and sometimes of very 
long duration. Loss of consciousness during an epileptic fit necessa- 
rily involves loss of sensation and incapacity for voluntary motion. In 
incomplete epilepsy, the “ petit mal ” of the French, there usually are 
no convulsions during the seizure, or else merely a few twitchings. 
Such rudimentary attacks, of course, are not to be called incomplete 
epilepsy unless they alternate with well-pronounced seizures, or arise 394 
GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN. 
from them, or unless, in the further course of the case, the rudimen- 
tary fits gradually developed into perfect ones. 
In some patients an epileptic fit is regularly, or at all events gen- 
erally, ushered in by an aura. This aura receives its name from a 
sensation as of a vapor which rises from the extremities toward the 
head, and terminates in the fit. This prodromic feeling, however, is 
only described by a few patients. Far more frequently there are other 
sensations, such as a sense of creeping, of warmth, or numbness, or a 
peculiar pain in some part of the body darting thence to the brain, 
which herald the attack, and which are called the “ aura epileptica.” 
Instead of this sensible signal, the fit is preceded in other instances by 
twitching or palsy of some part of the body. This is called the motor 
aura, in contradistinction to the sensory aura above described. In 
other cases, again, the seizure is ushered in by abnormal phenomena in 
the organs of sense, hallucinations, visions of sparks or of colors, buzz- 
ing in the ears, the report of a loud crack or other sound, dizziness, 
and sometimes by the regular recurrence of phantasmagoria of more 
or less grotesque character. This latter form of sensorial or mental 
aura by no means proves that the epilepsy is of central origin, in the 
sense, at least, that the malady is the result of appreciable lesion of the 
brain; nor is the occurrence of an aura arising from the extremities to 
be regarded as a proof of the peripheral origin of a case of epilepsy. 
It is an extraordinary fact that an epileptic fit may sometimes be 
averted by binding a ligature firmly above the starting-point of the 
aura, and thus, as it were, isolating it. That even such a phenomena 
as this is no proof of the peripheral origin of an epilepsy is in some 
degree manifested by the experiments above mentioned of J3roum- 
Sequard. Here it was demonstrated that, in the dogs made epileptic 
artificially by wounding of the spinal marrow, a fit occurred wherever 
the skin was irritated within the province of a particular branch of the 
trifacial nerve. We cannot tell whether the fit was preceded by an aura 
in these dogs, but we may positively conclude from these experiments 
that, even when the individual epileptic attacks are induced by periph- 
eral irritation, the real cause of the disease may consist in palpable 
structural disease of central organs. 
Whether preceded by an aura or not, the outbreak of the paroxysm 
is usually announced by a shrill cry, whereupon the patient loses all 
sense and falls to the ground, usually backward or sideways. He 
scarcely ever has time to seek a convenient place, but falls, regardless 
of place, often in the most perilous situations, striking, perhaps, against 
a hot stove, a sharp corner, or down the stairs. There are but few 
epileptics, whose disease is of long standing, who do not carry with 
them the marks of more or less severe injury. The fall is usually fob EPILEPSY. 
395 
lowed at first by tonic contractions, in which the body and extremities 
are extended, the head drawn backward or to one side, the mouth 
firmly closed, the eyes wide open, and rolled upward or inward, the 
thorax fixed, and the respiratory movements arrested. After a few 
moments, during which the jugular veins become distended and the 
face purple, the tonic spasms are converted into clonic ones, which soon 
convulse the whole body. The countenance, hitherto immovable, is 
now thrown into active agitation; the angles of the mouth are drawn 
hither and thither, the forehead and eyebrows twitch, the eyes open 
and shut, the jaws are forcibly pressed together, and are worked back- 
ward and forward, so that the teeth grate audibly. The teeth are not 
unfrequently broken off, the tongue bitten through, and even the lower 
jaw may be luxated. Upon the lips there appears a saliva, rendered 
frothy by the constant movements of the mouth, and which, too, is 
often bloody from wounds of the tongue or cheeks. The head is jerked 
forward and backward, and from side to side; while the convulsive 
twitchings of the muscle of the trunk pitch the body hither and thither. 
In the extremities, and especially in the upper extremities, quick 
kicking, striking, twisting, and twitching motions occur in turn, and 
with such violence as sometimes to result in luxation or fracture. The 
fingers usually are flexed, the thumb being pressed into the palm of 
the hand, a sign which the laity erroneously believe to be pathog- 
nomonic. Sometimes it seems as if the violence of the convulsions 
were remitting, and as though the fit were about to abate; but the 
lull is soon followed by a fresh outbreak, and the convulsions become 
more violent than ever. Sometimes the twitching is superseded, for a 
few moments, by a tetanic condition like that by which the paroxysm 
commenced. Throughout the whole fit the respiration is much em- 
barrassed, owing to the impediment offered by the tonic or clonic 
spasms of the respiratory muscles to the regular heave and fall of the 
chest. Still more is this the case when the glottis is closed by spasm 
of the laryngeal muscles. As on all other occasions of unusual mus- 
cular exertion, the beat of the heart is accelerated, the pulse is small 
and sometimes irregular, while the skin is bathed in sweat. The 
bowels and bladder are often evacuated unconsciously; more rarely 
erections and seminal emissions occur. Throughout the entire seizure, 
consciousness is so completely extinguished that the patient is not 
aroused, nor does he betray any sign of pain, even though he may 
strike against a red-hot stove, or fall into the fire so as to completely 
char a limb. Opinions are divided as to the state of the reflex ac- 
tion during the attack. I admit that I find it very difficult to take 
note of it in the more violent class of fits. During seizures which are 
mild from the beginning, or during the period of subsidence of more 396 
GENERAL NEtJROSES, OF UNKNOWN ANATOMICAL ORIGIN. 
severe attacks, I liave been able fully to confirm Romberg1 s observa- 
tions, that the reflex action is not arrested. The patient closes his 
eye if the conjunctiva be touched, and winces if his face be sprinkled 
with cold water. One observation of Haase’s is exceedingly strange 
and difficult of explanation. In a patient of his he found the electric 
contractility was extinguished in the muscles of the thorax and ex- 
tremities. After the fit has lasted for ten minutes, or, at most, for a 
quarter of an hour (although it may seem much longer to the by 
standers), either it subsides, the twitching gradually growing weaker 
and weaker, and finally ceasing, or else it may stop suddenly, the con- 
vulsions being all at once followed by complete muscular relaxation. 
The fit often terminates by a long, sighing expiration; more rarely by 
vomiting, by passage of gas upward or downward, or by a profuse 
evacuation of the bowels. 
It rarely happens that a severe epileptic seizure is immediately 
followed by complete recovery; after the attack is over, generally, 
unless violently roused, the patient falls into a deep sleep, with pro- 
longed stertorous respiration. If awakened from this, he usually looks 
blankly or anxiously around him. He does not know what has hap- 
pened, and can scarcely account for his being in a strange place, or in 
bed, or wounded. His sole desire is to be allowed to sleep. Next 
morning, though still somewhat unwell and low-spirited, and com- 
plaining of confusion about the head, he has recovered his faculties, 
and all traces of the attack vanish in course of the day. 
Many epileptic fits differ considerably from the typical seizure 
above described, varying in duration, violence, and in the extent of the 
convulsions. The variation of the condition which immediately suc- 
ceeds the paroxysm is of more importance. While, as a rule, the pa- 
tient is able to attend to his business the day after his fit, there are 
instances in which every attack, or else each severe one or rapidly 
recurrent succession of them, is followed by mental derangement, and 
other disorders of innervation. The former may consist of well-marked 
fits of mania. It is often necessary to protect both patient and by- 
standers from violence, to put on a strait-jacket, or even—horrible to 
relate—there is no other resource but to confine the patient in the 
mad-house, even during his lucid period, because it is known that his 
madness will recur with his next paroxysm. In other instances the 
fit is succeeded by a condition usually called partial insanity: for ex- 
ample, the patient may have an irresistible inclination to run. In 
other cases, the patient may be in an irritable mood, which is quite 
foreign to him on ordinary occasions, breaking out into violent rage 
upon the slightest provocation. Sometimes the memory and mental 
acuteness are impaired for some da vs. We may also mention that, in EPILEPSY. 
397 
stead of the latter condition, an opposite one has been reported by 
certain observers, the intelligence of the patient becoming remarkably 
acute. With regard to the other disturbances of innervation, we have 
already alluded to the transient and permanent paralysis of the ex- 
tremities, which perhaps is due to exhaustion of the irritability conse- 
quent upon excessive nervous excitement. The fit may also be fol- 
lowed by aphonia, by dysphagia, or by asthmatic attacks, etc. 
Two forms of the incomplete epilepsy are recognized (especially in 
France), slight convulsive movements accompanying the lapses of con- 
sciousness in one, and being absent in the other. In the former, the 
genuine “ petit mal,” the patient is seized with giddiness, often amid 
business or conversation. He has time, however, to seat himself, or 
staggers, and sinks slowly to the ground, without outcry. His face is 
pale, his eyes fixed. A few convulsive twitches play over the face, 
and the extremities, especially the upper ones, are slightly tremulous. 
In a few minutes, however, the patient recovers; looks wildly around 
him, not knowing what has happened, sometimes making confused 
utterances; then, after the lapse of a few minutes, all perturbation sub- 
sides ; there is no somnolent stage, and the patient is once more in 
a condition to resume his vocation. 
In the still milder and more rudimentary form, the vertige epilep- 
tique, the patient does not fall. His consciousness alone is clouded; 
his eyes stare, and his countenance is pale. He does not twitch, but 
lets fall whatever he may have in his hand, and halts in his speech. 
The attack passes off in a few seconds, and the patient proceeds with 
nis conversation or business, as if nothing had happened. There are 
many intermediate stages between epileptic vertigo, the petit mal, 
and complete epilepsy, a description of which we forego. 
It would be quite difficult to furnish a concise account of the gen- 
eral course of the disease, and of the condition of the patient between 
the paroxysms. We have stated already that epilepsy is a chronic 
affection. Hence cases in which one epileptic fit is not followed by a 
second one ought not to be counted as epilepsy, but rather should be 
regarded as belonging to the eclampsia, a form of disease only distin- 
guishable from epilepsy by the acuteness of its course. The pauses 
which intervene between the fits differ greatly in different individuals. 
In some patients, a year or even several years elapse, and, in many, 
months and weeks pass away, ere a new attack occurs, while in other 
patients one or more fits occur daily. Very often, during a period of 
four or six weeks, there is not a single attack; this is followed by a 
series of fits, recurring at short intervals. As a general rule, however 
the pauses between the paroxysms in the same individual remain toler- 
ably uniform; although, as the malady progresses, especially in young 398 
GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN. 
persons, the fits gradually come closer together. Perfect regularity 
in their sequence is never seen, or but for a short time; although in 
women a periodical type is sometimes approximated to when the seiz- 
ures only occur at the periods of menstruation. In some persons the 
attacks are more frequent during the day; in others they occur chiefly 
at night. Nocturnal epilepsy is considered to be of an especially 
malignant and obstinate character. Generally speaking, it is im- 
possible to detect the exciting cause of the fit; but, besides the fits 
which occur spontaneously, there are always some which are unmis- 
takably ascribable to psychical emotion, especially to fear; others 
which may be traced to onanism, to coitus, and, as we have already 
stated, to menstruation. Sometimes we can tell, from the altered mood 
of the patient, and from his complaint of a sense of weight in the 
limbs, headache, or dizziness, that an attack is coming on. In the out- 
set of the disorder, the seizures are usually of the complete form; as 
it advances, and especially in inveterate cases, both complete and in 
complete paroxysms occur. It more rarely happens, instead of this, 
that the attacks are incomplete in the beginning of the disease, and 
afterward develop into complete ones as it advances. As, in some 
cases, each fit is followed by temporary mental aberration, so, too, in- 
veterate epilepsy often results in permanent and incurable insanity— 
either mania, confusion, or idiocy. But, besides the large number of 
epileptics who close their lives in the insane asylum, the “morbus 
sacer” (which the ancients ascribed to the wrath of the gods), in course 
of time, nearly always completely changes the mental and physical 
habit of the patient. Acuteness of judgment is lost; memory and 
power of imagination diminish; the gentler and nobler impulses recede 
more and more; while the excited and unbridled propensities, lascivi- 
ousness and gluttony, often impel the patient to commit violent or 
criminal actions. They often avoid society, are odd and capricious; 
are very troublesome to those around them, and are apt to burst into 
violent fits of anger. The personal appearance of the patient also un- 
dergoes a change in cases of long-standing epilepsy. JEsquirol calls 
attention to the coarseness of the features of an epileptic, to his swollen 
eyelids, his thick lips, faltering look, and clumsy body, remarking that 
this malady deforms the most beautiful countenance. 
With regard to the termination of epilepsy, recovery must be re- 
garded as rare, in spite of the opposite opinion of many observers, 
especially Herpin. The more distinctly the malady is traceable to 
hereditary tendency, and the more plainly it depends upon structural 
disease of the brain; the longer it has lasted, the more violent the fits, 
the more frequent their recurrence, and the deeper the impression 
which they leave behind them, so much the less is the chance of re- EPILErSY. 
399 
covery. Such a termination appears to occur somewhat more fre- 
quently among women than among men; and it is likewise more 
common among children and old persons than among those in the 
prime of life. We must beware of building our hopes too sanguinely 
upon the long-continued intermission of the fits, as this disease very 
rarely terminates with one violent paroxysm. A better sign is when 
the fits not only grow rarer, but feebler, and when a distinct change is 
taking place, both in the physical and mental condition of the patient. 
In some women, but not in all, there is an intermission of the fits 
during pregnancy. Such an intermission, however, is nearly always 
observed during the course of acute febrile disease. Sometimes a per- 
manent cure dates from the period of invasion of some acute intercur- 
rent malady, from the appearance or cessation of the menses, or from 
the occurrence of some violent mental emotion. It is said that the 
exanthematous eruptions, and the breaking out of old ulcers, some- 
times have a similar effect. But, although epileptics seldom recover 
fully from their disease, and although they are not often long-lived, yet 
they rarely die during an epileptic fit, in consequence of suspended 
respiration, or of extravasation of blood into the brain, or of general 
paralysis during the comatose state which follows the fit. Their death 
is much more frequently due to the progress of cerebral disease, which 
has given rise to the epilepsy, or to the effects of injuries which the 
patient has received during his paroxysms, and, oftener still, he dies 
of some acute or chronic affection, which is in nowise connected with 
the epileptic disease. 
We shall have more to say regarding the difference between epi- 
leptic and hysterical convulsions when we come to treat of hysteria. 
In my opinion no sharp distinction can be drawn between epilepsy 
and eclampsia, although the convulsions occurring in protracted cases 
of uraemic intoxication are considered to be eclamptic by some authors 
and epileptic by others. It is tolerably easy to unmask simulated cases 
of the disease. The anaesthesia is often enough cleverly imitated, and 
we must not expect that all malingerers will wince when burnt, 
pricked, or pinched, although such reaction hardly ever fails to occur 
when a violent stimulus of this kind is applied to them unawares and 
suddenly. Watson’s suggestion, to direct the nurse, in the hearing 
of the patient, to pour hot water upon his feet, the nurse being 
previously instructed to pour cold water instead, is both practical and 
original. Nearly all malingerers keep the fit up too long, and devote 
too much attention to certain symptoms, which they believe to be 
pathognomonic, such as turning in the thumbs, foaming at the mouth, 
etc., which an attentive observer cannot fail to perceive. It is a sus- 
picious sign, wThen a person who claims to have been epileptic for a 400 
GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN. 
long time has no traces of injury upon the tongue or peripheral part s. 
Very often the simulation is recognizable because the patient makes a 
bad imitation cf the aura. He usually includes this symptom in his 
comedy, believing it to be an essential one, and in enacting it often 
makes a most wonderful exhibition. The surest sign that the fit is 
not feigned, is the dilatation of the pupil, even upon exposure of it to 
bright light. This is a token which no impostor can imitate. 
Treatment.—As a prophylactic means against epilepsy, Romberg 
recommends that the intermarriage of families, in whom the malady is 
hereditary, should be avoided. An epileptic mother should never 
suckle her own child, but should intrust it to a vigorous wet-nurse. 
In fulfilment of the causal indication, the treatment of epilepsy is 
extremely difficult. Apart from the cases whose history gives no clew 
as to the cause of the malady, and even when our information is com- 
paratively of a satisfactory nature, we can only ascertain a few of the 
secondary causes; and it is not at all common for the disease to sub- 
side after they have been allayed. An epilepsy, whose first outbreak 
was unmistakably provoked by the presence of worms in the intestine, 
or by a neuroma, usually persists, although the worms have been ex- 
pelled, and the neuroma extirpated. If the malady be consequent 
upon fright, the fits nearly always recur, though the patient be screened 
from further terrors. However, our poor prospect of success should 
not deter us from taking account of all causes which may have contrib- 
uted to produce the malady, trifling though their apparent effect may 
be. Experience teaches that such practice sometimes, although rarely, 
leads to the happiest results. In the present uncertain state of our 
means of treatment of this disease, even such exceptional successes 
are of importance, and may serve as a guide to our proceedings. It is 
our duty, in assuming the charge of an epileptic, before resorting to 
the so-called specifics, so to regulate the external relations of the pa- 
tient, his habits, and his bodily health, that every suspicious condition, 
to which the origin of the disease can in any way be ascribed, may be 
corrected. Thus, as feeble, cachectic persons are more liable to the 
disease than robust and vigorous ones, all excessive or exhausting 
mental occupation should be forbidden to the patient, and in its stead 
a moderate exercise both of body and mind should be advised. Epi- 
leptic children must not sit six hours a day on the school-benches; 
but, if possible, should live in the country, should spend most of their 
time in the open air, and should take cold baths under proper super- 
vision. We should carefully ascertain whether the patient be addicted 
to great sexual indulgence, to onanism, or to intemperance in drink • 
and, where such vices are discovered, they must be opposed with inex- 
orable sternness. When the patient shows signs of anaemia and hy- EPILEPSY. 
401 
ircemia, a nourishing diet, an abode in the open air, wine, and iron, are 
the proper remedies. If the impoverishment of the blood and cachexia 
depend upon scrofula, rachitis, or tertiary syphilis, appropriate treat 
ment must be employed. Should there be suspicion of plethora, let 
the diet be reduced, and made to consist more of vegetables, and cause 
the patient to drink plenty of water and to exercise freely. On the 
other hand, avoid general blood-letting; for epileptics, though quite 
tolerant of medicines (particularly the nauseants), do not bear bleed- 
ing well. If a scar, foreign body, or tumor be found pressing upon a 
peripheral nerve, or if a neuroma be discovered upon it, an operation is 
indicated. This applies especially to cases in which an aura arises from 
the affected spot. As positive benefit is sometimes obtained by such 
operations, the knowledge that in many cases neuromata and tumors 
are extirpated in vain, should not deter us from operating again. The 
application of setons and moxas, and the use of pustulating ointment 
to the nape of the neck, are measures which are much in vogue in the 
form of epilepsy dependent upon structural disease of the brain and 
skull. Inunction of pustulating salve upon the scalp, and even trepan- 
ning, has also been advised in such cases. We refer to the principles 
laid down in the second part of this section with regard to this subject. 
Where a tumor, a spicula of bone, an exostosis, or other disease, 
encroaches upon the cavity of the cranium, and compresses the cere- 
bral vessels, we can comprehend why trepanning should be of benefit, 
especially to the convulsions, upon the supposition that the operation 
affords more room for the brain and its vessels. When there is reason 
to suspect that the epilepsy is induced by the presence of intestinal 
worms, anthelmintics are indicated. We must be cautious, however, 
how we encourage the too sanguine hopes of recovery, in which a 
patient is too apt to indulge who has discovered joints of tape-worm 
in his stools. 
For other forms of abdominal epilepsy a cure may perhaps be found 
at the baths of Karlsbad, Marienbad, etc. (Romberg). In uterine epi- 
lepsy, chronic uterine infarction and excoriation of the os must be 
treated according to rules already laid down. It is in this form of all 
others that the causal treatment affords the best results. 
In order to meet the indications from the disease itself, Schroeder 
van der Kolk urgently recommends repeated application of cups and 
leeches to the nape of the neck, followed by blisters, issues, and 
setons. This author regards the above as the only rational treatment, 
believing that it alone is capable of reducing the morbid irritability of 
the medulla oblongata, and of relieving its congestion, He considers 
that all other remedies tend merely to promote the cure by their action 
upon the remote cause of the disease, by benefiting any morbid condition 402 
GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN. 
which may exist in the brain or intestines, etc. Whether the theory 
be right or wrong, the success which Schroeder van der Kollds mode 
of treatment has attained imperatively demands its adoption. In two 
very severe but still recent cases of epilepsy I have applied leeches to 
the back of the neck (four at a time), repeating the application at in- 
tervals of from a fortnight to four weeks. The after-bleeding was en- 
couraged by means of elastic cups. The influence of this treatment 
upon the number and violence of the fits was so brilliant that I could 
not make up my mind to desist from the blood-letting, and to proceed 
to the derivatives and medication. If the measures advised in discuss- 
ing the causal indication, as well as the procedure above proposed, 
remain without effect, nothing is left but to have recourse to the 
remedies which are reputed to have a specific action against epilepsy. 
It would savor too much of pessimism to deny that the commendation 
awarded to these articles is based upon a certain amount of benefit 
derived from them, but, unfortunately, it must be admitted that we 
are quite ignorant as to the conditions under which one or other of 
them is to be preferred. In this respect the most experienced physi- 
cian stands upon a par with the tyro. He must try one or other of 
these remedies, and, if it fail, must try another; and, in this frightful 
disease, he should never remain idle on account of mere theoretical 
considerations. With respect to the use of the anaesthetics and nar- 
cotics, excepting atropine, we agree with Schroeder van der Kolh in 
condemning them, and for similar reasons. In epilepsy our task is not 
to allay an exalted sensibility or pain, but to soothe the undue reflex 
irritation which causes the convulsions. Now, narcotics actually tend 
to increase reflex irritability, insomuch that in large doses they pro- 
duce convulsions. Chloroform, too, although it interrupts sensation 
generally, augments the reflex action. A person under its influence 
is like a decapitated frog; its reflex movements are more active than 
ever, although it feels no pain. Atropine is an extremely energetic 
article, but it seems nearly always to act favorably upon both the se- 
verity and number of the fits, even in cases of very long standing. 
True, I have not seen complete recovery of inveterate cases, and T 
have never used atropine in recent ones. Moreover, even at a dose 
not exceeding one-fiftieth of a grain, not only did some of my patients 
complain of a disturbance of vision, so that they could not do the sim- 
plest work, but they suffered for hours with a dryness in the throat 
which actually prevented them from swallowing solid food. Trousseau, 
who believes belladonna to be the most efficient remedy against epilepsy, 
gives the following directions for its exhibition with his characteristic 
thoroughness and precision: Extract of belladonna and the pulv. herb, 
belladonna, aa 3 j, are to be made into one hundred pills. Of these EPILEPSY. 
403 
the patient must take one daily during the first month; with every 
succeeding month he is to raise the dose one pill up to five, ten, fif- 
teen, and twenty pills or more. The entire dose is always to be taken 
at once. When any improvement takes place, the last dose is to be 
continued for a while, and then gradually reduced in quantity. The 
prime condition of success is patience on the part both of physician 
and patient. Instead of the pills, we may use a solution of atropine 
(atropine gr. ij—in spirit vini. rectif. 3 ijss), a drop of which corre- 
sponds to one of the pills. We, therefore, begin with one drop, and 
gradually increase to twenty. Of the metallic preparations, those of 
zinc have the greatest reputation. Latterly, instead of white oxide of 
zinc, formerly given to the extent of two drachms daily, the salts 
of zinc have come into use, especially the valerianate and hydrocya- 
nate, and, above all, the acetate. The dose of the latter is twelve grains 
a day at first; subsequently more. This remedjr is said to be most 
efficacious in young subjects, and in so-called abdominal and uterine 
epilepsies. Heim and Romberg recommend nitrate of silver in doses 
of two to four grains, but it must not be continued long enough to 
produce argyria • ammoniated sulphate of copper and arsenic are now 
little employed. Of the vegetable nervines, artemisia vulgaris and 
valerian have the best reputation. Five or ten grains of the former 
are to be given in powder, or else an infusion of one or two drachms 
in beer. Of the valerian we at first may give a drachm daily, in pow- 
der or electuary, gradually increasing the dose to half an ounce. 
Quite recently, bromide of potassium has been one of the most gener- 
ally employed articles in the treatment of epilepsy; many say they 
have used it with remarkable success, while others report its absolute 
failure. 
My experience of the efficacy of bromide of potash in epilepsy has 
been greatly increased of late, and I can now speak much more 
decidedly on the subject than two years ago, when preparing the 
seventh edition of this work. The following circumstance induced me 
to use the remedy in as many cases as possible, and to watch the 
results: I heard that two cases of inveterate epilepsy, that I had for 
years treated without any benefit, had been completely cured by a 
so-called specialist, whose advertisements were to be found in the 
columns of almost every newspaper. I investigated the subject more 
closely, and found that in one patient, whose governess had for years 
kept an accurate journal, and whom I had not lost sight of, the 
attacks had been absent for several months, and that the general 
health, which had been much impaired, was decidedly better. This 
“ specialist ” refused the petitions of numerous patients of limited 
means to moderate the high price of his medicine or to give a pre- 404 
' GENERAL NEUROSES, OR UNKNOWN ANATOMICAL ORIGIN. 
scription for it, so I had a bottle of it analyzed by my colleague 
Hoppe-Seyler. The analysis showed that the blue mixture consisted 
of a solution of bromide of potash (3 jss— § vj) colored with indigo. 
Both patients had taken the remedy in considerable doses. At first 
only two tablespoonfuls were given daily—but after ten days four, 
after ten days more six spoonfuls ; after that the dose was increased 
more slowly, being gradually raised to ten, fifteen, and twenty table- 
spoonfuls. So it appeared that in this case, as in most others where 
secret remedies prove useful, it w7as not the remedy but the mode of 
using it that was the secret; and I thought it probable that the 
contradictory assertions about the action of bromide of potash were 
greatly due to the fact that different observers had not given it with 
equal perseverance and in the same doses. I determined to imitate 
the treatment of the “ specialist ” where practicable, and induced other 
physicians to do the same—and I became convinced that, thus used, 
in large doses for a long time, although it will not cure all cases of 
epilepsy, it will in many cases relieve the attacks for a considerable 
period, and in some will even remove advanced impairment of the 
psychical functions. Neither in my own practice, nor in that of 
others, have I, of late, seen a case where the intervals between the 
attacks did not grow longer. Even patients who had previously 
received no benefit from the bromide of potash began to improve, when 
the dose was raised to eight or ten tablespoonfuls of the above solution 
daily. On long-continued administration of the bromide of potash, I 
have often observed a papulous exanthema, and in one case an exten- 
sive furunculosis which disappeared on stopping the medicine, and 
again recurred after it had been resumed. After taking large doses 
of the bromide for a time, some patients complained of loss of appe- 
tite, confusion in the head, and catarrh of the air-passages, just as 
they do after protracted use of preparations of iodine. Lastly, in two 
cases there was some psychical change, evinced by great restlessness, 
and diminished mental activity. In most cases, there were none of 
these unpleasant concomitants; hence I feel justified in urgently recom- 
mending further trials of the bromide of potash in epilepsy, especially 
in long-continued and large doses. 
To these specifics may be added a large number of medicaments 
which have been recommended with more or less urgency. Among 
these are assafoetida, folia aurantiorum, radix pseonse, viscum album, 
oleum terebinthina, and oleum animale Dippelii, indigo, and others. 
It is a good rule, in administering specifics, to give them exactly 
in the form and dose prescribed, and not to pass too soon from one 
article to another; and, on the other hand, to bear in mind the ECLAMPSIA INFANTUM. 
405 
fact that there are a great number of medicines which, for a while, 
seem to do good, but which afterward fail as though the system had 
become used to them. 
The indications from the disease itself require that the patients 
should be protected from the injuries which they are apt to inflict 
upon themselves during the fits. Whenever circumstances permit, an 
epileptic should not be permitted to go unwatched. This is the best 
and surest preventive. It is a good plan to let the patient sleep in a 
bed made with high sides, like a child’s crib, but such measures do 
not dispense with the necessity of further watching, since, if the pa 
tient were to happen to lie upon his face in such a bed, he might read 
ily be smothered. The patient must not be bound nor held fast dur- 
ing the fit, nor should his thumbs be forcibly unclinched. Many people 
believe that the attack will soon subside if this be done. After the 
fit is over, those patients generally feel best who have been allowed to 
struggle through it unmolested. The next symptomatic indication is 
to take the measures already recommended for the purpose of averting 
a coming paroxysm and of cutting it short. On the whole, compres- 
sion of a limb, from which the aura seems to proceed, is not advisable, 
even although we may avert the fit by so doing, since, in the first 
place, the patient feels worse after thus repressing an attack than if 
he had had one ; and, in the second, because his next seizure is apt to 
be of unusual violence. This is also true as regards the use of strong 
emetics at the commencement of the aura. Sometimes it is possible 
to arrest the fit by compression of the carotids. Such a practice, how- 
ever, is very difficult to carry out during the attack, and might do 
harm if awkwardly performed; hence we would hardly recommend it.1 
CHAPTER IV. 
ECLAMPSIA INFAHTUM. 
The eclampsia of parturient and of puerperal women is very often 
dependent upon a morbid condition of the gravid uterus, upon the re- 
tention of portions of placenta after delivery, or upon other and un- 
known disorders of pregnancy or of child-bed. We therefore refer the 
subjects of puerperal and parturient eclampsia to the text-books of 
obstetrics, just as we have already referred those of other puerperal 
conditions of the womb, ovaries, and vagina. 
Etiology.—We have called eclampsia an acute epilepsy. Here, 
too, there are convulsions with loss of consciousness; but, unlike epi- 
lepsy, the recurrence of the fit, instead of continuing for years, lasts 406 
GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN. 
for a few davs or hours only, at the end of which time the eclampsia 
terminates either in recovery or death. 
As regards the pathogeny of eclampsia, the same remarks apply 
which we have already made concerning epilepsy. For reasons al- 
ready given in detail, we may regard it as proved that the morbid 
irritability of the motor nerves, of which the convulsions are an indica- 
tion, originates from the medulla oblongata and base of the brain. 
There also seems to be no doubt but that causes, similar to those 
which result in an habitual irritative condition of the medulla ob* 
lo'ngata, and epilepsy, may often (and especially during childhood) 
induce an acute temporary state of irritability in the medulla with 
eclampsia. Strictly speaking, the animals upon which Tenner and 
KiXssmaul experimented died of eclampsia, and not of epilepsy. It 
is more than probable, also, that congestion may be capable of in- 
ducing a state of acute irritability of the medulla, and may thus give 
rise to eclamptic seizures. This sometimes happens, owing to the in- 
troduction of foreign matter into the blood, as is shown in the rapidly 
fatal convulsions wThich sometimes arise in uraemia and in cases of 
narcotic poisoning. In this category, too, the convulsions belong, 
which arise—especially in children—in consequence of infection from 
miasmatic or contagious diseases, as also are those which usher in an 
attack of scarlatina, measles, or small-pox; as well as those arising’ 
from the febrile crasis, and from fever-heat, and which often announce 
the commencement of pneumonia and other inflammatory diseases of 
childhood. The convulsions proceeding from the progress of acute 
diseases of the brain and spinal marrow, and which are analogous to 
the form of epilepsy arising from cerebral tumors and other chronic 
disorders of the brain, are not counted as eclampsia, or, if so counted, 
are distinguished as a separate and symptomatic form. Convulsions, 
however, which proceed from excitement of the cerebral ganglia, trans- 
mitted thence to the medulla oblongata, and which are the result of 
terror and other emotions, are regarded as true eclampsia. Most fre- 
quently, however, the medulla oblongata seems to derive the morbidly 
irritative state, from which eclampsia proceeds, from an excitement 
which is transmitted to it from the peripheral nerves. To this class 
belong the convulsions from teething and from intestinal worms, and 
those which occur from painful injury of the skin. 
The antagonism between the hemispheres and the basilar portion 
of the brain is as great in this disorder as it is in epilepsy; and we are 
quite unable to explain why the convulsions are accompanied by loss 
of consciousness. 
With regard to its etiology, it is to be remarked that, at the period 
during which a state of habitual irritation of the medulla is most rare. ECLAMPSIA INFANTUM. 
407 
its predisposition to acute irritation is greatest. Newly-born infants, 
and those who are but a few months old, are the most frequent suffer- 
ers from eclampsia. The disease is rare after the first dentition, and 
still more rare after the second. The tendency to eclampsia is often 
congenital, all the children of a family sometimes being afflicted in 
this way. We do not know what the diseases or constitutional defects 
are, on the part of the parents, which determine this predisposition in 
their children. It occurs in vigorous, full-blooded children, as well as 
in the puny and anaemic, and in boys quite as often as in girls, perhaps 
oftener. Besides the exciting cause of the disease already mentioned, 
the practice of allowing the child to nurse immediately after the 
mother has been extremely angry, is believed to be a frequent cause 
of eclampsia. Inexplicable as such an idea may be, it would be 
neither judicious nor figh* to slight it, and to oppose the appropriate 
precautionary measures, which consist in not letting the child have the 
breast immediately after the mother has been angry, until after the 
breast has been drawn. 
Symptoms ayd Course.—The only form of the disease which is 
apt to set in suddenly and without warning is that which, during child- 
hood, often substitutes the chill of older persons as a precursory symp- 
tom of the acute exanthemata in pneumonia, and in other inflammatory 
disorders. For a day or two the child is restless during sleep, and 
sleeps with its eyes partly open, contorting its face and grating its 
teeth from time to time, and starting when touched. Even while 
awake, a difference in its manner is observable. The child is cross, 
does not seem to enjoy its play, cries a great deal, and often changes 
color. The character of an eclamptic fit is precisely like that of an 
epileptic one. Here, too, at first, there are usually tonic convulsions, 
which last for some moments; the head is thrown back, the extremi- 
ties extended, the eyes turned up, and the respiratory movements 
arrested. Then, clonic spasms begin, which extend over the muscles 
of the face, head, trunk, and extremities, throwing the entire body (or, 
what is more rare, one side of it alone) into convulsive motion. The 
spasms equal the epileptic convulsions in violence. The face is red- 
dened and slightly cyanotic; frothy saliva appears upon the lips; the 
skin is bathed in sweat; the belly is inflated from air which has been 
swallowed; the respiration is much embarrassed, and the pulse is 
small and frequent. At the same time, consciousness is entirely sus- 
pended, and with it all sensation, even of the most powerful stimulus, 
is extinguished. A fit of this kind, however, rarely passes off as soon 
as an epileptic fit, but often lasts from a quarter to half an hour, or 
even longer. In private practice, the physician far more frequently has 
opportunity to see eclamptic fits than epileptic ones, as the former 408 
GENERAL NEUROSES, OE UNKNOWN ANATOMICAL ORIGIN. 
often last until he arrives, while the latter usually pass over while the 
messenger is still seeking him. A year or two ago I saw a child in an 
eclamptic fit, which lasted for twenty-four hours, without interruption, 
although there were occasional remissions. The fit usually terminates 
with a long-drawn deep expiration, often, too, by a profuse evacuation 
from the bowels. This rarely occurs suddenty during the height of the 
attack, but more usually after its violence has somewhat subsided. 
The child then falls into a deep sleep, and if, next day, we do not 
make our visit too early, we may find it playing busily, as if nothing 
had occurred. But it frequently happens that there is more than one fit. 
A series of them often succeed one another at short intervals. A 
repetition of them may be anticipated, when the sleep is not sound 
after the first one has subsided, and when the children throw them- 
selves about, gnash their teeth, and when their limbs twitch from time 
to time. The subsequent fits resemble the first one in all essential 
points, differing only in their degree of violence and in their duration. 
Many children never have more than one eclamptic attack. In others, 
they recur from time to time. The more plainly it can be shown that 
these recurrences are the result of fresh irritation, so much the less 
doubt will there be that we have an eclampsia to treat, and not 
epilepsy. And, on the other hand, the less distinctly demonstrable 
the exciting cause of the repeated paroxysms is, so much the more 
doubt will there be whether they are eclamptic or epileptic. This 
point can never be determined at the first fit, since its exciting cause 
often enough eludes detection. Death may occur, during the fit, from 
arrest of the respiration, and acute carbonic-acid poisoning, from ex- 
haustion, or during the subsequent period of coma. Eclampsia is a 
very dangerous complaint among children during the first months of 
life, and a large proportion of those attacked die. In older children 
the prognosis is more favorable, and the disease usually terminates 
in recovery. It will be readily understood that both children and 
older persons are apt to die where the convulsions, with loss of con- 
sciousness, are an accompaniment of grave disease of the brain or 
spinal marrow, although in such instances it can hardly be said that 
they die of eclampsia. The same may be said of the so-called sequeke 
of eclampsia. When seizures of this nature are followed by idiocy, 
palsy, squinting, or other grave disorder, it certainly is more than 
probable that they, as well as the fits, depend for their origin upon 
nutritive disorder of the central organ. 
Treatment.—I believe that it is very difficult, and often quite im- 
possible, to determine whether an attack of convulsions, accompanied by 
loss of consciousness, depends upon ansemia or hyperasmia of the brain, 
or whether either of these conditions exists. If the previous health of HYSTERIA. 
409 
the child have been good, and his appearance still be one of robust 
ness and vigor during the fit, I wTould advise the administration of a 
clyster of one part vinegar and three parts water, the application of 
cold compresses to the head; and, if the convulsions do not soon sub- 
side, the application of leeches behind the ears, in numbers correspond- 
ing to the age of the patient. We cannot give medicine during the 
fit. After it is over, and should we fear a recurrence, we may give a 
laxative of calomel and jalap, or one or two doses of calomel with the 
oxide of zinc. On the other hand, if the child be puny and enfeebled by 
long sickness, let him have an enema of valerian, or camomile tea, with 
one or two drops of tincture of castor; or, if this be ineffectual, a clys- 
ter of emulsion of assafoetida (3ss—j to § iv). Sinapisms may also 
be applied to his calves, and he may be put into a warm bath. Other 
means are not to be had recourse to until after the fit has subsided. 
Apart from the cases in which eclampsia is symptomatic of cerebral 
disease, of uraemia, or the initiatory stage of some acute disorder, it is 
of importance to determine from which province of the nervous sys- 
tem the morbid irritation proceeds which is acting upon the medulla 
oblongata, for it will depend upon such determination whether we 
give a laxative, an emetic, an antacid, or an anthelmintic, or whether 
we ought to resort to some other course of treatment. I consider it 
unjustifiable to dose every child, who has had an eclamptic fit, with 
calomel and oxide of zinc, “in order to prevent his having another.” 
If the stupor which follows the paroxysm be very profound, cold affu- 
sion should be prescribed. On the other hand, if there be severe col- 
lapse, we should order wine, camphor, and musk, and other stimulants. 
UHAPTEK Y. 
HYSTERIA. 
Etiology.—Hysteria is even still less susceptible of classification 
in any particular category of nervous diseases than are epilepsy and 
eclampsia. In this protean malady, derangement of the sensory, mo- 
tor, and psychical functions is nearly always combined with disorder 
of the circulatory and nutritive systems. Sometimes one set of symp- 
toms predominates, sometimes another; and there often is an exalted 
excitability in one part of the nervous system, expressed in the form of 
hyperaesthesia or spasm, and which is complicated with interrupted irri- 
tability of some other region, evinced by anaesthesia and paralysis. "We 
cannot as yet give a satisfactory answer to the question as to the exist- 
ence of actual although impalpable material alteration in the nervous 
elements, to which the various forms of nervous derangement characteris- 410 
GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN. 
hie of hysteria are ascribable. For instance, although most patients are 
extremely susceptible to external influences, yet this may be due quite 
as well to exalted irritability of the peripheral nerves as to an over- 
excitability of those portions of the brain whence consciousness of the 
impression is derived. The former supposition is contradicted by the 
wide-spread character of the hypereesthesia, as well as by the simul- 
taneous derangement of the psychical function; the latter by the in- 
tensity of the reflex action by which the hyperaesthesia is accompanied. 
The latter condition is only ascribable to increased irritability of the 
peripheral nerves, or to coexistent increase of irritability in the spinal 
ganglia. Hence the most plausible theory of the origin of hysteria 
is that to which Ilasse adheres, namely, that the affection springs from 
a nutritive derangement of the general nervous system, both central 
and peripheral. 
The facts that hysteria is observed almost exclusively in females, 
and principally in females between the age of puberty and that of the 
extinction of the sexual function, and that in a great number of cases 
hysteria is accompanied by a morbid condition of the sexual organs, 
have given rise to the supposition that hysteria is a disorder of the 
general nervous system originating in the nerves of the organs of gen- 
eration. This theory, although somewhat too narrow, is true in a 
large number of cases. We have come to the conclusion, from the 
various phenomena described in previous chapters, that disease not 
unfrequently is transmitted from the nerves which it immediately af- 
fects to other nerves, and to central organs; and by analogy we may 
infer that a morbid state of the nerves of the sexual apparatus may ex- 
pend to those of the rest of the body, as well as to the central organs. 
The mild derangements of innervation, the hyperaesthesia, the aug- 
mented reflex irritability, and the psychical disorder which shows itself 
in some women during the period of menstruation, would seem to de- 
pend upon a process of this nature, and, as it were, form a physiolo- 
gical analogue to the pathological state of the sexual organs which 
exists in hysteria. There cannot be any doubt that some cases of 
hysteria arise in this manner. If a uterine infarction should develop 
after an abortion or a severe labor in a woman who has previously 
been healthy, and should this be accompanied by a well-marked hys- 
teria ; should the hysteria continue as long as the uterine disease lasts, 
and should it disappear as soon as we succeed in discussing the infarc- 
tion, it would be manifest that to the uterus alone were due the mani- 
fold nervous derangements which we call hysteria. All diseases of 
the womb and ovaries do not exert an equal influence in producing 
this disease. Besides the infarctions, it is more especially the ulcera- 
tions of the os uteri and the flexions of the womb which induce hvs- HYSTERIA. 
411 
terical symptoms, while, in cases of malignant growth and in destruc- 
tive affections, hysteria is much less common. Of the ovarian diseases, 
the dermoid cysts of moderate size cause hysteria much oftener than 
do the very large sacs resulting from cystoid growth. In some cases 
irritation of the genitals arising from excessive coitus, or imperfectly 
effected coitus, from onanism, or from simple sexual excitement, has 
an influence upon the nervous system, similar to that of the textural 
lesions of the sexual apparatus above mentioned. But it would be 
both narrow-minded and frivolous, and indicative of a most imperfect 
comprehension of the nature of woman, to ascribe all cases of hysteria, 
whose source could not be traced to structural change of the genitals, 
to over-excited sexual appetite, or to its unnatural gratification. I 
certainly am no optimist, and indeed rather incline in the other direc- 
tion, but I cannot believe that all the hysterical widows and old maids 
who are hysterical, without exhibiting any structural disease of their 
genital apparatus, suffer from suppressed sexual passion, or gratify it 
in an illegitimate manner. 
Where there is much predisposition to hysteria, it may proceed 
from any other organ of the body which may happen to be diseased. 
I have seen a strongly-pronounced case of it in a young girl with a 
tedious affection of the stomach, but whose sexual function was per- 
fectly normal. 
We must entirely agree with Iiasse, in his delicate and excellent 
description of hysteria, that the frequence with which hysteria occurs 
in childless women, in widows, and in old maids of the upper class of 
society, is attributable rather to psychical than to physical influences. 
The effect of strong psychical impressions upon the nervous system at 
large is often quite evident even in perfectly-healthy subjects. Per- 
sons under the influence of great terror stand as if thunderstruck, un- 
able to move from the spot; an angry man clinches his fists, bites his 
lips, and moves restlessly to and fro without act of his will. More- 
over, we not unfrequently find that the influence of extreme terror or 
anguish of mind produces complete anaesthesia, and excessive intel- 
lectual exertion often gives rise to hyperassthesia. Indeed, every day 
we have the opportunity of observing that mental emotion has an in- 
fluence upon the excitability of the vaso-motor and nutritive nerves; 
that it causes the cheeks to redden or to grow pale, the muscles or 
the skin to contract or to relax, the tears or saliva to flow. If all 
these various disturbances of innervation can arise from transitory 
psychical impressions, it is easy to imagine that permanent nervous 
derangement, with disease of texture of the nervous system, may de- 
velop under the influence of the permanent mental emotions, which 
beset a woman who finds all the expectations and hopes of her life dis- 412 
GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN. 
appointed, who believes that she has failed in her vocation, and who, 
under the depression consequent upon such feelings, is unable to divert 
her thoughts into other channels. I admit that the manner in which 
the continuous action of psychical impressions modifies the nutrition 
of the general nervous system, and thus leads to hysteria, is obscure ; 
but it cannot be maintained that our insight into the mode in which 
disease of the genital nerves extends to other portions of the nervous 
system is any more clear. The state of mind which leads to hysteria 
depends not only upon external accidents, but much more upon the 
mental impression made by the accident upon the individual. A fate 
which may befall one person, without producing any apparent effect, 
may be the source of the deepest and most lasting depression in an- 
other. I heartily agree with Ilasse, that, though hysteria is often 
seen in women wedded to impotent men, yet it originates quite fre- 
quently in the sombre feeling and miserable consciousness of a wasted 
life, which result when social claims of married life are not duly re- 
spected, or when the sentimental anticipations and fantastic ideals of a 
foolish girl are not realized. 
The nutritive derangement of the nervous system from which hys- 
teria arises may also be induced by improper nourishment. We have 
sufficient proof of this fact in the frequent occurrence of this complaint 
in cases of chlorosis and impoverishment of the blood, unaccompanied 
by any disease of the sexual organs, by sensual excitement or onanism, 
and where it cannot be traced in the remotest degree to the psychical 
impressions above alluded to. 
There is great variety as to the degree of predisposition to hys 
teria. All the women with uterine infarction, or uterine flexion, or 
wdio have ulceration of the os uteri, are not necessarily hysterical, noi 
are all the old maids who believe their lives to have been thrown 
away, nor all the chlorotic girls. On the other hand, I have no hesi- 
tation in asserting that a tendency, either congenital or acquired, plays 
a much more important role in inducing this affection than all other 
causes mentioned hitherto. The truth of this assertion is easy of 
proof. If wrc examine large numbers of women, we find moderate de- 
grees of uterine infarction, slight flexions of the uterus, and erosions 
of the os, to be so very common that the number of hysterical women 
would be equal to that of the non-hysterical ones, if affections like 
these alone sufficed to occasion hysteria, without the coexistence of a 
decided predisposition to such disease. It rarely begins to manifest 
itself before the twelfth or fifteenth year of life, and very seldom ap- 
pears in old age. It frequently outlasts the period of child-bearing, 
and continues in a moderate degree during the climacteric years. The 
tendency to it is often congenital; but, although a patient may have HYSTERIA. 
413 
descended from an hysterical mother, and she, too, be descended from 
hysterical parents, this alone is no absolute proof of the existence of 
such hereditary tendency, as it may have proceeded from injudicious 
training, which has likewise propagated itself in the family for gen 
erations. 
Constitution and temperament have no distinct effect upon the 
tendency to hysteria. On the other hand, the mode of life of a pa- 
tient, and her education, have a most decided influence in this respect. 
The less a child is taught to control itself, the more it is allowed to 
indulge in immoderate grief over a broken toy; the more the rod is 
spared, when it gives way to outbursts of excessive anger or passion, 
stamping its feet and throwing itself upon the floor, all on account of 
some disappointed expectation, or the refusal of some request, so much 
the more apt will it afterward be to become hysterical. If we teach a 
child to be industrious, to be conscientious, and to control itself; if we 
prevent growing girls from knitting or doing worsted work all day 
long, or from occupying themselves in other ways, which permit of 
their indulging in dreams and reveries; if we keep improper books, 
likely to give them stilted ideas, out of their hands, we shall have 
done our best toward averting the danger of hysteria. Hysteria is a 
very rare phenomenon among men. Here, too, it usually proceeds 
from derangement of the sexual apparatus, although this is not al- 
ways the case; but in men, likewise, it is only in instances of decided 
congenital or hereditary tendency to the disease that it can be excited 
by venereal excess, onanism, spermatorrhoea, and the like. 
Symptoms and Course.—Owing to the complicated nature of the 
symptoms of hysteria, and to the varied character of its course, it is 
impossible to give a brief and comprehensive description of this dis- 
ease. Hence we depart from our usual practice in describing hys- 
teria, and, instead of drawing a picture of the affection itself, shall 
give a classified discussion of its symptoms. 
Derangement of sensibility is a very common symptom, and is 
scarcely ever absent in any case of hysteria. General hypercesthesia, 
or “ nervousness,” as the laity call it, is the first symptom of this class 
to which we shall refer. It often exists for years uncomplicated by 
any other form of the disease. This hyperaesthesia is sometimes 
evinced by an unusual acuteness of the senses. Some patients are 
able, by touch alone, to perceive the most trifling differences of 
weight and temperature, and thus to distinguish objects from each 
other, with their eyes shut, which healthy persons could not have 
distinguished. It is easy to understand that a faculty of this kind 
seems wonderful to the masses, and that it often is used for purposes 
of imposture. In a similar manner some patients have their sense 414 
GENERAL NEUROSES, Of UNKNOWN ANATOMICAL ORIGIN. 
of smell developed to a degree usually found in brutes alone. They 
are able to distinguish persons and things in the most remarkable 
manner merely by their olfactory sense; or they may be able to hear 
and to recognize the step of a person who is still far off. Similar 
acuteness of the sense of taste has also been reported. Fortunately, 
however, hysterical hyperaesthesia very rarely takes the form of ab- 
normal acuteness of the senses, or else the number of clairvoyants 
would be still greater than it is. Far more frequently the hyper- 
esthesia of hysteria shows itself in the annoyance produced by a very 
slight degree of stimulation of the nerves of special sense. While, in 
a healthy person, it requires a very loud sound, a very strong smell, a 
very bitter or acrid substance, or a very bright light, to produce an un- 
pleasant effect upon the senses, hysterical persons complain if we 
elevate our voice a little in speaking, and beg us to talk in a ■whisper. 
They will often banish all flowers from their room because they can- 
not endure their odor; or will reject their food if it contain the slight- 
est particle of spice. To some hysterical persons bright daylight is 
quite intolerable, so that they constantly keep their eyes closed; to 
others a red color is unendurable, and no one must approach them with- 
out first putting off any red ribbon or article of clothing they may be 
wearing. This great sensitiveness to comparatively slight stimulus is 
often associated with idiosyncrasies. Certain forms of irritation, which, 
from their quality rather than from their intensity, are repulsive to 
healthy subjects, afford a sense of gratification to hysterical persons, 
and conversely stimulants, which are pleasant to a well person, often 
offend the senses of one wrho is hysterical. It is notorious that many 
hysterical people love the smell of burnt feathers, and take assafoetida 
without repugnance, while the odor of hyacinths, violets, and other 
most agreeable perfumes is insupportable, to them. 
Besides these signs of morbid irritability, there are other states of 
excitement of the sensory nerves which must be regarded as of a dif- 
ferent character. In the first place, there are neuralgias, especially 
prosopalgia, migraine, mastodynia, and ischias, all of wbich are of com- 
mon occurrence in hysteria. Closely related to these there is a form 
of pain which is also very common, and which is generally confined to 
one small point in the head (usually to one side of the sagittal suture), 
and which is known by the name of clavus hystericus. Besides this, 
there is the almost never-failing tenderness, on pressure, of the back, 
and finally those very peculiar hysterical affections of the joints 
(Arthropathia hysterica) which consist in pain in the articulation, 
often of such exquisite severity and so obstinate a duration as to be 
liable to be mistaken for grave inflammation. Morbid excitement of 
the nerves of special sense may also occur, which cannot be accounted HYSTERIA. 
415 
for by the action of any corresponding irritant. Some patients are 
never free from the sense of a certain taste or smell; some complain 
of roaring and buzzing in the ears, or of spots before their eyes. It 
is very remarkable that, besides these phenomena, indicative of exalted 
excitability, and of a morbid irritability of the sensory nerves, there 
should also be an anaesthesia, involving a variable extent of the surface 
of the body. It is doubtful whether this anaesthesia be attributable to 
suspension of function of the peripheral nerves, or to an extinction of 
irritability at the nerve centres. I consider it very hard to determine 
whether an hysterical person really is suffering from anaesthesia, or 
merely indulging the caprice of not showing signs of pain when 
pricked, pinched, or burnt in particular parts of the body. There is 
not the least doubt that such notions are of daily occurrence among 
hysterical patients. If they only knew what a puzzling and interest 
ing subject this matter of anaesthesia is, the number of hysterical cases 
of this land, no doubt, would increase vastly. I have seen a patient 
who did not move a muscle while two streaks were being burnt along 
her back with a red-hot iron, and yet there was not the slightest 
ground for believing that she had anaesthesia of the back. 
All the derangements’ of sensation hitherto described have de- 
pended upon morbid irritability of the cutaneous nerves, and of the 
nerves of special sense. Connected with these there is a series of per- 
verted sensations in internal organs. While, under ordinary circum- 
stances, we have either no perception at all (or, at most, a very ob- 
scure one) of the condition of the internal viscera, as long as they are 
in good order, and while, without laying our hand upon the heart, we 
are unaware of its pulsation; and while respiration goes on without 
our consciousness of the necessity for such an act; and while we have 
no perception whatever of the ordinary state of our stomachs and 
bowels, yet hysterical individuals have the greatest variety of com- 
plaints to make as to the condition of their internal organs, and claim 
to suffer the most extraordinary sensations. They nearly all complain 
of palpitation of the heart—many of them of pulsation of the vessels. 
Upon examining the heart-beat and the pulse, we may easily satisfy 
ourselves that such sensations are but subjective ones; and that the 
shock of the heart is not really increased, nor is the pulse full and 
hard. It is the same with the shortness of breath. Sometimes the 
patients breathe laboriously and quickly, complain of the utmost op- 
pression ; but, after exclusion of the possible existence of any disease 
of the air-passages or circulation, or of a morbid state of the blood 01 
nutrition, capable of accounting for such dyspnoea, we may assure our- 
selves that it is purely a case of hyperassthesia or of perverted sensa- 
tion. Resides this, although their digestion may be excellent, nearly 416 
GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN. 
all hysterical patients complain of a sense of pressure and fulness in 
the region of the stomach, or else of cardialgia, and, independently of 
the colic which sometimes troubles them, give most extraordinary ac- 
counts of the sensations which they feel in their abdomens. Under this 
head also come the thirst, often observed in hysterical persons, and 
the frequently-recurring desire to empty the bladder, although it 
is not full. Perverted sensation in the sexual organs is much more 
rare than might be supposed, more so, indeed, than has been rep- 
resented by many authorities. Husbands of hysterical women often 
declare that their wives evince a disinclination to sexual intercourse, 
and do not often exhibit much excitability. They seldom give an ac- 
count of an opposite condition. Even in hysterical prostitutes it is 
exceptional to see symptoms of nymphomania. In other cases, again, 
coitus is very painful to the patient, although there may be no palpable 
lesion of the genital organs. 
The derangements of the motor function observed in hysteria are 
scarcely less numerous and varied than those of sensation. Their 
most common form is that of hysterical convulsions. There is no 
doubt but that the morbid excitement of the motor nerves, which gives 
rise to hysterical spasms, proceeds from the spinal marrow and me- 
dulla oblongata. One of their characteristic signs is, that they never 
cause loss of consciousness. It is usually supposed that hysterical 
convulsions are of reflex origin, so that the spinal cord can only trans- 
mit the impressions conveyed to it from the sensory nerves to the 
motor nerves. As the convulsions frequently spring from impressions 
produced upon the sensory nerves, or the nerves of special sense, it 
seems probable that this theory is the correct one; hence, in cases 
where the convulsions seem to occur spontaneously, we must suppose 
that the cause has eluded our observation. In some cases, hysterical 
fits consist in a mere twitching of one or more of the limbs, especially 
of the arms. They often recur, at short intervals, for a while, when- 
ever the temper of the patient is excited, and whenever stimuli, even 
of moderate strength, act upon the nerves of sensation or those of 
special sense. In other cases the spasms extend more or less over the 
entire body. They occur in violent paroxysms, and may almost assume 
the appearance of tetanic spasms, and still oftener of epileptic convul- 
sions. Opisthotonos, pleurostliotonos, and orthotonos, are seen often 
enough in hysteria, as are also clonic convulsions, which set the face, 
trunk, and extremities into spasmodic motion. The patient often 
foams at the mouth, his thumbs are clinched in the palms of the 
hands—the only sign, by which the attack may be distinguished from 
an epileptic one, being loss of consciousness. Very often spasm in- 
volves the group of muscles which operate in producing some complex HYSTERIA. 
417 
act, such as yawning, laughing, crying, although the mental emotion 
by which they are generally induced is not present. In tins way fits 
of spasmodic yawning, laughing, and weeping arise. Thus, spasmodic 
expiratory movements, combined with spasmodic contraction of the 
rima glottidis, and tension of the vocal cords, give rise to that obsti- 
nate cough known as hysteric cough, and to its modifications, consist- 
ing of barking and howling sounds. Spasmodic contraction of the 
oesophagus, extending from below upward, gives the patient a feeling 
as if a ball were rising from the epigastrium into the throat, a symp- 
tom commonly called globus hystericus. Very often hysterical per- 
sons are troubled for a quarter of an hour, or even for hours at a time, 
with eructations, which recur at short intervals, and during which a 
quantity of inodorous air is belched up, usually with a loud sound. 
If we watch the patient carefully, we can see, by the movements of her 
mouth and throat, that she has previously swallowed this air. As 
however, the majority of healthy persons are unaware of it, when they 
swallow air in the movements of chewing and deglutition which they 
make under the influence of violent nausea, I do not suppose that hys- 
terical persons do it consciously and intentionally; hence I have classed 
this symptom among the disorders of motion. Just as anaesthesia and 
hyperaesthesia of the sensory nerves may coexist, so in the motor sys- 
tem hysterical convulsions may be accompanied by hysterical palsy. 
Sometimes a single extremity alone is involved; sometimes there is 
hemiplegia. The fact, that the electric contractility is preserved in the 
muscles of the palsied part, argues strongly against the peripheral 
origin of this form of paralysis. If the peripheral nerves were diseased, 
if they had lost their functional excitability, then electricity would be 
just as powerless to excite them as the will is. Now, in hysteric 
palsy, as every muscle which the patient is unable to contract volun- 
tarily may be made to contract by application of the electrode to its 
nerves, the palsy must be of central origin. Moreover, the rapid 
changes which occur in hysterical palsy, especially the sudden way in 
which it sometimes subsides, proves that its source is some slight and 
easily-adjusted derangement of nutrition, and that it does not consist 
in serious structural change at the centre of volition, but, in some cases, 
an excessive indecision and incapacity on the part of the patient tc 
make up her mind to move the limb seem to be the reasons for the 
palsy. I have no doubt that any one, as long as he is firmly persuaded 
that he is unable to perform a certain act, is indeed incapable of gen 
erating the necessary motor impulse. As the palsy in this class of cases 
is due to a perverted mental impression, it should, properly speaking, 
take rank among the psychical disturbances. Some time ago I saw a 
patient suffering from a hemiplegia, which had lasted for months. The 418 
GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN. 
history of the case was, that, for years past, the patient had suffered 
from a similar palsy, which had disappeared at times, and then had re- 
turned again. This peculiar behavior, together with other hysterical 
symptoms, left no doubt as to the hysterical nature of the case. The 
patient had repeatedly been assured that she could be cured by the 
application of electricity, and, as her reception at the clinic was delayed, 
her anticipations as to the success of the treatment were wrought up 
to the utmost pitch. The opening of her firmly-clinched hands, upon 
the first application of the electrodes, unmistakably made a great im- 
pression upon the patient, and from that time forth the paralysis im- 
proved, and disappeared altogether in the course of a few weeks. No 
doubt, any other remedy, in which the patient had felt equal confidence, 
would have been quite as successful.2 
Among the derangements of the vaso-motor and nutritive nervous 
systems, the most striking are the uneven and fluctuating state of the 
circulation in peripheral regions. Most patients constantly have cold 
hands and feet, while, without apparent cause, the natural color of the 
face gives place to a glowing redness, often accompanied by a disa- 
greeable burning sensation. It is uncertain -whether the, secretion of 
saliva, and that of the juices of the stomach and intestines, are also 
modified by spasmodic contraction or paralytic dilatation of the vessels 
of these organs; on the other hand, it undoubtedly is through de- 
rangement of innervation that the determination of blood to the kid- 
neys arises, which causes the profuse secretion of urine so often seen in 
hysteria. This urine, which is voided in large quantities, contains but 
little of the solid constituents of urine, is of a limpid apjiearance, and 
is often described as hysterical urine—urina spastica. 
It is very difficult to furnish a brief and comprehensive description 
of the psychical derangements observed in hysteria. In the first place, 
at the outset of the affection, we are struck by the rapid fluctuations 
which take place in the spirits of the patient, and by the sudden tran- 
sitions from the most unbounded gayety to the profoundest gloom. 
These symptoms are in part ascribable to the physical liyperassthesia 
described above, and in part to psychical liyperassthesia, by which it 
is accompanied. As mental impressions produce an unusual influence 
upon the temper of the patients, so, too, suggestions which would pro- 
duce no apparent effect upon the spirits of a healthy person produce a 
sense of annoyance or of repugnance in an hysterical one, although 
more rarely the sensation is one of gratification and pleasure. While 
the affection is still recent, it is almost always possible, by adroitly 
conducting the conversation, in the course of a few minutes, to make 
the patient laugh and weep alternately. It would seem also that, 
besides this psychical hypenesthesia, there may also be a psychical HYSTERIA. 
419 
idiosyncrasy in hysteria, and that the odd and often very extraordinary 
state of mind into which the patient falls is to be ascribed to this. As, 
however, the real and imaginary impressions which inspire the patient 
with a sense of disgust or displeasure are the predominant ones, her 
spi cits gradually become more and more depressed. She is constantly 
sad, unhappy, and in despair about her fate, even although she may be 
in possession of every thing which can tend to make life enjoyable. 
This constant and apparently unreasonable lamentation and weeping 
gradually tire out the sympathy of the friends of the patient. Her 
relatives become indifferent to her troubles, do not listen to her com- 
plainings, or allow it to be perceived that they are becoming tired of 
them. Unfortunately, hysterical persons often become objects of 
ridicule to inexperienced physicians. It is to this absence of sympathy 
and to this gradual diminution of interest that we may most reason- 
ably ascribe the tendency which develops in nearly all hysterical pa- 
tients to exaggerate their complaints and to feign diseases—a tendency 
which, although really a symptom of the malady, does away with the 
last vestige of sympathy for their condition. Cases are on record 
where patients have undergone the most painful operations, in order 
to regain the attention and sympathy which have been withheld from 
them. Krukeriberg tells of an hysterical girl, at his clinic, who mal- 
treated a wound upon her skin with irritating substances until ampu- 
tation became necessary, and who, after the stump began to heal, re- 
commenced the practice. The capacity of such a patient for inventing 
conditions calculated to excite notice or sympathy is something in- 
credible. It is often very difficult to separate the truth from false- 
hood. Credulous persons are often duped, and we should make it a 
rule to accept all unusual reports with the utmost distrust, such as, 
that the patient never takes any food, that she never passes either 
water or feces, that she has vomited blood or maggots, or other odd 
objects. It is a very common occurrence for a patient to declare that 
she cannot make water, and for her to submit to the passage of a 
catheter twice a day. It is equally common for her to remain in bed 
for months or years, asserting that she cannot stand upright. It is 
easy to see what a treasure animal magnetism must be to hysterical 
persons, and with what alacrity they submit to the manipulations of 
the “ magnetizers,” and that, having once “ got into magnetic rapport ” 
with some other person, and thus become enabled to perform all man- 
ner of new tricks, they leave off their old ones, and thus are “ cured 
of the most wonderful diseases by animal magnetism.” In my opinion, 
it is only necessary for the right man to appear (like the magic tailor 
in ImmermanrCs “Milnch-hausen”), in order to convert any decidedly 
hysterical female into a “ somnambulist ” or clairvoyant. At the same 420 
general neuroses, of unknown anatomical origin. 
time it is to be admitted that fanatical enthusiasts, who devoutly be- 
lieve in then* own wonderful gifts, and who are sustained in such be- 
lief by their experiments with hysterical persons, are capable of much 
more than mere impostors, who speculate in animal magnetism. The 
power of reason usually remains unimpaired in hysteria. Like other 
people, they are able to connect one idea with another, and to form 
correct conclusions, although they are so preoccupied with a sense of 
their own sufferings as to be unwilling to think of other matters. A 
very prominent peculiarity in hysteria consists in the loss of power of 
the will to control the movements of the body. This peculiarity is also 
attributable to the almost absolute control which the mental excite- 
ment has obtained. Even persons in good health, when agitated in 
mind, pay less attention to the motions of their limbs, and do not, by 
any action of their will, restrain their reflex movements which arise 
during the agitation. In spite of the authority of Romberg, I cannot 
agree with those who believe the enfeeblement of will of the hyster- 
ical to be the result of a reflex action of such intensity as to overcome 
the action of volition. The real state of the case I believe to be ex- 
actly the reverse. At my clinic, I have nearly always succeeded in 
producing a fit of hysterics in suitable cases, or in exciting a slight 
attack into one of great violence, by expressing great sympathy with 
the patient, and by assuring her that the fit was going to be a bad 
one, thereby so agitating her as to hinder her from bringing her will 
to act upon her motions. On the other hand, by treating the patient 
roughly during the paroxysm, by throwing glass after glass of water 
in her face, and by threatening to keep it up to the end of the attack, 
I have nearly always been able to stimulate the patient to a vigorous 
exertion of her will, and thereby have put an end to the involuntary 
movements. Uneducated bystanders, and superficial observers, when 
they see how manifestly the fits depend upon psychical influences, are 
very apt unjustly to suspect the patient of an imposture. Besides, the 
course of the attack, as described above, corresponds exactly with the 
well-established facts of physiology regarding reflex action and the 
effect of the will upon it. 
There is much variety as to the course, duration, and results of 
hysteria. In most instances the disease comes on gradually. At 
first, the only symptoms are those of bodily and mental hyper- 
aesthesia and their consequences; and it is not until afterward that 
the convulsions and other symptoms of greater or less violence show 
themselves. Sometimes they never appear. In rare instances the 
complaint begins with an attack of hysterics running an acute course, 
the other symptoms not making their appearance until afterward. At 
the menstrual period, and immediately prior to it, the disease is almost HYSTERIA. 
421 
always aggravated; sometimes, indeed, there never are any fits, ex- 
cepting at this period. There is no fixed rule as to the duration of 
hysteria. It may continue for years, with varying intensity, although, 
during the climactei-ic years, it nearly always becomes milder. Recov- 
ery is not uncommon, the physician’s art having many a triumph over 
hysteria to celebrate. There are plenty of cases, it is true, which are 
never cured, and, indeed, which do not even improve. Sometimes the 
malady runs into epilepsy or insanity. Death from hysteria, however, 
is rare. There are only a few ■ scattered cases on record, in which 
death has occurred during violent convulsions, probably owing to em- 
barrassment of respiration. 
Treatment.—After what has been said above regarding the effect 
of education and of habit in inducing hysteria, the necessary prophy- 
lactic measures so important to the patient will have become suf- 
ficiently evident, and will not require any further specification. 
Cases where there is no doubt that the nervous derangement pro- 
ceeds from disease of the sexual organs, call for appropriate treatment 
of the infarction, ulcer, flexion, or other disease of the womb which 
may be present. For further remarks upon this subject we refer to 
the second division of this volume. Where the hysteria is the result 
of psychical influences, and nevertheless the patient is compelled to 
submit to the extremely unpleasant procedures necessary for the appli- 
cation of leeches or caustic to the os uteri, the malady is almost always 
aggravated. In hospital practice, it generally is impossible to meet 
the indication as to cause in cases of this kind; but, in private prac- 
tice, a physician, who is intrusted by his patients with a most intimate 
knowledge of their private relations, is often able to exert the most 
happy influence in this variety of hysteria. It is impossible to lay 
down any general rules of procedure. When the disease depends 
upon impoverishment of the blood and upon chlorosis, the indication as 
to cause requires that we should endeavor to improve the state of the 
blood by the exhibition of iron and an appropriate diet. By means 
of such treatment our object is soon effected, and the hysteria disap- 
pears as the red cheeks return, without it having been necessary for 
us to have recourse to antihysteric remedies. Hysteria which is trace- 
able to anaemia is perhaps the most satisfactory of all forms of the 
disease to treat. 
The indications as to the disease demand that we shall attempt to 
allay the nutritive derangement of the nervous system upon which the 
hysterical phenomena depend. We must not expect to effect a final 
cure of an hysteria by the mere healing of an erosion upon the os uteri, 
although this may have been the original cause of the malady. It may 
happen, but is by no means the rule. The proper means for attaining 422 
GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN. 
our object are, first, remedies which have an active influence upon the 
general nutrition of the system. Secondly, those which seem to act 
specifically upon the nervous system—the so-called nervines. The 
success in the relief of hysteria, of which the hydropaths justly boast, 
is due to the effect of the so-called hydropathic treatment. When the 
cause has been removed without benefit to the patient, or if it be im- 
practicable to allay the cause of the hysteria, the cold-water cure is, in 
many cases, strongly to be recommended. We must warn the patient 
from the very first, that the “ cure ” cannot have the desired effect in 
a few weeks, and that their abode at the water-cure establishment 
must be continued for several months at least. Nor is it advisable to 
allow a patient to undertake the water-cure at her own house, as it is 
of the utmost importance that the treatment should not be conducted 
by halves. The use of sea-batlis also is often of remarkable benefit in 
hysteria. When the patient is vigorous and well-nourished, the 
springs of Marienbad, Kissingen, and Franzenbad, are often of great 
service. The action of these springs is to be ascribed to the modifica- 
tion which they exert upon nutrition. The nervines which have the 
greatest reputation as remedies against hysterics are castor, valerian, 
hartshorn, assafoetida, and other evil-smelling and ill-tasting articles. 
The greatest skeptic cannot deny that a cup of valerian tea, a few 
drops of the tincture of valerian, or a tincture of castor, taken by the 
mouth, or an injection of the infusion of valerian, or an emulsion of 
assafoetida, often act admirably as palliatives, although no radical 
relief can be effected by such articles. I have accidentally hit upon a 
nervine of great efficacy in hysteria, and have made use of it with 
signal effect in many cases where there was no indication for the local 
treatment of uterine disease, or else, where the hysteric symptoms per- 
sisted although the local uterine affection had been cured. I mean the 
chloride of sodium and gold. I had read that Dr. Martini, of Bibe- 
rach, regarded this article as an efficient remedy against the various 
diseases of the womb and ovaries. As the diseases which this gentle- 
man (a much-respected gynecologist in his district) claims to have 
cured by this drug, for the most part, belong to that class of disorders 
which are incapable of resolution, and which are incurable, in the 
strictest sense of the word, and as I had no reason to doubt the 
veracity of Dr. Martini, I could only infer that the cases had been 
imperfectly observed. My suspicion that the chloride of gold and 
sodium, like other metallic articles, was an active nervine, and that the 
improvement effected upon Dr. Martini?s patients was probably due 
to this property, was fully confirmed by what followed. After having 
employed the medicine in question for several years, and in a great 
number of cases, and, encouraged by my success, having recommended HYSTERIA. 
423 
it to my pupils as one of the most effective of nervines, I ascertained that 
the chloride of gold has been recognized as a special re-agent upon the 
nerve-tissues, and that it is much used for this purpose in microscopic 
investigations. Such a discovery, probably, would never have induced 
me to make use of it as a remedy, but now this piece of information is 
of great importance to me, as a confirmation of the fact that the cura- 
tive action of this remedy had been rightly interpreted. I prescribe 
the chloride of gold and sodium in the form of a pill (It auric, chlorat 
natronat. gr. v; gummi tragacanth. 3 j ; sacc. alb. q. s. u. f. pil. No. 40). 
Of these pills I at first order one to be taken an hour after dinner, and 
another an hour after supper. Afterward I order two pills to be taken 
at these hours, and gradually increase the dose up to eight pills daily. 
In some cases of severe hysteria where fulfilling the causal indica- 
tions does not answer the purpose, or where the origin of extensive hys- 
terical disturbances of innervation cannot be discovered, either in the 
sexual apparatus or other organs, I have experienced some excellent 
results from the use of bromide of potash in increasing doses (fully 
described in the treatment of epilepsy), while in other cases it failed 
entirely. An esteemed colleague also, who has a large consultation 
practice, informs me that, when he is unable to refer severe nervous 
symptoms to structural changes in the central organs or the peripheral 
nerves, he often resorts to this effective but empirical remedy. 
Moral treatment is of the utmost importance in all cases of hys- 
teria, whatever may be the source of the disease. Romberg very 
properly observes : “ Psychical treatment is of such importance that, 
without it, all other remedies fail.” Every thing depends upon our 
exercising the patient to “ oppose the impulse of the will to the reflex 
impulse.” It of course depends upon the peculiarities of the patient 
as to what measures we shall resort to in special instances. When 
they have shown themselves to be willing and obedient, and seemed 
to place reliance upon my directions, I have ordered them to take 
a cold shower-bath twice a day, and to keep under the shower as 
long as the utmost exertion of their will would enable them to 
do so. 
[Electricity is serviceable not only against certain symptoms of 
hysteria, such as paralysis, anaesthesia, neuralgia, etc., but it is as- 
serted to be of positive benefit for the general disease. The best 
application is the induced current in the form of “ general electri- 
zation,” as recommended by Beard and Rockwell, where currents 
of moderate intensity are passed over the entire surface.] 424 
GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN- 
CHAPTER VI. 
CATALEPSY. 
Etiology.—Catalepsy belongs to the neuroses of stability (Sta- 
bilitdts-neurosen), according to the classification of Hlazius. Dur- 
ing a cataleptic fit, the limbs of a patient remain in the attitude in 
which the patient voluntarily placed them prior to its commencement, 
or in which they may be placed by a bystander during the seizure. 
The limbs do not sink by reason of their weight, nor can the patient 
of his own will bring them into any other position. The resistance to 
gravitation opposed by the limbs proves that the muscles must be in 
a state more or less of contraction. In all conditions in which the 
muscles are fully relaxed, as in a swoon, or after death, the limbs fall 
of their own weight as soon as support is withdrawn from them. It 
would seem most natural to attribute the steady continuance of the 
limbs in one attitude to a continued excitement of the nerves which 
induce the muscular action requisite to produce such an attitude. This 
explanation, however, is contradicted by the other phenomenon, for, 
if we alter the position of the limbs of the patient, the new pos- 
ture is retained, just as the former one was. It is contrary to all ex- 
perience that a change of attitude in a limb, effected by foreign inter- 
ference, should arrest the action of one nerve and induce action in 
others. Cataleptic attacks are not sufficiently common to enable us 
to decide these points positively; but it is most likely that all the 
motor nerves are in a state of medium excitement in this disease, and 
hence that all the muscles of the body are in a state of contraction 
sufficient to counteract the resistance afforded by the weight of the 
limbs. The facility with which the posture of a limb may be changed 
(flexibilitas cerea), and the fact that a limb remains bent, if we bend it, 
or straight, if we straighten it, lead to the conclusion that the con- 
traction of the antagonistic muscles fully preserves their equipoise. 
The supposition that the medium state of irritability of the motor 
nerves, wThich is the cause of this condition, proceeds from the spina] 
marrow, is also the most satisfactory and general. The incapacity of 
the patients to modify this excited condition of the motor nerves and 
contractile state of the muscles by the force of their will indicates that 
there is also a morbid state of the brain. In cases of catalepsy, where 
consciousness is entirely suspended, no struggles occur; and, in cases 
where consciousness is retained, the patients wish to move, but can- 
not, because that particular part of the brain is thrown out of function, CATALEPSY. 
425 
tvhose duty it is to conduct the impressions from the central organs 
of imagination and volition to the motor nerves. 
Catalepsy is quite common among the insane, especially among 
persons suffering from melancholia attonita. It also sometimes pre- 
cedes the convulsive attacks of hysteria. Cataleptic fits may also ac- 
company St. Vitus’s dance, the chorea Germanorum, tarantism, and 
other epidemic and endemic forms of convulsion of psychical origin, 
and which Romberg aptly terms psychical convulsions. It is very 
rarely met with as an independent affection in persons whose health 
.s otherwise good. Children and young persons seem to be most 
liable to its attacks. Mental emotion is said to be its principal exciting 
cause; indeed, in healthy individuals, slight indications of this morbid 
condition are sometimes observable as a result of such impressions. 
It is a very common thing to see persons, under the influence of sudden 
fear or horror, standing motionless, with outstretched hands, until the 
emotion subsides. 
Symptoms and Course.—In my description of the symptoms and 
course of catalepsy, as an independent disease, I must rely entirely 
upon the representations of others, since all the cases which I have 
had an opportunity of observing personally have inspired me with the 
suspicion that they were simulated. The precursors of a cataleptic 
fit are said to be headache, dizziness, buzzing in the ears, broken 
sleep, extreme irritability, and other symptoms of nervous derange- 
ment. The paroxysm itself sets in suddenly. The patient remains 
motionless as a statue in the attitude in which he may happen to 
be at the moment of the attack. At first, some force is required 
to move the limbs ; afterward, they can be moved with ease, 
and it is possible to adjust them in any desired posture, and they will 
retain that posture much longer than a healthy person would be able 
to retain it of his own will. During the fit, consciousness and sensi- 
bility to external impressions are either entirely suspended, or else, 
though the senses may be retained, and though external impressions 
are perceived, the patient is unable, either by word or act, to give any 
sign of consciousness. The respiratory movements and the beat of 
the heart and pulse are usually so feeble as scarcely to be perceptible. 
The urinary and alvine evacuations usually are arrested. Deglutition 
proceeds undisturbed, if the bolus be thrust far enough back into the 
pharynx. Generally speaking, such a fit only lasts a few minutes; 
more rarely it continues for several hours or several days. When it 
is over, the patients yawn and sigh like persons who have waked out 
of a profound sleep. If the seizure be a very transient one, and be 
accompanied by loss of consciousness, the patient often is quite unaware 
that any thing unusual has happened to him, and, after the fit is over 426 
GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN. 
goes on with his business quite undisturbed, taking it up where he 
left it off. In other cases, the patient remains stunned and dizzy, for a 
while complaining of a feeling of confusion in the head. There is 
often but one attack; more rarely there is a series of them, recurring 
at varying intervals. Between the fits the health is good, unless 
there be complications. Recovery is the most frequent termination 
of simple catalepsy. The dread lest cataleptic patients should be buried 
alive has become exploded in modern days. It is stated that, in some 
cases of the disease, the length of the fits, and the frequence of their 
recurrence, and the consequent diminution in the supply of nourish- 
ment to the patient, have sometimes resulted in marasmus, and even 
in death. In such cases, however, it is probable that there was a com- 
plication of diseases. 
Treatment.—In spite of the old caution, not to interfere too ac- 
tively with a cataleptic fit, I should not hesitate to resort to affusion 
of cold water, to apply a strong electric current, and, unless the respi- 
ration and pulse should seem too feeble, to give an emetic. In a pro- 
tracted seizure, it may become necessary to feed the patient through 
an oesophagus tube. As the treatment of the case between the fits 
must be addressed to their apparent cause, to any derangement in the 
nutrition of the patient, or to any other symptom which may appear, 
no fixed rules can be laid down for our guidance. 
CHAPTER Y11. 
HYPOCHONDRIASIS. 
Etiology.—Properly speaking, hypochondriasis is a disease of the 
mind, and, in the books on psychiatria, is usually classed with melan- 
choly, lypemania, and phrenalgia, that is, to that class of diseases in 
which, as their names indicate, the mind of the individual is oppressed 
by a painful impression. The hypochondriac is always plagued by 
the idea that he is sick, or that he is going to be sick. Hence, in the 
opinion of Guislaine, an appropriate name for the disease would be 
pathophobia or monopathophobia. All persons who are possessed by 
the idea that they are sick, however, are not to be regarded as hypo- 
chondriacs, but only those in whom such an impression constitutes a 
symptom of disease. A father of a family, who is informed by his 
physician that he is suffering from some incurable malady, and from 
that hour is insane upon that point, suffering constant apprehen- 
sion, and watching his bodily condition with all the attention and anx- 
iety of a hypochondriac, quite assumes the aspect of one laboring 
under this disease. He is not a hypochondriac, however, for his HYPOCHONDRIASIS. 
427 
mental and bodily derangement correspond, and do not stand in con 
tradiction to the psychical peculiarities of the patient prior to his 
discovery. 
Like all symptoms of mental disease, hypochondriasis proceeds 
from nutritive derangement of the central organs of all psychical ac- 
tion, but we are not able to trace back the morbid state of mind, char- 
acteristic of this malady, to any particular lesion of the brain. We 
can scarcely ever point out the nutritive disorders of the brain to 
which the derangements of its functions are due in any other form of 
insanity, and, in hypochondriasis, it is equally impracticable to trace 
the causes of the morbid mental condition to cerebral lesion. Where 
a tendency to the disease exists, it may arise either from psychical or 
from physical influences. There is no objection to the application of 
the terms hypochondria sine materia to that form of the affection 
which proceeds from psychical causes, and hypochondria cum materia 
to that which arises from physical influences, but the expressions are 
not to be employed in any other sense. 
The predisposition to hypochondriasis is very slight indeed during 
childhood, and is far less in females than in males. It is greatest be- 
tween the ages of twenty and forty. Not unfrequently it is of con- 
genital origin. In other instances it seems to proceed from debili- 
tating influences, such as sexual excess, onanism, digestive disorder, 
or want of fresh air, as well as from an inactive mode of life, or im- 
moderate self-indulgence, from disappointment, failure of speculations, 
and an ill-selected career. 
The exciting causes of hypochondriasis are, first, physical diseases. 
Certain morbid conditions are more liable to cause hypochondriasis 
than others are, or (to speak more precisely) to produce those mate- 
rial lesions in the brain which are the cause of hypochondriasis. The 
principal of these are the gastric affections, especially chronic gastric 
or intestinal catarrh; next come diseases of the genitals, and, finally, 
gonorrhoea and syphilis. In the latter, however, the mental impres- 
sion made by the disease ought to be taken into account quite as 
much as its physical effect. If these diseases sufficed of .themselves 
to produce such disorders, the world would be full of hypochondriacs. 
Regarding them as mere exciting causes, however, only capable of 
bringing on the disease where a predisposition to it already exists, 
the disproportion between the frequence of gastric catarrh, of syphilis, 
or of clap, and that of hypochondriasis, will not appear at all remark- 
able. 
The operation of mental impressions- has a very similar effect. 
The most important of these consists in the reading of those pernicious 
books of “popular medicine,” innumerable copies of which are in cir- 428 
GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN. 
dilation all over the world. Now, although there is no doubt that the 
reading of this kind of literature has often resulted in an attack of hy- 
pochondriasis, yet persons free from any morbid predisposition may 
read these books with impunity. An effect very much like that pro- 
duced by reading popular medical books may arise from the exclusive 
occupation of the mind with stories of disease and death, such as are apt 
to be current in any region where an epidemic disease is prevailing. 
Such impressions do no harm to the majority of people, but there are 
a few who become hypochondriacs. It will be readily understood, 
moreover, that the companionship of a hypochondriac is dangerous to 
an individual of a hypochondriacal predisposition. 
Symptoms and Coukse.—Hypochondriasis usually develops grad- 
ually. At first, there is an indefinite sense of illness, which troubles 
and oppresses the patient, but which does not as yet disturb his judg 
ment or possess him completely. Nor are this restlessness and distress 
usually permanent in the beginning. They generally cease at times, 
and then reappear with somewhat increased intensity. The more pro- 
foundly the disease takes root, so much the more assiduously does the 
patient endeavor to discover the cause of his indisposition. He scru- 
tinizes his tongue, his stools, his urine ; he counts his pulse and han- 
dles his abdomen. Every trifling irregularity which he perceives, the 
slightest irritation, the faintest coating of his tongue, a transient colic, 
an insignificant cough, are all of the utmost importance in his eyes; 
not because he suffers more than any one else from such symptoms, 
but because they seem to him to afford a clew to the nature of the 
grave and obscure imaginary disease. To-day he may dread an apo- 
plexy, to-morrow he may think that he has an ulcer of the stomach ; at 
other times he may imagine his heart diseased, or that he is consump- 
tive, or afflicted with some other serious malady of a character corre- 
sponding to his sensations of distress. He studies all the “ medical 
advisers ” and other books of “ domestic medicine,” but, instead of de- 
riving comfort and aid from them, merely finds out new diseases, by 
which he immediately imagines himself afflicted. As the disease gains 
mastery over the patient, his belief as to his condition becomes more 
and more biassed and incorrect. Argument is useless, as it cannot re- 
lieve him of his feelings. A few hours only may have elapsed since 
we last saw the patient. We then may have spared neither time nor 
trouble in explaining to him that his condition was perfectly free from 
danger, when a messenger arrives from him, begging us to come in 
haste, that some serious change has taken place, and that his con- 
dition has become a most critical one. In other instances, especially 
when the patient really has some insignificant disorder, the hypo- 
chondriac is not so apt to change his opinion as to the nature of hig HYPOCHONDRIASIS. 
429 
disease, but sticks to a belief in one, and cannot be dissuaded from it. 
He is not like other patients, satisfied with simply complaining of pain, 
oppression, or fever; partly, because he really feels worse than other 
people, and, in part, because he is convinced that the doctor “ makes 
light of his sufferings.” Hence he exaggerates, and often exhibits the 
utmost fluency in description of his infinite suffering. In spite of the 
severity of these imaginary symptoms, however, they by no means 
despair of recovery; hence hypochondriacs seldom attempt suicide, 
and never weary of seeking fresh medical advice and of trying new 
treatment. Sometimes their hopes are so much in the ascendant, and 
are so productive of happiness to them, that, for a while, in spite of 
their sense of illness, they are cheerful and in even high spirits. Such 
intervals, however, are usually very brief, and occur most frequently 
immediately after the engagement of a new medical man or the con* 
mencement of a new “ cure.” The old mood very soon returns. The 
false realizations of their sensations, and the erroneous ideas of the par 
tients as to the condition of their own bodies, which we sometimes see 
in hypochondriasis, are a genuine delirium. Like other insane ideas in 
other forms of psychical disorder, this proceeds from morbid bias of 
the mind, and is to be regarded as an attempt to clear it ( Griesinger). 
Hallucinations—“ sensations originating inwardly ”—also arise in hy- 
pochondriasis, owing to this sense of illness, and to the attempts of 
the patient to account for it. Thus the idea that the heart is stand- 
ing still, or that a limb is withered, or that the body is putrefying, 
although it is not the result of a genuine sensation incorrectly inter- 
preted, yet it is so vivid that the patients cannot distinguish it from 
an impression actually furnished by the senses; and they really believe 
they can feel that the heart does not beat, that the skin is dried up, or 
that they can smell the putrid emanations from their body. In spite 
of their mental aberration and morbid fancies, most hypochondriacs are 
able to transact their business, and to take care of their house and 
family; and this is the reason why hypochondriasis, usually, has not 
been regarded as a disease of the mind, being looked upon rather as a 
nervous disorder, a custom with which we have complied. In the 
worst forms of the disease, the patient loses all interest for matters 
which do not bear upon the state of his health. He becomes ab- 
stracted, forgetful, and negligent of his affairs, gives himself no further 
concern about his family, and often remains idle in his bed for years. 
It is often a long time before his nutritive condition begins to suffer. 
Gradually, however, especially in bad cases, the patient grows thin, 
and acquires a sickly appearance, and derangement of the secretory 
and digestive functions arises. We are not at liberty to account for this 
emaciation and the other nutritive disorders, by supposing that the 430 
GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN. 
perversion of sensation in the patient’s various organs has led to 
perversion of their functions; for the same emaciation and the same 
disorder of nutrition may likewise be seen in persons who have fallen 
into a state of permanent mental depression, as a result of objective 
conditions, and who feel no morbid sensations in the organs which 
ultimately become diseased. Moreover, the very improper way in 
which hypochondriacs often live, and their immoderate use of medi- 
cines, contribute a great deal toward the development of a cachectic 
condition. 
Hypochondriasis always runs a chronic course. The cases in 
which peculiar causes, acting upon a constitutionally timid and im- 
aginative person, induce a transitory belief that he is ill, or a fear 
that he is about to be ill, are not to be regarded as genuine hypo- 
chondriasis. Recovery is not uncommon. More frequently the dis- 
ease persists throughout life, with varying intensity. It rarely termi- 
nates fatally, although there have been instances where the patient 
died of marasmus and exhaustion. 
Treatment.—It is useless to dispute with a hypochondriac, and 
to try to convince him of the error of his ideas. The only way to cure 
the patient is to rid him of his morbid sensations. For this purpose it 
is necessary, in the first place, to correct any existing derangement of 
the system which, as we have said, is often the exciting cause of the 
disease, and which would cause a feeling of illness in a sane person. 
The necessary therapeutic measures vary according to the peculiarity 
of the case. The benefit often derived from the springs of Karlsbad, 
Marienbad, and Kissingen, in the treatment of this affection, are, no 
doubt, mainly due to the beneficial effect exerted by these waters upon 
diseases of the gastric organs, which so frequently prove a source of 
hypochondriasis. In other instances, preparations of iron will be ap- 
propriate, while the springs will do harm. In others, again, sea-bath- 
ing and cold foot-baths are to be used. We must be cautious in the 
employment of the drastic cathartics, although they can seldom be 
dispensed with altogether, and although they usually afford the patient 
a temporary relief; and, above all, we must distinctly warn the patient 
against over-dosing himself, a practice to which hypochondriacs are 
very prone. This likewise applies to the use of carminatives, fo* 
which the patients nearly always earnestly beg. The bbject of tlu 
psychical treatment, as Romberg aptly says, should be diversion of 
the attention from the sensory to the motor and intellectual spheres. 
This object will not be attained in educated patients by ordering them 
to take long walks, to saw wood, to practise gymnastics, and to occupy 
themselves in other mechanical pursuits, because the attention of the 
patient is not diverted, by such actions, out of the sphere of sensation. PARALYSIS AGITANS. 
431 
A hypochondriac merchant, while sawing wood, is always busy with 
the thought that he is sawing wood because he is sick. Such ordi- 
nances, however, especially active gymnastic exercise, are of great 
service, because, like the cold baths, they induce a vigorous modifi- 
cation in the process of transmutation of the tissues, and because 
they tend to restore the patient to a sense of physical energy. 
Diverting amusements, as the excitement which they produce soon 
becomes extinct, are seldom productive of lasting benefit. Travel- 
ling with some definite object in view, or the study of agreeable 
objects, is much more commendable. Of course, no general rules 
can be laid down for the fulfilment of the task in question, as our 
directions must always be in accordance with the capacity, educa- 
tion, and means of the patient. 
[CHAPTER VIII. 
PARALYSIS AGITANS—SHAKING PALSY. 
The most apparent symptoms of this disease are involuntary 
movements of parts of the body, either a simple trembling or a 
regular shaking ; sooner or later these are accompanied by partial 
paralysis of the muscles affected. The disease is uncommon ; it 
affects chiefly aged men; exceptionally it occurs in middle age, and 
very rarely in youth. In some cases it has followed severe fright 
or great anxiety ; in others it has seemed due to unfavorable sur- 
roundings, exhausting work, continued exposure to moisture and 
cold, or to irritation of peripheral nerves from injury ; in other cases 
no external cause has been found. 
The trembling usually begins in the fingers, hands, or arms, and 
may remain limited there, or may spread to the whole upper or 
lower limbs ; exceptionally it affects the muscles of the face, larynx, 
or neck. The tremor may be restricted to the limbs of one side of 
the body, rarely to one arm and the opposite leg. The movements 
may cease temporarily, especially in the horizontal position ; but 
when fully developed it is apt to be continuous, though varying in 
intensity from mental or physical excitement; during sleep or an- 
sesthesia the movements cease. 
The paralysis may not come on for some time, the impaired use 
of the limbs meantime being due to disturbance from the motion. 
Late in the disease there may be a tenseness and rigidity of the 
muscles, with preponderance for the flexors ; after the tenseness 
has lasted some time it will cause deformity ; the head may be 432 
GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN. 
drawn down, the arm raised from the thorax, the forearm flexed. 
If the lower limbs are affected, the rigidity may resemble paraplegia 
with contractions. There may be various anomalies of sensation, 
such as numbness, prickling, neuralgia, anaesthesia, heat, etc., and 
cerebral symptoms, such as headache, dizziness, sleeplessness, etc. 
The disease may drag along for years, death at last resulting 
from age, debility, or some intercurrent disease. The autopsies 
made have proved nothing about the seat of the disease or the an- 
atomical changes causing it; their results have been so varied that 
it is not even certain whether the original seat of the disease be in 
the brain or spine. 
Senile tremor, or that of very excitable persons, is less marked 
than that of paralysis agitans. That due to poisoning by alcohol, 
lead, or mercury is accompanied by other synxptoms of poisoning ; 
but it may be mistaken for multiple sclerosis, although this comes 
earlier in life, and paresis appears as one of its first symptoms, and 
the tremor usually comes only when the patient tries to execute 
some movement. 
Although some recent cases have seemed to recover, this must 
be considered as spontaneous rather than as a triumph of medicine; 
in some of the cases there may have been an error of diagnosis. 
Among the remedies said to have proved beneficial are hyoscyamus, 
hypodermic injection of small doses of Fowler’s solution, continued • 
use of carbonate of iron, cold douches while in a warm bath, gal- 
vanism, etc.] 
[CHAPTER IX. 
DELIRIUM TREME1STS MANIA A POTU. 
The name delirium tremens is used even by the laity, and un- 
fortunately it is so common that the symptoms which characterize it 
are very generally known. Frequent as is this affection, the opin- 
ions as to its immediate cause are not unanimous. Some believe 
that it is the direct result of the abuse of alcoholics, while others 
say that it is due to their sudden withdrawal. It is not improb- 
able that it may be caused either way ; perhaps the worst cases are 
those that come on during the use of liquors; those that result from 
the patient’s inability to obtain liquor, from having a broken leg or 
some acute disease, or from being locked up, have seemed to us to 
run a much lighter course than the former. Possibly the long-con- 
tinued use of alcohol may induce such a state in the gastric mucous 
membrane that it will absorb neither liquor nor nourishment; this DELIRIUM TREMENS. 
433 
might make the cases due to direct poisoning worse than those 
arising from sudden withdrawal of stimulants. 
This disease may develop more or less suddenly. It may be 
preceded by a stage of melancholy, but the actual commencement 
of the trouble is characterized by marked hallucinations; the patient 
sees numerous insects or small animals around him; has hairs in his 
mouth, which he constantly removes with his fingers and spits out; 
he hears music, voices, etc. While subject to these hallucinations, 
the patient may still control himself enough to answer questions 
rationally; but while speaking coherently he will look past you and 
around the room, and it is evidently by a great effort of will that he 
keeps his attention fixed on the conversation. 
As the disease progresses the harmless animals seen may be re- 
placed by frightful forms, robbers, the devil, and other terrifying 
personages, who pursue and threaten the poor patient till he is a 
most pitiable object. At this time more than ever his nerves are 
unstrung, his limbs in a perfect quiver from excitement and fear, 
perspiration bedews his face, the tongue is dry, and he constantly 
stares around as if following his persecutors with his eyes. He can- 
not sleep or eat. A good nurse, or a courageous, vigorous friend, 
may persuade him to drink milk, beef-tea, etc. ; but the power of 
masticating and of supplying saliva for solid food seems to be 
absent. 
In the first attack very frequently, and in subsequent ones more 
rarely, the above symptoms will only last a couple of days ; then 
the patient will eat a good beef-steak, have a sound sleep, and sub- 
sequently be well except for a slight gastric catarrh, which is very 
apt to have been induced by his previous prolonged use of liquor. 
In severe cases, after one or several days of the delirium, while the 
patient does not seem to be dangerously ill, he may suddenly die 
from paralysis of the heart; or in trying to escape his imaginary 
tormentors he may jump from a window or otherwise do himself 
serious injury. If the disease lasts several days, with delirium and 
inability to eat, the tongue becomes dry, the pulse frequent and 
dicrotic, and the patient dies in a typhoid state. In these cases 
there is usually chronic disease of the kidneys and liver ; evidences 
of chronic inflammation of these organs, and perhaps of the cerebral 
meninges, being the chief changes found on autopsy. 
Delirium tremens rarely lasts a fortnight; in our own experience 
those cases that last over six days end in recovery. It must be 
regarded as a very treacherous disease, and our prognosis may 
always be guarded till the patient has eaten and retained some safe 
solid food, such as tender beef or mutton. 434 
GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN. 
In all cases of delirium tremens the condition of the kidneys and 
of the thoracic organs should be carefully scrutinized ; for we should 
bear in mind that pneumonia attacking a person of intemperate 
habits presents all the symptoms of delirium tremens, and in many 
such cases there is neither cough nor expectoration, nor does the 
patient complain of pain, nor indeed of any symptom likely to 
direct the attention of the physician to the real nature of the dis- 
ease. It has not unfrequently happened that a man has died under 
diagnosis of delirium tremens, and a pneumonia, which had not 
been even thought of during the progress of the case, has been re- 
vealed upon dissection. 
The symptoms of Bright’s disease also are not always so marked 
as to attract immediate attention. A uraemic convulsion sometimes 
admonishes the unwary practitioner that a grave condition of the 
kidneys has been overlooked. 
Treatment of delirium tremens, as of any disease, must depend 
greatly on the symptoms ; but numerous special plans have had 
their advocates, such as that by opium, alcohol, and digitalis ; each 
of these has doubtless proved useful in the hands of its advocates, 
but no one has proved universally acceptable. The remedy at pres- 
ent most generally relied on is bromide of potassium. It may be 
given in doses of thirty grains every hour till the patient sleeps ; 
if a few doses do not accomplish the desired result, an equal quan- 
tity of hydrate of chloral may be added to it. When a good sleep 
has been secured, the hallucinations may not recur, and further 
treatment may be unnecessary, except such as is required for the 
general state of the patient. 
Another remedy which is very quieting, and may be used sub- 
cutaneously when there is difficulty in getting the patient to take 
bromide of potassium, is hyoscyamin, which may be given in doses 
of the twenty-fourth of a grain, and if necessary increased to the 
twelfth or sixth of a grain. 
When the patient comes under treatment with a stomach full of 
alcohol and undigested food, “ just off a spree,” it is well to give a 
mild emetic and a cathartic (perhaps calomel) ; then, unless there 
are complications, to rely greatly on a good-natured, stout, resolute 
nurse, and good diet. If the symptoms be not urgent, we may give 
the mineral acids, Horsford’s acid phosphates, and similar remedies. 
If there is marked sleeplessness, we may try one of the above reme- 
dies. An important question is whether the patient shall have any 
alcoholic stimulant. If the stomach is quiet, and apparently in a 
condition to digest food wThich the patient objects to taking, it may MORPHINE HABIT. 
435 
be well to promise a drink if he will eat a piece of steak ; but as a 
matter of treatment, or by way of “ tapering off,” we may gener- 
ally reject alcoholics. 
When a quiet sleep has been secured, and a meal of solid food 
has been eaten and retained, the patient generally progresses favor- 
ably.] 
[CHAP TEE X. 
MORPHINE HABIT OPIUM-EATING. 
Closely allied to chronic poisoning hy alcohol, with its frequent 
accompaniment delirium tremens, is the result of long-continued 
use of opium or the salts of morphine. This habit is not uncom- 
mon, and as it is generally begun under the physician’s recommen- 
dation, we may consider ourselves as responsible for its cure. 
As a patient suffering from indigestion finds his pain relieved 
by alcoholic stimulants, he resorts to them more and more frequent- 
ly, and finally employs them to excess ; in the same way frequent 
attacks of pain from neuralgia, rheumatism, or inflammation induce 
repetition of the doses of narcotics that have once been found effi- 
cacious. Hence it would seem imperative that, when prescribing 
the various pain-quellers, we should warn the patient against too 
frequently resorting to them, and explain to him that they all grad- 
ually lose their effect, and after being used for a time cease to afford 
relief, or must be given in gradually increasing doses. The prepara- 
tions of opium being especially liable to abuse in this way, we may 
picture to the patient the painful symptoms of chronic poisoning 
that are likely to result from their continued use, and which may 
finally prove more annoying than the original pains for which the 
anodyne was given. It is also claimed that protracted use of opium 
begets a special tendency to neuralgia, and demoralizes the entire 
nervous system. 
There is no doubt that many opium-eaters reach advanced age 
under the influence of that drug ; many of those who drink intoxi- 
cating liquors, even to excess, live to be quite old, and many aged 
men have been smokers from their youth ; but, as a rule, free and 
continued use of opium, alcohol, or tobacco will be followed by 
their peculiar toxic effects. It seems that any of these articles may 
be used with greater impunity on a full stomach ; and those who 
habitually indulge in them only after a full meal are less liable to 
suffer bad results. 436 
GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN. 
The symptoms of opium-eating or morphine habit are not always 
very marked, even where the patient’s life is rendered a burden by 
it; they vary greatly in relation to the time which has elapsed since 
the dose last taken. While the effect is recent, and the nerves are 
“ keyed up,” the patient may be lively and unusually bright; as the 
effect begins to wear off, there comes a quiet, rather drowsy time, 
and.those who are entirely regardless of the results do not go be- 
yond this stage while their digestion and nerves will stand repeti- 
tion of the dose, for they at once resort to their stimulus. But if 
limited means, a troublesome conscience, or other cause prevents 
the use of more than a certain quantity daily, the second stage is 
followed by a third, where we have what are usually given as the 
symptoms of opium habit, viz. : sunken features (as if the skin were 
drawn tightly over the cheek-bones), lack of healthy color, furred 
tongue, constipation, loss of appetite, sleeplessness, shaky hands 
covered with clammy moisture, and great mental depression or rest- 
less longing for more of the drug. Cold hands and feet, tendency 
to sweat, and complaints of most varied pains and discomforts are 
common. An almost universal symptom is emaciation, which is 
magnified by the sunken look above referred to. Mentally the pa- 
tients are depressed, suffer from loss of memory and energy, and 
are apt to be untrustworthy. 
If the use of the drug be suddenly and completely stopped, a 
state resembling delirium tremens may supervene and result in 
death. In strong patients, however, this sudden arrest is one of the 
modes of treatment recommended; but if we have the earnest co- 
operation of the patient, or have complete control of him, we may 
pretty certainly break off the habit without this rude shock, by 
gradually reducing the amount of the drug, substituting for it if 
necessary a variety of other remedies, not relying on any one for a 
length of time for fear of replacing the opium habit by some other 
only a little less pernicious. During the period of withdrawal the 
doses of opium given will have to be regulated to some extent by 
the previous habits of the patient; i. e., if he has taken his dose 
only at night, we have simply to reduce this dose gradually (with- 
out the patient’s knowledge). If it has been taken more frequently, 
it is well to give a dose of the opiate with a tonic shortly before the 
midday meal; this will enable the patient to eat well, and possibly 
the effects may last till the evening meal. If we can get along with 
two doses daily, the second dose should be given about bedtime. 
Administering the two doses in this way gives the best chance for 
plenty of nourishment and plenty of sleep, which will be found ADDITIONS TO THE REVISED EDITION OF 1880. 
437 
absolutely necessary to keep the patient’s “ courage to the sticking- 
point ” of resisting the craving which exists even when the dose is 
not being reduced. During the treatment appetizing food should 
be offered and mental and physical occupation provided. Addition 
of atropin to the opiate, occasional hot baths for the extremities, and 
frictions with alcohol, seem to check the pain and sweating in the 
hands and feet.] 
ADDITIONS TO THE REVISED EDITION OF 1880. 
SECTION IV. GENERAL NEUROSES, OF UNKNOWN ANATOMICAL 
ORIGIN. 
1.— P. 405. 
Occasionally the urine passed a few hours after an epileptic 
seizure contains albumen. Sometimes there is temporary mental 
perturbation instead of a regular epileptic fit. The seizures may 
be followed by paresis or paralysis, in which case we may suspect 
disease of the brain ; or there may be aphasia, aphonia, dysphagia, 
asthenia, etc. 
The investigations of Reynolds oppose the general view that the 
disturbance of intelligence is in direct proportion to the number and 
severity of the seizures. Nothnagel even thinks that the mental 
disturbance in the majority of cases is not the result of changes 
in the pons and medulla oblongata, but accompanies them ; i. e., the 
epilepsy and psycopathia are both due to some neuropathic dispo- 
sition. 
It is always important to decide whether any given case is idio- 
pathic or secondary to some other disease, and this must be de- 
termined by a careful examination of the whole body and of the 
surrounding circumstances. We may suspect organic disease of the 
brain when there is a permanent partial spasm, or when it always 
begins at the same part of the body. 
Attention has been called to pain in the hypogastric region, 
which was attributed to the ovary ; this pain may be spontaneous 
or induced by pressure over one or both ovaries (oftenest the left). 
It is said that an hysterical aura is often induced by this pressure 
—a feeling of constriction about the stomach and neck, nausea, 
palpitation, tinnitus, disturbance of vision on the side of the pain- 438 
GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN. 
ful ovary ; and that further pressure upon the affected part may 
induce a true hysterical attack. 
The following is said to be a favorite prescription with Dr. 
Brown-Sequard: Bromides of sodium, iodinium, and ammonium, 
each 3 iij; iodides of potassium and ammonium, each 3 iss. ; am- 
mon. sesquicarb. 3 j ; tinct. calumbas § iss ; aquae dest. ad § viij. 
S. teaspoonful and a half before each meal and three teaspoonfuls 
at bedtime. If bromide of potassium fails, try conium, cannabis 
indica, or oxide of zinc. 
Chapman’s ice-bags applied to the spine for two to eighteen 
hours have proved useful in some cases. Electricity, even in the 
constant current, has not fulfilled expectations ; when used as an 
adjunct, we try to affect the pons and medulla oblongata by placing 
the electrodes on each side of the neck ; or we may galvanize the 
sympathetic or peripheral nerves from wdiich there is any reflex ex- 
citement. 
Dr. JS. W. Mitchell recommends inhalations of from two to five 
drops of nitrite of amyl for averting attacks ; but they can only be 
tried where there is a protracted aura, and in cases where the face 
becomes pale at the onset, showing spasm of the vessels. Sometimes 
this remedy seems not only to avert attacks, but to render them less 
frequent and severe ; in other cases the escape was followed by 
severe attacks. 
2.—P. 418. 
Hysterical spasms may resemble epilepsy, or the latter may oc- 
cur in hysterical patients. There may be hysterical paralysis of 
almost any muscles, but especially of those of the extremities. The 
electro-muscular contractility remains normal; in most cases there 
is cutaneous anaesthesia. Rarely with paralysis of a limb there is 
facial paralysis, anaesthesia of the skin of the face, ptosis, etc. 
There may be paralysis of the pharynx or oesophagus, which may 
be diagnosed from spastic dysphagia by the passage of a sound. 
Sometimes enormous tympanites occurs, the accumulation of gas 
seeming due to temporary arrest of the gastric and intestinal con- 
tractions ; the same sluggishness of peristaltic action may cause 
constipation. Aphonia, due to paralysis of the glottis muscles, is 
seen quite often. In rare instances paralysis of the diaphragm has 
been seen, when on respiration the movements were in the reverse 
direction, viz., sinking in inspiration and protruding in expira- 
tion. There may be paralysis of the bladder with hemi- or paraple- ADDITIONS TO THE REVISED EDITION OF 1880. 
439 
gia. These paralyses may last for days or weeks, and then sud- 
denly disappear. 
There may be great variation in the heart’s action—palpitation 
with a feeling of fulness and pressure in the chest, of constriction 
and anxiety ; or, on the contrary, a tendency to temporary lack of 
action, and faintness with hysterical trance. 
There are changes in the vessels, the skin changing from red to 
pale, either on part of or the entire body. These changes of the 
vessels may affect different organs, as brain, lungs, uterus, etc., or 
cause bleeding from the nose, mouth, stomach, respiratory passages, 
etc. But hysterical patients sometimes simulate such things, drink- 
ing blood and vomiting it, causing bleeding from the skin, etc. DISEASES OF THE SKIN. 
No notice has been taken, in the following chapters, of the altera- 
tions which the skin undergoes in the acute and chronic infectious 
diseases. Like other symptoms of measles, scarlatina, small-pox, 
typhus, and syphilis, these cutaneous affections are to receive the 
attention due them, when we come to discuss the subject of the infec- 
tious diseases themselves, as they only form a single link in the chain 
of nutritive disturbances to which these maladies give rise. 
We classify diseases of the skin as we do diseases of other organs, 
according to the anatomical nature of the lesion which the disease 
produces. We shall, therefore, have to speak of hypertrophy, atrophy, 
hyperaemia, anaemia, haemorrhages, inflammations, neoplastic growths 
and parasites of the skin. Since, however, it is in our power to observe 
the variety in extent, in intensity of the morbid process, more accu- 
rately upon the skin than upon other organs, and as we are able directly 
to watch certain anomalies of secretions which are not accompanied by 
palpable change of structure, diseases of the skin admit of a much more 
minute classification than is possible in diseases of other organs. We 
must so far conform to the practice of applying names to the cuta- 
neous affections other than those belonging to the analogous lesions 
upon other parts of the body, as to associate their proper pathological 
and anatomical title with their customary name. Of the unpractical 
and useless classification of the various forms of skin-disease into innu- 
merable subdivisions, we shall merely make cursory mention. 
1.—HYPERTROPHY OF THE SKIN. 
An hypertrophy, involving all the component parts of the skin, 
the connective tissue, the vessels, nerves, epidermis, hair, and glands, 
only occurs in small isolated spots as a congenital anomaly. Most of 
the prominent “mother’s marks” belong to this class, as well as the HYPERTROPHY OF THE SKIiN. 
441 
soft cutaneous warts or moles. But, even here, the hypertrophy does 
not involve all the tissues of the skin in equal degree. In the majority 
of the projecting “ mother’s marks ” and moles, there is a predominant 
development of pigment and hair; their brown or blackish color and 
the strong growth of hair with which they are covered being one of 
their striking features. 
Large accumulations of horny epidermic cells are often found upon 
certain spots of the body; the callosities, the corns (clavi), and the 
cutaneous horns, originate in this way. Callosities consist of low 
flat, horny elevations, of a rounded or irregular form; the condition of 
the cutis which they cover being either normal or slightly hyperasmic. 
Callosities are most apt to form at points exposed to irregular pres- 
sure. Hence they are found upon the heels and upon the soles of the 
feet of most persons; upon the hands of blacksmiths, locksmiths, and 
other mechanics; and upon the index-fingers of tailors and of seam- 
stresses. Corns are small, but very hard and thick conical callosities, 
induced by the pressure of the boots or shoes, and which cause a cir- 
cumscribed atrophy of the skin. The so-called cutaneous horns con- 
sist in an excessive hypertrophy of the epidermis over a circumscribed 
spot of skin. Some horns do not spring from the papilla of the skin, 
but develop from dilated hair-follicles, and may be regarded as mon- 
strous hairs. There is also a diffuse hypertrophy of the epidermis, 
which is accompanied by hypertrophic development of the papilla of 
the skin. Of this affection, which, when of moderate intensity, is 
called pityriasis, and when more severe is called ichthyosis, we shall 
treat more in detail hereafter. 
The brunette complexion, congenital in some persons, is due to a 
copious deposit of pigment in the cells of the rete Malpighii. Another 
congenital anomaly, which is seen in many persons, consists in a heavy 
deposit of pigment in circumscribed patches upon the rete Malpighii, 
producing brown or black spots (chloasmata, melasmata). When the 
patches are of wider circumference, they are called pigmentary navi 
(ncevus spilus). If only as large as a lentil, they are called ephelides 
or lentigines (Leber-flecke). The pigmentary marks and spots, which 
are unaccompanied by hypertrophy of the cutis, and which, therefore, 
do not project above the surface of the skin, are likewise often covered 
with hair. In the majority of persons the formation of pigment in the 
rete Malpighii is increased under the influence of the sun’s light and 
heat, and under that of wind and dampness; hence, among soldiers, 
field-laborers, and particularly among seafaring persons, the exposed 
portions of the skin assume a uniform brown color. It is remarkable, 
too, that in some persons irritation of this kind does not produce such 
deposit of pigment, or, as people say, they do not become “ sunburnt ” 442 
DISEASES OF THE SKIN. 
or “ tanned.” There is another circumstance, too, which is very diffi 
cult of explanation, namely, that in certain persons with very white 
skins, especially in blondes and in red-haired individuals, the pigment 
formed under the influences just mentioned is only deposited in small 
circumscribed specks and spots upon the unprotected surface. In 
summer, the hands, face, and arms of such persons, though screened 
from the direct rays of the sun, become covered with rounded spots of 
a more or less dark color, called “freckles” (epheUdes). The bronzed 
skin of a seaman gradually loses its deep color if he stays at home in 
winter, and, under similar circumstances, freckles also fade or entirely 
disappear. Freckles may be removed by means of applications capa- 
ble of producing desquamation of the epidermis, together with its 
deeper pigmentary layer; but, if the exciting cause be continued, they 
will return in course of a few weeks. The well-known Lilionese is 
merely a palliative cosmetic, as is also the wash recommended by 
Hebra (hydrarg. chlor. corrosiv. gr. v; aquas 3 j). The application 
is only to be kept on for a few hours, and care must be taken that the 
compress upon which the solution is applied is free from folds. If the 
skin becomes much inflamed, it is to be covered by compresses dipped 
in oil. In a few days, as the epidermis scales off, the freckles disap- 
pear. 
In pregnant women, and women suffering from disease of the sex 
ual organs, brown spots often appear upon the face, especially upon 
the forehead and upper lip {chloasmata uterina). In most women they 
disappear some time after confinement, but in some they are very per- 
sistent or even become permanent. This phenomenon is as inexplica- 
ble as is the increase in the pigmentation of the rete Malpighii, and 
of the areola of the nipples and skin of the linea alba during preg- 
nancy. 
Besides the diffuse hypertrophy of the papillary portion of the 
skin, which occurs in ichthyosis, hypertrophy of a single papilla, with 
hyperplasia of the epidermis which covers it, is of very common occur- 
rence. It is in this manner that warts and condylomata are formed. 
Warts arise by the elongation and combination of a few papillfe, so as 
to form a cone. It is covered by a very thick and hard layer of epi 
dermis. If the several papillfe of which the wart consists be each 
covered separately by its epidermic envelope, the wart has a cloven 
fibrous appearance. The cause of these growths is unknown. Un- 
cleanliness of habit certainly plays but a very subordinate role in their 
production, for, even among the cleanest people, the skin, especially 
that of the hands, often becomes covered by them in a short time. 
The sudden manner in which this papillary hypertrophy often disap- 
pears is equally puzzling. The laity are accustomed to ascribe the HYPERTROPHY OF THE SKIN. 
443 
disappearance of warts to the action of the so-called sympathetic reme- 
dies or charms. Condylomata differ from common warts, as their papillae 
not only grow longer, but they also throw out lateral offshoots, and 
the epidermis which covers them is not so thick and tough. There 
are two forms of them, the pointed and the broad. The former appear 
upon the mucous membrane of the external genitals, the urethra 
and vagina, as well as upon parts of the skin which have been moist- 
ened by the vaginal or urethral blenorrhoeal secretion. Their appear- 
ance is that of a mulberry or cauliflower, or, if compressed laterally, 
they look like a cock’s comb. Pointed condylomata require local 
treatment. The structure of the wide condylomata is very like that 
of the pointed form. They are less prominent, however, and show a 
tendency to superficial ulceration. The most common seat of the 
broad condylomata is upon the labia, the scrotum, and between the 
nates. More rarely they occur upon the lips and between the toes. 
As they are the consequence of constitutional disease, they require gen- 
eral antisyphilitic treatment for their cure, instead of local applications. 
The so-called polypi of the skin, and the hard and sometimes 
pedunculated tumor, known as molluscum simplex (<fibroma mollus- 
cum of Virchow), are results of a circumscribed hypertrophy of the 
connective tissue of the skin. The so-called keloid is a peculiar form 
of partial hypertrophy of the cutis, resulting in the formation of irregu- 
lar tumors, which in structure resemble a scar. Pachydermy, or 
elephantiasis Arabum, is due to a diffuse hypertrophy of the cutis and 
subcutaneous connective tissue. Of this we shall speak more fully 
hereafter. 
The hypertrophic development of the capillaries of the cutis, which 
sometimes is combined with an hypertrophy of its connective tissue, 
gives rise to the formation of red or reddish-brown sjoots, or tumors in 
the skin, called telangiectasis. They may be congenital (ncevi vascu- 
lares), or they may not form until some time after birth. Telangiectasis 
must be regarded as of two kinds—a kind which, after attaining a 
certain size, remains stationary; and a kind which grows continually, 
its capillaries finally becoming so much dilated as to give way and to 
bleed profusely. 
The majority of “ mothers’ marks ” are nearly always complicated 
with hypertrophic development of the hairs and cutaneous glands 
upon small portions of the skin. Curious cases are also met with in 
which there is an extraordinary premature development of the beard, 
and of the hair upon the pubis, and sometimes a remarkable growth 
of hair covering the whole body, or parts of it, no other irregularity 
coexisting. Molluscum contagiosum (epithelioma molluscum of Vir- 
chow) is the result of hypertrophy and dilatation of the hair-follicles, 444 
DISEASES OF THE SKIN-. 
which become distended by a collection of epithelial scales and glolv- 
ules of a fatty lustre. The tumors, which at first are scarcely larger 
than a pea, and are covered by the normal skin, gradually enlarge, 
while the skin becomes tense, red, and depressed in the middle, like a 
funnel. New nodules develop in the vicinity of the first one, so that 
finally a large area of the skin is often covered by these molluscous 
tumors. This continuous progress, and the communication of the dis- 
ease to other persons, the actual occurrence of which has been well 
authenticated in several instances, indicate that it is of a contagious 
character. * The bearer of the contagion seems to be the fatty globules 
above mentioned. 
CHAPTER I. 
DIFFUSE HYPERTROPHY OF THE PAPILLARY LAYER AND OF THE 
EPIDERMIS ICHTHYOSIS. 
Etiology.—It has been stated already that the exuberant forma- 
tion of epidermis, which takes place in ichthyosis, is due to an abnor- 
mal development of the papillary layer of the matrix of the epidermis. 
Barensprung, of whose excellent work upon cutaneous diseases we 
have made free use whenever the publications of this profound inves- 
tigator have been available, makes a distinction between congenital 
ichthyosis in its narrowest sense, where the child comes into the world 
clad in a thick horny corselet, and the true ichthyosis. In the former 
affection the child is born dead, or dies soon after birth, and it would 
appear that the horny case which covers it must have formed at an 
early period of intra-uterine life, probably through melting together of 
the caseous varnish composed of cells of epidermis and cutaneous se- 
cretion. It is always evident that the rigid horny coat, which is all 
cracked into fragments, has become too small to cover the fully-grown 
foetus, and has crippled the development of its nose, lips, ears, fingers, 
and toes. 
The papillary hypertrophy, which is the cause of the true ichthy- 
osis, likewise appears to be an hereditary and congenital disease. The 
fact that the malady nearly always remains undetected during the first 
year of the child’s life, is to be ascribed to the manner in which the 
skin is cared for during that time. The family history of a patient 
with ichthyosis often shows that other members of the family, brothers, 
parents, or grandparents, or other relatives, have suffered from the 
same disease. 
Besides the congenital true ichthyosis, which usually extends 
over the entire surface of the body, there is a milder and acquired form ICHTHYOSIS. 
445 
of the disease, which remains confined to portions only of the skin, 
and which complicates pachydermy. 
Symptoms and Coubse.—Instead of presenting the smooth ap- 
pearance usually seen upon the skin of a healthy person, the skin in 
the milder grades of ichthyosis is roughened and covered with delicate 
white scales. It is this milder form of the disease which is usually 
called pityriasis. The term pityriasis, in this sense, signifies a des- 
quamation of the cuticle depending upon a mere exuberant growth of 
epidermis, and not upon other disease. We know such to be the case, 
from the habitual presence of the conditions above described, and by 
the absence of any symptoms of congestion or of inflammation, or of 
any derangement in the secretion of the glands and sebaceous follicles. 
Most cases of desquamation of the epidermis upon the head, in which 
the fine white scales adhere to the hair, and cover the collar of the coat, 
do not depend upon exuberant formation of epidermis, but upon a 
superficial dermatitis. The scaling off of the skin of the palms of the 
hands and soles of the feet, too, is generally due to superficial inflam- 
mation of the skin, and will be discussed more in detail in the chapter 
upon eczema. In genuine ichthyosis, the epidermis is detached in the 
form of larger and thicker scales, usually stained of a dark color by 
pigment and dirt. In the worst forms of the disease the epidermis is 
in horny plates, and even forms warty or spinous projections. Hence a 
great number of subordinate varieties of ichthyosis have been recog- 
nized, ichthyosis simplex, cornea, hystrix, etc., which, however, are not 
varieties in kind, but merely in the degree of the disease. Certain 
parts of the body, the face, the palms of the hands, the soles of the 
feet, the armpits, and the bends of the knees and elbows, are not at- 
tacked by the affection, while its favorite seat is upon the dorsal sur- 
face of the extremities, especially upon that of the knees and elbows. 
Hebra accounts for the fact that we cannot, at first, detect the ex- 
istence of ichthyosis in newly-born children, upon the ground that a 
child in the womb of its mother is in a continual warm bath, which 
keeps the epidermis in a state of maceration. Moreover, owing to the 
continual necessity for washing little children in their first year, the 
scales of epidermis are not allowed to collect, and hence the disease 
usually remains undetected. 
Treatment.—This disease is incurable, as we know of no remedy 
capable of producing involution of the hypertrophy of the papillary 
layer of the skin. Our experience as to the uselessness of arsenic, anti- 
mony, tar, and other external and internal medicines, is too ample to 
warrant our making further trial of them. It is well to advise the 
patient to take a warm bath daily, with or without the addition of an 
alkali, and diligently to anoint his skin with some unctuous substance. 446 
DISEASES OF THE SKIN. 
as by these means the extensive accumulation of detached epiderm 
may be prevented. 
CHAPTER II. 
DIFFUSE HYPERTROPHY OF THE SKIN AND SUBCUTANEOUS CONNEC 
TIVE TISSUE—PACHYDERMIA—ELEPHANTIASIS ARABUM. 
Etiology.—Repeated inflammation of the skin, and especially re 
peated and permanent obstruction of the veins or lymphatics of a part, 
sometimes lead to enormous growth of the connective tissue of the 
skin, subcutaneous and intermuscular substance, and even of the perios- 
teum of the bones of the affected part. This condition is called pachy- 
dermia, or, from the clumsy, deformed appearance of the limb attacked, 
it is also called elephantiasis arabum. This disease has nothing in 
common with the elephantiasis grcecorum, or leprosy {lepra, Spedal- 
sldied). We do not know the reason why it is that a case of repeated 
dermatitis, or phlebitis and primary thrombosis, or of obliteration of a 
vein or lymphatic, only now and then terminates in pachydermia, and 
why it does not always occur. It is also quite strange that this dis- 
ease should be much more common in certain countries, especially in 
the torrid zone (Barbadoes leg), than it is with us. 
Anatomical Appearances.—The most usual seat of the disease 
is upon the leg, which undergoes more or less irregular enlargement, 
and attains more than two or three times its normal size. The skin 
is immovable, and, when the papillary layer also takes part in the hy- 
pertrophy, it is covered with scaly crusts. The tissue of the skin, and 
of the adipose layer below it, is converted into a dense firm mass, re- 
sembling bacon, whose microscopic elements consist of connective-tis- 
sue cells of different stages of development. The muscles are atro- 
phied and in a state of fatty degeneration, owing to a want of exercise, 
and to the pressure to which they are subjected by their surrounding 
connective tissue, which is likewise involved in the thickening. The 
veins and lymphatics are often obliterated, and there is frequently a 
varicose enlargement of them below the point of obstruction. The 
anatomical appearances are quite similar when the disease attacks the 
upper extremity, the scrotum, the penis, or the labia majora. 
Symptoms and Course.—The first symptom of the disease is 
either an erysipelatous inflammation of the skin, or else a lymphangitis 
or a phlebitis. Some authorities state that the local disease is often 
preceded by violent fever. This cannot be regarded as at all singular, 
as in other inflammations the febrile disturbance is generally most 
severe at the commencement of the attack, and attracts attention be ELEPHANTIASIS ARABUM. 
lore the functional disease becomes apparent. The portion of the 
body which swells during the inflammation does not return to its nor- 
mal size after the fever subsides, but remains moderately enlarged, 
and assumes a soft, boggy consistence. Soon, usually within a few 
months, another attack occurs, which runs the same course as the first 
one, and results in a further enlargement of the affected part. As the 
attacks are repeated, and as the intervals between them diminish, the 
deformity and weight of the limb increase, and the doughiness, which 
is a result of cedematous infiltration, gives place to a board-like hard- 
ness, due to the formation of dense connective tissue. If, as the in- 
flammation recurs, the pachydermy spread beyond the point originally 
attacked, all the different grades of the disease are often exhibited 
simultaneously in the same extremity. Excepting during the periods 
of inflammation, there is no pain in the swollen part. It is often the 
seat of a superficial (eczematous) inflammation of the skin, accompanied 
by a liquid exudation beneath the epidermis and upon the free surface. 
The mobility of the afflicted member is, of course, seriously impaired. 
Treatment.—A suitable treatment will often afford great relief 
in cases of pachydermia which have not advanced too far, and may 
even effect a complete cure. During the initiatory stage of inflam- 
mation the limb must be elevated, and this posture must be retained 
for some time after the inflammation has subsided. Cold applications 
are then to be made. The inunction of mercurial ointment is also 
urgently recommended in this stage. After the inflammation has sub- 
sided, we must proceed to methodical compression of the part. Ilebra 
recommends that the limb be enveloped in a cotton bandage previous- 
ly soaked in water. This is to be applied from the toes upward, so 
that each turn of the bandage shall almost cover the preceding one. 
It may be drawn very tightly, as the patient can bear a very firm 
pressure without inconvenience, and as even a very tight bandage 
usually becomes loose in a few hours. This simple treatment, if kept 
up methodically, often produces a most beneficial effect. 
In elephantiasis scroti, in which the scrotum sometimes reaches 
down as low as the knees, and weighs over a hundred weight, and in 
elephantiasis of the labia majora, the tumor must be removed by the 
knife. 
Atrophy of the skin may appear as one of the symptoms of a gen- 
eral marasmus, and not only in the senile marasmus, but also in that 
premature general atrophy induced by exhausting illness. Upon 
pinching up the skin of a marantic individual into a fold, or, upon cut- 
II.—ATROPHY OF THE SKIN. 448 
DISEASES OF THE SKIN. 
ting it in post-mortem examination, a striking diminution of its thick 
ness will be observed. A coating of detached scales of epidermis is 
usually found upon the skin of such subjects. This is not a product 
of any coexisting hypertrophy of the epidermic layer, but has formed 
simply because the cutaneous secretion is diminished, which keeps the 
skin pliable during health, and which causes the epidermis of healthy 
persons to fall imperceptibly. In other words, in the so-called pityriasis 
tabescentium the epidermic cells are not generated in undue quantity, 
but they are shed in a more conspicuous manner than is natural to a 
person in good health. Atrophy of the skin may also proceed from 
continued pressure either from within or from without. We have al- 
ready said that a corn induces partial atrophy of the corium. Favus 
crusts and scabs, which have adhered to the skin for a long time, have 
a similar effect. As pressure from without sometimes injures the pap- 
illary layer of the skin, the product of the latter, the epidermic cells, 
is formed in diminished quantity, and hence the cuticle over the com- 
pressed point is remarkably thin. The effect is different when the 
pressure upon the skin proceeds from within, as, for instance, in the 
great distention of the belly which occurs in pregnancy or during 
dropsical effusion, and in cases of excessive swelling of other parts of 
the body covered by skin. In such cases it is the deeper layers of the 
corium and the glandular structure of the skin which suffer, the pro- 
duction of epidermis not undergoing any derangement. I have no 
doubt that the pityriasis of the abdomen and extremities consequent 
upon repeated pregnancy and extensive dropsy, as well as pityriasis 
tabescentium, is attributable to atrophy of the deeper layers of the 
corium and cutaneous glands, with abnormal dryness of the epidermis. 
A congenital absence of pigment throughout the rete Malpighii of 
the whole body occurs in albinos. Sometimes from unknown causes 
the pigment disappears from circumscribed patches of skin. These 
spots are of a milky whiteness, and, as they most frequently occur in 
individuals of a strongly-marked brunette complexion, they create a 
striking contrast with the surrounding surface (vitiligo, achroma). 
The hair-follicles often undergo atrophy, particularly the follicles 
of the scalp, and, in consequence of this, the hair falls off. If the 
atrophy does not cause complete destruction of the hair-bulb, the pro- 
duction of hair does not cease entirely, but the wasted follicles can only 
produce a fine woolly down, instead of vigorous normal hair. Bald- 
headed persons, finding this downy growth upon their heads, are often 
inspired with fallacious hopes, especially if just before they have been 
using the “ eau de lob ” or “ lion-pomade,” and have faith in the tales 
told of these articles. Baldness arising from atrophy of the hair-bulbs is 
called calvities, or calvities senilis, from its liability to occur in old per ATROPHY OF THE SKIN. 
449 
sons. Not unfrequently, however, this calvities occurs in younger per- 
sons ; hereditary predisposition apparently being one of the most com- 
mon of its causes. No reliance is to be placed upon the statement of 
oaldness’s having arisen from over-exertion of the brain, over-anxiety, 
or from sexual excess. There is a very large number of profoundly- 
learned persons, as well as careworn and dissipated people, whose hair 
grows luxuriantly; while many others, who think but little, and live con- 
tinently and unoppressed by care, lose their hair early in life. Of course, 
there is no means of producing a development of new hair-bulbs; 
hence, in spite of the pretensions of charlatans, this form of baldness 
is incurable. This is not the case with the dejluvium capillorum, or 
falling out of the hair, which occurs during and after certain acute and 
chronic diseases, during which the hair-follicles suffer temporary de- 
rangement of nutrition. Here the follicle is not destroyed, nor is it 
even permanently injured. When the disease causing the loss of the hair 
has subsided, and when its effects upon the general constitution have 
disappeared, the hair-follicles are restored to health, and reproduce 
new hairs in place of the fallen ones. Among the acute diseases, 
typhus, and of the chronic ones, syphilis, are the most frequent causes 
of defluvium capillorum, as this latter form of falling of the hair is 
called. Severe pneumonia, however, and nearly every other exhaust- 
ing disease, and in a slighter degree the puerperal state, almost al- 
ways occasion more or less loss of the hair. Alopecia circumscripta 
seu area Celsi also seems to depend upon temporary derangement of 
the nutrition of the hair-follicles. In this complaint, which is not un- 
common, round spots of variable size appear upon the head, or, as is less 
usual, upon the beard, or upon other regions, in which the hairs break 
off close above the roots, split into brushes, and fall out, so as event- 
ually to form a bald spot closely surrounded by a dense growth of 
hair. The skin of the bald spot appears perfectly healthy, and this 
will readily enable us to distinguish alopecia circumscripta from herpes 
tonsurans, which may also produce round bald spots upon the skin. 
The cause of alopecia circumscripta is unknown. It is not due to the 
presence of a vegetable parasite. After a while the bald spot is once 
more covered with healthy hair. Loss of the hair induced by inflam- 
mation of the scalp, and by parasites (favus, herpes tondens), is to be 
treated of by-and-by in its appropriate chapter. 
In very old persons the hair almost always loses its color, 
and, according to the observations of Seitz, the discoloration begins 
at the tip, and extends rapidly—i. e., in a few days—over the 
whole hair. Now and then the hair loses color throughout its whole 
extent from the first. The hair of young persons also loses its color 
sometimes, and it then often takes place more rapidly than is usually 450 
DISEASES OF THE SKIN. 
the case among older persons. As in premature baldness, hereditary 
tendency seems to be the main cause of premature grayness of the 
hair, although, perhaps, care and sorrow may also play some part in 
producing the change. It is a curious fact that a hair, which is only 
gray at its tip, if pulled out, does not become gray throughout, but re- 
mains permanently in the same condition. From this circumstance it 
would seem that the matrix exerts some vital influence in rendering 
the hair gray. This fact, moreover, renders those stories, which have 
been handed down to us, far less incredible, although their truth has 
been much doubted, of the hairs becoming gray in a few days from 
the effect of intense mental emotion; all the more so, since, according 
to JPfaff.\ the grayness does not depend upon a disappearance of the 
pigment from the hair, but upon a thickening of its cortical layer. In 
a case reported by Landois, sudden grayness of the hair took place in 
consequence of an increased development of air in the hair. The pig- 
ment does not disappear from the medullary substance of the hair un- 
til in advanced old age. 
III.—HYPERAEMIA AND ANEMIA OF THE SKIN. 
The quantity of blood contained by the skin varies more than that 
contained by any other organ, because the skin is far more exposed 
than other parts of the body to influences capable of modifying the 
circulation. In our first volume we have already given a detailed ac- 
count of those abnormities of the cutaneous circulation which arise 
from disease of the heart, including both the overloading of the ar- 
teries and arterial capillaries from increased cardiac action, and the 
engorgement of the veins and venous capillaries (cyanosis), which re- 
sults from lack of power in the heart. 
Active hyperaemia of the skin (fluxion) occurs upon exposure of 
the skin to great heat, especially to heat and moisture combined. It 
also may result from the application upon it of irritating substances, 
such as cantharides, mustard, or spurge-laurel, or from mechanical in- 
jury. In all such cases, as has repeatedly been mentioned, the first 
effect of the irritant seems to be a relaxation of the cutaneous tissue j 
and a dilatation of the capillaries seems to be consequent upon the re- 
duced power of resistance of the tissues which surround them. If the 
hyperaemia be intense enough to produce a redness of the skin, visible 
through the epidermis which covers it, it is called erythema, and is fur- 
ther distinguished as erythema caloricum, solare, venenale, according 
as the redness proceeds from heat, the sun’s rays, or the action of mus- 
tard, cantharides, or spurge, and the like. With equal reason, redness HYPEKiEMIA AND ANiEMIA OF THE SKIN. 
451 
of the surface, caused by a blow, might be called erythema traumati- 
cum. Such a variety of names for hyperacmia of the skin is quite use- 
less, and, as some of the inflammatory cutaneous affections, when ac- 
companied by redness, are also called erythema, it only creates mis- 
understanding and confusion. Partial hyperasmia of the skin, more- 
over, is the first symptom of most of the acute and chronic exanthe- 
mata, in whose subsequent course exudation is thrown out either 
within the skin or upon its surface. Finally, partial cutaneous hyper- 
mrnia is very often observed in certain febrile diseases, without our 
being able to account for its occurrence. In such cases the hyper- 
aemia usually is limited to a very small circumscribed area, forming 
rounded or irregular red spots, varying in size from that of a lentil to 
that of a farthing, and is thus called roseola. This name, however, is 
not applied exclusively to the red spots of simple hyperacmia {macula), 
but also to the small red nodules arising from an infiltration of the 
skin combined with hyperaemia [papula). Typhoid fever, the typhoid 
stage of cholera, and other infectious disorders, are accompanied by 
roseola, but it also is by no means rare in the febrile, gastric, and intes- 
tinal catarrhs of children, as well as in inflammatory diseases of the 
brain and lungs. When we can discover a cause for the fever, we call 
the roseola a symptomatic roseola / when no cause for the fever can 
be found, the eruption is said to be idiopathic. To the latter class 
belong the so-called roseola sestiva, ros. autumnalis, ros. infantilis, 
and some of the affections entitled measles (“ Rotheln ”). 
The only symptoms of erythema are reddening of the skin and an 
augmented sense of heat. The hyperaemic surface becomes blanched 
if the blood be expelled from the skin by pressure, while the redness 
arising from haemorrhage into the cutis is not effaced by pressure. 
When the reddened spot is likewise much swollen and painful; when 
the pressure leaves a white spot instead of a yellow one behind; when, 
after the redness subsides, the epidermis scales off, the disease is not 
simple hyperasmia, but inflammation with infiltration. 
Anaemia of the skin is an important symptom of poverty of the 
blood. It also arises from exposure of the skin to a very low temper- 
ature, both owing to the physical action of cold and to the contraction 
of the cutaneous muscles to which cold gives rise. Both of these ef- 
fects render the skin denser and more resisting, and thereby impede 
the influx of blood into the capillaries. This effect is increased by the 
contraction of the smaller arteries which takes place at the same time. 
Finally, a partial anasmia or ischaemia of the skin may arise independ- 
ently of the influence of cold, from spasmodic (?) contraction of the 
cutaneous muscles and muscles of the arterial walls. This phenome- 
non is most frequently observed during the rigor which ushers in a 452 
diseases of the skin. 
fever. Sometimes, however, it occurs spontaneously, and without as- 
signable cause, as is seen in the so-called “ deadness ” of the fingers 
and toes. 
Hyperasmia and anaemia of the skin seldom require active treat- 
ment. The application of cold is indicated in the former, and, in the 
latter, warmth, combined with moisture, as well as the application of 
cutaneous stimulants and stimulating friction, is the proper remedy. 
IV.—.INFLAMMATION OF TEE SKIN. 
Under this heading we treat of all the nutritive disturbances of 
the skin in which an exudation is thrown out within its substance or 
upon its free surface. However, it is questionable whether, strictly 
speaking, all these forms of disease ought to be regarded as inflam- 
matory, as, in my opinion, an interstitial exudation is neither a neces- 
sary condition nor a sure criterion of inflammation. We shall not, 
however, indulge in further discussion of the question, and, after the 
example of Simon, in the following chapters, shall employ the term 
dermatitis to signify a process attended by exudation. 
Infiltration of a somewhat extensive portion of skin results in the 
so-called erythematous and erysipelatous inflammations. When the 
infiltration is limited to small discrete spots of the capillary layer, we 
have the papular exanthemata. The variety of dermatitis, character- 
ized by the formation of wheals or wales, proceeds from a more super- 
ficial and extended infiltration. In the erysipelatous form of inflam- 
mation, a simultaneous exudation upon the free surface of the cutis 
often lifts the epidermis, forming vesicles and blebs of variable size. 
An exudation upon the surface of the cutis, which elevates the epider- 
mis into blisters, also occurs in other kinds of inflammation, both acute 
and chronic, which are not attended by infiltration of the skin itself. 
The vesicular exanthemata consist in superficial inflammation 
which, like catarrh, is characterized by exudation upon the free surface 
of the skin, unaccompanied by serious organic lesion, while in the 
pustular form the exudation contains an abundant admixture of young 
cells. There are also forms of cutaneous inflammation where the dis- 
ease of the cutis is accompanied by a morbidly profuse growth of epi- 
dermis, the so-called psoriasis. Besides these varieties, which diffei 
chiefly in the intensity of the inflammation and the seat of the exu- 
dation, there are others distinguished by the peculiar character of the 
course of the disease, and by the causes which produce it, and which 
compel us to treat of them in separate chapters, in order to avoid the 
classification under one head of dissimilar diseases. ACUTE INFLAMMATION OF THE SKIN. 
453 
CHAPTER III. 
TUE SLIGHTER FORM OF ACUTE INFLAMMATION OF THE SKIN WITH- 
OUT VESICATION—ERYTHEMATOUS DERMATITIS—ERYTHEMA. . 
Etiology.—In this form of dermatitis, the papillary layer of the 
skin, and, in most cases, the tissue of the cutis, becomes the seat of 
hypersemia and of serous infiltration. Since the epidermis usually 
scales off after the erythema has subsided, it is to be presumed that 
the attachment of the cuticle to the papillary layer has been loosened 
by a simultaneous effusion upon the surface of the cutis. This effu- 
sion, however, is insufficient in quantity to raise the epidermis into 
blisters. Heat, the direct rays of the sun, mechanical and chemical 
irritation, and other exciting causes to which we already have alluded 
in speaking of hyperaemia of the skin, when allowed to act with great- 
er intensity and for a longer time, give rise to erythematous inflam- 
mation. Special names have been given to some forms of erythema 
from mechanical irritation. Where it arises from the friction of two 
opposing surfaces, it is called erythema intertrigo. This is very com- 
mon among infants, especially among feeble ones, appearing in the 
folds of the skin, upon the genitals, behind the ears, and in the neck. 
It also occurs underneath the pendulous breasts of very corpulent fe- 
males. When it arises between the nates, from their continuous fric- 
tion upon one another during a long march, it is popularly called “ a 
wolf” (“Wolf”). The erythema which appears in cases of protract- 
ed illness, caused by the pressure of the bed upon the sacrum, tro- 
chanters, and other prominent parts of the body, is called decubitus. 
That which is induced by tension of the skin in cases of severe dropsy, 
or by trifling wounds, takes the name of erythema Iceve. Where there 
long has been a discharge from the nose, and in blenorrhoea of the 
conjunctiva, the acrid secretion which constantly bathes the skin often 
gives rise to a superficial erythema of the upper lip and nose. Ery- 
thema of the prepuce, scrotum, and inner surfaces of the thighs also 
results from the continual moisture of the skin in cases of incontinence 
of urine. 
Besides these forms of erythema, which are the result of local irri- 
tation, there is another variety, the symptoms and course of which are 
peculiar, and the cause of which is unknown. In this country it some- 
times appears sporadically, but not often, but shows a great tendency 
to periodic relapses. In other places (Constantinople, Paris), it has 
been observed to extend epidemically. 
Symptoms and Coukse.—Erythema, arising from local irritation, is 
characterized by red, slightly-prominent patches, the color of which grad- 454 
DISEASES OF THE SKIN 
ually becomes fainter at tbe edges. They become pale when pressed 
upon, assuming a yellowish tinge; and, when the pressure is removed, 
the redness returns. The spots are the seat of a more or less severe pain. 
If the irritant which has caused the erythema be speedily removed, 
the redness and swelling disappear in a day or two, and a slight des- 
quamation of the epidermis finishes the process, which is always an 
insignificant one. If the irritant be not removed; if it be allowed to 
operate continuously and vigorously, the erythema assumes a more 
serious character, and new lesions form. Erythema solare becomes 
an eczema solare/ blisters form upon burns; in intertrigo, the epider- 
mis is lost; while erythema laeve may terminate in gangrene of the 
skin. 
Spontaneous erythema, that is to say, the erythema which appears 
without assignable cause, always attacks the dorsal surface of the 
hands and feet, much more rarely the body or face, the backs of the 
hands and feet always suffering at the same time. Ilebra lays stress 
upon the constancy in the situation of the disease as an important di- 
agnostic point. The attack commences with a moderate reddening 
and tumefaction of the regions just mentioned as its first symptom. 
Soon nodules and lumps of a deeper red hue, and sometimes even of 
a bluish red, appear upon the reddened and swollen basis. Hence 
the name erythema papulatum seu tuberculosum. In some persons 
this eruption is attended by a disagreeable sense of burning at the 
point affected; in others there is fever. In a day or two the redness 
and swelling about the nodules begin to subside; a day or two later 
the lumps themselves grow smaller and paler, and finally disappear 
altogether. The epidermis scales off, and the entire duration of the 
disease is from one to two weeks. Both the bluish color of the no- 
dules, and the yellowish tinge of the skin where the nodules were sit- 
uated, which remains for some time after the nodules have disap- 
peared, show that, besides the exudation, erythema papulatum is also 
attended by slight extravasations of blood into the tissue of the cutis. 
Sometimes erythema papulatum becomes chronic, and lasts for weeks 
and months; it then spreads from the point first attacked to other re- 
gions. "When new nodules form upon the periphery of the first erup- 
tion, the disease meantime having abated in its centre, it is tailed ery- 
thema annulare or circinatum. If there be a red spot remaining in the 
middle of the ring, it is called erythema iris, or mamillatum. If, as the 
circles extend, they become confluent and broken at the point of con- 
tact, and thus form arched lines, they constitute the so-called erythema 
gyratum. These names recur in other eruptions, in which the disease 
extends upon the periphery of the original seat of the eruption, having 
subsided at the centre, that is, at the point first attacked. The various ACUTE INFLAMMATION OF THE SKIN. 
455 
lines or marks which are thus made upon the skin are not indicative 
of different forms of disease, but merely of different stages of develop- 
ment of the same morbid process. 
Erythema papulatum or tuberculosum, however, differs from ery- 
thema nodosum. This affection is most liable to attack young per- 
sons, and is far more common in females than in males. Its seat is 
almost without exception upon the lower extremities, especially upon 
the legs. It consists in small circumscribed infiltrations in the deeper 
layers of the skin, accompanied by extravasation of blood. We at 
first perceive rounded knots of the size of a hazel-nut or of a walnut, 
covered by slightly-reddened skin, and somewhat painful to the touch, 
so that they strongly resemble bruises (dermatitis contusiformis). The 
rose-red color of the skin gradually grows darker, and then changes 
successively to a violet, to blue, green, and finally to yellow, the se- 
ries of changes being entirely similar to that which occurs in traumatic 
extravasations beneath the skin. Erythema nodosum is always accom- 
panied by febrile disturbance, which debilitates the patient and con- 
fines him to bed. The disease usually lasts one or two weeks, and its 
termination is also followed by desquamation of the epidermis. As 
a great rarity, erythema nodosum also becomes chronic, the first nodes 
subsiding with desquamation of the epidermis, and new ones succeed- 
ing them.1 
Treatment.—Erythema resulting from local irritation soon sub- 
sides when the exciting cause is removed. When the burning pain is 
severe, we may make applications of cold water or of lead water. In 
erythema intertrigo, in order to prevent the friction of the opposing 
surfaces, we must sprinkle them with fine powder, lycopodium seeds 
mixed with oxide of zinc being the one most in use (sem. lycopod. § ss, 
zinci oxid. 3 ss), or else a pledget of charpie, smeared with zinc oint- 
ment, may be inserted between the surfaces. Erythema arising from 
the pressure against the bed {decubitus) may be relieved by the use 
of circular india-rubber pads filled with air. When it results from 
contact of acrid secretion, the skin should be protected from it by a 
coating of lip-salve or other grease. Erythema papulatum requires no 
particular treatment, although, if it be attended by much burning, we 
may make use of cold compresses. In erythema nodosum proper at 
tention must be paid to the fever and to the strength of the patient. 
Compresses wet with cold water, or with lead-water, should be applied 
'o the nodules if they are painful. 456 
DISEASES OF THE SKIN. 
CHAPTER IV. 
ERYSIPELATOUS DERMATITIS—ERYSIPELAS. 
Etiology.—Erysipelatous dermatitis is distinguished by an intense 
liyperaemia of the cutis, and by a profuse serous transudation, not only 
into the skin itself, but into the subcutaneous areolar tissue, and some- 
times between the cutis and the epidermis. It is also marked by the 
slightness of its tendency to form abscesses, and by the invariable im- 
plication of the lymphatic vessels and glands in the inflammation. 
Erysipelas not unfrequently results in rupture of small vessels and of 
haemorrhages into the skin and upon its free surface. The disease is 
sometimes so violent as to end in gangrene. 
I believe that it is an error to suppose that any cutaneous irritant, 
if of sufficient intensity, may produce erysipelas. Comparison of ery- 
sipelatous inflammation with that caused by a blistering plaster, in 
spite of the blisters which may form in either case, seems to me de- 
cidedly to contradict the identity of the two processes. Besides, the 
inflammatory derangements of nutrition produced by burns and by me- 
chanical injuries, and similar sources of local irritation, do not present 
the characteristics of erysipelas, as they either produce simple blisters 
without any other exudation either in the skin or under it, or else, 
when of greater intensity, cause destructive disease of the part. We 
may regard it as proved that most forms of erysipelatous dermatitis 
proceed from the extension of an inflammation from the wall of an 
inflamed lymphatic vessel into the surrounding tissue of the cutis. 
First among these forms is that resulting from inoculation with some 
acrid or venomous material. In such cases it can often be demon- 
strated by direct observation that the poison was first taken up by the 
lymphatics, and thus gave rise to inflammation of their w'alls, and 
that the inflammation of the skin is a secondary occurrence. Here a 
reddened cord, with nodular enlargements, is first observed, and 
it is not until afterward that a diffuse and uniform redness and 
swelling make their appearance upon the skin. Next to this form 
comes the erysipelas, arising from the absorption of the ichorous se- 
cretion of a wound, or of the putrid contents of an abscess by the lym- 
phatics, and their consequent inflammation. Not to encroach too far 
upon the province of surgery, I will merely call to mind the so-called 
‘‘ tooth-rose.” This consists in a dermatitis with all the peculiarities 
of erysipelas; and there can hardly be any doubt that it proceeds 
from the extension of a lymphangitis to the skin, and that it is caused 
by the absorption of the liquid from the foetid contents of a gumboil. 
The simplest explanation, for the fact that, in hospitals, erysipelas now ERYSIPELATOUS DERMATITIS—ERYSIPELAS. 
457 
and then attacks the most trifling wounds, even leech-bites, is, that the 
material which excites inflammation in the lymphatics, when absorbed 
by them, needs not absolutely to be inoculated, nor to have been 
generated by the decomposition of the secretion of a wound, but that 
it may be contained in the surrounding air or in the dressings which 
cover the wound. Although, however, I regard it as almost certain 
that many forms of erysipelas proceed from the extension of an inflam- 
mation from the walls of the lymphatics to the skin, yet I do not be- 
lieve that all forms of the disease arise in this way; and, in the so- 
called erysipelas verum seu exanthematicum in particular, I believe 
this mode of origin to be improbable. This primary idiopathic form 
of dermatitis, which attacks persons previously in good health, and 
which appears most commonly upon the face and scalp, bears some 
analogy to pneumonia, pleurisy, laryngitis, bronchitis, angina, etc., 
which also occur primarily and idiopathically, and which likewise ap- 
pears in previously healthy subjects. We have no reason for looking 
upon true erysipelas as one of the acute exanthemata, or of regarding it 
as infectious; indeed, the great tendency which the complaint shows 
to recur again and again, in the same individual, may be advanced as 
an argument against its analogy with scarlatina, small-pox, measles, 
etc., and against the supposition of its infectious origin. The causes 
of exanthematic erysipelas are as obscure as are those of pneumonia 
and the other inflammations above alluded to. In both forms of dis- 
ease it cannot generally be ascribed to local irritation, nor to cold, to 
errors of diet, nor to other pernicious agents. Violent mental emo- 
tion, however, seems to have an influence in producing the disease, 
especially in persons who already have suffered from it. Like pneu- 
monia, angina, and the other inflammations, erysipelas sometimes pre- 
vails without assignable cause, under the influence of a so-called 
genius epidemicus stationarius. We are unable to determine whether 
these inflammatory disorders are secondary local manifestations of 
some primary general disease, or whether the affection is of a local 
character from the outset. Erysipelas also resembles pneumonia and 
the other inflammations, by its tendency to attack persons who have 
already suffered from the disease in preference to those who never 
have had it. It occurs most often during middle age, and is seen 
somewhat more frequently in women than in men. The disease is 
more common in warm weather than in cold. 
Symptoms and Course.—Erysipelas proceeding from external 
causes belongs to the province of surgery. In this work we shall 
only consider the symptoms and course of the erysipelas verum seu 
exanthematicum. 
In many cases of true erysipelas, the local symptoms are preceded 458 
DISEASES OF THE SKIN. 
by some hours, and still more often by some days, of general disturb- 
ance of the health, accompanied by more or less fever. As the pro- 
dromic stage is not constant, and as sometimes the general derange- 
ment of health and the fever do not appear until after the local symp- 
toms, the precursory signs of erysipelas are not to be compared with 
the fever of the acute exanthemata, but are rather to be regarded as 
analogous to that which often, for several hours or days, precedes a 
severe coryza, or the stitch and cough of a pneumonia. The first local 
symptom of the disease which is developing, is a sense of heat, ten- 
sion, and pain in the skin, which is not as yet reddened or swollen 
The neighboring lymphatic glands are already enlarged and sensitive 
to the touch. Soon the skin, begins to redden and to swell. At first 
the redness is speckled and clear, but it soon becomes diffuse and 
dark. The swelling increases and soon becomes extreme, especially 
where the skin is attached to the parts beneath by loose connective 
tissue (as in the eyelids), where it renders the skin smooth and 
shining from the tension. With the swelling, the sense of burning 
and fulness also increases. At this period there is almost always a 
violent fever, which grows worse toward evening. The pulse is usu- 
ally full, beating from a hundred to a hundred and twenty times a 
minute, and the temperature rises to 105° F., or even higher. The 
thirst is increased, the appetite lost. As in facial erysipelas, the mu- 
cous membranes of the mouth and tongue sympathize with the inflam- 
mation of the skin ; there are also signs of violent oral catarrh. The 
tongue is heavily coated and dry from the effects of fever, while a 
fetid odor proceeds from the putrefying epithelium which covers it. 
There is a slimy or bitter taste in the mouth. 
Although facial erysipelas may also be accompanied by symptoms 
of dyspepsia, yet, from this, we are not justified in assuming that the 
disease proceeds from a saburral condition, or from “ biliousness,” as 
nearly all fevers are accompanied by more or less gastric derangement, 
the patient sleeps badly, and his rest is troubled by dreams. Some- 
times there is delirium, which, however, but rarely depends upon 
implication of the meninges, and is due to the fever alone. At this 
stage of facial erysipelas the patient is much disfigured and scarcely 
recognizable. The epidermis is usually elevated here and there in 
small vesicles, or even in large blisters, while elsewThere the blisters 
have burst, and their contents, with the debris of the epidermis, are 
dried into yellow scabs. It is quite useless to give special names to 
the unimportant variations observed in different cases of erysipelas, 
caused by the degree of the swelling, the presence or absence of vesi- 
cation, the size of the blisters, the nature of their contents, such as 
erysipelas loevigatum s. erythematosum,—miliare, vesiculosum, hullo ERYSIPELAS. 
459 
crustosum, md the like. The redness usually begins to fade 
about the third or fourth day, the swelling subsides, the pain abates, 
and the tension of the blisters, which still remain, diminishes, part of 
their contents undergoing absorption, another portion drying up into 
a crust. It nearly always happens, in facial erysipelas, that the disease 
spreads beyond the region first attacked, and that while the inflamma- 
tion is subsiding at one point it is still at its height elsewhere. Hence, 
patients often suffer more after the tumefaction of the face has sub- 
sided, and they have again become able to open their eyes, because the 
disease has invaded the scalp, which, being firmly attached and but 
slightly distensible, is much more sensitive when in a state of inflam- 
matory tension. 
Excepting the “ wandering erysipelas,” to be described presently, 
the disease does not generally spread over more than a moderate area 
of skin. Facial erysipelas almost always involves the eyes, ears, hairy 
scalp, and a portion of the throat, but scarcely ever attacks the back 
of the neck or the trunk. Hence, as it also has to run its course upon 
the region last attacked, its whole duration is usually about a week, or 
somewhat longer. The process terminates in the peeling off of the 
cuticle in large pieces, even where there were no blisters. If the scalp 
has been inflamed, the hair always falls out soon afterward, for the 
hair follicles have also been the seat of an exudation which loosens 
the hair and detaches it from its matrix. Erysipelas, however, does 
not cause any permanent injury of the hair follicles, hence the baldness 
which it occasions soon disappears completely. In the somewhat rare 
instances in which erysipelatous dermatitis passes into suppuration, 
fluctuation appears at one or more points of no great magnitude (and 
most frequently in the eyelids). Generally speaking, this is not ob- 
served until the redness and swelling of the surrounding parts have 
begun to subside. Puncture of the abscess or its spontaneous open- 
ing, which is apt to be somwhat delayed, is usually followed by a dis- 
charge of yellow laudable pus, and by speedy recovery. Reddening 
of the contents of the vesicles by effusion of blood is not always an 
unfavorable sign, although it is sometimes due to a gangrenous stasis 
of the capillary circulation in the inflamed skin. Upon the appearance 
of gangrene of the skin (which is not rare in the malignant forms of 
symptomatic erysipelas, but which is of quite exceptional occurrence in 
the true, or exanthematic form of the disease), the contents of the ves- 
icles assume a dark color, and the skin beneath is converted into a 
grayish discolored slough. The general condition of the patient 
changes. The fever becomes asthenic; the temperature is very high : 
the pulse very small and frequent, and there is an intense prostration 
which may be fatal to life. Even the most favorable cases of gan 460 
DISEASES OF THE SKIN. 
grenous erysipelas are very tedious in their course, as the loss of sub- 
stance resulting from the separation of the sloughs is repaired very 
slowly. 
Erysipelas is sometimes complicated with bronchial or with intes- 
tinal catarrh, sometimes with intense hypereemia of the kidneys, and 
with catarrhal or croupous inflammation of the uriniferous tubules. 
A far more serious but less common complication is the extension of 
the inflammation from the scalp to the meninges. There is no me- 
tastasis in such cases, however. The so-called “ striking-in ” of 
the erysipelas is a consequence of the malignant character of the 
disease, and of incipient collapse, and is not to be regarded as the 
cause. 
Wandering erysipelas (erysipelas ambulans s. migrans) generally 
attacks the extremities, and spreads toward the trunk and head. It 
usually advances steadily, so that the disease, while subsiding in one 
place, is commencing in the immediately adjoining one. Much more 
rarely it advances by skips, so that there are intervening regions of 
sound skin between the inflamed surfaces. The hypermmia and swell- 
ing are not generally so severe in the wandering erysipelas as in the 
stationary; and while in the latter the redness and tumefaction are 
most intense at the centre and gradually fade toward the edges, in 
the former the seat of the greatest swelling and reddening is close to 
the healthy skin. This form of erysipelas is usually accompanied by a 
more moderate fever. However, as the disease often continues for 
weeks and even for months, during which time the inflammation some- 
times reverses the direction of its progress, and even goes back to its 
original point of departure, even this lesser degree of fever is capable 
of so exhausting the patient as to endanger life. 
Treatment.—A large number of so-called “sympathetic reme- 
dies ” against “ the rose ” are in popular use; even intelligent and 
educated people often carry amulets to protect them from its attacks, 
and submit to conjuration of the disease if the amulet fail. Owing to 
the short, cyclical, and almost invariably favorable course of the dis- 
ease, therefore, every new attack of erysipelas is a fresh proof, in the 
eyes of superstitious people, of the efficacy of their sympathetic cures. 
Hence, as one seldom receives any thanks for attempting to combat 
such superstition, and as it usually is labor lost; moreover, as the “ in- 
vocation of the rose ” has this advantage, that the patients, confident 
in the efficacy of the procedure, accommodate themselves to their dis- 
tressing position with patience, and without longing for superfluous 
medication, I deem it advisable to allow patients, wrho believe in such 
remedies, to do as they like. At all events, they do much better thus 
than when (as often happens) the physician commences the treatment of ERYSIPELAS. 
461 
every erysipelas with an emetic, because the tongue is coated and the 
breath is foul, and when he attacks the inflammation with all the exter- 
nal and internal antiphlogistics, and applies irritants to the already in- 
flamed skin, in order to prevent the “ striking-in ” of the disease. How- 
ever, although in most cases we cannot cut the disease short, and as it 
almost always terminates favorably, even without treatment, it is bet- 
ter to let it alone, or, at most, to envelop the inflamed part in cotton; 
still accidents may arise, which call for active interference. When the 
skin is very tense and painful, Skoda strongly recommends the appli- 
cation of cold in the form of wet or iced compresses. But existing 
prejudices will oppose insuperable obstacles to applications of this kind, 
and, as any accident which may occur under such treatment will cer- 
tainly be attributed by the laity to repression of the disease, I prefer, 
not so much on my own account, but to save the patient and his rela- 
tives from useless and erroneous qualms of conscience, to resort to 
slight compression and to mild scarification instead of cold. The result 
is the same. The painful tension usually soon subsides under the 
compression induced by painting the inflamed surface with collodion, 
similar relief is obtained by making minute superficial punctures with 
the point of a lancet. One or two pencillings of the inflamed surface 
and the surrounding parts with lunar-caustic in substance, or painting 
't with a somewhat strong solution of nitrate of silver (argent, nitr. 
Siv, acid, nitric, gtt. viij; aquae dest. § ss), seems to have a similar 
action, although I cannot speak from my own experience. The prac- 
tice, formerly much in vogue, of drawing a line with lunar-caustic 
around the area of inflammation, in order to prevent its spreading, has 
proved useless, and is now generally abandoned. Especial attention 
should be paid to the fever in treating erysipelas, particularly to that 
slow form of moderate but very persistent fever which accompanies 
erysipelas ambulans. Quinia and its preparations are particularly 
appropriate to such cases, as are also a nutritious diet, wine and 
strong-beer. 
Will art's indorsement of William’s treatment of erysipelas with 
from four to eight ounces of port-wine daily, and his assertion that 
the worst case of erysipelas of the head and scalp that he ever saw 
was cured by Burton ale, should be accepted as meaning merely, 
that when the fever threatens to consume the patient, alcoholic stimu- 
lants must be given freely. The complications of the disease, espe- 
cially the meningitis, are to be treated upon principles already laid 
down. When the inflammation disappears, it is not advisable to at- 
tempt to reestablish it upon the surface again by means of vesicants 
and other cutaneous irritants. Abscesses and gangrene of the skin are 
to be treated upon surgical principles. 462 
DISEASES OF THE SKIN. 
The treatment of phlegmonous erysipelas, and of boils and car bun 
des, we refer to the handbooks of surgery. 
CHAPTER V. 
HERPES—ACUTE SUPERFICIAL DERMATITIS, ATTENDED BY FORMATION 
OF GROUPS OF VESICLES UPON THE SKIN. 
Etiology.—Herpes closely resembles erysipelas, in being an acute 
dermatitis arising from unknown causes. It differs from it, however, 
both in the abruptness of the limits of the inflammation and in its seat, 
which is confined exclusively to the most superficial layers of the skin. 
Hebra defines the various forms of herpes as “ a series of acute cuta- 
neous diseases of cyclical course, marked by an exudation which col- 
lects in drops under the epidermis and elevates it; forming vesicles 
which are never solitary but always appear in groups.” These vesi- 
cles are all of about the same size and shape. The various groups do 
not appear simultaneously, but follow one another at intervals of sev- 
eral days, so that crops of recent vesicles and of older declining ones 
are usually to be found at the same time. Eruptions of herpetic vesi- 
cles (called hydroa febriles) often appear upon the face, and especially 
upon the lips of patients suffering from pneumonia, intermittent fever, 
ephemera, and epidemic cerebro-spinal meningitis. This eruption is 
hardly ever seen in other diseases, particularly in typhoid fever (typhus 
abdominalis). The appearance of herpes upon the face in acute febrile 
disease has long been regarded as a favorable prognostic sign; perhaps 
merely because the diseases, to which it is almost peculiar, recover 
more frequently than those in which it is rarely or never seen. Her- 
petic eruptions, however, occur also in individuals previously healthy, 
as well as during the course of other diseases. 
It may be regarded as established that herpes zoster depends upon 
disease of the trophical fibres of the motor and sensory nerves, which 
supply the part affected. Further confirmation is required of the sup- 
position that all forms of herpes are of similar origin; for instance, 
that herpes labialis proceeds from disease of small nervous branches 
in the lips. 
Symptoms and Course.—According to the region attacked, herpes 
is classified into, first, herpes labialis, which is situated upon the lips, 
and which often extends to the mucous membrane of the mouth. When 
the groups of vesicles appear upon some other part of the face, such as 
the cheeks or eyelids, it is called herpes phlyctenodes. Hebra pro- 
poses the name of herpes facialis for all forms of herpes appearing 
upon the face. There is also a herpes preputiaUs, which, as it likewise HERPES. 
463 
arises upon other parts of the external genitals, might more properly 
be called herpes pudendalis. Finally, there is herpes zoster or zona 
(shingles), which extends, in a very peculiar manner, along the course 
of the cutaneous nerves. When herpes zoster appears upon the 
thorax, the groups of vesicles form a somewhat broad, interrupted belt, 
which begins at one of the vertebrae, and, following the line of one of 
the intercostal spaces, reaches to the sternum, but scarcely ever ocdurs 
upon both sides of the body. When the eruption is upon the belly, 
the groups of vesicles are arranged much as they are in zoster of the 
chest, and extend from the lumbar vertebrae to the linea alba and 
mons veneris. Upon the neck the vesicles sometimes form a half-collar, 
sometimes they extend downward toward the second rib. Upon the 
face, the eruption spreads along the course of the facial nerve, espe- 
cially along the cheek, to the dorsum of the nose. Upon the scalp it 
runs over the forehead and skull along the course of the supraorbital 
nerve, or else spreads over the occiput along the course of the occipital 
nerve. Finally, in zoster of the arm and thigh, the eruption of vesicles 
follows the courses of the nerves which spring from the brachial and 
crural plexus. All forms of herpes begin with a sense of burning pain, 
usually not of a very severe character, in the affected region. Numerous 
red points soon become visible, which coalesce, forming red specks of 
irregular shape, which, on the next day, usually are covered with small 
transparent vesicles. The contents of the vesicles, which rarely exceed 
the size of a lentil or a split pea, become turbid in two or three days, 
or else reddened from admixture of blood. About the third or fourth 
day the vesicles commence to shrivel, and they and their contents sub- 
sequently dry up into a brownish scab. The scabs fall off in from ten 
days to a fortnight after the first appearance of the eruption, and for 
some time afterward there remains a reddish spot, covered with thin 
epidermis. The pain, which is of a burning character, though not very 
severe, usually abates when the vesicles begin to shrivel. Herpes 
zoster is sometimes accompanied by fever, and in rare instances the 
eruption of vesicles is preceded by febrile disturbance, like the inflam- 
matory cutaneous exudation of erysipelas. There is no fever in the 
other varieties of herpes, or the fever, if present, does not depend upon 
the herpes, but upon the disease with which the herpes is associated. 
Besides the forms of herpes above enumerated, there is also a 
herpes circinatus and a herpes iris. These species are not classified 
according to their locality, like the other forms, but according to the 
arrangement of the vesicles. This is quite analogous to that of the 
nodules in erythema circinatum and erythema iris. In herpes circina- 
tus, a circle of vesicles encloses a tract of healthy skin. Moreover, the 
vesicles themselves are usually smaller than those of other kinds of 464 
DISEASES OF THE SKIN. 
herpes, and they do not always form a scab as thej subside, but termi- 
nate in reabsorption of their contents, with desquamation. In herpes 
iris a few solitary vesicles stand in the centre of a circle of vesicles, or 
of several concentric circles of them, whose vesicles exhibit different 
stages of development and decline. Most cases both of herpes circina- 
tus and herpes iris, if not all of them, owe their origin to the presence 
of vegetable parasites. 
Treatment.—As the various forms of herpes run a cyclical course, 
and as they soon subside, and are not followed by any serious conse- 
quences, their treatment should be simply expectant. It is sufficient 
to protect the vesicles, and the scabs after they have formed, from 
friction or other violence. In herpes zoster, which is the most exposed 
to friction, the eruption should be enveloped in cotton, which should 
be allowed to remain just as in the treatment of slight bums. The 
expectant treatment is especially advisable in herpes preputialis. The 
spontaneous healing of an excoriation, which remains after the burst- 
ing of a vesicle, affords the best confirmation of the diagnosis that we 
have to deal with a herpes and not with a chancre. True, the diagnosis 
is easy enough at first, as the grouping of the vesicles in herpes is 
quite characteristic, and, in the excoriation which remains immediately 
after they have burst, it is easy to perceive from its shape that it has 
been formed by a cluster of several vesicles. Somewhat later, how- 
ever (especially if the patient, in his anxiety, have cauterized them 
with lunar-caustic), the diagnosis is more difficult, and frequently our 
onty sure criterion is in observation of their subsequent progress. If 
the excoriation heal in a few days, under the application, twice a day, 
of a bit of lint moistened in water, between the prepuce and glans, or 
if the recovery is not delayed beyond a week, we may be sure that it 
is not a chancre. 
CHAPTER YI. 
URTICARIA—NETTLE-RASH— ACUTE SUPERFICIAL DERMATT1 IS, WITH 
FORMATION OF WEALS. 
Etiology.—In urticaria a serous infiltration of the papillae of the 
skin, and, probably, too, a swelling and infiltration of the cells of the 
rete Malpighii cause the formation of circumscribed flattened eleva- 
tions, whose width is greater than their height, and which are called 
weals. Owing to the rapidity with which the infiltration that pro- 
duces the weals appears and disappears, we should not have reckoned 
urticaria among the inflammatory affections, but should rather have 
described it as a local oedema characterized by great peculiarities in its URTICARIA. 
465 
distribution and limits, were it not that in a previous section we have 
applied the title dermatitis to all the exudative diseases of the skin 
without considering whether or not they are accompanied by genuine 
inflammatory symptoms. We have also placed urticaria among the 
acute inflammations, although there are cases in which patients have 
suffered for years from it. However, the disease has not been a 
chronic one in such cases, but rather a series of acute relapses occur- 
ring at very short intervals. The causes of nettle-rash are very varied. 
Some of them we know, the rest are quite unknown. Urticaria has 
been classified according to the different exciting agents which pro- 
duce it. 
1. Urticaria from External Irritation.—Under this head come 
all forms of nettle-rash arising from local irritation of the skin from 
contact with stinging nettles, with the leaves of the rhus toxicoden- 
dron, with the hairs of certain caterpillars, and with some of the mol- 
lusca. It also includes the rash induced by the bites of fleas and 
midges, and that caused in the skin of some people by scratching with 
the finger-nails. 
2. Urticaria from Ingesta.—This variety breaks out upon some 
persons immediately after they have eaten strawberries, crabs, mus- 
cles, mushrooms, or other unaccustomed food. It is quite hypothetical 
to assume that in these cases an acrid material enters the blood and 
upon reaching the skin occasions the irritation. It is very strange 
that such food should only have this effect upon a few people, and that 
in these it never fails to produce urticaria. The rash which we not un- 
frequently see after the exhibition of large doses of balsam copaiba is 
also included among the urticaria ab ingestis. 
3. Urticaria febrilis or febris urticata.—The causes of this form 
of the disease, which is accompanied by severe fever and gastric de- 
rangement, and which greatly resembles the acute exanthemata in its 
course, are unknown. 
4. Chronic Urticaria.—The cause of this somewhat rare disease 
is also obscure. It occasionally seems to depend upon hereditary pre- 
disposition. 
5. There is a form of urticaria mentioned by Ilebra, which is evi- 
dently dependent upon uterine irritation, and which appears in some 
women during pregnancy; in others, during menstruation; while in 
others, again, it accompanies diseases of the womb, or follows the in- 
troduction of pessaries. 
Symptoms and Course.—The weals always rise from a base red- 
dened by hyperaemia. They themselves, however, are often white 
{urticaria alba s. porcellana), probably owing to compression of the 
vessels of the papillae by the infiltration. Sometimes they are dis 466 
DISEASES OF THE SklJN. 
Crete; at others, they stand so closely together as to coalesce (urti- 
caria conferta). Sometimes the duration of the individual weals is 
very brief (u. evanida:), then again it may be very persistent (u. per- 
stans). When the weals are large and hard, the urticaria is called 
tuberous / when small, it is said to be papulous (lichen urticarius) ; 
and, if the epidermis upon them be elevated into the vesicles here and 
there, it is called urticaria vesiculosa. The rash is always accompa- 
nied by a most tormenting itching of the part, so that the patient can- 
not refrain from scratching it. With exception of the febrile urticaria, 
the itching and the objective signs upon the skin are the only symp- 
toms of all forms of the disease. It seldom lasts over a few days; 
although, in chronic urticaria, the rash recurs at short intervals for 
weeks, months, and years, one eruption following another, but none 
of them ever lasting very long. The fever which accompanies and 
sometimes precedes the febrile urticaria may be so intense as to cause 
dryness of the tongue, disturbed sleep, and even delirium. If the 
fever be attended by violent vomiting (and, as often happens, by diar- 
rhoea, due, no doubt, to an affection of the intestinal mucous mem- 
brane similar to that upon the skin), the disease may present an as- 
pect of great gravity. However, the eruption, fever, and gastric dis- 
turbance subside in a few days, and a rapid convalescence ensues. 
Treatment.—It would be a great gain, could we only relieve pa- 
tients from the itching of that form of urticaria which sets in rapidly 
and subsides spontaneously, and which so torments them as to deprive 
them of all comfort and sleep. The palliatives recommended for this 
purpose, however, the chief of which are bathing the skin in very di- 
lute acids, and rubbing it with slices of lemon, are often ineffectual. 
Neither do we know of any efficient remedy for chronic urticaria. We 
must, therefore, confine our treatment to the endeavor to restore the 
general health of the patient by suitable diet and medicines, to correct 
digestive derangement, and to forbidding the use of such articles of 
food as we know to be liable to cause the disease. 
CHAPTER VII. 
ECZEMA—DIFFUSE SUPERFICIAL DERMATITIS, WITH SEROUS EXUDA- 
TION UPON THE FREE SURFACE, AND WITHOUT TYPICAL COURSE. 
Etiology.—By far tlie most common form of dermatitis is eczema. 
As in herpes, the inflammation is limited to the superficial layers of 
the skin, and is accompanied by a serous exudation upon its free sur- 
face. But it differs from herpes, on the one hand, in its tendency to 
spread over the surface—a tendency which is quite unmistakable even ECZEMA. 
467 
in eczemas of very small extent; and, on the other hand, it differs in 
the irregularity of its course, which, unlike that of herpes, is not con- 
fined to any fixed period of time. Eczema may he regarded as the 
analogue of catarrh. It is the most common of all diseases of the 
skin, just as catarrh is the most common affection of the mucous mem- 
branes. Like catarrh, too, it is a disease of the surface rather than of 
the parenchyma, and it is accompanied by a profuse superficial serous 
transudation. It also usually involves wide tracts of the skin, or, if 
its area be small, it shows a tendency to spread. 
Eczema being a diffuse dermatitis, with superficial serous exuda- 
tion, it is plain that the formation of vesicles must be a frequent oc- 
currence in this disease; but it is equally certain that the presence of 
vesicles is by no means one of its constant or essential symptoms. If 
the superficial exudation be profuse enough to form small drops, and 
if the epidermis possess sufficient resisting power, not to give way im- 
mediately before it, vesicles form, producing the variety of eczema 
known as eczema simplex, seu vesiculosum. When there is a profuse 
admixture of young cells with the contents of the vesicles (which 
always contain a few such cells), so that the serum is turbid, yellow, 
and purulent, the vesicles become pustules, and the disease is called 
eczema impetiginosum. When the transudation is not so copious 
as to elevate or to break through the epidermis, it usually soon dries 
up ; and then, instead of vesicles or pustules, nothing is to be seen 
except dry scales rising from the reddened skin. This has been 
called pityriasis rubra, and is now known as eczema squamosum. 
From its anatomical and pathological point of view,. I cannot 
regard the form of pityriasis rubra, which Hebra considers as dis- 
tinct from eczema squamosum, as any thing more than a squamous 
eczema capable of endangering life from its superficial extent. Ac- 
cording to HebrcCs description, this affection is also a superficial 
dermatitis, whose scanty superficial exudation, mingled with epi- 
dermic cells, dries into scales, and which, like all exanthemata in- 
volving the whole surface, is a dangerous disease. 
Finally, when the exudation detaches the epidermis so as to deprive 
the red, moist corium of its covering, and expose it to view, it is called 
eczema rubrum (“ salt rheum ”). After the epidermis has disappeared, 
the exudation upon the surface often dries up into scabs and crusts, 
whence many other names formerly applied to moist eczema were 
derived, such as tinece or crustae lactece, granulates, mucosae, etc., etc. 
Hebra also counts that form of eruption as an eczema which is usually 
called lichen, and which appears as a rash of solid papules. He thus 
adds a fifth species, eczema papulosum, to the series. Since a serous 
exudation is also thrown out upon the surface in the papular erup- 468 
DISEASES OF THE SKIN. 
tions, which swells up the cells of the rete Malpighii, but is not co- 
pious enough to overflow its free surface and to elevate the horny 
layer of the epidermis into vesicles, we accept the classification of 
lichen as a form of eczema; but we deem it improper to make excep- 
tion of certain of its varieties, and to distinguish them from eczema as 
a separate affection. 
The causes of eczema are : first, direct irritation of the skin. The 
action of an atmosphere hotter than the normal temperature of the 
body is the cause of eczema caloricum, which, no doubt, is identical 
with the calori of the Italians, and with the lichen tropicus. Eczema 
solare is produced by the rays of the sun. The effect of warm baths 
of simple or medicated water is to produce a kind of eczema known 
as “ bath itch,” while abuse of the skin, by means of cold compresses 
and cold douches, gives rise to the “ critical ” eruptions of the hydro- 
paths, and the inunction of blue ointment will cause a mercurial ec- 
zema. If we were to give a name to the eczemas which proceed from 
other causes, such as the action of the vegetable and mineral irritants, 
parasites, pressure, and the like, the number of species of eczema 
might be much increased. The itch, a dermatitis usually of an eczem- 
atous character, and excited by the presence of the acarus scabiei 
shall be treated of in a separate chapter. Miliaria rubra, induced by 
excessive sweating, is also an eczematous affection. The contents of 
its vesicles is an inflammatory exudation of an alkaline reaction, and 
is not acid like the sweat of the miliaria alba. 
Secondly: Eczema may arise from obstruction of the venous circu- 
lation. As such derangements of circulation usually arise in the lower 
extremities, it is upon these that the eczematous inflammation usually 
appears and forms an analogue with the catarrh of the stomach, which 
arises in cases of compression of the portal vein, and with catarrh of 
the rectum when the haemorrhoidal vein is obstructed. 
Thirdly: Eczema is often of constitutional origin. A tendency to 
eczema and to other diseases of the skin is often called a herpetic dia- 
thesis, or a herpetic dyscrasia. The term herpetic dyscrasia is based 
upon the idea that the blood and humors of a patient with constitu 
tional eczema have undergone some qualitative or quantitative change. 
The soundness of such an hypothesis is not only unproved but quite 
unlikely. Eczema of an indubitably constitutional origin is seen as 
often in plethoric subjects as in ansemic ones, and in cachectic person? 
quite as frequently as in those who are robust and whose humors cer- 
tainly have not deteriorated. No objection can be made to the term 
herpetic diathesis, because it leaves the question undecided whether 
the predisposition to eczema and to other cutaneous diseases is depen 
dent upon a perversion of nutrition or upon other conditions. The her ECZEMA. 
469 
petic diathesis is frequently congenital, and, as Veil in Canstatt has 
demonstrated, is hereditary in many instances. One would naturally 
suspect congenital predisposition to eczema in a family in which all the 
brothers and sisters were afflicted by it, and that it was hereditary 
if the parents and grandparents also have had it. We need hardly 
state that a herpetic diathesis is not always transmitted from parent 
to child, any more than any other hereditary disease. Scrofulous and 
rachitic children always exhibit a most pronounced tendency to ec- 
zema, especially to eczema impetiginosum. Sometimes there is a 
connection between eczema and chronic dyspepsia or derangement of 
menstruation. In such cases, although we may succeed in healing the 
eczema by local treatment, yet there will always be relapses of the 
eruption so long as the other complaint remains uncured. Much more 
frequently, although there may‘be a most decided herpetic diathesis, it 
is not accompanied by general nutritive derangement, nor by disease 
of any particular organ. The appearance of eczema, unprovoked by 
any appreciable irritation of the skin, and its frequent recurrence, in 
spite of the most careful avoidance of all sources of irritation, is often 
the sole sign of constitutional derangement. 
Symptoms and Course.—The subjective signs of eczema consist 
in itching, accompanied by an irresistible inclination to scratch, symp- 
toms -which are common to all cutaneous diseases, where the papillary 
layer is affected. The objective signs have already been given above. 
We have already seen that the cutaneous surface, which is the seat of 
that atypical, diffuse, superficial dermatitis called eczema, sometimes is 
studded with vesicles; at others, with vesicles and pustules intermin- 
gled, and sometimes again with scales; that, in other instances, it 
presents a red, moist surface, denuded of its epidermis, and that, in 
still others, it is covered with crusts and scabs. 
Besides the four forms of eczema (e. simplex, e. sqamosum, e. ru- 
brum, e. impetiginosum), it is also customary to recognize a chronic 
form of the disease. But not only is it illogical to associate one spe- 
cies, distinguished by the nature of its course, with four others, classi- 
fied upon an entirely different basis, but in practice this arrangement 
is found to be attended by many inconveniences. Chronic eczema can 
only be contrasted with acute eczema; like the latter, it sometimes 
assumes the simple form, sometimes the squamous or the impetiginous 
form, and sometimes again that of eczema rubrum. In cases of very 
.ong standing, which usually assume the type of eczema rubrum, the 
disease upon the surface is occasionally accompanied by changes in the 
structure of the cutis. This generally consists in an inflammatory hy- 
pertrophy, quite analogous to that which occurs in the mucous mem- 
branes in chronic, bronchial, and gastric catarrh. Less frequently there 470 
DISEASES OF THE SKIN. 
is an atrophy of the cutis caused by pressure of the crusts and scabs 
adhering to it. 
Classification of eczema, according to the extent and locality of the 
surface which it involves, is of much greater importance than that 
based upon its form and duration. Upon this basis, in the first place, 
it may be divided into universal and partial eczema. The term uni- 
versal, however, is not to be accepted literally, because, although the 
eruption often involves a very large portion of the surface, it seldom 
covers the whole of it. Universal eczema is a much less common 
affection than partial eczema. It is either acute, when it usually 
assumes the simple or squamous character less frequently than 
that of eczema rubrum; or else it is a chronic disease, and then 
takes on different aspects upon different parts of the body, showing 
preference, however, to the type of eczema rubrum, so that the surface 
is generally either moist and raw, or else covered with large crusts. 
Chronic universal eczema is always a very distressing and very ob- 
stinate disease, although it does not imperil life, and indeed often 
does not seem materially to prejudice the health of the patient. 
Partial eczema is often situated upon the seal}}. Even when the 
disease commences as a vesicular eruption, the vesicles are apt to be 
overlooked, and to be destroyed by combing or scratching. If eczema 
impetiginodes, or E. rubrum, appear on the scalp, the eruption dis- 
charges very freely, the hairs are glued together and crusts form, which 
are sometimes soft and flat, sometimes thick and hard, and to this 
the name of tinea favosa, granulata, etc., was formerly applied. Such 
a scalp, covered with scabs, is a very favorite and favorable abode for 
lice. The cervical glands often become enlarged in moist eczema of 
the head, and sometimes even suppurate. The disease presents a very 
different appearance when the transudation is too scanty to form ves- 
icles or to burst through the skin. In such cases it assumes the squa- 
mous type, and a great quantity of small white detached scales of epi- 
dermis are found, not merely upon the reddened skin, but among the 
hairs and upon the collar of the coat. This was formerly called tinea 
furfuracea ; or tinea amiantacea, when the epidermic scales, mixed 
with exudation, formed thick, shining layers, like asbestos. All forms 
of eczema frequently appear upon the face, although the impetiginous 
and rubrous types are the more prevalent ones during childhood. 
Although it does not spare other regions, its favorite seat is upon the 
cheeks and chin, which become reddened and shiny, and after a few 
vesicles have formed upon them, and burst, they are covered by a cleai 
yellow liquid. This soon dries up, forming yellow crusts. If we re- 
move these before the disease has subsided, we come immediately upon 
the bare, moist corium, and can find no intervening epidermis. Ecze ECZEMA. 
471 
ma rubrum, et impetiginosum, of the face used formerly to be called 
pomgo larvalis, tinea faciei, crusta lactea, crusta serpiginosa, etc. 
It often extends into the external auditory meatus, and still more fre- 
quently is complicated with coryza, with ophthalmia, and with enlarge- 
ment of the submaxillary and cervical glands. In many cases facial 
eczema is confined to the ears, the eyebrows, the eyelids (especially 
the commissures), and, above all, to the lips. These points are some- 
times studded with vesicles; sometimes stripped of their epidermis 
and bathed in liquid secretion, or covered by scabs, and sometimes 
again they are attacked by the squamous forms of the eruption. A 
very obstinate species of eczema rubrum is also observed about the 
nipples of nursing women, although it may also attack the nipples of 
women who are not nursing, and even those of children. The vicinity 
of the navel is also the seat of a partial eczema which is most common 
in corpulent persons. A very important variety of the disease is 
eczema pudendorum. In men, it usually attacks the penis and scro- 
tum ; in women, the labia majora. Sometimes it is acute, assuming 
the simple form; sometimes chronic, when it presents a very moist 
eczema rubrum. The intolerable itching which accompanies it almost 
drives the patient to desperation. A similar eruption appears about 
the anus and upon the perinaeum, only its secretion is not so profuse 
as in eczema pudendorum. Under the name of eczema marginatum, 
Ilebra describes an eruption which is most common among shoemakers 
and cavalry soldiers. It commences at the point where the scrotum 
comes into contact with the thigh, but usually extends; and after a 
while a similar spot appears, symmetrically upon the inner surface of 
the other thigh. Eczema of the lower extremities is most common 
upon the legs, where it forms large red patches, which either secrete 
profusely or else are covered by scabs. This is generally called “ salt 
rheum.” When the eruption attacks the flexures of the joints, they 
become covered by a layer of rough crisp epidermis, mingled with dried 
exudation, which is apt to crack when the joint is extended, and to 
form painful fissures. Sometimes a moist eruption also appears on the 
flexures of the joints. It is remarkable that eczema always attacks 
the hands and feet simultaneously. When its chief seat is upon the 
dorsum of the extremity, the eruption takes the simple vesicular form, 
and may easily be mistaken for scabies. Vesicles are not so apt to 
form upon the volar surface. More usually there is a hard and some- 
what thick crust of dried exudation, mixed with epidermis, upon the 
reddened cutis, and as this coating of the palms and soles is con- 
stantly scaling off in the form of white scales, eczema at these points 
is often and erroneously called psoriasis, for pityriasis, palmaris, oi 
plantaris. 472 
DISEASES OF THE SKIN. 
Treatment.—Errors in the treatment of cutaneous diseases in 
general, and in that of eczema in particular, are liable to assume one 
of two directions. One class of physicians are possessed by the preju- 
dice that all local treatment is wrong, because they can never be sure 
that the suppression of an eruption will not be attended by dangerous 
consequences. Hence, from the apprehension (which certainly is nearly 
always groundless) that they may, perhaps, do harm to their patients 
by treating eruptions locally, they resort to an internal medication, 
which is injurious beyond all doubt. Another party, blindly following 
the authority of Hebra, look upon all internal medication as super- 
fluous, and treat all cutaneous diseases locally, without the exception 
even of cases where an eruption has been followed by the abatement 
of serious disease of internal organs. Hebra?s success leaves no doubt 
that the direct treatment of disease of the skin is the best for many 
patients. Not only is the disorder itself relieved and cured more 
surely and quickly by such means, but it often does much less harm to 
the patient than the old-fashioned practice of giving laxatives, metal- 
lic preparations, and other noxious medicines. Moreover, with few 
exceptions, it is a groundless prejudice to suppose that other diseases 
proceed from the suppression of cutaneous eruptions by means of local 
applications. On the other hand, it must not be denied that exanthe- 
mata, when trea ted by local means alone, are very apt to relapse; and 
that cases really do occur now and then, in which there is reason to 
fear that their repression, under direct applications, may give rise to 
disease of internal organs. 
The forms of eczema in which I consider it inadmissible, or at all 
events hazardous, to employ vigorous local treatment are— 
1. The moist form which appears upon the scalp and face of children. 
It is an unmistakable fact that the sudden disappearance of such erup- 
tions is often quickly followed by bronchial catarrh, croup, or hydroceph- 
alus ; and it is equally certain that a tedious catarrh or other affection 
will often subside as soon as an eruption of this kind makes its appear- 
ance. However, it does not by any means follow that the internal 
maladies have arisen in consequence of the cessation of the cutaneous 
disease, nor, on the other hand, have we any proof that it is because 
of the outbreak of the eruption that they subside. But we are equally 
uncertain of the contrary propositions, and even the possibility of the 
existence of such a cause should contraindicate local treatment of 
moist eczema upon the heads and faces of children. It is true that a 
similar belief formerly prevailed regarding the supposed injurious 
effects of the treatment of itch by local means. Such views are now 
recognized as prejudices, and exploded; and I readily admit that here- 
after my fear of treating facial eczema locally may prove equally ECZEMA 
473 
groundless; but, according to our present knowledge, such apprehen- 
sion seems well founded, and the fact, that it is safe to cure other 
exanthemata by external applications, does not prove any thing re- 
garding the disease in question; since, in spite of the great externa] 
similarity of the exanthemata, they differ essentially in their influence 
upon nutrition, and in their effect upon the general health of the 
body. 
2. Local treatment is contraindicated in all forms of eczema 
of adults that seem to appear vicariously for other diseases, which 
have subsided upon the outbreak of the eruption. It is true that 
Hebra expressly affirms that he has suppressed such eczemas without 
injury to the patient, solely by the employment of local applications; 
but, in spite of his authority, I should not dare to resort to an external 
treatment of a case of eczema, the establishment of which had been 
followed by the recovery of an ophthalmia of long standing, or of a 
chronic derangement of digestion, or other serious disease. 
3. Local treatment, or, at all events, an exclusively local treat- 
ment, is unadvisable in an eczema, the cause of which is evidently 
constitutional. The number of cases suitable for external treatment 
would then be a very small one, however, in the eyes of the class of 
physicians who ascribe all exanthemata, whose origin they do not 
know, to a dyscrasia. One of the important steps recently made in 
the therapeutics of cutaneous disorders, however, consists in our no 
longer ascribing an eczema to a constitutional origin, and subjecting 
it to “ anti-dyscratic ” treatment, unless we have better evidence of 
the genuineness of such origin than is afforded by the mere existence 
of an eruption. The impropriety of treating the syphilitic exanthemata 
locally is universally admitted, but even in the eczema which afflicts 
scrofulous and rachitic subjects, as well as in that which attacks chlo- 
rotic females, and in that which accompanies disorders of the sexual or- 
gans, an exclusively local system of treatment is unwise ; not that direct 
remedies are hurtful in themselves, but they should only be employed 
as corroborants to general treatment, directed against the fundamental 
disease. At the same time, we should mention that eruptions which 
are undoubtedly of constitutional origin often continue, as it were, 
independently, after the original disease has subsided, and require a 
vigorous local treatment for their eradication. This is sometimes the 
case even in syphilitic exanthemata. I knew a merchant in Magde- 
burg, who, in addition to other signs of syphilis, had a very unsightly 
eruption upon his face and head, which had lasted for years after all 
the other syphilitic symptoms had disappeared. This man, after con- 
sulting the most eminent physicians, and after undergoing all sorts of 
anti-syphilitic treatment without benefit, was completely and per- 474 
DISEASES OF THE SKIIs. 
manently relieved of his disease by means of an ointment of white 
precipitate and carbonate of lead, prescribed by a second-rate sur- 
geon. 
The moist eruptions upon the heads of children, vicarious eczemas, and 
eczemas of constitutional origin, after all, form but a small class compared 
with the number of eczemas against whose local treatment no objections 
can be made, and in the cure of which the most brilliant success may be 
attained. The topical remedies which I would recommend before all 
others is the white precipitate in the form of an ointment (hydrarg. 
ammoniat. 3 j, adipis. § j), and corrosive sublimate in weak solution 
(hydrarg. bichlor. gr. j—ij, aquae destillat. 3 j), as these articles are 
much less disagreeable to the patient than tar ointment, soft soap, and 
the like, and since in a great majority of cases they amply suffice to 
effect a rapid and complete cure even of the most obstinate forms of 
eczema. I am quite unable to account for the beneficial action of 
these articles upon eczematous dermatitis; but I will suggest that 
both white and red precipitate have long been considered as among 
the most effective remedies in conjunctivitis. The forms of eczema 
in which I prefer to use the white precipitate ointment are eczema of 
the face and scalp, when not too extensive, and particularly when it 
has not already produced too much thickening of the corium. In such 
cases the treatment has hardly ever failed me, either in the clinic or 
in private practice; and under its use I have seen eczemas disappear 
in a few weeks which had lasted not merely for a year or two, but for 
eighteen or twenty years. Although I have hesitated to employ it 
where the eruption was very extensive, from fear of causing mercurial 
poisoning, yet I have had especial opportunity of satisfying myself 
that in such cases it likewise does excellent service and does no harm. 
By means of white precipitate ointment I once cured the wife of an 
official, in the neighborhood of Greifswald, in a few weeks, of an ecze- 
ma about the ears and scalp, which had existed for years. Some time 
afterward, this lady, who was very philanthropic to the poor in her 
husband’s district, and who used to prescribe “ homoeopathically ” for 
the sick, informed me that she could not thank me sufficiently for my 
recipe; for she had made a quick and radical cure of a large number 
of very extensive and obstinate cases of “ salt rheum.” The patients 
did not suffer in the least from the rapidity of the cure, and none of 
them were salivated. The application of white precipitate, however, 
by no means secures the patient against a relapse, and it is well to 
warn him of the probability of a fresh outbreak, and to recommence 
the treatment as soon as he perceives any new signs of the disease. 
Moreover, as the eczema is all the more easily and quickly cured by 
the ointment, when the eruption is recent and slight, it is very impor- ECZEMA. 
475 
tant to enjoin upon the patient to keep a sharp lookout for the first 
traces of it, as I can illustrate by a most striking example. I cured 
the wife of an officer, in Magdeburg, in less than a fortnight, of a 
chronic eczema, for which she had in vain gone through a succession of 
courses of Zittman’s decoction, arsenic, iodide of potassium, mercurials, 
baths, and mineral waters. This eczema had a great tendency to re- 
turn. When the patient’s husband was at home, in Magdeburg, he 
used every day to examine her face with a lens, and to anoint every 
suspicious-looking spot with the salve, thus protecting her from any 
unsightly extension of the disease. When her husband was on duty, 
and absent from Magdeburg for any length of time, during the autum- 
nal manoeuvres of the army, the eczema sometimes spread consider- 
ably, and did not afterward yield so readily to the white precipitate, 
and has sometimes even compelled me to resort to the corrosive sub- 
limate instead. Two or three inunctions daily of this ointment, or an 
equal number of pencillings with the solution of corrosive sublimate, 
are usually sufficient. Of course, any adherent scabs must be softened 
and removed, and the surface must be carefully dried before applying 
either the ointment or the solution. I have often found that my for- 
mer pupils, as they came home from their travels, fresh from a course 
of lectures upon cutaneous diseases, and full of new ideas, at first treat 
all the eczemas which come to them with soft soap, oil of cade, cod-liver 
oil, and the like. In a year or two, however, they abandon such treat- 
ment, or, at all events, before resorting to it, they try whether the old, 
simpler, and far more convenient treatment by white precipitate will 
not answer the purpose. The preparations of lead and zinc stand next 
in virtue to the white precipitate salve, and the solution of corrosive 
sublimate, as they are both best adapted for the treatment of spots of 
eczema of no great magnitude, and where there is no hypertrophic 
thickening of the subjacent corium. We generally prescribe a solu- 
tion of sulphate of zinc (zinci sulp. 3 ss—aquas § vj), or an ointment 
of the oxide of zinc, or of the carbonate of lead, in the proportion of a 
drachm to the ounce of lard; or else, when the patient does not bear 
salves well, we may order a paste of oxide of zinc with glycerine, or 
dust the surface with a powder composed of oxide of zinc and lycopo- 
dium seeds, or starch (zinci oxid. 3 j, amyl § j). In the very moist 
eczema, which arises behind the ears, and in the hollows of the joints, 
and between the fingers and toes, Hebrews diachylon ointment does 
excellent service. It is to be prepared as follows: Melt the simple 
diachylon plaster over a slow fire, and add to it equal parts of linseed- 
oil, and stir the mixture well when cool; or else the following: (R. 
olei olivarum optimi § v, lithargyri 3 x, coque 1. a. in molle, dein adde 
ol. lavendulae Sij, f. ung. S. Rub the ointment upon the affected spot 476 
DISEASES OF THE SKIN. 
two or three times a day, or, what is preferable, apply it upon linen 
compresses). In very extensive eczema accompanied by great itching, 
especially in eczema universale, the shower-bath is strongly to be rec- 
ommended. Some patients are quite unable to tolerate the irritating 
remedies to be mentioned presently, llebra directs the shower-bath 
to be used two or three times a day for ten or fifteen minutes at a 
time in a warm room. By this means the most obstinate eczemas, 
which have defied all previous treatment, are often made to heal, but 
only after a somewhat persistent employment of the shower. A suit- 
able apparatus may be made at little cost. In partial eczema, which 
does not tolerate irritating remedies well, cold compresses may be 
substituted for the cold douche, especially in recent cases. When the 
eczema is of very long standing, and particularly when the disease has 
extended from the surface into the substance of the true skin, and the 
more difficult it is to pinch up the skin in a fold, so much the more 
often shall we be compelled to resort to that class of remedies which, from 
the vigorous alterative action which they exert upon the skin, play 
an important part in the therapeutics of nearly all inveterate cutaneous 
affections. Experience teaches that of this class the preparations of 
sulphur are the least adapted to the treatment of eczema, that it is 
only in exceptional instances that they do good (as in eczema mar- 
ginatum, according to llebra), and that in most cases they actually do 
harm. On the other hand, “ green soap,” tar, and caustic potash, are 
of the utmost benefit in old cases of eczema accompanied by infiltra- 
tion of the corium; hence we shall briefly relate Hebra1 s directions for 
their employment. The green soap must either be rubbed once or 
twice daily into the affected surface, or else a piece of flannel is to be 
smeared with the soap and laid upon the sore spot. This application 
is also to be renewed once or twice daily, and the procedure should be 
continued for from three to six days. It must then be discontinued; 
but the soap which has been rubbed in ought not to be removed. Af- 
ter three days more the patient is to take a bath, when there must 
be a pause in the treatment. This course is to be repeated until 
all the infiltration has disappeared, and until the transudation has 
ceased. At this stage, when a previously moist eruption has changed 
into a dry scaly one, Hebra directs applications of tar to be substi- 
tuted for the soft soap. Of the various kinds of tar Hebra prefers the 
birch-tar (oleum rusci) and the oil of cade, prepared from the wood of 
the Juniperus oxycedrus, as having a less offensive smell than the com- 
mon pine-tar, or oleum empyreumaticum coniferum (pix liquida). In- 
stead of pure tar, or tar-ointment, I for years have used a solution of 
tar in alcohol (picis liquid., alcohol, aa, or else picis liq., sapon. virid., aa 
ss, alcohol f j); for it answers every purpose, is much more com ECZEMA. 
477 
venient to apply than pure tar, or than tar-ointment, and is much 
easier to remove from the skin. The solution is to be rubbed in once 
a day until the brown coat which forms, instead of being quickly de- 
tached, adheres for several days, and until the skin ceases to look red 
after the brown coat has been shed. As long as the tar-crusts con- 
tinue to shed rapidly, leaving a reddened surface beneath them, the 
disease is not extinct. Although the external application of tar is 
generally borne without inconvenience, yet in some patients the first 
inunction occasions such an intense irritation of the skin as to render 
further prosecution of the treatment impracticable. It is still more 
common for the continued use of tar over a large extent of surface to 
be followed by violent irritation of the intestine and kidneys, accom- 
panied by vomiting, diarrhoea, the discharge of a blackish-looking 
urine having a distinct odor of tar, which becomes still plainer upon 
the addition of one or two drops of sulphuric acid; these symptoms 
being accompanied by fever and distress in the head, thus necessitat- 
ing an immediate suspension of the treatment. Not only is the appli- 
cation of soft soap or of tar inadmissible in some cases of eczema, but 
there are also examples in which, although the remedies are well 
borne, they do not produce the desired effect. It is in these instances 
that the cauterization of the part, with a concentrated solution of 
caustic potash, is indicated (potassae caustic. 3 j, aquae 3 ij). The 
cauterization is not to be repeated oftener than once a week. A swab 
of charpie dipped in the solution is rapidly to be passed over the dis- 
eased surface, which is immediately to be covered with cold com- 
presses, in order to allay the intense pain which the application al- 
ways occasions. Even the most inveterate cases of eczema usually 
recover after five or six repetitions of the cautery. 
Since local applications will merely rid the patient of his eruption, 
but will not insure him against its return, the question finally arises, 
whether we should limit ourselves to an exclusively local treatment, or 
whether the topical applications should be combined with a general 
internal medication, even when there is no evidence of scrofula or of ra- 
chitis, and when the disease is not a consequence of chronic dyspepsia or 
menstrual derangement. Hebra pronounces decidedly against such 
practice. Veiel, on the other hand, who attaches quite as much im- 
portance to local treatment as Hebra does, combines it with laxative 
tisans and with iodide of potassium in increasing doses, even when 
there is no perceptible constitutional taint. The success obtained at 
VeieVs institution is very brilliant; and moreover, it being a private es- 
tablishment, to which most of the inmates return if they have a relapse, 
its superintendent has the opportunity of taking note of the ultimate 
fate of his patients. 478 
DISEASES OF THE SKIN. 
For my part, I consider it to be not only advisable, but impera- 
tively necessary, that local and general treatment should be combined 
whenever the disease tends to repeated relapses, in spite of careful 
protection of the skin from noxious influences. It is of but little ad- 
vantage to a patient to be discharged from a hospital cured, if his dis- 
ease is going to be as bad as ever again in a few weeks. We need not 
search far to find innumerable examples, in which, in spite of the skill 
of practitioners familiar with the most approved and newest modes of 
treating diseases of the skin, persons have remained afflicted with eczema 
for years, now suffering from the eruption, now resorting to treatment, 
but seldom remaining free from it for any length of time. No general 
rules can be laid down for the constitutional treatment of those ecze- 
mas which depend upon a herpetic diathesis; but in special instances 
it is not very difficult to ascertain the suitable remedy, since the indi- 
viduality of the patient, his physical habit, and his mode of life, furnish 
a clew to the means by which his constitution may be modified effec- 
tively and at the same time without injury. It would be unfortunate 
if the conviction, that the effect of Hebrews treatment is often merely 
palliative, were to lead physicians back again to the old routine of 
systematically purging all forms of this disease; but I do not hesitate 
to declare that I regard Hebrews assertion, that, “ in chronic eczema, the 
mere use of purgatives never does good, and often does harm,” as quite 
inaccurate. When chronic eczema attacks a corpulent patient who 
eats and drinks more than enough for the requirements of his system, 
and who is fond of fat food, and of food rich in fat-producing elements, 
he will recover more quickly, and the cure will last longer, if placed 
upon a methodical course of laxatives combined with suitable regula- 
tion of his food, than if his treatment be merely local and no attention 
be paid to diet. In such cases, where the eruption is very extensive, I 
often prescribe Zittmarfs decoction—in spite of its absurd composi- 
tion—simply because patients follow out the directions for its use with 
such punctilious and almost superstitious exactness. But there is an- 
other class of habitual sufferers from eczema, whose idiosyncrasies are 
exactly the opposite of those described above, and who, without being 
really sick:, are poorly nourished and much emaciated. To purge such 
patients as these, and to reduce their diet, would be to make the evil 
worse. On the contrary, they require a treatment calculated to aug- 
ment the supply of nutriment, and to diminish the wear and tear of 
the system, such as the exhibition of cod-liver oil and similar medi- 
cines. These suggestions must suffice. It would take too long were 
we to attempt to detail all the indications for internal treatment which 
may accompany the topical applications, and which are deducible from 
the constitutional peculiarities of the patient. IMPETIGO. 
479 
CHAPTER VIII. 
IMPETIGO—DIFFUSE SUPERFICIAL DERMATITIS, WITH FORMATION OF 
SMALL PUSTULES. 
Etiology.—In impetigo, as in eczema, a serous exudation is se- 
creted upon the surface of the corium, but at the same time young cells 
form in great abundance and are mingled with the serum. Hence, the 
contents of the vesicles which arise in impetiginous dermatitis are not 
limpid and transparent, like those of eczema, but turbid and yellowish, 
and, upon rupture of their epidermis, a purulent liquid runs out from 
them, which afterward dries up into yellowish or greenish crusts. 
As the serum in the vesicles of eczema also contains a few young 
cells, and since in eczema impetiginosum the contents of some of the 
vesicles are yellow and puruloid, owing to the copious admixture of 
young cells, it is plain that no distinct boundary line can be drawn be- 
tween eczema and impetigo; and that there are intermediate forms to 
which either name might be applied with equal propriety. This is 
especially the case in the moist eruption upon the scalp of children 
which sometimes bears the title of eczema capitis or faciei, and some- 
times that of impetigo or porrigo faciei or capitis. 
The first cause of impetigo which we shall mention is the direct ac- 
tion of irritants upon the skin. The more delicate the skin, so much 
the more easily do even slight irritants cause exudation, and prolifera- 
tion of cells upon its surface. In some persons, the application of a pitch- 
plaster or of a poultice is sufficient to provoke an eruption of impeti- 
ginous pustules. This “ vulnerability ” of the skin is most common 
among people with a thin epidermis and clear complexion; but, above 
all, among scrofulous individuals. Among the latter, indeed, impetigo 
often appears without any appreciable irritation of the skin, and, to- 
gether with chronic catarrh, and enlargement of the lymphatic glands, 
is one of the most decided symptoms of scrofula. Finally, impetigo at- 
tacks children without perceptible irritation of the skin, scrofulous 
diathesis, or other assignable cause. In such cases, which are not at 
all rare, it is generally assumed that the food is too nutritious, that the 
mother’s milk is too rich, or that the eruption has been caused by the 
presence of an “ acrid ” material in the blood. No sound reasons can 
be advanced in support of such an idea. 
Symptoms and Course.—The inflammation of the papilla, from 
which the exudation proceeds, is accompanied by a sense of itching, 
and by a desire to scratch. These subjective phenomena, and the 
objective ones, of small acuminated pustules (psydracia) upon a red- 
lened base, and of yellow scabs, are about the only symptoms pre- 480 
DISEASES OF TEE SKIN. 
seated by impetigo. It is very rarely, and then only when the disease 
is very violent and acute, that impetiginous dermatitis is attended by 
fever and by general constitutional disturbance. According as the 
eruption is limited to a small part of the surface, or extends widely 
over a large area, it is called impetigo figurata, and impetigo sparsa. 
The former variety is most often seen upon the face, especially upon 
the cheeks, lips, nose, and scalp; but its appearance upon the trunk 
and extremities is also not uncommon. At first red specks, which 
may be either discrete or confluent, are observed upon rounded, oval, 
or irregularly-shaped spots of varying size. Extreme redness of the 
skin, with tension and glistening, accompanied by fever, constitutes a 
variety of impetigo, to which Willan has applied the name of impetigo 
erysipelatodes. Upon the reddened base, minute yellow points imme- 
diately develop, which soon grow to the size of small lentils, and rise 
a little above the level of the surrounding parts. After a day or two, 
perhaps sooner, the pustules burst and discharge their contents, which 
dry up into yellow crusts. Beneath these, the formation of pus con- 
tinues, causing a gradual thickening of the crusts, while new pustules 
continue to spring up at their edges. At first, upon removing these 
crusts, which sometimes attain considerable thickness (impetigo scar 
bida), we find beneath them the naked corium bathed in puruloid 
liquid; but, toward the end of the disease, a new, delicate covering of 
epidermis appears, through which the redness of the cutis is visible, 
and in which slight cracks form when the part is moved. The course 
of impetigo figurata usually is subacute, so that the process termi- 
nates in two or three weeks by detachment of the crusts. However, it 
sometimes lasts for several months, and even for several years, al- 
though this is not very common. In such instances, the substance of 
the corium takes part in the process, and becomes thickened and indu- 
rated just as it does in chronic eczema. The favorite seat of impetigo 
sparsa is upon the extremities; and it often covers an entire limb, 
sometimes, indeed, extending over the whole surface of the body. 
The reddening and itching of the skin, the appearance and bursting 
of the pustules, the formation and thickening of the crusts, and the 
continued development of new pustules around them, and, finally, the 
shedding of the crusts, all occur just as in the form previously described; 
only impetigo sparsa more freqently assumes a chronic character, and, 
since the cell-formation is not confined exclusively to the surface of 
the corium, but is also going on within it, it is more apt to result in 
superficial ulceration. 
Treatment.—Many cases of impetigo require no treatment at all, 
and heal ot themselves in a few weeks. Hence, in recent cases, we 
may confine our interference to softening the crusts with fresh butter ECTHYMA. 
481 
or otner grease, when they grow too thick and hard, and to removing 
them with a poultice. But, if the disease already have lasted for 
weeks or months, expectant treatment is no longer appropriate, and 
we must consider whether to treat the disease locally or generally, 
according to the principles laid down in the previous chapter. The 
latter is more frequently indicated in impetigo than in eczema, as this 
form of dermatitis often constitutes one of the symptoms of a consti- 
tutional disease. In the treatment of impetigo, as a rule, the same 
local remedies may be employed which have already been proposed 
for the treatment of eczema. The disease, however, is not so tolerant 
of strongly irritating applications as eczema is, on account of its more 
inflammatory character, as is shown by the suppuration which charac- 
terizes it. White precipitate, the oxide and the sulphate of zinc, and 
slight cauterization, with nitrate of silver, are usually to be preferred to 
the preparations of sulphur, the soft soap, and tar. 
CHAPTER IX. 
ECTHYMA DERMATITIS, WITH FORMATION OP LARGE, ISOLATED, PER- 
MANENT PUSTULES. 
Etiology.—Although the pustules of ecthyma always arise from a 
brightly-reddened, swollen, and infiltrated base, yet, in spite of the in- 
tensity of the inflammation, the suppuration is usually confined to the 
surface of the cutis, and is not apt to involve its parenchyma. In the 
latter case only does ecthyma cause ulceration of the skin, and produce 
scars, owing to contraction of the young connective-tissue cells by which 
the loss of substance is supplied. 
Ecthyma often proceeds from direct irritation of the skin. The 
pustules caused by tartar-emetic ointment (ecthyma antimoniale), and 
those which appear upon the hands and arms of smiths and masons, 
from the contact of lime, or of detached particles of red-hot iron, are 
of this class, as well as the large pustules which arise from the violent 
scratching provoked by the presence of parasites, or by the itching of 
other eruptions. In other instances, ecthyma arises without any ap- 
preciable previous irritation during the course of febrile diseases, assum- 
ing a form somewhat analogous to what is generally called hydroa 
febrilis. Finally, ecthyma is also seen in persons broken down by 
privation, or other cause of exhaustion, or who have become cachectic 
by a physical drain upon the system, by severe or tedious illness, and 
by an abode in prisons, or in other unwholesome dwellings; as well 
as among drunkards and in scorbutic individuals. We shall treat of 
syphilitic ecthyma hereafter. 482 
DISEASES OF THE SKIN. 
Symptoms and Course.—The inflammation and infiltration of the 
skin, which precedes and accompanies the development of ecthyma 
pustules, are usually attended by lancinating pain, and in irritable per- 
sons by fever. The pustules are scarcely ever very numerous. They 
are isolated, surrounded by a broad, red areola, and are most fre- 
quently situated upon the extremities, the seat, the bosom, the throat, 
and, far more rarely, upon the face. These pustules are hemispherical, 
project distinctly above the level of the surrounding skin, and are 
usually somewhat larger than a pea (phlyzacium). Their contents 
consist of a yellow, purulent liquid, often mingled with blood. After 
a few days, the contents of the pustules dry up, forming round, brown- 
ish scabs, which either remain flat, and soon fall off, or else, where the 
suppuration continues beneath them, they gradually grow thicker, and 
adhere for a longer time. In the first instance the scabs, after falling, 
leave behind them red spots, covered with new epidermis, and in the 
latter they leave ulcers, which, although usually shallow ones, some- 
times eat deep into the skin. The course of ecthyma is sometimes 
acute, sometimes chronic. In the acute form, induced by external 
causes, or in that Avhich arises symptomatically in febrile disease, there 
is generally but a single eruption of pustules. Each pustule lasts but 
for a short time, and the scab soon falls, leaving no excoriation, or at 
most a very slight one. In the chronic form, which is peculiar to 
cachectic ecthyma, successive eruptions of pustules take place at vary- 
ing intervals; the redness of the surrounding areola of inflammation 
is often livid, and the contents of the pustules are bloody, or discolored 
(ecthyma luridum). Moreover, beneath the thick scab, which is long 
in forming, and late in falling, very obstinate ulcers develop, which 
often penetrate deeply into the cutis. 
Treatment.—The only species of ecthyma which requires active 
treatment is the chronic variety, with tendency to ulceration of the 
skin. First of all, the cachectic condition must be corrected, if pos- 
sible, by means of proper ventilation, generous food, the use of wine, 
good beer, and the preparations of iron and quinine. Externally, 
while the inflammation continues, warm poultices must be applied; 
afterward, when the ulcers are indolent, they require stimulation, 
especially by touching their surface with nitrate of silver. 
CHAPTER X. 
PEMPHIGUS POMPHOLIX SUPERFICIAL DERMATITIS, WITH THE 
FORMATION OF LARGE ISOLATED BLEBS. 
Etiology.—In pemphigus, large blebs (bullas), filled tensely with 
clear liquid, form upon a base which is slight,!}7 reddened but not infih PEMPHIGUS. 
483 
trated. They resemble the blisters produced by vesicating plasters, 
or by chafing of the skin. We have no satisfactory explanation of 
the cause of this curious disease. In new-born children, pemphigus 
is nearly always, if not absolutely always, of syphilitic origin. Chil- 
dren are more frequently attacked than adults. Some persons ex- 
hibit signs of a general cachexia prior to the outbreak of the pem- 
phigus ; while others retain their blooming appearance, and feel per- 
fectly well throughout the disease, unless exhausted by its repeated 
recurrence and by loss of sleep. Pemphigus sometimes assumes an 
epidemic form. 
Symptoms and Course.—The first change noticed in the skin 
consists in the appearance, upon the back, belly, and extremities, of 
red circular spots, which itch and burn. In a few hours, at the middle 
of the spots, small transparent vesicles arise, wThich quickly enlarge 
and soon cover the whole of it, or else merely leave a narrow margin 
unoccupied. The vesicles are round or oval in shape, and of the size 
of a pea, a cherry, or perhaps of a walnut. At first their contents 
are transparent, afterward they become turbid and curdy. In two or 
three days the blebs burst, leaving an excoriation. For some days 
this continues to discharge, and then becomes covered by a scab, 
under which a new epidermis forms. A stain of pigment remains to 
mark the spot where the bulla was situated. Before the first blebs 
heal, new ones form; these are succeeded by others, and thus succes- 
sive crops continue to spring up ; so that we are often able to study 
all the stages of pemphigus simultaneously upon one patient. In 
some cases this only continues for a few weeks, and then ceases. But 
even then there is usually another attack, the whole process repeating 
itself after a lapse of weeks or months. These relapses, which are often 
three, four, or even more in number, resemble the first attack in their 
course and duration. In other instances, the formation of new blebs 
does not cease at the end of a few weeks, but continues for months, 
and even for years. Although at the beginning of the disease the 
general health of the patient is entirely undisturbed, yet as it pro- 
gresses he grows pale, thin, and debilitated, either because the dis- 
charge exhausts him, or because the unknown cause of pemphigus 
exerts a noxious influence upon the entire economy. The emaciation, 
and pallid, cachectic look make all the more rapid progress, if rest at 
night be disturbed by the itching which attends the eruption of the 
blebs. Nearly all patients with chronic pemphigus finally die of 
marasmus. 
The question has been actively debated, whether pemphigus be 
always chronic, or whether there be not also an acute pemphigus. 
This seems to me to be a mere dispute about words. When the erup- 484 
DISEASES OF THE SKIN. 
tion does not last over two or three weeks, we certainly are warranted 
in calling it acute; but, if we choose, we may regard the interval 
when no blebs form, which often lasts for months, and during which 
the patient feels as well as before his first attack, as a period of 
“ latence,” and call the series of relapses chronic pemphigus. 
Ilebra and Cazenave describe a truly horrible malady called 
pemphigus foliaceus. In this affection a very few, or perhaps only 
a single bleb forms. They are not as tensely filled as those of other 
forms of pemphigus, but have a tendency to spread. In pemphigus 
foliaceus the liquid constantly pushes further and further beneath the 
epidermis, until finally the entire skin looks as if it were flayed, or 
else is covered with a brownish-yellow rind. It generally takes a 
year for the disease to arrive at this pitch of progress. Meantime 
portions of the skin heal, but only to be attacked anew. The malady 
always terminates in death. 
Treatment.—We can only treat the symptoms of pemphigus, 
since, in spite of the meritorious labors of Bamberger, who has de- 
tected ammonia in the recently-passed urine of pemphigus patients, as 
well as in their blood and in the contents of the blebs, the cause of 
the malady, and the nature of the cachexia, or dyscrasia, giving rise 
to the eruption, are quite unknown. We can merely support the 
strength of the patient until the disease subsides spontaneously, and 
can endeavor to postpone his exhaustion and ultimate death as long 
as possible. As in all similar cases, whatever tends to increase the 
waste of the organism must be avoided, and every thing must be fur- 
nished in abundance which can replace what is consumed, or which 
can retard the consumption of tissue. With regard to external treat- 
ment, Ilebra prohibits the use of baths and ointments as expressly as 
he does the internal administration of specifics. However, he recom- 
mends sprinkling of the moist spots with dry vegetable powder, es- 
pecially lycopodium-seeds. 
CHAPTER XI. 
RUPIA—DERMATITIS, WITH FORMATION- OF ISOLATED FLAT VESICLES, 
FROM WHICH SCABS OF A PECULIAR SHAPE ARE FORMED. 
Etiology.—Rupia, like pemphigus, forms isolated blebs. Those 
of pemphigus, however, soon burst, while the rupia blebs last longer. 
Their contents become purulent, and often are bloody, and, after a 
while, dry up into a scab. Having once formed, the scab is gradually 
thickened by the addition of fresh exudation, which generally proceeds 
from ulceration of the deeper parts of the skin, and which also dries PSORIASIS. 
485 
into a crust, while upon its edges a border of bullse forms, the contents 
of which dry up like those of the first one. Thus, the peripheral part 
of the scab is flatter than the older portion; the scabs of rupia are 
thick in the middle and flat at the edges, bearing some resemblance 
to oyster-shells. In most cases, but not in all, rupia is a symptom of 
constitutional syphilis. The causes of non-syphilitic rupia are un- 
known. Like ecthyma, it occurs most commonly in broken-down and 
cachectic subjects. 
Symptoms and Course.—The usual seat of non-syphilitic rupia is 
upon the extremities. The blebs are isolated, and have a reddened 
base. They are not tightly filled, and their contents at first are limpid, 
afterward yellow or reddish. The scabs which form are of a dark 
color, and, after lasting some time, assume the shape described above. 
According as the thickness of the scabs is slight or considerable, they 
are distinguished into rupia simplex and rupia prominens. Removal 
of the scab exposes either an excoriation, or else a deep ulcer, over 
which a new scab soon forms. Sometimes the base of the bleb not 
only ulcerates, but becomes gangrenous (rupia escharotica s. gan- 
grenosa). In such case the contents of the blebs are discolored or 
blackish. Beneath them, or beneath the scab, we find the corium de- 
stroyed and converted into a foul ulcer, covered with debris of the 
tissue, and indisposed to heal. Rupia simplex and prominens usually 
recover, leaving behind them a shallow scar, which is often stained 
with pigment; while rupia gangrenosa may cause death from exhaus- 
tion, or may accelerate the end of the already exhausted patient. 
Treatment.—Our principal task in the treatment of rupia consists 
in 'combating the constitutional vice upon which it depends. If we 
succeed in this, young epidermis soon forms beneath the scabs, and 
the ulcers heal. But if we do not succeed in improving the constitu- 
tion, local treatment will generally be found useless also. Besides 
the constitutional remedies, the scabs may be softened by poulticing. 
The ulcers which remain require stimulating applications, such as re- 
peated touching with lunar caustic. 
CHAPTER XII. 
PSORIASIS CHRONIC DERMATITIS WITH INFILTRATION OF THE CORIUM, 
AND ABNORMAL GROWTH OF EPIDERMIS. 
Etiology.—In psoriasis, the effusion which forms upon the sur- 
face of the corium is insufficient to elevate the epidermis into vesicles. 
On the contrary, this form of dermatitis, which is always chronic, con- 
sists merely of a hyperasmia and infiltration of the skin, capable of 486 
DISEASES OF THE SKIN. 
causing the papillae to produce an unhealthy epidermis, which, mingled 
with the exudation, scales off in large flakes. The cause of psoriasis 
is quite unknown. This disease, which is of very frequent occurrence 
among all classes of society, cannot be regarded as the exponent of a 
dyscrasia, for it attacks perfectly healthy subjects, and, in fact, seems 
to prefer them, while invalids and decrepit persons often remain ex- 
empt. In some families psoriasis is hereditary. Men and women seem 
to be about equally liable to it, while it rarely attacks either children 
in their first year or very aged persons. 
Symptoms and Course.—The disease always commences in small 
round spots upon the skin. These are reddened; project slightly 
above the surrounding level, and immediately after their appearance 
are smooth, looking as if the covering of epidermis had been raised by 
a serous effusion, and had sunk back again after the liquid had been 
reabsorbed. This small, round, red, infiltrated spot soon becomes cov- 
ered with dry, white scales. According to Hebrews apt and simple 
description, it is from this form of psoriasis—psoriasis guttata—that 
all the other varieties of psoriasis arise, developing sometimes through 
extension of the morbid process, sometimes through retrocession of the 
disease at the point first attacked. An enlargement of the affected 
spot converts a psoriasis guttata into a p. numularis / this latter, 
when the process begins to decline in the central and older portion of 
the area of disease, so that the scales grow thinner and commence to 
fall off, becomes a p. scutellata, and this again becomes a p. annulata, 
when the redness disappears from the centre, and the skin at that 
point resumes its healthy appearance (lepra vulgaris, Willan). When 
the circles thus formed touch one another, interruptions occur at the 
points of contact, so that at last there merely remain segments of cir- 
cles, producing a new form of the disease, called p. gyrata. Finally, 
p. conferta s. diffusa is the result of the confluence of numerous spots 
of the eruption. The favorite seat of psoriasis is upon the dorsal or 
extensor surfaces of the extremities, and, above all, upon the knees 
and elbows. The disease often remains confined to these regions, no 
trace of it being discoverable elsewhere upon the body. In cases of 
this land, and indeed in cases wThere the eruption is quite extensive, it 
is often arranged upon each half of the body with remarkable sym- 
metry. This, however, occurs in other cutaneous diseases also; for 
instance, in eczema. In very rare instances, psoriasis is confined to the 
eyelids, or to the lips, the prepuce, the scrotum, or to the labia majora r 
and there is no reason why these varieties should not be called p. pal 
pebrarum, labiarum,prceputii, scroti, orpudendorum, etc. But neither 
the diffuse nor the circumscribed form of psoriasis palmaris and plan- 
taris is included in this series of varieties. In the diffuse form, the PSORIASIS. 
487 
palm of the hands and soles of the feet are reddened and covered with 
dry scales. We have ascertained that this is really a species of eczema. 
The circumscribed variety is always of syphilitic origin, and is to be 
spoken of hereafter. The circumstance that the morbid process from 
which psoriasis arises does not act continuously upon one spot for any 
great length of time, is not only the reason for the peculiar figuration 
of the eruption, but also accounts for the rarity with which degenera- 
tion of the deeper layers of the skin occurs in tins disease. The excep- 
tional cases in which the eruption does not soon subside, and in which 
the skin is thickened, rigid, and fissured, are called psoriasis inveterata. 
The diffuse or irregularly extended variety of the disease is the one 
most apt to assume this form. 
Treatment.—Although it seldom is possible to effect a radical 
cure of a psoriasis, yet the treatment which merely aims at a tem- 
porary abatement of the eruption is very satisfactory. The objections 
which exist against the local treatment of certain forms of eczema and 
impetigo are not valid in case of the disease in question; psoriasis is 
never of constitutional origin, and never appears vicariously for other 
diseases. Moreover, vigorous local treatment is tolerated much better 
in psoriasis than in any other cutaneous affection hitherto described. 
Psoriasis must always be treated locally and with the most energetic 
remedies. Instead of the white-precipitate ointment, and the prepara- 
tions of zinc and of lead, which often suffice to effect a cure of an 
eczema or an impetigo, and which, indeed, are often the only remedies 
applicable to the case, the articles best adapted to its treatment are 
green soap, tar, and the preparations of sulphur. It is best to com- 
mence the cure with one or two vapor-baths, in which, by means of 
soap and a moderately hard brush, the skin is to be cleansed as much 
as possible from the scales which adhere to it. If these vapor-baths 
cannot be had, the same object may be obtained by means of long- 
continued warm-water baths. After removal of the scales, the green 
soap is to be rubbed in twice daily, for a period of from three to six 
days, or else it must be applied upon a compress, which is to be re- 
newed twice in the day. While this is going on, it is best that the 
patient should be enveloped in a woollen blanket, and that he should 
remain in bed, and in a well-warmed chamber. The treatment should 
then be suspended for about three days, during which the inunctions 
should cease, and the compresses may be laid aside. At the end of the 
interval, the patient must take another vapor-bath, 6r long-continued 
warm-water bath. If the infiltration of the cutis has not yet disappeared, 
the process is to be repeated. If, however, all the diseased spots seem 
soft and pliant, we may proceed to the application of tar or of tar-oint- 
ment (see page 476). We have already said that we prefer a solution 488 
DISEASES OF THE SKIN. 
of tar and green soap (aa § j), in alcohol ( f ij), to the pure tar or the 
tar-ointment. If, from the first, there has only been a moderate degree 
of infiltration of the cutis, we may begin with two or three daily applica- 
tions of the above solution immediately after the bathing and removal of 
the scales; and we shall nearly always effect our object in two or three 
weeks by this means. Similar results, of which, however, I have no 
personal experience, may be obtained by the use of ointment of iodide 
of mercury or of sulphur and iodide of sulphur. For a time, Hebra 
used to recommend the application of a concentrated solution of sul- 
phuret of lime, in psoriasis ( Vleminclcx’s solution). (IJ. sulphur, 
oitrini Bbij, calcis vivae lb j, to be boiled in three gallons of water down 
to a gallon and a half; the liquid to be filtered when cool.) Hebra 
orders the solution to be rubbed vigorously into each diseased spot, 
upon a bit of flannel, until all the scales have come off and the papillae 
are exposed. He then puts the patient in a warm bath, where he is 
to remain for an hour. After the bath, the diseased spots are to be 
rubbed with any unctuous substance (such as cod-liver oil) or else with 
tar-ointment or ointment of chrysophanic acid. 
The above plan of treatment is adapted for psoriasis in its more 
severe and extensive forms. Pencilling the affected spot with a solu- 
tion of corrosive sublimate (hyd. chlor. corrosiv. 3 j; alcohol § j) is 
an excellent way of treating slighter efflorescences of the disease. Such 
pencillings have the advantage of being much simpler, but they cause 
such severe pain that they cannot well be used where the eruption is 
at all extensive. 
Although the quickest and surest way of treating psoriasis is by 
making topical applications, yet it cannot be denied that the same 
object will be attained by the internal exhibition of arsenic. In view 
of this, as well as of the fact that the treatment just described is quite 
unable to prevent relapses, and bearing in mind the well-known harm- 
lessness of treatment by arsenic, if carefully conducted, I hold it to be 
doctrinary and incompatible with the interests of the patient to adopt 
one or other method of cure exclusively, and not to combine the two. 
Arsenic is usually given in the form of Fowler’s solution. At first, six 
drops are to be taken daily; and the dose is to be increased one drop 
every fifth day, until it amounts to about thirty drops. Veiel uses the 
“ Asiatic pills ” almost exclusively, because he can regulate the dose 
much better when the arsenic is in this form than when it is in the 
form of drops. He dissolves white arsenic in boiling water, mixes it 
with bread and pepper, and makes it into pills, each of which contains 
the thirtieth of a grain of arsenic. Of these, at first, he gives three 
daily, gradually raising the dose to eight or nine pills daily (that is, to 
a quarter of a grain of arsenic per diem). As soon as any sense of LICHEN. 
489 
oppression occurs in the region of the stomach, or when tears begin to 
flow from the eyes, the treatment is to be suspended for a few days. 
Cantharides, the antimonials, anthracokali, tar-pills, and other articles, 
formerly in vogue, having proved themselves worthless in treatment 
of psoriasis, have very justly been abandoned of late years. However, 
in plethoric, vigorous subjects, the cure may be accelerated by restrict- 
ing the diet, and by combining the use of laxative tisanes with the 
specific treatment; for we know that such measures alone, when 
pushed vigorously, will cause a psoriasis to disappear. 
CHAPTER XIII. 
LICHEN—DERMATITIS FORMING GROUPS OF PERSISTENT CONICAL 
NODULES. 
Etiology.—In lichen, instead of the appearance of vesicles, filled 
with serum, upon the skin, there is an eruption of solid nodules (papu- 
lae). The exudation which forms in this disease infiltrates the cutis, 
and produces a circumscribed swelling of its parenchyma, but the por- 
tion of it effused upon the free surface of the cutis is only sufficient to 
swell the cells of the rete Malpighii, and to loosen the layer of epider- 
mis above it. This is why lichen terminates by desquamation. It 
is only in a few cases that the source of lichen can be traced to the 
action of slight external irritants; for instance, to the bites of parasites, 
to chafing of the skin by roughness of the clothing, to the effect of 
dirt, or to the influence of high temperature. In most cases we can- 
not tell why the numerous small circumscribed portions of the cutis, 
of which the lichen-knots consist, should be thus affected, while the 
rest of the skin about them appears sound. Lichen is especially com- 
mon among scrofulous persons. 
Symptoms and Course.—Lichen is characterized by nodules of 
about the size of a millet-seed. They are of normal color, or else of a 
pale, yellowish red; sometimes they are even paler than the surround 
ing skin. In the latter case, the blood-vessels, from which the exuda 
tion originally proceeded, have afterward been compressed by the exu ■ 
dation. The nodules usually form groups; sometimes they only ap 
pear upon particular regions of the body; at others, they spread ove 
a wider extent of surface. In the milder forms of lichen (lichen sim 
plex), the papules itch but slightly, or give no annoyance whatever, 
and only last for a short time. They disappear in a week or two, and, 
after desquamation of the epidermis covering the papules, the disease 
usually terminates. More rarely, lichen simplex assumes a chronic 
form, fresh eruptions of the nodules following one another in rapid 490 
DISEASES OF THE SKIN. 
succession. In the severer form (lichen agrius), the outbreak is some- 
times accompanied by fever, and by general disturbance. The nodules 
are often crowded closely together, and stand upon a reddened base. 
They are likewise red themselves, and itch and burn intensely. The 
inflammation readily becomes aggravated, so that in a feAV days the 
lichen changes into an eczema rubrum. The course of this variety may 
also be acute, and terminate in recovery at the end of a week or fort- 
night ; more usually, however, it becomes chronic. 
Ilebra—who never applies the term lichen to a papular eruption 
unless the papules retain their solid form from beginning to end of 
their course, and do not transform into vesicles or pustules—describes 
lichen ruber as a disease which, in its later stages, bears some resem- 
blance to psoriasis. Here there are red nodules of the size of a millet- 
seed, which are covered with thin scales, and which at first are separate, 
and do not itch nor extend at the periphery. With every succeeding 
outbreak of the eruption, the part becomes more thickly studded w ith 
nodules, and the intervening surface grows smaller, until at last the 
edges of the papules touch one another, and form large, infiltrated, red 
patches. Finally, the entire cutaneous surface may become the seat 
of such a papular eruption, and of the diffuse infiltration arising from 
it. Like all other universal exanthemata, this has a prejudicial effect 
upon the general health of the patients, the majority of whom die in a 
state of marasmus. 
Teeatmeot.—The slighter forms of acute lichen require no treat- 
ment. In especially obstinate cases we may have recourse to the 
exhibition of arsenic. Veiel believes this to be of most service in all 
those cutaneous diseases in which the cutis is infiltrated, while in other 
forms it is much less efficient. Cold applications and the exhibition 
of laxatives are the suitable remedies for lichen agrius; but blood-let- 
ting, which likewise has been recommended, should never be practised. 
Chronic lichen agrius often defies the most active treatment. Baths, 
soft soap, tar, and the preparations of sulphur, but especially the inter- 
nal administration of arsenic, are the remedies most to be advised. 
CHAPTER XIY. 
PRURIGO DERMATITIS WITH SMALL, SCATTERED, ITCHING NODULES. 
Etiology.—The flat nodules which are peculiar to prurigo have 
the color of the surrounding skin. If punctured, they usually dis- 
charge a drop of clear liquid, while the puncture of a papule of lichen 
is followed by the flow of a drop of blood. Upon squeezing a prurigo 
nodule laterally, we observe that the epidermis becomes stretched PRURIGO. 
491 
and transparent, and that a watery liquid appears. From these pecu- 
liarities of the nodule, and from the results of the treatment of prurigo, 
Hebra concludes that in tills disease we have to deal with a liquid 
effusion in the deeper layers of the epidermis, which, however, is not 
profuse enough to form vesicles, but merely produces flat nodules, at 
first perceptible to the touch, and afterward to the eye. The subjec- 
tive symptoms and course of the disease, especially the intolerable 
itching which accompanies it, seem fully to substantiate the correct- 
ness of this hypothesis, which, indeed, cannot be demonstrated directly 
upon the dissecting-table, as the lesions described above always disap- 
pear after death. In spite of the identity of their symptoms, it is 
usual to discriminate between the form of prurigo provoked by lice, 
ticks, irritating dust, and other external influences, and that very ob- 
stinate disease known as true prurigo, which, arising without known 
cause, often continues throughout life. Want of proper care of the 
skin and scanty food seem to play an important role in the etiology 
of true prurigo, which is much more common among the poorer classes 
than among the well-to-do. The disease appears at every age, except- 
ing only the first years of childhood. Men are more liable to it than 
women. 
Symptoms and Course.—The most prominent objective signs of 
prurigo consist in those resulting from the violent scratching, and not 
in the nodules themselves, which are scattered and flat, and, indeed, 
are often hard to find, although, from the irritation which they produce 
upon the skin, they create an itching as intolerable as that produced 
by the bites of insects, or by gently tickling the surface of the skin 
with the tips of the fingers, or with a foreign body. Scratching with 
the nails tears off the epidermis from the nodules; a slight bleeding is 
the result, and the blood effused dries into a crust. It is these innu- 
merable little crusts which remain after the papule has disappeared 
that form the most conspicuous object upon the skin of a patient with 
prurigo. As scratches and papules are also induced by the bites of 
vermin, we must always ascertain in such cases whether we have to 
deal with lice and itch-insects, or with genuine prurigo in its stricter 
sense. Gross errors, especially the mistaking of the itch for prurigo, 
m persons whom one would not be apt to suspect of having the itch, 
are of daily occurrence. One of the most important distinctive points 
consists in the locality upon which the papules and scratches lie thick- 
est. In prurigo the principal seat of the papules and scratched places 
is upon the extensor side of the limbs, especially upon the legs—which 
is never the case in the itch—and they are quite as numerous upon 
the back as upon the belly. Body lice, on the other hand, lodge 
chiefly where the shirt is thrown into folds, as about the neck and DISEASES OF THE SKIN. 
492 
waist-band, while the favorite harbor of the itch-insect is upon the 
flexor sides of the limbs, between the fingers, and upon the belly, where 
the prurigo-papules do not often come. However, the positive dis- 
covery of the tracks of the itch-insect, or the detection of the insect 
itself, or the presence of lice, or their nits, furnishes a criterion for dis- 
tinguishing between scabies, prurigo pedicularis, and true prurigo, bet- 
ter even than that afforded by the seat of the papules and excoria- 
tions. But even in the face of such testimony as this, when the itching 
is of very long standing, and involves an unusually large extent of sur- 
face, we should bear in mind the possibility of a complication of these 
diseases, the more so since persons of the class most liable to prurigo 
are equally likely to be infested by lice and the itch-insect. The dark 
stain, seen upon the skin of patients who have long suffered from pru- 
rigo, is a consequence of the scratching, and is of no service as a diag- 
nostic mark, since it is nearly always seen upon the skin of people 
who have long been infested by vermin. Slighter grades of prurigo 
are called prurigo mitis / the severer grades are called prurigo fomni- 
cans, from the resemblance of the sensations to the intolerable itching 
and burning produced by the contact of a multitude of ants. Prurigo 
ani, which is limited to the region of the anus, and that form which 
appears upon the labia majora in women, and upon the penis and 
scrotum in men—or prurigo pudendorum—is intermediate between 
prurigo and eczema. As has already been stated, this is a most ob- 
stinate affection, and may last with undiminished intensity for months, 
and even for years. Generally, however, it grows worse during the 
autumn and winter, and makes a remission during the spring and sum- 
mer. The itching is usually most distressing in the evening, and at 
night. So constant are the disquiet and torment of the patients, who 
are often deprived of their sleep night after night, that, driven to des- 
peration, they sometimes commit suicide, while others become insane. 
On the other hand, the general state of the nutrition does not often 
suffer; at all events, not until very late in the disease. Any prema- 
ture marasmus which may exist is much more frequently dependent 
upon complications, or upon the needy circumstances of the patient 
(cachexia pauperum), tnan upon the prurigo itself. 
Treatment.—The radical cure of prurigo is a task so difficult 
that it is rarely accomplished. On the other hand, it is nearly always 
possible to produce a temporary abatement of the symptoms, and 
sometimes, indeed, to effect a complete although transient relief, b\7 
stimulating the process of desquamation of the cuticle by means of 
cutaneous irritants, thus accelerating the process of its regeneration. 
Hence, baths or lotions containing a solution of common salt, potash, 
corrosive sublimate, lime-water, or dilute acid, inunctions of tar-oint- ACNE. 
493 
ment and of soft soap, and vapor baths, are preferable to the tepid 
baths of bran-water, milk, or mucilage. A very sure remedy for pru- 
rigo—although merely a palliative one—consists in friction of the skin 
for half an hour at a time with a piece of flannel dipped in the solu- 
tion of sulphuret of lime mentioned above (see p. 488), and known as 
Vleminckx’s solution. After being rubbed down, the patient is to be 
put in a bath, in which he must spend at least an hour. It is a good 
plan to follow the bath by a shower-bath, and then to rub the body 
with oil. Even the first bath always affords great relief, and the itch- 
ing generally subsides completely after continuing the bathing for a 
week. Unfortunately there is always a relapse, rendering a repetition 
of the treatment necessary. Any complication which may exist must 
be combated by internal medication and by suitable diet; and, when 
the nutritive state of the body is deranged, that also must be regu- 
lated, if possible. Veiel regards arsenic as a real specific in prurigo, 
and claims never to have used it without effect. 
CHAPTER XY. 
ACHE, ACNE VULGARIS, ACNE DISSEMINATA—INFLAMMATION AND SUP- 
PURATION OF OBSTRUCTED SEBACEOUS FOLLICLES. 
Etiology.—Barensprung very properly classes inflammation and 
suppuration of the sebaceous follicles with similar derangement of the 
mucous follicles; and in truth the acne pustule of the skin and the 
follicular ulcer of the mucous membrane both originate by the same 
process—obstruction of the outlet of a follicle, inflammation of its walls, 
and bursting of its covering externally. By and by we shall consider 
the effects of obstruction of the follicles by inspissated sebaceous matter 
upon which the development of the so-called comedones (Mitesser) 
depends. A comedo is not an acne at first, and does not become one 
until the obstructed follicle inflames. In most cases such inflammation 
terminates in suppuration, producing acne pustules. But it sometimes 
happens that the inflammation is resolved, and then only leads to 
chronic infiltration and thickening of the wall of the follicle, or, in other 
words, to the formation of acne nodules or tubercles. Very few per- 
sons ever remain perfectly exempt from acne vulgaris. The majority, 
however, merely suffer from it during the period of puberty, and the 
form of the disease is mild, and, even in individuals who have been 
afflicted by acne vulgaris in its worst form for years, the affection has 
never commenced in childhood, but only appears at the time of ado- 
lescence, although it may considerably outlast that period. It is, how- 
ever, extremely rare for acne to last until the age of advanced man- 494 
DISEASES OF THE SKIN. 
hood. Although the male sex is more predisposed to acne than the 
female, yet, to the dismay of vain mothers, “ a bad complexion ”—the 
usual euphemism for acne—often disfigures their daughters, at the 
very time when they are about to be introduced into society. Hence, 
it can hardly be denied that some connection does really exist between 
the development of acne and the process which is going on in the 
sexual system. The laity go further; and, according as they are 
inclined to regard mankind from a gloomy or a favorable point of view, 
they ascribe acne to masturbation or to sexual excess, or else attribute 
it to excessive chastity and over-continence. 
Symptoms and Course.—The most frequent seat of acne is upon 
the face ; next in frequence it appears upon the back, bosom, buttocks, 
and upper arms. The disease commences by the reddening and swell- 
ing of the skin at a circumscribed spot, in the middle of which there is 
a black point—the comedo—(acne punctata). If resolution of the 
inflammation takes place, the swelling subsides in the nodule, the epi- 
dermis, loosened by the inflammation, scales off, leaving a reddened 
and somewhat hardened spot which remains upon the skin for some 
time. After a while, however, this likewise disappears. If the inflam- 
mation passes on into suppuration, a small pustule forms at the apex 
of the nodule, and after a while bursts, leaving a yellow scab. In 
rare instances, the nodule upon which the pustule is situated disap- 
pears soon after the pustule forms, or else after it bursts; generally, 
however, it subsides slowly and gradually. It not unfrequently hap- 
pens that the cutis surrounding the inflamed follicle is more extensively 
involved in the inflammation, and, becoming infiltrated, swells, hardens, 
and acquires a deep-red hue. Inflammation of the skin arising from 
this cause closely resembles furunculous dermatitis. This may end in 
resolution, the rounded, flat, broad, elevation of the skin into which the 
acne nodule has converted itself gradually subsiding, casting off its 
cuticle, and slowly losing its color; but it frequently terminates in sup- 
puration. The follicle which in such cases has become loosened from 
its attachments is discharged just as the dead “ core ” of a boil is dis- 
charged, and a scar remains. 
Treatment.—Acne is quite independent of “impurity of tin. 
blood; ” and the “ decoctions of Avoods ” and the laxatives—even if 
they had any real title to their supposed properties as “ blood puri 
fiers ”—would not be suitable remedies in this affection. But it is not 
enough that the physician should merely refrain from prescribing these 
articles; he must also Avarn his patients—Avho usually take them behind 
his back—of the impropriety of so doing. Other internal medication 
should also be abstained from, as it is useless, and since the treatment by 
external application is ahvays effective. Great benefit is often obtained SYCOSIS. 
495 
by washing the acne nodules in solutions of caustic potash or of corrosive 
sublimate, or with tincture of benzoin. VeieVs treatment also, which 
is exceedingly efficacious, consists in vigorously brushing the nodules 
with soft soap and a tooth-brush. The preparations of sulphur are 
still more preferable; they are very generally used, and JKdimmerfeld's 
lotion enjoys a great reputation among the laity. (. sulphur, precip. 
3 ij, camphor, gr. x, gum. mimosas 3 j, aquas calcis, aquas rosar. aa 3 ij.) 
The directions for the use of Kummerf eld's lotion are: after shaking 
it well, to apply it at bed-time to all that portion of skin affected by 
acne, and the next morning to rub off all the sulphur which adheres to 
the skin, without whetting it. Ilebra directs precipitated sulphur to be 
mixed with equal parts of alcohol, carbonate of soda, laurel-water, and 
glycerine, so as to form a paste, and this is to be rubbed into the 
nodules which are previously to be energetically scrubbed with soap 
and water. This treatment is also to be practised in the evening, and 
then the paste may remain upon the tubercles through the night. In 
persons who can afford the time, the paste may be applied night and 
morning, and left continuously in contact with the acne nodules. 
Where matter has formed, it is to be evacuated by cautious punctures. 
If the inflammation be very intense, the best application is a warm 
poultice. 
CHAPTER X YI. 
MENTAGRA — SYCOSIS INFLAMMATION AND SUPPURATION OF THE 
SEBACEOUS GLANDS AND HAIR-FOLLICLES OF THE BEARD. 
Etiology.—Sycosis is an inflammation of the sebaceous glands 
and of the deeply-rooted hair-follicles of the beard, but the tissues of 
the cutis about these glands and follicles likewise take part in the in 
flammation and become the seat of intense hyperaemia, swelling, infil- 
tration, and suppuration. The disease scarcely ever occurs in women 
and children, who never shave; but only affects adult males, particu- 
larly at a time when the beard has acquired a tolerably thick growth. 
Dull razors, awkward shaving, the effect of irritating soap, of snuff, oi 
of dirt, seem to cause the disease, or, at all events, to predispose tow- 
ard it. In the majority of cases, it has no assignable cause. I can 
confirm the statement often made, that mentagra sometimes proceeds 
from the penetration of the parasitical growth of herpes tondens and 
herpes circinatus into the large and deeply-seated follicles of the beard. 
I have seen a case in which a man, who had contracted herpes tondens 
from a sick cow, had mentagra a few weeks afterward. What was 
very characteristic in this case was, that the eruption, half of which 496 
DISEASES OF THE SKIN. 
was in the beard, the other half without it, presented the features of 
herpes circinatus in the latter situation and that of mentagra in the 
former. 
Symptoms and Course.—The disease commences with a sense of 
heat and tension, accompanied by the development of red infiltrated 
nodules, of the size of a pea or lentil, between the hairs of the beard 
upon the lips, chin, cheeks, and, in rare instances, between the hairs 
of the eyebrows and armpits. After a while, pustules, which are al- 
Avays perforated by a hair, appear upon the tips of the nodules. The 
pustules burst in a day or two, and pour out their contents, which im- 
mediately dry into brownish crusts. The nodules still continue beneath 
the crusts, and, even after the latter have fallen, they diminish very 
slowly or not at all. Although at first the eruption is scanty and 
scattered, yet, under the influence of successive attacks, the tubercles 
multiply gradually, until, from the close croAvding of the nodules, 
together Avith the infiltration of the intervening skin, the appearance 
of the surface becomes suggestive of a fig—whence its name, “ syco- 
sis.” Sometimes sycosis is confined to single spots of no great mag- 
nitude ; in other cases, every part of the face where the hair grows is 
covered Avith dusky-red nodules, pustules, and scabs. The disease is 
of indefinite duration, and often lasts for years and even tens of years 
Avithout subsiding, but also without leading to other lesions. When 
it heals, the hair-follicles having been destroyed, the hair does not 
groAV again upon the affected spot, which presents the appearance of 
a scar. 
Treatment.—I used formerly to regard sycosis as one of the most 
intractable of diseases, as it generally resisted all treatment, notA\Tith- 
standing the numerous remedies which have been proposed for its cure. 
In the last few years, lioweA7er, during which I have adhered strictly 
to the treatment proposed by Ilebra, in Virchow's hand-book, I have 
altered my opinion, and recommend the following procedure. In the 
first place, all the scabs are to be softened and removed by rubbing 
them Avith oil, or by the application to them of a rag saturated AArith 
oil. We must then insist upon the patient’s shaving daily, in spite 
both of his opposition and his barber’s. The pustules which appear 
after the shaving are all to be opened with a delicate scalpel; and 
where they are confluent, long incisions must be made through the 
clusters. Like the shaving, this scarification is far less painful than 
might be supposed, and it likewise must be repeated daily. In ex- 
traordinarily obstinate cases the opened pustules must be touched with 
concentrated acetic acid, or Avith a solution of corrosive sublimate, 
consisting of one part of the sublimate to tAVO of alcohol. During the 
night it is generally sufficient to cover the affected part with a rag, ACNE ROSACEA. 
497 
thickly smeared with white-precipitate ointment, or with a paste made 
of equal parts of sulphur, glycerine, and alcohol. 
CHAPTER XVII. 
ACNE ROSACEA—GUTTA ROSACEA CHRONIC INFLAMMATION OF THE 
SEBACEOUS GLANDS OF THE FACE, WITH DILATATION OF THE BLOOD- 
VESSELS AND GROWTH OF THE CONNECTIVE TISSUE ABOUT THEM. 
Etiology.—In acne rosacea the sebaceous glands of the face, 
especially those of the nose, become the seat of a chronic inflamma- 
tion. The tendency to suppuration in this affection is much less than 
in acne vulgaris and sycosis ; but, on the other hand, it is always ac- 
companied by an inflammatory hypertrophy of the surrounding connec- 
tive tissue, as well as by considerable dilatation of the blood-vessels 
about the diseased glands. Acne rosacea is particularly common 
among tipplers, especially among wine and brandy drinkers; although 
it is by no means so exclusively confined to such individuals as to war- 
rant the inference that a person is intemperate because he has acne 
rosacea on his face. Women at the climacteric epoch, even though they 
never touch wine, beer, or spirituous liquor, are often afflicted by this 
disorder, which is all the more distressing to them because of the pre- 
vailing prejudices regarding its cause. Young women, also, with de- 
ranged menses, sometimes are attacked by acne rosacea. 
Symptoms and Course.—The disease commences by the appear- 
ance upon the face of discrete coppery-red spots, whose color depends 
upon the varicose dilatation of small blood-vessels. Acne nodules 
then develop upon these bluish-red spots; but, even when pustules 
mature, the nodules do not decrease in size, but continue gradually to 
grow larger. The effect of this constant formation of new tubercles, 
and of the excessive hypertrophy of the adjacent connective tissue of 
the skin, is to give rise to most unsightly deformity. The nose, which 
is the usual seat of acne rosacea, becomes enlarged and misshaped, and 
in bad cases it is studded with knobs and humps of various size, and 
assumes a purple color. The forehead and cheeks are often similarly 
affected, and sometimes the disease involves the whole face. 
Treatment.—As soon as acne rosacea begins to appear, the use 
of spirituous liquors is to be strictly prohibited. If there be any de- 
rangement of menstruation, it is to be treated according to directions 
already given. It is also advisable to endeavor to compress the ves- 
sels of the reddened spots by painting them with collodion. When 
this treatment is not well borne, Veiel obtains benefit from concen- 
trated lead-water, with the addition of terra sigellata and a little cam 498 
DISEASES OF THE SKIN. 
phor. When the acne nodules appear, the preparations of sulphur may 
be employed; but, instead of the paste recommended for the cure of 
acne vulgaris and sycosis, it is better to use JKummerfeld''s lotion, or a 
turbid mixture of sulphur and water, or alcohol. In old cases, almost 
every treatment will prove ineffectual. 
V.—HEMORRHAGES OF THE SKIN—PUBPUEA. 
Etiology.—All hasmorrhages of the skin proceed from a solution 
of continuity of the walls of the cutaneous vessels; blood never trans 
udes through the wall of a blood-vessel, unless it be ruptured. Pur- 
pura are reddish, bluish, or blackish spots, the result of extravasation 
of blood into the parenchyma of the cutis, the blood filling up the in- 
terstices between the elements of the cutaneous tissues, but causing 
no swelling of the skin. When the purpura are small and round, they 
are generally called petechice / when elongated into stripes, they receive 
the name of vibices/ and when diffuse and of irregular shape, they are 
called ecchymomata. If the effusion of a somewhat large quantity of 
blood causes the skin to swell in the form of small nodules, we have 
the lichen lividus (Willem), or the purpura papulosa (.Hebra). The 
broader flat tumefaction of the skin caused by a more diffuse extrava- 
sation, and which resembles the wheals of nettle-rash, is called pur- 
pura urticans. Sometimes a haemorrhage separates the epidermis 
from the papillary layer, forming blebs, purpura bullosa; in other 
cases the blood perforates the epidermis and appears upon its exterior. 
In the so-called “ bloody sweat,” blood really exudes through the pores 
of the skin. It is not mingled with sweat, however; and since, more- 
over, this bleeding has nothing to do with the secretion of sweat, the 
above term is inappropriate. 
The causes of haemorrhage into the skin are : 
1. External injury. The traumatic haemorrhages caused by the 
bites of fleas deserve some attention, since inexperienced physicians 
are occasionally misled by them, and are induced to diagnosticate 
some serious disease of the blood. Immediately after the bite of a 
flea, a roseola spot or wheal makes its appearance, in the middle of 
which the small, dark-red wound—the stigma—is perceptible. 
Besides this, however, in persons whose blood is deficient in fibrin, 
a hmmorrhage takes place into the cutaneous substance, about the 
puncture, similar to that much more considerable extravasation which 
occurs around a leech-bite in persons of a similar constitution. These 
little hremorrhages from flea-bites continue visible after the puncture 
has disappeared ; so that, although the stigma may afford a distinctive PURPURA. 
499 
mark between a roseola or urticaria pulicosa, and other forms of roseola 
and urticaria, it cannot be used to distinguish between purpura puli- 
cosa and other forms of purpura. Besides the discovery of fleas and 
of fresh flea-bites, the mere consideration of the region upon which the 
purpuric spots are situated will often enable us to estimate their origin 
correctly. Fleas generally lodge in positions from which they can 
crawl between the folds of the shirt. Hence, when we find petechiae 
upon the neck and shoulders, and about the waist in women, while 
few or none are visible upon other regions, especially upon surfaces 
which are usually exposed, we may conclude that the haemorrhagic 
spots are the vestiges of old flea-bites. 
2. Haemorrhage into the skin may proceed from over-distention and 
rupture of its blood-vessels. Thus, after severe coughing, or after vio- 
lent vomiting, we often see the face speckled with purpuric spots; and, 
when the venous circulation of the lower extremities is obstructed, we 
often find purpura upon them, accompanied by varicosities of the veins. 
Even intense fluxionary hypersemia seems sometimes to cause rupture 
of blood-vessels in the skin. At all events, the English physicians 
describe an affection called purpura simplex, -which appears in healthy 
and robust subjects, particularly in those who indulge freely in spirit- 
uous liquors. 
3. The most frequent source of haemorrhage into the skin is a nu- 
tritive derangement of the walls of the blood-vessels. Under this 
head comes the purpura senilis, one of the symptoms of senile maras- 
mus, as well as the purpura which appear in severe constitutional dis- 
ease, such as typhus, small-pox, measles, and scurvy, and that which 
is the chief symptom of the morbus maculosus of Werlhoff. The pe- 
liosis rheumatica, a form of purpura accompanied by rheumatic pains, 
and which is only met with upon the lower extremities, is probably of 
this class likewise. 
Symptoms and Course.—Red spots resulting from haemorrhage 
may be distinguished from similar spots caused by mere vascular dis- 
tention, by the fact that the latter disappear under pressure of the 
finger, while the former remain unchanged. They vary considerably 
in size, situation, and duration; but these variations, as well as the 
subjective symptoms which accompany them, depend principally upon 
the character of the original disease, or its complications. Hence, we 
must refer to the chapters upon typhus, small-pox, measles, scurvy, 
and morbus maculosus "Werlhofii for a further account of these haemor- 
rhages, and shall now merely add a few words about peliosis rheumat- 
ica. This affection, first observed and recognized as a distinct disease by 
Schonlein, usually attacks young subjects with delicate skin, who have 
already suffered from rheumatism. It is generally accompanied bj 500 
DISEASES OF THE BEIN'. 
fever. The patient first becomes aware of a pain in the lower extrem- 
ities, particularly in the legs. Upon examination, the painful part is 
found slightly swollen, oedematous, and studded wfith red spots of the 
size of a millet-seed or lentil. At first the spots are bright red, and 
disappear under pressure of the finger, which shows that at this period 
they depend upon hyperasmia. They afterward assume a dirty-brown 
color, and then no longer are effaced by the finger, proving that blood 
has escaped from its vessels into the substance of the skin. This erup- 
tion of spots generally recurs by fits several times in succession, so 
that the disease usually lasts for several weeks, although, if the pa- 
tient maintain a recumbent attitude, the first crop of spots usually 
fades out again in from four to eight days. In some cases the disease 
drags on for months, with repeated relapses. 
Treatment.—In treatment of haemorrhage into the skin, special 
attention must be paid to whatsoever constitutional disorder may exist. 
Besides this, it is customary in these cases, as in almost all other 
haemorrhages, to give the mineral and vegetable acids internally, and 
to bathe the purpuric spots with dilute acids—especially with vinegar 
and water. The efficacy of these prescriptions is very problematical. 
In the treatment of peliosis rheumatica it is an important rule that 
the patient should be kept in bed, and in an uninterruptedly horizontal 
attitude, until the eruption disappears, and for some little time after- 
ward. 
We shall leave the description of a majority of the cutaneous 
growths to text-books of surgery, especially the account of carcinoma, 
sarcoma, and epithelioma, and shall confine ourselves here to a brief 
sketch of the disease known as lupus, a neoplastic formation peculiar 
to the skin, and to the mucous membrane of the nose, mouth, and 
fauces. 
VI.—GROWTHS IN THE SKIN 
CHAPTER XVIII. 
LUPUS — LUPUS EIEDENS. 
Etiology.—The neoplasm, upon whose development in the skin 
lupus depends,is classed among the “granulation growths” (Granula- 
tionsgeschwulste), by Virchow. It arises in the form of nodules, 
which either remain distinct (lupus tuberosus), or else coalesce, caus- 
ing a diffuse thickening of the skin (lupus hypertrophicus). The ele- 
ments which form a nodule of lupus consist of small cells which greatly LUPUS. 
501 
resemble the cells of the rete Malpighii. The epidermoid elements 
also suffer “ accidentally.” The epidermis over the diseased region is 
very thin, and is usually covered with fine scales. Small white gram 
ules, like millet-seeds, are produced from the sebaceous glands; the 
hairs become deformed and humped from irregular deposit of the horn- 
cells, and perish as the disease advances. The neoplasm penetrates 
deeper and deeper below the surface; it advances from the skin to 
the subcutaneous tissues, and thence often attacks the cartilages and 
bones. As the malady goes on, ulceration generally sets in. Crusts 
form, under which the tissues break down into “ devouring ulcers ” 
(lupus exedens). But it sometimes happens that the lupus-nodules 
subside, their cellular elements undergoing fatty degeneration, fol- 
lowed by absorption. The site of the disease then becomes depressed, 
and is marked by a deep scar, although it has never been in a state of 
ulceration {lupus non exedens). 
The etiology of lupus is quite unknown. It is true that the disease 
often attacks scrofulous persons; but there are many well-marked cases 
of scrofula who remain free from lupus, while quite as many, who never 
have been scrofulous, and who previously had seemed quite sound in 
other respects, are attacked by it. Its relations with congenital syphi- 
lis are very similar. It cannot be denied that lupus is tolerably com- 
mon among persons whom we suspect, or whom we know, to suffer 
from hereditary syphilis; but, on the other hand, it is well estab- 
lished that the majority of persons so affected never suffer from lupus. 
Hence we are not warranted in distinguishing lupus into lupus scrof- 
ulosus, syphiliticus, idiopathicus, etc. Statistics as to the frequence of 
lupus at different ages, and in the two sexes, and in the various ranks 
of society, show that the malady is rare before the tenth year of age, 
and still more rare after the fortieth, and most common between the 
ages of ten and twenty; that both sexes are afflicted by it with about 
equal frequence, although perhaps women suffer a little more often 
than men; and, finally, that lupus is less frequently seen among the 
rich than among the poorer classes. 
Symptoms aistd Course.—The most frequent seat of lupus is 
upon the face, especially upon the nose. Nevertheless, the disease 
may attack other regions, such as the neck, shoulders, chest, and ex- 
tremities, especially over the joints. The first symptoms are often 
overlooked, or at least too little importance is attached to them. 
They consist in the formation of small, painless, brownish-red specks or 
nodules (l. maculosus, s. tuberculosus), which, although quite hard, are 
so remarkably vulnerable and tender, that they bleed readily; and with 
very slight force the point of a pencil of nitrate of silver may be made 
to penetrate them deeply. The disease may remain at this stage, with 502 
DISEASES OF THE SKIN. 
out advancing for a long time, even for several years. It is only m 
rare instances that lupus takes on a subacute course, so as to produce 
extensive destruction in a few weeks. As the malady advances, its 
appearance changes. In some instances the nodules multiply and 
grow larger; their surface becomes tense and shining, and is covered 
with detached scales of epidermis {lupus exfoliativus). As the disease 
goes on, the hardness of the spots and nodules is resolved, and the 
affected portion of the skin, which formerly rose above the surround- 
ing level, or which at least was even with it, now sinks gradually, and 
attaches itself firmly to the part beneath it; and, as the recovery pro- 
gresses, shrinks and is converted into a white, hard, shining cicatrix. 
When the course of a lupus is as above described, large portions of 
the skin becoming transformed into a tissue resembling that of a scar, 
without any ulcerations having occurred, it is called lupus non execlens. 
Apart from the unsightliness of the scars themselves, the face may 
suffer great deformity, in this form of lupus, from contraction or dilata- 
tion of the nostrils, and from ectropion caused by retraction of the 
cicatrices. In other instances the outset of the disease is quite similar 
to the above; brownish-red spots and nodules form, which continually 
shed scales of dry epithelium. This condition, however, having con- 
tinued for a variable period of time, the nodules begin to grow, the 
maculas become papules; new nodules form, and while the surround- 
ing skin becomes more hyperannic, red, and shining; a superficial ero- 
sion occurs upon the summit of one of the nodules, the product from 
which rapidly dries into a scab. These scabs gradually grow thicker 
and broader by accretion of fresh matter at their base. If forcibly 
detached, a slight bleeding ensues, and we can perceive that there is a 
loss of substance of the skin, in which the middle of the scab is embed- 
ded more or less profoundly. This is the characteristic course of that 
form of the malady known as lupus exedens or exulcerans, and also as 
l. rodens, as well as herpes rodens s. exedens, s. esthiomenos. Some- 
times the disease begins from a pustule, without the previous develop- 
ment of a reddish-brown spot or nodule. In such instances, lupus at 
its outset might easily be mistaken for a simple impetigo, and the 
error would only become apparent upon the discovery that there is a 
loss of substance in the cutis, beneath the scab. According to Hiett, it 
is convenient to distinguish two forms of ulcerative lupus, a superfi- 
cially destructive and a profoundly destructive form. The former often 
involves a large extent of surface, and occurs not only upon the face 
but upon the shoulders, and other parts of the body enumerated above. 
Sometimes the process subsides at the point first attacked, leaving a 
scar, which, by its ribbed and reticulate aspect, closely resembles the 
scar of a bum; meanwhile it continues to extend at the edges of the LUPUS. 
503 
cicatrix; the disease is then called lupus serpiginosus. The more 
deeply destructive form of lupus exedens begins almost exclusively 
upon the aim nasi and the tip of the nose. It is accompanied by de- 
cided swelling and hypermmia of the anterior part of the nose. The 
scab which forms upon these deeply-seated nodules is of great thickness, 
proportionate to the depth to which the destructive process has pene- 
trated. Beneath this scab, which is continually renewed, the skin, 
subcutaneous tissue, cartilage, and even the bones of the nose, are 
destroyed, sometimes in the space of a few weeks’ time, but more 
frequently in course of several months or years. Sometimes the dis' 
ease, instead of commencing in the integument of the nose, first at- 
tacks the mucous membrane, causing great devastation of the interior 
of the nasal cavity, and even destroying the septum narium before the 
ulceration involves the skin. 
It now remains for us to describe lupus hypertrophicus. The most 
frequent seat of this form of lupus is also upon the face, although it 
not unfrequently appears upon other parts of the body. I have known 
it to attack the face and extremities simultaneously. Here, too, numer- 
ous nodules of variable size are first observed; they are covered with 
desquamating epithelium, and do not usually ulcerate except upon 
the nose. In consequence of the generation and confluence of new 
nodules, the skin becomes diffusely, and often quite uniformly, thick- 
ened. The surface is red, shining, and tense ; here and there upon it 
there are a few spots of a darker red, covered with denser scales of 
epidermis. 
Lupus hypertrophicus also shows a tendency to subside at its 
point of origin, and to extend into the surrounding skin. In con- 
sequence of the retraction of the new connective tissue which forms 
during cicatrization, the swollen and reddened integument becomes 
traversed by interlacing, hard, white cords. In the case of lupus hy- 
pertrophicus mentioned above, the whole face had become a rigid, cal- 
lous cicatrix, traversed by varicose vessels, and presented a frightful 
deformity. The eyelids were everted, the nostrils dilated ; while upon 
the ears the process was only just commencing. It must not be sup- 
posed that, in a given case of lupus, one only of these varieties appears, 
to the exclusion of the others. On the contrary, they usually exist to- 
gether, one form generally predominating, although traces of the others 
are nearly always to be found. 
Treatment.—In the treatment of lupus our task is a double one. 
In the first place, we have to remove the neoplasm which is embedded 
between the fibres of the cutis, or else, by its gradual growth and sub- 
sequent retrocession, it will cause great destruction of the skin; and, 
in the second place, we must endeavor to prevent the formation of 504 
DISEASES OF THE SKIN. 
further and similar deposits in the substance of the cutis. With regard 
to the first point, all surgeons and dermatologists entirely agree that 
the lupus nodules must be removed or destroyed; but opinions differ 
greatly as to the surest and most advantageous means and method of 
effecting this object. It is not for me to go into the merits of purely 
surgical questions, nor to express a preference for the use of the knife, 
the actual or the potential cautery, nor to declare in favor of nitrate 
of silver, or caustic potash, rather than for nitric acid, arsenic, iodide 
of mercury, or chloride of zinc. In my opinion it matters much less 
what particular caustic is employed, than that the operator should be 
well versed in the management of the caustic, and should be familiar 
with its action. Yery obscure and ill-educated surgeons often acquire 
a reputation from their wonderful success in the treatment of cancer, 
and of “eating-sores,” by means of a secret remedy. It would be 
wrong to assume that all such reputations are without foundation. 
Individuals of this class, the so-called “ cancer-doctors,” by dint of 
operating daily, and in numerous cases, with one particular kind of 
caustic, finally become more skilled in its use, and know better how 
to adapt it to especial instances, than the most distinguished surgeons. 
Patients, in whom the application of caustic is indicated, may be in- 
trusted to their hands with perfect reliance. But if the state were to 
buy the secret, science would be but little benefited by the purchase, 
even though the seller were to act with perfect honesty; for other 
surgeons operating with the same caustic will not be nearly so suc- 
cessful as the original possessor of the nostrum. 
The second indication in the treatment of lupus is far more difficult 
of fulfilment than the first. Unfortunately, we know of no sure means 
of preventing the recurrence of lupus nodules in the vicinity of the old 
site of the disease, nor in the scar of an old lupus, whether healed 
spontaneously or by artificial means. We are not agreed even as to 
the necessity of an internal medication for lupus, in addition to the 
local treatment; or whether we should rely upon external application 
to produce an alterative effect upon the nutrition of the endangered 
region. The internal medicines most in vogue are the iodide of potas- 
sium, with or without an addition of iodine, and cod-liver oil, which 
has been given in the enormous dose of twenty-five tablespoonfuls a 
day. In badly-nourished subjects, and even in those who are not 
scrofulous, experience warrants the trial of these articles, especially 
the oil, in very large doses, although not such excessive ones as the 
above—say six tablespoonfuls a day. In recent cases, and in robust 
and plethoric subjects, in whom the lupus was making rapid progress, 
I have seen remarkable benefit obtained from ZittmanrCs decoction. 
If the disease should come to a stand-still during this treatment, and LUPUS 
505 
for some time after it, and should it break out again several weeks or 
months after the treatment has been suspended, the same procedure 
must be repeated. 
Among the external applications which have been employed for 
the purpose of modifying the nutritive state of the skin, and to pre- 
vent the recurrence of the eruption, are the ointments of the iodides of 
mercury, sulphur, and potassium.2 
YU.—PARASITES IN TEE SKIN 
The development of microscopic fungi is a constant accompani- 
ment of certain diseases of the skin; in others, again, they are some- 
times present, while as a general rule they are absent. Favus, pity- 
riasis versicolor, and herpes tondens belong to the former class. The 
constant presence of fungi in these diseases, and their contagiousness 
by transfer of the fungi from one individual to another, is our sole proof 
that the generation of such fungi is the primary and essential lesion 
of the diseases. As the fungi are always found, and as transmission 
of the disease by transfer of the fungi always succeeds, no doubt can 
be entertained of the parasitic nature of these affections. To our 
description of favus, herpes tondens, and herpes versicolor, we shall 
add an account of the itch, as the cause of the cutaneous lesions in this 
disorder is the presence of a parasitic animal. 
The acarus folliculorum is also a very common parasite. It exists 
in most persons, and may easily be obtained by scraping the nose with 
the back of a knife. As this animal does not give rise to any disease 
of the skin or its follicles, of which it seems to be a perfectly harmless 
inhabitant, it possesses no pathological interest, and we may forego 
further description of it, and omit the account of the various hypotheses 
which have been advanced as to its importance as a matter of natural 
history. 
CHAPTER XIX. 
FAVUS—PORRIGO FAYOSA, LUPINOSA. 
Etiology.—Schonlein was the first to demonstrate that certain 
dry, straw-colored crusts, found chiefly upon the hairy scalp, and for- 
merly called porrigo favosa, or tinea lupinosa, and which were re- 
garded as the product of a dyscratic pustulous inflammation of the 
skin, really consisted of a mass of fungous spores and germinal fila- 
ments (the oidium, or achorion Schonleinii). The spores of favus 506 
DISEASES OF THE SKIN. 
do not take root very readily; hence the transfer of a mass of such 
spores from one person to another by no means invariably results in a 
transplantation of the disease. However, the cases in which a healthy 
person has been thus infected artificially are numerous enough to place 
the fact beyond a doubt that the growth of the fungi is no mere accident, 
but that it is an essential condition of the disorder. Whence the seeds 
of favus have come, cannot, in many instances, be determined; but I 
believe that the enormous multitude of sporules of different kinds 
constantly floating in the atmosphere will always afford opportunity 
for the implantation of favus, and that such implantation will always 
take place whenever conditions favorable to the growth of the germ 
present themselves. Opinions differ as to whether or not the favus- 
plant is a peculiar species of fungus which only appears upon the scalp 
and which always develops in the same manner. Hebra inclines to 
the view that the various shapes presented by the skin-diseases due to 
the presence of vegetable organisms, depend rather upon the stage 
of development of the plant, upon whether the spores preponderate over 
the filaments, and upon whether the parasite take root upon the epi- 
dermis or upon the hairs, and that it does not depend upon any spe- 
cific difference of species in the spores themselves. I have this objec- 
tion to make against this opinion: that, to the best of my belief, com- 
plications of these diseases, and transitions of pityriasis versicolor, 
with favus or herpes tondens, never occur, and that complications of 
favus and herpes tondens are rare. These facts make it improbable 
that the differences between these parasitic diseases are mostly due 
to differences in the situation and stage of development of the 
same fungus. The most simple explanation of the exceptional cases 
is, that sometimes the favus and herpes fungi are transplanted simul- 
taneously to the same individual. According to the researches of 
Hofmann of Giessen, who has cultivated the fungus, it is identical with 
the mucor racemosus, and is sometimes accompanied by the penicil- 
Hum glaucum, but only as an accidental occurrence. Dirt seems to be 
the condition most favorable to the implantation and growth of the 
germs of favus; at all events, the disease is far more common among 
the lower classes, whose members often neglect to wash and comb 
themselves, than among the well to do, among whom the appearance 
of favus is exceptional. 
Symptoms and Course.—The seat of favus is amiost exclusively 
upon the hairy portions of the scalp, and it is rarely found in other 
situations. At the commencement of the disease we find the affected 
skin studded with small yellow oodies, scarcely of the size of a pin’s 
head, which lie somewhat embedded in the skin, and each of which is 
perforated by a hair. These bodies consist of masses of spores, which FAVUS. 
507 
nave developed in the funnel-shaped mouth of the hair-follicle, and 
have elevated the epidermis around the hair. When the masses of 
favus are numerous, and as they increase in size, they come into con- 
tact, coalesce, and finally form a continuous rind of fungi, covering the 
entire scalp (favus conferlus s. confluens). If, however, the favus - 
spots are separate and do not encroach upon their neighbors, a very 
characteristic formation takes place, consisting of round, concave scabs, 
like crabs’-eyes, the lower convex surface of which lies embedded in a 
depression in the atrophied cutis, while their upper surface has ele- 
vated edges with a depressed centre (favus scutiformis). This 
thick, dry, sulphur-yellow scab consists of a structureless capsule, 
which adheres very firmly to the thin layer of epidermis beneath it, 
and of innumerable filaments and spores. As the hair-follicle and hair it- 
self become overgrown by the fungi, the growth of the hair is impeded; 
it loses color, and becomes dry, thin, brittle, and falls out. When 
favus is situated upon a part of the skin destitute of hair, the mass 
of spores generally becomes loose after a few weeks and falls off, 
thus putting an end to the disease. Its course is different upon 
the hairy scalp. Here, too, the duration of the individual masses of 
favus is limited, but the scabs adhere longer, and the fungi which they 
contain infect the parts about them. When finally the scab detaches 
itself, the pressure which it has exerted upon the skin leaves the latter 
in a state of atrophy which is never repaired. The hair does not 
usually grow again upon the former site of the disease, and the pa- 
pillae which have more especially suffered from the atrophy can only 
reproduce a thin layer of epidermis ; hence, for the rest of the patient’s 
life, there remain upon his head bald smooth depressed spots, whose 
edges are often surrounded by more recent crusts of favus. The 
growth of the fungus, the scratching provoked by it, and the lice by 
which it is often accompanied, frequently cause eczematous and impe- 
tiginous inflammation of the scalp. When this complication occurs, 
besides the favus-crusts, there are other scabs, the desiccated product 
of the eczematous exudation. These scabs are easily distinguishable 
from those of favus. Under the latter, the skin, though depressed, is 
always covered by a thin layer of epidermis; under the former, we 
always find an excoriation.3 
Treatment.—Difficult as it is artificially to induce the favus-spores 
to grow, it is equally difficult to destroy them when once established 
upon the hairy scalp, and to arrest their further ravages. We have 
said that the fungi form within the hair-follicles and upon the hairs 
themselves; hence, not only must all the crusts be removed, but all 
hairs upon the diseased surface must likewise be extracted. The for- 
mer object is best attained by saturating the crusts with grease, until 508 
DISEASES OF THE SKIN. 
they are completely softened. Tke head is then to be enveloped in a 
poultice for some time, after which it is to be carefully washed several 
times a day, with soap and water applied on a soft brush. For the 
removal of the diseased hairs, the method formerly in vogue, of cover- 
ing the head in a so-called “ pitch-cap,” and, when the hairs had become 
firmly adherent, of forcibly tearing it off again, is both cruel and un- 
certain. It is far better to draw them out one by one with a pair of 
cilia-forceps. After the first few days, this process ceases to seem 
tedious and troublesome, and, after a few sessions, a quarter of an hour 
daily devoted to the purpose will be all that is required. Besides the 
criterion afforded by their dryness, their lack of lustre and faded color, 
the diseased hairs may be distinguished from the sound ones by the 
fact that they may be extracted with greater ease and with less pain 
than the latter. This daily brushing and depilation must be steadily 
continued for several months, if we expect to cure the favus radically. 
Tedious and troublesome as this treatment is, yet it is the only one 
from which we can anticipate any benefit. Other remedies are useless, 
unless applied in combination with the above procedure; and if so 
combined, it always is questionable which of the two has really been 
of service. Even the famous cures of favus, of the brothers Mahon in 
Paris, which consisted in the inunction of a salve of carbonate of soda 
with lime, and in afterward powdering the head with charcoal, seem 
to have been effected mainly by careful depilation. The pariciticide 
remedies most to be depended upon, during and after depilation, are 
weak solutions of corrosive sublimate (gr. ij-iv to a pint of water or 
of alcohol), the oil of turpentine, and very dilute creasote. 
CHAPTER XX. 
HERPES TOXDENS. 
Etiology.—Not only herpes tondens, but most cases of herpes cir~ 
cinatuSy as well as many of lichen circumscriptus, impetigo Jigurata, 
pityriasis rubra circumscripta, and porrigo asbestina, depend upon 
the development of a fungus, the trycliophyton tonsurans, which 
breeds between the epidermic cells, converting them into a white dust, 
and penetrates into the hairs and hair-bulbs, the latter becoming more 
or less inflamed thereby. In most cases it may be determined posi- 
tively, by careful search, that this parasitic disease is transmitted by 
contagion, and that this transmission takes place less often between 
man and man, than between man and beast, especially the transfer of 
the parasite from horses and cows, which are quite often afflicted by it, 
to men who are brought into contact with them. HERPES TONDENS. 
509 
Symptoms and Course.—All the above-named diseases exhibit 
great uniformity of appearance; the differences between them are un- 
important, and are based solely upon the difference of intensity in the 
inflammation to which the growth of the fungi in the hair-follicles gives 
rise. In mild kinds of the disease, papules form, and an exanthema 
appears, having the character of lichen. In cases of greater intensity, 
vesicles or pustules arise, accompanied by a herpetic or impetiginous 
eruption. When there is no real inflammation of the hair-follicles, we 
have pityriasis rubra, or porrigo asbestina. When the disease is situ- 
ated upon the scalp, round spots become observable as large as a six- 
pence and sometimes as large as a dollar, which, unlike alopecia cir- 
cumscripta, are not quite bald, but are covered with short, broken 
hairs, and which so much resemble tonsures, that the affection is well 
entitled to its name, herpes tondens seu tonsurans. Between the 
short hairs, the scalp is covered with scales. Upon microscopic exam- 
ination, the roots of the hair are found to be split up like a broom, and 
between the twigs so formed there is an innumerable quantity of 
spores and filaments, which spread into the shaft of the hair in wreaths. 
The same elements are also found in the scales of the epidermis. 
When the disease is situated upon a portion of skin which is merely 
covered with a fine down, this is not so apparent, but it is still charac- 
teristic enough to place the diagnosis beyond a doubt, without the 
assistance of the microscope. If a herpes circinatus, a lichen circum- 
scriptus, or an impetigo figurata, be of a well-marked circular form, 
abruptly distinguishable from the parts about it, when its edge is of a 
bright red, and studded with nodules, vesicles, and pustules, its centre 
being paler, smoother, and covered with mealy dust; when each point 
of eruption is perforated by a hair; and, finally, when it can be ascer- 
tained that the patient has been in contact with a man or beast simi- 
larly affected, the diagnosis is sufficiently insured. Herpes tondens 
may recover without medical aid, the growth of the fungi finally ex- 
hausting itself, the broken hairs falling out, and the diseased epidermis 
becoming detached. Upon the hairy regions of the head, however, the 
disease will exist for a long time before terminating in this way, while 
upon surfaces void of hair it is usually of but short duration.4 
Treatment.—Depilation is indicated in the treatment of herpes 
tonsurans, but, owing to the brittleness of the hairs, the process is by 
no means easy of accomplishment; moreover, it is often possible to 
cure the disease wuth comparative ease without it, by dint of daily and 
vigorous washing with soft soap, which is always to be followed by 
an inunction of white-precipitate ointment. 510 
DISEASES OF THE SKIN. 
CHAPTER XXI. 
PITYRIASIS VERSICOLOR. 
Etiology.—JEichstedt, of Greifswald, was the first to demonstrate 
that pityriasis versicolor, which used to be ascribed to a derangement 
of the hepatic function, is really dependent upon the growth of fungi 
in the epidermis. In this affection, the filaments are more numerous 
than the spores. Its very common occurrence among patients with 
pulmonary disease shows that the skin of such individuals often presents 
favorable conditions for the implantation and growth of the parasite. 
Pityriasis versicolor is a very common affection, and often appears upon 
perfectly healthy persons. 
Symptoms and Course.—The most common seat of pityriasis 
versicolor is upon the neck, back, chest, and arms; but I have never 
seen it spread from the neck to the face. In recent cases, small, round, 
yellow spots, which readily peel off, are found upon the affected skin ; 
in cases of longer standing, the spots are larger or have coalesced, 
forming irregular patches, which often extend over a large portion of 
the skin. The yellow spots can easily be scratched off by the finger- 
nail, and by this means, as well as by their ordinary situation, and, 
still better, by the discovery of the parasite in them, they may be dis- 
tinguished from chloasma uterinum and from freckles. Pityriasis versi- 
color often occasions a slight itching. During summer it generally 
improves somewhat, probably because the perspiration is freer; but it 
scarcely ever disappears unless judiciously treated. 
Treatment.—I used formerly to treat pityriasis versicolor with 
a mixture of carbonate of potash 3 vj, liquor liydrarg. nitric, oxydul. 
3 iij, and aquae rosarum § vj, which must be well shaken, that the sub- 
oxide of mercury may not remain at the bottom of the bottle. Under 
this application, made morning and evening, pityriasis versicolor has 
nearly always disappeared in a week or ten days. Recently I have 
found that the same object may be attained with equal facility, by in- 
unction of green soap twice a day. 
CHAPTER XXII. 
Etiology.—The itch is an inflammation of the skin characterized 
by the formation of nodules, vesicles, and pustules, and caused by the 
presence of an animal parasite, the itch-mite, acarus scabiei, or sar- 
coptes hominis. The parasite is about in length, and has a breadth 
SCABIES ITCH. SCABIES. 
511 
of about and is recognizable as a round white body to the naked 
eye. Under a sufficient magnifying power, it is seen somewhat to re- 
semble a tortoise in shape; its convex back is marked with curved 
parallel transverse stripes, and is armed with spines of varying length. 
The young insect has six, the adult eight, articulated feet, the anterior 
pair of which are provided with suckers. In the female, two pair of 
the hindmost of the feet terminate in long bristles ; in the male, only 
the first of them has bristles, while the posterior pair are also provided 
with suckers. The head of the mite, which is armed with two horny 
jaws, separated by a cleft, projects from between the anterior pair of 
legs. The male insect is smaller than the female, and much less nu- 
merous ; it is provided with a penis shaped like a horse-shoe ; the fe- 
male, when pregnant, embeds itself between the lamelfe of the epi- 
dermis, and forms a burrow which is often several lines in length, and 
sometimes an inch or more. These passages contain emptj’- shells of 
the mites, together with their blackish feces, and their eggs in every 
stage of development. The burrows dug by the males are shorter, 
and therefore more difficult to find. The eggs seem to mature in 
about eight days. The young mites, after escaping from their shells, 
abandon the gallery of their mother, and burrow for themselves in the 
vicinity. After casting their skin repeatedly (twice at least), and ac- 
quiring an additional pair of legs with the first moulting, they come 
out of their holes and pair—generally during the night, when the skin 
is warm, in the bed. Sometimes the male insect visits the female in 
her burrow. If a fecundated female be transferred from the skin of 
one individual to another, the latter also becomes infected by itch. 
As there is no opening in the galleries, and as those in which the 
pregnant females lodge are stopped up by the eggs and fecal masses, 
it may be assumed that the female only comes to the surface when 
her burrow is scratched open. Sleeping with a person afflicted with 
itch is, therefore, an especially dangerous procedure, although a very 
brief pressure of the hand will suffice to transfer a mite scratched out 
of her abode. It is not known how long the insect is capable of liv- 
ing after it has been removed from its natural habitation and feeding- 
ground ; but it seems that those which get into the clothing and linen 
soon die. One of HebrcCs discoveries proves the truth of this most 
strikingly, and indeed better than the most minute observation of a 
few captured mites. In Vienna, where fifteen hundred itch-patients 
are treated annually, the number of relapses does not amount to one 
per cent., although their linen, and other clothing, is not steamed nor 
baked in the louse-oven, nor subjected to any other particular process, 
in order to kill the itch-mite and its eggs. We are indebted to JEich- 
stedt, Furstenberg, Gudden, and others, for our more intimate acquaint- 512 
DISEASES OF THE SKIN. 
ance with the habits of the acarus scabiei, a knowledge which nas 
completely overthrown the ancient errors regarding the origin of 
the itch. 
Symptoms and Course.—Generally speaking, a patient is first 
made aware of his having scabies by an intense itching, which is worse 
when he is warm in bed, and which is by no means limited to the re- 
gions most frequented by the acarus, namely, between the fingers, ir. 
the bends of the joints, upon the genitals, and between the nates ; for 
it is also very severe upon the legs, abdomen, and chest. The most 
conspicuous objective symptoms are nodules, pustules, and vesicles in 
variable number, occupying the regions mentioned. In very little 
children, Avhose head is often kept buried in bedclothes, they are 
sometimes, although rarely, found upon the face. These nodules, vesi- 
cles, and pustules do not denote different kinds of itch, but rather are 
indicative of the stage of dermatitis excited in the skin by the presence 
of the parasite, and still more by the scratching. In children, and in 
other persons with tender skin, the inflammation is most apt to be so 
severe as to form pustules, and even to suppurate. These nodules, 
vesicles, and pustules are often excoriated by the nails, and converted 
into bloody scabs. A much more characteristic sign of the disease is 
afforded by the burrows of the itch-mite, which, with a little care and 
practice, are not hard to find. They consist of dotted, sinuous, or zig- 
zag seams, which look like the scars of needle-scratches. At their be- 
ginning—that is, at the place at which the insect embedded itself— 
there is often a vesicle, more rarely a papule or pustule ; at its termi- 
nation there is a somewhat larger blackish or whitish point, corre- 
sponding to the actual position of the insect. The burrows are most 
numerous between the fingers, and upon the inner surfaces of the 
wrist and elbow-joints, and upon the penis. In order to catch the 
acarus, a needle must be thrust into the beginning of the burrow, and 
carefully pushed toward its end, at the same time ripping open the 
covering. A minute white point, which, upon attentive examination, 
will be seen to change its position slowly, and which, after this pro- 
cedure, is generally found on the point of the needle, is the acarus. 
Not unfrequently an egg may be seen within her, which may be 
squeezed out of her body by gently pressing upon the fine glass 
cover. The itch-tracks found upon the penis are always accompanied 
by infiltration of the skin beneath them. When the insects are ex- 
cessively numerous, instead of the discrete efflorescences, there is a 
diffuse eczematous dermatitis, whose scabs are inhabited by legions 
of mites. This form, which is rare with us, but which used to be of 
frequent occurrence in Norway, is “Norwegian itch,” or Borken- 
kratze. SCABIES. 
513 
Scabies never gets well spontaneously, but is very amenable to 
treatment; hence it is an innocent disease. No educated physician 
now believes in “ metastasis of the itch ” as a result of “ incautious 
suppression ” of the malady. Even the homoeopaths—in spite of the 
anathemas hurled by Hahnemann against suppression of the “ psora ” 
by local applications—now prescribe green soap and sulphur, regard- 
less of consequences. However, notwithstanding the ease with which 
it is cured, the itch is an affection greatly feared by the so-called edu- 
cated classes, by whom it is regarded as a plebeian and disgraceful dis- 
ease. This prejudice is so great, that their horror over the discovery 
that they have the itch is by no means diminished by the information 
that it is more harmless and easier to cure than almost any other cu- 
taneous disorder. 
Treatment.—To cure the itch, it is only necessary to kill the in- 
sects and their eggs, or to remove them from the skin. This done, 
the eruption induced by the parasites, and by the scratching which 
their presence provoked, soon subsides. There are many methods of 
curing the itch with certainty; of one, however, it is claimed, that it 
affords the most rapid possible relief; that it is less irksome to the 
patient, and that it costs less, at all events in hospitals. The reme- 
dies most commonly employed are green soap and sulphur. When 
green soap alone is used, every suspected part of the skin must be 
rubbed with it twice daily, until a decided eczematous dermatitis sets 
in. With the exfoliation of the epidermis consequent upon this ecze- 
ma, the itch-mites and their eggs are also got rid of, as the burrows 
never extend down to the cutis. This cure is a certain one, but it re- 
quires from six to eight days for its accomplishment. Meantime, the 
patient must not wash himself nor change his clothing, and must re- 
main in a room heated to a temperature of 75° to 80° Fahr. He must 
not bathe until the sixth or eighth day, when the cure is complete. 
This treatment is not adapted for private practice, being too irksome 
and unpleasant. The object may be effected somewhat more quickly 
by using a mixture of two parts of green soap to one of powdered sul- 
phur, which is to be rubbed in as directed above. The English method 
also consists in an application of green soap and sulphur, with certain 
additions. The treatment is commenced by a warm bath, after which, 
for two or three periods of twenty-four hours, the patient is to remain 
packed in woollen blankets at a temperature of 90° or 96° Fahr. After 
the first twelve hours, one-third of the ointment (consisting of sulphur 
§ j, white hellebore 3 ij, nitre gr. x, soft-soap § j, lard 3 iij) is to be 
rubbed into all suspected regions; after the second twelve, a second 
portion is to be applied ; and in twelve hours more the remaining 
third. Twelve hours after the last inunction, the treatment terminates 514 
DISEASES OF THE SKIN. 
by a bath. This method, also, though sure and rapid, is unfit for pri- 
vate practice, being inconvenient and disagreeable, and because pa- 
tients do not like to sacrifice a pair of woollen blankets to the itch. 
IVilJcinson’s ointment, which contains tar and chalk in addition to the 
soft-soap and sulphur, is still less adapted for treatment of private pa- 
tients. For this purpose the simple ointments of lard ( § j), and sul- 
phur (§ ss), are more suitable, as is also IlelmericNs ointment, con- 
sisting of carbonate of potash 3 ij, sulphur § ss, and lard § ij. After 
one or two initiatory warm baths, the ointment is to be rubbed twice 
or thrice daily over the entire body, excepting the face, or, at all 
events, over every spot where any eruption or traces of itch can be 
found. By this means the disease can be cured with certainty in from 
eight to fourteen days. When the patient cannot conveniently absent 
himself from his business, let him take a warm soap-bath at night, then 
rub the suspected spots, or, better, the entire body, excepting the face, 
with Ilelmericli's ointment, and in the morning let him take another 
bath. This procedure also cures the itch in a few days. Helmerich’s 
ointment is likewise employed in Hardy's “ speedy cure.” This con- 
sists in half an hour’s rubbing with green soap, an hour’s bathing, 
during which the rubbing is to be continued, followed by half an 
hour’s inunction with the ointment. The cure is perfected in a few 
hours, but, though often successful, is not quite sure. The Vie- 
minckx’s solution, already described, would be a remedy preferable to 
any of the above-mentioned, being both simpler, more cleanly, and 
cheaper, were it not that it often produces severe and obstinate eczema 
in persons with delicate skins. The directions for the use of Vie- 
minckx’s solution, as practised in the Belgian army, are as follows: 
Half an hour’s bathing, half an hour’s rubbing with green soap ; then, 
half an hour’s rubbing with the solution of lime and sulphur; then, 
another bath for half an hour, when the treatment is ended. 
Under the impression that it is sufficient to kill the mites and their 
eggs, and, that if this be done, it is unnecessary to open the burrows, 
and to effect the removal of both insects and eggs, by the production 
of an artificial eczema, it has been proposed to rub the skin with para- 
siticide substances, capable of easily penetrating the epidermis, and 
especially to use petroleum and balsam of Peru. Nothing can be said 
against the correctness of the theory; and a series of experiments, by 
rubbing in these articles, has succeeded. Nevertheless, according to 
experimenters who have tested the treatment fairly, its effects are un 
certain ; and it has not superseded the old treatment in many of the 
hospitals where it has been tried. It would only be advisable to have 
recourse to Peruvian balsam, or (when that is beyond the patient’s 
means) to try the efficacy of petroleum, when the use of sulphur and DERANGEMENTS OF SECRETION IN THE SKIN. 
515 
soft soap is contraindicated. It used formerly to be thought neces- 
sary to expose the clothing to a temperature at which albumen will 
coagulate, in order to kill the insects and eggs lodged in them. The 
linen was boiled; and the cloth garments were baked in the so-called 
“ itch-oven,” or sent to the “ kettles ” at the establishments for clean- 
ing feather beds, which exist in all large cities. We have already 
mentioned that Ilebra declares this to be superfluous. According to 
the undisputed testimony of this authority, the treatment of the itch 
in private houses is much less difficult, and promises far more success 
than was formerly supposed; and the danger of catching the disease 
anew from clothing, bedding, furniture, or other utensils that have not 
been disinfected, is purely imaginary.6 
Ylll.—DERA NGEMENTS OF SECRETION IN TEE SKIN. 
We are aware that gaseous, watery, and oleaginous secretions are 
given off from the surface of the skin. There is no doubt that, under 
certain conditions, the quantity and quality of these secretions vary 
from the normal; but we are imperfectly acquainted with the nature 
of these variations, and with the sources whence they arise. 
The secretion of gases, especially of hydrogen gas, is increased in 
febrile disease—apparently from causes purely physical—whenever 
there is much elevation of the temperature of the skin. If we weigh 
a patient who has had a fever, we shall find him much lighter than he 
was prior to his illness. If we take account of every thing eaten and 
drunk by him, and if we deduct from this the loss of weight, and the 
weight of the ffeces, sputa, urine, etc., which have been evacuated 
during the sickness, it wfill be found that the excretion through 
the skin (and lungs) greatly exceeds the normal amount. It is 
well known that an increase of the insensible perspiration is not 
always accompanied by an augmentation of the secretion of sweat; 
and indeed, that the skin usually is dry while the former is going on 
most rapidly. A copious supply of watery liquid greatly increases the 
amount of gaseous perspiration. An athletic medical student, for the 
sake of experiment, dieted himself for a long period of time upon ex- 
actly the same quantities of food and drink as were given to two patients 
with diabetes mellitus. The quantity of urine which he secreted was 
much increased, but upon calculating the daily amount supplied to the 
system, and upon deducting the weight of the daily excretions of urine 
and feces, as well as the gain in weight of the body, from the weight 
of the food and drink which he consumed, it was found that the insen- 
sible evaporation from the skin and lungs had been very considerably 516 
DISEASES OF THE SKIN. 
augmented. There had been no profuse sweating; and it is veiy 
probable that, besides the conditions mentioned above, there are others 
which likewise serve to increase the imperceptible perspiration. 
A diminution of the insensible perspiration is probably of common 
occurrence, for instance, in a very cold or very moist atmosphere; but 
hitherto, this fact has only been demonstrated directly by weighing, in 
cases of diabetes mellitus. 
We know nothing positive about the qualitative changes in the 
cutaneous evaporation, and can merely suppose that in febrile dis- 
orders this excretion not only increases in quantity, but is altered in 
its composition. That such a change does take place seems to be indi- 
cated by the peculiar odor emitted by the gaseous perspiration of pa- 
tients suffering from the acute exanthemata. 
The secretion of sweat is much increased in most people when they 
are exposed to certain influences. Both healthy persons, and persons 
suffering from chronic diseases free from fever, if weighed before and 
after a course of profuse artificially-induced sweating, are found some- 
times to have lost four or five pounds’ weight in a few hours. We 
have no precise knowledge of the conditions which regulate the pro- 
duction of sweat. Healthy persons sweat profusely when covered by 
blankets and made to drink copiously; but in most febrile diseases 
they do not perspire at all, though treated in the same manner; while 
there are other disorders attended by fever (not merely the inexpli- 
cable sudor angelicus of the middle ages, but many cases of pneumonia 
and rheumatism), in which the sweating is profuse throughout the 
whole attack. That the secretion of sweat, like that of the saliva, is 
dependent upon nervous influence, is evident from the effect which the 
mental emotions exert upon its production. Some persons perspire 
more readily and profusely than others. An excessive tendency to 
perspiration is called hyperidrosis. It generally depends upon un- 
known causes; but in some instances it unmistakably is a consequence 
of repeated artificially-induced diaphoresis. Barensprung mentions 
many examples of hyperidrosis proceeding from the above cause. I 
myself have never noticed any great increase in the secretions of the 
skin at the commencement of a course of diaphoretics, and have on!} 
observed it in persons who had been under treatment for some time, 
and hence can confirm the assertion that profuse sweating augments 
the tendency to diaphoresis. When the secretion of the sudoriferous 
glands cannot escape, owing to obstruction of the gland-ducts, or be- 
cause the latter are incapable of transmitting all the secretion formed, 
it emerges around the sweat-duct under the epidermis, and, lifting the 
latter, forms small, clear vesicles containing an acid liquid, which are 
called sudamina. Obstruction of the efferent ducts of the sudoriferous DERANGEMENTS OE SECRETION IN THE SKIN 
517 
glands occurs most frequently when the secretion of sweat has been 
arrested for some time; for instance, in the first weeks of typhus. 
Sudamina, also called miliaria alba, have nothing in common with the 
miliaria rubra, excepting that the source of both affections is in the 
sudoriferous glands. Miliaria rubra has nothing to do with retention 
of perspiration, but consists in an inflammation and exudation, induced 
by excessive diaphoresis; and for this reason we have classed miliaria 
rubra under the eczematous affections. An eruption of sudamina has 
no influence upon the course of the disease which it accompanies, and 
is seen as often in critical sweats as in the profuse perspirations which 
break out in unfavorable phases of a disease, and even in that stage 
which immediately precedes dissolution. The profuse sweats of the 
miliary fevers of the middle ages could hardly have been of a critical 
character, as they appeared when the disease assumed a malignant 
form; hence the miliary eruption was considered an unfavorable 
sign. 
A partial hyperidrosis, confined to the palms of the hands, the soles 
of the feet, to the armpits, and to the region of the genitals, is of far 
more common occurrence than general hyperidrosis. The “sweaty 
hands and feet,” by which many people are troubled, are unnaturally 
cool. The disgusting odor emitted by the perspiration of the feet and 
armpits is not dependent upon the presence of ill-smelling ingredients 
in the secretion, but upon putrefactive decomposition of the perspira- 
tion, sebaceous matter and macerated epidermis of the skin. Hebra, 
undoubtedly, goes too far in asserting that this offensive decomposition 
only takes place in old shoes saturated with sweat, and that people 
usually accused of having stinking feet really have stinking boots. 
This offensive perspiration was formerly regarded as a wholesome ex- 
cretion, to be encouraged and cherished; and many complaints were 
ascribed to its repression. Such views nowadays have been declared 
altogether unfounded, upon the high authority of Hebra and others; 
and indeed, to say nothing of the fact that it is by no means easy to 
check sweating of the feet, its arrest immediately before the outbreak 
of a fit of illness is, in most cases, the result of the illness and not its 
cause. But I think that it is saying too much to deny absolutely that 
such suppression of perspiration may possibly now and then be the 
cause of disease. There is no doubt that people are often made ill by 
exposure to a degree of cold while perspiring, which would have done 
them no harm had the skin not been moist with perspiration; and it is 
equally certain that diaphoresis artificially induced, often is of the ut- 
most benefit in diseases caused by exposure to cold. Admitting the 
correctness of these facts, it is not absurd to suppose that sometimes 
the chilling of perspiring feet may induce disease, nor that the reestab- 518 
DISEASES OF THE SKIN. 
lishment of tlie perspiration may act beneficially upon disease so in- 
duced. The utmost objection that can be made against the statement, 
that “ suppression of the perspiration has caused illness,” is, that it is 
too indefinite; since we are quite ignorant as to why it is that the 
chilling of a perspiring body so often gives rise to disease. Hence, I 
consider it to be entirely warrantable, when it has been proved, or 
even when it is very probable, that the cessation of an habitual hyperi- 
drosis of the feet has been followed by sickness, that we should attempt, 
by means of hot stimulating foot-baths and by warmly clothing the 
feet, and by sprinkling the stockings with flour of mustard, to reestab- 
lish copious diaphoresis of the extremities. I do not mean by this, 
that persons suffering from offensively-perspiring feet and armpits are 
to be forbidden to wash and bathe, or to use cold water for the pur- 
pose. On the contrary, the judicious use of cold baths and of cold 
washing, so far from being hurtful, is of the utmost benefit to persons 
who perspire too freely, and who are liable to take cold. In fact, I 
think it probable and by no means inconsistent with the opinions ex- 
pressed above, that the cautious checking both of local and general 
hyperidrosis is the best means of obviating the danger of catching cold 
by which it is accompanied. At all events, people with sweating feet 
should frequently change their shoes and stockings. When the epi- 
dermis becomes soft and pasty from maceration, and when it inclines 
to peel off, exposing the rete Malpighii, making it painful and difficult 
for the patient to walk, Hebra recommends, as an excellent remedy, 
that the soles and toes should be smeared for some days with the un- 
guentum diachyli, and then be wrapped in linen rags. He claims 
that, by this treatment, not only does a new and firmer layer of epi- 
dermis take the place of the old and softened one, but it causes a dim- 
inution of the hyperidrosis for some time afterward. I have no ex- 
perience of my own testifying to the efficacy and harmlessness of this 
procedure. 
We have already mentioned that a diminution of the cutaneous 
secretions may form one of the symptoms of senile marasmus. In 
other instances, as has already been mentioned, it depends upon de- 
rangement of innervation; in others, again, it is due to disease of the 
skin, to psoriasis or to ichthyosis, while, finally, cases exist of anidrosis 
and now and then even anidrosis of half the body, the causes of whick 
are quite unknown. 
With regard to the qualitative alterations of the perspiration, the 
presence of biliary pigment in the sweat of persons with icterus, upon 
which the yellow stain of their clothing depends, is perhaps the best 
known. JBcirensprung, however, believes that the vehicle of the pig- 
ment is not the liquid of the perspiration, but the epithelial cells which DERANGEMENTS OF SECRETION IN THE SKIN. 
519 
it contains. The composition and source of other substances, which 
sometimes appear in the sweat and which likewise stain the linen, are 
unknown. In a few instances of suppression of urine, trustworthy 
observers have discovered crystals of urea upon the skin. 
In some persons, the sebaceous secretion of the skin is so much 
increased that the hair and cutaneous surface, especially that of their 
face, always shines as if it had been freshly anointed with pomade or 
grease. In others it is so deficient that, unless replaced by an un- 
guent, the skin and hair are always dry, dingy, and disposed to crack. 
The former condition is most likely to exist in persons with an exube- 
rance of fat throughout the entire body; the latter in individuals with 
little fat, or in those who are suffering from wasting disease. 
Qualitative changes in the sebaceous secretion are often observed, 
in which the unctuous matter of the skin does not remain liquid, but as- 
sumes a more solid consistence. Bcirensprung believes that the in- 
creased solidity of the cutaneous secretion is due in part to a prepon- 
derance of solid fat, and in part to an admixture of a larger amount of 
cast-off glandular epithelium. The increased solidity of the sebaceous 
matter of the skin is usually accompanied by exuberance in its quantity, 
thus in some measure justifying the name seborrhoea, applied to a con- 
dition of the skin in which it is covered with crusts of dry sebaceous 
matter. Seborrhoea is most frequently observed upon the scalps of 
infants, where the inspissated secretion, rendered brown by admixture 
of dust, often forms scaly crusts of nearly a line in thickness, of which 
superstition forbids the removal; and it is not until the second year, 
when the scabs are lifted from the scalp by a freer growth of the hair, 
that they break up into separate scales, and are removed as such with 
a comb. Many a case of the so-called pityriasis capitis, in which there 
are many white scales, some of which adhere to the skin, some stick- 
ing to the hairs, while still others are sprinkled upon the clothing, are 
the result of seborrhoea. Microscopic examination, by which it is found 
that the scales contain numerous oil-globules, affords the best means 
of distinguishing this form of seborrhoea from a dry eczema capillitii. 
Finally, thick crusts of sebaceous matter, browned by admixture with 
dust, and whose surface is generally broken up into numerous blocks, 
appears upon the cheeks, nose, eyelids, ears, and nipples, as well as 
upon other parts of the skin where a copious lanugo prevents the fall 
of the crusts. Abnormal secretion of sebaceous matter may go on so 
rapidly, that the cast-off scabs are speedily replaced by new ones, 
which greatly disfigure the patient, who is usually a female suffering 
from menstrual derangement {ichthyosis sebacea, Hayer). Thick, hard 
crusts of sebaceous matter are to be softened with liquid fat, and then 
removed with caution, since the epithelial coat beneath them is ex- 520 
DISEASES OF THE SKIN. 
tremely tender. Systematic washing with soap and water, or alcohol, 
is the best preventive of the formation of new crusts, although it does 
not alter the abnormal character of the cutaneous secretion. For 
seborrhoea capillitii the hair-dressers use an evening lotion of “ honey 
water,” and a morning inunction of the head with macassar-oil. This 
is a most rational procedure ; for the honey-water, which contains al- 
cohol, loosens the scales, and the admixture of liquid of Macassar-oil to 
the solidifying sebaceous matter prevents it from drying up into new 
scales. Instead of the honey-water, however, any other liquid contain- 
ing alcohol, such as French brandy, or eau de cologne, may be em- 
ployed, and any other oil will do instead of Macassar-oil. In treating 
Mayer's ichthyosis sebacea, especial attention must be paid to the 
state of the sexual organs, since experience teaches that, upon relief 
of any existing derangement of the latter, the tendency to excessive 
production of sebaceous matter also subsides. Local applications 
alone merely prevent accumulation of the secretion, but not its super- 
abundant generation. When, instead of flowing from the follicle, the 
secretion solidifies within it, creating hard masses like the shell which 
forms on the scalp in seborrhoea (as above described), we have the 
comedo, the milium, or atheroma. In a comedo, the outlet of the fol- 
licle is obstructed by a plug of black, hardened sebaceous matter, 
mingled with dust.. Upon compressing the follicle, its contents are 
squeezed out of the contracted orifice, and, like any other pasty sub- 
stance, forced through a sieve, it assumes a fusiform shape. A milium 
means a follicle distended by hardened secretion to the size of a mil- 
let-seed, and covered by epidermis, so that there is no visible black 
speck in its middle. Atheromata are sebaceous glands distended by 
their inspissated contents to the size of a hazel-nut, walnut, or pigeon’s- 
egg. It is easy to understand that an excessively distended sebaceous 
gland blends with the hair-follicles, into whose outlet it opens. In 
treatment of the comedo we can merely remove the accumulated mat- 
ter, it being out of our power to prevent its production. For persons 
who are vain enough to submit to a somewhat unpleasant process, in 
order to rid themselves from time to time of their comedones, I em- 
ploy the following prescription (originally proposed by Micliter), and 
have always obtained very good results from it, if not very speedy 
ones : A mixture is to be made of rye-meal, honey, and yeast; after 
waiting until it ferments, the fermenting paste is to be applied at bed- 
time upon the part of the face upon which the comedones are situ 
ated. Next morning, those comedones which evidently are somewhat 
loosened and elevated—but only those—are to be pressed out, not 
oetween the nails, or under a watch-key, but under a gentle pressure 
of the fingers. This process must be kept up for several weeks. We APPENDIX TO DISEASES OF TIIE SKIN. 
521 
have already mentioned the beneficial effect of the preparations of 
sulphur, when treating of acne. For the treatment of milium, 
iTeSra recommends removal of the epidermic covering by bathing 
it with a moderately strong solution of caustic potash (one drachm 
to a pint of water), or by the application of soft soap upon a flan- 
nel rag. Treatment of atheroma consists in division and extirpation 
of the degenerated follicle. 
[APPENDIX TO DISEASES OF THE SKIN. 
SCLERODERMA, 
Scleroderma occurs at any age, but especially in middle-aged 
women from unknown causes, and is due to a gradual increase and 
atrophy of the cutaneous connective tissue especially of the face, 
arms, etc., which becomes hardened, pale, red, or pigmented, and 
adherent to the parts beneath, so that the lineaments of the face may 
be stiffened, the lips and nostrils shortened, the lingers stiff, etc. The 
disease goes on for years, and when arrived at the stage of atrophy 
is incurable ; but earlier it may subside. This favorable result does 
not appear due to rubbing, bathing, mercurial salve, or the internal 
use of iodide of potash ; but tonic treatment and good nourishment 
may do good. The nature of this disease is not fully understood ; 
while some attribute the changes in the skin to stasis of lymph, either 
from thickening or from disease of the lymphatics (and regard it as 
related to elephantiasis), other observers, who have seen the joints 
and some bones implicated, refer the disease to trophic neurosis 
originating in the ganglionary system. A different form of the dis- 
ease is sclerema neonatorum, or cellular-tissue hardening, which 
attacks feeble, premature children under fourteen days old. There 
is decided disturbance of circulation in the outer portions of the 
body and great depression of the temperature ; the skin begins to 
harden on the legs, and this hardening extends to the trunk, arms, 
and even face. The portions of skin affected are sometimes oede- 
matous, and subsequently hard as boards, cold and cyanotic ; the 
stiffness greatly hinders all motion, the face is wrinkled, sucking and 
drinking are impaired, the bodily temperature falls markedly, and 
death usually occurs within a week. On autopsy, besides oedema of 
the skin and perhaps of the deeper parts, the fatty tissues are found 
unusually firm ; some regard this as due to the sinking of the bodily 522 
DISEASES OF THE SKIN. 
temperature. But generally there are remains of other morbid af- 
fections, which have existed with or before the skin trouble, and 
must have impaired the circulation, as pulmonary atelectasis, pneu- 
monia, heart-disease, intestinal catarrh, and ulcei’s. 
Treatment is to be directed against these causal diseases, to 
securing good nourishment by a wet nurse, Nestle’s food, nutrient 
enemata, wine, ether, musk, etc., and improving the circulation by 
wrapping the child in flannel, hot baths, etc. 
LEPROSY—ELEPHANTIASIS GRJSCORUM. 
Leprosy, which was formerly so dreaded, and which is still en- 
demic in some countries, and was so even in Europe previous to the 
fifteenth century, still occurs sporadically. Although our knowd- 
edge of this disease has of late been greatly enriched, its origin is 
still uncertain ; but it has been ascertained that a minority of cases 
were hereditary, and that the disease is not contagious. Although 
the symptoms of leprosy are not always the same? still the cases 
show that they are of the same general character. Among the 
forms that have been described are lepra maculosa, l. tuberculosa, 
and l. anoesthetica. The disease rarely begins before the seventh 
to the tenth year; it is more common in youth and middle age. 
The local symptoms are usually preceded for a long time by 
general symptoms, such as heaviness, chills, loss of appetite, vague 
pains, evening fever, etc. In the maculous variety, spots come on 
the skin ; these may disappear on pressure, and they may be dark 
or white ; the disease may run its course with these appearances, or 
combine .with the other two forms. In the tuberculous form, sen- 
sitive nodules as large as a nut form on the maculse or on healthy 
skin. These nodules may be scattered or congregated ; they come 
especially about the face and limbs. After it has lasted a long 
time, the mucous membrane of the mouth, larynx, nose, and eye 
may be affected. Leprous nodules may last for years and then pass 
away, leaving a dark pigmentation or spot of white atrophy in the 
skin ; more rarely they soften and form abscesses, or ulcerate, even 
going deep enough to expose the bones and open the joints, espe- 
cially of the hand and foot. 
Although cutaneous anaesthesia accompanies spotted and nodular 
leprosy, in the form called anaesthetic loss of sensation exists in the 
skin without spots or nodules. Later the anaesthetic spots become 
flabby, yellow, and atrophied ; the muscles of the face and hands 
participate in the atrophy ; the skin breaks through, leaving a tor- 
pid, lifeless opening, which slowly enlarges, and finally exposes or 
even detaches phalanges or portions of limbs. The anassthesia of ADDITIONS TO THE REVISED EDITION OF 1880. 
523 
the skin and the trophical changes have long directed attention to 
the nervous system, and large nerve-trunks have been found nodu- 
lated. But in the central nervous system also changes have been 
found, and perhaps more perfect methods of examination will there 
find the causal changes. In one case Lcinghans found great soften- 
ing of the gray commissures and posterior horns, showing the spinal 
cord to he the seat of disease in that case at least. The neurotic 
nature of leprosy is rendered more probable by the frequent coin- 
cidence of pemphigus (which is regarded as a neurosis), and by its 
tendency to occur symmetrically on the two sides. 
The prognosis is bad. Though perhaps not for years, it usually 
causes death, preceded by loss of the limbs, face, etc. Sometimes 
the course is milder, and after many years ends in recovery. 
Treatment is of little avail. None of the vaunted specifics 
have held their own. So far as at present known, the best treat- 
ment is change of residence, good hygienic surroundings, cleanli- 
ness, nourishment, fresh air, iron and cod-liver oil, and attention to 
special symptoms. At a leper asylum in British Guiana gurjun oil 
is said to have proved beneficial, as has also chaulmoogra oil, in 
doses of five to twenty drops three times daily, w'hile it was applied 
externally combined with psoralea corylifolia.] 
ADDITIONS TO THE REVISED EDITION OF 1880. 
DISEASES OF THE SKIN. 
1.—P. 455. 
Besides ordinary erythema nodosum, which occurs in children 
and youth otherwise healthy, Uffelmcmn describes a modified form 
with certain constitutional peculiarities, where the patients have 
an hereditary tendency to tuberculosis, feeble health, and delicate 
frames. 
Bohn regards erythema nodosum (as well as peliosis rheumatica) 
as an inflammatory infarction from embolism of the cutaneous 
arteries, while other observers make a decided distinction between 
cutaneous embolism as seen in endocarditis and exudative erythema 
proper. 
Bewin defines exudative erythema as a vasomotor neurosis, and 
calls attention to its symmetrical occurrence on the two sides of the 
body. It is not unfrequently so modified as to resemble other dis- 
eases. Pustules forming on the erythematous spots may induce the 524 
DISEASES OF THE SKIN. 
appearance of variola ; or it may be accompanied or followed by 
articular inflammations, giving a resemblance to articular rheuma- 
tism ; it is even possible that some of those cases of valvular dis- 
ease of the heart of obscure origin may have been related to a pre- 
cedent erythema exsudativum. Finally, Lewin believes that in 
women the erythema may be due to inflammation of the urethra ; 
that is, it is the manifestation of an irritation starting from the 
urethral mucous membrane and reflected to the vasomotor nerves 
of the skin, as gonorrhoeal rheumatism is in males. 
Another form has been observed as an epidemic in Paris, the 
Crimea, Mexico (acrodynia), as well as that called pellagra in Italy 
and the South of France. 
2.—P. 505. 
Tlie use of even nitrate of silver requires some practice. Each 
lupus nodule should be bored into with a sharpened point, and 
loosened up from the sound skin ; which is not difficult, as the for- 
mer is readily broken up, while the latter is resistant. The pain in- 
duced ceases after a few hours. The operation may be repeated once 
or twice a week ; it would be too painful to destroy all the nodules 
at once, where the nodules are numerous and disseminated. Hebra 
and Kaposi recommend a sort of weak Cosmo’s paste (arsenic, alb. 
gr. x, cinnabar. 3 ss, ung. aquae ros. 3 ss), which is spread on muslin 
and applied for three days, being renewed every day. The second 
day there is mild, the third day tolerably severe pain, and cedema- 
tous swelling of the face and eyelids ; but the lupus nodules have 
become dark-brown sloughs, which are detached by suppuration 
after a few days, leaving cavities which soon granulate. If the 
nodules have already ulcerated, it may suffice to apply the plaster 
for one or two days. Arsenical poisoning rarely if ever occurs from 
the above treatment. Another plan is to scarify the nodules at 
intervals of some weeks. Volkmann recommends scraping out the 
nodules with a sharp scoop, and if necessary subsequently scarify- 
ing or cauterizing the raw surface ; this operation is painful, and 
requires anaesthesia ; the same is true of treatment by the galvano- 
cautery. 
But destructive treatment is not always required. Where in- 
stead of nodules there is merely infiltration of the skin, resolution 
may take place without ulceration ; so we may try to aid resolution 
by irritating the part with concentrated solution of nitrate of sil- 
ver or tincture of iodine with intervals of rest. Mercurial oint- 
ment may be applied daily. ADDITIONS TO THE REVISED EDITION OF 1880. 
525 
3.—P. 507. 
The microscope shows that the favus bodies consist of an epider- 
mis coating, containing fungi and fine granular cement. From the 
surface of the capsule numerous fungous filaments project into the 
favus body. At first these filaments are simple, but deeper they 
become branched and finally form chains. The same fungous ele- 
ments are found in the roots of the hairs and in the hairs themselves. 
4.—P. 509. 
We should not confound herpes tondens capillitii with the dis- 
ease known as alopecia areata. In the latter, which occurs both in 
children and adults, the hair falls from a circumscribed spot in the 
midst of a luxuriant growth, leaving circular bald spots, which may 
unite with other similar spots. But alopecia areata is not due to 
fungi ; it is a trophic nervous affection. The bald spot is not red 
or covered with scales, and after some months the hair grows again 
without treatment. 
Herpes tondens might be mistaken for roseola syphilitica or pso- 
riasis ; but in the syphilitic affection there is no scaly deposit; in 
psoriasis, on the contrary, the red spots are covered with thick regu- 
lar scales. 
A treatment for scabies, recently again resorted to and highly 
spoken of, is with balsam of Peru, which when brought in direct 
contact is said to kill the insect in 20 to 40 minutes. The patient is 
to have a warm bath, then to rub the whole body except the head, 
but more especially the parts most affected, viz., the hands, feet, 
large joints, penis, scrotum, breasts, and nates. The treatment 
requires about one ounce of balsam, which may be used in four to 
six applications, made within two days and without changing the 
underclothes ; then wash the body well. This treatment has the ad- 
vantage of not inflaming the skin or being so disagreeable as most 
others. A similar but somewhat less expensive treatment is by 
using petroleum 30 parts, olive oil 8 parts, in the same manner. 
5.—P. 515. DISEASES OF THE ORGANS OF LOCOMOTION. 
In the present section we would briefly call attention to all the 
diseases of the joints, bones, or muscles coming within the reach of in- 
ternal remedies, whether they be idiopathic affections of these organs, 
or the prominent symptoms of constitutional disease, of a cachexia or 
dyscrasia. 
KHEUMATISM. 
The series of morbid processes which were formerly grouped to- 
gether as rheumatism has grown smaller, it is true; all those dis- 
eases of the mucous membrane, and in the parenchymatous organs, 
which were formerly called rheumatism, have been excluded; and 
we have also ceased to designate as rheumatic those cases of in- 
flammation of the pleura, pericardium, and peritonaeum, referrible to 
cold, or for which we can find no cause; but still the number and 
variety of morbid processes classed under the head of rheumatism are 
sufficient to render a precise definition of the term impossible. 
We may mention the following points as characteristic of the forms 
of disease at present considered as rheumatic : 1. The seat of the dis- 
ease in the fibrous tissues, the joints, aponeuroses, sheaths of the ten- 
dons, neurilemma, periosteum, or in the muscles and tendons ; 2. The 
painfulness of the affection, which is due in many, probably in all cases, 
to stretching of and pressure on the elements of the tissue by the di- 
lated capillaries and an inflammatory oedema ; 3. The absence of trau- 
matic causes and a kind of independent occurrence of the disease, that 
is, its independence of other acute and chronic diseases. I think that 
the negative description given in 3 is more distinctive than a posi- 
tive one would be in its place, which would perhaps refer the origin 
of the affection to catching cold and to atmospheric influences. Fre- 
quently as catching cold and atmospheric influence lead to rheuma- 
tism, it is not at all proved that they are its sole cause. In practice, 
all painful inflammatory affections of the above-named tissues that oc- ACUTE ARTICULAR RHEUMATISM. 
527 
0111 primarily and idiopathicalty, and are not of traumatic origin, are 
termed rheumatic, no matter whether the disease can be referred to 
catching cold or not. Another characteristic of rheumatic affections 
is the frequent disproportion between the severe subjective symptoms 
and the insignificant anatomical changes, as well as the tendency of 
the disease to pass from the part first affected to others of analogous 
structure and function. But the proportionately severe pain in rheu- 
matism is less due to the variety than to the location of the disease ; 
at least traumatic, gouty, and other inflammations of moderate degree, 
are very painful, when they attack fibrous tissues. Nor is the fugacity 
of rheumatic affections, their tendency to shift position, entirely char- 
acteristic, for no one would object to terming rheumatic an idiopathic, 
painful affection of a joint, which did not show this fugacity, but "e- 
mained limited to the same joint for years. 
CHAPTER I. 
ACUTE ARTICULAR RHEUMATISM—RHEUMATISMUS ARTICULORUM 
ACUTA—RIIEUMARTHRITIS ACUTA—FLYIKG GOUT.1 
Isr acute articular rheumatism the synovial capsule of a greater or 
less number of joints is the seat of an inflammatory disturbance of nu- 
trition. The simple name of polyarthritis acuta would be enough for 
this disease, if there were not a secondary polyarthritis acuta occurring 
in the course of infectious diseases from which acute articular rheuma- 
tism is to be distinguished as polyarthritis acuta rheumatica seu idio- 
pathica. In most cases of acute articular rheumatism, the inflamma- 
tion of the synovial capsule does not attain a very high grade. The 
exudation into the joint is usually neither copious nor fibrinous, nor 
does it contain many pus-cells. The swelling visible about the affected 
part depends mostly on inflammatory oedema of the connective tissue 
around the joint. But this slight degree of inflammation and the 
quality of the exudation are by no means constant peculiarities of the 
disease ; on the contrary, there are some cases where the inflammation 
has attained a far higher grade, and where a fibrinous or purulent ex- 
udation is deposited. 
The predisposition to acute articular rheumatism is very unequal in 
different persons, without our knowing the reasons for this dissimilarity. 
Some persons seem to inherit a predisposition to the disease. Those 
who have had one or more attacks are very liable to it. The disease 
is rare in early childhood and in old age; it occurs most frequently be- 
tween the ages of fifteen and forty years. Men are attacked as often 
as women, or perhaps more frequently. The predisposition appears to 528 
DISEASES OF THE ORGANS OF LOCOMOTION. 
be somewhat stronger in robust, full-blooded persons than in those 
who are weak and amemic. 
Among the inducing causes of acute articular rheumatism the more 
important are temporary exposure to cold, either by suddenly wet- 
ting the heated body, or by being subjected to a draught, and con- 
tinued residence in damp dwellings and working in damp places. The 
working-classes, who are chiefly exposed to these bad influences, are 
consequently more subject to the disease than the well-to-do classes. 
In most cases the exciting cause cannot be recognized. The disease 
occurs all over the world, but is more frequent in the temperate zones 
than in the polar regions or the tropics. At some times, particularly 
during the winter and spring, the disease is so common that the num- 
ber of cases reminds us of an epidemic. In summer and autumn the 
cases are usually solitary. 
Anatomical Appearances.—We do not often have the oppor- 
tunity of examining the bodies of persons who have died during an 
attack of acute articular rheumatism. When we do, the changes 
found in the joints are often unimportant, being limited to a moder- 
ate liyperaemia of the synovial capsule and a slight increase and tur- 
bidity of the synovia. In some cases even these do not remain to tell 
of the inflammation that has undoubtedly existed during life, and the 
result of the autopsy is almost as negative as in most cases of erysipe- 
latous dermatitis. On the other hand, on post-mortem examination, 
we occasionally find the synovial capsule of some joints of a dark-red 
color, from hypersemia and ecchymosis, relaxed and puffed up, the joint 
dilated and filled with purulent fluid; the ends of the neighboring bones 
even may be injected and contain extravasations of blood. In all recent 
cases the blood contained in the heart and large blood-vessels shows 
very plentiful deposits of fibrin. There are also the frequent anatom- 
ical changes due to the complications of articular rheumatism, par- 
ticularly of pericarditis, endocarditis, and myocarditis. 
Symptoms and Course.—In some cases the outbreak of the dis- 
ease is preceded for a few days by general uneasiness and a feeling of 
weariness in the limbs. In others, the premonitory symptoms are 
wanting, and the attack begins suddenly and unexpectedly. The 
onset of the disease is not frequently marked by a chill, as we have 
learned is the case in pneumonia and some other inflammatory dis- 
eases. Usually there is only a slight rigor, which is often repeated 
during the first few days ; in the other cases even this is absent, and 
there is from the first the hot feeling, which otherwise does not occur 
till after the chill. Just as the symptoms of fever begin, or soon after- 
ward, the patients complain of pain in one or usually in several joints; 
this is moderate at first, but quickly and steadily becomes more severe ACUTE ARTICULAR RHEUMATISM. 
529 
and soon grows very decided. As long as the patient makes no 
attempt to move the affected joint, and it is not touched, the pain is 
endurable; but every attempt to move the joint or the slightest pres- 
sure on it, in severe cases even the weight of the bedclothes, increases 
the pain so that the patients often moan and cry till they have re- 
mained quietly for a time in a comfortable position protected from 
any injury. If we examine the affected joint, we sometimes find it 
moderately, sometimes very much swollen. As we have already 
said, the swelling only partly depends on the effusion into the joint; 
being partly due to oedema of the skin and subcutaneous tissue, it 
usually extends to the neighboring parts of the limb, and on careful 
examination it looks as if the ends of the bone were enlarged. The skin 
over the affected joint is either of normal color or else light, or excep- 
tionally dark red. The degree of the swelling and the severity of 
the pain are not always in exact proportion; the pain is often very se- 
vere, while the swelling is scarcely observable. The large joints, par- 
ticularly the knee, foot, hand, elbow, and shoulder, are most frequently 
affected; but the small joints, especially the finger, sterno-clavicular 
and intervertebral articulations, are be no means exempt. The toe- 
joints are only exceptionally implicated. Occasionally also the sym- 
phisis pubis is attacked. Not very unfrequently the inflammation 
extends to the muscles and fascia about the affected joint. The num- 
ber of joints involved varies. Even at the commencement of the dis- 
ease it is rare for a single joint to be attacked; far more frequently, 
two, three, or even more, are simultaneously diseased. It is customary, 
as the disease progresses, for joints, that have previously remained free, 
to become involved, and for the symptoms to reach their height in 
these, while it is subsiding or has even disappeared in those first 
inflamed. If the pain and swelling disappear slowly in the joints first 
seized, while they develop in others, the number of joints implicated 
at one time may be very large, and the patient’s state be very help- 
less and pitiable. Occasionally such patients cannot make any move- 
ments ; they are unable to stir from any position in which they have 
been placed; they fear even the most careful passive motion rendered 
necessary for urination, defecation, eating, or drinking. Even slight- 
ly shaking the bed increases their pain, and induces groans and com- 
plaints. But this extent and severity of the symptoms are not frequent. 
In most cases two or three, or at least only a moderate number of 
joints, are simultaneously affected with severe pain, while the others 
remain free, or are somewhat stiff and only pain when freely moved; 
sometimes also they crepitate. 
Fever usually accompanies the commencement of the disease; 
occasionally it precedes the local symptoms, and only exceptionally 530 
DISEASES OF THE ORGANS OF LOCOMOTION. 
comes on late; it usually corresponds to the severity and extent of the 
local symptoms, and has all the characters of a sthenic inflammatory 
lever. The bodily temperature does not usually attain the high grade 
observed in infectious diseases; in most cases it does not rise more 
than two or three degrees above normal, but exceptionally it becomes 
104°—105.5°, or even higher. The pulse is more frequent, usually 
from 90—100 beats in the minute, and is generally full and soft. Only 
in those cases where the temperature becomes very high does the 
pulse reach 120—] 30 beats in the minute. In many cases, even where 
there is no complication with endocarditis, we hear blowing murmurs, 
so-called blood-murmurs. The respiration is hastened, the skin is al- 
most always covered with very profuse perspiration of acid odor, which 
has no critical significance, but is usually just as abundant during the 
advancing stage, and at the height of the disease, as in the declining 
stage. The skin is often covered with an eruption of miliaria rubra. 
We have previously shown that this exanthema belongs to the eczemas, 
and results from irritation of the skin at the orifices of the perspiratory 
glands from excessive sweating. Besides vesicles filled with a milky 
fluid, we often see efflorescences in the shape of red papules, where 
there has not been sufficient exudation to raise the epidermis into a 
vesicle. More rarely sudamina, or miliaria alba, occur. The great 
loss of water, due partly to increased evaporation caused by the high 
temperature, partly to the profuse sweating, is shown not only by the 
thirst, but by the scantiness of the urine. Frequently only twelve to 
fourteen ounces of urine are evacuated in twenty-four hours. As the 
amount of urea is increased on account of the accelerated change of 
tissue, the concentrated urine has a very high specific gravity; and, as 
the amount of water it contains is insufficient to retain the urates in 
solution at low temperature, copious sediments of these salts form as 
soon as the urine cools. These appear darker red than common, on 
account of the quantity of coloring matter which is deposited with the 
salts. A very copi ous sediment of urates does not always allow us to 
conclude that the amount of urea excreted in twenty-four hours is in- 
creased ; at least, in two cases of acute articular rheumatism, treated 
at the Greifswalder clinic, where Iloppe-Seyler had the kindness to 
examine the very thick urine which deposited a large sediment, the 
amount of uric acid was only normal. It is, to some extent, justifiable 
to term such urine almost pathognomonic of acute articular rheuma- 
tism ; for in scarcely any disease is the loss of water so great from 
profuse sweating as well as from increased evaporation, caused by the 
high temperature. 
Among the complications of acute articular rheumatism, pericar- 
ditis, endocarditis, and myocarditis, deserve especial mention. When ACUTE ARTICULAR RHEUMATISM. 
531 
speaking of heart-diseases, we fully showed that the frequency of these 
complications has been greatly exaggerated, particularly by Bouillaud. 
Apparently, Bouillaud considered inflammation as the cause of the 
above-mentioned “ blood-murmurs,” which are probably due to an abnor- 
mal tension and consequent irregular vibration of the valves and walls 
of the vessels. We have mentioned that, according to Bamberger'& 
statistics, the complication with endocarditis occurs in about twenty 
per cent., with pericarditis in about fourteen per cent., of the cases of 
acute articular rheumatism, while myocarditis is much rarer. Accord- 
ing to Bamberger's observation, the tendency to complicating inflam- 
mation of the heart and pericardium is greater in proportion to the 
number of joints affected. In these cases the heart-affection is a com- 
plication and not a metastasis, as is shown by the fact that, when any 
form of carditis develops, the affection of the joint continues as it was 
previously. For the symptoms and course of the heart-affection, we 
will also refer to what has been said, and shall only again call atten- 
tion to the fact that, in many cases, there are no subjective symptoms, 
and the complication is only recognized by physical examination' 
Pleurisy and pneumonia are far rarer complications than the different 
forms of carditis, and still rarer ones are cerebral and spinal menin- 
gitis. In protracted cases, suppuration of the joints may lead to pyae- 
mia ; but, as this termination of idiopathic arthritis is rare, such cases 
are very uncommon. 
The disease has no cyclical course, and lasts, with varying inten- 
sity, in mild cases, one or two weeks; in severe ones, for many weeks. 
The pain and fever usually remit in the morning, and exacerbate in 
the evening; but these variations are not regular. Frequently, cases, 
which at first appeared mild and favorable, subsequently become very 
obstinate and malignant; and, in the midst of an apparent improve- 
ment, which has given hopes of a speedy recovery, the fever and local 
symptoms suddenly become worse again, and advance to a height not 
previously attained. 
In regard to the results of acute articular rheumatism, we must 
especially bear in mind that not only the mild cases, where few joints 
are affected and the fever is slight, may recover completely, but that 
recovery is also the usual termination for severe cases, where numerous 
joints are inflamed, very painful, and much swollen, and where the 
severe local symptoms are accompanied by corresponding fever. But, 
even in favorable cases, recovery does not take place with sudden sub- 
sidence of the symptoms, but with their gradual and not always regular 
diminution. Notwithstanding its treacherous course and its frequent 
complication with inflammation of the most important organs, this 
malady rarely terminates fatally. Death seldom occurs, except when 532 
DISEASES OF THE ORGANS OF LOCOMOTION. 
the cardiac complications are unusually severe and are accompanied by 
inflammation of the lungs and pleura; even in such cases, recovery often 
takes place, contrary to all expectation. Occasionally, also, death oc- 
curs with the symptoms of sudden collapse, when there is no complica- 
tion, being preceded for a short time by delirium, coma, or other symp- 
toms of great nervous disturbance. On autopsy, in such cases, no 
changes can generally be found in the central organs of the nervous 
system; hence it has been supposed that they depend on an unex- 
plained blood-poisoning. But it seems to me that this hypothesis is 
unjustifiable, till careful observations of the bodily temperature have 
shown that, in these cases, the fatal result is not due to the fever and 
the increase of the temperature to a point fatal to life; particularly 
since it has been shown that, in this disease, the temperature, which is 
usually moderate, may rise quite high. In a few instances, moreover, 
the severe brain-symptoms depend on inflammation of the meninges, 
that is, on changes analogous to those in the joints. I myself have only 
seen one case where the moderate increase of bodily temperature, the 
delirium in the first stage, and the subsequent coma, together with ex- 
cessive retardation of the pulse and repeated vomiting, left no doubt 
as to the nature of the disease. This case ended in recovery, so that 
the diagnosis was not confirmed by autopsy; but in a dissertation 
written by Dr. Flamrn, under the direction of my colleague Kohler, 
on “ Meningeal Symptoms in Acute Rheumatism,” cases are reported 
where post-mortem examination showed the presence of inflammatory 
disease of the meninges. It has not yet been decided whether the 
chronic cerebral disturbances, occasionally left after acute articular 
rheumatism are due to perceptible anatomical changes. Griesinget 
speaks of them as follows: “ The severe cerebral disturbance, lasting 
for months or more, caused by articular rheumatism, appears as insan- 
ity without fever, characterized by depression, or as pronounced melan- 
choly with stupor. It may be followed, or may alternate, with states 
of excitement; sometimes this disturbance is accompanied by convul- 
sive choreic movements; the prognosis is, on the whole, favorable; 
recovery seems to result most rapidly and certainly where, after a time, 
during the cerebral disturbance, the joints are again attacked -with 
acute rheumatism.” Acute articular rheumatism very often ends in 
incomplete cure. In many cases the fever, severe pain, and the swell- 
ing of most of the joints disappear, but a chronic rheumatism remains 
in certain joints, proves very obstinate, and often never entirely disap- 
pears. Still more frequently the patients live through the acute artic- 
ular rheumatism and its complications, but acquire valvular disease of 
the heart, which is never cured, and of which they soon die. After 
the disease has lasted a long time, particular!v if the fever was severe, ACUTE ARTICULAR RHEUMATISM. 
533 
the convalescents are usually very anaemic, and we may hear false 
murmurs in the heart and great vessels, which, on careless examination 
and insufficient attention to the general state of the patient, may be 
confounded with valvular affections. 
Treatment.—For acute articular rheumatism all kinds of antiphlo- 
gistic remedies have been used, particularly general and local bleed- 
ing, nitrates of potash and soda, tartrate of antimony in small doses, 
and many have thought it possible to shorten the course of the disease, 
and to prevent the complications, by energetic antiphlogistic treatment. 
From what we have said of the varying course and duration of the dis- 
ease, it is evident that it would be very difficult to prove any such 
suppositions. On the other hand, if energetic antiphlogosis did have 
a beneficial effect in some cases, the fact that the disease has often 
persisted for weeks and that heart-affections have often developed in 
spite of it, speaks against its infallibility. Hence, in recent times, the 
treatment by repeated bleeding, by large, and even dangerous doses 
of saltpetre, as well as the systematic use of tartar emetic, has been 
abandoned, and we now employ other remedies which may, perhaps, 
be as uncertain, but are, at all events, less dangerous. Nitrate of 
soda, in moderate doses ( 3 ij to 3 vi of water, a tablespoonful every 
two hours), has alone maintained its position in the treatment of acute 
articular rheumatism, and is prescribed by most physicians, without 
any great expectations from it, just as it is given in pneumonia and 
other febrile diseases. Since this remedy can hardly prove injurious 
in small doses, and since its antiphlogistic action has not been dis- 
proved, and is not at all improbable, arid, finally, as we know no other 
remedy that will certainly arrest or shorten the course of acute articu- 
lar rheumatism, we have nothing to say against its employment. Per- 
haps it has been wrong to follow Rademacher’s advice, and prescribe 
nitrate of soda instead of nitrate of potash, which is probably more 
active. Recently, great authorities recommend a return from cubic 
nitre to common nitre {Kohler). The next most popular remedies are 
colchicum (tinct. or vin. sem. colchici § ss, tinct. opii 3 ss, 15—20 
drops every three hours), lemon-juice ( § ss three times daily), iodide 
of potassium ( 3 ss— 3 j dissolved in 3—4 oz. water, during the day), qui- 
nine and the narcotics, especially opium and morphine We cannot, 
with our present experience, give any special indications for the em- 
ployment of colchicum, lemon-juice, and iodide of potassium, which 
seem to have proved serviceable in some cases, but most generally 
have no effect on the course of the disease. In very obstinate cases, 
with frequent relapses, we will employ these remedies, slight as is the 
hope of benefit from them. Quinine is no more a specific in acute 
articular rheumatism than in pneumonia, typhus, and many other dis 534 
DISEASES OF THE ORGANS OF LOCOMOTION. 
5ases in which it is, nevertheless, an important remedy. But it is one 
of the most powerful antipyretics, and it should be used when the 
fever is high. It is customary to give a scruple or half a drachm during 
the day, and it is best to give such large doses, for, according to my 
experience, it is only from large doses that we can expect any decided 
effect on the bodily temperature and frequency of the pulse. After 
the experiments of Weber and Billroth, there can scarcely be any 
doubt that the quality of the blood in fever patients decidedly favors 
inflammatory disturbances of nutrition. If this be so, an antipyretic 
treatment has also an antiphlogistic action, and quinine as well as 
other antipyretic remedies would answer not only the symptomatic 
indications, but also the indications from the disease, particularly in 
acute articular rheumatism, where, while the fever continues, new 
joints are continually becoming affected. At all events, quinine de- 
serves a full trial in acute rheumatism, when there is any great in- 
crease of bodily temperature. Most of the narcotics can be dispensed 
with; but opium and morphine are not only invaluable remedies for 
moderating the sufferings of the patient, but it also seems as if their 
exhibition prevented the inflammation in the joint reaching so high a 
point. I shall not attempt to say whether they shorten the course of 
the disease, as some observers claim they do; but I can affirm that, 
even where there is great fever, large doses of opium or morphine are 
well borne. Where the pain disturbs the night’s rest, it is advisable 
to give the patient a grain of opium, or one-quarter of a grain of mor- 
phia, in the evening; and, when the pain is uncommonly severe, we 
may order this dose every two hours, till relief is obtained. In the 
treatment of most cases of articular rheumatism, I limit myself to the 
exhibition of quinine and opium. Among the external remedies, warm 
and cold compresses, leeches, blisters, as well as numerous narcotic and 
irritant lotions and liniments are recommended. As might be sup 
posed from their number, these remedies have, on repeated trials, been 
of less service than was claimed by the person proposing them ; we 
must acknowledge that external remedies also usually have no effect 
on the course of the disease, and are at most only palliatives. Anv 
physician in good piactice will not deny that cases of acute articular 
rheumatism, coming under treatment at the commencement of the 
disease, often resist all external or internal treatment for three to 
six weeks or more. 
In cases of moderate intensity, it is well to envelop the affected 
joint in wadding; where the pain is severe, cool evaporating lotions 
are best, particularly as ice and cold-water compresses are popularly 
considered as bad antirheumatics and are consequently used irregularly, 
Elaylchlorfire ( 3 ss— 3 j, lightly rubbed in), as recommended by Wien CHRONIC ARTICULAR RHEUMATISM. 
535 
derlich, is an excellent palliative; but frictions with ether, which I 
used on economical grounds as a substitute for elaylchloriire, answered 
the same purpose. Local abstractions of blood should be limited to 
those cases where a single joint has been considerably swollen and 
painful for a long while. If, after repeated leeching, the pain and 
swelling do not subside, if they remain fixed in one joint after disap- 
pearing from the rest, we may cover it with blisters, or paint the skin 
with tincture of iodine. When ordering the diet of the patient, we 
must bear in mind the exhaustion threatened by the fever. Hot 
drinks should be forbidden, as they uselessly increase the perspiration. 
The room should not be kept too warm, but its temperature should be 
regular. The complications are to be treated as advised elsewhere. 
If, during the disease, severe cerebral symptoms come on, we must 
decide whether they depend on excessive increase of the bodily tem- 
perature, or on inflammation of the meninges. In the former case it 
will be well to reduce the temperature by wrapping the body in wet 
sheets, or by cool baths. Both should be repeated as often as the 
temperature threatens to increase to a great height. If, when the 
brain symptoms occur, the temperature be not greatly increased, we 
should apply leeches to the head, and then cover it with frozen com- 
presses.5 
CHAPTER II. 
CHRONIC ARTICULAR RHEUMATISM RHEUMATISMUS ARTICULORUM 
CHRONICUS RHEUMARTHRITIS CHRONICA. 
Etiology.—Chronic articular rheumatism is the njme applied to a 
chronic idiopathic inflammation of the joints, which usually attacks 
only one or a very few joints, which passes from one joint to another 
far more rarely than acute articular rheumatism does, and which, in 
spite of its long duration, induces comparatively little anatomical 
change. When chronic articular rheumatism leads to suppuration of 
the joint and caries of the ends of the bones, it is generally customary 
not to consider it any more as chronic articular rheumatism, but as 
chronic inflammation of the joint, and to transfer it to surgery just as 
we do arthrocace and tumor albus. Chronic deforming rheumatism we 
shall treat of in the next chapter. Chronic articular rheumatism often 
develops from the acute thus: after the disease has run its course in 
the other joints, one or more of them do not return to the normal state, 
Dut remain the seat of permanent disturbances. In other cases it ap- 
pears as a chronic disease from the start. Very frequently there is a 
decided congenital predisposition to chronic articular rheumatism ; on 536 
DISEASES OF THE ORGANS OF LOCOMOTION. 
the other hand there are numerous cases where such a predisposition 
is acquired. First among the predisposing causes are previous attacks 
of acute articular rheumatism, for after these there often remains a 
peculiar tendency to the chronic form which did not previously exist. 
The same is true of one or more attacks of chronic articular rheuma- 
tism, as this also usually leaves behind a so-called rheumatic predispo- 
sition. The most frequent exciting cause is catching cold, but espe- 
cially a protracted sojourn in cold, damp, and windy places. Thus 
almost all old wash-w’omen suffer from chronic articular rheumatism. 
In many cases the exciting cause cannot be determined. 
Anatomical Appearances.—In the comparatively rare cases 
where we have an opportunity to examine joints that have been the 
seat of chronic articular rheumatism, we generally find the synovial 
capsule and the ligaments of the joints thickened, the fringe-like pro 
cesses of the membrane hypertrophied, and not unfrequently degener- 
ated, the cartilages relaxed and shaggy, the synovia is cloudy. 
Symptoms and Course.—Chronic articular rheumatism appears 
under two different forms. In the first form, single joints are often for 
months or years the seat of constant pain. This is increased by press- 
ure, but particularly by active or passive motion, and there are also 
severe paroxysms of pain which apparently come on spontaneously, 
especially at night. If we place the hand on the joint in motion, we 
often perceive a distinct crackling or crepitation. Occasionally the 
joints are decidedly swollen; but the swelling does not depend on in- 
flammatory oedema of the subcutaneous tissue, as is the case in acute 
articular rheumatism, but entirely on an increase of the synovia in the 
joints, and on thickening of the capsule and ligaments. In other 
cases there is swelling, as there is no considerable effusion in the 
joint, or else the swelling is only apparent; the joint becomes more 
prominent, because the muscles are atrophied on the affected limb, 
which is always less used. Where this form lasts a long time, in- 
complete, false anchyloses are readily developed; but it rarely leads 
to tumor albus, or arthrocace. The second form of chronic articu- 
lar rheumatism consists mainly of a series of attacks of acute artic- 
ular rheumatism, occurring at short intervals, in wdiich certain joints 
are always affected. Persons suffering from this form often become 
“ rheumatic ” at every change of the weather, every time they are ex- 
posed to a draught, and just as often without any perceptible cause. 
Sometimes one joint is affected, sometimes another; it is slightly 
swollen, very sensitive to pressure, but particularly painful when 
moved. The fever, which is almost always present, is evinced by con- 
tinued frequence of pulse, constant perspiration, by thick sedimentary 
urine, as well as by the gradually increasing apathy and emaciation CHRONIC ARTICULAR RHEUMATISM. 
537 
of the patient. This form also of chronic articular rheumatism is very 
obstinate, and, once rooted, often lasts for life. It is frequently com- 
plicated with muscular rheumatism, and not unfrequently with those 
forms of neuralgia and paralysis which are usually termed rheumatic. 
Treatment.—The form of chronic articular rheumatism, limited to 
certain joints, requires chiefly a local treatment; while vague chronic 
articular rheumatism, on the other hand, requires to be treated gen- 
erally. In recent cases, the best local treatment is by leeches or wet 
cups. To attain satisfactory results, these should be frequently re- 
peated at moderate intervals; they then do excellent service, and 
cannot be replaced by any other remedy. Even in obstinate cases it 
is well to begin the treatment with leeches or wet cups, unless con- 
traindicated by the general state of the patient. The result of the 
first abstraction of blood must decide us whether to repeat it in such 
cases also, or to use derivatives instead. Among the latter, such as 
redden the skin, or cause superficial inflammation of it, are to be pre- 
ferred to those which, from their volatility, irritate the nasal mucous 
membrane, but cause no perceptible change in the skin. Heretical as 
it may sound, we still believe, that when the disagreeable opodeldoc, 
volatile liniment, spirits of camphor, as well as the fragrant mixtura 
oleoso-balsamica, prove beneficial, their efficacy is chiefly due to the 
manipulation of the parts. For support of this assertion, we may re- 
fer to the fact that of late even the laity, who formerly used the above 
remedies as a matter of course in all rheumatic affections, use them 
less frequently, and employ frictions with French brandy and salt in- 
stead. The application of sinapisms and frictions with spirits of mus- 
tard, by which the skin is temporarily reddened, are sometimes of un- 
doubted benefit, and, when continued regularly, may cause permanent 
improvement. Frictions with veratrine and chloroform liniment induce 
peculiar sensations in the skin, which, to some extent, speak for their 
derivative action. In mild cases I have employed a solution of veratria 
(gr. vj—x), in chloroform ( § ss), and mixt. oleoso-balsamica ( § ij), 
with apparently favorable effect. Vesicants are far more efficacious 
than rubefacients; among these may be classed painting the skin 
with tincture of iodine, as it causes the epidermis to be thrown off; 
and, if the undiluted tincture be used, it often induces blisters. In 
very obstinate cases, in order to secure a good result, the portions of 
surface denuded of cuticle must be kept suppurating for a time. I 
consider a powerful douche over the affected joint as the most efficient 
derivative, and even place it before the hot iron and moxaj, which art 
also advised in localized articular rheumatism. We may readily sat- 
isfy ourselves that an energetic douche will leave a hyperasmia of the 
skin lasting for several hours I have no personal experience of the 538 
DISEASES OF THE ORGANS OF LOCOMOTION. 
action of the steam douche. Besides the above-named local remedies, 
and the popular resin and narcotic plasters, the application of “ gout- 
paper ” (gicht papier), skins of animals, wadding, raw wool, cotton, etc., 
which partly favor derivation to the skin, partly maintain an equable 
temperature, other remedies are also used locally, which are expected 
to be absorbed, and consequently act favorably on the course of rheu- 
matism. Chief among these remedies are iodine and mercury. Little 
as I recommend frictions with mercurial ointment in these affections 
generally, I must still decidedly advise continued frictions of ointment 
of iodide of potassium, or of mercurial ointment, with iodide of potas- 
sium (3j— 3 ss), in old cases of fixed arterial rheumatism, where ab 
straction of blood and derivatives have proved inefficacious. The sec 
ond of these salves causes slight derivation to the skin at once, and, 
after a few days, there is an eczematous eruption of the part. Paint- 
ing the part once or twice daily with a lugoVs solution (iodine 3 ss, 
potass, iod. 3 ss, aq. dest. § j—ij) does excellent service. Among 
the most efficient methods of treating chronic articular rheumatism is 
the constant current of electricity. My experience with it is not very 
great, it is true; but it fully confirms the reports of HemaJc and Erb, 
that even obstinate cases of chronic articular rheumatism are usually 
cured after a few sittings. I pass quite strong currents through the 
affected joint, by applying thin metallic plates to the skin over the 
joint, instead of using the common olive-shaped electrodes. When 
the pain becomes too severe at the point where the negative pole is 
applied, I change the electrodes. The very favorable results of the 
constant current in chronic articular rheumatism confirm me in the be- 
lief that its results in neuralgias and paralysis also depend on its cata- 
lytic action. In the constitutional treatment, which must take a promi- 
nent part in the vague form of chronic rheumatism, and must be used 
in connection with local treatment in the fixed form, the systematic 
employment of warm baths deserves most confidence. As no physi- 
cian of experience will deny, man}?- persons are perfectly cured by one 
or more courses of treatment at Wildbad, Gastein, Pfiiffers, Ragaz, 
Teplitz, Wiesbaden, Rehme, etc., who had previously resisted all kinds 
of treatment for years. The fact that warm springs of very varied 
chemical composition, as well as those whose waters contain very little 
mineral matter, have equal reputation in chronic rheumatism, indicates 
very decidedly that the effect is much more dependent on the bathing 
in warm water than on the different qualities of the water. In well- 
constructed hospitals, provided with suitable baths, just as good re 
suits are attained in the treatment of chronic rheumatism as at Aix-la- 
Chapelle, Teplitz, and Wildbad, as I can show by some very striking 
although not very numerous cases from the Greifswalder clinic. In CHRONIC ARTICULAR RHEUMATISM. 
539 
private practice it is difficult to conduct the bath-treatment with the 
necessary care and prudence; hence it is generally better to send 
patients, whose means permit, to one of the above-mentioned warm 
springs. Baths of 95°—100° are sufficiently warm, and are probably 
to be preferred to those of higher temperature ; at least, according to 
my experience, Russian vapor-baths do less good in chronic rheuma- 
tism than warm-water baths. The same observation has been made 
elsewhere. The erection of a Russian vapor-bath, at a place where 
there has formerly been none, usually pays very well the first and 
second year, for most persons with chronic rheumatism crowd to it, ex- 
pecting to be cured; but the third and fourth years the number of 
customers is usually much less, and this is certainly not because the 
persons with rheumatism have all been cured, but because their hopes 
have been disappointed. From the experience at Wildbad, Leuk, 
and elsewhere, it seems advisable to gradually extend the duration of 
the bath, and, toward the end of the treatment, to let the patient 
pass an hour or more in it. It is very important for them to avoid 
taking cold after bathing, and it would be well to give them a blanket- 
sweat. It is customary to give about thirty warm baths in succession, 
and if this number proves insufficient, it seems better to stop their use, 
and take up the treatment again a few months later. In “ cold-water 
cures,” patients with chronic rheumatism, especially old cases, are not 
usually cured. I know not a few cases of this class who left the cold- 
water cure establishment, after a sojourn of several months, sicker 
than wrhen they entered. In recent cases, on the contrary, hydropathy 
appears to have a favorable effect. Among the “ anti-rheumatic ” 
medicaments, tine, colchici sem. ( f ss), with extract, aconit. ( 3 ss), 
and tine, opii ( 3 ss), in doses of 15—20 drops four times daily, has a 
great reputation, and is probably the most common prescription in 
chronic articular rheumatism. Unfortunately, we do not yet know in 
which cases colchicum (which is certainly not altogether inactive) is 
indicated, nor when we cannot expect any thing from it. Ammo- 
niated tincture of guaiac. and the antimonials, which formerly had the 
reputation of being active anti-rheumatics, are little used of late. In 
some cases of chronic articular rheumatism, and, as it seems, chiefly in 
those cases where the ligaments are mostly affected, iodide of potash 
in large doses (3 j—3 j daily) appears to be very serviceable. Im- 
provement ordinarily begins with the appearance of slight iodism, and 
it is advisable to increase the dose until the effect of the medicine is 
observed on the skin, or the mucous membrane of the nose. In recent 
cases, and in young persons, the regimen of the patient must differ from 
that in old cases, or patients of advanced age. "While, in the former, 
especially after improvement has begun, we should advise a careful 540 
DISEASES OF THE ORGAN'S OF LOCOMOTION. 
hardening process by washing in cold wrater, cold bathing in rivei or 
sea, regular walks in all kinds of weather, etc., in the latter, all op- 
portunities of catching cold should be avoided, the sea and river baths 
forbidden, and the patient should be advised to wear flannel next 
the skin. If the sleeping-room be dark and damp, we cannot too 
strongly urge its exchange for a healthier and drier one. 
CHAPTER III. 
DEFORMING ARTICULAR INFLAMMATION, ARTHRITIS DEFORMANS, AR- 
THRITIS NODOSA, ARTHRITIS PAUPERUM, ARTHRITE CHRONIQUE 
SECHE. 
Etiology.—By arthritis deformans, we mean those forms of artic- 
ular inflammation where not only the synovial capsule and ligaments 
of the joint exhibit the signs of a chronic inflammation having no ten- 
dency to suppuration, but where, at the same time, the cartilages and 
surfaces of bone in the joint show peculiar changes characteristic of 
this form of arthrophlogosis. The latter consist chiefly of a loss of 
the articular cartilage and surface of the bones, and in a central indu- 
ration of the epiphyses, accompanied by a proliferation of bone-sub- 
stance at the periphery. Arthritis deformans is by some authors re- 
garded as a peculiar form of chronic articular rheumatism, while others 
consider it as essentially different from the rheumatic affections. From 
the great elasticity of the term rheumatism, one view is as correct as 
the other. Arthritis deformans has at least this in common with the 
rheumatic inflammation of the joints described in the last chapter; it 
cannot always be traced to catching cold from living in damp places 
exposed to draughts. Arthritis deformans never occurs during child- 
hood. Solitary cases are seen about the age of puberty; it is most 
frequent between the twentieth and fortieth years ; but it also occurs 
later in life, and even in advanced age. It attacks women more fre- 
quently than men. It is so much more common among poor people 
than among the wealthy, that it has been termed arthritis pauperum. 
We do not know whether this depends on the bad, damp dwellings, on 
the want of good nourishment, or on some other causes to which the 
poor are more exposed than are the well-to-do classes. 
Anatomical Appearances.—On anatomical examination of the 
swollen, misshapen joints, we find the articular capsule decidedly 
thickened and covered with ragged proliferations. The joint contains 
a very small amount of synovia (hence the name arthrite chronique 
sbche). The articular cartilages are broken down into filaments, occa- 
sionally ossified, and in advanced cases they have entirely disappeared DEFORMING ARTICULAR RHEUMATISM. 
541 
by wasting away, so that the ends of the bones come in contact, and 
have smooth, articular surfaces. As a result of inflammatory atrophy 
the central parts of the epiphyses appear porous, while their size is 
decidedly increased, either regularly or in warty protuberances, by the 
formation of osteophytes. 
Syaiptoms and Course.—Arthritis deformans results from acute 
articular rheumatism much less frequently than the above-described 
chronic inflammation does; in most cases it develops slowly, and grad- 
ually reaches its height. A halt sometimes occurs in its progress, but 
never a retrogression or a disappearance of the existing deformity. 
At the commencement of the disease the patients complain of pain in 
the affected joints; this is usually slight, but is sometimes so severe as 
to rob them of sleep. The pain is increased by pressure, and still 
more by movement of the joint; if the hand be laid on it, we may al- 
most always perceive a crackling or crepitation. The affected joints 
seem decidedly thicker; the skin covering them is of normal color, or 
slightly reddened. The above changes most frequently affect the joints 
of the hand and feet, especially those of the fingers, toes, and the 
metacarpal and metatarsal articulations, but they may also attack any 
of the other joints of the body and even the spinal column. Cases 
where the patient is confined to his bed for years, or sits up during the 
day in an arm-chair and at night is carried to bed, may be found in al- 
most any large poor-house. The laity usually call this state being 
“ drawn up by the gout.” The symmetrical appearance and progress 
of the disease on the two sides of the body are often very remarkable. 
It is rare for one hand to be affected first, and the other one subse- 
quently ; the process is apt to begin simultaneously in both hands, and 
to pass to the two feet at the same time. Characteristic subluxations 
almost always occur in the affected joints, especially in the fingers; 
these are hardly explained by the widening of the epiphyses over 
which the tendons pass, by the destruction of the articular cartilages, 
and the smoothing off of the bony surfaces of the articulation. The 
phalanges are almost always flexed on the metacarpal bones, and are 
at the same time deviated toward the ulnar sides, so that the fingers 
lie over each other like the shingles in a roof. In the phalanges them 
selves the subluxations are sometimes in the flexed, sometimes in the 
extended position, in the different joints. Patients with this tedious 
disease may attain very old age. It is remarkable that, in spite of the 
long duration, there is rarely complete anchylosis. The above process 
sometimes occurs exclusively in the hip-joint, and then either induces a 
wearing off of the head of the bone, or the formation of large stalac- 
tite-like osteophytes, about its periphery. This disease, called malum 
coxae, senile, belongs to surgery. 542 
DISEASES OF THE ORGANS OF LOCOMOTION. 
Treatment.—Little hope as we have of removing by treatment 
the deformity that has once developed, I cannot agree with those 
authors who say that treatment is entirely useless in arthritis defor 
mans. The impairment of motion does not usually depend solely on 
the deformity, but to a considerable extent also on the still existing 
inflammation. The remedies which we placed in the first rank against 
chronic articular rheumatism, particularly the warm baths and the 
painting with tincture of iodine, have in many cases at least a favor- 
able effect on the inflammation. Every season at Toplitz, as I actu- 
ally know, and probably also in the other watering-places mentioned 
in the preceding chapter, some patients with arthritis deformans have 
improved so much that they were able to leave the chair with rollers, 
and after the termination of their treatment could roll other patients 
to the baths. 
CHAPTER IV. 
Etiology.—Under the terra muscular rheumatism it is customary 
to class not only rheumatic affections of the muscles, but also those of 
the fascia, periosteum, and other fibrous tissues, except those about 
the joints. The changes induced in these tissues by rheumatic affec- 
tions are not exactly known. The negative results of most autopsies 
seem to render it very probable that the anatomical changes are of 
that class that leave little trace in the cadaver, that is, that they consist 
chiefly in hypenemia and scanty serous exudations. In rare cases, how- 
ever, the rheumatic process appears not to be arrested at this point, 
but to lead to inflammatory proliferations of connective tissue. Fro- 
riep and Virchow found places in the muscles where the muscular 
tissue was replaced by callous connective tissue (rheumatic callosities), 
and Vogel observed thickenings and adhesions of the neurilemma of 
the corresponding nerves in several cases of chronic rheumatism. 
These cases are so rare compared with those where no changes can be 
discovered, that it is hazardous to base a definition of rheumatic affec- 
tions on them. Even supposing that hypermmia and serous exuda 
tions, and in severe cases an inflammatory proliferation of connective 
tissue, be the basis of the rheumatic affection, it still remains undeter- 
mined whether the sensory nerves traversing the muscles are morbidly 
excited by changes in the muscles and sarcolemma, or by simultaneous 
changes in their neurilemma. In the latter case, muscular rheumatism 
would be a so-called rheumatic neuralgia of the small nerves supply- 
ing the muscles. Regarding the etiology of muscular rheumatism, we 
MUSCULAR RHEUMATISM—RHEUMATISM LIS MUSCULARIS. MUSCULAR RHEUMATISM. 
543 
may refer to what we have said of the etiology of acute and chronic 
articular rheumatism, and the more so as muscular rheumatism is very 
often complicated with the articular form of the disease. Catching 
cold is certainly the most frequent cause; but the sudden occurrence 
of some forms, as lumbago, renders it very probable that, besides catch- 
ing cold, there are other causes, especially straining or fatigue of the 
muscles, etc. 
Symptoms and Course.—The most important, and usually the 
only symptom of muscular rheumatism, is the pain which is generally 
designated as stretching or tearing. Moving or rubbing the affected 
tissues increases this pain, while regular pressure generally diminishes 
it. Occasionally the pain is accompanied by inability to shorten the 
affected muscle, and to make active movements with it. The skin 
covering the part does not appear red and swollen, or warmer than 
the surrounding parts. The pain usually exacerbates toward evening, 
and remits in the morning. It is generally made worse by cold and 
dampness, and improved by dry warmth. But sometimes the warmth 
of the bed increases rheumatic pains. Occasionally muscular rheuma- 
tism is “ wandering,” that is, the pain leaves one place and appears in 
another. Sometimes it remains “ fixed ” in certain muscles, fascias, 
etc. In most cases muscular rheumatism is an acute disease, which 
entirely disappears after a short duration ; rarely it is a chronic affec- 
tion, and either the wandering or fixed form may become chronic, just 
as wandering or articular rheumatism does. According to its 
location, muscular rheumatism has received various and sometimes pe- 
culiar names. If the frontal, occipital, or temporal muscles, the galea 
aponeurotica, or the periosteum of the skull be affected, we term it a 
cephalalgia rheumatica. We should make it a rule not to misuse this 
name, and in each case, before making a diagnosis of cephalalgia rheu- 
matica, to determine carefully if the above tissues be really the seat of 
the pain, whether movement of their fibres or contraction of the muscles 
increases the pain, and, finally, whether the affection be primary and 
idiopathic. Rheumatism of the head is most readily mistaken for neu- 
ralgia, or syphilitic periostitis. It is a very common, bad habit, to 
ascribe to rheumatism the numerous cases of severe and obstinate 
headache whose true cause we cannot discover. The laity, who do 
not make any great distinction between rheumatism and gout, gener- 
ally call all obstinate headaches gout in the head. If the muscles of 
the neck be affected with rheumatism, the movements of the head be- 
come painful; the patients fear and shun them. There is “ stiff neck,” 
an affection which complicates many cases of angina faucium. If the 
muscles of only one side of the neck be affected, the head is held con- 
stantly io one side (“wry neck,” torticollis rheumaticas). This affeo 544 
DISEASES OF THE ORGANS OF LOCOMOTION. 
tion, which is generally mild, and subsides in a few days, becomes 
chronic, and may induce permanent shortening of the muscles in some 
cases, which, however can hardly be distinguished from the previously 
described spastic form of torticollis. Rheumatismus pectoris, or pleu- 
rodynia rheumatica, occurs chiefly in the pecfcoralis major and inter- 
costal muscles. In the former case, the movement of the arm forward 
and motion of the affected muscular filaments are painful; in the sec 
ond case, the respiratory movements, and especially coughing and 
sneezing, as well as bending the thorax laterally, are so. From the 
hinderance to the respiration, these patients look as if the pain were 
deeper seated—as if the lung or pleura were diseased; and as mov- 
ing the skin, fascia superficiahs and pectoralis, does not increase the 
pain, the physician also might be deceived, if moving the intercostal 
muscles from before backward with the point of the finger did not ren- 
der the pain unbearable, while laying the hand on the part and making 
even pressure usually moderates it; and if the absence of cough, and 
especially the physical examination of the breast, did not confirm the 
diagnosis. Rheumatism of the back, particularly of the shoulders, 
omodynia rheumatica, is among the most frequent forms of muscular 
rheumatism; it is easily recognized by the impaired motion of the 
shoulder-blade and arm, as well as by the severe pain induced by mov- 
ing the filaments of the trapezius, latissimus dorsi, and deltoid, or if the 
deeper layer of muscles be affected by the stiff position of the patient, 
and the severe pain induced by stooping. Painful affections of the 
abdominal muscles occur chiefly after severe straining in coughing, and, 
from their severity, may excite the suspicion of severe disease. Noting 
the state of the pain on regular pressure over the abdomen, and on 
movement of the muscular filaments, is the best means of avoiding 
error. Rheumatism of the lumbar muscles and lumbo-dorsal fascia, 
lumbago rheumatica, is remarkable for its severity and its frequently 
very rapid occurrence. Not unfrequently, patients who, a few minutes 
previously could move with perfect ease, cannot rise from their seat, 
or at least suffer severely while doing so. When they go to bed, or 
get up also, or even when they wish to sit up in bed, or on any at- 
tempt to move the lower part of the spinal column, they make wry 
faces, cry out, and place themselves in the most peculiar attitudes to 
favor the painful parts, and attain their end without motion of these 
parts. Hence, patients suffering this “ witch’s spell ” (“ Hexenschuss ”) 
excite laughter as well as pity. Lastly, all the muscles of the extrem- 
ities may be attacked with rheumatism either individually or in groups, 
so that sometimes one and sometimes another set of motions becomes 
painful or impossible. 
Treatment.—The same principles answer for the treatment of MUSCULAR RHEUMATISM. 
545 
muscular rheumatism that we laid down for that of chronic articular 
rheumatism; that is, in the fixed form the treatment must be rather 
local; in the wandering form, more general. But, as the former is 
usually a milder and less obstinate disease than the latter, less ener- 
getic treatment is necessary in most cases. The most successful local 
treatment is abstraction of blood, by wet cups, if possible. The life- 
invigorator (Lebenswecker) has, of course, just the same effect as cup- 
ping ; formerly its effect in rheumatism was regarded, even by physi- 
cians, as miraculous. The success of irritating liniments, blisters, sina- 
pisms, plasters, gout-paper, or skins of animals, in muscular rheuma- 
tism, is about the same as in articular rheumatism. Perhaps one of 
the most effective, but at the same time most painful, rubefacients, is 
the application of the induced current by means of the electrical brush. 
The same is true of the use of the constant current in this affection as 
in chronic articular rheumatism. I can fully confirm the brilliant re- 
sults reported by Erb. Stroking and kneading the painful muscles, 
which forms the regular business of some persons called “ rubbers,” is 
one of the most efficient means of local treatment. Diaphoresis is the 
most reliable constitutional remedy. Treatment by baths is rarely 
necessary, and is so only in obstinate cases which are usually compli- 
cated with chronic articular rheumatism. A few cups of elder-blow 
tea, or some warm drink, and plenty of blankets over the patient to 
excite profuse perspiration once or twice, usually improve or remove 
muscular rheumatism. In recent cases a vapor-bath often gives in- 
stant relief; and although I have spoken against the continued use of 
vapor-baths in chronic articular rheumatism, I can recommend the trial 
of one or two in recent cases of muscular rheumatism. 
CHAPTER Y. 
GOUT—PODAGRA—ARTHRITIS. 
Etiology.—There is scarcely any disease that shows so great a 
similarity of symptoms at the commencement of all cases, and which 
consequently is so markedly a peculiar disease, as gout. It is true, 
old cases may resemble other diseases, particularly rheumatism ; but, 
in such cases, it is only necessary to inquire about the commencement 
of the affection, in order to prevent its being mistaken for rheumatism. 
But although it is certain that gout is a peculiar form of disease, and 
although constant chemical changes have been observed in the blood 
of gouty patients (Garrod), and uric acid, the substance w7hich is in 
excess in the blood, has been found in the products of gouty inflam- 
mation, still we have no exact knowledge of the pathogeny of this 546 
DISEASES OF THE ORGANS OF LOCOMOTION. 
disease. We neither know whether the u uric-acid diathesis ” be the 
primary and chief anomaly in gout, and whether it be not accompa- 
nied by other and more important changes in the composition of the 
blood; nor do we know the disturbances of nutrition by which one 
of the constant products of normal nutrition, uric acid, is formed 
in excess. The remote causes of gout are somewhat better known. 
It is proved by statistics that hereditary tendency is the most impor- 
tant factor in the etiology of gout. It can be traced in about half the 
cases. If there be an hereditary predisposition, a slight amount of the 
following exciting causes will induce the disease, while persons with- 
out this hereditary tendency are rarely affected by gout, even when 
they are greatly exposed to the same injurious influences. Gout does 
not occur during childhood; it is rarer among women than men; in 
the latter it usually occurs after the thirtieth year of life. Among 
poor folks it is so rare, that the disease is hardly ever seen in hospital, 
among the well-to-do classes, it chiefly affects persons given to the 
pleasures of the table, who drink wine or beer regularly, and take 
little exercise. All these points render it probable that, next to he- 
reditary predisposition, the supply of more nourishment than is used is 
to be regarded as the most important etiological factor of gout. 
Among children, women, mechanics, and poor people, this dispropor- 
tion is rare ; but even during manhood, where it is common among 
the better classes, those persons escape the gout who do not eat and 
drink more than is necessary to replace what has been used up in the 
body. The assertion that in the above mode of life a larger amount 
of uric acid is formed, because so much of the nitrogenous constituents 
of the body are broken up, that there is not sufficient oxygen intro- 
duced by respiration to transform them into urea by further oxidation, 
and that this increased formation of uric acid and its collection in the 
blood appears under the form of gout, is a pure hypothesis which is 
not supported by facts, although it seems very plausible. If the case 
were so simple, the world would swarm with gouty patients, while, as it 
is, only a small proportion of topers and gourmands are affected by gout. 
The experiments of Ilopps-Seyler and Zalesky, who, in order to 
find out something about the origin of uraemia, tied the ureters in geese 
and chickens, and, a few days after the operation, found almost all the 
viscera covered with crystals of the urates and the joints incrusted 
with them in a manner that very strongly reminded of gout, render 
die following hypothesis of the relation of the gouty diathesis to the 
attack of gout 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 ser- 
pents. As long as the excess of uric acid is regularly excreted by the GOUT. 
547 
iddneys, tlie affected persons get along tolerably well, or have 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 urine is 
impeded; for then, just as in the animals above mentioned, there is a 
collection of urates in the blood, and they are deposited in the joints 
and other organs, and we have an attack of gout. If the deposit of 
urates in the uriniferous tubules be soon washed away, and the red 
sandy sediment form in the urine, which we sometimes find even on 
the diapers of young children, the attack of gout passes over; if this 
do not take place, and the kidneys atrophy, the acute attack becomes 
chronic gout. This hypothesis is strongly supported by the fact that 
Garrod and other trustworthy observers have always found the kid- 
neys diseased, they being irregularly atrophied and the seat of uric- 
acid infarctions. I am far from considering this theory, to which 
Traube also is inclined, as proved; but I think that it agrees with the 
physiological and pathological facts better than any other theory. If it 
should finally be proved that the blood of gouty patients always con- 
tains more uric acid than normal, while the urine constantly contains 
less than usual during the attack, our theory would receive a still fur- 
ther support. 
Anatomical Appearances.—On autopsy of gouty patients, which 
is of rare occurrence in hospital, in the affected joints we find the re- 
mains of a more or less intense inflammation, and genuine gout is 
characterized by incrustation of the surfaces of the joint by chalk-like 
masses, consisting of urates. In mild grades of the disease, only a few 
joints are changed in this way. Frequently only the first joint of the 
great toe is in this state. In severe and old cases, we usually find 
numerous joints diseased; their articular surfaces are covered with thick 
layers of urates, the cartilages are rough, the ligaments, periosteum, 
and the mucous bursas near the diseased joints, are covered with thick 
deposits of these salts. In such cases the joints are often much de- 
formed, and through the dark, bluish-red skin we may often see white 
chalky masses. We may also find these deposits at other points, 
especially in the knuckles, eyelids, and cartilages of the ears. In the 
auricle, where they are only covered by thin skin, they form white 
pearls surrounded by varicose vessels (a certain sign of arthritis). I 
know nothing from personal observation of the above-mentioned 
changes in the kidney. According to Garrod, who has very carefully 
described and pictured them, gouty kidneys very much resemble those 
in the third stage of Bright’s disease, except that, in the pyramids, 
there are always white stria?, consisting of urates running in the direc- 
tion of the tubuli recti, and on the apex of each papilla a white point 
of the same substance. 548 
DISEASES OF THE ORGANS OF LOCOMOTION. 
Symptoms and Course.—Most gouty patients have shown, by 
their appearance or sensations, some other results of high living before 
the first attack of gout. They have usually become fat; the face, 
particularly the nose, is reddened, from the development of varicose 
vessels; they have hemorrhoids; we cannot, however, say that these, 
and other signs which occur in various modifications, are premonitor} 
tokens of this disease. 
But, besides the above symptoms, the first attack, as well as the 
subsequent ones, is usually preceded by true premonitory constitu- 
tional symptoms, arthritis imperfecta, or status arthriticus. The 
patients feel languid, their sleep is restless; the appetite is impaired, 
and they have indigestion; they complain of palpitation of the heart 
and constriction of the chest; they sweat profusely, and frequently 
pass small amounts of concentrated urine. Careless patients do not 
generally pay much attention to these premonitions, say nothing about 
them to their physician, and continue their previous mode of life. 
Hence the attack of gout almost always comes unexpectedly, in 
spite of the premonitions, and surprises the patient like a thief in 
the night. After he has gone to bed, without dreaming of the com- 
ing evil, and has gone quietly to sleep, he is awakened, generally soon 
after midnight, by a severe burning piercing pain in the metatarso- 
phalangeal articulation of the great toe. The pain rapidly becomes 
unbearable. The patient feels as if the affected joint were in a vice; he 
sighs, moans, throws himself around in bed; the leg or even the entire 
body trembles with pain. Soon after the commencement of the attack, 
the skin covering the affected joint begins to swell and redden, and 
there is fever, with a full, bounding pulse, dry skin, intense thirst, con- 
centrated urine, and great mental excitement. Toward morning there 
is a remission, and in the course of the following day the state of the 
patient generally becomes endurable, although the pains have not 
entirely disappeared, and the ball of the affected toe is more swollen, 
shining, and very red, and the whole leg is slightly swollen by oedema. 
The next night the scene of the past one is repeated with equal or some- 
what less severity; the following day brings another remission, and so 
passable days alternate with bad nights for about a week, rarely 
onger, at least in the first attack; then the patient is temporarily free 
from his trouble. After the redness and swelling have gradually sub- 
sided from the ball of the great toe, there is a desquamation of the 
cuticle, and the parts return to their normal state. The first attack of 
gout hardly ever leaves any deformity. It does not often affect any 
joint but the first one of the great toe; in other words, it is rare for 
the first attack, instead of being a podagra, to be a chiragra, gonagra, 
or omagra. After the patient has recovered from his pain and sleep GOUT. 
549 
'ess nights, he usually feels better than before the attack; hence the 
gouty attack has often been considered as critical, and it has been as- 
serted that during or through it a materies peccans has been removed 
from the body. There is no reason for assuming this hypothesis in 
explanation of the improved condition. The attack of gout places the 
patient under circumstances directly opposite to those which have in- 
duced his illness. The transmutation of the constituents of the body 
is greatly increased by the fever, while there is a very insufficient sup- 
ply of replacing material; the sleeplessness and pain also increase the 
consumption, or hinder the change of tissue ; the disproportion between 
supply and demand, which we have indicated as the most important 
etiological factor in gout, and which also lies at the root of its compli- 
cations, such as corpulence, piles, etc., is thus more than equalized by 
the gouty attack and the accompanying fever; and this is the simple 
explanation of the improved condition of the patient after the fit. If 
pain and suffering that have left no mark were not so soon forgotten, the 
first attack of gout would often be the last. But, after following their 
good resolutions and the advice of the physician for a few months, gouty 
patients generally return to their previous habits; the first attack is 
followed by a second, this by a third, and so on by a series of parox- 
ysms whose course corresponds with that of the first. At first, the 
interval between the attacks lasts a year or more; later, several at- 
tacks occur in one year. As the intervals become shorter, the attacks 
usually deviate more and more from the first type; the free intervals 
are then generally less perfect; the gout, instead of being regular, be- 
comes irregular, chronic instead of acute, atonic instead of tonic. 
We give the name of chronic gout to those irregular forms where 
the attack is preceded for some time by premonitory symptoms, espe- 
cially dyspepsia, where the seizures are accompanied by less pain and 
fever, but last for weeks or months, and several joints are affected at 
the same time, or in succession; and the previously-described chalky 
deposits of the urates in and about the joints occur chiefly in chronic 
gout. The swelling and redness, which in acute attacks attain their 
height the second day, develop more slowly in chronic gout; the red- 
ness is generally less intense, the swelling more diffuse and oedematous. 
After the termination of the paroxysm, the swelling does not disap- 
pear with desquamation of the cuticle, as it does in acute gout, but it 
continues, feels soft and doughy at first, and later it contains firm bodies 
of variable size, and at last a hard tophus is left. This is small in pro- 
portion to the tumor whose remains it represents, but after repeated 
attacks it grows by new deposits, and may attain a considerable size. 
The deposits within the joints, the calcareous masses as well as the 
inflammatory changes in the capsule and ligaments of the joint, induced 550 
DISEASES OF THE ORGANS OF LOCOMOTION. 
by the continued irritation of the deposits, after a time cause pain, dif- 
ficulty of motion, and deformity of the affected joints during the inter- 
val between the attacks. The patients often have difficulty in getting 
about with the aid of a cane, and the usefulness of the hands and arms 
is impaired if these be affected. In some cases, irritation of the sur- 
rounding parts, by the concrements, induces phlegmonous inflamma- 
tion. Abscesses form about the joint, and mortar-like masses, or firm 
concrements, are not unfrequently mingled with the pus evacuated 
from them. In proportion as the function of the limbs is gradually 
impaired in chronic gout, the patient becomes infirm. The fulness of 
body and strength are lost, and the digestion is impaired; the patient 
suffers from acid stomach, flatulence and irregular bowels; often, also, 
there is disturbance of the circulation, and generally great irritability 
and uneasiness. It is customary to refer the numerous disturbances 
of function and nutrition that occur in the course of chronic gout to 
the anomalous condition of the blood, or the gouty dyscrasia; still it 
is possible that an insidious fever, only to be recognized by the ther- 
mometer, accompanies chronic gout, and induces the general cachexia. 
As a rule, chronic gout results from the acute form, as we said above, 
after the patient’s constitution has suffered from repeated attacks of 
the latter, or from debilitating treatment; but cases also occur where 
the disease is primary. 
Atonic or anomalous gout is the designation generally applied to 
those forms where there is no actual attack of gout; or, as the name 
“ atonic ” indicates, where the debilitated organism is not in condition 
to develop a normal attack of gout. Formerly the diagnosis of atonic 
or anomalous gout was carried to excess ; but, on the other hand, it is 
certainly going too far to class many of the symptoms, some of them 
very peculiar, as accidental complications of the disease, and not 
directly dependent on it. In persons who have previously suffered 
from attacks of regular acute gout, we not unfrequently meet a con- 
dition which we are perfectly justified in calling atonic gout. In such 
patients there is a permanent constitutional affection, which shows 
itself chiefly by excessive general hyperacsthesia, muscular weakness, 
and dyspepsia, and usually also by an increased amount of perspira- 
tion, and thick, cloudy urine. The most insignificant causes, such as 
slight errors of diet, excitement, exposure to cold, changes of weather, 
and often without perceptible cause, these constitutional symptoms 
are accompanied by pains in one or more joints, which are very severe, 
and resemble commencing attacks of gout. But there is only a mod- 
erate redness and slight swelling, which disappear after a few hours ; 
in other cases there is no redness or swelling, and the severe pain is 
the only indication of the gouty attack. If there have already beer GOUT. 
551 
ordinary attacks of the disease, this not unfrequent condition is readily 
recognized, and intercurrent acute attacks place the diagnosis of atonic 
gout beyond doubt. 
The correct appreciation of the symptoms, and the diagnosis of the 
disease from chronic wandering rheumatism, is far more difficult, if 
there have been no precedent or intercurrent attacks of gout. It 
seems to me there is no doubt that this atonic form of the disease is 
also occasionally primary, and even Avhen there have been no attacks 
of gout I think it must be diagnosed, where there is an hereditary pre- 
disposition, and where the disease has been preceded by luxurious liv- 
ing, and where it is chiefly the smaller joints of the foot and hand that 
become painful, red, and swollen. I have seen such cases where the 
diagnosis was strongly supported by the experience of the patient. 
The patients themselves have not only remarked that they could ex- 
pose themselves to catching cold with impunity, while the return to 
careless diet, and the use of beer and wine, always made them worse; 
but they have also observed that antirheumatic treatment did not im- 
prove their case, wThile there was actual and permanent improvement 
both of the local symptoms and general cachexia, by a course of treat- 
ment hastening the transformation of tissue. 
I have no doubt that in gouty patients there is sometimes a de- 
posit of urates, accompanied by hypenemia and inflammation, in other 
organs instead of in the joints; or, in other words, that an anomalous 
internal gout, the arthritis metastatica retrograda of the old authors, 
actually occurs. For the support of this view, I lay less weight on 
the observations of Zalesky, who, after ligating the ureters of chickens 
and geese, found deposits of urates not only in the joints, but in al- 
most all the organs, among others in the stomach, heart, and lungs, 
than on a series of clinical observations, which admit of no other 
interpretation. For instance, some time ago, in an old gentleman, 
who had suffered for years from gout, I saw an angina begin simul- 
taneously with a typical attack of gouty inflammation of the joints; it 
was characterized by a peculiar blue color of the fauces, by a very dif- 
ferent course from ordinary forms of angina, and lasted as long as the 
inflammation of the joints did. I have not the slightest doubt that 
this was a case of gouty angina. In two other patients, who also suf- 
fered from gout, I have seen cerebral troubles, which I must regard as 
circumscribed gouty inflammation of the meninges. All other diseases 
of the brain or membranes could be excluded with certainty, especially 
when the symptoms, which appeared very dangerous, and had excited 
great anxiety, disappeared in the one case with a copious excretion of 
urates in the urine; in the other, with an attack of gouty inflammation 
of the joints. It is true, autopsy has not proved the occurrence of in- 552 
DISEASES OF THE ORGANS OF LOCOMOTION. 
ternal gout. But we must remember how rarely we have the oppor- 
tunity of making autopsies on gouty patients, and how carefully an 
examination would have to be made to discover deposits of urates in 
the gastric mucous membrane, lungs, or heart; also, that it is not at 
all improbable that these deposits disappear after the attack is over. 
The organs most frequently attacked by gout appear to be the stom- 
ach, brain, and heart. 1. Gout in the stomach appears with the 
symptoms of severe cardialgia, which is occasionally accompanied by 
violent vomiting, and sometimes with haematemesis. 2. Gout in the 
brain may sometimes present the appearance of apoplexie foudroyante, 
while in other cases it manifests itself by severe circumscribed head- 
ache, dizziness, and vomiting. 3. Gout in the heart induces irregular 
and enfeebled action of that organ, and, as a consequence of the dis- 
turbed circulation, dyspnoea, or fainting. Lastly, cases are reported 
where there was metastasis to the spinal marrow, inducing sudden 
paraplegia, and to the lungs, causing asthmatic attacks. We must 
take care not to refer every intercurrent disease, affecting a patient of 
gouty diathesis, to an attack of anomalous gout. We are only justified 
in so doing when the disease runs its course with unusual symptoms ; 
also when the patient is affected with gouty inflammation of the joints 
at the same time; when disease, running a peculiar course, occurs 
suddenly in an internal organ while a gouty affection of the joints is 
subsiding or developing ; and lastly, when the termination of the dis- 
ease is accompanied by a copious excretion of urates through the kid- 
neys. 
The course of the disease is tedious and insidious. The termina- 
tion in permanent cure is rare, but would be more common if the 
patient would entirely change his mode of life before the disease be- 
comes firmly rooted. Death, also, is a rare termination, and results 
almost exclusively from severe attacks of anomalous internal gout. 
Most patients die of complications, or of intercurrent diseases. 
Treatment.—Since, next to hereditary predisposition, the dispro- 
portion between supply and demand is the most important cause of 
gout, the causal indications require the removal of this disproportion 
by limiting the supply and increasing the consumption. During the 
course of gout, particularly when the disease has become irregular 
instead of regular, there is a time when the state of the patient does 
not permit a restriction of the supply, and where the increase of con- 
sumption must be made very carefully; but in all recent cases of regu- 
lar gout, and in all patients whose general health and nutritive condi- 
tion indicate a continuance of this disproportion, the fulfilment of this 
indication is the only means from which we can expect a cure. Hence 
we see that in treating gout we should write few prescriptions, but GOUT, 
553 
should regulate the habits of the patient. First, it is necessary to 
prescribe precisely the form, quantity, and quality of his food. A 
gouty patient should be carefully taught what and how much he may 
eat, because, although he breaks the rules often enough, he gives way 
to excess less readily than he would if he could excuse his errors by 
the plea of ignorance. How many patients there are who fear the 
evil results of breaking the rules laid down for them far less than they 
do the reproaches of their physician! Gouty patients must be abso- 
lutely forbidden to go to dinners, etc., even if they promise to be very 
moderate. It is best for them to eat only vegetables, soups, etc., and 
to have meat only once a day. The use of beer and wine retards the 
transformation of tissue, and hence is injurious for gouty patients. 
Any one may observe on himself that he requires less to eat when he 
drinks wine or beer with his meals, and also that when using these 
articles moderately he bears fatigue better than he does without. Per- 
sons but little inclined to the production of fat, under the regular and 
free use of wine and beer, become very obese, and from this mode of 
life most persons have a red face and distended veins, until their diges- 
tion is impaired or there is some other injurious consequence. This 
consideration, as well as the fact that in persons who drink neither 
wine nor beer the occurrence of gout is very exceptional, should in- 
duce us to forbid these drinks altogether, or else to give directions to 
have them stopped off gradually. The same is true of the use of tea 
and coffee. Although there is but little nutritive material in these 
drinks, and consequently the actual supply of nutriment to the body 
is but little increased by their use, still there is no doubt that tea and 
coffee have the same influence on the transformation of tissue that 
wine and beer have; they preserve the strength, diminish the need of 
uutriment, limit the consumption, and hence are injurious to gouty 
patients. Drinking large quantities of water has just the opposite 
effect on the transformation of tissue from what is induced by the use 
of tea and coffee, or of beer and wine. After drinking freely of water, 
no one feels less need of food, fatigue is not better borne, it does not 
induce corpulence and a red face; on the other hand, it has been 
shown that, when plenty of water is taken, the amount of water passed 
is greater than it would be under like circumstances, without this in- 
creased supply; and as the amount of urea excreted after drinking 
plenty of water is increased permanently, not temporarily, we are led 
to the conclusion that much water hastens the transformation of tissue, 
and hence is as beneficial for the gouty patient as drinking coffee and 
tea or wine and beer is injurious. Lastly, since muscular action also 
nastens the transformation of tissue and the consumption of the con- 
stituents of the body, it may be readily seen that a lazy, easy life is 554 
DISEASES of the organs of locomotion. 
bad for gouty patients, and that active exercise is important in the 
treatment. We should not have entered into this discussion of theo- 
ries, if theory and practice did not fully agree in the treatment. The 
rules that we might lay down for the treatment of gout, from the 
known action of certain substances on the transformation of tissue, 
have long since been proved correct at the bedside of the patient. 
The treatment by mineral waters forms a kind of connecting link be- 
tween dietetic and medical treatment; it is perhaps more highly es- 
teemed in gout than in any other disease. The springs celebrated as 
being antiarthritic are those of Vichy, Karlsbad, Marienbad, Kissin- 
gen, Homburg, etc. The favorable effect of these mineral waters 
appears to depend on their reducing the plethora, due to a mispropor- 
tion between supply and demand in the body, whether the plethora 
depend solely on hypertrophy of the blood, i. e., an increase of its 
cellular elements and a certain density of the intercellular substance 
(the serum of the blood), or on an accompanying absolute increase of 
the amount of blood contained in the body. It is very interesting to 
note that the beneficial influence of these natural mineral waters on 
plethora, which has been long known, and which far exceeds that of 
ordinary water, agrees with the observations of C. Schmidt and Vogel, 
according to which the amount of albumen in the serum of the blood 
is inversely proportional to the amount of salt. I am undecided as to 
which of the above springs deserves the preference in the treatment 
of gout, whether the solution of salt, of which the Kissingen and 
Homburg waters consist, removes the plethora more rapidly and com- 
pletely than Karlsbad and Marienbad water, or the reverse. Nor 
shall I attempt to say whether the supply of those solutions of salt 
act beneficially not only on the plethora but also on that anomaly of 
the change of tissue which shows itself as the gouty (uric acid) dia- 
thesis in some plethoric persons. Nor can we, with our present knowl- 
edge, say whether in any particular case the preference should be 
given to Kissingen, Karlsbad, Wiesbaden, Homburg, or Vichy, and 
what would constitute the peculiarity of the case which indicates one 
rather than the others. It cannot be denied that in recent times the 
regular therapeutic employment of the so-called BuUricK’s salt, a mix- 
ture of bicarbonate and sulphuret of soda, rivals the world-renowned 
success of these springs—a fact which is at least opposed to the 
asserted latent peculiarities and advantages of the natural solutions 
of salt. Advantageous as the above treatment proves in recent cases 
of regular gout, if carefully and judiciously instituted, there is often 
great harm done by excessive limitation of the supply of nourishment, 
by the sudden complete abstraction of spirituous liquors that had 
been used for years, as well as by all other debilitating courses of GOUT. 
555 
treatment which are employed carelessly or hastily. The patient is 
often freed from attacks of acute gout by this too zealous or too hasty 
treatment, but becomes affected instead with irregular, chronic, or 
atonic gout, an exchange by which he certainly gains nothing. As 
soon as gouty patients begin to show the signs of general cachexia, 
their disease is rendered worse by a continuation of this debilitating 
treatment; we should then prescribe nutritive diet for them, and even 
allow them to drink wine. But we must warn against excess even in 
the strengthening treatment then indicated. Although in this stage 
of the disease it is not admissible to limit the supply of nutriment, we 
should nevertheless carefully try to increase the change of tissue. 
Under no circumstances should we allow the patient to give himself up 
to sluggish ease, but should see that he exercises as much as his 
strength permits ; we should not allow more wine than is sufficient 
for a slightly tonic and refreshing effect, and it is always better to let 
the patient use the ferruginous, alkaline-saline and alkaline-muriatic 
mineral waters, such as Eger, Kissingen, or Homburg, than to pre- 
scribe simple chalybeate waters or preparations of iron. If there be 
at the time no indication for prescribing solutions of salts, we should 
at least see that the patient drinks plenty of water. In order that this 
prescription may be regularly obeyed, we should direct how much 
water is to be drunk daily. The probability that a retention of urates 
from obstruction of the uriniferous tubules induces the attack of gout, 
makes it appear practical to maintain the secretory pressure in the 
kidneys at a certain height, and to dilute the urine, as the urates re- 
quire a great deal of water for their dilution. In the later stages of 
the disease the akratothermal springs, Wildbad, Gastein, Pfaffers, etc., 
are very serviceable. We may have the patient drink of these waters 
and bathe in them; perhaps the infarctions obstructing the tubules 
may be carried away by the former, and the kidneys washed out, as it 
were, while the latter has the most beneficial effect on the inflamma- 
tion of the joints. 
We cannot give any rules for fulfilling the indicatio morbi, as the 
gout is a peculiar and obscure disease, which we can neither cure by 
so-called rational treatment, nor have we any specific for it. It is true 
some physicians consider colchicum as a specific in gout; but its action 
appears to be only palliative. The practice of giving colchicum for a 
long time is being gradually discontinued, and it is administered only 
luring the acute attacks. Most physicians of the last century, who 
generally had a high opinion of the efficacy of medicines, considerea 
gout as a noli me tangere, and even at present we cannot sufficient!) 
warn against the uncalled-for and injurious administration of medica- 
ments in this disease. 556 
DISEASES OF THE ORGANS OF LOCOMOTION. 
The symptomatic indications require us, first of all, to shorten the 
attack and to render it as bearable as possible; for the idea that the 
gouty attacK must be guarded and cared for, because it has a beneficial 
depurative effect on the organism, has been very justly abandoned. 
Experience has shown that, in gouty inflammation, antiphlogistics 
neither alleviate the pain nor shorten the attack; and it has also 
shown that the untimely use of antiphlogistics, especially general and 
local bleeding and active saline purges, favors the passage of regular 
acute gout into irregular chronic and atonic gout. We should also 
advise against the application of cold or of warm and narcotic com- 
presses over the painful joints; on the other hand, in attacks of acute 
or chronic gout, the narcotics, and, above all, colchicum, should be 
freely given. It has not yet been decided to what peculiarity colchi- 
cum owes its efficacy. Garrod has shown that it is not chiefly due to 
its diuretic power and the removal of the collected urates from the 
body. It is customary to give twenty to thirty drops of the tincture, 
or vinum seminum colchici, four times daily. These doses do as much 
good as larger ones, which cause pain in the abdomen, and diarrhoea. 
Besides the colchicum, it is well to give the patient plenty of acid drink 
during the attack; perhaps the favorable effect of this treatment 
depends, as I above indicated, on the dilution of the urine and the 
increased lateral pressure in the kidneys. Our theory would also 
agree with the treatment of the attack after the method of Cadet de 
Vaux, according to which the patient is to drink six ounces of simple 
water, as hot as possible, every fifteen minutes. It really seems as if 
this were of some benefit, although it is not altogether free from dan- 
ger. During the attack the affected limb should be elevated and cov- 
ered with cotton or wool, and the patient placed on low diet. If the 
motions be impaired after the attack, treatment by baths in Wildbad, 
Teplitz, or Wiesbaden, is indicated. If abscesses form near the joints 
attacked by gout, we should use cataplasms; if the abscesses lead to 
ulcers, the applications should if possible be continued till the ulcers 
have healed. No general rules can be given for the treatment of 
attacks of anomalous internal gout. Abstraction of blood readily 
induces dangerous collapse, and, on account of the threatening paraly 
sis, stimulant treatment is usually more appropriate. If the disap- 
pearance of a peripheral affection be followed by an attack upon the 
brain, stomach, or heart, we may cover the part previously affected 
with irritating and vesicating plasters, although this rarely does much 
good. RACHITIS. 
557 
CHAPTER VI. 
Etiology.—The actual changes in the bones in rachitis consist, 
1. In proliferation of the cartilage of the epiphysis and of the periosteum, 
which are the sources of the normal growth in length and thickness 
of the bones. 2. The cartilaginous and fibrous tissues, resulting from 
this proliferation, ossify more incompletely and later than in the nor- 
mal growth of bone. Hence, in rachitis, there is not, as was formerly 
supposed, a morbid softening of tissues previously hard; but tissues 
which normally become hard, from deposits of chalky salts, remain ab- 
normally soft. This view is not in opposition to the fact that rachitic 
bones bend more readily than they did before the disease. The me- 
dullary cavity increases in rachitic just as it does in healthy bones; 
but, while in the latter the new formation of firm, bony substance 
at the periphery preponderates over its loss from within, so that, in 
spite of the latter, the strength of the bone increases; in rachitic 
bones, the loss of firm, bony substance from within is not replaced 
by a corresponding new formation at the periphery, and conse- 
quently their resisting power is decreased. The excessive prolifera 
tion of the cartilages of the epiphysis and of the periosteum, with 
which rachitis begins, is by some regarded as inflammatory. The 
great vascularity and infiltration of the affected parts, the pains which 
accompany the disease from the first, as wTell as the many analogies 
of the proliferation, with other undoubtedly inflammatory affections, 
support this view ; but, on the other hand, it is opposed by the etiol- 
ogy, course, and constant results of the disease. Many attempt to ex- 
plain the retarded ossification of the newly-formed cartilage elements, 
and the fibrous proliferation of the periosteum, by saying that, in ra- 
chitic children, the calcareous salts taken up with the food cannot be 
deposited in the terminal and peripheral layers of bone, because they 
are held in solution by the lactic acid in the blood of the patient, 
and are excreted through the kidneys. Part of the analyses of urine 
made favor this explanation, as they showed that the urine of rachitic 
children was not unfrequently very rich in lactic acid, and that it con- 
tained four or six times as much phosphate of lime as is contained in 
normal urine. Another point in favor of this view is, that children 
who suffer from dyspepsia are especially apt to be attacked with ra- 
chitis. The active decomposition going on in the stomachs of these 
children forms quantities of acid, particularly lactic acid, and it is pos- 
sible that their reabsorption and their presence in the blood hold the 
phosphate of lime in solution, and that by their excretion with the 
RACHITIS — RICKETS. 558 
DISEASES OF THE ORGANS OF LOCOMOTION. 
urine, the material for the formation of bone-substance is withdrawn 
from the blood. But this hypothesis is not tenable ; the increase of 
lactic acid and phosphate of lime in the urine of rachitic children is 
not constant. Rachitis not unfrequently develops without precedent 
disturbance of the digestion or formation of acid, and the proliferation 
of the epiphyseal cartilages and of the periosteum, which are just as im - 
portant factors of rachitis as the retarded deposit of calcareous salts is, 
cannot be explained by the excretion of phosphate of lime through the 
urine. Virchow, to whom we owe the most important explanations 
of the histology of rachitic bones, and the pathogeny of rachitis, 
says that the cause of the retarded ossification is more probably a 
diminished supply of chalky salts than their increased excretion 
through the urine. He reminds us of the recommendations of the car- 
bonates and phosphates of lime as remedies in rachitis, and calls par- 
ticular attention to the fact that, in the dyspepsia of children, which 
usually precedes rachitis, as there is less albuminate taken into the 
system, the amount of earthy salts required for the normal growth of 
the bone absorbed is also diminished, as they are, for the most part, 
introduced into the body as albuminate. Virchow does not pretend 
that this view also is not problematical. It does not explain why the 
disturbance of the supply of nutritive material should affect the bones 
more than the other parts; it is also opposed by the fact that rachitis 
occurs not only in dyspeptic children, but also in those who are other- 
wise well nourished ; lastly, it is evident that the diminished supply 
of nutritive material does not suffice to explain also the proliferation of 
the epiphyseal cartilages and of the periosteum. From these considera- 
tions, it seems to me that the most probable hypothesis regarding the 
cause of rachitis is that which refers it to inflammation of the epi- 
physeal cartilages and periosteum. In other tissues, also, as in the skin, 
mucous membrane, etc., we often see diffuse inflammations (exanthe- 
mata, catarrhs, etc.), whose immediate cause we cannot discover. Like 
rachitis, these occur chiefly, but not exclusively, in badly-nourished, 
cachectic persons, and are also often accompanied by rachitis. From 
what we know of periostitis, it is not surprising, as Virchow aptly 
says, that the disturbance of circulation at the height of the disease 
should hinder the deposit of calcareous salts in the morbidly-proliferating 
tissue. Lastly, the excessive excretion of phosphate of lime through 
the urine may just as well be the result as the cause of the lime-salts 
not being deposited in the bones. Rachitis is a disease of childhood, 
and it is doubtful whether the rare cases, where the disease is said to 
have occurred in adults, or during foetal life, were actually rachitis. 
The disease is most frequently seen from the second half of the first 
year till the time of the second dentition ; before the seventh month, RACHITIS. 
559 
and after the seventh y »ar, it is far more rare. In some families, the 
tendency to it appears to be hereditary. Improper nutrition of chil- 
dren is undoubtedly the most frequent cause of the disease. I also 
believe that the gastric and intestinal catarrh, due to the improper nu- 
trition, greatly favor the occurrence of the disease, although I do not 
consider it as proved that this results from reabsorption of the lactic 
acid. The occurrence of rachitis in well-nourished children, with un- 
impaired digestion, shows that, besides the above, there are some 
other unknown causes of the disease. 
Anatomical Appearances.—For the histological details of the 
examination of rachitic bones, I refer to the works of TVirchow, Kolli- 
ker, and II Mayer. Virchow enumerates the changes observed in 
the epiphyseal cartilages during rachitis as follows : 1. Arrest of the 
line of ossification while the preparatory line of proliferation of the 
cartilage relatively increases. 2. Encroachment of the medullary space 
into, or even beyond, the line of ossification, while the proliferation of 
cartilage continues. 3. Formation of fibrous medullary spaces, osteoid 
transformation of the parts around them, as well as of distant parts, 
with calcareous deposits. The processes observed in the diaphyses are 
grouped as follows, by Virchow: 1. Greater density of the periosteal 
proliferation, with progressive rarefaction of the substance in the 
areolae and cancellated tissue. 2. Deficient ossification of the cancel- 
lated tissue, and continuance of the deep layers of compact exterior 
substance. 3. Partial formation of cartilage in the areolae. 
The clumsy appearance of rachitic bones and the swelling of the 
epiphyses are sufficiently explained by the proliferation of the perios- 
teum and epiphyseal cartilages. The epiphyses are thickened and not 
elongated, according to Virchow / not because the proliferation is 
chiefly lateral, but because the soft proliferating layers are compressed, 
and deflected laterally by the weight of the parts pressing on them, 
and by muscular action. The distortions of rachitic bones depend 
partly on curvatures, partly on angular deformity. The curvatures 
occur chiefly at the epiphyses and at the points of cartilaginous union 
of bones wrhich have no epiphyses, while the angular deformities occur 
chiefly at the diaphyses. In the long bones of the extremities it often 
looks as if the epiphysis had slipped past the diaphysis. Curvature of 
the posterior ends of the ribs of one side of the thorax not unfre- 
quently induces asymmetry or obliquity of the thorax. In many 
cases the points of union between the anterior ends of the ribs and the 
costal cartilages are bent inward, while the sternum, with the sternal 
end of cartilages, is pressed forward. This deformity, 'pectus carina- 
tum seu gallinaceum, is due to the softness of the parts mentioned, 
they having lost the power of resisting the pressure of the atmosphere 560 
DISEASES OF THE ORGANS OF LOCOMOTION. 
by inspiratory dilatation of the thorax. Any point of the ribs where 
an elastic ligament replaces the bone would become depressed on in- 
spiration. Curvatures of the upper and lower ends of the individual 
vertebrae cause distortion of the spinal column; curvatures of the pel 
vie bones at their points of union cause pelvic deformities ; the most 
frequent form is the so-called rachitic pelvis, where the antero-posterior 
diameter is shortened, but occasionally, also, when the curvature does 
not occur at the point of union of the sacrum with the ilion, but at 
that of the pubis with the ischium, we have a heart-shaped deformity. 
In the angular deformities the bone is only curved on the convex side, 
but on the concave side it is actually broken. The medullary cavity 
of a sharply-bent bone is, like the cavity of a sharply-bent quill, 
greatly contracted at the bent portion, and is subsequently entirely 
closed by callus. Total fractures, also, are not rare in rachitic bones, 
but they differ from fractures of healthy bones, in never being accom- 
panied by injury of the periosteum, which is separated from the com- 
pact bone-substance by a soft, incompletely-ossified layer. The sutures 
of the skull, which correspond to the epiphyses of the long bones, ossify 
very late; hence, in rachitic children even two or three years old, we 
not unfrequently find the fontanelles still open, and so large as to in- 
duce the suspicion of chronic hydrocephalus. The bones of the head 
and face, which correspond to the diaphyses of the long bones, undergo 
the same changes as the latter do; imperfect ossific proliferations of 
the periosteum occur on the bones, especially near their edges, and de- 
form the head and face. Besides this thickening, a partial thinning of 
the cranial bones is also observed in rachitis (.Elsdsser’s soft occiput, 
craniotabes). This thinning, which may finally let the dura mater 
and pericranium come in contact, results from gradual disappearance 
of the cranium under the pressure of the gradually-increasing brain, 
which is not accompanied by coincident formation of new bone-sub- 
stance on the surface of the skull. These membranous spaces are 
most frequently observed in the occiput, more rarely in the parietal or 
frontal bones; they occur chiefly at places where the impressiones 
digitatae, corresponding to the convolutions of the brain, are normally 
found. A symptom analogous to craniotabes is also seen in the 
lower jaw, the anterior wall of the alveolus being often perforated by 
the milk-teeth. If the rachitis goes on to recovery, the swelling of the 
articular ends of the bones subsides; the bones become firm, while 
only a small amount of the curvature of the limbs is corrected; after 
the disease has run its course, the cartilaginous proliferations of the 
epiphyses often ossify sooner and more completely than is desirable 
for the longitudinal growth of the bones, for which it is necessary that 
the epiphyses should remain cartilaginous. It is, probably, on this ao RACHITIS. 
561 
count that persons who have suffered from extensive rachitis usually 
remain very small, or even dwarf-like. If certain bones only have been 
rachitic, wdiile others have escaped, a marked disproportion remains 
after the disease has subsided, from the irregular growth of the bones. 
The shortness of the extremities has much less effect on the general 
health than the distortion of the thorax or the rachitic pelvis, which 
are also due to the slow growth of the thoracic and pelvic bones after 
rachitis. Since the sutures and fontanelles of the skull remain open 
for a long time, and since, until the sutures are closed, the growing 
brain does not permit any distortion of the skull, the growth of the 
skull is not arrested, and we often find persons, formerly rachitic, very 
much deformed, having a small face surmounted by a large head, out 
of all proportion to the misshapen body. 
Symptoms and Course.—Rachitis occurring during the first 
months of life is so often preceded by chronic intestinal catarrh, with 
stools at first green and mucous, subsequently copious and watery, 
that it appears almost justifiable to regard this form of chronic intes- 
tinal catarrh, the “ diarrhoea ablactatorum,” “ yeasty diarrhoea of chil- 
dren,” among the prodromata of rachitis. But the fact, that numerous 
cases of this chronic intestinal catarrh do not pass on to rachitis, but 
sometimes remain uncomplicated, sometimes induce other disturbances 
of nutrition, renders this view doubtful, as well as that of Stiebel, ac- 
cording to which, “ cacotrophia ” is the first, muscular atrophy the 
second, and disease of the bones the third stage of rachitis. If, after 
the above state has lasted for a time, we cannot find any changes in 
the bones during life or on autopsy, there is hardly any proof that the 
disease is rachitis. The first symptom, showing that rachitis has suc- 
ceeded the diarrhoea and consequent marasmus, is the pain that the 
children unmistakably suffer when they attempt to move their limbs, 
or when they are moved by any one. Stiebel very truthfully describes 
how children, whose greatest pleasure had been to kick out their legs 
and put their toes in the mouth, then lie quiet, with their thin legs held 
straight out, as if afraid to move; how they cry at every motion, and even 
begin to whimper for fear of being taken out of the bed when persons, 
that they had formerly loved, approach them. These symptoms are 
succeeded by enlargement of the epiphyses—which is most noticeable 
at joints not thickly covered by soft parts, or normally very prominent— 
as the knee and elbow are, and in the lower epiphyses of the radius and 
ulna, as well as at the point of union of the ribs with their cartilages. 
If rachitis begin in the manner above described, from diarrhoea ab- 
lactatorum, that is, if it begin when the child has not yet attempted to 
walk, it often escapes any distortion of the extremities, even if the dis- 
ease last for years. This shows clearly that the curvatures and partial 562 
DISEASES OF THE ORGANS OF LOCOMOTION. 
fractures of rachitic bones are chiefly due to the weight of the bodj 
resting on them, and to the action of the muscles. We have given a 
different explanation for the occurrence of pectus carinatum; and the 
fact, that children who have become rachitic during their first year, and 
still have straight legs, usually have chicken-breast, perfectly agrees 
with this explanation. Children attacked by rachitis during the first 
year are the ones who are affected with craniotabes, from lying so 
long on their backs, probably from the pressure of the brain on the 
inner surface of the skull, while the bed presses on the outer surface. 
It is of little importance whether the rolling the head, thinness of the 
hair over the occiput, disturbed sleep, attacks of spasmus glottidis, 
eclampsia, and other symptoms of anomalous cerebral functions, which 
are often seen in such children, are to be regarded as the results of 
craniotabes, or as concomitant symptoms. Careful pressure on the 
soft parts of the head is well borne by many children, while in others 
it induces convulsions. We must further mention that chronic bron- 
chial catarrh is the most frequent complication of rachitis early in life; 
its absence is exceptional. In this disease, the teeth are generally cut 
very late, and often irregularly; it frequently happens that the child 
is a year old before he has a tooth in his mouth. Finally, there is no 
question that rachitic children, who have acquired their disease during 
the first months of life, usually differ from other children of equal age, 
by their bright answers, and their attentive, sensible manners ; but, in 
spite of the large head, we cannot agree to refer this precocious men- 
tal development of rachitic children to hypertrophy of the brain, be- 
cause we also see it in other children who are confined to the bed by 
any disease, and so kept away from other children, and constantly sur- 
rounded by sedate, growrn persons; and because in so-called hyper- 
trophy of the brain tliore is not an increase of the nerve-elements, but 
of the neuroglia. Moreover, the contrast between the physical help- 
lessness and the mental development causes the latter to appear 
greater than it really is; and children three years of age, who cannot 
yet walk, are usually considered younger than they really are. If the 
disease end in recovery, the first sign of improvement is generally a 
decrease of the emaciation. The loose skin is again filled by the 
limbs, the wrinkled and old face grows smooth, while the protuberant 
belly becomes smaller. After a while the children begin to sit up in 
bed, and play. At this time there is great danger of curvature of the 
upper and lower ends of the vertebra, and permanent distortions of 
the spinal column. At the commencement of convalescence, curva- 
tures and partial fractures of the extremities also are most likely to 
occur when the children attempt to get out of bed, and walk around, 
holding on to the chairs. The symptoms of rachitis differ in some RACHITIS. 
563 
points from the above description, when the disease occurs in older 
children. In them the symptoms of chronic intestinal catarrh, and 
general emaciation, do not usually precede the symptoms of rachitis ; 
the children often have, apparently, normal digestion, and are well 
nourished when the disease develops. Nor do they usually suffei 
the pain that is induced in smaller children by all active and passive 
movements. They only complain of pain when they make a misstep, 
and easily become fatigued. Finally, when the children attacked by 
rachitis are two or three years old, or older, the ribs and vertebra 
escape in the commencement, and the extremities first become de- 
formed. They are affected with curvatures, and partial fractures, 
whose direction is not always the same. Sometimes they form an 
increase of the normal curvature of the bones; sometimes they are in 
the opposite direction, variations whose cause is unknown. Not un- 
frequently the thighs are bent outward, the legs inward; the children 
acquire a clumsy, waddling gait. It is generally a long time, often 
many years, before the disease extends to the whole skeleton. Then 
we notice frequently, but not always, as Guerin asserts, that the dis- 
ease extends with a certain regularity; first, the bones of the legs, 
then of the thighs, later those of the forearms, of the arm, and lastly 
those of the trunk, are attacked. Even when we succeed in arresting 
the disease at an early stage, the small size, the misshapen limbs, as 
well as slight curvatures remaining in the lower extremities, remind us 
through life of the rachitis that occurred during childhood; in severe 
cases very unsightly curvatures and shortenings of the bones remain, 
which not unfrequently impair the functions of the body. 
Treatment.—In cases where the rachitis develops from chronic 
intestinal catarrh and marasmus, the causal indications require the 
treatment described in Yol. I. We there remarked that it was diffi- 
cult to arrest the active process of decomposition going on in the intes- 
tinal canal of children, which induces the diarrhoea, and we must con- 
sider the want of success in the treatment of this diarrhoea as the chief 
cause of the tardy and imperfect results of treatment in rachitis. If 
we succeed in curing the intestinal catarrh speedily and completely, 
and in improving the nutrition of the child, the rachitic symptoms, in- 
duced by these disturbances, also generally disappear in a short time; 
and, if the disease be recognized early, the children escape any per- 
manent results of the rachitis. In the treatment of irritative diarrhoea, 
if it be accompanied by rachitis, in view of the diminished deposit of 
chalky salts in the tissues, it is customary to prefer carbonate of lime, 
in the form of prepared chalk, to the carbonates of potash and soda, 
which are generally used. In other cases, where the disease occurs 
without our being able to discover chronic intestinal catarrh, or other 564 
DISEASES OF THE ORGANS OF LOCOMOTION. 
disturbance of nutrition as its cause, we cannot fulfil the causal indi- 
cations. 
The indications from the disease are not answered by giving car- 
bonate and phosphate of lime, for the absence of the bony earths from 
the bones is not the chief anomaly in rachitis. As soon as the disturb- 
ance of nutrition in the epiphyseal cartilages and in the periosteum has 
ceased, the ossification of the proliferation begins, and, indeed, often 
becomes excessive, even if no material for aiding ossification be sup- 
plied, except the calcareous salts taken in the ordinary articles of food. 
Bitter and tonic remedies also, as well as rubia tinctorium, have not 
fulfilled the hopes entertained of them on theoretical grounds, and 
have been almost superseded by cod-liver oil, which is very efficacious 
in most cases where it can be taken, as it generally can be. We do 
not know to what peculiarity cod-liver oil owes its apparently specific 
effect in rachitis. Brine baths are also of unmistakable benefit, and 
should be used, particularly where the children are in a fair condition 
as regards nutrition, or are even moderately fat. The diet suitable 
for scrofulous patients, consisting of a small supply of vegetables, with 
plenty of animal food, is also very important for the successful treat- 
ment of rachitis. We would particularly recommend the administra- 
tion of a moderate amount of finely-shaved raw beef twice a day, fol- 
lowed by a small spoonful of Tokay or Malaga wine. Finally, we 
should take care that rachitic children be not kept in damp, dark 
rooms, but sent out of doors as much as possible. 
The symptomatic indications are, to guard against curvatures of the 
bones, and to rectify any existing curvatures. The former indication 
is more readily fulfilled than the latter; the means for fulfilling it con- 
sist, as may be inferred from what we have already said, of the mode 
of origin of the curvatures and partial fractures, in carefully protecting 
the soft, pliable bones from the weight of the body, the action of. the 
muscles, and external force. Rachitic children should sleep on mat- 
tresses, not on feather beds. It does not make so much difference about 
the material in the mattress as about the care with which it is made, 
for on this depend its regular fulness and the evenness of its surface. 
High pillows should be forbidden. The nurse should carry small chil- 
dren out in a basket; larger ones should be drawn about in the open 
air, in a carriage provided with a mattress. Until the bones are con- 
solidated, sitting up in bed for a length of time should be prohibited, 
and still more should we forbid the children running about on their 
flexible, fragile legs. But if the curvature has already occurred, we 
should send the child to a reliable orthopaedic institute, that is, to one 
where the actual results after the treatment correspond to some extent 
with the promises made before its commencement, and the accounts OSTEOMALACIA. 
565 
given while it is being carried out. Of course, institutions where 
some particular plan of treatment is not followed exclusively, or with 
partiality, but where all the aids of orthopaedia are employed, and es- 
pecially where the general health of the patient is attended to, should 
be preferred to others.3 
CHAPTER VII. 
OSTEOMALACIA. 
Etiology.—In osteomalacia, bones which have been hard become 
soft from reabsorption of the salts of lime, to which they owed their 
hardness. This explanation of the disease at once shows its difference 
from rachitis, where the lime-salts do not disappear from the bones, 
but have never been deposited there. The immediate causes of the 
solution and reabsorption of the salts of the bones in osteomalacia are 
obscure. The hypothesis, that the appearance of an acid in the tissue 
of the bones lies at the root of the processes by which the phosphate 
of lime is dissolved, is refuted by Virchow, who found the gelatin es- 
caping from fresh osteomalacic bones was of alkaline reaction. There 
is a great deal in support of Virchow’’s theory that osteomalacia is, per- 
haps, to be classed among the parenchymatous inflammations where 
no interstitial exudation is deposited, but where the inflammatory dis- 
turbances of nutrition atfect the tissue-elements of the affected organ. 
The rarefaction, the porous, spongy, or areolar condition of these bones, 
which are perfectly analogous to the changes in osteitis proper, the 
frequent occurrence of the disease in the puerperal state, its customary 
origin from the pelvis, which has been injured during parturition, and 
lastly, the severe pain accompanying it, render it very probable that 
osteomalacia is of an inflammatory nature. This is a rare disease; up 
to the present time it has been observed almost exclusively in women. 
The exciting causes are unknown ; we only know that the first signs 
of it, in most cases, appeared some time after confinement, so that 
pregnancy, parturition, or the puerperal state, undoubtedly have much 
to do with its etiology. 
Anatomical Appearances.—In osteomalacia, the bones become 
very porous; in the spongy substance, the trabeculae decrease in num- 
ber, and disappear; hence the medullary cavities coalesce, and in the 
long bones induce enlargement of the medullary spaces; in the com 
pact cortical substance, also, the vascular channels increase, and form 
areolae, which unite and change the cortical substance also into a coarse, 
meshed, spongy tissue. Finally, in the highest stage of the disease, 
the soft, flexible bone, which may be readily cut, consists only of 566 
DISEASES OF THE ORGANS OF LOCOMOTION. 
periosteum and medulla, with a few delicate, bony trabeculae. In 
recent cases the medulla is dark, brownish-red; later, it is yellow, and 
very fatty. There are cases of osteomalacia, where the disease is con- 
fined to certain bones, especially the pelvis and spine; in other cases 
it affects almost the whole skeleton; but, even then, the bones of the 
skull almost always escape. Distortions of the body and limbs result 
from the softness and flexibility of the bones; these are often very 
great, and actually frightful. The weight of the head occasionally 
induces angular curvature of the cervical portion of the spinal column; 
the distortion of the dorsal vertebras, and the ribs, may not only cause 
deformity of the thorax, but may also greatly encroach on its capacity. 
The pelvis is almost always compressed laterally by the thigh-bones, 
often to such a degree that the horizontal branches of the pubis come 
in contact, and project like a beak. The sacrum is also generally 
curved into the pelvis. Sometimes the curvatures of the extremities 
attain such a grade, that the feet are at last directed outwardly. In 
some cases the shortening of the body is so decided, that women of 
stately size become quite dwarf-like during the disease. 
Symptoms and Course.—The first symptoms of osteomalacia are 
boring, tearing pain, which the patients often locate in the bones. 
This pain is usually relieved by perfect quiet, while it is increased by 
motion. In some, but not in all cases, the pain, which at first is usu- 
ally considered rheumatic, is accompanied by a remittent or intermit- 
tent fever. According to many observers, copious sediments of phos- 
phate of lime form in the urine of the patient; where they do not 
occur, renal calculi, consisting of phosphate of lime, are found after 
death. It is also said that lime-salts are excreted through the sali- 
vary glands and skin. Gradually, the gait becomes uncertain and 
tottering, and, after a time, any motion becomes so painful, that most 
patients fear leaving their bed. The pain is followed by distortion 
and deformity of the body and limbs, which vary from accidental cir- 
cumstances. Occasionally, the well-nourished state of the patient con- 
trasts for a long time with the pain and deformity; while in other 
cases the general health is affected early, and the patients appear mis- 
erable, and badly nourished. Osteomalacia has not ended in recover}- 
in any of the cases so far reported; but in most of them it was not till 
after several years of severe suffering that death occurred, from ex- 
haustion, or from disturbances of the circulation and respiration. 
Treatment.—The remedies theoretically recommended for osteo- 
malacia, such as calomel and opium, phosphoric acid, lime-water, cod- 
liver oil, and iron, have not answered in practice, and we are, unfortu 
•lately, obliged to confine ourselves to the prevention of distortions. PROGRESSIVE MUSCULAR ATROPHY. 
567 
CHAPTER VIII. 
PROGRESSIVE MUSCULAR ATROPHY—ATROPHIE MUSCULAIRE GRAIS- 
SEUSE PROGRESSIVE PARALYSIE MUSCULAIRE PROGRESSIVE ATRO- 
PHIQUE. 
[Friedreich ascribes progressive muscular atrophy to chronic in- 
flammation of the perimysium, inducing hyperplasia of the inter- 
stitial connective tissue and destruction of the muscular filaments. 
But of late the more perfect means for examining the spinal cord 
show changes in its gray anterior horns, such as atrophy, increased 
pigmentation, or even disappearance of its ganglion-cells. Appar- 
ently the anterior ganglion-cell columns of the spinal cord are the 
centre of nutrition for the muscles of the trunk and limbs ; hence 
disease in this region would cause muscular atrophy ; this disease 
may be primary, or may be secondary to other spinal diseases, such 
as locomotor ataxy, sclerosis of the lateral cords, central myelitis, 
etc. The anterior nerve-roots, which are traversed by the muscular 
nerve-filaments, and even the peripheral nerves, participate more or 
less in the atrophy of the trophic spinal centre. The affected mus- 
cles atrophy and become pale-red or yellowish ; in cases not far 
advanced we may find normal, fatty, and atrophied filaments in the 
same muscle. Sometimes, instead of fatty degeneration in the 
primitive filaments, it occurs in the interfibrillar connective tissue ; 
so that a division has been made into parenchymatous and inter- 
stitial. Allied to the latter form is pseudo-muscular hypertrophy ; 
this occurs chiefly in young males, and is due to proliferation of the 
interfibrillar connective tissue, with deposit of numerous fat-cells 
and atrophy of the muscular filaments ; the deposit of fat enlarges 
the muscle and gives the appearance of hypertrophy. This affec- 
tion comes chiefly in the lower limbs, and then in the erector spinae 
muscles. 
Progressive muscular atrophy is most common in males between 
thirty and fifty years. It is often hereditary, but is most frequently 
due to continued strain of certain muscles ; sometimes also to cold, 
excesses, certain diseases, such as typhoid, diphtheria, etc., and to 
injuries. 
Progressive muscular atrophy and bulbar paralysis differ in the 
location of the original disease; the former being due to changes 
in the motor ganglion-cells of the anterior horns, the latter to 
changes on the floor of the fourth ventricle.] 
Symptoms and Course.—The first symptom of progressive mus- 568 
DISEASES OF THE ORGANS OF LOCOMOTION. 
cular atrophy is a gradually increasing feeling of weakness in certain 
muscles or groups of muscles, with their very evident and steadily 
increasing emaciation, but without pain or other trouble. The dis- 
ease does not originate with equal frequency in the different mus- 
cles ; but, in most cases, the muscles of one hand or one shoulder 
are first affected, occasionally those of the neck, rarely those of the 
face. The power of conduction and the size of the muscle, which 
diminish about equally in the course of the disease, are finally so 
much reduced, that the movements depending on the affected mus- 
cles are entirely lost or very imperfectly made, and, where the belly 
of the muscle was formerly prominent, we find a flatness or even a 
depression. The effect induced is most apparent in the disappear- 
ance of the ball of the thumb, depressions between the metacarpal 
bones, flattening of the shoulder, and prominence of the spinous 
processes of the vertebrae, when the muscles of the neck have atro- 
phied. In the weak and atrophied muscles we may always see a 
peculiar fibrillar twitching that has no effect on the point of inser- 
tion of the muscles, and hence induces no movement of the corre- 
sponding joint ; this twitching becomes more evident when we blow 
on the skin covering the muscle, or irritate it in any other way by 
exposure to cold. It is usually said that the excitability of the sen- 
sory cutaneous nerves remains normal, and only that of the sensory 
muscular nerves is lost (the “ electro-muscular sensibility ” of the 
electricians) ; but I have seen many cases where the excitability of 
the cutaneous nerves was much diminished, while all the other 
symptoms were those of progressive muscular atrophy. A very im- 
portant and even pathognomonic symptom is the above-mentioned 
condition of the affected muscles and their motor-nerves in regard 
to the induced current; this current does not fail to induce con- 
traction until the muscle is entirely atrophied ; up to that time the 
contractions correspond to the strength of the current and the 
amount of muscular substance that still remains. In some cases 
progressive muscular atrophy is limited to certain parts of the 
body; in others it gradually extends to the greater part of the 
muscles supplied by the cerebro-spinal nerves, while it never affects 
the muscles of the heart, intestines, or bladder. The latter form is 
a terrible disease ; patients affected with it preserve a good appetite 
and good digestion, their intellect is clear, and the mental functions 
are so unclouded that they can fully comprehend their lamentable 
loss, while they lose the use of one limb after another. In advanced 
cases the patients cannot walk or change their position ; they must 
be fed too, as their arms hang useless by their sides ; the changes 
of expression cease, the saliva runs out of the mouth, the speech is PROGRESSIVE MUSCULAR ATROPHY. 
569 
indistinct, and the tongue cannot pass food into the pharynx, even 
after it has been placed in the mouth. Finally, after years of suf- 
fering, the patients die, because at last the muscles of deglutition 
and respiration also become atrophied, and fail to perform their 
functions. Some intercurrent disease of the respiratory organs, in- 
significant in itself perhaps, proves dangerous to the patient and 
hastens his end, because, owing to the paralysis of the abdominal 
muscles, he is unable to cough up the secretion collecting in the 
bronchi. 
[In the last stages of some cases there is local anaesthesia ; and 
sometimes there is contraction or faulty reaction of the pupil from 
paralysis of the radial fibres of the iris. Besides the atrophy of the 
muscles, there may be other trophic disturbances, such as atrophy of 
the skin, herpes in the region of the affected nerves, and affections 
of the joints and bones of the phalanges, carpus, etc. There may 
be profuse sweating, and changes in the urine, especially diminution 
of creatin (the product of muscular changes). Sometimes the tem- 
perature of the affected limbs is at first higher ; later, it may be 
several degrees below normal. 
Progressive muscular atrophy may be mistaken for what Char- 
cot has recently described as sclerosis of the lateral cords (scle- 
rose laterale amyotrophique); this sclerosis is most extensive in the 
cervical medulla, but may extend up into the pyramids and pons or 
down into the dorsal and lumbar regions. As the anterior horns 
of the gray substance are implicated in the disease, and undergo the 
same changes as in progressive muscular atrophy, the symptoms of 
the two diseases are mingled. But there are other symptoms which 
do not occur in progressive muscular atrophy ; there is a true para- 
lysis and a subsequent atrophy of all the muscles of the limb af- 
fected ; these are followed by spastic contractions, which it is said 
do not occur from progressive muscular atrophy.] 
Treatment.—In those forms of progressive muscular atrophy 
resulting from overwork and limited to certain parts of the body, 
the methodical use of the induced or constant current of electricity 
and massage sometimes arrests the progress of the disease, and even 
improves the nutrition of the emaciated muscles. But great pa- 
tience and perseverance are requisite for the attainment of this end. 
All remedies, even the methodical employment of electricity, have 
proved inefficacious in the form of the disease which spreads from 
muscle to muscle. 570 
DISEASES OF THE ORGANS OF LOCOMOTION. 
CHAPTER IX. 
PROGRESSIVE MUSCULAR PARALYSIS AS A RESULT OF HYPERTROPHY 
OF THE INTERSTITIAL FATTY TISSUE. 
In 1869-70 a series of very peculiar cases of progressive mus- 
cular paralysis were published, in which the volume of the paralyzed 
muscles was decidedly increased instead of being lessened, as it was 
in the myopathic paralysis described in the last chapter. 
On examining the affected muscles, as was done in several cases 
during life by excising small pieces, they showed a changed appear- 
ance even to the naked eye. They did not have the red hue of 
healthy muscles, but were pale and yellowish, resembling lipoma 
more than muscle. Microscopic examination showed a decided pre- 
ponderance of the interstitial fatty tissue over the muscular; in 
some places the latter was entirely displaced by the former ; the 
muscular filaments still remaining were atrophied, pale and small, 
but not affected with fatty metamorphosis. Hence, in this disease 
there is proliferation of the interstitial fatty tissue, which probably 
induces simple atrophy of the muscular fibrillse by pressure on them. 
The disease has been repeatedly observed in children of the same 
family, and, curiously enough, only in boys. Occasionally the pa- 
tients appeared to bring the predisposition to the disease into the 
world with them. At least, in one case observed in my clinic, whose 
history was published by my former assistant, Dr. Siegmund, in his 
inaugural dissertation, and in the first volume of the “ Archives fur 
klinische Medicin,” and in a case described by Griesinger, it ap- 
peared that the patient did not learn to walk till late, and had al- 
ways remained somewhat helpless. 
Of course the symptoms of the disease vary with the group of 
muscles affected. In my patient, the disease started from the gluteal 
muscles. As long as these were exclusively or chiefly affected, the 
patient could only walk when, by aid of his arms, he had given his 
head and shoulders a position where their point of equilibrium fell 
behind the pelvis ; if this position was changed, he doubled forward 
at the liip-joint. Now the disease affects all the muscles of his 
lower extremities ; the patient cannot leave his bed, and can only 
change his position by great exertion of his arms. 
I know of no cases of improvement or recovery except those of 
Benedikt, who claims to have attained positive good results in three 
cases by electricity. In my patients, who were treated for a long 
time as advised by Benedikt (by placing the copper pole on the 
lower cervical ganglion, and applying the zinc pole along the side ADDITIONS TO THE REVISED EDITION OF 1880. 
571 
of the lumbar vertebras by means of a broad metal plate), neither 
this treatment nor long-continued faradization of the diseased muscle 
had any decided effect. 
ADDITIONS TO THE REVISED EDITION OF 1880. 
DISEASES OF THE ORGANS OF LOCOMOTION. 
1.—P. 527. 
Without doubt the articular inflammations in acute rheumatism 
are not due to purely local causes, but evince a general morbid pro- 
cess. This is shown by the inflammation of numerous joints distant 
from each other, its disappearance from one on attacking another 
which was previously unaffected, the frequent implication of the 
heart and other internal organs, the remarkable sweating, etc. The 
nature of this apparently constitutional disease has not yet been 
solved, but there have long been two theories about it: 1. A hu- 
moral theory, according to which there is a change in the blood 
and fluids of the body, where from imperfect assimilation there is 
an excess of lactic acid ; 2. A neuropathologic theory, which refers 
the disease to a morbid excitement of the vasomotor trophic nerve- 
centres ; this view finds some support in the tendency to symmet- 
rical occurrence, and in the well-known dependence of certain other 
joint-affections on spinal diseases. 
From its frequence and severe consequences, acute articular rheu- 
matism is one of the most important of diseases, and ranks along 
with consumption, pneumonia, bronchitis, typhoid fever, etc. It 
is rare in childhood, more frequent from the fifth to the fifteenth 
year, and most so between fifteen and thirty-five ; after that its oc- 
currence as a first attack is more rare. Both sexes are about equally 
liable. A considerable percentage shows a hereditary predisposi- 
tion, especially among the younger cases. There seems to be a 
greater tendency to its development after certain diseases, such as 
scarlatina, dysentery, and in the puerperal state, after abortions, etc. 
2.—P. 535. 
In those cases with high fever and cerebral symptoms, we may 
resort to cold baths, as spoken of in the treatment of typhoid fever. 
In place of wrapping the joints in wadding or applying narcotic 
liniments, firm bandages may sometimes be applied with benefit ; 
for this purpose we may use pasteboard moistened and moulded, or 
gutta-percha, placing plenty of wadding under them ; after the ap- 
plication of such firm dressings the pain sometimes subsides very 572 
DISEASES OF THE ORGANS OF LOCOMOTION. 
quickly. Among remedies said to be specifics for rheumatism are 
propylamin, trimethalin, and more especially salicylic acid or sali- 
cylate of soda. The latter may be given in doses of 15 to 20 grs. 
every hour or two hours, till the pain is relieved, unless tinnitus, 
cerebral symptoms, or signs of collapse should require discontinu- 
ance of the medicine. The possibility of such symptoms being in- 
duced demands that the patient should be watched. Under the 
influence of the salicylate, the fever and local symptoms usually 
subside within twenty-four to forty-eight hours, the tongue cleans 
off, and the appetite improves ; when the change has taken place, 
the remedy is to be carefully and gradually discontinued by decreas- 
ing the dose or lengthening the interval. The patient should be 
watched for at least a week. Under this remedy heart complica- 
tions are said to be much less frequent. Should the joints remain 
swollen, we may try iodide of potash and warm baths, especially 
alkaline baths. 
3.—P. 565. 
Observers agree that the most important point in the treatment 
of rachitis, as well for preventing curvatures as for curing the exist- 
ing disease, is proper diet. Infants should be nursed till the erup- 
tion of the first teeth, say the seventh month ; then we may give in 
addition meat broths, egg, rare or raw shaved meat, etc. They 
should not be nursed over nine months or a year. When the mother 
cannot nurse, and a good wet nurse is not to be found, something 
must be substituted. About this substitute opinions are not unani- 
mous. Some recommend cow’s milk diluted and neutralized with 
magnesia, others JVestle,s food, others again Liebig's food or con- 
densed milk. Probably none of these is to be chosen under all cir- 
cumstances ; but if the child does not thrive on one, try another. 
Biedert discovered that the casein of human milk is chemically dif- 
ferent from that of cow’s milk, and claims that this is the cause of 
their difference, and that cow’s milk cannot be made to resemble 
human milk simply by diluting with water and adding sugar. He 
recommends a mixture of one-eighth of a pint of sweet cream and 
three-eighths of a pint of boiled water, with the addition of 15 grs. 
of sugar of milk. This mixture contains the proper amounts of fat, 
salts, and sugar, and only one per cent, of casein, which is just 
about what a child’s stomach will digest, according to Biedert. 
This is the proportion to begin with, but as the child grows older 
more cream is to be added. The yolk of egg may be mixed with 
water, sugar of milk, and a very little salt. Finely-ground linseed 
meal is said to be the chief constituent of revalenta arabica, which 
has some reputation as an article of nutriment. CONSTITUTIONAL DISEASES. 
The diseases to be discussed in the following sections I have termed 
constitutional diseases, in contradistinction to the diseases of the or- 
gans, which have been thus far described; because, from its greater 
comprehensiveness, this term appears to me preferable to the names 
dyscrasias and cachexias, or diseases of the blood, as I originally in- 
tended to call them. I shall first discuss the acute infectious diseases, 
then chronic infectious diseases, and, lastly, the general disturbances 
of nutrition, which do not depend on infection, but, at the same time, 
shall confine myself to those complaints which occur in Germany. In 
regard to exotic diseases, with which I am not personally acquainted, 
and for whose description I should have to rely entirely on other 
authors, I refer to the excellent works of Griesinger and Eirsch, 
where the descriptions of these diseases are as concise as they are 
complete. 
SECTION I. 
ACUTE INFECTIOUS DISEASES. 
CHAPTER I. 
MEASLES MORBILLI RUBEOLA ROUGEOLE, 
Etiology.—Measles is a purely contagious disease. There is no 
doubt that a person is never affected with measles without having 
been infected by a person with measles. This assertion has been ob- 
jected to, on the ground that the first case of measles could not have 
been induced by infection, because at that time there was no measles 
for the patient to be infected from; and it is asserted that, if the dis- 
ea se developed spontaneously once, there is no reason for denying the 574 
ACUTE INFECTIOUS DISEASES. 
possibility of its doing so again. Such reasoning is idle. We know 
nothing about the first development of measles, and the fact, observed 
wherever it is possible to watch carefully the commencement and 
spread of the disease, that measles never occurs without a case having 
been brought in from somewhere else, justifies us in concluding that 
the same thing occurs where it is not possible to detect infection direct- 
ly. It is just the same with syphilis; we know that at the present 
day it is only propagated by transfer; the question how the first case 
of syphilis originated lies outside of the circle of physical investiga- 
tion. The infecting material which induces measles has not been dis- 
covered, either chemically or microscopically. We do not even know 
certainly whether it be organized or inorganic, and the hypothesis, that 
the infection is due to the transfer of small, imperceptible, vegetable 
organisms, is only to be preferred to other hypotheses, because it 
agrees better with the facts. I shall only mention a few of the rea- 
sons for this hypothesis. The period of incubation, that is, the day 
or week intervening between the infection and the outbreak of the 
malady, speaks against the infection being caused by substances which, 
from their chemical or physical peculiarities, are injurious to the organ- 
ism. If such a substance were transferred, its injurious effects would 
appear at once, or in a very short time, and the infected person could 
not remain free from all signs of disturbance for from eight to fourteen 
days, and then have these suddenly break out with great severity. 
But if healthy persons be infected by measles patients, through micro- 
scopic organisms, the period of incubation is much more readily under- 
stood ; for it is easy to suppose that these organisms are transferred 
in too small numbers to do harm, but that they multiply in the in- 
fected person, and immediately after this process, which is completed 
in a certain time (the period of incubation), their injurious influence is 
made manifest. A further reason for supposing that measles-poison 
is organized, is its reproduction in the bodies of the infected patients. 
For instance, in an epidemic in the Faroes observed by Panurn, one 
case that was introduced infected the attendants of the patient; these 
infected other inhabitants of the island, and, finally, in the course of 
seven months, 6,000 persons, out of a population of 7,782, were at- 
tacked. If the observations of Ilallier should prove correct, the con- 
tagious principle of measles has been lecently discovered by the micro 
scope. In the blood and sputa of measles patients, Ilallier found 
microscopic cells of a fungus which grew on various substrata, but wTas 
always the same fungus, the mucor muado {verus) of Pres. It is cer- 
tain that the blood, tears, and secretion of the air-passages, are vehicles 
for the contagion ; for inoculations made with these fluids have induced 
measles in previously healthy persons. But, as the disease most fre MEASLES. 
575 
quently occurs in persons who have not come in direct contact with 
either the blood or secretions of measles patients, but have only been 
near those affected with the disease, we cannot doubt that the conta- 
gion is also contained in the emanations from the skin and lungs. 
From some very striking observations of Panum, it has been proved 
that tliis contagion in the atmosphere can, without losing its activity, 
be carried for miles by the body and clothes of healthy persons who 
have been near a patient, and who are not themselves attacked by the 
disease. The period of incubation lasts from ten to fourteen days. 
In one epidemic of measles that I carefully observed, of which Dr. 
Pfeilsticker has given some very interesting accounts in his disserta- 
tion, written under my superintendence, school-children only were at 
first affected, and exactly ten days later, after the latter remained 
home from school, a large number of smaller children, who had been 
infected by their brothers and sisters, wTere attacked. In some cases, 
particularly where the infected person is already suffering from some 
other disease, the period of incubation appears to be somewhat longer. 
To the question, When is measles infectious ? with our present 
knowledge, we should say that it is most infectious while the eruption 
is out; that it is probably not infectious in the stage of desquamation, 
while numerous cases speak for its being so in the prodromal stage 
The popular opinion, that measles is most catching in the desquamative 
stage, arises from inattention to the period of incubation. A child in- 
fected by its brother or sister breaks out with the disease while the 
latter is desquamating, it is true, but was infected while the exan- 
thema was at its height, or, perhaps, even before the eruption. The 
probability of infection during the prodromal stage is supported by 
the wonderful spread of measles through schools. Great care is 
usually taken to keep out of the school any children who have not 
gotten through the desquamative stage, as well as those having any 
suspicious exanthema; but children with catarrh and cough are al- 
lowed to sit on the seat with well children. If the disease were only 
transferred by the former class, it would be quite impossible to under- 
stand why, during an epidemic of measles, a school is often entirely 
emptied, while the children attending another school are not affected 
oy the disease. The predisposition to measles is very extended. Al- 
most every one has the disease once during life; but one attack al- 
most invariably exhausts the susceptibility to new attacks. Since 
measles occurs quite frequently in populated countries, most persons 
are attacked during childhood, and have lost the predisposition when 
they are grown up. It is only in this sense that measles can be called 
a disease of childhood. Of 196 children, under fourteen years of age, 
that had not had the measles, who lived in a small town near Tiibin- 576 
ACUTE INFECTIOUS DISEASES. 
gen during the epidemic described by Dr. Pfeilsticker, 185 were taker; 
sick; or, only eleven out of the entire number escaped. Hence, it ap- 
pears that in isolated places, which are rarely visited by measles, chil- 
dren are not more liable to the disease than grown persons are. The 
above-mentioned epidemic in the Faroes, described by Panum, was 
the first that had occurred for sixty-five years in that isolated island ; 
hence almost all the inhabitants under sixty-five years of age, who had 
not had the measles somewhere else, were attacked by the disease, 
whether they were young or old. Children under six months often 
escape during an epidemic of this disease. In the above-mentioned 
epidemic, not a child under five months was attacked; while, above 
six months, almost all were. Very old persons also rarely have the 
disease. Acute and chronic maladies, pregnancy, and the puerperal 
state, do not protect from measles; but, as was above said, the dis- 
order not unfrequently makes its appearance at the end of an acute 
disease, during which the infection has occurred. Measles occurs in 
more or less extensive epidemics; the extent of the epidemic depends 
chiefly on the length of the interval that has elapsed since the last one, 
and consequently on the number of persons who have not yet been at- 
tacked. The epidemic at the Faroes furnishes an excellent example 
of this also. But the state of the weather appears to have a great in- 
fluence on the extent of epidemics, for the greatest number and the 
largest epidemics occur in the winter and autumn, or in cold, damp 
summers. Great extent of the disease generally corresponds with 
great severity of the individual cases, and the most malignant cases 
usually occur at the height of the epidemic. 
Anatomical Appearances.—The normal exanthema of measles 
disappears after death, and only the haemorrhages in the tissue of the 
cutis, which sometimes occur, are discoverable in the dead body. The 
anatomical changes observed during life on the skin of a measles pa- 
tient consist in an eruption of numerous roundish red spots about the 
size of a millet-seed, somewhat elevated, and generally having a small 
papule at the middle. In some places several spots unite, forming 
irregular semilunar patches; at other places the spots are isolated. 
Between the spots the skin retains its normal color; in the face, it is 
usually somewhat oedematous. According to G. Simon, the papules 
on the measles eruption, although chiefly located at the point where 
the hairs escape from the skin, are not swellings of the hair-follicles or 
sebaceous glands, but consist of small collections of inflammatory exu- 
dation at circumscribed points in the skin. Occasionally the eruption 
shows an unusual tendency to confluence (morbilli confluentes); even 
in such cases, however, the diffuse redness is not regular, but main- 
tains an irregularly spotted appearance. In most of the spots which MEASLES. 
577 
have existed for any time, a very slight escape of blood into the cutis 
appears to complicate the hyperaemia, because these spots only lose 
their color slowly and incompletely under the pressure of the finger, 
and, after disappearing, they generally leave, for a time, a dirty-brown 
stain. In some cases the spots acquire a dark, blood-red color, from 
greater extravasation of blood in the cutis, and in these cases we also 
occasionally notice petechias between the spots (morbilli petechiales, 
mbeolce nigrce). 
Since a large number of the deaths occurring during measles result 
from complications with croupous laryngitis, bronchitis, or pneumonia, 
we often find anatomical changes due to these diseases. Where death 
is caused by laryngitis, it is by the croupous form. But in this second- 
ary croup we do not find coherent pseudomembranes so often as we do 
in common idiopathic croup. On the contrary, the exudation usually 
infiltrates the upper layer of the mucous membrane, so that the inflam- 
mation approaches the diphtheritic form of inflammation of the mucous 
membrane. The lesion most frequently found in the bodies of children 
who have died of measles, is capillary bronchitis, which has sometimes 
induced permanent inspiratory distention of the alveoli (called acute 
vesicular emphysema, by most authors; see Yol. I., p. 71), sometimes 
collapse of the lung, and catarrhal pneumonia (Yol. I., p. 194). The 
blood shows no characteristic change, but, as in other infectious dis- 
eases, is poor in fibrin, fluid, and dark-colored. 
Symptoms and Course.—During the period of incubation, there 
is no sign of the disease. This is followed by the first stage, stadium 
prodromorum, which rarely begins with a single chill; more fre- 
quently with repeated rigors, and is accompanied by all the symptoms 
of a severe catarrh of the conjunctiva and air-passages, and the actual 
disease can only be rightly interpreted from the existing epidemic. 
Unless it be known that there is measles in the neighborhood, the 
most experienced physician can hardly recognize in the existing severe 
catarrh the prodromal stage of measles. Increased frequence of pulse, 
heightened temperature, constitutional disturbance, pain in the head 
and limbs, dyspepsia, nausea, vomiting, disturbed sleep, and, in exci- 
table children, delirium, occur also during simple catarrh, from catching 
cold. The local symptoms are generally very decided; the burning, 
reddened eyes shun the light, and are filled with tears, there is pain 
in the forehead, the nose is stopped, and discharges a copious, limpid, 
salty secretion ; attacks of sneezing occur at short intervals, and often 
continue for hours; there is, sometimes, epistaxis, the voice is husky, 
the painful cough is hoarse and barking; at night, the attendants are 
often frightened by the symptoms of pseudo-croup, previously described 
(Yol. I., p. 6). The catarrhal affection appears generally to begin in 578 
ACUTE INFECTIOUS DISEASES. 
the nose, and to extend upward to the mucous membrane of the frontal 
sinus and conjunctiva, and downward to that of the larynx and trachea. 
The stadium prodromorum usually lasts about three days, while the 
above symptoms are of variable intensity; but in some cases it lasts a 
week or longer, and in others the symptoms are very slight, and 
readily overlooked. Even in malignant epidemics, the fever preceding 
the eruption is rarely severe enough to threaten life, as it is in scarlet 
fever. Nor are the local symptoms, severe as they often are, and ter- 
rifying as they seem to the friends (especially the croupy cough and 
nocturnal dyspnoea), usually dangerous. True croup rarely occurs at 
this time. PfeilsticJcer's observations of the course of the fever during 
the prodromal stage showed that the temperature was highest the 
first day, and subsequently sank till the day of the eruption. Ziems- 
sen and Helm also mention cases where, after the bodily temperature 
had attained a considerable height the first day, it became perfectly 
normal the following days, and remained so till the eruption appeared, 
when it rapidly increased. During the prodromal stage, liehn ob- 
served an eruption of pale-red, rather undefined spots on the mucous 
membrane of the cheeks, gums, lips, and fauces; and he explains the 
increase of temperature at the commencement as being the eruptive 
fever of this exanthema. 
The second stage of measles, the stadium eruptionis, commences 
with an exacerbation of the fever; the pulse becomes more frequent, 
the bodily temperature rises to the highest point; in some cases there 
are convulsions. The above-described eruption appears first in the 
face, especially about the mouth and eyes; it soon spreads to the neck 
and breast; even in twenty-four hours it usually reaches the feet, so 
that the whole body is covered. At this time the perspiration of the 
patient has a peculiar odor, which strongly reminds me of a freshly- 
picked goose. In rare cases, which generally show some other anom- 
aly also, the eruption does not spread from the face to the extremi- 
ties, but makes its first appearance on the arms or legs, and afterward 
elsewhere. Still more rarely, the exanthema is limited to certain 
regions of the body, or, at least, on the rest of the body it is very in- 
distinct. These cases resemble the morbilli sine exanthemate, which 
unmistakably results from infection with measles poison, but from first 
to last runs the course of a very severe catarrh, without the appear- 
ance of any eruption. Lastly, cases occur where the eruption comes 
out so slowly, that the stadium eruptionis is not completed in twenty - 
four or thirty-six hours, but continues to the third or fourth day. In 
these cases, the last spots frequently do not appear till the first ones 
are fading away. During the eruptive stage, the constitutional dis 
turbance and catarrhal symptoms usually increase, and attain theii MEASLES. 
579 
height as the exanthema reaches its full extent. The stadium flores- 
oentioe cannot be distinctly distinguished from the eruptive stage, for 
in most cases the exanthema is just at its height as the eruption is 
completed, and it generally begins to disappear in twenty-four hours. 
The fever, also, which usually attains its height at the completion of 
the eruption, rapidly moderates, and sometimes disappears in the sta- 
dium florescentise, so that the parents have great difficulty to keep in 
bed the little patients, who are often still covered with red spots, but 
are already full of spirits. The catarrhal symptoms continue, it is true, 
but they are much milder; the photophobia is less, the secretion from 
the nose is more scanty and thick, sneezing is rarer, the voice less 
rough, the cough looser, and older children, who do not swallow the 
sputa, cough up more or less muco-purulent masses (sputa cocta). On 
the third or fourth day after their occurrence, the spots, especially those 
of the first crop, are ordinarily much paler, or have entirely disappeared, 
commonly leaving a bright-yellow discoloration on the skin for a time. 
In favorable cases, the fourth stage, stadium desquamationis, usu- 
ally succeeds the stadium florescentia the eighth or ninth day of the 
disease. At this time the spots have entirely disappeared, and their 
former seat is covered by a bran-like desquamation of the epidermis. 
If the detached epidermic scales be softened, and macerated by con- 
stant perspiration, the desquamation is not so evident as if the skin be 
dry; hence, it is less perceptible on the parts covered by the bed- 
clothes than on the face, neck, and hands. In the desquamative stage, 
the fever has almost always disappeared. The catarrh also passes off 
gradually, and about the fourteenth day of the disease, or somewhat 
later, as the desquamation ends, the measles terminates. 
In many cases the disease runs its course without much deviation 
from the description above given. These cases, where there is no 
material deviation from the “ normal ” course, and where the different 
stages are not accompanied by any peculiar symptoms, are usually 
called morbilli vulgares, simplices, or erethici. 
In other cases, usually called inflammatory or synochal measles, 
the exanthema appears with very violent symptoms ; the spots, which 
are usually close together, and often confluent, do not begin to lose 
color in twenty-four hours, but at this time grow darker, and remain 
visible on the skin for five or six days. Occasionally the exanthema 
assumes a violet or bluish color, and does not disappear under the 
pressure of the finger; this depends on partial rupture of the over- 
filled capillaries, and may be regarded as analogous to the haemor- 
rhages occurring in the inflammatory disturbances of nutrition. The 
correctness of this view is supported by the fact that this form of 
haemorrhagic measles usually runs a favorable course, and is not at alj 580 
ACtTTE INFECTIOUS DISEASES. 
complicated with the signs of dissolution of the blood. The fever 
symptoms accompanying so-called inflammatory or synochal measles 
resemble those observed in the course of acute inflammations. The 
action of the heart is increased, the carotids pulsate strongly, the pulse 
is strong, full, and more frequent, but not excessively so; the bodily 
temperature does not much exceed 104°. Just as in the case of the 
exanthema, the affection of the mucous membranes is characterized by 
longer duration, greater intensity and extent, in synochal measles. 
As long as the exanthema is at its height, the photophobia, nasal 
catarrh, and cough remain the same. It is this form of measles also 
which is chiefly accompanied by croupous instead of catarrhal laryn- 
gitis, in which the inflammation of the air-passages often extends to 
the alveoli of the lungs, in which also the gastric and intestinal mu- 
cous membrane is often affected with catarrh (gastric measles). If a 
hoarse, barking cough and the dyspnoea characteristic of croupous 
laryngitis occur in the stage of efflorescence, the state of the patient 
is by no means so free from danger as if these symptoms accompany 
the prodromal stage ; but in such cases the disease readily takes a bad 
turn, the dyspnoea increases, the breathing is impeded, and, as the 
skin becomes congested, the exanthema subsides, or, if it has been ac- 
companied by haemorrhage in the cutis, blue spots remain, which do 
not disappear on pressure. In regard to the modification of the symp- 
toms induced by an extension of the catarrh to the finer bronchial 
tubes, we must refer to the first volume, where we have fully de- 
scribed the symptoms of capillary bronchitis and the dangers accom- 
panying it, particularly during childhood. The description of collapse 
of the lung and catarrhal pneumonia in the first volume also gives the 
symptoms from which we may determine that these complications ex- 
ist. Indeed, it is to the numerous observations of collapse of the lung 
and catarrhal pneumonia, afforded by extensive epidemics of measles, 
that we owe our accurate knowledge of the pathological anatomy and 
symptomatology of these diseases. Far more rarely than catarrhal 
pneumonia we have croupous pneumonia during synochal measles; it 
is almost always limited to one side, while catarrhal pneumonia usually 
affects both sides; the fever accompanying the latter is ordinarily in- 
sidious, and disappears gradually, while that with the former runs a cyc- 
lical course and defervesces suddenly. The course of the fever due to 
the measles is decidedly modified by the above complications. This 
is especially true in the case of the pneumonia. While, in uncom- 
plicated measles, the fever, which has reached its acme at the height 
of the eruption, subsides steadily, and often rapidly, it may attain 
its acme much later when there is a complication with catarrhal or 
croupous pneumonia. If measles be accompanied by severe disease of MEASLES. 
581 
the respiratory 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 falsely interpreted, 
as the disappearance of the eruption is regarded as the cause, not the 
result, of the distress and of the bad symptoms in the respiratory ap 
paratus. 
A third class of measles described is the asthenic, typhous, or sep- 
tic. In this very malignant form of the disease, the danger lies, not in 
the extension of the catarrh to the bronchi, or in severe complications, 
but in the pernicious influence of the measles poison on the entire or- 
ganism. Measles resembles most acute infectious diseases in regard to 
the great difference in the constitutional disturbance induced by the 
infection during different epidemics. A physician who has only ob- 
served epidemics of erethitic or synochal measles, such as have exclu- 
sively occurred in Germany during the past ten years, may readily 
suppose that measles poison has little constitutional effect. But this 
view will soon be altered the first time he sees a case of asthenic sep- 
tic measles. Even in the prodromal stage, the pulse, which is at first 
full and strong, may become small, weak, and very frequent; the pa- 
tient very much depressed, the intellect cloudy, the tongue dry and 
crusted, and patients may die of the increasing prostration, which is 
occasionally interrupted by eclamptic spasms, even before the appear- 
ance of the eruption. In other cases, these typhoid symptoms, which 
are often accompanied by abundant epistaxis, do not begin, or do not 
become dangerous, till the outbreak of the eruption. The exanthema, 
which is usually irregular, is sometimes pale red; sometimes bluish- 
violet, as a result of coincident haemorrhage into the skin; occasionally 
there are petechias between the spots, or bluish spots remain after the 
exanthema has quickly disappeared. When the pulse has become 
very small, and cannot be counted—the extremities cool, while the 
body is hot—most patients die in a soporose state, with or without 
general convulsions. It has not yet been accurately ascertained 
whether the adynamia and paralysis occurring during measles, in- 
ducing the so-called asthenic, typhous, or septic form of the disease, 
be a direct result of the blood-poisoning, or if they be due to the ex- 
cessive increase of bodily temperature induced by the infection. The 
latter view is apparently supported by the fact, that in diseases not in- 
duced by infection, as soon as the bodily temperature rises above a 
certain point, the pulse becomes small and weak, and the same ner- 
vous or typhoid symptoms appear; as well as the second fact, that 
remedies which lower the bodily temperature have a decidedly favor- 
able effect on these symptoms. 
The cough continuing during the desquamative stage forms a con- 582 
ACUTE INFECTIOUS DISEASES. 
necting link with the sequel® of measles; for it often remains for 
weeks or months after tne desquamation is over, and grows worse 
from the most trifling causes. In many cases this cough appears to 
depend on simple bronchial catarrh, and its obstinacy and occasional 
exacerbations seem due to increased vulnerability of the bronchial 
mucous membrane, or to a sensitiveness of the skin remaining after 
measles; but, in other cases, the cough is more serious, and depends 
on severe disease of the lungs. It is well proved that measles often 
induces pulmonary consumption, and, consequently, that after an ex- 
tensive epidemic of measles, the rate of mortality among children is 
usually increased for a few years. But it appears to me very doubtful 
whether the chronic pulmonary tuberculosis, often induced by measles, 
is always or chiefly due to a deposit of tubercles in the lungs during 
measles, or to softening of tubercles already existing there. Most 
cases of phthisis pulmonum in children are not due to deposit and 
softening of miliary tubercles, but to caseous transformation and disin 
tegration of the products of lobular pneumonia, which is generally also 
accompanied by caseous degeneration of the bronchial glands. But 
as lobular pneumonia is one of the most common complications of 
measles, it appears very probable that the frequent occurrence of pul- 
monary consumption, as a sequel of measles, is due to further meta- 
morphosis of the products of inflammation, which have not yet been 
resolved. But this does not mean that true tuberculosis of the lungs 
never occurs as a sequel of measles (for I have several times seen acute 
miliary tuberculosis directly follow measles), but only that most cases 
of pulmonary consumption after measles depend on chronic destructive 
pneumonia. Besides chronic bronchial catarrh and chronic pulmonary 
consumption, the whole series of scrofulous diseases, especially ophthal- 
mia, otorrhoea, chronic rhinitis, swelling of the lymphatic glands, chronic 
inflammation of the periosteum and joints, may be mentioned as se- 
quelae of measles. At least, we very frequently see children, who 
had never before suffered from scrofula, troubled for years with various 
forms of these chronic inflammations after recovering from an attack of 
measles. Among the sequelae of measles, which, fortunately, are rare, 
we may mention the mortification of the cheeks or vulva, noma, and 
the diphtheritis of the oral mucous membrane, stomacace, which occur 
even during desquamation. 
Treatment.—The only efficient prophylaxis is a strict isolation 
of healthy persons, who have not yet had the measles, from those in 
whom the disease has broken out, as well as from those that are sus- 
pected of being in the prodromal stage. To protect children from the 
affection, it is necessary to keep them out of school; and it is still 
better, if possible, to send them away from the place where an eni MEASLES. 
583 
demic is raging. This plan will probably only be adopted in those 
rare epidemics that are characterized by their malignancy and fatality ; 
in mild epidemics this will not be done, because we know that sooner 
or later almost every person has the measles. As inoculated measles 
is not milder than other cases, and as malignant epidemics are rare, 
inoculation during mild epidemics has not proved popular. 
If measles has once broken out in a person, we must remember 
that we have no remedy for cutting short the attack; also that the 
medicines usually given for the different symptoms are not only uncer- 
tain, but often act injuriously on the course of the disease; lastly, that 
the great majority of cases end in recovery without any medical treat- 
ment. If we remain convinced on this point, we shall abstain from 
superfluous and dangerous medication. To most of the patients we 
shall probably give no medicine, but only order proper regimen, and 
shall only act energetically when actual danger threatens. All mea- 
sles patients should be kept in an even and moderate temperature. The 
physician should insist that the temperature of the room be regulated 
by the thermometer, not by the feelings of the nurse, and kept at 
about 60° to 65°. And the chamber must be aired every day, while a 
thin cloth is thrown over the head and face of the patient, and his bed 
is protected from draughts by a screen. The old custom of leaving a 
measles patient at least fourteen days without washing him, or chang- 
ing his linen, has very justly been given up, since it has been proved 
that, notwithstanding the dirt, the exanthema sometimes disappears, 
but in most cases does not do so, in spite of careful daily ablutions. 
But this excess of care is no worse than neglect of attention when 
washing or changing the linen of the patient. Both of these opera- 
tions must be done quickly, and without unnecessary exposure. Luke- 
warm water is preferable to either cold or hot. The body and bed- 
linen should not be taken from the clothes-press and placed directly on 
the patient, but should be first warmed, and aired, or, still better, worn 
for a night by some well person. The chamber should be darkened in 
proportion to the degree of conjunctivitis and photophobia. If we 
make the room too dark, by thick, green curtains, we render the eye- 
trouble worse, for the patients are dazzled every time the door is 
opened, and light enters the room. In the prodromal as well as in 
the eruptive stage, we should order absolute diet, water-soup, bread, 
and, if there be constipation, stewed fruit. If the fever subsides dur- 
ing the stage of efflorescence, we may give meat broth and milk, and, 
in the desquamative stage, let the patient return gradually to his cus- 
tomary diet. Simple cold water, that has stood in the room for a 
while, should be freely given, as it is never injurious, and does not 
even render any of the symptoms worse temporarily. On the other 584 
ACUTE INFECTIOUS DISEASES. 
hand, it is cruel and injurious to withhold from the patient the only 
thing that will quench his thirst, as long as he is feverish and thirsty, 
and in place of it to make him drink warm tea or water. Sweet 
drinks, which generally soon become distasteful to the patient, and do 
not alleviate the cough, as they are expected to, are superfluous. The 
time that the patients are to pass in bed, and in their chamber, should 
not be measured in the customary way by days and weeks, but we 
should insist on his remaining in bed as long as there is any indication 
of fever, while the desquamation is going on, and the cough is severe, 
and he should keep his chamber as long as there is any trace left of 
the measles-catarrh, whether the customary fourteen or forty-two days 
have elapsed or not. Even after the patient has fully recovered, the 
physician should keep a watchful eye on him for months, and should 
particularly attend to any cough, no matter how slight and insignifi- 
cant it may appear. Among the accidents that demand active treat- 
ment, during measles, most authors place the “ striking in of the erup- 
tion ” in the first rank, and consider its “ restoration ” as the most 
important point in treatment. We do not hesitate to say that it is 
just as unscientific as it is dangerous to carry out this indication; it is 
dangerous because it readily induces rules which may have an injurious 
effect on the course of the disease. As above shown, the so-called dis- 
appearance of the eruption is not to be regarded as the cause, but 
as the result of a bad turn of the disease, and is due to the general 
collapse of the patient, in which the skin participates; but, as we have 
also shown above, this bad turn of the disease usually depends on the 
appearance of some complication, especially pneumonia; if this fact be 
not borne in mind, if the patient be rubbed with irritating tinctures 
and liniments, placed in a hot bath containing mustard or caustic pot- 
ish, or wrapped up in blankets wet 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. Among the symptoms of the prodromal stage, 
the attacks of hoarseness, aphonia, and severe dyspnoea, which occur, 
particularly during sleep, require the same treatment as when they 
occur in the course of genuine laryngeal catarrh, such as emetics, hot 
applications to the throat, and plenty of warm drinks. If the cough be 
uncommonly severe and persistent, we may give adults five or ten 
grains of Dover’s powder at night, and for children, where opium is 
dangerous, especially during fever, we may prescribe small doses of 
lactucarium, or a weak infusion of ipecac, (gr. vj to § iv water, with 
syrup 3 ss). If, during the stage of eruption and efflorescence, the fever 
show a synochal character, there is no reason why we should not give SCARLATINA. 
585 
nitrate of soda, although it will very rarely prevent any inflammatory 
complications. Great care must be exercised in the employment of 
tartar emetic, for violent vomiting and purging are injurious to measles 
patients, and readily induce sudden collapse, even during so-called in- 
flammatory measles. Laryngitis and pneumonia complicating measles 
are to be treated in the same way as wdien they occur primarily, al- 
though the prognosis is not so good; the same is true of other com- 
plications. In asthenic, typhous, and septic measles, quinine, mineral 
acids, and stimulants, are most frequently given. I have not seen any 
malignant measles recently; but should it prove that they induce a 
very high bodily temperature, from my experience in analogous forms 
of other infectious diseases, I should not hesitate in such cases also to 
wrap the patients up in cold, wet cloths, at short intervals, and to givr- 
them large doses of quinine. 
CHAPTER II. 
SCARLET FEVER—SCARLATINA. 
Etiology.—Scarlatina is an infectious disease, as is shown by a 
few cases of successful inoculation, and by many well-known instances 
where the disease was carried from one place to another by scarlatina 
patients. It is less clearly proved that contagion is the only mode of 
propagating the disease, and that scarlatina never develops sponta- 
neously. At least, epidemics have occurred in places where its exten- 
sion could be readily observed without its being detected, or even being 
probable that the disease had been imported. We know no more about 
scarlatina poison than we do about that of measles. The infection of 
persons who have been near scarlatina cases, without being immedi- 
ately in contact with them, appears to show that the poison is con 
tained in the exhalations of the patient, and is mingled with the atmos- 
phere about them. Well-proved facts also render it probable that the 
contagion may be carried by persons who are not themselves affected 
by the disease. Past experience has not yet taught us whether the 
blood and secretions are also means of conveyance. The period of in- 
cubation appears to be shorter than in measles, and to last only eight 
or nine days. But, from the difficulty of deciding the time when the 
infection terminates, this point is not exactly determined; and, for the 
same reason, we cannot accurately answer the question, In what stage 
is scarlatina infectious ? The predisposition to scarlatina is far less 
common than that to measles; there are not a few persons who never 
nave it. One attack almost unexceptionally removes the liability to 
another. Nursing children often escape during an epidemic; while 586 
ACUTE INFECTIOUS DISEASES. 
those over two years old are most susceptible to the disease; but even 
adults, who have not had scarlatina during childhood, are often at- 
tacked by it, and cases occur even in old age. In very large cities it 
seems never to disappear entirely; we do not know why the disease 
occasionally spreads, and why, after occurring sporadically for a year, 
it should suddenly break out into an epidemic. Nor do we know the 
causes of the differences between epidemics in regard to the mildness 
or malignancy of the attacks. Epidemics of scarlatina occur chiefly, 
but not exclusively, in autumn and spring; they succeed each other at 
longer or shorter intervals, and are of very variable duration.1 
Anatomical Appearances.—The anatomical changes in the skin 
during life are those of a very extensive erythematous inflammation, 
consisting of a very intense hyperaemia and an inflammatory oedema 
of the superficial layers of the cuticle. The redness of the skin caused 
by the hyperaemia begins as numerous small points, close together, 
which soon unite and form an even redness (scarlatina laevigata). Far 
more rarely the redness is limited to a few spots of variable size and 
irregular shape, or the surface is pale red, with some darker red spots 
over it (scarlatina variegata). More rarely than in measles, collections 
of inflammatory exudations at circumscribed spots form small papules 
(scarlatina papulosa); on the other hand, exudation effused on the 
surface frequently elevates the epidermis to numerous small vesicles 
(scarlatina miliaris seu vesicular is), or to larger vesicles filled wit! 
limpid or cloudy-yellow liquid (scarlatina pemphigoidea seu pustulosa) 
In malignant cases, the hyperaemia of the skin is occasionally accom- 
panied by more or less extensive haemorrhages, causing petecliiae and 
extensive ecchymoses. If death occurs at the height of the scarlatina, 
the skin of the cadaver often appears thickened and hardened by infil- 
tration, and we frequently find dried vesicles and dark-colored petechiae 
on it, that have not disappeared after death as the hyperaemia has done. 
Inflammation of the pharyngeal mucous membrane is induced by 
scarlatina poison just as often as inflammation of the cutis is. The 
most frequent form of this pharyngitis is the catarrhal, in which the 
mucous membrane of the palate, tonsils, and pharynx, is dark red, 
swollen, at first dry, but subsequently covered with quantities of mu- 
cus. In malignant epidemics, scarlatina is not unfrequently localized 
in the pharyngeal mucous membrane as a diphtheritic inflammation; 
in such cases, the fauces and pharynx are at first covered with gray 
plaques, which cannot be wiped off from the mucous membrane, be- 
cause they are due to infiltration of its tissue with fibrinous exudation. 
After lasting for a short time, this infiltration causes necrosis of the. 
patches of membrane, which are thrown off as discolored, badly-smell 
ing sloughs; and irregular losses of substance, covered with disinte SCARLATINA. 
587 
grated tissue and dirty sanies, are left. In many cases this process 
advances through the fauces to the nares, inducing the notoriously 
malignant scarlatina coryza. The diphtheritic inflammation also occa- 
sionally extends to the mouth and lips, and particularly to the angle 
of the mouth, while it rarely attacks the larynx. Lastly, in some 
cases, scarlatinous pharyngitis runs its course as a parenchymatous 
angina, inducing great swelling, and, after a time, suppuration of the 
tonsils. 
Combined with the malignant pharyngitis, or even independent of 
it, we often have inflammations of the parotids and lymphatic glands 
and of the connective tissue of the neck; these rarely end in resolu- 
tion, but generally after a hard swelling of the inflamed parts has 
lasted for a variable period, they terminate in suppuration or diffuse 
necrosis. 
Scarlatina is localized in the kidneys just as often as it is in the 
skin or mucous membrane of the pharynx. The usual form of this 
localization is an intense hyperaemia and catarrh (throwing off of the 
epithelium) by the uriniferous tubules; but, in many cases, and in 
some epidemics in almost all the cases, the scarlatina infection induces 
croupous inflammation of the uriniferous tubules instead of simple 
nyperaemia. We should not consider either diphtheritic angina or mor- 
bus Brightii among the complications of scarlatina; or else we shall 
have to regard the inflammation of the skin, catarrhal pharyngitis and 
hyperaemia of the kidneys as complications and not symptoms of 
scarlatina. 
Perhaps the same thing is true of inflammation of the joints, pleura, 
pericardium, and also with that of the ear, cornea, and other rarer dis- 
turbances of nutrition observed during the course of this disease; at 
all events, there is no proof that, in cases where these inflammations 
have occurred in scarlatina patients, there has been any second cause, 
besides the scarlatina infection, acting on the patient to excite these 
diseases as complications. It is, at least, fully as probable that the 
infection, which generally only induces palpable changes in the skin, 
throat, and kidneys, decidedly modifies the nutrition of the entire body, 
and, under some unknown circumstances, excites severe, and conse- 
quently perceptible, changes in the organs above mentioned. 
Lastly, we may mention that, in the bodies of those who have died 
oi scarlatina, the blood is generally poor in fibrin, thin and dark, and 
occasionally the spleen and intestinal glands are tumefied. 
Symptoms and Course.—It is customary to give the name sim- 
ple, normal, or benign scarlet fever to those cases where the fever 
maintains a synochal character, and where the perceptible localizations 
of the disease are limited to the exanthema, severe catarrhal angina, 588 
ACUTE INFECTIOUS DISEASES. 
and simple hyperacmia of the kidneys. We shall first describe the 
symptoms and course of this simple form (which is, however, quite a 
serious disease), and subsequently shall speak briefly of the modifica- 
tions caused partly by the asthenic character of the fever, probably 
from the great increase of bodily temperature, partly by the extent 
and variety of the local affections. 
During the stage of incubation, some patients complain of weari- 
ness and depression, and an undefined feeling of sickness; but most 
of them feel quite well. 
The prodromal stage begins with repeated rigors, more rarely with 
a single chill. This is followed by a feeling of burning heat, nausea, 
or actual vomiting, severe headache, feeling of great relaxation, pain 
in the limbs, and the series of symptoms that accompanies almost any 
severe fever. Even at this time the pulse is often 120 to 130 beats a 
minute, and the bodily temperature occasionally rises to 104° to 105°, or 
higher. Such an increase of the pulse and rise of temperature are not 
often observed at the commencement of other diseases, even in inflam 
mation of important organs, hence these symptoms alone should excite 
the suspicion that we are dealing with the first stage of an infectious 
disease. And, since, along with the fever, the subjective and objective 
symptoms of pharyngitis usually, occur, we may generally decide with 
great probability, even at this time, that the case is one of commen- 
cing scarlatina, and not of commencing measles, small-pox, or other in- 
fectious disease. The patients complain of a feeling of dryness and 
heat in the throat, and of pain, which is increased by swallowing. On 
examining the throat, we find the mucous membrane of the tonsils and 
soft palate dark red and swollen. And in some cases the tongue is 
already very red at the edges. Occasionally, the prodromal stage only 
lasts a few hours, or the eruption may occur almost at the same time 
with the fever, so that there is no real prodromal stage; but in most 
cases this stage lasts one or two days, and rarely longer. The inten- 
sity as well as the duration of the prodromal stage varies in different 
cases; this is partly due to the individuality of the patient, partly to 
unknown causes. Some patients are very much excited or delirious; 
others lie benumbed and apathetic; children not unfrequent.ly have 
convulsions, just as they do in other febrile diseases. Other patients 
are less severely affected by the prodromal stage of scarlatina, and 
have no serious symptoms. 
The stadium eruptionis almost always begins with an exacerbation 
of the fever. The symptoms accompanying the fever, also the head- 
ache, weakness, excitement, or apathy, increase, and it is at this time 
that convulsions most frequently occur in children. The eruption does 
not come first on the face, as that of measles does, but begins on the SCARLATINA. 
589 
neck, and thence extends over the body. Even in twenty-four or thirty- 
six hours the whole surface is usually covered with a scarlet color. In 
the face, the cheeks only are generally red; hence the exanthema is 
less readily recognized here than elsewhere. The deepest redness is 
usually on the neck, outside of the limbs, joints, hands, and feet. The 
exhalations of the patient are said to smell like mouldy cheese, or 
caged wild beasts in menageries. When the eruption appears, the 
throat troubles increase, the fauces become more intensely red, the 
tongue is of a dark raspberry redness, not only at the edges, but also 
on its dorsum, from which the previous coating is thrown off; the 
swollen and erect papillae give the surface of the tongue a rough ap- 
pearance (cat’s tongue). During the stage of eruption there are varia- 
tions from the above symptoms, wThich have no material effect on the 
course of the disease. For instance, in some cases the exanthema 
spreads over the surface with uncommon rapidity; sometimes the red- 
ness is brighter, at others much darker; in other cases the exanthema 
presents the characters of scarlatina miliaris. In the same way che 
throat troubles are sometimes very severe, again very slight; they are 
rarely accompanied by catarrh of the larynx, trachea, and bronchi. 
In the stadium florescentice, which usually lasts four or five daj-s, 
the fever at first increases, reaching its height about the second day. 
At the same time the eruption is in its bloom, and the throat trouble 
has reached its height. The urine contains quantities of detached 
epithelium, and often, traces of albumen; the general health of the 
patient is also most affected at this time. Then all the symptoms 
usually begin to decrease, the frequency of the pulse and the tempera- 
ture go down, the exanthema fades, the difficulty of swallowing grows 
less, the general health improves. In this stage also, besides the mate- 
rial deviations due to increase of the fever, or extensive and unusual 
local affections, different cases do not agree in all respects; occasion- 
ally, the exanthema remains out longer, or it fades and disappears 
earlier; the same is true of the changes in the pharyngeal mucous 
membrane, and of the fever symptoms. 
The stadium desquamationis usually begins on the fifth day after 
the appearance of the eruption. While the eruption continues to some 
extent in the extremities, especially about the joints, it disappears 
about the neck, and here we first notice that the skin is rough and 
dry, the epidermis is raised, and falls off in small shreds. A few days 
later the redness usually disappears from the extremities also, and 
desquamation begins. This does not occur in the extremities as it 
does in the neck, with a detachment of small scales, but large flakes 
come off, particularly from the hands, and they are not unfrequentl} 
peeled off by the patient. During the stage of desquamation, which 590 
ACUTE INFECTIOUS DISEASES. 
lasts from eight to fourteen days, the last traces of fever and angina 
disappear, and, when the disease runs a favorable course, it ends in 
perfect recovery during the third or fourth week. 
Scarlatina sine exanthemata and scarlatina sine angina belong to 
the simple, or, at all events, to the benign cases. The former is only 
to be distinguished from simple angina by its occurrence during an 
epidemic of scarlatina, by the high fever, by the great constitutional 
disturbance, and by a marked prodromal stage. In scarlatina sine 
angina, the fever symptoms and the exanthema are characteristic; but 
localization of the scarlatina process on the pharyngeal mucous mem- 
brane either cannot be found, or is limited to slight pain in swallow- 
ing, or to faint redness of the fauces We should be very careful 
about diagnosing scarlatina sine angina, particularly if it cannot be 
proved that the patient has been near scarlet-fever patients; from the 
great similarity of the eruption, scarlatina sine angina can occasionally 
only be diagnosed from some forms of roseola, especially roseola ab 
ingestis, by considering the causes. Like measles, scarlatina may 
prove very injurious, without any dangerous local symptoms ; the pa- 
tients may even die of the disease before the customary local symp- 
toms have appeared on the skin or pharyngeal mucous membrane. In 
such cases the patients die of paralysis of the heart, which is preceded 
by the symptoms of excessive adynamia. Here, as in the case of malig- 
nant measles, we shall not attempt to say whether the alteration of 
the blood has a directly paralyzing effect on the nervous system, and 
especially on the nerves of the heart, or whether the injurious effect be 
due to the high grade of the fever, that is, to the excessive increase of 
bodily temperature. But since, even in simple benign scarlatina, 
the temperature is usually very high, and since, as we have before 
shown, a still further increase destroys life, as is proved by physiologi- 
cal and pathological experiments, we regard it as very probable that 
the excessive increase of bodily temperature in malignant, asthenic, or 
typhoid scarlatina, induces the paralysis. The symptoms of asthenic 
or typhous scarlatina closely resemble those of asthenic or typhous 
measles and the same forms of other diseases, especially infectious dis- 
eases. Even in the prodromal stage, the patients are very much de- 
pressed ; they lie in a state of apathy, cannot collect their thoughts, 
scarcely answer any questions, and finally become perfectly comatose 
The pupils are usually dilated. Slight twitchings of the muscles, and. 
in children, general convulsions, not unfrequently occur; the tongue 
becomes dry, the pulse small, and scarcely to be counted; the body is 
often burning hot, while the extremities are cool. Even before the 
eruption appears, the patient may die with the symptoms of excessive 
collapse, and oedema of the lungs. The scarlatinous sore throat, which SCARLATINA 
591 
from the severe constitutional disturbance, is often overlooked in such 
cases, is frequently of diphtheritic nature. If the patient do not die 
during the prodromal stage, the eruption usually appears slowly and 
irregularly, is pale or livid, only remains on the skin for a short time, 
and is often accompanied by petechia?, which remain after the disap- 
pearance of the exanthema. The appearance of the eruption does not 
generally induce any amelioration of the patient’s symptoms ; on the 
contrary, the high fever continues, the pulse becomes weaker, the pros- 
tration greater. Diarrhoea and meteorism often occur, and the tongue 
and gums are covered with dry sordes. Most of the patients die in 
this stage of the disease, and of the few who reach the stage of des- 
quamation the greater part die of the sequelae. 
Cases, where angina maligna, infiltration, and suppuration of the 
lymphatic glands, or other disturbances of nutrition, of themselves dan- 
gerous, occur, may run just as malignant a course as those where gen- 
eral paralysis is induced, directly or indirectly, by the excessive fever; 
we can only point out the various forms of the disease due to malignant 
local affections, because any exhaustive description of them would be 
impossible within the limits proposed for this work. Angina maligna 
not unfrequently occurs during an apparently benign, or so-called nor- 
mal scarlatina, and in its first stages is not by any means universally 
accompanied by dangerous symptoms ; the difficulty of swallowing 
only attains a high grade when, as happens in many cases, there is at 
the same time a parenchymatous inflammation of the tonsils, which 
often renders swallowing impossible. The participation of the nasal 
cavities in the diphtheritic inflammation of the fauces is so constant 
that the occurrence of a coryza, with a discharge of secretion which is 
apparently bland and has no peculiar odor, is a very suspicious and 
usually threatening symptom. This coryza rarely accompanies the 
catarrhal form of scarlatinous angina; hence we should dispel the illu- 
sions of the parents, who consider this discharge from the nose as 
favorable, and, when they see it, expect their children to escape any 
cerebral trouble. The only certain point for the diagnosis of diphthe- 
ritic angina, in its first stage, is the examination of the fauces, which 
shows the above-described dirty-white, firmly-adherent plaques on the 
dark-red mucous membrane. But, even in a few days, the symptoms 
change, and the disease appears very dangerous; it is true the exan- 
thema offers no peculiar symptoms, but in the vicinity of the patient 
we may perceive a fetid odor, which comes from his mouth and nose. 
The sloughs, changed to dirty tags, adhere to the fauces, or, after they 
have been detached, unhealthy-looking ulcers form. A yellowish, 
badly-smelling secretion flows from the nostrils over the cheeks, and 
corrodes the skin with which it comes in contact; the cervical glands, 592 
ACUTE INFECTIOUS DISEASES. 
also, are much swollen, and form unsightly hard lumps at the sides ol 
the neck. The patient usually lies with the head thrown back, in a 
half comatose or perfectly unconscious state; the pulse, which was 
previously full, becomes small and beats 140 to 160 times a minute; the 
bodily temperature rises to 104° or even higher. In such cases, just 
as in measles complicated with lobular pneumonia, the fever induced 
by the scarlatina infection becomes excessive from the accompanying 
pharyngeal inflammation, and the bodily temperature is elevated to a 
point where adynamia and paralysis always occur. Laryngitis, com- 
plicating this form of angina, occasionally hastens the fatal result; it 
is characterized by hoarseness and dyspnoea rather than by croupy 
cough. If the patient lives through the stage of efflorescence, des- 
quamation often takes place normally; but, in the most favorable 
cases it lasts a long time, till the ulcers in the neck have healed, and 
till the discharge from the nose has ceased. Quite often the inflam- 
mation extends through the Eustachian tubes to the tympanum, result- 
ing in otitis interna, which leads to perforation of the drum, and often 
also to caries of the petrous bone. Hence, after scarlatina, many pa- 
tients have otorrhoea for years, and suffer from deafness for the remain- 
der of life. If the diphtheritic process has extended to the mouth and 
lips, the resulting ulcers, especially those at the angles of the mouth, 
heal very slowly. During the stage of desquamation and convales- 
cence, the patients are liable to great danger from inflammatory infil- 
tration of the lymphatic glands and subcutaneous connective tissue of 
the neck. These rarely end in resolution; and even suppuration re- 
sults slowly, and is accompanied by fever, which wears out the patient. 
I have seen patients die from suppuration of these enlarged glands, 
even six or eight weeks after recovery from the scarlatina. Inflam- 
matory infiltration of the cervical glands may also develop without 
angina maligna, and in such cases also it induces increase of the fever 
and consequent “ typhoid symptoms.” It is more probable that the 
brain symptoms are due to the high fever accompanying this infiltra- 
tion of the glands than that they are caused by pressure on the vessels 
supplying blood to the brain. Parotitis, which sometimes occurs dur- 
ing the stage of desquamation, just as it does in the course of typhus 
and cholera, must not be confounded with the above inflammations 
and suppuration of the lymphatic glands. It is chiefly in this stage, 
too, that we see inflammations of the synovial membranes, pleura, and 
pericardium. 
We have mentioned croupous nephritis as a frequent and im- 
portant localization of the blood-poisoning in scarlatina. The fact that 
scarlatina dropsy, which generally depends on this localization, usually 
makes its appearance during this stage, has given rise to the still preva SCARLATINA. 
593 
lent belief that the dropsy and renal disease are due to cold, tc 
which the patient has been exposed during the height of the exan- 
thema or during the desquamative stage. The fact that albuminuria 
and dropsy are very rarely seen in some epidemics, while they occur in 
almost every case in others, sufficiently proves the error of this hypoth- 
esis, although we cannot explain the causes of the difference in fre- 
quency of nephritis, angina maligna, and other local affections in dif- 
ferent epidemics. We have already (Yol. II., p. 12) fully described the 
symptoms and course of croupous nephritis, and we can now refer to 
that description the more readily, because most of the cases of croup- 
ous nephritis, which formed the basis of that description, occurred in 
children in the desquamative stage of scarlatina. While part of the 
patients affected with hydrops scarlatinosum, which is a symptom of 
acute inflammation of the kidney, recover and another part die with 
the symptoms of uraemic intoxication, and still more of pneumonia, 
pleurisy, pericarditis, etc., the second form of scarlatinous dropsy, not 
accompanied with albuminuria, is a sequel of scarlatina as free from 
danger as it is inexplicable. It generally develops gradually, may be- 
come very extensive, is not limited to the subcutaneous connective 
tissue, and rarely extends to the serous cavities. In some cases of very 
extensive scarlatinous dropsy without albuminuria, recovery takes place 
in a remarkably short time, as I know from my own observation. 
Treatment.—Prophylaxis requires the isolation of healthy persons 
from those affected with the disease and from those who have inter- 
course with such patients. This is the only rule that promises any 
good results ; hence it should be urgently recommended during malig- 
nant epidemics. Belladonna (extract belladonna; gr. iij, aq. dest. 3 j; 
give daily twice as many drops are there are years in the patient’s 
age) is regarded as a prophylactic by some physicians as well as by 
the homoeopaths; but experience has shown that, even when continued 
for weeks, this remedy affords no protection against scarlatina. The 
same is true of all other medicines, either internal or external, that 
have been recommended as prophylactics. The same rules apply to 
the treatment of scarlatina as we gave for that of measles. Before 
asking ourselves what we shall prescribe, we should decide whether 
it is necessary or even admissible to interfere actively with the regular 
course of the disease. We should keep the sick-chamber at an even 
temperature, not exceeding 55° to 65°, not allow the patient to be cov- 
ered with heavy bedclothes, freshen the air of the room occasionally 
by opening the window, and have the patient carefully washed daily. 
The best drink is pure cold water or lemonade; as nourishment, we 
may at first give water-soup, bread, stewed fruit, etc.; later, we may 
give meat-broths, milk, etc. If there be constipation, we may order 594 
ACUTE INFECTIOUS DISEASES. 
an enema of tepid water, avoiding active purges, except in case of 
necessity. It is an old custom to keep scarlatina patients in bed till 
the stage of desquamation is over, and it is well to keep up this cus- 
tom, undeterred by the fact that patients neglecting this rule do not, 
by any means, always suffer for so doing. Even after desquamation is 
completed, the patient should be protected from cold, and in winter 
should be kept in his room for at least a fortnight. During this time 
he should take several baths in lukewarm water. In simple, mild 
cases of scarlatina this expectant plan is sufficient, and should be pre- 
ferred to any medicinal, hydropathic, or other treatment. 
But, during scarlatina, changes often arise which urgently demand 
therapeutic interference, and which are sometimes successfully com- 
bated by energetic treatment. Chief among these changes are exces- 
sive increase of the bodily temperature and consequent occurrence of 
symptoms of adynamia and threatening paralysis. Formerly, in such 
cases, general stimulants were employed, occasionally with the effect 
of arresting the impending paralysis, as it seemed; but most of the 
patients died, in spite of the carbonate of ammonia, which was given 
as a specific in scarlatina maligna. Recently, the knowledge that the 
hydropaths treat scarlatina very successfully by wrapping the patient 
in wet sheets, and by cold douches, has greatly increased the popular- 
ity of this treatment, which had already been extensively used by 
Currie, and other physicians, in the treatment of asthenic or typhoid 
cases. And this is the most important therapeutic remedy in malig- 
nant scarlatina; and, in cases where there is no dangerous local disease, 
it often has a surprising effect. The employment of wet sheets and 
cold douches cannot be replaced by Schneemann's treatment of smear- 
ing the whole body with grease twice daily during the first three 
weeks, once daily during the fourth week, although this operation 
renders the patient more comfortable. I shall not attempt to say 
whether placing the patient in an empty tub and pouring cold water 
over him, or wrapping the naked body in wet sheets, deserves the 
preference ; but we should abstract heat by one method or the other 
every time the temperature of the body becomes excessive, and the 
symptoms of adynamia reappear. The wet sheets should be reapplied 
from three to six times, at intervals of ten or fifteen minutes ; the pa- 
tient should then be placed in bed, and left quiet till it is necessary to 
repeat the process. As even the laity are tolerably familiar with the 
success of the hydropaths, we rarely meet any great objection to the 
above treatment, even in private practice. If we should find this ob- 
jection, large doses of quinine should be given, although I cannot 
speak of its benefits from personal experience, as I can of those from 
the energetic abstraction of heat. In desperate cases, where the ROSE-RASII. 
595 
above plan fails, we may try to prevent the impending paralysis by 
powerful stimulants, such as carbonate of ammonia, camphor, musk, 
etc. The development of angina maligna is not arrested by abstrac- 
tion of blood, or the local application of cold; but pieces of ice taken 
into the mouth, and allowed to melt there, have a favorable palliative 
effect in this as in other severe forms of scarlatinous pharyngitis. As 
soon as the sloughs have been detached, and foul ulcers are left in the 
throat, we should proceed to energetic local treatment. We may 
touch the ulcers daily with a solution of nitrate of silver ( 3 j to § ij 
water), applied by means of a probang, and for the coryza, which al- 
most always coexists, we may inject a weak solution of nitrate of sil- 
ver (gr. v—x to | ij water) into the nostrils. I have not only seen 
unmistakable benefit from this treatment in some cases, but I have 
found that older children submit to the annoying operation without 
much opposition, because they find that it relieves them. Croup com- 
plicating angina maligna indicates the administration of an emetic, and 
the application of a solution of nitrate of silver to the glottis. We 
cannot do much against inflammatory infiltration of the lymphatic 
glands and connective tissue of the neck. According to my experience, 
abstraction of blood, cold, irritant, and resorbent remedies, cataplasms, 
etc., have no effect on these hard, indolent tumors, which are covered 
by normal skin. When they show a tendency to suppurate, and the 
skin over them grows red, we may apply cataplasms. As soon as 
there is fluctuation, the pus should be evacuated, to prevent extensive 
mortification of the tissues, which the pressure of the pus threatens to 
induce. We sufficiently explained the treatment of croupous nephritis 
when treating of renal affections, and may also refer to what has been 
already said for the treatment of scarlatinous dropsy, accompanied with 
albuminuria. According to my experience, a mild diaphoretic treat- 
ment suffices for simple cases of dropsy without albuminuria. 
CHAPTER III. 
Cannstatt aptly defines rose-rash as an eruption witn red spots, 
concerning which, from its general symptoms and the affections of the 
mucous membranes, we are in doubt whether it should be classed with 
scarlatina, measles, urticaria, or erythema, as it resembles one or other 
of these diseases in some points, while differing in others. Epidemic 
roseola arising from infection, which alone we shall discuss here, from 
unknown causes consists in modifications of scarlet fever or measles. 
By rubeola scarlatinosa, we mean a scarlet fever where the exanthema 
ROSE-RASH ROSEOLA FEBRILIS. 596 
ACUTE INFECTIOUS DISEASES. 
resembles measles, while the high fever, the throat affection, and the 
dropsy, which often follows, resemble the course of scarlatina. By 
rubeola morbillosa is meant a form of measles where the exanthema 
is confluent, and resembles that of scarlatina, while the affection of 
the respiratory mucous membrane and the escape of the pharyngeal 
mucous membrane leave no doubt of the morbillous nature of the 
disease. 
CHAPTER IV. 
SMALL-POX—VARIOLA-—PETITE VEROLE. 
Etiology.—Small-pox spreads solely by contagion; at least, any 
other cause of its extension and a spontaneous development of variola 
poison is very improbable, as we can always trace the contagion where 
there is no peculiar obstacle in the way of our seeking it. Small-pox 
poison, which we only know from its effects, is contained in the con- 
tents of the pustules, and in the perspiration of patients having the 
disease. This is proved on the one hand by successful vaccination 
with the contents of the pustules, and on the other by the contagion, 
which, in most cases, results without immediate contact with small- 
pox patients. The poison is most active at the period when the 
clear contents of the pocks begin to turn cloudy. The negative 
results of attempts at vaccination with the blood and secretions of 
small-pox patients, seem to prove that the poison is not contained in 
these fluids. Variola poison is very tenacious of vitality; it is not de- 
stroyed by drying; it clings for a long time to objects that have been 
near a patient with the disease, and, when protected from the air, it 
remains active for years. The same poison induces the severe forms 
of variola as well as the mild ones of varioloid. If a healthy person 
be infected by a patient with varioloid, he may have a severe variola, 
and the reverse. The different effect of the poison, that is, the un- 
equal intensity of the symptoms, appears chiefly due to the greater or 
less susceptibility of the patient exposed to the poison. This indi- 
vidual predisposition has always been very unequal; for, in former 
centuries also, there were some persons who were perfectly insuscep- 
tible to variola poison, so that they could expose themselves to it with 
impunity ; there were others in whom the susceptibility was so slight 
that they were only attacked by the milder forms (varioloid); while, 
in most persons, it was so decided that, on exposure, they were affected 
with the severe form of the disease (variola). The liability to small- 
pox, which, with the above exceptions, is common to all mankind, well 
and sick, young and old (even the foetus), men and women, expires at SMALL-POX. 
597 
most entirely for the rest of life, after one attack. The disease arti- 
ficially induced by vaccinating with the cow-pock has a similar effect 
on the predisposition. In some persons it seems to remove the ten- 
dency to the disease for life, in others only for a number of years; but 
the latter class are rarely affected with severe forms of small-pox when 
exposed to infection. Since, in our day, almost every one has been 
vaccinated during childhood, it may be readily understood why the 
number of cases of small-pox is far smaller now than before the intro- 
duction of vaccination ; and since, after vaccination, any returning dis- 
position to small-pox rarely reaches a high grade, we may also under- 
stand why, in the epidemics of the present day, the milder forms of 
the disease (varioloid) preponderate over the severer forms, which 
were formerly the most common. At certain times, in more or less 
extensive localities, from some unknown cause, the intensity of small- 
pox poison, or the susceptibility to it, is greatly increased ; epidemics 
result. These are more apt to occur in summer, but are not limited 
to any season. They have a variable duration, and the cases are 
sometimes malignant, at others very mild, although we cannot dis- 
cover any cause for this difference. 
Anatomical Appearances.—The anatomical changes in the skin, 
after infection with small-pox, are those of a superficial dermatitis, with 
a tendency to suppuration. In the milder forms of the disease, the 
suppuration starts from the cells of the rete Malpighii only; in the 
severer forms, on the other hand, it attacks the tissue of the cutis, 
destroys it, and leaves a loss of substance, which is replaced by cicatri- 
cial tissue. It is only in the latter cases that evident traces of the 
disease (pock-marks) remain for life. In the somewhat malignant 
epidemic that raged in Germany last year, these extensive and 
deep destructions of the skin, such as used to occur frequently, were 
rarely seen. 
Variolous dermatitis commences with circumscribed hyperasmia of 
the skin, which, according to Bilrensprung, extends through the cutis 
into the subcutaneous tissue. Very soon, elongation of the papillae in 
the efflorescence, and, more particularly, swelling of the cells of the 
rete Malpighii, change the hyperaemic spot of skin into a sharply- 
bounded nodule, flattened on top, which is not as yet excavated, and 
contains no fluid, but is perfectly solid. If the process advances 
(which is not always the case), the outer layer of the epidermis is ele- 
vated to a vesicle by a fluid exudation. The contents of this vesicie, 
at first clear, are soon clouded by the formation of pus-cells, which form 
from the young cells of the rete Malpighii, and the vesicles are thus 
changed to pustules. Besides the fluid exudation, the pus-corpuscles 
mixed with it, and the swollen cells of the rete Malpighii (which offer 598 
ACUTE INFECTIOUS DISEASES. 
form a ring-shaped swelling at the edge of the pock), we find a mesh 
work in the pock pustule, which results from old cells of the rete Mal- 
pighii, compressed by the exudation, particularly of the central cells 
of the epithelium dipping down between the papillae. This mesh- 
work traverses the middle of the pock more particularly, and causes 
the fan-like formation which has been so much discussed. If the vari- 
olous inflammation has not extended to the papillae, they are com- 
pressed and flattened by the pressure of the pock; in such cases the 
pock-pustules dry up early. New epidermis forms under the resulting 
scabs; when it is fully formed, the scabs fall off. A shallow excava- 
tion is occasionally left at the point where they have been, as the flat- 
tening of the papilla is not removed. The case is different when the 
papilla becomes infiltrated with pus, and breaks down. In such cases 
the contents of the pustules are changed into a more purulent fluid by 
the greater admixture of pus-cells, and by the detritus resulting from 
the breaking down of the papillae. The pustules become more dis- 
tended, and thus the umbilications (or shallow depressions in the cen- 
tre) of some pustules are obliterated. Some pocks burst, and allow 
their contents to trickle out, others dry up; in the latter case, as the 
middle part dries first, the umbilication is sometimes renewed. The 
resulting scabs do not fall off for some time, and they leave depressed, 
radiated cicatrices, on whose base we may see the dilated openings of 
the hair-follicles. 
The variety in extent and form of the pocks has induced the divi- 
sion into different classes. According as the pustules remain separated 
by intervals of healthy skin, or touch each other, or, lastly, unite to- 
gether into vesicles, the cases are divided into variolas discretce, cohce- 
rentes, and confluentes. Where the pocks do not pass beyond the 
first stage, so that no vesicles form on the sharply-bounded flattened 
nodules, it is called variola verrucosa. Variola lymphatica or serosa 
is where the contents of the pock do not become yellow and purulent, 
but remain a clear or slightly-clouded fluid; variola cruenta is where 
Ihe pocks are colored red or blackish, by the admixture of blood 
(“ black pox”). A form where the contents of the pock are absorbed, 
and the empty covering alone remains, is called variola siliquosa seu 
emphysematica; where the pock is filled with a discolored, ichorous 
matter, and accompanied by gangrene of the skin, the disease is termed 
variola gangrenosa. 
We do not find pocks on the serous membranes in autopsy of 
small-pox patients, but we not unfrequently find the remains of inflam- 
mation, with haemorrhagic exudation. Sick found fatty, extensive 
degeneration in the liver, kidneys, heart, and muscles of patients whc 
had died of variola. SMALLPOX. 
599 
Symptoms and Course.—During the period of incubation there 
are usually no symptoms either in mild or severe cases. After the in- 
oculation of variola, changes occur at the point of inoculation, even on 
the third day; but the general health of the patient remains undis- 
turbed, and no other symptom shows the infection till about the ninth 
day; as the pustule completes its development, the period of incuba- 
tion terminates. Then there is an eruptive fever, followed by an out- 
break of pocks on the other parts of the body, and by other signs of 
general infection. According to the observations of Bdrensprung and 
Ziemssen, the period of incubation of non-inoculated pocks lasts twelve 
or thirteen days. 
We shall first describe the symptoms and course of the severe 
forms, true variola, and close with a description of the milder forms, 
varioloid. 
The first stage of variola, the stadium prodromorum seu invasionis, 
commences with a chill, or with several rigors, which soon give place to 
a feeling of permanent heat. The pulse is full, and frequent, the tem- 
perature increased sometimes to 104° or 106°, the face is reddened, 
the carotids pulsate strongly; the patients have great thirst, loss of 
appetite, a bruised feeling in the limbs, and a sensation of pressure 
and fulness in the epigastrium; the tongue is coated, the taste slimy; 
nausea and vomiting are frequent, sometimes there is severe epistaxis. 
Sleep is restless, and broken by dreams. Some patients become de- 
lirious ; in children we not unfrequently see twitchings, and gnashing 
of the teeth, or a somnolent condition, which is occasionally interrupted 
by general convulsions. The high fever and severe constitutional dis- 
turbance are not accompanied by such characteristic affections of the 
mucous membranes as would enable us to decide the nature of the ex- 
isting infectious disease before us, as we can do in the prodromal stage 
of measles and scarlatina; but the symptoms above mentioned are al- 
most always accompanied by such severe pain in the sacral and lumbar 
regions, that we may very strongly suspect the existence of small-pox, 
when this disease is prevalent. It is not known whether the sacral 
and lumbar pains, so characteristic of the prodromal stage of variola, 
depend on hyperaemia of the spinal medulla, on pressure on the spinal 
nerves, where they escape from the vertebral canal, by the distended 
venous plexus, or on the excessive hyperaemia of the kidney, concern- 
ing which Beer has made some important suggestions in his valuable 
examinations into the.connective tissue of the kidneys. After imper- 
fect remissions during the second and third day, the fever and accom- 
panying disturbances usually increase, and attain their height on the 
evening of the third day. Generally, the intensity of the symptoms in 
the prodromal stage is in direct proportion to the subsequent eruption, 600 
ACUTE INFECTIOUS DISEASES. 
and the highest fever and most severe disturbances usually precede 
confluent small-pox. But this is not always the case; sometimes a 
severe prodromal stage is followed by a scanty eruption; in other 
cases, a very mild prodromal stage precedes a confluent eruption. 
Deviations m the duration of the prodromal stage are rarely observed, 
and still more rarely it is entirely absent, and the eruption is the first 
symptom. 
The second stage, stadium eruptionis, almost always begins with 
the appearance of the first papules in the third exacerbation of the 
fever. If the eruption be very copious, the red points lie close to- 
gether, and unite at some places, as they do in measles, or by a general 
confluence they cause a regular redness, and granular swelling of the 
face ; if the eruption be scanty, the different nodules remain isolated, 
and are separated by more or less extensive patches of normal skin. 
The next day the eruption usually spreads from the face to the neck, 
breast, and back, and on the third day to the extremities. The num- 
ber of papules on the body and extremities is proportionately far less 
than on the face; so that, even when the disease is confluent on the 
face, the pustules on the body and extremities usually remain discrete, 
or at most would be called variolas cohasrentes. The points gradually 
become large, blunt conical nodules; the second or third day these 
change to vesicles, and the third or fourth to pustules, the contents 
becoming cloudy and purulent. The pocks appear late on the extrem- 
ities ; they also develop late; on the face, the papules have become 
larger, and changed into vesicles, or their contents have become 
cloudy when the first nodules appear on the extremities. The erup- 
tion on the mucous membrane begins at the same time it does on the 
skin; but we do not generally notice it till later, as it at first causes 
little trouble. The pocks in the mouth induce increased flow of saliva; 
those in the pharynx, difficulty of swallowing; those in the air-passages, 
hoarseness and cough; those on the conjunctiva, lachrymation and pho- 
tophobia. The fever, the severe pains in the sacral and lumbar re- 
gions, and the constitutional disturbance, which attain their height 
toward the end of the prodromal stage, always remit when the erup- 
tion comes out, decrease still more as it extends to the body and 
limbs, and toward the end of the eruptive stage the patient usually 
feels quite well. He is then encouraged because he thinks he has 
passed through the worst. A few years since, a patient with conflu- 
ent small-pox presented himself at my clinic, who, after lying in bed 
for three days at Esslingen, with severe fever, had walked the five 
miles from Esslingen to Tubingen without difficulty. In confluent 
small-pox the eruptive stage is usually shorter, the exanthema spreads 
iver tire body more rapidly, the contents of the pocks become purulent SMALLPOX. 
601 
earlier, and from the confluence of the pustules the face often looks as 
if it were covered with one large bladder of matter. The affections of 
the mucous membrane also, which in variola discreta do not usually cause 
much trouble at this time, are also accompanied by very painful symp- 
toms, severe salivation, dysphagia, croupy cough, great photophobia, 
and by ischuria and burning pains in the external genitals. The high 
fever and severe constitutional disturbance of the prodromal stage re- 
mit diming the eruptive stage of confluent small-pox also, but only to 
a moderate extent; the fever never disappears entirely, as it does in 
discrete variola, nor does the patient feel well toward the end of the 
eruptive stage, as he does in the latter form. 
The third stage, stadium suppurationis seu maturationis, begins 
about the sixth day after the first appearance of the eruption, and about 
the ninth day after the first symptoms of fever. The pocks become 
larger; the bluntness of their summit gives place to a hemispherical 
shape. If they be punctured, their thick purulent contents escape all 
at once, because of the atrophy of the partitions, which previously let 
only part of the contents escape on puncture. The skin around the 
pocks swells decidedly, and becomes dark red; even in discrete variola 
the red areola surrounding one pock unites with that around the next. 
The redness and swelling thus become diffuse. The patients are 
greatly disfigured, and complain of severe, tense, pulsating pain in the 
reddened skin, which is covered with large pustules. More or less of 
these pustules rupture, and their contents flow over the surface, where 
they dry into crusts, which are at first yellow, subsequently brown. 
In these changes, also, the pocks on the body and extremities are one 
or two days behind those on the face. The pain and distress induced 
by the intense dermatitis are increased, during the suppurative stage? 
by the annoying symptoms due to the eruption on the mucous mem- 
brane. The saliva trickles constantly from the mouth of the patient, 
swallowing becomes almost impossible, the nose is stopped, the voice 
inaudible, the cough distressing and hoarse, the eyes, dark red and 
filled with muco-pus, burn and are very sensitive to the weakest light. 
The eruption in the vulva, vagina, and urethra, comes later than that in 
the mouth, pharynx, and larynx; hence the tense, burning pain in the 
external sexual organs and the ischuria are most severe after the sali- 
vation, dysphagia, and laryngeal symptoms have subsided. The fever, 
which had moderated or even disappeared during the eruptive stage, 
exacerbates during the suppurative stage, or begins anew with re- 
peated chills. This fever is generally called the secondary or suppu- 
rative fever, and it really seems as if the secondary fever did not 
directly depend on the variolous infection, but were chiefly or solely 
due to the dermatitis. The more severe and malignant the inflamma 602 
ACUTE INFECTIOUS DISEASES. 
tion of the skin, the mere intense is the fever; the dermatitis and the 
fever attain their height together, and the decrease and disappearance 
of the eruption go hand in hand with the decrease and subsidence of 
the suppurative fever. In many cases the suppurative fever becomes 
dangerous, because the bodily temperature rises so high as to induce 
the symptoms of adynamia and fatal paralysis (asthenic, nervous, 
typhous small-pox). In such cases, just as in asthenic measles and 
scarlatina, the symptoms of adynamia are not unfrequently accom- 
panied by those of an acute haemorrhagic diathesis ; the contents of 
the pock become bloody, and petechiae appear between the pocks. 
Occasionally, also, there is profuse epistaxis, more rarely haematem- 
esis, bronchorrhagia, or metrorrhagia (haemorrhagic or septic small- 
pox). In some rare cases, during the excessive adynamia of the sup- 
purative stage, the inflammation of the skin increases to partial morti- 
fication of the inflamed tissue ; gangrene of the skin results, and the 
pocks fill with a discolored ichor. Such patients almost always die 
early with the symptoms of excessive prostration (gangrenous small- 
pox). Besides the adynamia induced by the high fever, and besides the 
occurrence of a haemorrhagic diathesis or of cutaneous gangrene, which 
favor the threatening paralysis, the suppurative stage is especially 
dangerous on account of the localization of the variolous process on 
the serous membranes and in the parenchymatous organs, which occurs 
most frequently during this stage, and from the frequent increase of 
the affection of the mucous membrane to croupous and diphtheritic in- 
flammations. Thus, in many cases, increased dyspnoea, sharp pain in 
the side, tormenting cough, bloody expectoration, as well as the phys- 
ical signs of condensation of the lung, show the occurrence of pneu- 
monia. In other cases the subjective and objective signs of pleurisy 
accompany the above symptoms of the stage of maturation. The 
symptoms of the disease are also variously modified by the occurrence 
of suppuration of the joints, suppurative periostitis, subcutaneous, and 
intermuscular abscesses, inflammation and suppuration of the lym- 
phatic glands, panophthalmitis which begins as a hypopion and may 
be readily overlooked, as well as by the symptoms of pericarditis, 
meningitis, or of pyaemia from absorption of ichor. It is chiefly in 
confluent small-pox that the fever assumes an asthenic character during 
the suppurative stage, and that unusually dangerous local diseases of 
the internal organs occur. Moreover, in confluent small-pox, during 
the stage of maturation, the eruption on the mucous membrane of the 
pharynx and larynx readily becomes complicated with croupous exuda- 
tion and oedema of the glottis. Hence, this form of the disease is 
correctly considered very malignant; and confluent smal l-pox is often 
regarded as identical with malignant. SMALL-POX 
603 
The fourth stage, the stadium exsiccaiionis, usually begins on the 
eleventh or twelfth day. Part of the pustules, which have remained 
unruptured up to that time, burst, and their contents, which are thrown 
out, dry to soft, yellow crusts, which subsequently become hard and 
brownish. The other pocks lose their tension, become brown in the 
middle, dry, and sink in; gradually the contents and wall of the pock 
dry into a round scab. In proportion as the formation of the crusts 
progresses, the parts around lose their redness and swelling; the pa- 
tients again become recognizable; the tense, pulsating pain subsides, 
and gives place to a very annoying itching, so that the patient finds it 
very difficult to avoid scratching. In the stadium exsiccationis it is 
usually most evident that the pocks on the extremities are of more 
recent origin than those on the face; for just at the time the painful 
tension and the disfigurement of the face are disappearing or are al- 
ready gone, the patients complain of unbearable pain in the swollen 
fingers and toes. The scabs are detached very irregularly; at the 
points where there has been no ulceration of the skin (and these are 
more or less frequent, even in the most malignant cases) the crusts do 
not generally remain attached more than three or four days; on the 
other hand, at points where the ulceration has entered deeply into the 
cutis, the crusts remain attached longer; as the suppuration contin- 
ues, they become thicker and horny. The crusts that fall off early 
leave red spots, which are somewhat elevated as long as the skin re- 
mains swollen, and which, after a time, disappear without leaving a 
trace, or else change to slight depressions. On the other hand, when 
the crusts that have remained adherent for a long time at last fall off, 
round deep cicatrices are left, these have inverted edges and a punc- 
tate, seamed base. They are at first red, then become very white, and 
last during life. The symptoms induced by the eruption on the mu- 
cous membrane disappear when the redness and swelling of the skin 
subside. The salivation, dysphagia, hoarseness, cough, photophobia, 
and ischuria, all cease gradually. At the commencement of the stadi- 
um exsiccationis the fever continues, but is moderated (exsiccation 
fever) ; but the more the formation of the crusts progresses the more 
the fever decreases; the pulse becomes quiet, the skin is covered with 
perspiration, the urine deposits a sediment, the general health becomes 
normal. In confluent small-pox, which usually extends more in depth, 
as well as superficially, than other varieties, during the drying stage 
thick, dark crusts form, which cover the face like a mask. The irreg- 
ular crusts constantly increase on account of the continued suppuration, 
and cracks form in them, from which the pus trickles out. Finally, the 
crusts fall off in large pieces, and extensive irregular losses of sub- 
stance are left, instead of small round cicatrices, as after variola dis 604 
ACUTE INFECTIOUS DISEASES. 
3reta. In such cases, just as after deep burns, the retractions of the 
cicatricial tissue readily induce tense cicatrices, or bridge-like strings, 
ectropion, distortion of the mouth, etc., which cause the most hideous 
deformities. Not unfrequently, a previously beautiful countenance is 
rendered disgustingly ugly by confluent small-pox. Salivation, hoarse- 
ness, cough, and the other symptoms of variolous affections of the mu- 
cous membranes, disappear far more slowly after confluent small-pox 
than after the discrete form. And the affections of important organs 
that have been caused by the infection during the eruptive stage have 
not usually terminated in the suppurative stage. At this time the 
patient often has subcutaneous and intermuscular abscesses, boils, and 
other localizations of the variolous process, but especially pyaemia. 
Hence, too, the secondary fever is usually more severe and continued 
in confluent small-pox than in the discrete, and even in the most favor- 
able cases a long convalescence follows the severe disease. 
We may describe varioloid very briefly, because its symptoms dif- 
fer from those of variola only in degree. The prodromal stage is the 
same as that of small-pox, except that it is shorter and less intense. 
But there are numerous exceptions to this, a severe and protracted 
prodromal stage being sometimes followed by varioloid instead of by 
variola. The appearance of an erythematous rash, forming large red 
spots, or of a diffuse scarlatinous redness over a large part of the body, 
particularly the lower part, is somewhat characteristic of varioloid, be- 
cause it occurs more rarely in variola. This exanthema precedes the 
varioloid eruption from twelve to twenty-four hours. In the eruptive 
stage, which usually begins with the third exacerbation of the fever, 
the eruption does not spread from the face to the body and extremities 
quite so regularly as it does in variola. The eruption usually ends in 
twenty-four or thirty-six hours. The pocks are generally less numer- 
ous than in variola; they rarely become confluent, and then only at 
certain spots. The papules become vesicles, and the vesicles pustules, 
much sooner than in variola; the form of the efflorescence offers no 
peculiarities. In varioloid also, the mucous membranes are affected, 
and we have salivation, difficulty of swallowing, hoarseness, cough, etc. 
As the eruption terminates, the fever usually disappears entirely, and 
the patient almost always feels quite well, except suffering some incon- 
venience from the affection of the mucous membrane. The most im- 
portant differences between varioloid and variola occur in the stage of 
maturation; for it is then most evident that in the milder form the 
dermatitis is more superficial, while in variola it affects the parenchyma 
of the cutis deeply. During the suppurative stage the pocks are filled 
with thick fluid pus, they become larger, and hemispherical; some of 
them burst, and let out their contents; but the areola around them is SMALL-POX. 
605 
smaller, and less swollen, consequently the tension of the skin, the 
pain, and deformity, are always less than in variola. As the dermatitis 
is not so severe, the secondary fever is less, and, when the eruption is 
very scanty, the stage of maturation may run its course almost with- 
out fever. During the suppurative stage variola and varioloid differ 
less in regard to the affections of the mucous membranes; for the pho- 
tophobia, dysphagia, cough, and hoarseness in varioloid often trouble the 
patient as much as they do in variola; on the other hand, croupous and 
diphtheritic inflammations of the mucous membranes, and malignant af- 
fections of the internal organs, are very rare. The suppurative stage 
usually passes into the stage of desiccation by the fifth or sixth day of 
the eruption. But few pustules rupture; most of them dry up with 
their contents; a brown, dry spot forms in the centre, gradually be- 
comes larger, and as it reaches the periphery, the pock changes into a 
brown scab; most of the scabs fall off in three or four days, and leave 
red, somewhat prominent spots. The contents of some of the pocks 
are not thickened, but are reabsorbed, and, instead of a slough, the 
wrinkled, dry envelope is thrown off; this course is seen quite often, 
especially in the pocks on the extremities. But, as, in the severest 
cases of variola, some pocks always spare the tissue of the cutis, and 
do not leave a scar, so, in the mildest cases of varioloid, single pocks, 
which exactly resemble those of variola, often cause a loss of substance, 
and leave cicatrices. If we group the peculiarities that distinguish 
varioloid from variola, we should mention especially: 1. The short 
duration of the different stages, and of the entire disease. 2. The 
mildness or total absence of the secondary fever. 3. The escape of 
the cutaneous tissue, and the recovery without cicatrices. 4. The 
slighter mortality. In the times when, during small-pox epidemics, 
variola prevailed, or occurred exclusively, a third, or in some epidemics 
even a half, of the patients died. Of late, as the disease almost exclu- 
sively affects persons who have been vaccinated, and consequently 
varioloid is in excess, the mortality is very low; scarcely four or five 
per cent, of the patients die. 
Treatment.—Prophylaxis demands vaccination or re vaccination. 
All objections to vaccination, even if well founded, would have to give 
way to the facts, proved by statistics, that in the last century one- 
tenth of the population died of small-pox (about 400,000 people dying 
of the disease every year in Europe), another tenth were disfigured by 
the disease; and that, since the introduction of vaccination, the general 
mortality is less, and that of small-pox is reduced to a minimum. Dur- 
ing an epidemic, persons who have been vaccinated, but in whom the 
Vaccination has not yet taken, are attacked by small-pox, and the two 
diseases run their course at the same time without modifying each 606 
ACUTE INFECTIOUS DISEASES. 
other. These cases show that vaccination during the period of incuba- 
tion of small-pox cannot cut short the disease, and also that the sus- 
ceptibility to vaccination is not lost during the period of incubation. 
To avoid vaccinating persons who are already in the incubation stage 
of variola, it is well fcr a physician to vaccinate without delay all of 
his patients, where he considers the operation necessary, as soon as he 
knows of the appearance of small-pox in the vicinity. Inoculated 
small-pox generally runs a milder course than that due to infection, it 
is true; but the exceptional cases where the inoculated variola runs 
a malignant course, and ends fatally, are still so numerous that at pres- 
ent we should not think of inoculation, as we have vaccination to rely 
on. Besides vaccination and revaccination, we should not be deterred 
by any personal considerations from exercising the most stringent rules 
for the isolation of small-pox patients, even if they should be very an- 
noying for the patient and his friends. 
The treatment of small-pox can only be symptomatic, as we know 
of no remedy for cutting short the disease, and averting dangerous 
accidents. In the prodromal stage the patient should be kept mod- 
erately cool, the temperature of his room should be about 60°, the bed- 
covers should not be too heavy; we should not dose him with warm 
tea, but let him have cold water or lemonade, absolute diet, and, where 
there is constipation, we may order enemata of three parts of water to 
one of vinegar. If the prejudices of the patient render it necessary to 
give some medicine, we may order a solution of nitre. Even in severe 
congestion of the head, with a full pulse, we should avoid bleeding, 
which was formerly so popular in inflammatory small-pox, and limit 
ourselves to the application of cold to the head, and repeated ablutions 
of the body with cold water. The administration of camphor and other 
remedies, for causing derivation to the skin and hastening the eruption, 
formerly so much in vogue, is very objectionable. During the eruptive 
stage we should especially attempt to prevent the development of a 
severe eruption on the conjunctiva. This may be done by the assidu- 
ous employment of cold water compresses, or, still better, by com- 
presses moistened with a weak solution of corrosive sublimate (gr. j to 
water § vj). Cold and the mercurials are also much used for the pre- 
vention of deep destruction of the skin, and disfiguring cicatrices. For 
this purpose it is best to cover the face (which is the only part usually 
protected) with a mercurial plaster, emplastrum de vigo, and to leave 
it on for several days. /Skoda prefers compresses moistened with solu- 
tion of corrosive sublimate (gr. ij—iv to water § vj) to mercurial plas- 
ter, which induces an injurious elevation of temperature. Hebra re- 
jects both mercurial plaster and solution of corrosive sublimate, as 
well as collodion, and touching the individual pocks with nitrate of SMALL-POX. 
607 
silver, which have also been recommended. He has come to this deci- 
sion from the observation in his wards that the pocks do not leave 
cicatrices any oftener since he has stopped employing these remedies, 
than when he used them. Hebra applies only cold-water compresses ; 
while the skin is tense, these relieve the patient, although they cannot 
protect the skin from destruction. During the eruptive stage, the 
chief attention should be directed- to the fever, for the patient may be 
much endangered if it become severe. Unless the temperature rise 
very high, we may abstain from treatment; if it do rise high, we 
should give large doses of quinine. In the stage of desiccation, we 
should let the patient have an easily-digestible but nutritious diet, 
and a little wine; for the exhausted strength requires building up, and 
the frequent pulse subsides more readily under the careful supply than 
under the continued withholding of the nutritive material necessary 
for the restitution of the body. The patient should be warned against 
scratching off the crusts, and we should take measures to prevent his 
doing so involuntarily, while asleep. If the crusts be firmly adherent, 
and especially if suppuration under them continue, we should employ 
cataplasms. Among the other symptoms requiring especial attention 
during variola, are the troubles from the affections of the mucous mem- 
branes. We cannot hope for an abortive treatment of the pocks on the 
mucous membrane, except in those in the mouth; and, even there, as- 
tringent mouth-washes, and touching the individual efflorescences, are 
of no material service. If dangerous dyspnoea, and other symptoms of 
croupous laryngitis occur, we may give an emetic of sulphate of cop- 
per, and attempt to apply a solution of nitrate of silver through the 
entrance of the glottis, by means of a probang. In oedema glottidis, 
if we cannot relieve the patient by scarification, we should perform 
laryngotomy. Inflammation of the serous membranes, and of the 
parenchymatous organs during small-pox, may require venesection, 
especially when, during pneumonia or pleurisy, collateral oedema in- 
duces difficulty of respiration; but it should only be employed in cases 
of absolute necessity, for experience shows that abstraction of blood 
is badly borne in all infectious diseases. In other respects pneumonia, 
pleurisy, and other local affections induced by variola, are to be treated 
according to the rules given when speaking of the primary forms of 
these diseases. Abscesses of the cellular tissue and suppurating lym- 
phatic glands should be opened early.2 608 
ACUTE INFECTIOUS DISEASES. 
CHAPTER V. 
COW-POCK — VACCINA. 
Etiology.—Vaccina is an excessively infectious disease. The re- 
markable fact, that, even at the present day, extensive epidemics of 
small-pox occur in spite of most persons being vaccinated, or even in 
many cases revaccinated once or oftener, has induced me to make 
some very careful observations regarding the duration of the protec- 
tive power of vaccination. I have not yet completed this work, but 
have gone far enough to satisfy myself that the protection against 
variola afforded by vaccination is for a far shorter period than is gen- 
erally believed. 
On the presumption (which is certainly correct) that a person who 
takes vaccina after vaccination would have taken variola or varioloid if he 
had been exposed to infection, I have made a large number of observa- 
tions on revaccination. Through the politeness of Surgeon-General 
Von Klein and Dr. Von Kollreutter, in Stuttgart, among other cases, 
I have had the opportunity of following, day by day, the effect of re- 
vaccination in five hundred recruits. In these cases, where I had per- 
fect control, I satisfied myself that the number of the recruits in whom 
normal cow-pocks developed was proportionally small, and corresponded 
very nearly with the number given by other observers. But it also 
showed that the number where there was no result was also slight. 
In most cases, a few days after the vaccination, there were redness and 
infiltration of the skin, papules, vesicles, etc. Among the latter class, 
in many cases, eight days after the operation, the has 
run its course, and, if the case has not been watched during the inter- 
val, it would be classed among those where the vaccination had no 
effect. These inflammations at the point of vaccination may have been 
the result of the wound from the lancet, and of the foreign body intro- 
duced under the epidermis through it, or a result of scratching; but 
there was also a possibility that it was due to incomplete vaccina run 
ning a rapid course, and holding the same relation to ordinary vaccina 
that varioloid does to variola, and which consequently has been called 
vaccinoid or varioloid-vaccina, in opposition to variola-vaccina. To 
settle this question, I first vaccinated a number of persons with the 
contents of blisters and of pustular eruptions. In none of these per- 
sons was the like result produced. I also revaccinated a number of my 
pupils and house-patients, in whom, at the first attempt, this modified 
result had occurred, and in them also the effect failed. These facts 
make it appear to me very probable that, at the time of a small-pox 
epidemic, in spite of the common vaccination and revaccination, the VACCINA. 
609 
number of persons liable to variola or varioloid is quite large; and, al- 
though I have arrived at no conclusion as to the duration of the pro- 
tective power of vaccina, I think I may still advise physicians to revao- 
cinate all their patients at the outbreak of an epidemic, no matter what 
the length of time since their last vaccination. The contents of the 
vaccina pustule are the only known vehicle of the contagion ; the ema- 
nations from the skin and lungs, which convey the variola poison, do 
not carry vaccina poison ; at least, a well person is never infected by 
entering the atmosphere of a person or beast with vaccina. A second 
important difference between variola and vaccina poison is, that the 
latter only induces an eruption at the point where it wTas introduced, 
never at remote parts, as the former does. It is not necessary to de- 
cide the question whether this difference depends on the fact that 
vaccina poison is of a different nature from variola poison, or whether 
the latter is weakened by being transferred to another species of ani- 
mal, being more imperfect and less active when reproduced in the cow. 
The predisposition to vaccina is very general, and it is rare for a per- 
son vaccinated for the first time to escape the disease. A single at- 
tack sometimes removes the liability to the disease for the rest of life; 
but, in the majority of cases, this immunity only lasts a number ot 
years, and then ceases. The important discovery, that having had 
vaccina removes the susceptibility to small-pox just as it does to a 
second attack of vaccina, is still more important, since it has been 
shown that even this protection is only temporary, and that vaccina- 
tion must be repeated from time to time, if we would prevent a return 
of the liability to small-pox. Leaving out of consideration certain 
foolish objections, that have been advanced against vaccination, it can- 
not be denied that it sometimes endangers life, and in other cases 
leaves permanent impairment of health, especially cutaneous erup- 
tions, and other scrofulous affections. The hypothesis that scrofula 
was transferred, by the vaccination, from one child to the other, is 
false, as may be proved. Sometimes children become scrofulous after 
vaccination, although the lymph have been taken from the arm of a 
perfectly healthy child; and sometimes children remain perfectly 
healthy after being vaccinated with lymph from a decidedly scrofulous 
child. The occurrence of scrofula after vaccination seems to be due 
to the debilitating influence of the fever accompanying the vaccina, 
and the prominence of the exanthema among these scrofulous affec- 
tions appears to depend on the disease of the skin, artificially induced 
at the point of vaccination. At least other febrile diseases, as well as 
all debilitating affections, occurring in young children with a tendency 
to scrofula, have the same influence in developing this disease that 
vaccina has. And we know that blisters, and other irritants to the 610 
ACUTE INFECTIOUS DISEASES. 
skin, not only induce inflammation at the point of application, but alsc 
increase the predisposition to other cutaneous affections. Many chil- 
dren, who have never previously suffered from any exanthema, are 
affected for months with moist eczema of the face, after having their 
ears pierced, as well as after vaccination. But it is only in rare cases 
that the occurrence of scrofulous affections is due solely to vaccination, 
and is not influenced by other causes, such as weaning and teething, 
which usually take place about the time that vaccination is done, and 
it is still rarer for life to be endangered by the operation. Complete 
ignorance of statistics of mortality, which show a decided decrease of 
mortality since the introduction of vaccination, must be the only ex- 
cuse for urging these exceptional cases as grounds against vaccination. 
It may be readily seen why more children die of measles, scarlatina, 
croup, and hydrocephalus, since small-pox leaves a larger number for 
these diseases to attack, as it were. But the slight increase of mor- 
tality in the above diseases does not, by any means, equal the diminu- 
tion of mortality in variola. Unless the occurrence of a small-pox 
epidemic throws all other considerations into the shade, I do not vac- 
cinate weakly children, inclined to scrofula, during their first year, but 
wait till the second or third, after the teeth have developed, because I 
am satisfied that, in such children, very much depends on protecting 
their first development from injurious influences. 
Anatomical Appearances.—The anatomical changes in the skin 
after the first vaccination exactly resemble those in variola, except 
that they are confined to one point. The third day after the vaccina- 
tion there is a small red nodule at the point of operation; the fifth or 
sixth day this changes to a vesicle; by the eighth day the vesicle at- 
tains the size of a lentil, and has a central depression, the umbilica- 
tion, and a cellular formation. The ninth day the contents of the 
pock become cloudy and whey-like, while a broad, dark-red halo de- 
velops around their periphery; on the tenth day they become puru- 
lent; from this time the pock begins to dry up, rarely rupturing. 
Toward the end of the third week, or even later, the crust falls off, 
and leaves a somewhat excavated, round, white cicatrix, whose base is 
stippled and ridgy. The umbilication of the vesicle, according tc 
Simon, depends on the puncture made during the vaccination; as a 
result of the inflammation caused by the puncture, there is an adhesion 
of the epidermis to the cutis, hence, when a serous liquid is subse- 
quently effused between the two membranes, the epidermis does not 
become loosened at the point where it is most firmly attached; this 
hypothesis is supported, among other points, by the fact that the form 
of the umbilication corresponds to that of the wound: if we have 
vaccinated through a puncture, the depression is small and round; if VACCINA. 
611 
through an incision, there is an elongated depression along the middle 
of the oval pock. The changes that occur at the point of vaccination, 
in persons whose susceptibility to vaccina is diminished, are very varied. 
They always take place sooner, and run their course more rapidly, than 
in normal vaccina. In some cases we see nodules, or wart-like swell- 
ings, surrounded by a dark-red and infiltrated areola, which either do 
not develop farther, or else change to vesicles, whose contents quickly 
dry up. In other cases, on the reddened and infiltrated spots we see 
no efflorescence; in still other cases, there is a furuncular inflammation 
of the skin, resulting in superficial ulceration. To determine, in 
any case, whether this inflammation be modified vaccina, we would 
have to vaccinate a child, who has not yet been vaccinated, with the 
products. 
Symptoms and Course.—Regarding the symptoms and course of 
normal vaccina, a short description may suffice. There is no premoni- 
tory stage. In the eruptive stage, the anatomical changes in the skin, 
above described, are the only symptoms of the disease. In the stage 
of maturation the inflammation causes severe tense pains, and hinders 
motion of the affected arm. The lymphatic glands in the axilla often 
swell. Sometimes an eruption, resembling lichen, or eczema, instead 
of the pock eruption, appears in the vicinity of the vaccina pustule and 
at other parts of the body. While fever never occurs at the com- 
mencement of vaccina, the stage of maturation is always accompanied 
by a secondary fever. In incomplete, modified vaccina, the inflamma- 
tion of the skin sometimes causes insupportable itching, sometimes 
tense or burning pain. From numerous measurements of temperature, 
I have satisfied myself that the patients have a fever which is not at 
all in proportion to the intensity and extent of the dermatitis. Where 
the local symptoms were very slight, I have noticed a temperature of 
104°. But, from the less extent of the dermatitis, the fever never be- 
comes so high as in variola; it can only prove dangerous to very weakly 
children, and even then only in rare cases. It is rare also for danger- 
ous erysipelatous or pseudo-erysipelatous inflammation of the arm to 
occur during the stage of maturation. 
Treatment.—In the following paragraphs we have to treat not so 
much of a cure of vaccina, as of conducting the disease to a proper 
termination. The most important rules to follow, in vaccinating, are: 
1. To take the lymph from a healthy child, who has not previously 
been vaccinated. Little as we believe in the transfer of dyscrasias by 
vaccination, we still consider it foolhardy and improper to make use- 
less experiments as to whether this view is correct. Experience shows 
that the lymph taken from the vesicles of revaccinated persons is 
much less certain to produce normal pocks than that taken from pe^- 612 
ACUTE INFECTIOUS DISEASES. 
sons vaccinated for the first time. 2. We should take this lymph, the 
seventh or eighth day after vaccinating, from pocks which are perfectly 
normal as regards size, form, and areola. The lymph from older or 
younger pocks, or from those in any way abnormal, is less certain. 
3. When possible, we should vaccinate from arm to arm. If obliged 
to use old lymph, that which has been preserved in glass tubes, with 
the ends sealed, is the best. 4. We should vaccinate through punc- 
tures made with the lancet or vaccinating needle, and should choose a 
part of the arm which would be covered even when short sleeves are 
worn. About five punctures should be made in each arm; sufficient 
space should be left between the punctures to prevent the confluence 
of the pocks or their areolse. 5. Except during the prevalence of a 
small-pox epidemic, we should only vaccinate healthy persons. If the 
vaccination do not succeed, we should repeat it after a few months. 
6. When an epidemic of the disease breaks out, it is well to revaccinate 
persons who have not been vaccinated for seven years or more. 7. We 
should protect the pocks from pressure and friction, and should espe- 
cially guard against children scratching their arms; and we should 
keep the patient in his room during the maturating fever. If there be 
much inflammation around the point, we may apply compresses wet 
with lead-water; if ulcers remain, use cataplasms. 
CHAPTER YI. 
WIND-POX, WATER-POX, SHEEP-POX, VARICELLA, CHICKEN-POX. 
Etiology.—Many dermatologists consider varicella as identical 
with variola and varioloid, and as being the mildest form of small-pox. 
From this view, the almost exclusive occurrence of this disease in 
children is explained by saying that in them, from the short time which 
has elapsed since vaccination, although the liability to small-pox is not 
entirety gone, it is reduced to a minimum; while in older persons the 
liability to small-pox is usually so much reestablished by the long pe- 
riod that has elapsed since vaccination, that, when exposed to the con- 
tagion, they are affected with varioloid. The falseness of this view 
may be shown by striking examples. In the first place, the frequent 
occurrence of varicella in children that have never been vaccinated, 
speaks against the identity of varicella and variola poison. Why 
should persons who might be supposed to have the greatest predispo- 
sition to small-pox be so often attacked by the mildest form of the 
disease ? But experience also shows that varicella offers no immunity 
to vaccina or variola; on the contrary, many children who have just 
recovered from varicella are successfully vaccinated, or, during an eni VARICELLA. 
613 
demic of small-pox, may take variola or varioloid; this is in direct 
opposition to the almost absolute protection afforded by an attack of 
either of the latter diseases to another attack. Lastly, cases also occur 
where children who have been vaccinated or had variola a few weeks 
previously, are attacked by varicella. The above facts render it certain 
that varicella is not the mildest form of small-pox, but is a disease sui 
generis. The cases where persons with varicella are said to have in- 
fected others with variola or varioloid, and vice versa, appear due to 
mistaking mild cases of varioloid for varicella. Tire infectious origin 
of varicella may almost always be traced; but all those infected, 
whether vaccinated or not, are attacked by varicella, not by variola or 
varioloid. Varicella usually occurs in more or less extensive epidemics, 
which occasionally accompany, precede, or follow small-pox epidemics, 
but in other instances coexist with epidemics of measles or scarlatina; 
varicella not unfrequently occurs sporadically also. 
Anatomical Appearances.—The exanthema begins as small, red, 
distinct spots, which, after a few hours, are changed to limpid vesicles 
of the size of a pea or lentil, by a copious serous effusion between the 
cutis and epidermis. These vesicles have neither a central depression 
nor a cellular formation. After a time their contents become whey-like, 
but never purulent. Thin crusts form from the dried vesicles, which 
fall off after a few days, without leaving a cicatrix. From the form of 
the vesicles, the different varieties, varicellae globulosae, ovales, lenti- 
culares, coniformes, and acuminatae, are distinguished. We often see, 
especially when the eruption is very extensive, that, besides numerous 
varicella vesicles running the usual course, a few filled with pus (vari- 
cellas pustulosae) acquire the appearance of variola pustules, and even 
leave cicatrices. Since the form of variola pustules is not specific, but 
exactly resembles that of some erythema pustules, we should not at- 
tach too much importance to the external resemblance of some of the 
efflorescences in varicella to those in variola, and consequently consider 
the two diseases as identical. 
Symptoms and Course.—In some cases the appearance of the 
eruption is the first symptom of the disease. Even the most careful 
and anxious mothers often notice no prodromal stage, and assure us 
that, the day before the eruption appeared, the child was perfectly 
well. More rarely the exanthema is preceded for a day or two by 
slight fever and general discomfort, derangement, loss of appetite, 
headache, etc. The varicella spreads over the body without any regu- 
larity. The eruption is usually thickest on the back and breast. The 
face occasionally remains perfectly free. Individual vesicles develop 
in from six to twelve hours; their contents become cloudy the second 
day, and dry up the fourth. It is rare to have only a single crop of 614 
ACUTE INFECTIOUS DISEASES. 
vesicles; new crops usually appear for several days, so that the disease 
is often protracted for a fortnight, or longer; and in the later stages 
we find dried vesicles and fresh ones alongside of each other. Rarely 
vesicles form on the mucous membrane of the mouth and fauces, and 
they soon change to small, round ulcers. There is no constitutional 
disturbance. 
Treatment.—Treatment is scarcely necessary in varicella, as the 
disease is not dangerous, or very inconvenient, and always terminates 
in recovery, after lasting a week or two. Nevertheless, it is advisable 
to protect the patients from all injurious influences while the affection 
lasts, to keep them in their chamber, and to regulate the diet. 
CHAPTER VII. 
TYPHUS FEVEK EXANTHEMATIC TYPHUS PETECHIAL TYPHUS, 
SPOTTED EEVEK. 
Etiology.—Exanthematic typhus (morbus acutus, febrilis, conta- 
giosus, exanthemate proprio ac eminenti systematis nervosi passione 
stipatus, Hildebrand) is very closely related to the previously de- 
scribed infectious diseases, measles, scarlatina, and small-pox, by its 
contagiousness, and by the local affection of the skin in the shape of 
an extensive exanthema; while, on the other hand, its symptoms cor- 
respond so closely with those of abdominal typhus, that many authors 
consider it a variety of the latter. The contagiousness of exanthe- 
matic typhus can only be doubted by those who have had the opportu- 
nity of observing the disease in large epidemics solely. When an 
epidemic disease first affects a large city, or still larger district, it is 
almost impossible to decide whether the disease be transferred from 
one person to another, or if different individuals be affected inde- 
pendently from having been exposed to the same causes of injury. 
The case is quite different when the disease attacks smaller places, 
where it may readily be watched and its extension observed. In such 
cases there is a more favorable opportunity of observing the contagious 
or non-contagious nature of the malady. All observers who have had 
such an opportunity in exanthematic typhus agree that the power of 
contagion is just as evident, in this disease, as in any other. Among 
the numerous observations tending to prove the contagiousness of ex 
anthematic typhus, I may mention two of my own, which are particular- 
ly striking. In the year 1854 two typhus patients were received into 
the Magdeburg hospital from the prison, which was much crowded. Foi 
months previous there had been only a few cases of abdominal typhus, 
and not a single case of exanthematic typhus in mv wards. Eight TYPHUS FEVER. 
615 
days after the reception of these patients, two patients that had lain 
alongside of them were attacked by the same disease (one of them 
had been received into the hospital for intermittent fever, the other for 
epilepsy) ; in a short time the attendants who had taken care of the 
patients were similarly attacked. After the isolation of these patients, 
all the other persons in the hospital escaped the disease; nor were 
there any other cases in the city at this time. In March, 1855, a 
tradesman from Heiligenstadt was attacked with exanthematic typhus 
while away from home; he was received into my ward; a year had 
almost elapsed since the appearance of the last case there. Eight days 
after the reception of this patient, a blacksmith’s apprentice and a me- 
chanic, lying next to him, were attacked by the disease. After these pa- 
tients were isolated, my assistant, a washer-woman, and every one who 
had been chosen to attend the patients, were also attacked. It was not 
till a convalescent from exanthematic typhus was placed as the sole at- 
tendant for the typhus patients, that new cases ceased to appear. (These 
patients were nursed with great conscientiousness and self-sacrifice by 
the convalescent, who, for twenty years previously, had been in chains 
for the murder of a clergyman, and had only obtained his liberty a short 
time before.) The contagion is contained in the atmosphere about the 
patient, in his clothes, bed linen, and other property. Hence the treat- 
ment and nursing of patients with exanthematic typhus is much more 
dangerous than is the case with patients having cholera or abdominal 
typhus. Like measles, the disease may be carried by persons wTho do 
not themselves become affected. The more patients are crowded to- 
gether, the more intense the contagion becomes ; this fact agrees per- 
fectly with the recently-adopted view of a contagium vivum (see page 
673). A place of a certain size, where many patients produce the 
germs of the disease, is more thoroughly filled with the poison than- 
one where the germs are only produced in the body of a single patient. 
I do not agree with most recent authors in considering the ques- 
tion settled in regard to whether exanthematic typhus be exclusively 
propagated by contagion, or if it be also due to miasm,. There is no 
solid ground for such assertions as this, “ that a disease is either only 
miasmatic, or only contagious,” and even the persons making them do 
not always strictly adhere to them. When one acknowledges that 
the germs of cholera probably develop from diseased rice, and are thence 
brought to us by cholera patients and their dejections, he cannot deny 
the possibility, and even probability, that the germs of contagious dis- 
eases native among us may, under favorable circumstances, develop 
and increase outside of the human body. The hypothesis of a “ spon- 
taneous generation” of infectious diseases, in the sense that their 
cause is a new agent induced by injurious influences, is, of course, to 616 
ACUTE INFECTIOUS DISEASES. 
be rejected, for, in that case, we should be inferring a generatio aequi- 
voca, which has been disproved; but it has not by any means been 
proved that, besides purely miasmatic affections, whose germs develop 
outside of the organism and are not reproduced in the bodies of pa- 
tients suffering from them, there are no miasmatic-contagious dis- 
eases, whose germs develop outside of the body, but are also repro- 
duced in the bodies or dejections of patients suffering from them. I 
know of no absolute objections to this theory, and a series of facts 
agrees better with it than with the unproved assertion that there is no 
miasmatic-contagious disease. We not unfrequently see the disease 
in question appear under circumstances which render origin from con- 
tagion very doubtful; for instance, in ships at sea (ship-fever), in care- 
fully-guarded prisons (jail-fever). On the other hand, under certain 
circumstances, which appear favorable to low organisms and to their 
reception into the body, as in years of famine, where bad, spoiled food 
is eaten (famine typhus) and in over-filled lazarettos, where the air is 
loaded with exhalations from the patients (lazaret-fever), exanthematic 
typhus occurs so frequently, that, where these circumstances prevail, 
its appearance may almost be predicted. Of course, this does not prove 
that the body of a patient diseased by the introduction of these germs 
may not be a more favorable soil for its development and reproduction 
than decomposing flesh, or the air of a lazaretto overloaded with ex- 
cretions, and that the disease may not only continue to exist, but to 
extend and even spread greatly, long after the disappearance of the 
circumstances which favored the development of the germs of the dis- 
ease outside of the body. If the above-mentioned assertion, that the 
cholera-germ is developed on dried rice, should be confirmed, it would 
be still more probable that the germ of exanthematic typhus developed 
outside of the human body in decomposing animal matter, and when 
circumstances were peculiarly favorable, increased so as to become 
dangerous to man. The susceptibility to the miasm or contagion of 
exanthematic typhus is very general. Males and females, strong, 
healthy persons and weak, sickly ones, are about equally liable to the 
disease. Only early childhood and extreme age are usually exempt. 
Excessive exertion and other debilitating influences appear to in- 
crease the predisposition. One attack seems to destroy the suscepti- 
bility to the affection. 
Griesinger and Hirsch speak of the geographical extension of ex- 
anthematic typhus in Europe thus: from the beginning of the sixteenth 
to the end of the eighteenth century, this disease extended over all 
Europe as the common form of typhus; during the war, at the com- 
mencement of this century, it attained its height. After that time 
it was so rare on the continent, that there was a current belief thai TYPHUS FEVER. 
617 
typlius never occurred without ulcers in the intestines. It is only in 
the last ten years that the epidemics in Upper Silesia, the fatal epi- 
demics during the Crimean War, and recently the epidemics in East 
Prussia, etc., have dispelled this error. In the British Islands, and in 
certain places in middle Europe, exanthematic typhus is the endemic 
form of the disease. In Southern Europe, Lower Italy, the Oriental 
countries, Hungary, etc., exanthematic typhus occurs, sometimes alone 
and sometimes combined with other forms. Small epidemics of exan- 
thematic typhus are occasionally seen almost everywhere, and may 
usually, but not always, be traced to contagion. 
Anatomical Appearances.—The characteristic exanthema of ty- 
phus, typhus roseola, cannot be recognized on the dead body any morp 
than the exanthema of measles and scarlatina can, for the circumscribed 
hyperaemia, on which the roseola depends, disappears in the general 
paleness of the surface. Occasionally, indeed, this circumscribed cuta- 
neous hyperaemia causes rupture of the vessels and small haemorrhages 
in the cutis, and we then find the skin of the cadaver covered with more 
or less numerous and extensive petechia?; but this is by no means con- 
stant, and we must not consider petechiae as pathognomonic of “ pete- 
chial typhus.” The roseola-spots, observed on the skin of the patient 
during life (which we shall describe under the anatomical appearances, as 
we did measles, scarlatina, and small-pox), resemble those of measles, 
are about the same size, shape, and color; like these they unite to irreg- 
ular figures, but, unlike the spots in measles, they are not capped by 
small papules. Sometimes they are on a level with the surrounding 
skin, sometimes they project slightly above it, while in abdominal ty- 
phus the eruption of roseola on the chest and abdomen is usually 
scanty and does not always exist; in exanthematic typhus it is not 
always confined to those parts, but usually covers the trunk and ex- 
tremities in great numbers, and is so apparent that, even on superficial 
examination, it is not readily overlooked. The roseola rarely occurs 
on the face, and this one fact is sufficient to prevent a mistake in diag- 
nosis between the exanthema of measles and typhus. 
The other anatomical appearances also usually resemble those 
found after other exanthemata. If death takes place early, the bodies 
are but little emaciated, the rigor mortis is marked, and there is ex 
tensive hypostatic congestion in the dependent parts of the body. 
The muscles are dark-colored, the heart and great vessels contain 
cherry-colored blood. The bronchial mucous membrane is always 
strongly injected, and covered with tough mucus. In the lungs we 
find more or less extensive hepatization and atelectatic spots. The 
bronchial glands are swollen, but not infiltrated. There are no con- 
stant, marked changes in the intestinal canal and mesenteric glands, 618 
ACUTE INFECTIOUS DISEASES. 
The spleen is enlarged and soft. If death do not occur till late in the 
disease, the rigor mortis is less marked, and soon passes off; the bodies 
are more emaciated; the al® nasi seem smoked, the teeth and gums are 
covered with sordes; the blood rarely contains any fibrinous clots; it 
is smeary, dark, or inclined to cherry-color, and the walls of the vessels 
are infiltrated. There is usually extensive hypostatic congestion in 
the lungs; the spleen is decidedly enlarged; it is sometimes the seat 
of h®morrliagic infarction, or of small abscesses. There are no con- 
stant anomalies in the stomach or intestinal canal; at most, there is 
swelling of the solitary and JPeyer’s glands, such as is also seen in the 
acute exanthema. Nor do the other organs show any constant char- 
acteristic deviations from their normal state. In the rare cases, where 
death occurs still later from the sequel®, on autopsy we find the most 
varied anomalies, suppurating parotid glands, the remains of croup 
and diphtheria, extensive necrosis of connective tissue, bed-sores, gan- 
grene of the extremities, etc. 
Symptoms axd Course.—There are few diseases whose symp- 
toms correspond so exactly in different cases, and which run such a 
similar course in different persons, as exanthematic typhus. 
The period of incubation, which appears to last eight or nine days, 
rarely longer, is not usually free from symptoms of the disease ; but 
these consist of slight chills, headache, disturbed sleep, loss of appe- 
tite, a feeling of dulness, depression, and discomfort; in short, of symp- 
toms such as precede the outbreak of other diseases, and give no clew 
to the disease which is commencing. It is only during the prevalence 
of exanthematic typhus that we should suspect from these symptoms 
that the patient was infected with typhus poison; the suspicion would 
increase in certainty if there were, at the same time, catarrhal troubles, 
cough, coryza, burning feelings in the eyes, etc. The first two cases 
of exanthematic typhus that I saw in the Magdeburg hospital during 
the stage of incubation, I at first supposed to be cases of simple catar- 
rhal fever. The intensity of these prodromat® varies, so that, while 
they last, some patients go about their business, while others are con- 
fined to bed even at this stage of the disease. 
The stadium invasionis begins with a single protracted chill of 
great violence, or with repeated slight rigors, followed by a continued 
feeling of great heat. After the first chill, the patients are rarely able 
to leave their bed; they feel excessively fatigued and weak, complain 
of heaviness and numbness in the head, occasionally also of headache, 
which is not unfrequently temporarily relieved by nose-bleed. These 
symptoms are followed by dizziness, flashes of light, tinnitus, deafness, 
pain in the muscles, trembling of the extremities on motion; the pa- 
tients usually lie in a state of apathy, talk in their sleep, and even TYPHUS FEVER. 
619 
while awake have a muttering delirium. Others are excited and rest- 
less, have anxious, wild fantasies, and can scarcely be kept in bed. 
At my first visit I found one of the patients, sent to me from jail with 
exanthematic typhus, in a strait-jacket. Besides these symptoms 
of disturbed innervation, there are almost always signs of intense 
catarrh during the invading stage; the eyes shun the light, and are 
red ; there is an increased flow of tears ; the nose is dry and stopped 
up, or its secretion is at first fluid, afterward more tenacious, and dries 
to crusts; the act of swallowing also is often difficult and painful, the 
tongue has a white coating, the taste is slimy; occasionally there are 
nausea and vomiting, and not unfrequently some diarrhoea. These 
symptoms are absent, or only slight, in some cases ; a more constant 
one is a painful, hoarse cough, which brings up a tough mucus, occa- 
sionally mixed with blood. On auscultation we hear numerous ronchi. 
We have but few exact observations as to the grade and course of the 
fever; these are especially due to Wunderlich. According to these, 
even at first the temperature rises to 104° to 106° ; the pulse is usually 
large, full, soft, rarely double, and beats about 100 in a minute. From 
the great loss of water from the body of the patient, induced by the 
increased perspiration due to the high temperature, the thirst is great, 
the urine scanty and of high specific gravity. Even in this stage, en- 
largement of the spleen may usually be discovered by percussion. 
With the first appearance of the roseola spots, which occurs in the 
second half of the first week, usually between the third and fifth, rarely 
on the seventh day of the disease, the stadium eruptionis et florescen- 
tice begins (if we keep up the analogy between exanthematic typhus 
and the acute exanthemata, which, however, only exists at first, and is 
subsequently lost). At first the spots are few in number and only 
appear on the trunk, but they soon multiply and spread toward the 
neck and extremities, till finally the entire body, except the face, is 
covered with them; at some places they are more numerous than at 
others; the eruption is only exceptionally scanty; but even in these 
cases it is more extensive than the roseola eruption in abdominal 
typhus. The exanthema lasts longer than it does in measles or scar- 
latina ; the roseola spots do not disappear till toward the end of the 
second week, when the fever defervesces and the other symptoms sub- 
side. The longer the roseola spots last, the more their bright-red color 
changes to a livid hue; they then disappear imperfectly under the 
oressure of the finger; part of them often change to petechiae. The 
general symptoms do not improve with the outbreak of the eruption. 
It is true the patients complain less of pain in the head and limbs, 
but this is only because their mind is more affected; they can no 
longer think clearly, give slow and incomplete answers to questions, 620 
ACUTE INFECTIOUS DISEASES. 
and after their recovery they scarcely remember this period, during 
which they are in a quiet or noisy, violent delirium, and sometimes 
make constant attempts to jump out of bed and run away. They 
often become very hard of hearing. The tongue is dry and covered 
with a brownish crust; the cough has usually subsided, but the res- 
piration is superficial and rapid; ronchi are more numerous, and at the 
dependent parts of the chest the percussion-sound is often dull. In 
some cases there is constipation, in others there is more or less diar- 
rhoea, and the urine is often passed involuntarily. According to TVun- 
derlich, in mild cases the fever retains till the end of the first week 
the height that it had attained the third or fouth day of the disease, 
or in the second half of the first week there is a slight decrease of the 
temperature, and on the seventh or eighth day a decided remission. 
In severe cases, on the contrary, the temperature increases during the 
second half of the first week, and there is no remission the seventh 
day. At this time the pulse is often very small and soft, and its fre- 
quence corresponds to some extent with the height of the temperature, 
so that in mild cases the pulse is about 100, in severe ones 120 or more, a 
minute. Toward the end of the first week even, the spleen is usually 
enlarged. In the second week, while the exanthema becomes more 
livid, all the symptoms increase, and about the middle of this week 
they attain their height. Then the patients lie almost constantly on 
their back, the eyes half closed, the knees rolling outward, the hands 
between the thighs, they are in a deep stupor from which they can 
scarcely be awakened. From time to time they mumble unintelligi- 
bly, make grimaces, gesticulate, pick the bedclothes, attempt to rise, 
and to thrust the feet out of bed, and it is evident that while all sense 
of shame and propriety is gone, and the real world is lost to the 
patients, they still live in an imaginary world, and their minds are 
more or less active. They do not appear thirsty, although the tongue 
is dry, and often covered with a blackish hard crust; but, if a glass of 
water be placed to their lips, they show great avidity for drink; at- 
tempts to satisfy their thirst often fail, because the tongue trembles 
or is stiff and immovable, and the act of swallowing is more difficult. 
The nostrils are usually filled with a sooty crust, the teeth and gums 
are covered with a smeary coating, whose decomposition causes a dis- 
agreeable fetor ex ore. In many patients the skin is at this time 
covered with petechiae and miliary vesicles; in some there are symp- 
toms of pneumonia and extensive atelectasis, in others those of par- 
otitis. Not unfrequently the urine contains albumen. The above 
symptoms of severe constitutional disease and great disturbance oi 
innervation, as well as those of pneumonia, collapse of the lung, paro 
titis, etc., occur even in those cases of exanthematic typhus that run s TYPHUS FEVER. 
621 
favorable course, a fact that we should know, to avoid exaggerating 
the danger. Whether a remission occur on the seventh day or not, 
the fever always increases in the beginning of the second week. In 
mild cases, this increase only lasts a few days, and is not excessive; 
but in severe cases the increase lasts till the end of the second week, 
or even till the sixteenth or seventeenth day, and the temperature may 
become very high (108° or more). At this time the heart’s action is 
not only much increased, but it is weakened; hence the heart-sounds 
are very imperfectly heard, the pulse is small and indistinct, the cir- 
culation is so much retarded that, in the extremities, the temperature 
of the skin approaches that of surrounding objects, and the hands and 
feet appear cool while the trunk is burning hot. 
The third stage of exanthematic typhus, which authors very cor- 
rectly call the stadium criticum, almost always begins in the latter part 
of the second week, or, exceptionally, in very severe cases, at the begin- 
ning of the third week. Before actually seeing such cases, it is almost 
impossible to imagine the wonderful change in the symptoms, during a 
single night, in the stadium criticum. In no other disease is there so 
rapid a change from an apparently hopeless to a very comfortable 
state. After a peculiarly marked exacerbation of all the symptoms, 
the patients fall into a quiet deep sleep for several hours, from which 
they awake with unclouded mind, but usually without any recollection 
of what they have passed through for the previous days or weeks. 
During this critical sleep the temperature often falls four degrees, the 
pulse twenty or thirty beats; the calor mordax disappears from the 
skin, and there is a gentle perspiration; the roseola spots become 
pale. In favorable cases defervescence is immediately succeeded by 
convalescence, which, however, is always slow. The patients sleep a 
great deal; on waking, their intellect gradually becomes less clouded, 
although they retain an idiotic, stupid expression for weeks. The 
dirty coating is thrown off from the teeth and gums, the tongue again 
becomes moist, and the appetite returns. Sputa cocta are raised by a 
loose cough; the skin, from which the roseola spots have disappeared, 
begins to peel off, any remaining petechiae fade out, the temperature and 
pulse fall to the normal standard or below it, and the spleen decreases 
in size. But, even in the best cases, weeks pass before the patient can 
leave his bed and move about his room. In most of my cases the 
mental vigor returned even more slowly than the bodily strength. 
The. stadium criticum does not always pass immediately into con- 
valescence ; the typhus proper is often followed by sequelae, which 
are apparently caused by the high fever, disturbance of respiration, 
continued abstinence, absorption of exudation, and other unknown 
causes. This view of the sequelae of typhus is supported by the fact ACUTE INFECTIOUS DISEASES. 
that the same sequela? also occur after abdominal typhus, puerperal 
fever, cholera, and some other severe diseases. Some patients, with- 
out our being able to find inflammations of any important organ or 
other material cause for it, are attacked by a new fever, of which they 
die, with the symptoms of great prostration, the already exhausted 
powers being rapidly consumed. In other patients, after the typhus 
has run its course, there are inflammation and suppuration of the paro- 
tids ; in others, there are pneumonia, pleurisy, diptheritic and follicular 
inflammation of the intestine; in still others there are numerous furun- 
cles, ecthyma pustules, or large abscesses in the subcutaneous and in- 
termuscular connective tissue. In many cases, the slowly-healing bed- 
sores prove dangerous, partly from the drain on the system, partly 
from reabsorption of ichor. Lastly, there is frequently thrombosis of 
the femoral veins, with its results. Recovery is by far the most fre- 
quent termination of exanthematic typhus in most epidemics, especially 
in those which are not very extensive. The circumstance that a fatal 
termination is less frequent than persons unacquainted with the disease 
would expect from the severity of the symptoms, is probably because 
the disease, which runs a cyclical course, is of comparatively short 
duration. The organism could not long stand such a fever as ac- 
companies typhus. The hypothesis which we have frequently ad- 
vanced, that the chief danger in infectious diseases is from the eleva- 
tion of the temperature to a point where general paralysis is induced 
and the continuation of life impossible, is well supported by the obser- 
vations made in Wunderliches clinic during a small epidemic of typhus. 
In the fatal cases, death almost always resulted at the height of the 
fever; moreover, all patients in whom the temperature reached 108° 
died; and of fourteen patients that died, five, or more than one-third, 
had this high temperature. Of the patients whose temperature never 
rose above 105.5°, not one died. Besides the high temperature, capil- 
lary bronchitis, pneumonia, and atelectasis, are dangerous to the pa- 
tient ; other patients die of the sequelae. Exhausting haemorrhages, 
gangrene of the tip of the nose, fingers, toes, and lungs, and other 
complications, which formerly proved so destructive in the malignant 
form of exanthematic typhus, called putrid fever, are rarely observed 
in the present day; but, in the severe epidemics, such as occurred dur- 
ing the Crimean War, which cannot be compared in danger to those 
above mentioned, half the persons attacked died. 
Lastly, I shall speak of a rarely-mentioned abortive form of typhus, 
of which I observed some cases in the Magdeburg hospital; a large 
number of observations made in the Prague epidemics of 1843 and 
1848 exactly correspond with mine. The patients, who, in my cases, 
had always been exposed to typhus poison (among others, the nurse TYPHOID FEVER. 
623 
of my assistant), complained of rigors, great depression, tightness of 
the head, frontal headache, weakness of the limbs, loss of appetite, and 
other symptoms common to the incubation stage of typhus. After a 
time there were stronger chills, with subsequent continued feeling of 
heat, increase of pulse, great apathy, and disturbed sleep. Some pa- 
tients were slightly delirious. There were also catarrhal symptoms; 
the injected eyes were very sensitive to light, the nasal mucous mem- 
brane was swollen and dry, the nose stopped up; but, more especially, 
there was troublesome cough, by which a scanty tough secretion wTas 
brought up. We daily expected the eruption and the enlargement of 
the spleen, not doubting that the cases were commencing typhus; but 
these two characteristic symptoms did not occur; toward the end of 
the first week, the constitutional disturbance, fever, and- catarrhal 
symptoms disappeared, and the patients began to convalesce; they re- 
covered very slowly, and were not generally able to leave their bed 
before the end of the second week. 
Treatment.—We have no remedy for arresting exanthematic ty- 
phus ; hence we are limited to a symptomatic treatment. As this is to 
be directed chiefly against those symptoms that threaten the life of the 
patient, particularly against the fever, and since in treating abdominal 
typhus also combating the fever is the most important indication, we 
shall defer our remarks on this subject to the next chapter. We may 
also refer to the next chapter for the treatment of dangerous increase 
of respiratory difficulty, for great collapse, bed-sores, and other danger- 
ous symptoms, for just the same points arise in abdominal typhus, and 
require the same remedies. 
CHAPTEK VIII. 
ABDOMINAL TYPHUS—ILEOTYPHUS (TYPHOID FEVER). 
Etiology.—The belief that exanthematic typhus is a simple, and 
abdominal typhus a complicated form of the same disease; that, in ab- 
dominal typhus, besides the changes that the blood undergoes in exan- 
thematic typhus, there are changes in other organs directly concerned 
in the formation of the blood, in the intestinal and mesenteric glands, 
lacks all foundation. We shall not deny that there is a certain resem- 
blance between the symptoms of the two diseases; but the resem- 
blance is not perfect, and is not much greater than that between exan- 
thematic typhus and typhous measles; hence, we do not consider it 
justifiable to regard the changes of the blood in the two diseases as 
being the same, or that the poison producing the one is the same as 
that causing the other. It is perfectly inadmissible to represent ab 624 
ACUTE INFECTIOUS DISEASES. 
dominal typhus as a higher grade, exanthematic typhus as a lower 
grade of the infection with typhus poison, for there have been epidem- 
ics of the latter that were more malignant than those of abdominal ty- 
phus ; and even in the milder epidemics of exanthematic typhus, the 
intensity of the symptoms, especially, of the fever, was almost always 
greater in the individual cases than in most cases of abdominal typhus. 
While the fact that patients with varioloid often infect others with 
variola, and vice versa, sIioavs us that variola poison and varioloid poi- 
son are identical; the fact that persons infected by patients with ex- 
anthematic typhus always have that disease, never abdominal typhus, 
shows us that the poison inducing the former is not identical with that 
of the latter, and that, in spite of some similarity of symptoms, the twc 
diseases are of different nature. If the resemblance between measles 
and scarlatina were even greater than it actually is, the single fact, that 
infection with measles poison never induces scarlatina, would suffice to 
prove the non-identity of these diseases, and that the difference be- 
tween them is not only one of degree; but we shall not deny the 
possibility that the two typhus poisons resemble each other more 
closely than do those of scarlatina and measles; nor shall we compare 
the prevalence of one or other form of typhus, at certain times and 
places, with the repeated epidemics of measles at certain times and 
places, or with the almost exclusive occurrence of scarlatina epidemics 
at other times and places. The belief in the relationship, or, to speak 
more generally, in the resemblance of the poisons which induce exanthe- 
matic and abdominal typhus, is supported by the similarity of the 
causes favoring their development, as well as by the similarity of their 
effects, that is, of the symptoms of the disease, as will appear from what 
follows. 
I consider the extension by contagion, as well as by miasm, as even 
more probable in abdominal than in exanthematic typhus, or (to speak 
in a way that shall better show my position in regard to the views on 
contagion and miasm), that the germs Avhich cause abdominal typhus 
may develop and multiply as well in the organism of a typhus patient 
as they would under favorable circumstances outside of it. It is true, 
I cannot prove the correctness of this hypothesis, but I must also deny 
that the recent assertions, that abdominal typhus spreads solely by 
contagion, have been proved, or even rendered very probable, by the 
facts adduced. 
The contagion of abdominal typhus is not so intense as that of ex- 
anthematic typhus. There is no doubt that it clings particularly to 
the dejections of the patient, and that persons exposed to the emana- 
tions from typhus stools are most apt to be infected. On the other 
hand, I consider it doubtful if the contagion be transferred by the ex TYPHOID FEVER. 
625 
nalations from the skin and lungs (which, in exanthematic typhus, are 
certainly vehicles for the contagion, while in cholera they just as cer- 
tainly are not so). Infection of the nurses and physician is rarely seen 
in abdominal typhus, and, when it occurs, it is always questionable 
whether it be due to the emanations from the patient, or from his de- 
jections. At all events, using the bed-pans, night-stools, and privies, 
where the dejections of the patients have been emptied, appears more 
dangerous than being brought in contact with the patient himself. 
The miasmatic origin of abdominal typhus is rendered probable by 
cases occurring in places removed from travel, where no cases of this 
disease have occurred for years, and where there is not the slightest sus- 
picion of a contagious origin. If it be not considered an axiom that mi- 
asmatic diseases are never contagious, no wild hypotheses are necessary 
for the explanation of such cases. The most simple and probable ex- 
planation of them is, that the low organisms, which we suppose con- 
stitute the germs of abdominal typhus, may originate and increase not 
only in the bodies of patients and their dejections, but outside of them 
also. We at least partially know the circumstances that favor the 
origin and development of this poison, since we know that abdominal 
typhus occurs sporadically, and in so-called house-epidemics, especially 
in places where quantities of animal matter are decomposing. The 
absorption of the germs appears to take place chiefly through the 
lungs; but there are some instances where several persons, drinking 
water from a well that communicated with the privy, were attacked 
with abdominal typhus. I consider it doubtful whether the germs of 
this disease can also be swallowed with decomposing meat. The cele- 
brated Andelfinger epidemic is often quoted as such an instance, but 
Liebermeister, in opposition to Griesinger, has shown that this was 
not abdominal typhus; while the latter, in opposition to the former, 
nas shown that it was not a trichina epidemic. 
In large, overcrowded cities, it can rarely be determined whether 
the cases of abdominal typhus be of miasmatic or contagious origin. 
At all events, the requirements for the development and increase either 
of spontaneous germs, or those from the dejections of typhus patients, 
are excessively favorable in such places, as the soil of large cities 
always contains quantities of decomposed and putrid animal sub- 
stances. JPettenJcofer reckoned that the excrement of Munich amounted 
to one hundred and fifty loads daily, and that on an average scarcely 
ten were removed, so that over seven-eighths of the excrement of the 
city remained and were absorbed by the soil. We shall hereafter show 
that the number of cases of intermittent fever in malarious regions 
varies with the rise and fall of the water in the marshes, because this 
induces the decay of vegetable matter, on which the production of the 626 
ACUTE INFECTIOUS DISEASES. 
morbific germ of intermittent depends. In the same way, experience 
shows that the number of typhus cases, in any place where the disease 
prevails, varies with the greater or less moisture of the soil; this is 
simply because certain degrees of moisture of the ground are favorable 
or unfavorable to the decomposition of animal substances on which 
the production of the typhus poison depends. It has often been ob- 
served that the sudden drying of previously moist soil, or, as is usually 
said with doubtful propriety, the sudden fall of the sub-soil water, cor- 
responded with an increase of the typhus cases. The explanation of 
this is simple, according to what we have already said. But even the 
exceptions, where a moist state of the previously dry soil, sudden rise 
of the sub-soil water, coincided with an increase of the disease, are not 
surprising, nor are those where, while the height of the water remains 
the same, the number of cases varies. Of course other causes besides 
the moisture of the soil influence the decomposition of animal sul> 
stances, and consequently affect the production of typhus germs. 
The susceptibility to typhus poison varies greatly with the individ- 
ual. There is one very interesting point, which is also seen in other 
infectious diseases, that persons who have lived for some time in a 
place peculiarly liable to the disease (as Munich), without being at- 
tacked, are in less danger when epidemics occur than those who have 
recently come to the place. It can scarcely be supposed that this is 
because the former were originally less disposed to the disease than the 
latter, but because, after a long absence from their native place, on 
iheir return to it, they are just as liable to the disease as new-comers 
who have only been there a short time. This fact probably depends 
on some unexplained accommodation to typhus poison. Statistics 
concerning the influence of age, sex, condition of life, and constitution, 
on the susceptibility for typhus, have shown that infants and old people 
are rarely attacked by abdominal typhus ; persons of middle age are 
most liable to it; males are attacked oftener than females; strong, 
well-nourished persons, oftener than weak, badly-nourished ones; and 
that the disease is proportionately more frequent among the poor than 
among the well-to-do classes. Formerly, it was generally believed 
that tuberculous patients were never attacked by abdominal typhus ; 
this is not absolutely true, although it rarely occurs. The same is 
true of patients with heart-disease, carcinoma, and other chronic or 
acute diseases, and of pregnant or nursing women. Pregnancy gives 
almost absolute immunity to the disease. Except in rare cases, one 
attack removes the susceptibility. Since 1820-1830, during which 
time exanthematic typhus has become more rare, abdominal typhus 
has become more frequent. With the exceptions mentioned in the pre- 
ceding chapter, it is the common form of typhus throughout Europe, TYPHOID FEVER. 
627 
It occuis far north in Russia and Denmark; in middle Europe, espe- 
cially in Germany, France, and the Netherlands; and even in the 
south—in Italy, Syria, and Turkey—it is not rare. In Great Britain, 
exanthematic typhus is the common form, but abdominal typhus also 
occurs, especially in the country towns, and the parts of England not 
visited by Irish emigrants (Hirsch, Griesinger). 
Anatomical Appearances.—It will be most convenient to 
speak first (as Ilcimernik does) of the post-mortem appearances when 
death has occurred early in the disease, before the typhus process 
proper has set in, and then to give a description of the lesions that 
are found when death has occurred later, during the repair of the 
changes induced by the typhus. 
The bodies of persons who have died early in the disease do not 
appear greatly emaciated; rigor mortis is very marked; we find ex- 
tensive hypostatic congestion in the dependent parts of the body, and 
occasional bed-sores commencing over the sacrum. The nostrils often 
appear smoky, and the teeth and gums are covered with a black coat- 
ing. There are often numerous sudamina on the skin. On opening the 
body, the muscles appear very dark red, hard, and dry. The blood in 
the heart and large vessels is thick, dark colored, and contains little, 
loose, blackish-red coagula, rarely a small amount of discolored fibrin. 
Chemical and microscopical examinations of typhus blood have so far 
given negative results as regards the actual anomalies, that is, as to 
those which depend directly on the infection with typhus poison. The 
decrease of fibrin occurs in other infectious diseases also; the increase 
of blood-corpuscles, on which the dark color chiefly depends, seems to 
be only relative, and to result from the thickening of the blood, caused 
by great perspiration, and loss of water by diarrhoea. After the typhus 
nas continued some time, the blood is consumed, and becomes poor in 
albumen and blood-corpuscles. The brain and spinal medulla show no 
constant changes corresponding to the severe functional disturbances 
of these organs during life. They sometimes contain more, sometimes 
less blood, and vary in consistence. We find changes in the respira- 
tory organs in all cases; the typhous laryngeal ulcer already described 
(Yol. I.) is not unfrequently found, especially in certain epidemics. 
There are always signs of an extensive catarrh, even in the smallest 
bronchi, marked by dark redness of the mucous membrane, and scanty, 
tough secretion. At the dependent parts of the lungs there is more 
or less hypostatic congestion, sometimes only great hypostatic hyper- 
aemia and condensation of the pulmonary tissue from swelling of the 
alveolar walls (splenization); sometimes hypostatic oedema; sometimes 
the so-called hypostatic pneumonia (Yol. I.). Besides the above, more 
or less extensive portions of lung are not unfrequently collapsed, or in 628 
ACUTE INFECTIOUS DISEASES. 
a state of atelectasis, from collections of secretion or swelling of the 
mucous membrane of the bronchi leading to them having rendered the 
passage impervious. In some cases also we find lobular and lobar 
pneumonia, not affecting the dependent part of the lung, and not de- 
pending on hypostasis, even at the height of the disease, although it 
is more common after it has run its course. The bronchial glands are 
swollen, vascular, and occasionally have a medullary appearance, such 
as we shall describe for the mesenteric glands. The heart is usually 
relaxed, its muscles pale, sometimes of a dirty-red color; the endocar- 
dium and lining membrane of the vessels are infiltrated, red, and dis- 
colored. The spleen is greatly enlarged, occasionally twice, or even 
six times its normal size; its capsule is tense, its parenchyma pulpy, 
and of a dark-violet or blackish-red color. In rare cases we find the 
capsule of the spleen ruptured, and blood poured through the rupture 
into the peritoneal sac. In the great curvature of the stomach, some- 
times only the large vessels are distended, sometimes the mucous mem- 
brane appears dark red, from injection of the finer vessels, and relaxed 
from infiltration after death. The most important changes occur in 
the small intestine; to these ileotyphus owes its name. PoMtansJcy, 
on whose unsurpassed description of the “typhous affection of the 
mucous membrane of the ileum” we base our description, divides it into 
four stages. In the first or congestive stage, the mucous membrane 
of the small intestine is the seat of great hyperasmia. It appears 
swollen, relaxed, cloudy, covered with mucous and epithelial masses. 
This condition extends over all the membrane of the intestine, it is 
true, but it is most marked in the lower part, near the valvula JBauhini. 
The mesenteric glands are moderately swollen, soft, vascular, and dark 
colored. In the second stage, or that of typhous infiltration, the gen- 
eral redness and swelling of the mucous membrane increase, and con- 
centrate on the parts around the solitary and Peyer’s glands in the 
lower part of the ileum. In these tissues there are very peculiar 
changes, which are pathognomonic of typhus. More or less of the 
glands, and parts around them, swell so as to rise half a line or a line 
above the surrounding mucous membrane. These prominences are 
rather hard, and show through the mucous membrane with a gray or 
yellowish-red color; they have flat or steep edges; they are seated 
firmly on the muscular coat, and are intimately connected with the 
mucous membrane covering them. The size of the swollen solitary 
glands varies from that of a millet-seed to that of a pea. Peyer’s 
patches, on the conti ary, form patches from the size of a silver gros- 
chen to that of a dollar; they are generally oval in shape, and in the 
vicinity of the valve they usually coalesce, so that at this point they 
often cover a strip of intestine several inches long. On the cut surface TYPHOID FEVER. 
629 
it looks as if the diseased intestinal glands were infiltrated with a soft, 
grayish-white, or pale-reddish encephaloid mass; and although it has 
of late been found that in typhus disease the intestinal glands are not 
infiltrated with amorphous exudation, but that there is an increase of 
their cellular elements which, even under normal circumstances, are 
peculiar; still the expression “ medullary infiltration ” has almost uni- 
versally been preserved. Occasionally the degeneration extends be- 
yond the follicles, and there is a “ medullary infiltration ” of the con- 
nective tissue of the mucous membrane in their vicinity, a cellular 
neoplasm, originating from the connective-tissue corpuscles ( Virchow). 
In this stage the mesenteric glands are swollen to the size of a bean, 
or a hazel-nut, are of a grayish-red color, and quite hard. In the third 
stage, which* Rokitansky calls the stage of relaxation, softening, and 
breaking down, the changes in the affected glands vary greatly in dif- 
ferent cases. 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 elements have 
been destroyed by fatty metamorphosis. These cases appear chiefly 
to correspond to the so-called abortive typhus. In other cases, the 
covering of the follicles is changed to a dry, friable slough, colored yel- 
low by the feces; this slough sometimes extends over the whole of 
the gland, so that its form and size correspond to those of the plaque; 
sometimes it is limited to part of the covering, and the slough has an 
irregular, angular, or roundish form. In still other cases, 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 plaque looks as if full of holes, or has a net-like appear- 
ance (plaques d surface reticulee). The mesenteric glands are most 
swollen in this stage; some of them attain the size of a pigeon’s or 
even of a hen’s egg. Their covering is usually bluish or brownish red, 
while their substance has a grayish-red, medullary appearance. In the 
fourth stage, or that of ulceration, the sloughs formed on the plaques 
or solitary glands are either thrown off in mass, or, after precedent dis- 
integration, and a loss of substance, a typhous ulcer remains. PoJci- 
tanslcy gives the following as the most important characters of the 
typhus ulcer: According as it has resulted from a solitary follicle or 
from a Peyer's patch, it is round or oval, and, if there has only been a 
partial slough on the Peyer's patch, it is irregular; it varies in size 
from that of a hemp-seed or a pea to that of a dollar; its seat is in the 
lower part of the small intestine, and the ulcers proceeding from Peyer's 
patches are of course opposite to the insertion of the mesentery. The 
long diameter of the elliptical ulcer corresponds to the long axis of the 630 
ACUTE INFECTIOUS DISEASES. 
intestine; the margin of the ulcer is formed by a bluish-red, later slate- 
gray border of mucous membrane, about a line broad, which is movable 
over the surface of the ulcer. The floor of the ulcer is a delicate layer 
of submucous connective tissue, which covers the muscular coat. As 
soon as the slough is detached, the swelling of the mesenteric glands 
begins to subside, but they long remain larger and more vascular than 
normal. There are many deviations from this customary course of the 
disease on the mucous membrane; we shall briefly mention the more 
important of them: Occasionally, in the second and third stage, the 
hyperaemia of the mucous membrane over the swollen glands, and in 
their vicinity, becomes excessive. The mucous membrane is dark red, 
covered with ecchymoses; the patches resemble spongy, vascular, 
polypous proliferations, and the contents of the intestines are often 
mixed with a quantity of blood. A very serious event in the third, or 
sloughing stage, is the perforation of the intestine, which results from 
gangrene, not only of the mucous covering, but also of the correspond- 
ing part of the serous and muscular coats. The perforation is followed 
by severe peritonitis. Milder peritonitis also occurs without perfora- 
tion. The deviations of the intestinal affection in typhus, as regards 
extent, are very marked; sometimes only a few Peyer’s and solitary 
glands are affected; sometimes the ileum is almost covered with them. 
In the latter case we usually find the process further advanced in the 
vicinity of the valve than in the upper part of the intestine, and oc- 
casionally the difference of the stages in the different points is so 
marked as to lead us to suspect a succession of attacks. Not unfre- 
quently the colon participates in the disease (colotyphus), then the 
solitary glands of the colon undergo the same changes as those of the 
small intestines. Far more rarely the process extends to the jejunum, 
and even to the pyloric portion of the stomach (gastrotyphus), the 
solitary glands, and certain portions of the mucous membrane, which 
usually correspond to the folds, undergoing the changes characteristic 
of typhus. 
Where death occurs during the recovery of the ulcer and the other 
results of the disease, after the proper typhus process has run its course, 
the post-mortem appearances differ from those above described, and we 
must not limit ourselves to describing the processes which precede the 
healing of the ulcer, but must give a short glance at the state of the 
other organs, particularly as they show certain anatomical changes 
which never or very rarely occur during the first weeks of the disease. 
The bodies of patients who have died during the third or fourth week 
of the disease, or later, are more or less emaciated; the skin is pale, 
rigor mortis moderate, and, if there be decided anaemia, there is but 
little hypostatic congestion. In many cases the teeth and gums are TYPHOID FEVER. 
631 
still covered with a blackish coating. Over the sacrum, trochanters, 
and elbows, we usually find bed-sores; there may be destruction of 
the skin only, or of the other soft parts also, extending to the bones. 
In many bodies there is slight oedema of the lower extremities, and, if 
one or other femoral vein be obstructed by a thrombus, there is very 
marked oedema of the corresponding limb. Lastly, on the skin we 
often find petechiae, miliary vesicles, ecthyma pustules, and, in some 
cases, abscesses in the subcutaneous and intermuscular connective 
tissue, and suppuration of the parotid glands. On opening the body, 
the muscles no longer appear red and dry, but are pale and infiltrated. 
The blood in the heart and great vessels has lost its dark color, is 
fluid, and not unfrequently contains fibrinous clots, particularly when 
there has been inflammation of any organs. The brain is usually pale, 
moist, and the blood-points appearing on its cut surface are lighter, 
and contrast less with the white brain-substance than they did earlier 
in the disease. In the lungs, besides extensive hypostasis, we often 
find lobar or lobular pneumonia, and occasionally there are inflamma- 
tory exudations in the pleural sac; any laryngeal ulcers extend deeply 
and reach or destroy the perichondrium. In rare cases we find peri- 
chondritis laryngea without ulceration of the mucous membrane (Vol. 
I.). The heart is very relaxed and flabby, the endocardium and tunica 
intima of the vessels are greatly infiltrated. The swelling of the spleen 
has subsided, its capsule is often wrinkled, its tissue relaxed and pale; 
occasionally it contains haemorrhagic infarctions. The distention of the 
vessels and capillary hyperaemia of the stomach have disappeared at the 
same time as the swelling of the spleen. The ulcers of the intestine are 
on the road to recovery, or are already cicatrized, especially in those cases 
where death was due to other causes. Rokitansky describes the healing 
and cicatrization of typhus ulcers as follows: The loose border of mu- 
cous membrane, forming the edge of the ulcer, becomes attached to the 
floor of the ulcer gradually from the periphery toward the centre, at the 
same time it becomes more pale and less thick; the delicate connective- 
tissue layer, which covers the muscular coat in the floor of the ulcer, be- 
comes whitish, thickened, and is finally transformed into a serous plate, 
into which the adherent border passes imperceptibly, thinning as it ap- 
proaches the centre. The mucous membrane gradually extends over 
this plate toward the centre of the ulcer, but, at the same time, be- 
comes thinner, from the tension to which it is subjected. When the 
edges of the mucous membrane come together and adhere, the healing 
is complete. From the thinning of the mucous membrane, the cicatrix 
forms a slight depression; it is often somewhat pigmented, it is 
smoother than the parts around, and studded with a few tufts. Cica- 
trization of typhus ulcers never causes stricture of the intestines. As 632 
ACUTE INFECTIOUS DISEASES. 
the ulcers heal, the mesenteric glands return to their normal size, and 
often shrink to small, firm, slate-gray bodies. Some, also, become case- 
ous and subsequently calcareous. Typhus ulcers do not always heal 
up, as above described. Occasionally the healing is delayed, but does 
finally occur. In other cases there is ulceration at the edges and base 
of the ulcer, which may cause erosion of vessels and abundant intes- 
tinal haemorrhage or perforation of the intestine. It is difficult to de- 
termine whether rupture of the serous coat in these slow ulcers finally 
results from suppuration of its tissue, from extensive gangrene, or, after 
destruction of the muscular coat, from simple rupture of the thin wall. 
The fact, that, not unfrequently, errors of diet and mechanical causes, 
such as compression of the abdominal contents by vomiting, precede 
the perforation, seems to show that the perforation of the serous coat 
is often induced mechanically. When death occurs late in the disease, 
besides the remains of the typhus processes, we occasionally find the 
evidences of croupous and diphtheritic inflammation of the mucous 
membrane of the intestinal canal, especially of the large intestine, and 
very rarely in the gall-bladder also. Lastly, we must add that more 
or less extensive nephritis, as well as thrombi in the veins, is among 
the changes not unfrequently found after the typhus proper has run 
its course. 
Symptoms and Course.—In many cases, the evident commence- 
ment of the disease is preceded for days or weeks by indefinite pre- 
monitory symptoms, which do not at the time enable us to determine 
the nature of the malady, but are of diagnostic importance after the 
disease has developed, as in doubtful cases they aid us in distinguish- 
ing typhoid fever from other affections that begin suddenly, without 
premonitory symptoms. These prodromata are feelings of general 
illness, mental disquiet, great dulness and relaxation, loss of appetite, 
indigestion, restless sleep disturbed by dreams, headache, dizziness, 
wandering pains in the limbs, which are usually considered rheumatic, 
and repeated epistaxis. These symptoms may last from a few days to 
several weeks. 
We generally consider that the disease proper begins when 
the first chill occurs during the premonitory symptoms, or, if there 
has been no prodromal stage, when a chill notifies the patient of his 
illness. This chill is rarely so severe and continued as in intermittent 
fever or pneumonia; there is usually no shivering or chattering of the 
teeth. Frequently there is not a single chill, but several, and cases do 
occur without any chill. Hence, especially in inattentive patients, we 
cannot always tell whether the disease is at the seventh or eighth, or 
at the thirteenth or fourteenth day. 
The pathologico-anatomical changes in the intestines during ty- TYPHoID FEVER. 
633 
phoid fever do not correspond to any marked clinical stages, so as to 
enable us accurately to distinguish the symptoms corresponding to the 
stages of congestion, typhus infiltration, sloughing, and ulceration, and 
to give the symptoms of these different phases of the intestinal dis- 
ease. Nor does the time that has elapsed since the first chill give any 
definite clew to the pathologico-anatomical stage of the bowel affec- 
tion ; but, on the other hand, we may suppose that, at the end of the 
third, or, at latest, at the end of the fourth week, the true typhus pro- 
cess has terminated, and that any existing morbid symptoms are only 
its remains, and belong to the secondary diseases of the blood and of 
different organs, induced by the typhus infection. Therefore Hamer- 
nik makes “ a first and second period of the typhus blood-crasis; ” in 
his communications from the Pfeufer’s clinic, Vogel speaks of two 
groups of symptoms, the “ intoxication ” and the “ reaction ” symp- 
toms ; Griesinger makes a “ first and second period of the disease.” 
We also shall divide the symptoms into two classes, and shall speak 
first of the symptoms of the disease itself afterward of the symptoms 
of the sequelae. As we mentioned above, the former occur in the first 
three or four weeks of the disease, the latter later in its subsequent 
course. 
Even during the first week the patient becomes very weak and 
much prostrated; but few can leave their beds during the first days; 
at the same time they complain of headache, which is chiefly in the 
forehead; of vague pains in the extremities, of buzzing in the ears, 
flashes before the eyes; of dizziness, which is particularly severe when 
they rise in bed, or attempt to walk. The sleep is restless and broken 
by dreams, in which the patients often speak single words, or whole 
sentences, in a loud voice. During the first week, while awake, the 
patient is usually perfectly conscious, but shows little interest in 
things around, and answers slowly and unwillingly to questions. 
There is great thirst, no appetite; there is a slimy or bitter taste in 
the mouth ; many patients ask for an emetic, because their stomach 
is out of order. Occasionally there is diarrhoea, but at first the 
bowels are usually constipated, and it is not till the end of the week 
that the patient has several pulpy or even fluid stools daily; in still 
other cases, the bowels remain constipated throughout the week, and 
induce imprudent physicians to prescribe laxatives. If these or an 
emetic be given at the commencement of the disease, they almost al- 
ways induce severe diarrhoea, which it is difficult to arrest. The pas- 
sages are rarely accompanied by much pain. During the first week 
of typhoid, there is often repeated epistaxis, which is not apt to be 
abundant, and which relieves the headache. In most, but not in all 
oases, cough and mucous expectoration betray the bronchial catarrh, 634 
ACUTE INFECTIOUS DISEASES. 
vhich may be discovered by physical examination even during the 
first week. Among the objective symptoms comes next the changed 
appearance of the patient. While in bed, the face, especially the 
the cheeks, appears red; but, if he has been sitting up for some time, 
lie looks pale and meagre. At first the tongue is rarely thickly coated, 
moist and broad, showing impressions of the teeth along its sides ; it 
usually has a thin, whitish, epithelial coating, through which some 
papillae project as red points ; it is covered with a tough, slimy mucus, 
and appears narrow and pointed. The thin, epithelial coating usually 
falls off, gradually leaving, as Vogel aptly describes it, “ a moist, red, 
smooth tongue, that looks as if covered with gold-beater’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 posterior- 
ly, and from the sides toward the middle, so that the wThitish yellow 
fioating appears enclosed in a very red border, which constantly in- 
creases in width ; but in some cases the detachment begins centrally, 
so that in the middle of the tongue there is a red stripe, that has a pe- 
culiar tendency 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 posteriorly.” In spite of this peculiar disturb- 
ance of nutrition on the surface of the tongue, and of the diminution 
of secretion in the mouth, on microscopical examination of the coating 
of the tongue, Vogel could find nothing characteristic. Palpation and 
percussion do not show any anomaly of the heart or lungs, but on 
auscultation even at first, and always by the end of the first week, we 
find a more or less extensive whistling sound (rhonchus sibilans), due 
to catarrh of the smaller bronchi. Even during the first days the ab- 
domen is usually somewhat puffed up and tense; deep pressure over it 
is generally painful, and this sensitiveness to pressure exists not only in 
the ileo-coecal region, but also about the navel and in the epigastrium. 
On pressure in the right iliac region, particularly if there has already 
been severe diarrhoea, we notice a gurgling sound, the so-called ileo- 
coecal gurgling, whose diagnostic importance was formerly much over- 
estimated. Toward the end of the first week, the enlargement of the 
spleen is ordinarily marked. The enlarged organ usually has a horizon- 
tal position; it rarely projects beyond the ribs, and is pressed upward 
and backward against the spinal column by the distended intestines. 
Hence, the typhus spleen is rarely to be reached on palpation, and, 
even when it caii be touched, it is so soft that we are unable to define 
its outlines. But, if we lay the patient on his right side, with his left 
hand on his head, on percussing the lower ribs of the left side, we find 
a dull space, which may be six inches long by four wide, and which, TYPHOID FEVER. 
635 
corresponding to the eighth, ninth, and tenth ribs, nearly reaches the 
spinal column posteriorly, and the margin of the ribs anteriorly. An 
increase or decrease of the spleen-dulness, to the extent of a centime- 
tre or so, cannot be made out with certainty, in spite of what enthusi- 
asts in physical diagnosis assert. Even when the dulness has undoubt- 
edly increased or decreased slightly, we must bear in mind that this 
may depend not only on diminution or enlargement of the organ, but 
also on changes of its position. A greatly enlarged spleen may in- 
duce but little dulness when it is pressed into the hollow of the dia- 
phragm by the distended intestines, and only a small part of it lies in 
contact with the thoracic wall. Toward the end of the first week, on 
careful examination, we often find a few pale-red, roseola spots, about 
the size of a lentil, on the epigastrium and neighboring portions of the 
abdomen and breast. Finally, the most important objective symptom 
is the fever. The temperature rises very regularly, in a manner al- 
most pathognomonic of abdominal typhus. During the first week, 
the evening temperature is nearly two degrees higher than that of 
the morning; the morning temperature of the next day is about one 
degree lower than that of the preceding afternoon. For instance, a 
patient who has a temperature of 104°. 6 this evening, will, as a rule, 
have a temperature of 103°.7 to-morrow morning, and to-morrow even- 
ing a temperature of 105°.5. Toward the end of the first week, oc- 
casionally there is no increase of evening temperature; but even then 
the morning temperature is almost always about one degree lower 
than that of the evening (Wunderlich). During the first week, the 
pulse usually increases to ninety or a hundred, or even higher. Its fre- 
quence does not by any means always correspond to the temperature 
of the body, for, besides this, there are other causes, not always evident, 
that influence the heart’s action. Among other things, the pulse is ac- 
celerated from twenty to thirty beats in the minute, if the patient sits 
up in bed awhile, strains himself, or becomes excited in any way. 
Regarding the quality of the pulse, the blood-wave is usually quite 
large, but the artery remains soft during its diastole, and we often no- 
tice that the first pulsation is followed by a second, weaker one, that 
the pulse beats double. The double pulse, which does not occur exclu- 
sively in abdominal typhus, but is more frequent here than in any 
other disease, and consequently is not without diagnostic importance, 
is probably due to deficient activity of the contractile elements of 
the arterial walls, which are in a sub-paralytic state, as it is called. 
At least it may be shown that, if the arterial walls possessed no 
contractile filaments, but only elastic elements, the first pulsation, 
caused by the blood-wave, would be followed by a second evident 
pulsation (“ Nachschwingung ”). During the first week, in accord- 636 
ACUTE INFECTIOUS DISEASES. 
ance with the severity of the fever, the urine is concentrated, high 
colored, and of increased specific gravity (1020 or more). If the pa 
tients replace the water they lose in perspiration and diarrhoea by 
drinking freely, the absolute amount of urine is not diminished ( Vogel). 
The production of urea, which is increased in proportion to the supply 
of nourishment, as shown by Vogel, corresponds to the elevation of 
temperature, which depends on the increased transformation of tissue. 
Later in the disease, when the fever disappears, the increased produc ■ 
tion of urea also ceases, and, like the temperature, falls below the nor- 
mal amount. The chlorides are diminished in the urine of typhus pa- 
tients. The explanation of this is less simple than that of the increase 
of urea. It partly depends on less salt being eaten with the food, 
partly on increased excretion of the chlorides by the bowels, partly 
perhaps because, while the blood is deficient in albumen, it retains 
more salts. However, neither the increase of urea, nor the decrease 
of chlorides, nor, finally, the slight albuminuria, is characteristic of 
typhus, as it also occurs in other diseases accompanied by severe 
fever and copious exudations. 
In the second week of the disease the complaints of pain in the 
head and limbs cease, but the dizziness becomes worse and the noises 
in the ears are accompanied by deafness, which, however, does not 
depend on disturbance of innervation, but, on a propagation of the 
typhous oral and pharyngeal catarrh to the Eustachian tube and cavity 
of the tympanum. The expression becomes more stupid, the inatten- 
tion greater; the intellect, which was usually clear during the first 
week, becomes cloudy, and the patient gradually falls into a somnolent, 
stupid state, from which he can only be aroused with difficulty, and for 
a short time. In spite of the dry mouth, he manifests no desire for 
water, but drinks with avidity when a glass of water is placed to his 
lips. It is often necessary to urge the patient repeatedly, to make him 
show his tongue, and when he has at length, after several unsuccessful 
attempts, succeeded in protruding the trembling organ, he occasionally 
forgets to draw it back, and must be reminded and urged to do this 
act also. Toward the end of the second week particularly, the stools 
and urine are often passed in bed, because the patient does not per- 
ceive the necessity of evacuating the distended rectum or bladder, oi 
because he neglects to contract the sphincters energetically by an ac 
tion of his will. Many patients lie unconsciously on their backs ; if 
placed on the side, the body and limbs follow their own weight, with- 
out the patient making any attempt to change his position, even if it 
be uncomfortable. The occasional trembling movements of the lips, or 
a few incomprehensible words that the patients mumble, alone show 
that the mental activity is not all lost (febris nervosa stupida): Othei TYPHOID FEVER. 
637 
patients, who are just as insensitive to the external world, who denude 
themselves without any modesty, do not answer questions, and scarcely 
react to the strongest irritants, show by their whole manner that they 
are living in an excited dream; they are constantly agitated, throw 
off the bed-covers as fast as they are replaced; thrust first one foot, 
then the other, out of bed, attempt to stand up or run away, talk loud 
or disjointed words, gesticulate, speak unknown tongues, and become 
morose and angry when they are held or in any way restrained 
(febris nervosa versatilis). It is astonishing what energy and persist- 
ence such patients often show in attempting to carry out their morbid 
impulses. Occasionally, during the entire disease, a certain circle of 
hallucinations recurs; the patients pursue any object that they can- 
not attain, are grieved by any sorrow that they are constantly combat- 
ing, etc.; in other cases the phantasms alternate confusedly with 
others having apparently no connection with them. Occasionally this 
alternation is so great that during the day the case appears to be a 
febris nervosa stupida, while during the night it seems to be a febris 
nervosa versatilis. In some cases the patients are constipated, even 
during the second week of typhoid fever; but, as a rule at this time, 
there are several watery evacuations daily. They vary in number 
from three to six, or even to twenty or more in twenty-four hours, but 
we cannot, from their frequence, decide the number and extent of the 
typhus ulcers, as the diarrhoea does not depend on them, but on the 
catarrh accompanying them; it is exceptional for the stools to be ex- 
cessively frequent, and it is most common to have only three or four 
passages daily. The dejections have the color and appearance of 
badly-cooked pea-soup, in which the meal is not thoroughly mixed, 
but has sunk to the bottom. They have an alkaline reaction, contain 
only traces of albumen, and have no microscopic elements or chemical 
constituents peculiar to typhus. The upper watery layer contains 
chiefly salts, and owes its alkaline reaction to the large amount of car- 
bonate of ammonia in it. The lower stratum consists of remains of 
food, detritus, epithelium, mucous corpuscles, numerous crystals of triple 
phosphates, and small yellow flocculi and globules, of whose origin and 
character we know nothing definite. Respiration is hastened and 
superficial. In some cases, in spite of the extensive catarrh, there is 
neither cough nor expectoration; in other cases the patients cough a 
good deal, and expectorate quantities of tough mucus. The objective 
symptoms also have changed to some extent in the second week. The 
cheeks are now more brownish red or bluish, the eyelids are half- 
closed, there is dried mucus at their corners, the conjunctiva is injected, 
the nostrils smoky-looking. A brown, tough mucous, fuliginous coating 
clings to the teeth and gums, and the tongue is covered with a browr 638 
ACUTE INFECTIOUS DISEASES. 
crust, which gradually becomes blackish by admixture with blood 
from small fissures in its mucous membrane. Decomposition of the 
coating of the tongue and teeth causes a very disagreeable, penetrating 
odor; movement of the tongue is much impaired, so that speech be- 
comes indistinct, chewing of hard substances often impossible, and 
even drinking difficult. Physical examination of the thorax almost 
always shows more or less extensive condensation of the dependent 
portions of the lungs; on both sides of the spine the percussion-sound 
is less intense; on ausculting over the back, we find a weak vesicular 
or undecided breathing and fine mucous rale, rarely bronchial respira- 
tion, and at other parts of the chest there are numerous loud rhonchi. 
The belly is usually puffed up by the excessive meteorism of the intes- 
tines, which has never been explained. Its sensitiveness to pressure 
continues, as does the ileo-csecal gurgling in many cases. The en- 
largement of the spleen has increased; and that organ is pressed still 
farther backward and upward by the inflated intestines. In some 
cases the roseola spots have become quite numerous, and have spread 
from the epigastrium and lower half of the thorax to the back; suda- 
mina frequently occur. Among the objective symptoms of fever, the 
bodily temperature in the evening is usually 104° to 106°; in the 
morning there is only a slight remission. The pulse, which is less 
full, soft, almost always double, is often as high as 110 to 120, ox- 
more. In many cases the urine contains traces of albumen. 
In the third week of typhoid fever, the patient becomes excessively 
weak; he cannot sit up; and, if the bed be inclined, he slides down 
toward the foot of it, as often as he is lifted up. In the relaxed mus- 
cles we may often see and feel contractions of single fasciculi, the so- 
called subsultus tendinum. The somnolence and stupor reach the 
highest grade; the noisy delirium ceases, and the restlessness gives 
place to increasing stupor; some patients make automatic motions 
with the hands, or pick at the bedclothes, and almost always pass 
their feces and urine in bed. Occasionally the detrusor urinrn is also 
paralyzed, and the bladder excessively distended. The coating on the 
tongue and teeth becomes thicker, crusty, and fetid; the stammering 
speech grows unintelligible; drinking is very difficult. The chest and 
abdominal symptoms, also the frequency of respiration, rhonchi and 
mucous rales, dulness along the back, diarrhoea, and meteorism, become 
very decided. The spleen does not enlarge any more, but its swell- 
ing begins to subside. In the third week the roseola spots also 
begin to grow pale, while the sudamina increase, and petechfe some- 
times appear. In most patients there is erythema about the sacrum 
and detachment of the epidermis, and the exposed cutis sloughs. At 
the commencement of the thi~d week there is also apt to be an in- TYPHOID FEVER. 
639 
crease of the temperature and of the pulse. The morning remissions are 
indistinct. Fatal termination is most common in the third week, if not 
induced by some peculiar accident, death results from oedema of the 
lungs, after the prostration, weakness, temperature, and pulse have 
reached the highest grade. The more the respiration is affected, the 
sooner and more readily paralysis of the heart occurs. In favorable 
cases there is a subsidence of the symptoms about the middle of the 
third week. The state of deep sopor, during which the patient lives 
a dream-life, gives place to natural sleep. While awake, the expres- 
sion of the patient shows that he pays some attention to the things 
about him, which, at the height of the disease, had no existence for 
him; he also recognizes his attendants. The first glance in which 
affection and gratitude again appear may be regarded as an advance, 
although the danger is not yet over, and although the hopes awakened 
by this and other signs are often blasted. The more quiet and con- 
tinued the sleep, the clearer the intellect usually is during the waking 
state. The patients begin to complain of the bed-sores, and to lie on 
the side, so as to avoid pressure on the sore parts. They no longer 
pass their urine and feces in bed, but call for the bed-pan when they 
wish to have a stool, or empty the bladder. The number of respirations 
decreases, the patients cough oftener, and more strongly, and easily 
expectorate the mucus collecting in the bronchi, which has become 
less tough, and is usually yellowish. The passages are less frequent, 
and contain some consistent matter. The blue, sodden appearance of 
the patient disappears, the face becomes paler. The tongue grows 
moist at the edges and tip, its coating is gradually thrown off; speech 
becomes more intelligible; there is less difficulty in drinking. We 
hear moist rales in the chest, the dulness along the spine disappears ; 
even at these points the respiratory murmur becomes distinct, mete- 
orism decreases, the spleen dulness grows less, the roseola spots dis- 
appear. With the abatement of the other symptoms, the difference 
between the morning and evening temperatures becomes remarkable ; 
while the thermometer placed in the axilla still rises to 104° to 106° in 
the evening, in the morning it is often only 101° to 103°, or even less. 
These lower degrees are not observed in the evening for some time 
yet. As the temperature decreases, the pulse also falls, although the 
two do not keep pace. At the same time the pulse becomes fuller, 
and loses its rebounding character. This general improvement, which 
often does not occur till the fourth week, while the symptoms have 
maintained their intensity, or even increased till the end of the third 
week, often passes directly into convalescence, and the slow recovery 
alone shows that remains of the typhus process, especially intestinal 
ulcers, still exist; in other cases, the improvement is only temporary; 640 
ACUTE INFECTIOUS DISEASES. 
the symptoms grow worse, and the patients die of paralysis of the 
heart and suffocation. In some cases, finally, the above symptoms are 
followed by those of retarded repair of the typhous local affections 
and sequelae. The appetite, which often becomes wolfish during con- 
valescence, may prove fatal, if the physician be careless, or the patient 
intractable. We shall again refer to the danger accompanying this 
symptom. Almost all convalescents lose their hair. But, as the hair- 
follicles have undergone no permanent disturbance of nutrition, a new 
growth of hair sprouts up soon after the old has fallen out. 
We have attempted to give as comprehensive a view as possible, 
and, at the same time, a tolerably complete one, of a severe “ normal ” 
case of typhus.* But it would lead us too far to describe with equal 
fulness the numerous and varied deviations that it presents in differ 
ent cases, and we must satisfy ourselves with noting the most impor- 
* Wunderlich, who has made a very large number of measurements of tempera- 
ture in typhoid fever, gives the most important results of his observations about as 
follows: The course of the fever is typical and perfectly characteristic; it distin- 
guishes abdominal typhus from any other disease. Besides the cases Avhich exactly 
follow the regular type, there are others which deviate from it—irregular cases. The 
causes of the irregularities cannot be recognized in every instance. The course of the 
disease shows two sharply-bounded, distinct periods, which correspond to the deposi- 
tion and rcabsorption of the infiltrations and exudations. These periods agree with 
certain portions of time, and in regular or nearly regular cases they respectively 
correspond to the first and last half of the disease. In mild forms, the first period 
lasts only a week, or a week and a half; the entire disease lasts three or four weeks. 
In severe cases, the first period lasts two, three, or three and a half weeks ; the en- 
tire disease lasts five, six, or occasionally from eight to ten weeks. 
In the first week, it is such an absolute rule for the temperature to rise two de- 
grees toward evening, and to fall one degree before the next morning, that, if the 
temperature on the second or third day be 104° or over, we may exclude typhoid ; 
the same is true, if between the fourth and sixth days the evening temperature do 
not rise to 103°, and, lastly, if the evening temperature begins to decrease again 
as early as in the second half of the first week. A decided increase of temperature 
during the first week is generally an unfavorable sign, while a slight increase is 
favorable. 
In the second week we may exclude typhoid, if the temperature be below 104° on one 
or mere evenings between the eighth and eleventh day, and, conversely, on the evenings 
of the second week, scarcely any other acute disease shows repeated rise of the even- 
ing temperature to 104°. A favorable course of the disease during the second week 
renders it probable that the third week will be still milder, while, on the contrary, a 
severe and unfavorable second week may lead us to expect that the subsequent course 
of the disease will be unfavorable. Among the favorable indications during the sec- 
ond week are: an evening temperature between 104° and 105°; a morning tempera- 
ture one or two degrees lower; late occurrence of the exacerbation (not before 10 
a. m.) ; early occurrence of the remission (before midnight); regular and daily moder- 
ate decrease of temperature, as compared with that of the preceding day. Among the 
unfavorable indications are: continued elevation of the morning temperature; in 
crease of the evening temperature to 105°.5, or more; early occurrence of the daily TYPHOID FEVER. 
641 
*ant modifications of its course, and the severest and most dangerous 
accidents that present themselves. 
First, there are many cases which are not characterized by any re- 
markable lack of intensity of the symptoms, or by any other peculiari 
ties during the first week; but in the second week the symptoms do 
not grow worse and prove dangerous, as in “normal” typhus, but 
they decrease, and toward the end of the second or third week have 
all disappeared. Lebert has proposed the name abortive typhus for 
these cases, and it seems to me preferable to other names, such as 
“ febricula,” “ febris typhoides,” etc., because it better expresses the 
fact that these cases are only modified, benign, brief forms of typhoid, 
and not a peculiar variety of disease. After what we have said, it 
would be a useless repetition to give a description of the course of 
abortive typhoid during the first week; so we shall only remark, that 
many of the cases which former writers call “ gastric fever ” or “ mu- 
cous fever ” are to be regarded as abortive typhus. The old customary 
precaution, of waiting till the ninth day of the disease before saying 
whether the case was “ one of gastric or nervous fever,” was and still 
is very justifiable. The designations “ gastric fever ” and “ nervous 
fever,” in common use, exactly correspond to what modern physicians 
mean by “ abortive typhus ” and “ normal typhoid,” and since the laity 
do not understand precise scientific terms, it would be well to keep up 
this old custom. As in the first week the thermometer is the most 
certain means of distinguishing typhoid from a genuine febrile gastric 
and intestinal catarrh (Yol. I.), so in the second week it is the most 
certain means of deciding whether the disease will be an abortive ty- 
phus or not; the other symptoms are far more deceptive. If we find 
thvd on the eighth or ninth day of the disease the temperature 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 typhus. Cases where the temperature rises again 
exacerbations; late occurrence of the daily remissions ; and very high temperature at 
any time. 
In the third week, in mild cases, there are great morning remissions, so that the 
morning temperature may be three to three and a half degrees lower than the even- 
ing temperature, and may become normal toward the end of the week. And from 
the middle of the week the evening temperature also decreases. Iu 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 posi- 
tively expect a severe fourth week, and not look for a decided decrease of the fever 
before the fifth week. 
We may look for the approach of death, if the temperature remain for some time 
at 107J ; if it suddenly rise to lOY.S or 108°, or when it suddenly falls very low, say 
to 94°. We must not expect perfect convalescence till the temperature is normal in 
the evening also. 642 
ACUTE INFECTIOUS DISEASES. 
toward the end of the second week, and the subsequent course of the 
disease is as above described, are rare. Even in abortive typhus, 
the sleep is restless and disturbed by dreams, and patients talk in 
their sleep during the second week; but when awake their mind is 
clear, and only a moie or less marked apathy reminds us of the coma 
vigil of severe cases. The bronchitic symptoms are moderate; the 
daily evacuations are few in number, or there is no diarrhoea. The 
patient looks pale and worried rather than blue and sodden. The 
tongue is inclined to dryness, but is not covered with a firm crust. 
There is either no deafness, or else it is only slight, like the oral and 
pharyngeal catarrh. The abdomen is soft and only moderately promi- 
nent. Frequently there is no ileo-cascal gurgling or sensitiveness of 
the abdomen to pressure. The spleen-dulness is but little increased. 
Only exceptionally a few roseola spots occur on the epigastrium. 
During the morning, and while the patient remains in bed, the pulse 
is only moderately hastened. In the third week, or toward the end 
of the second, the temperature is usually normal, and is only elevated 
moderately toward evening; the tongue remains moist, and the patient 
begins to have some appetite. The morbid symptoms of the thoracic 
and abdominal organs have disappeared, particularly the diarrhoea. 
Many patients are anxious to get up; but, on attempting to rise or 
move about the room, are usually surprised at their feebleness, of 
which they were not aware while in bed. The strength returns slowly, 
and this tardy convalescence shows the severity of the disease that 
the patient has had. The conjecture above advanced, that in abortive 
typhus there is no sloughing of the diseased intestinal glands, is not 
founded on post-mortem examination, for which the favorable course 
ef the disease gives no opportunity, but on the early cessation of the 
diarrhoea, and the absence of the sequelae, so common in severe and 
tedious cases of typhus, especially of those depending on retarded cica- 
trization of the intestinal ulcers, and on the ulceration occurring in 
their place. 
There is a second modification of typhus which differs materially 
from that above described ; it is usually termed typhus ambulator ius. 
It is not very rare for persons who have only suffered from a slight 
amount of weariness and depression, loss of appetite and slight diar- 
rhoea, but have still been able to attend to business, or go on a jour- 
ney, to die suddenly of perforation of the bowel or intestinal haemor- 
rhage. On autopsy of such cases, we may find numerous intestinal 
ulcers along with sloughing patches and medullary infiltration of the 
mesenteric glands; in short, the anatomical changes of advanced ty- 
phous disease of the intestines. It is difficult to explain this peculiar 
form of disease, except on the supposition that, under some circum- TYPHOID FEVER. 
643 
stances, the infection with typhous poison may give rise to local 
changes in the intestines, but induce so little alteration in the blood 
and nutrition as to cause no noticeable functional disturbance. 
While in typhus ambulatorius the constitutional disturbance and 
fever are so slight as to be scarcely observable, some other cases of 
typhoid are characterized by unusual intensity of the constitutional 
disturbance, and especially by the height of the fever. In these cases 
the disease usually runs a “ tumultuous ” course. Even in the first 
week the temperature rises to 106° or more, and the pulse beats 120 
to 130 per minute. During the day, the patients lie in a state of 
deep somnolence, and look stupid; at night they have high delirium, 
and can scarcely be kept in bed. Subsultus tendinum, picking at the 
bedclothes, and occasionally convulsive movements, begin early. The 
ntensity of the local symptoms usually corresponds to that of the gen- 
eral disease. The tongue becomes dry and crusted early; even during 
the first week the bronchitic symptoms, the signs of condensation of 
the lungs, the meteorism, diarrhoea, and the enlargement of the spleen, 
attain as high a grade as they usually do by the end of the second 
week. Toward the end of the first or the beginning of the second 
week the patient is greatly prostrated, slips down in bed, has a small, 
irregular pulse, and very rapid superficial respiration. Such patients 
often die early of paralysis of the heart and oedema of the lungs. In 
other patients, after a tumultuous course during the first week, the 
symptoms moderate and show no marked peculiarities during the 
second or third week. Between typhus of great intensity and tu- 
multuous course, and typhus of moderate intensity, and between this 
and typhus ambulatorius, there are numerous intermediate forms, 
which we shall not fully describe. Many cases, treated for weeks as 
“ gastric ” or “ mucous ” fever, and finally recovering without any affec- 
tion of the intellect or dryness of the tongue, are mild cases of ty- 
phoid ; but it is certainly going too far to scratch gastric and mucous 
fevers entirely out of the list of diseases. As we have shown above, 
the height of the bodily temperature is more important than the roseola 
or the enlargement of the spleen in diagnosing between typhoid, that 
is, an infectious disease, and a genuine intestinal catarrh. 
The appearances are also modified when the typhous intestinal 
disease is very slight, or, to use the customary expression, when the 
typhus localizes itself very slightly, if at all, in the intestines, and 
“ runs almost exclusively in the blood.” Since, in the first weeks espe- 
cially, the distinction between abdominal typhus and other acute in- 
fectious diseases is based chiefly on the intestinal symptoms, an exact 
diagnosis is entirely impossible in such cases, and we must occasionally 
content ourselves with a probable diagnosis, by the exclusion of other 644 
ACUTE INFECTIOUS DISEASES. 
infectious diseases. If the intestinal symptoms fail entirely, or if there 
are only slight indications of them, while the bronchitis is severe and 
is early complicated with collapse and hypostasis of the lung or with 
decided pneumonia, we have the disease which, especially in those 
fatal cases where autopsy has shown medullary infiltration of the 
bronchial glands, has been called pneumo-typhus or broncho-typhus. It 
is evident that these cases, where the patients have a very cyanotic 
look and hastened and painful respiration, belong to the malignant 
forms. While the severe fever increases the production of carbonic 
acid, the disease of the bronchi and lungs impedes the excretion of the 
extensively formed deleterious gases. The formation of typhous ulcers 
in the larynx is not usually accompanied by any characteristic symp- 
toms, and modifies the appearance of the disease so little that we are less 
justified in making “ laryngotyphus ” a separate class than we should 
be in so considering broncho- and pneumo-typhus. But while, during 
the first weeks of the disease, laryngeal ulcer is not usually recognized, 
and is accidentally found on autopsy, it plays a very important part 
in the sequela? of typhus. 
Among the accidents that interrupt the normal course of the dis- 
ease during the first weeks, the most important are perforation of the 
bowel, intestinal haemorrhage, and the abundant epistaxis which 
occasionally occurs during the second or third week. 
The perforations of the intestine, which occur during the first 
weeks of the disease from the formation of a slough not only in the 
mucous coat covering the patches, but also in the muscular and serous 
coats at the affected parts, induce intense peritonitis; but since, pre- 
vious to the perforation, there has occasionally been adhesion between 
different loops of intestine, from inflammation of the peritoneum, this 
inflammation is sometimes partial, not total, at first. The first signs of 
perforation are a severe pain in the abdomen, which usually arouses 
the patient even from deep stupor, and which becomes excessive on 
the lightest pressure over the abdomen; the patient collapses sud- 
denly, the face becomes distorted, the pulse small, the extremities cool, 
and death usually occurs in from twenty-four to thirty-six hours, with 
the symptoms that we have described (Yol. I.) as indicative of peri- 
tonitis from perforation of the bowel. The most certain point in the 
diagnosis of perforation of the intestine is the escape of air into the 
peritoneal cavity, which is shown by the liver being pressed away from 
the abdominal wall and a consequent disappearance of the liver-dul- 
ness. If this symptom be absent, there is at least a possibility that 
the peritonitis is not due to perforation of the intestine. 
Intestinal hemorrhages, occurring in the first weeks of typhus, from 
erosion of the vessels on the detachment of the slough, or from rupture 1YPH0ID FEVER. 
645 
of the overfilled capillaries in the spongy elevations of the mucous 
membrane over the plaques above described, if abundant, often betray 
themselves before the appearance of blood in the dejections, by the 
collapse of the patient, which is accompanied by a sudden fall of his 
temperature, and occasionally by a clearing of the intellect. The loss 
of blood is often very considerable, but patients rarely die as a direct 
result of the haemorrhage; the bleeding usually ceases, the typhus 
pursues its course, but the strength of the patient does not carry him 
through, and most patients die, sooner or later, after the haemorrhage, 
from the exhaustion that is completed by the fever and diarrhoea. 
The abundant haemorrhages from the nose during the second and 
third weeks are far less dangerous than the intestinal haemorrhages; 
they are due to an acute haemorrhagic diathesis, which frequently 
occurs from excessive debility. They may be so severe as to require 
the tampon, they exhaust the patient, and at least retard convalescence. 
In women there is often haemorrhage from the genitals also, which does 
not always occur at the menstrual period. Although the loss of blood 
is not great, those haemorrhages which are greeted by the laity as 
favorable signs are usually mail ominis. 
If we bear in mind that most typhus patients recover very slowly 
even when the intestinal ulcers heal, the fever disappears, and the ap- 
petite returns immediately after the disease has run its course, and do 
not fully regain their strength for five or six 'weeks, it is not difficult 
to understand that retarded healing of the intestinal ulcers, and the 
continuance of even a moderate fever by the bowel-disease, should in- 
crease the danger to the patient. In these cases we find the typhus 
proper followed for weeks by symptoms of an asthenic fever, or of a 
fever in debilitated and anrnmic persons. The intellect remains cloud- 
ed, although the violent delirium usually disappears; the patient be- 
comes weaker, and slips down in bed more frequently than before. 
The tongue does not again become moist, or else becomes dry again, 
the bronchitic symptoms disappear, but the hypostases extend; en- 
largement of the spleen and roseola spots can no longer be found, but 
the meteorism and diarrhoea continue more or less marked. The bed- 
sore over the sacrum spreads, increases in depth, and may cause fright- 
ful destruction. Bed-sores also develop over the trochanters, elbows, 
and on the knees also, if the patients be laid on the belly. Petechias 
and ecchymoses form at different parts of the body, especially where 
there has been any temporary pressure. Emaciation becomes exces- 
sive ; the pallid skin is constantly bathed in perspiration. The visible 
mucous membranes also become pale and bloodless. There is often 
slight oedema of the lower extremities, or excessive oedema of one leg 
from thrombosis of the femoral vein. Many patients die in the sixth 646 
ACUTE INFECTIOUS DISEASES. 
3r seventh week, or even later, of this slow form of typhoid In other 
cases the diarrhoea ceases, the intestinal ulcers heal; but the bed-sores 
nduce fatal exhaustion; at least, we not unfrequently find deep de- 
struction of the soft parts and exposure of the bones, and recently- 
healed intestinal ulcers, as the only post-mortem appearances in cases 
that have proved fatal late in the disease. The pneumonias, pleurisies, 
suppurations of the parotid, diphtheritic inflammations of the intestines, 
nephritis, and other sequela) of typhoid above mentioned, show them- 
selves, just as in other debilitated persons, by objective rather than by 
subjective symptoms. Chills, and renewed increase of the bodily tem- 
perature, should excite the suspicion of one of these consecutive diseases 
and induce a more careful examination. Repeated chills, very high 
temperature, quick collapse, generally depend on pyaemia, induced by 
absorption of ichor from the bed-sores. The occurrence of severe pain 
in the larynx, hoarseness, aphonia, and the signs of acute laryngeal 
obstruction, indicate perichondritis laryngea, which is caused by ty- 
phous laryngeal ulcers penetrating deeply, but also occurs indepen- 
dently of this as a sequel of typhus. 
Lastly, we must mention that in some cases perforation of the in- 
testine occurs in the fifth or sixth week, not only while the patient is 
debilitated by the fever, induced by sluggish ulcers, but even while 
convalescence is going on perfectly well. Far more rarely haemor- 
rhages occur at this time, from slowly-healing ulcers. 
Recovery is the most frequent termination of typhoid fever; it 
takes place in about three-fourths of all cases; but some epidemics are 
far more malignant, while in others the mortality is much less. In 
most fatal cases death occurs in the second or third week of the dis- 
ease, that is, at its height; but we have already stated that, where 
the course is very rapid, the disease may prove fatal in the first week, 
and, in protracted cases, not till the fifth or sixth week, or even later. 
The different causes of death have been sufficiently described when 
speaking of the symptoms and course. 
Sometimes typhoid ends in incomplete recovery; sequel®, such as 
disturbances of innervation, neuralgias, partial paralyses, partial anaes- 
thesias, or mental disturbances, remain; occasionally typhus leaves a 
tabes and a lasting anaemia and hydraemia, which are not thoroughly 
understood. The material changes on which these disturbances of in 
nervation depend have not been discovered on post-mortem examina- 
tion. The supposition, that the remaining sickness and the deficient 
formation of blood depend on destruction of the intestinal glands and 
impermeability of the mesenteric glands, is incorrect. Pulmonary con- 
sumption not unfrequently develops during convalescence from severe 
typhoid fever. TYPHOID FEVER. 
647 
Treatment.—Prophylaxis requires that, in large cities, where 
typhoid fever is endemic, there should be sanitary police rules to pre- 
vent the soil from becoming soaked with putrid decomposing materials. 
Of late, many attempts have been made, by drainage in cities, to re- 
move the moisture of the soil, which greatly favors the decomposition 
of animal substances, and, consequently, the occurrence of typhus and 
cholera germs. Should the drainage succeed, and should it decrease 
the number of typhus and cholera cases, as the drying up of swamps 
sometimes does that of intermittent fever, the still youthful science of 
hygiene would boast of a brilliant triumph. Some physicians still 
doubt the contagiousness of abdominal typhus, or, at least, consider it 
as not proved. But such views must not be brought to the bedside 
of the patient; here the fact, that the non-contagiousness has not 
been proved, must make us act as if its contagiousness had been de- 
monstrated. The sick should be isolated from the well, and only 
those attendants required in caring for the patients should be allowed 
in his vicinity. It is just as important that all healthy persons, who 
can be spared, should be removed from the locality where the infection 
of one or more persons has occurred. I have learned of one very sor- 
rowful instance in Rheinland during the past few years, where, ap- 
parently, from the neglect of this precaution, almost all the members 
of one family, one after another, died of abdominal typhus. Lastly 
we must take care that the dejections of patients be not thrown into 
privies used by other persons. We know no prophylactic remedies 
that protect from infection by typhoid. 
When abdominal typhus has once begun, we may, under some cir- 
cumstances, attempt to cut short its course. It is now generally recog- 
nized that this cannot be done by emetics or venesection, which, for a 
time, were recommended for this purpose; in fact, these measures al- 
most always have an injurious influence on the course of the disease. 
Only when there is undigested food in the stomach, should we give a 
dose of ipecac.; in all other cases we must remain immovable to the 
senseless and often annoying requests of the laity for the administra- 
tion of an emetic. The case is very different with a few large doses 
of calomel. After the accurate observations of Wunderlich, we can 
scarcely doubt that by this remedy we may, in some few cases, cut 
short the disease (according to Wunderlich, one or two five-grain 
doses are enough), and that in the great majority of cases where this 
remedy is given during the first week, and before the occurrence of 
much diarrhoea, the course of the disease is rendered milder and shorter. 
The experience of Pfeufer’s clinic, as well as my own, perfectly agrees 
with Wunderlich'1 s. We shall not attempt to say whether the calo- 
mel has a favorable influence on the typhous intestinal disease, by op- 648 
ACUTE INFECTIOUS DISEASES. 
posing the sloughing and ulceration, and whether, consequently, we 
can only expect benefit from it in the first weeks of the disease, when 
these changes have not yet taken place. TVillebrand has lately rec- 
ommended iodine as a specific in typhoid, and the results published 
by him, Liebermeister, and others, urge us to make more trials with 
the preparations of iodine in this disease, although the treatment is 
not a new one. Willebrand dissolves six grains of iodine and twelve 
of iodide of potassium in one drachm of water, and gives three or four 
drops of this solution in a wineglassful of water every two hours. It 
is said that, even after one, two, or three days of this treatment, there 
is a decided remission of the temperature; sordes do not come on the 
gums, or they disappear early; the fever ceases in an unusually short 
time. 
In most cases of typhus, the indications are to protect the patients 
from all injurious influences, to combat dangerous symptoms, and to 
maintain the strength of the patient by dietetic rules. In the first 
place, wherever circumstances permit, we should see that the sick- 
room be not too small, and be very careful to have it well ventilated. 
Fresh, pure air is very necessary for all typhus patients, and they do 
not catch cold nearly so readily as the laity imagine. The tempera- 
ture of the room should be regulated by the thermometer, and should 
be kept as nearly as possible at 60° to 65°. In North Germany there 
is a belief that a vessel of water under the bed prevents bed-sores. If 
it do not fulfil the expected end, this practice is probably useful in 
maintaining a certain degree of moisture in the room. We should also 
attend carefully to the patient’s bed. The coverings should not be too 
heavy, and the sheet should have no creases in it. The bed and body 
linen should be changed as often as soiled. We should not neglect to 
see that the body of the patient is kept scrupulously clean through- 
out the attack. Even among the neatest persons this is not super- 
fluous, for they are often prejudiced, or else fear to injure the patient 
by exposure, or do not carefully inspect the parts about the anus and 
sexual organs, so as to cleanse them from any excretions. Neglect 
of this precaution frequently cannot be subsequently made good. 
The most insignificant erythema on the nates, which might have 
been avoided, may prove very dangerous late in the disease, by 
forming the commencement of an extensive bed-sore. If the pa- 
tient be too weak to clean his own mouth, we should have it washed 
out regularly with a linen rag wet with cold -water, or, still better, 
with cold soda-water. Particular care should be paid to washing 
ff the sticky mucus clinging to the teeth and gums, before it dries 
and decomposes. Even when the patient is in a state of stupor, he 
usually shows some signs of pleasure and gratitude after this proceed TYPHOID FEVER. 
649 
,ng. The best article of drink is pure spring-water or soda-water; if 
there be severe diarrhoea, we may give oat or barley water. All addi- 
tions of fruit-juices, vegetable acids, toasted bread, etc., to the drinks, 
soon become objectionable to the patient. The patient must drink 
freely, in order to replace the loss of water induced by the copious 
perspiration. If, during the advanced stages of typhoid, they do not 
ask for drink, because they do not perceive the want of it, it should be 
offered to them. Badly-instructed or thoughtless nurses sin a great 
deal against this rule. Shall we give the patient nourishment, or 
place him on absolute diet ? Views vary greatly on this point. Most 
German and French physicians consider the administration of meat- 
broths, eggs, and other nutritious substances in fevers generally, as so 
decidedly injurious, that they regard “ fever-diet ” and water-soup as 
identical. From England, there is an accusation against the German 
physicians particularly, that their dietetic rules cut off from the patients 
the supply of material by which the consumed portions of the body 
might be replaced, and that, consequently, the mortality is greater in 
Germany than in England, because the patients are starved, as it 
were. There is some truth in this assertion. I have no hesitation in 
saying, that the aggravation of a fever by giving the patient milk, 
eggs, and meat, has not been proved by actual observation, and I be- 
lieve that much injury may be done by blind faith in the correctness 
of this hypothesis. There is no doubt that in every fever the con- 
sumption of the constituents of the body is greatly increased, and that 
no sort of exercise will use up the body so rapidly as a fever does. 
While continued bodily exertion is usually borne with impunity, be- 
cause the increased consumption is hidden by increased supply, most 
fatal cases of fever are due to insufficient material being furnished for 
the replacement of that used up. Regarding typhoid fever, particu- 
larly, we find that in this disease the bodily temperature is above the 
normal for several weeks, and the consumption of tissue, by which this 
calorification is induced, is greatly increased. We see that in the 
most favorable cases, during convalescence, the greatly debilitated pa- 
tients, who have often lost ten to twenty pounds in weight, recover 
very slowly; and we must agree, that these facts urge us to give 
meat, milk, eggs, etc., rather than water-soup, until it shall be proven 
that such diet increases the fever. But, on the other hand, it cannot 
apparently benefit the patient if we give him this nourishment, and he 
is not able to assimilate it; on the contrary, it would hurt him to fill 
his stomach with food that will not be digested, but will decompose 
and cause irritation of the gastric and intestinal mucous membrane. 
We have before seen that dyspepsia is a constant accompaniment of 
all fevers. If we do not attend to this fact in regulating the diet of 650 
ACUTE INFECTIOUS DISEASES. 
typhoid cases, but expect that their stomachs will supply plenty of gas 
trie -juice to digest large quantities of protein substances, we shall not 
increase their strength, but shall add a complication which will aug- 
ment the danger. From this we have the rule, supported by ex- 
perience, that at first we should give typhoid patients small quantities 
of milk and strong broth several times daily, whenever they desire it. 
The longer the disease continues, and the greater the exhaustion of the 
patient, the more untiringly we must attempt to supply nourishing food, 
but always in small quantities and in fluid form. In addition to these di- 
etetic rules, we should have typhoid patients washed all over with pure 
cold water, or with a mixture of three parts of water to one of vinegar. 
This should be repeated several times daily, and should be done very 
carefully, so that its beneficial and soothing effects may not be an- 
nulled by the fatigue induced by the act itself. In a mild, regular 
course of typhoid, we need give no medicine; but probably the old 
prescription of dilute chlorine-water (aqua oxymuriat. 3 ij, aqua des- 
till. § vj, det. ad vitr. nig., tablespoonful every two hours), or of mu- 
riatic acid in mucilage (acid, muriat. cone. 3 ss, mucil. salep § vj, syr* 
simp. 3 j, tablespoonful every two hours) is at least of palliative ser- 
vice ; and, as there are few patients that can be treated entirely with- 
out medicine, we should prescribe the above mixture, and it deserves 
the preference over other more active prescriptions. We may also 
follow the old custom of giving the muriatic acid in a weak infusion 
of ipecac, (gr. viij to § vj), instead of in simple mucilage, during the 
second week, if the diarrhoea and bronchitic symptoms increase, and 
in a weak decoction of Peruvian bark during the third week. 
The above treatment answers for most cases; but there are many 
others which require a different procedure, and in which threatening 
danger can only be averted by energetic treatment. In abdominal 
as in exanthematic typhus and other infectious diseases, the greatest 
danger is from the severity of the fever. But against this we hav6 a 
most efficient remedy. The danger from the fever is a double one. 
On the one hand, the increase of bodily warmth above a certain point 
induces paralysis of the heart and renders life impossible; on the other 
hand, continued increase of the production of heat, or, what is the 
same thing, protracted increased transformation of tissue, on which the 
feverish over-heating depends, induces consumption of the body of the 
patient. In fevers of proportionately short duration, as in the acute 
exanthemata, exanthematic and abdominal typhus, the danger from 
increase of the bodily temperature is, of course, more to be feared than 
that accompanying the increased production of heat. But, in combat- 
ting the former, we should not lose sight of the latter, or else we may 
injure the patient instead of benefiting him. Without fear of being TYPHOID FEVER. 
651 
misunderstood, I may give this warning before urgently advising the 
abstraction of heat in treating either exanthematic or abdominal ty- 
phus ; because, so far as I know, the hydrotherapeutic treatment of 
typhoid fever was first introduced and carefully observed in my clinic. 
Until within a few years, when the bodily temperature had risen to a 
dangerous height, and there was occasion to lower it, I have had the 
patients wrapped in cold, wet sheets, and the proceeding repeated at 
intervals of ten to twenty minutes, until the desired end was attained. 
After satisfying myself that the patients were unnecessarily annoyed 
by the repeated transportation from one bed to another, which was 
unavoidable in this operation, I have used cold baths in its place, and 
they are much more convenient. I found that they had the same effect, 
and were better borne by the patient than was the repeated envelop- 
ment of the body in wet sheets. But I could not hide from myself 
that, immediately after the bath even, there was occasional exhaustion 
along with the retardation of the pulse, sinking of the temperature, 
and clearing of the intellect. This exhaustion usually passed off 
quickly, and the disease finally terminated in recovery; but, along with 
such cases, others occurred where the exhaustion continued longer after 
the baths, and where early death made me doubt if I had actually 
benefited the patient, or if, while removing one danger, I had not in- 
duced another. Perhaps this anxiety was overstrained, but, after the 
careful observations made at my clinic by Liebermeister and Immer- 
mann as to the amount of heat passing from the patient into the 
water, the possibility of this danger cannot be denied. It is true we 
reduce the temperature of the body by cold sheets and cold baths, but 
we at the same time increase the production of heat. If this were 
not so, the patient would be cooled much more. I think it would be 
proper to compare the action of an energetic abstraction of heat to 
that of excessive exercise; then it will be asked if it be advisable to 
subject an already exhausted patient to this action. The question, is 
it not possible, by hydrotherapeutic means, to reduce the temperature 
of the body without exhausting the patients by an excessive increase 
of the production of heat ? which I consider a very important one, has 
been solved by Obernier and especially by Ziemssen. I consider the dis- 
covery, that a far less energetic and less sudden abstraction of heat than 
was accomplished by the methods formerly employed by myself and 
others will reduce the temperature of a typhoid patient two degrees 
or more, is a very important advance in the therapeusis of the disease 
I have not observed the above-mentioned state of exhaustion, which 
formerly alarmed me, since I have ceased to wrap patients in cold, wet 
sheets, or place them in cold baths, but have employed the following 
plan, recommended and tried by Ziemssen: As often as his tempera- 652 
ACUTE INFECTIOUS DISEASES. 
ture rises above 104°, the patient is placed in a bath, whose tempera- 
ture is about 10° below that of his body, or about 94°. While the 
body and limbs are gently rubbed, we add cold water gradually till the 
temperature of the bath is reduced to about 68°. The patient is to 
remain about twenty or thirty minutes in the bath, till he is slightly 
chilled, and then to be placed quickly in a warm bed. At first, four or 
five baths daily are necessary, subsequently two or three. The method 
of Ziemssen has one great advantage, that in private practice there is 
no great objection made to it. The laity consider it much less objec- 
tionable to place a patient in a lukewarm bath than to wrap him up in 
wet sheets, or to pour cold water over him, etc. For moderating the 
fever in exanthematic as well as in abdominal typhus, next to the ab- 
straction of heat, the administration of quinine deserves most confidence. 
This remedy has been repeatedly recommended in abdominal typhus, 
and almost as often it has been given up, because it did not equal the 
expectations of the employers. The only effect of quinine on the 
disease is to moderate the fever. If the temperature of a typhoid pa- 
tient rise above 102°, I give quinine, but of late do not give such large 
doses as formerly, when I prescribed ten-grain doses and during the 
day gave as much as thirty grains. Now I usually prescribe one or 
two grains at a dose, in solution with dilute sulphuric acid. If we use 
quinine at the same time with the abstraction of heat, we are not 
obliged to repeat the latter so often, which is a decided advantage. 
Wunderlich has recommended digitalis as an antipyretic in abdominal 
typhus, and the results claimed by this trustworthy observer, in cases 
with frequent pulse and continued high temperature, urge us to 
further trials of this remedy, of whose antipyretic action, in the treat- 
ment of pneumonia and other inflammatory diseases, we have already 
spoken. 
Next to the fever, the most dangerous symptoms, when extensive, 
are the disturbances of the respiratory organs, the bronchial catarrh, 
hypostasis, and collapse of the lung; but, unfortunately, we are far 
more powerless in regard to these dangers than in regard to that in- 
duced by the fever. The advice of most authors to give lukewarm, 
instead of cool drinks, when there is severe bronchitis, is based rather 
on theory than practice ; when feeling the burning skin of a typhoid 
patient, no one would think seriously of combating the bronchitis by 
warm infusions. In severe typhous bronchitis, the most customary 
prescriptions are wet or dry cups, warm compresses, sinapisms, and 
blisters to the chest, and the internal administration of an infusion 
of ipecac, (gr. vij to § vj), or of an infusion of senega ( 3 ss to § vj), to 
which may subsequently be added liquor ammonia* anisat. ( 3 ss— 3 j). 
None of these prescriptions do much good, though the occasional ap- TYPHOID FEVER. 
653 
plication of wet and dry cups most frequently causes temporary allevia- 
tion, and in most cases the cutaneous irritants are even injurious. If 
we hear extensive moist rales in the chest, while the expectoration is 
arrested, we may give a few doses of flores benzoes (gr. ij—iv), and, 
if they fail, give a certain emetic, which will be of service here, and, 
avert the threatening danger, if any remedy can. To prevent the ex- 
tension of hypostasis, we may attempt to preserve the patient from 
constantly lying on the back, by changing him from one side to the 
other; but, unfortunately, this good advice cannot always be carried 
out continuously. The treatment of collapse of the lung and of pneu- 
monia is the same as that of the bronchitis. In profuse epistaxis, we 
should not try mineral acids and cold applications too long, but apply 
a tampon early. 
Among the intestinal symptoms, moderate diarrhoea requires no 
especial treatment. If the evacuations become very profuse, we may 
give astringents, especially solutions of alum (3 j to 3 vj), or of 
tannin (3j — 3 ss to 3 vj), with an addition of tinctura opii (3j— 
3 ss). For the tenesmus, which is occasionally very annoying, starch 
injections containing ten to twelve drops of laudanum are almost al- 
ways beneficial. Where there is much meteorism, we may attempt to 
evacuate the gas by passing a stomach-tube up the anus. Constipa- 
tion is to be overcome by injections, or by castor-oil. In intestinal 
haemorrhage, we should apply cold or ice compresses to the abdomen, 
and renew them frequently, at the same time giving alum internally 
in the form of serum lactis aluminatum. In perforation of the intes- 
tines, we should also employ cold compresses to the abdomen, but 
especially should give opium in quickly-repeated large doses (a grain 
every hour or two). At the same time, the patient may take small 
quantities of ice-water, or small portions of ice, to quench his thirst, 
but should have no food at all for several days. If peritonitis occur, 
independently of perforation of the bowel, cold compresses over the 
abdomen still deserve the preference to leeches. If there be paralysis 
of the detrusor vesica?, which, to the great injury of the patient, is 
often overlooked by inexperienced and careless physicians, the bladder 
should be evacuated at least twice daily by the catheter. 
It has already been stated that scrupulous cleanliness greatly aids 
in preventing bed-sores. On the first appearance of erythema, we 
should protect the reddened spot from further pressure by an air-cushion, 
and wash it several times daily with lead-water, dilute brandy, or with 
red wine. Eroded spots should be covered with lead or zinc salve, 
or with ungt. tannicum (ungt. contra decubitum Autenreithii), and 
lightly touched with nitrate of silver. If there be a deep loss of sub- 
stance, with unhealthy base, it should be treated, according to the 654 
ACUTE INFECTIOUS DISEASES. 
rules of surgery, with cataplasms, stimulating salves, red precipitate, 
or nitrate of silver. 
If, in spite of all our care, the strength of the patient sink more 
and more, if the pulse become small, the collapse and prostration 
dangerous, we should boldly give strong wines, such as madeira, port, 
etc., or strong beer (Pfeufer). No analeptic or roborant medicine in 
the pharmacopoeia has an effect equal to that of a strong wine. The 
fear of increasing the fever by administering alcoholic liquors is un- 
grounded ; and it is best not to wait for great exhaustion before giv- 
ing wine, but, in all cases where the patients begin to grow weak 
toward the end of the second or commencement of the third week, to 
give them half a pint of light wine daily. 
Lastly, during convalescence, the diet of the patient should be 
most carefully watched. The number who die during convalescence 
from typhoid fever, from the fault of the physician, because he has 
neglected to say exactly what and how much they may eat, or from 
their own, because they have not followed the rules laid down for 
them, is proportionately large. It is best to let the patient eat fre- 
quently, but only a little food at a time, so that the slight amount of 
gastric juice secreted by the convalescents may suffice for its com- 
plete digestion. All indigestible food, which forms large amounts of 
fasces, should be strictly forbidden. An apparently insignificant indi- 
gestion, a moderate diarrhoea, or slight vomiting, should be regarded 
as a very dangerous occurrence, because it may induce perforation of 
an ulcer that has not yet cicatrized.3 
CHAPTER IX. 
FEBRIS RECURRENS RELAPSING FEVER. 
Etiology.—Relapsing fever is among the acute infections about 
whose propagation by contagion there is no doubt; but we hesitate to 
proclaim this as a purely contagious disease, such as the acute exan- 
themata, measles, scarlatina, and small-pox, which never occur in a 
person who had not been infected by a measles, scarlatina, or small- 
pox patient. There are certain points in favor of the view that the 
infecting substance, which induces relapsing fever, is not only pro- 
duced in the body of the patient, but that it may be produced outside 
of the human body. The mere fact, that certain regions, whose telluric 
conditions give rise to a pure miasm, malaria, are also subject to epi* 
demies of relapsing fever, can hardly be made to agree with the ex- RELAPSING FEVER. 
655 
tension of the disease by contagion alone; this is still more true of 
the fact taught by experience, that, in places where relapsing fever 
has not been seen for years, if a famine occur, and, from lack of proper 
food, people are obliged to eat bad or spoiled provisions, the disease 
will not unfrequently break out. On the other hand, there are grave 
objections to this double mode of origin and extension. The same 
reasons that satisfied us that the contagion in other infectious dis- 
eases consists in low organisms, are just as valid in relapsing fever; 
and, although we cannot say it is impossible, we are still very averse 
to supposing that organisms which reproduce themselves in the human 
body may also develop and increase outside of it under such different 
conditions. 
The great resemblance in the mode of extension of relapsing fever 
and in its symptoms to the forms of typhus already treated of, cannot 
escape notice. On the other hand, there are some points indicating a 
difference between relapsing and typhus fevers, and a certain relation- 
ship to intermittent fevers. This circumstance, as wrnll as the fact 
that there is no case known where a patient with typhoid or typhus 
fever has communicated relapsing fever to another person, and vice 
versa, has decided the best authorities to rank febris recurrens as 
a third form of typhus after abdominal [typhoid] and exanthematic 
[typhus] typhus fever. Now, if, after typhoid and typhus fevers had 
long reigned, relapsing fever occurred with them or in their place, 
this might probably be simply due to a modification of the low organ- 
isms forming the contagion of typhoid or typhus fever, induced by the 
vicinity of a marsh or the effect of bad food; in other words, to the 
development of a new species allied to but differing from the former 
ones. 
I believe generally that the history of epidemics strongly supports 
the correctness of Darwin's theory of the origin of new species. For 
my part, I have no doubt that, in the course of centuries, new infec- 
tious diseases have developed and taken the place of others that for- 
merly prevailed. In the writings of the ancients we find wonderfully- 
accurate descriptions, even of forms of disease, whose recognition and 
distinction offered the greatest difficulties. There can be no doubt 
that the regular and easily-recognized combination of symptoms char- 
acterizing measles, scarlatina, typhoid fever, etc., would not have es- 
caped the sharp observation of Hippocrates, if it had existed then as 
it does now about the native place of the great Asklepiad.* 
If the correctness of this hypothesis be accepted, and the depen- 
* But in the writings of Hippocrates there is one place which seems to indicate 
that febris recurrens occurred even in his day. 656 
ACUTE INFECTIOUS DISEASES. 
dence of contagious diseases on an infection of the body from low or- 
ganisms be regarded as certain, the appearance of new infectious dis- 
eases must seem a proof of the development of new species of organic 
beings. Should not the varied malignity shown by epidemics of the 
same disease at different times, and certain peculiarities of the indi- 
vidual epidemics, be most simply referred to slight modifications, and 
the gradual passage of certain phases of infectious disease in other 
forms as extensive modifications of the low organisms ? 
The susceptibility to relapsing fever seems very general, and it 
has often been noticed that almost every dweller in even large houses 
exposed to the contagion was attacked by the disease. No age es- 
capes the affection; but most cases are among the young and middle- 
aged. The predisposing influence of bad dwellings and insufficient 
food is not to be mistaken. Poor people furnish so large a contin- 
gent of the cases of relapsing fever that this cannot be explained solely 
by their numerical preponderance over the well-to-do classes. Peo- 
ple in good circumstances have no immunity from this disease, and 
nurses and physicians attending patients with it are not unfrequently 
infected. One occurrence of relapsing fever does not seem to remove 
the liability to it, as it does in other forms of typhus. 
Anatomical Appearances.—The result of autopsies made in epi- 
demics of febris recurrens of different intensity and malignity, together 
with symptoms observed during life, justifies the following conclusions: 
The infection of the organism by contagion not only induces high 
fever running a peculiar course, but also pathological changes in vari- 
ous organs, especially in the spleen, liver, and kidneys. Usually these 
pathological changes consist only of disturbances of the circulation 
and in such changes of structure as may be readily removed. But in 
malignant epidemics more extensive structural changes develop in the 
above organs, bearing partly the character of parenchymatous, partly 
of suppurative inflammation. The disturbances of nutrition due to 
relapsing fever have not a specific character, and do not differ from 
those induced by other injurious influences. 
The corpses long retain a rigor mortis which occasionally begins 
very early. The skin is usually light yellow, sometimes typically 
jaundiced. At the dependent parts of the body there is extensive 
post-mortem hypostatic congestion. 
The muscles are not so dark as in other forms of typhus. On mi- 
croscopical examination a more or less extensive degeneration of the 
muscular fibrillm will be found; they appear cloudy, indistinctly trans- 
versely striated, filled with molecular fine granules, which disappear 
on the addition of acetic acid, while the filaments become pale, and 
show neither transverse nor longitudinal strife (Kilttner). This degen REnAPSING FEVElt. 
657 
eration is not confined to, or even chiefly localeu in muscles, which, 
during life, were the seat of severe pain, but, when found at all, usu 
ally extends to all the muscles of the body. 
In recent cases the blood is dark cherry-red, and contains but few 
fibrinous clots. In protracted cases the blood is watery and without a 
trace of coagulation. 
When death occurs at the height of the disease, the brain and 
meninges are vascular and dry, the ventricles empty. If death does 
not result till the later stages of the disease, the meninges are slightly 
injected, the brain itself bloodless and pale, the subarachnoid spaces 
and lateral ventricles containing quantities of serous fluid. 
Some observers (Kremianshy) found haemorrhagic pachymeningi- 
tis very often, partly in its commencing stage, partly as an extensive 
haematoma of the dura mater. 
The bronchial mucous membrane presents no constant changes; 
the lungs are more or less congested, especially at the dependent 
parts; in protracted cases they sometimes contain haemorrhagic in- 
farctions or extensive pneumonic infiltrations. 
The heart is flabby, pale, and friable. On microscopical examina- 
tion, Ruttner found it infiltrated with an albuminous or fibrous mass. 
If the disease has lasted long, the walls of the heart are occasionally 
much thinned. 
As a rule, the gastric and intestinal mucous membrane is reddened 
by injection and ecchymosis. The intestinal glands are sometimes 
enlarged, but never sloughing. The ductus choledochus is occasion- 
ally closed, by swelling of its mucous membrane, and obstructing 
masses of mucus. In such cases the contents of the intestine are but 
little colored, while the gall-bladder is distended. 
The liver is considerably enlarged, apparently from the increased 
amount of blood in it. According to KiXttner, it sometimes has a mar- 
bled appearance, distinct, yellowish-white, wax-like spots appearing in 
the normal parenchyma; .when far advanced, these resemble nodules 
of medullary cancer. At such points the individual acini are not rec- 
ognizable. The liver-cells have lost their polygonal form; the nuclei 
are perceived with difficulty, and filled with homogeneous contents. 
In cases beginning with icterus, and proving fatal in the first attack 
(bilious typhoid), the same author found the liver smaller, the paren- 
chyma jaundiced, much relaxed, and broken down. There were the 
same microscopical appearances as in acute yellow atrophy of the 
liver. 
The spleen also is enlarged; it may attain five or six times its 
normal size and weigh four pounds or more; its parenchyma is only 
exceptionally as soft and fluid as in the first stages of the other forms 658 
ACUTE INFECTIOUS DISEASES. 
of typhus; usually it is hard and friable, and on section the Mal- 
pighian bodies project as grayish-white or jaundiced points the size of 
a pin’s head. Occasionally in the spleen we find yellowish-white foci, 
roundish or irregular in shape, from the size of a hemp-seed to that 
of a hazel-nut, at first quite firm, but later breaking down into pus. 
KUttner considers these as ruptures in the cavernous venous meshes 
of the spleen, which subsequently, as in phlebitis after venous throm- 
bosis, induce inflammation, suppuration, and putrefaction of the parts 
around. 
The kidneys also are enlarged, sometimes to double their normal 
size; this is due solely to swelling of the cortical structure. It is 
difficult to detach the capsule, and, when this is done forcibly, small 
portions of the renal tissue remain adherent to it. On microscopical 
examination we find the epithelium of the uriniferous tubules swollen 
and filled with fine molecules; in the later stages the epithelial cells 
have been destroyed, and the tubules are filled with fine granular de- 
tritus. Rarely there are numerous small abscesses scattered through 
the kidneys. 
Symptoms and Course.—The length of the period of incubation 
is not yet accurately determined. Many patients feel perfectly well 
from the inception of contagion till the outbreak of the disease, while 
others complain, a few days before the actual commencement of the 
malady, of ill-defined and uncharacteristic disturbances of their 
general health, of great weariness, pain and heaviness in the head, 
increased thirst, and occasionally of migratory pain in the extrem- 
ities. 
Whether the above prodromata have occurred or not, the disease 
itself almost unexceptionally begins with a chill of variable duration 
and intensity, followed by a persistent feeling of great heat. 
With the commencement of the fever the patients become very 
weak, complain of pain in the head, especially in the forehead, often 
also of dizziness and tinnitus, and of severe muscular pains almost 
characteristic of the disease, which affect chiefly the neck and limbs, 
and are among the most annoying symptoms of the disease. A slight 
amount of psychical excitement, usually present at first, generally 
passes off. The feeling of illness is unmistakable, the patients show- 
ing no interest in their surroundings. Delirium and deep sopor are 
exceptional, even where the fever is very high, which is a strong argu- 
ment against the exclusive dependence of psychical disturbances, in 
acute infectious diseases, on the height of the bodily temperature. 
At first, the face is slightly flushed, the skin hot and dry, rarely is it 
covered with slight perspiration. We must beware of regarding this 
moisture of the skin at the height of the disease as a favorable sign. RELAPSING FEVER. 
659 
(I have already stated that, of two patients with equal bodily temper- 
ature, the one whose skin is moist is the more feverish.) There is 
great thirst, but no appetite, although the patients do not obstinately 
refuse food. The tongue is broad, rounded anteriorly, and bears the 
imprint of the teeth along its sides; it has a thick, white coating, the 
edges and point are red. Even where the fever is high the tongue 
usually remains moist, and is scarcely ever covered by the dry, black 
coating visible on the small pointed tongue, and on the teeth, and 
gums, in typhoid fever. 
The pharynx also is affected by catarrh, usually mild, but some- 
times very intense, characterized by more or less injection of the mu- 
cous membrane and secretion of a tough mucus. In some cases bil- 
ious vomiting occurs at the commencement. As a rule, there is con- 
stipation ; far more rarely, diarrhoea, perhaps from excessive drinking. 
The respirations are increased in proportion to the fever, and, without 
any complication of the lungs or bronchial tubes, may attain to thirty 
or forty, or even more, in a minute. There may be symptoms of bron- 
chial catarrh or not. The abdomen is neither distended nor depressed; 
the regions of the liver and spleen are sensitive to pressure, and some- 
times spontaneously painful. Physical examination early shows con- 
siderable enlargement of the liver and spleen. Not unfrequently the 
former extends almost to the navel and far into the left hypochon- 
drium. The latter is also perceptible to the touch when it extends 
beyond the angles of the ribs. 
According to the careful researches of Obermejer, in most cases 
the urine shows the peculiarities of parenchymatous nephritis. Be- 
sides more or less albumen, blood-corpuscles and dark epithelial cyl- 
inders were found in about two-thirds of his patients; later in the 
course of the disease the cylinders were covered with granular epi- 
thelial detritus, and finall}” perfectly pale cylinders were passed. As 
a rule, during the fever the amount of urine passed is diminished; its 
specific gravity is 1012 to 1020. 
A slight degree of icterus, sometimes accompanying the above 
symptoms and depending on catarrh of the ductus choledochus, is 
readily recognized to be hepatogenous by the diminished color of the 
feces and the discovery of bile-acids in the urine, and is to be distin- 
guished from the icterus hereafter described, which is probably htema- 
togenous and renders the disease malignant. 
From the above description it is evident that, apart from the se- 
vere muscular pains, the patient’s symptoms resemble those accompa- 
nying intense fever; and in fact we may regard the fever as the most 
prominent and characteristic symptom of this disease. This fever shows 
not only the peculiarities to which the disease owes its name, but it 660 
ACUTE INFECTIOUS DISEASES. 
has others which enable a certain diagnosis, even in the first at- 
tack. 
From the observations of Obermejer, who has taken accurate meas- 
urements of temperature during the chill, with which the later at- 
tacks also usually begin, we may assume that the bodily tempera- 
ture is elevated even during the initial chill, and that this is even 
preceded by a slight elevation of temperature. The bodily tempera- 
ture attained is very unusual; it is not at all rare for it to reach 
107.3°, and in some cases 109°, or an elevation that never occurs in 
other diseases, and at which many regard the continuance of life as 
impossible. This, like typhoid fever, has a remittent type. The daily 
variation is usually about one degree, the greatest differences being in 
the morning and evening. The pulse also is more frequent in relapsing 
fever than in almost any other disease. In nearly every case it rises 
to 110 or 120, not unfrequently to 120 or 130 and even to 150 beats 
per minute, without being in itself of very evil import. The frequency 
of the pulse corresponds far less than in other diseases to the bodily 
temperature. As a rule, the pulse is at first hard and tense, later, from 
paresis of the muscular coats of the vessels, it becomes soft, undulat- 
ing, and not unfrequently dicrotic. With slight modifications the dis- 
ease goes on thus for from five to seven, rarely longer than eleven or 
twelve days; then there is a sudden change. After a transient increase 
of all the symptoms, in which the bodily temperature reaches its 
highest point, the peripheral arteries pulsate strongly, and abundant 
epistaxis often occurs ; the previously-dry skin breaks into a copious 
perspiration, and there is an alleviation of all the symptoms. Accord- 
ding to Obermejer, the duration of defervescence is usually eight or 
nine hours, during which time the body cools off about 9°, so that, if 
before the crisis the temperature was 106.4°, afterward it will be 
96.8°, or less than normal. I have no doubt that the excessive loss 
of warmth, caused by the evaporation of the perspiration, contributes 
materially to this rapid fall of temperature. During a critical sweat, 
the active flow of blood from the interior of the body to the surface 
will almost equalize over the body the loss of warmth that is induced 
by evaporation of the perspiration. Such a sweating must induce 
cooling, such as could not be attained in the same length of time by 
any hydropathic procedure. It does not lessen the loss of heat by 
conduction and radiation ; and to this is added the great loss due to 
evaporation of the perspiration. I would call attention to the im- 
mense amount of heat withdrawn by evaporation of the abundant 
perspiration during a Turkish bath; for there, in spite of the sur- 
rounding air being 40° or more warmer than the body, and the con- 
tinued heating from within, there is no considerable elevation of its RELAPSING FEVER. 
661 
temperature. I should like to know if such a rapid defervescence of 
the fever is seen in cases where, instead of sweating, there is critical 
diarrhoea. 
In the days following the crisis, the bodily temperature, which had 
almost always fallen below the normal, rises one to two degrees. 
The pulse varies from 48 to 50 beats a minute, the appetite returns, 
the tongue cleans off, the muscular pains subside, the patients feel 
stronger, and many of them wish to leave their beds. 
But only in rare cases, where the disease is incorrectly termed re- 
lapsing, does this very agreeable condition (which, to the uninitiated, 
must seem a commencing convalescence) actually form the beginning 
of recovery. In most cases, in from six to eight days, rarely less, or 
from twelve to fourteen, there is a new attack, closely resembling the 
first. This second attack also usually begins with a chill of variable 
duration and intensity; the subsequent feeling of heat, debility, de- 
pression, and thirst, attains about the same degree as in the first stage 
of the disease. The muscular pains also recur, but are less severe ; 
the tongue, which had cleared off, is again coated, the appetite is 
lessened. The spleen and liver, which during the interval had some- 
what decreased in size, again swell, and occasionally become even 
larger than in the first attack. During this second paroxysm, the 
bodily temperature rises just as high as, in many cases higher than, 
in the first, but the pulse is usually less frequent. 
The second attack is commonly shorter than the first, lasting only 
three or four days. The crisis terminating it has about the same symp- 
toms as that closing the first attack. The disease generally ends with 
the second attack. Far more rarely it is followed by a third, fourth, 
or even fifth, which have essentially the same symptoms. 
By far the most common termination is in recovery; the very 
slight mortality, which in most epidemics is only two or three per 
cent., and rarely higher than six or eight per cent., is in great con- 
trast to the severity of the symptoms, especially to the temperature. 
If the disease prove fatal, death results either during the attack, from 
collapse and general paralysis, or more rarely during the interval, from 
exhaustion, or lastly as a result of secondary diseases and complications, 
among which pneumonia is the most important. 
JPastau, as well as Obermejer, has given us valuable investigations 
as to the weight of the body in relapsing fever. These show that 
during the disease the body loses from a tenth to a fifth of its weight, 
and that this cannot be solely referred to the diminished supply of 
nutriment. Exact investigations prove again the correctness of the 
doctrine that increased transformation of the constituents of the body 
plays the most important part in the elevation of temperature during 662 
ACUTE INFECTIOUS DISEASES. 
fever. It is very interesting to me to find that Obermejer lias proved 
that there is a steady decrease of the weight of the body during the 
attack, but that it is far greater and more rapid on the critical days. 
These observations agree perfectly with those which were made in 
my clinic by Dr. Steiner even before the Leyden investigations, and 
which led to the following conclusions: Where the bodily tempera- 
ture is only moderately increased, the loss of weight may be less than 
that observed during the same length of time in healthy persons. This 
is because during fever the function of the perspiratory glands, as 
well as of other secretory organs, is suspended, and the loss of bodily 
weight from evaporation depends chiefly on evaporation of the per- 
spiration. But, if the bodily temperature rise to 102° or 104°, the loss 
of weight is always greater than in healthy persons under circum- 
stances as nearly as possible the same. When the temperature of the 
body is so high, even if the secretion from the sweat-glands be entirely 
arrested, more fluid is evaporated from the mucous membrane of the 
respiratory passages than is usually evaporated from the surface of the 
body and the air-passages together of persons with normally-acting 
sweat-glands. The most rapid decrease of bodily weight occurs at the 
defervescence of the fever, for then the sweat-glands again act, while 
the still-elevated temperature is accompanied by accelerated evapora- 
tion. I believe in the correctness of the idea that, at the height of the 
fever, there is only a relative retention of water in the body, but do 
not think it necessary to refer this retention to diminished action of 
the sweat-glands. 
Under certain influences still unknown, possibly merely as a re- 
sult of the action of a particularly intense contagion, relapsing fever 
assumes a very malignant character. The appearance of the disease 
is especially modified by excessive participation of the biliary appara- 
tus, and in most cases death appears with severe symptoms. Grie- 
singer describes this malignant form of relapsing fever, from his obser- 
vations made in the East, and terms it bilious typhoid. The St. Peters- 
burg epidemic of 1864 to 1866, where, besides simple recurrent fever, 
there were numerous cases of bilious typhoid, especially at its com- 
mencement, fully confirmed Griesinger's description of the disease, 
as well as his opinion that it was a severe form of recurrent fever. 
At first the symptoms vary little from those of simple recurrent 
fever, except that there are more depression and headache, and greater 
mental sluggishness, bilious vomiting is more frequent, and the 
tongue shows a tendency to dryness, while in simple recurrent fever 
it is apt to remain moist during the whole course of the disease. 
Usually, after a few days there is diarrhoea, with evacuation of bilious 
looking masses; or else the passages have a dysenteric appearance RELAPSING FEVER. 
663 
Often also there is bronchial catarrh of variable intensity; and gen- 
erally from the fourth to the sixth day of the disease, after the liver 
and spleen have swollen considerably, and become painful, there is 
severe icterus without discoloration of the feces. About this time the 
prostration of the patients is very great; they are perfectly apathetic 
and somnolent or delirious. The tongue is dry and crusted, pulse 
slow, the hot skin loses its turgescence; and, in this state, many die 
with the symptoms of sudden collapse. 
In others, at about the same time as in simple recurrent fever, 
there is a more or less complete crisis, followed by a rapid improve- 
ment of all the symptoms. The patients seem to be convalescing, 
tiL a relapse occurs with the former symptoms, and they generally 
soon succumb. 
Finally, in other cases there is no crisis, and in the second week, 
except for the intense icterus, we are reminded of severe and protracted 
cases of other forms of typhus. According to Griesinger’s description, 
this period of the disease is characterized by more or less profound 
sopor, delirium, great sensitiveness of the abdomen, involuntary pas- 
sages of dark, thin feces, or markedly dysenteric dejections, or occa- 
sional large evacuations of clotted blood, difficulty of swallowing, 
croupous coating on the pharynx, bronchitis, extensive lobular pneu- 
monia, occasional pericarditis, petechia and miliaria of the skin, and 
irregular chills. It almost always terminates with slight convulsions, 
sometimes by sudden collapse, internal haemorrhages (rupture of the 
spleen), or secondary disease of the thoracic organs. Rarely, the 
patient recovers either with a rapid change, or slowly and irregularly 
—the latter is especially the case if there has been extensive disease 
of the thoracic or abdominal organs, such as pneumonic infiltration or 
dysentery. 
Treatment.—The prophylactic rules for preventing the spread 
of or protecting one’s self against relapsing fever appear at once from 
what we have said of its etiology. Improvement of the condition of 
poor people, care for healthy nourishment, and roomy dwellings, ne- 
cessary as they are for prophylaxis, will probably never be fully car- 
ried out, as it is so much easier to separate the healthy from the sick, 
as is required by the contagiousness of the malady. 
The slight mortality contraindicates an energetic treatment of the 
disease. Thus far attempts to cut short the process and prevent 
relapses by quinine have failed. In the same way digitalis did no 
especial good in the Berlin epidemic. 
By cold baths, in recurrent fever also, we may almost always lower 
the temperature from one to five degrees; but this usually continues 
only a short time, the bodily temperature soon rising again to its 664 
ACUTE INFECTIOUS DISEASES. 
previous height or even higher (Obermejer). I have repeatedly said 
that I consider energetic abstraction of heat by cold baths quite a he- 
roic remedy. If the high temperature in recurrens were accompanied 
by great danger to life, of course we should have no hesitation in com- 
bating the exhaustion of the body, from the increased production of 
heat, by the energetic and continued use of cold baths; but, since, in 
spite of the high temperature, relapsing fever has a low mortality, 
scacely three per cent, of the patients dying, I do not consider cold 
baths indicated in this disease. It will be well to limit ourselves to 
sponging the body with cold lotions, and, if the cerebral symptoms be 
severe, to the application of ice to the head. At the same time we 
should attend most carefully to the patient’s cleanliness and supply of 
fresh air, and internally give dilute mineral acids. Obermejer recom- 
mends the administration of lemon-juice when the kidneys are much 
affected. We should carefully give the patients nourishment early, 
and, if there be much debility, prescribe some wine. From the ten- 
dency to diarrhoea, they should not drink much water. During con- 
valescence, iron and quinine may be given. 
Griesinger recommends large doses of quinine (gr. x-xxx daily) 
in bilious typhoid. He says it is just as useful here as in intermittent 
fever ; but it is well not to begin the quinine treatment till after the 
administration of a mild purgative of salts, oil, or cream of tartar, at 
the commencement of the disease. 
CHAPTER X. 
EPIDEMIC DIPHTHERITIS MALIGNANT PHARYNGITIS—ANGINA 
MALIGNA DIPHTHERIA. 
Etiology.—Epidemic diphtheritis belongs among the infectious 
diseases, and even among those that are most typically contagious. 
The miasmatic origin of the disease is doubtful, at least in our coun- 
try, where it has only occurred during the past ten years, and has ap- 
peared almost exclusively as more or less extensive epidemics which 
occasionally spread around from one place to another. The contagion 
is contained in the false membrane and shreds of tissue detached from 
the fauces, and in the air breathed out by the patient. Physicians are 
in great danger of being infected by the morbid products coughed out 
by the patient when they are painting or cauterizing his throat, or per- 
forming a tracheotomy. Science has to mourn the loss of a series of 
excellent physicians and observers who fell victims to diphtheria while DIPHTHERIA. 
665 
in the line of their duty. The numerous cases of infection of persons 
who have been in the same room with diphtheritic patients, without 
coming in their immediate vicinity, prove that the air exhaled by the 
patient, which does not contain shreds of exudation or tissue, is a ve- 
hicle for the contagion, Further observation must decide, if, besides 
the above vehicles for the poison, there be still others; how tenacious 
the infection is; whether persons who do not themselves take the dis- 
ease may carry it to third parties, etc. The predisposition to diphthe- 
ria is unmistakably very extensive. The greater frequency of the dis- 
ease among children than adults does not seem to me due to greater 
predisposition of the former, but to their being more exposed to infec- 
tion than adults are. 
Anatomical Appearances.—Just as in other infectious diseases, 
in diphtheritis also certain organs are chiefly subjected to the disturb- 
ances of nutrition, and (to employ our former mode of expression) 
diphtheritis is constantly localized in the fauces, less constantly in the 
upper portion of the air-passages, in the kidneys, spleen, and in some 
very obscure manner in the nervous system. The disturbances of nu- 
trition in the above organs do not anatomically correspond. In the 
pharynx we find the form of diphtheritic inflammation to which the 
disease owes its name, and which we have often described. The 
fauces, and especially the tonsils and soft palate, are covered with 
grayish-white pseudomembrane, which is not easily removed, and 
which leaves an ulcerated loss of substance, when it finally breaks 
down into a discolored fetid mass, and falls off. The diphtheritic 
pseudomembranes, or, to speak more precisely, the diphtheritic sloughs, 
result from superficial gangrene of the mucous membrane, which again 
depends on compression of its nutrient vessels by an interstitial fibrin- 
ous exudation, or from swelling of the tissue-elements, which are filled 
with a cloudy substance. If the larynx and trachea participate in the 
disease, the croupous, not the diphtheritic, form of inflammation of the 
mucous membrane occurs; that is, the surface of the mucous membrane 
is covered with a more or less tough and consistent false membrane, 
which may readily be removed, and leaves no loss of substance after 
its removal. This circumstance has induced some physicians to iden- 
tify primary genuine croup, which is due to catching cold, etc., with 
croupous laryngitis caused by infection with diphtheritic contagion. 
I consider this a false view. The division of diseases, according to the 
pathologico-anatomical changes they induce, is only a make-shift. In 
all cases where, as in genuine and diphtheritic croup, we find that two 
anatomically similar disturbances of nutrition depend on very different 
causes, we should consider them as distinct. A small-pox pustule 
may very much resemble one induced by rubbing antimonial ointment 666 
ACUTE INFECTIOUS DISEASES. 
into the skin; a pemphigus bleb may resemble a blister induced by 
a circumscribed burn, but no one would assert that these scarcely-dis- 
tinguishable disturbances of nutrition were due to the same disease. 
The previously-described parenchymatous degeneration of the kidneys 
is found in about half of the cases. The spleen is usually enlarged 
and soft. The anatomical changes of the nerve centres, or peripheral 
nerves, on which diphtheritic paralyses depend, have not yet been dis- 
covered. We know as little about the anomalies of the blood in diph- 
tlieritis as in other infectious diseases. 
Symptoms and Course.—The disease almost always begins with 
apparently insignificant and harmless symptoms. In some cases the 
general health is disturbed a few days before the disease breaks out; 
the appetite is less; the patients complain of dulness, depression, and 
chilliness. More rarely the disease begins with a severe chill, ac- 
companied by nausea and vomiting. At the same time the patient 
complains of difficulty of swallowing; but in most cases this is no 
greater than it usually is, in simple catarrhal angina. If the fauces be 
not yet covered with false membrane, but only somewhat reddened 
and swollen, at this stage we can only suspect or recognize the disease, 
when we know that diphtheritis is epidemic, or that persons about the 
patient have or have had the disease. A very suspicious, and usually 
a very early, symptom is a hard swelling of the lymphatic glands lying 
at the bifurcation of the carotid artery, which, as Luschka especially 
insists on, are directly connected with the lymphatic vessels of the soft 
palate. Not unfrequently the persons about the patient have their 
attention first called to the disease by swelling of these glands, the 
complaints of slight difficulty of swallowing having passed unnoticed. 
It is far more common for us to find more or less extensive grayish- 
white patches in the fauces at our first examination, than to have the 
opportunity of examining the throat at the commencement of diphthe- 
ritis, before the formation of false membranes has begun. And then 
we can have no doubt about the dangerous and malicious foe with which 
we have to deal. Even in cases where the disease has begun without a 
chill, where the fever is slight, or entirely absent, where the general 
health is excellent, so that the patient can hardly be kept in bed, even 
where the difficulty of swallowing is very insignificant, and where the 
deposits are very slight, are thrown off without putrescence, and leave 
a scarcelv-perceptible loss of substance, we are not at all sure that 
the disease will run a favorable course, that the dangerous accidents, 
of which we shall hereafter speak, will not occur, and that there will 
be no paralysis during convalescence. The fact, which I have fre- 
quently observed, that albuminuria occurs during the above cases, 
which run their course without fever, shows that the parenchvmatous DIPHTHERIA. 
667 
degeneration of the kidneys in diphtheritis is not due to excessive in 
crease of the bodily temperature, but is a direct result of the infection 
with diphtheritic poison. 
If the disease has begun violently, if a chill and repeated vomit- 
ing have been the first symptoms, the subsequent course of the dis- 
ease also is usually more severe. It is true, the difficulty of swallow tr- 
ing generally remains moderate, and the fever does not become very 
high, but the patient grows pale, the eyes become dull, the pulse 
small, and usually frequent, rarely retarded; the patients are very 
sluggish and apathetic. In many cases the putrefaction of the false 
membrane causes a penetrating, foul breath. If the nasal mucous 
membrane participate in the disease, a discolored, fetid fluid flows 
from the reddened and eroded nostrils. The swelling of the cervical 
glands becomes more marked; the enlarged glands are very hard and 
resistant, but have no tendency to suppurate. In about half the cases, 
examination of the urine shows the presence of a considerable amount 
of albumen. Even, after a few days, death may occur from general 
paralysis, while the intellect remains clear. Some patients, whose 
state had not excited any anxiety, and whose general condition was 
previously very satisfactory even, die unexpectedly with the symptoms 
of general collapse, without our being able to find any explanation for 
the occurrence. Sometimes also attacks of deep syncope occur, and 
pass over, till finally a new attack ends in death. Even the last- 
mentioned severe cases may terminate favorably. Then the false 
membranes are detached, and no new ones are formed; the remaining 
ulcers clean up and cicatrize. At the same time the difficulty of 
swallowing disappears, the glandular enlargement subsides, the de- 
pression of the patient disappears, and, if there be no sequelae, perfect 
convalescence follows in two or three weeks; but it is usually a long 
time before the patients recover entirely. 
The disease, as above described, is greatly modified when the 
diphtheritic inflammation of the fauces is accompanied by croupous in- 
flammation of the larynx and trachea; for then the above symptoms 
are complicated with hoarseness, aphonia, excessive dyspnoea, and 
other symptoms described when speaking of genuine croupous laryn- 
gitis. This complication occurs in the mild, as well as in the severe 
cases. Frequently, examination of the fauces and the epidemic occur- 
rence of diphtheria alone enable us to decide to which form of croup- 
ous laryngitis the case belongs. Even such cases may end in re- 
covery ; but most of the patients die, some with the symptoms of col- 
lapse, some with those of insufficient respiration, and poisoning of the 
Dlood with carbonic acid. 
Even when the disease apparently ends in recovery, it is often fol 668 
ACUTE INFECTIOUS DISEASES. 
lowed by paralysis. The not unfrequent occurrence of diphtheritic 
paralyses after very mild cases, as well as the curious fact that they 
never follow the disease immediately, but come on from two to four 
weeks after its disappearance, sufficiently explains why the connection 
between the paralyses and the diphtheritis so long escaped recogni- 
tion. Paralysis of the soft palate and pharynx is the most frequent 
form of diphtheritic paralysis, and generally precedes the other forms; 
when the soft palate is paralyzed, the patients have a nasal voice; on at- 
tempting to swallow fluids, they enter the nose. If the pharynx also be 
palsied, the act of swallowing is greatly impaired, and we are some- 
times obliged to nourish the patient through a stomach-tube. This 
paralysis of the muscles near the seat of diphtheritic inflammation is 
most frequently accompanied by that of the muscles of the eye, by 
which the power of accommodation is lost, and the patients begin to 
squint. The extremities also, especially the feet, are occasionally at- 
tacked by more or less complete paralysis. In a very small epidemic 
I saw two cases of total paralysis of all the extremities. The progno- 
sis of diphtheritic paralysis is generally favorable; almost all cases re- 
cover sooner or later. The various attempted explanations of these 
cases are unsatisfactory. We do not even certainly know whether 
they are of peripheral or central origin. It has been suggested that 
the paralyses after diphtheria are analogous to those occasionally ob- 
served after other severe diseases, especially after severe typhus. But 
this suggestion is opposed by the great frequency of diphtheritic paral- 
ysis compared to that after other diseases, as well as by the marked 
disproportion between the intensity of the malady and the consequent 
paralyses, distinguishing diphtheritic paralyses from those remaining 
after other diseases. 
Treatment.—Prophylaxis requires that the physician should pro- 
tect himself from contact with the false membrane and shreds of tissue 
that are coughed up, and that he should warn the attendants on the 
patient of the danger of this contact. When circumstances permit, 
those who have nothing to do with the care of the patient should keep 
out of the sick-room. 
The recommendations of the varied internal and external remedies 
that are said to have proved efficacious against diphtheritis, have usu- 
ally originated in the last stages of epidemics, at which time the cases 
are usually milder, and recoveries more frequent, even without treai 
ment. Almost all physicians, experienced in the treatment of diph 
theria, agree that, in severe attacks, the most prized remedies are per 
fectly useless. In recent cases I deem it advisable to remove the false 
membrane carefully, and touch the dried bases with nitrate of silver, 
concentrated muriatic acid, or liquor ferri sesquichlorat., but not to re- DIPHTHERIA. 
669 
peat this operation more than once or twice daily, and not to continue 
t too long. Besides this, as long as the mucous membrane is still 
very red and swollen, I let the patient swallow small pieces of ice 
slowly, and prescribe a solution of chlorate of potash ( 3 i to § vi), 
with directions to take a tablespoonful in the mouth every two hours, 
and to keep it in contact with the pharyngeal tissues for some time 
before swallowing it. I have no personal experience about the local 
application of chlorine-water, or the solutions of sulphite of soda 
( 3 i to the | j), or of permanganate of potash, which are said not 
only to remove the fetid odor, but also to arrest the putrefaction. On 
account of the threatening collapse, we must avoid all debilitating 
treatment, especially abstraction of blood; on the contrary, we should, 
from the first, attend to keeping up the strength of the patient by 
tonics, quinine, and iron, and by wine and nutritious diet. If collapse 
occur, we should give analeptics, camphor, musk, and particularly 
plenty of strong wine. Croupous laryngitis coming on during the 
disease requires about the same treatment that we advised in the first 
volume for idiopathic croupous laryngitis; only I do not employ ab- 
straction of blood or calomel even in recent cases. Tracheotomy 
should not be deferred too long, if we hope to have it succeed, which 
it rarely does. 
Short, cold ablutions, cold douches, and sea-bathing, have obtained 
the most confidence in diphtheritic paralysis. The induced and con- 
stant currents have also been advised. I have subjected many cases 
to long-continued treatment by electricity without benefit. In one 
case, where the patient was paralyzed in all her extremities, and was 
treated at my clinic by electricity, without benefit, for four weeks, she 
completely recovered, without any treatment, a short time after be- 
ing dismissed from the hospital.4 
[Diphtheria so often occurs without our being able to detect the 
source of contagion, that we may very strongly suspect its occa- 
sional spontaneous origin. 
Some authors regard general blood-infection as the first step, 
and say the throat-affection is only a local expression of this, as 
the bronchitis is of measles or pharyngitis of scarlatina ; while 
others say the affection is at first local, and may remain so or may 
become a general disease. Numerous vegetable organisms (micro- 
cocci) have been found in the diphtheritic membranes and even in 
the blood of the patients. The transmissibility of diphtheria to 
the lower animals by inoculating in the muscles, trachea, cornea, 
etc., has been proved, and the excessive multiplication of bacteria 
at these points has indicated them as the bearers of the contagion. 
In favor of the first view is the fact that at the commencement of 670 
ACUTE INFECTIOUS DISEASES. 
the disease there may be high fever, but no change perceptible at 
the point where the diphtheritis subsequently appears ; also that in 
scarlatina, which is a primary blood-disease, diphtheria often occurs. 
The claims for the local origin of the disease are supported by the 
results of inoculation, which tend to show that the disease starts 
from the point of inoculation and spreads through the body. It 
has been asserted that these experiments prove nothing certainly, 
and that inoculation of other decomposing substances may induce 
the same changes as the diphtheritic membrane causes. If the diph- 
theritic poison entered the lungs and was thence transferred to the 
blood in some cases, and located and was propagated in the pharynx 
in others, it would perhaps explain both classes of cases. Some 
English observers consider it as established that milk is frequently 
an infectious agent; whether the poison is generated in the cow 
itself, or whether the milk is merely a carrier of germs taken in 
the cow’s food, is not decided. 
Persons in the vicinity of a diphtheria patient may have a catar- 
rhal angina due to the poison. A second form is croupous diph- 
theritis, with a membrane which may be readily detached from the 
subjacent mucous membrane. The third and severest form is where 
the fibrinous deposit is both on and in the membrane ; between the 
fibres are pus- and blood-cells, micrococci, etc. ; the mucous mem- 
brane is quickly destroyed, leaving gray or brown sloughs, which 
render the breath very foul; this slough may extend to the sub- 
jacent cartilage or bone. 
Deeper in the air-passages, diphtheria is croupous in nature ; 
the ulceration of the mucous membrane does not usually extend 
below' the larynx, that is, where pavement changes to cylindrical 
epithelium. In persons who have died of diphtheria, the blood is 
generally imperfectly coagulated, dark, and tar-like. Changes in 
the kidneys are very common. 
The latent stage of diphtheria is usually short, though cases 
occur w'here it is possibly of some weeks’ duration. The catarrhal 
form has the same symptoms as ordinary angina, and it may be only 
the surrounding circumstances that would lead us to suspect diph- 
theria ; it may run its course in this way, or become a severe dis- 
ease. Croupous diphtheria is usually accompanied by high fever; 
there may be burning in the throat or pain on swallowing ; if these 
symptoms be absent, the disease may for some time escape recogni- 
tion. Inspection shows the mucous membrane to be dark red and 
swollen, with deposits of false membrane, which develop rapidly, 
and may even cover the whole pharynx and extend into the nares 
or middle ear, but especially into the larynx, or else may remain 
confined to the pharynx. The latter cases are apt to terminate INTERMITTENT FEVER. 
671 
favorably, the false membranes being detached and the fever sub- 
siding in a few days. Such cases are common in youths and adults, 
but advance of the disease to the larynx is more to be dreaded in 
infants. As the first deposits clear off, others may take their place. 
In septic or putrid diphtheria there is infiltration and mortifica- 
tion of the mucous membrane itself, with consequent ulcers and 
gangrenous loss of tissue. The detached fragments putrefy and 
give a foul odor to the breath ; the submaxillary and lymphatic 
glands are swollen ; there is fever characteristic of septicaemia ; and 
usually the patient dies in a few days. But a line of demarcation 
may form around the necrosed parts, and recovery take place. If the 
disease attacks the nose, it causes a running, which may be mistaken 
for cold in the head till the discharge becomes bloody or sanious. 
Diphtheritic paralysis may not occur till four or five weeks after 
the disease ; it is peripheral in character, as is shown by the diminu- 
tion of electro-muscular excitability ; it lasts several weeks or even 
months ; it most frequently affects the muscles of the pharynx and 
eye ; the prognosis is usually favorable. 
In the treatment, various disinfectants, such as chlorine one part 
to six of water, weak solutions of carbolic acid, salicylic acid, per- 
manganate of potash, also alcohol, etc., may be employed locally in 
conjunction with hot vapors, wdiich hasten suppuration, and possibly 
the pus may wash off the micrococci; these hot vapors may be tried 
every half hour or so. We should avoid rough or frequent cauter- 
izations, for fear of increasing the inflammation. In diphtheria of 
the larynx we may use sprays of lime-water and salicylic acid. 
Tracheotomy has rarely proved a successful operation in this dis- 
ease. Internal administration of chlorate of potash and tincture of 
muriate of iron, properly diluted, and in doses suited to the age, 
every half hour to two hours, is perhaps one of the most favorite 
methods of treatment.] 
MALARIAL FEVERS. 
CHAPTER XT. 
INTERMITTENT FEVER. 
Etiology.—Intermittent fever results from infection of the body 
with a poisonous substance called marsh miasm, or malaria. Malaria 
is not a product of decomposition (see below), but the decomposition 
of vegetable substance has an unmistakable influence on the devel- 
opment or excessive increase of this poison. I shall only adduce the 
following circumstances in support of this fact: Malarial fevers are 672 
ACUTE INFECTIOUS DISEASES. 
endemic chiefly in marshy regions, and in such places the number of 
persons affected increases or decreases according as circumstances favor 
or do not favor the decomposition of dead vegetable matter in the 
marshes. If it grow very cold, so that the marshes freeze up, the in- 
termittent fever ceases. The same thing occurs when, in dry seasons, 
the marshes entirely dry up, or if, in very wet seasons, a thick layer 
of water protects the mouldering bottom of the marsh from the action 
of the sun and air. On the other hand, in marshy regions, hot seasons, 
if not too dry, so that the sun’s rays can act freely on the exposed but 
still moist bottom of the marsh, are characterized by the great preva- 
lence of intermittent fever. It is uncertain whether the decomposi- 
tion of certain vegetables, or a peculiar quality of the water, favors the 
development of malaria more than other causes. A mixture of sea- 
water with spring and rain water—which occurs in marshes near the 
ocean, from high tides or heavy winds forcing the sea-water into the 
marshes—so-called brackish water, appears to be peculiarly injurious, 
because many fresh-water plants, as well as many marine plants, con- 
tained in the mixture, cannot thrive in it, and consequently die and 
decompose. Malarial fever is endemic in low lands near rivers, which 
are flooded yearly, just as in marshy regions. No especial explanation is 
necessary to show that this flooding also causes the death of quantities 
of vegetable matter, which subsequently decomposes when exposed to 
great heat. Intermittent fever occurs where land has lain for a long time 
uncultivated, and is then broken and tilled again, from the same causes 
as it does in marshy regions; for here, too, quantities of dead vege- 
table matter are brought up and undergo decomposition. Lastly, in 
some cases where intermittent fever occurs under apparently opposite 
circumstances, that is, when it is very dry, it has been shown that 
the soil was rich in subsoil water, and that, under a dry, porous sur- 
face, parched by the summer heat, there were subterraneous swamps. 
These common peculiarities, which appear in most of the regions where 
malarial fever prevails, do not, however, as was before said, justify us 
in concluding that malaria is a chemical body, an organic or inorganic, 
a solid or gaseous product, formed by the decomposition of vegetable 
substances. On the contrary, the non-occurrence of intermittent fever, 
in some typically swampy places, and its appearance in some places 
where extensive or specific putrefaction would be most unlikely to 
take place, seem to indicate that while the conditions peculiar to 
swamps, marshes, etc., favor the development of malaria, they are not 
a sine qua non, nor do they alone suffice to induce the disease. This 
view is even more strikingly supported by the observations that all 
the persons drinking water from a certain swamp were taken sick with 
intermittent fever, as these observations contrast with a large number INTERMITTENT FEVER. 
673 
of others, where the water of other marshes was drunk without this 
effect. If the morbific power were simply the product of chemical de- 
composition, this exclusiveness would be entirely inexplicable. I have 
no hesitation in saying decidedly that marsli 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 “ mala- 
ria spores,” but the facts above mentioned, as well as many other 
causes, urge us to believe that the poison exhaled by marshes, as well 
as that given off by a patient with measles, is an organic living sub- 
stance. There is, however, an important difference between the mias- 
ma vivum, which is the specific cause of intermittent fever, and the 
jontagium vivum by which the acute exanthemata, exanthematic ty- 
phus, and other infectious diseases, spread. The latter reproduces 
itself in organisms infected with it; malaria, on the other hand, is not 
reproduced in the body, of a patient with intermittent fever. There is 
no soil in the human body favorable to its development or increase. 
Intermittent fever is never introduced into other places by patients 
w ho have caught it in a svrampy region. While a short residence in a 
malarious district is often enough to give intermittent fever, one may 
share the same v7ard with a large number of intermittent patients in a 
hospital, at some distance from such a place, without danger. Hence, 
in distinction to the “ contagious ” diseases, malarial fever is termed 
“ miasmatic contagious ” or “ purely miasmatic.” 
There are extensive sections of country where the circumstances 
for the formation of malaria exist everywhere, in all parts of which in- 
termittent fever occurs; but there are also small circumscribed mala- 
rial foci, where numerous cases of intermittent are seen every spring 
and summer, wdiile the whole surrounding country remains free. In 
these last-mentioned circumscribed malarial foci, in towns lying near 
marshes, in certain sections or streets of cities, where intermittent fever 
is endemic, some very interesting observations have been made about 
the extension of malaria: among other things, it has been shown that, 
from its point of origin, miasm spreads more readily in a horizontal 
than in a vertical direction, it is often arrested by insignificant obsta 
cles, such as groves, stone walls, etc., and rarely passes the boundaries 
thus formed, unless the wind be in a particular direction. 
The extensive epidemics of intermittent fever which occasionally 
appear are very remarkable. During such epidemics, while the cases 
are unusually frequent in places where the disease is endemic, they 
also occur in places where either no cases or only sporadic ones had 
been seen for years. These epidemics do not always come in very 
hot, moist seasons, so that they might be referred to the circumstances 674 
ACUTE INFECTIOUS DISEASES. 
being very favorable to decomposition of vegetable substances, and 
hence uncommonly favorable for the development of malaria, and for 
its spread from places where it always exists to others that are gen- 
erally free from it; but they appear to be due to other unknown 
causes, which also favor the development of malaria, or to an extension 
of the disease from its point of origin to distant places by currents of 
air. We do not know why, but great epidemics of intermittent have 
often preceded epidemics of Asiatic cholera. In hot countries, cholera 
and intermittent, and, still oftener, dysentery and intermittent (see 
next chapter) frequently prevail at the same time. 
The sporadic occurrence of intermittent is most curious. Those 
cases where persons affected with malaria move from places where ma- 
laria is prevalent, and continue to present the symptoms of infection 
for a time after settling in their new home, are not to be counted as 
sporadic. But, both in city and country, cases occur where the persons 
could not have been infected elsewhere. There is no explanation for 
these cases, except the supposition of very limited foci, which are 
harmless for persons outside of them, or of a very diluted miasm, which 
only affects a few persons who are peculiarly disposed. There is not 
the least ground for the supposition that, under some circumstances, 
intermittent may result from other causes than from infection with 
malaria. 
Every age, both sexes, and all constitutions, have a predisposition 
to intermittent fever, and the greater or less tendency to the disease, 
in various persons, does not depend on the constitutional differences to 
which it has been referred, but to other only partially understood in- 
dividual peculiarities. Exhausting exercises, and other debilitating 
influences, errors of diet, and particularly catching cold, increase the 
predisposition so much, that persons, who have long been exposed to 
malaria with impunity, are not affected by it till one of these causes 
has acted on them. The same explanation must answer for those 
cases where persons who have escaped the disease in malarious places 
are attacked by it after leaving them. Then the infection has evi 
dently taken place earlier, but has not shown its effects in the person 
who was little disposed to the disease, and has not caused injurious 
results till the necessary predisposition was induced by other noxious 
agents. Among the influences that increase the predisposition to 
intermittent, the most evident is one or more previous attacks of the 
disease, which is just the opposite of the case in the acute exanthe- 
mata and typhus. There is only an accommodation of the organism 
to the poison to the extent that persons who have been exposed tc 
it for some time have a chronic disease with enlargement of the 
spleen, without fever, instead of having intermittent fever. The INTERMITTENT PETER. 
675 
geographical extension of intermittent fever is immense; in the torrid 
zones the disease is especially frequent, and it prevails in most places 
that are not very dry: in the temperate zones it chiefly affects certain 
more or less extensive districts; in the frigid zones it does not occur. 
For further information, we refer to Griesinger’s work and to the very 
exhaustive treatise of Hirsch on the geography of intermittent fever. 
Anatomical Appearances.—Autopsies of persons who have died 
of simple intermittent fever are rare. They show no characteristic 
changes beyond those that we have already described (Vol. I., Dis- 
eases of the Spleen). If simple intermittent fever depends on infection 
with malaria, the anomalies of the blood dependent on the infection 
have so far escaped chemical and microscopical examination. The im- 
poverishment of the blood in red corpuscles and albumen, which always 
results from long-continued intermittent, depends on consumption from 
high fever, and perhaps also on degeneration of the spleen. On 
autopsy of persons who have died of pernicious intermittent, we often 
find signs of melanremia and occasionally remains of inflammation, 
effusions of blood, or excessive hypereemia in different organs. 
Symptoms and Course.—I. Simple Intermittent Fever.—The pe- 
riod of incubation of the malarial infection is not exactly known. It 
is probable that, at most, two weeks may pass from exposure to the 
miasm till the first symptoms appear; in some cases the latter seem 
to follow the former immediately. 
Before the intermittent character of the disease, to which it owes 
its name, becomes very evident, before attacks of fever (paroxysms) 
and intervals of exemption from fever (apyrexias) alternate, the infec- 
tion with malarial poison not unfrequently evinces itself by a con- 
tinued, only more or less remitting and exacerbating, disturbance of 
the general health and various functions. This constitutional disturb- 
ance, which is called the prodromal stage of intermittent, has no char- 
acteristic peculiarities, and can only be rightly interpreted and distin- 
guished from the prodromal stage of other infectious diseases by bear- 
ing in mind the endemic and epidemic circumstances. After the pro- 
dromal symptoms have lasted several days, or in other cases without 
their appearance, the first fever paroxysm occurs. 
A paroxysm of intermittent fever consists of three stages: chill, 
fever, and sweating. The chill begins with a fit of weakness, and 
great faintness; the patients gape, and stretch their limbs. These 
symptoms are soon accompanied by a subjective sensation of cold, at 
first consisting of cold sbiverings over the skin; afterward, of continued 
chilliness, so that the patient wants to wrap up as warmly as possible. 
When the chill increases, the limbs tremble involuntarily, the lips 
quiver, the teeth chatter, and the whole body is often shaken around 676 
ACUTE INFECTIOUS DISEASES. 
ill bed. When the chill begins, there is also more or less headache, 
oppression of the chest, and hurried respiration; the latter, and the 
quivering of the lips, render speech indistinct and interrupted; there 
is often vomiting also, especially if the chill comes soon after eating. 
Objective examination first shows the altered appearance of the pa- 
tient ; he looks like a person exposed to severe cold, without sufficient 
clothing, and who is consequently thoroughly chilled. The size of the 
body appears diminished; the face is sunken; the nose pointed, the 
rings are too large for the fingers. As the flow of arterial blood to 
the skin is impeded, the latter appears pale, and, as the blood collects 
in the veins and capillaries, the lips, ends of the fingers and toes, look 
blue. The flow of blood to the fingers is often entirely arrested; they 
look waxy, have no feeling, and do not bleed if wounded. The skin 
of the extremities and body has the appearance known as goose-flesh 
(cutis anserina). The pulse is very frequent, small, and hard; the se- 
cretion of urine is usually increased; the urine passed is limpid, and 
of low specific gravity. Physical examination generally shows en- 
largement of the spleen. While the diminished supply of warm blood 
during the chill causes the periphery of the body to assume more and 
more the temperature of the surrounding atmosphere, and to actually 
sink several degrees, the temperature of the blood and internal organs 
rises rapidly. This rise, which begins even before the chill, reaches 
two or three degrees, and, in severe cases, still more. The above 
symptoms are mostly to be ascribed to spasmodic contraction of the 
muscles of the skin and peripheral arteries during the cold stage. 
The immediate results of this spasm are the goose-flesh, the small, 
hard pulse, and the deadness of the fingers. The contraction of the 
muscles of the skin and peripheral blood-vessels secondarily in- 
duces the apparent diminution in size, the dryness and pallid ap- 
pearance of the skin, the collection of blood in the veins, and the 
fall of temperature on the surface of the body. The chilly feeling 
of the patient is too decided to be referred exclusively to the fall 
of temperature of the periphery; on the other hand, the contin- 
ued coolness of the surface, even under thick feather-beds (which is 
peculiarly remarkable, because the body gives off but little heat 
to the parts around), is certainly due to the fact that, during the 
chill, there is less warmth supplied to the surface, on account of the 
diminished supply of blood. Lastly, the disturbance of the peripheral 
circulation increases the lateral pressure in the vessels of the internal 
organs. But, as we do not know whether the spasm of the muscles of 
the vessels is limited to the peripheral arteries, and does not extend tc 
the internal ones, it is doubtful whether the headache, oppression, ao 
celerated respiration, vomiting, increased secretion of urine, swelling of INTERMITTENT FEVER. 
677 
the spleen, etc., can be referred to collateral fluxion to tlie organs impli- 
cated in these symptoms. At all events, as we have before said, col- 
lateral fluxion to the spleen is not the sole cause of enlargement of 
that organ. The cold stage lasts from half an hour to three hours; in 
the first paroxysms, it is usually shorter and less severe than subse- 
quently ; and its intensity and duration generally decrease again if the 
disease last a long time. The hot stage does not begin suddenly, but 
gradually; at first the chill is only interrupted by temporary flashes 
of heat, and a permanent feeling of warmth only comes on by de- 
grees. The headache becomes more severe; the patients grow rest- 
less, and not unfrequently slightly delirious or somewhat stupid; the 
feeling of oppression on the chest increases, while the breathing almost 
always becomes deeper, freer, and slower. Thirst is greatly increased. 
The appearance of the patient changes. The size of the body ap- 
parently increases, the color returns to the skin, the pale, livid look, 
the goose-flesh, the cyanotic hue of the lips and ends of the fingers 
disappear; the face becomes flushed, and herpetic vesicles often come 
out on the lips; the previously small pulse grows full and strong, the 
carotids throb, the urine becomes more saturated, and the enlarge- 
ment of the spleen increases. In the hot stage, the bodily temperature 
is increased at the periphery also; at the commencement of this stage, 
the temperature of the blood reaches its highest point, and remains 
there till toward its termination, when it gradually begins to fall. All 
these symptoms show that the spasm in the muscles of the skin and 
vessels has disappeared and given place to a subparalytic state. The 
relaxation of the cutaneous tissue and of the walls of the vessels suf- 
ficiently explains the increased entrance of blood into the previously 
bloodless tissues, and their consequently increased color and warmth. 
The severe headache, the oppression of the chest, which are often 
accompanied by catarrhal symptoms, and finally the continued enlarge- 
ment of the spleen, render it very probable that the arteries of the 
brain, bronchi, and spleen, are in the same condition as those of the 
periphery. The duration of the hot stage varies; sometimes it is only 
a few hours, in severe cases the dry heat continues six, eight, or even 
twelve hours before a pleasant perspiration breaks out on the skin. 
The sweating stage begins with moisture in the armpits and on the fore- 
head ; but soon the perspiration, at first moderate, but later very copi- 
ous, extends all over the body. The patients feel greatly relieved, the 
headache remits and gradually disappears, the mind becomes clear, the 
oppression passes off, the depth and frequence of the respiration be- 
come normal, the thirst is less annoying, the pulse is full, soft, and 
less frequent. The dark urine generally deposits rich sediments of 
urates; this depends on the great concentration resulting from the loss 678 
ACUTE INFECTIOUS DISEASES. 
of water bj evaporation and sweating; it does not occur ii the patients 
replace the loss of water by drinking freely. During the sweating 
stage, the bodily temperature gradually falls, and toward its end be- 
comes nearly normal. When the paroxysm is over, and the apyrexia 
begins, most patients fall into a deep sleep, from which they awake 
much fatigued and dull, it is true, but feeling relatively wrell. When 
all the stages of the paroxysm are well marked, the disease is called 
an intermittens completa; if one or other stage fails or is indistinct, it 
is called incompleta. In rare cases, the stages of the fever are said 
not to follow the regular order; for instance, the cold stage closes the 
paroxysm instead of opening it (typus inversus). 
After the first paroxysms of intermittent, the apyrexia is rarely 
“ pure.” The patients have no fever, it is true; in some cases the 
temperature is even low and the pulse slow; but the appetite is 
often poor; the tongue coated, digestion disturbed; the patients are 
sensitive to changes of temperature, and complain of an indefinite feel- 
ing of illness. After a few paroxysms the disturbances usually sub- 
side, and during the apyrexia the only symptoms we notice are 
steadily-increasing debility and more evident impoverishment of the 
blood. If intermittent fever is very protracted, the apyrexias often 
become impure again, and the intermittent type approaches the remit- 
tent (febris intermittens subcontinua). 
According to the rhythm in which the paroxysms follow each other, 
we distinguish intermittens quotidiana, tertiana, and quartana. In the 
quotidian, the paroxysms recur in nearly or exactly twenty-four hours ; 
in the tertian, in twice twenty-four hours; in the quartan, in three 
times twenty-four hours after the commencement of the last one. It 
is less certain if there be also a five, six, or seven day rhythm, or if 
the intervals be even longer. The most frequent varieties are the 
tertian and quotidian. If the paroxysms recur at an earlier hour than 
it did the last fever-day, the disease is called anticipating, in the oppo- 
site case it is called retarding. By continued anticipation or retarda- 
tion, the rhythm of the fever may change, and a tertian may become a 
quotidian, or the reverse. If a paroxysm last almost till the com- 
mencement of the next one, we have a febris intermittens subintrans. 
When the apyrexia of a quotidian, tertian, or quartan intermittent is 
interrupted by a weak, short paroxysm, -which often occurs at a differ- 
ent time of day, it is called febris intermittens duplicata. In quo- 
tidiana duplicata there are two attacks each day, one severe, the 
other mild; in tertiana duplicata there is one attack each day, but 
one day it is mild, the next weak, etc.; in quartan duplicata, parox- 
ysms occur on two successive days, while the third day remains free. 
Intermittent fever never begins double ; this rhythm usually develops INTERMITTENT FEYER. 
679 
after the disease has lasted a long time, or particularly after numerous 
relapses. 
The course of intermittent is so often modified by the administra- 
tion of medicines, especially of quinine, that few physicians have 
actually observed a case left to itself, or, as is generally said, the nor- 
mal course of an intermittent. On this point also we are indebted to 
the homoeopaths for some important information. In the first place, 
there is no doubt that the peculiar fever paroxysms and apyrexias, 
which characterize infection with malaria, almost always continue for 
a time, even if the patient be removed from further action of the 
poison. Among other cases, I know of a young sailor who suffered 
from intermittent fever in Greifswald, and who had a relapse while at 
sea, four weeks after his last attack. It is also certain that, when a 
long time has passed since the action of the poison, the symptoms of 
malarial poisoning almost always disappear without medical aid. To 
avoid illusion, we must bear in mind that it is not only those who fly 
from the malarious region after acquiring intermittent fever, but also 
those who remain in the place till the malaria has disappeared, that 
finally escape the action of the poison. At a time when no new cases 
are observed in a place which has been visited by intermittent, it 
would be foolish to regard the final cure of a case, which had previous- 
ly been treated ineffectually, as a proof of the peculiar efficacy of the 
remedy last used. As the prevalence of the malaria among us only 
lasts a few months, the number of spontaneous cures is certainly much 
greater than is usually supposed. 
Another question is, whether, from continued action of the poison, 
the organism becomes so blunted to its injurious influence, that the 
symptoms of intoxication cease. At all events, such cases are rare, 
and it is more frequent to find those where continued action of the 
malaria has only modified the symptoms of intoxication, so as to 
change a pure intermittent into an intermittens subcontinua, or 
chronic malarial illness without fever. As was stated, when speak- 
ing of the individual paroxysms and apyrexias, after a prodromal 
stage but little characteristic, most cases of intermittent begin as 
tertian or quartan fevers, the apyrexias being at first imperfect, 
but becoming pure after a while. When the disease has lasted even 
a very short time, the patient appears very pale and cachectic, and 
this symptom is the earlier and the more marked, the greater the en- 
largement of the spleen. If the spleen remain small, from rigidity of 
its capsule, or from other unknown causes, the patient does not have 
this peculiar pale and sickly appearance until later. From this fact, 
which may be observed in most cases, as well as from the second fact, 
that the healthy color quickly returns when we can rapidly reduce the 680 
ACUTE INFECTIOUS DISEASES. 
size of the spleen, we have concluded that the great pallor of the 
patients after the first attacks of intermittent does not solely, and, at all 
events, does not exclusively, depend on general impoverishment of the 
blood, but mostly on the lack of blood in the skin, which must be induced 
by its collection in the spleen. While Junod's boot is applied to one 
extremity, there is great hypersemia of that limb, and consequent 
anaemia of the rest of the body; if the boot be removed, the normal 
distribution of blood is soon reestablished. We do not, however, 
mean to say that the fever of intermittent differs from other fevers in 
regard to the consumption of the body; on the contrary, intermittent 
fever would be one of the most dangerous of diseases, if those inex- 
plicable pauses did not occur between the paroxysms, during which 
the consumption is interrupted, and the tissues of the body restored 
by plentiful supply of nourishment, more than in any other feverish 
disease. From the high temperature (106° Fahr. or more), reached in 
intermittent fever, the consumption of the body is very marked. This 
is evident, not only from the increased production of urea, but also 
from the emaciation and hydrasmia that occur in protracted cases. 
There is no doubt that the production of urea is only increased during 
the paroxysm, and not during the apyrexia; on the other hand, in two 
cases of quartan intermittent, I found that the excretion of urea was 
increased during the apyrexia also, or, in other words, that the in- 
creased amount of urea produced during the paroxysm was not all ex- 
creted till some time during the following apyrexia. If the paroxysms 
be not temporarily or permanently arrested by the administration of 
quinine, or if they do not soon cease spontaneously, the hydrsemia at 
length becomes so excessive, that in many cases more or less dropsy oc- 
curs, without the urine being diminished in quantity, or containing albu- 
men. This dropsy is analogous to those occurring during other exhaust- 
ing diseases, although it is probable that the organic and functional 
disturbances of the spleen accompanying protracted intermittent fever 
add to the degree of hydrsemia, and to the frequency of the dropsy. The 
longer the affection lasts, the more reason there is to fear the devel- 
opment of permanent organic change in the spleen, liver, or kidneys • 
this usually assumes the form of lardaceous degeneration, with coinci 
dent deposit of pigment, and leads to incurable disease. Continued 
intermittent fever often induces chronic parenchymatous nephritis also, 
and, in other cases, a haemorrhagic diathesis. These severe sequelae 
of simple intermittent fever are generally prevented by proper treat- 
ment ; and, even where intense malaria is endemic, under careful man- 
agement, excessive dropsy, fatty degeneration of the abdominal or- 
gans, and cachexia, rarely occur. It is true, neither quinine, nor any 
other known remedy is so certain an antidote for malarial poison as INTERMITTENT FEVER. 
681 
to cut short the entire disease; but, for the most important and dan- 
gerous symptom, the fever, quinine is almost infallible. After giving 
proper doses of quinine, the patient almost always escapes a series of 
paroxysms; and, as the cachexia and impoverishment of the blood, 
and, to some extent, the spleen-affection also, probably depend on the 
fever, the patients not only do not grow worse during the administra- 
tion of the quinine, but they improve and pick up even if the disease 
be not entirely extinct. Although, for the sake of brevity, we may 
designate as relapses the many cases where paroxysms recur shortly 
after stopping the quinine, strictly speaking, it is incorrect; for the 
cases where these so-called relapses occur, even after moving into a 
region free of malaria, prove that the disease was not cured, but only 
one of its symptoms removed. The homoeopaths assert that under 
their treatment there are no relapses : there is some truth in this as- 
sertion ; for, when the paroxysms have ceased under homoeopathic 
treatment, the disease is certainly all gone. The fact, that, after the 
administration of quinine in sufficient doses, relapse does not occur in 
many cases, rather favors the view that, besides its palliative action 
on the paroxysms, this medicine has also a favorable influence on the 
entire disease caused by the malarial infection ; but it is also possible 
that in such cases the palliative action continues till the disease passes 
off spontaneously. When the action of quinine is only palliative (as 
it is in the majority of cases), usually about seven, fourteen, or twenty- 
one paroxysms are missed, and the next one occurs in about two, three, 
or four weeks, rarely sooner. According to my own observation, the 
assertion, that the relapses almost regularly take place the fourteenth, 
twenty-first, or twenty-eighth day, is exaggerated; I have far more 
frequently seen relapses a few days before or after these dates. It is 
not at all rare for relapses to occur three or four times, or oftener, and 
for the disease to run on interruptedly for months, before actually 
ceasing. I deem it proper to speak of the modification of the course 
of intermittent fever by quinine under symptomatology, because, as 
we have already said, most physicians have no opportunity of ob- 
serving intermittent fever without this modification of its course. 
Much that is said in the text-books on medicine, about the course of 
intermittent fever, certainly does not refer to the disease when left to 
itself. 
II. Pernicious Intermittent Fever.—Intermittent fever may prove 
dangerous to children, to the aged, and to very debilitated or sickly 
persons, without being of unusual intensity or duration, or having any 
complications. Children inclined to convulsions not unfrequently have 
an epileptiform attack during the cold stage, as they also have in the 
initiative chill of inflammatory diseases. This is not usually danger- 682 
ACUTE INFECTIOUS DISEASES. 
dus, but occasionally it passes into general paralysis, ending in death. 
In very old or broken-down persons, the danger from a simple par- 
oxysm lies chiefly in the threatened exhaustion of the still remaining 
strength. Such cases, which only take on an acute course from indi- 
vidual peculiarities of the patient, are not usually called pernicious. 
Some cases of intermittent acquire a pernicious character, from the 
usual symptoms becoming very intense, or being protracted a long 
time. In this class belong the cases where the liyperaemic swelling 
of the spleen is so great that its capsule is ruptured, or where the 
chill is so severe as to cause dangerous obstruction of the circulation, 
as well as those cases where the paroxysms do not cease in from six 
to ten hours, but continue for twenty-four hours, or longer, and leave 
the patient very much exhausted, or where only certain stages con- 
tinue beyond the usual time. It seems to me very probable that some 
forms of the so-called pernicious fever also should come under this 
head, as it is probable that they are not complicated, only that the 
customary symptoms are greatly increased. Even in simple normal 
intermittent there is an increase of the temperature, such as is ob- 
served in scarcely any other disease; and the short time that this 
increase lasts is the only reason that it does not prove dangerous to 
the patient. In all diseases where the bodily temperature becomes 
excessive, or remains high for a long while, we have the symptoms of 
great adynamia, and finally of paralysis of the heart, and these are the 
most prominent symptoms of pernicious fever. The deep stupor of 
patients with febris intermittens comatosa, as well as the delirium 
preceding the coma, reminds us strongly of the symptoms in severe 
typhus, malignant measles, and other infectious diseases accompanied 
by high fever. When these cases terminate fatally, we do not gen- 
erally find any anatomical changes in the brain. In febris algida the 
heart’s action grows feebler, the pulse smaller; the blood collects in 
the veins; there is cyanosis; the temperature of the periphery closelj 
approaches that of the surrounding air, because the loss of warmth 
due to the obstructed circulation is not replaced by a supply of warm 
blood; the patients grow cool; in short, we have the symptoms of 
acute paralysis of the heart, which may even result from the intensity 
of the fever without complications. There is no doubt that, in these 
severe forms of intermittent fever, there is often pigment in the blood; 
but the coincidence of melanaemia with severity of intermittent fever 
does not justify us in regarding the latter as a result of the former. 
On autopsy of several cases of intermittent fever that died with severe 
brain-symptoms, Frerichs found melanaemia, it is true, but he found 
no pigment in the capillaries of the brain; and I have observed simi 
lar cases. INTERMITTENT FEVER. 
683 
Under the head of congestive, pernicious intermittent, in the strict 
sense, we must class those cases where the malignant course of the 
disease is caused by hyper®mia, effusions of blood, inflammations, and, 
perhaps, also by obstructions of the circulation in different organs, in- 
duced by stoppage of the capillaries with pigment. Probably these 
disturbances of nutrition and circulation in the central organs of the 
nervous system are the origin of the maniacal, apoplectic, epileptiform, 
and tetanic convulsions, which occasionally complicate the paroxysms, 
and have led to the designations febris intermittens perniciosa, mani- 
acalis, apoplectica, epileptica, tetanica. A rather frequent but rarely 
dangerous complication of intermittent fever-is a severe bronchitis, 
which exacerbates with every paroxysm and remits with each apyrexia. 
Febres intermittentes comitat® pneumoniacac and pleuritic®, or cases 
of intermittent h®moptysis, are rare. In many cases of congestive in- 
termittent, there is jaundice. Copious watery transudations from the 
intestinal canal, violent vomiting, and profuse diarrhoea, may cause 
thickening of the blood, and give the paroxysm a great resemblance to 
the algid stage of cholera. In some cases there are also profuse inter- 
mittent intestinal h®morrhages. (Among fifty-one cases of pernicious 
intermittent, observed by Frerichs, there was profuse diarrhoea seven- 
teen times, profuse intestinal h®morrhage three times.) The serous 
transudations and h®morrhages into the intestinal canal may depend 
on acute congestion due to obstruction of the hepatic capillaries by 
pigment, but this has not been proved in all cases. Lastly, we have to 
mention the complications of intermittent with diseases of the kidneys. 
They evince themselves by albuminuria, h®maturia, and in severer cases 
by the suppression of urine. (In the fifty-one cases of Frerichs, albu- 
minuria was seen twenty times, suppression of urine five times.) 
Pernicious intermittent fever occurs chiefly in tropical-fever regions, 
it is true, but even with us, in places where intense malaria prevails, 
it is not rare, and individual cases are seen in every large epidemic of 
intermittent fever. The malignant character either appears at the 
Start, or does not manifest itself till the second or third paroxysm, or 
even later. After malignant congestive symptoms have appeared, the 
apyrexias are often so imperfect that the diagnosis is very difficult or 
even impossible. In the epidemics observed by Frerichs, most patients 
were sent into the hospital with the diagnosis of a typhus. 
III. Concealed Intermittent Fever.—While, as a rule, intermittent 
fever results from infection with malaria, we not unfrequently see ex- 
ceptional cases where, instead of fever-paroxysms, there is neuralgia, 
the attacks of neuralgia being separated by regular intermissions, cor- 
responding to the apyrexias of a simple intermittent. These deviations 
from the rule are inexplicable, it is true, but this is also true of regular 684 
ACUTE INFECTIOUS DISEASES. 
simple intermittent fever, which we do not in the least understand. 
The intermittent neuralgias resulting from malaria, which chiefly bear 
the name of intermittentes larvatas, most frequently affect the supra- 
orbital, more rarely other branches of the trigeminus or other nerves. 
We may omit a description of the attacks, as they are about the same 
as those of neuralgic attacks from other causes. They are accompa- 
nied by a slight elevation of temperature, perceptible by the thermom- 
eter. In rare cases, other anomalies of excitement of the cerebro- 
spinal and vaso-motor nerves appear to result from malaria. Among 
these are intermittent anaesthesia, paralysis, spasms, psychical dis- 
turbances, and hyperaemia or oedema of different organs. 
Treatment.—Prophylaxis requires that the State should attempt 
to remove by sanitary laws (which do not come in our province) the 
injurious influences which notoriously favor the development of mala- 
ria ; that it should drain the marshes in whose vicinity intermittent 
fever is endemic, and should protect by dikes those lands that are 
overflowed yearly. Moreover, persons obliged to reside temporarily or 
permanently in malarial regions should observe certain rules, which 
afford more protection than any prophylactic medicines. ITauschJca, 
who has apparently had great experience, gives very precise and prac- 
tical rules for life in malarial regions. In his special pathology and 
therapeutics, he advises: 1, on going to a dangerous place, to assume at 
once the peculiar mode of life of the inhabitants; on the Weichsel to 
drink schnaps, in Banate slivovitz, in Hungary only to eat melons and 
pickles with plenty of pepper, in Italy to drink plenty of lemonade 
and black coffee, and avoid eating at night, also to drink water pre- 
pared as is customary at different places ; 2, to suit the clothing to the 
temperature of the time of day, especially to protect the person by 
warmer clothes against the cool evening air, and to keep the windows 
closed at night; 3, to seek a dwelling high and dry above the marshes, 
etc.; 4, to avoid getting wet through, errors of diet and other excesses, 
so as not to bring on any other disease by which the tendency to ma- 
laria will be increased; 5, to avoid certain things, such as the use of 
vegetables, milk, and bathing in rivers or the sea, especially after sun- 
down. Sleeping in the open air seems to be most dangerous. 
Treatment of the paroxysm may almost always be dispensed with, 
except as regards directing the regimen. As soon as the first symp- 
toms of chill are observed, the patient should go to bed; but we 
should warn the attendants against piling on too many bed-clothes, as 
they do not warm the skin, and only interfere still more with the cir- 
culation in the peripheral parts, and with the impeded respiration. If 
the chill be very severe, the skin may be rubbed with warm woollen 
cloths, and warm bottles placed in the bed. Hot drinks neither re- INTERMITTENT FEVER. 
685 
aeve tne feeling of chilliness nor increase the temperature in the pe- 
ripheral parts, which is diminished in spite of the increased temperature 
of the blood; but we may yield to the generally urgent entreaties of 
the patient for warm drink, so far as to allow him a few cups of tea, if 
we are certain that he will be moderate. If there be severe vomiting 
during the cold stage, w'e may give effervescing powder, and, if this 
fail, a few drops of laudanum. If the patient become so collapsed as 
to alarm us, we may give analeptics, strong coffee, wine, camphor, 
ether, and opium, have the patient rubbed, and apply sinapisms. In 
the hot stage we may try cooling treatment, light covering, plenty of 
cold drink in small quantities; where there is severe congestion of the 
brain, use cold water or ice-compresses to the head, and sometimes 
local blood-letting. Venesection is only to be practised in the most 
urgent cases, as it rarely does good, and may cause dangerous collapse; 
in its place, in attacks of pernicious fever, besides local blood-letting 
and derivatives, the use of opium has proved the most efficient treat- 
ment. The sweating stage must be awaited in bed. Especial treat- 
ment to increase the sweating is unnecessary, as there is no advantage 
from its being very profuse. The patients should not change their 
underclothes till this stage has terminated. The treatment during the 
apyrexia aims at preventing the return of paroxysms by the adminis- 
tration of quinine, unless there be some peculiar objection to giving 
that medicine. The formerly common idea, that it was advantageous 
for the patient to have a certain number of paroxysms, and that the 
fever should not be arrested till after the third, fifth, or even seventh 
attack, was based on false premises. The sooner he is freed of his 
paroxysms the better for him. A morbid state of the gastric mucous 
membrane, however, which occasionally occurs after the first paroxysm 
of intermittent, contraindicates the administration of sulphate of 
quinine, and, in mild cases at least, this morbid state should be re- 
moved before ordering the irritating salt. In treating intermittent 
fever, the diagnosis of gastric catarrh, or foul stomach, is not made 
very exactly, and emetics are used too freely; some physicians begin 
the treatment with an emetic, as a matter of course; others prescribe 
muriate of ammonia till the tongue is thickly coated, and then give an 
emetic to prepare the patient for quinine. Unless certain indications, 
that we have given for the administration of emetics in gastric catarrh, 
be present, we consider it improper, or at least superfluous, to open 
the treatment of intermittent with one. But if, at the commencement 
of the fever, the patient has made great errors of diet, especially if, 
just before the paroxysm, he has filled his stomach with food which 
has remained undigested, and by decomposing has irritated the gastric 
mucous membrane, there is just cause for giving an emetic. We have 686 
ACUTE INFECTIOUS DISEASES 
already described the difference between gastric catarrh due to indi 
gestion and the slignt dyspepsia accompanying most fevers which re- 
quires no emetic, and does not prevent our giving quinine. Pfeufer'k 
recommendation, to give quinine in one large dose instead of in several 
smaller one sduring the apyrexia, has very rightly become popular. 
Usually, in adults, one dose of ten grains of sulphate of quinine suffices 
to arrest the chills; in children, five grains suffice, in still smaller chil- 
dren, two or three grains answer. Another slight chill often occurs, 
and the attacks then cease. It is best to give this dose of quinine 
some hours before the expected chill, so that we may be sure of its 
acting during the apyrexia. Small doses should only be preferred 
when large ones are vomited by the patient; in such cases we may 
give two grains every two hours, till twelve or fifteen grains have been 
taken during the apyrexia. Quinine is most frequently given in pow- 
der or pill (quiniae sulphat. gr. x, ext. gentian, q. s. ut f. pill. no. iv). 
Solution of bisulphate of quinine (quiniae sulph. gr. x, aquae meliss. 
§ iij, acid, sulphur, dilut. 3 ss, syrup. § ss) is said to be particularly 
effective, but it is unpleasant to take, especially in large doses. If 
quinine is not borne by the stomach, it may be given by injection, as 
it acts just as well by the rectum (or by hypodermic injection). Other 
salts of quinine have no advantage over the sulphate; quinoidine and 
tincture of quinoidine are cheaper, and hence may be preferably used 
in poor practice ; of the latter remedy we may give twelve or fifteen 
drops every two hours, or give a teaspoonful a short time before 
the expected chill. According to Wunderlich, this is quite as effica- 
cious as quinine. If the patient has escaped one chill under the above 
treatment, he almost always escapes a second and third, or even a 
number; but it is advisable to continue small doses of quinine for a 
few days longer, unless the spleen has distinctly and steadily de- 
creased in size. The more perfectly the spleen returns to its normal 
bulk, the greater is the probability that there will be no relapse. I 
have already given my ideas about the custom of repeating the qui- 
nine on the seventh, fourteenth, twenty-first, and twenty-eighth days. 
When this is being done, the chill often occurs on the day just pre- 
ceding the one when the medicine was to be given. I think it much 
safer to tell the patient that he will probably have a relapse toward 
the end of the second, third, or fourth week, and that at these times he 
must watch carefully for any premonitory symptoms, and on the 
slightest suspicion of a chill he must take a full dose of quinine. By 
careful attention to the rudimentary attacks which almost always pre- 
cede perfect relapses, most patients of moderate intelligence may pro- 
tect themselves from the latter. The belief, that, in cases of relapse, 
the patient must daily take an ounce of tincture of Peruvian bark ir REMITTENT AND CONTINUED MALARIAL FEVER. 
687 
stead of quinine, is antiquated. Besides the administration of quinine 
or its repetition, we should urge the patient to adopt all the rules 
spoken of under prophylaxis. When the circumstances of the patients 
permit, we should have them leave the affected place for six or eight 
weeks. We have already explained that this does not render the ad- 
ministration of quinine superfluous. 
If chronic malarial dyscrasia develop, besides a nutritious and 
strengthening diet, the patient should twice a day take half a glass of 
bark and wine (tine, cinchonas 3 i, tine, cinnamom. 3 i, acid, sulph. 
aromat. 3 ij to a bottle of Rhine wine), or three or four teaspoonfuls 
daily of tine, cinchonas comp., combined with large doses of iron. In 
most cases the benefit of this treatment is very evident: even advanced 
dropsy usually disappears in a short time without any diuretic reme- 
dies ; should it unexpectedly fail, we ought to absolutely insist on a 
temporary change of residence, even if it be very inconvenient. 
The above treatment is almost always successful in simple inter- 
mittent. Experiments with substitutes for quinine, such as salacin, 
piperin, salt, etc., have led to negative or doubtful results. The only 
febrifuge, except Peruvian bark and its preparations, that deserves con- 
fidence, is arsenic, in the form of Fowler’s solution (four to six drops 
three times daily during the apyrexia). In view of the far more cer- 
tain and safe action of quinine, I consider the use of arsenic as only 
justifiable in those rare cases where quinine fails, even in large doses. 
In pernicious intermittent, our first object is to prevent the occur- 
rence of the next attack. While carrying out the treatment required 
by the congestive symptoms during the attack, we should not wait 
for a complete intermission before giving quinine; but, as soon as there 
is the slightest abatement of the symptoms, we should give large doses 
of quinine (3 j to 3 ss. or more), and, if the patients cannot swallow, 
give it by enema [or, better, by hypodermic injection, giving about 
one-third the dose by the mouth, perfectly dissolved]. 
In the concealed form of intermittent, quinine is almost as effica- 
cious as in the simple form ; but even here its action appears only pal- 
liative and symptomatic, as it does not prevent relapses. 
CHAPTER XII. 
REMITTENT AND CONTINUED MALARIAL FEVER. 
Etiology.—Remittent malarial fevers occur chiefly in the tropics, 
it is true, but they are occasionally observed among us also, in places 
where malarial diseases are endemic, and at other places also when 
epidemics of intermittent are prevailing. Hence I cannot class remit 688 
ACUTE INFECTIOUS DISEASES 
tent malarial fever among the exotic diseases and pass it by, but 1 
shall follow the excellent description of Griesinger in my short ac- 
count of it, as I have but little knowledge of the affection from per- 
sonal observation. 
The dependence of remittent fever on malarial infection is shown, 
first, by its exclusive occurrence in places where we know, from the 
quality of the soil and climate, and from the occurrence of numerous 
cases of intermittent, that there is an intense malaria ; secondly, from 
the many cases where remittent fever becomes intermittent. We do 
not know whether the change of symptoms be due to a modification 
of the poison, and, if so, in what this modification consists. The more 
severe the cases of intermittent, the more frequent are the remittent 
cases. 
Anatomical Appearances.—As regards the melanaemia, the post- 
mortem appearances of remittent fever correspond with those of per- 
nicious intermittent. At least, in almost all places where remittent 
fever is endemic, in the rare cases of autopsy it has been noticed that 
the cortical substance of the brain is of a dark, ashy hue, and the 
spleen and liver are blackish. Besides these changes, which are not 
constant, traces of more or less severe icterus are often found, some- 
times with, again without, obstruction of the gall-ducts; as well as the 
remains of catarrhal and diphtheritic inflammation of the intestines, 
and, more rarely, haemorrhages into the stomach, haemorrhagic infarc- 
tions in the lungs, or lobular pneumonia. 
Symptoms and Course.— Griesinger distinguishes three forms of 
remittent fever. According to him, the first and mildest form begins 
with a sudden feeling of severe illness, high fever, and foul stomach. 
These are soon accompanied by enlargement of the spleen, mild jaun- 
dice, irregularity of the bowels, discoloration of the faeces, and herpes 
labialis. The depression of the patient, the pain in the head and 
limbs, the dizziness, noise in the ears, and not unfrequent bronchitis, 
remind us of a commencing typhus; but from the first the fever shows 
a decided remittent character. Irregular exacerbations, which subse- 
quently become regular, and usually have a quotidian type, are fol- 
lowed by distinct remissions. These gradually pass into perfect inter- 
missions, the patient sweats freely, and feels well; the remittent 
becomes a simple intermittent. In other cases, even without this 
change, the disease terminates in recovery, by a gradual decrease of 
the symptoms; it lasts from a few days to three weeks. 
In the severer form the fever is very high, the remissions are well 
marked only at first; the disease reminds us of a severe typhus; the 
patients become stupid and delirious; the tongue grows dry, and the 
spleen is enlarged. Generally, also, but not always, there is icterus; REMITTENT AND CONTINUED FEVER. 
689 
other cases are complicated with pneumonia, dysentery, etc., and still 
others have indications of the so-called pernicious attacks. The dis- 
ease usually lasts from eight to fourteen days. If it ends in recovery, 
it usually first becomes intermittent. Death may occur suddenly with 
the symptoms of a pernicious intermittent. 
The severest forms run their course with the symptoms of an indis- 
tinct and irregular exacerbating and remitting fever of very adynamic 
character. The patients collapse quickly, and soon fall into deep 
apathy. There are also various but not constant disturbances of func- 
tion and nutrition in almost all the organs, so that the symptoms of 
the disease vary greatly. Many patients become jaundiced. There is 
often epistaxis, vomiting of blood, and hsematuria; in other cases 
there is albuminuria, or suppression of urine; in others, symptoms of 
cholera or dysentery; the spleen and liver enlarge considerably, and 
often become the seats of inflammation and suppuration. Inflamma- 
tory exudations not unfrequently form in the serous membranes and 
lungs also, and in the skin there are petechias, bed-sores, and gangrene. 
Death usually occurs in this stage, with coma or convulsions, or with 
the symptoms of febris algida. 
Treatment.—According to Griesinger, in the milder forms of re- 
mittent fever, the acute affection of the gastro-intestinal mucous mem- 
brane should be combated by absolute diet, acids, and, if requisite, by 
emetics and laxative medicines. We should give quinine as soon as 
the remissions and exacerbations become decided, and the latter begin 
with a chill. Any complications should be treated separately, as 
quinine alone does not answer for them. In the severer and severest 
forms, the most important indication is the early and continued use of 
quinine in large doses, till improvement begins. At the same time, 
the congestive symptoms are to be treated symptomatically, just as in 
pernicious intermittent fever. 
[At present malarial poison is by many supposed to consist of 
microscopic vegetable parasites, in algse cells and spores, from the 
decomposition of vegetable substances. IlarJcness asserts that the 
algae cells, which Salisbury found in the sputa of patients and re- 
garded as the active principle of malaria, are found not only in 
malarial regions, but on the highest Alps, and occur in the sputa 
and other secretions of healthy persons. 
Intermittent fever is a wide-spread disease. It is especially 
frequent in the tropics at places which are not particularly dry ; 
in the temperate zones it occurs at certain places ; but the frigid 
zones escape. It is very common in Western Africa, the West 
Indies, Mexico, and our Southern States, but occurs to some extent 
in all the States. 690 
ACUTE INFECTIOUS DISEASES. 
The period of incubation for malaria is uncertain. Patients sub- 
jected to the poison for a long time, or suffering from the disease, 
look pale and cachectic, probably from changes in the blood, per- 
haps partly due to fever,, partly to affection of the blood-forming 
organs. The red blood-corpuscles are less numerous ; the remains 
of those destroyed appear as pigment in the blood and some of the 
organs. This diminution in number is greatest at first, but goes on 
till recovery begins ; but at the same time it is said they increase 
in size. Kelsch says the white corpuscles decrease in number faster 
than the red do, but in the interval increase gradually, and that at 
the time they are least numerous the spleen is largest. 
If after the intermittent paroxysms have ceased the spleen or 
liver remain enlarged, the patient cannot be regarded as cured. 
Chronic enlargements of the spleen may attain an enormous size ; 
or there may be amyloid degeneration of the spleen, the liver, or 
the kidneys. 
Where in the treatment of malarial diseases the preparations of 
cinchona prove ineffectual, we may try eucalyptus globulus, of 
which we may give 3 ss-3 ij of the tincture, or 10-20 drops of 
fluid extract, several times daily. Another substitute for quinine 
is arsenic, either as pills of arsenious acid or as Fowler’s solution. 
In cases of malarial neuralgia, or where there is gastric disturbance, 
the Fowler’s solution may be used hypodermically. Faradization 
of the splenic region is said often to diminish the size of the spleen, 
as also the use of cold douches over that organ while the patient is 
in a tepid bath.] 
[CHAPTER XIII. 
YELLOW FEVER. 
Without discussing the question as to when and where yellow 
fever originated, we may say that in the United States its different 
epidemics seem to come from the West Indies, and to start among 
us from New Orleans ; thence its course of travel is along rivers or 
by the seaports. 
The cause of the disease is not certainly known, but it is sup- 
posed to be in the nature of germs. The affection is not conta- 
gious ; i. e., a patient having it, if stripped of his clothing and dis- 
infected, may be placed among other patients without spreading 
the disease. So, the germs do not develop and multiply in the YELLOW FEVER. 
691 
patient, but they do so in articles about him (fomites) ; germs may 
be carried in clothes and other articles, or in ships, especially in 
the bilge-water. These germs are deprived of activity by a freez- 
ing temperature, but may be awakened by a heat of 90° Fahr. ; 
they are destroyed at 250° Fahr. 
It has been maintained that yellow fever is only a variety of 
malarial fever, but the evidence seems to be very strongly against 
this view. 
The National Board of Health (United States, 1879) reaches 
conclusions about as follows : 
The essential cause of yellow fever is a “ germ ” wThich is capa- 
ble of growth and propagation outside of the human body, and 
which flourishes especially in decaying organic matter. Disinfec- 
tion must attack the germ and that on which it grows. Disinfec- 
tion is a poor substitute for cleanliness ; it is best done by sulphate 
of iron, carbolic acid, fresh quicklime, fresh charcoal-powder, chlo- 
rides of zinc and aluminium, and permanganate of potash. The 
disinfectant must be brought into actual contact with the germ ; 
when the germ is dry, it must be moistened or else subjected to a 
dry heat of 250° Fahr. While the infected articles are dry, move 
them as little as possible ; moisten them with boiling water or 
some disinfectant solution. The Board advises moist cleansing, 
followed by fumes of sulphur, using about 18 ounces of sulphur 
to 1,000 cubic feet of the space to be disinfected. The removal of 
an unpleasant odor is no proof of disinfection. Textile fabrics 
which have been exposed to yellow-fever infection should be placed 
in boiling water or in an oven ; rooms and houses which have been 
occupied by yellow-fever patients should be disinfected as soon as 
possible. Lastly, they suggest that “ every suspicious case of sick- 
ness should be at once isolated, and every possible precaution taken 
to prevent infection, by providing attendants who have had the 
disease, and thorough disinfection of all discharges from the sick. 
If the disease proves to be yellow fever, all articles of clothing and 
bedding used about the sick should be burned, the house should be 
vacated, and every room tightly closed and fumigated with burning 
sulphur.” 
Yellow fever only occurs when the temperature is high ; in the 
northern part of the United States most of the epidemics have be- 
gun in July and August. A frost suddenly checks the spread of 
the disease. 
Susceptibility to this affection is greatly influenced by race and 
acclimation ; in many epidemics negroes escape ; acclimation may 692 
ACUTE INFECTIOUS DISEASES. 
cause some change in the tissues that impedes absorption of the 
germs. It is said that acclimated persons are not troubled by 
mosquitoes, which are usually very plentiful in yellow-fever re- 
gions. 
Anatomical Appearances.—Rigor mortis is early and decided. 
The skin is more or less jaundiced. The heart is often pale and 
relaxed ; its muscles may have undergone fatty degeneration. The 
greatest changes are seen in the abdomen ; there is acute catarrh 
of the mucous membrane of the alimentary canal; rarely there 
may he ulcers in the stomach, and there is usually more or less 
dark blood (black vomit is blood mixed with the fluids of the 
stomach). The liver is but little changed in size, but is of uneven 
yellow color (more marked in the left lobe), and its cells are filled 
with fat; it looks like the fatty liver of drunkards. The spleen 
is not especially changed. The cortical substance of the kidneys 
is often swollen, and there are signs of inflammation in all parts 
of them. 
Symptoms and Course.—The period of incubation is not set- 
tled, but probably is from a few hours to three days. The first 
symptoms are chilliness alternating with fever, or perhaps a severe 
chill, great restlessness, red face and eyes, headache (“ the most 
characteristic symptom of the disease is the p>eculiar pain in the 
forehead and eyeballs, with the drunken appearance of the eye”), 
pain in the joints, fever (102° Fahr. or more), frequent respira- 
tion, and frequent pulse. Severe cases sometimes have a cadav- 
eric odor early in the disease. The tongue is coated and swol- 
len, the pharynx reddened ; the gums swell and bleed readily. 
The epigastrium is very sensitive, and there is usually vomiting. 
The kidneys are affected, and albuminuria is common ; it is said 
that if the albumen disappears gradually, it is a favorable sign, 
while its continuance or increase is ominous. The symptoms in- 
crease till the second or third day, the temperature rising to 
about 105°. Then there may be jaundice of the skin and conjunc- 
tiva ; the urine contains bile ; the faeces retain their color, show- 
ing that the jaundice is haematogenous. There is frequent haemor- 
rhage from the nose, or more rarely from the stomach ; the latter 
is of evil import. 
After increasing in severity for about two or three days, the 
symptoms subside ; the temperature may fall to normal in twelve 
hours, but does not usually go below 100° ; the patient may feel so 
much better as to think he is well; but the nausea and sensitiveness 
of the epigastrium remain. This stage of remission may last one or YELLOW FEVER. 
693 
two days, or it may be the commencement of convalescence. In 
the third stage the symptoms again grow worse, the temperature 
rising to 104° ; the patient is usually apathetic, though he may 
completely retain consciousness. Now come the jaundice and haem- 
orrhages from the alimentary canal ; that from the stomach con- 
stitutes the “ black vomit ” which has given one name to the dis- 
ease. While this “ vomit is thick and pasty, being raised in small 
quantities, and thrown up mixed with natural mucus, the physician 
does not despair of his patient. The thin black fluid with the coffee- 
ground sediment is always, in Mobile, a fatal symptom.” If the 
disease continues, the kidney trouble may grow worse, and entire 
suppression of urine occur. If this third stage is severe, it mostly 
terminates in death (“from syncope, uraemia,-apoplexy, or asphyx- 
ia”) ; but sometimes the temperature falls suddenly, the patient 
sweats freely, and the severe symptoms all subside. Convalescence 
is slow, and for a long time the stomach remains weak. In severe 
cases- the strength of the patient may not be “ reestablished sooner 
than from ten to ticenty days after the cessation of the febrile symp- 
toms,.” “ The average duration of fatal cases is less than a week.” 
The Treatment of yellow fever, as of other epidemic diseases, 
has varied greatly with different epidemics. Bleeding, salivation, 
purging, sweating, etc., have each had their advocates ; but at pres- 
ent the most favored plans may be considered—first, that of ad- 
ministering at the start a large dose (gr. xx each) of calomel and 
quinine, followed after a few hours by a purge, and subsequently 
to treat symptoms ; and, secondly, the treatment by laxatives, such 
as cream-of-tartar and tamarind-water, followed by tonics, and, 
if the disease goes on, by active stimulants. It is considered very 
desirable to keep the patients well covered in bed, and in moder- 
ate perspiration; the latter may be aided by hot foot-baths under 
the bed-clothes and by warm aromatic teas. Possibly frequent 
small doses of jaborandi or its active principle, piloearpin, might 
prove beneficial.] 694 
ACUTE INFECTIOUS DISEASES. 
CHAPTER XIY. 
SUDOR ANGLICUS.—SUETTE MILIAIRE.—SWEATING-SICKNESS.— 
FRIESEL EIEBEE. 
A large number of authorities, especially the Germans, deny the 
existence of sudor anglicus as a peculiar disease. Thus Hebra ignores 
the well-known fact that the prevalence of this malady is restripted 
within extremely narrow geographical limits, and that, between the 
various epidemics of it which have arisen long intervals have elapsed ; 
so, having never met with a case of it himself, he concludes that there 
is no such disorder. His remarks that there is no febrile affection in 
which fever-vesicles may not appear, and that the invasion and course 
of malaria are never accompanied by symptoms which accord with those 
of sudor anglicus, prove nothing, save that the exanthema is not patho- 
gnomonic of this disease, and by no means disprove the fact attested 
to by many trustworthy authorities, that, besides typhus, acute ar- 
ticular rheumatism, puerperal fever, and many other febrile com- 
plaints, there also exists a peculiar sickness characterized by sweating 
and a miliary eruption more profuse than is often observed in any 
other disease. 
That suette miliaire, or the sweating-sickness, should be named 
after one of its prominent symptoms, is quite consistent with the ordi- 
nary practice in the case of a disorder not referable to some simple 
pathological state of a special organ. 
Etiology.-1—Sudor anglicus, beyond a doubt, is an infectious dis- 
ease. Its exclusively epidemic appearance, its independence of the 
action of the weather, and other assignable antihygienic influences, 
as well as the results of the few autopsies which have been made, 
sufficiently warrant our classing it with typhus, the acute exanthe- 
mata, and other disorders which we believe to proceed from infection 
of the organism by a specific and probably organic poison, and which 
diseases are certainly more numerous and varied than they are said to 
be in the schools. Whether the specific poison of the sweating sick- 
ness be reproduced in the person of the patient, and thence be trans- 
mitted to others; or, in other words, whether it be a contagious dis- 
ease, is doubtful. All inoculations with the contents of the miliary 
vesicles, hitherto made, seem to have afforded negative results. This 
fact, as well as its narrow territorial confines, make it seem more prob- 
able that sudor anglicus is not contagious, but that it proceeds from a SWEATING SICKNESS. 
695 
miasma, tliat is, a poison which originates without the body, and 
which is not reproduced within it. 
Regarding the geographical range of sudor anglicus, and the influ- 
ence of the seasons, and other causative agents upon its epidemic oc- 
currence, Hirsch, who has made it the subject of a most thorough 
historical, geographical, as well as pathological study, speaks as fol- 
lows : “ But few diseases have so limited a geographical range. Its 
home is in France, southwest Germany, and Italy, while in the Neth- 
erlands, middle and northern Germany, and latterly in Spain, it has 
only been met with in occasional epidemics. In other parts of Europe, 
and the continents of either hemisphere, it is quite unknown.” Of the 
recorded epidemics, five-sixths broke out in the spring or summer. 
In autumn they were rare, in winter somewhat more frequent, but 
never very extensive. The appearance of sudor anglicus does not 
seem to depend upon any particular atmospheric conditions, and arises 
as often in mild spring weather as during hot summer. Most fre- 
quently epidemics broke out during weather characterized by a 
moderate temperature and remarkably moist atmosphere. Swampy 
ground seemed less favorable to its development than a dry, sterile 
soil. In contrast with many other infectious disorders, sudor anglicus 
is less frequently seen in large, densely-populated cities, than in small 
rural communities, country market-towns, and other similar localities. 
Of the older physicians, Lancisi, and more recently Schonlein, accuse 
the water in which hemp has been steeped, of favoring the develop- 
ment of the sweating-sickness. 
With regard to the conditions in life which, during an epidemic of 
this disorder, have been found to predispose to it, it has everywhere 
been observed that vigorous persons of middle age are peculiarly 
liable to be attacked, and that women, especially those who are preg- 
nant, or in child-bed, or suckling their children, are more prone to it 
than men are. In other respects the mode of life seems to have no 
effect upon the predisposition to the sweating fever. The poor, who 
usually afford the greatest number of victims to epidemics, do not 
suffer from sudor anglicus more than the rich. 
Anatomical Appearances.—Nearly all authorities speak of the 
early appearance and rapid progress of putrefaction of the corpse. 
There are no fibrinous clots in the blood, which is thin and dark of 
color. The cerebral veins and sinuses are full of blood, and the serum 
in the ventricles is sometimes increased in quantity. The mucous 
membrane of the air-passages appears reddened. Somewhat rarely 
pneumonic infiltration is found in the lungs. The assertion that vesi- 
cles similar to those of the skin are found upon the mucous membrane 
of the intestine as yet lacks confirmation. The spleen is swollen and 696 
ACUTE INFECTIOUS DISEASES. 
soft; the liver filled with blood ; the general appearance corresponds 
with that usually revealed upon the autopsy of an exanthematous 
patient. 
Symptoms and Course.—In a few instances the disease is pre- 
ceded by languor, headache, soreness of the limbs, loss of appetite, 
indigestion, and other premonitory but non-characteristic symptoms. 
Much more commonly the disorder breaks out suddenly, without 
any precursory signs whatever. The patient goes to bed feeling per- 
fectly well, and awakes in the night bathed in sweat, the flow of which 
in a few cases is preceded by a slight chill. He complains of a painful 
sense of constriction about the precordium, and of an indescribable ter- 
ror and restlessness. The countenance is reddened, the skin hot, pulse 
frequent, and urine scanty and concentrated; strange to say, thirst is 
not always much augmented. Most patients further complain of head- 
ache, of a feeling of stiffness and tension about the nucha; many also 
suffer from mental confusion, dizziness, roaring in the ears, palpita- 
tion of the heart, and painful spasms of the extremities, like those of 
cholera. These are accompanied by a more characteristic symptom, a 
sense of numbness and pricking of the skin, particularly in the fingers 
and over the regions where the eruption afterward breaks out most 
profusely. The sweating is so copious as to saturate the clothing and 
bedding, and sometimes even the mattress. A peculiar odor has been 
ascribed to this perspiration by some, who compare it to the smell of 
rotten straw or musty vinegar; but more probably the odor proceeds 
from decomposition of the sweat which soaks the bedding. 
At the end of about three or four days, the eruption appears, pre- 
ceded by an aggravation of all the above symptoms, but particularly 
by an increase of the perspiration, and the prickling of the skin. 
Scattered here and there among the spots of the eruption, solitary 
sudamina appear—limpid vesicles filled with sweat, beneath which 
the skin seems so normal that one might mistake them for drops of 
water.* The greater part of the eruption, however, is of the miliary 
form and should rank with the eczemas, since the elevation of the 
cuticle is not the result of mere perspiration, but of an inflammatory 
effusion. The vesicles at first are tolerably transparent, but soon be- 
come pearly and turbid; and according as they are or are not surround- 
ed by an intensely reddened areola they are described as miliaria 
rubra or miliaria alba. Sometimes the effusion accompanying the 
hyperaemia of the sudoriparous glands in miliaria rubra is so slight 
that there are apparently no distinct vesicles, but merely solid nodules 
* To guard against misunderstanding, the term miliaria crystallina should be 
disused. SWEATING SICKNESS. 
697 
{eczema papulatum). The eruption then bears a great resemblance 
to measles. When the effusion is very profuse beneath the cuticle 
the vesicles become so large as to suggest a varicella.—The first ap- 
pearance of the exanthema is upon the sides of the neck and the upper 
part and front of the chest. Thence it spreads to the belly, back, 
arms, and legs; it rarely attacks the face or hairy scalp. The erup- 
tion breaks out either all at once, the whole body becoming cov- 
ered with vesicles within a few hours; or else it comes out in crops, 
one part of the body after another being assailed. The latter is a very 
common form of the eruption. The fresh outcroppings of the rash 
are always preceded by an aggravation of the other symptoms, espe- 
cially of the sweating and pricking of the skin. 
Sometimes there is no eruption at all. Such instances are not 
to be regarded as analogous to the rare cases of scarlatina with- 
out exanthema and of abdominal typhus without intestinal lesion. 
Here the rash seems to depend upon mere sweating; and the 
latter is the real pathognomonic sign of sudor anglicus. Whether 
or not there be also a miliary eruption depends a good deal upon 
the degree of susceptibility of the skin of the individual, just as in 
cases of sun-burn or of mercurial inunction, it depends in part 
upon the activity of the irritant and in part upon the sensitiveness 
of the skin whether or not an eczema solare or eczema mercuriale 
shall ensue. 
When the disease takes a favorable type, the fever and other 
symptoms assume a remittent and sometimes even an intermittent 
form, and about the sixth to the tenth day the sweating begins to 
abate, and no more fresh crops of the vesicles arise. The restlessness 
also ceases, as well as the headache, prickling, and loss of appetite; 
the fever subsides, sleep is tranquil, urine copious, the vesicles dry up, 
and convalescence is established; during which the macerated and 
loosened cuticle exfoliates, sometimes in large sheets, sometimes in 
bran-like scales. 
Occasionally a relapse interrupts convalescence, and runs a course 
like that of the original seizure. The malady may thus drag on for 
weeks, and greatly exhaust the patient, rendering his recovery very 
slow. 
While in many epidemics the favorable type is so much the rule, 
that the majorit}T or even all patients recover, yet there are others in 
which the sudor anglicus, without especial complication, makes many 
victims. It may terminate fatally at any period, death taking place 
suddenly and without warning, either with symptoms of excessive 
dyspnoea, or else of cerebral and cardiac palsy. Sometimes the end 
is preceded by a cessation of the sweating and a fading of the exam 698 
ACUTE INFECTIOUS DISEASES. 
thema. This has been accounted for upon the obscure hypothesis of 
a metastasis of the disease to internal organs. 
The most common complications of sweating-sickness observed 
in the more accurately described epidemics are angina and a diphthe- 
ritic stomatitis, generally termed aphthae. More rarely it is compli- 
cated with bronchitis and pneumonia. In a few of the epidemics 
dysentery was observed instead of the usually obstinate constipation. 
When of very protracted duration, or unusual intensity, then, like 
other tedious and very severe infectious disorders, it develops a 
haemorrhagic diathesis with abundant epistaxis and the appearance 
of petechia, and in women by abnormal bleedings from the genitals. 
Unfortunately, no accurate measurements of the bodily tempera- 
ture during sudor anglicus have as yet been taken. This circumstance 
greatly embarrasses our estimate of the physiological value of the 
symptoms. How, for instance, is the peculiar restlessness to be ac- 
counted for ? Is it due to inspissation of the blood through enormous 
sweating, and upon consequent impediment to its circulation through 
the capillaries of the lungs, as in cholera, with which sudor anglicus 
has been compared ?—Or, is the calorification so much heightened 
during the fever as to occasion a surcharge of carbonic acid which 
cannot be neutralized by respiration ? Indeed, we are forced to the 
inference (owing to the considerable cooling which the skin must 
suffer through evaporation of the profuse perspiration) that the pro- 
duction of heat is much more active in sudor anglicus than in infec- 
tious diseases in which the skin remains dry, always supposing the 
temperature of the diseases to be equal. Cooling of the body by 
evaporation of the sweat may protect the patient from the perils aris- 
ing from too high a temperature of the blood, but not from its over- 
charge with carbonic acid—one of the necessary results of excessive 
calorification; at all events, this would account for the apnoea of 
sweating-sickness. Again, does the supposed danger of checking the 
sweating depend upon the fact that, without the cooling effect of 
rapid evaporation of the sweat, the temperature will reach a point at 
which the brain and heart are palsied ? Such questions must be de- 
ferred until our knowledge of the temperature in sudor anglicus shall 
be made as exact as that of typhus and other disorders. 
Treatment.—Until we shall have more thoroughly investigated 
the conditions upon which the sweating-sickness depends, prophy- 
lactic measures against its invasion and extension are out of the 
question. 
At the outset of the attack an emetic is urgently recommended by 
many. From all reports, however, it is by no means clear that the 
disease has ever been cut short by this means; and we shall CHOLERA ASIATICA. 
699 
therefore do well to confine its exhibition to cases which commence 
with well-marked gastric disturbance. Its administration, however, 
at the beginning of a sudor anglicus, during which the bowels are 
generally confined throughout, is not so hazardous a step as it would 
be at the commencement of a typhoid fever, when an emetic might 
seriously aggravate the diarrhoea which always sets in. 
The various drugs which have been deemed specifics in certain 
epidemics have invariably failed in others, and quinine alone seems to 
have maintained its reputation as an antipyretic. It may be given in 
doses of twelve or fifteen grains daily, not only when the type of the 
malady is decidedly remittent or intermittent, but even when the type 
is continued and the temperature exceeds a certain height. The fact 
that the danger of the sweating-fever is greatly dependent upon the 
height of the temperature has already forced itself upon the attention 
of the best observers, even without the use of the thermometer. 
When there is no occasion to use quinine, it is best to prescribe acids, 
especially muriatic or phosphoric acids properly diluted. 
An important step in the treatment of sudor anglicus dates from 
the time when the practice ceased of keeping the patients immod- 
erately warm, for fear that the sickness should “ strike in.” If my 
opinion be correct, namely, that the production of heat is intensely 
active, but that the danger of an overheating of the body is averted 
by evaporation of the sweat, then it is plain that it would be danger- 
ous to envelop the patient in thick blankets, beneath which the air is 
so saturated with moisture as to impede further evaporation. Light 
clothing and free ventilation are imperatively indicated. At the same 
time the patient must not be set in a draught, lest he take cold, the 
danger from which is greater in sudor anglicus than in kindred affec- 
tions, owing to the profuseness of the perspiration. 
CHAPTER XV. 
CHOLERA ASIATICA. 
Etiology.—It is possible, and even probable that, where cholera 
is endemic, it results from miasm. Whether this miasm, the cholera 
germ, develop in India, on diseased rice or not, and whether or not 
the disease rage in India, more especially in years when circum- 
stances particularly favor the increase of these vegetable germs, among 
us, it is not indigenous; but all the cholera epidemics occurring among 
us are due to the exotic parasite being brought to us by cholera pa- 
tients, and finding for a time a suitable soil and favorable circum- 700 
ACUTE INFECTIOUS DISEASES. 
3tances for increasing; with us cholera is never miasmatic. (I shall 
not dwell on the question whether Hallier and Klobb, who have found 
numerous fungi in the dejections of cholera patients, have actually 
discovered the cholera germ, for I do not feel competent to decide it.) 
Cholera is not contagious in the strict sense of the word, for a healthy 
person never takes cholera from contact with a patient having that 
disease. (My experience in the first cholera epidemic that I saw, 
where I wrapped many naked patients in blankets, and often held 
them in my arms for some time, made me a decided anti-contagionist, 
and I took this ground in my first publication, some twenty years 
since.) But, as the word contagion is universally used in the sense, 
that diseases which are transferred from sick to healthy persons are 
contagious, and as this is very decidedly the case in cholera, we must 
class cholera among the contagious diseases. The vehicle of conta- 
gion is not, as in the acute exanthemata and exanthematic typhus, the 
exhalation from the skin and lungs, but the dejections of cholera pa- 
tients. It has been certainly proved that fatal cholera epidemics have 
broken out in places previously free from it, because some traveller, 
having cholera germs in his intestines, has used a privy, or that the 
dejections of a cholera patient have been emptied into a privy, fre- 
quented by other persons. In 1848, a transport of recruits from Stet- 
tin, where cholera was raging, came to Magdeburg; two of these re- 
cruits sickened of cholera the night of their arrival. They were imme- 
diately taken from their quarters to the military hospital, which was 
some distance off, without coming in contact with the inhabitants. A 
few days after, the cholera broke out in the house, and in the street 
where they had passed the night. The fatal epidemic did not spread 
to the rest of the city for some weeks. In large, thickly-populated 
cities, where there are numerous cases of the disease, the extension of 
an epidemic is more difficult to follow than it is in small, thinly-settled 
towns where the number of cases is limited. A small epidemic in Greifs- 
wald gave me an excellent opportunity for observing the spread of 
cholera. In almost every case I could find that the patient had used 
the privy of some house containing cholera patients, or one whose cess- 
pool communicated with that of the privy of affected houses, or that 
they had used a privy in common with persons from these houses who 
had diarrhoea. Since it has been known that cholera is only trans- 
ferred to healthy persons through the dejections of cholera patients, a 
series of previously enigmatical and apparently contradictory observa- 
tions, concerning the spread of the disease, have been satisfactorily ex 
plained. "YVe may readily understand that cholera should spread from 
place to place more rapidly than it formerly did, since in these days of 
railroads and steamboats people travel more quickly than thev used to CHOLERA ASIATICA. 
701 
do. It is no longer surprising that cholera should follow the routes of 
travel, that it should spread sometimes with the wind, sometimes 
against it; sometimes from west to east, again from east to west. 
The long leaps that cholera epidemics often make are simply due to 
the fact that travelling cholera patients only infect those places where 
they leave their dejections, while all intervening places escape. If 
the cholera germ were contained in the dejections of those patients 
only who suffered from the severest form of the disease (cholera as- 
phyxia), as they cannot travel, long springs of cholera epidemics could 
only occur when persons infected with cholera poison travelled during 
the period of incubation, and the disease did not fully develop in them 
till they had reached some place distant from their previous residence. 
But besides such cases, among which are the cases in Magdeburg 
above mentioned, numerous examples show that a person suffering 
from simple choleraic diarrhoea, and who does not feel very sick at the 
time, nor even become so later, contains the germs of cholera, so that 
he may infect a privy, and thus start an epidemic. 
Against the view that cholera was spread by the evacuations of 
the patients, it has been urged among other things that in some cases 
persons who had swallowed the dejections of cholera patients escaped 
the disease, and that attempts to give animals cholera, by introducing 
into their bodies the contents of the intestines of patients who had 
died of cholera, or the evacuations of cholera patients, had generally 
failed. These facts cannot be denied. To make them agree with 
those above mentioned, it has been suggested that the recent dejec- 
tions of cholera patients do not contain the cholera germ in the stage 
of development necessary to infection, nor in the necessary amount, but 
that the dejections only become dangerous when the germs of the dis- 
ease are placed under circumstances favorable to their development 
and increase, by admixture with decomposing animal substances. This 
hypothesis is very plausible, and has been generally accepted, as it is 
supported by numerous facts ; for, while, according to the observations 
of Thiersch, recent cholera dejections were not dangerous for animals, 
feeding them with old dejections of the same sort induced cholera. 
Experience has taught that persons who wash the clothes of cholera 
patients, after they have lain for some time, and persons who change 
the bed-clothes a few days after the death of the patient, are more apt 
to be infected than those who place the bed-pan under the patient, oi 
replace the wet sheets by dry ones. It is most dangerous for the per- 
sons in a house, if the evacuations of a cholera patient are emptied 
into a privy filled with excrement, into a cess-pool, or thrown on a 
dung-hill. At such places the cholera germ seems to find circum- 
stances most favorable to its development and increase. 702 
ACUTE INFECTIOUS DISEASES. 
When cholera has been introduced into a place, it sometimes hap- 
pens that only those persons are attacked who live in the same house, 
or use the same privy. It has even been observed that, in certain 
cities where cholera has been repeatedly introduced, it has always 
been limited to these house epidemics. But, in other cases, the dis- 
ease spreads from the house where it was introduced, to neighboring 
streets, large portions of the city, or even over the whole vicinity. 
This may either happen every time the cholera visits the place, or only 
in certain epidemics, while in others this extension does not occur. 
We are indebted to Pettenkofer for the discovery that porosity of the 
soil, enabling the contents of the privies and cess-pools containing the 
cholera germs to freely permeate and soak the ground for some dis- 
tance around with this dangerous mixture, favors the rapid extension 
of the disease, while the opposite quality to some extent protects from 
such an extension. We are also indebted to Pettenkofer for the dis- 
covery that the occasional predisposition of a place to an extension of 
cholera depends on the excrements containing the germs, and per- 
meating the soil, being exposed to circumstances favorable to decom- 
position. As we have already shown, when speaking of the etiology 
of typhus, moisture of the soil plays a very important part among 
these circumstances, but it is not the only one. There is no doubt 
that the conditions for decomposition may be peculiarly favorable 
when a very moist soil suddenly dries to a certain extent; and it can- 
not be denied that the sudden fall of the water of the soil may prove 
very dangerous for the spread of cholera. The opposing facts, which 
have also been proved, show that the number of cholera cases may in- 
crease independently of the sudden fall of the water in the soil, and 
that it is one-sided to regard the fall of the water as the sole cause for 
favoring decomposition of the excretory matters, mingled with cholera 
germs, which have soaked through the soil. 
The cholera poison is rarely taken into the system by drinking 
water containing it. As a rule, it undoubtedly enters the nose and 
mouth with the air, and is swallowed with the saliva. Using infected 
privies is so dangerous, because they are the favorite lurking-places 
for cholera germs, and the gases arising always contain dust-like par- 
ticles. The poison passes from the privy into the atmosphere of the 
house, and we must agree with Piermer in considering the dwellings 
as more liable than the inhabitants to infect. Next to the soaking of 
tne infecting substance through the soil, the disease appears to spread 
from one house to another, chiefly through the gutters and drains. 
The susceptibility to cholera poison is very extensive. No age, 
sex, or constitution, escapes it. When the cholera poison spreads over 
the whole city, almost every one suffers from it; even those not a6 CHOLERA ASIATICA. 
703 
feoted with the severer forms have some troubles, apparently depend- 
ing on the weaker action of the poison. Certain influences appear to 
increase the predisposition to the severer forms of the disease, or to 
diminish the resisting power of the organism to the action of the poi- 
son. Chief among these are errors of diet, emetics, and laxatives, 
catching cold, and other debilitating influences. It is true, foolish 
people seek to excuse their excesses at the time of cholera epidemics 
by saying that the mode of living can have no effect in inducing cholera, 
because persons who lead the most proper lives are attacked by and 
die of the severest forms of the disease. Even if this reasoning was 
meant in earnest, it does not require refutation. Whoever is exposed 
to a poison, whose action kills many persons, while others recover 
from it, is foolish to subject himself to injurious influences which lessen 
his chances of recovery, even if the avoidance of these injurious influ- 
ences gives no guaranty for a favorable termination. The number of 
cholera patients taken into the Paris hospitals is said to be one-eighth 
greater on Monday than any other day. In the Magdeburg epidemics, 
the commencement of a fair, which gave opportunity for excesses of all 
sorts, has repeatedly been observed to have a very unfavorable influence 
on the number of cases and deaths. 
For the numerous important historical and geographical data that 
have been collected concerning cholera, since 1830, when it first ap- 
peared in Europe, I must refer to special works where the principal 
epidemics are fully described; for imperfect extracts from them would 
be unsatisfactory. 
Anatomical Appearances.—Bodies of patients who have died 
of cholera remain warm a long time; a post-mortem increase of the 
bodily temperature has sometimes been observed. A second pecu- 
liarity of these bodies is the occasional contraction of certain muscles 
after death, by which the extremities, especially the fingers, are moved, 
and change the position they had just after death. The movements 
of the fingers that I have actually seen, and the changed position in 
which I have found the bodies a few hours after leaving them, have 
always made a very disagreeable impression on me. 
If death has occurred at the height of the disease, the appearance 
of the body is characteristic. We usually find it in a position to which 
the clinched hands, variously bent limbs, and swollen muscles, give a 
peculiarly threatening appearance (“ fighting attitude The rigor 
mortis is hard to overcome. The face is often so distorted as to be 
hardly recognizable. The eyes are deep in the orbit, and are sur- 
rounded by wide, blue rings; the eyelids are half closed; the uncov- 
ered portions of the eyeballs are dry as parchment, the nose is pointed 
and projects far bejmnd the sunken cheeks. The lips are bluish, 704 
ACUTE INFECTIOUS DISEASES. 
sometimes deep blue. The other parts of the body also have a more 
or less marked cyanotic appearance. This is most apparent in the ter- 
minal phalanges of the fingers and toes. The skin of the fingers is 
often shrunken, and wrinkled like that on the fingers of a washer- 
woman who has had her hands in the suds all day. On opening the 
bodies we remark the hardness and dryness of the subcutaneous con- 
nective tissue, and the dark-red color of the muscles. The blood is 
thick, of the color of huckleberry-juice, and contains a small amount 
of soft, black clots; it is collected in the right heart and veins, while 
the arteries and left heart are often perfectly empty. The cerebral 
sinuses and veins of the meninges are distended with dark blood, while 
the cerebral substance is dry and hard. The pericardium does not con- 
tain a trace of serum, its inner surface feels pasty, and is often covered 
with ecchymoses; the muscular substance of the heart is contracted, 
hard, and of a dirty-red color. The surfaces of the pleura, like those 
of the pericardium and other serous membranes, are covered with an 
adhesive layer. They also often contain small ecchymoses. On open- 
ing the thorax, the lungs collapse very quickly and completely, appar- 
ently because the empty, dry bronchi offer no opposition to the escape 
of air from the alveoli. On cutting into the lungs, we find them re- 
markably dry, and free from hypostasis and oedema. The relaxed, 
baggy small intestine has a peculiar rosy appearance, even before it is 
opened, while the large intestine preserves its natural color. On open- 
ing the intestines, quantities of a colorless or faintly-colored fluid, con- 
taining white flocculi, often escape ; this liquid exactly resembles the 
“rice-water discharges” of cholera patients, which we shall more 
minutely describe. I have found the greatest amounts of transuda- 
tion in the intestines, in cases of so-called cholera sicca. The mucous 
membrane of the small intestine is finely injected, especially near the 
valve, and growing less so as we pass upward. The vascularity is 
occasionally accompanied by greater or less escape of blood into the 
tissue, and on the free surface of the mucous membrane. Then the 
mucous coat shows numerous, often extensive, ecchymoses, and the con- 
tents of the intestines appear reddened from the admixture of blood. 
Sometimes the small intestine is pale, and neither vascularity nor ecchy- 
moses can be found; but since we find the intestines filled with watery 
transudations even in such cases, and as these transudations come from 
distended, not from empty vessels, it follows that the pale hue of the 
mucous membrane is to be regarded as a post-mortem appearance. It 
is a matter of daily experience for visible mucous membranes that have 
been very hyperasmic, and secreted abundantly during life, to become 
pale after death. The mucous membrane and whole intestinal wall are 
swollen and relaxed from oedematous infiltration. As a rule, also, the CHOLERA ASIATICA. 
705 
solitary and Payer's glands are swollen and distended. The individual 
follicles may attain the size of a hemp-seed. In consequence of this 
swelling of the intestinal glands, the inner surface of the bowel looks 
as if sprinkled with isolated and conglomerated granulations. Occa- 
sionally certain follicles of the patches burst, and then the surface has 
a sieve or net like appearance {plaques d surface reticulee). The most 
important appearance in the intestine is the great loss of epithelium 
The intestinal villi are stripped of their protecting envelope; occa 
sionally, at certain spots, the epithelial covering is only elevated by a 
serous effusion, and is still loosely adherent to the villi; but in most 
places it is already detached, and lies on the intestinal Avail as shreds 
of mucus, or forms the whitish flocculi already spoken of as floating in 
the transudation. The comparison of the intestine in cholera to a por- 
tion of the skin from which the epidermis has been removed by a blis- 
ter, or by boiling water, is very correct; and, if it be remembered thai 
the denuded portion of intestine is quite extensive, it will be diflScuH 
to understand why some observers speak of a “ disproportion ” be- 
tween the anatomical changes in the intestinal canal and the severe 
symptoms observed during life. The large intestine does not show 
any constant changes, and there is but little alteration in the jejunum. 
The gastric mucous membrane is more or less reddened by hypenemia 
and ecchymosis; its tissue is swollen and relaxed from serous infiltra- 
tion. The liver is of normal consistence and pale; on being incised, 
only a small amount of thick, huckleberry-colored blood flows out 
slowly from the large vessels. The gall-bladder is almost always dis- 
tended with thin, brownish or greenish bile. The spleen has no con- 
stant change. In the first stages of cholera the kidneys are appar- 
ently normal, except an excessive venous liyperaemia; in other cases, 
even at this time, certain places, especially in the pyramids, are whit- 
ish ; and at these points, on microscopical examination, we find the 
uriniferous tubules filled with cloudy, swollen epithelium and fibrous 
exudation. The mucous membrane of the urinary passages is covered 
with mucous and epithelial masses, the bladder is contracted, and 
almost always entirely empty. Hence we see, when death occurs at 
the height of the disease, the characteristic changes consist chiefly in 
extensive catarrh of the intestines, accompanied by detachment of the 
epithelium and copious transudation, in decided thickening of the 
blood and excessive venous liyperoemia of the kidney. 
When death occurs during the stage of reaction, or so-called cholera 
typhoid, the anatomical appearances differ in some respects from the 
above. Then the limbs are less constantly contracted, rigor mortis is 
less marked; the teeth and gums are often covered with a dirty coat- 
ing, the cyanosis has disappeared or is slight. The subcutaneous con- 706 
ACUTE INFECTIOUS DISEASES. 
nective tissue and muscles are moister; the blood is more fluid and 
less dark. The cerebral membranes are usually injected; not unfre- 
quently there is a considerable amount of fluid in the meshes of 
the pia mater and m the lateral ventricles; the cerebral substance 
itself is moister ; the right heart is usually overfilled, the endo- 
cardium and lining membrane of the large vessels is greatly infil- 
trated. In this stage the lungs are no longer dry, but are vascular, 
and are often the seat of extensive oedema and hypostasis, and not 
unfrequently also of lobular or lobar pneumonia, or of haemorrhagic 
infarctions. The outer surface of the small intestine has lost its rosy 
tint; the contents are colored with bile. In some cases the epithelium 
is replaced, and no disturbances of nutrition are discoverable in the 
mucous membrane; but it is often the seat of a typical diphtheritic 
inflammation, which changes more or less extensive patches of the 
mucous membrane into brown, dry sloughs. This secondary diphthe- 
ritis occurs not only in the small intestine, but often extends to the 
large intestine ; it may also attack the gall-bladder, vulva, and vagina. 
The liver and spleen are not always changed, but are usually very 
hyperaemic. Not unfrequently rupture of the spleen has been found. 
The kidneys also are vascular, and often show the signs of acute 
croupous inflammation. The bladder contains more or less urine, 
which is usually albuminous. 
Symptoms and Course.—Almost every one exposed to cholera 
poison complains of light oppression in the prcecordium, rumbling in 
the bowels, and a feeling of impending diarrhoea. These symptoms of 
slight indigestion, which unmistakably result from the action of the 
poison, apparently only increase where the infection is rather intense, 
or the organism inclined to a more or less severe disease. It has also 
been attempted to refer the feelings of terror, the fainting-fits, cramps 
in the legs, and other disturbances of innervation occurring during a 
cholera epidemic, to the action of cholera poison ; and among the laity 
the idea has become so firmly implanted, that the fear of cholera is 
very dangerous, or is even the commencement of the disease, that 
during a cholera season there are plenty of persons who dread having a 
fear of the cholera (!). I regard this belief as groundless, and think that 
the above symptoms are solely the result of the psychical impressions 
induced in excitable persons, by the terrible disease, the accounts of 
sickness, the numerous and unexpected cases of death. The same, or 
very similar symptoms are experienced by the inhabitants of a bom- 
barded town; and, although timid persons show no immunity to chol- 
era, they are not more frequently attacked than unterrified persons 
are. According to my observation, cholera attacks never begin with 
a feeling of terror, fainting, cramps in the legs, etc., although it often CHOLERA ASIATICA. 
707 
happens that these symptoms urge the patient to seek medical aid. 
If we examine such cases carefully, we always find that they have 
been preceded by diarrhoea, to which the patient paid no attention. 
Some observers estimate the period of incubation at from one to 
three days; others say from eight to fourteen. We rarely have the 
opportunity of exactly determining the time between the action of 
the poison and the outbreak of the disease. In a few cases that I 
observed in Greifswald, in 1859, as well as in a number observed by 
Dr. Grttttner, then assistant physician in the Medical Polyclinic, in a 
small town on the Mecklenburg boundary, where the limits of the in- 
fection could be pretty accurately determined, the period of incubation 
was certainly not less than thirty-six hours, and not more than three 
days. 
The mildest form of cholera is a simple diarrhoea, which is not ac- 
companied by colicky pains or tenesmus, and causes no constitutional 
or other disturbance, except a moderate degree of depression and re- 
laxation. The evacuations follow each other more or less closely; 
they are very copious and watery, but have neither lost their odor nor 
color. These cases do not appear on the official lists as cholera; but, 
although the police do not consider them as such, science should do so. 
This is shown: 1. By the large number of cases of diarrhoea occurring 
in cholera times, although almost all sensible people carefully avoid 
errors of diet, catching cold, and other sources of injury. 2. The great 
obstinacy of these diarrhoeas, and the slight efficacy of opium against 
them. 3. The well-known transportation of cholera by persons suffer- 
ing from these diarrhoeas. 4. But especially the numerous transfor- 
mations of simple “ cholera-diarrhoea ” into the severest forms of the 
disease. Many patients, especially of the poorer classes, worried by 
a diarrhoea that would not give way to domestic remedies, go to the 
doctor’s house for a prescription at noon, and in the evening lie cold, 
pulseless, and cyanotic, in an almost hopeless state. The investiga- 
tions concerning cholera, made during the late epidemic, especially in 
the hospitals, which are otherwise very serviceable and valuable, have 
made some believers in the false views concerning the significance of 
the intestinal affection in cholera, which I combated twenty years ago 
It has again been forgotten that very many cholera patients, who do 
not seek admission into hospital, have no symptoms but the profuse 
diarrhoea. I consider it much more important to determine the fre- 
quent occurrence of a gradual transformation from simple cholera diar- 
rhoea to cholerine, and to malignant cholera, and to prove the iden- 
tity of these three forms, than to seek for pathognomonic signs of epi- 
demic cholera. 
The transformation from the mildest forms of cholera to the severest 708 
ACUTE INFECTIOUS DISEASES. 
is formed by those cases where violent vomiting accompanies the diar- 
rhoea, where the discharges acquire the well-known “ rice-water ” ap- 
pearance, but without the occurrence of the paresis of the heart and 
thickening of the blood, which constitute the terrible symptoms of 
cholera asphyxia. This still mild form, or, rather, these comparatively 
low grades of the disease, which, however, often increase to the highest 
grades, have been distinguished from cholera diarrhoea on the one hand, 
and from cholera asphyxia on the other, by the names “ erethitic chol- 
era,” or “ cholerine.” The discoloration of the dejections depends 
chiefly, or entirely, on their excessive dilution by the quantities of 
fluid transuded into the intestine; hence the more copious the pas- 
sages, and the more rapidly they succeed each other, the more com- 
pletely and speedily they lose their brown color and fecal odor. Oc- 
casionally all the contents of the intestine are passed at the first evac- 
uation. In such cases, even after the second movement, the dejections 
consist of an almost colorless and odorless fluid, holding in suspension 
more or less white flocculi. We must not conclude, from the lack 
of color in the passages, that the formation or excretion of bile has 
ceased; for even if the bile be produced in normal amount, and poured 
into the intestines, it can have no great effect on the color of the large 
quantity of liquid. Chemical and microscopical examinations of chol- 
era stools have shown that the serum, transuded from the intestinal 
capillaries, contains little albumen, but plenty of salts, especially of 
chloride of sodium, and that the white flocculi floating in the serum 
rarely consist of perfect cylindrical epithelium, but generally of its re- 
mains, in the shape of fine, loose nuclei, with coarse and fine granular 
masses embedded in a mucous basement substance, and of round, nu- 
cleated, coarse, or finely-granulated cells (Bruberger). Cholera-stools 
occasionally contain crystals of triple phosphate, remains of food, para- 
sites, vibriones, and fungi. Lastly, the dejections sometimes contain 
blood-corpuscles; then the fluid is somewhat richer in albumen, which 
has escaped from the capillaries along with the blood. These charac- 
teristics of cholera-stools, which all authors consider pathognomonic, 
fully explain the symptoms of cholera. We are justified in comparing 
the effects induced in the bowels by cholera poison, with those pro- 
duced on the skin by a blister. In both cases the protective covering 
is removed, and there is an excessive transudation from the capillaries. 
It only depends on the intensity, and particularly on the extent, of the 
process, whether symptoms of paralysis of the heart develop, and 
whether the loss of water from the blood shall prove dangerous. Case? 
where the heart’s action is but little weakened, and where the loss of 
water from the blood is to some extent replaced, correspond to chole- 
rine. When the characteristic cholera stools begin, the thirst already CHOLERA ASIATICA. 
709 
caused by the simple cholera diarrhoea is decidedly increased. This 
torturing symptom hardly requires explanation, as it always follows 
loss of water from the blood, whether induced in fevers by the increase 
of insensible perspiration, by sweating, or by increased excretion of 
urine. In cholerine the loss of water from the blood is greater, and 
consequently the thirst is more intense than in cholera diarrhoea. The 
characteristic evacuations, severe thirst, weariness, and depression, are 
usually accompanied by a very annoying symptom, which it is difficult 
to explain; there are occasional spasmodic contractions of certain mus- 
cles, especially of the calves of the legs, which last from half a minute 
to a minute, and are very painful. These cramps are not pathognomo- 
nic of Asiatic cholera, however, for they also occur in severe attacks 
of cholera morbus. In favorable cases, the discharges gradually be- 
come less frequent and copious; the bile poured into the intestines 
again suffices to color the passages. Finally, the diarrhoea ceases, and 
the patient begins to recover; but convalescence is always slow. In 
other cases the disease relapses after it appeared to be doing well, and 
then becomes dangerous. Lastly, in still other cases there is no im- 
provement, the cholerine changes to cholera asphyxia. 
Cholera asphyxia depends on the highest development of the intes- 
tinal affection. At least all its characteristic symptoms may be directly 
referred to the severe and extensive disease of the intestinal mucous 
membrane and to the copious exudations from the intestinal capil- 
laries. The accounts of persons dying during cholera epidemics with 
the symptoms of pulselessness, cold skin, cyanosis, etc., who had had 
neither diarrhoea nor vomiting, and in whose intestines no characteristic 
changes were found, have become more rare in late epidemics; so that 
at present almost all experienced physicians deny the occurrence of 
“ cholera sicca,” which was generally considered as proved in the first 
cholera epidemics. But the case is different in regard to the views 
about the dependence of the other symptoms of asphyctic cholera on 
the intestinal disease. Many physicians, who consider the latter as 
constant, do not refer the other symptoms of cholera to it, but think 
that the intestinal disease in Asiatic cholera has no more effect on the 
general appearance of the disease than the bowel lesion in abdominal 
typhus has on the symptoms of that affection. We shall again refer 
to the erroneousness of this view. In many cases asphyctic cholera 
develops from a cholera diarrhoea or a cholerine that has existed for 
several days; but, fully as often, the symptoms to which this form owes 
its name come on a few hours after the first cholera passage. By this 
all the contents of the intestines seem to be evacuated; the patients 
are astonished that the vessel which they used is nearly filled, but do 
not suspect that they are in great danger and neglect to seek aid for 710 
ACUTE INFECTIOUS DISEASES. 
the simple and painless diarrhoea, while previously they have perhaps 
worried the physician about every insignificant colicky pain. The first 
passage is soon followed by a second, this by a third, and so on till a 
great number have occurred at short intervals. The evacuations are 
very copious and fluid, and, as they lose their fecal odor and become 
colorless, they soon acquire the rice-water appearance. Even after the 
second or third passage, many patients feel very weak and depressed, 
or they may be so faint as to be unable to move from the close-stool to 
the bed without assistance ; at this time, also, painful contractions of 
the muscles of the leg usually begin, and a longing for drink, which 
increases with every passage. The more the patients drink, the sooner 
the diarrhoea is accompanied by vomiting, by which at first merely the 
contents of the stomach, but, after a time, large quantities of a pale, 
yellow liquid, are evacuated. The patient rapidly grows weak, the 
voice loses its power (vox cholerica), the evacuations are passed in- 
voluntarily, the secretion of urine ceases, the painful muscular cramps 
increase and return more frequently; the torturing thirst cannot be 
allayed, and these symptoms are accompanied by a feeling of great 
anxiety and oppression, which, together with the cramps in the legs, 
forms the most painful symptom of cholera. Meantime the appearance 
of the patient has become frightful; the eyes are sunken, the nose 
pointed, the cheeks hollow (facies cholerica); the skin of the hands is 
wrinkled like that of a washerwoman who has washed all day; if it be 
picked up in a fold, the fold remains for a time and disappears slowly. 
The lips, extremities, and genitals, grow blue; the whole surface some- 
times assumes a bluish or grayish look. The radial pulse, which be- 
comes smaller after the first passages, frequently cannot be felt an hour 
after the commencement of the cholera attack. Finally the pulse dis- 
appears from the carotids also, the impulse and sounds of the heart 
become indistinct, and, while the circulation grows more imperfect, 
while less warm blood reaches the periphery, the temperature becomes 
corpse-like, particularly at the uncovered parts (stadium algidum). 
Rarely the patients complain of headache, more frequently of black 
spots before the eyes, noises in the ears, or dizziness. The mind is 
not cloudy, but most patients are apathetic; while they complain of 
pain and oppression they are indifferent to the danger, and answer in- 
attentively and slowly. Reflex excitability is diminished; in severe 
cases even irritating vapors induce neither coughing nor sneezing; the 
patients do not wink if the finger be approached to the conjunctiva, 
and do not wince if we dash water on them. It cannot be wondered 
at, that in the first cholera epidemics even those physicians who re- 
garded rice-water passages as pathognomonic of cholera, who ordered 
careful anti-diarrhceic regimen for their patients, and treated every diar- CHOLERA ASIATICA. 
711 
rhcea energetically, should not have gone a step further, and recognized 
the intestinal lesion as the starting-point of the other symptoms and 
as the true source of danger. The rapidity with which the patients 
changed, the great disturbance of all the functions, the pulselessness, 
coldness, suppression of urine, vox cholerica, facies cholerica, lack of 
contractility in the skin, and the fact that many patients were received 
into the hospital in this state, who had no diarrhoea or vomiting after 
their reception, and who did not always tell that they had previously 
had violent evacuations, led to untenable hypotheses. It is true it was 
acknowledged, that cholera poison led to an affection of the intestinal 
canal; but at the same time it was accused of having a directly per- 
nicious effect on the blood, nervous system, and more or less on all the 
organs and tissues, the intestinal canal escaping altogether sometimes. 
Cases where the algid stage develops in a few hours are certainly less 
suited to explain the dependence of all the symptoms on the intestinal 
affection than are those where it develops in the course of several days. 
From the identity of the symptoms that finally result, however, we 
cannot doubt that the rapid cases are to be explained in the same 
way as the others. The immediate result of acute intestinal catarrh, 
of the excessive transudation from the intestinal capillaries, and of the 
diminished absorption of the fluid drank, is a thickening of the blood, 
its sudden impoverishment in water and salts. As long as the disease 
is moderate, it has no particular effect on the circulation and distribu- 
tion of blood through the body; only the thirst is increased and the 
secretion of urine diminished. But, as a burn of the second order is 
free from danger as long as it affects only a limited portion of the sur- 
face, while it becomes very dangerous if widely extended, and as we 
dare not deprive the entire surface of its epidermis by blisters, so an 
extensive and intense choleraic affection of the intestines induces the 
severe and threatening symptoms that characterize the algid stage. 
The heart’s action is palsied, the blood, deprived of its water, eagerly 
takes the fluid from the interstices of all the tissues. Hence the tis- 
sues all become dry and diminished in size; the nose becomes pointed, 
the cheeks hollow, the eyes sink into the orbit, the skin of the fingers 
shrivels, and, when pinched up, stands in folds. Even pathological 
collections of fluid, which had previously resisted all treatment, effu- 
sions in the pleura, joints, etc., are absorbed. Moist eruptions and 
ulcers acquire a parchment-like surface. In spite of the patient’s 
drinking constantly, the loss of fluid so far exceeds the supply that 
he may lose one-fifth of his weight in a few hours. The thicken- 
ing of the blood explains the drying up of all the secretions of the 
saliva, tears, sweat and urine, just as well as it does the absorption of 
the interstitial fluids; the blood actually does not contain the material 712 
ACUTE INFECTIOUS DISEASES. 
for these secretions. In the suppression of urine, however, the stag- 
nation of the circulation also plays an important part. The feebleness 
of the heart’s action, which causes the weakness and indistinctness of 
the impulse and tones of the heart, the diminution and disappearance 
of the pulse in the radial arteries, and even in the carotids, appear to 
depend chiefly on the depressing influence that severe acute disease, 
especially of the abdominal organs, has on the organic nervous system, 
and particularly on the nerves of the heart. Immediately after the 
perforation of an ulcer of the Stomach I have often seen loss of pulse* 
cyanosis and coldness of the extremities, and in one case, already men- 
tioned, perforation of the duodenum, was diagnosed as cholera sicca. 
Such cases, where there could not be the slightest suspicion of an in- 
fection, show that the hypothesis that the cholera-poison poisons the 
sympathetic, is untenable. On the other hand, it is not improbable 
that the stagnation of blood in the capillaries of the heart’s substance 
has something to do with the paralysis of that organ. We know that 
blood can only pass freely through the capillaries wrhen the blood-cor- 
puscles are separated from each other by a sufficient amount of inter- 
cellular fluid. Hence a loss of wrater from the blood, such as occurs in 
cholera, must hinder or even arrest the circulation in the capillaries; 
and, if the blood in the capillaries of the heart stagnate, according to 
all physiological and pathological experience, paresis of the heart is 
the inevitable result. The cyanosis that occurs in the algid stage of 
cholera depends on the same cause as that occurring in other diseases, 
on an abnormal distribution of the blood—the arteries, which receive 
no blood from the heart, contract and press their contents into the 
capillaries and veins; but the collection of the blood in these vessels 
causes very great cyanosis in cholera, because the blood is so concen- 
trated, and hence is relatively rich in colored corpuscles, and because, 
from the retardation of the circulation, it has become so venous in 
character, and consequently very dark. If an attempt be made to 
bleed in the algid stage, as was often done in the first epidemics, a 
thick, dark stream springs from the swollen vein, but no more blood 
follows the first spirt, the stream soon ceases, and then it is difficult to 
bring out even a few drops by pressure and rubbing. As the circula- 
tion is reestablished, the cyanosis rapidly disappears, although the 
blood still remains of a dark, huckleberry color. As early as 1848, in 
my pamphlet, “Die Symptomatische Behandlung der Cholera,” I 
showed that the cyanosis and asphyxia did not depend exclusively on 
the thickening of the blood, but was mostly due to the paralyzing 
influence of the extensive intestinal disease on the sympathetic nerve. 
The correctness of this view is supported by the frequently rapid dis- 
appearance of the cyanosis, etc., by its ceasing before the thickening CHOLERA ASIATICA. 
713 
of the blood could possibly be remedied by the absorption of liquid. 
The stagnation of blood in the capillaries of the lungs, induced by the 
paralysis of the heart and thickening of the blood, explains one symp- 
tom, for which I could give no explanation in 1848, that is, the feeling 
of anxiety and oppression, which is rarely absent in the algid stage. 
The change of the blood in the pulmonary capillaries is just as neces- 
sary for the respiratory act as the change of air in the air-cells ; and 
stagnation of the circulation induces the feeling of want of air and 
oppression, just as is done by obstructions in the bronchi and alveoli, 
which impede the entrance and exit of air. The very slight amount 
of carbonic acid in the air expired by cholera patients shows that, in 
spite of the extensive movements of the chest and the unimpeded en- 
trance of air to the air-cells, respiration is imperfectly performed. 
Lastly, the complete arrest of the secretion of urine in the algid stage, 
and its diminution even in cholerine and cholera diarrhoea, are easily 
explained. "We know that the amount of urine secreted depends chiefly 
on the amount of lateral pressure in the glomeruli of the Malpighian 
capsule; we have already explained, that in heart and lung diseases, 
which induce imperfect filling of the heart and arteries, the secretion 
of urine is diminished; hence it is not strange that the urine should 
be suppressed in the algid stage of cholera, where the heart’s action is 
reduced to a minimum, and the pulse cannot be felt even in the large 
arteries. The low temperature of the periphery of the body appears 
partly due to the diminished production of warmth, partly to the 
diminished supply of warm blood to the skin (from the weakened ac- 
tion of the heart). 
Cholera asphyxia runs a very acute course. Many patients die in 
six, twelve, or twenty-four hours. The algid stage rarely lasts longer 
than two days. The evacuations often cease some time before death, 
and we must be careful about regarding this as a favorable sign, as it 
is not due to cessation of the transudation, but to paralysis of the in- 
testinal muscles. On the contrary, patients in whom the evacuations 
continue for a long time recover more frequently than those in whom 
they cease suddenly. It would be wrong to decide from this fact that 
an excessive and long-continued transudation into the intestine had a 
favorable influence on the course of the disease, or was at least unim- 
portant. It would be much more correct to interpret the fact thus: 
In cholera, the occurrence of paralysis of the intestines is one of the 
most unfavorable symptoms, and the continuance of the evacuations 
shows that the intestines are not yet paralyzed, and so justifies a more 
favorable prognosis. The death of the patient is a gradual “ going 
out; ” the rattling in the throat especially, which takes place shortly 
before death in most diseases, is absent. In favorable cases the pas- 714 
ACUTE INFECTIOUS DISEASES. 
sages become fewer and less copious, and the liquids taken into the 
stomach are no longer vomited. The first signs of improvement, which 
always introduce the change in the disease, are soon followed by symp- 
toms which show that part of the liquid taken is absorbed, and that 
the blood is consequently thinned. The capillary circulation is re- 
stored, the pulse returns to the carotids, then to the radial arteries; 
the cyanosis disappears; the skin resumes its color, and the face loses 
its distorted appearance; the disease passes from the algid stage to 
that of reaction. Occasionally, this stage offers no peculiarities, and 
forms the beginning of convalescence; then, when the asphyctic symp- 
toms have ceased, there are a few more copious passages, with dis- 
tinctly fecal odor. Even on the second or third day there are pulpy 
or formed stools, or else constipation. Every thing indicates that the 
lost epithelium has been regenerated. We may compare these cases 
to those where a superficial dermatitis from a blister has been entirely 
removed in a few days by regeneration of the epidermis. When the 
stage of reaction forms the commencement of convalescence, even the 
stagnation in the capillaries during the algid stage has not led to 
considerable disturbance of nutrition in any organ; only there is ex- 
ceptionally albumen in the first urine evacuated, on account of the 
stagnation in the veins that precedes the reestablishment of the nor- 
mal circulation. In other cases, where the damage to the intestine is 
less quickly and completely repaired, the violent evacuations cease dur- 
ing the stage of reaction, but a moderate diarrhoea, with fluid, badly- 
smelling greenish stools, continues; the pulse remains small; the tem- 
perature of the extremities low, and the patients are in great danger 
of dying from exhaustion on an exacerbation of the intestinal disease. 
But there is not generally a return of the algid stage with disappear- 
ance of the pulse, cyanosis and coldness of the body; the incomplete 
reaction is more apt to pass into the so-called typhoid stage of cholera, 
but not unfrequently it ends in protracted convalescence, after the 
diarrhoea has ceased. Sometimes after the algid stage the pulse not 
only returns, but becomes unusually full and strong, the previously 
sunken temperature rises above the normal height, the cheeks turn 
dark red, the eyes are injected, and the signs of fluxionary hypereemh 
to the brain and other organs appear. These violent reactive symp 
toms are difficult to interpret. They most probably depend, at least 
partly, on the abnormal quality of the blood, and the consequent im- 
pediment to the capillary circulation. The symptoms of violent reac- 
tion also pass imperceptibly into those of the typhoid stage, or into 
convalescence. The opinion, which I advanced from my observations 
of the first cholera epidemics, that the temperature was only dimin- 
ished at the periphery while it was elevated within the body, has been CHOLERA ASIATICA. 
715 
proved to be correct on the whole. From numerous careful observa- 
tions of the temperature in cholera patients, J:lterbogTc arrived at the 
following results: 1. In the algid stage, the head, extremities, etc., are 
colder than in almost any other disease. 2. In the algid stage, the 
temperature of the cavities of the body, such as the vagina and rectum, 
is the highest (that can be measured) in the body, and it should always 
be taken for measurements. 3. In the algid stage, whether the case 
be favorable or fatal, the temperature within the body is usually in- 
creased, more rarely normal, most rarely diminished, although no cause 
for this has ever been found in the pathological symptoms during life, 
or on autopsy. 4. In the algid stage, the temperature of the whole 
body usually rises with the approach of death, but does not appear to 
increase afterward. But there are cases where this rise does not take 
place without our being able to find any reason for this deviation. 5. 
The commencement of reaction is not accompanied by any elevation of 
temperature, but the interior of the body usually cools off, while the 
outer parts warm up. 6. In cases of protracted reaction, the tempera- 
ture of the whole body generally sinks below the normal. 7. The in- 
flammatory sequelae generally, if not always, cause a decided eleva- 
tion of temperature. 8. During perfect convalescence, an abnormal 
elevation of temperature is often seen, without any pathological cause 
for it being discoverable. 
The general name of “ cholera typhoid ” has been given to the 
secondary symptoms that often follow the proper cholera attack. 
From the fact that these sequelre follow cholera asphyxia almost 
exclusively, never simple cholera diarrhoea, rarely cholerine, and do not 
constantly follow the first form of the disease, we may conclude that 
they do not directly depend on infection with cholera poison, but are 
based on the pathological processes during an attack of cholera, par- 
ticularly of the severest form. As we have already seen, the same 
state of affairs occurs in typhus, where also the proper symptoms of 
poisoning are often, but not always, followed by secondary affections 
due to the typhus. It may be readily seen that the stagnation of the 
thickened blood in the capillaries, and the consequent interruption of 
nutrition, if they last for several hours, a day, or more, may have a 
very injurious effect on the nutritive condition and functions of the 
organs; and we have already mentioned a series of inflammatory 
symptoms whose remains were found in the bodies of persons who 
died after the termination of the actual cholera attack. This view of 
the origin of the secondary diseases (the cholera typhoid) also agrees 
with the fact that they most frequently occur when the algid stage 
has been very marked and protracted. The fact that the secondary 
inflammations remain more or less latent, and often betray them- 716 
ACUTE INFECTIOUS DISEASES. 
selves only by symptoms of excessive adynamia (“typhous symp- 
toms”), is a peculiarity shown also by other inflammations when they 
attack debilitated persons. We shall only call attention to the fact 
that in old, decrepit persons, if physical examination be neglected, the 
outward resemblance and the subjective symptoms often cause pneu- 
monia to be diagnosed as catarrhal fever, nervous influenza, typhus, 
etc. According to my experience, acute croupous nephritis, with the 
retention of urine that it causes, by plugging up the uriniferous tubules, 
is the most frequent sequel of cholera asphyxia, but is by no means 
the constant cause of cholera typhoid, as is often asserted. If the se- 
cretion of urine remain suppressed after the disappearance of the symp- 
toms of collapse, or if the scanty urine contain quantities of albumen 
and fibrinous casts for days, if vomiting recommence, and the patients 
complain of severe headache, and become comatose, or have epilepti- 
form convulsions, we may make a diagnosis of acute croupous nephri- 
tis and so-called uraemic intoxication. In such cases the skin has oc- 
casionally been found incrusted with crystallized urea. The first or 
second day after the cessation of the asphyctic symptoms many pa- 
tients pass a normal or even very large amount of urine; and the albu- 
men, which is at first constant in it, usually disappears after a few days, 
nevertheless they fall into a state of great apathy and stupor, or mut- 
tering delirium, the tongue becomes dry and crusted, the pulse fre- 
quent, and often double; the temperature is elevated; the patients 
slip down toward the foot of the bed, and the disease so exactly re- 
sembles a severe typhoid, that there is no doubt the name cholera 
typhoid wTas intended for these cases. Besides the above symptoms, 
there is usually diarrhoea, with fetid evacuations mingled with shreds 
of epithelium; and, while the patients can scarcely be aroused from 
their comatose state by loud cries or other irritants, they twitch the 
face or recover consciousness, and complain of pain, if strong pressure 
be made on the abdomen. In these cases there is diphtheritic inflam- 
mation of the intestines, which often succeeds the catarrhal or proper 
choleraic enteritis, and which is perhaps induced by the irritation of the 
denuded intestines by their contents; most patients who fall into this 
state die of exhaustion. If, instead of diphtheritic inflammation of the 
intestine, there be a similar affection of the genitals, a pneumonia, 
pleurisy, or some other inflammatory sequel of cholera, the appearance 
of the patient does not materially differ from the above description. 
The typhoid symptoms due to the fever prevail, and the subjective 
symptoms of the local disease fall into the background, or disappear 
entirely. Lastly, in some cases, neither during life nor on autopsy can 
we find any local disease to which to refer the exhausting fever, of 
which many patients die after the cholera proper has run its course CHOLERA ASIATICA. 
717 
Peculiar importance has been attached to the fact that, during the so- 
called cholera typhoid, a maculated, papular, or erythematous exanthe- 
ma has been observed ; and the “ cholera-exanthema ” has even been 
compared to the “ typhus-exanthema,” and its occurrence regarded as 
a proof of the similarity or relationship of cholera typhoid and typhus. 
The exanthema is not, however, so constant a symptom of cholera ty- 
phoid as to be pathognomonic, and according to my observation it oc- 
curs chiefly in those cases where sinapisms have been applied repeat- 
edly or continuously to the extremities during the algid stage, or where 
the extremities have been rubbed energetically. The exanthema, which 
chiefly affects the limbs, often extends to the trunk, hence its occur- 
rence seems to me to be due to continued stagnation of the circulation, 
and consequent interruption of the nutrition of the skin, and to be 
favored by precedent irritation of the skin. Moreover, attention has 
recently been called to the fact that the diagnostic importance of the 
exanthema of typhoid fever has been overvalued, and that roseola 
spots and erythema also occur in many other feverish diseases. 
Treatment.—We shall not discuss the sanitary police regulations 
by which we may hope to arrest the progress of cholera epidemics; 
and shall only call attention to the fact that, in the Mecklenburg epi- 
demic of 1859, it was shown that the quarantining and locking up, 
which, from the experience of previous epidemics, were declared to be 
utterly useless, were found to afford full protection when energetically 
and perseveringly followed out. Since a person, suffering from an ap- 
parently simple and harmless diarrhoea, may carry the cholera-poison 
to a previously healthy place and there induce a fatal epidemic, places 
that would be protected must cut themselves off from all communica- 
tion with the rest of the world. It would be very satisfactory if the 
attempts to dry the soil of cities by drainage, and by improving the 
erection of privies, should have the desired result of lessening the pre- 
disposition of the affected places for extensive cholera epidemics. It 
would also lead us too far, were we to treat fully of the police regula- 
tions that physicians, in places where the cholera has appeared, must 
require of the proper authorities, and here we can only make certain 
suggestions. Since the privies, cess-pools, dirty gutters, etc., favor the 
development of the cholera-poison, they should be energetically 
cleaned and disinfected. Stools of cholera patients should never be 
thrown into the common privy. One of my pupils, Dr. Reich, while 
still a student at Greifswald, was cholera physician at Tribsees, a 
small town on the Mecklenburg border, where he succeeded in urging 
the police to empty all the privies and have a certain quantity of solu- 
tion of sulphate of iron poured into them. Large tanks, filled with 
this fluid, were placed before each house to facilitate this procedure, 718 
ACUTE INFECTIOUS DISEASES. 
which was strictly enforced on the inhabitants. But it has not been 
proved, on the contrary, it is much doubted by competent authority, 
whether sulphate of iron, which so well removes the unpleasant smell 
from privies, also interferes with the development and increase of the 
cholera germs. The epidemological section of the Berlin Academy 
of Medicine recommend the disinfection of body and bed linen by 
boiling in water; for the disinfection of privies, chloride of lime (ten 
parts, in solution, to one hundred of feces); for bed-pans, night-stools, 
etc., they recommend a mixture of two parts of permanganate of soda, 
forty-five parts of sulphate of iron, and fifty-three parts of water (ten 
parts to one hundred of feces, or a wineglassful for each person); for the 
disinfection of dwellings where cholera patients have been sick, chlo- 
rine gas. Physicians should also persuade the proper authorities to 
have prepared sufficiently large and properly-constructed lazarettos, 
well supplied with nurses, where patients with suspicious diarrhoea may 
be separated from those with well-marked cholera; they should urge 
the supply of healthy nourishment to the poor by soup and eating 
houses, and that the people may be informed, by temperate and simple 
publications, of the danger they run by neglecting an ordinary, pain- 
less diarrhoea. Lastly, where it is possible, places should be arranged 
where the inhabitants of houses that have been attacked may find 
shelter. 
The prophylactic rules for physicians to recommend to their own 
patients, on the outbreak of a cholera epidemic, are as follows : since 
there is far more danger in a city where cholera is prevalent, and still 
more in a house where it has broken out, than in other places, it is 
sensible for persons, who can make a long journey without great incon- 
venience, to fly from the disease. Such persons should be sure—1, to 
start on their journey soon enough; 2, to go off as far as possible; 
3, not to return till the last trace of the disease has disappeared. We 
should strictly forbid those who must remain from using a strange 
privy. It is remarkable that this important and certainly not super- 
fluous advice is not given in the cholera regulations published by 
Griesinger, JPettenTcofer, and Wunderlich. If I were writing regula- 
tions for the cholera, before treating of disinfection of privies, I should 
urge not to rely on it, and not to visit even a carefully-disinfected 
privy that is used by strangers. There are many heads of families 
who would not object to buying a night-stool for themselves and 
family during a cholera epidemic. We should also let our patients be 
careful about their diet; i. e., avoid all food that is difficult of diges- 
tion, and all articles of diet and drink that tend to produce diarrhoea. 
Complete and sudden change of the mode of life is not advisable, and 
wc should allow the moderate use of good red wine and strong beei CHOLERA ASIATICA. 
719 
that is not too new and has not become sour. On the other hand, 
all excess should be carefully shunned. The foolish assertion, that 
these rules are useless, as many persons who are careful of their diet 
are taken sick, while others who live carelessly escape, should be an- 
swered with rational arguments, and persons who are susceptible to 
reason should be shown that no one knows that he is not already in- 
fected with cholera, and that the impending attack will certainly have 
a very severe course, if some other injurious influence besides the 
cholera-poison be acting on the intestinal canal. Lastly, the patients 
should be advised to send for a physician as soon as they are attacked 
by a diarrhoea, and to remain in bed till the physician comes, to drink 
a few cups of hot coffee or peppermint-tea, and to take some “ cholera 
drops ” which they should have on hand. It cannot be denied that 
energetic diaphoresis occasionally averts an attack of cholera. At 
least, in every cholera epidemic, we see persons that have been at- 
tacked by copious diarrhoea, great debility, cramps in the legs, and 
even vomiting, and who, on account of these symptoms have drunk 
large quantities of hot liquids (usually coffee with rum), buried in the 
bed-clothes and reeking with perspiration, while the passages, which 
were often discolored and beginning to resemble rice-water discharges, 
and the vomiting also, have ceased. Experience also teaches that in 
such cases, if the sweating be arrested too soon, a true cholera attack 
not unfrequently comes on, and that it is well not to let a cholera 
patient leave his bed till he has had a formed stool. The cholera 
drops, usually named after some well-known physician, that are sold 
by the apothecaries during cholera epidemics, consist of laudanum, 
generally with the addition of some ethereal tincture, which is super- 
fluous and often detracts from the efficacy. Their use without medical 
advice should be recommended, because opium is one of the most 
efficient remedies against cholera diarrhoea, and because its success is 
the more certain the more recent the case. The so-called Russian 
cholera drops are particularly celebrated: I>. tinct. valer. aeth. 3 ij; 
vin. ipecac. 3i; tinct. opii 3j; ol. menth. pip. gtt. v. Hi. S. twenty 
to twenty-five drops every hour or two. 
While the most careful prophylactic treatment often fails, vre are 
still less able to fulfil the indications from the cause or from the dis- 
ease, after cholera has once broken out. In almost every epidemic, 
especially tovrard its close, when the malignancy of the disease has 
abated, and the number of recoveries is greater than that of the deaths, 
certain specifics are recommended both by physicians and quacks. 
But their reputation has never lasted through the first weeks of a sub- 
sequent epidemic. Radix sumbul, carbo trichloratus, and other rem- 
edies recommended as panaceas in cholera, have very justly been 720 
ACUTE INFECTIOUS DISEASES. 
thrown aside. Hence we must content ourselves with striving1 to ful 
fil the symptomatic indications, and we shall do this the more success- 
fully, the more closely we attend to and combat those symptoms on 
which the others depend. The symptomatic treatment which, in the 
first epidemics, consisted in attempts to elevate the fallen temperature 
by vapor-baths, and by having the patient drink hot teas during the 
algid stage, but not allowing them a drop of cold water, and in at- 
tempting to draw blood from all cases of cholera asphyxia, was cer- 
tainly incorrect. Depression of the temperature of the body is a late 
occurrence in the series of symptoms induced by the cholera infection; 
warm tea, which is more readily vomited than any other drink, is not 
nearly so well borne as small quantities of cold water; venesection 
cannot raise the depressed action of the heart, on which the venous 
congestion depends. The symptomatic treatment of cholera requires, 
first of all, attention to the intestinal disease, the arrest of the acute 
catarrh and extensive transudation of serum from the intestinal capil- 
laries, the source of all the other symptoms and of the danger. The 
second symptomatic indication is, to replace the water lost from the 
blood. If we succeeded in making a cholera patient sweat while the 
transudation into the intestines continued, we should injure him by 
the increased abstraction of Avater. Lastly, the third indication, Avhich 
we must bear in mind from the first, is to combat the threatening 
paralysis of the heart. We shall not discuss whether opium (the most 
frequent prescription in genuine intestinal catarrh, and the last refuge 
in all other diarrhoeas), besides retarding the movement of the intes- 
tines, also lessens the secretion of the intestinal mucous membrane, 
and the increased transudation from the intestinal capillaries; at all 
events, it OAves its frequent use in cholera to its antidiarrhoeic action. 
Even after satisfying themselves that, in many cases, opium has had no 
effect on cholera diarrhoea, most physicians seek its aid in new cases, 
because they have sometimes found it of undoubted benefit even in 
this affection. I fully agree Avith this treatment, and, before trying 
other methods, I give opium for cholera diarrhoea, although not in the 
form of cholera drops but in the shape of Dover’s poAvder, or as tinc- 
ture in mucilage, Avithout the addition of any ethereal substance. If 
the patient has taken a number of doses of opium (half a grain to a 
grain) in the course of a feAV hours, and the diarrhoea has improved, it 
is Avell to continue it in smaller doses till a formed stool shows that the 
excessive transudation into the intestines has ceased. If, on the other 
hand, in spite of the repeated doses of opium, the diarrhoea continues or 
groAvs Avorse, if the patient collapses visibly, if his skin groAvs cool, and 
the dejections lose their color, I regard the continuation of opium as 
contraindicated; Avhile, in such cases, I haATe had the best results from CHOLERA ASIATICA. 
721 
cold compresses frequently applied to the abdomen, and from the ad- 
ministration of calomel (a grain every hour). In regard to the speedy 
favorable effect of this treatment, especially of the application of cold 
compresses to the abdomen, on most patients, in regard to its favor- 
able influence on the entire disease, and the principles which induced 
me to employ it, I refer to my brochure already mentioned, “Die 
Symptomatische Beliandlung der Cholera,” Magdeburg, 1848, and would 
only mention that, in 1854, when Ifeufer was commissioned to instruct 
the Bavarian physicians in the treatment of cholera, he recommended 
my method as being the most successful, according to his experi- 
ence. Nitrate of silver, which has been recommended by many per- 
sons, especially by Levy of Breslau, and which I have frequently em- 
ployed, because, a priori, it seemed the most efficient, did not succeed 
with me. The second indication, to replace the loss of water from the 
blood by supplying water, is best attained by giving the patient small 
portions of ice-water, or small pieces of ice to swallow at short inter- 
vals. Large quantities of liquid, especially of warm drink, are usually 
vomited at once. At all events, since cholera patients have been 
almost universally allowed to drink cold water, they suffer less than 
when, in spite of the torturing thirst, they were allowed no drink, or, 
at most, warm tea. As the paralysis of the heart disappears, as the 
transudation from the capillaries ceases, and the normal functions of the 
stomach and intestines are restored, the circulation usually becomes 
normal at once, and, without the use of any stimulant, the action of 
the heart, even where reduced to a minimum, may become greater 
than normal within a few hours. But this does not prove that stimu 
lants are useless or unnecessary in the treatment of cholera; in the 
earlier epidemics, they were almost exclusively employed. As soon 
as the pulse grows small and the patients are evidently in collapse, 
stimulants should be given from time to time, to try and prevent com- 
plete paralysis of the heart, until the termination of the acute disease 
in the intestines. Among the stimulants, champagne that has stood 
on ice is preferable to most others, especially to the ethereal oils, car- 
bonate of ammonia, etc., because, along with its stimulant action on 
the nervous system, it has no irritant effect on the gastric and intes- 
tinal mucous membrane. In poor practice, rum or arrack, diluted with 
water, is best. In some cases it is well to alternate the administra- 
tion of ice and ice-water with a few cups of hot strong coffee. It is 
often vomited again, but frequently not till the pulse has become fuller, 
and the temperature somewhat elevated. If the evacuations upward 
and downward have ceased, while the continuance of the symptoms 
of collapse shows that paralysis of the intestinal muscles, and not arrest 
of the transudation, has induced this change in the disease, stimulation 722 
ACUTE INFECTIOUS DISEASES. 
is the proper treatment, and the return of the evacuations is the best 
evidence of its success. Frictions of the skin with tincture of mustard 
often relieve the painful cramps in the muscles; but I would warn 
against the very common application of mustard-plasters. For, even 
if they be left on a long while, the patients rarely complain of their 
burning, and the attendants are so excited by the fearful appearance 
of the patient that they lose their presence of mind, and forget the 
sinapisms, and I have seen them left on half a day, and during conva- 
lescence the patient has been troubled by obstinate and painful inflam- 
mations of the skin induced by the mustard. Of course, nourishment 
cannot be given to cholera patients during the actual attack; but, even 
after the attack is over and reaction has begun, we should be very 
careful about the food, and in order to protect the diseased intestine 
from injury, we should give nothing more irritating than diluted milk, 
meat-broth, and biscuit. Nutritious and solid food should not be 
allowed till pulpy and consistent stools appear. Infringement of this 
rule is generally severely punished. 
No general rules can be given for the treatment of the stage of re- 
action, and still less for the sequelae of cholera comprised under the 
name of cholera typhoid, for the treatment must be based on a careful 
analysis of the symptoms in each case. The former custom of bleed- 
ing for violent reaction should be discontinued. If there be evidences 
of great fluxion to the brain, we should apply ice compresses to the 
head and leeches behind the ears. But we must take care not to mis- 
take the hydroceplialoid that often occurs in children after an attack 
of cholera with hyperacmia and oedema of the brain. If the severe 
symptoms of cholera typhoid depend on uraemic intoxication, we may 
employ the treatment already laid down, little as is the prospect of 
success. If the attack be followed by an asthenic fever with typhoid 
symptoms, and the belly be puffed up and painful, and thin but colored 
and badly-smelling evacuations are passed from time to time, we may 
cover the abdomen with cataplasms, and order small doses of calomel 
and opium. In the same way, when treating inflammations of the 
different organs occurring after cholera, we must bear in mind the ex- 
haustion of the patient. 
BLOODY FLUX—DYSENTERY. 
CHAPTER XVI. 
Etiology.—Dysentery is an infectious disease (when treating of 
diseases of the intestinal canal, in the first volume, we spoke of “ca- 
tarrhal dysentery,” which does not depend on infection) ; but it differs 
from typhus, and other infectious diseases, in that the infection with 
dysenteric poison induces perceptible pathological changes in the in- DYSENTERY. 
723 
testinal canal only. The anomalies observed in other organs, and in 
the blood, during dysentery, as well as the more or less severe fever 
accompanying the disease, are secondary symptoms, induced by the 
intestinal affection. Dysentery is thus closely allied to cholera, where 
the infection also causes, first, a severe disease of the intestinal mucous 
membrane, and, secondarily, as a result of this primary disease, changes 
in the composition of the blood, in the circulation, and in the nutrition 
of the various organs. Of course, the intestinal affection is not the 
same in dysentery as in cholera, and consequently its influence on the 
blood differs from that of cholera. 
Dysentery poison cannot be directly observed, as an organic, living 
substance, any more than the poisons inducing other infectious diseases 
can, but the reasons so often repeated, especially when speaking of 
typhus, induce us to refer dysentery also to an infection of the body 
by a certain species of low vegetable organism, and to speak of a 
“ dysentery germ,” as we have already spoken of a “ typhus germ ” 
and a “ cholera germ.” From this point of view, we may, to some 
extent, understand the facts which have been determined by thorough 
observation concerning the spread of the disease. 
Dysentery results, although not exclusively, from a miasm; or, in 
other words, the dysentery germ grows, flourishes, and increases, out- 
side of the human body, and persons staying near its locality are in 
danger of being attacked by it. The circumstances favorable to the 
increase and propagation of dysentery poison, among which a high 
temperature and a certain amount of moisture are prominent, exist in 
the tropical regions; there the disease is endemic through large por- 
tions of country. According to the classical work of Jlirsch, in Europe 
only the peninsulas, as the south of the continent, and the islands 
about them, constantly offer such favorable conditions for the increase 
of the dysentery germ as to cause the disease to be endemic there. 
But, through almost all Europe, the conditions for the increase and 
propagation of dysentery, which is endemic with us also, are occasion- 
ally so favorable, especially late in the summer, that the disease be- 
comes epidemic. The circumstance that dysentery is not endemic or 
epidemic in all regions where high temperature and moisture con- 
stantly exist, justifies the conclusion that these are not the only things 
necessary for the growth of the germ, or else that it is not so widely 
spread as to be found everywhere that conditions favorable to its de 
velopment exist. The coincident epidemic or endemic occurrence of 
dysentery and intermittent is frequent, but not at all constant, accord- 
ing to the recent observations of Ilirsch. Dysentery exists where the 
requirements for malaria, marshes, etc., are not present. It attacks 
the open country oftener than the city. 724 
acute INFECTIOUS DISEASES. 
The dysentery germ appears to reproduce itself always, or un- 
der favorable circumstances, in the body of the infected person, and it 
would seem that the dejections of the patient contain the contagion 
thus formed, or its components; for, while it has not been proved that 
one person catches dysentery from another, it is more than probable 
that the disease may be communicated to healthy persons through the 
dejections of dysentery patients, or by the night-stools, bed-pans, or 
enema syringes that have been used by them. This causes dysentery 
to resemble cholera, while it speaks against the asserted connection 
between it and malaria. Why should not the same or similar influ- 
ences, such as high temperature and moisture, favor the development 
of various specific low organisms, just as it does the increase of differ- 
ent varieties of higher plants and animals ? 
Catching cold, getting wet, great fatigue, the use of unripe vege- 
tables, and other injurious influences, have been advanced as causes of 
dysentery, and it cannot be denied that persons exposed to these influ- 
ences are more readily affected than others. Nevertheless, infection 
with a specific poison is the sole cause of this disease, and the part that 
the above influences play in the etiology is only to render the organ- 
ism more sensitive to the action of the poison; in other words, they 
increase the predisposition to dysentery. 
Anatomical Appeakances.—The anatomical changes found in 
the intestines of dysentery patients, on autopsy, are a type of diph- 
theritic inflammation. The diseased portions of mucous membrane are 
infiltrated with a fibrinous exudation, and, as a result of their compres- 
sion by the exudation, are necrosed and changed to a slough. If the 
slough be cast off, a loss of substance in the mucous membrane re- 
mains. According as this loss of substance is superficial and of slight 
extent, or deep and extensive, the destruction of the mucous mem- 
brane is, or is not, capable of complete repair. In the former case only 
can the intestine become perfectly well, while in the latter, in place 
of the membrane destroyed, there is a callous cicatricial tissue, which 
not unfrequently constricts the intestine. 
In the mildest grades of dysentery we find the mucous membrane 
of the large intestine, especially the summits of the folds projecting 
inward, deeply reddened by ecchymosis and injection, and to some 
extent infiltrated by a grayish-white, soft exudation, covering the epi 
thelial coating. In these cases, it looks as if the diseased part wyere 
covered by a bran-like coating; but if we scrape off this coating with 
the handle of a scalpel, tlfere remains a superficial loss of substance, 
which shows that the exudation did not lie on the mucous membrane, 
but entered into it. The submucous connective tissue is infiltrated 
with serum, and swollen. The serous coat appears cloudy and dull DYSENTERY. 
725 
from oedema. This change occurs chiefly, and generally exe.usively, 
in the large intestine, and it is rare for the dysenteric affection to ex- 
tend to the lower portion of the small intestine. In higher grades of 
the disease, more glutinous, or more hard, membranous gray-white 
layers cover large portions of the interior surface of the intestine; they 
are removed with difficulty, and only along with the mucous mem- 
brane. If they are already detached, the submucous tissue lies exposed. 
The whole intestinal wall appears thickened by the excessive oedema 
of the submucous tissue, and of the muscular and serous coats, but cer- 
tain parts, corresponding to the spots formed by the exudation, are 
especially swollen, so that they form nodular prominences on the inner 
surface of the intestine. When dysentery is of this high grade, the 
serous coat of the intestine usually participates in the inflammation, 
and is covered with a thin layer of fibrin, which unites it to the sur- 
rounding parts. The diseased intestine is evidently dilated, and is 
filled with epithelial masses, shreds of exudation, and with an albumi- 
nous fluid mixed with more or less blood; it usually contains no feces. 
In the highest grades of dysentery, according to Rokitansky, “ large 
portions of the mucous membrane are changed to a black, rotten, 
friable, charred mass, which subsequently is not unfrequently thrown 
off and passed as tubular pieces; the submucous tissue either appears 
infiltrated by charred-looking blood and by a bloody serous fluid, or 
else pale, and the blood in its vessels is consumed to a black, stiff, 
powdery mass; but later, as a result of the throwing off of the dead 
parts by a reactive inflammation in the deeper layers, it appears infil- 
trated with pus. Besides a dirty-grayish discoloration and loss of 
lustre, the peritoneal coat is in some places injected by dilated capil- 
laries, and covered by a brownish, discolored, ichorous exudation. 
The foul-smelling intestine, containing a blackish-brown fluid, like 
coffee-grounds, is either in a state of passive dilatation, or it is collapsed, 
and, when the process has lasted a long time, the muscular coat is 
shrunken, pale, faded, and readily torn.” 
The glands of the mesocolon belonging to the diseased portion of 
intestine are more or less vascular, swollen, and relaxed. The liver is 
nyperasmic, and in the malignant dysentery of the tropics it is not un- 
frequently the seat of abscesses, which are doubtless due to the intes- 
tinal veins carrying ichor or emboli from the diseased intestine to the 
liver. 
If death do not occur at the height of the disease, the dysenteric 
process either subsides, or a slow inflammation (“ chronic dysentery ”) 
remains, which subsequently carries off not a few of the patients. In 
the former case, the edges of the loss of substance are approximated, 
by the contraction of the connective tissue which forms their base, till 726 
ACUTE INFECTIOUS DISEASES. 
they finally come in contact, if the loss has not been too great. Then, 
as in cicatrizing ulcers of the stomach, there is sometimes stricture, 
sometimes not. If, on the other hand, the opening be very large, its 
edges do not come together, and we find more or less extensive patches 
of the inner surface covered, not by mucous membrane, but by callous 
connective tissue. According to Rokitansky’s apt description, this 
tissue not unfrequently forms “ fibrous bands and striae, which project 
in the shape of seams into the intestine, cross each other in various 
directions, and often form valvular or ring-shaped duplicatures in the 
intestine, thus inducing a very peculiar stricture of the colon.” If, on 
the other hand, the intestinal disease takes a chronic course or tends 
to recovery, the losses of substance become chronic ulcers, and those 
changes occur in the intestine which we described as follicular ulcera- 
tion. In the thickened, strongly pigmented, mucous membrane, the 
inflamed follicles become ulcers, at first round, afterward irregular; 
occasionally, also, in the thickened submucous tissue, abscesses and 
fistulous passages form, and subsequently perforate the muscular coat 
and induce peritonitis or abscesses about the rectum. 
Symptoms and Course.—Occasionally, premonitory symptoms 
precede the actual outbreak of the disease for several days; these 
consist in an undefined constitutional disturbance and irregularity of 
digestion, especially loss of appetite, thirst, slight colicky pains, and 
inclination to diarrhoea. The commencement of the disease is rarely 
characterized by a chill, and not often by rigors even, or other symp- 
toms of fever. But in most cases dysentery begins with an apparently 
innocent diarrhoea, during which the faeces passed are not suspicious- 
looking, which is preceded by very moderate colicky pain, and is ac- 
companied by very little, if any, of the tenesmus which afterward be- 
comes so painful. But the more frequently the passages succeed each 
other, the more severe and continued become the colicky pains (tor- 
mina ventris) which begin some time before each evacuation, and 
shortly before its occurrence attain great severity. The evacuations 
are accompanied by a very torturing and painful bearing down of the 
rectum, to which is often added strangury. In spite of the severe and 
long-continued straining, proportionately slight, non-feculent, mucous, 
gray-colored masses (dysenteria alba) or muco-bloody masses (dysen- 
teria rubra), 'and occasionally pure blood, are evacuated. In some 
cases a few hard scybala are from time to time passed with the mucous 
or muco-bloody masses. Immediately after an evacuation the patient 
feels relieved, and usually has pain only on hard pressure against the 
abdomen, especially in the region of the colon; but soon, often even 
in a few minutes, the tormina begin again; the patient writhes ana 
groans, and, when the pains have attained the highest grade, tenesmus DYSENTERY. 
727 
recommences, and again a small quantity of dysenteric dejections of a 
sickening odor is passed. Sometimes this scene is repeated twenty or 
thirty times in twenty-four hours. If at first absent, febrile symptoms 
always come on in the course of the disease. Where the intestinal le- 
sion is moderately intense, the fever has an erethetic or synochal char- 
acter ; the pulse is moderately frequent, full, and hard. But in the high- 
est grades of the disease the fever acquires an asthenic character very 
early; the pulse becomes small, and very frequent. According to the 
character of the fever, dysentery has been divided into inflammatory, 
adynamic, and putrid, or typhous. This classification corresponds very 
nearly with the different grades that we described above. Even in 
the mildest grades, and when the fever is moderate, the patients are 
greatly run down by the loss of albumen, the pain, and the loss of 
sleep; they become pale; the pulse, at first full, grows small; there 
is great mental depression; the dulness and want of spirits are very 
marked. If we filter the dejections, and add nitric acid to the filtrate, 
we shall find that the albumen in it is sufficient to stiffen almost the 
whole contents of the reagent-glass, even where the dejections scarcely 
have a reddish tinge, and only solitary blood-corpuscles are found un- 
der the microscope. This great loss of albumen also explains why, in 
favorable cases—where, after four to eight days, the tormina and tenes- 
mus grow less and gradually disappear, and where, often by the end 
of the first, or the beginning of the second week, the masses passed 
again become feculent—the convalescence is almost always slow. The 
character of the blood of a convalescent from dysentery is, as Schmidt 
aptly remarks, very similar to that of a person with Brights disease; 
and I can confirm, from my own experience, the observation that gen- 
eral dropsy follows slight cases of dysentery far more frequently than 
it does other diseases of equally short duration. 
In the higher grades of dysentery, the evacuations succeed each 
other at very short intervals, the colicky pains scarcely cease, and oc- 
casionally become unbearable; the abdomen is sensitive to even a 
light pressure. The tenesmus also is more continued and severe than 
in the milder forms. The dejections contain a great deal of blood, nu- 
merous flocculi and shreds, and occasionally large membranous masses. 
In many cases large quantities of pure blood are evacuated. At first 
the pulse is more frequent and full; later it becomes very frequent, 
while its fulness usually diminishes rapidly. There are also great con- 
stitutional disturbance, loss of appetite, dry tongue, deep physical and 
mental depression, and frequently dulness of the mind and slight delir- 
ium. If the disease runs a favorable course, the symptoms gradually 
subside, the intervals between the evacuations become longer, the 
dejections again grow brownish and feculent; the epithelial and exu- 728 
ACUTE INFECTIOUS DISEASES. 
dation masses, as well as the blood, which long continues to be mixed 
with them, diminish; the pulse rises, the tongue grows moist, the mind 
clearer ; but convalescence is always slow, and, in the most favorable 
cases, weeks elapse before the patient can leave his bed. If the dis- 
ease is to prove fatal, the pulse becomes smaller, the apathy increases, 
consciousness is lost, the complaints of pain and tenesmus cease, the 
evacuations are involuntary, and the patient dies, as in other rapidly- 
exhausting diseases, of general paralysis. If the disease pass from the 
acute to the chronic form, as is very often the case in the higher grades, 
the fever disappears, and we have the symptoms of follicular ulcera- 
tion of the intestines. Diarrhoea generally alternates with constipa- 
tion ; occasionally normal feces, with muco-bloody masses clinging to 
them, at other times only a puriform fluid from the ulcerating mucous 
membrane, is evacuated; the patients become very much emaciated, 
and, after languishing for months, usually die of marasmus and dropsy. 
If the losses of intestinal mucous membrane heal, leaving a cicatricial 
stricture, the symptoms of protracted dysentery of high grade are fol- 
lowed by those of stricture of the intestine. For the rest of his life 
the patient suffers from habitual constipation, and the various incon- 
veniences accompanying this state. On carefully inquiring into the 
causes of chronic abdominal diseases, we can frequently trace them to 
a dysentery that existed several years previous^. 
In the highest forms of dysentery, the putrid or septic forms of 
authors, after the disease begins as above described, the passages as- 
sume a discolored, brownish-red or blackish color, and a carrion-like 
odor; and large, black, sloughy shreds of mucous membrane are not 
unfrequently mixed with them. The pulse soon becomes small and 
very frequent, the extremities cool, and the body burning; the patients 
are collapsed, the countenance distorted, the tongue and gums are cov- 
ered with dry sordes, and the mind is very dull. Tormina and tenes- 
mus cease very early in the disease; the discolored, thin, fetid passages 
are passed involuntarily, owing to the relaxation of the sphincter, and 
they excoriate the parts with which the}'’ come in contact. In such 
cases, to the symptoms of adynamia are often added those of an acute 
haemorrhagic diathesis, bleeding from the nose, petechia, etc. During 
the first days even, the patient may die of septic dysentery; and re- 
covery is very rare in this form of the malady, which occurs chiefly in 
camps, besieged towns, or under other unfavorable conditions. Dysen- 
tery patients with the higher and highest forms of the affeetion do not 
often die of peritonitis or pyaemia ; in the tropics not a few probably 
die later from the hepatic abscesses which develop during the disease. 
Treatment.—Prophylaxis demands that the circumstances which 
experience shows to favor the development and propagation of dysen- DYSENTERY. 
729 
teiy poison be removed as much as possible; the rules for obtaining 
this end are, according to what was said above, partly the same as 
those treated of in the prophylaxis of intermittent fever, partly those 
of typhus and cholera. Since the dejections of dysentery patients are 
very probably the bearers of the poison reproduced in the infected or- 
ganism, prophylaxis further requires that the bed-pans, enema syringes, 
etc., of dysentery patients should never be used for other persons, and 
that the dejections should not be thrown into the common privy, but 
into a separate pit, and disinfected with a solution of sulphate of iron. 
Lastly, prophylaxis requires the avoidance of all those causes which 
increase the tendency to dysentery by rendering the body more sus- 
ceptible to the action of the poison. Little probability as there is of 
a person acquiring dysentery by eating unripe fruit, sleeping on the 
wet ground, etc., if he be not at the same time exposed to the dysen- 
tery poison, it is still certain that, during an epidemic, these causes 
favor the outbreak of the disease. 
We cannot fulfil the causal indications, or those from the disease 
in dysentery, as we know no antidote that counteracts the poison. 
The attempt to arrest the disease by active treatment with bleeding, 
emetics, purgatives, large doses of opium, etc., has very properly been 
abandoned, and, at present, the treatment is limited to combating the 
symptoms. But the symptomatic treatment of dysentery only prom- 
ises good results, if we bear in mind the dependence of the diarrhoea, 
tormina, tenesmus, and other symptoms, on a diphtheritic inflammation 
of the intestinal mucous membrane. If we do not attend to this fact, 
but give opium to arrest the diarrhoea even in cases where hard masses 
of faeces are collected above the inflamed portion of intestine, we shall 
render the disease worse, for impacted and decomposed faeces alone 
are enough to excite a diphtheritic inflammation. In the milder grades 
of dysentery it is well to begin the treatment with a mild laxative, 
such as castor-oil or decoction of tamarinds, and to return to this rem- 
edy every time that the dejections contain no faecal matter for a day or 
two. The reason for this treatment has just been explained. It is 
only advisable to give an emetic, of ipecac, or tartrate of antimony, in 
cases where the stomach is filled with undigested substances. Even 
in the mildest grades of dysentery, the patient should carefully keep 
in bed, and eat nothing solid, but live on soup diet. If he be strong 
and full-blooded, mucilaginous water-soup is sufficient; but, if he be 
weak and anaemic, it is well to attend to keeping up the strength from 
the first and to advise concentrated meat-broths. Most patients are 
relieved by the application of warm poultices to the abdomen. If the 
tormina be very severe, and be not relieved by the cataplasms, or if 
the abdomen be unusually sensitive to pressure, we shall find great 730 
ACUTE INFECTIOUS DISEASES. 
benefit from the application of leeches to the abdomen (in adults ten 
to twenty), and allowing the bites to bleed for a time under the poul- 
tices. Internally we may give an emulsion, and at evening a moderate 
dose of opium. This treatment is enough for many cases of mild dys- 
entery ; but in others, in spite of it, the passages increase in number, 
the tormina and tenesmus are more severe, and the fever augments 
greatly. In such cases, as well as in the higher grades of dysentery 
where local abstraction of blood is almost always indicated, the ad- 
ministration of calomel with opium is the most trustworthy treatment. 
It is customary to give one grain of calomel with a quarter of a grain 
of opium every two hours; and I think this treatment, especially when 
combined with five to ten grains of Dover’s powder at bed-time, de- 
serves the preference over large doses (gr. x) of calomel, which have 
also been recommended. If salivation result from the continued use 
of calomel, we must stop it, and continue the opium alone, then it is 
best to give the tincture in mucilage, or in a weak infusion of ipecac. 
In just such cases a combination of opium and acetate of lead is highly 
spoken of. But I always consider it best, besides the small doses of 
opium given during the day, to give a full dose at night. If this treat- 
ment also fail, we have still less to expect from the internal adminis- 
tration of nitrate of silver and the vegetable astringents, especially 
tannin. According to my experience, the employment of the latter 
remedy in the form of enema, which is praised by many authors, is 
objectionable on account of the difficulty of giving a clyster when the 
tenesmus is so great, and on account of the increase of the tenesmus 
caused by the most careful injection as well as by the medicament 
itself. Moreover, if the remedy is to come in contact with the whole 
of the diseased surface, the enema must be very large; the contents 
of a simple enema syringe do not pass much above the rectum. In 
the highest grades of dysentery, treatment is almost always with- 
out benefit. The great prostration of the patient, the threatening 
paralysis forbid the abstraction of blood as well as the administration 
of calomel and opium, and we must limit ourselves to maintaining the 
strength of the patient as well as possible, and preventing general 
paralysis, by the administration of tonics and stimulants. In chronic 
dysentery, especially when the tenesmus has abated, enemata of solu- 
tions of nitrate of silver or sulphate of zinc deserve most confidence. 
If there be no collection of faeces above the seat of disease, or if the 
muco-purulent and bloody masses are accompanied by the passage of 
thin faecal matter, we may give astringents internally also, and in such 
cases I prefer catechu ( 3 ij to § vj water and § ss gum-arabic, a table- 
spoonful every two hours) to tannin and nitrate of silver, as it is 
doubtful if the latter reach the intestines in a very efficient form. If TRICHINOSIS. 
731 
stricture of the intestine remain after dysentery, it is to be treated as 
previously described. 
CHAPTER X Y 11. 
TRICHINA DISEASE—TRICHINOSIS. 
There may be some doubt in what division of special pathology 
trichina disease should be considered; whether it should be treated 
of among the diseases of the stomach, as the first seat of the disease 
is there, or among the diseases of the organs of motion, as the trichinae 
pass from the intestinal canal into the muscles; or among the infec- 
tious diseases. In the present edition I have decided to treat of tri- 
chinosis among the infectious diseases, as I here uphold the depend- 
ence of the infectious diseases on the presence of a lower organism, 
more strongly than I did in former editions. The origin of trichinosis 
from a contagium vivum is proved. The symptoms have the greatest 
resemblance to those of the infectious diseases. Even the period of 
incubation is common to both. "VVe may go still further and say that 
there is far less doubt about trichinosis being an infectious disease 
than about any other disease belonging to this class. 
Etiology.—For more than twenty years numerous punctate, white 
bodies had occasionally been seen in the muscles, on autopsy, which 
the microscope showed were small cysts containing a thread-like worm, 
wound up spirally. This worm, the trichina spiralis, showed no sexual 
organs, and it was altogether obscure whence it came, how it reached 
the muscles, and whether it was capable of further development. We 
have already shown that the supposition, according to which the muscu- 
lar trichina was the undeveloped state of the tricocephalus dispar, was 
soon found to be erroneous. From experiments, by Virchow, Leuck- 
art, and others, of feeding animals with flesh containing trichina?, it 
was shown that the muscular trichinae become free in the stomach and 
intestines of the animals fed, during the digestion of the meat; in a 
few days they attain the length of three or four millimeters, and form 
male and female perfect animals, intestinal trichinae. In the female, 
which is far more numerous and about two-thirds larger than the male, 
innumerable eggs develop, and from these young ones escape, living, 
from the body of the mother, even in from five to eight days, and move 
freely in the intestines. The young brood of the intestinal trichinae 
now soon perforate the Avail of the intestine, part of them passing into 
the abdominal cavity, part betAveen the folds of the mesentery to the 
spinal column, thence to the diaphragm, abdominal muscles, and fol- 
lowing the intermuscular connective tissue to the other muscles of the 
body. The number of these Avandering trichinae is innumerable. They 732 
A.CUTE INFECTIOUS DISEASES. 
are particularly numerous about the ends of the muscle, where it be- 
comes tendinous, probably because their further progress is obstructed 
at these points. Trichinae have a particular preference for the muscles 
of the loins, diaphragm, the intercostal and cervical muscles, and for 
those of the eye and larynx. In the extremities, as a rule, “ the fur- 
ther from the trunk, the fewer tricliinas in the muscles” (Reny). In 
the human Being, at least, they seem never to enter the muscles of the 
heart. The wandering of trichinae induces parenchymatous and inter- 
stitial myositis. The free, emigrating trichinae, which gradually attain 
the length of one-third of a line, are not visible to the naked eye. At 
the point where they finally become attached, the irritation they induce 
leads to a development of the sarcolemma, and thus to the formation 
of a capsule, which is egg or lemon-shaped. This capsule grows 
thicker; calcareous salts are deposited in it, and it is the trichinae 
enclosed by such calcified capsules that are visible to the naked eye. 
At least two months are required for the formation of a perfect 
capsule. 
The etiology of the trichina disease in animals is still obscure. Of 
course the solution of the question, whence come the trichinas in pork ? 
is very interesting, and of great practical importance. It is probable 
that they acquire them chiefly or solely by eating tricliinous rats. It 
is well known that pigs not unfrequently eat live and dead rats, and it 
is also known that rats not only frequently have trichinas, but that they 
often die of them. 
In the human being the trichina disease results solely from eating 
tricliinous pork. The raw flesh is the most dangerous, hence the dis- 
ease is proportionately more frequent and more severe in those who 
have the bad habit of eating raw meat than in others. More fre- 
quently than in the raw form, pork is eaten prepared in a manner that 
does not kill the trichinae. Even large pieces of well-boiled or baked 
pork, which do not show any red spots on being cut, and into which 
we may easily pass a fork without a feeling of grating, never contain 
tricliinas. But they may exist in roast pork, whose external portion 
only has been exposed to a temperature of 55° R. [156° F.], while 
the inner part has not been heated so much, looks bloody, and 
is somewhat hard and coherent. . And even in small pieces of meat, 
and in the various forms of sausages, if they be cooked for only a 
short time, the trichinas remain alive in the parts distant from the 
surface. Trichinas are found especially often after the use of so- 
called fresh blood and meat sausages, of meat-balls, and similar 
preparations. Long-continued salting (pickling) of pork, without the 
addition of water, kills the trichinas even in large pieces ; on the other 
hand, numerous trichinae may survive in pickled meat that has onlv TRICHINOSIS 
733 
remained a short time in a weak solution of salt. Smoking the meat 
only kills those trichinae that are near the surface. The so-called quick 
smoking, where the ham is painted with pyroligneous, acetic acid, or 
creasote, and left in the smoke only a short time, or not at all, affords 
the least protection. Poisoning by raw hams, chitterlings, brain pud- 
ding, chopped sausage, and other slightly-smoked varieties of sausage, 
is often seen. The fact that smoked trichinous flesh is repeatedly 
eaten without injury, is partly because it has been carefully pickled 
for a long time before smoking, and partly because the meat in ques- 
tion had been kept for a long time, and completely dried, which also 
kills the trichinae. Very few cases of encapsulated trichinae, and not 
a single one of acute trichina poisoning, have been observed in southern 
Germany; this is because the people there dislike raw flesh, even when 
pickled and smoked. 
Since all persons who eat living trichinae are not equally affected, 
and as the severity of the disease is not by any means always in pro- 
portion to the number of trichinae probably introduced into the stom- 
ach, we may speak of a greater or less predisposition to trichinosis. 
But the causes on which this predisposition depends are not yet 
known. We can only assert that it is connected with the condition 
of the gastric and intestinal mucous membrane, or with the character 
of the contents of the stomach and intestines, and that, after the use 
of trichinous meat, severe diarrhoea, by which the still undigested por- 
tions of flesh, with the trichinae contained in them, are evacuated, is 
to be regarded as favorable. Children have a certain immunity to 
trichinosis; at least children recover from trichina poisoning, from 
which they certainly are not exempt, more readily than adults, per- 
haps because they do not digest a part of the meat. 
Anatomical Appearance.—On autopsy of the lower animals that 
have been poisoned with trichime, if they have died or been killed dur- 
ing the first weeks, besides the numerous intestinal trichime and young 
ones that have already entered the muscles, we find in many cases the 
remains of enteritis and peritonitis. On the other hand, on autopsy of 
human beings who have died in the first week or two after accidental 
poisoning by trichime, we never find exudation in the intestine or peri- 
tonaeum, but only the signs of a more or less intense intestinal catarrh, 
and often a decided swelling of the mesenteric glands. This is doubt- 
less because, on intentionally poisoning, a much larger number of 
trichinae is given them than is swallowed by a person accidentally so 
poisoned, consequently a much larger number of the trichinas pass 
through the intestinal walls, and the lesion caused by them is far 
more intense. After the fifth week, distinct signs of interstitial and 
parenchymatous inflammation appear in the muscles as fine, grayish- 734 
ACUTE INFECTIOUS DISEASES. 
red striae. The microscopic examination of such spots shows that in 
them the muscular fibrillae have broken down to a granular detritus 
mass, while the interstitial connective tissue is increased by fresh pro- 
liferation. The number of trichinae in the muscles is the greater, and 
the parts affected more extensive, the longer the disease has lasted. 
In protracted cases we find even the muscles of the extremities con- 
taining quantities of trichinas. This circumstance, and the experience 
that even in the seventh and eighth week we find living intestinal 
trichinae, filled with eggs and embryos, render it not improbable that 
the intestinal trichinae bear young not only once but repeatedly, and 
that they pass into the muscles at different times. The other changes 
found in the bodies of trichina patients are not pathognomonic, and cor- 
respond with those found in the bodies of persons who have died of 
other diseases, accompanied by high fever and rapid exhaustion. Ac- 
cording to Cohnheim, even the muscles have no constant and charac- 
teristic appearances, except the above-mentioned anomalies, and a cer- 
tain density and toughness, but in regard to their color and moisture 
vary greatly, just as they do in typhus. In many cases there are signs 
of extensive bronchitis, and of hypostasis in the lungs, or pneumonic 
infiltration, and sometimes thromboses in the veins. Lastly, when the 
disease has lasted a long while, and the fever has been very severe, in 
some bodies we find the parenchymatous degenerations of the liver, 
kidneys, and heart, which we have already mentioned. 
Symptoms and Course.—Since Zenker, in 1860, made the impor- 
tant discovery that the entrance of trichinas into the human body 
caused a severe and even fatal disease, a number of violent epidemics 
of trichinosis have been so carefully observed and described, that the 
symptomatology of the newly-discovered disease is now as well de- 
termined as that of most other maladies that have been known a long 
time. 
Before the trichinas which have entered the stomach are set free 
by the digestion of the flesh in which they are embedded, the patients 
have no trouble. In some cases, which Henz calls insidious trichino- 
sis, even when the trichinae have become free, when they have mated 
and are rearing their young, and when the young brood perforate the 
intestinal canal, there are no signs of an intestinal disease. Such pa- 
tients have a good appetite, regular bowels; they feel fatigued and 
depressed, and complain of travelling pains, and a certain stiffness in 
the limbs, it is true, but they can go out and attend’ to their business. 
Gradually the vague pains are localized in certain muscles: these swell, 
become hard and rigid; oedema, fever, and other symptoms characteris- 
tic of trichinous myositis are developed. It is most probable that, when 
the disease runs this course, onlv a few trichinae have reached the stom< TRICHINOSIS. 
735 
ach, or remained there, and that consequently the development of the 
intestinal trichinae and their passage through the walls have only slightly 
interfered with the functions of the stomach and intestines, while suc- 
cessive broods and repeated emigrations of young trichinae have filled 
the muscles with the parasites. It is difficult to explain the occasional 
sudden change of insidious trichinosis into dangerous forms, unless it 
be due to an extensive emigration of a new generation of trichinae into 
the respiratory muscles. 
This insidious commencement of the disease, with its total absence 
of gastric disturbance, is in striking contrast with the very trouble- 
some intestinal symptoms observed at the commencement of some 
cases. The first cases in the famous Hederleben epidemic were re- 
garded as cholera, because the patients were attacked with severe 
vomiting and purging, which could not be checked. Three of them 
died on the sixth day of the disease, with the symptoms of paralysis 
and thickening of the blood. For the diagnosis between “trichinous 
cholera ” and Asiatic cholera, and cholera morbus, Kratz and Ruprecht 
lay particular stress on the peculiar stretching, muscular pain, which is 
located chiefly in the flexors of the extremities, and is increased both 
by movement and pressure. The commencement of trichinosis with 
cholera symptoms, which is not frequent, shows that an unusually 
large number of living trichinae have reached the stomach, and that 
consequently the gastric and intestinal walls have suffered more than 
usually. This idea is supported by the fact that cholera symptoms 
have hitherto been observed only in cases of poisoning with raw meat. 
The absence of all intestinal symptoms, as well as severe attacks 
of vomiting and purging, is only exceptionally observed after the use 
of trichinous flesh. Far the greater number of patients complain in a 
few hours, or not till a few days after the poisoning, when the young 
brood has been hatched, of severe pressure in the stomach, of eructa- 
tion and nausea, combined with a feeling of great heaviness and de- 
pression. There is almost always diarrhoea, the passages being at first 
brownish, subsequently yellow, thin, and accompanied by more or less 
severe colicky pain. These gastric symptoms are soon accompanied by 
those of the entrance of the trichinae into the muscles, vague pains, and 
a feeling of stiffness, as well as a peculiar oedema of the face affecting 
chiefly the eyelids, in which the conjunctiva also participates occasion- 
ally, so that there is chemosis. The movements of the patient are 
now sometimes very much impaired, partly because their muscles be- 
come more rigid and less supple, partly because every attempt to 
stretch them is very painful. The different muscles swell considerably, 
become tense and as hard as caoutchouc, just as in the rigor mortis. 
According to Cohnheirri’s description, in severe cases the constant and 736 
ACUTE INFECTIOUS DISEASES. 
characteristic position of the patient is as follows: “ He lies on the 
back with the shoulder and elbow-joints sharply bent, and the hands 
slightly flexed; on the other hand, the knee and hij> joints are but 
slightly bent, or nearly straight; so that the patient is unable to lift 
the arm, extend the forearm, sit up, or bend the knees.” Cohnheim 
explains this position correctly, by ascribing it to the patient’s attempt 
to assume a position where the different groups of muscles are the lease 
extended; with the swelling of the muscles there is oedema extending 
from the arms toward the hands, from the thighs toward the feet, but 
not affecting the scrotum or labia. Besides the above symptoms, from 
the third to the fifth week of the disease, there are frequently attacks 
of severe dyspnoea, which subside again in the sixth week; they doubt- 
less depend on trichinous disease of the respiratory muscles. Where 
the disease attacks the muscles of the glottis, the voice is sometimes 
lost; sometimes affection of the masticatory muscles causes trismus; 
participation of the glossal and pharyngeal muscles induces impaired 
movement of the tongue and dysphagia. Trichinosis is accompanied 
by high fever, with slight morning remissions. Although this fever is 
unmistakably not of zymotic origin, but depends on the extensive dis- 
ease of the muscles, and is to be regarded as a symptomatic inflamma- 
tory fever, it very closely resembles the fever observed in the course 
of typhus and other infectious diseases, and occasionally the tempera- 
ture curves can scarcely be distinguished from those of typhus. The 
evening temperature sometimes reaches 106°, that of the morning re- 
mains somewhat lower. The bodily temperature does not become 
normal for a long time, often not till the sixth or seventh week. The 
frequency of the pulse corresponds with the temperature, and in severe 
cases reaches 120 to 140 beats a minute. Copious perspiration, with 
a miliary eruption, is somewhat characteristic of the fever accompany- 
ing trichinosis. The constitutional influence of trichinous fever, the 
effect that it has on the sensoriuin and other functions, is just the same 
as that from great elevation of the bodily temperature in other dis- 
eases. The pulse becomes small and weak, the thirst painful, the 
tongue dry, the patients sink into apathy, or become delirious; occa- 
sionally there are twitching and trembling of small groups of muscles, 
bed-sores over the sacrum, and with these symptoms the patients may 
die of exhaustion. The usual symptoms of trichinosis are more or less 
modified by the occurrence of extensive bronchitis, hypostasis, or 
pneumonic infiltration; but the pneumonic infiltrations alone (which 
are frequent) betray their presence by subjective as well as objective 
symptoms, by piercing pain in the side, cough, dyspnoea, etc. If the 
disease takes a favorable course, as not unfrequently happens in severe 
cases, the muscles gradually become less rigid and painful, the bodih TRICHINOSIS. 
737 
temperature and tlie pulse lower, the perspiration less copious, the 
thirst abates, appetite returns, but the exhausted patients are confined 
to bed for a long time, and regain strength very slowly. Just as after 
other severe diseases, oedema often occurs during convalescence, affect- 
ing even the scrotum and labia. 
Treatment.—Prophylaxis.—When the flesh of a slaughtered hog 
is carefully examined microscopically, and no trichina; can be found, it 
may be used, even raw, without danger. There is no doubt that, if 
competent microscopists examined the flesh of all the pigs killed, new 
epidemics of trichinosis might be avoided with certainty. I do not 
think it would be at all difficult, either in the city or country, to find 
competent persons, who could be so instructed, by microscopical courses 
and popular theoretical teaching, that they could tell certainly whether 
specimens of meat referred to them contained trichina? or not. My 
brother, by his trichina catechism, and by practical courses, has fully 
qualified a large number of the laity for the microscopical examination 
of pork for trichina?. Nevertheless, in opposition to celebrated author- 
ities, I must say that I regard the introduction of an obligatory micro- 
scopical examination of meat as no guaranty against new epidemics 
of trichinosis. I have not sufficient trust in the conscientiousness of the 
persons to whom this would be intrusted, especially in the rural dis- 
tricts, to believe that, after they had examined for trichina? in vain for 
years, they would continue their examinations with the necessary ex- 
actness. It is evident that a microscopical examination, if not carefully 
conducted, might prove dangerous, because persons relying on it might 
carelessly eat uncooked meat. The only certain protection against 
trichina-poisoning is, to eat no pork that has not been prepared in a 
way that would kill any trichina? present. Whoever wishes to eat 
uncooked pork, smoked ham, sausage, etc., should previously inform 
himself that the pig from which they came contained no trichina?. I 
advise my students to warn their patients (even those living in places 
where the flesh is examined) against the use of all dishes prepared from 
pork, which we mentioned under Etiology as being dangerous. 
Treatment of the Disease.—From what we have said of the tenacity 
of life of muscular trichina?, there is little hope of finding a remedy by 
which they may be killed without injury to the patient in whom they 
exist. Friedreich's proposal, to use the very bitter nitropicrate of pot- 
ash in trichinosis, has not proved serviceable; it certainly permeates all 
the tissues of the body, but the views regarding its anthelmintic action 
differ. It is also doubtful whether benzine, as recommended by Mosler, 
has any effect. There is far more hope that, some time, we shall find 
a remedy to kill intestinal trichinae, or remove them from the bowels. 
This indication exists, not only in recent cases, but must be remem- 738 
ACUTE INFECTIOUS DISEASES. 
bered later in the disease, since it is proved that, after Aveeks, liv- 
ing intestinal trichinae, filled AATith embryos, may exist in the bowels, 
and consequently it is not improbable that there may be neAV emi- 
grations of trichinae into the muscles. The presence of diarrhoea 
should not deter us from beginning the treatment Avith a few doses 
of calomel or castor-oil, and, if necessary, repeating this treatment 
occasionally, as advised by Huprecht. It does not seem to me to 
be proved that benzine, of which Master gives 3 j to 3 ij in gela- 
tin capsules, is inefficacious against intestinal trichinae, so that we 
should cease using it. The rest of the treatment is symptomatic. 
For the fever, quinine is advised ; for progressive prostration, stim- 
ulants ; for the subsequent anaemia, the preparations of iron. Mos- 
ler proposes, as the most efficacious remedy for the painful SAvelling 
of the muscles, the use of long-continued Avarm baths. 
[The origin of the trichinae in SAvine is an interesting question. 
The assertion that the disease originates in the rat is doubted, for it 
is said that trichinous rats come from slaughter-houses, where they 
may have fed on hogs’ flesh. It is at least as probable that trichinae 
are original with sAArine as that they are so with rats ; and they 
may be propagated by pigs which eat offal of other pigs containing 
intestinal trichinae and embryos, or by their eating the flesh itself, 
as sometimes happens.] 
ADDITIONS TO THE REVISED EDITION OF 1880. 
SECTION I.—ACUTE INFECTIOUS DISEASES. 
1.—P. 586. 
Bacteria have been found in the blood of scarlatina patients, as 
in that of measles and small-pox patients ; when rabbits were inoc- 
ulated with this blood, the bacteria were found in their blood. Dr. 
Carpenter thinks that scarlatina is sometimes caused by decompos- 
ing blood from slaughter-houses. It has been variously stated that 
cases occur from defective seAverage. The sources of contagion are 
so \raried and often so obscure that in a large city at least it is dif- 
ficult to exclude this mode of origin from any case. 
Among the complications of scarlatina, acute nephritis is proba- 
bly the most common. Its symptoms usually begin in the desqua- 
mative stage during the third Aveek. In this stage also comes a 
rarer complication, viz., acute articular rheumatism ; this lias the 
same symptoms and endocardial complications as simple rheuma- ADDITIONS TO TIIE REVISED EDITION OF 1880. 
739 
tism, but it is more apt to be accompanied by severe joint-disease 
and suppuration. Besides these, there may be inflammations of 
serous membranes, pleuritis, pericarditis, or meningitis, also pneu- 
monia, etc. 
The prognosis is less favorable than in measles ; mild epidemics 
are less frequent, and even mild cases often become complicated ; 
this is justly called a treacherous disease. In not a few epidemics 
the mortality will reach one-third. Cases in children under five 
years or in old persons, those with high fever, intense and long-con- 
tinued eruption, or with any of the severe complications, are unfa- 
vorable. 
2.—P. GOT. 
Some persons are so susceptible to the poison that it acts ever 
when very dilute, as coming through the windows from the next 
house, or by letters, paper money, etc. The nature of the poison is. 
not understood. Minute spherical bodies (bacteria) have been found 
in the contents of the pustule, in the shin around it, and in the in- 
ternal organs ; but it is not certain that these bacteria are the vehi- 
cles of the contagion. The results of the experiments of Chauveau, 
Burdon-Sanderson, and others, in removing the bacteria from vac- 
cine lymph, do not agree with those of M. Wolff and Hillier. 
Weigert believes that the first changes, which occur in the cells of 
the rete Malpighii, are not of inflammatory nature, but are analogous 
to changes caused by diphtheritis in the epithelium. The cells of 
the rete are transformed into translucent flakes of irregular shape 
and size, and without nuclei; they cause an irritation, which induces 
an effusion of lymph that separates the affected cells, forming small 
interspaces in a sort of mesh-work made by the remains of the epi- 
dermis. About these interspaces there is active cell-proliferation, 
and numerous pus-corpuscles escape from the vascular loops lying 
under the swollen papillse of the skin, which gradually fill the meshes 
as the efflorescence ripens. In regard to the central excavation in 
many pocks, it is not sc constant appearance, and is said by Bind- 
ffeisch to occur where the pustules develop around a hair-follicle or 
sweat-gland, and to be caused by the covering of the pustule being 
held down by the epidermis projecting into these depressions. 
On the mucous membranes variola is often accompanied by 
catarrhal redness and swelling ; but where these membranes are 
exposed to the air, there is a pustular eruption like that on the skin. 
When patients die in the eruptive stage, the spleen is usually much 
enlarged. 
When delirium occurs in small-pox, it may be due to the fever, 740 
ACUTE INFECTIOUS DISEASES. 
and partly perhaps to the inflammation of the scalp causing liyper- 
semia of the brain. Delirium is more apt to occur in those who 
have previously been drinkers. A stage of great excitement is often 
followed by one of weakness with feeble heart-action, which may 
end fatally. 
As the pocks dry up the parts around become pale and less swol- 
len, and the patients are again recognizable ; the inflammatory pain 
gives place to excessive itching, and probably many of the resulting 
cicatrices may be due to scratching. 
Small-pox has numerous complications, such as bronchitis, pneu- 
monia, pleurisy (often with purulent effusion), diseases of the larynx, 
meningitis, uterine haemorrhages, abortions, and affections of the eye 
and ear. 
Some observations seem to show that the protection from vacci- 
nation does not begin till twelve or thirteen days after the opera- 
tion ; but it should be resorted to even after exposure, in hopes it 
may at least render the course of the disease milder. Inoculation, 
which was formerly in vogue, usually induced very light cases, but 
deaths sometimes occurred. 
It is a question how long a patient convalescent from small-pox 
continues to produce contagion, and how long he should be isolated. 
He should be isolated till the stage of desquamation is entirely 
past—say fourteen days after the disease is over. 
Dr. Waters, in the London “ Lancet,” says if sun-light be ex- 
cluded from the room, the disease is arrested at the papular or 
vesicular stage, and the pain, itching, and smell are less annoying. 
Constant applications of emulsion of bitter almonds seem to have 
the same effect. 
3.—P. 654. 
If the fresh dejections of a typhoid patient spread the contagion, 
persons immediately about him would be most apt to contract the 
disease, but this does not seem to be the case ; so the stools proba- 
bly undergo some change which render the germs in them more 
active. Some authors believe that typhoid may develop spontane- 
ously, others that it is always due to contagion ; the poison from 
the patient reaching some place favorable to its development, and 
thence again entering the human body. 
Most epidemics of typhoid begin after the heat of summer, when 
the soil is dried to the greatest depth ; but others occur indepen- 
dently of the time of year or of the dryness. Their extent is usually 
limited, perhaps to a town or one part of a city, or perhaps to a single 
house, in which case it must be referred to infected drinking-water ADDITIONS TO THE REVISED EDITION OF 1880. 
741 
or defective drainage. Typhoid is relatively rare during pregnancy, 
but doubts are rising against the-old view that it hardly ever occurs 
in the puerperal state. 
The period of incubation probably varies, but seems to average 
about fourteen days. 
The parenchymatous degeneration of the muscles of the heart 
may result in passive dilatation ; the feeble action following the de- 
generation may induce disturbances of the circulation, especially 
emboli, particularly if the weakened contractions favor coagulations 
in the heart, and particles from these coagula pass from the right 
heart into the lungs or from the left into the aorta, and reach the 
spleen, kidneys, etc., causing haemorrhagic infarctions and possibly 
abscesses. Venous thrombosis, especially of the crural vein, not 
unfrequently follows the impairment of circulation. 
Among the nervous symptoms, besides the febrile delirium or 
stupor, there may be others referrible to cerebral cedema or haemor- 
rhage, meningitis or embolism ; mental disturbances, which usually 
recover ; paralyses of the facial, ocular, or vocal muscles, or para- 
plegia. If these paralyses cannot be attributed to severe changes 
in the nervous centres, they usually recover. 
Besides the albuminuria, which disappears with the disease, 
there are sometimes haemorrhagic infarctions or even diffuse ne- 
phritis. 
In severe cases of typhoid, bed-sores are not uncommon in spite 
of the greatest care, and as a sequel of the disease there may be 
numerous furuncles. 
According to JOiebermeister, from 7 p. m. to 8 a. m. is the best 
time for baths ; this being the natural period for remission, if the 
patient can be kept for several hours at a temperature approach- 
ing normal, he may better stand a brief increase of temperature. 
Another good time for the bath is about noon, at which time also 
most patients show a tendency to remission. 
Menstruation, which usually comes in typhoid at its regular time, 
is customarily regarded as a contra-indication to baths ; but in severe 
cases they may be continued, as they may with almost any of the 
complications, such as diarrhoea, meteorism, etc. Even in threaten- 
ing paralysis of the heart, some stimulant may be given, and fol- 
lowed by short tepid baths. SECTION II. 
CHRONIC INFECTIOUS DISEASES. 
CHAPTER I. 
SYPHILIS. 
Of late years the study of syphilis has undergone a complete 
revolution, and the new doctrines have been adopted with remarkable 
readiness by almost all prominent writers upon the subject, even by 
those who a few years ago were their most zealous opponents. In 
previous editions of this work I have expressed a disbelief in the an- 
cient views, according to which inoculation by one and the same poison 
at one time acts locally, and at another induces infection and disorder 
of the entire system; and I there declared my preference for the modern 
theory, according to which there are two poisons, one of which merely 
induces local disease, namely, an ulcer at the point of inoculation, ac- 
companied in some instances by inflammation and suppuration of the 
neighboring lymphatic glands; while the other always gives rise to 
constitutional disorder, with extensive derangement of nutrition. At 
that time, however, I did not declare myself so unreservedly in favor 
of the doctrine of the duplicity of the virus (or duality, to use another 
common expression) as I now do. 
I think that it will be to the advantage of my readers if I devote a 
few lines to a brief analysis of the belief which a short time ago was 
universally current, regarding the relation of the chancre, or primary 
syphilitic ulcer, to constitutional syphilis, or lues venerea. It was sup 
posed that the secretion of the ulcer possessed virulent properties, 
whereby, when brought in contact with an excoriated surface, or upon 
penetrating through a thin coating of epidermis, it induced a specific 
dermatitis, and a primary syphilitic ulcer. At this stage, it was be- 
.ieved that the noxious power of the virus often became exhausted; 
and that, if we could succeed in destroying or in healing the ulcer be- 
fore the infection from it could involve the constitution, the disease TIIE CHANCRE. 
743 
would remain local; if the attempt failed, then a series of affections of 
remote parts of the body, resulting from constitutional implication, fol- 
lowed the local ulcer, the secondary and tertiary syphilitic diseases. 
The formation of an induration upon the base or edges of the primary 
sore was considered an ominous sign, proving the almost certain infec- 
tion of the system. Hence the attempt was usually made to destroy 
recent non-indurated ulcers with strong caustics, while older and in- 
durated sores were nearly always treated constitutionally, especially 
with mercury, which was almost universally regarded as the antidote 
for syphilis. Finally, the majority of syphilologists, following the teach- 
ing of Hicord, supposed that syphilis could only be propagated by the 
primary sore, or chancre, or, in other words, that the secretion of the 
chancre was the only vehicle of contagion; and that it was not con- 
tained in the discharge of secondary affections, nor in the blood, or 
secretions of syphilitic persons, a theory which was never fully credited 
by practising physicians. It would take too long to relate in detail 
how each of these propositions in turn first was doubted, then was re- 
futed, until at last the whole theory was abandoned as false, or, at all 
events, as based upon erroneous observation. We shall touch upon 
some of these errors in laying down the tenets of the modern doctrine. 
In the present chapter we shall treat first of the chancre, and of 
the glandular chancre or acute bubo/ after which we shall describe 
constitutional syphilis, the first manifestation of which consists in 
syphilitic induration and the primary syphilitic ulcer. To the latter 
we shall not apply the term chancre, according to the usage of most 
modern authors. 
As the chancre is not a constitutional disease, it might, perhaps, 
have been entirely separated from the subject of syphilis, and classified 
with gonorrhoea, and other affections of the genitals; but, although 
such an arrangement would be more systematic, yet, considering the 
extremely frequent coexistence of the chancre with syphilitic indura- 
tion, it does not seem so practical. 
The chancre often is called the w soft chancre,” in contradistinction 
to the sore of primary syphilis, the “ hard chancre.” Other authors 
call it the “chancroid,” reserving the term chancre for the primary 
syphilitic ulcer. Other syphilologues apply the epithet “ virulent ” to 
the chancre, and call the ulcer of primary syphilis the “ infectious ’ 
ulcer. It is very desirable that authors should agree as to the names 
of the two diseases, in order to allay the confusion arising from a diver- 
sity of nomenclature. 
Etiology.—We shall not discuss the question as to the origin of 
A.—THE CHANCRE. 744 
CHRONIC INFECTIOUS DISEASES. 
the chancrous virus, since we have no means of deciding it; but there 
is no doubt that at the present time it never develops spontaneously, 
and that no one nowadays contracts a chancre who has not been in- 
fected with its virus. The chancre, then, belongs to the class of purely 
contagious diseases; and we are fully entitled to employ the term 
chancre-contagion instead of chancre-virus. 
Unlike the contagion of measles, scarlatina, and small-pox, the con- 
tagion of the chancre is not volatile, nor capable of poisoning the at- 
mosphere about the patient, and of infecting individuals within its 
reach. It is of a fixed nature, and is only found in the secretion of the 
sore, and in the contents of a chancrous bubo. The poison itself can- 
not be detected in either of these vehicles, either under the microscope 
or by means of chemical examination. The matter which covers the 
sore, and the contents of a glandular chancre, do not differ perceptibly, 
either morphologically or chemically, from the discharge of an ulcer of 
any other kind, or from the pus of other suppurating glands. 
The predisposing conditions for the chancre are usually more gen- 
eral perhaps than those of any other disease. Neither age, sex, nor 
constitution, seems capable of modifying the susceptibility to its infec- 
tion. It is true that individuals in the prime of life are more often af- 
fected than children or old persons; that men suffer oftener than wo- 
men, the vigorous and healthy more frequently than the feeble and 
sickly; but this is simply because the former expose themselves to 
contagion more than the latter, and not because they are more sus- 
ceptible to its influence. Hence persons with a thin epidermis are 
more liable to infection, because slighter injuries suffice to produce 
solution of continuity of their skin, thereby enabling the poison to act 
upon the corium. The results of sypliilization, that is, the artificial 
production of chancres by inoculation, seem to show that such inocula- 
tions, when repeated a great many times, have the effect of extinguish- 
ing the susceptibility to contagion. 
By far the most common mode of transmission of the chancre is by 
coitus with a person who is already diseased. Infection also some- 
times results from lewd embraces, from kisses, and from the use of 
water-closets, tobacco-pipes, tumblers, and similar articles, impregnated 
with the chancre-virus. Physicians and midwives are sometimes in- 
fected in making vaginal examinations, and conversely, women are 
now and then inoculated by nurse or doctor; but these and all other 
modes of origin of the chancre, often as they are assigned by patients, 
are extremely rare in comparison with that of impure intercourse. 
Excoriation of the cuticle or epithelium, at the point where the poison 
comes in contact with the genitals, favors transmission of the disease, 
but it has not been proved that an abrasion of the surface is essential TIIE CHANCRE. 
745 
to infection. On tlie contrary, chancres are often observed to develop 
upon parts of the genitals where the most careful search immediately 
after coitus had failed to detect any breach of continuity of the epider- 
mis. Upon other parts of the body, too, tvliere the epidermis is thin, 
such as the lips or the nipples, infection may occur without wound of 
the cuticle, while upon the hand or other region thickly covered with 
cuticle, as long as there is no breach of continuity, the contact of the 
poison produces no effect. The seat of the chancre, therefore, is most 
generally upon the genitals, far more rarely upon the anus, between 
the breasts, in the mouth, or upon the hands. 
Symptoms and Course.—According to the concurrent belief of 
all trustworthy observers, the period of incubation of the chancre-virus 
is a very brief one. Iticord goes so far as to declare that it has no 
incubative period, but that changes arise at the point of contact of the 
poison immediately upon its implantation, although they are not com- 
monly noticed at first, owing to their apparent insignificance. 
Course of an Inoculated Chancre.—Upon introducing some of the 
secretion of a chancre beneath the epidermis, through a puncture from a 
lancet-point, no change takes place at the point of inoculation during the 
first twenty-four hours. At about the thirty-sixth hour a slight redness 
appears, and in forty-eight hours there is a distinct, bright-red macula. 
In the course of the third day the macula rises into a flatfish papule, 
and upon the fourth day the epidermis is raised, forming a vesicle, sur- 
rounded by a reddened areola. In the next day or two its contents 
become more yellow and purulent, the vesicle transforming into a pus- 
tule, which bursts between the fifth and eighth day; or else, together 
with its contents, dries up into a scab. After rupture of the pustule, 
or after removal of the scab, we see an ulcer of the size of a pin’s 
head, or perhaps as large as a pea; it is almost circular, and penetrates 
into the corium in a manner disproportionate to its size. Its edge, 
which is oedematous from inflammation, has a puckered appearance. 
In the next few days, the base and edges of the sore are attacked, by 
a diphtheritic process, and it begins to enlarge. As the elements of 
the tissues are necrosed, and broken down into detritus, the base of 
the sore assumes a grayish, dirty, lardaceous appearance. As the diph- 
theritic destruction goes on irregularly at its periphery, the borders of 
the ulcer acquire a gnawed, ragged form. If the point of inoculation 
be destroyed by caustic within the first four days, the destructive pro- 
cess may generally be cut short. After the fourth day this is scarcely 
ever possible. 
A chancre of accidental origin begins either by a macule or papule, 
upon which, after repeated exfoliation of the cuticle, an excoriation 
and loss of substance takes place, or else a vesicle or pustule forms 746 
CHRONIC INFECTIOUS DISEASES. 
first and bursts; or, what is more common still, the chancre proceeds 
from infection of a laceration, which, instead of healing immediately, 
becomes covered with a dirty-looking exudation. The characteristics 
of a sore arising in this way are not always so well marked as to admit 
of its ready distinction from other forms of ulceration. In doubtful 
cases, therefore, it is very advisable to inoculate the thigh of the patient 
with some of the secretion of the sore; two or three such punctures 
should be made, and should be covered with a watch-glass attached by 
adhesive plaster. As we shall hereafter learn, the inoculation of a 
patient having a syphilitic ulcer with some of his own matter results 
negatively. When the inoculation takes place, and the changes de- 
scribed above occur, there can be no further doubt of the chancrous 
nature of the ulceration. For the present, we shall merely describe 
the more common forms of simple uncomplicated chancre; then, after 
giving an account of the primary syphilitic ulcers, we propose to treat 
of the modifications of the chancre which arise from its complication 
with syphilitic induration. 
The common diphtheritic chancre is characterized by ragged and 
detached edges. The loss of substance looks as if it were made by a 
punch. Its most common seat in men is upon the inner surface of the 
prepuce, the surface of the glans and sulcus between the prepuce and 
glans, and, above all, the fraenulum ; less frequently, it is upon the outer 
surface of the prepuce, or the integument of the penis. Ulcers of the 
feenulum are nearly always deep and excavated, and the framulum 
itself is perforated. When the sore is situated in the sulcus, between 
the prepuce and glans, the ulceration is apt to extend, by spontaneous 
inoculation, over a large portion of the corona glandis. If it penetrate 
deeply at this point, the loose subcutaneous tissue becomes infected 
by the secretion, and gives rise to a virulent abscess. When seated 
upon the glans, it usually penetrates more profoundly than when 
upon the prepuce, although perforation down to the urethra, with the 
formation of a urethral fistula, is rare. The urethral chancre is not 
common. It usually begins at the mouth of the urethra, and a small 
loss of substance which extends inward is visible upon its swollen and 
deeply-reddened lips. At other times the urethral chancre is more 
deeply situated, and only betrays its existence by the purulent flow 
from the meatus and by pain in the urethra, situated at some particu- 
lar point, and which is increased by pressure or by making water. If 
a concealed urethral chancre be not complicated with gonorrhoea, it is 
easy to recognize it, as the scantiness of the purulent flow will attract 
attention, and prevent its being mistaken for a clap. Successful inocu- 
lation, however, is the only means of making the diagnosis sure. It 
is hardly ever detected, though, when accompanied by a gonorrhoea. THE CHANCRE. 
747 
as, owing to the copiousness of the discharge, and to the absence of 
other conspicuous symptoms, inoculation is almost always neglected 
In women, the most frequent seat of the common chancre is the vulva 
upon the posterior commissure, and at the entrance to the vagina. In 
very rare instances it appears in the vagina, and even upon the vaginal 
portion of the neck of the womb. When the common chancre begins 
to heal, the destruction ceases, and the lardaceous appearance of the 
base of the ulcer disappears (“the chancre cleans up”), granulations 
appear upon the base and edges of the ulcer, which gradually fill up 
the loss of substance. After the chancre has healed, there remains a 
cicatrix, more or less distinctly stellated, according to the depth of the 
ulcer. The period at which the process of repair commences is very 
variable. Some chancres become covered with granulations, and trans- 
form into simple sores, which do not secrete inoculable pus in a week 
or two, while others go on extending for months, and retain all their 
characteristics; that is, ragged edges, lardaceous base, and virulent 
discharge. 
The superficial chancre occurs most frequently upon the glans and 
prepuce in men; and between the labia and nymph®, and at the en- 
trance to the vagina, and on the neck of the womb, in women; and it 
appears in both sexes with equal frequence on the skin. When situ- 
ated upon the glans, an exact counterpart of the ulcer is usually found 
upon the corresponding inner surface of the prepuce. The form of the 
ulcer is irregular, and its surface looks as if the cuticle had been scald- 
ed off. At its edge there is a white border. The destructive process 
never extends deeply. When situated at the orifice of the prepuce, 
cracks occur in its folds, which render retraction of the prepuce very 
painful. The superficial chancre often results in phimosis and para- 
phimosis. In the former instance it is almost indistinguishable from 
balanitis, excepting by means of inoculation. When a superficial 
chancre is situated upon the external integument, the scanty secretion 
soon dries up into a thin crust, and it is not until after it has been 
treated with a wet dressing that its raw, reddish-yellow surface, spar- 
ingly covered with secretion, becomes visible. 
The follicular chancre develops from a sebaceous gland. Its sur- 
face is very small, disproportionately deep, and long retains its regular 
round form. 
The phagedenic chancre usually originates from the common 
chancre. Its secretion is thin, ichorous, and very offensive; its form 
is irregular, its base is of a grayish-white or greenish color, consisting 
of necrosed tissue and of infiltration; its edges are livid, and sur- 
rounded by coppery-red areola. It spreads rapidly, and in men it 
sometimes destroys a large portion of the prepuce, glans, skin of the 748 
CHRONIC INFECTIOUS DISEASES. 
penis, and scrotum; and in women, eats away the labia, perinseum, 
and parts about the anus. The phagedenic ulcer only appears in 
broken-down, cachectic subjects, and loses its malignant character as 
the constitution improves. Then the devastation ceases; the diphthe- 
ritic coating upon the base of the ulcer is castoff; healthy granulations 
form, and the malignant, eating sore changes into a simple ulcer, with 
a tendency to cicatrize. If the constitution of the patient does not 
improve, or if it becomes still more depraved by the further exposure 
to noxious influences, especially by the use of mercury, the destructive 
jwocess, which continues without stopping, finally becomes complicated 
by a slow fever which consumes the patient. 
The gangrenous chancre is sometimes a modification of the phage- 
denic chancre, while at other times it develops from the ordinary form 
of the disease; in either case, the base of the ulcer and the parts about 
it become bluish, and are afterward converted into a black, insensi- 
ble moist slough. There is a dusky redness immediately around the 
eschar, which is encircled by a somewhat extensive and severe oedema. 
The disease may advance until it has destroyed a large portion of the 
penis, or labia and perinaeum, and life itself may be imperilled by the 
constitutional disturbance which accompanies the gangrene. At other 
times the destructive process ceases sooner; a line of demarcation 
forms, the sloughs separate, and the disease recovers, leaving a more or 
less extensive loss of substance behind it. We do not always know 
why chancres become gangrenous. Now and then, owing to the action 
of unknown causes, gangrenous chancres become of very frequent 
occurrence, or, at least, are more common than usual. In many in- 
stances, however, mechanical action, such as straining or tension of the 
inflamed part (as, when the chancre is complicated with phimosis or 
paraphimosis), chemical agents, or irritation of the sore by the putre- 
faction of retained secretion, may be regarded as causes of the malady. 
Treatment.—In proportion as the opinion has gained ground that 
the chancre never leads to constitutional syphilis, the old and erroneous 
practice of treating chancres by mercury has died out. The progress 
of knowledge has speedily borne fruit in this instance, the importance 
of which cannot be sufficiently prized. We have only to consider that, 
but a few years ago, at least one-half of the physicians used to subject 
all patients with chancres to a course of mercury, and thus often enough 
ruined their health by means of this pernicious poison, under the mis- 
taken impression that they thereby averted induration of the ulcer, and 
prevented constitutional contamination. Nowadays, a physician who 
treats a simple chancre with mercury makes a gross blunder. On the 
other hand, I do not think it judicious to make the treatment of a sim- 
ple chancre a purely local one. It will heal much more rapidly if the THE CHANCRE. 
749 
patient be brought under favorable hygienic influences, and if he be de- 
fended from all noxious agencies throughout the course of the disease. 
If the circumstances permit, it is well to confine him to his chamber, or, 
at all events, to forbid all unnecessary walking. Moreover, since the 
majority of this class of patients are young and vigorous, living more 
or less freely, and drinking spirituous liquors, it is generally advisable 
to place them upon a rigid diet (gruel morning and evening, with broth 
and a little meat at mid-day), to forbid coflee, beer, wine, or spirits, and 
now and then to give small doses of some saline cathartic (one or two 
glasses of Friedrichshaller, or Piillnaer bitter water), which may be 
taken in the morning, fasting. Although a chancre usually heals much 
more quickly under this treatment than when a strict regulation of the 
diet is neglected, it is merely because of the luxurious mode of life led 
by most patients who have exposed themselves to the infection of the 
chancre. The above directions are not applicable, and indeed might 
do great mischief, and retard the healing of the sore, if applied in the 
case of a badly-nourished, cachectic patient. In such a case, the diet 
must be nutritious and rich; the use of wine and beer is indicated, 
and often exerts a favorable effect upon the healing of the ulcer. 
The local treatment of a chancre must be similar to that of any 
other atonic ulcer, of which the chancre may be regarded as the proto- 
type. Until after the fourth or seventh day, it is advisable to de- 
stroy the ulcer by caustics. For this purpose, it is best to make use 
of the potassa fusa, the Vienna paste (quicklime, five parts; caustic 
potash, six parts), or the chloride of zinc, which makes a dry eschar 
(I*, zinci chlor., butyr. antim., aa 3 ij, f. c. pulv. alth. past, mollis). 
After the seventh day it is not advisable to cauterize, as then the pro- 
cess of healing is retarded rather than promoted thereby. As a rule, 
ointments should not be used, and the sore should be dressed with 
warm camomile-tea, or other mild, stimulating liquid. The most 
common applications are the aromatic wine, the black-wash (calomel 
3ss; aquae calcis § ij), the yellow-wash (hyd. chlor. corrosiv. gr. j; 
aquae calcis § ij). The blue-wash (cupri sulp. gr. j ; aquae § j), which 
is almost exclusively used by Von JBarensprung, is also highly to be 
recommended. When the chancre is very painful, and when its dis- 
charge is very profuse, compresses, wet with lead-water and cold sitz- 
.baths, are of benefit. It is generally sufficient to dress the wound 
twice a day, after previously washing it or bathing the part in camo- 
mile-tea. Too frequent dressing does harm. If, in spite of this treat- 
ment, the floor of the ulcer retains its lardaceous aspect, it is advisable 
to sprinkle the surface now and then with a thin layer of red precipi- 
tate. After the sore has lost its specific character, and nevertheless is 
slow in healing, it may be touched lightly with lunar caustic, or dressed 750 
CHKONIC INFECTIOUS DISEASES. 
with a wash of zinc or lead. When the fraenulum has been perforated, 
it is best to divide the remaining bridge of mucous membrane at once. 
Where a phimosis prevents the proper treatment of the chancre, injec- 
tions beneath the prepuce must be practised methodically, in order 
to remove the accumulated secretion. It is sometimes necessary to 
operate for phimosis; but this is never to be done excepting in urgent 
cases, as the entire wound generally becomes converted into a chancre. 
In the treatment of the phagedenic chancre, the general health of 
the patient must receive our first attention. Ilis strength is to be 
husbanded rather than reduced; and a nourishing diet, and sometimes 
wine, bark, and iron, are indicated. The utmost cleanliness is to be 
observed. As a topical application we recommend dressings of dilute so- 
lution of acetate of lead, or of chloride of lime ( § ss— § j to water % vj). 
Treatment of the gangrenous chancre is to be conducted upon simi- 
lar principles, paying due attention to the surgical rules for the treat- 
ment of mortification. 
APPENDIX. 
THE GLANDULAR CHANCRE.—THE VIRULENT, ACUTE BUBO. 
Etiology.—We have seen that the virus which the chancrous mat- 
ter undoubtedly contains (although we are unable to isolate it or to de- 
monstrate it to view) may be transferred to other parts of the body, and 
that it will cause inflammation and ulceration at its point of implanta- 
tion. In a similar manner the virus is very often taken up by the lym- 
phatic vessels, and conducted to the neighboring lymphatic glands, in 
which it also gives rise to specific inflammation and suppuration. A 
lymphatic gland thus inflamed and suppurating from absorption of 
the chancre-poison is called an acute, virulent bubo, or, what is better, 
a glandular chancre. All chancres do not cause virulent adenitis with 
equal frequency. It is most apt to accompany an ulcer of the frasnu- 
lum. Neglect of cleanliness and a too irritating mode of treatment 
seem to favor absorption of the virus, and the production of the viru- 
lent bubo. Cases seem to occur now and then, in which the virus 
reaches the corium through the epidermis without producing any lesion 
at its point of entry, but is there taken up by the lymphatics, carried . 
by them to their glands, where it gives rise to specific inflammation and 
suppuration. Such a bubo, which has not been preceded by a chancre, 
is called a “ bubon d’embl^e.” 
Symptoms ixd Course.—A virulent bubo generally makes its ap- 
pearance in the second, third, or fourth week, more rarely in the fifth 
or sixth week, and it sometimes develops immediately after the forma- THE GLANDULAR CHANCRE. 
751 
tion of the chancre. The first symptom of this troublesome complica- 
tion consists in a feeling of pain at a circumscribed point in the groin, 
not far from the genitals. Upon examination, we find a small lump, 
which, already even, is sensitive to the slightest pressure, and which 
corresponds to a moderately enlarged inguinal gland. The dispropor 
tion between the severity of the pain and the smallness of the swell- 
ing, the proximity of the latter to the genitals, the fact that one or two 
only of the glands are enlarged and never a large number of them, 
make us aware, even thus early, that we have to deal with an acute 
virulent bubo, and not with the so-called sympathetic bubo, or with 
the syphilitic glandular enlargements hereafter to be described. The 
further course of the virulent bubo varies. In very rare instances the 
inflammation is resolved, and the pain and swelling of the affected 
gland gradually subside. In such cases it is not improbable that it is 
merely the inflammation which has spread along the lymphatic vessels 
to the gland, but that the chancrous virus has not been absorbed with 
it, or, in other words, that the bubo is a sympathetic one. The process 
above alluded to, namely, the extension of an inflammation along the 
lymphatics to the lymphatic glands is a very common occurrence also 
among non-specific ulcers. Far more frequently, and probably always, 
in the case of a virulent bubo, the inflamed gland suppurates. In 
favorable cases the pus soon perforates the capsule of the gland and 
the adherent skin which covers it. In other instances, the connective 
tissue about the gland becomes the seat of an extensive inflammatory 
exudation, the tumor becomes much enlarged, and is no longer mova- 
ble. It becomes very difficult for the patient to walk, and, in spite of 
the efforts which he usually makes to conceal it, we can perceive that 
he favors the affected side as he steps. In persons with a tendency to 
fever, there is also an elevation of temperature, acceleration of the 
pulse, general malaise, and other febrile symptoms. Considerable time 
elapses thus, ere the skin begins to redden, and ere the circumscribed 
point of fluctuation makes its appearance. If a puncture then be made 
at this point, or if the skin assume a dark-red hue and grow thinner 
and thinner, until the matter is discharged spontaneously, a small 
portion only of the swelling subsides, and it is often as large as a 
man’s fist, and of an irregular, knobby form. By-and-by fluctuation, 
followed by escape of matter, occurs at other points; but, in spite of 
the numerous abscesses, weeks and months often pass by without any 
diminution in the size of the tumor in which they form. The course 
of a virulent bubo is equally tedious and intractable, if the matter 
which has escaped from the inflamed gland into the surrounding 
areolar tissue have formed sinuses and fistulous tracts, as well as 
when the accumulation of matter within the gland is slow to point and 752 
CHRONIC INFECTIOUS DISEASES. 
does not discharge itself until the inflammation of the surrounding tis- 
sues has also resulted in numerous abscesses. After breaking of the 
abscess and discharge of the matter, the resulting ulcer shows the 
properties of a chancre and discharges inoculable pus. Its edges are 
ragged, bluish red, and generally somewhat undermined; its floor is 
covered with false membrane, and it is very slow to heal. A chancre 
thus produced from a virulent bubo may become phagedenic or gan- 
grenous, and may give rise to wide-spread destruction, which some- 
times terminates in erosion of the femoral vessels, or in peritonitis. 
Treatment.—It matters little whether a virulent adenitis be ac- 
companied by a chancre or not; in either case, the probability that the 
inflammation of the gland will not end in suppuration is so small, that 
we may spare the patient the applications usually recommended to 
discuss a bubo, such as leeching, inunction of blue ointment, method- 
ical bandaging, and the like. I usually cover a bubo with a simple 
plaster, generally the emplastrum fuscum (emplas. galbani. co.), and 
make it fast with a spica bandage. Under such treatment the bubo 
now and then subsides; in other instances, it suppurates without 
causing the patient much annoyance. Should fluctuation appear at a 
point which unmistakably corresponds to the gland, I immediately let 
out the matter through one or more punctures; but if the surrounding 
areolar tissue be already in a state of phlegmonous inflammation, and 
if fluctuation appear, which does not seem to be in a gland, but to 
proceed from a phlegmonous abscess, I am not so hasty in opening it, 
but prefer to wait until the parts about the softened spot are also in 
a state of suppuration, and until the hardness has disappeared under 
the pressure of the pus. As soon as this occurs, and after the skin 
over the point of fluctuation has become well thinned, I convert the 
entire top of the abscess into an eschar, by persistent rubbing with 
caustic potash. During this process (which I learned at the Hamburg 
hospital) the adjacent parts must be protected from contact with the 
liquefying potash. This treatment is, no doubt, painful, but has this 
great advantage, that no fistulous track nor sinuses ever form, and that, 
the day after the separation of the eschar, the bottom of the abscess 
presents the aspect of a healthy ulcer. According to my experience, 
also, this cure is much more rapid than when we have to make punc- 
ture after puncture, as fresh points of fluctuation show themselves, to 
lay open fistulae as they form, and to remove the undermined edges of 
the ulcer. 
Latterly, I have often had recourse to another mode of treating 
virulent buboes, and with striking effect. I put a vesicatory upon the 
tumor, cautiously open the resulting blister, and then allow a new 
cuticle to form under a simple dressing. I then immediately blister CONSTITUTIONAL SYPHILIS. 
753 
again, and repeat the procedure until the infiltration about the gland, 
which usually begins to resolve after the first vesication, disappears 
entirely. Then, if a fluctuating point appear, I puncture it, or destroy 
its covering with caustic paste. In none of the cases thus treated by 
me have any sinuses or fistulas formed 
B.—CONSTITUTIONAL SYPHILIS 
The question as to the origin of the syphilitic poison is quite as 
obscure as is that of the origin of the chancre-virus. At the present 
day, syphilis is a purely contagious disorder. Its venom reproduces 
itself in the organism which it infects, and the transplantation to an- 
other person, of the virus thus reproduced, is the only manner in which 
syphilis can be propagated. 
The exact nature of the syphilitic virus, or, as we may say with 
equal propriety, the syphilitic contagion, is unknown, since we are un- 
able to obtain it in an isolated form, and to test its chemical and phys- 
ical properties. Like the chancre-virus, however, it is of a fixed char- 
acter, and does not pervade the atmosphere around the patient; but 
its habitat is by no means confined to the secretion from the syphilitic 
ulcer, and to the contents of syphilitic tumors, for it is also contained 
in the blood. It does not seem to exist in the natural secretions of 
the body, such as the saliva or urine, nor in pathological exudations 
produced by intercurrent disease. Thus, if we inoculate a healthy 
child with pure vaccine lymph, obtained from a syphilitic subject, the 
child thus vaccinated does not become syphilitic; but, if the lymph 
contain a little blood, which is a vehicle for the syphilitic poison, the 
latter will also be implanted upon the patient. It has not yet been 
determined whether the virus exists in the milk of a syphilitic woman. 
The frequence with which the disease is transmitted to infants, from 
wet-nurses, may be due to the existence of bleeding excoriations upon 
the nipples of the nurse. In the following chapter we shall treat of 
its propagation during the act of generation. 
Liability to syphilis is so general, that an immunity to its virus, if 
it exist at all, is certainly very rare. The fact that healthy persons, 
adults, and men, are more frequently infected than invalids, women, or 
children, is simply because the former are more apt to be exposed to 
the disease than the latter. Like the chancre-virus, the syphilitic poi- 
son is more difficult of inoculation when the cuticle is thick and resist- 
ing than when it is the reverse, a circumstance which argues in favor 
of the practice of circumcision. Infection is also more likely to occur 
when the genitals are strongly developed than when they are small. 
Eczema of the glans and prepuce, likewise, greatly increases the dan- 
ger. Notwithstanding this very general susceptibility to the syphilitic 754 
CHRONIC INFECTIOUS DISEASES. 
virus, however, the system once contaminated by it obtains an immu- 
nity almost absolute against subsequent infection. This very interest- 
ing fact is analogous to the freedom from further attacks of scarlatina, 
measles, and small-pox, enjoyed by persons who have once suffered 
from those diseases. If we inoculate the discharge of a syphilitic sore, 
or any other vehicle of syphilitic contagion, upon a person who has a 
primary syphilitic induration or syphilitic ulcer, at the moment of in- 
oculation, or who has already had one, we shall obtain negative results, 
It is this fact which has given rise to such gross errors. For a long 
time experimental inoculation was only practised upon individuals who 
were already syphilitic, and, from the negative results which followed, 
when blood or the secretion of secondary sores was employed, it was 
inferred that blood and secondary secretions were not contagious. It 
was not until it was determined to inoculate healthy, or, at least, non- 
syphilitic persons with these vehicles that it was ascertained that the 
want of result of the former experiment was simply due to the immunity 
of syphilitic persons to further infection, and that their blood, and the 
discharge from secondary syphilitic ulcers, were quite as infectious as 
the secretion of a primary sore. Exceptions to this rule seemed to oc- 
cur ; inoculation of the secretion of a primary sore upon the person 
having the sore resulting sometimes in another sore. It is now deter- 
mined that in such cases the syphilitic ulcer is complicated by the 
chancre. The ulcer which follows the inoculation is a chancre, and 
not a syphilitic ulcer. Contamination of the system with syphilitic 
virus affords no protection against infection by the chancre, any more 
than does the preexistence of one or several chancres secure the pa- 
tient from further action of the chancrous virus. 
Since even a person having a primary syphilitic ulcer or induration, 
but who has no secondary symptoms, is already secure from further 
syphilitic infection, we may regard the primary induration and ulcer as 
a sign of contamination of the system, and as the first symptom of con- 
stitutional syphilis. Since, however, the above-named affections stand 
first in the series of disorders which occur, and as the first sign of con- 
stitutional infection always appears in the form of an ulcer or indura- 
tion at the point of entry of the virus, the terms “ primary induration ” 
and “ primary sore ” may be regarded as perfectly appropriate. The 
immunity against fresh infection, which contamination with 
poison affords, accounts for the interesting and formerly very perplex 
ing fact that infants are infected by syphilitic nurses more frequently 
than by syphilitic mothers. Generally, a child sucking at the breast 
of its nurse is not at first syphilitic, and, therefore, is liable to infec- 
tion, while the child which sucks the breast of a syphilitic mother i? 
nearly always syphilitic itself, and hence can not be inoculated. CONSTITUTIONAL SYPHILIS. 
755 
By far the most frequent exciting cause of syphilis is coitus with 
an infected individual; but there are many well-authenticated cases 
where infection has been conveyed by the hand of a physician or mid- 
wife, by using a pipe, or tumbler, or privy, polluted by the venereal 
virus. There is no doubt, moreover, that the disease has often been 
propagated by vaccination, and another series of cases is known to 
have sprung from the use of dirty lancets, and in bleeding and cupping, 
by careless surgeons. 
Symptoms and Course.—I. The Primary Syphilitic Indura- 
tion, and Primary Syphilitic Ulcer.—The period of incubation of the 
syphilitic virus is from three to four weeks. A correct knowledge of 
this fact is of recent date. Prior to this discovery, which was made 
by inoculating healthy subjects with syphilitic virus, we were unable 
to account for the phenomenon that, in a large number of cases, a chan- 
cre (chancroid), after lasting for some weeks, would become indurated 
at its base and edges; and this it was which caused the false impres- 
sion that a soft chancre could assume a pernicious character, and 
change into a hard one. Experience has taught that the indurated 
chancre is almost always the precursor of secondary symptoms. The 
following is the correct interpretation of these facts: Both poisons, 
the chancrous, as well as the syphilitic, act simultaneously upon one 
and the same point; in a few days the chancre forms; the period of 
incubation of its virus being a very short one. Three or four weeks 
afterward, the time of incubation of the syphilitic contagion having ex- 
pired, the syphilitic induration develops at the base and edges of the 
ulcer. It may happen that the chancre has healed before the incuba- 
tive stage of the syphilis has terminated. In such a case an indura- 
tion forms in the scar of the chancre. The conversion of a syphilitic 
induration into a chancre, by the implantation of chancrous virus, may 
also take place. 
[Some observations seem to indicate that the poison of chancre 
and chancroid may be present on the same sore, giving a “ mixed 
ulcer ; ” so that an apparently soft chancre may become indurated 
and be followed by constitutional symptoms, and, on the other hand, 
inoculation from an apparently hard chancre on the bearer of it may 
induce a chancroid. It has, however, been asserted that inoculation 
of pus of any hind in a syphilitic patient may induce an ulcer re- 
sembling a chancre. Even on this point, where so many observa- 
tions have been made, opinions are not undisputed ; and we may 
consider that the relation of chancre and chancroid to each other, 
and to syphilis, is not absolutely determined in all details. 
After exposure to the disease, some time elapses before the de- 
velopment of the indurated sore, then some weeks longer before the 756 
CHRONIC INFECTIOUS DISEASES. 
appearance of the other symptoms of constitutional syphilis. There 
is considerable regularity in the succession of these symptoms, re- 
minding us of the course of the acute exanthemata. There may 
even be premonitory fever and enlargement of the spleen. The 
so-called “secondary” symptoms affect the skin and mucous mem- 
branes ; in the “ tertiary ” stage there are changes in the subcu- 
taneous and submucous connective tissue, the bones, fibrous and 
serous membranes, and internal organs. This division into stages is 
not always accurate, as they may extend into each other ; but usu- 
ally they are separated by an interval of latency more or less long. 
Chancroid sometimes occurs in the anus and rectum from un- 
natural coitus, or from the pus of a neighboring chancre. A care- 
less physician may mistake syphilitic ulcerations of the anus for 
haemorrhoids ; they may cause stricture of the rectum. If syphilitic 
iritis be accompanied by much dimness of vision, this may be due 
to cloudiness of the vitreous or to retinitis. 
"When the periosteum and bones are diseased, the joints may 
become affected from the same cause ; but other joint-affections 
may occur incidentally, and be called syphilitic rheumatism. Even 
in these cases, iodide of potassium is very useful. 
All authors do not agree that treatment of the primary sore is 
useless ; but some claim that where it is recent and favorably situ- 
ated (on the prepuce, etc.), it may be excised and sequela? be thus 
prevented. Fournier says, in treating syphilis, he gives one or two 
grains of iodide of mercury daily for two months, then discontinues 
for one month ; a second treatment for two months is followed by 
an interval of three months, and a third treatment for one or two 
months. This treatment with increasing intervals is continued for 
two years. The second year iodide of potash is combined with the 
mercurial.] 
After inoculation of a suitable subject with syphilitic virus, whether 
accidental or intentional, that is to say, of a subject who is not syphi- 
litic, and who has never been so, and after expiration of the term of in- 
cubation, there arises, not a vesicle nor pustule which breaks, leaving 
a sore—as occurs after infection from the chancre—but a hard papule, 
or nodule of variable size and thickness. The smaller syphilitic indu- 
rations are of the size of a lentil or pea, the larger attain the size of a 
bean, or of a small hazel-nut. Microscopic research shows the indura- 
tion to be the product of profuse proliferation of cells and nuclei, which 
have no characteristic peculiarities, and which lie embedded between 
the normal elements of the parts, in the scanty connective tissue. The 
epidermis, or epithelium, over this lmi'd infiltration, at first does not ex- 
hibit any lesion; but soon the epithelial covering begins to exfoliate, CONSTITUTIONAL SYPHILIS. 
the new coating becomes thinner, the surface shows a peculiar glitter- 
ing, dirty redness, and, after repeated exfoliations, the epithelial coat 
is not renewed, but the surface remains raw, and gives off a scanty 
secretion. In other instances the surface forms a scab, which, after 
separation, leaves an ulcer with a hard base. The primary syphilitic 
ulcer may be called the ulcerative induration of syphilis. Its most 
common situation is upon the genitals; in men, upon the inner surface 
of the prepuce, and in the coronary fossa; in women, between the 
nymphse, at the posterior commissure, and at the entrance to the 
vagina. Sometimes, however, it appears upon the nipples, at the 
angles of the mouth, upon the tongue, and not unfrequently upon the 
fingers. No part of the body is exempt, and a syphilitic induration 
will arise wherever the virus touches a spot where the cuticle is thin, 
or where it has been abraded. The localities above mentioned, how- 
ever, are the ones most favorable to the occurrence of infection. When 
but a single follicle is implicated, the induration assumes the form of an 
upright cylinder, and, if a series of them lying close together be in- 
volved, the confluence of these indurations forms a hard elevation. 
When the induration is situated upon the lips of the meatus urinarius, 
that orifice forms a somewhat gaping, rigid funnel, which feels carti- 
laginous to the touch. Not unfrequently, when the mouth of the pre- 
puce is somewhat narrow, its anterior border becomes fissured during 
coitus. If this point becomes indurated in consequence of syphilitic 
infection, the prepuce can no longer be drawn back, its outlet having 
been converted into a hard ring. A phimosis of this kind will subside 
after the induration has been resolved. 
The bottom of a syphilitic ulcer is not lardaceous, its edges are not 
eroded, nor does it show any tendency to spread. All these charac- 
teristics are peculiar to the chancre (chancroid), nor is a syphilitic sore 
painful, like a chancre, being usually very indolent. It is also soli- 
tary, as a rule; and it is only as an exception, when several points are 
infected simultaneously, that several syphilitic sores are ever seen to- 
gether. Until the induration ulcerates, it is often overlooked; and it 
is not until the sore is established, that the attention of the patient or 
physician is drawn to it. Sometimes, the induration is so slight, that 
the sore may be mistaken for a chancre. In such cases all doubt may 
be dispelled by inoculation. 
The following are the more important forms recognized among 
syphilitic ulcers: 
The superficial ulcer (Ricord's chancre parchemine). In this 
Variety the induration forms a thin cake. An attempt to pinch up a 
spot of this kind between the fingers imparts a feeling as though a bit 
of parchment had been slipped beneath the ulcer. Its surface secretes 758 
CHRONIC INFECTIOUS DISEASES. 
a scanty thin liquid, in which no pus-cells can be found under the micro- 
scope, but only a granular detritus. It often heals quickly, but the 
secondary symptoms follow this form of sore quite as surely and 
promptly as any other variety. 
The elevated sore (ulcus elevatum) presents an excoriation which 
is almost void of discharge, seated upon an indurated base of varying 
thickness and consistence, by which it is elevated above the surround- 
ing level. From time to time it is coated by a thin layer of epithelium, 
which generally soon exfoliates in fine scales, leaving a new excoriation. 
The Hunterian chancre (ulcus vallatum) not only has a hard base, 
but is surrounded by an elevated, hard, callous border, so that it is 
deeper in the middle than at the periphery. It rarely heals in less 
than five or six weeks. 
All the different forms of syphilitic sore may become phagedenic, 
that is, they may be attacked by a rapidly-extending diphtheritic pro- 
cess. The destruction then often spreads beyond the limit of the in- 
duration, largely involving the skin or mucous membrane. When the 
syphilitic induration is associated with the chancre, the operation of 
both poisons upon the same point results in a modification of the ulcus 
vallatum, that is, the border of the chancre becomes hard and callous, 
and surrounds it like a wall. At a later period the induration likewise 
appears in the bottom of the ulcer. 
The duration of a syphilitic induration or a syphilitic sore varies. 
Three months, at least, nearly always elapse ere the hardened spot 
recovers its normal consistence. The induration often lasts half a year, 
and even longer. It is remarkable that, as the secondary symptoms 
begin to appear, the induration begins to dissolve, and then soon sub- 
sides, leaving behind it a brown pigmented spot. The pigment marks 
the former site of the disease for a tolerably long time. When it 
finally disappears, the spot remains whiter than the adjacent parts, 
like the cicatrix of a neoplastic growth. Unless the indurated spot 
has also been the seat of a chancre, there is no depression. 
II. The Indolent Bubo and Extended Syphilitic Disease of the 
lymphatics,—An acute enlargement of the lymphatic glands occurs 
in many of the acute infectious diseases and in syphilis, the prototype 
of the chronic infectious maladies, the lymphatic glands always parti 
cipate in the disorder induced by infection of the system by this per 
nicious poison. The changes which take place in the glands consist ir 
a cellular hyperplasia, and they are but seldom the seat of actual in 
flammation or suppuration. More frequently, especially when the dis- 
ease lias been of long standing, caseous metamorphosis occurs here and 
there in them, and this is afterward followed by a calcification. In a 
few days after its development, the primary syphilitic induration CONSTITUTIONAL SYPHILIS. 
759 
almost always gives rise to a painless or else to a very slightly pain- 
ful enlargement of the inguinal glands—to indolent buboes. The 
number of the glands implicated is always somewhat large, and they 
are seldom very greatly swollen. Each gland usually attains the size 
of a bean or almond; and it is exceptional, and only in scrofulous sub- 
jects, that it becomes as large as a walnut. The surrounding con- 
nective tissue is not affected; the glands remain isolated, and, even 
when their number and the degree of tumefaction are such as to pro- 
duce a large lump, it is always of an irregular nodulated shape, and it 
can readily be perceived that it consists of a conglomeration of iso- 
lated glands. Sometimes a thickened and indurated chain of lymphat- 
ic vessels can be detected between the primary sore and the indolent 
bubo. In the rare instances in which indolent buboes suppurate, the 
skin becomes adherent to the glands beneath it, and gradually reddens, 
and the tumor becomes painful; some time elapses, however, before 
fluctuation appears. If, finally, the purulent contents escape, or if they 
be evacuated artificially, they leave sinuous and tedious fistulous ulcers 
behind them. Involution of an indolent bubo proceeds very slowly. 
Several months always elapse ere the swelling of the glands dimin- 
ishes, and often the last trace of the enlargement does not disappear 
for years. Whenever cheesy metamorphosis with calcification has oc- 
curred, small hard elevations remain for life. The usual seat of pri- 
mary induration being upon the genitals, indolent buboes are generally 
found upon the inguinal region; and it is almost without exception 
the glands which lie above the fascia lata, on the side corresponding to 
the seat of the primary sore, which are affected. In primary affections 
of the mouth and fingers, it is respectively the submaxillary and axil- 
lary glands which are involved. 
About five or six weeks after the formation of the indolent buboes, 
upon careful investigation, we shall find numerous enlarged lymphatic 
glands, lying far away from the point of infection and from the indolent 
bubo, and situated in various regions of the body. This enlargement 
is most frequent and conspicuous in the cervical and axillary glands, 
the inguinal glands of the opposite side, and the cubital and submaxil- 
lary glands. The size attained by these enlargements varies from that 
of a pea to that of a bean or hazel-nut. They are quite painless; and. 
even when pressed upon, are not more sensitive than other parts of 
the skin. These diffuse glandular swellings often last for years; and, 
as long as they continue to exist, the syphilis is not extinct, even 
though no other manifestation of lues be discoverable. Inflammation 
and suppuration of such glandular swellings are quite exceptional, and 
are then always the consequence of a complication. 
HI. Condylomata.—The only condylomata which are of syphilitic 760 
CHRONIC INFECTIOUS DISEASES. 
origin are the broad ones covered by a thin coat of epidermis, 3m 
which, if seated upon the skin, are usually in a state of superficial 
ulceration, and bathed in a slimy, ill-savored secretion. The dry, 
pointed condylomata, which are covered by a thick layer of epidermis, 
are the result of local irritation, and most commonly appear at points 
moistened by gonorrhoeal discharge. The syphilitic condyloma is one 
of the most frequent symptoms of general infection of the system, 
and it rarely fails to appear in the series of morbid processes which 
gradually develop under the influence of the venereal poison. As a 
rule, too, the condyloma is the first symptom which succeeds the pri- 
mary affection and the enlargement of the lymphatics. Its external 
aspect and histological character have already been described. Upon 
the skin, the most frequent seat of the 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. Their appearance at the angles of the mouth is 
quite common; they are more rare at the commissure of the eyelids, 
between the toes, and under pendulous breasts. They often become 
fissured, especially when they have coalesced so as to form extensive 
growths, and in this way painful and obstinate ulcers often form. 
Fissures and cracks (rhagades) frequently appear in the skin about 
the condylomata. They are attended by severe pain and heal slowly. 
We have already treated of the condylomata of the mucous membrane, 
of the mouth and fauces (plaques muqueuses), and of the condyloma- 
tous growths which accompany syphilitic laryngeal ulceration. 
IV. Syphilitic Disease of the Skin—Syphilides—Syphilitic Ex- 
anthemata.—Syphilitic affections of the skin depend partly upon hy- 
peraemia and exudation, and partly upon the development and meta- 
morphoses of the “ gummy tumor ” (tubercular syphiloma) of the skin. 
In the former class the exudation is sometimes thrown out upon the 
surface of the skin, sometimes within the tissues, and sometimes in 
both together. A classification of the syphilides into many species 
has been based upon the modifications thus induced, and upon the 
variety in extent and magnitude of the eruption. Since, however, 
the classification of all other non-specific hyperoemic and inflammatory 
cutaneous affections is also founded upon similar data, we may be 
brief in our discussion of the syphilides, and confine ourselves to a 
description of the differences by which the syphilitic exanthemata may 
be distinguished from the non-syphilitic ones. 
The general peculiarity of syphilitic eruptions, upon which most 
weight has always been laid, is their color; and, indeed, all syphilitic 
exanthemata, when of somewhat long standing, are of a peculiar 
coppery-red hue ; and chronic eruptions which do not present this color, CONSTITUTIONAL SYPHILIS. 
761 
even though the}7 appear upon notoriously syphilitic subjects, ought not 
to be regarded as of syphilitic origin. This proposition, however, does 
not admit of inversion. A rash need not be syphilitic because it has a 
coppery color, as is sufficiently proved in cases of psoriasis and of acne 
rosacea (commonly known as “ copper nose,” on account of its appear- 
ance). The origin of this color is to be attributed to the addition to 
the redness, caused by the capillary hyperaemia, of yellow, blue, and 
brown pigment, the result of minute extravasations of blood, and the 
metamorphoses of the hsematin thus set free. In very recent cases the 
coppery hue is not observable, no extravasations having as yet oc- 
curred, or because the effused blood has not yet undergone change of 
color. 
Another characteristic of the syphilitic exanthemata (which is 
closely related to the foregoing one, as it also depends upon gradual 
transformation of the coloring matter of extravasated blood into pig- 
ment) is, that, after they have recovered, stains of pigment are almost 
always left in the skin. 
Syphilitic eruptions may be further distinguished from non-syphilitic 
ones, from their type being still less distinctly marked than that of the 
latter. In the same subject we almost always find patches which be- 
long in part to one and in part to another species, and here and there 
a spot about w7hich wTe shall be in doubt what category to assign it to 
For instance, there are often red spots which we hesitate to call roseola/ 
because they are covered with scales of epidermis; but, on the other 
hand, we cannot regard them as psoriasis, because their coat of epi- 
dermic scales is so much thinner than in the non-syphilitic psoriasis. 
The situation of the efflorescence is also of great importance in dis- 
tinguishing between the simple and the specific eruptions. The spe- 
cific exanthemata are most apt to appear upon parts of the skin which 
are exposed to the air, and upon • such as lie immediately above the 
periosteum. It is a very suspicious circumstance, when a rash which 
has a peculiar predilection for certain localities—as psoriasis has for 
the knees and elbows—appears elsewhere, upon some unusual region 
instead of upon its favorite seat—as when psoriasis affects the palms 
of the hands. Another peculiarity of a syphilitic eruption is, that the 
various efflorescences generally take the form of circles, or of segments 
of circles. It is to be borne in mind, however, that it is only -when 
this circular arrangement is the result of grouping, and not when it 
proceeds from healing of a disease in the middle while it continues to 
spread at its edges, that it is characteristic of syphilis. Finally, it 
may be added, that syphilitic eruptions scarcely ever itch. In order to 
determine the question of the syphilitic origin of a doubtful case, it is 
of importance to ascertain whether it has been preceded by a primary 762 
CHRONIC INFECTIOUS DISEASES. 
ulcer, and whether there be any other concomitant syphilitic disease. 
The crusts and scabs which form in syphilis are distinguishable by being 
much thicker, as a rule, than those of non-syphilitic origin. This is 
generally because, beneath the dried, purulent contents of a syphilitic 
pustule, there is usually an ulcer, the product of which also thickens 
and dries into a scab. The kidney-shape or horse-shoe shape of specific 
ulcers of the skin is also somewhat characteristic. This is due to the 
healing of the sore at one edge while it spreads at another. 
The most common form of syphilitic cutaneous disease is the macu- 
lous exanthema, the roseola syphilitica. This is an eruption of small, 
irregular round spots of roseola, which here and there are often con- 
fluent ; and its appearance is often preceded by a febrile disturbance. 
The favorite seat of the rash is upon the belly, on the sides of the chest, 
and upon the flanks. The face is hardly ever affected beyond where 
the forehead and scalp join. At first the spots are bright red, but 
afterward become livid and coppery. Some of them are level with the 
skin, while others rise slightly above it. In the latter case they re- 
semble the wales of urticaria, although, unlike the latter, they do not 
itch. After lasting a long time, the roseola spots assume a dirty 
brownish-red appearance, and, when they finally fade, they leave a 
grayish-brown stain behind them. Sometimes the eruptions extend to 
the glans penis. In the latter situation, the epidermis over the efflo- 
rescence soon separates, leaving a bright-red, moist erosion, which 
bleeds readily, and which is not to be confounded with the superficial 
chancre. The roseola is one of the earliest symptoms of constitutional 
infection. It is never seen in inveterate cases. When treated by 
mercury, it usually subsides within four weeks. When neglected, it 
passes over into the papulous, squamous, and pustulous forms of syphi- 
lide. The papulous syphilide (lichen syphiliticus) is characterized by 
its coppery-red, and frequently, in old cases, by its brownish-red color. 
The papules are sometimes no larger than a millet-seed (miliary pap- 
ules) ; sometimes they attain the size of a lentil (lenticular papules); 
sometimes they are solitary; sometimes they form groups, which latter 
usually assume the form of circles, or the segment of a circle. Their 
most common seat is the junction of the forehead with the hairy scalp, 
although they also appear upon the trunk and extremities. When of 
long standing, they are usually covered with scales of detached epider 
mis. If, instead, small pustules form upon the apices of the papules, 
the eruption is generally called acne syphilitica. Like the maculous 
syphilide, the papulous exanthema appears early in the disease, although 
it is sometimes observed in its later stages. In such cases, the points 
of efflorescence are less numerous, and evince a still more marked ten- 
dency to form circles or arcs of circles. The papulous sjqflnlide is CONSTITUTIONAL SYI HILTS. 
763 
more intractable than the maculous, and several weeks usually elapse 
before it yields even to an energetic treatment. 
The scaly syphilitic eruption (psoriasis syphilitica) often com- 
mences as a syphilitic roseola or lichen. The spots are discrete, and 
rarely become large, although they may be very numerous. The color 
of a specific psoriasis is generally darker than non-specific, and the 
scaly layer is usually thin. Not unfrequently cracks form in the infil- 
trated skin, which lead to ulceration. As we have already remarked, 
the knees and elbows are hardly ever affected in syphilitic psoriasis. 
Palmar and plantar psoriasis, which always is of syphilitic origin, 
begins with the formation of small, round, or oval callous spots of a 
pale-red or yellowish color. After the thickened cuticle has become 
detached from these spots, or has been scratched off by the patient, 
the copper-colored, infiltrated cutis is exposed to view, surrounded by 
concentric circles of dried desquamating epidermis. This circle en- 
larges, while sometimes the centre begins to heal, or covers itself 
afresh with a coat of horny cuticle. Now and then the efflorescences, 
which at first were separate, afterward coalesce, causing great thick- 
ening of the epidermis, which cracks readily, forming extremely painful 
fissures or rhagades. 
The pustulous syphilide is called impetigo, or ecthyma, according 
as it produces small and pointed or large and flat pustules. They are 
sometimes solitary, sometimes formed in groups, and appear upon the 
face and scalp as well as upon the body and extremities. They are 
surrounded by a coppery areola, and dry up into scabs, which, when 
situated upon the scalp, are very annoying, owing to their liability to 
be torn off by the comb. Beneath the scabs of the ecthyma pustules, 
and more rarely under those of impetigo, there are ulcers, which eat 
more or less deeply into the cutis. The color of the scars, which 
always remain after the healing of ecthyma, is at first a coppery-red, 
and afterward remarkably white. Syphilitic impetigo and ecthyma 
are more serious affections, and appear at a later stage of the disease 
than any of the exanthemata hitherto described. In spite of the most 
careful treatment, many months often elapse ere they begin to heal. 
The pustulous syphilides are quite intractable, and sometimes outlast 
all the other symptoms of the disease. 
There is an eruption known as varicella syphilitica, and which, in- 
deed, bears a great resemblance to varicella. It is almost always pre- 
ceded by febrile disturbance. The vesicles, which are numerous, and 
scattered more or less over the whole body, spring from red maculae. 
The liquid contained in them is at first slightly turbid, afterward 
purulent, and finally dries up into round, blackish crusts, which, when 
they fall, leave brownish stains behind. This, also, is an obstinate 764 
CHRONIC INFECTIOUS DISEASES. 
variety, and often drags on with repeated relapses for weeks and 
months. 
Rupia syphilitica, like ecthyma, originates in a destructive derma- 
titis. Its mode of development is as follows: Upon a livid, red spot, 
of the size of a pea or bean, there rises a flabby bleb, containing a 
dirty, turbid, and sometimes bloody liquid. The contents of the bleb 
dry up into a scab, which gradually is built higher and higher by the 
product of the ulceration, which is constantly eating deeper into the 
skin beneath it, while a ring of new vesicles forms around its border, 
the drying of whose contents makes the scab wider. If we detach 
one of these oyster-shell-like crusts, we find beneath it a foul, ulcerated 
surface, secreting a thin ichor. Sometimes large portions of the body 
are studded with numerous rupia scabs, which here and there are con- 
fluent. In other instances, there are only a few, which then are very 
large. Like ecthyma, rupia belongs to the graver affections, and only 
appears at an advanced stage of the disease. They heal very slowly. 
Not unfrequently, only one side of the ulcer beneath the scab heals, 
while on the other it continues to spread. In this way, horseshoe- 
shaped, or kidney-shaped ulcers form. The scars, which always result 
from rupia, are like those of ecthyma, only larger. 
While the syphilitic cutaneous affections hitherto described are the 
result of irritative and inflammatory processes, syphilitic lupus depends 
upon the development and degeneration of a neoplasm peculiar to this 
disease, which arises in the form of nodules (“ tubercula syphilitica ”) 
not merely in the skin, but in a variety of other organs. These syphi- 
litic tubercles (called “ gummata,” or “ gummy tumors,” by Virchow, 
even when they are of a hard consistence, and remain so while they 
exist, and which are called “ nodular syphiloma ” -by Wagner) have 
nothing in common with tubercle in the common sense of the word. 
Virchow counts them in the class of “ granulation tumors,” that is, 
tumors which even at their fullest stage of development contain no 
mature connective tissue, nor any analogue of it, but consist mainly of 
elements of a transitory nature, and in which degeneration, death, 
softening, and ulceration is the regular and necessary consequence of 
existence. Wherever the syphilitic tubercle appears, it consists of 
nests of very numerous small cells, with large nuclei, which are lodged 
in the interstices of the affected tissue, and from which they have sprung 
through profuse multiplication of its cellular elements. The recent 
nodules are soft, of a grayish-red color, and infiltrated with a scanty 
juice. After lasting for some time, they either soften and ulcerate, or 
else undergo an incomplete cheesy metamorphosis. The most frequent 
seat of the syphilitic cutaneous tubercle is upon the face, especially 
upon the forehead (corona veneris), and, next in frequence, upon the CONSTITUTIONAL SYPHILIS. 
765 
region of the shouider-blades, and the dorsal surface of the extremities. 
Some of the nodules are superficial, while others are deeply seated. 
The more superficial ones are smaller, while the deeper seated ones 
are larger. At first a small, movable tumor, somewhat sensitive to 
pressure, appears in the skin, which gradually reddens above it, and 
rises into a dark-red hemispherical nodule, which rather resembles a 
boil. Sometimes the covering of the tubercle remains unbroken, and, 
its contents becoming absorbed, its surface gradually grows paler, 
sinks in, and a scar forms without there ever having been any ulcera- 
tion. If the tubercle breaks, a turbid, serous liquid escapes under the 
cuticle, and, thickening, forms with it a scab. Beneath this scab the 
ulcer continues to penetrate more and more profoundly. Not unfre- 
quently one common, broad crust covers a cluster of nodules. The 
ulcer may retain the circular shape of the tubercle, but it more com- 
monly happens that the sore extends at one edge, while it granulates 
and cicatrizes at the other. Thus, like the rupia, the tubercle produces 
horse-shoe and kidney-shaped ulcers. The scars, which remain after 
healing of a syphilitic lupus, long retain a brownish-red stain, and, after 
the disease has subsided, become remarkably white. 
The hair often falls out, in syphilis; but, as a rule, this is merely a 
defiuvium capillorum, unless the scalp be the seat of an eruption. The 
hair-bulbs do not perish, and, after the disease has abated, the growth 
of the hair is as luxuriant as ever. The syphilitic exanthemata, on the 
other hand, usually destroy the hair-follicles, and cause permanent 
baldness or alopecia. 
The nails, also, undergo changes from implication of their matrix 
in the cutaneous disorder. In the simple infiltration of the matrix of 
the nail, which often accompanies psoriasis syphilitica, the nails de- 
generate, becoming misshapen, fissured, and homy. In the more rare 
ulceration of their matrix, they often become detached. 
V. Syphilitic Disease of the Mucous Membranes.—Next to the 
external integument, the mucous membranes are the most common 
seat of syphilitic disease, although all of them are not affected by con- 
stitutional syphilis with equal frequence. The lining of the mouth, 
fauces, nose, and larynx, and, next to these, the mucous surface of the 
rectum, are the regions upon which the malady is most prone to local- 
ize itself. 
The mildest form of syphilitic disease of the mucous membrane, 
and at the same time the one which appears soonest after the primary 
infection, is syphilitic catarrh. In special instances, it is not always 
easy to distinguish between a catarrh depending upon syphilis, and 
one arising from other causes. A remarkably deep, bluish redness, an 
abruot line of demarcation between the affected spot and the sound 766 
CHRONIC INFECTIOUS DISEASES. 
parts, and a milky, turbid appearance of its epithelial coating, are sus- 
picious, but not pathognomonic signs. In most cases the diagnosis 
depends mainly upon the history of the case, and upon the coexistence 
of other syphilitic symptoms, particularly enlargement of the lymphatic 
glands, and maculous or papulous exanthemata, and above all upon 
the refractoriness of the catarrh to simple treatment, and its speedy 
disappearance when treated by mercury. 
The appearance of mucous papules, with their transformation into 
condylomata, erosions, and ulcers, is one of the earlier symptoms of 
syphilitic infection. Their mode of development is as follows : A spot 
of mucous membrane of about the size of a pea rises above the sur- 
rounding level, and seems firmer, and somewhat reddened. If it does 
not heal after reaching this stage, the epithelium covering the flattened 
nodule becomes opaque, and assumes a milky, or pearly appearance. 
After separation of the thickened epithelium, a bright-red erosion re- 
mains, which bleeds easily. This is followed by a sore, with an un- 
even, whitish-gray bottom, the product of molecular disintegration, or 
else plaques muqueuse and mucous condylomata form, from augmented 
vegetation and development of connective-tissue fibres. We have al- 
ready treated of the syphilitic mucous papule, and of the ulcers and 
condylomata of the mouth, fauces, and larynx, to which they give rise. 
We rarely obtain an opportunity of observing the earlier stages of 
syphilitic disease of the rectum. The ulcers which arise from mucous 
papules of the rectum, and the scars which they leave after healing, 
bear a close resemblance to dysenteric scars. A distinction may be 
based in some measure upon the seat of the sore, and resulting cicatri- 
cial stricture, the syphilitic ulcers being situated in the cloaca of the 
gut, or else close to the anus, while the dysenteric ones are found in 
the sigmoid flexure. 
The gummata and tubercular syphilomata of the mucous membranes 
have the same character and mode of development as those of the 
skin. A nodule of the size of a shot forms in the mucous membrane, 
and gradually grows until it projects above the surrounding level. 
If not made to resolve itself by judicious treatment, it softens, bursts 
its epithelial cover, and turns into a sore. Wide-spread destruction of 
the nose, palate, fauces, and larynx, may thus occur. Not unfrequently 
the disease spreads to the submucous tissue, and the cartilage, perios- 
teum, and bones. The ulcers often produce contractions in healing. 
YI. Syphilitic Iritis.—The syphilitic contagion not unfrequently 
gives rise to inflammation of the iris and the choroid coat of the eye. 
This is a very common complication of the syphilitic exanthemata. 
Modern ophthalmologists deny the existence of any specific mark of 
distinction between the syphilitic and non-syphilitic inflammations of CONSTITUTIONAL SYPHILIS. 
767 
these membranes—such as distortion of the pupil inward and up- 
ward. Besides the simple syphilitic iritis, there is another form, 
known as “ gumraous” iritis. For a description of the very character- 
istic symptoms and course of this affection, we must refer to the text- 
books upon ophthalmology. 
VII. Syphilitic Disease of the Periosteum and Bones.—One of 
the common symptoms of syphilis consists in a pain along the bones, 
unaccompanied by any appreciable objective manifestations. At first 
these pains are vague and ill-defined. Afterward they are fixed at 
certain points, particularly in the bones lying close beneath the skin, 
such as the tibirn and the cranial bones. They are increased by pres- 
sure, and usually remit during the day and recur at night. These 
osteocopic pains are probably dependent upon a slight disease of the 
periosteum, capable of complete and speedy recovery, and which prob- 
ably consists in moderate hyperaemia with an inflammatory oedema. 
The severe strain which the naturally-unyielding periosteum suffers, 
even when but slightly infiltrated by serum, fully accounts for the vio- 
lence of the pain. 
In bad cases of inveterate syphilis, swellings form here and there 
upon the bones, accompanied by great suffering, which becomes excru- 
ciating at night. Such swellings, when of a boggy consistence, are 
called “ gummata; ” if their consistence be somewhat hard, they are 
colled “tophi” (nodes). Like all other syphilitic affections of the 
periosteum and bones, they are most apt to appear upon the skull, the 
shins, the sternum, and other bones lying close beneath the skin. 
Gummata receive their name from the viscid-looking liquid which 
flows from them when punctured. They consist of cells and nuclei, 
with very little connective tissue, and a great deal of liquid intercel- 
lular substance, their elements corresponding closely to those of the 
recent succulent syphiloma. These tumors may decrease and disap- 
pear entirely, the liquid and cells both being absorbed, the latter first 
undergoing fatty degeneration. In other instances pus forms in them, 
and they turn into abscesses, which, when opened, either naturally or 
artificially, discharge their contents. 
Tophi, although their consistence is very hard from the outset, so 
that they are apt to be mistaken by ignorant persons for excrescences 
from the bone, are circumscribed neoplastic thickenings and elevations 
of the periosteum by inflammatory exudation. The periosteum whence 
they spring has but little tendency to suppuration, and by means of 
an early and appropriate treatment we can often bring about their 
resolution. When of longer standing, bone forms in the thickened tis- 
sue ; the tophi are thus converted into exostoses, and are then no longer 
capable of reabsorption. Besides the form of exostosis just mentioned. 768 
CHRONIC INFECTIOUS DISEASES. 
which proceeds from ossification of the periosteum, there is another, 
dependent upon inflammation and proliferation of the bone itself 
Tophi and exostoses by pressure upon neighboring1 nerves may cause 
neuralgia, anaesthesia, or palsy, and when situated upon the inner sur- 
face of the skull may occasion serious disorder of the brain. 
Syphilitic caries and necrosis are sometimes the consequence of 
purulent periostitis, where the pus effused between the bone and peri- 
osteum has cut off the portion of bone affected from its nutrient blood- 
vessels. At other times it proceeds from an ulceration, originating in 
the soft parts, and which has destroyed the periosteum, and laid bare 
the bone; while, in still another series of instances, the periosteum, at 
first, is healthy, and the caries and necrosis are the result of a simple 
or gummy syphilitic inflammation. The question why the denuding 
of the bone of its periosteum and the ostitis sometimes cause an ul- 
ceration of the bone, or caries, while, at others, it induces the death 
and separation of large pieces of bone, or necrosis, we shall leave un- 
discussed, as being a question belonging to general surgery. When 
bone exfoliates from syphilitic necrosis, the loss of substance is seldom 
filled up by new bone. A depressed spot almost always remains, or, 
if the bone has been perforated, there will always be a hole in it with 
smooth edges. Syphilitic caries and necrosis occur more frequently 
upon the bones of the face and skull than upon those of the trunk 
and extremities, although the latter, especially the sternum, tibia?, and 
clavicles, do not always escape. The most dreadful devastation occurs 
in the bones qf the nose and hard palate. The vomer and the vertical 
plate of the ethmoid usually go first, so that the two nostrils commu- 
nicate by an orifice of variable size. Afterward the entire bony sep- 
tum perishes, and the turbinated bones, the walls of the ethmoid cells 
and frontal sinus, the nasal and lachrymal bones, are also destroyed. 
The nose thus loses its support, and sinks in behind its apex, which 
then points upward. If the disease attack the floor of the nostrils, 
after perforation of the hard palate, a communication is established be- 
tween the cavities of the mouth and nose; so that food and drink can 
enter the latter. More rarely, destruction of the hard palate com- 
mences in the mouth, although I have seen a piece of bone as large as 
a florin exfoliate from the lower surface of the hard palate, without 
any syphilitic ozeena. When caries and necrosis of the nasal bones 
arise from ulceration of the mucous membrane which has penetrated 
and destroyed the periosteum, the patients suffer long from an ill-smell- 
ing ichorous and often bloody discharge from the nose, which, at a later 
period, also contains bits of blackened bone. The septum of the nose is 
often perforated in such cases without its external covering exhibiting 
any particular change; but, if the destruction of the nasal bones be CONSTITUTIONAL SYPHILIS. 
769 
preceded by syphilitic periostitis, the skin soon becomes reddened, and 
the face grows cedematous upon the affected side. Sometimes the 
integuments are perforated by the pus and fragments of bone, and 
thus a fistulous opening is established in the back of the nose. Syph- 
ilitic ozasna, often causing a more or less extensive destruction of the 
bones of the nose, may recover completely. Some time ago, at the 
autopsy of a syphilitic person, besides an extensive recent anostosis 
excentrica (see below), I found a complete absence of the bony sep- 
tum, the turbinated bones of the nose and the inner walls of the antra 
of the upper jaws. But there was no bare bone to be found, the huge 
cavity which represented the nose being everywhere lined by a smooth 
cicatricial membrane. 
Besides caries and necrosis, a third destructive disease of the bones 
occurs in syphilis, which was first accurately described by Bruns, 
although Virchow first pointed out how frequently it originated from a 
syphilitic taint. Bruns describes this peculiar form of consumption of 
bone, to which he gives the name anostosis excentrica, as a dissolution 
and liquefaction of the bone, beginning excentrically, proceeding from 
the medullary canals and medullary cells, and marked by swelling and 
redness of the tissues contained in these spaces, but never accompa- 
nied by suppuration. The calibre of the canals is first enlarged at the 
expense of their walls, the progressive absorption of which ultimately 
causes the canals to blend into irregular cavities. The effect of this 
process is to render the diseased bone porous, and spongy, like carious 
bone, and in a macerated specimen it is impossible to tell whether the 
destruction is the result of caries or of anostosis excentrica. When 
the disease commences upon the exterior of the skull, its surface first 
assumes the worm-eaten, rough appearance of superficial caries; but 
afterward the loss of substance extends more deeply, and here and there 
may even perforate the cranial wall. The inner surface of the pericra- 
nium is said to be reddened, swollen, and granulated over the whole 
diseased region, and the medullary tissue within the diseased bone is 
converted into a red vascular mass, intimately connected with the peri- 
cranium. Not a trace of pus is anywhere to be found. The adjacent 
bone is either unaltered, or else a reproduction of bony matter takes 
place on the edges of the seat of disease, which is thus surrounded as 
by a wall. When the process attacks the outer surface of the cranial 
wall, an extensive growth of new bone may also occur on the interior 
of the vault of the skull. This description of anostosis excentrica, 
which has been taken almost word for word from the text-book of 
Bruns, agrees so closely with Virchow"'s account of “ caries sicca,” 
or the inflammatory atrophy of the bones of syphilitic persons, that it 
can hardly be doubted that both observers have described one and the 770 
CHRONIC INFECTIOUS DISEASES. 
same disease. From microscopic examination of the soft tissue and 
of the more solid and resisting masses, the points of which contain a 
yellowish-white and very dry substance, Virchow has satisfied himself 
that the conical or spindle-shaped contents of the cavities, resulting 
from the loss of bone, consist of the specific neoplastic product of 
syphilis, to which he gives the name of gummata even when it is not 
soft, and which Wagner calls the syphiloma. 
YIIL Syphilitic Sarcocele.—Syphilitic contagion sometimes gives 
rise to an inflammation of the testicle, distinguishable from other 
forms of orchitis by certain peculiarities, particularly by its seat, 
and the tediousness of its course. The disease begins in the tunica 
albuginea and its continuations, and induces a proliferation of young 
cells and new connective tissue upon the interior of the tunic, and be- 
tween the seminal tubules. Under the pressure caused by this tumor, 
which afterward contracts and indurates, the proper substance of the 
gland disappears. Besides this simple syphilitic orchitis, there is a 
second form, distinguished by the formation of dry, whitish-yellow, 
homogeneous nodules in the affected organ, in addition to the prolif- 
eration of the albuginea. Virchow calls the former disease simple 
syphilitic orchitis, and the latter, gummy orchitis. Wagner believes 
that there is no essential difference between the nodular syphiloma, or 
gummy tumor, and the diffuse syphiloma. According to his views, 
the form first mentioned is the diffuse syphiloma, while the latter con- 
stitutes the nodular syphiloma of the testicle. The symptoms of syphi- 
litic sarcocele consist in a slowly-progressing enlargement of one or 
both testicles, which develops either without any pain at all, or else is 
accompanied by occasional lancinating twinges. The testicle becomes 
very hard, loses its regular shape, and may grow to the size of a fist. 
Sarcocele is often accompanied by a serous effusion in the tunica vagi- 
nalis propria. Sometimes the disease, after making some progress in 
one testicle, attacks the other. 
Virchow describes a syphilitic periorchitis: This may commence as a 
hydrocele, but soon occasions thickening of the albuginea and tunica vag- 
inalis propria, causing adhesions, or even complete synechia of the latter. 
IX. Syphilitic Disease of the Connective Tissue, Muscles, and 
Viscera.—In cases of inveterate syphilis, tumors presenting the char- 
acteristics of the gummy tumor, or syphilitic tubercle, are also found in 
the subcutaneous and submucous connective tissue, and in the inter- 
stices of the muscles (Virchow). When properly treated, they 
sometimes disappear, while at other times they suppurate, producing 
abscesses and intractable ulcers. 
The muscles also, especially those of the upper extremity, the 
throat and neck, are sometimes the seat of syphilitic disease. Virchow CONSTITUTIONAL SYPHILIS. 
771 
describe? a simple and a gummy myositis. The former depends upon 
proliferation of the interstitial connective tissue, producing an indura- 
tion of the latter, while the primitive muscular fasciculi suffer atrophy, 
and perish. In the latter form, tumors, often of considerable size, arise 
in the muscles, and upon section show reddish-white or yellowish- 
white, slightly striped deposits, which are usually not absolutely dry. 
Microscopic examination reveals a finely-cellular, dense granulation of 
the intramuscular substance, with premature fatty degeneration, in 
which the cells perish, leaving a granular, fatty, and apparently struc- 
tureless mass. Similar masses are sometimes found in the substance 
of the heart. Perhaps some cases of induration of portions of the car- 
diac muscles depend upon simple syphilitic myocarditis. 
Among the syphilitic diseases of internal organs, syphilitic hepatitis 
has been described in detail. TVagner and other authorities have ob- 
served syphilitic lesions in other organs, the spleen, the kidney, and 
even the pancreas, wThich closely corresponded w'ith those found in the 
liver, sometimes inducing thickening in the envelope of the viscus, some- 
times diffuse induration of its substance, and sometimes producing cir- 
cumscribed nodules in it. Dittrich has already recognized the occur- 
rence of syphilitic disease of the lung, in the form of nodular, firmly-re- 
sisting indurations, either of a white color, cr else stained black, by 
deposit of pigment, and which enclosed dry, cheesy accumulations. It 
would also seem that, besides this gummous pneumonia, an interstitial 
syphilitic pneumonia also occurs. It may sometimes be very difficult, 
or even quite impossible, to decide whether a disease of the lung de- 
pends upon syphilis or not. 
Syphilitic affections of the encephalon consist in part of chronic in- 
flammation of the meninges, which may involve the pia mater, the 
arachnoid, or the dura mater, in the form of a pachymeningitis externa 
(endocranitis) or interna; and, among other symptoms, sometimes give 
rise to palsy of one of the cerebral nerves. Sometimes, syphilitic de- 
posits occur, which formerly were often mistaken for inspissated ab- 
scesses, or for caseous tubercles. (See “Diseases of the Brain.”) 
It follows, from this brief enumeration of the various syphilitic dis- 
eases of the tissues and organs, that the points on which the disease 
localizes itself are far more numerous than was formerly supposed; 
and that Wagner’s statement, that syphilis attacks all the tissues which 
contain vessels, is fully warranted. 
The General Course of Syphilis.—It is a remarkable fact that, 
while the syphilitic taint at times gives rise to palpable symptoms, at 
others no sign of the persistence of the infection can be detected, ex- 
cepting the enlargement of the lymphatic glands After the healing 
of the primary ulcer, a period of several weeks usually elapses before 772 
CHRONIC INFECTIOUS DISEASES 
condylomata, exanthemata, or other consequences of the infection, ap 
pear; and, after the latter have subsided, another interval of exemption 
usually ensues, ere a second series of disorders disturbs the apparent 
good health of the patient. For these alternations, which usually re- 
cur again and again during the course of the disease, no satisfactory 
explanation has as yet been furnished. The time which intervenes 
between the healing of the primary ulcer and the appearance of the 
secondary symptoms, as well as that between the various outbreaks 
of the secondary manifestations themselves, varies greatly in different 
cases. The causes of this difference, and the influences which shorten 
or prolong the period of latency, are likewise in a great measure un- 
known. It seems, however, that in vigorous constitutions, and in per- 
sons who live luxuriously, the secondary symptoms set in sooner, and 
recur at shorter intervals, and that the length of the period of latency 
is somewhat dependent upon the treatment adopted. 
Rarensprung, relying upon a large experience, affirms that, when 
mercury is not employed, a period of latency of several months, or even 
years, never occurs, and that the secondary symptoms and their re- 
lapses appear within six weeks at latest, after the healing of the in- 
durated ulcer, or after the subsiding of the outbreak last treated. 
He does not hesitate to declare a patient treated without mercury to 
be safe and permanently cured, who continues free from constitutional 
symptoms three months after treatment has been discontinued. If 
this assertion could be substantiated, the well-authenticated cases of 
latency of syphilis, during a period of ten or twenty years, would be 
attributable entirely to mercurial treatment. Such protracted periods 
of latency, however, if they really do occur, are at all events extremely 
rare, be the treatment non-mercurial or mercurial. It is equally rare, 
also, for secondary symptoms to arise prior to the healing of a recent 
primary sore. As a rule, they do not make their appearance until 
from eight weeks to three months after infection, and the relapses 
usually follow one another at similar intervals. 
A certain degree of regularity can be recognized in the manner in 
which the various manifestations of the disease succeed one another 
After the healing of an indurated ulcer, there is a great probability 
that in a few weeks or months it will be followed by condylomata, a 
maculous exanthema, or by a syphilitic angina; but, at this stage, the 
patient is quite secure against rupia, syphilitic lupus, or disease of the 
bones. Conversely, an individual, who for years has suffered repeated 
relapses of syphilis, is in danger of destructive disease of the skin and 
subcutaneous areolar tissue, of caries and necrosis of the bones, but not 
of broad condylomata, or of sypnilitic roseola. The disorders and 
complications of disorders which stand first in order in the series of CONSTITUTIONAL SYPHILIS. 
773 
syphilitic affections are called secondary affections; others, which are 
ikewise frequently combined one with another, but which appeal* later, 
are called tertiary affections. The former are usually considered to 
include indolent buboes, the condylomata, the exanthemata with the 
exception of rupia and lupus, the superficial ulcers of the mucous mem- 
brane, and iritis; while lupus, rupia, disease of the bones, and the 
gummy tumors of the submucous and subcutaneous areolar tissue, and 
the disorders of the muscles and viscera, belong to the tertiary class. 
Upon comparing the two classes, it will be found that the secondary 
diseases are less malignant, that is, are less destructive than the ter- 
tiary; and that they usually are limited to the superficial tissues, to 
the skin and mucous membrane ; while the tertiary affections attack 
the deeper-seated, “ more noble ” organs. This mode of classification, 
however, makes it impossible to draw a sharp boundary between the 
two forms, and it is idle and unprofitable to dispute as to whether the 
intermediate varieties rank as secondary or tertiary, such as sarcocele, 
which, though not one of the earlier consequences of infection, still 
usually precedes lupus and disease of the bone, and which, in respect 
to its malignity and to its locality, occupies an intermediate position. 
In rare and exceptional instances, disease of the bones forms one of the 
early symptoms of general syphilis. The opponents of the treatment 
by mercury attribute this early appearance of the so-called tertiary 
accidents to the mercury, and even go so far as to assert that the em- 
ployment of mercurials, by aggravating the pernicious influence of 
syphilis upon the organism, actually is the cause of the tertiary mani- 
festations ; and that, under non-mercurial treatment, syphilis does not 
affect the bones. Although both statements, in their fullest accepta- 
tion, are decidedly untrue, yet neither of them is quite without foun- 
dation ; for, if the disease be not subdued, while the constitution has 
been ruined by immoderate and reckless dosing with mercury, perni- 
cious forms of syphilis, such as lupus and disease of the bones, are more 
liable to arise than when it still lurks in the system of a robust indi- 
vidual. It would almost seem, indeed, that the constant increase in 
malignancy which shows itself in each succeeding attack, in cases of 
syphilis where mercury has not been employed, is the result of deterio- 
ration of the constitution induced by the previous attacks. At all 
events, the contrary effect is seen in robust constitutions, in whom, 
when the disease is not completely extinguished at first, each relapse 
is less severe than the preceding one. 
While, with the exception of a slight fever, which usually precedes 
and accompanies the secondary symptoms, the disease is borne for a con- 
siderable length of time without constitutional disturbance, yet, when 
the attacks recur constantly, when the patient’s rest is continually dis- 774 
CHRONIC INFECTIOUS DISEASES. 
turbed by nocturnal pain, when protracted suppuration consumes his 
strength, and, above all, if an active mercurial treatment be superadded, 
a general marasmus, the so-called syphilitic cachexia, sets in. This term 
is not exactly appropriate, since it does not proceed directly from syphi- 
litic infection, but indirectly from the nutritive disturbance to which it 
leads, or from the method of treatment adopted. Accordingly, the 
syphilitic cachexia has no peculiar features by which it may be distin- 
guished from other non-specific forms of cachexia. Even amyloid de- 
generation of the liver, spleen, kidneys, and other organs, which often 
accompanies the syphilitic cachexia, is not peculiar to this disease, but 
also develops in the course of other non-syphilitic diseases of bone as 
well as in malarious affections, scrofula, and rickets. 
Treatment.—The treatment of the primary syphilitic induration 
and primary syphilitic ulcer must be directed mainly against the con- 
stitutional disease, the first manifestation of which we have found it to 
be. Abortive treatment is out of the question, save when we have to 
treat an excoriation produced during a suspicious coitus ; but in such a 
case, after destroying the affected part, we cannot tell whether the 
absence of induration and of subsequent symptoms is the result of 
the treatment or not, as we have no criterion for distinguishing an in- 
fected excoriation from a non-infected one. The extirpation of an in- 
duration, or its destruction by means of caustics, is altogether useless. 
As a general rule, a new induration forms upon the edges of the wound 
thus produced. Besides the use of constitutional remedies, the primary 
syphilitic sore should be treated according to the principles already 
laid down for treatment of the chancre. First of all, the utmost clean- 
liness must be maintained. Washes, mild or strong, according to cir- 
cumstances, should be used, together with gentle applications of lunar 
caustic, or sprinklings with red precipitate, and the like. Internally, 
unless contraindicated by special circumstances, I treat the primary 
ulcer and primary sore with mercurials. I am wTell aware that the in- 
duration is capable of disappearing without their use, and that this 
treatment affords no guaranty against the appearance of consecutive 
symptoms ; but the indisputable fact, that the secondary symptoms are 
fewer and later in appearing when treated by mercury than when 
treated without it, induces me to prefer the former treatment to the 
latter. Besides, a cautious employment of this drug is far less liable 
to be followed by mischievous results than is asserted by its opponents. 
In the first year of my practice I did not employ mercury in syphilis, 
but in my second I commenced to use it upon almost every indurated 
sore, and in all cases of secondary disease. The number of patients 
which I have treated in this manner cannot of course be compared with 
that treated in the course of a year or two in the syphilitic ward of one CONSTITUTIONAL SYPHILIS. 
775 
of the great hospitals, but it is large enough to prove that the mis- 
chief produced by mercurial treatment has been greatly overestimated. 
As I have kept most of the patients, whom I have treated for syphilis, 
under observation for some time afterward, and since, after the marriage 
of many of them, I have become their family physician, it would have 
been more difficult for the pernicious effects of a course of mercury to 
escape my notice, than that of many a chief of a large syphilitic ward, 
who loses sight of his patients as soon as they are discharged. A se- 
ries of observations, many of them very close ones, and now continued 
for over eleven years, of a by no means inconsiderable number of per- 
sons who have undergone a careful mercurial treatment, has converted 
me from an opponent into a decided advocate of mercury. 
It lies out of the plan of this work to recount all the celebrated 
modes of treatment by mercury, or to detail the minute directions en- 
joined in the different methods, the number of pills to be taken daily, 
the manner of raising and reducing the dose, etc. I admit that I re- 
gard all sharply-defined routines not only as useless, but as absolutely 
dangerous, as it induces inexperienced or careless physicians to treat 
all varieties of constitution by the same formula. Experience has 
taught that the efficacy of mercury, as a remedy against syphilis, does 
not depend upon the form in which it is administered, whether as a 
suboxide, an oxide, a basic salt, a chloride, or an iodide. It is equally 
immaterial, as regards its efficiency as a remedy, how the mineral enters 
the blood, whether it be by the intestinal mucous membrane or through 
the skin. Hence our choice of a preparation of the drug should fall 
upon one which, while an effective remedy, does the least possible 
harm to the constitution. Since, however, the pernicious influence 
wffiich this mineral exerts upon animal life is susceptible only of a par- 
tial explanation, we can merely diminish or avert the more subordinate 
mischief to the intestinal mucous membranes, to which the use of mer- 
curials gives rise, by choosing preparations which are the least irritat- 
ing to them, or by not introducing the drug through the intestines at 
all, but through the skin. If we deemed the action of calomel and 
iodide of mercury upon the intestine, when cautiously administered, to 
be very great or very pernicious, we should regard the reintroduction 
of the “ inunction-cure ” as a most important step in the therapeutics 
of syphilis; but, believing as we do, that these disadvantages are 
trifling, and nearly always temporary, we cannot concur in the ecsta- 
sies of those who see the beginning of a new era in the reestablish- 
ment of the treatment of syphilis by mercurial inunction. I do not 
mean by this that I look upon mercurial inunction as an improper 
method of treating syphilis; indeed, I very often make use of it myself, 
especially in clinical practice, for it does all that mercurial treatment is 776 
CHRONIC INFECTIOUS DISEASES. 
capable of doing; and I know of no objection to it, excepting that 
salivation sometimes occurs more suddenly and with greater severity 
m this than in other cures. As a rule, I follow the directions laid 
down by Sigmund for this mode of treatment (which, compared with 
the notorious and dangerous “grand inunction-cure” of Louvrier, 
scarcely deserves the name of inunction), but I do not pedantically 
hold myself strictly to Sigmund'1 s precepts. The patient having taken 
several daily warm baths, I cause a half drachm of blue ointment to be 
rubbed into the skin, and, where there seems to be danger from delay, 
I rub in a whole drachm. Upon the first day I apply it to the legs, 
the second to the thighs, the third to the arms, the fourth to the back, 
the fifth to the legs again, and so on. The precise order in which the 
rubbings succeed one another is of course unimportant. At points 
within the patient’s reach he can rub the ointment in for himself; at 
others, an attendant must do it. Each inunction should continue from 
ten minutes to a quarter of an hour, and, before rubbing again, the 
surface previously rubbed is to be washed with soap and water. The 
temperature of the room should not be above sixty-five or seventy de- 
grees Fahrenheit, and must be ventilated daily. There is no objec- 
tion to the patient’s changing his linen. It is useless to combine the 
hunger-cure with the inunction-cure; and it may even do harm. As 
soon as the least trace of salivation shows itself, the treatment must 
be suspended; and any of the ointment still adherent to the skin 
should be carefully removed by a bath, or by a thorough washing. 
Should the healing of the ulcer or resolution of the induration come to 
a stand-still after cessation of the salivation, or, in cases of secondary 
disease, should the improvement not continue after the salivation 
abates, I recommence the mercurial frictions, one or two of which then 
almost always perfect the cure. I observe the rule of always suspend- 
ing the treatment upon the occurrence of salivation, not only when the 
mercury is employed in the form of ointment, but in all other forms of 
mercurial treatment, and simply because I regard salivation as a sign 
that a sufficient quantity of the mineral has been absorbed. It mat- 
ters not whether the mercury be applied upon the skin, or to the in- 
testines ; in either case a part only of what is administered is absorbed, 
and the rest either remains upon the skin or else is expelled in the 
stools. Hence, even if we could tell how large an amount of it must 
be introduced into the system in order to effect a cure of a syphilitic 
affection, we should still be ignorant of the number of inunctions of 
ointment, or of internal doses of calomel, corrosive sublimate, or iodide 
of mercury, requisite to produce the desired result. Salivation, of 
course, affords no criterion of the amount of mercury absorbed, but it 
certainly indicates that enough of the drug has been taken up to pro CONSTITUTIONAL SYPIIILIS. 
777 
duce a decided impression upon the system. That the one effect, 
namely, the salivation, is almost always accompanied by another, the 
improvement of the syphilitic lesion, follows even from the erroneous 
belief entertained by many old physicians, that salivation is a beneficial 
crisis. Notwithstanding that I regard salivation as a valuable guide in 
the treatment of syphilis by mercury, just as I regard dilatation of the 
pupil as valuable in treatment of epilepsy by atropin, showing that 
the dose administered is sufficient, and although I do not regard the 
appearance of slight traces of salivation as an objection to such method 
of cure, yet I consider it extremely unsafe when we have not the op- 
portunity to suspend the treatment before the salivation has made any 
considerable progress. Salivation has no curative effect whatever, and 
I always seek to allay it by administration of chlorate of potash, either 
in solution ( 3 j to water § ij), a tablespoonful of it to be taken every 
two hours, or else in the form of pastilles. If, when in doubt whether 
to continue the cure or to discontinue it, we decide to give one or two 
more doses of calomel, corrosive sublimate, or iodide of mercury, we 
run far less risk, by so doing, of producing a severe sore mouth, than 
if we rub in another half drachm of mercurial ointment. 
The great objection to the inunction treatment, that in it we 
cannot say how much of the mercury enters the body, does not 
exist in using subcutaneous injections of corrosive sublimate. In 
this treatment, which of late has run a strong opposition to the 
inunction treatment, and has to some extent supplanted it, we may 
even more certainly control the dose than we can in internal adminis- 
tration, and we save the gastric and intestinal mucous membrane just 
as completely as we do by the inunction treatment. 
I acknowledge that I began the employment of subcutaneous 
Injections of corrosive sublimate with a certain distrust, and that I did 
not resort to it till it had been urgently recommended to me by 
various persons. I feared that the pain and inflammations, with 
partial necrosis of the skin that it must cause, would be out of 
proportion to any possible benefits arising from its use; indeed, it 
seemed doubtful to me if this inflammation and necrosis of the skin 
would not interfere with or entirely prevent the absorption of the 
remedy. Experience soon taught me better. If sufficiently dilute 
solutions are employed, the pains are perfectly bearable and of short 
duration ; by the same precaution, severe inflammations and necrosis 
of the skin may be avoided. The absorption of corrosive sublimate 
appears to follow subcutaneous injection just as quickly as that of 
morphine does; in short, the advantages seem to outweigh the objec- 
tions so much, that any practitioner, who has treated his syphilitic 
patients for a short time with subcutaneous injections of corrosive 778 
CHRONIC INFECTIOUS DISEASES. 
sublimate, will acknowledge that we are much indebted to Lewin 
for its introduction. In my clinic, we at first used Letter's syringe, 
which holds twelve grains of fluid, and with this injected twelve drops 
of a solution of corrosive sublimate (gr. j to 3 j). Later, with the 
best results, we injected a solution (gr. j to § ss) with one of PaikrVs 
syringes, holding half a drachm (that is, the eighth of a grain of cor- 
rosive sublimate in a solution one fourth the strength of the former) 
once or twice daily. We obtained this syringe also from Letter in 
Vienna, but, as the canula was rather thick, and consequently the 
puncture pained and bled, we had a canula made like that on the 
ordinary hypodermic syringe. 
Nevertheless, the conviction, that the internal administration of mer- 
curials, cautiously conducted, does not produce any lasting injury to the 
mucous membranes, has caused me, in spite of the general commenda- 
tion of injections and the inunction-cure, to adhere to the internal ex 
liibition of mercury in private practice. The article I generally employ 
in cases of primary induration and primary sore, is calomel. Of all 
mercurials, this one is the least open to the charge of causing serious 
or permanent detriment to the mucous membranes when given in mod- 
erate doses. If it really were injurious, considering how universally 
it is employed, especially in diseases of children, the number of persons 
suffering from its effects would be very large. I will only call to mind 
that the Plummer's powders, used in ophthalmia and other scrofulous 
complaints, the minute doses of calomel used in infantile diarrhoeas, 
the larger ones, pushed almost to salivation in croup, pleurisy, and 
other inflammations, still are among the most common of prescriptions, 
and that ten or twenty years ago they were even more generally ad- 
ministered than now. An exceedingly rich experience has taught us, 
that the innumerable multitude of persons who have used calomel 
more or less, for other purposes than antisyphilitic treatment, have not 
suffered any permanent injury to their digestion or their general 
health, but are now as healthy as they were before. Calomel, how- 
ever, has no great reputation as an antisyphilitic (at least, in Ger- 
many), and the corrosive sublimate is preferred to it by most prac 
titioners, as a means of treating primary and secondary symptoms 
The reasons for this are twofold: firstly, it often causes diarrhoea; 
secondly, it soon produces salivation. I do not regard either of these 
objections as valid. I have never found that the diarrhoea which 
nearly always sets in at the beginning of a course of calomel (but which 
usually subsides in a few days) interferes materially with the cure, and, 
as salivation soon occurs in spite of it, we may confidently infer that 
the medicine is not all evacuated, but that a sufficient amount of it is 
absorbed and taken into the blood. With regard to the second objec- CONSTITUTIONAL SYPHILIS. 
779 
lion, for reasons given above, I rather look upon the early appearance 
of salivation as an advantage, insomuch that, in cases where, owing to 
idiosyncrasy of the patient, salivation occurs later than I had expected, 
oi where it fails to appear at all, I have been anxious lest I might ad- 
minister too large a quantity of mercury, not having this valuable guide 
to inform me when to discontinue the remedy. To adult patients I 
usually give a grain of calomel twice daily, or half a grain three times 
a day. When given in the form of powder, I have it wrapped in 
a wafer, in order to screen the mucous membrane of the mouth from 
contact with the drug. Generally, however, I have it made up with 
liquorice into pills, each of which contains half a grain. Next to calo- 
mel, I have most frequently made use of the protiodide of mercury. I 
am not aware that this article possesses any advantage over calomel, 
and I have generally noticed that its exhibition oocasions severe pain in 
the bowels, which scarcely ever occurs in the diarrhoea induced by calo- 
mel. On account of these annoying symptoms, Ricord (to whose au- 
thority the protiodide of mercury mainly owes its reputation and exten- 
sive adoption) combines it with narcotics ; but, even with Ricord’s pills 
(hydrarg. protiodid., lactucar. gall., aa 3 iss, ext. opii aquaeos. gr. ix, ext. 
guaiac. aquasos. 3 j, f. pil. no. xxxvj), I have often been obliged to give 
opium, on account of severe pain in the bowels, so that I have now been 
induced to abandon the use' of the protiodide. I shall now merely add 
a few words about corrosive sublimate, for, although I am by no means 
one of its admirers, and consider it as far inferior to other preparations 
of mercury, yet it probably is more generally employed in syphilis 
than any other. The corrosive properties of the drug forbid its ad- 
ministration in large doses, and I believe a gradual increase of the 
dose to be improper. Can one expect the stomach to accustom itself 
to the action of the medicine so as to tolerate large quantities without 
becoming corroded ? and why should we increase the dose when it is of 
importance to be able to suspend the treatment at precisely the right 
moment, in order to avoid introducing too much mercury into the sys- 
tem ? Corrosive sublimate is valued principally because, in the first 
place, it is slow to produce salivation, and because, under its use, less 
mercury is taken into the system than under other mercurial treat- 
ment. I cannot regard it as an advantage that the chemical proper- 
ties of corrosive sublimate should compel us to administer it in such 
doses that the object aimed at, the introduction of a certain amount 
of mercury into the system, is only very slowly attained; and I can- 
not admit that much more mercury is taken up in a treatment by cal- 
omel, if discontinued when salivation commences, than in a treatment 
by corrosive sublimate when pushed to the same point. It cannot be 
denied, however, that many people are cured of their syphilis by cor 780 
CHRONIC INFECTIOUS DISEASES. 
rosive sublimate, and especially by the very injudicious method of 
Dzondi. If we employ this article, it must not be given on an empty 
stomach, and is best administered in the form of pills; but they should 
not be made up with bread-crumbs and sugar, according to Dzondi/s 
formula, but with powdered extract of liquorice; and the dose should 
not be raised, as is done in Dzondi1 s treatment, from the fifth of a 
grain to a grain and a half, but from half to three-quarters of a grain 
should be given daily, in divided doses. In order to protect the gas- 
tric mucous membrane from the corrosive action of the sublimate, it 
has been proposed to give the albuminate of mercury, and thus at 
once to furnish the combination which, when the pure bichloride is 
used, eventually forms in the stomach, at the expense of the gastric 
mucous membrane, and experience shows that double doses of this 
preparation can be tolerated without detriment. If it were not that 
I am already perfectly satisfied with the medicines already spoken of, 
[ should have recourse to the albuminate. Ddremprung proposes 
the following formula: 5 Hydrarg. bichlor. corrosiv. gr. ij, ovum 
uuum, aqua destillat. 3 vj, ammon. muriat. 3 j, misce exactissime. 
Filtra. D. S., a tablespoonful every two hours. The dietetic rules to 
be observed during internal mercurial treatment must be regulated 
according to the condition of the patient. As a general rule, it is ad- 
visable to restrict his diet, without going so far as to let him sulfer 
from hunger; but now and then it may become desirable to feed the 
patient upon the most nutritious food, under conditions already de- 
scribed in treating of the chancre. The common practice of administer- 
ing large quantities of “ decoction of woods ” is superfluous. Finally, 
while we subject the patient to an active treatment, in order not to 
expose him to other prejudicial influences, we must regulate his habits 
and carefully watch over his general health. For this reason it is ur- 
gently advised that syphilitic patients, who are undergoing a course 
of mercury, should keep their room, particularly in winter, and that 
they should be visited daily. 
We have said above that the primary ulcer and primary sore would 
heal without the use of mercury; but that under such treatment the 
recovery was slower, and the secondary attacks came on more fre- 
quently and earlier. This is equally true of the privation-cure (En* 
tziehungs-cur), and the hunger-cure, the methodical use of cathartic 
salts, and of Zittmunn's decoction, and other compound decoctions, the 
object of which is to throw the skin, kidneys, and intestine, into a state 
of increased activity, the supply of nourishment, meantime, being re- 
duced to a minimum. If this kind of treatment be very energetically 
conducted, and if the state of nutrition be depressed by a severe course 
of simple or double Zittmann's decoction, we may, no doubt, succeed CONSTITUTIONAL SYPHILIS. 
781 
ra accelerating the healing of the primary affection. But, frequently, 
just as the patient is beginning to recover from his eleven or twenty- 
two days of fasting, purging, and sweating, the first crop of secondary 
symptoms begins to develop. 
The preparations of iodine are altogether useless against the pri- 
mary affections; although certain physicians, who only practise in the 
country, or in the smaller towns, and who, rarely having occasion to 
treat syphilis, have an exaggerated dread of the effects of mercury, 
place great confidence in iodine. During my practice in Magdeburg, 
I remember many cases, w’here travellers visiting the small towns, and 
consulting the physician of the place for indurated chancres, afterward 
came under my hands, suffering from the worst iodine eruptions that I 
have ever seen. From the recipes which they brought with them, it 
was often quite evident that the iodic exanthema had been mistaken 
for a syphilide, and the worse it grew, the larger were the doses of 
iodine prescribed. 
The secondary and tertiary symptoms of syphilis must always be 
treated with the utmost circumspection and care, since there is no dis- 
ease in which therapeutic errors can do such serious harm as in consti- 
tutional syphilis. Mercurial treatment is nearly always of signal bene- 
fit in the secondary and tertiary forms of the disease, and frequently 
not only relieves and allays the symptoms as they arise, but some- 
times brings about a complete and permanent cure. If, however, it be 
administered again and again in unsuitable cases, instead of mitigating 
the malady, it renders it still more pernicious, causing destruction of 
the bones, degeneration of internal organs, and even endangering life 
itself. The fact that horrible forms of syphilis are more rare than 
they used to be, probably is partially because the “ grand inunction- 
cure ” and other methods of over-treatment are being banished more 
and more from the therapeusis of the malady, and that our employ- 
ment of mercury is now more cautious and restricted. The indications 
for mercurial treatment of constitutional syphilis have generally been 
summed up as follows: The secondary affections alone call for mer- 
cury, while the tertiary accidents demand the exhibition of iodine. 
Although this formula is somewhat inexact, yet, upon the whole, it is 
perfectly true. Mercurials are indicated in nearly all cases where the 
affection belongs to the secondary group, while, in cases of a manifestly 
tertiary character, they are generally contraindicated. To this rule an- 
other is very properly added, that even in secondary affections mer- 
cury is contraindicated, when it has already been used repeatedly with- 
out success. The principles upon which the mercurial treatment of 
syphilis is based may be deduced from what I have said above, re- 
garding the course of the disease, and from the same remarks it will 782 
CHRONIC INFECTIOUS DISEASES. 
also become apparent why I have spoken of the customary formulary 
of indications as inexact, although right on the whole. When an in- 
dividual, sooner or later after his recovery from an indurated chancre, 
begins to suffer from condylomata or from eruptions, I do not hesitate 
to prescribe mercury, either by inunction with blue ointment, or in the 
form of calomel, to be taken-internally, without regard to whether the 
indurated ulcer has already been treated by mercury or not, for at this 
period it very seldom happens that, owing to the state of the patient’s 
general health, or to the form of the syphilitic outbreak (then usually 
a lupus or an affection of the bones), or from both the causes combined, 
the constitution of the patient has suffered much either from the effects 
of mercury or from the disease itself. It is only in these very excep- 
tional instances that I consider a mercurial treatment contraindicated 
at the period when signs of constitutional infection first appear, for we 
may be almost certain that, if the syphilis cannot be successfully eradi- 
cated by means of mercury, its next attack will be of a most pernicious 
character. On the other hand, where the constitution is still unim- 
paired, the good effect of mercury in allaying secondary symptoms is 
most striking. The condylomata, exanthemata, and sore throat, dis- 
appear much more rapidly than an indurated ulcer does, when treated 
by mercury, and it often happens that not only are the immediate 
symptoms allayed, but a permanent cure is effected. There are other 
cases, however, in which the disease only becomes latent and not ex- 
tinct ; and where it reappears some time after the subsidence of the 
first set of symptoms, or relapses, to use the common expression. The 
maAagement of these relapses varies greatly, according to their character. 
When the disorder is slight, as when plaques muqueuses appear upon 
the tongue, or when a few scattered pustules form upon the scalp, the 
attack is manifestly of a less serious character than the previous mani- 
festations have been, and it is not advisable to renew the mercurials. 
Syphilis never subsides suddenly, but usually dies out slowly and 
gradually, and we may always hope for this favorable termination 
when the new symptoms are of a less serious nature than their prede- 
cessors. Although I do not advise a repetition of the mercurials in 
such cases, yet the patient should be most carefully watched, kept 
upon a reduced diet, and preserved as far as possible from all othei 
noxious influences, until the last traces of the disease have disappeared. 
The “privation-cure” (“ Entzieliungs-cur”), and even the Zittmami’s 
decoction, are suitable remedies for such cases. At the height of the 
disease, the action of these methods of treatment is merely palliative, 
but when it is beginning to decline, they really seem to accelerate its 
complete disappearance. On the other hand, when the relapse shows 
that the disease has not assumed a milder character, if the new mani- CONSTITUTIONAL SYPHILIS. 
783 
festations are as severe as tlie former ones, or even more severe, but 
still retain the nature of the secondary disorders, and if, as is generally 
the case, the patient’s constitution still seems to be unimpaired, I re- 
commence the mercurial treatment, and, indeed, under oertain circum- 
stances (for instance, in case of rapidly-spreading ulceration of the 
fauces, liable to become complicated with- syphilitic laryngitis), I even 
make the treatment more energetic than before. I order daily inunc- 
tions of a drachm of blue ointment, or else give daily, or every other 
day, two doses of calomel, of ten grains each, after the method of 
Weinhold. It has often been objected, regarding TVeinholcVs treat- 
ment, that its only action is a laxative one; that it does not salivate, 
and that it exerts no important influence upon syphilitic affections. 
These a priori view's stand in direct opposition to the results of my 
own experience in many cases where I have given half-scruple doses 
of calomel. 
If the relapse be unmistakably of a tertiary character, or if it be 
merely of an intermediate nature between the secondary and tertiary 
forms; or, if the constitution of the patient have begun to suffer, wheth- 
er from the disease or the treatment, then mercury is not only contra- 
indicated, but even dangerous. Never use a grain of it under such cir- 
cumstances, and I am certain that by such precautions the evil effects 
of mercurial treatment may be averted. 
I may be brief in stating the indications for the use of iodine in the 
treatment of syphilis. In all cases vdiere the spontaneous and speedy 
extinction of the malady is not to be calculated on, and in which the 
employment of mercurials is contraindicated, the exhibition of iodine 
is urgently indicated, and then affords the utmost benefit. If we limit 
the administration of the medicine to the above class of cases, and are 
as methodical in its employment as we have been with mercury, we 
shall find that its value in the treatment of syphilis is by no means in- 
ferior to it. The preparation of iodine most generally employed is the 
iodide of potassium, from ten to thirty grains of which are usually given 
daily, in the form of a watery solution. Some physicians give larger 
doses, or strengthen the solution, by adding one or two grains of iodine 
to it, but apparently do not thereby augment its effect. According to 
my experience, Bdrensprung to the contrary notwithstanding, I have 
found the iodide of iron to be a very efficient preparation, especially 
where there is advanced anaemia. I usually employ it in the form of 
6yrup of the iodide of iron syr. ferri iodid. 3 ij, syr. simpl. 3 ij. m,. S. 
3 j every twro hours), and by its means have often produced iodic 
eruption and catarrh. The appearance of this symptom, like that of 
mercurial salivation, requires a suspension of the remedy. If the sus- 
pension be followed by an arrest of improvement in the symptoms, the 784 
CHRONIC INFECTIOUS DISEASES. 
iodine must be resumed after the catarrh or eruption has subsided. 
The diet should not be reduced; not on account of the remedy, how- 
ever, but because of the condition of the patient’s general health. On 
the contrary, his food should be nourishing, and he should be allowed 
a little wine or beer. For persons of broken-down constitution I not 
rmfrequently prescribe iron, quinine, and cod-liver oil, besides the iodine. 
The local treatment of the secondary and tertiary symptoms should 
be restricted to the extirpation of old condylomata (wdiich, though they 
always dry up under mercurial treatment, do not always disappear en- 
tirely), to the application of atropine in iritis, to local blood-letting, 
and to occasional surgical procedures, which may be demanded on ac- 
count of destructive inflammation of the skin, caries, or necrosis. The 
majority of the secondary and tertiary affections do not require local 
treatment. 
S}rphilization, wdiich, during the last ten years has been much 
lauded as a certain means of eradicating syphilis, and of protecting 
the system against further infection, has again fallen into disrepute, 
or at all events is now merely practised by its introducers, and by the 
enthusiastic disciples of their new doctrines. The process of syphiliza- 
tion consists in the production of chancre pustules upon the skin of a 
person afflicted with constitutional syphilis, which process is continu- 
ally to be repeated, until the inoculation ceases to act. Apart from 
the fact that some persons do not become proof against the chancre- 
virus, after suffering several hundred and even as many as two thou- 
sand inoculations, it has not by any means always followed that, the 
immunity once attained, the syphilitic affection has healed; and, where 
recovery lias taken place, it remains more than doubtful w hether it has 
been in consequence of the syphilization. 
CHAPTER II. 
CONGENITAL AND HEREDITARY SYPHILIS. 
Etiology.—We shall pay no attention to the forms of infantile 
syphilis, arising from the infection of a child during birth by syphilitic 
ulcers upon the genitals of its mother, or upon the nipples, lips, or 
other parts of the body, of its nurse, for these forms of syphilis do not 
differ, either in point of origin, or of course, from the syphilis of adults. 
By the term congenital hereditary syphilis, of which alone we now 
propose to treat, wre mean a form of that malady occurring in newly- 
born children, and originating in the embryo, from constitutional dis- 
ease existing in the father at the time of begetting the child, or in the CONGENITAL AND HEREDITARY SYPHILIS. 
785 
mother during the period of pregnancy. The manner in which the 
contagion is transmitted to the embryo from the father or mother is 
altogether unknown, and we shall, therefore, confine ourselves to a 
statement of a few known and authentic facts, without attempting any 
explanation of them. 
If a woman who has secondary syphilis becomes pregnant, the 
foetus nearly always dies prematurely, and is expelled by an abortion 
or miscarriage. In such cases, the foetus is generally so much putre- 
fied that it cannot be determined whether it bears traces of syphilis 
upon it or not. In like manner, a woman who is healthy at the time 
of conception, but who subsequently contracts syphilis, usually aborts 
or miscarries, giving birth to a decomposing foetus. In other cases, the 
child is carried to term, but dies either at the time of its birth or shortly 
before. It then either bears distinct evidence of syphilis upon its 
wasted body, or else there is no anomaly beyond its extreme emacia- 
tion. In rare instances the child is born alive, and lives for a longer 
or shorter period of time. In such cases, the syphilis may appear im- 
mediately after birth, or else may remain latent, and develop weeks or 
months afterward. Inasmuch, then, as constitutional syphilis of the 
mother exerts so pernicious an influence upon her offspring, that it 
usually perishes either long before or else during birth, it will be 
readily understood that the majority of cases of congenital syphilis, 
which become the object of clinical investigation and medical treat- 
ment, are the progeny of syphilitic fathers. It is an extraordinary but 
well-established fact that syphilis may be thus transmitted from father 
to child, without infecting the mother who bears the infected offspring 
in her womb. Hereditary syphilis, derived from a syphilitic father, 
sometimes manifests itself immediately after birth, while at other 
times the characteristic symptoms do not appear until later. 
Symptoms and Cotjese.—The symptoms of congenital syphilis 
consist principally of affections of the skin and mucous membranes; 
and it is only in rare instances, when the disease drags on incurable, 
Dut without killing the child, that it causes disease of the bones. 
When children are born with evidence of the disease upon them, or 
when it makes its appearance a few days after birth, it usually proves 
to be of a more malignant nature than when it remains latent for 
some weeks. 
The former class, in which the malady assumes the character of a 
bullous or pustulous syphilide, occasionally accompanied by a coryza 
(see below), was for a long time misunderstood, and used to bear the 
name of pemphigus neonatorum. When the child does not come into 
the world with the disease already upon him, it usually commences 
upon the palms of the hands and soles of the feet, and afterward 786 
CHRONIC INFECTIOUS DISEASES 
spreads to the arms, legs, and body, and sometimes to the face. 
Roundish spots, as large as a pea or bean, and of a dirty-red color, are 
first observable. In a short time the cuticle which covers them is 
elevated into a bleb by the effusion of a turbid liquid. These blebs 
burst, leaving excoriated, moist spots upon the skin, which show no 
tendency to heal, and new blebs form upon the toes and fingers. Not 
unfrequently some of the nails fall off, The later crops of blebs be- 
have like their predecessors, and, as, day after day, new ones arise, the 
unhappy child becomes excoriated at innumerable points. I have even 
seen the blebs form in the mouth and nose. The malady may last 
from a week to a fortnight; more rarely three or four weeks, and al- 
ways terminates fatally. Some of the cases occurring in my private 
practice, in which the mother, with touching patience, daily cleansed 
and bound up the fingers and toes of her babe, never suspecting that 
its dreadful disease was the consequence of the excesses of its father, 
have made an indelible impression upon my mind. 
When syphilis remains latent for a few weeks, it presents another 
aspect. (The bullous syphilide never commences latei than the first 
week of infancy.) The child is often born in apparently good condi- 
tion, and does not seem to differ in any respect from a healthy child. 
About a fortnight after birth, and in some instances as late as a month, 
or even two months after birth, it grows restless and thin, and its sur- 
face assumes a remarkable dirty color. The skin also becomes ex- 
tremely dry, rough, and shrivelled; and, in particular, the hands and feet 
look as if covered by a delicate husk, like that of an onion. It soon be- 
comes difficult for the child to nurse, the nasal mucous membrane being 
swollen, and the nostrils always filled by a thin secretion. This swell- 
ing of the mucous membrane, and the profusion of the discharge, give 
rise to a peculiar snorting and snuffling, which is almost pathognomonic 
of congenital syphilis; so that, in the absence of other signs, we can 
hardly err in diagnosticating the disease from this symptom, together 
with the peculiar condition of the skin. In most cases, the coryza is 
accompanied by an eruption, which, beginning in the region of the 
anus, spreads to the genitals, thighs, and loins, as well as to other 
parts of the body, particularly to the face. This eruption is generally 
of a character intermediate between that of the maculous, papulous, 
and squamous forms. The separate maculae are rounded, of the size 
of a pea or bean. Their color is a coppery or yellowish red, which be- 
comes actually yellow when pressed upon by the finger. They may 
be either distinct or confluent. At first they are level with the skin, 
afterward they project somewhat above it; then their surface is not 
rounded, but flattened, as if the top had been shaved off. As the 
affection advances, the maculae are often covered with scales of epider* CONGENITAL AND IIEREDITxVRY SYPHILIS. 
mis, or with a continuous coating of thin desquamating layers of 
cuticle, and, where the surface is habitually soiled by urine or the ex- 
crements, it becomes excoriated. Another constant symptom of con- 
genital syphilis consists in the formation of rhagades at points where 
the skin changes into mucous membrane, especially upon the mouth 
and anus. It can often distinctly be perceived that the lips of the 
child are incurved and bleed readily upon the slightest movement, and 
that it dreads to use them either in suckling, laughing, or crying. The 
act of defecation cannot be accomplished without great suffering, so 
that the child cries and moans whenever the bowels are moved. The 
rhagades are often accompanied by condylomata, and in neglected 
cases large ulcers, of a peculiar irregular, angular figure, form between 
the nates, and sometimes in the flexures of the thighs, and in other 
regions where intertrigo is apt to arise in healthy children. The dis- 
charge from these sores is scanty, and readily dries up into a scab, 
which is of a blackish color, owing to its containing an admixture of 
blood. We have already stated that it is rare for congenital syphilis 
to attack the bones. Cases are reported now and then, however, in 
which the usually slight ulceration of the nasal mucous membranes 
causes destruction of the bones of the nose, and depression of that 
feature in the first year of childhood. In other equally rare instances, 
congenital syphilis of early infancy either is overlooked or becomes 
latent in consequence of treatment, and breaks out again at the period 
of puberty in the pernicious form of syphilitic lupus, or disease of the 
bones. , 
In the autopsies of children who have died of congenital syphilis, 
or who have been born dead by syphilitic mothers, the characteristic 
lesions of the disease are sometimes found in the internal organs, 
especially the liver and lungs, more rarely in the brain. In the former 
it consists merely of a diffuse, uniform induration, the sequel of a simple 
non-gummous hepatitis. In the lungs, nodules, with cheesy centres of 
the size of a pea or walnut, are formed, as well as a form of diffuse 
condensation, first described by Virchow, who calls it “ white hepatiza- 
tion,” and which consists of a filling up of the air-vesicles with epithelial 
cells in a state of partial fatty degeneration. In the brain, Schott, in 
one case, has found gelatinous tumors of the size of a hazel-nut situ- 
ated beneath the lower surface of the two anterior lobes of the cere- 
brum. Finally, the thymus gland is sometimes considerably enlarged, 
and contains abscesses. 
Treatment.—Hitherto, the treatment of the bullous syphilide has 
always been in vain. On the other hand, in the second form of con- 
genital syphilis just described, comparatively good results may be ob- 
tained by means of appropriate medication. The most common and best 
method of cure consists in the exhibition of small doses of calomal (gr. £} 788 
CHRONIC INFECTIOUS DISEASES. 
morning and evening, and the inunction of five or ten grains of mercurial 
ointment daily, or every other day. The treatment must not be pushed 
to salivation, but should be suspended as soon as a decided improve- 
ment in the symptoms begins to manifest itself, and renewed again 
whenever the improvement seems to flag. It is very important that 
the strength of the child should be supported by the most nutritious 
diet possible. It would be wrong, however, to intrust it to a wet- 
nurse, since this would expose the latter to the danger of infection. 
That a syphilitic child, although it rarely infects its mother, often does 
so to its nurse, is simply because the mother is generally syphilitic 
already, and hence is proof against further contagion. 
APPENDIX. 
INFECTIOUS DISEASES TRANSMISSIBLE FROM BRUTES TO HUMAN BEINGS. 
We shall merely discuss the subjects of glanders and hydrophobia 
in the following chapters. Regarding the malignant pustule, though 
this is likewise an infectious malady, communicable from the lower 
animals to man, yet, as it is more especially a matter of surgical inter- 
est, I refer to the text-books of surgery. 
CHAPTER I. 
HUMAN GLANDERS.—MALLEUS HUMIDUS ET FARCINOSUS. 
Etiology.—There is an infectious disease which attacks animals 
possessing an undivided hoof, especially horses, asses, and mules, and 
which is called glanders or farcy, according to the locality in which the 
lesions induced by the virus develop themselves. 
The virus of glanders, which is identical with that of farcy, repro- 
duces itself within any organism which it has infected, and the trans- 
mission of the virus thus reproduced in one individual to another is the 
most frequent, and indeed probably the only manner in which the 
malady is propagated. In other words, glanders is a contagious dis- 
ease, and probably is a purely contagious one. Its virus, like other 
contagions, is insusceptible of demonstration under the microscope, or 
by means of chemical analysis, and we only recognize its presence by 
its effects. It is contained in the discharge of the farcy-buttons pres- 
ently to be described, in the flow from the nostrils, the blood, and 
( Viborg) in the excretions, the saliva, urine, and sweat. Whether it 
is volatile, and capable of pervading the insensible perspiration of the 
.nfected oerson, is doubtful. The fact that the disease may be traus- GLANDERS. 
789 
mitted at a distance of ten or twelve paces, might be dependent upon 
the circumstance that particles of nasal secretion might be thrown that 
distance by a horse, or because the snorting of the animals produces 
small bubbles of the secretion capable of floating for some time, and 
of being propelled by the faintest current of air. The glanders may 
be communicated from the horse, ass, or mule, to various other mam- 
malia. Man is likewise susceptible to it, so that coachmen, grooms, 
cavalry-soldiers, horse-doctors, and other persons having business 
among diseased animals, are not unfrequently infected by it. In rare 
instances, and probably during post-mortem, sections only, the disease 
has been transmitted from man to man. The virus of glanders seems 
to be capable of penetrating the epidermic and epithelial coats, since 
most cases of infection by it have not been preceded by any wound 
of the skin. 
Anatomical Appearances.—The lesions induced by infection 
with the poison of glanders consist in peculiar nodules in the mucous 
membrane of the nose, the lymphatic glands, the skin, the muscles, 
the lungs, and other organs. At first they are hard, but afterward 
soften, disintegrate, and form abscesses and ulcers. According to 
Virchow, whose description of glanders we follow, these nodules are 
the product of a proliferation of cells. In the more recent nodules the 
cells are young, small, and delicate, and there are many free nuclei; 
in the older ones the cells are large, distinctly nucleated, lie closely 
together, and make up almost the entire mass of the tumor. As they 
progress, the older cells degenerate, and become partially filled with 
fat globules ; they then lose their sharply-defined contour, and break 
down, so that the nodule finally contains only a mass of detritus, with 
a few isolated elements. Virchow calls attention to the similarity in 
thp progress of development of the farcy and glander nodules, and 
that of tubercle; but remarks, pointedly, that no inference ought to be 
drawn from the coincidence of these processes, as the transformation 
of cells into caseous material is not peculiar to tubercle, and occurs not 
only in that disease, but also in pus, cancer, and sarcoma. 
The nodules which develop upon the nasal mucous membrane of 
horses, asses, and similar brutes, and which constitute glanders par 
excellence, are of the size of a hemp-seed or pea. The ulcers which re- 
sult from their bursting are at first solitary, or grouped, but gradually 
coalesce, imparting to the mucous membrane a peculiar worm-eaten 
look. The destruction then extends by the development and burst 
ing of new nodules upon the edges of the ulcer, as well as upon its 
floor, and upon the surrounding parts, and by gangrenous disintegra- 
tion of large portions of its surface. The ulceration also strikes 
deeply laying bare the cartilages and bones, which die and are dis- 790 
CHRONIC INFECTIOUS DISEASES. 
charged. The eruption of nodules is attended by a nasal catarrh 
which is very intense around the ulcers, and is at first accompanied by 
a thin transparent secretion. The discharge subsequently becomes 
thick, tenacious, and purulent; and when the ulceration is far ad- 
vanced, it is discolored by the admixture of blood, and becomes acrid 
and fetid, and contains the debris of the necrosed tissues. 
In farcy, a disease which develops in the skin and lymphatics of 
horses and similar animals, the tumors are larger than the genuine 
tubercles of glanders. They contain a greater quantity of caseous mat- 
ter, are discrete, or else congregate in clusters, or chains and wreaths. 
After bursting, they form rounded ulcers, with elevated or everted 
edges, with a foul, irregular bottom, furnishing a profuse ichorous dis- 
charge, which often glues the surrounding hairs together, drying up 
with them into hard crusts. 
Both glanders and farcy appear in man. The latter form, however, 
is the more common, and usually attacks the skin, upon which it gen- 
erally produces an eruption of tubercles, which are larger and more 
numerous than those occurring in brutes. The lesions of the nasal 
mucous membrane are exactly like those found in the horse. Those 
of the skin, subcutaneous areolar tissue, muscles, and lungs, are puru- 
lent rather than caseous; so that in the skin they look like pustules, 
and in the connective tissue, muscles, and lungs, they bear a great 
similarity to metastatic abscesses. The lymphatics and their glands 
are likewise often implicated in the disease in man, and, as in horses, 
they sometimes produce a chain of farcy-buttons. An inflammation 
not unfrequently extends from the lymphatics to the neighboring skin, 
which thus becomes the seat of a malignant erysipelas, with a ten- 
dency to gangrene. 
Symptoms and Course.—The period of incubation of glanders or 
farcy is of very variable duration. Where the virus has been im- 
planted upon a wound, the first symptoms generally appear within 
three or four days; but, when infection occurs where there has been 
no breach of surface (as when the virus is inhaled), the malady often 
does not break out for months. The course and magnitude of glan- 
ders also differ in the two cases. When the poison acts upon an 
abrasion, the first symptoms which appear are usually local; the 
wound inflames ; the lymphatics of the part form knotted chains, and 
their glands swell painfully. The inflammation assumes an erysipela 
tous character, and is attended by an intense oedema. Blebs form, 
and pustules, having discolored ichorous contents, and sometimes real 
gangrenous bullae, arise upon the skin, and abscesses often develop, or 
diffuse phlegmonous destruction takes place in parts about the in- 
flamed lymphatics. Sometimes the disease seems to go no furthei GLANDERS. 
791 
than this, its effects remaining confined to the lesions about the wound 
just described, and to a fever of an intensity corresponding to the 
severity of the case. Signs of a general implication of the system 
often accompany the above symptoms, however; and indeed they 
usher in the disease whenever it has not been preceded by a wound. 
The term prodromal stage, or stage of invasion, is usually applied 
to the period during which, although none of the lesions characteristic 
of glanders or farcy have as yet appeared, still the fever, constitutional 
disturbance, and certain subjective symptoms, announce a general in- 
fection of the system. 
Sometimes a single rigor occurs at the beginning of the attack, in 
others the rigor is repeated several times. The skin grows hot, the 
thirst augments, the pulse is accelerated, the patient feels depressed 
and languid, complains of pain in the head, sleeps badly, has no appe- 
tite ; in brief, exhibits a series of symptoms such as accompany other 
infectious diseases or local disorders which are accompanied by fever. 
These manifestations, however, are accompanied by another constant, 
and somewhat characteristic phenomenon, namely, a violent pain in 
the joints and muscles. The seat of this pain is usually in the vicinity 
of the greater articulations. It is generally augmented by motion or 
pressure, and is sometimes, although not always, attended by moderate 
swelling of the painful part. Although these articular and muscular 
pains often cause the disease to be mistaken for rheumatism, yet, when 
they occur in an individual whose history is suspicious, they may aid 
us in an early and correct interpretation of the symptoms. 
The first stage of the disease lasts for a longer or shorter period 
(and it may continue for three or four weeks, or more) ; the symptoms 
either increase steadily all the time, or else gradually grow milder, so 
as to subside almost completely when the second or eruptive stage, 
the stage of localization of the malady, sets in. The aspect of the dis- 
ease at this period presents many varieties, according as the malady 
selects one or other tissue as its seat. If it attack the nasal mucous 
membrane as glanders in the stricter sense of the term, an erysipela- 
tous inflammation makes its appearance upon the exterior of the nose 
and its vicinity. The nose, the eyelids, and the forehead swell, as- 
suming a dusky redness, and are covered by blebs, the precursors of 
gangrene. The patient cannot breathe through his nostrils, from 
which there flows a liquid, at first scanty, thia, and mingled with 
streaks of blood; afterward foul, bloody, and sanious. If the patienl 
lie upon his back, the discharge flows through the posterior nares into 
the pharynx, and provokes him to hawk and cough. The discharge 
causes erosion of the lining of the mouth, soft palate, and tonsils, 
which are of a deep-red hue, and are covered with ulcers and sloughs 792 
CHRONIC INFECTIOUS DISEASES. 
[n addition to these manifestations of glanders, or independently of 
them, when the nose is not attacked, characteristic lesions usually are 
found upon the skin, which were formerly regarded as a pustulous 
eruption, until Virchow demonstrated that in glanders there was no 
elevation of the epidermis by an exudation thrown out from the sur- 
face of the cutis, but that the skin suffered a circumscribed disintegra- 
tion, above which the cuticle for some time remained intact. Accord- 
ing to Virchow, the affected portions of skin at first are intensely red- 
dened, and very small, almost like flea-bites; they then change into 
papules, and the little elevations afterward assume the aspect of pus- 
tules. Beneath their epidermis we find a tolerably thick, yellow 
liquid, filling up a hole in the corium. The contents of the glanders- 
pustules, enormous numbers of which often appear upon the body, 
sometimes grow bloody, and dry up into small blackish or brownish 
crusts. Besides this scattered eruption, Virchow describes clusters 
of larger “ farcy-buttons,” which lie deeper in the skin, 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 bluish bullae. The upper por- 
tion of the cutis, which covers these clusters, is also infiltrated by a 
haemorrhagic exudation, and afterward breaks down into a pulpy 
detritus. 
The “ farcy-buttons ” of the subcutaneous areolar tissue and mus- 
cles arise either with diffuse inflammatory infiltration of the adjacent 
parts and all the symptoms of a severe phlegmon, or else small cir- 
cumscribed, hard, or boggy tumors form, which are quite painless, and 
then may develop unobserved. Sometimes the contents of the nodules 
are absorbed; more commonly the skin either ulcerates or sloughs, and 
great destruction, occasionally extending even to the bones, is the con- 
sequence. 
Participation of the lungs and bronchial mucous membrane in the 
disease is announced by shortness of breath, cough, and rales. The 
deposits are too minute to admit of detection by physical examination. 
The larger the number of these symptoms simultaneously pre- 
sented by the case, and the more rapidly they progress, so much the 
sooner will the patient succumb with all the signs of the most intense 
adynamy, and of the so-called typhous or putrid fever, the malady 
always ending fatally. Death may occur as early as the first day or 
two, while other cases drag on until the third week. 
In chronic glanders and chronic farcy the characteristic lesions of 
the nasal mucous membrane, muscles, and areolar tissue, are more 
sparing and less speedy of development than in the acute form, which 
is of far more frequeut occurrence. The skin usually remains intact, 
while the lungs and bronchial lining are soon affected. Pauses not HYDROPHOBIA. 
793 
unfrequently occur in the'eruption, so that the disease seems to have 
subsided until another cold abscess begins to form or a new eruption 
breaks out. In chronic glanders and farcy also, the majority of pa- 
tients finally perish of marasmus, and there are very few instances in 
which the disease is reported to have ended in recovery. 
Tkeatmeot.—One of the important tasks of a sanitary police 
should be to diminish the opportunity for the propagation of the virus 
as much as possible, by the enforcement of strict regulations. Such 
precautions alone can be productive of certain results, while the 
utmost vigilance and care will not furnish security, when, either from 
carelessness or selfishness, the regulations are neglected. 
Prevention of constitutional infection, by vigorous destruction of 
the point of inoculation of the glanders, can only be hoped for imme- 
diately after contact of the virus with the wound. The remedies 
proposed for the cure of pronounced glanders, calomel in large doses, 
iodine, Fowler’s solution, injections of a strong solution of creosote into 
the nostrils, and the cold-water cure, are all productive of but little 
benefit, according to our present experience. A treatment of the 
symptoms, in which local disturbance, fever, and the strength of the 
patient, are taken into account, is the one most to be commended. 
CHAPTER II. 
HYDROPHOBIA—LYSSA—RABIES. 
Etiology.—The difficult question about the nature of rabies and 
its proper position in the nosological system remains unsettled. The 
fact that the poison, the absorption of which induces the disease, is 
reproduced in the body of the patient, goes far toward proving that it 
is infectious. This view is also favored by the symptoms occurring 
among certain classes of animals. The two chief forms of rabies in 
dogs, the quiet and raging, remind us of the febris nervosa stupida and 
febris nervosa versatilis of old authors. On the other hand, there are 
certain objections to classing lyssa among typhus fevers, the acute 
exanthemata, and other acute infectious diseases. I would especially 
call attention to the variable duration of the period of incubation in 
different persons. We do not certainly know the length of time 
between the action of the contagion and the outbreak of the malady in 
all infectious diseases, but we suppose that the difference of this 
interval is only slight in different persons. In lyssa the period of 
incubation varies weeks and months, even if we do not consider 794 
CHRONIC INFECTIOUS DISEASES. 
extreme cases. Moreover, there is an essential difference between the 
character of the fever in this and other acute infectious diseases. 
In lyssa, among the symptoms are some nervous ones, slightly analo- 
gous to the neuralgias which occasionally occur, instead of the fever 
in malarial infection. Lyssa lxumana most resembles tetanus, although 
I cannot understand how it is possible to deny the occurrence of lyssa 
as an independent disease, and to identify it with tetanus. In the 
well-observed cases, neither continued tension of the spinal muscles 
nor pain in the contracted muscles has been mentioned, while neither 
is ever wanting in true tetanus. The difference between lyssa and 
tetanus is, that the spasms, which may be termed tetanic, only occur 
in some paroxysms, and are limited to certain nerves, and more par- 
ticularly to those which are by no means chiefly affected in traumatic 
or rheumatic tetanus. When Romberg terms lyssa a toxoneurosis, he 
says all that we actually know of the nature of the disease. 
Without the experience that the poison is reproduced in the body 
of the patient, we might most reasonably suppose that a toxic neuritis, 
or a toxic neuropathia, spread from a peripheral nerve, on which the 
poison had worked, to the medulla oblongata and cerebrum; and, 
since in many cases changes in the wound or in the cicatrices precede 
the outbreak of the malady, and the time between these changes and 
the outbreak is very short, it would be most probable that the poison 
had remained latent at the seat of injury, but afterward had rapidly 
spread in a centripetal direction. This latency would most remind 
us of that of syphilis between the different outbreaks of the disease. 
However, all this reasoning lacks a solid foundation. 
Lyssa, or rabies, in its stricter sense, is a disease which origi- 
nates in animals of the dog kind, and which indisputably is propa- 
gated, in most instances, by infection of one animal by another. 
We shall not discuss the question whether this be its only mode of 
propagation, or whether, under certain circumstances, it may develop 
spontaneously. The rabies of other races of animals and the hydro- 
phobia of human beings are purely contagious maladies. This 
poison, which exists in the saliva, blood, and perhaps in other 
fluids of the body, is not volatile, but fixed in character; it cannot pass 
through the epidermis, and hence does no mischief, unless brought ir 
contact with an ulcerated or excoriated surface. 
The most common cause of human rabies is the bite of a mad dog. 
More rarely the disease originates in the bite of some other rabid 
animal, such as the wolf, the fox, the cat, or the ox. The possibility 
of infecting a healthy man by the bite of a man suffering from hydro- 
phobia has not yet been proved positively; but the inoculation of the 
disease from human beings to brutes has reoeatedlv been successful HYDROPHOBIA. 
795 
Bites of rabid animals upon bare portions of tlie body are far more 
dangerous tlian if the part bitten be covered by the clothing; as, in 
the latter case, the poisonous saliva is not so readily conveyed to the 
wound, being wiped off from the teeth by the clothing. For the same 
reasons, there is no danger from the licking, or otherwise moistening, 
of the sound skin by the saliva, blood, or other fluids of a rabid animal, 
unless there should happen to be an abrasion or fissure upon its surface,. 
The virus, when implanted upon an excoriation of the skin, does 
not lead to hydrophobia unless there be a certain degree of predispo- 
sition to the disease. Inoculations of the saliva of rabid animals, as 
practised by Jlertwig, succeeded only in twenty-three per cent, of the 
animals operated upon, seventy-seven escaping; and, according to Fa- 
ber's statistics, out of one hundred and forty-five persons bitten by 
rabid animals, in Wiirtemberg, only twenty-eight had hydrophobia. 
Anatomical Appearances.—No lesions characteristic of the dis- 
ease are found in the bodies of those who have died of hydrophobia. 
The most common conditions consist in intense rigor mortis, extensive 
post-mortem hypostasis, early putrefaction (so that, soon after death, 
blebs full of gas begin to arise), intense staining of the endocardium and 
walls of the vessels, hypermmia and serous exudation in the brain and 
its membranes, in the spinal marrow, in some of the sympathetic gan- 
glia and nerves; hypersemia and swelling of the mouth and fauces, 
both of which contain a collection of tenacious mucus; hypostasis and 
oedema of the posterior parts of the lungs ; engorgement of the walls 
of the stomach, and great abdominal glands. All these lesions, espe- 
cially the injection of the nervous centres and nerves, upon which, at 
times, great stress has been laid as explanatory of the nature of the 
disease, are not constant, and, for the most part, seem to arise just 
prior to dissolution, in consequence of the disturbance suffered by the 
functions of respiration and circulation during the attacks presently to 
be described. In the cases which I have seen, autopsy showed a 
decided swelling of the tonsils and follicular glands at the root of the 
tongue and the posterior wall of the pharynx, exactly corresponding 
with Virchow's observations. 
Symptoms and Course.—Most cases of lyssa that have been 
well observed and described closely resemble each other. One that 
I have seen corresponds closely to the dreadful picture which 
Romberg drew from his own and other cases. As it is universally 
assumed that morbid processes due to the action of a specific poison 
run their course with symptoms which only vary through personal idio- 
syncrasy and the variable intensity with which the poison has acted, 
those reports of lyssa humana differing from our description, in which 
the characteristic symptoms and their peculiar sequence are not 796 
CHRONIC INFECTIOUS DISEASES. 
mentioned or really did not occur, must arouse the suspicion that they 
were badly observed, or that there was an error of diagnosis. 
Opinions differ as to the length of its period of incubation. The 
statements that hydrophobia has made its appearance twenty or thirty 
years after the bite of a rabid animal, as well as those according to 
which the disease has broken out as early as the second or third day, 
are probably dependent upon imperfect observation. The shortest 
term of incubation appears to be about eight or ten days; the longest, 
twelve or thirteen months. In the majority of instances, the malady 
breaks out in about forty days after the reception of the bite. The 
reasons for this inequality of the period of incubation are obscure. The 
assertions of Marochetti, who claims that, during the incubative stage, 
vesicles form beneath the tongue, and that, by destroying these vesi- 
cles, the outbreak of the disease can be averted, have not been substan- 
tiated. But there are numerous instances in which, toward the end 
of the stage of incubation, and a day or two before the onset of the 
malady, peculiar alterations have been observed in the wound or its 
scar, for the wound has generally healed by this time. The bite as- 
sumes a livid color, grows painful, and discharges a yellow ichor. 
The scar, which has generally soon formed without remarkable symp- 
toms, grows bluish red, swells, and sometimes breaks out afresh. 
The patient also complains of painful sensations, shooting centripetally 
from the wound or scar, or of a sense of numbness in the bitten mem- 
ber. These disturbances at the point of entry of the virus are very 
often wanting. 
The first or prodromic stage of the disease is marked by a peculiar 
depression of the patient’s spirits, amounting to an acute melancholy, 
and which has caused the term stadium melancliolicum to be applied 
to this period of the disorder. The patient seeks solitude, is timid 
and apprehensive, and either sits motionless and plunged in deep ab- 
straction, or else is unable to rest at all. Some complain of an indefi- 
nite feeling of dread and oppression, and sigh repeatedly without 
any reason for so doing. Some are preoccupied with sad forebodings, 
or, if aware of their perilous condition, are incessantly tormented by 
dread of the onset of the malady. Sleep is restless and broken by 
frightful dreams. The precursory signs of the spasmodic disturbance 
of respiration, afterward to attain so terrible an intensity, soon super- 
vene. The patient complains of pressure in the proecordium, draws 
profound, sighing inspirations, the diaphragm is depressed, the epi- 
gastrium bulges, and the shoulders are drawn upward. This spas- 
modic breathing is the first token of the tonic spasm of the muscles 
of inspiration which causes such frightful torments in the second stage 
of the disease. HYDROPHOBIA. 
797 
The prodromic term having lasted two or three days, the second 
or furious stage begins. Its onset is marked by a fit of choking, sud- 
denly induced by an attempt to drink, which renders the patient in- 
capable of swallowing a drop. 
The moment the fluid enters the mouth and the motion of swallowing 
is made, spasmodic inspiratory motions begin; the thorax rises inter- 
ruptedly, and remains in the position of deepest inspiration for ten or 
twenty seconds. During this time the features betray anxiety and 
terror, the eyes protrude, head and shoulders are thrown back, then 
comes an expiration, with which the attack passes off. I have satisfied 
myself that the inspiratory muscles, as well as those of the pharynx, 
are implicated in these seizures. This combination of spasmodic con- 
tractions in both of these sets of muscles is a frequent symptom; it 
always appears in the straining preceding vomiting, as well as in the 
retching following irritation of the pharynx by the finger, etc. Retch- 
ing is always accompanied by a feeling of suffocation, from the contrac- 
tion of the inspiratory muscles complicating the spasm of the pharynx; 
and we are justified in giving the name of retching-fits to these spasms, 
which form the pathognomonic symptom of lyssa, and are given in 
every well-recorded case. 
The dread of water is entirely due to the dreadful experience of 
the patient on trying to drink. This was so, not only in my case, where 
the patient, an energetic and courageous man, voluntarily made 
repeated attempts to drink, before he rejected with terror any sugges- 
tion of the kind, but it is the same in all cases of undoubted lyssa 
that have been well observed and accurately described. Reports of 
cases where hydrophobia is given as a primary symptom are worthy of 
no credence. It is a curious fact that, at first, the act of swallowing 
solid food is not followed by spasms. Even a draught of air on the 
skin, or touching any thing cold, sudden irritation of the eye by dazzling 
light, even sudden mental excitement or surprises, may induce attacks. 
According to my observation, the pharyngeal muscles do not partici- 
pate in the reflex spasms induced by irritating other parts, as the 
mouth or palate. On suddenly arousing my patient, he opened his 
mouth widely, threw the head back, the thorax was raised as in full 
inspiration, the epigastrium became prominent, but there was no 
actual retching. At the height of the disease, it looked as if attacks 
occurred from time to time, even without cause ; but I think that even 
these apparently spontaneous attacks must be regarded as reflex 
spasms, and be referred to collections of tough mucus in the pharynx 
or to the trickling into it of saliva. This supposition is based on the 
haste and abandon with which the patients eject saliva and mucus, 798 
CHRONIC INFECTIOUS DISEASES. 
and their attempts to introduce the finger far into the throat, for the 
purpose of removing mucus and sputa. 
Various authors name tetanic or epileptiform spasms among the 
symptoms of lyssa ; but, on careful examination, I have not been able 
to discover a case where the detailed description of the spasms fully 
convinced me that they were tetanic or eclamptic. It is nowhere 
stated that the muscles of the back were tense, except during the 
attacks, or that consciousness was lost during the general convulsions. 
In my patient, there was also opisthotonos—he threw his hands and 
feet about, and pitched around, so that he frequently fell on the floor. 
But these symptoms reminded one far more of hysterical spasms, or of 
the actions of a tortured, despairing man. 
The above symptoms are soon accompanied by attacks of 
boundless rage, in which the patients are hard to manage, destroy all 
fill at comes in their way, strike, kick, scratch, and bite, if held fast— 
and, not unfrequently, kill themselves, if they are carelessly watched. 
The biting, inarticulate howling, and barking sounds, are not made 
more frequently by a hydrophobic patient than by another madman 
in the maniacal stage of chronic cerebral disease.* The patient often 
warns his attendants between the fits, which seldom last longer than 
a quarter or half an hour, and begs pardon for his misbehavior toward 
them, and sets his worldly affairs in order, in perfect consciousness of 
the near approach of his end. The paroxysms of madness and convul- 
sions, having steadily grown more frequent for two or three days, now 
begin to diminish in violence as the patient loses strength. Rarely, 
it happens that death occurs at the height of the malad}T, during a 
severe and long-continued choking-fit. The exhaustion and collapse 
usually augment from hour to hour; the voice grows hoarseand feeble, 
the respiration shallow, the pulse small, irregular, and very frequent, 
and death ensues with the signs of a general paralysis, which is some- 
times preceded by a deceptive amelioration of the symptoms. 
It might be supposed that the attacks of madness occurring in 
lyssa were simply a result of the despair that would affect even a 
person not having this disease, if he suffered from retching at short 
intervals for a day or two. I once attended a patient suffering from 
severe pharyngitis, who, when I asked him to try to drink, hurled the 
glass from him, and acted like a madman. 
We find something like this, too, in patients with croup or oedema 
glottidis. The fact, also, that sometimes patients of very temperate 
* 7iomberg says that a great inclination to bite, along with the absence of charac- 
teristic reflex spasms, is one of the diagnostic points between true lyssa and those 
hypochondriacal and maniacal conditions that fear of the disease not unfrequently 
develops in persons that have been bitten. This state might be termed lyssophobia. HYDROPHOBIA. 
799 
and resigned natures do not become maniacal would also favor this 
view. But there are some objections to it, especially the fact that, 
even in persons the most resigned, the absence of mania is one of the 
rarest exceptions, as well as the excessive height that the madness 
usually reaches in lyssa patients. It is certainly more probable that 
the madness in lyssa is not due to moral grounds, but is caused by a 
propagation of the excessively increased morbid excitability of the 
motor-central apparatus of the pharyngeal and respiratory nerves 
to the central organs of the psychical functions. The symptoms of 
the mania have many analogies to reflex spasms. Trifling mental 
excitement causes severe outbreaks, violent motions, and excited 
actions in manaical patients, just as slight irritation of the skin causes 
severe reflex spasms in patients with tetanus. 
Treatment.—We shall only make the following brief remarks 
about the sanitary measures by which the state should try to protect 
its subjects. The only prophylaxis is by confinement of dogs. No 
attention should be paid to the lovers of dogs. Any one who 
expends sympathy on the “ poor dog,” and petitions against his 
being tied up, or wearing a muzzle, should be made to watch a patient 
with hydrophobia for half an hour, and he would soon be cured. 
Most muzzles that dogs wear do not prevent their biting, and they are 
only protective when they do so. It is very important not to kill 
dogs suspected of madness, but to shut them up and observe them 
closely. Death, which soon takes place spontaneously, and the 
symptoms under which it occurs, are far more important in deter- 
mining that the dog was mad, than are the results of autopsy; for, 
from the latter, especially if the dog was killed by violence, it cannot 
be said with certainty whether the dog was mad or not, and harm 
has been done by such unreliable, demonstrative assertions. The 
most we can say is that negative results of an autopsy, where no 
changes have been found in any organ of a dog suspected of rabies, 
to explain the symptoms and death, go to prove the probability of 
the diagnosis—especially if we find hair, straw, rubbish, etc., in the 
stomach ; for, while a healthy dog would not be apt to swallow 
them, a mad one would. 
If a man has been bitten by a dog suspected of rabies, prophy 
laxis requires a destruction of the spot with which the poison may 
have come in contact; and every dog that has bitten without pro- 
vocation, or without previous inclination to bite, should be sus- 
pected. 
The object of prophylactic treatment should be to destroy the por 
tions of skin which have come in contact with the virus. It consists 
in excision of the wound, and in the vigorous cauterization of the part 800 
CHRONIC INFECTIOUS DISEASES. 
with the hot iron, or with a deliquescent caustic, such as caustic potash, 
butter of antimony, and the like. It is also advisable not to permit 
the sore, resulting from detachment of the eschar thus made, to heal 
too rapidly, but, if practicable, to keep it suppurating for months. 
These measures are all the more likely to be successful, the earlier 
they are applied, but they should never be neglected, even though 
weeks have elapsed since the infliction of the bite. 
As a further precautionary treatment, the exhibition of mercury to 
the point of salivation, large doses of belladonna, and a series of other 
so-called antilyssa, are employed; but it is very questionable whether 
the disease has ever been averted by the use of any of these articles, 
and whether the cases in which hydrophobia has not followed upon the 
bite after the use of anagallis arvensis, gentiana cruciata, rosa canina, 
genista luteo-tinctoria, cantharides, or may-worm, did not belong to the 
seventy-seven per cent, of subjects in whom the predisposition to rabies 
did not exist, and without which hydrophobia never occurs. Inasmuch 
as, after the establishment of the disease, these measures do not pro- 
duce even the slightest palliative effect, their prophylactic virtue is 
more than doubtful; hence, I by no means regard it necessary to 
subject a man, who has been bitten by a mad dog, to the baneful in- 
fluence of mercury, although I should not hesitate to resort to any 
procedure, be it never so severe or dangerous to the life of the 
patient, if, according to actual experience, any benefit were to be 
expected from it. 
If the disease has broken out, there is little hope of curing it, or 
even of alleviating the sufferings of the patient, for hitherto there 
has been no accurately observed case of lyssa having any other termi- 
nation than a painful death. Even the waiting and nursing are very 
difficult, and should only be trusted to persons who are humane as well 
as fearless and energetic. Every thing that can induce return of the 
spasms, and, later, of the paroxysms of madness, should be carefully 
avoided. To relieve the thirst, small enemata of cold water may be 
given from time to time. In the case I saw, these were well borne 
and quickly absorbed. In recent cases, where the patient is young 
and vigorous, we may bleed, as in some cases this has proved of 
undoubted benefit. If the patient will bear it, we may also let him 
inhale chloroform from time to time, and give subcutaneous injections 
of a strong solution of morphine. The favorable results said to have 
been attained in some cases of tetanus, by the use of curare, decided 
me to try it in a case of lyssa under my care. At first later 
•|th of a grain of carefully-tested curare was subcutaneously injected 
at intervals of three to four hours. Distrustful as we were about the 
result, this treatment still seemed of palliative benefit, and seemed HYDROPHOBIA. 
801 
to afford greater relief than the morphine injections. The patient 
repeatedly prayed for the continuance of the curare injections, as he 
was firmly persuaded that they relieved him. This experience is 
enough to make me urge injections of curare in any case of lyssa 
humana; and, as nothing can be lost by it, to give it even more boldly 
than we did. SECTION III. 
GENERAL DISORDERS OF NUTRITION WHICH DO 
NOT DEPEND UPON INFECTION. 
CHAPTER I. 
CHLOROSIS. 
Etiology.—The subjects of anaemia and hydraemia belong rather to 
the province of general pathology, since such anomalies of the quan- 
tity and quality of the blood never arise as independent affections, but 
always appear as an accompaniment or consequence of other diseases. 
The state of the blood which gives rise to the condition known as 
chlorosis differs from that which induces hydraemia. In chlorosis, only 
the cellular elements of the blood are diminished in number, while its 
quantum of serum, albumen, and saline constituents, is generally nor- 
mal. In hydraemia, on the other hand, not only is the blood poor in 
cellular elements, but its serum is deficient in albumen, and it probably 
is overcharged with salts. A chlorotic state of the blood (oligocytliae- 
mia, Vogel) often develops with a certain degree of independence; or, 
to speak more accurately, it frequently arises without our being able 
to perceive any morbid condition which, by augmenting the consump- 
tion of the blood, or by diminishing its production, might induce chlo- 
rosis, and which generally can be discovered in anaemia and hydraemia. 
In the present chapter it is the former class of cases alone with which 
we have to do, and we shall not notice those rare instances in which 
oligocythaemia develops as a symptom in certain diseases. 
In females between the ages of fourteen and twenty-four, chlorosis 
is one of the most common of disorders. It is very natural, then, to 
ascribe the disease to the effects of those processes which are going 
on in the bodies of young girls at the period of puberty; but we 
are still ignorant as to what physiological connection exists be- 
tween the two conditions. We know equally little of the causes CHLOROSIS. 
803 
winch favor the occurrence of chlorosis at the time of puberty; for, al- 
though it is not improbable that the development of this affection is 
often encouraged by a want of fresh air and exercise, by improper 
nourishment, mental excitement, improper reading, masturbation, or 
by a generally unhealthy mode of life, yet the disease arises often 
enough under conditions precisely the opposite of these, in girls who 
work all day in the open air, who are well fed, do not read novels, and 
are not addicted to any secret vice. I may add that, according to my 
observation, obstinate chlorosis attacks all young girls without excep-' 
tion, in whom the menses have appeared in the twelfth or thirteenth 
year, and before the development of the breasts and pubes. 
Far more rarely chlorosis—oligaemia without assignable cause— 
appears in children and in pregnant women, and sometimes even in 
males. The number of instances of chlorosis in this class is very 
limited. 
Ax atomical, Appearances.—The lesions characteristic of chloro- 
sis lie mainly in the blood, which, with Virchow, we may regard as a 
tissue consisting of cells with a liquid intercellular substance. As has 
been said already, this intercellular substance, the serum, does not 
present any constant anomaly. Its composition generally is normal; 
more rarely there is a diminution of its albumen. In other cases, again, 
the amount of albumen of the blood-serum seems to be increased, so 
that, besides the oligocythaemia, there is hyperalbuminosis. In the first 
two instances, the whole volume of the blood is probably reduced, 
while in the latter the possibility cannot be denied that, in spite of 
the diminished number of the blood-corpuscles, the absolute bulk of 
the blood is augmented, adding a serous plethora to the oligocythaemia. 
In pronounced chlorosis, the disease in the red-blood corpuscles 
may be so great that a thousand parts of blood may contain but sixty 
or forty parts of dried blood-cells, instead of the normal average of one 
hundred and thirty parts. Upon the autopsy of a chlorotic person, 
who has died of intercurrent disease, the viscera are all found to be 
remarkably pale. In some cases, the signs of simple fatty degenera- 
tion are found in the tunica inthna of the great vessels.1 
Symptoms axd Course.—The most striking symptom of chlorosis 
consists in the pallor of the skin and visible mucous membranes. When 
the skin contains but little pigment, as is the case in blondes, the sur- 
face of the body is of a pure white; while, when the pigmentation is 
intense, as in black-haired persons, it is more of a dirty-gray or yel- 
lowish hue. The pallor is often most distinctly pronounced upon the 
ears, while in the mucous membranes the loss of color is most remark- 
able in the conjunctiva and the gums. The reason for this blanching 
of the complexion is manifest. The number of red-blood corpuscles 804 
GENERAL DISORDERS OF NUTRITION. 
upon which the blood itself depends for its redness, and the tissues 
through which it circulates for their tints, is reduced one-half, or one- 
third, or even lower. The exceptions to this rule, namely, the occa- 
sional instances of chlorosis in which the cheeks retain their redness, 
are easy of explanation, when we come to know that the color of the 
blood is but one of the causes upon which the tint of the cheek de- 
pends ; another consisting in the filling and distention of the capil- 
laries. Just as there are persons whose cheeks are pale, in spite of 
the deep hue of their blood, because their capillaries are inadequately 
filled, so there are other chlorotic persons who, notwithstanding that 
their blood is pale, always have red cheeks, because their capillaries 
are filled to bursting, and are varicose. The transient flush observed 
in almost all chlorotic persons when excited or heated, and to which 
we shall refer hereafter, is also to be ascribed to a momentary disten- 
tion of the capillaries wTith blood. 
The fat in the subcutaneous areolar tissue of chlorotic persons is 
often normal in amount, and is sometimes even in a state of exuberant 
development. This condition furnishes an important distinctive marie 
between chlorosis and the chronic anaemia which often manifests itself 
in latent consumption, and in other concealed disorders which affect 
the quality of the blood. In a symptomatic anaemia or hydrasmia of 
this kind, which is frequently confounded with chlorosis, the subcutane- 
ous fat soon vanishes as the color of the skin fades. CEdematous 
effusion into the subcutaneous cellular tissue is rare in this disease. 
Hence a moderate paleness of the surface, accompanied by oedema of 
the feet, warrants the suspicion of hydraemia and not of chlorosis; and 
conversely, when the lips, cheeks, and ears are white as wax, and yet 
there is no sign of oedema, it is probable that the serum of the blood 
retains its normal composition, and that the case is a pure oligocythae- 
mia and not a hydraemia. 
Chlorosis is always accompanied by more or less shortness of 
breath, owing to a diminution in the number, sometimes amounting 
to one-half or more, of the bodies which take up oxygen, and give out 
carbonic acid. The normal number of respiratory acts is insufficient to 
supply oxygen to the lungs in quantity adequate to the wrants of the 
system. Every bodily effort, by increasing the consumption of tissue, 
and augmenting the production of carbonic acid, aggravates the dysp- 
noea, and multiplies the patient’s breathings to a distressing degree. 
Hence patients with pronounced chlorosis scarcely ever fail to com- 
plain that they “ get out of breath ” when they walk fast, or mount 
the stairs. The diminution in the interchange of gases, and especially 
the impediment to oxygenation of the blood, also accounts for a second 
series of symptoms peculiar to chlorosis. The strength of the muscles, CHLOROSIS. 
805 
which, to be vigorous, calls for a supply of well-oxygenated, blood, is 
greatly reduced. The patient is easily fatigued, and complains of a 
sense of weight in his limbs, and not unfrequently (pseudo-rheumatic) 
muscular pains are induced by the slightest effort, such as only are felt 
by healthy folk after unusual and excessive exertion. Important as it 
is to the normal function of the muscles that a free supply of well- 
oxygenated blood should circulate within them, this is equally essen- 
tial to the proper action of the nerves. In treating of the neuroses, 
in almost every instance, we have referred to the state cf the blood in 
chlorosis as an important point in their etiology. Hence, neuralgia is 
extremely common among chlorotic patients, that of the trigeminus 
being especially frequent among the peripheral neuralgias, while in 
the internal organs cardialgia is more common. Anaesthesia, convul- 
sions, and palsy, are rarer, and are seldom observed excepting when (as 
sometimes happens) hysteria develops during the disease. There are 
nearly always signs of hysteria in chlorosis, which consist of general 
bodily and mental hyperaesthesia, a troubled, irritable temper, a dis- 
position to weep, perverted appetite (for instance, a craving for coffee- 
beans, slate-pencils, etc.). 
The organs of circulation present numerous deviations from the 
normal. The patients nearly all complain of palpitation. I have 
already declared that this symptom is not altogether due to an aug- 
mented or accelerated action of the heart, being also in some degree 
dependent upon a general hyperesthesia, whereby the impulse of that 
organ is rendered distressingly perceptible, whereas it is not felt at 
all by most persons, even when its beat is enormously intensified by 
hypertrophy (Vol. I.). Upon auscultation of the chest, over the heart 
and great vessels, we hear the blowing sounds so often alluded to, 
and which are known as “ blood murmurs,” to distinguish them from 
the morbid murmurs depending upon alteration of the structure of the 
heart. This name is inappropriate, however, as the sounds are not 
caused directly by the altered condition of the blood. They most 
probably arise from an abnormal tension of the valves and arterial 
walls. 
Far more frequently, upon listening over the jugular vein, a pecu- 
liar humming, singing murmur is heard, known as the “Nonnen- 
gerausch,” or “ bruit de diable.” The name is derived from the sound 
of the humming-top, called “ Brummkreisel ” in North Germany, and 
“Nonne” (nun) in other places; while in France it is called the 
4 diable.” The sound is more intense upon the right side than upor. 
the left, and subsides when the patient assumes a horizontal attitude 
or draws a forced breath. The mode of origin of the “ bruit de diable ” 
seems to be as follows: The lower part of the internal jugular veins 806 
GENERAL DISORDERS OF NUTRITION. 
lying behind the sternoclavicular articulation is attached upon all 
sides, so that it cannot collapse, like other veins, when the stream of 
blood is reduced in volume. When the jet of blood which enters 
this large space is too small, it can only fill it by forming an eddy. 
This whirling current throws the walls of the veins into sonorous 
vibration. If the neck be turned to one side so as to compress the 
jugular of the opposite side between the omohyoid muscle and the 
cervical fascia, the bruit de diable becomes audible in the majority 
even of full-blooded, healthy persons. When the sound is perceptible 
without such a turning of the neck, it may always be inferred that the 
patient’s blood is impoverished and that his veins are scantily filled. 
The excessive nervous irritability arising from inadequate oxygenation 
of the blood also involves the vasomotor nerves; whence the sudden 
flushing and paling of chlorotic persons. 
Besides the cardialgia already alluded to, other serious disorders 
of the digestive system arise in chlorosis, which, unless watched with 
patience and attention, might give rise to dangerous mistakes. The 
appetite is nearly always diminished; after eating, there is a sense of 
pressure and fulness in the epigastrium, with acid eructations and other 
symptoms of dyspepsia, which, in most patients, depend on “ atonic 
weakness of digestion ” (Vol. I.), and generally disappear as the state 
of the blood improves. Affections such as these are not dangerous, 
and nearly always get well under proper treatment; unfortunately, 
however, the chronic ulcer of the stomach is also a very common occur- 
rence in chlorosis, and often develops undetected. In treatment of a 
chlorotic patient, it must never be forgotten that the cardialgia and 
dyspepsia may be dependent upon this grave lesion of the stomach, 
and all suitable means must be invoked to aid us to a correct diagnosis. 
Neglect of such precautions may terminate in an unexpected and tragic 
denouement by haamatemesis, or even by perforation. 
The urine of a chlorotic patient, unless there be intercurrent fever, 
is remarkably limpid and light. The lowness of its specific gravity is 
probably owing to the small amount of urea which it contains, and its 
light color to a deficience in coloring matter. Reduction in the supply of 
oxygen sufficiently accounts for the decrease in the destructive assimi- 
lation, and consequently for the diminution of the urea in the urine. 
We know but little regarding the formation of its coloring matter, but 
it can scarcely be doubted that it is derived from that of the blood; 
lienee, when the number of the blood-corpuscles, which contain the 
red matter, is diminished, it is not surprising, caeteris paribus, that the 
coloring of the urine should decrease. 
The sexual function nearly always suffers derangement, generally 
in the form of amenorrlioea, more rarely in the form of excessive men- CHLOROSIS. 
807 
struation or of dysmenorrhoea (Yol. II.). When amenorrhoea occurs, it 
is almost always because the ovules do not mature; for, generally, all 
the other signs which attend ripening and expulsion of the ovum are 
absent, besides the bleeding. By the laity, and even by some physicians, 
amenorrhoea is supposed to be a constant symptom of chlorosis, an error 
which may sometimes be productive of the utmost mischief, by inducing 
the premature suspension of remedies still urgently required, on ac- 
count of the presence or appearance of the menses. Indeed, owing to 
this erroneous idea, that chlorosis is always attended by amenorrhoea, it 
not unfrequently happens that chlorotic girls, suffering from dysmenor- 
rhoea or menorrhagia, and complaining of headache and palpitation, are 
supposed to be “ too full-blooded,” and are therefore purged and bled. 
Finally, in many chlorotic patients, besides the irregular menstruation, 
there is a catarrh of the uterus and vagina (Yol. II., pp. 123, 171). 
The course of chlorosis, unless cut short by proper medication, is 
almost always slow and tedious. This disease, if not detected, or if 
treated homoeopathically, often lasts for months, and sometimes for 
many years. It generally terminates in recovery, although, in very 
young persons, one or more relapses are apt to occur. More rarely, 
chlorosis passes over into other disorders, such as tuberculosis. It 
never endangers life, excepting through its complications, particularly 
the very common one of chronic ulcer of the stomach. The stories 
about acute febrile chlorosis terminating in death are the result of 
erroneous diagnosis ; although it is true that unimportant febrile dis- 
eases, when they attack chlorotic patients, are often accompanied by 
typhoid symptoms and assume a malignant type. 
Treatment.—Attempts to fulfil the causal indication in chlorosis 
are very seldom followed by benefit, a proof that the causes to which 
the disease is generally ascribed are not relevant ones. Chlorotic 
girls are often restored to health in a few weeks, by the fulfilment of 
the indications from the disease itself, although they had been long 
and carefully, though fruitlessly, protected from pernicious agencies, 
had passed months in the country, lived on the best of food, exercised 
daily, and taken a course of German or Swedish gymnastics without 
bringing color to their lips and cheeks, relief to their shortness of 
breath, or improvement to their irritable and fretful temper. The 
reputation which dietetic treatment enjoys, as a remedy for chlorosis, is 
mainly attributable to the circumstance that not only does pure oligo- 
cythaemia bear this name, but it also is given to a great variety of 
anaemic conditions, in which such treatment is indispensable, while the 
use of iron is but of secondary importance. Experience teaches daily 
that brilliant cures of pure chlorosis may be made under the most un- 
favorable external conditions. 808 
GENERAL DISORDERS OF NUTRITION. 
The indications from the disease itself demand the exhibition of 
iron. If any medicine ever deserved the name of a specific, iron does, 
as a remedy in this disease. The surer our diagnosis, so much the more 
certain may we be of succeeding; and when, contrary to our expecta- 
tions, we fail of success, there will be reason for suspecting that the 
case is not simple chlorosis, but an anaamia depending upon some 
other unperceived or unrecognizable disorder. The progress of a chlo- 
rosis, which, developing in a young girl at the period of puberty, has 
defied all treatment, often proves it to have been but the initiatory 
stage of a tuberculosis, or the anaemia consequent upon a chronic 
gastric ulcer. We are ignorant of the manner in which the iron 
improves the defective state of the blood. The existing red-blood 
corpuscles are not wanting in iron, but there is a deficiency of the red 
corpuscles themselves, into whose chemical composition iron enters 
to a slight extent. Perhaps the iron stimulates the activity of the 
region where the red corpuscles are formed, or perhaps it regulates 
the digestion, and thus promotes the supply of material for the forma- 
tion of blood-corpuscles. But there is no sound foundation for any of 
these hypotheses, the number of which might be materially increased. 
Opinions vary greatly as to the proper form and dose of iron. Iron- 
filings are much prized by certain well-known and fortunate practition- 
ers ; others, equally celebrated and successful, prescribe one or other 
of its salts, to the exclusion of all the rest, claiming its effects to be 
more certain, and better borne. Others, again, begin treatment with 
the “ mildest ” of the ferruginous preparations, as the mallate or lac- 
tate of iron, proceeding thence to the “ stronger ” ones, the chloride 
and sulphate, winding up the treatment with the filings. Besides the 
limatura ferri, which may be given in three to six grains as a dose, 
generally with an addition of powdered cinnamon, the tinct. ferri pomat. 
(gtt. xv-xxa), the lactate of iron (gr. ij-v), the ferri carb. saccliarat. 
(gr. iv-x), the tinct. ferri chlor. (gtt. x-xxx), ferri sulph. (gr. j-iv), 
are the preparations of iron in most common use. From the estimate 
in which these various preparations are held by different established 
authorities, and from the fact that nearly every practitioner has his 
“ pet article,” which he uses in the majority of cases, it may be in- 
ferred : 1. That the efficacy of iron in chlorosis does not depend upon 
the form in which it is administered. 2. That nearly all ferruginous 
preparations are well borne in chlorosis. 3. That special indications 
for the exhibition of one or other of them cannot be laid down. Foi 
more than twenty years I have used BlaucVs pills almost exclusively 
in chlorosis, and have witnessed such brilliant results from them in a 
large number of cases, that I have never found any opportunity to ex- 
periment with other articles. Instead of the forty-eight huge boli, CHLOROSIS. 
809 
according to Bland's original prescription (fiE, Ferri sulp. pi.lv., potass, 
carb. pur®, aa § ss, tragacanth. q. s. u. f. pil.), I have ninety-six 
pills made. Nor am I so timid in increasing the dose according to 
Bland's formula, but order three pills thrice daily, and sometimes four 
or five if they are well borne, which they almost always are. Three 
boxes of Bland's pills nearly always suffice to cure the most persistent 
chlorosis. At Magdeburg and Greifswald I often had to send my re- 
cipe for the pills to a great distance, my good fortune in the treatment 
of chlorosis—to which, by-the-by, I owe the rapid growth of my prac- 
tice—having given me a groat reputation as the possessor of a sover- 
eign remedy against that disease. 
I do not suppose that Bland's pills excel all other ferruginous 
preparations in virtue; indeed, I have repeatedly satisfied myself that 
colleagues who made use of other recipes obtained equal results, pro- 
vided only that they gave doses of equal size; but I also believe that 
the efficacy of Bland's pills cannot be surpassed, simply because they 
can be administered in very large doses without distressing the patient. 
I had an opportunity to test the truth of this some ten years ago. I 
was asked for my recipe by one of my colleagues, and at first referred 
him to the Canstatt text-book, which contained the well-known formula 
for Bland's boli; but, as he did not have that book, I told him the 
formula, adding, that I began with three boli, raising the dose one 
bolus every three days. Some time afterward my colleague took occa- 
sion to thank me, extolling the excellent effect of the medicine, and 
stating how well it had been borne by the patient. As it turned out, 
however, he had misunderstood me, and, instead of raising the dose 
every three days, had added one bolus at every dose. 
It has been maintained that the treatment of chlorosis does not 
require large quantities of iron, because the amount of it taken up by 
the blood is very small, and since, even when small doses are given, a 
large portion of the metal always passes off in the stools as superflu- 
ous, and further, because the efficacy of the chalybeate springs in this 
disease proves that a minimum of iron will suffice. Without going 
into groundless theoretical discussions, I will admit that the disease 
will also recover (although somewhat slowly) under the use of smaller 
doses of iron, and may be cured by chalybeate waters; but the numbej 
of patients who have recovered in my practice through the employment 
of Bland's pills, and under that of my colleagues under the use oi 
carbonate of iron (pil. ferri carb.), or of lactate of iron in large doses, 
after they had taken small doses of tincture of iron and wine of iron 
for years without positive effect, and had repeatedly visited Pyrrnont 
and Driburg, is large enough to warrant the assertion that we shall 
cure chlorosis most speedily and surely by means of those ferruginous 810 
GENERAL DISORDERS OF NUTRITION. 
preparations which can be tolerated in the largest doses, and of these 
Bland's pills stand highest on the list. 
A very common error in the treatment of this affection consists in 
the attempt to relieve the erethism, digestive disturbance, and other 
troubles due to the state of the blood, by means of mineral acids, bit- 
ters, and other medicines; while iron, from which alone, or at least 
from which the greatest benefit is to be anticipated, is neglected. 
Such preparatory treatment almost always retards the recovery un- 
necessarily. 
I will finally observe that, as long as my chlorotic patients continue 
languid, indisposed to exertion, and void of appetite, I do not urge 
them to walk or to eat, generally to their great satisfaction; but I 
make them promise that they will exercise assiduously as soon as they 
feel the strength and inclination to walk, and that they will take food 
freely whenever they gain an appetite to eat, the acquirement of which 
is seldom long withheld. I have already said that relapses of chlorosis 
cannot be averted, especially when it sets in at the commencement of 
the period of evolution; hence I always take the precaution of suggest- 
ing the possibility or even the probability of a relapse, and have often 
found that the patient and her relatives do not take the prospects much 
to heart, when I assure them that the second attack will be as speedily 
curable as the first. 
Although, as I have said, I consider the chalybeate springs super- 
fluous, and far less effective than iron given in large doses, yet, when 
a convalescent from chlorosis fears a relapse, I would recommend the 
springs of Pyrmont, Driburg, Cudowa, Altwasser, St. Moritz, in Swit- 
zerland, and Imnau, in Swabia. 
CHAPTER II. 
Etiology.—The abnormal changes in the quality of the blood t( 
which chlorosis is due can be detected by microscopic and chemical in 
vestigation; these aids fail us in our researches upon scurvy. It has 
been stated, indeed, that, in scorbutic blood, the fibrin is diminished, 
or has lost its coagulability; or that the salts of soda are abnormally 
increased, while those of potash are diminished; but, after repeated in- 
vestigation, the truth of none of these statements has been established. 
Nevertheless, the . commonly adopted opinion, that scurvy is a disease 
dependent upon a derangement in the composition of the blood, is 
probably correct. Independently of the fact that the disease arises 
under conditions unfavorable to a normal composition of the blood, we 
SCORBUTUS SCURVY. SCURVY. 
811 
shall see, while discussing its symptoms, that these depend upon a 
disease of the capillary walls, extending throughout so large a portion 
of the system that wTe must infer that the starting-point of the malady 
is an imperfect state of nutrition of the capillary walls resulting from 
improper nourishment. 
With regard to the etiology of scurvy, we shall limit our remarks 
to a statement of the conditions which are found to favor the develop- 
ment of the disease, since, until we know in what the scorbutic state 
of the blood consists, all theoretical reasoning upon its connection with 
these pernicious conditions is idle. Scurvy is so common an occurrence 
during long voyages at sea (sea-scurvy), where the crew live almost 
entirely upon hard bread and salt meat, and are entirely deprived of 
potatoes and fresh vegetables, that the disease has been attributed 
sometimes to the over-supply of salt in the food, sometimes to wTant 
of fresh meat and vegetables, and sometimes again to both causes com- 
Dined. The theory, that in scorbutic blood there is an undue prepon- 
derance of the salts of soda over the salts of potash, seems to find 
support from the frequence of this affection among seamen who are 
deprived of vegetables, while profusely supplied with salt. Neverthe- 
less, although it cannot be denied that the food of sea-faring people 
during long voyages furnishes one of the conditions which favor the 
occurrence of scurvy, yet this is by no means to be regarded as the 
sole cause of the disease. Scurvy has been known to break out early, 
and with great virulence, in ships where the crew have been greatly 
exposed to cold, particularly to moist cold, as well as in ships which 
have been detained by protracted calms at the equator. It has also 
been observed that immoderate fatigue and a despondent, melancholy 
state of mind favor the development of the disease, while a crew who 
work moderately, and keep up their spirits and courage, retain their 
health much longer, in spite of the badness of their food. That scurvy 
does not depend exclusively upon the use of salt food, and want of 
fresh provision, is proved still more forcibly, and moreover, the hypoth- 
esis regarding the preponderance of the salts of soda over those of 
potash in scorbutic blood is overthrown by the fact, that it also appears 
among people whose diet is almost entirely vegetable, but who suffer 
from destitution, and live in cold, moist cellars, as is the case m north- 
ern countries, especially in Russia (land-scurvy). 
The repeated outbreaks of scurvy among the inmates of garrisons 
and prisons, and other humanely and conscientiously kept institutions, 
is a remarkable fact, and one which cannot always be ascribed to the 
influences above mentioned. 
Anatomical Appearances.—The bodies of persons who have 
died of scurvy, if the disease has been of long duration, exhibit ex- 812 
GENERAL DISORDERS OF NUTRITION. 
treme emaciation and a moderate oedema, particularly of the lower 
extremities. The integuments are of a dirty, ashy hue, and are gen- 
erally covered by dry detached epithelium. Here and there extrava- 
sations of variable size are found in the tissue of the cutis as well as 
in the subcutaneous and intermuscular connective tissue. Besides the 
liquid effusions of blood, hard coagulated infiltrations, stained red by 
an admixture of blood, are almost always found beneath the skin, be- 
tween the muscles ; more rarely within the muscles themselves. The 
blood is remarkably liquid and dark in color. The walls of the vessels 
and the tissues about them are deeply stained by it. In the cavities 
of the pleura, pericardium, peritonaeum, and articular capsules, there is 
almost always a serous or serofibrinous effusion, with an admixture of 
blood. The lungs are more or less compressed by the pleural effusion, 
while the uncompressed portion is the seat of a bloody oedema. The 
liver, spleen, and kidneys, are studded with ecchyinoses, and appear 
relaxed and filled with blood, which also is extravasated, and infiltrates 
the tissues. Ecchymoses also exist between the serous and muscular 
coats of the intestine. The mucous membrane of the intestine is red- 
dened, swollen, and relaxed, and sometimes is in a state of follicular 
ulceration. 
Symptoms and Course.—The first signs of scurvy are usually 
those of a general cachexia; the patients complain of great debility 
and lassitude, and particularly of a sense of excessive weight in their 
lower limbs. Their spirits are deeply depressed, they can no longer 
devote themselves to the slightest work, and are excessively sad and 
despondent. At the same time the face of the patient loses its bright 
hue and grows pale and muddy, the lips acquire a bluish, livid tinge, 
the eyes sink into their sockets, and are surrounded by a blue ring. 
These symptoms are usually accompanied by darting or piercing pains 
in the limbs and joints, which might easily be mistaken for rheumatic 
pains. It is not usual for the characteristic local manifestations of 
scurvy to show themselves until the precursory symptoms have con- 
tinued for some days or even for some weeks ; although CejJca has 
often observed the disease to commence locally, the signs of cachexia 
not appearing until the gums had grown very sore, and all the body 
was covered with scurvy-spots. 
In our first volume we have described the scorbutic sore mouth in 
detail. It is the most common and generally is the first of the local 
symptoms of the disease. There are exceptions, however, to this rule 
also. CejJca mentions instances in which sugillations, tense oedema 
of the feet, and hard, painful infiltration of the connective tissue, pre- 
ceded the bloody oedematous relaxation of the gums. The effusions 
of blood into the tissue of the skin, mentioned above, sometimes take SCURVY. 
813 
the form of small round petechias, sometimes of vibices, and sometimes 
of extensive ecchymoses. They almost always appear first upon the 
lower extremities, and afterward spread over the rest of the body. 
Regions exposed to the action of trifling mechanical violence are espe- 
cially liable to become the seat of the ecchymoses. In the epidemic in 
the house of correction at Prague, described by Cejka, the influence of 
mechanical action was strikingly apparent. In most patients the hol- 
lows of the knees were most affected, but, in wood-cutters and in per- 
sons who worked at the spinning-wheel, the right arms were attacked. 
Wool-combers and laundresses suffered in their forearms; women in the 
place where their garters pressed. The spots which at first were violet, 
and of almost a blackish brown, pass through the well-known changes 
of color peculiar to extravasations, blue, green, yellow, etc. When 
new spots appear, while the old ones are fading, dark-blue and green- 
ish-yellow spots are found simultaneously upon the skin. Sometimes 
circumscribed effusions beneath the epidermis give rise to blebs filled 
with a bloody liquid (purpura bullosa, pemphigus scorbuticus), which, 
if they burst and are treated carelessly, may result in obstinate ulcers. 
Ulcers also form in some patients after the receipt of trifling injuries. 
They are characterized by the flabby, spongy, bleeding granulations 
which cover their surface. The hard infiltration of the subcutaneous 
and intermuscular areolar tissue forms rounded tumors beneath the 
skin, varying in size from that of a hazel-nut to that of a fist, situated 
usually upon the lower, more rarely upon the upper extremities, and 
upon the belly, throat, and cheeks; they cause more or less pain, and 
are covered by a skin which either retains its normal color or else is 
suffused by blood. Sometimes the indurations are extensive and dif- 
fuse, covering the hams, the calves of the legs, and the inner surface 
of the thighs. They are hard as a board, and, owing to the pressure 
which they exert upon the muscles, they render all movement of the 
affected limb impossible. The cutis. remains immovable above this 
diffuse induration, and is either of normal appearance or is suffused 
with blood. Besides the bleeding from the gums, which, though not 
always very profuse, is seldom absent, haemorrhage from other mucous 
membranes occurs in some patients, especially epistaxis, haemoptysis, 
metrorrhagia, and bleeding from the bowels. Ecchymosis of the con- 
junctiva and effusions into the chambers of the eye, with malignant 
ophthalmia, have occasionally been noticed. 
The inflammations of internal viscera, particularly scorbutic peri- 
carditis and pleuritis, do not differ in any characteristic or peculiar man- 
ner from primary inflammation. Voluminous effusions are often rap- 
idly deposited, putting the patient in danger of suffocation; but I have 
also witnessed the rapid and unexpected reabsorption of large collec- 814 
GENERAL DISORDERS OF NUTRITION. 
tions in the pleura and pericardium of scorbutic persons. Owing to 
the variety and irregularity in the succession of the symptoms of this 
disease, the few cases which have come under my observation have 
presented very different aspects. 
Its course is chronic, and, if the pernicious influences under which it 
has arisen be not allayed, it is often extremely tedious. In these pro 
tracted cases the prostration of the patient becomes excessive; some- 
times he faints with every attempt to sit upright; he complains of a 
distressing palpitation and great dyspnoea; the action of the heart 
grows very weak and rapid, extensive oedema arises in the subcuta- 
neous connective tissue, while the soreness of the gums, the ecchy- 
moses, the brawny infiltration of the areolar tissue, and the other local 
affections, increase greatly in extent and intensity. A marked feature 
of the disease consists in the rapidity of its abatement and the sudden 
transformation from a condition of the utmost distress to one of rela- 
tive convalescence, often terminating in full recovery, when the patient 
is rescued from noxious influences, and placed in a condition favorable 
to a cure. It is true that, under such circumstances, their recovery is 
very slow, and they always retain a great tendency to relapse. 
A fatal termination of scurvy occurs either late in the disease from 
extreme exhaustion and general dropsy, or else it takes place earlier 
and before the prostration has acquired much intensity from pleurisy, 
pericarditis, profuse bloody diarrhoea, or other complications. 
Treatment.—In modern days the sea-scurvy has become rare, 
owing to the shortening of voyages, and to the better supplying of 
ships, especially by the provision now made of lemon-juice, sauer-kraut, 
and hermetically sealed vegetables. Land-scurvy also, which formerly 
was of much more common occurrence, has become a rare disease in 
this country, from the wholesomeness of the dwellings and the improved 
diet which paupers now enjoy, thanks to the progress of modern cul- 
ture, so that a prophylaxis against scurvy is no longer talked of. In- 
deed, precautionary remedies are now superfluous, excepting when 
several cases of scurvy break out in a barrack, or workhouse, or similar 
institution, causing apprehension of an epidemic appearance of the dis- 
ease. These precautions consist in the most scrupulous attention to 
cleanliness, warmth of clothing, ventilation of apartments, exercise in 
the open air, a sufficient allowance and proper choice of food, which 
should consist of fresh meat, and, if possible, also of fresh vegetables, 
and salad. Good beer should also be provided, and, where this is un- 
obtainable, brandy-and-water should be administered. The cost of 
such attentions is amply compensated for, if we succeed in putting a 
check upon the disease. 
In cases of pronounced scurvy, the freshly-expressed juice of eertaiu PURPURA HEMORRHAGICA. 
815 
plants, especially that of the order of crucifera, such as water-cresses, 
cabbage, mustard, radishes, horse-radishes, spoon-wort (scurvy-grass), 
and the like, is extremely beneficial, while the extracts of the same 
plants are quite useless. The healing effect of a fresh vegetable diet 
upon scurvy is much more positively ascertained than is. the depend- 
ence of the disease upon a want of such nourishment. Next in virtue 
is the juice of certain acid fruits, especially that of lemons and 
oranges, although that of cherries, currants, apples, and the like, is 
also serviceable. The mineral acids are of no benefit whatever. The 
bitters and aromatics, also, are of a questionable and certainly of a 
very secondary value. The barm of beer, also, has a great reputation 
as an anti-scorbutic, when given to the amount of six or eight ounces 
daily. It is very important that the rules as to diet and regimen, laid 
down above, in treating of the prophylaxis, should be carefully ob- 
served. The local treatment of the sore mouth has been discussed 
already. For the ecchymoses and infiltrations, lotions and compresses 
wet with aromatic vinegar, spirits of camphor, and the like, may be 
applied. The haemorrhages and internal inflammations are to be 
treated upon general principles, due regard always being had to the 
prostrate condition of the patient. 
CHAPTER III. 
PURPURA HJEMORRHAGICA—THE MORBUS MACULOSUS ” OP 
WEKLHOF. 
Etiology.—The symptoms of the spotted disease of Werlhof re- 
semble those of scurvy, as far as regards the appearance of extravasa- 
tions of blood from the capillaries of the skin and mucous membrane; 
but the haemorrhages are not accompanied by any affection of the 
mouth, nor by the peculiar subcutaneous and intermuscular infiltra- 
tions, nor the haemorrhagic inflammations of the serous membranes, 
which we know to be symptoms of scurvy. 
The reason for the tenderness of the capillaries in Werlhof's dis- 
ease is obscure. The extension of the haemorrhages over various parts 
of the body, its frequent occurrence among feeble and debilitated per- 
sons, and among convalescents from severe illness, and its appearance 
m those who dwell in damp, unwholesome lodgings, or in other unfa- 
vorable conditions, make it probable that the disease of the blood- 
vessels depends upon an improper state of this nutrition, or upon 
insufficient or bad nutriment. On the other hand, robust, powerful 
.ndividuals, living under the most advantageous circumstances, and 816 
GENERAL DISORDERS OF NUTRITION. 
who do not offer the slightest reason for a defective state of blood, aie 
also sometimes attacked. 
Symptoms and Course.—Sometimes the first symptoms of Werl- 
hof's disease consist in the appearance of numerous purpuric spots 
upon the skin; in other instances the haemorrhages are preceded for 
some days or weeks by digestive derangement, languor, debility, but 
never by the signs of severe cachexia, such as generally precede the 
onset of scurvy. The purpuric spots, though small, are generally nu- 
merous. Their most common seat is upon the extremities and body, 
although the face is often speckled by numerous petechiae. While the 
first set of petechiae are passing through the blue and green stages, 
new blood-red ones make their appearance. Now and then haemor- 
rhages from the surface are observed ; but such phenomena cannot prop- 
erly be called bloody sweat (p. 453). Minute, punctiform ecchymoses 
are also found upon the mucous membranes, especially those of the 
mouth and fauces. Epistaxis, haematemesis, haematuria, and bloody 
evacuations from the bowels, are of far more common occurrence in this 
disease than in scorbutus. When it attacks an otherwise healthy and 
vigorous individual, and when the haemorrhages do not recur too fre- 
quently, the undisturbed condition of the patient’s general health often 
forms a marked contrast with the objective symptoms. Very numer- 
ous and oft-repeated haemorrhages may result in intense anaemia, a 
tendency to syncope, dropsy, and even death. In previously healthy 
persons, however, such a termination of the disease is rare. As a gen- 
eral rule, the affection ends in recovery after a duration of between 
two and four weeks. 
Treatment.—The customary treatment of IVerlhof's disease, 
which originated with Werlhof himself, consists in the administration 
of sulphuric acid and quinine. Although there is no proof that the use 
of these articles exerts any decidedly beneficial influence upon the 
course of the disease, yet, not to be too skeptical, and for want of more 
certain remedies, it is advisable to give the dilute sulphuric acid or the 
elixir of vitriol in doses of ten or twelve drops every two hours in the 
beginning of the disorder, followed at a later period by a decoction 
of bark with an addition of sulphuric acid. In cases of profuse epis- 
taxis which do not readily subside under the application of cold, the 
tampon must be employed promptly, since the longer the bleeding is 
allowed to last, so much the more obstinate does it become. For the 
haematemesis, bits of ice, alum-curds, and cold compresses to the abdo- 
men, should be employed; for haematuria, large doses of tannin. In ex- 
treme anaemia it is of importance that the patient should preserve a 
horizontal attitude as a precaution against swooning. PROGRESSIVE PERNICIOUS ANAEMIA. 
817 
[CHAPTER IY. 
PROGRESSIVE PERNICIOUS ANAEMIA. 
The old names of “ essential,” “ idiopathic,” “ fatal anaemia,” 
etc., probably referred to the disease now called “ progressive per- 
nicious anaemia.” Little is known of the causes of this gradually 
progressing disease, which is nearly always fatal. It is most fre- 
quent in middle age, but occurs later, as well as in childhood. It is 
more frequent in females, especially after confinement or during 
pregnancy, in which case it is apt to induce miscarriage, followed 
quickly by death. Sometimes the disease can be ascribed to no 
cause ; at others it may be referred to bad nourishment, repeated 
losses of blood, diarrhoea, etc. The onset is usually insidious, with 
great paleness of the skin and mucous membranes ; if there is no 
fever, the nutritive condition of the patient may be little disturbed. 
The patients are very feeble, with great tendency to faintness, 
dyspnoea, palpitation, blood-murmurs, and gastric disturbances, 
vomiting being very common. The spleen and lymphatic glands 
are not swollen, wherein it differs from leueluemia, nor does the 
skin have the brownish color of Addison’s disease. There is no 
regular fever curve ; indeed, there is no fever till the disease is far 
advanced ; autopsy has revealed no sufficient cause for the fever. 
Often, especially late in the disease, there may be epistaxis, pe- 
techise, ecchymoses on the legs, and haemorrhages from the female 
genitals, from the stomach, air-passages, etc., or into the tissue of 
the heart, the pericardium, dura mater, brain, retina, etc. ; the lat- 
ter are said to be quite frequently discoverable on ophthalmoscopic 
examination of the region of the papilla as reddish spots or radiat- 
ing stria3 ; it is said that these spots are characterized by peculiar 
gray or white specks. These haemorrhages are not, however, lim- 
ited to this disease ; they may occur in various other forms of anae- 
mia ; they may be due to the retinal vessels being diseased and 
being ruptured by vomiting. 
As pernicious anaemia begins very gradually, and is not at first 
detected, its duration cannot be determined; it may prove fatal 
within a few weeks from the time of its discovery, but usually runs 
on for months or even years. All cases do not prove fatal. 
The diagnosis is difficult in the commencement. It is said that 
even in the early stages some of the blood-corpuscles are very small, 
but this is a disputed point. The anaemic symptoms cause it to re- 
semble leuchaemia, but in the latter there is marked increase of the 818 
GENERAL DISORDERS OF NUTRITION. 
white corpuscles, and in pseudo-leuchaemia there is swelling of the 
spleen and lymphatic glands. Cases occur where it is impossible to 
make an accurate diagnosis, especially when an enlargement of the 
spleen accompanies the pernicions ansemia. There seem to be cases 
of transition between this and other diseases. Litten says that 
changes of the medulla of the bones are found in pernicious anae- 
mia, just as in medullary leuchaemia; and time must teach us how 
far this is a constant process, and whether the real lesion in this 
affection is a disease of the medulla of the bones, as that of the 
spleen and lymphatic glands is in pseudo-leuchaemia. 
Cases where cachectic states accompany undiscovered cancers 
may be mistaken for pernicious anaemia. 
Treatment has proved unsatisfactory ; even the cases ending 
in recovery seem to have done so spontaneously. We can do little 
more than remove injurious influences, and give good diet, air, and 
tonics, especially iron. 
It has been claimed that great benefit has followed the adminis- 
tration of phosphorus, but other observers deny the efficacy of this 
remedy. In some of these forms of anaemia the employment of 
arsenic by the mouth and subcutaneously is reputed to be very 
efficacious, but it has not yet been sufficiently tried to enable us to 
say in which cases it will do good and in which it will fail. It 
seems quite certain that some patients who are not benefited by 
administration of iron, will improve if the iron is continued while 
inhalations of oxygen gas are given in doses of two or three gallons 
diluted with air several times daily.] HEMOPHILIA. 
819 
CHAPTER Y. 
HAEMOPHILIA (HAEMORRHAGIC DIATHESIS). 
Etiology.—The names haemophilia, hmmorrhapliilia, are applied 
to a congenital haemorrhagic diathesis distinguished either by the un- 
usual obstinacy of traumatic haemorrhage or a tendency to sponta- 
neous bleedings. Hitherto no abnormity capable of accounting for the 
symptoms has been detected either in the blood or the vascular walls 
of the patient, although in a small number of cases the walls of the 
blood-vessels have been found to be remarkably thin and delicate. In 
most cases of haemophilia the disease is hereditary, that is, the patient 
descends from a family one or more of whose members in preceding 
generations have suffered from the same affection. There are instances 
in which it has been transmitted through four generations; others in 
which a generation has been “ skipped,” the grandchildren having 
haemophilia, but not the children. It is rare for every member of a 
family to inherit this dangerous disorder, and the daughters seem to 
remain free from it with especial frequerice. There also are well- 
authenticated observations which leave no doubt of the occurrence of 
congenital haemophilia not dependent upon hereditary predisposition. 
Symptoms and Course.—Until the discovery is made that a tri- 
fling wound will give rise to an irrepressible and dangerous loss of 
blood, there is no symptom to warn the patient of his perilous con- 
dition. Some observers, indeed, claim that this class of patients are 
distinguishable by the remarkable delicacy of their complexion, their 
superficially situated and conspicuous veins, blonde hair, and blue eyes, 
and, in one family that I know of, this description is equally applicable 
to the whole of them, including the female members, who are exempt 
from the disorder. Other observers, again, state expressly that the 
patient’s appearance presents no perceptible characteristics. 
The accidents which give rise to these alarming haemorrhages are 
generally extraction of a tooth, a puncture, a small cut or laceration, 
and it would almost seem as if such injuries were more dangerous 
than severe wounds. The blood oozes out as if from a sponge, al- 
though no bleeding vessel is discoverable ; all attempts to stanch the 
bleeding are in vain, and it persists for days. The blood, which at 
first is normal, gradually growls thin and wTatery, forming small, loose 
coagula. At last the complexion of the patient acquires a waxy pallor, 
the lips lose their color; syncope and other signs of exsanguinity oc- 
cur, and the patient may perish in a few days. More commonly, how- 
ever, the bleeding ceases, and the patient, in a state of utter exhaus- 
tion, slowly recovers from the effects of his enormous loss of blood. 820 
GENERAL DISORDERS OF NUTRITION. 
which often amounts to many pounds. Besides these dangerous ex- 
ternal haemorrhages, extensive extravasations occur beneath the skin, 
in consequence of the slightest contusion. Wunderlich tells of a boy, 
who, after receiving a flogging at school, came home black and blue, 
and so covered with stripes and welts that a charge was preferred of 
cruelty. It afterward appeared that he had the haemorrhagic dia- 
thesis. 
Spontaneous bleeding cr haemorrhages without assignable cause do 
not generally take place until after the patient has suffered repeatedly 
from traumatic haemorrhages. They generally proceed from the nose: 
but likewise arise from the bronchi, stomach, intestines, and kidney, and 
may also occur in the substance of the skin and subcutaneous areolar 
tissue. They are generally preceded by molimina, such as palpitation 
of the heart, stupor, signs of cerebral congestion, pain in the limbs, 
and, in some cases, painful tumefaction of the joints, particularly those 
of the knee and ankle. There have been instances in which the bleed- 
ing from the navel-string could not be stanched, but more usually it 
is not until the period of dentition, and sometimes after the sixth or 
eighth year of life, or later, that the diathesis betrays itself by a dan- 
gerous haemorrhage. Most patients die young—few surviving the 
period of childhood. Cases are known, however, in which the patient 
has lived to a good old age, the tendency to bleed diminishing, or 
ceasing altogether, as life advanced. 
Treatment.—No remedy is known likely to prove efficacious in 
congenital haemorrhagic diathesis, and we must therefore confine our 
efforts to a careful regulation of the habits, and the removal of all nox- 
ious agencies; so that, perhaps, by improving the general condition of 
the constitution, this dangerous diathesis may subside. Of course, all 
wounds must be scrupulously avoided. When the bleeding occurs in 
spite of such precautions, besides the ordinary haemostatic articles, 
among which steady pressure and the actual cautery are the best, 
glauber salts in cathartic doses should be prescribed, and, when the 
bleeding threatens life, two to five grains of secale cornutum every 
half-hour. These two prescriptions have been of great benefit in some 
instances. 
CHATTER VI. 
SCROFULA. 
Etioi.ogy.—The term scrofula signifies a morbid (cachectic) con- 
dition of the system, manifested by a remarkable liability to certain 
forms of nutritive disorder of the skin, mucous membranes, joints, 
bones, organs of special sense, and, above all, the lymphatic glands. SCROFULA. 
821 
A person having merely a tendency to such diseases may also be 
called scrofulous, although not actually suffering from any one of the 
above symptoms. 
The hypothesis that scrofula depends upon a faulty composition of 
the blood (dyscrasia), and that the lesions found in scrofulous persons 
were due to the deposit in the tissues of a matter circulated by the 
blood, and called a “ scrofulous material,” is almost universally aban- 
doned. The alterations which take place in the skin, mucous mem- 
brane, joints, bones, and organs of special sense, are of an inflamma- 
tory nature, and cannot be distinguished from similar affections of a 
non-scrofulous character, excepting by their intractability and the 
tediousness of their course. It is impossible to point out any charac- 
teristic features in a scrofulous eruption or arthritis, or to find any dif- 
ference between them and similar non-scrofulous affections. Even the 
caseous metamorphosis, to which the inflammatory products are so 
prone, is by no means pathognomonic of scrofula, but is common to all 
diseases of a chronic character which have a tendency to disintegra- 
tion or destruction. Notwithstanding, however, that such inflamma- 
tion presents no distinguishing mark whereby its scrofulous nature 
may be recognized, yet there will rarely be any doubt as to whether 
or not a case of this kind is entitled to the name. If its exciting cause 
have been so slight as to be overlooked ; if we are informed that “ the 
disease came on of itself; ” if this attack, or other similar ones, have 
arisen repeatedly without assignable cause; if it be accompanied by a 
series of other disorders, especially chronic inflammation and persistent 
enlargement of lymphatic glands, it is to be called scrofulous. If, on 
the contrary, there be known external conditions, whose action upon 
the system sufficiently accounts for the occurrence and the obstinacy 
of the affection, without necessitating the supposition that there is any 
special morbid tendency; if it exist independently, and be uncompli- 
cated with chronic enlargement of the lymphatics, then it is not to be 
called scrofulous, notwithstanding the great similarity, nay, the abso- 
lute resemblance, of its external symptoms to those of a scrofulous 
disorder. 
In its origin, scrofula, perhaps, is quite as often a congenital mal- 
ady as an acquired one after birth. 
Congenital scrofula is particularly common among offspring of 
scrofulous parents. There are families, nearly or quite all the children 
of which inherit the disease. This hereditary form of scrofula is close- 
ly allied to that in which parents were tuberculous at the time of be- 
getting the child, or in which the mother was so during pregnane}7, or 
else suffered from cancer, tertiary syphilis, or some other malady, as 
well as that form of scrofula occurring in children begotten of aged 822 
GENERAL DISORDERS OF NUTRITION. 
parents. As we know that many of the bodily and nental traits of 
parents are transmitted to their progeny, it will not seem extraordi- 
nary that children of feeble, sickly fathers or mothers should have a 
greater tendency to disease than those whose progenitors are vigorous 
and healthy; but we are totally unable to account for the fact that 
scrofula is also very prevalent in the children of parents who are too 
closely related to one another by blood. It must be added, moreover, 
that it is not every child of scrofulous, sickly, feeble, or superannuated 
parentage, and not all of the issue of the marriages of near relatives, 
who suffer from congenital scrofula. Indeed, many children thus born 
are healthy, and without any decided tendency to disease; and, on 
the other hand, this malady often attacks the offspring of parents 
entirely exempt from the action of any of the above predisposing 
agencies. 
Acquired scrofula generally arises as a result of pernicious in- 
fluences which have impeded the healthy development of the system 
during the first years of life. First of all, among these, stands im- 
proper nourishment; a coarse diet, containing but little nutriment in 
comparison with its bulk, being very properly held in especially evil 
repute. The earlier this injudicious feeding of an infant commences, 
so much the greater is the danger that it will become scrofulous; 
hence, the children fed on pap furnish a very important contingent to 
the army of scrofulous persons. Want of fresh air and exercise exerts 
an influence as baneful as that of improper food. Hirsch has collected 
a large number of facts, proving that, in foundling hospitals, orphan 
asylums, boarding-schools, factories, and similar institutions, the con- 
tinual 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. 
It springs most frequently, however, from the combined effects of 
all these different anti-hygienic influences. Although we have declared 
the chief cause of scrofula to be the impairment of the normal develop- 
ment of the system during childhood, through the action of the above- 
mentioned noxious agencies, yet it must be added that, in prisons, poor- 
houses, and workhouses, the disorder also breaks out among adults 
subjected to the simultaneous effects of bad nourishment and want of 
fresh air. The development or reestablishment of scrofula is, like- 
wise, a not unfrequent sequel to certain acute and chronic diseases; 
and this is all the more likely to be the case, the younger and the 
more undeveloped the subject of disease happens to be. Among SCROFULA. 
823 
the diseases of childhood, measles is especially mischievous in this 
way. 
Anatomical Appearances.—Having already stated that scrofu- 
lous inflammation has no peculiar characteristics, it would now be ab- 
surd to attempt to describe the anatomical alterations of the skin and 
mucous membranes, induced by scrofulous eruptions and catarrh. And, 
indeed, we may refer altogether to the article upon cutaneous diseases 
for a description of the anatomical alterations of the skin; and to other 
parts of this work, for an account of the lesions found in the various 
mucous membranes, merely adding that in scrofula the inflammatory 
products are generally richly provided with young cells, which accounts 
for their tendency to caseous metamorphosis. A description of the 
esions of the bones, joints, and organs of special sense, particularly 
those of the eye, observed in scrofulous subjects, and which, likewise, 
are not marked by any distinctive peculiarity, belongs to the province 
of surgery and ophthalmology. The latter science has anticipated the 
others by the discovery of the illusory nature of the oft-described 
symptoms of scrofulous ophthalmia. 
The alterations which take place in the lymphatics of scrofulous 
subjects require further attention: first, because the disorders of these 
organs as yet have received but cursory notice, no special section of 
this work having been devoted to their consideration; secondly, be- 
cause, in persons thus afflicted, disease in the lymphatics is so common 
that, among the laity, scrofula is commonly spoken of as having “ en- 
larged kernels,” or simply “ having kernels.” 
In the first place, it happens more frequently in scrofulous persons 
than in non-scrofulous ones, that the lymphatic glands around an inflam- 
mation of the skin or mucous membrane become the seat of an inflam- 
matory process, which has extended along the lymphatic vessels from the 
skin, and has involved the glands. The connective tissue around the 
gland next participates in the inflammation of the glandular parenchy- 
ma, and abscesses and ulceration ensue, which, like all abscesses and 
ulceration of glandular substance, are very intractable, and often heal, 
leaving an irregular, ragged, unsightly scar. Owing to the extreme 
frequence of scrofulous eruptions upon the face and scalp, and of 
scrofulous otorrhcea, the lymphatic glands of the neck are the most 
common seat of this form of inflammation and ulceration. 
Besides these, however, a chronic non-inflammatory enlargement of 
the lymphatic glands is so often observed in scrofulous subjects, that 
their presence may almost be regarded as pathognomonic. They may 
attain a very considerable size, and, when several of them are clustered 
together, they form huge, knotted cords, or shapeless lumps. The 
individual tumors are regular in form, smooth of surface, and of a tol 824 
GENERAL DISORDERS OF NUTRITION 
erably firm consistence. No foreign elements can be detected in them 
under the microscope. They are the product of simple hypertrophy, 
or, rather (since it is the cells that are multiplied, and not the tissue of 
the stroma), of a “ cellular hyperplasia.” But, as the number of cellu- 
lar elements contained in a lymphatic gland, even during health, is a 
very variable one, the complete subsidence of the enormously enlarged 
glands of scrofulous subjects, which enlargement is entirely due to an 
excessive accumulation of cells, will not seem extraordinary. Never- 
theless, the gradual diminution of, the tumor, with its final return to its 
normal dimensions, is not the sole termination of this form of glandular 
affection. Sometimes the tumors, which at first were the result of 
mere hyperplasia, sooner or later become inflamed. The surrounding 
areolar tissue takes part in the inflammation, after which, it is no 
longer practicable to distinguish the individual glands in the general 
mass. The skin becomes adherent to the tumor, and cannot be made 
to glide over it. Suppuration and the formation of abscesses generally 
follow slowly and gradually upon the inflammation, and the skin, hav- 
ing become extremely attenuated, is perforated by the pus, leaving a 
sinuous ulcer, with undermined edges. In other instances, inflamma- 
tion and suppuration only take place at a solitary point in the tumor; 
and the matter formed at this spot does not burst through the capsule 
of the gland, but thickens, and undergo escaseous metamorphosis. In 
such a case, if the swelling subside, the caseous mass projects above 
the surface of the gland, giving it an irregular shape. A partial or 
complete caseous degeneration may also take place in the hyperplastic 
mass, without any previous inflammation or suppuration, the over- 
crowded cells drying up, and suffering “ anaemic necrosis ” (necn> 
biosis). Such an occurrence at circumscribed points likewise renders 
the contour of the gland irregular and angular. The caseous deposit 
may subsequently become calcified, but, since it acts as an irritant upon 
surrounding parts, like any other foreign body, it may subsequently 
give rise to an obstinate inflammation and suppuration. When an 
entire gland underwent caseous metamorphosis, the process used for- 
merly to be called infiltrated glandular tuberculosis. If, on the other 
hand, the deposit of caseous matter was limited, the gland was sup- 
posed to be affected by miliary tuberculosis, although there wTere no 
miliary tubercles to be found in it. The most frequent seat of scrof- 
ulous hyperplasia of the lymphatic glands, like that of scrofulous in- 
flammation, is in the neck, especially behind the ear, and under the 
lower jaw, extending thence to the shoulder. The bronchial and me- 
senteric glands are also very often the seat of scrofulous hyperplasia, 
with all its consequences, as above described. The terms scrofulous 
catarrh of the bronchi or intestines is perfectly appropriate to bronchial SCROFULA. 
825 
and intestinal catarrhs, accompanied by enlargement or caseous de- 
generation of the bronchial or mesenteric glands. 
Symptoms ayd Course.—In many instances the scrofulous ca- 
chexia betrays itself by the patient’s habit of body, which will often 
arouse suspicion of his delicacy and of his feeble power of resistance 
against disease, long before any actual morbid tendency (diathesis) is, 
as it were, officially announced by the occurrence of frequent and ob- 
stinate attacks of illness induced by causes so insignificant as to have 
escaped observation. 
The “ scrofulous habit ” is marked by a deficience of blood and by 
a bad nutritive state of the more important and more highly-organized 
tissues; sometimes accompanied by an accumulation of fat in certain 
regions, especially in the ■ upper lip and nose. When the imperfect 
nutrition is accompanied by an over-production of fat, there seems to 
be an indolent state of the processes of constructive and destructive 
assimilation; but when not only the skin and the muscles, but also 
the subcutaneous fat, is in a state of imperfect development, it is 
probable that these processes are in a condition of unnatural activity. 
Based upon these differences, in the patient’s bodily habit, a classifica- 
tion of scrofula into the torpid and erethitic forms has been made. 
Canstatt very aptly describes the torpid scrofulous habit in the follow- 
ing words: “ An unusually large head, coarse features, a thick chin, 
swollen abdomen, enlarged cervical glands, and flabby, spongy flesh; ” 
and depicts the habit of erethitic scrofula as follows: “ A skin of re- 
markable 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 transparent 
sclerotica, 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 
4eeth are handsome, and of a bluish lustre, though long and narrow; 
the hair is soft.” There is no lack of examples of either of these forms 
of disease, and though it may not be possible immediately to assign 
every case to one or other category, yet in practice it will be well to 
adhere to the classification into torpid and erethitic scrofula, since, as 
we shall find by-and-by, we thereby obtain valuable data for the estab- 
lishment of therapeutical indications. 
Scrofula, although principally a disease of childhood, rarely declares 
itself in the first year of infancy, excepting through a few faint tokens. 
At the period of puberty scrofulous diseases usually subside, and with 
them the scrofulous habit more or less completely disappears. More 
rarely, exposure of the body to pernicious influences at this time excites 
the subsiding scrofulous tendency to renewed activity, or even induces a 826 
GENERAL DISORDERS OF NUTRITION. 
relapse of disease which has been dormant for years. We have already 
stated that, under such circumstances, persons, who during childhood 
did not suffer from the disease, are attacked by it later in life. 
It is impossible to describe scrofula briefly, and at the same time 
comprehensively; for its various manifestations combine in the most 
diverse manner: in one case, this group of symptoms, in another, that 
one assuming prominence ; and since many patients, notwithstanding 
the tedious course of their malady, remain free from symptoms which 
form the most important feature in other cases. And although it is 
little to be doubted that the localization of scrofulosis (if we may use 
the term) depends either upon the action of causes which are especially 
hurtful to the organ attacked, or else upon the morbid susceptibility 
of the organ to influences whose effect is universally injurious, never- 
theless we can seldom tell why it should be marked in one case by a 
scrofulous exanthema, in another by an ophthalmia; why, in a third, a 
disease of bone should prevail; and it is equally inexplicable why the 
inflammation and hyperplasia of the lymphatic glands should be more 
extensive and obstinate in one case than in another. It has not been 
determined even whether there be such a thing as primary hyperplasia 
of the glands, or if this process, like the inflammation, be always of a 
secondary character, proceeding from irritation transmitted to the 
gland from some neighboring focus of inflammation. As the reality 
of the latter fact is susceptible of proof in a great majority of instances, 
it is not improbable, where it cannot be proved, that the irritation for- 
merly existed at the point of origin of the lymphatic vessels involved, 
but that it has already subsided; for it is a rule that glandular enlarge- 
ments long outlast the morbid process which has induced them. 
The cutaneous eruptions which are the most common, and often the 
earliest symptoms of the diathesis, are usually situated upon the face 
and scalp. They generally belong to the form of dermatitis, in which 
an exudation, more or less fdled with cells, is effused upon the surface 
of the cutis, and which nowadays are known as eczema and impetigo, 
and used formerly to be called tinea and porrigo. The more destruc- 
tive affections of the skin—such as lupus—do not usually appear until 
a later period of life. 
Scrofulous inflammation of the mucous membrane is most apt t< 
appear in the vicinity of the natural orifices of the body, where if 
readily implicates the neighboring skin, especially if it be moistened 
by the superabundant secretions. Thus scrofulous coryza is usually 
complicated with eczema of the upper lip ; inflammation of the exter- 
nal auditory passage with eczema about the ear; catarrhal conjuncti- 
vitis with eczema of the cheek ; conversely, the cutaneous eruptions 
about ail orifice often spread to its mucous membranes, thus inducing SCROFULA. 
827 
coryza, otorrhcea, conjunctivitis, or ulceration of the cornea. Catarrhs 
of the intestine and bronchi, and the rarer affections of the genito- 
urinary apparatus by their obstinacy, may readily excite a suspicion of 
a more malignant destructive process; and indeed scrofulous catarrh 
of the bronchi, by extending into the air-cells of the lung, and by in- 
ducing caseous metamorphosis, with subsequent destruction of the 
pneumonic deposits, not unfrequently terminates in pulmonary con- 
sumption. Besides, it often happens that enlarged bronchial glands 
soften and break down, forming vomicas, which discharge their con- 
tents into the bronchi. Scrofulous ulceration of the bowels has already 
been described in detail. 
Scrofulous inflammation of a joint sometimes takes the form of a 
simple hydrarthrosis, sometimes that of a so-called tumor albus, while 
at others it assumes the nature of a malignant arthrocace, accompanied 
by suppuration, caries of the articular surfaces, burrowing of pus, and 
the establishment of fistula. The disease of the bones sometimes 
begins in the periosteum, sometimes in the bone itself, now presenting 
the character of periostitis and ostitis, and now that of caries, necrosis, 
or of the two combined. 
As long as the existence of cheesy masses was regarded as char- 
acteristic of the tuberculous nature of a disease, it was of course neces- 
sary to ascribe many of the inflammations of the joints and bones of 
scrofulous persons to a complication of scrofulosis with tuberculosis. 
Among the organs of special sense, the eyes and more particularly 
their superficial tissues, the Meibomian glands, the conjunctiva palpe- 
brarum, the conjunctiva bulbi, and the cornea, are often afflicted by 
obstinate inflammation. Indeed, in doubtful cases, the presence of 
opacity or of scars upon the cornea, has been accepted as important 
evidence that a patient has been scrofulous during childhood. In the 
nose, excepting the rare instances in which that organ is destroyed by 
lupus, scrofulous inflammation merely takes the form of an obstinate 
coryza, which, however, is hardly ever absent. In the ears, besides 
the inflammation of the external auditory canal, already alluded to, 
caries of the petrous bone, with all its mischievous consequences, is 
apt to ensue. 
The objective symptoms of scrofulous disease of the lymphatic 
glands have been described above. The adenitis and the phlegmonous 
inflammation of the parts about them may be attended with great 
pain and by more or less of fever, with evening exacerbations. In 
consequence of this, not only does the patient’s general health suffer, 
but, if the inflammation and its attendant pain continue for weeks and 
months, as they often do, his strength is consumed, and his nutritive 
condition is greatly impaired. After the abscesses which form have 828 
GENERAL DISORDERS OF NUTRITION. 
burst spontaneously, or liave been lanced, and if no new centre of in 
flammation have formed meantime, the fever gradually abates, the 
patient’s strength returns, the emaciation ceases, often long before the 
ulcers have begun to heal, and while they still secrete large quantities 
of pus. 
Glandular tumors depending upon cellular hyperplasia are not 
attended either by pain or fever; but, when very voluminous, particu- 
larly when seated upon the neck, they not only produce great deform- 
ity but hinder the mobility of the head. Hitherto it has not been 
ascertained whether scrofulous enlargement of the lymphatic glands 
exerts any detrimental influence upon the composition of the blood, 
whether the cellular elements destined for the blood are retained in 
the gland, or whether scrofulous glands affect the quality of the blood 
as the glands of leucaemia do, but in a far slighter degree. 
The progress of scrofula is tedious and treacherous, and nearly 
always is marked by periodical alternations of improvement and aggra- 
vation. Either the same series of symptoms recurs again and again 
with renewed severity, or else, the former set having abated, or sub- 
sided, new ones arise. Complete recovery from scrofula is a very com- 
mon occurrence, especially if we include the cases in which no trace of 
the disease remains excepting a peripheral speck upon the cornea, an 
unsightly cicatrix, or other mark, which does not disturb the general 
health and comfort. Death rarely results from the lesions to which 
the epithet of scrofulous is usually given. Of these, tedious disease 
of the bones and joints, and suppuration of the bronchial glands, are 
the only ones which endanger life. On the other hand, a large num- 
ber of scrofulous children die of croup, hydrocephalus, and other acute 
maladies, for which such subjects have a predisposition quite as decided 
as for the affections to which the term scrofulous usually is applied. 
Finally, it should be mentioned that lardaceous disease of the liver 
(BudcTs scrofulous tumor of the liver), spleen, and kidneys, often de- 
velops during scrofulous disorders, particularly in tedious cases of 
suppuration and disease of the bones. 
Regarding the relationship of scrofula to tubercle, we have already 
stated that no doubt many scrofulous children afterward become 
tuberculous; but also that a large number of them escape tuberculosis, 
especially those in whom the constitutional delicacy, upon which the 
former affection depends, subsides in after-life, and in whom no caseous 
deposits remain as residua of scrofulous disease. 
Treatment.—The prophylaxis against congenital scrofula lies 
almost beyond the sphere of the physician. It is devoutly to be de- 
sired that scrofulous, tuberculous, sickly, and superannuated persons 
should not marry at all, and that healthy and vigorous individuals SCROFULA. 
829 
should not wed their near relatives. But the representations of the 
physician, that the issue of such alliances are likely to be scrofulous, 
will rarely deter a man from marrying. On the other hand, it is not 
only an imperative, but a grateful task to the physician, to endeavor to 
provide, by proper precautionary measures, against the extension of 
acquired scrofula. How to fulfil this duty becomes apparent from what 
has already been said regarding the causes of acquired scrofula. Above 
all, it should be borne in mind that the development of this disease is 
promoted, not by one particular noxious influence merely, but by every 
condition incompatible with health, to which the system, especially 
during childhood, can be exposed. It often happens that, from the 
moment when the first tokens of scrofula appear, or even as soon as 
the parents begin to dread its attacks, the child is carefully deprived 
of every particle of bread and butter, potato, and the like, and dosed 
with huge prophylactic spoonfuls of cod-liver oil, while at the same time 
he is suffered to sit all day long in a close chamber, or upon the benches 
of an overcrowded school-room. A sufficiency of fresh air and muscular 
exercise are prophylactic measures of quite as much importance as 
regulation of the diet is; and we shall here call attention to an error 
upon this subject, to which we have referred once before while discuss- 
ing the prophylactic treatment of consumption: namely, the belief that 
the use of bread and potatoes favors the development of scrofula and 
tubercle, and the consequent complete privation of children of this kind 
of food; while in reality the mischief is due to an insufficient supply 
of animal food—a diet of potatoes and other articles, containing little 
nourishment in proportion to their bulk, not being injurious unless it 
forms their sole or at least their principal subsistence. This error is 
so prevalent, that the discovery that the child has surreptitiously eaten 
a potato has cost many an anxious mother a sleepless night, and many 
a child has uselessly been sent to bed hungry on this account. 
The treatment of pronounced scrofula, where the prophylaxis has 
been neglected or unsuccessful, requires, first of all, a careful regulation 
of the regimen upon principles already laid down. Children wfitli con- 
genital scrofulosis must not be the subjects of experiment with artifi- 
cial food; but, if the mother have not milk enough, or if she be sickly 
or feeble, so that, both in her own interest and in that of the babe, she 
must be forbidden to suckle it, a good wet-nurse must be selected with 
the utmost care. There is no substitute for the mother’s or nurse’s 
milk, and the first year of infancy is perhaps the most important to the 
constitution of the whole life. When the child is older, the directions 
as to the diet and the mode of life must be given with the utmost pre- 
cision. It is not advisable to order that “the patient shall eat but 
little bread, and a good deal of meat, soup, milk, and the like;” and 830 
GENERAL DISORDERS OF NUTRITION. 
that “he must not work too long,” and should take “plenty of out- 
of-door exercise.” To be successful in our object, the quantities of food 
and drink must be prescribed definitely, as well as the number of hours 
allotted to each form of occupation. 
Cod-liver oil has a special and well-merited reputation as a remedy 
against scrofula, and there are plenty of instances where it has done 
good service. On the other hand, perhaps no remedy has ever been 
so much abused as this one. Whosoever supposes that the mere pres- 
ence of a thick nose, a sore upper-lip, or a bunch of enlarged cervical 
glands, affords sufficient ground for the prescription of this medicine, 
will often fail to benefit his patient, and sometimes will do him harm. 
Daily experience teaches, however, that such is the general belief, and 
that he who seeks to combat it does not merely fight a windmill. Let 
any one ask a patient whose scrofula has outlasted his childhood, and 
who has passed again and again from one practitioner to another, how 
often he has had cod-liver oil prescribed for him since the time of its 
first failure during childhood; how many months or years he has taken 
it; and how much the whole aggregate quantity would amount to; 
and he will be surprised at the answer. Nevertheless, in all proba- 
bility, the next physician whom the patient consults will prescribe it 
again. A most serviceable means of distinction, between the cases in 
which cod-liver oil is indicated and those in which nothing is to be ex- 
pected from it, is afforded by the symptoms of the torpid and erethitic 
forms of scrofula. When the patient’s slender frame, the lack of fat 
beneath his skin, and his accelerated pulse, warrant the belief that his 
nervous system is in a state of over-activity, cod-liver oil is generally 
of the most signal benefit. Under its use the plumpness of the body 
increases, while the general susceptibility of the system, and the dis- 
eases consequent upon it subside. These are the cases to which this 
article owes its name as an anti-scrofulous remedy. But if the patient 
be clumsy and thick-set; if the nose and upper-lip be enlarged, and 
the adipose layer over the rest of the body strongly developed; if the 
action of the heart be retarded rather than accelerated; if the irrita- 
bility of the nervous system seem unusually obtuse; in short, should 
there be reason to suppose that the waste of the system is diminished 
rather than increased, we cannot hope to relieve the disease by means 
of the oil. Nevertheless, it is precisely this class of patients who in 
vain have taken such enormous quantities of it in the course of their 
lives. Besides the oil, and as a corroborant of its effects, so to speak, 
articles containing a little tannin, such as parched acorns, “ acorn-coffee,” 
and home-made infusions of walnut-leaves, are very often prescribed. 
Such a practice is greatly to be commended whenever there is a chronic 
catarrh of the intestines embarrassing the digestion and the absorption SCROFULA. 
831 
of cliyle, and where apprehensions are entertained that the oil may 
aggravate the intestinal disorder. When used in appropriate cases, we 
prize the efficacy of cod-liver oil, with acorn-coffee, and walnut-tea, most 
highly, although we strongly deprecate its indiscriminate employment 
in every form of scrofula; but, as it is requisite that its exhibition 
should be long continued in order to produce favorable results, certain 
rules for its administration must be laid down. The disgust for the 
oil, which in adults is sometimes invincible, is soon overcome by chil- 
dren, who generally speedily cease to fight against the customary dose 
of two teaspoonfuls daily, and even ask for it themselves when the 
period for its administration has expired. But, if the treatment be 
kept up for months without occasional intermission, an unconquerable, 
and theh too generally a permanent aversion to the disgusting medi- 
cine will arise, even among children, so that vomiting and retching 
ensue after every attempt to force it down. This awkward occurrence, 
which often renders further treatment futile, may nearly always be 
avoided by interrupting the “ cure ” for a week or a fortnight after 
continuing it for four or six weeks. In order to make children take 
the acorn-coffee as willingly as real coffee, it is sufficient to add a few 
coffee-beans to the acorns before roasting them. 
It is far more difficult to furnish definite instructions for the use of 
the brine-baths, whose anti-scrofulous virtues enjoy a reputation almost 
as great as that of cod-liver oil. We know too little about the action 
of these baths, and about the effect which they produce upon nutri- 
tion, and the advantages derived from the salt, iodine, and bromine, 
which they contain, to enable us to determine upon theoretical princi- 
ples where they are indicated and where they are unlikely to do good. 
A calm analysis of the positive and negative effects of brine-baths in 
scrofula, which would be the best means of obtaining fixed indications 
for their use, has not, as yet, been made; and the doctors at the baths, 
who certainly ought to be the best judges of the extent and limits of 
their healing powers, rarely send away a scrofulous patient as unfit to 
use the brine. Hence, there is no resource but to send persons, who 
have in vain tried cod-liver oil and other anti-scrofulous remedies, to 
Kreutznach, Isold, Kosen, or Wittekind, or some similar watering- 
place, in the hope that they may be among those to whom the baths 
will exhibit their anti-scrofulous virtues, which are by no means illu- 
sory ; and, if the circumstances of the patients do not admit of this, 
they must use artificial brine-baths at home. 
In recent times the cold-water cure has earned for itself a most 
favorable reputation as a remedy for scrofula; and, indeed, a series of 
cases is on record in which complete and perfect cures have been ob- 
tained by these means, after all other modes of treatment had been 832 
GENERAL DISORDERS OF NUTRITION. 
applied in vain. We certainly are justified in asserting that cod-liver 
oil treatment cannot be substituted for the water-cure, nor vice versa; 
but we may go still further, and declare that the oil is not only useless 
in a case adapted for the water-cure treatment, but is absolutely per- 
nicious ; and the same holds good regarding the hydropathic treatment 
in a case where large doses of cod-liver oil are indicated. When we 
consider that formerly the “ decoctions of woods,” laxative tisanes, an- 
timonials, mercurials, and other drugs intended to stimulate the emuno 
tories into activity, were much employed in scrofula, and when, after 
weeks of such treatment, a profuse flow of urine or of sweat was final- 
ly induced, or, when the patient began to purge copiously, very good 
results were sometimes obtained, it will be plain that this treatment 
(the effect of which is to cause an intensely active destructive assimi- 
lation and consumption of the tissues) can only benefit the class of 
patients in whom these processes are in a state of indolence and inac- 
tivity. The hydropathic treatment has a similar though far less per- 
nicious influence, and is of signal benefit in the torpid form of scrofula, 
that is, in that form where cod-liver oil is powerless, as I have repeat- 
edly had opportunity of satisfying myself. 
Iodine and the mercurials are also generally regarded as good anti- 
scrofulous medicaments. It is impossible to hold such views while 
believing scrofula to consist in a cachexia, marked by a peculiar prone- 
ness to disease, and evinced by a series of nutritive disturbances; for 
one cannot well suppose that the use of iodine or mercury can aug 
ment the power of the system to resist noxious influences. I therefore 
consider it improper to prescribe these articles solely on account of the 
scrofula, and without fixed indications arising from the peculiarities of 
the case. At the same time I will not deny that the cases are pretty 
numerous in which the preparations of iodine and of mercury are indi- 
cated. For further details, I refer to the books of local pathology and 
therapeutics, surgery and ophthalmology, merely alluding to the great 
benefit derivable from the internal and external exhibition of iodine in 
the chronic hyperplasia of the fymphatics. In particular, where chronic 
indolent enlargements of the lymphatic glands form the sole remaining 
vestige of a former disease, astonishing advantage is often gained by 
the use of the Adelheid springs and the Krankenlieil waters.2 
CHAPTER VII. 
DIABETES MELLITUS—MELLITURIA. 
Etiology.—The pathogeny of diabetes still remains obscure. The 
discovery of the physiologists, that sugar appears in the urine of animals 
after puncture of the floor of their fourth cerebral ventricle, has not as DIABETES MELLITUS. 
833 
yet thrown light upon the mystery. We know that the presence of 
sugar in the urine, whence diabetes mellitus derives its name, does not 
depend upon functional abnormity of the kidneys; that the sugar is 
not formed in them, and that it is excreted from the blood ; but we 
are altogether ignorant wherein the constitutional anomaly consists, in 
consequence of which a diabetic patient’s blood contains sugar, and a 
healthy person’s none. As the various hypotheses offered to account 
for diabetes are of little practical value, we shall mention a few merely 
of those most generally entertained. 
In the first place, diabetes has been ascribed to an insufficient de- 
gree of transformation of the sugar in the blood. Indeed, if the sugar 
into which the amylaceous substances that have been eaten are con- 
verted, and that which is formed in the liver, were to circulate in the 
blood without undergoing further alteration, and if this substance did 
not disappear again from the blood during its passage through the 
lungs, it would necessarily form one of the normal constituents of the 
urine; hence it cannot be denied that the pathological presence of 
sugar in the urine may possibly depend in some cases upon a failure 
of the conditions under which the normal transformation of the sugar 
takes place. However, as long as we are ignorant as to what these 
conditions are, we obtain but little aid from the hypothesis that their 
absence is the cause of diabetes. The assertion, that the non-assimila- 
tion of sugar in the circulation of diabetic persons is due to a want of 
alkalies in the blood, has been disproved. The theory of the existence 
in the blood of healthy persons of a certain unknown ferment, which 
induces the assimilation of sugar, but which is absent in the blood of 
diabetic persons, is untenable. 
Others have sought to trace the origin of diabetes to an abnormal- 
ly accelerated conversion of amylaceous matter into sugar, this being 
due to a diseased condition of the digestive juices. To this theory 
there are still greater objections than to the preceding ones. It seems 
that even in healthy persons the amylaceous ingesta are all changed 
into sugar (Trommer has proved this to be the case even in geese 
that have been “crammed”), and yet we know that healthy urine 
never contains sugar even after the ingestion into the system of very 
large quantities of amylaceous matter, or of pure sugar. But the re- 
sult of the treatment based upon these hypotheses has afforded the 
best evidence of their unsoundness. Were the source of diabetes an 
over-active and immoderate conversion of amylum into sugar, the dis- 
ease should cease upon the stoppage of the supply of amylum. Ex- 
perience, however, teaches us the contrary; as, even where for weeks 
and months the food of the patient has been exclusively animal food, 
the sugar rarely disappears from the urine. Finally, since Claude 834 
GENERAL DISORDERS OF NUTRITION. 
Bernard has shown that the liver produces glycogenous substances 
and sugar, the hypothesis that diabetes depends upon a disease of the 
liver has gained ground, although the theory is not supported either 
by pathological or clinical observation. Claude Bernard himself 
thinks that the diabetes induced experimentally in animals, by the 
“ diabetic puncture,” depends upon the nervous derangement of the 
liver to which the operation gives rise. As a consequence of abnormal 
innervation, not only is the production of glycogenous matter aug- 
mented, but its conversion into sugar is also hastened. He believes, 
too, that in the human subject, diabetes mellitus likewise is due to an 
over-activity of the nerves which stimulate the function of the liver, 
and considers it probable that, “ if it were in our power to galvanize 
the sympathetic nerve,” this would be the best possible mode of treat- 
ing diabetes symptomatically; the function of this nerve being weak- 
ened by the undue activity of its antagonists. The possibility cannot 
be denied that more glycogenous matter is formed in the liver of a 
diabetic person than in that of a healthy one ; but it is neither proved 
nor even probable that this anomaly constitutes the only or even the 
essential lesion of the disease. It is not to be supposed that the pound 
of sugar which some patients discharge in the course of every twenty- 
four hours is only a small portion of the sugar which they produce 
daily, and that a larger portion undergoes that transformation in the 
blood which, normally as we know, is undergone by very large quan- 
tities of sugar, while a smaller portion of it remains, as it were, super- 
fluous, and passes away in the urine. In conclusion, I will present 
another very specious hypothesis, which really accounts better than 
any other for the origin of diabetes. According to Tscherinoff\ the 
liver-sugar is not made from the glycogen, but, on the contrary, the 
glycogen is formed from the sugar which arrives in the liver. Hence, 
instead of glycogen (sugar-former), it should be called glycoplithin- 
ium, or sugar-consumer. If the liver loses its capacity to convert the 
sugar into glycophtliinium, the sugar remains in the blood, and thus 
causes diabetes. 
Regarding the etiology of diabetes, our knowledge is equally 
vague, for although we learn from the history of many cases that the 
disease has arisen sooner or later after the exposure of the patient to 
certain noxious influences, yet these influences are so general in their 
character, and act so often upon the system without being followed 
by diabetes, that it becomes questionable whether the disease be at- 
tributable to their action at all. 
Griesinger, after collecting a large number of foreign and domestic 
cases, has come to the following conclusion: Diabetes occurs much 
more frequently in males than in females, the proportion being about DIABETES MELLITUS. 
835 
three to one. During childhood and old age it is rarer than dining 
the prime of life, the period of greatest frequence being between the 
ages of thirty and forty in males, and in females between ten and 
thirty. The disease sometimes appears to depend upon hereditary 
predisposition. The most commonly recognized exciting causes are: 
exposure to cold and wet, external violence, concussions of the whole 
body being a more fertile source of the disease than injuries to the 
brain and spinal marrow; also immoderate eating of sugar, new wine, 
and “ fruit-must,” unfermented juice of fruit, indulgence in immoderate 
mental exertion, mental depression, intoxication, etc. 
Anatomical Appearances.—No constant lesion is found post- 
mortem in the bodies of those who have died of diabetes mellitus. 
The most common appearances are the following: extreme emacia- 
tion, the integument often presenting remains of bed-sores, boils, car- 
buncles, and sloughs. There is no remarkable lesion in the brain ; in 
the lungs there are almost always tuberculous, or caseous deposits, of 
variable age, and not unfrequently pneumonia, or gangrene. The heart 
is flabby and atrophied; the liver usually normal, though sometimes 
hyperasmic. Hypertrophy of the pancreas occurs with remarkable fre- 
quence, considering how seldom this organ is the seat of disease. The 
walls of the stomach are moderately thickened, through muscular hy- 
pertrophy, probably the result of distention. The kidneys are en- 
larged by hyperremia, and sometimes are in a state of chronic paren- 
chymatous inflammation (Bright's disease). 
Symptoms and Course.—The most conspicuous and remarkable 
symptom of diabetes mellitus consists in the evacuation of enormous 
quantities of pale urine, whose high specific gravity, contrasted with 
its limpid aspect and sweetish taste, often alone suffices to place the 
diagnosis beyond a doubt. It is by no means rare for a diabetic pa- 
tient, in the course of twenty-four hours, to pass from five to ten thou- 
sand cubic centimetres of urine (from five to ten quarts), and, in some 
instances, the daily discharge has been much larger. No credence 
should be given to the stories of diabetic patients passing six or eight 
times this amount, or even more. It is maintained by some that the 
quantity of urine discharged exceeds the amount of liquid which has 
been drunk during the meals. If this were true, and unless there were 
a corresponding waste of the body, we should be compelled to assume 
that, instead of exhaling liquid through the skin and lungs, the patient 
actually imbibed moisture in this way from the surrounding atmos- 
phere. Since, as long as the temperature of the body remains higher 
than that of the air about it, such an occurrence would be incompatible 
with physical laws, I think it most likely that the observations have 
been erroneous in the instances where individuals have been reported, 836 
GENERAL DISORDERS OF NUTRITION. 
for long periods together, to evacuate a larger weight of urine and 
feces than they had taken in of food and drink, without losing in 
weight. Every investigator and experimenter, who has given his at* 
tention to the subject of diabetes, has to suffer from the strong in 
elination on the part of the patient to deceive him, and to conceal a 
portion of the liquid that he drinks. In the researches and experi- 
ments of Reich and Liebermeister at the Greifswalder clinic, the re- 
sults of which have been published by Dr. Reich, at first, the quantity 
of urine and feces, evacuated by both of the patients under observa- 
tion, seemed to exceed the amount which they ate and drank. But 
after they began to watch the patients so closely that they were never 
left alone for a moment, nor withdrawn from immediate observation, 
the quantity of ingesta began to exceed that of excreta of urine and 
feces. 
With regard to the cause of the immense increase in the secretion 
of urine in diabetes, Liebermeister and Reich have proved by their 
experiments that the very large quantity of liquid which they imbibe 
is not of itself sufficient to account for it. For a number of days, and 
with great care, they measured out equal portions of food and drink to 
two patients with diabetes, and a similar portion to a perfectly healthy 
and trustworthy man (Mr. Hoffmann, student of medicine), and meas- 
ured the flow of urine for every twenty-four hours, from each of them, 
with the same accuracy. The result showed, that in Candidate Hoff 
mann the secretion of urine was considerably augmented by the very 
large quantity of liquid which he had swallowed in the cause of science, 
but that it was far less than that passed in the same time by the sick 
men. Hoffmann passed from five thousand to six thousand cubic 
centimetres (five to six quarts), while the patients passed from 
seven thousand to ten thousand. It is possible that the presence of 
sugar in the blood may increase the power of filtration through the 
glomeruli of the Malpighian capsules, thereby augmenting the amount 
of urine secreted. However, this hypothetical explanation of the 
polyuria of diabetes is superfluous, since it is fully accounted for by 
Vogel, in his classical work upon this disease, as follows: “ What- 
soever may be the source of the sugar contained in the blood in dia- 
betes, the necessary consequence of its presence is, that the saccharine 
serum of the blood greedily attracts to itself, by endosmosis, all the 
liquids from the parenchyma, and all the water of the food and drink 
which enters the alimentary canal. The more the blood attracts 
water, so much the more does it increase in volume, and augment the 
intravascular pressure. The increase of pressure in the glomeruli of 
the Malpighian capsules of the kidneys then produces polyuria.” 
The high specific gravity of diabetic urine, which in mild cases DIABETES MELLITUS. 
837 
ranges from 1020 to 1030, and in severe ones from 1030 to 1050, de- 
pends almost exclusively upon the quantity of sugar in it; for although 
the common belief has not proved true, that the absolute amount of 
urea and salts is reduced in diabetic urine, yet, owing to the enormous 
quantity of water in which they are dissolved, their relative quantity 
is very small indeed. Liebermeister and Reich found that the produc- 
tion of urea of their patients not only was greater than that of healthy 
persons moderately supplied with mixed food, but that it also exceeded 
that of a healthy man, who ate as much food as the diabetic patients 
did. The amount of urea fluctuated in the patients from thirty-two to 
fifty-five grammes, and in a healthy subject from twenty-nine to thirty- 
two grammes. 
Although the profusion of the urine, its high specific gravity, and 
its sweetish taste, are decidedly indicative of the presence in it of 
sugar, yet its positive existence can be easily proved by means of one 
of the many “ sugar-tests.” Although it is important to select the most 
delicate and surest of these, when we wish to determine the presence 
of very minute quantities of sugar, and although the supposed discov- 
eries of traces of sugar in healthy urine, and in many other pathologi- 
cal and physiological conditions, are in a measure due to our mistaking 
other substances, having similar reaction, for sugar, yet, when it appears 
in large quantities, as it does in diabetic urine, Trommels test is quite 
sufficient to settle the diagnosis. An excess of liquor potassae is to be 
mingled with a portion of the urine to be examined; a dilute solution 
of sulphate of copper is then to be added, drop by drop, as long as the 
precipitate which first forms will redissolve when stirred. The liquid 
(which, if sugar be present, will show a blue color) is then to be 
filtered and warmed. The precipitation of red oxide of copper in the 
liquid, while still below the boiling-point, furnishes absolute proof that 
the solution contains sugar. If albumen also be present, it must pre- 
viously be separated by boiling and filtration. Another more simple 
test consists in warming the urine after adding a solution of potassa. 
The presence of sugar is indicated by the liquid’s assuming a yellow 
color, which gradually deepens into a dark brown. If this color does 
not appear, the non-existence of sugar is certain; but, even when visi- 
ble, it is always advisable to try Trommer’s test also. For the details 
of the somewhat elaborate fermentation-test, and the other tests for 
sugar, we refer to the text-books upon organic chemistry. Felding’s 
“ liquid ” furnishes a very sure means of determining the percentage 
of urea, and also of the sugar, if the quantity of urine passed in twenty- 
four hours be measured. Aiebermeister and Reich, who, in their many 
experiments, examined each portion of the urine separately, only 
noting as reliable those observations which agreed, hardly ever had 838 
GENERAL DISORLERS OF NUTRITION. 
occasion to repeat the process in the same portion of urine, aftei 
they had conducted their researches for a few days. The polarizing 
apparatus of Soldi- Ventzlce is a more convenient and rapid method 
of ascertaining the percentage of sugar in the urine. The cheaper 
polarizing apparatus of Iiobiquel, though less accurate, is also appli- 
cable to this purpose. In low grades of the malady, the quantity of 
sugar is not more than from one to two per cent.; in more intense 
forms, it is as much as six or seven per cent., or more. In well-pro- 
nounced instances, the entire amount excreted daily may exceed a 
pound. The proportion of sugar, however, varies greatly during the 
progress of the disease, sometimes even fluctuating perceptibly in the 
course of a day. The causes of these fluctuations are in a great meas- 
ure unknown, and we are acquainted with a few only of the agents 
which are capable of increasing or diminishing the percentage of sugar 
in the urine. Of the former, large draughts of liquid, heavy meals, 
especially eating large quantities of sugar or of amylaceous matter; 
of the latter, the exclusion of sugar from the food and drink, particu- 
larly the removal of amylaceous matter and similar glycogenous food. 
The influence of a meal upon the percentage of sugar voided continues 
for several hours, and then is replaced by a similar discharge of a much 
more gradual character. Dr. Moritz Traube infers, from the great de- 
crease in the elimination of sugar which takes place after several hours’ 
fasting, that, at a certain period during the night, there must be none 
at all. Had Dr. Traube but tested the truth of his conclusion (and he 
states expressly that he has not done so), had he merely examined a 
little of this urine of the last few hours of the night, which he supposes 
should not contain sugar, he would probably find himself to be in the 
wrong. Among the cases under observation at my clinic, one of which 
was of quite recent origin, affecting a young, vigorous man, still capa- 
ble of work, and in the fourteen cases investigated by Seegen in 
Karlsbad, the urine passed in the latter hours of the night and those 
of early morning invariably contained sugar. Hence Dr. Traube1 s 
proposed “ law ” is undeserving of credit until it shall have been 
proved that cases do occur in which it is as he supposes. 
The parching thirst which distresses the patient day and night is 
easily accounted for, as it has been proved that the polyuria of diabetes 
is not merely a consequence of much drinking, but rather that the 
patients drink much because they suffer an excessive loss of water 
through the kidneys. Claude Bernard ascribes the thirst of diabetic 
patients to the elevated temperature of the liver, which undoubtedly 
induces an increased absorption in the intestinal canal. This hypoth- 
esis, like the others, is idle. A diabetic patient is thirsty on account 
of the thickening of Ins blood, much of whose water has been dis- DIABETES MELLITUS. 
839 
charged from his kidneys, just as another one thirsts who sweats pro- 
fusely, or who suffers a great evaporation from his skin from fever, or 
like a cholera patient who is discharging water through the capillaries 
of his intestines. A second factor consists in the desiccation of all the 
tissues as a result of intense endosmotic action from the parenchyma 
into the vessels. Sugar may be employed as well as salt for the pur- 
pose of drying meat in order to preserve it. It is by no means rare foi 
a patient to drink from ten to fifteen quarts of water during the day. 
The thirst is most intense an hour or two after meals, that is, while 
the formation of sugar is most active and the production of urine the 
most copious. 
This immense waste of water through the kidneys likewise accounts 
for the complete arrest of perspiration, and for the decrease in the in- 
sensible evaporation from the skin, which have been observed at my 
clinic. The antagonism between the secretions of the skin and kid- 
neys is as well shown in the dryness of the surface of diabetic people 
as in the reduction of diuresis, which usually accompanies profuse per- 
spiration. Griesinger reports an interesting case, in which sugar was 
present in the urine and sweat alternately, and in which, whenever the 
sweat became strongly saccharine, the percentage of sugar in the urine 
sank one-half. In the aforementioned researches of Liebermeister and 
Reich, it was found that a diabetic patient scarcely perspired a third 
of the quantity given off by a healthy person. Finally, according to 
the experiments of Kundc and JDj/mhorn, who, by artificial abstraction 
of water from frogs and mammalia, have induced opacity of the crys- 
talline lenses of these animals, it seems not improbable that the cataract 
which often accompanies diabetes is a consequence of the excessive 
loss of water, although indeed the ophthalmologists have raised many 
objections to this explanation. 
An insatiable hunger is a symptom of diabetes, quite as constant 
as is the unquenchable thirst. It is almost incredible how much food 
such a patient will consume during a day, often quite regardless of its 
quality. This voracious hunger, as well as the steadily increasing and 
finally extreme emaciation, manifestly are due to the fact that a large 
part of the food eaten is of no profit to the system, because, instead 
of being devoted to the repajr of used-up constituents of the body, it 
is immediately excreted. Moreover, the consumption of the nitro- 
genous components of the body is considerably increased in diabetes, 
as is shown by the augmentation in the quantity of urea produced. 
Of course there can be no elevation of the bodily temperature, a large 
part of the heat-producing material passing off from the blood unused. 
The impotence, which is nearly always observed in this disease, is 
probably dependent upon a general decline in the patient’s strength 840 
GENERAL DISORDERS OF NUTRITION. 
and nutriiivt condition; nevertheless, the attempt has been' made to 
ascribe diabetic ipipotence to the drying up of the sperm for want of 
water, and to a saccharine condition of the semen, supposed to deprive 
it of its power of inducing nervous excitement. 
Finally, we have to mention a series of phenomena, which, al- 
though less constant than those heretofore described, still often accom- 
pany them and serve to complete the picture of the disease. Caries 
of the teeth is a symptom which sets in early in the majority of cases. 
Falk explains this phenomenon by supposing that the teeth are ex- 
posed to the action of a free acid, formed by decomposition of saccha- 
rine secretion within the mouth. Then, again, phymosis and excoria- 
tions of the prepuce and glans in men, and of the parts about the 
meatus urinarius in women, are very distressing occurrences, due prob- 
ably to wetting of these parts with saccharine urine. Finally, there 
is often a great tendency to inflammation, ending in necrosis and mor- 
tification, exhibited in the very frequent occurrence of furuncles, car- 
buncles, lobular pneumonia, and pulmonary abscesses and gangrene. 
Consumption of the lungs develops as a terminal symptom in many 
diabetic persons. According to Griesinger, nearly one-half of all pa- 
tients die in this way. Now and then albuminuria is associated with 
mellituria, thereby augmenting the exhaustion and accelerating the 
demise of the sufferer. It is not improbable that the parenchymatous 
nephritis, upon which the albuminuria depends, is a consequence of the 
constant irritation of the kidney by the presence of sugar in the urine, 
thus forming a sort of analogue with diabetic balanitis. 
The course of diabetes is always chronic, lasting for months and 
years. In but a very small number of the cases reported, the disease 
has been acute, terminating fatally within a few weeks, or even sooner. 
We have scarcely any trustworthy observations of the incipient stages 
of the malady. Nearly all patients only come under treatment at a 
period when the profuse urination, tormenting thirst, insatiable hun- 
ger, and steadily advancing emaciation, have awakened the suspicion 
of the existence of serious disease; and they are scarcely ever able 
accurately to state when the present symptoms first arose, or by what 
others they had been preceded. Even in the few examples in which 
the malady has developed quickly, an augmented hunger, thirst, and 
an unnatural diuresis, were the first manifestations which attracted the 
attention of the patients and their friends. 
Diabetes usually lasts from one to three years. More than sixty 
per cent, of the cases collected by Griesinger terminated fatal I3 
within that period. It must, however, be recollected that statistics 
usually refer to cases treated in hospital, while the majority of those 
treated in private practice are never published. There is no doubl DIABETES HELLITUS. 
841 
that patients in comfortable circumstances, and who possess the means 
of taking1 good care of themselves, hold out against diabetes much 
longer than those who are obliged to seek refuge in hospitals. A 
complete and permanent recovery from diabetes (if it ever occur at all) 
is extremely rare; although plenty of cases have been recorded in 
which a pause in the symptoms, of longer or shorter duration, has 
been observed. Death, when not the result of some intercurrent com- 
plication, usually takes place with the signs of extreme marasmus. 
Sometimes nervous symptoms arise shortly before death, calling to 
mind the characteristics of uraemic intoxication. 
Treatment.—Numerous remedies and “ cures ” have been recom- 
mended for diabetes; unfortunately, most of them have been devised 
upon principles based on purely hypothetical views as to the nature 
of the disease, and very few of them rest upon facts established by ex- 
perience. We shall not discuss procedures such as that whose object 
is to hinder the conversion of amylum into sugar by exhibition of acids; 
or that in which nitrogen is to be supplied to the system by adminis- 
tration of ammonia; or in which it is sought to allay irritability of the 
kidneys by means of opium ; or to act upon the liver by means of ox- 
gall, or gallic acid, or any of the other purely theoretical suggestions. 
We are indebted to Griesinger for a positive experimental demonstra- 
tion of the inefficacy, and in some cases even the detrimental character, 
of some of these modes of treatment, such as that by alcohol, rennet, 
yeast, sugar—intended to supply the place of that lost from the blood. 
Experience has also established the fact of the beneficial influence 
of certain dietetic rules, the first hints of which, however, were derived 
from theoretical reasoning. It is of the utmost importance that dia- 
betic patients should live principally upon animal food, and that they 
should eat but very little starchy or saccharine matter. The absolute 
prohibition of food containing starch and sugar has been abandoned 
of late; experience having taught, in the first place, that although the 
loss of sugar might undergo temporary diminution by this procedure, 
yet it could not cure the diabetes ; and besides, it has been found that 
there are very few patients who for years can endure a diet consisting 
exclusively of meat, eggs, fish, oysters, crabs, salad, and JBouchardafs 
bran-bread. It relieves the patients greatly, in carrying out the rest 
of the treatment, to allow them to eat a small portion of bread daily; 
and it does them no material harm. If we do not allow them this in- 
dulgence, we run the risk of their soon becoming so impatient, at the 
excessive restraint, as to refuse further obedience, and make up for lost 
time by eating copiously of bread and fruit, for which they almost 
always have a great desire. Besides the meats, the patient ma}r be 
allowed such vegetables as do not contain either sugar or starch, oi 842 
GENERAL DISORDERS OF NUTRITION. 
but very little of them. Bouchardat has proved, by the comparison 
of the articles of food which a diabetic may take without prejudice, 
that it is quite possible to keep up a sufficient degree of variety in the 
character of the meals. The list of articles which he permits is about 
as follows: All sorts of meats roasted, stewed, and even dressed with 
spices, but not with flour; fresh water fish and marine fish, in eating 
which the want of bread is less felt than in eating meat; oysters, mus- 
cles, crabs, lobsters, etc. ; eggs in all the forms known to the culinary 
art; rich, good cream, but no milk; of the vegetables, spinach, arti- 
chokes, asparagus, green beans, the different varieties of cabbage; of 
the salads, water-cresses, endives, lettuce; of fruits, strawberries and 
peaches. Although the loss of sugar is augmented by very free sup- 
ply of liquid, and decreased by a privation of it, yet it is not advisable 
to forbid the patient to quench his thirst. Griesinger, who has ex- 
perimented upon this subject also, concludes that there is no rapid 
or considerable decrease in the loss of sugar until the thirsting has 
been pushed to the point of general disturbance of the system; and, as 
such a condition can only be endured for a very short time, he allows 
the patient just enough liquid to slake his thirst. Besides spring- 
water, acidulated water may be allowed as a beverage, as well as 
coffee, well-fermented beer, and wine, if not too new, especially red 
wine. 
Inasmuch as diabetic persons are very liable to take cold, and 
show a predisposition to pneumonia, and the like, directions regarding 
their clothing must also be laid down, and especially must they be 
urged to wear flannel next the skin. 
' Besides these dietetic rules, under the conscientious oDservation 
of which diabetes, although incurable, is often tolerated for a great 
length of time without appreciable decline (as can be proved by many 
well-attested instances), there are certain medicinal remedies whose 
effects in diabetes are very decided. In private practice, no credit 
should be given to the claims of any drug based upon the bare asser- 
tion that it has benefited or cured a case of diabetes, particularly when 
it has been known to fail in other instances. But even those remedies 
which only exert a slight influence upon the course of the disease 
(proved, however, by accurate and •continuous measurement of the 
urine, sugar, weight of the body, etc.) should be urgently recom- 
mended to private patients by their physicians. At present, however, 
the alkaline carbonates are the only medicines whose beneficial action 
upon diabetes can be claimed with certainty. In Griesinger1 s clinic, 
the exhibition of doses of bicarbonate of soda effected a distinct al- 
though slight improvement in the disease. The equally well-estab- 
lished success of the springs of Carlsbad and Vichy have been much DIABETES INSIBIDUS. 
843 
more marked. The old reputation of the Carlsbad waters, as a cure 
for diabetes, has vindicated itself most brilliantly, according to the ob- 
servations of Seegen. According to him, there can no longer bo any 
doubt that in many cases of diabetes mellitus, a course of several 
weeks at these springs results in an abatement of the thirst, a decrease 
in the urination, a gain in weight, and in a disappearance of the 
sugar from the patient's urine. Whether or not these results be per- 
manent, or merely transitory, still, in our present state of knowledge, 
a course of waters at Carlsbad is the measure which should deserve the 
chief reliance as a remedy for diabetes mellitus.3 
CHAPTER VIII. 
DIABETES INSIPIDUS. 
Diabetes insipidus and diabetes mellitus, in spite of the agree- 
ment of their most conspicuous symptoms, polyuria and unquenchable 
thirst, are altogether distinct diseases. In the former, the urine does 
not contain any foreign ingredients, the presence of which might ac- 
count for the symptoms. 
It is true that not long since, in the urine of a patient with dia- 
betes insipidus, Mosler discovered inosite, which is not among the 
normal constituents of urine, and he advanced the hypothesis that 
inosite played the same part in diabetes insipidus (inosuria) that 
sugar does in diabetes mellitus (mellituria). But the very slight 
amount of inosite excreted in the urine of Mosler’s patient would 
render this idea improbable, and it is entirely refuted by one of my 
pupils, Dr. Strauss, who wrote an excellent monograph on diabetes 
insipidus.* 
After finding inosite in the urine of two cases of diabetes insi- 
pidus—in one case 0.14-74 grm. in 6,700 ccm. of urine, in the other 
1.508 grm. in 9,600 ccm. of urine—Strauss caused three healthy 
persons, in whose urine there was no inosite, to drink large quan 
tities of water (about ten quarts in twenty-four hours); after this . 
inosite was found in the urine of all three patients, in about the same 
proportion as in the patients with diabetes insipidus. These beautiful 
experiments show that a body which normally exists in the kidneys, 
liver, lungs, and muscles, but, as it undergoes changes in the body, is 
not found in normal urine, may be excreted through the kidneys by 
giving large quantities of ■water. 
* Die einfache zuckerlose Hamruhr, von Dr. F. Strauss. Tubingen, 1870. 
Terlag der Lauppschen Buchhandlung. 844 
GENERAL DISORDERS OF NUTRITION. 
The most specious of the hypotheses, as to the pathogeny of 
insipid diabetes, is that which ascribes the polyuria to derangement 
of innervation of the blood-vessels of the kidney. If the afferent 
vessels of the Malpighian capsules were to become dilated, in conse- 
quence of paralysis of their walls, the pressure within the glome- 
ruli would increase, and with it the rate of filtration of the urine 
would augment, thus giving rise to polyuria. This primary symptom 
would be accompanied secondarily by polydipsia. When large quan- 
tities of water are withdrawn from the blood, as a consequence of pro- 
fuse urination, then (just as also occurs after profuse sweating, or 
intense liquid diarrhoea) the fluids from the interstices of the tissues 
are greedily absorbed by the now concentrated blood, thus giving rise 
to an increased need for liquid, and to a sense of severe thirst. Al- 
though I regard this as probably a true explanation, and although it 
acquires further support from the discovery of Bernard, that polyuria 
may be induced in animals by wounding their medulla oblongata at a 
point somewhat farther up than that at which the so-called “ diabetes 
puncture ” is performed, yet I am by no means inclined to regard it 
as absolutely correct. 
With regard to the somewhat obscure etiology of diabetes insipi- 
dus, we must confine ourselves to the announcement of the following 
facts : The disease is more common in males than in females, and in 
youth than during middle age. I cannot confirm the assertion that 
old age is exempt from it, as I have seen a case in a patient fifty years 
old. Its exciting causes have so often been referred to mental affec- 
tions, to the drinking of cold beverages while the body was over- 
heated, to cold, to over-exertion, to abuse of spirituous liquors, and 
other agencies, of a nature so various, and of such common occurrence, 
that the dependence of the malady upon their influence must be 
regarded as questionable. 
It is different with the observations of cases where diabetes 
insipidus has occurred after injuries of the skull, and in the course 
of acute and chronic diseases of the brain. These cases, in con- 
nection with the above-mentioned experiments of Bernard\ are 
peculiarly interesting. 
Anatomical Appearances.—The results of the small number of 
autopsies held upon persons who have suffered from diabetes insi- 
pidus agree so imperfectly, that nothing positive can be affirmed 
regarding the anatomical lesions from which the malady originates. 
Thus, in a case described by Neujfer, the kidneys, contrary to all expec- 
tation, were found small and atrophied, while in another, mentioned by 
Lebert, they were enlarged and hypertrophied. 
Symptoms and Course.—The amount of urine discharged by a DIABETES INSIPIDUS. 
845 
patient with diabetes insipidus is as great as, or even greater than, 
that passed in diabetes mellitus. In twenty-four hours it often 
amounts to from 10,000 to 15,000 com. (ten to fifteen quarts), and 
sometimes even more. 
A little girl, ten years old, with diabetes insipidus, who was 
very undeveloped, and only weighed twenty-three pounds, during her 
stay in the Tubingen clinic, passed daily an amount of urine that 
weighed about one-third as much as her body. The urine is very 
limpid, and, in contradistinction to diabetic urine, of low specific 
gravity. It rarely rises above 1.005, and often sinks to 1.001 or 
1.0005. The relative amount of urea and salts in the urine is low, 
but the absolute amount of urea excreted in twenty-four hours is 
usually normal or somewhat increased. In one case that I observed, 
where the patient consumed a moderate quantity of nitrogenous 
material, he passed 9,000 ccm. of urine, containing 38 grm. of urea, 
in twenty-four hours. Rarely the amount of urea passed in the twenty- 
four hours is diminished. Thus, in one of the cases in my clinic, 
published by Strauss, where the patient weighed about 114 pounds 
and had good diet, he passed only 23.42 grm. of urea in the 
twenty-four hours.* 
The excretion through the skin and lungs seemed to be consider- 
ably reduced, judging by the relative quantities of the liquid drank 
and urine voided. Doctors Schrrddtlein and Spaeth, who for some time 
ate and drank exactly the same quantities of food and drink taken 
by a patient with diabetes insipidus at my clinic, in twenty-four hours 
excreted from two thousand to twenty-six hundred grammes through 
their lungs and skin, while the patient only lost from five hundred and 
forty to six hundred and forty grammes by the same way and in the 
same time. 
Strauss's observations also led to the result that, taking the same 
amount of fluid, the patients passed from five hundred to two 
thousand centimetres more urine than healthy persons, while, in the 
latter, the loss of weight by insensible perspiration was considerably 
more than in the former. 
* In some cases of diabetes insipidus the urine is said to have a very high specific 
gravity, and to contain an abnormal amount of urea. In this form of disease, 
about which the observations are very scanty, the original disease would consist 
of an increased destruction of tissue; the great thirst, as well as the increased 
secretion of urine, would be very insignificant as compared with the severe con- 
stitutional disturbance, and would be explained as in diabetes mellitus. The serum 
of the blood is abnormally concentrated, and, on endosmotic principles, draws water 
from the tissues. We shall not further consider this obscure and problematical form 
of diabetes insipidus. 846 
GENERAL DISORDERS OF NUTRITION. 
Strauss |ustly regards this as another proof that polydipsia is not 
the cause ol polyuria, but the reverse. He writes as follows: 
“ What reasonable and satisfactory grounds are there for assuming 
that the cutaneous and pulmonary exhalations of a polydiptic person 
should differ from those of a healthy person who voluntarily drinks 
copiously of water ? ” 
But if we suppose a polyuria with consequent concentration of the 
blood, and decrease of water in the tissue, there would be nothing 
strange in a diminished gaseous excretion of water by the skin and 
lungs. In our cases, as in most others, among the symptoms referring 
to the skin, we find mentioned dryness, harshness, and frequent itch- 
ing, while profuse perspiration is not mentioned in a single case. 
The quantity of liquid imbibed daily, including that contained in 
the food, is said to have amounted sometimes to sixty or eighty pints. 
Of course, such a quantity could never permanently be less than that 
of the urine secreted, without the occurrence of a corresponding de- 
crease of the weight of the body. All cases, wherein it is claimed 
that the quantity of urine secreted exceeded that of the liquid imbibed, 
must have been inaccurately observed. 
In my case, the sense of hunger was considerably augmented. 
Trousseau also tells of a patient who ate such enormous quantities 
that, at a certain restaurant where bread was furnished d discretion, 
they paid him to stay away. In this disease (unlike diabetes mellitus, 
in which a part of the food consumed, instead of going to repair the 
used-up constituents of the body, is voided unused), this unnatural 
hunger—which, moreover, is not a constant occurrence—can only be 
accounted for by supposing that the exaggerated consumption and dis- 
charge of water accelerate the waste of the nitrogenous elements of 
the body. It may be accepted as a law that, during an accelerated 
flow of the juices of the parenchyma through the organs, a larger 
quantity of albuminous material is consumed. 
In some patients the general health and vigor long remain undis- 
turbed. A girl twenty years of age, with insipid diabetes, who 
remained under observation at my clinic for a considerable time, 
retained her blooming aspect, and could even do hard work without 
special effort. In other patients, signs of digestive derangement, 
cardialgia, vomiting, irregularity of the bowels, emaciation, and an un- 
accountable sense of debility, set in early. In the instance reported by 
Neuffer, the patient died with these symptoms, no appreciable cause 
of death being discoverable upon autopsy. The course and duration 
of the disease vary. In some cases it develops gradually, in others 
it sets in suddenly. Not unfrequently a transient improvement in the 
symptoms is observed. It may also happen that, during the attack ADDITIONS TO THE REVISED EDITION OF I860. 
847 
of some intercurrent disease, the daily flow of urine becomes normal, 
and returns to its former profusion after the attack has terminated. As 
a rule, the malady lasts for years without imperilling life. It is only 
in rare instances, as in that of Neuffer, already alluded to, that death 
takes place without the intervention of some other disease. Complete 
and permanent recovery from diabetes insipidus is likewise an ex- 
tremely rare event. 
Treatment.—It is always suspicious when numerous remedies are 
recommended for a disease; in such cases, usually, none of them have 
any special effect on the course and termination of the affection. This 
is also true of the recommendations of saltpetre, in the shape of sal 
prunelke, of valerian, belladonna, opium, ergotine, creosote, and 
other remedies in diabetes insipidus. They are not based on the 
results of experience, but on theoretical grounds. I have not used 
any of these remedies persistently and energetically, as my patients 
bore their disease pretty well—so that there was no necessity for 
energetic treatment. On the whole, I would advise you, in treating 
simple diabetes, to limit yourselves to preventing the bad results 
induced by the disease, or to combating them if they have already 
appeared. Especial attention should be paid to the disturbances of 
digestion and nutrition, which are not uncommon. Rational diet, 
combined with cod-liver oil, malt extract, and iron, improved the con- 
dition of the little girl above-mentioned, without diminishing her thirst, 
or the secretion of urine; and, although her early death had been 
expected, she was discharged from the clinic considerably increased in 
weight and much improved in health. 
ADDITIONS TO THE REVISED EDITION OF 1880. 
SECTION III. GENERAL DISORDERS OF NUTRITION. 
1.—P. 803. 
According to Virchow, in obstinate cases of chlorosis there is 
defective development and small size of the aorta and vessels gen- 
erally. The aorta may be so small as not to admit the little finger, 
while its walls may be uncommonly thin ; they, however, retain 
their elasticity, unless there has been fatty degeneration of the 
inner and middle coats. This failure of vascular development is 
sometimes accompanied by stunted growth of the whole body. 
The heart is sometimes small, but is usually normal, or slightly di- 
lated ; exceptionally it is hypertrophied. There is an inclination 848 
GENERAL DISORDERS OF NUTRITION. 
to endocarditis of the left ventricle. In women with this trouble of 
the heart and blood-vessels, child-bearing may induce ulcerous endo- 
carditis. Feverish diseases ai’e more dangerous in chlorotic persons 
than in others. In giving iron in chlorosis, it is well to administer 
it after eating. Mineral waters containing pyrophosphate of iron 
may be drunk at meal-times. This drug may have to be discon- 
tinued when there is gastric disturbance or fever. Iron is to be 
aided by good, easily digestible diet, and residence in a healthy 
locality. In chlorosis and ansemia generally, alcoholic beverages 
may be useful by impeding transformation of tissue, but should 
be avoided if they induce excitement, palpitation, rush of blood to 
the head, etc. Trial must decide whether wine or beer answers the 
best purpose. 
2.—P. 832. 
Of late it has been considered possible that the use of milk from 
cows with murrain might have an injurious effect, because forma- 
tions similar to those in tubercles in men have been found in the an- 
thrax-nodules of cattle, and because experiments have shown that 
feeding other animals on the milk of these cows will give them 
tuberculosis and diseases of the lymphatic glands of the mesentery 
and neck, similar to those in scrofula. Hence the use of such milk 
may be suspected as a cause of the trouble, but has not yet been 
proved to be so. 
In the treatment of scrofula considerable reputation is enjoyed 
by the mud-baths of Nauheim, Kreuznach, etc., in Germany ; they 
increase the transformation of tissue, and prove advantageous for 
the glandular enlargements, as well as for the affections of the mu- 
cous membrane and skin. When cod-liver oil is given, it is some- 
times better borne when not taken on an empty stomach, but half 
an hour or so after eating. Pale, anaemic children often require 
some preparation of iron. When the patient is not anamiic or fee- 
ble, at proper seasons it is often well to order a laxative mineral 
water, such as a continued moderate use of Carlsbad water. The 
waters containing iodine have so very small a percentage of it, that 
it is doubtful if it has any special effect. 
3.—P. 843. 
There have been numerous disputes as to the glycogene builders ; 
among them are grape, cane, milk, and fruit sugar, inulin, glycerin, 
etc. Amylaceous food has the greatest effect on the formation of 
sugar ; under its use the portal vein is always rich in dextrin. It ADDITIONS TO TEE REVISED EDITION OF 1880. 
849 
is not known just how sugar is made from the food ; it normally 
exists in the blood in such slight quantity that it does not transude 
into the urine ; in the blood of diabetic patients Cantani found it 
as high as 8 parts in 1,000. 
Artificial mellituria may be induced by dividing the inferior cer- 
vical ganglia, or by irritating the floor of the fourth cerebral ven- 
tricle (which at the same time induces polyuria) ; division of the 
splanchnics has no effect. Schiff induced diabetes by destruction 
of the spinal medulla before and behind the origin of the brachial 
nerves, etc. Artificial diabetes may also be induced by injections 
of curare, solutions of common salts, some of the salts of soda, 
nitrite of amyl, morphine, etc. ; this effect is prevented by previous 
division of the splanchnics. 
Diabetes is a disease of the vasomotor nerve-system ; on au- 
topsy the liver is found normal, but there are frequently changes 
in the brain (tumors, etc.). Possibly the sugar formed during 
digestion of amylaceous substances, being taken up by the lymphat- 
ics and portal vessels, enters the blood directly. Cantani regards 
sugar in the blood as necessary to life, and thinks it is one source 
of strength ; it appears as grape-sugar, and is broken up by some 
ferment; if the organs furnishing this ferment (the pancreas ?) be 
diseased, the sugar appears in the urine. In the first stages of 
diabetes, by withdrawing amylaceous food, the collection of sugar 
in the blood and its excretion by the urine may be prevented, and 
by continuing this treatment for some time the disease may perhaps 
be entirely cured ; even later in the disease, the excretion of sugar 
may be arrested, but it is doubtful if the disease can be cured. 
Although the above theories are not universally accepted, the treat- 
ment advocated is probably the most successful of the many that 
have been tried. 
Possibly diabetes may depend on a variety of causes, having as 
a common result the non-consumption of sugar and its excretion by 
the urine. Senator divides it into neurogenous, gastro-enteroge- 
nous, and hepatogenous forms. . The first wrould include the cases 
caused by injuries, tumors, etc., affecting the nervous system ; the 
second, the Cantani cases ; and the third class, cases where, as a 
result of hyperaemia of the liver, hepatic sugar passes more rapidly 
into the blood. There would seem to be either two forms of dia- 
betes, or else two stages of the same disease, in one of which exclu- 
sion of amylaceous substances from the diet prevents the appearance 
of sugar in the urine. 
Diabetic urine often has a peculiar odor, which is ascribed to 
aceton. Bottcher tests for sugar by adding to urine m a test-tube 850 
ADDITIONS TO THE REVISED EDITION OF 1880. 
a small quantity of nitrate of bismuth ; then freely adding a con- 
centrated solution of carbonate of soda, or some potash lye ; then 
heating to the boiling-point. If sugar be present, the bismuth 
turns gray, then black. This test may be used in addition to others, 
but is less delicate than the copper test. IIDEX. 
A. 
Abscess of the Brain, ii., 255; of the 
Heart, i., 355 ; of the Kidneys, ii., 36; 
of the Liver, i., 669; of the Lungs, 
i., 169; of the Ovaries, ii., 110; of the 
Spleen, i., 752; metastatic of the Liver, 
i., 668; metastatic of the Lungs, i., 158. 
Abscess, retropharyngeal, i., 476. 
Acarus scabiei, ii., 510. 
Acholia, i., 677. 
Achroma, ii., 448. 
Achromatopsia, ii., 310. 
Acinesis, ii., 359. 
Acne, ii., 493. 
Acne rosacea, ii., 497; syphilitica, ii., 762. 
Acorn Coffee, ii., 830. 
Addison’s Disease, ii., 49. 
yEgophonv, i., 186. 
Agenesis, ii., 283. 
Ageustia, ii., 349. 
Agraphia, ii., 286. 
Akinesis, i., 491. 
Albino, ii., 448. 
Albuminate of Mercury, ii., 780. 
Albuminuria, Origin of, Test for, ii., 22; 
after Scarlatina, ii., 592. 
Alcoholic Poisoning, ii., 184, 
Alopecia circumscripta, ii., 449 ; syphi- 
litica, ii., 765; anata, ii., 525. 
Amaurosis in Bright’s Disease, ii., 30. 
Amenorrhcea, ii., 160, 807. 
Amylea, ii., 300. 
Anaemia et Cachexia splenica, ii., 817. 
Anaemia, progressive pernicious, ii., 817. 
Anaesthesia dolorosa, ii., 345 ; of the cu- 
taneous Nerves, ii., 342 ; of the Trige- 
minus, ii., 348. 
Analgesia, ii., 345. 
Aneurism, true and false, i., 418; dis- 
secting, i., 426; cylindrical fusiform, 
i., 419; cardiac, i., 346; of the Aorta, 
i., 417; of the cardiac Valves, i., 393. 
Angina catarrhalis, i., 463 ; Ludovici, i., 
477; membranacea, i., 15; paren- 
chymatous, i., 465 ; pectoris, i., 384; 
syphilitica, i., 467; maligna, ii., 664. 
Anidrosis, ii., 518. 
Anostosis excentrica, ii., 769. 
Anteflexion of Uterus, ii., 141, 
Anteversion of Uterus, ii., 144. 
Anthracosis, i., 201. 
Antiperistaltic Motion of the Bowels, i., 
594. 
Aorta, Aneurism of, i., 417; Calcification 
of, i., 415; Atheroma of, i., 415; fatty 
Consumption of, i., 415; Rupture of, 
1., 426 ; Inflammation of Coats of, i., 
413; Stricture and Obliteration of, i., 
427. 
Aortic Valves, Constriction of, i., 359. 
Aphasia, ii., 285. 
Aphonia paralytica, i., 54; ii., 438. 
Apneumatosis, i., 130. 
Aphthae, i., 437. 
Apomorphia, i., 563. 
Apoplectic Stroke, ii., 215; Cicatrix, ii., 
218 ; Cyst, ii., 218. 
Apoplexia meningea, ii., 230 ; sanguinea, 
11., 215; serosa, ii, 278. 
Apoplexie foudroyante, ii., 227. 
Apoplexy, cerebral, ii., 215, 320; pulmo- 
nary, i., 139. 
Appetite, perverted, ii., 805. 
Ai’ea Celsi, ii., 449. 
Argyria, ii., 403. 
Arsenic, i., 339. 
Arteriosclerosis, i., 430. 
Arthritis, ii., 545; deformans, ii., 540. 
Arthrogryposis, ii., 357. 
Arthropathia, ii., 226, 414. 
Artificial Anus, i., 589. 
Ascaris lumbricoides, i., 623. 
Ascites, i., 649. 
Asthma acutum Millari, i., 51; convul- 
sive, i., 88; humid, i., 74; laryngeal, i., 
51; thymic, i., 51; urinous, ii., 27. 
Asymbolia, ii., 286. 
Ataxie locomotrice progressive, ii., 302. 
Atelectasis Pulmonum, i., 130. 
Atheroma, i., 415, ii., 520; of the Ar- 
teries, i., 359. 
Aubree’s Specific, i., 94. 
Aura epileptica, ii., 394. 852 
INDEX. 
B. 
Bacteria, ii., 738. 
Balanitis, ii., 91. 
Baldness, ii., 448, 765. 
Barbadoes Leg, ii., 446. 
Basedow’s Disease, i., 388. 
Basilar Meningitis, ii., 240. 
Bath Itch, ii., 468. 
Baths in Bronchitis, i., 82; Rheumatism, 
ii., 535; Scarlatina, ii., 594; Typhoid 
Fever, ii., 651. 
Belladonna, ii., 402. 
Bile Fever, i., 631; Test for, i., 708. 
Black Vomit, ii., 692. 
Bladder, Acinesis of, ii., 84; Anaesthe- 
sia of, ii., 80; Cancer of, ii., 73; Ca- 
tarrh of, ii., 66; distended, ii., 70; 
Haemorrhage from, ii, 74; Hyperaes- 
thesia of, ii., 80 ; Ilypercinesis of, ii., 
82; Neuroses of, ii., 79 ; Palsy of, ii., 
84; Spasm of, ii., 82; Stone of, ii., 75 ; 
Tuberculosis of, ii., 73. 
Bladder-worm, i., 624. 
Blaud’s Pills, ii., 808. 
Bleeding at Nose, i., 305. 
Blepharospasm, ii., 352. 
Blindness from Tumors of Brain, ii., 269. 
Blood-murmurs, ii., 531, 806. 
Blood Test, ii., 8. 
Bloody Flux, ii., 722. 
Bloody Sweat, i., 160; ii., 498. 
Bothriocephalus latus, i., 623. 
Brain, Abscess of, ii., 255 ; Anaemia of, 
ii., 195 ; partial Anaemia of, ii., 201; 
Atrophy of, ii., 282 ; Aneurisms in, ii., 
262, 287 ; gummy Tumor of, ii., 264; 
Hyperaemia of, ii., 175; partial Hy- 
peraemia of, ii., 193 ; Haemorrhage 
into, ii., 215 ; Hypertrophy of, ii., 280; 
Inflammation of, ii., 254; Softening 
of, ii., 201; yellow Softening of, ii., 
204; white Softening of, ii., 206; 
Sclerosis of, ii., 260; syphilitic Disease 
of, ii., 771; Tumors of, ii, 262. 
Brayera anthelmintica, i., 628. 
Breast, irritable, ii, 337. 
Bright’s Disease, acute, ii., 10; chronic, 
11., 14. 
Brine Baths, i., 13 ; ii., 831. 
Bromide of Potassium in Epilepsy, ii., 
403. 
Bronchi, Diseases of, i. 61; Catarrh of, 
1., 61; Catarrh of, in the newly-born, 
i., 72; Croup of, i., 86; Dilatation of, 
i., 65, 202 ; Haemorrhage from, i., 145; 
Hyperaemia of, i., 61; Spasm of, i., 
88. 
Bronchial Asthma, i., 88; Respiration, 
i., 140, 185. 
Bronchiectatic Cavities, i., 199. 
Bronchitis, capillary, i., 70. 
Bronchophony, i., 185. 
Bronchopneumonia, i., 194. 
Bronchorrhoea, chronic, i., 76. 
Bronzed Skin, ii., 49. 
Bruit de Diable, ii., 805. 
Bubo, acute, ii, 750; indolent, ii., 758. 
Bulbar Palsy, ii., 372. 
Bullrich’s Salt, ii., 554. 
Buttermilk, i., 519, 564. 
c. 
Cacotrophia, ii., 561. 
Calcareous Infarction, ii., 62. 
Calculus, ii., 77; renal, ii., 60. 
Callosities of Skin, ii, 441. 
Calomel as an Anti-syphilitic, ii., 778. 
Calori,' ii., 468. 
Calvities, ii., 448. 
Cancrum Oris, i., 439, 462. 
Capillary Bronchitis, i., 70. 
Caput obstipum, ii., 354. 
Carbonic-acid Poisoning, i., 23. 
Cardialgia, i., 551. 
Carlsbad Water in Diabetes, ii., 843. 
Catalepsy, ii., 424. 
Cataract in Diabetes, ii., 839. 
Catarrh, i., 1; syphilitic, ii., 765. 
Catarrhal Fever, i., 631. 
Cerebral Arteries, Aneurisms of, ii., 262, 
287; Thrombosis of, ii., 201; Sinus, 
Inflammation of, ii., 233. 
Cerebrospinal Meningitis, epidemic, ii., 
247. 
Chancre, ii., 743; glandular, ii., 750; 
parcliemine, ii., 757; inoculated, ii., 
745 ; phagedenic, ii., 747 ; gangrenous, 
ii., 748; diphtheritic, ii., 746; Hun- 
terian, ii., 758. 
Chancroid, ii., 743. 
Chicken-pox, ii., 612. 
Chloasma, ii., 441; uterina, ii., 442. 
Chloride of Sodium and Gold, ii., 422. 
Chlorosis, ii., 802, 847. 
Cholaemia, i., 677, 720. 
Cholelithiasis, i., 733. 
Cholera Asiatica, ii., 699; infantum, i., 
504 ; morbus, i., 501; quarantine, ii., 
717 ; typhoid, ii., 715. 
Cholerine, ii., 708. 
Cholesteatoma, ii., 264. 
Chorda Tympani, ii., 327. 
Chordae tendincae, Adhesions and .Rup- 
ture of, i., 393. 
Chordce, ii., 92. 
Chorea, ii., 378. 
Cirrhosis of Liver, i., 670. 
Clairvoyants, ii., 419. 
Clap, ii., 88. 
Clavus hystericus, ii., 414. 
Cliquetis metallique, i., 325, 
Club-foot, ii., 375. INDEX, 
853 
Cod-Liver Oil in Scrofula, ii., 830. 
Cold Applications in Inflammation, i., 
28, 282. 
Cold Beverages as Causes of Consump- 
tion, i., 220. 
Colic, i., 617; biliary, i., 734 ; Painters’, 
1., 619; of Prostitutes, ii., 110; renal, 
11., 63. 
Comedones, ii., 493, 520. 
Compressed Air, Respiration of, i., 92. 
Conception, ii., 159. 
Condyloma of Larynx, i., 37; syphilitic, 
ii., 759. 
Constipation, habitual, i., 571, 590. 
Consumption, galloping, i., 253; pulmo- 
nary, i., 212, 235. 
Convulsions, ii., 189. 
Coqueluche, i., 95. 
Cor taurinum, i., 318. 
Corns, ii., 441. 
Corona veneris, ii., 764. 
Coryza, i., 299. 
Cosme’s paste, ii., 524. 
Cough, induced by irritation, i., 767. 
Cow-pox, ii., 608. 
Cracked-pot Sound, i., 238. 
Cramp, ii., 350; idiopathic, of Extrem- 
ities, ii., 357. 
Craniotabes, ii., 560. 
Crepitant Rale, i., 185. 
Critical Eruption, ii., 468. 
Croup, i., 15; Membrane, i., 17; false, 
spasmodic, i., 7. 
Crusta lactea, ii., 471. 
Curare in Chorea, ii, 383; in Tetanus, 
11., 389. 
Cyanosis, acute, i., 123, 133; in Croup, 
1., 23 ; in Disease of the Heart, i., 205, 
376, 382; of Hunchbacks, i., 133 ; of 
Cholera, ii., 712; in congenital Mal- 
formation of the Heart, i., 382. 
Cysticercus cellulosus, i., 624 ; of Kid- 
ney, ii., 47 ; of Brain, ii., 205. 
Cystitis, catarrhal, ii., 66; croupous and 
diphtheritic, ii., 72. 
Cystoplegia, ii., 84. 
Cystospasm, ii., 82. 
D. 
Darwin’s Theory, ii., 655. 
Deafness, from Tumors of Brain, ii, 269 ; 
from Uraemia, ii., 31. 
Death-rattle, i., 69. 
Decubitus, ii., 453. 
Defluvium Capillorum, ii., 449. 
Deglutition, Disturbance of, ii., 514. 
Delirium, ii., 1S6; tremens, ii., 432. 
Derangement of Secretion in the Skin, 
11., 217. 
Dermoid Cyst, ii., 114. 
Dextro-cardia, i., S80. 
Diabetes mellitus, ii., 832 ; insipidus, ii., 
843. 
Diachylon Ointmemt, ii., 475. 
Diapedesis, i., 160. 
Diaphoresis, ii., 35. 
Diaphragm, Movements of, i., 120. 
Diarrhoea serosa stercoralis, i., 569; 
lienterica, i., 572 ; ablactatorum, i., 
572, ii., 561. 
Diet of Infants, i., 505. 
Digestion, Diseases of Organs of, i., 431. 
Digitalis in Heart Disease, i., 329, 371, 
406. 
Diphtheria, epidemic, ii., 664. 
Diuretics in Heart Disease, i., 372. 
Diverticuli of (Esophagus, i., 488. 
Dizziness, ii., 187 ; from Tumors of Cere- 
bellum, ii., 213, 273, 561. 
Dropsy of Kidney, ii., 12, 24; malarial, 
ii., 680. 
Duodenal Ulcer, i., 583. 
Dura Mater, Inflammation of, ii., 233. 
Dysentery, epidemic, ii., 722; chronic, ii., 
725 ; catarrhal, i., 570. 
Dysmenorrhoea, ii., 125, 164. 
Dyspepsia, i., 502, 555. 
Dysphagia, i., 480, 491. 
Dysphagia inflammatoria, i., 480. 
Dysphonia, i., 54. 
Dyspnoea, i., 229, 283, 290. 
Dysuria spastica, ii., 83. 
E. 
Ecchymomata, ii., 498. 
Echinococci of Liver, i., 697; of Kidney, 
ii., 47 ; of Brain, ii., 262. 
Eclampsia Infantum, ii., 405; Puerpe- 
rarum, ii., 44. 
Ecthyma, ii., 481. 
Ectropion of Os Uteri, ii., 124. 
Eczema, ii., 466. 
Eczema solare, mercuriale, ii., 468. 
Electricity in Chorea, ii., 383 ; in Consti- 
pation, i., 596 ; in Diagnosis of Paraly- 
sis, ii., 312, 363, 377; in essential in- 
fantile Palsy, ii., 376 ; in facial Neu- 
ralgia, ii., 370; in facial Palsy, ii., 
370; in Neuralgia, ii., 322; in Impo- 
tence, ii., 108; in Torticollis, ii., 354; 
in Sciatica, ii., 341; in Scriveners’ 
Spasm, ii., 356. 
Elephantiasis Arabum, ii., 443, 446; 
Grsecorum, ii., 522. 
Embolism, renal, ii., 7, 37; cerebral, ii., 
292. 
Emphysema of the Lung, i., 110. 
Emphysematous Thorax, i., 125. 
Emprosthotonos, ii., 386. 
Empyema, i., 268, 272. 854 
INDEX. 
Encephalitis, ii., 254. 
Endarteritis deformans, i., 314, 414. 
Endocarditis, i., 342 ; ulcerative, i., 346, 
392. 
Enteralgia, i., 617. 
Enteritis catarrhalis, i., 565. 
Enuresis, ii., 306 ; spastica, ii., 83 ; noc- 
turna, ii., 81, 87. 
Ephelides, ii., 441. 
Epididymitis, ii., 93. 
Epiglottis, tuberculous Ulcer of, i., 40. 
Epilepsy, ii., 390; simulated, ii., 399. 
Epileptiform Convulsions, ii., 259, 271. 
Epistaxis, i., 305 ; ii., 816. 
Erysipelas, ii., 455 ; ambulans, ii., 460. 
Erythema, ii., 453; nodosum, ii., 323, 
455. 
Eucalyptus globulus, ii., 690. 
Eustachian Tube, Closure of, i., 475. 
Exanthemata, syphilitic, ii., 760. 
Expectorants, i., 83. 
Expectoration, Absence of, in Senile 
Pneumonia, i., 179; in Abscess of 
Lung, i., 182; in Bronchial Croup, i., 
87; in Bronchial Dilatation, i., 204; in 
Bronchorrhcea, i., 76 ; cocta, i., 6 ; of 
Croup, i., 21; cruda, i., 6 ; elastic Fi- 
bres in, i., 233 ; of Empyema, i., 269; 
gangrenous, i., 182; globosa fundum 
petentia, i., 233 ; mucopurulent homo- 
geneous, i., 67; in (Edema of the 
Lungs, i., 140; of Pneumonia, i., 173; 
of Pulmonary Abscess, i., 182 ; of Pul- 
monary Consumption, i., 233. 
F. 
Facial Palsy, ii., 225, 366. 
Facies Cholerica, ii., 710. 
Faeces, i., 636. 
Fallon Palate, i., 468. 
Falling Sickness, ii., 390. 
Farcy, ii., 788. 
Fauces, chronic Catarrh of, i., 463. 
Favus, ii., 505. 
Fecal Fistula, i., 589. 
Fever, bile, or catarrhal, i., 631 ; essen- 
tial, i., 633; typhus, ii., 614; ship, 
jail, camp, lazaretto, ii., 616 ; gastric, 
mucous, nervous, ii., 641; hectic, i., 
234; spotted, ii., 614; typhoid, ii., 
623; intermitting, ii., 671; malarial, 
ii., 671 ; remittent and continued, ii., 
687; relapsing, ii., 654; pernicious, 
ii., 681; concealed malarious, ii., 683 ; 
yellow, ii., 690. 
Flea-bites, ii., 498. 
Fluor albus, ii., 126, 173. 
Formication, ii., 294. 
Fothergill’s Face-ache, ii., 327. 
Freckles, ii., 442. 
Fremissement cataire, i., 424. 
Friction Sounds, endocardial, extraperi- 
cardial, pericardial, i., 404; pleuritic, 
i., 278. 
Friesel Fieber, ii., 694. 
G. 
Gall-bladder, Dropsy of, i., 731. 
Gall-ducts, Catarrh of, i., 726 ; Croup and 
Diphtheritis of, i., 729 ; Dilatation of, 
i., 730. 
Gall-stones, i., 733. 
Galloping Consumption, i., 253. 
Gangrene of Lung, i., 207. 
Gangrenous Sore Mouth, i., 451. 
Gastric mucous Membrane, acute Catarrh 
of, i., 493 ; chronic Catarrh of, i., 511; 
Croup and Diphtheria of, i., 524. 
Gastric Influenza, i., 64. 
Gastricismus, i., 499. 
Gastritis phlegmonosa, i., 524. 
Gastrodynia neuralgica, i., 545. 
Gastromalacia, i., 497. 
Genu valgus, ii., 375. 
Gin Liver, i., 671. 
Glanders, ii., 788. 
Gleet, ii., 91. 
Glioma, ii., 264. 
Globus hystericus, i., 490; ii., 417. 
Glossitis, i., 449. 
Glossopharyngeal Palsy, ii., 372. 
Glottic Muscles, Palsy of, i., 20, 54. 
Glottis, G'ldema of the, i., 45. 
Gluge’s Inflammation Globules, ii., 254. 
Gonorrhoea, ii., 88; in the Female, ii., 
170. 
Gonorrhoeal Abscess, ii., 92; Gout, Or- 
chitis, Ophthalmia, Rheumatism, ii., 93. 
Gout, ii., 545 ; flying, ii., 527 ; atonic or 
anomalous, ii., 550; internal, ii., 551. 
Goutte militaire, ii., 91. 
Grape-cure, i., 142, 329. 
Gravedo, i., 299. 
Gravel, ii., 607. 
Graves’s Disease: see Basedow’s Dis- 
ease. 
Grayness, ii., 450. 
Green Soap, ii., 476. 
Grippe, i., 64. 
Gummata, or gummy Tumors, ii., 764. 
H. 
Hematocele, retro-uterine, ii., 165. 
Hematoma of Dura Mater, ii., 230. 
Hematuria toxica, ii., 74. 
Ilemometra, ii., 137. 
Hemophilia, Hemorrhagic Diathesis, ii., 
819. 
Hemoptysis, i., 150; from Inhalation of 
Astringents, i., 13. INDEX. 
855 
Haemorrhoids, i., 609 ; of Bladder, ii., 
75. 
Hallucinations, ii., 186. 
JIaut mal, ii., 390. 
Headache, ii., 1S5. 
Heart, Abscess of, i., 355 ; acute Aneu- 
rism of, i., 346 ; chronic Aneurism of, 
i., 356 ; Atrophy of, i., 339 ; Ausculta- 
tion of, i., 380 ; congenital Anomalies 
of, i., 351; Cancer, Tubercle, and Par- 
asites of, i., 376 ; Degeneration and 
Growths of, i., 375; Dilatation of, i., 
330; fatty Metamorphosis of, i., 375 ; 
fibrinous Deposits in, i., 379; Hyper- 
trophy of, i., 371, ii., 28 ; Neuroses of, 
1., 384; Percussion of, i., 324; Palpita- 
tion of, i., 384; Rupture of, i., 378; 
valvular Disease of, i., 358 ; Immunity- 
of Persons with Heart Disease to 
Phthisis, i., 222. 
Heat-stroke, ii., 182. 
Hectic, i., 234. 
Heim’s Pill’s, i., 250. 
Helminthiasis, i., 622. 
Hellor’s Test for Blood, ii., 8. 
Helmerich’s Ointment, ii., 514. 
Hemicrania, ii., 331. 
Hemiplegia, ii., 225, 286. 
Hepar adiposum, i., 685. 
Hepatitis, chronic, i., 670 ; metastatic, i., 
666 ; suppurative, i., 665 ; syphilitic, i., 
681. 
“ Herdsymptome,” ii., 194, 206. 
Herpes, ii., 462 ; rodens, ii., 502; ton- 
dens, tonsurans, ii., 449, 508 ; circina- 
tus, ii., 463 ; zoster, ii., 463. 
Hip Gout, ii., 338. 
Hoarseness, i., 5, 232. 
Hodgkin’s Disease, i., 767. 
Hump-backed Persons, i., 133. 
Hunger in Diabetes, ii., 839. 
Hydatids, i., 697. 
Hydroa febrilis, ii., 462. 
Hydrocephalic Softening, ii., 276. 
Hydrocephaloid, ii., 199. 
Hydrocephalus acquisitus, ii., 275; acute, 
11., 242 ; chronic, ii., 277 ; congenitus, 
ii., 278 ; externus, ii., 275; ex vacuo, 
ii., 276 ; senilis, ii., 276. 
Hydrometra, ii., 137. 
Hydronephrosis, ii., 54. 
Hydropathy in Scrofula, ii., 831. 
Hydropericardium, i., 408. 
Hydrophobia, ii., 793. 
Hydrops vesicas Fellas, i., 731 ; Ovarii, ii., 
115. 
Hydrorachis acquisita, ii., 293; congen- 
ita, ii., 300; rheumatica, ii., 294. 
Ilydrothorax, i., 284. 
Hyperaesthesia, ii., 413. 
Hyperidrosis, ii., 516. 
Hyperinosis, i., 171. 
Hyperkinesia, i., 490; ii., 350. 
Hypertrophy: see various organs. 
Hypochondria, i., 515. 
Hypochondriasis, ii., 426. 
Hypostasis, i., 136. 
Hysteria, ii., 126, 409, 438. 
I. 
Ichthyosis, ii., 444 ; scbacea, ii., 579. 
Icterus, i., 705 ; catarrhal, i., 726 ; hsema- 
togenous, i., 714 ; in Relapsing Fever, 
11., 659 ; in Cirrhosis, i., 675 ; from Gall- 
stones, i., 735 ; in Pneumonia, i., 175 ; 
spasticus, i., 714. 
Idiocy, ii., 283. 
Idiosyncrasies, ii., 414. 
Ileus, i., 574. 
Illusions, ii., 186. 
Impetigo, ii., 479 ; figurata, ii., 50S. 
Impotence, ii., 104. 
Infantile Palsy, ii., 373. 
Influenza, i., 64. 
Inhalation of nebulized Liquid, i., 12. 
Injections of hot Water, ii., 129. 
Inoculation of Tubercle, i., 39. 
“ Insanity of the Muscles,” ii., 380 
Insolation, ii., 181. 
Intestine, Catarrh of, i., 565 ; Carcinoma 
of, i., 604; Contraction and Closure of, 
1., 586; Haemorrhage from, i., 609, ii., 
644 ; Invagination of, and Intussuscep- 
tion of, i., 587; Perforation of, ii., 
644; Rotation of, upon axis, i., 587; 
Scrofulosis of, i., 598; stony Concre- 
tions in, i., 588 ; Strangulation of, i., 
587 ; Tuberculosis of, i., 598. 
Iritis, syphilitic, ii., 766; gummous, ii., 
767. 
Iron in Chlorosis, ii., 807. 
Irritable Breast, ii., 337. 
Ischias, ii., 338. 
Ischias antica, ii., 342. 
Ischuria spastica, ii., 83. 
Itch, ii., 510. 
J. 
Jail Fever, ii., 616. 
Jaundice, i., 705. 
Joints, hysterical, ii., 414. 
Jugulars, Pulsation of, i., 374. 
Junod’s Boot, i., 135. 
K. 
Keloid, ii., 443. 
Kidney, Diseases of, ii., 1 ; Abscess of, 
11., 36; amyloid Degeneration of, ii., 
41 ; Bright’s Disease of, acute, ii., 10; 
chronic, ii., 14; contracted, ii., 17: 856 
INDEX. 
Carcinoma of, ii., 45 ; Carcinoma and 
Tubercle of Pelvis of, ii., 64 ; Deform- 
ities of, ii., 48 ; Dilatation of the Pel- 
vis of, ii., 54 ; Diseases of the Pelvis 
of, ii., 54; granular, ii., 18; Haemor- 
rhage from, ii., 7 ; Horse-shoe, ii., 48; 
Hypcraemia of, ii., 7 ; Infarction of, ii., 
9 ; Irregularities of Position of, ii., 48 ; 
metastatic Deposits in, ii., 36; Mobil- 
ity of, ii., 48; pain in, ii., 4; Para- 
sites of, ii., 47; parenchymatous De- 
generation of, ii., 43 ; stony Concre- 
tions in Pelvis of, ii., 59; Tuberculosis 
of, ii., 46. 
Kummerfeld’s Lotion, ii., 495. 
Kussmaul’s Treatment, i., 522. 
L. 
Laryngismus stridulus, i., 51. 
Laryngitis, croupous, i., 15; catarrhal, 
i., 1. 
Laryngo-stenosis, i., 8. 
Larynx, acute Catarrh of, i., 1; chronic 
Catarrh of, i., 7 ; Cancer of, i., 43 ; 
Croup of, i., 15; Fistula of, i., 40; 
Growths and Polypi of, i., 43 ; nervous 
Affections of, i., 57; Ossification of, 
i., 40; Perichondritis of, i., 49 ; Syphi- 
litic Disease of, i., 35; typhous and 
variolous Ulcers of, i., 33 ; tuberculous 
Disease of, i., 38 ; Ulcers of, i., 31. 
Lead Colic, i., 617. 
Lead Palsy, ii., 361. 
Lebenswecker, ii., 545. 
Lentigincs, ii., 441. 
Lepra maculosa, ii., 522. 
Lepra vulgaris, ii., 486. 
Leprosy, ii., 522. 
Leuchasmia, i., 756. 
Leucocythsemia, i., 756. 
Lcucorrhoea, ii., 173. 
Lichen, ii., 489 ; circumscriptus, ii., 508 ; 
lividus, ii., 498. 
Lilion&se, ii., 442. 
Lipomata, ii., 264. 
Liver, Abscess of, i., 668; acute yellow 
Atrophy of, i., 717; Anatomy of, i., 
722; Budd’s scrofulous Tumor of, ii., 
828; Cancer of, i., 692 ; Cirrhosis of, 
i., 670; Degeneration of, amyloid, lar- 
daceous, waxy, i., 690; fatty, i., 685; 
granular, i., 670; Hydatids of, i., 697 ; 
Hypersemia of, i., 657; Inflammation 
of, suppurative, parenchymatous, i., 
665; interstitial, i., 670; Metastasis of, 
i., 666 ; nutmeg, i., 659 ; physical signs 
of Enlargement of, i., 662; Syphilo- 
ma of, i., 681 ; Tuberculosis of, i., 696. 
Lockjaw, ii., 384. 
Locomotor Ataxia, ii., 302. 
Lumbago rheumatiea, ii., 543. 
Lungs, Abscess of, i., 109 ; Apoplexy of, 
i., 165; Atrophy of, i., 109 ; Atelectasis 
of, i., 130; Cancer of, i., 257; catar- 
rhal Inflammation of, i., 194; croupous 
Inflammation of, i., 166 ; chronic inter- 
stitial Inflammation of, i., 199; cheesy 
Infiltration pf, i., 1*70; Cirrhosis of, 
1, 170; Collapse and Compression of, 
i., 130; Consumption of, i., 212; Em- 
bolism of, i., 158; Emphysema of, i., 
110 ; Gangrene of, i., 169, 207 ; Haem- 
orrhagic Infarction of, i., 157; Ilmm- 
orrhage into, i., 157 ; Hepatization of, 
1., 168 ; Hyperemia of, i., 134; Hyper- 
trophy of,i., 108; Induration of, i., 199; 
Metastasis into, i., 157; miliary Tuber- 
culosis of, i., 253; Gldema of, i., 134, 
258; permanent inspiratory Expan- 
sion of, i., 69 ; syphilitic Disease of, i., 
771; acute miliary Tuberculosis of, i., 
253 ; chronic Tuberculosis of, i., 210 ; 
tubercular Infiltration of, i., 212. 
Lupus, ii., 500 ; syphilitic, ii., 704. 
Lyssa, ii., 793. 
Lyssaphobia, ii., 798. 
M. 
Magnctizers, ii., 419. 
Malarial Fever, ii., 671. 
Malignant Pustule, ii., 788. 
Malleus hmnidus et farcinosus, ii., 788. 
Malt Extract, i., 252, 536. 
Malum Coxe senile, ii., 540. 
Mania, ii., 190. 
Mania a Potu, ii., 432. 
Marasmus, i., 572. 
Mastodynia, ii., 337. 
Measles, ii., 573. 
Meeglin’s Pills, ii., 331. 
Melanemia, i., 761, ii., 682. 
Melasmata, ii., 441. 
Mcllituria, ii., 832. 
Membranous Croup, i., 15. 
Meningite foudroyantc, ii., 251. 
Meningitis simplex, ii-, 236 ; spinalis, ii., 
292 ; rheumatic, ii., 532. 
Menorrhagia, ii., 163. 
Mentagra, ii., 495. 
Menstruation, Anomalies of, ii., 158; 
Absence of, ii., 159; precocious, ii., 
158; vicarious, ii., 161; difficult, ii., 
163; excessive, ii., 163; irregular, 
suppression of, ii., 161. 
Mental Depression, i., 515. 
Mercurial Stomatitis, Sore Mouth, i., 431 ; 
Eczema, ii., 468 ; mercurial Inunction, 
11., 776; mercurial hypodermic Injec- 
tion, ii., 777. 
Mercury in Syphilis, ii., 773. INDEX. 
857 
Mesenteric Glands, scrofulous Disease,of, 
1., 598. 
Metalbumen, ii., 113. 
Metallic Click, i., 325. 
Metritis, ii., 131 ; haemorrhagica, ii., 132. 
Metrorrhagia, ii., 132. 
Miasm, ii., 625, 671, 689. 
Migraine, ii., 331. 
Miliaria rubra et alba, ii., 468, 517. 
Miliary Tuberculosis, acute, i., 253. 
Milium, ii., 520. 
“ Milk Cure,” i., 435. 
Mimic Spasm of Face, ii., 351 ; facial 
Palsy, ii., 366. 
Miserere, i., 574. 
Mistura solvens, i., 81. 
Mitral Valve, Insufficience of, i., 385; 
Constriction of, i., 370. 
Mogigraphia, ii., 355. 
Molluscum simplex contagiosum, ii., 443. 
Monopathophobia, ii., 426. 
Morbilli, ii., 573 ; confluentes, ii., 576. 
Morbus maculosus of Werlhof, ii., 815. 
Morbus sacer, ii., 390. 
Morphine Poisoning, chronic, ii., 183; 
hypodermic Injection of. ii., 326; 
Habit, ii., 435. 
Mother’s Marks, ii., 443. 
Mouth, Catarrh of, i., 431; Excoriations 
and ulcers of. i., 441; syphilitic Affec- 
tions of, i, 444 ; scorbutic Affections 
of, i., 445. 
Mucor muado, ii., 574; racemosus, ii., 
506. 
Muguet, i., 447. 
Mulberry Calculi, ii., 60. 
Mumps, i., 453. 
Muscular Atrophy, progressive, ii., 570. 
Muscular Rheumatism, ii., 542. 
Myelitis, ii., 295. 
Myocarditis, i., 354. 
Myxoma of Brain, ii., 263. 
N. 
Naevus, ii., 441. 
Nasal mucous Membrane, Catarrh of, i., 
299 ; Haemorrhage from, i., 305 ; Poly- 
pus of, i., 301. 
Nasal Tone of Voice, i., 466. 
Nebulizer, i., 12. 
Nephogene, i., 12. 
Nephritis, croupous, ii., 16 ; parenchyma- 
tous, ii., 40 ; vera, ii., 86; interstitial, 
11., 36. 
Nerves, Inflammation of, ii., 313. 
Nervous Cardialgia, i., 551. 
Nervousness, ii., 413. 
Nettle-rash, ii., 464. 
Neuralgia, ii., 314, 317, 376; cardiac, i., 
385; coeliaca, i., 619; cervieo-occipi- 
tal, ii., 333; cervico-brachial, ii., 
' 834; crural, ii., 842; intercostal, ii., 
338 ; isehiadica, ii., 336 ; lumbo-abdo- 
minal, ii., 338 ; of tlic Trigeminus, ii., 
327. 
Neuritis, ii., 313. 
Neuroma, ii., 315. 
Neuromantia, ii., 316. 
Neurotomy, ii., 330. 
Nictitatio, ii., 352. 
Night-sweats, i., 253. 
Nodding Spasm, ii., 353. 
Nodes, ii., 767. 
Noma, i., 451. 
Norwegian Itch, ii., 512. 
Nosebleed, i., 305. 
0. 
Gldema of the Brain, ii., 191 ; in Blight’s 
Disease, ii., 25 ; of Lungs, i., 134 ; of 
Glottis, i., 45; hypostatic, i., 137. 
Oesophagitis, i., 480. 
Oesophagus, Auscultation of, i., 485 ; Di- 
latation of, i., 486; morbid Growths 
of, i., 488 ; nervous Affections of, i., 
490 ; Perforation of, i., 4S9 ; Rupture 
of, i., 489; Strictures of, i., 482 ; spas- 
modic Stricture of, i., 490. 
Oidium albicans, i., 447 ; Schonleinii, i., 
505. 
Oligocythaemia, ii., 802. 
Omodynia rheumatica, ii., 544. 
Onanism, ii., 105. 
Oophoritis, ii., 109. 
Ophthalmoscope in Brain Lesions, ii., 270. 
Opisthotonos, ii., 386. 
Opium-eating, ii., 435. 
Optic Nerve, Atrophy of, ii., 306. 
Orchitis, ii., 93; syphilitic, ii., 770. 
Orthotonos, ii., 386. 
Ossification, deficient, in Rachitis, ii., 557. 
Osteocopic Pain, ii., 767. 
Osteomalacia, ii., 565. 
Otorrhcea, a cause of Brain Disease, ii., 
255. 
Ovaritis, ii., 109. 
Ovary, Abscess of, ii., 110; Cysts in, ii., 
Ill; Dropsy of, i., 652; Inflamma- 
tion of, ii., 109; Inflammation of, in 
Parotitis, i., 456 ; Tumors of, ii., 120. 
Ovula Nabothi, ii., 124. 
Oxalic Diathesis, i., 559. 
Oxaluria, i., 560. 
Oxyuris vermicularis, i., 623. 
Ozaena, i., 303; syphilitica, ii., 73S. 
P. 
Pacchionian Bodies, ii., ISO. 
Pachydermy, ii., 443. 
Pachymeningitis, ii., 230; externa, ii., 
233. 858 
INDEX. 
Palpitation of Heart in Chlorosis, ii., 805. 
Palsy of Bladder, ii., 84; central, ii., 
268 ; of Deglutition, i., 491 ; diptli- 
theritic, ii., 668; essential, of Chil- 
dren, ii., 373; facial, ii., 366; hys- 
teric, ii., 360; of Insane, ii., 239; 
intermitting, ii., 684; peripheral, ii., 
268, 359 ; of Pharynx, ii., 372; pho- 
nic, of the Glottis Muscles, i., 54; 
phonic, of the Glottis-closers, i., 56; 
progressive, of the cerebral Nerves, 
11., 372; psychical, i., 55; spinal, ii., 
373 ; shaking, ii., 431. 
Papules, ii., 489. 
Paracentesis Thoracis, i., 284, 298. 
Paralbumen, ii., 113. 
Parametritis, ii., 135, 
Paraplegia, ii., 298. 
Parasites in the Skin, ii., 505. 
Parenchymatous Nephritis, with amyloid 
Degeneration, ii., 35. 
Paresis, ii., 360. 
Parotitis, i., 453. 
Pai’s vagum, Section of the, i., 20. 
Pathophobia, ii., 426. 
Pectoral Fremitus, i., 183. 
Pectoriloquy, i., 186. 
Peliosis rheumatica, ii., 499. 
Pelvis of Kidney, Cancer of, ii., 64 ; Dila- 
tation of, ii., £4 ; Inflammation of, ii., 
56; stony Concretions in, ii., 59 ; Tu- 
berculosis of, ii., 64. 
Pemphigus, ii., 482; foliaceus, ii., 484. 
Penicillum glaucum, ii., 506. 
Pericarditis, i., 394 ; scorbutic, ii., 753. 
Pericardium, Adhesion of, to Heart, i., 
406; Cancer of, i., 412; Tuberculosis 
of, i., 412. 
Perichondritis laryngca, i., 49. 
Pericystitis, ii., 72. 
Periencephalitis, ii., 239. 
Perimetritis, ii., 135. 
Perinephritis, ii., 40. 
Periostitis, syphilitic, ii., 767. 
Periproctitis, i., 607. 
Peritonaeum, Air in, ii., 644 ; Cancer of, 
1., 654 ; Dropsy of, i., 649; Tubercu- 
losis of, i., 654. 
Peritonitis, i., 638. 
Perityphlitis, i., 568, 574, 607. 
Pertusds, i., 92. 
Petechiae, ii., 498. 
Petit mal, ii., 397. 
Pharyngitis, catarrhal, i., 463 ; croupous, 
i., 462; diphtheritic, i, 479; follicu- 
laris, granulosa, i., 465 ; phlegmonous, 
i., 471; syphilitic, i., 474. 
Pharynx, Catarrh of, i., 463; gummy Tu- 
mor of, i., 475. 
Phlegmasia alba dolcns, i., 430. 
Phonetic Paralysis, i., 54. 
Phthisis pituitosa, i., 76 ; tuberculosa, i., 
212 ; renalis, ii., 39. 
Pia Mater, simple Inflammation of, ii., 
236; tuberculous Inflammation of, ii., 
240. 
Piles, bleeding, blind, i., 609. 
Pills, Asiatic, ii., 48S; Blaud’s, ii., 80S; 
Heim’s, i., 250; Martini’s, ii., 422; 
Ricord’s, ii., 779. 
Pine-needle Bath, i., 80. 
Piss-abed, ii., 81, 87. 
Pityriasis of the Mouth, i., 448; rubra 
circumscripta, ii., 508; tabescentium, 
1., 220, ii., 448; versicolor, ii., 510. 
riaques muqucuses of Larnyx, i., 36. 
Pleura, Cancer of, i., 295 ; Inflammation 
of, i., 264; Tuberculosis of, i., 294. 
Pleurisy, Pleuritis, acute, i., 264; fibrin- 
ous, i., 266 ; purulent, i., 268 ; rlieu- 
matica, i., 265; scorbutic, ii., 813; 
sero-fibrinous, i., 266; sicca, i., 269. 
Pleuritic Effusion, i., 274. 
Pleurodynia rheumatica, ii., 544. 
Pleurosthotonos, ii., 386. 
Pneumogastric Nerve, Neuralgia of, i., 
551. 
Pneumonia, i., 166; bilious,?., 175; ca- 
tarrhal, i., 194; caseous, i., 212; 
chronic, i., 199; croupous, i., 166; hy- 
postatic, i., 137; interstitial, i., 199 , 
lobular, i., 131; metastatic, i., 162; 
migratory, i., 261; notha, i., 69. 
Pneumopericardium, i., 410. 
Pneumorrhagia, i., 150. 
Pneumothorax, i., 287. 
Podagra, ii., 545. 
Poisons, Effect of, on Stomach, i., 525. 
Pollutions, diurnal and nocturnal, ii., 100. 
Polypi of the Skin, ii., 443. 
Polypus of Nose, i., 301; of the Womb, 
11., 152. 
Pompholyx, ii., 482. 
Porrigo asbestina, ii., 508; favosa, ii., 
505; larvalis, ii., 471; lupinosa, ii., 
505. 
Portal Vein, Inflammation of, i., 683. 
Progressive fatty muscular Paralysis, ii., 
* 570. 
Progressive muscular Atrophy, ii, 567. 
Progressive pernicious Anaemia, ii., 817. 
Prosopalgia, ii., 327. 
Prostate, Inflammation of, ii., 92. 
Prune-juice Expectoration, i., 87. 
Prurigo, ii., 490; Pudendorum, ii., 492. 
Psammoma, ii., 263. 
Pseudo-Croup, i., 60. 
Pseudoleuchaemia, i., 767. 
Psora, ii., 518. 
Psoriasis, ii., 452, 485 ; annulate, con- 
ferta, diffusa, grcllata, gyrata, etc., ii., 
486 ; inveterata, ii., 486 ; of the Mouth, INDEX. 
859 
1., 449; Palmaris and Plantaris, ii., 
486, 763; syphilitica, ii., 763. 
Ptyalism, i., 458. 
Pulmonary Artery, Diseases of, i. 428; 
Aneurism of, i., 429 ; Contraction of 
Mouth of, i., 373. 
Pulmonary Diseases : see Lung?. 
Pulsation, epigastric, i., 126 ; of the Ju- 
gulars, i., 3.74. 
Pulse, diehrotic, ii., 635 ; jerking, i., 364 ; 
small, of Pneumonia, i., 191; slow, of 
Icterus, i., 710. 
Pulsus celerrimus, i., 364. 
Punaisie, i., 303. 
Pupil, Contraction and Dilatation, ii., 187. 
Purpura, ii., 498 ; bullosa, ii., 813; huem- 
orrhagica, ii., 815; papulosa, ii., 198; 
pulicosa, ii., 499; rheumatica, ii., 
499; senilis simplex, ii., 499; urti- 
cans, ii., 498. 
Pustules, atheromatous, i., 415. 
Pyelitis, ii., 56. 
Pylephlebitis, i., 683, 723. 
Pylorus, Stricture of, i., 513, 516. 
Pyothorax, i., 268. 
Pyuria, ii., 58. 
Q. 
Quinia as an Antiperiodic, ii.,686. 
R. 
Rabies, ii., 793. 
Rachitic Pelvis, ii., 560. 
Rachitis, ii., 557, 572. 
Rales, crepitant, i., 785 ; moist, in Phthi- 
sis, i., 238; subcrepitant, i., 69 ; tra- 
cheal, i., 69. 
Rectum, Cancer of, i., 604. 
Relapsing Fever, ii., 654. 
Renal Abscess, ii., 36. 
Renal Colic, ii., 69; Apoplexy, ii., 7; 
granular Degeneration of Epithelium, 
11., 43. 
Respirators, i., 248. 
Respiratory Muscles, Spasm of, i., 94. 
Retro-uterine Ilaematocele, ii., 165. 
Retroversion of Uterus, ii., 145. 
Ilevelenta Arabica, ii., 572. 
Rheumatic Callosities, ii., 542. 
Rheumatism, ii., 526, 571; acute articu- 
lar, ii., 527 ; chronic articular, ii., 535 ; 
deforming articular, ii., 540; gonor- 
rhoeal, ii., 93 ; muscular, ii., 542. 
Rhonchi, sibilant, i., 68; sonorous, i., 68. 
Rickets, ii., 557. 
Ricord’s Pills, ii., 779. 
Risus caninus, sardonicus, ii., 352. 
“ Rose,” the, ii., 460. 
Roseola aestiva, autumnalis, ii., 451; 
febrilis, ii,, 595 ; idiopathica, infan- 
tilis, symptomatica, ii., 451; syphi- 
litica, ii., 762; typhosa, ii., 638. 
Rose Itasli, ii., 595. 
Rougeole, ii., 573. 
Rubeola morbilosa, ii., 573. 
Rupia, ii., 484; syphilitic, ii., 764. 
Rush of Blood to the Head, i., 364 ; ii., 
175. 
Russian Clap, ii., 92. 
s. 
Saint Vitus’s Dance, ii., 378. 
Salaam Convulsions, ii., 353. 
Salivation, i., 458; in Syphilis, ii., 716. 
Salt-rheum, ii., 467. 
Sand-tumors of Brain, ii., 263. 
Sarcina, i., 514, 542. 
Sarcocele, syphilitic, ii., 770. 
Sarcoptes Hominis, ii., 510. 
Scabies, ii., 510. 
Scarlatina, ii., 585. 
Scarlet Fever, ii., 585, 738. 
Schneemann’s Treatment, ii, 594. 
Sehroth’s Treatment, i., 522. 
Sciatica, ii., 338. 
Scleroderma, ii., 521. 
Sclerosis, ii., 569. 
Scorbutus, ii., 810. 
Scriveners’ Spasm, ii., 355. 
Scrofula, i., 217; ii., 820, 848. 
Scrofulous Habit, ii., 825. 
Scurvy, ii., 810. 
Seborrhoea, ii., 519. 
Semilunar Valves, insufficience of, i., 359, 
373. 
Serous Effusions in the immature Skull, 
ii., 278; in the mature Skull, ii., 275. 
Serratus Muscle, Palsy of, ii., 370. 
Sheep-pox, ii., 612. 
Shingles, ii., 419. 
Ship-fever, ii., 616. 
Siderosis, i., 202. 
Skin, Diseases of, ii., 440; Hypertrophy 
of, ii., 440; Atrophy of, ii., 447 ; Hy- 
peraemia of, ii., 450; Anaemia of, ii., 
450; Inflammation of, ii., 452. 
Small-pox, ii., 596. 
Snuffles, i., 303. 
Soor, i., 447. 
Spasms, clonic and tonic, ii., 350; of the 
facial Nerve, ii., 351; of the spinal 
Accessory, ii., 353 ; hysterical, ii., 416 ; 
idiopathic, ii., 357;. intermitting, ii., 
684; psychical, ii., 422; nodding, ii., 
353. 
Spasmus Glottidis, i., 51. 
Spermatorrhoea, ii., 100. 
Spina bifida, ii., 300. 
Spinal Marrow, Apoplexy of, ii., 290; 
Atrophy of, ii, 302 ; Carcinoma of, ii., 860 
INDEX. 
300; Consumption of, ii., 302 ; Cysti- 
cerci and Echinococci in, ii., 299; gray 
Degeneration of, ii., 302 ; Growths in, 
11., 299 ; Haemorrhage into, ii., 290; 
Ilypcraemia of, ii., 290 ; Inflammation 
of, ii., 295; Inflammation of Mem- 
branes of, ii., 292 ; Irritation of, ii., 
290; Tubercle of, ii., 300. 
Spleen, Diseases of, i., 739 ; Abscess of, 
1., 752; amyloid Degeneration of, i., 
750; Carcinoma of, i., 754; acute 
Enlargement of, i., 740; chronic En- 
largement of, i., 745; haemorrhagic 
Infarction of, i., 347, 751 ; Hydatids 
of, i., 754 ; Ilypcraemia of, i., 739 ; Hy- 
pertrophy of, i., 746; Inflammation 
of, i., 751 ; lardaceous, i., 750 ; Size of, 
i., 743; Tuberculosis of, i., 754; En- 
largement of, in Typhoid Fever, ii., 
628; wandering, i., 754. 
Spotted Fever, ii., 614. 
Sprue, i., 447. 
Sputa: see Expectoration. 
Status gastricus, i., 499. 
Stenosis, i., 358. 
Stiekhusten, i., 95. 
StoYnacace, i., 439. 
Stomach, Catarrh of, i., 493 ; Cancer of, 
i., 538; Cough, i., 123; Dilatation of, 
i., 522 ; Haemorrhage from, i., 516, 
545; Position of, i.. 542; Softening 
of, i., 497 ; Spasm of, i., 551; Ulcer 
of, i., 516, 528. 
Stomatitis, i., 431; croupous, i., 437. 
Stone in the Bladder, ii., 77. 
Stricture, cardiac, i., 356. 
Strychnine in Palsy, ii., 366. 
Sudamina, ii., 576. 
Sudor anglicus—suette miliaire, ii., 694. 
Sugar, Test for, ii., 837, 849. 
Sunstroke, ii., 181. 
Suppressio Mensium, ii., 161. 
Supraclavicular Region in Croup, i., 19. 
Suprarenal Capsules, Disease of, ii., 49. 
Sweat, ii., 516. 
Sweating of Hands and Feet, ii., 517; 
Sweating in Phthisis, i., 253; Sweating 
Sickness, ii., 694. 
Sycosis, ii., 495. 
Syphilides, ii., 760. 
Syphilis, ii., 742; congenital, ii., 784; 
constitutional, ii., 753 ; hereditary, ii., 
784. 
Syphilitic Acne, ii., 762; Alopecia, ii., 
765; Catarrh, ii., 765; Disease of 
Bone, ii., 767; Disease of Muscle and 
Viscera, ii., 770; Disease of Perios- 
teum, ii., 766; Disease of mucous 
Membranes, ii., 765 ; Exanthemata, ii., 
760; Iritis, ii., 766; Lupus, ii., 764; 
Roseola, ii., 762; Rupia, ii., 764; 
Sarcoccle, ii., 770; primary Ulcer, ii., 
750; Varicella, ii., 762. 
Syphilization, ii., 784. 
►syphilomata, ii., 264. 
T. 
Tabes dorsualis, ii., 302. 
i Ta?nia mediocanellata, solium, i., 622. 
| Tape-worm, i., 622, 630. 
j Tarentism, ii., 425. 
Telangiectasis, ii., 443. 
Temperature of Body, i., 637; in Cholera, 
11., 703 ; Danger from high, ii., 650; 
in Typhoid Fever, ii., 640 ; in Sudor 
anglicus, ii., 608; in Ileat Fever, ii., 
182; in spinal Diseases, ii., 387. 
Temporal Bones, Caries of, ii., 235. 
Testicle, Inflammation of, in Parotitis, i., 
456. 
Tetanus, ii., 384; Neonatorum, ii., 388. 
Thrombosis, i., 430. 
Thrush, i., 447. 
Tic convulsive, ii., 351. 
Tic douloureux, ii., 327 
Tinea favosa, ii., 505 ; furfuracca, ii., 
470. 
Tongue, parenchymatous Inflammation 
of, i., 449; Deviation of, ii., 36S. 
Tonsils, Inflammation of, i., 474, 479. 
Tooth-rose, ii., 455. 
Tophi, ii., 767. 
Torpid Indigestion, i., 558. 
Torticollis, ii., 354; rheumatica, ii., 543. 
Trachea, Diseases of, i., 61; Croup of, 
1., 86. 
Tracheotomy, i., 594. 
Trembling, ii., 261. 
Trichina Disease, Trichinosis, ii., 731. 
Trichomonas vaginalis, ii., 172. 
Tricoccplmlus dispar, i., 624. 
Tricuspid Valves, Disease of, i., 374. 
Trismus, ii., 384. 
Trychophyton tonsurans, ii., 508. 
Tubercle, i., 214; syphilitic, ii., 764; 
painful, ii., 316 ; Inoculation of, i., 262. 
Tubercula dolorosa, ii., 316. 
Tuberculosis of the Bladder, ii., 73; in 
Emphysema and Heart Disease, i., 222; 
of the Intestines, i., 598; of the Kid- 
neys, ii., 46 ; of the Larnyx, i., 38; of 
the Liver, i., 696; of the Lungs, i., 
212 ; of the Pleura, i., 294. 
Typhlitis stercoralis, i., 581. 
Typhoid Fever, ii., 623 ; Poison, ii., 740. 
Typhus, abdominal, ii., 623; abortive, 
11., 641; ambulatorius, ii., 642; ex- 
anthematic, ii., 614; ileotyphus, ii., 
623 ; Sequela? of, ii., 646 ; Observation 
of Temperature in, ii., 637. INDEX. 
861 
u. 
Ulcer of the Cervix Uteri, ii., 157; of 
the Duodenum, i., 553 ; of the Larynx,' 
i., 40; of the (Esophagus, i., 489; of 
the Pharynx, i., 464 ; of the Stomach, 
i., 528, ii., 806; of the Endocardium, 
1., 346. 
Umbilication of Vaccine Vesicle, ii., 610. 
Uraemic Amblyopia, ii., 30; Intoxication, 
11., 28. 
Ureters, Cancer of, ii., 62; Closure of, 
ii., 54; Diseases of, ii., 54; Tubercu- 
losis of, ii., 62. 
Urethra, Abscess of, ii., 92 ; non-virulcnt 
Catarrh of, ii., 98; virulent Catarrh 
of, ii., 8S. 
Uric-acid Infarction, ii, 62. 
Urina spastica, ii., 418. 
Urinary Organs, Diseases of, ii., 1. 
Urine, Amount of, ii., 4. 
Urine in Bright’s Disease, ii., 20. 
Urticaria, ii., 464. 
Uterine Colic, ii., 125, 133. 
Uterus, Anteflexion of, ii., 141 ; Antever- 
sion of, ii., 144; Cancer of, ii., 154; 
Catarrh of, ii., 122; Curvature and 
Flexions of, ii., 140; Descent and Pro- 
lapse of, ii., 145; Displacements of, 
ii., 145; fibrous Polypi of, ii., 147; 
Infarction of, ii., 131 ; Eetroflexion of, 
ii., 140; Stricture of the Mouth of, ii., 
137; Ulcers of, ii., 122, 124; Injec- 
tions into, ii., 130; lacerated Cervix, 
ii., 134 ; Tumors of, ii., 147. 
Y. 
Vaccina, ii., 508. 
Vaccination, ii., 605. 
Vaccinoid, ii., 608. 
Vagina, croupous and diphtheritic In- 
flammation of, ii., 173 ; non-virulent 
Catarrh of, ii., 171; virulent Catarrh 
of, ii., 170. 
Valves of Heart, Aneurism of, i., 393; 
Hypertrophy of, i., 358; Vegetations 
upon, i., 345. 
Valvular Disease of Heart, i., 358 ; com- 
pensating Hypertrophy of the Ven- 
tricles in, i., 360; Origin of, i., 351. 
Varicella, ii., 612; syhilitica, ii., 763. 
Variola, ii., 595. 
Varioloid, ii., 604. 
Veins, Diseases of, i., 429. 
Venesection in Apoplexy, ii., 228; in 
acute (Edema of the Lungs, i., 149; 
in cerebral Hyperaemia, ii., 192; iu 
acute Pneumonia, i., 188, 190; in En- 
docarditis, i., 854. 
Venous Trunks, Diseases of, i., 429. 
Veratria in Pneumonia, i., 192, 2G2. 
Vermiform Appendix, Perforation of, i., 
575. 
Vcrtige (ipileptique, ii., 397 ; stomacale, 
i., 561. 
Vertigo it Stomacho laeso, i., 561. 
Vesical Palsy, ii., 82; Catarrh, ii., 58; 
Phthisis, ii., 70. 
Vesie k Colonne, ii., 59. 
Vichy Water in Diabetes, ii., 842. 
Virus, venereal, Duality of, ii., 74S. 
Vitiligo, ii., 448. 
Vleminckx’s Solution, ii., 488. 
Vocal Chords, Palsy of, i., 55. 
Vomiting in gastric Catarrh, i., 501, 523 ; 
' in Disease of Brain, ii., 187 ; in Penal 
Disease, ii., 12. 
Vomitus Matutinus, i., 514. 
Vox cholerica, ii., 710. 
w. 
Warts, ii., 440, 442. 
Water-brash, i., 514. 
Water-canker, i., 451. 
Water on the Chest, i., 2S4; on the 
Heart, i., 409. 
Water-pox, ii., 612. 
Werlhof’s Disease, ii., 815. 
Whey-cure, i., 11. 
Whooping-cough, i., 95. 
Wilkinson’s Ointment, ii., 574. 
Will in Motion, ii., 220. 
Wind-pox, ii., 612. 
Wolfish Appetite, i., 514. 
Worms in the intestinal Canal, i., 622. 
Writers’ Cramp, ii., 355. 
Wry-ncck: see Torticollis. 
Wunderlich on Typhus, ii., 640. 
X. 
Xanthopsia, i., 710. 
Y. 
Yeasty Diarrhoea, ii., 561. 
Yellow Fever, ii., 689. 
Yellow Vision, i., 710. 
z, 
Zona, ii., 462. 
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